[Script Info]
Title: 
[Events]
Format: Layer, Start, End, Style, Name, MarginL, MarginR, MarginV, Effect, Text
Dialogue: 0,0:00:01.34,0:00:02.02,Default,,0000,0000,0000,,>> Hey, what's up guys?
Dialogue: 0,0:00:02.02,0:00:05.29,Default,,0000,0000,0000,,Today we're going to be talking\Nabout the routine administration
Dialogue: 0,0:00:05.29,0:00:07.77,Default,,0000,0000,0000,,of vaccines in the adult population.
Dialogue: 0,0:00:08.34,0:00:11.96,Default,,0000,0000,0000,,Now in adults there are really going to be only\Nthree vaccinations that we have to worry about.
Dialogue: 0,0:00:11.96,0:00:14.99,Default,,0000,0000,0000,,We're going to be talking about\NHPV, the pneumococcal vaccine,
Dialogue: 0,0:00:14.99,0:00:17.67,Default,,0000,0000,0000,,and finally we're going to\Ntalk on herpes zoster.
Dialogue: 0,0:00:18.30,0:00:19.54,Default,,0000,0000,0000,,Now, starting with HPV.
Dialogue: 0,0:00:19.54,0:00:23.85,Default,,0000,0000,0000,,The HPV vaccine is really going to\Nbe used to prevent cervical cancer,
Dialogue: 0,0:00:24.10,0:00:26.19,Default,,0000,0000,0000,,penile cancer, and genital warts.
Dialogue: 0,0:00:26.78,0:00:31.100,Default,,0000,0000,0000,,Now as far as cancer goes, there's really\Ngoing to be two main types of HPV strains
Dialogue: 0,0:00:31.100,0:00:36.36,Default,,0000,0000,0000,,that are going to cause 70 percent of\Ncervical cancers and anal cancer as well.
Dialogue: 0,0:00:36.36,0:00:38.40,Default,,0000,0000,0000,,These are going to be strains 16 and 18.
Dialogue: 0,0:00:39.09,0:00:43.19,Default,,0000,0000,0000,,The remainder 20 percent or 20 percent\Nafter that is going to be caused
Dialogue: 0,0:00:43.19,0:00:47.87,Default,,0000,0000,0000,,by strains 31, 33, 45, 52, and 58.
Dialogue: 0,0:00:48.25,0:00:53.04,Default,,0000,0000,0000,,So these seven strains here are going to\Naccount for 90 percent of cervical cancers.
Dialogue: 0,0:00:53.45,0:00:55.82,Default,,0000,0000,0000,,Now finally we have to worry about\Ngenital warts, and these are going
Dialogue: 0,0:00:55.82,0:00:58.54,Default,,0000,0000,0000,,to be caused by strains 6 and 11.
Dialogue: 0,0:00:58.88,0:00:59.63,Default,,0000,0000,0000,,So what does this mean?
Dialogue: 0,0:01:00.19,0:01:04.06,Default,,0000,0000,0000,,This means that when we have vaccines,\Nwe are targeting these types of strains,
Dialogue: 0,0:01:04.30,0:01:07.12,Default,,0000,0000,0000,,and there are really three types of\Nvaccines that we're going to be giving.
Dialogue: 0,0:01:07.57,0:01:10.57,Default,,0000,0000,0000,,We have bivalent, quadrivalent and 9-valent.
Dialogue: 0,0:01:11.13,0:01:14.53,Default,,0000,0000,0000,,Bivalent, which is going to be Cervarix, is\Nreally going to be targeting two strains.
Dialogue: 0,0:01:15.34,0:01:19.88,Default,,0000,0000,0000,,Gardasil has the quadrivalent and\N9-valent, which means we have four strains
Dialogue: 0,0:01:19.88,0:01:21.33,Default,,0000,0000,0000,,and we're targeting nine strains.
Dialogue: 0,0:01:21.70,0:01:25.74,Default,,0000,0000,0000,,So Cervarix, which is bivalent, is\Ngoing to be focused on cervical cancer,
Dialogue: 0,0:01:25.93,0:01:29.36,Default,,0000,0000,0000,,meaning it's going to target\Nthe strains 16 and 18.
Dialogue: 0,0:01:29.98,0:01:35.52,Default,,0000,0000,0000,,Gardasil, which is the quadrivalent, is\Ngoing to target the cervical strains 16
Dialogue: 0,0:01:35.52,0:01:38.13,Default,,0000,0000,0000,,and 18 for cancer and 6 and\N11 for genital warts.
Dialogue: 0,0:01:38.43,0:01:42.24,Default,,0000,0000,0000,,The Gardasil-9 is going to be the 9-valent,\Nand it's going to target all of these strains
Dialogue: 0,0:01:42.24,0:01:43.67,Default,,0000,0000,0000,,that we just previously talked about.
Dialogue: 0,0:01:43.91,0:01:46.67,Default,,0000,0000,0000,,So it's going to cover the most, or\Nit's going to give the most protection
Dialogue: 0,0:01:46.85,0:01:48.81,Default,,0000,0000,0000,,against cervical cancer and genital warts.
Dialogue: 0,0:01:49.36,0:01:54.01,Default,,0000,0000,0000,,As far as when to give, we want to\Ngive males and females at age 11,
Dialogue: 0,0:01:54.01,0:01:57.13,Default,,0000,0000,0000,,start the dosing at age 11\Nfor both males and females.
Dialogue: 0,0:01:57.63,0:02:00.50,Default,,0000,0000,0000,,Females you want to stop immunization at 26.
Dialogue: 0,0:02:01.48,0:02:04.58,Default,,0000,0000,0000,,Guys we want to stop at 21 with one exception.
Dialogue: 0,0:02:05.09,0:02:12.50,Default,,0000,0000,0000,,If the male patient is immunocompromised and/or\Nit's a male that has sex with other males,
Dialogue: 0,0:02:12.91,0:02:15.67,Default,,0000,0000,0000,,we want to extend that age to 26.
Dialogue: 0,0:02:16.78,0:02:19.87,Default,,0000,0000,0000,,When we give the dosing, it's\Ngoing to be a vaccination of three.
Dialogue: 0,0:02:20.37,0:02:22.80,Default,,0000,0000,0000,,So we're going to give the\Nfirst dose at zero months.
Dialogue: 0,0:02:23.26,0:02:25.47,Default,,0000,0000,0000,,The second dose is going\Nto be at two months later.
Dialogue: 0,0:02:25.75,0:02:30.09,Default,,0000,0000,0000,,The third dose is going to be four months\Nafter the second dose, which means it's going
Dialogue: 0,0:02:30.09,0:02:32.22,Default,,0000,0000,0000,,to be six months after the initial dose.
Dialogue: 0,0:02:32.39,0:02:36.29,Default,,0000,0000,0000,,This is going to be the same for\Nboth male and female populations.
Dialogue: 0,0:02:36.94,0:02:39.74,Default,,0000,0000,0000,,It doesn't matter if the patient has HPV.
Dialogue: 0,0:02:39.74,0:02:41.13,Default,,0000,0000,0000,,You can still vaccinate.
Dialogue: 0,0:02:41.46,0:02:44.75,Default,,0000,0000,0000,,It doesn't matter if they've\Nhad sex or they haven't had sex,
Dialogue: 0,0:02:44.75,0:02:46.55,Default,,0000,0000,0000,,you can still vaccinate the patients.
Dialogue: 0,0:02:47.03,0:02:51.59,Default,,0000,0000,0000,,If cost is not a problem, then obviously we want\Nto go with the 9-valent, which is Gardasil-9
Dialogue: 0,0:02:51.89,0:02:54.02,Default,,0000,0000,0000,,because it's going to offer the most protection.
Dialogue: 0,0:02:54.09,0:02:57.29,Default,,0000,0000,0000,,All right, moving onto the\Npneumococcal vaccination.
Dialogue: 0,0:02:57.72,0:02:59.85,Default,,0000,0000,0000,,Now there are really going to\Nbe two types of vaccines here
Dialogue: 0,0:02:59.85,0:03:01.10,Default,,0000,0000,0000,,that we're really going to focus on.
Dialogue: 0,0:03:01.47,0:03:07.45,Default,,0000,0000,0000,,This is going to be prevnar, which is going to\Nbe PCV13 and the pneumovax, which is PPSV23.
Dialogue: 0,0:03:07.93,0:03:11.50,Default,,0000,0000,0000,,Now the entire purpose of pneumococcal\Nvaccination is to prevent pneumonia.
Dialogue: 0,0:03:12.14,0:03:18.03,Default,,0000,0000,0000,,So if we have a patient from age 19 to 64\Nwho is at intermediate risk for disease,
Dialogue: 0,0:03:18.46,0:03:23.41,Default,,0000,0000,0000,,meaning we have chronic heart disease, chronic\Nlung disease, chronic liver disease, smoker,
Dialogue: 0,0:03:23.41,0:03:28.62,Default,,0000,0000,0000,,alcoholic, and/or diabetes, we're going to\Nbe treating or we're going to be vaccinating,
Dialogue: 0,0:03:28.62,0:03:31.20,Default,,0000,0000,0000,,I should say, with the pneumovax PPSV23.
Dialogue: 0,0:03:31.20,0:03:36.34,Default,,0000,0000,0000,,If we're at high risk for pneumonia,\Nthen we're going to give prevnar first,
Dialogue: 0,0:03:36.90,0:03:39.65,Default,,0000,0000,0000,,and we're going to give the\Npneumovax eight weeks later.
Dialogue: 0,0:03:40.70,0:03:44.72,Default,,0000,0000,0000,,So two months after the prevnar\Nwe're going to give the pneumovax.
Dialogue: 0,0:03:45.03,0:03:47.46,Default,,0000,0000,0000,,These are patients that are at\Nhigh risk and intermediate risk.
Dialogue: 0,0:03:47.86,0:03:51.80,Default,,0000,0000,0000,,For everyone else, universal\Nvaccination starts at age 65,
Dialogue: 0,0:03:52.55,0:03:55.15,Default,,0000,0000,0000,,and it's going to be starting with the prevnar.
Dialogue: 0,0:03:55.15,0:03:57.09,Default,,0000,0000,0000,,Prevnar is, again, PCV13.
Dialogue: 0,0:03:58.18,0:04:01.09,Default,,0000,0000,0000,,So we hit age 65, we vaccinate with prevnar.
Dialogue: 0,0:04:01.30,0:04:04.14,Default,,0000,0000,0000,,One year later we're going to\Nvaccinate with the pneumovax.
Dialogue: 0,0:04:04.47,0:04:06.16,Default,,0000,0000,0000,,Now the prevnar is fairly recent.
Dialogue: 0,0:04:06.50,0:04:09.83,Default,,0000,0000,0000,,Beforehand it used to be\Nvaccination with pneumovax only.
Dialogue: 0,0:04:09.83,0:04:13.15,Default,,0000,0000,0000,,So if for whatever reason the patient\Nwas vaccinated with the pneumovax
Dialogue: 0,0:04:13.15,0:04:16.27,Default,,0000,0000,0000,,but not the prevnar, then go\Nahead and give the prevnar second.
Dialogue: 0,0:04:16.46,0:04:20.24,Default,,0000,0000,0000,,Just make sure that we're waiting\None year after the prior vaccination.
Dialogue: 0,0:04:21.06,0:04:27.01,Default,,0000,0000,0000,,Now, if you have a high risk patient that\Nreceived the pneumovax before the age of 65,
Dialogue: 0,0:04:27.50,0:04:28.82,Default,,0000,0000,0000,,we're going to follow the same schedule.
Dialogue: 0,0:04:29.25,0:04:31.50,Default,,0000,0000,0000,,So let's say at age 40 they\Nreceived the pneumovax.
Dialogue: 0,0:04:31.73,0:04:35.12,Default,,0000,0000,0000,,Now they hit 65, again, we're\Ngoing to give prevnar at 65.
Dialogue: 0,0:04:35.57,0:04:37.61,Default,,0000,0000,0000,,One year later we're going\Nto give the pneumovax.
Dialogue: 0,0:04:38.04,0:04:41.50,Default,,0000,0000,0000,,The only nuance here is that we\Nhave to make sure that the two doses
Dialogue: 0,0:04:41.50,0:04:44.71,Default,,0000,0000,0000,,of the pneumovax are at least five years apart.
Dialogue: 0,0:04:44.100,0:04:50.17,Default,,0000,0000,0000,,So it's going to be pneumovax before\N65, prevnar at 65, and then pneumovax.
Dialogue: 0,0:04:50.17,0:04:52.94,Default,,0000,0000,0000,,So those two pneumovax vaccines need\Nto be at least five years apart.
Dialogue: 0,0:04:53.45,0:04:55.79,Default,,0000,0000,0000,,That is the only nuance here\Nthat we have to keep in mind.
Dialogue: 0,0:04:55.96,0:04:59.13,Default,,0000,0000,0000,,All right, finally we're going\Nto be touching on the zoster vax.
Dialogue: 0,0:04:59.13,0:05:02.59,Default,,0000,0000,0000,,Now the zoster vax is really going\Nto be for the prevention of shingles,
Dialogue: 0,0:05:03.04,0:05:08.46,Default,,0000,0000,0000,,and if we do get shingles, it's going to be\Nfor the prevention of postherpetic neuralgia,
Dialogue: 0,0:05:08.60,0:05:11.96,Default,,0000,0000,0000,,which is a pain syndrome that\Nhappens after the rash has cleared.
Dialogue: 0,0:05:12.81,0:05:16.48,Default,,0000,0000,0000,,Now shingles, the shingles vaccine,\Nwhich is zoster vax is really going
Dialogue: 0,0:05:16.48,0:05:19.83,Default,,0000,0000,0000,,to be approved at the age of 50 and over.
Dialogue: 0,0:05:19.83,0:05:23.93,Default,,0000,0000,0000,,However, guidelines say to start\Nvaccinating after the age of 60,
Dialogue: 0,0:05:24.32,0:05:28.16,Default,,0000,0000,0000,,and guidelines are really going to be\Nmade by the CDC, and interestingly enough,
Dialogue: 0,0:05:28.49,0:05:32.94,Default,,0000,0000,0000,,the reason why the CDC takes the\Nstance on vaccinating after 60 is
Dialogue: 0,0:05:32.94,0:05:36.61,Default,,0000,0000,0000,,because at the time these guidelines\Nwere made, they said there was a shortage
Dialogue: 0,0:05:36.61,0:05:39.19,Default,,0000,0000,0000,,of vaccinations to start them at 50.
Dialogue: 0,0:05:39.49,0:05:44.94,Default,,0000,0000,0000,,There was a shortage, and also they aren't\Nsure as to how long the patients are protected
Dialogue: 0,0:05:45.13,0:05:48.74,Default,,0000,0000,0000,,after the initial vaccination, and\Ncurrently there are no recommendations
Dialogue: 0,0:05:48.74,0:05:50.75,Default,,0000,0000,0000,,to vaccinate again after initial dosing.
Dialogue: 0,0:05:50.89,0:05:55.77,Default,,0000,0000,0000,,So, for that reason, they state that\Nwe should start vaccinating at age 60.
Dialogue: 0,0:05:56.66,0:06:00.80,Default,,0000,0000,0000,,You should keep in mind though that\Nit is approved by the FDA at age 50.
Dialogue: 0,0:06:01.29,0:06:05.47,Default,,0000,0000,0000,,So patients with diabetes or\Nimmunocompromised or who are high risk
Dialogue: 0,0:06:05.47,0:06:09.35,Default,,0000,0000,0000,,of having severe pain post\Nshingles, you might want to think
Dialogue: 0,0:06:09.35,0:06:11.36,Default,,0000,0000,0000,,about vaccinating these patients at age 50.
Dialogue: 0,0:06:11.68,0:06:15.16,Default,,0000,0000,0000,,Now, again, keep in mind this\Nis a live attenuated vaccine,
Dialogue: 0,0:06:15.34,0:06:18.05,Default,,0000,0000,0000,,so there's going to be some contraindications\Nthat we have to keep in mind here.
Dialogue: 0,0:06:18.05,0:06:22.04,Default,,0000,0000,0000,,This is going to be contraindicated\Nin pregnancy, those who have a primary
Dialogue: 0,0:06:22.04,0:06:26.30,Default,,0000,0000,0000,,or acquired immunodeficiency, those who\Nare undergoing chemotherapy or radiation,
Dialogue: 0,0:06:26.37,0:06:31.29,Default,,0000,0000,0000,,have had solid organ transplant, are receiving\Ndaily corticosteroid therapy with a dose
Dialogue: 0,0:06:31.29,0:06:36.01,Default,,0000,0000,0000,,of 20 milligrams a day or above, are\Nreceiving immunomodulatory therapy,
Dialogue: 0,0:06:36.08,0:06:40.01,Default,,0000,0000,0000,,and/or have HIV with a CD4 count under 200.
Dialogue: 0,0:06:40.28,0:06:44.50,Default,,0000,0000,0000,,Now the last thing that I really want to\Ntouch on with the vaccination here is going
Dialogue: 0,0:06:44.50,0:06:48.16,Default,,0000,0000,0000,,to be the issue that we have with\Nco-administration with the pneumovax.
Dialogue: 0,0:06:48.88,0:06:53.34,Default,,0000,0000,0000,,Now in a perfect, idealistic world, we're\Nnot going to want to vaccinate the patient
Dialogue: 0,0:06:53.34,0:06:59.43,Default,,0000,0000,0000,,with the pneumovax and the zostervax\Nin the same visit, the reason being is
Dialogue: 0,0:06:59.43,0:07:02.68,Default,,0000,0000,0000,,that have been studies that have shown\Nthat if vaccinated at the same time,
Dialogue: 0,0:07:02.88,0:07:07.06,Default,,0000,0000,0000,,the pneumovax is going to reduce\Nthe efficacy of the zostervax.
Dialogue: 0,0:07:07.27,0:07:12.35,Default,,0000,0000,0000,,By how much, it's not known, but if we look\Nat the CDC guidelines, they still recommend
Dialogue: 0,0:07:12.35,0:07:16.16,Default,,0000,0000,0000,,that we administer at the same time,\Nand that's only because of compliance.
Dialogue: 0,0:07:16.32,0:07:19.84,Default,,0000,0000,0000,,They found that if we separate\Ninto two different visits,
Dialogue: 0,0:07:20.13,0:07:22.32,Default,,0000,0000,0000,,the patient won't get the second vaccination.
Dialogue: 0,0:07:22.75,0:07:26.12,Default,,0000,0000,0000,,So although it might reduce\Nthe efficacy of zostervax,
Dialogue: 0,0:07:26.51,0:07:29.58,Default,,0000,0000,0000,,it's still better than not getting\Nthe zoster vaccination at all.
Dialogue: 0,0:07:29.78,0:07:33.73,Default,,0000,0000,0000,,So for that reason, the CDC still\Nrecommends that co-administration
Dialogue: 0,0:07:33.73,0:07:37.42,Default,,0000,0000,0000,,of these vaccinations be given at\Nthe same time if they are indicated
Dialogue: 0,0:07:37.42,0:07:41.76,Default,,0000,0000,0000,,and if the patient is of appropriate age.
Dialogue: 0,0:07:41.96,0:07:44.35,Default,,0000,0000,0000,,So that's the end of the vaccination.
Dialogue: 0,0:07:44.35,0:07:47.07,Default,,0000,0000,0000,,There are really only, like I said, there are\Ngoing to be three vaccinations that we have
Dialogue: 0,0:07:47.07,0:07:49.01,Default,,0000,0000,0000,,to worry about in the adult population.
Dialogue: 0,0:07:49.01,0:07:53.50,Default,,0000,0000,0000,,It's going to be HPV, the\Npneumococcal vaccination, and zostervax.