Hospital Medicine

Immunizations

I. Problem/Challenge.

Immunizations help prevent thousands of illnesses every year. However, the immunization rates for vaccine preventable disease remains unacceptably low. Between 50,000 and 70,000 people die every year of influenza and pneumococcal disease alone. Hospitalists play a key role in preventing these deaths by taking the opportunity to administer vaccines when patients are hospitalized.

II. Identify the Goal Behavior.

Hospitalized patients are a group of particularly high risk patients who could most benefit from immunizations. Hospitalists can play a key role in the reduction of vaccine preventable disease.

Ideally, as part of a patient's admission history, their immunization status would be documented. After any allergies are addressed, the appropriate age related immunizations which are not up to date would be administered.

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

What are the types of vaccinations?

ACTIVE- Vaccines are made from whole killed bacteria, live attenuated bacteria or viruses or antigenic portions of the intended organism. When one of these components is administered, it will promote the host to have aprimary immune response. When the patient is later in contact with the pathogen, the patient will mount asecondary response which helps protect the patient from developing the disease. Boosters are sometimes needed to prolong the protection.

PASSIVE- These vaccines are given to patients who are unable to mount their own immune response (immunocompromised). They consist of the administration of antibodies to provide a short term protection against a potential or real pathogen.

TOXOIDS- These are used for active immunization. They are made from bacterial toxins that are altered to make them non-infective, and administered to promote antibody production. When a patient is subsequently exposed to the pathogen, the antibody that was produced can bind to the toxin and prevent disease.

Most healthy adults receive active immunization since they should be able to mount the proper immune response.

How are the vaccines administered?

Usually intramuscularly or subcutaneously at the deltoid muscle, where the immune response can be elicited with the greatest strength.

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. Anyone who has had any neurological sequelae after a vaccination should not receive that vaccination again. Adults with an underlying immunocompromised state should not receive live attenuated vaccines. Finally, pregnant women should not receive live virus vaccines because of the risk to the fetus.

What are the side effects of vaccines?

They are generally minor and include fever, local injection site reactions and occasionally a serum sickness like illness.

Can vaccinations be given together?

The pneumococcal and influenza vaccine can be given at the same time, although there does appear to be an increased risk of local reactions and fever. Live virus vaccines should be given on the same day or at least a month apart so that the immune response is not affected. Immune globulins are generally not given with live virus vaccines as the antibodies given passively can affect the immune reaction to the live virus.

What are the different vaccinations that are available?

Pneumoccal:

This is a polysaccharide polyvalent vaccine. This vaccine is given to patients older than 65 years old and to younger patients with co-morbidities who are at increased risk for invasive pneumococcal disease. Data is conflicting on whether the vaccine prevents against pneumonia, but it has shown to decrease bacteremia and meningitis.

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.

Additional patients younger than age 65 who should get this vaccine include those with chronic lung disease (including asthma), chronic cardiovascular disease, diabetes, chronic liver disease, cirrhosis, chronic alcoholism, functional or anatomic asplenia (sickle cell disease or splenectomy and 2 weeks prior to a planned splenectomy), immunocompromising conditions (including chronic renal failure or nephrotic syndrome), cochlear implants, CSF leaks, HIV, and residents of nursing homes or long term care facilities who smoke cigarettes.

It is an active vaccine, given intramuscularly with the possibility of a mild local injection site reaction and discomfort. It can be given concurrently with influenza vaccine at a different site.

Influenza:

Prevents against influenza virus. It has a high rate of mutation and thus the vaccine is reconfigured yearly based on the prior year's most common strains. This vaccine should be given yearly 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, a live attenuated vaccine or an inactivated vaccine. All other people should receive the inactivated vaccine. People older than 65 can get the regular vaccine or a high dose version.

Reactions to the live attenuated vaccine include runny nose, nasal congestion, headache and sore throat. Reactions to the inactivated vaccine include local injection site soreness, and mild low grade fever and systemic symptoms for up to 8 to 24 hours later.

Tetanus, diptheria and acellular pertussis (Tdap):

All adults who have not received a Tdap before or who are unaware of their vaccine status can receive one dose of Tdap. Postpartum women, close contacts of infants younger than age 12 months and health care personnel with direct patient contact should receive the vaccine. Adults over the age of 65 can also receive the vaccine if indicated. Adults who have an unknown history of vaccination should have a three dose primary vaccination series. They can administer the first two doses 4 weeks apart and the third dose 6-12 months after the second dose.

Immunization history with Tdap should ALWAYS be reviewed with patients presenting with an acute injury or wound and prophylaxis should be administered accordingly. Td without the acellular pertussis is given in 10 year intervals throughout life. The most common side effects are headache, fatigue and injection site swelling, pain or redness.

Measles/Mumps/Rubella (MMR):

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.

Measles/Mumps - 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 arthralgias, which occurs from the rubella component of the vaccine.

Hepatitis A:

Vaccination is recommended for men who have sex with men, people who use injection drugs, people working with HAV infected primates or HAV in a research setting, people with chronic liver disease, those receiving clotting factor concentrates, people traveling or working in countries with a high rate of HAV, those with close personal contact with an international adoptee from a country with high endemicity during the first 60 days of arrival and all others who wish to be vaccinated.

It is a two dose vaccination series with the second 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. It is an inactivated vaccine.

Side effects include local injection site pain, headaches, loss of appetite and fatigue.

Hepatitis B:

Sexually active adults not in a monogamous long term relationship, those seeking evaluation or treatment for a sexually transmitted disease, injection drug users, men who have sex with men, health care personnel and public safety workers exposed to infectious body fluids, people with end stage renal disease including those on hemodialysis, HIV, chronic liver disease and household contacts and sexual partners of people with chronic HBV infection should get a 3 dose series of the HBV vaccine.

It is also recommended to all adults in STD treatment facilities, HIV testing and treatment facilities, facilities providing drug-abuse treatment and prevention services, healthcare settings targeting services to injection-drug users or men who have sex with men, correctional facilities, end stage renal disease programs and facilities for chronic hemodialysis patients and institutions and non-residential day-care facilities for persons with developmental disabilities.

The second dose is given one month after the primary dose, and the third dose given 2 months after the second dose. Side effects include local injection site soreness and fever.

Human Papilloma Virus:

Best administered prior to engaging in sexual activity, can be given to women and men in a series of 3 vaccinations with the second dose given 1-2 months after the first dose and the third dose given 6 months after the first dose.

Side effects include local injection site reactions such as pain, redness and swelling, fever, headache, fatigue, nausea, vomiting, diarrhea, abdominal pain, possible fainting spells and muscle or joint pain.

Varicella:

Adults without evidence of immunity to varicella need two doses of varicella vaccine if they have not been previously vaccinated. If they have received a dose in the past, a second dose should be given. It should be given at least 4 weeks after the initial dose. People in close contact with those at high risk for disease such as health 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.

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. Pain, erythema and fever are the most common side effects.

Meningococcal:

This vaccine should be given to adults with functional or anatomic asplenia, or complement component deficiencies in a 2 dose series. The second dose should be given 2 months after the first dose. 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.

Side effects include local injection site redness or pain. Very rarely reported is the serious nervous system disorder called Guillain-Barre Syndrome.

Herpes Zoster:

Given to prevent shingles. One dose is recommended for adults aged 60 years and older. Side effects include redness, soreness, swelling or itching at the site of the injection, and headache.

Haemophilus influenzae type B (Hib):

One dose for patients with sickle cell disease, leukemia or HIV infection, and those who have had a splenectomy. Side effects that have been reported are redness, warmth or swelling at the injection site and fever.

What vaccines should be given in certain high risk conditions?

The physician should assess the patient's co-morbidities, risk factors, and age to determine which vaccinations are recommended.

Pregnancy- Influenza, Tdap, Pneumococcal, Meningococcal, Hepatitis A/B

Immunocompromised conditions- Influenza, Tdap if vaccine status not known then Td boosters every 10 years

HIV infection (CD 4 count >200)- Influenza, Tdap/Td, HPV, MMR, pneumococcal, meningococcal, hepatitis A

HIV infection (CD 4 count <200)- Influenza, Tdap/Td, HPV, pneumococcal, meningococcal, hepatits A, Varicella

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

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?

While practitioners often worry that if someone is currently ill, vaccinating could interfere with recovery, this has not be substantiated by the literature. Additionally, the benefit obtained from administering the vaccine to this high risk group cannot be outweighed by any theoretical association between delayed recovery with antibody administration. The general recommendation is to administer vaccines if a patient has a mild respiratory tract illness or other mild acute illness with or without fever. If a patient has a moderate or severe acute illness, it is appropriate to defer vaccination to help avoid complicating the clinical picture created by manifestations of the underlying acute illness and the adverse effects of the vaccination itself.

Can I give vaccines to someone on steroids?

While steroids can suppress the immune system and a possible immune response to vaccination administration, 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 to ensure safety with immunization with live virus vaccines and to ensure patients can have the appropriate immune response to the vaccine.

Can I give vaccines to someone on antibiotics?

Antimicrobial medications are not a contraindication to vaccination. The only exception is the live oral typhoid vaccine. This 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 get the live, attenuated vaccine for 48 hours after the medication is discontinued. Ideally antiviral drugs would not be given until 14 days after the live vaccine is administered. This also holds true for the live varicella and zoster vaccines. They should not be given until 24 hours after antivirals are stopped, and antiviral therapy should not be resumed until 14 days after vaccination. This helps ensure efficacy of the vaccine. Inactivated vaccines will not be affected by antiviral drugs.

Is it safe to give a vaccine to someone who is unsure of their vaccination status and may have had one recently?

There are no known problems with revaccinating with influenza. While there is a small chance of a local injection site reaction with repeat administration of the pneumococcal vaccine, it generally does not require any treatment.

Are there special recommendations for pregnant women?

Live attenuated virus and live bacterial vaccines are contraindicated during pregnancy due to the theoretical risk to the developing fetus. Women who have not previously received a Tdap should receive a dose as soon as possible after delivery to achieve pertussis immunity and to reduce transmission to the baby.

While Tdap is not contraindicated during pregnancy, it is generally advised that a mother be vaccinated with Td for tetanus immunity for both mother and baby during pregnancy with Tdap given as soon as possible after delivery. All pregnant women should get an influenza vaccination. Smallpox, varicella and MMR vaccines are contraindicated during pregnancy.

It is important that pregnant women 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.

What can you do?

There are many initiatives to help improve the vaccination rates to high risk individuals. On the inpatient side, using standing orders on admission or discharge, that do NOT require a physician's signature have reportedly been the most effective measure to improve immunization rates.

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. For this reason, it is especially 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?

Physicians can ask patients their immunization status upon admission and if not immunized or status is unknown, include the vaccine as part of the admission order set. In addition, prior to discharge, it may be helpful to confirm again that immunizations are up to date prior to writing a discharge order.

Are surgeons and other physicians who perform procedures adverse to immunizations?

If a patient develops a fever after receiving an immunization and having a procedure, they feel they may not know if it is a complication of the procedure or from the vaccine. However, in patients who have poor compliance with medical care, it is important to administer vaccines when the opportunity arises (such as during hospitalizations requiring procedures).

V. National Standards, Core Indicators and Quality Measures.

Several groups have established national standards for improving vaccination initiatives. The most notable of these include:

JCAHO-In 2007, an initiative was mandated to improve healthcare worker influenza vaccination in accredited health care facilities. Core indicators include the requirement of influenza and pneumococcal vaccines for all patients admitted with pneumonia or congestive heart failure.

Advisory Committee on Immunization Practices (ACIP) of the CDC has an immunization schedule for healthy adults.

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