Hospital Medicine

Immunizations

I. Problem/Challenge.

Immunizations decrease the incidence of vaccine-preventable diseases and the morbidity and mortality associated with these diseases. Unfortunately, rates of vaccine coverage overall among adults is low. Tens of thousands of adults die yearly from vaccine-preventable diseases, with most deaths caused by influenza. Pneumococcal disease also causes thousands of deaths annually. Despite this, influenza and pneumococcal vaccine rates are particularly low for high-risk and elderly patients. Racial and ethnic differences in vaccination rates also persist.

II. Identify the Goal Behavior.

Hospitalized patients are a group of high-risk patients who could most benefit from immunizations. Hospitalists can play a key role in the reduction of vaccine preventable disease. Immunization status should be a routine part of the admission history, and appropriate vaccines should be administered during hospitalizations.

III. Describe a Step-by-Step approach/method to this problem.

What are the types of vaccinations?

Active Vaccines: When administered, these vaccines promote a primary immune response from the patient. If subsequently exposed to the pathogen, a secondary immune response helps protect the patient from developing the disease. The following represent the types of active vaccines:

  • Live-attenuated vaccines include MMR, varicella, oral typhoid, yellow fever, intranasal influenza virus, BCG, and rotavirus. As the name suggests, these vaccines contain live, but weakened versions of the microbe.

  • Subunit vaccines contain antigens, including those that are protein-based (Hepatitis B vaccine), polysaccharide-based (pneumococcal, meningococcal), or conjugated (pneumococcal).

  • Toxoid vaccines contain inactivated toxins that cause disease (Tetanus and diphtheria).

Passive Vaccines:- These vaccines are given to patients who are unable to mount their own immune response. They consist of the administration of antibodies to provide a short-term immunization.

How are the vaccines administered?

Vaccines should be administered according to manufacturer directions. Injectable vaccines can be administered intramuscularly or subcutaneously, though intramuscular administration can minimize local irritation caused by vaccine components. Some vaccines are also administered orally (i.e., oral typhoid) or intra-nasally (i.e., live-attenuated influenza vaccine).

Are there any contraindications to vaccinations?

There are few true contraindications, but they include a history of anaphylactic reaction to a specific vaccine or anaphylaxis to egg or egg protein. Patients who have had any neurological sequelae after a vaccination should not receive that vaccination again. Immunocompromised patients and pregnant women should not receive live attenuated vaccines.

Moderate to severe acute illness is generally a precaution to the administration of vaccines. Mild illnesses, including diarrhea or upper respiratory symptoms, are not contraindications to vaccination.

What are the side effects of vaccines?

Most common side effects include local reactions (redness, pain), systemic reactions (fever, arthralgia, or flu-like illness), and syncope.

Can vaccinations be given together?

Simultaneous administration of all due vaccines increases the chance of complete coverage for patients, and is generally safe, and results in similar seroconversion compared to patients who receive vaccines separately. Patients who are due for both pneumococcal and influenza vaccines should receive them both simultaneously. Live vaccines should be given on the same day or at least 28 days apart if given separately. Immune globulins are generally not given with live virus vaccines.

Pneumococcal:

Two vaccines exist for pneumococcal immunization: the pneumococcal polysaccharide vaccine (PPSV23) and the pneumococcal conjugate vaccine (PCV13). These vaccines protect against invasive pneumococcal disease, including bacteremia and meningitis.

Adults 65 years and older should receive one dose of PCV13 followed by a dose of PPSV 1 year later. If PPSV23 has been given previously, PCV13 is given one year after the most recent PPSV23 dose. One time revaccination is recommended after 5 years for people 65 and over if they were vaccinated more than 5 years ago or if they were less than 65 when they were first vaccinated.

For patients aged 19-64 with an underlying medical condition necessitating vaccination, it is recommended that they have a second vaccine 5 years after the primary vaccine.

PPSV23 should be given to adults younger than 65 with underlying comorbidities including: chronic heart disease, lung disease, liver disease, renal disease, diabetes mellitus, alcoholism, (CSF) leaks, and immunocompromised state, including malignancy, immunodeficiencies, iatrogenic immunosuppression, solid organ transplant, HIV, and functional or anatomic asplenia. Residents of nursing homes or long-term care facilities who smoke cigarettes should also be vaccinated.

PCV13 should be given to adults younger than 65 with CSF leaks, cochlear implants, solid organ transplant, sickle cell disease and other hemoglobinopathies, and immunocompromised states such as malignancy, immunodeficiencies, iatrogenic immunosuppression, HIV, and functional or anatomic asplenia.

Influenza:

The influenza vaccine is reconfigured yearly based on the prior year's most common strains and should thus be given annually to all people 6 months and older. Healthy non-pregnant adults who do not have significant co-morbidities and are less than 50 years old can receive either a live- intranasal (check the national recommendation annually since this may vary from year to year), a live attenuated vaccine or an inactivated vaccine. All other people should receive the inactivated vaccine. People older than 65 can receive a high-dose vaccine.

Reactions to the live attenuated vaccine include runny nose, nasal congestion, headache and sore throat.

Tetanus, diptheria and acellular pertussis (Tdap):

All adults who have not previously received Tdap or who are unaware of their vaccine status should receive Tdap. Postpartum women, close contacts of infants younger than age 12 months, and health care personnel with direct patient contact should receive the vaccine. Td (tetanus and diphtheria) should be given every 10 years, and Tdap can replace this booster if vaccination status is unknown. Tdap history should be reviewed and administered accordingly for patients presenting with an acute injury or wound.

Measles/Mumps/Rubella (MMR):

MMR is a live-attenuated vaccine, and should not be administered to pregnant patients or those with immunocompromised state.

Adults born before 1957 are considered immune to the measles and mumps. Those born after 1957 need to have one or more doses of MMR unless they have a contraindication to the vaccine, have laboratory documentation of immunity against the disease or health care provider confirmation of prior measles or mumps. Health care provider diagnosis of rubella is not acceptable. A second dose of MMR given 28 days after the first dose is recommended for adults exposed to the disease, are in college, work in a health care facility or will be traveling internationally.

Rubella - All women of child-bearing age should have their rubella immunity checked. If they are not pregnant, it is appropriate to vaccinate at that time. Pregnant women can be vaccinated upon completion of their pregnancy prior to discharge from the hospital.

Side effects include arthralgia, which is usually due to the rubella component of the vaccine.

Hepatitis A:

Vaccination is recommended for people traveling in countries with a high rate of HAV, men who have sex with men, people who use injection drugs, work with HAV infected primates or HAV in a research setting, have chronic liver disease, receive clotting factor concentrates. In addition, others who wish to be immunized can be vaccinated.

Hepatitis A vaccination is a two-dose series with the booster dose administered 6 to 12 months after the first dose. Protection after the two-dose series is said to last at least 25 years in adults and between 14-20 years in children. The vaccine can be given to someone after being exposed to the hepatitis A virus and can prevent HAV infection when given within 2 weeks of exposure.

Hepatitis B:

Hepatitis B is a 3-dose series. The second dose is given one month after the primary dose, and the third dose given 2 months after the second dose.

Adults should be vaccinated if they are health care or other personnel and public safety workers exposed to infectious body fluids, people with end stage renal disease including those on hemodialysis, have HIV, chronic liver disease, are sexually active with more than 1 partner or who have a known infected partner, men who have sex with men, seek evaluation or treatment for a sexually transmitted disease, or use injection drugs.

Human Papilloma Virus (HPV):

The HPV vaccine is a 3-dose series, with the second dose given 1-2 months after the first dose and the third dose given 6 months after the first dose.

HPV vaccine is usually administered to both girls and boys age 11-12. The vaccine is ideally given before initial sexual contact, but can be given to women until they are 27 years old and men until they are 21 years old. Men who have sex with men, transgender people, and those who are immunocompromised can receive the vaccine until 27 years old.

Varicella

Varicella is a live-attenuated vaccine and should not be administered to pregnant women or those who are immunocompromised. Adults without evidence of immunity to varicella require vaccination. Individuals who have never received vaccination should be given two doses of varicella vaccine. If a person has received a dose in the past, a second dose should be given at least 4 weeks after the initial dose.

Evidence of immunity includes documentation of administration, US born before 1980, history of varicella based on diagnosis by health care provider or laboratory evidence of immunity or confirmation of disease.

Heath care personnel, family contacts of persons with immunocompromising conditions, people at high risk for transmission such as teachers and child care employees, military personnel, college students, residents and staff of institutional settings, international travelers and non-pregnant women of childbearing age, should consider the vaccine.

Herpes Zoster:

Zoster vaccine is a live-attenuated vaccine like the varicella vaccine, and should not be administered to pregnant women or immunocompromised patients. The zoster vaccine contains the same live-attenuated virus as the varicella vaccine, but at a higher dose.

One dose is recommended for adults aged 60 years and older for the prevention of herpes zoster.

Meningococcal:

There are 3 types of meningococcal vaccine: the conjugate, polysaccharide, and serogroup B vaccines. The conjugate vaccine is given in a 2-dose series, with the second dose given 2 months after the first.

The conjugate vaccine is usually given in youth, but should be administered to adults who at increased risk for meningococcal disease, including individuals with complement component deficiency, functional or anatomic asplenia, HIV, or men who have sex with men. A single dose is recommended for unvaccinated first-year college students living in dorms, military recruits and those traveling to endemic countries. Revaccination is necessary for adults with ongoing increased risk for infection.

Haemophilus influenzae type B (Hib):

Hib vaccine is usually given in childhood. However, adults should receive one dose of Hib vaccine if they have functional or anatomic asplenia, or plan on undergoing elective splenectomy. Patients who have undergone hematopoietic stem cell transplantation should receive the 3-dose series in at least 4 week intervals, 6-12 months after transplant regardless of vaccine history.

Summary of vaccine recommendations for certain high-risk conditions:

Hospitalists should assess the patient's co-morbidities and other risk factors to determine which vaccinations are recommended.

HIV infection - Influenza, Tdap/Td, HPV, MMR, pneumococcal, meningococcal, hepatitis A, Varicella (CD4 <200)

Diabetes, heart disease, chronic lung disease, chronic alcoholism- Influenza, Tdap/Td, Varicella, HPV, Zoster, MMR, Pneumococcal, Meningococcal, Hepatitis A/B

Asplenia and persistent complement component deficiencies- Influenza, Tdap/Td, Varicella, HPV, Zoster, MMR, Pneumococcal, Meningococcal, Hepatitis A/B, Hib

Chronic liver disease- Influenza, Tdap/Td, Varicella, HPV, Zoster, MMR, Pneumococcal, Meningococcal, Hepatitis A/B

Kidney failure, end-stage renal disease, hemodialysis- Influenza, Tdap/Td, Varicella, HPV, Zoster, MMR, Pneumococcal, Meningococcal, Hepatitis A/B

Health care personnel- Influenza, Tdap/Td, Varicella, Zoster, MMR, Pneumococcal, Meningococcal, Hepatitis A/B

Can I give the vaccines to someone who is sick?

As noted previously, patients with moderate or severe acute illness can have vaccinations deferred to help avoid complicating the clinical picture created by symptoms and signs of the acute illness and possible adverse effects of the vaccinate. Generally, most vaccines can be given at the time of discharge, as mild illness or fever are not contraindications to vaccination.

Can I give vaccines to someone on steroids?

While steroids can suppress the immune system and a possible immune response to vaccines, taking corticosteroids is not an absolute contraindication to immunization. However, in patients taking more than 2 mg/kg of body weight or greater than 20 mg of prednisone a day for more than 14 days, it is advisable to defer live virus vaccination for at least one month after discontinuation of the steroids.

Can I give vaccines to someone on antibiotics?

Use of antibiotics is not a contraindication to vaccination. The only exception is the live oral typhoid vaccine, which should not be given to anyone on antibiotics until 24 hours after the last dose to avoid a decrease in effectiveness of the vaccine. Antibiotics ideally would not be given until a week after the dose of the vaccine.

If someone is taking antiviral medications, they should not receive live-attenuated vaccines (i.e., varicella, intranasal influenza) for 48 hours after the medication is discontinued. Ideally antiviral drugs should not be given until 14 days after the live vaccine is administered. Inactivated vaccines are not affected by antiviral drugs.

Is it safe to give a vaccine to someone who is unsure of their vaccination status?

There are no known problems with early or repeat vaccination.

Are there special recommendations for pregnant women?

Live-attenuated vaccines (MMR, varicella, intranasal influenza) are contraindicated during pregnancy due to theoretical risk to the developing fetus. Td can be given during pregnancy and Tdap should be administered as soon as possible after delivery. All pregnant women should receive influenza vaccination.

Pregnant women should be tested for immunity to rubella and varicella. If they are not immunized, they should be vaccinated after delivery. Pregnant women should also be screened for the presence of Hepatitis B surface antigen, as infants born to infected mothers need HBIG and Hepatitis B vaccination after delivery.

IV. Common Pitfalls.

What are the barriers to full compliance with immunizations?

Generally, many people do not seek medical attention when they are feeling well, and both patients and clinicians may not be aware of the age-appropriate vaccination schedules. Thus, it is important for patients to have their immunization status addressed when they are in the hospital. In addition, vaccines can be given under the supervision of a physician and several other health care providers in the event of an adverse reaction.

How can we improve the immunization rates?

As discussed previously, routine review of immunization status upon admission should be encouraged and operationalized. The inclusion of appropriate immunizations within admissions or discharge order sets can improve immunization rates.

V. National Standards, Core Indicators and Quality Measures.

Several groups have established national standards for improving vaccination initiatives.

Advisory Committee on Immunization Practices (ACIP) of the CDC publishes the full immunization schedule for adults.

The Joint Commission has mandated initiatives to improve healthcare worker influenza vaccination in accredited health care facilities. Core quality indicators include the requirement of influenza and pneumococcal vaccines for all patients admitted with pneumonia or congestive heart failure.

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