Adult Vaccination

Today, we're going to go over the details for the three main adult vaccinations: pneumococcal, zoster, and HPV. Here's what you need to know about prescribing these vaccinations for your patients.
Website: http://physicianassistantboards.com
Personal IG: https://www.instagram.com/and_reid
PABoards IG: https://www.instagram.com/paboards
FB: https://www.facebook.com/paboards1

>> 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.