August is National Immunization Awareness Month, a perfect time to talk to your patients about vaccines! These important dates are also a great reminder for you to brush up on your medical knowledge and stay current in your practice. This month, tackle your review of vaccines with the high-yield pearls you must know from the Infectious Disease section of our Internal Medicine Core.
Current vaccine schedule
The specific schedule for vaccinations changes frequently. Vaccinations that are recommended for adults, according to age groups:
- Td or Tdap: 1 dose Tdap each pregnancy. 1 dose Td/Tdap for wound management. Tdap should be given only once as an adult if the 3-dose primary childhood series has been given; after that, Td can be given.
- HPV: 2- or 3-dose series depending on age at initial vaccination or condition, 27-45 years of age for both males and females.
- Varicella (chickenpox vaccine): 2 doses, if born in 1980 or later. 2 doses for patients ≥65 years of age.
- Zoster (booster to prevent shingles): 2 doses for immunocompromising conditions or patients > 50 years of age.
- MMR: For patients born after 1957 or those who have not had naturally occurring infection or laboratory evidence of immunity, give 2 doses if not vaccinated or 1 more if received only 1 vaccine as a child.
- Influenza: Given annually to all persons > 6 months of age.
- Pneumococcal vaccination: > 65 years of age and those at risk. There are 2 vaccines that should be given to most individuals.
- Hep A: 2- or 3-dose series depending on vaccine for at-risk adults or those seeking protection.
- Hep B: 2, 3, or 4 doses depending on vaccine or condition.
- Meningococcal polysaccharide or conjugate: everyone 11–18 years of age and at-risk adults 19–55 years of age.
Be sure to check the CDC's adult vaccine schedule for the most up-to-date information!
Approach to tetanus prevention
Tetanus can be prevented with the appropriate use of tetanus toxoid (Td) and tetanus immunoglobulin (TIG). The use of these depends on the type of wound and the vaccination status of the patient.
Tetanus-prone wound: Tetanus-prone wounds include crush injuries, bite injuries, dirt- or fecally contaminated wounds, puncture or missile wounds, deep penetration wounds, wounds containing foreign bodies (e.g., wood splinters), and reimplantation of an avulsed tooth. Tetanus can be prevented based on how certain it is that patients have had the primary series of 3 injections of Td or not.
Give a booster dose of Td to those who have had a primary series if they have not received Td in the last 5 years. This stimulates sufficient production of antitoxin antibodies before the tetanus toxin can travel from the wound site to the CNS.
Patients with a tetanus-prone wound who have not received the primary series (or have uncertain immunization history) are considered at high risk for tetanus. Give these patients Td to begin the primary series. However, since they have not had adequate prior immunization, boosting of their immune response cannot be relied upon. Therefore, these are the patients for whom TIG is indicated.
Nontetanus-prone wound: Persons who do not have tetanus-prone wounds (often called “clean wounds”) are not at risk for tetanus from the wound. However, the patient encounter provides an opportunity to begin immunization in the previously unvaccinated or to boost immunity in people who haven’t received a booster in the last 10 years. Thus, give those who have not received all 3 primary series injections of Td (or are uncertain) as many Td injections as needed to complete the 3-shot primary immunization sequence. Give a Td booster to those who have completed the primary series but have not been boosted in the last 10 years. TIG is never indicated in the management of nontetanus-prone wounds.
Uncommon vaccines for special situations
Japanese encephalitis vaccine is recommended for travelers who plan to stay a long time in rural Asia.
Typhoid vaccine is recommended for travelers > 2 years of age who go outside of the usual tourist areas within Latin America, Asia, and Africa. An oral live attenuated vaccine is recommended for those > 2 years of age. It has a protection rate of only 35−60% and can be repeated every 5 years. A parenteral polysaccharide vaccine has an efficacy of 60−70% and can be repeated every 2 years.
Polio vaccine is not routinely recommended to persons > 18 years of age. Polio vaccine is recommended for previously unimmunized travelers to endemic areas. A booster is indicated for travelers who have had only the primary vaccination and who travel to areas where exposure to the wild-type virus is likely. Only the inactivated vaccine is recommended in the U.S.
Yellow fever vaccine is recommended for travel in equatorial Africa and much of tropical South America. It is a live vaccine; therefore, do not give to immunosuppressed patients. As of early 2020, supply of yellow fever vaccine was totally depleted, and the manufacturer is expected to have an update by the end of 2020.
Cholera vaccine was approved in the U.S. in 2016 and is a live attenuated oral vaccine that can be given to adults traveling to regions with active cholera cases within the last year.
Keep in mind, these are just the high-yield pearls from the Infectious Disease topic in the Internal Medicine Core. Get all this information, plus every other topic from the ABIM blueprint when you buy the Internal Medicine Core!
For both the review articles and current internal medicine practice guidelines, visit the MedStudy Hub. The Hub contains the only online consolidated list of all current guidelines focused on internal medicine. Guidelines on the Hub are easy to find, continually updated, and linked to the published source. MedStudy maintains the Hub as a service to the medical community and makes it available to anyone and everyone at no cost to users.