Vaccinations in Adults

Featured in the April, 2015 Scleroderma, Vasculitis & Myositis eNewsletter

Barry D. Brause, MD
Barry D. Brause, MD
Attending Physician, Hospital for Special Surgery
Director of Infectious Diseases, Hospital for Special Surgery
Professor of Clinical Medicine, Weill Cornell Medical College
Michael W. Henry, MD
Michael W. Henry, MD
Assistant Attending Physician, Hospital for Special Surgery
Assistant Professor of Clinical Medicine, Weill Cornell Medical College

There are many diseases for which there are preventative vaccines available. The Centers for Disease Control makes specific recommendation regarding when and to whom these vaccines should be given. Michael Henry, MD and Barry Brause, MD with the HSS Center for Infection Diseases explain vaccine recommendations for adults, including some recent additions to the guidelines.

Vaccine-Preventable Infections

A vaccine-preventable infection is an infection for which there is a vaccine available that can help keep a patient from developing the infection. In some cases, as with the Influenza vaccine, the vaccine can at least reduce the symptoms and severity of an illness, even if the disease itself cannot always be fully prevented. The following is an updated list of commonly given vaccines, and the infections they protect against.

Common Vaccines:

  • Influenza: Since the influenza vaccines change every year, the influenza vaccine needs to be given every year. Also, the present vaccines confer immunity which is protective for approximately only 6 months. This vaccine helps to reduce the occurrence and severity of influenza
  • Pneumovax + Prevnar: These two vaccines prevent infections caused by Streptococcus pneumonia. This bacterium is the most common cause of bacterial pneumonia and meningitis in adults.

  • TdaP: This protects again three infections: Tetanus, diphtheria, and pertussis. Pertussis is the bacteria that causes Whooping Cough. There has been a sharp rise in the number of children and adults diagnosed with Whooping cough over the past decade in the United States.

  • Zostavax: Reduces the occurrence of shingles, a painful rash that is caused by the same virus that causes chicken pox.

  • MMR: Protects again measles, mumps, and rubella (German measles). The vaccine is often received in childhood. However, as an adult you may need a booster. This should be discussed with your doctor.

Vaccinations in Adults with the Scleroderma, Vasculitis, and Myositis

Patients with scleroderma, vasculitis or myositis are at increased risk for vaccine-preventable infections. This is in part due to the effect of these illnesses on the immune system. Mostly, however, this risk is a result of the immunosuppressive medications used for treatment, including steroids like prednisone.

Immunosuppressive medications treat scleroderma, vasculitis and myositis by altering or damping the patient’s immune system. This weakening of the immune system can be highly beneficial in treating these illnesses. However, it can increase the risk of developing infections, many of which are vaccine-preventable.

The effectiveness of the vaccine depends greatly on the recipient’s ability to develop an immune response to the vaccine. If the immune system is not functioning well, the body may not develop a strong immune response to the vaccine. Therefore, the recipient may not develop full protection and the benefit of the vaccine will be diminished or lost.

Types of Vaccines:

Vaccines can be divided into two basic groups: Killed vaccines and Live vaccines.

A Killed vaccine does NOT contain any living virus or bacteria. A person receiving a killed vaccine cannot become infected by the vaccine.

A Live vaccine contains a living, but weakened, form  of a virus or bacteria. The risk of developing an actual infection from a live vaccine is extremely low. However, this risk does increase in patients who are taking medications which suppress the immune system. In some instances, a live vaccine will need to be withheld because of this risk. This can be an important consideration in patients being treated for scleroderma, vasculitis or myositis.

It is important to remember that the vast majority of vaccines given to adults are Killed vaccines, and therefore cannot cause an infection.

It is also important to remember that scleroderma, vasculitis and myositis by themselves do not make anyone ineligible to receive a vaccine -t his includes Live vaccines.

Who Gets Which Vaccines and When?

The type of vaccines you will need will be based on your age, prior medical history, especially your history of prior infections, current pregnancy status, and current medications – especially if you are taking immunosuppressive medications. In addition, the recommendations for vaccines are updated over the years, and new vaccines are introduced. Your doctor may wish to vaccinate before immunosuppressive treatment is started, or may wish to wait until the treatment is completed and allow your immune system to recover. This will increase the likelihood that you will develop a good response to the vaccine and it will reduce the potential of developing an infection from a live vaccine

You should review with your doctor which vaccines you should be receiving and when. A considerable amount information regarding vaccinations is available on the CDC’s web site.

Vaccines Commonly Given to Adults

Influenza Vaccine

Influenza is an unpredictable respiratory virus. It has the capacity to cause a large amount of inflammation of the larynx, trachea and bronchi. It can damage and weaken the cells lining your respiratory tract, so they will not protect you to the same degree. This creates greater risk of developing influenza pneumonia and bacterial pneumonia. Influenza infections can also exacerbate underlying chronic lung diseases, like asthma and emphysema.

Transmission

Influenza may be transmitted through saliva, nasal secretions and feces. Sneeze and cough particles can travel up to three feet. An infected person is contagious 24 hours prior to and up to seven days after symptoms of onset of the disease. Viruses can also continue to live days to weeks on dry surfaces. A person is most likely to be exposed through touching a contaminated surface and then touching one’s nose, eyes or mouth.

Prevention

Transmission of influenza can be prevented by thorough and frequent hand-washing and coughing into a barrier such as a tissue or elbow. One should stay informed about the flu season, avoid touching eyes, nose and mouth, and avoid close contact with those who are infected, even if that person is on anti-viral therapy, and should stay home if ill. Lastly, one can get vaccinated!

Side Effects of Influenza Vaccines:

  • Pain and inflammation at injection site
  • 5% experience fever and 3-12% experience malaise
  • 2-9% experience myalgias (muscle pain) and 5-6% experience arthralgias (joint pain)
  • These side effects can begin 6 hours after vaccination and can persist for 2 days [Resolve with aspirin, Tylenol, NSAIDs (such as ibuprofen)]
  • Allergies such as hives may occur, but these reactions are rare unless you are allergic to eggs
  • Guillain-Barré syndrome may occur, but the incidence is very low

Herpes Zoster (Shingles) Vaccine

Herpes Zoster (Shingles) is the reactivation of the chicken pox (varicella) virus and occurs more frequently as we age, since the immune system loses some strength as we get older. Taking immunosuppressive agents increases the risk for shingles as well. Once a person gets chicken pox and recovers from it, the virus continues to stay in the body forever, residing within specific types of nerve cells. At some point in life, the virus might start to reactivate in the nerve cells, causing a band-like painful rash on the body surface. After the reactivation of the virus resolves, some patients can continue to experience severe pain in the area where they had the rash. This pain, called post-herpetic neuralgia, can persist for weeks or months after the rash resolves. Treatment with anti-viral medications as soon as shingles is diagnosed can reduce the duration of the rash and the occurrence of post-herpetic neuralgia.

Herpes Zoster can also lead to other serious complications, including ophthalmic zoster, which is the involvement of the ophthalmic division of the trigeminal nerve and the eye and disseminated zoster which causes wide spread skin eruptions and multi-organ involvement, potentially including the central nervous system, lung, liver, and pancreas.

The Herpes Zoster vaccine can help prevent shingles from occurring, but it is not 100% effective. However, when a person who has previously received the Herpes Zoster vaccine does develop shingles, the vaccine reduces the likelihood of developing post-herpetic neuralgia. The ability of the Herpes Zoster vaccine to prevent shingles can decrease as we age. However, its ability to prevent post-herpetic neuralgia does remains constant.

Screening for Herpes Zoster Vaccine Eligibility

Screening for a history of chickenpox is not necessary in order to administer the vaccine to a person 50 years of age or older. Those who were born in the United States before 1980 are assumed to have been exposed to chickenpox regardless of their recollection of chickenpox.

Timing of Vaccination

For those anticipating receiving an immunosuppressive medication, the Zoster vaccine should be administered at least 14 days before initiation of immunosuppressive therapy, although some experts advise waiting a full month after zoster vaccination to begin immunosuppressive therapy. The herpes zoster vaccine cannot be given to patients on certain immunosuppressive therapies. Please speak to your doctor about when it would be safe the best time for you to receive the Zoster Vaccine.

Tetanus, Diphtheria and Acellular Pertussis (Tdap) Vaccine

Tetanus is a disease caused by bacteria that enters the body through breaks in the skin, and the symptoms are characterized by painful muscle spasms, breathing problems and paralysis.

Diphtheria is a disease that causes a thick coating in the back of the nose or throat, making it difficult to breathe and swallow. It may also attack the heart and nerves.

Pertussis, also called “whooping cough” is highly contagious, causing a respiratory infection with prolonged, distinct coughing, and remains incompletely controlled in the U.S. There is currently a worldwide epidemic of pertussis.

It is recommended that this vaccine be given once in adulthood. It is not a live virus vaccine.

Side Effects of Tdap Vaccine

Pain (67%), redness, swelling at injection site (20%); fever (1%), headache (40%), tiredness (33%), nausea, vomiting, diarrhea (1-3%), chills, body/joint aches, rash, swollen glands.

Patients are advised not to take this vaccine if they have had a life-threatening allergic reaction after a dose of any tetanus, diphtheria or pertussis-containing vaccines or if they have had a severe allergy to any part of this vaccine.

Patients should not take this vaccine if they have had a coma or multiple seizures within 7 days after a childhood dose of DTP or Dtap. In addition, those who have epilepsy, other nervous system problems, or patients who have ever had Guillain-Barre Syndrome should check with their doctors before taking this vaccine. However, bad reactions to this vaccine are very uncommon.

Pneumococcal Vaccines

Pneumococcal Infections: Streptococcus pneumonia (pneumococcus) is a major cause of vaccine-preventable illness and death in the US. Pneumococcal Infections can cause pneumonia, blood infections, meningitis and other respiratory infections. They are transmitted from person to person by respiratory droplets, and can be spread by a cough. Those who are at greater risk include those 65 years old and older, people with heart or lung disease, asthma, sickle cell disease, diabetes, smoking, alcoholism, cirrhosis, cerebrospinal fluid (CSF) fluid leaks, cochlear implants, lymphoma, leukemia, kidney failure, HIV infection, damaged or no spleen, and immunosuppressive diseases and treatment.

Two Vaccines for Pneumococcus in Adults: In August of 2014, the CDC recommended Prevnar for routine use in all adults 65 years and over. Prevnar is vaccine against infections caused by Streptococcus pneumoniae, which is the leading bacterial cause of pneumonia and meningitis in the United States. This vaccine will be given in addition to the Pneumovax vaccine, another vaccine again pneumococcal disease which is already recommended routinely to all adults 65 and over. The combination of the two vaccines in adults provides better protection that either of the vaccines alone. Prevnar has been routinely used in children in the US since 2000.

In healthy adults 65 and older, both Prevnar and Pneumovax only need to be given once. Prevnar should be given first, followed by Pneumovax some months later which you need to discuss with your doctor If Pneumovax is given first, you will then need to wait at least 1 year before receiving Prevnar.

Both Prevnar and Pneumovax are also recommended for adults younger than 65 if they have certain medical conditions, including treatment with certain medications that suppress the immune system. If you are on treatment that suppresses the immune system and are younger than 65, you should ask your doctor if you should receive Prevnar, Pneumovax, or both.

Important Facts About Vaccines to Remember

Each vaccine has its own schedule. Some vaccines, like the influenza vaccine, need to be given every year. Other vaccines may only need to be given once, and yet others will require boosters periodically.

You can receive a vaccination even if you are taking an antibiotic (the lone exception is when receiving the oral Typhoid vaccine).

It is safe to receive more than one vaccine in a single visit. Some vaccines however, like Prevnar and Pneumovax, cannot be given on the same day.

If you are planning to travel abroad, consult your physician regarding any pre-travel vaccines you might need to take. The CDC’s web site provides very comprehensive information regarding what vaccines are recommended depending on the countries you are planning to visit.

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