Standard immunizations for non pregnant a

Prerit Devkota
1st year Resident,
ER/GP
PAHS

Contents
1. Introduction
2. History
3. The principles of immunization
4. Recommended immunization vaccines in healthy as
well as in special situations by ACIP
5. Methods and routes of administration
6. Summary
7. References

Introduction
 Immunization is the process whereby a person is made
immune or resistant to an infectious disease.
 Vaccine : biological preparation that provides active
acquired immunity to a particular disease
 Vaccination vs. Immunization?
 Active vs. Passive ?

History
 429 BC : Greek historian
Thucydides noticed that
people who survive
smallpox do not get re-
infected.
 1796 AD : Edward Jenner
discovered vaccination in
its modern form and
proved to the scientific
community that it
worked.

History
 1920s: Vaccines become
widely available.
 1980s: Smallpox
eradicated from the
world.
 Louis Pasture (1885):
Rabies

Principles of Immunization
 Important factors:
 Type of immunization to be used:
active or passive
 Administration : im/sc
 Safety
 Responsibilities of the individual
giving the vaccination: maintain
records and report adverse events
 proper storage and transportation
 Records :
 site and route
 date that the vaccine was
administered
 date that the next dose is due
 manufacturer and lot number
 name, address, and title of the
person administering the vaccine

Adverse events:
 Anaphylaxis or anaphylactic shock
 Encephalopathy, encephalitis, or
seizures
 Any sequelae of reportable events
Vaccine specific reportable
events:
 Tetanus – Brachial neuritis
 Pertussis – Encephalopathy or
encephalitis

 MMR – Encephalopathy or
encephalitis
 Rubella – Chronic arthritis
 Measles – Thrombocytopenic purpura
 Oral polio – Paralytic polio

 Vaccines are not contraindicated when:
 Current or recent mild illness, with or without low grade fever
 Current or recent antibiotic therapy
 Previous mild to moderate local tenderness, redness, swelling, or
fever less than 40.5ºC after any vaccination
 Personal history of allergies
 Family history of adverse reactions to immunization

Administering vaccines to adults: Dose,
route, site, needle size, and preparation

But remember...
 Shake vaccine vial properly.
 If vial or vaccine is transparent , inspect for particulate matter and/or
discoloration prior to administration – discard if any dout noted
 Reconstituted vaccines:
 Use only the diluent supplied with the vaccine.
 Inject the volume of the diluent shown on the diluent label into the vial and gently
agitate to mix thoroughly.
 Withdraw the entire contents and administer immediately after reconstitution.
 Discard single dose MPSV, varicella, and zoster vaccines if not used within 30
minutes after reconstitution .
 Unused reconstituted MMR vaccine and multidose MPSV vaccine may be stored at
35° - 46°F (2° - 8°C) for a limited time.
 The reconstituted MPSV vaccine must be used within 35 days; the reconstituted
MMR vaccine must be used within 8 hours.
 Do not freeze either reconstituted vaccine.

List of vaccines strongly recommended on the basis of
the US Embassy Medical Unit, Kathmandu, WHO-EPI for
Nepal

Influenza vaccines
 Routine vaccination:
 Persons aged 6 months or older: 1 dose IIV, RIV, or LAIV appropriate for age and health status
annually.
 Special situations:
 Egg allergy, hives only: 1 dose IIV, RIV, or LAIV appropriate for age and health status annually.
 Egg allergy more severe than hives (eg, angioedema, respiratory distress): 1 dose IIV, RIV, or LAIV
appropriate for age and health status annually in medical setting under supervision of healthcare
provider who can recognize and manage severe allergic conditions.
 Immunocompromised conditions (including HIV infection), anatomical or functional asplenia,
pregnant women, close contacts and caregivers of severely immunocompromised persons in
protected environment, use of influenza antiviral medications in previous 48 hours, with
cerebrospinal fluid leak or cochlear implant: 1 dose IIV or RIV annually (LAIV not
recommended).
 History of Guillain-Barré syndrome within 6 weeks of previous dose of influenza vaccine:
Generally should not be vaccinated.

Tetanus and diphtheria toxoids, and
acellular pertussis (Tdap) vaccine
 Previously did not receive Tdap at or after age 11 years: 1 dose Tdap, then
Td booster every 10 years.
 Previously did not receive primary vaccination series for tetanus,
diphtheria, and pertussis: 1 dose Tdap followed by 1 dose Td at least 4
weeks after Tdap, and another dose Td 6 to 12 months after last Td
 Td booster every 10 years thereafter.
 Pregnancy: 1 dose Tdap during each pregnancy, preferably in early part
of gestational weeks 27 to 36.

Measles, mumps, and rubella
(MMR) vaccine
 No evidence of immunity to measles, mumps, or rubella: 1 dose MMR.
 Evidence of immunity: Born before 1957 (except healthcare personnel),
documentation of receipt of MMR, laboratory evidence of immunity or
disease
 Pregnancy: contraindicated
 After pregnancy (before discharge from healthcare facility): 1 dose
MMR.
 Non-pregnant women of childbearing age with no evidence of
immunity to rubella: 1 dose MMR.
 HIV infection with CD4 count ≥200 cells/microL for at least 6 months :
2-dose series MMR at least 4 weeks apart; MMR contraindicated in HIV
infection with CD4 count <200 cells/microL.
 Severe immunocompromising conditions: MMR contraindicated.

Varicella (VAR) vaccine
 No evidence of immunity to varicella: 2-dose series 4 to 8 weeks apart);
 If previously received 1 dose varicella-containing vaccine: 1 dose at least 4
weeks after first dose.
 Contraindications:
 Pregnancy
 Severe immunocompromising conditions
 VAR contraindicated in HIV infection with CD4 count <200 cells/microL
 1 dose if previously received 1 dose and 2-dose series if previously did not
receive any varicella-containing vaccine 4 to 8 weeks apart
 After pregnancy (before discharge from healthcare facility)
 Healthcare personnel with no evidence of immunity to varicella
 HIV infection with CD4 count ≥200 cells/microL with no evidence of immunity:
Consider 2-dose series 3 months apart

Zoster vaccines
 Age 50 years or older: 2-dose series RZV at 2-6 moths interval(minimum
interval: 4 weeks) regardless of previous herpes zoster or previously received
ZVL
 Age 60 years or older: 2-dose series RZV 2 to 6 months apart (minimum
interval: 4 weeks) or 1 dose ZVL if not previously vaccinated (if previously
received ZVL, administer RZV at least 2 months after ZVL); RZV preferred over
ZVL.
 Pregnancy: ZVL contraindicated; consider delaying RZV until after pregnancy if
RZV is otherwise indicated.
 Severe immunocompromising conditions (including HIV infection with CD4
count <200 cells/microL): ZVL contraindicated; recommended use of RZV
under review.

Human Papilloma Virus (HPV) vaccine
 Females through age 26 years and males through age 21 years: 2- or 3-dose series HPV
vaccine depending on age at initial vaccination
 Age 15 years or older at initial vaccination: 3-dose series HPV vaccine at 0, 1 to 2, 6 months
(minimum intervals: 4 weeks between doses 1 and 2, 12 weeks between doses 2 and 3, 5
months between doses 1 and 3; repeat dose if administered too soon).
 Age 9 through 14 years at initial vaccination and received 1 dose, or 2 doses less than 5
months apart: 1 dose HPV vaccine.
 Immunocompromising conditions (including HIV infection) through age 26 years: 3-dose
series HPV vaccine at 0, 1 to 2, 6 months as above.
 Men who have sex with men and transgender persons through age 26 years: 2- or 3-dose
series HPV vaccine depending on age at initial vaccination as above.
 Pregnancy through age 26 years: HPV vaccination not recommended until after
pregnancy; no intervention needed if vaccinated while pregnant; pregnancy testing not
needed before vaccination.

Pneumococcal vaccines
 Age 65 years or older (immunocompetent): 1 dose PCV13 if previously did not receive
PCV13, followed by 1 dose PPSV23 at least 1 year after PCV13 and at least 5 years after last
dose PPSV23.
 Previously received PPSV23 but not PCV13 at age 65 years or older: 1 dose PCV13 at least 1 year after
PPSV23.
 When both PCV13 and PPSV23 are indicated, administer PCV13 first
 Age 19 through 64 years with chronic medical conditions (chronic heart [excluding
hypertension], lung, or liver disease; diabetes), alcoholism, or cigarette smoking: 1 dose
PPSV23.
 Age 19 years or older with immunocompromising conditions: 1 dose PCV13 followed by 1
dose PPSV23 at least 8 weeks later, then another dose PPSV23 at least 5 years after previous
PPSV23; at age 65 years or older, administer 1 dose PPSV23 at least 5 years after most recent
PPSV23 (NOTE: only 1 dose PPSV23 recommended at age 65 years or older).
 Age 19 years or older with cerebrospinal fluid leak or cochlear implant: 1 dose PCV13
followed by 1 dose PPSV23 at least 8 weeks later; at age 65 years or older, administer
another dose PPSV23 at least 5 years after PPSV23 (NOTE: only 1 dose PPSV23
recommended at age 65 years or older).

Hepatitis A (HepA) vaccine
 Not at risk but want protection from hepatitis A : 2-dose series HepA ( 6 to 12 months
apart or [minimum interval: 6 months]) or 3-dose series HepA-HepB ( at 0, 1, 6 months
[minimum intervals: 4 weeks between doses 1 and 2, 5 months between doses 2 and 3]).
 At risk for hepatitis A virus infection: 2-dose series HepA or 3-dose series HepA-HepB as
above.
 Chronic liver disease.
 Clotting factor disorders.
 Men who have sex with men.
 Injection or non-injection drug use.
 Homelessness.
 Work with hepatitis A virus in research laboratory or nonhuman primates with hepatitis A virus
infection.
 Travel in countries with high or intermediate endemic hepatitis A.
 Close personal contact with international adoptee (eg, household, regular babysitting) in first 60
days after arrival from country with high or intermediate endemic hepatitis A (administer dose 1 as
soon as adoption is planned, at least 2 weeks before adoptee's arrival).

Hepatitis B (HepB) vaccine
 Not at risk but want protection from hepatitis B : 2- or 3-dose series HepB (2-dose series
HepB at least 4 weeks apart or 3-dose series at 0, 1, 6 months or 3-dose series HepA-HepB
(Twinrix at 0, 1, 6 months
 At risk for hepatitis B virus infection: 2-dose series or 3-dose series HepB, or 3-dose series
HepA-HepB as above.
 Hepatitis C virus infection.
 Chronic liver disease (eg, cirrhosis, fatty liver disease, alcoholic liver disease, autoimmune hepatitis,
alanine aminotransferase [ALT] or aspartate aminotransferase [AST] level greater than twice upper
limit of normal).
 HIV infection.
 Sexual exposure risk (eg, sex partners of hepatitis B surface antigen [HBsAg]-positive persons;
sexually active persons not in mutually monogamous relationships, persons seeking evaluation or
treatment for a sexually transmitted infection, men who have sex with men).
 Current or recent injection drug use.
 Percutaneous or mucosal risk for exposure to blood (eg, household contacts of HBsAg-positive
persons; residents and staff of facilities for developmentally disabled persons; healthcare and public
safety personnel with reasonably anticipated risk for exposure to blood or blood-contaminated body
fluids; hemodialysis, peritoneal dialysis, and predialysis patients; persons with diabetes mellitus
aged younger than 60 years and, at discretion of treating clinician, those aged 60 years or older).
 Travel in countries with high or intermediate endemic hepatitis B.

Meningococcal vaccines
 Special situations for MenACWY:
 Anatomical or functional asplenia (including sickle cell disease), HIV infection, persistent complement
deficiency, eculizumab use: 2-dose series MenACWY (Menactra, Menveo) at least 8 weeks apart and
revaccinate every 5 years if risk remains.
 Travel in countries with hyperendemic or epidemic meningococcal disease, microbiologists routinely
exposed to Neisseria meningitidis: 1 dose MenACWY and revaccinate every 5 years if risk remains.
 First-year college students who live in residential housing (if not previously vaccinated at age 16 years or
older) and military recruits: 1 dose MenACWY.
 Special situations for MenB:
 Anatomical or functional asplenia (including sickle cell disease), persistent complement component
deficiency, eculizumab use, microbiologists routinely exposed to Neisseria meningitidis: 2-dose series at
least 1 month apart, or 3-dose series at 0, 1 to 2, 6 months (if dose 2 was administered at least 6 months
after dose 1, dose 3 not needed)
 Pregnancy: Delay until after pregnancy
 Healthy adolescents and young adults age 16 through 23 years (age 16 through 18 years preferred) not at
increased risk for meningococcal disease: Based on individual clinical decision, may receive 2-dose series
at least 1 month apart

Haemophilus influenzae type b
(Hib) vaccine
 Anatomical or functional asplenia (including sickle cell
disease): 1 dose Hib if previously did not receive Hib; if
elective splenectomy, 1 dose Hib, preferably at least 14
days before splenectomy.
 Hematopoietic stem cell transplant (HSCT): 3-dose
series Hib 4 weeks apart starting 6 to 12 months after
successful transplant, regardless of Hib vaccination
history.

Adult Immunization challanges
 Inadequate funding for vaccines and administration in
public programs
 Lack of knowledge – both patients and providers
 Poor public health and private infrastructure for vaccine
delivery.
 Lack of availability of vaccine.
 High cost of vaccine.

Take home messeges
 Most vaccinations induce active immunity by promoting the development of
antibody in the recipient, a response which is expected to be durable.
 Passive immunization, which usually involves the administration of a globulin
product, produces transient immunity for a specific exposure through the
transfer of antibody directly.
 The recommended method of storage, preparation, and route of
administration of each vaccine is described in the package insert; these
instructions must be followed precisely.
 If any doubt about vaccine vial or vaccine constituent – never administer.
 Recording and reporting system is must.
 Adverse events associated with vaccines should be reported.

References
 UpToDate 2019
 Kim DK, Hunter P, Advisory Committee on Immunization Practices. Recommended
Adult Immunization Schedule, United States, 2019. Ann Intern Med 2019; 170:182.
 Kroger AT, Duchin J, Vázquez M. General best practice guidelines for immunization. Best
practices guidance of the Advisory Committee on Immunization Practices (ACIP). Availa
ble at: https://www.cdc.gov/vaccines/hcp/acip-recs/general-recs/index.html (Accessed o
n April 27, 2017).
 Poland GA, Borrud A, Jacobson RM, et al. Determination of deltoid fat pad thickness.
Implications for needle length in adult immunization. JAMA 1997; 277:1709.
 Honkanen PO, Keistinen T, Kivelä SL. Reactions following administration of influenza
vaccine alone or with pneumococcal vaccine to the elderly. Arch Intern Med 1996;
156:205.
 Pickering LK, Baker CJ, Freed GL, et al. Immunization programs for infants, children,
adolescents, and adults: clinical practice guidelines by the Infectious Diseases Society of
America. Clin Infect Dis 2009; 49:817.
 Centers for Disease Control and Prevention (CDC). Carbon monoxide poisonings
associated with snow-obstructed vehicle exhaust systems--Philadelphia and New York
City, January 1996. MMWR Morb Mortal Wkly Rep 1996; 45:1.
 Centers for Disease Control and Prevention (CDC). Update: influenza activity--United
States, 1993-94 season. MMWR Morb Mortal Wkly Rep 1994; 43:1.

Have we all in this room been vaccinated according to
recommendations? If not,then Hurry up,its never too
late...
Thank you!!!!

Standard immunizations for non pregnant a

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