WEBVTT

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>> Hey, what's up guys?

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Today we're going to be talking
about the routine administration

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of vaccines in the adult population.

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Now in adults there are really going to be only
three vaccinations that we have to worry about.

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We're going to be talking about
HPV, the pneumococcal vaccine,

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and finally we're going to
talk on herpes zoster.

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Now, starting with HPV.

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The HPV vaccine is really going to
be used to prevent cervical cancer,

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penile cancer, and genital warts.

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Now as far as cancer goes, there's really
going to be two main types of HPV strains

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that are going to cause 70 percent of
cervical cancers and anal cancer as well.

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These are going to be strains 16 and 18.

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The remainder 20 percent or 20 percent
after that is going to be caused

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by strains 31, 33, 45, 52, and 58.

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So these seven strains here are going to
account for 90 percent of cervical cancers.

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Now finally we have to worry about
genital warts, and these are going

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to be caused by strains 6 and 11.

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So what does this mean?

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This means that when we have vaccines,
we are targeting these types of strains,

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and there are really three types of
vaccines that we're going to be giving.

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We have bivalent, quadrivalent and 9-valent.

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Bivalent, which is going to be Cervarix, is
really going to be targeting two strains.

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Gardasil has the quadrivalent and
9-valent, which means we have four strains

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and we're targeting nine strains.

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So Cervarix, which is bivalent, is
going to be focused on cervical cancer,

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meaning it's going to target
the strains 16 and 18.

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Gardasil, which is the quadrivalent, is
going to target the cervical strains 16

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and 18 for cancer and 6 and
11 for genital warts.

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The Gardasil-9 is going to be the 9-valent,
and it's going to target all of these strains

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that we just previously talked about.

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So it's going to cover the most, or
it's going to give the most protection

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against cervical cancer and genital warts.

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As far as when to give, we want to
give males and females at age 11,

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start the dosing at age 11
for both males and females.

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Females you want to stop immunization at 26.

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Guys we want to stop at 21 with one exception.

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If the male patient is immunocompromised and/or
it's a male that has sex with other males,

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we want to extend that age to 26.

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When we give the dosing, it's
going to be a vaccination of three.

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So we're going to give the
first dose at zero months.

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The second dose is going
to be at two months later.

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The third dose is going to be four months
after the second dose, which means it's going

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to be six months after the initial dose.

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This is going to be the same for
both male and female populations.

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It doesn't matter if the patient has HPV.

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You can still vaccinate.

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It doesn't matter if they've
had sex or they haven't had sex,

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you can still vaccinate the patients.

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If cost is not a problem, then obviously we want
to go with the 9-valent, which is Gardasil-9

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because it's going to offer the most protection.

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All right, moving onto the
pneumococcal vaccination.

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Now there are really going to
be two types of vaccines here

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that we're really going to focus on.

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This is going to be prevnar, which is going to
be PCV13 and the pneumovax, which is PPSV23.

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Now the entire purpose of pneumococcal
vaccination is to prevent pneumonia.

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So if we have a patient from age 19 to 64
who is at intermediate risk for disease,

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meaning we have chronic heart disease, chronic
lung disease, chronic liver disease, smoker,

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alcoholic, and/or diabetes, we're going to
be treating or we're going to be vaccinating,

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I should say, with the pneumovax PPSV23.

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If we're at high risk for pneumonia,
then we're going to give prevnar first,

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and we're going to give the
pneumovax eight weeks later.

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So two months after the prevnar
we're going to give the pneumovax.

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These are patients that are at
high risk and intermediate risk.

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For everyone else, universal
vaccination starts at age 65,

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and it's going to be starting with the prevnar.

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Prevnar is, again, PCV13.

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So we hit age 65, we vaccinate with prevnar.

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One year later we're going to
vaccinate with the pneumovax.

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Now the prevnar is fairly recent.

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Beforehand it used to be
vaccination with pneumovax only.

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So if for whatever reason the patient
was vaccinated with the pneumovax

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but not the prevnar, then go
ahead and give the prevnar second.

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Just make sure that we're waiting
one year after the prior vaccination.

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Now, if you have a high risk patient that
received the pneumovax before the age of 65,

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we're going to follow the same schedule.

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So let's say at age 40 they
received the pneumovax.

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Now they hit 65, again, we're
going to give prevnar at 65.

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One year later we're going
to give the pneumovax.

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The only nuance here is that we
have to make sure that the two doses

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of the pneumovax are at least five years apart.

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So it's going to be pneumovax before
65, prevnar at 65, and then pneumovax.

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So those two pneumovax vaccines need
to be at least five years apart.

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That is the only nuance here
that we have to keep in mind.

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All right, finally we're going
to be touching on the zoster vax.

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Now the zoster vax is really going
to be for the prevention of shingles,

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and if we do get shingles, it's going to be
for the prevention of postherpetic neuralgia,

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which is a pain syndrome that
happens after the rash has cleared.

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Now shingles, the shingles vaccine,
which is zoster vax is really going

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to be approved at the age of 50 and over.

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However, guidelines say to start
vaccinating after the age of 60,

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and guidelines are really going to be
made by the CDC, and interestingly enough,

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the reason why the CDC takes the
stance on vaccinating after 60 is

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because at the time these guidelines
were made, they said there was a shortage

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of vaccinations to start them at 50.

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There was a shortage, and also they aren't
sure as to how long the patients are protected

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after the initial vaccination, and
currently there are no recommendations

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to vaccinate again after initial dosing.

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So, for that reason, they state that
we should start vaccinating at age 60.

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You should keep in mind though that
it is approved by the FDA at age 50.

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So patients with diabetes or
immunocompromised or who are high risk

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of having severe pain post
shingles, you might want to think

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about vaccinating these patients at age 50.

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Now, again, keep in mind this
is a live attenuated vaccine,

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so there's going to be some contraindications
that we have to keep in mind here.

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This is going to be contraindicated
in pregnancy, those who have a primary

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or acquired immunodeficiency, those who
are undergoing chemotherapy or radiation,

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have had solid organ transplant, are receiving
daily corticosteroid therapy with a dose

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of 20 milligrams a day or above, are
receiving immunomodulatory therapy,

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and/or have HIV with a CD4 count under 200.

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Now the last thing that I really want to
touch on with the vaccination here is going

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to be the issue that we have with
co-administration with the pneumovax.

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Now in a perfect, idealistic world, we're
not going to want to vaccinate the patient

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with the pneumovax and the zostervax
in the same visit, the reason being is

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that have been studies that have shown
that if vaccinated at the same time,

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the pneumovax is going to reduce
the efficacy of the zostervax.

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By how much, it's not known, but if we look
at the CDC guidelines, they still recommend

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that we administer at the same time,
and that's only because of compliance.

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They found that if we separate
into two different visits,

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the patient won't get the second vaccination.

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So although it might reduce
the efficacy of zostervax,

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it's still better than not getting
the zoster vaccination at all.

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So for that reason, the CDC still
recommends that co-administration

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of these vaccinations be given at
the same time if they are indicated

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and if the patient is of appropriate age.

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So that's the end of the vaccination.

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There are really only, like I said, there are
going to be three vaccinations that we have

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to worry about in the adult population.

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It's going to be HPV, the
pneumococcal vaccination, and zostervax.