Immunization – NACI 2013

1 Do not delay immunizations unnecessarily (e.g., vaccinate a child even if he or she has a runny nose).

Vaccine providers should recommend deferral or withholding of vaccines for true contraindications ONLY.

  • Withholding vaccines for conditions that are not true contraindications often results in the needless deferral of indicated vaccines.
  • Screening procedures for precautions and contraindications include, at a minimum, asking questions to elicit a history of possible adverse events following prior vaccinations and determining any existing precautions or contraindications.

Contraindications

  1. Anaphylaxis after previous dose of a vaccine
  2. Proven immediate or anaphylactic hypersensitivity to any component of the vaccine or its container (latex) –
    • C/I if receiving vaccine containing the same component
  3. Severe Asthma or medically attended wheezing in the 7days prior to vaccine – c/i to live attenuated influenza vaccine ONLY
  4. Congenital malformation of GI tract (uncorrected) – Rotavirus vaccine (↑Intussusception)
  5. Guillain-Barre syndrome within 6 weeks of receiving a vaccine – generally c/i if receiving the same vaccine. 
    • For influenza vaccine, the risk of GBS associated with influenza vaccination must be balanced against the risk of GBS associated with influenza infection itself
  6. Immunocompromised
    • no c/i to inactivated vaccine (may need to delay 1-3months after finishing immunosuppressive tx
    • Live vaccine contraindicated in most cases. Consult an immunologist. 
  7. Intussusception in the past – Rotavirus vaccine c/i
  8. pregnancy
    • no c/i with inactivated vaccine
    • live vaccine generally contraindicated
  9. Active TB
    • no C/I with inactivated vaccine
    • Live vaccines (MMR, MMRV, univalent varicella, herpes zoster, BCG c/i
  10. Measles vaccine c/i: neomycin + gelatine allergy, immunocompromised pt, allergy to MMR

When to immunize?

  1. Infancy
  2. Before pregnancy
  3. Before Traveling
  4. New to the country

2 With parents who are hesitant to vaccinate their children, explore the reasons, and counsel them about the risks of deciding against routine immunization of their children.

Vaccine providers should educate people in a culturally sensitive way, preferably in their own language, about the:

  • importance of vaccination
  • diseases that vaccines prevent
  • recommended immunization schedules
  • need to receive vaccines at recommended ages
  • importance of bringing the immunization record to every health care visit

Benefits of Vaccination

Immunization directly protects individuals who receive vaccines. Through herd immunity, immunization against many diseases also prevents the spread of infection in the community and indirectly protects:

  • infants who are too young to be vaccinated,
  • people who cannot be vaccinated for medical reasons (e.g., certain immunosuppressed people who cannot receive live vaccines),
  • people who may not adequately respond to immunization (e.g.the elderly).

Exploring fears and myths about immunizations

  1. Side effects – Most common side effects are mild fever and sore extremity.  Serious reactions such as death, and encephalopathy are so rare that their incidence cannot be calculated.
  2. Autism – Concern regarding risk of vaccines causing autism. This was originally associated with a preservative agent called thimerosal. The original paper in the Lancet publishing this association was withdrawn and there have been no definitive cases to support this claim.  The only vaccines in Canada that are given to children and contain thimerosal are the multidose influenza vaccine and Hepatitis B.  Both these vaccinations are available in formulations that do not contain thimerosal (ex. Vaxigrip for children and pregnant mothers).  The only true contraindication to thimerosal is anaphylaxis.
  3. Vaccines don’t work – No vaccine is entirely effective.  If a vaccine-preventable disease outbreak does occur, some vaccinated individuals will contract the disease.  However the proportion of unvaccinated individuals who contract the disease will be much higher than the proportion of vaccinated individuals.
  4. Vaccine-preventable diseases no longer exist in Canada – Unvaccinated individuals may still be exposed in their lifetime given the immigrant population that may not have been vaccinated or if the unvaccinated chooses to travel later in life.

Why to immunize yourself or your child?

  1. To protect yourself from common (HiB, Influenza, Varicella) or serious (Tetanus, Hepatitis, Meningococcemia) preventable infectious diseases.
  2. To protect individuals in society who are unable to receive vaccinations for true contraindications from common or serious preventable infectious diseases.

3 Identify patients who will specifically benefit from immunization (e.g., not just the elderly and children, but also the immunosuppressed, travellers, those with sickle cell anemia, and those at special risk for pneumonia and hepatitis A and B), and ensure it is offered.

Vaccines in Asplenia:
  • Pneumococcal
  • Haemophilus Influenza Type B
  • Meningococcal
  • Influenza

Immunization for adults

Vaccine Who should receive it
Pneumococcal >=65, <65 with specific risk factors
Herpes zoster >=60yo, may be given to adults 50-59yo
HPV 9-26yo (M+F), may be given to female >=27yo who are at ongoing risk
Tetanus Q10y
Diphtheria Q10y
Pertussis Once in adulthood
Influenza Recommended annually for adult >=65 & all adults in specific risk situations. Encouraged annually for all adults
Hep A&B People with medical, occupational, or lifestyle risks and anyone who wants protection from hep B
Meningococcal conjugate Unimmunized adult <=24yo & people at specific risk conditions
  • Measles
  • Mumps
  • Varicella
People who have not had the vaccine or the dz
Travel vaccines Varies by destination

4 Clearly document immunizations given to your patients.

Vaccine providers should ensure that all vaccinations are accurately and completely recorded.

  • Vaccine care providers must maintain a record of all vaccinations administered and must ensure that information is accurately and completely recorded in their files.
  • All vaccine providers should encourage vaccine recipients/parents to keep the personal immunization record and present it at each health care visit so that it can be updated. 
  • Vaccine providers should maintain easily retrievable summaries of immunization records to facilitate age-appropriate vaccination.
  • Vaccine providers should maintain up-to-date, easily retrievable immunization protocols at all locations where vaccines are administered.
  • Vaccine providers should operate an immunization tracking system.

5 In patients presenting with a suspected infectious disease, assess immunization status, as the differential diagnosis and consequent treatment in unvaccinated patients is different.

Vaccine providers should report all cases of vaccine preventable diseases as required under provincial or territorial legislation.

Diphtheria:
  • fever, bloody d/c from nose, sore throat, progressive airway swelling, cough
  • Psuedomembrane in the throat
HiB:
  • Meningitis, epiglottitis, pneumonia, septic arthritis, OM/sinusitis
Measles (rubeola):
  • 8-12d post-exposure (infectious 4d pre rash)
  • Conjunctivitis, cough, fever, photophobia, muscle pain, rhinorrhea, sore throat, white spots (Koplik’s spots)
  • Rash – 3-5d after symptoms start, lasts 4-7 days, starts on head, flat, macular, itchy, leaves a brown discolouration
Mumps
  • Neck stiffness, swollen glands, anorexia, fever, trismus, unable to fully open jaw, febrile, parotid enlargement
  • infectious 7d before and 9d after symptom onset

6 In patients presenting with a suspected infectious disease, do not assume that a history of vaccination has provided protection against disease (e.g., pertussis, rubella, diseases acquired while travelling).

10-15% % pt not forming antibodies


References:

NACI: http://www.phac-aspc.gc.ca/publicat/cig-gci/index-eng.php

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Posted in 49 Immunization, 99 Priority Topics, ID
2 comments on “Immunization – NACI 2013
  1. Gina says:

    Small inconsistency regarding the last point “pertussis vaccination …requires q10yr of booster”: It was stated in table above it that only one booster in adulthood is required. I believe the table is correct.

    Like

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