Saturday, July 11, 2009

Vaccines and Immunizations for Adults

This blog is a general (search the archives of Morbidity and Mortality Weekly Report, or the CDC travel page, or for more detailed info) review of the vaccinations/immunizations available for adults. I will be reviewing them in the order of the fatality rate for the infected but unvaccinated immunocompetent adults. WARNING: if you are pregnant, or immunosuppressed--e.g. on steroids, on cancer chemotherapy, have AIDS,etc., do NOT take any live virus vaccine without checking with your doctor, and avoid anyone who has had a live virus vaccine for 8 weeks after they have been vaccinated.

RABIES: Except for one fortunate female in Wisconsin, this disease has been 100% fatal once symptoms are evinced. The virus is carried in the salivary glands of infected meat-eating animals: bats, raccoons, skunks, foxes, dogs, cats,---.The vaccine is available from your state board of health, or vetinarians. You should seek vaccination for any bite or scratch from ANY unknown animal, as well as if you have been in the same room with a bat, since their needle-like teeth often can bite without your feeling it. It is also recommended for pre-exposure prophylaxis if you are traveling to a region where there is a high incidence of rabies in stray dogs, such as certain parts of Asia, including Katmandu, and India, Mexico, and other countries (check with CDC). Chloroquine, and possibly mefloquine, both used for malaria prophylaxis, may blunt your immune response to the vaccine, so be sure to notify the treating physician if you are taking either of these drugs, and ask for deep IM rather than SQ vaccination. Raccoons are nocturnal animals, so any raccoon seen in the daytime should be presumed to be rabid.

TETANUS: Last year there were over 50 fatalities from tetanus in the U.S., and there should be none.It is 100% preventable by an antitoxin shot (no longer made from horse serum, so there is little likelihood of a strong reaction). It is a paralysis caused by a toxin generated by an anaerobic bacterium that inhabits the soil, especially where there is horse manure. You should be vaccinated every 10 years, but there is no harm done if the ER vaccinates you whenever you come in with a laceration. More women than men die each year (often from a non-remembered puncture wound from a garden rose thorn, etc.): Since men get injured more often than women, they are more likely to have been in the ER and been re-vaccinated. If you don't remember when you received your last tetanus shot, please ask your doctor for one at your next visit. I should also mention that the only vaccine currently available in the USA is dT, so you are also re-vaccinated against diphtheria at the same time. It would take up too much space here to explain why, but the reason is not medical.

YELLOW FEVER: This is a LIVE vaccine, and the vaccination is good for 10 years. It is only available from physicians or centers certified by the US gov't. Yellow fever is endemic in many areas of countries in South America, Central America, and Africa. It is spread by mosquitoes both in jungles and cities and one infection confers lifetime immnunity. The case fatality rate can be as high as 50%, and there is no treatment, since we have no drugs that reliably attack flaviviruses. Therefore, when in doubt, take the vaccine. (As a historical point, at one time it was endemic in the United States, from New Orleans to Philadelphia.)

POLIOMYELITIS: The oral vaccine (OPV) is live, and the injected vaccine (IPV) contains inactivated virus. One dose if IPV is recommended for travelers to underdeveloped countries or those with poor sanitation (check with the CDC).

HEPATITIS B: This vaccine is recommended not only because Hepatitis B can progress to cirrhosis of the liver even with treatment, but also because infection with Hepatitis B (or C) is a proven risk factor for cancer of the liver. It can be spread by unprotected sex, exposure to blood, including transfusions, or sharing of needles by drug users. Because it is considered a STD, vaccination for all children has been recommended before they reach the age of sexual activity. As an adult, vaccination is recommended for those exposed to blood (ER workers, dental hygienists and dentists, etc.) and those with compromised immune systems, including those on renal dialysis. You should specifically ask your physician if you should have the vaccine. If you are immuno-incompetent, then it is recommended that you be tested for protective antibodies one month after vaccination. Unless you are tested annually for antibodies, it is unknown how long your protection will last.

N.B.: If you want to help your country, then please donate a unit of blood. The blood bank will test your blood, at no charge to you, for Hepatitis B and C, syphilis, AIDS, and a few other diseases. You will not be permitted to donate blood if you have been in a country where malaria is endemic (including Mexico, even if in a non-malarious area) within the previous 12 months.

SMALLPOX: A LIVE vaccine. No longer given routinely, except to U.S. military personnel. Cidofovir has shown some success in animal models of this disease. Case fatality rate at least 20%.

HPV: Vaccine against Human Papilloma Virus. This is considered to be permissive, if not an inducer for cancer of the cervix. There are many strains of HPV, and the vaccine does not protect against all of them, so women should still have pap smears, even if vaccinated. Recommended for all females before first menses, and any woman who has not received the vaccination.

INFLUENZA: Everyone should have annual vaccination with the regular flu vaccine.
Since the antibody levels decline after 4 to 6 months, I recommend biannual vaccinations to my all my patients. In the past, the vaccine was recommended only for those over 65, as well as health care workers and teachers, etc., because there was not enough to give everyone in the U.S. It is especially important to get this vaccine because Tamiflu is no longer effective against it.
AVIAN FLU: The government hopes to have a vaccine against this available by October, 2009. Fortunately, this flu virus is generally susceptible to Tamiflu. We are all sincerely worried about this flu strain developing resistance to Tamiflu so I(we) are not prescribing it to patients to have "just in case". Patients born after 1956 have no natural antibodies to this H1N1 strain, and so are at risk for death. Patients born before this date were probably infected with a strain somewhat homologous to avian flu, and therefore become less ill.

PNEUMOCOCCAL PNEUMONIA: Patients over 65, those without a spleen (either at birth or after surgery), patients with TB,diabetes and a host of other chronically ill patients are at risk of death from pneumococcal pneumonia. However, it was found that patients younger than 65 develop a stronger immune response than older patients, Most physicians now will give the vaccine to their (normal) patients when they reach age 60, and a booster is recommended 5 years later.

MENINGOCOCCAL MENINGITIS: Recommended for those traveling to areas where this is endemic. The antibody levels decline after 2 years. Saudi Arabia requires this vaccination for those traveling to Mecca.

JAPANESE B ENCEPHALITIS: May to September in Asia. Low risk of infection, and high rate of side effects and reactions. Discuss with your doctor.

PLAGUE: Recommended only for travelers in regions where it is endemic (but this does include the U.S. Southwest). Booster every 1 to 2 years.

TYPHOID: Oral vaccine. Spread by contaminated food and water. Suggested if you are going to be in underdeveloped country for 3 or more months, but you should still be careful what you eat and drink.

HEPATITIS A: Virtually never fatal, but it can ruin your vacation. Spread by contaminated food and water. can be combined with Hepatitis B vaccine.

SHINGLES/HERPES ZOSTER:LIVE virus. This is reactivation of the virus that gave you chicken pox. It lives in your body forever, and can be reactivated along pain nerves as you get older and your immune surveillance competence drops. Classically, it causes redness and blisters along the path of a pain nerve, but you can get non-eruptive zoster, wherein the virus re-activates WITHOUT the rash. The problem is extreme residual pain along the path of the inflamed nerve, and it seems that older patients get more severe pain. We recommend it for all patients, because the pain can be disabling. However, vaccination is not 100% protective. Also, a prior zoster attack does not prevent a second attack.

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