Immunizations/Birth Control
From “Family Medicine: Pearls, Perils, and Practice Guidelines,” sponsored by the Loma Linda University School of
Medicine, Loma Linda, CA
| IMMUNIZATIONS THROUGH THE LIFE CYCLE —Katherine R. Schlaerth, MD, Associate Professor, Department of
Family Medicine, Loma Linda University School of Medicine, Loma Linda, CA
|
| General principles: 2 live-virus vaccines administered nonsimultaneously should not be given within 28 days of each
other; measles vaccine given to child <12 mo of age during epidemic not counted, and should be given again at 12 mo;
vaccines made by different manufacturers for same illness usually interchangeable; lapse in immunization schedule does
not require repeating entire series; if immunization status uncertain, repeat; immunizations received in other countries
require documentation of name of vaccine, date of administration, and number and interval of doses, and must be compatible
with United States schedule; immune globulin—can interfere with immunogenicity of vaccine; if given within
14 days of measles immunization, necessary to repeat vaccination; blunts antibody response to live vaccines (but not to
inactivated vaccines); practical considerations—if administering purified protein derivative (PPD; tuberculin), give at
same time as measles-mumps-rubella (MMR) vaccine or wait 1.5 mo (measles blunts response to PPD); fever and rash
can occur after MMR; adverse effects of vaccine should be reported to Vaccine Adverse Effects Reporting System
(VAERS)
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| Hepatitis B vaccine: recombinant DNA vaccine with 5 to 40 µg of antigen protein and possibly trace amount of thimerosal;
do not give subcutaneously or in buttocks; efficacy 90% to 95%; immunity ≥15 yr; most people do not require booster
dose, except those immunodeficient or on hemodialysis (need to check annually for hepatitis B surface antibody [anti-
HBs] and boost if <10 mIU/mL); also, those with occupational risk or regular sexual contact with hepatitis B-positive person
require booster; adverse reactions infrequent and usually in adults; pregnancy or nursing not contraindications; adults
>20 yr of age receive double children’s dose of vaccine; immunosuppressed persons receive 4 times children’s dose; if
mother HBs antigen (HBsAg)-positive—give hepatitis B vaccine and 0.5 mL of hepatitis B immune globulin (HBIG) to
infant at separate sites within 12 hr of birth; second dose given at 1 to 2 mo of age, and third dose at 6 mo; make sure child
has developed antibodies; if mother’s HBsAg status unknown—treat infant as if mother HBsAg-positive, until status
known; give first dose within 12 hr of birth; draw maternal blood for HBsAg; if positive, give HBIG as soon as possible
before 1 wk of age, then follow schedule for nonpositive child; medically stable term infants weighing >2 kg receive single
dose before hospital discharge; premature infants receive first dose at 1 mo of age or at discharge; give only monovalent
vaccine at birth, but for subsequent doses, can use combination vaccine; second dose given 4 wk after first; third dose 16
wk after first and 8 wk after second
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| Diphtheria, tetanus, and acellular pertussis (DTaP) vaccine: pertussis becoming significant problem in adolescent and
young adult population (possibly also in geriatric population); contraindications to pertussis immunization—
immediate anaphylaxis and encephalopathy within 7 days; precautions for pertussis immunization—seizure within 72
hr of vaccination; screaming for 3 hr, shock-like state, and high temperature within 2 days of vaccination (uncommon
with newer vaccines); give at 2, 4, and 6 mo of age, with booster at 12 mo; if child likely to return, can give booster at 15
to 18 mo; reboost at 4 yr; tetanus and diphtheria (Td) booster every 10 yr; now giving tetanus, diphtheria, and acellular
pertussis (Tdap) vaccine instead of Td booster; Tdap—2 licensed products; Adacel (ages 11 to 64 yr) and Boostrix (ages
10 to 18 yr); adverse reactions—local reactions (eg, cellulitis) and fever usually abate within 1 wk; allergic reactions,
seizures, hypotonic-hyporesponsive episodes (HHE), and prolonged crying infrequent
|
| MMR vaccine: live attenuated vaccine with porcine gelatin as stabilizer; delayed local reaction (if allergic); ongoing concern
about autism possibly related to MMR; Institute of Medicine (IOM) Safety Review Committee felt increase in autism
not attributable to MMR; first vaccination given between 12 and 15 mo and second between 4 and 6 yr; if second
dose not given, give vaccine in preadolescence
|
| Varicella vaccine: live attenuated vaccine with traces of neomycin and gelatin; recommended at age 12 to 18 mo; 1 dose
if child <13 yr of age; 2 doses if child ≥13 yr of age, second dose given within 4 to 8 wk; vaccination important because
varicella severe disease in postpubertal patients (causes pneumonia in ≈50% of cases and affects all organs); given subcutaneously
and intramuscularly (IM); effective in preventing severe disease but not as effective against mild disease;
number of doses necessary currently being reevaluated (uncertain if vaccine lasts lifetime); can get varicella-like rash
≈1 wk after administration of vaccine; vaccine-associated virus transmission rare; 70% to 90% of individuals >18 yr of
age with no history of varicella immune; contraindications include those with severe illness, T-lymphocyte immunodeficiency
(excluding patients with acute lymphoblastic leukemia in remission and selected HIV-infected children doing
well), on high-dose steroids, pregnant, and allergic to vaccine components
|
| Pneumococcal vaccine: Prevnar—used in children <2 yr of age; vaccine used in children >2 yr of age conjugated to
diphtheria protein so body recognizes serotypes as antigenic; give 0.5 mL IM at 2, 4, and 6 mo, then at 12 to 15 mo; prevents
invasive disease in healthy elderly (herd immunity); pneumococcal conjugate vaccine—used in elderly as further
protection; composed of 23 purified capsular polysaccharides; 1 dose of conjugate vaccine given after Prevnar to children
at increased risk of getting invasive pneumococcal disease (those of American Indian descent, with sickle cell disease,
and with hemoglobinopathies); also given to adults at high risk for invasive disease because of coexisting conditions (eg,
asthma, HIV, immunodeficiency [acquired or congenital], pulmonary disease, cerebrospinal fluid leak); many adults vaccinated
at younger age because of risk factors (eg, diabetes, chronic obstructive pulmonary disease); unofficial recommendation
to give booster dose if, at 65 yr of age, patient has not received vaccine within last 5 yr
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| Haemophilus influenzae type b (Hib) vaccine: has contributed to decrease in incidence of meningitis; conjugate vaccine;
Hib polysaccharide; for American Indians and Alaskan natives, give polyribosylribitol phosphate conjugated to
outer membrane protein (PRP-OMP; more rapidly immunogenic); serum antibody response takes 1 to 2 wk; 3-dose regimen
if giving Hib vaccine with oligosaccharides conjugated to diphtheria toxin protein (Hib-OC) or PRP-T (tetanus conjugate);
administer doses at 2, 4, and 6 mo; 2-dose regimen if using PRP-OMP; booster at 12 to 15 mo of age; similar
regimen for children who miss 2- and 4-mo doses; if child 12 to 14 mo of age at time of first dose, give 2-dose regimen at
2-mo intervals; if child >15 mo of age, need only 1 dose
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| Polio vaccine: inactivated polio vaccine (IPV)—only type available in United States at present; 99% immunogenic after
3 doses; first 2 doses given at 2 and 4 mo of age; third dose at 1 yr of age, then another at 4 to 6 yr of age; can be given IM
or subcutaneously; oral polio vaccine (OPV)—not available in United States
|
| More on MMR vaccine: can be given to HIV-positive children if not severely immunocompromised (even though live virus
vaccine; illness lethal if not vaccinated); contraindicated in pregnancy (theoretic; no report of embryopathy caused by
rubella vaccine); if child on corticosteroids, wait until vaccine immunogenic; may provide protection if given within 72
hr of exposure to wild measles
|
| Hepatitis A vaccine: universal vaccination at 1 yr of age (formerly at 2 yr); human fibroblast-propagated virus; inactivated
and adsorbed; 2 vaccines in United States; Havrax (has preservative) and Vaqta (no preservative); generally, 2 doses 6
mo apart; adult and pediatric formulations; immunogenic even with 1 dose; after puberty, infection more severe; combination
(hepatitis A and B) vaccine available (Twinrix) for those >18 yr of age (requires 3 injections)
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| Influenza vaccine: 2 types—1) inactivated virus made in embryonated hen eggs, 2) live attenuated vaccine administered
intranasally (limited age group); recommended for children 6 to 23 mo of age and those with risks (eg, asthma); single-
dose vials recommended (no thimerosal); individuals 5 to 49 yr of age can use nasal vaccine; if <8 yr of age and getting
vaccine for first time, 2 doses needed (interval dependent on type of vaccine used); duration of protection <1 yr; immunogenicity
wanes over time, so need to vaccinate those at risk (eg, elderly) right before influenza season begins; necessary
to vaccinate pregnant women (second or third trimester), those on salicylates (risk for Reye’s syndrome), those with immunodeficiency
disease (regardless of age), and those in close contact with high-risk persons
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| Meningococcal vaccine: now given to preteens (while meningococcal disease peaks in infancy, subpeak in young adults
introduced for first time to close living quarters); serogroup-specific quadrivalent vaccine against A, C, Y, and W-135;
serogroup B currently not included; serogroup A immunogenic in children >3 mo of age; other serogroups poorly immunogenic
in children <2 yr of age (immune systems not fully developed); in epidemic scenario, can be administered to anyone
>2 yr of age; may need to reimmunize after 3 to 5 yr if potential for infection persists; meningococcal conjugate
vaccine (MCV4)—immunize all children at 11- to 12-yr-old visit, unvaccinated high school students, and all college
freshmen in dormitories; children with terminal complement deficiencies need polysaccharide vaccine (conjugate vaccine
not approved for children <11 yr of age); associated with cases of Guillain-Barré syndrome (all recovered completely)
|
| Rotavirus vaccine: rotavirus biggest threat to children <1 yr of age; recommended by Advisory Committee on Immunization
Practices for infants at 2, 4, and 6 mo; found no risk for intussusception
|
| Human papillomavirus (HPV) vaccine: Gardasil; recombinant vaccine; for prevention of genital warts, precancerous
genital lesions, and cervical cancer; approved for girls and women 9 to 26 yr of age
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| CONTRACEPTIVE UPDATE —Michelle Opsahl, MD, Associate Professor, Department of Family Medicine, Loma
Linda University School of Medicine, Loma Linda, CA
|
| Methods of contraception: method ideal if effective, used regularly, well tolerated, and patient satisfaction high; may
have noncontraceptive benefits (eg, prevention of sexually transmitted infection [STI], effect on menstrual periods, acne,
polycystic ovarian syndrome [PCOS], endometriosis)
|
| Abstinence: primary and secondary prevention
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| Breast-feeding: lactational amenorrhea; effective if primarily breast-feeding for first 6 mo of baby’s life
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| Fertility awareness methods: calendar method—ovulation usually 14 days before menses; cervical mucus—usually
clear, sticky, and stretchy at time of ovulation; basal body temperature—not recommended for contraception
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| Barrier methods: female condom—available over-the-counter (OTC); expensive; reusable; increased risk for urinary
tract infection, probably from urethral pressure; inserted before sexual contact; noisy; diaphragm—must be used with
spermicide; inserted before sexual contact (can be placed hours before anticipated intercourse) and left in place up to 6 hr
after; slightly decreases risk for certain infections (barrier to sperm carrying disease); different sizes; requires professional
fitting and dexterity; if not removed within 24 hr, risk for toxic shock syndrome; FemCap—OTC cervical cap
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| Hormonal methods: oral (combined estrogen and progesterone or progesterone only), patch-based, vaginal, injectable,
and implant; progestins—7 used; primarily inhibit luteinizing hormone (LH) surge and ovulation; produce thickened
cervical mucus and unfavorable endometrium; estrogen—5 different doses; 20 to 50 µg of ethinyl estradiol
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| Oral contraceptives (OCs): start with lowest dose possible with least amount of intolerable side effects; myth that all OCs
androgenic (actually antiandrogenic); improve acne and hirsutism and do not cause weight gain, male-pattern baldness,
or deepening of voice; newer progestins (norgestimate and desogestrel) slightly better; all testosterone-derived, except
drospirenone; drospirenone and ethinyl estradiol—Yasmin; mild level 1 evidence of benefit for premenstrual dysphoric
disorder (PMDD); used commonly for PCOS; use with caution if also using other potassium-sparing drugs (eg, nonsteroidal
anti-inflammatory drugs [NSAIDs], potassium-sparing diuretics, potassium supplements, angiotensin-
converting enzyme [ACE] inhibitors); packaging recommends checking potassium level monthly; estrogen dose—helps
control cycle, contraception, and has noncontraceptive benefits
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| Special considerations with OCs: side effects—include nausea, irregular bleeding, breast tenderness, and headache;
dose-dependent and vary among individuals; thrombogenesis—venous thromboembolism slightly increased in combined
OC (COC) users (3 in 10 000; pregnancy confers greater risk [higher estrogen state]); if patient at risk (eg, positive
family history), can screen for factor V Leiden, protein C, and protein S; risk for arterial thrombosis, stroke, and myocardial
infarction not increased unless patient smokes (especially if >35 yr of age, or smoking >1 pack daily at any age), hypertensive
(especially if >35 yr of age or hypertension uncontrolled), has other coronary disease risk factors, has
complicated migraines (with neurologic symptoms), or has new headaches (slightly increased risk for arterial thrombosis);
reasons for stopping—irregular bleeding; most COCs show acceptably low spotting and breakthrough bleeding
(BTB) after 3 to 6 cycles; if BTB or spotting persists, most experts recommend increasing estrogen dose; also consider
Chlamydia infection
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| Other OC options: phasic pills—vary progestin component; advantages of COCs—less bleeding; can manipulate timing
and frequency of menses with extended-cycle regimen; decrease risk for ovarian, endometrial, and metastatic breast cancer;
may also treat PCOS, premenstrual syndrome (PMS), and menopausal syndrome; disadvantages of COCs—mood
changes, BTB, amenorrhea, headaches, nausea and vomiting, chloasma (not always reversible), varicose veins, and breast
tenderness; increase risk for breast cancer diagnosis (not metastatic); hypertension (usually reversible); extended-cycle
regimens—extended dosing, by skipping placebo pills, can be used with other monophasic OCs; good option for severe
dysmenorrhea, heavy periods, endometriosis, PMS, cyclic migraines, and maintaining hormone steady-state; BTB decreases
over time; progestin-only mini pill—not as effective as COC; 92% effective when used by typical patient; primarily
thickens cervical mucus; does not suppress ovulation, except in 50% of cycles; has short-lived effect and must be taken
regularly; no hormone-free days; good for women who cannot take estrogen (eg, breast-feeding, smokers); disadvantages
include irregular bleeding, amenorrhea, and mood changes
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| Injectables: medroxyprogesterone (Depo-Provera); given every 3 mo; also works by affecting cervical mucus; inhibits follicle-stimulating
hormone (FSH) and LH (no ovulation); 1 mL given IM in buttocks every 11 to 13 wk; convenient; good
for women unable to take estrogen; high discontinuation rates
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Suggested Reading
American Academy of Pediatrics Committee on Infectious Diseases: Recommended immunization schedules for children
and adolescents--United States, 2007. Pediatrics 119:207, 2007; American Academy of Pediatrics Committee on
Infectious Diseases: Prevention of rotavirus disease: guidelines for use of rotavirus vaccine. Pediatrics 119:171, 2007;
Armstrong GL et al: The economics of routine childhood hepatitis A immunization in the United States: the impact of
herd immunity. Pediatrics 119:e22, 2007; Bakhru A et al: Performance of contraceptive patch compared with oral contraceptive
pill in a high-risk population. Obstet Gynecol 108:378, 2006; Campos-Outcalt D: The preteen visit: an opportunity
for prevention. J Fam Pract 55:1054, 2006; Colgrove J: The ethics and politics of compulsory HPV vaccination. N
Engl J Med 355:2389, 2006; David PS et al: Hormonal contraception update. Mayo Clin Proc 81:949, 2006; Juurlink
DN et al: Guillain-Barré syndrome after influenza vaccination in adults: a population-based study. Arch Intern Med
166:2217, 2006; Kaunitz AM: Beyond the pill: new data and options in hormonal and intrauterine contraception. Am J
Obstet Gynecol 192:998, 2005; Kripke C: Cyclic vs. continuous or extended-cycle combined contraceptives. Am Fam
Physician 73:804, 2006; Kripke C: Hepatitis B vaccine for infants of HBsAg-positive mothers. Am Fam Physician 75:49,
2007; Lesnewski R et al: Initiating hormonal contraception. Am Fam Physician 74:105, 2006; MacGregor EA et al: Incidence
of migraine relative to menstrual cycle phases of rising and falling estrogen. Neurology 67:2154, 2006; Peterson
HB et al: Clinical practice. Long-acting methods of contraception. N Engl J Med 353:2169, 2005; Pollard AJ: New combination
vaccines still need a boost. Arch Dis Child 92:1, 2007; Preston NW: Diagnosis and prevention of pertussis. Lancet
368:1769, 2006, author reply 1769-70; Santelli JS et al: Explaining recent declines in adolescent pregnancy in the
United States: the contribution of abstinence and improved contraceptive use. Am J Public Health 97:150, 2007; Singh M
et al: Whooping cough: the current scene. Chest 130:1547, 2006; Temte J et al: Family physicians and immunizations.
Am Fam Physician 74:2027, 2006; Westhoff C et al: Bleeding patterns after immediate initiation of an oral compared
with a vaginal hormonal contraceptive. Obstet Gynecol 106:89, 2005
Educational Objectives
| The goal of this program is to educate the clinician about immunization and birth control methods that can positively
influence public health. After hearing and assimilating this program, the clinician will be better able to:
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 | 1. Discuss the general principles of immunization.
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| 2. Recognize the appropriate use and time for administration of a vaccine.
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| 3. Assess the contraindications and side effects of currently available vaccines.
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| 4. Evaluate the different methods of contraception available to patients at various ages and stages of life.
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| 5. Help patients select the most appropriate method of contraception for their lifestyle.
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Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty members to disclose relevant
financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified conflicts
were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial
interest. For this program, the faculty reported nothing to disclose.
Acknowledgements
Drs. Schlaerth and Opsahl were recorded at Family Medicine: Pearls, Perils, and Practice Guidelines, held June 25, 2006,
in Loma Linda, CA, and sponsored by the Loma Linda University School of Medicine. The Audio-Digest Foundation
thanks the speakers and the sponsor for their cooperation in the production of this program.
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