ADULT IMMUNIZATIONS

 MAKE SURE YOU TAKE CARE OF YOURSELF

GET YOUR IMMUNIZATIONS

IMMUNIZATIONS ARE NOT JUST FOR BABIES

by Carol Ware Duff MSN, BA, RN

Vaccines are not just for infants and children.  There are currently seventeen diseases that are preventable with vaccines that are given to all age groups in the United States.

Every year about 50,000 Americans die from diseases which could have been prevented by vaccines. Ninety-five percent of these deaths are adults.  Vaccines work to protect people from infections and keep them healthy.  The lack of adherence to vaccine protection leads to an increased economic burden for society.  In particular, those with chronic illnesses such as diabetes, asthma, heart disease, kidney disease, should receive vaccinations. Vaccines protect public health.

The more people who have received their vaccinations, the less disease there will be. Immunizations not only protect the one who is vaccinated against many very harmful diseases, but also those who are not immunized can be protected because of the decreased ability of the disease to spread when it cannot find a host.  This is called the Herd Effect. Most of these vaccines have very limited side effects such as soreness at the site of injection. None of these vaccines can give you the disease they are given to prevent.

Eleven immunizations for adults are discussed in this article.

VACCINES FOR ADULTS:

Adults should receive Tetanus, Diptheria, Pertussis (whooping cough) TD/Tdap (one time shot and booster of tetanus and diptheria every ten years). Tetanus (lockjaw/tetany) is not a disease that others can catch, but is very serious, and often fatal because one cannot open the jaw, or swallow to eat or to drink.

It is important for adults to receive the vaccination against Pertussis (whooping cough) because children can catch the disease from them. Protecting infants who are too young to have had the full number of Pertussis vaccines is an important reason for adults to receive the vaccine. Did you know that Pertussis used to be called grandmother’s cough?  Adults who have Pertussis may only have a cough, but Pertussis can cause death in infants. Pertussis can cause pneumonia in adults.

Currently Tdap is licensed to be given up to the age of 64.  The VA recommends that the Tdap be given at least once. If you are 64 or younger you can receive the Tdap inoculation two years after your last tetanus injection. 

 Adults (with exceptions listed below) should receive the chickenpox (varicella zoster) vaccine because they are at a greater risk than children for complications from chickenpox. The chickenpox vaccine is also recommended for children.

The complications from chickenpox can include a risk of bacterial skin infection (where the chickenpox lesions develop), pneumonia and swelling of the brain.  

Those who should not receive the chickenpox vaccine:

• Those who are allergic to the antibiotic neomycin, gelatin, or to a previous chickenpox vaccine.
• Women who are pregnant or will become pregnant less than one month from having the vaccine.
• Those who are ill at the time of the scheduled vaccination appointment.

Who should specifically check with their healthcare provider before taking the vaccine?

• Those who have diseases which affect the immune system, such as HIV/AIDS.
• People who are receiving treatment with drugs (steroids) which affect the immune system.
• People with any type of cancer or who are being treated with chemotherapy or radiation.
• Those who have recently had a blood transfusion or received blood products such as plasma. 

 Adults should receive measles (rubeola), mumps, and rubella (MMR) vaccine if they have not had these diseases as a child. These three vaccines are given in one injection.  Even if the adult had these diseases in childhood the immunity level to fight these diseases later in life may decrease and a booster is required.

Those who should have the MMR vaccine are:

• A female old enough to get pregnant (rubella can cause congenital abnormalities or even death in the unborn fetus).
• Those who were born after 1957 and do not have proof of having measles, mumps, or rubella.
• Those who were vaccinated for measles before 1968.Those who travel outside of the United States.
• Anyone who works in a healthcare facility.

 You do NOT need the vaccine if you have blood work (titers) which show that you have immunity to measles, mumps, and rubella.

 The influenza vaccine is the best protection against getting the flu.  Influenza (flu)  kills over 36,000 people (mostly adults) every year and puts 200,000 more people into the hospital. There is currently plenty of vaccine on supply and the injection can be given yearly from October throughout the influenza season, as late as May. 

 Did you know that vaccinating children from age six months to 18 years can prevent influenza in older adults?  Staphylococcus and streptococcus infections can be associated with influenza so this is another reason to get the flu vaccine. 

 Strains in southern atmosphere (where winter has been for the past six months) are the same as what we are going to vaccinate for in the northern hemisphere.

 The VA recommends that the following people receive the annual flu vaccine:

• Anyone 50 years of age or older.Anyone who has a chronic illness such as diabetes, lung, heart, or kidney diseases.
• Anyone with a weakened immune systems caused by medications, disease,  HIV or AIDS.
• Someone who will be pregnant during the flu season.
• Anyone who has a condition which makes it difficult to breathe or swallow.
• Those who live in a long-term nursing facility or nursing home.
• Health care workers.
• Those people who live with someone who has a weakened immune system, chronic heart, lung, or kidney disease, diabetes, or a condition that affects breathing or swallowing.
• Someone who lives with or cares for children under the age of 5 or adults older than 50.

The VA mandates that healthcare workers who work with veterans have flu vaccine yearly. 

2009 H1N1 Swine Flu Vaccine: NOTE THAT THIS IS NOT THE REGULAR YEARLY FLU VACCINATION DISCUSSED ABOVE, BUT A NEW, ADDITIONAL FLU VACCINE.  BOTH VACCINES CAN BE GIVEN AT THE SAME TIME. 

2009 H1N1 Swine Flu vaccine, Novel H1N1, or Pandemic Influenza for the adult should be given from age 25 through 64 to those who are at high risk because of a chronic health condition or a compromised immune system.  This vaccine is different from flu vaccines over the past 30 years.

The Five key populations targeted to receive this vaccine are: 

• Those who will come in contact with those who are ill (healthcare workers).
• Pregnant women.
• Providers of care for children younger than 6 months.
• Persons between 6 months and 24.
• Those between 25 and 65 who have chronic illnesses.  

Those 65 and older tend to be less affected by this flu, possibly due to previous exposures over their life, but when flu vaccine is available in adequate amounts, all should get it.

Those who should not receive this vaccine are those who:

• Have severe or life-threatening allergies to chicken eggs, or to any substance in the vaccine

The most common side effect from the injected vaccine is soreness at the injection site.  Other side effects may include body aches, mild fever, and fatigue for a few days.  For the nasal spray vaccine there may be nasal congestion for all age groups and additionally sore throat for adults. In children between 2 and 6 there may also be fever.   

Pneumococcal polysaccaride vaccine is used to prevent infection caused by the Streptococcus pneumoniae bacteria. This organism can invade the lungs, bloodstream, brain and spinal cord. If you had the Pneumococcal vaccine before turning 65, you may need a revaccination five years after your first injection.

Please note that you cannot be given the pneumococcal vaccine with the Herpes Zoster Vaccine (to be discussed later in the article) because the effects of the Pneumococcal vaccine are decreased by the Herpes Zoster Vaccine.

People who should have the pneumococcal vaccine are:

• Those who smoke (75% of smokers also have other diseases). 
• Have asthma.
• Have reduced resistance to infection (Hodgkin’s disease, cancer treatment with drugs or x-rays, bone marrow or organ transplant, kidney damage, kidney failure, lymphoma, HIV/AIDS, leukemia, damaged spleen or no spleen.
• Have sickle cell disease.
• Are a Native Alaskan or a Native American.
• Those who live in a nursing home or healthcare facility.
• Everyone 65 or older.

Hepatitis A vaccine is given in two doses. People can be infected with this virus and never show signs of having it.  Hepatitis A is usually spread by the oral-fecal (stool) route and can also be spread by close personal contact such as sexual contact with an infected person or within a living situation where a person is already infected.  The Hepatitis A virus is spread by ingesting contaminated food or drinking contaminated water and is the most common vaccine preventable disease that one can encounter while traveling. This vaccine is given in two doses with the second dose given six to 12 months after the first.

Who should get the Hepatitis A vaccine?

• People with chronic liver disease.People traveling to countries where Hepatitis A is prevalent.  All countries except the US, Japan, Canada, Western Europe, Australia, New Zealand.
• People with blood clotting disorder such as hemophilia.
• Men who have sex with men.
• People who use illegal drugs by injection, or non-injection.
• People who work in research laboratories with Hepatitis A.

Hepatitis B is spread through contact with infected blood, semen, and other body fluids, through sexual contact, sharing needles, and during childbirth when an infected mother can pass it to her newborn. Body piercing and tattoos are other ways to get this virus.  The Hepatitis B vaccine prevents a virus that can cause serious liver diseases including liver cancer, liver failure, cirrhosis, and death. There is currently no cure for Hepatitis B.  As with Hepatitis A, people can carry the disease without showing signs of being ill. The Hepatitis B vaccine is given in three doses with the second dose give one month after the first and the third and final dose give six months after that first.  

Who should receive this vaccine?

• People who are not in long-term, mutually monogamous relationships.
• People whose sex partners are infected with Hepatitis B virus.
• Men who have sex with men.
• People who have had a recently treated sexually transmitted infection.People who share needles or any drug injection equipment.
• People who live with someone who is infected with Hepatitis B virus.
• Healthcare workers or those who may be exposed to blood or blood contaminated body fluids.
• People with chronic liver disease.
• People with HIV infection.
• People who receive hemodyalisis, peritoneal dialysis, home dialysis, and/or have end stage renal disease.
• Travelers who go to regions with moderate to high rates of the Hepatitis B infection.

Meningococcal polysaccharide vaccine prevents a potentially very harmful condition which can cause permanent disabilities, hearing loss, brain damage, or amputations of limbs or death.   Meningococcus can be found within your upper respiratory area and may not cause disease.  The potential for outbreaks of meningococcus are greatest in areas where people are living in close quarters such as college dormitories and military barracks.  This vaccine prevents a potentially fatal infection that occurs in about 1,400 to 2,800 Americans a year. Quick treatment for a meningococcal infection does not guarantee that one will not die, or have permanent disabilities.  One dose if given to those from the age of two to 55.

Those who should have the meningococcal vaccine are people who will be placed in close living conditions such as colleges and the military. 

Herpes Zoster Vaccine to prevent Shingles

The risk of getting shingles (Herpes Zoster) (for those who have had chickenpox, even as a child) is greater than 30%.  The pain from shingles can be severe and can cause a painful blistering rash on the body, which is usually only on one side or the face.   There may be tingling, numbness, or pain in the area that will be affected two to four days before the rash appears. The eyes or other organs can be involved. The most common complication from shingles is post-herpetic neuralgia (PHN) which can cause unbearable pain which is very hard to treat and can greatly diminish quality of life.   

Shingles are preventable with the Herpes Zoster vaccine and is recommended for anyone who is 60 years or older.  Herpes Zoster cases can cause chicken pox in others, who have not already developed chicken pox.   Serious illness in the elderly and can persist for a very long time.  The lesions can cause severe pain.

The pneumoccocal vaccine cannot be given at the same time as the zoster vaccine because the effectiveness of the zoster vaccine is decreased when given with the pneumoccocal vaccine.

There is currently a question of whether the Herpes Zoster Vaccine should be repeated five to seven years after the first immunization.

A note of interest here is that the Shingles Prevention Study was conducted over a five and one half year time frame and was headed by the Department of Veterans Affairs (VA), and carried out in partnership with the National Institute of Allergy and Infectious Diseases (NIAID) which is part of the National Institutes for Health (NIH), and Merck & Co. There were 22 clinical sites across the U.S. for this study and 16 of those sites were at VA medical centers.       

The Herpes Zoster (shingles) vaccine should be give to those :

• Who are sixty and over.
• Who have already had a case of shingles, because shingles can reoccur
• People in the recommended age group who cannot remember if they have had chickenpox (varicella)

 Human papillomavirus (HPV) vaccine is licensed to be given to girls between 11 and 26.  This vaccine prevents some viruses associated with cervical cancer, specifically against HPV 16, 18, and HPV 6 and 11 which cause genital warts.  Since this is a relatively recent vaccine. There have been clinical levels of high efficacy, but since this is a more recently available vaccine, there is no long term evidence of how long the protection of the vaccine will last.  The HPV vaccine is given in three doses. 

 For reduction of cervical cancer it is necessary that the vaccine be given as early as possible, ideally before the female has had intercourse.  Currently the vaccine is only licensed up to the age of 26. Some research is looking into use of this vaccine for boys and for older females.  In this older groups of women, if a female is affected with one type of HPV she could be protected against the other types.  

 100% of cervical cancers, and the majority of anal cancers are caused by HPV.  Cancers of vagina and vulva and 25% of head and neck cancers are related to HPV.

This vaccine is expensive costing $125/dose and many healthcare plans charge more than that.

Remember: The HPV virus exposure comes quickly after the start of sexual intercourse, especially with more than one partner. Even if one has received the full course of HPV vaccine, yearly pap smears for cervical cancer screenings are necessary.  The HPV vaccine does not protect against sexually transmitted diseases.    

REFERENCES

Mark S. Dworkin MD, MPH, & TM, Associate Professor, Division of Epidemiology and Biostatistics, School of Public Health, University of Illinois at Chicago.

Monica M. Farley, MD, Professor of Medicine, Emory University School of Medicine, Atlanta Veterans Administration Medical Center.

Janet R. Gilsdorf, MD, Professor and Director Pediatric Diseases, University of Michigan Medical Center, Ann Arbor, MI.

Kathleen N. Neuzil, MD, MPH, Director Influenza Project, PATH, Seattle, Washington.

Michael S. Simberkoff, MD, Chief of Staff, Veterans Affairs New York Harbor Healthcare System, New York University, New York.  

Gregory Poland, MD. Professor of Medicine, Molecular Pharmacology and Experimental Therapeutics, and Infectious Diseases; Director, Mayo Vaccine Research Group; Director, Program on Translational Immunovirology and Biodefense; Department of Medicine, Mayo Clinic and Foundation. Dr. Poland’s research interests include pediatric and adult vaccines, vaccine delivery and public policy, immunogenetic influences on vaccine responsiveness, and vaccines against agents of bioterrorism. Dr. Poland is the American College of Physicians’ (ACP’s) liaison representative to the ACIP.

National Foundation for Infectious Diseases

Centers for Disease Control.  http://www.cdc.gov/vaccines/ Retrieved on September 27, 2009. 

www.adultvaccination.org

 Department of Veterans Affairs. National Center for Health Promotion & Disease Prevention. Retrieved on September 27, 2009 from   http://www.prevention.va.go

Carol Duff graduated from Nursing School at Riverside White Cross in Columbus, Ohio.

She has a BA from Bowling Green University in History and Literature and a Masters of Science in Nursing as a Nurse Educator from the University of Toledo School of Nursing.