Continuing Education Activity
Immunization is a successful use of immunotherapy to treat many infectious diseases by stimulating the immune system to produce specific antibodies or specific lymphocytes to fight off pathogens and more recent to protect against malignant tumors. This immunotherapy creates an immunological memory that can be long-lasting. The current immunizations protect against diphtheria, tetanus, pertussis, poliomyelitis, measles, mumps, rubella, pneumococcal pneumonia, smallpox, sepsis, meningitis, hepatitis B, varicella-zoster, tuberculosis, cholera, diarrhea caused by rotavirus, salmonellosis, and dengue. However, the development of vaccine technology in recent years, the emergence of HIV, SARS, avian influenza, Ebola, and Zika emphasizes the need for global preparedness for a pandemic. This activity provides an overview of the indications, mechanism of action, methods and timing of administration, significant adverse effects, contraindications, toxicity, and monitoring for the most common approved vaccines so that providers can administer and monitor them for both individual and public health.
- Summarize the approved and recommended vaccines in the USA today.
- Outline the basic mechanism of action by which vaccines operate, citing individual agent differences where necessary.
- Describe the public health concepts that accompany vaccine administration.
- Review the importance of collaboration and coordination among the interprofessional team and how it can enhance patient care with vaccines to improve patient outcomes for patients and also prevent pandemic outbreaks of infectious disease.
Immunization is a successful use of immunotherapy to treat many infectious diseases by stimulating the immune system to produce specific antibodies or specific lymphocytes to fight off pathogens and more recent to protect against malignant tumors. This immunotherapy creates an immunological memory that can be long-lasting. The current immunizations protect against diphtheria, tetanus, pertussis, poliomyelitis, measles, mumps, rubella, pneumococcal pneumonia, smallpox, sepsis, meningitis, hepatitis B, varicella-zoster, tuberculosis, cholera, diarrhea caused by rotavirus, salmonellosis, and dengue. However, the development of vaccine technology in recent years, the emergence of HIV, SARS, avian influenza, Ebola, and Zika emphasizes the need for global preparedness for a pandemic.
Mechanism of Action
Live vaccines are most effective than killed vaccines because they retain more antigens of the microbes. However, toxoids, including those that cause tetanus and diphtheria, are the most effective bacterial vaccines of all because it bases on inactivated exotoxins that stimulate strong antibody production. Subunit vaccines, including hepatitis B, meningococcal, and Hemophilus influenzae B vaccines are effective when conjugated to carrier proteins such as tetanus toxoid. Vaccinologists produce subunit vaccines either by recombinant DNA technology or by antigen purification from different bacterial strains.
Vaccines contain one or various immunogens (peptides), which antigen-presenting cells can engulf, process, and present along with MCH antigens to CD4+ T cells. These lymphocytes can synthesize cytokines that activate humoral and cellular responses, including antibody production, activation of CD8+ T cells, macrophage stimulation, and other functions. Memory cells can develop in this process. They can proliferate more quickly in further encounters with the antigen.
B cells can recognize vaccines made of carbohydrates and other compounds except for proteins. Subsequently, B lymphocytes can differentiate into plasma cells that produce specific antibodies to protect against infectious diseases caused by bacteria (including meningitis caused by N. meningitidis and pneumonia caused by S. pneumoniae). This immune response against a non-peptidic antigen does not involve T-cell presentation, class switching, affinity maturation, or generation of memory T cells.
Using adjuvants enhances antibody synthesis and T-cell responses. Certain compounds, including aluminum salts added to immunogens, stimulate immune responses. This effect can mediate by two essential functions: cytokine induction that regulate T and B cell functions and increased antigen presentation in sites where lymphocytes can concentrate. Many bacterial substances can activate pattern recognition receptors that activate cytokine production by antigen-presenting cells.
Immunological studies for testing the humoral and cellular immunity after immunizing a host:
Quantitative Serum Immunoglobulins
IgG antibodies (post-immunization)
- Tetanus toxoid
- Diphtheria toxoid
- Pneumococcal polysaccharide
IgG antibodies (post-exposure)
Blood lymphocyte subpopulations
- Total lymphocyte count
- T lymphocytes (CD3, CD4, and CD8)
- B lymphocytes (CD19 and CD20)
- CD4/CD8 ratio
- Blood (bacterial culture, HIV by PCR, HTLV testing)
- Urine (testing for cytomegalovirus, sepsis, and proteinuria)
- Nasopharyngeal swab (testing for rhinovirus)
- Stool (testing for viral, bacterial or parasitic infection)
- Sputum (bacterial culture and pneumocystis PCR)
- Cerebrospinal fluid (culture, chemistry, and histopathology)
Most human vaccines are administered by injection, although this approach is risky in the developing world where the use of injections can transmit diseases such as HIV infections. Live vaccines can be given orally but not killed vaccines. Alternatively, the use of the oral route and other mucosal surfaces have been explored as immunization route. For example, polio vaccination underwent a successful implementation via the oral route.
Attenuated vaccines have several potential safety issues, including:
- Hypersensitivity to viral antigens (measles)
- Hypersensitivity to egg antigens (mumps)
- Persistent infection (varicella-zoster)
- In an immunodeficient patient, it may cause severe disease (BCG)
Killed vaccine safety issues include:
- Yeast contaminant (hepatitis B)
- Contamination with animal viruses (polio)
- Endotoxin contamination (pertussis)
All vaccines have as contraindications severe allergic reactions (e.g., anaphylactic reaction) after a previous dose or to a vaccine component. DTaP should contraindicate if the child develops encephalopathy within seven days of administration of a prior dose of DTP or DTaP and after ruled out other causes of brain illness. Hepatitis B vaccine contraindicates in patients with hypersensitivity to yeast. Hib vaccine is contraindicated in infants aged less than six weeks.
MMR vaccine is avoided in those with a known severe immunodeficiency due to lymphoid malignancies, congenital cause, chemotherapy, family history of immunosuppression, and in patients with HIV/AIDS. Rotavirus vaccine must contraindicate in children with a history of intussusception, and it should use with precaution in altered immunocompetence, other than severe combined-immunodeficiency disorder. Both varicella and zoster vaccines contraindicate in immunocompromised host and pregnancy. Live-attenuated influenza virus vaccine should be avoided when in the previous 48 hours, a patient has taken influenza antiviral medication; dosing should proceed with caution in patients who developed Guillain-Barre syndrome within six weeks after a prior dose of influenza vaccine and in patients who have asthma.
Most vaccines have adverse reactions as any drug or medication. For example, BCG vaccination may provoke fever, vomiting, hematuria, lymphadenitis, and redness at the site of injection. HiB vaccine has few adverse reactions, and none of them are dangerous. These reactions include redness, warmth, swelling, and fever over 101 degrees F. A rare and lethal adverse reaction secondary to vaccination is the Guillain-Barre syndrome.
Anaphylactic reactions are examples of allergic reaction that can affect individuals that vaccinated. They can treat with aqueous epinephrine 1 to 1000 dilution intramuscularly (IM), 0.01 mL/kg/dose. The adult dose can range from 0.3 mL to 0.5 mL. Optional treatment is the use of an H1 antihistamine for skin reactions (hives or itching). It can administer diphenhydramine (either orally or IM). Inject a dosage of 1 to 2 mg/kg every 4 to 6 hours, up to 50 mg) or hydroxyzine 0.5 to 1 mg/kg every 4 to 6 hours up to 100 mg.
The dosage of epinephrine can repeat every 5 to 15 minutes for up to 3 doses, depending on the clinical picture. Record the patient’s reaction, the medications, and the health care provided to the patient, and the name of the personnel who administer the drug.
Enhancing Healthcare Team Outcomes
An interprofessional team of scientists and healthcare professionals produces vaccines. Once the FDA approves the vaccines, it can be manufactured on a large scale by biotechnologists. In the healthcare setting, a pediatrician or family doctor orders or restricts the use of the immunization in a child. Nurses or pharmacists often carry out the immunization procedure. Side effects of the vaccines can monitor by primary care physicians, pharmacists, and nurses, and when adverse events occur, they need to be communicated to the rest of the team. The emergency service plays a vital role in cases of allergic reactions, including anaphylaxis, where it brings together primary health care services with secondary or tertiary healthcare institutions. The treating clinician, along with nursing and pharmacy, needs to manage the patient's vaccine record and ensure that they remain up to date. Only with this type of collaborative interprofessional effort can vaccinations be as effective as they need to be in preventing disease, both for the individual patient as well as in the public health arena for transmissible pathogens. [Level 5]