>> Hey, what's up guys?
Today we're going to be talking about the routine administration
of vaccines in the adult population.
Now in adults there are really going to be only three vaccinations that we have to worry about.
We're going to be talking about HPV, the pneumococcal vaccine,
and finally we're going to talk on herpes zoster.
Now, starting with HPV.
The HPV vaccine is really going to be used to prevent cervical cancer,
penile cancer, and genital warts.
Now as far as cancer goes, there's really going to be two main types of HPV strains
that are going to cause 70 percent of cervical cancers and anal cancer as well.
These are going to be strains 16 and 18.
The remainder 20 percent or 20 percent after that is going to be caused
by strains 31, 33, 45, 52, and 58.
So these seven strains here are going to account for 90 percent of cervical cancers.
Now finally we have to worry about genital warts, and these are going
to be caused by strains 6 and 11.
So what does this mean?
This means that when we have vaccines, we are targeting these types of strains,
and there are really three types of vaccines that we're going to be giving.
We have bivalent, quadrivalent and 9-valent.
Bivalent, which is going to be Cervarix, is really going to be targeting two strains.
Gardasil has the quadrivalent and 9-valent, which means we have four strains
and we're targeting nine strains.
So Cervarix, which is bivalent, is going to be focused on cervical cancer,
meaning it's going to target the strains 16 and 18.
Gardasil, which is the quadrivalent, is going to target the cervical strains 16
and 18 for cancer and 6 and 11 for genital warts.
The Gardasil-9 is going to be the 9-valent, and it's going to target all of these strains
that we just previously talked about.
So it's going to cover the most, or it's going to give the most protection
against cervical cancer and genital warts.
As far as when to give, we want to give males and females at age 11,
start the dosing at age 11 for both males and females.
Females you want to stop immunization at 26.
Guys we want to stop at 21 with one exception.
If the male patient is immunocompromised and/or it's a male that has sex with other males,
we want to extend that age to 26.
When we give the dosing, it's going to be a vaccination of three.
So we're going to give the first dose at zero months.
The second dose is going to be at two months later.
The third dose is going to be four months after the second dose, which means it's going
to be six months after the initial dose.
This is going to be the same for both male and female populations.
It doesn't matter if the patient has HPV.
You can still vaccinate.
It doesn't matter if they've had sex or they haven't had sex,
you can still vaccinate the patients.
If cost is not a problem, then obviously we want to go with the 9-valent, which is Gardasil-9
because it's going to offer the most protection.
All right, moving onto the pneumococcal vaccination.
Now there are really going to be two types of vaccines here
that we're really going to focus on.
This is going to be prevnar, which is going to be PCV13 and the pneumovax, which is PPSV23.
Now the entire purpose of pneumococcal vaccination is to prevent pneumonia.
So if we have a patient from age 19 to 64 who is at intermediate risk for disease,
meaning we have chronic heart disease, chronic lung disease, chronic liver disease, smoker,
alcoholic, and/or diabetes, we're going to be treating or we're going to be vaccinating,
I should say, with the pneumovax PPSV23.
If we're at high risk for pneumonia, then we're going to give prevnar first,
and we're going to give the pneumovax eight weeks later.
So two months after the prevnar we're going to give the pneumovax.
These are patients that are at high risk and intermediate risk.
For everyone else, universal vaccination starts at age 65,
and it's going to be starting with the prevnar.
Prevnar is, again, PCV13.
So we hit age 65, we vaccinate with prevnar.
One year later we're going to vaccinate with the pneumovax.
Now the prevnar is fairly recent.
Beforehand it used to be vaccination with pneumovax only.
So if for whatever reason the patient was vaccinated with the pneumovax
but not the prevnar, then go ahead and give the prevnar second.
Just make sure that we're waiting one year after the prior vaccination.
Now, if you have a high risk patient that received the pneumovax before the age of 65,
we're going to follow the same schedule.
So let's say at age 40 they received the pneumovax.
Now they hit 65, again, we're going to give prevnar at 65.
One year later we're going to give the pneumovax.
The only nuance here is that we have to make sure that the two doses
of the pneumovax are at least five years apart.
So it's going to be pneumovax before 65, prevnar at 65, and then pneumovax.
So those two pneumovax vaccines need to be at least five years apart.
That is the only nuance here that we have to keep in mind.
All right, finally we're going to be touching on the zoster vax.
Now the zoster vax is really going to be for the prevention of shingles,
and if we do get shingles, it's going to be for the prevention of postherpetic neuralgia,
which is a pain syndrome that happens after the rash has cleared.
Now shingles, the shingles vaccine, which is zoster vax is really going
to be approved at the age of 50 and over.
However, guidelines say to start vaccinating after the age of 60,
and guidelines are really going to be made by the CDC, and interestingly enough,
the reason why the CDC takes the stance on vaccinating after 60 is
because at the time these guidelines were made, they said there was a shortage
of vaccinations to start them at 50.
There was a shortage, and also they aren't sure as to how long the patients are protected
after the initial vaccination, and currently there are no recommendations
to vaccinate again after initial dosing.
So, for that reason, they state that we should start vaccinating at age 60.
You should keep in mind though that it is approved by the FDA at age 50.
So patients with diabetes or immunocompromised or who are high risk
of having severe pain post shingles, you might want to think
about vaccinating these patients at age 50.
Now, again, keep in mind this is a live attenuated vaccine,
so there's going to be some contraindications that we have to keep in mind here.
This is going to be contraindicated in pregnancy, those who have a primary
or acquired immunodeficiency, those who are undergoing chemotherapy or radiation,
have had solid organ transplant, are receiving daily corticosteroid therapy with a dose
of 20 milligrams a day or above, are receiving immunomodulatory therapy,
and/or have HIV with a CD4 count under 200.
Now the last thing that I really want to touch on with the vaccination here is going
to be the issue that we have with co-administration with the pneumovax.
Now in a perfect, idealistic world, we're not going to want to vaccinate the patient
with the pneumovax and the zostervax in the same visit, the reason being is
that have been studies that have shown that if vaccinated at the same time,
the pneumovax is going to reduce the efficacy of the zostervax.
By how much, it's not known, but if we look at the CDC guidelines, they still recommend
that we administer at the same time, and that's only because of compliance.
They found that if we separate into two different visits,
the patient won't get the second vaccination.
So although it might reduce the efficacy of zostervax,
it's still better than not getting the zoster vaccination at all.
So for that reason, the CDC still recommends that co-administration
of these vaccinations be given at the same time if they are indicated
and if the patient is of appropriate age.
So that's the end of the vaccination.
There are really only, like I said, there are going to be three vaccinations that we have
to worry about in the adult population.
It's going to be HPV, the pneumococcal vaccination, and zostervax.