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Source: Hayney MS. Vaccines, Toxoids, and Other Immunobiologics. In: DiPiro, JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM. Pharmacotherapy: A Pathophysiologic Approach. 8th ed. http://accesspharmacy.com/content.aspx?aid=8006646. Accessed July 26, 2012.

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  • Immunization: process of introducing antigen into body to induce protection against infectious agent without causing disease.
    • Antigens: substances that induce immune response.
      • Humoral immune response produces antibodies that can be measured.
      • Cellular immune response important but not measurable.
  • Vaccines: substances administered to generate protective immune response.
    • Can be live attenuated or killed.
  • Toxoids: inactivated bacterial toxins that retain ability to stimulate formation of antitoxins, antibodies directed against bacterial toxin.
  • Adjuvants: inert substances, such as aluminum salts (i.e., alum), which enhance vaccine antigenicity by prolonging antigen absorption.
  • Immune sera: sterile solutions containing antibody derived from human (immunoglobulin [Ig]) or equine (antitoxin) sources.

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  • CDC has comprehensive immunization schedules for children and adults.
  • Factors affecting response to immunization
    • Viability of antigen (live attenuated vs. inactivated)
    • Total dose
      • Interval between immunization doses
      • Number of doses given
    • Route and site of administration
    • Host factors
      • Immunocompromised
      • Increasing age
      • Underlying disease
      • Genetic background
  • Administration
    • In general, inactivated vaccines can be administered simultaneously at separate sites.
    • Inactivated and live attenuated vaccines may be administered simultaneously at separate sites.
    • If live vaccines not administered simultaneously, their administration should be separated by at least 4 weeks.

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  • Infants
    • Live vaccines not administered until maternal antibodies have waned, generally by age 12 months.
    • Premature infants should be vaccinated at same chronologic age using same schedule and precautions for full-term infants (Table 1).
  • Pregnant women and postpartum immunization
    • Most vaccines are pregnancy category C due to lack of information.
    • Administration of live attenuated vaccines should not be done during pregnancy; inactivated vaccines may be administered to pregnant women when benefits outweigh risks.
      • Universal influenza immunization recommended for women who will be or are pregnant during influenza season.
    • Administration of live vaccines, such as rubella or varicella, deferred until postpartum.
  • Immunocompromised hosts
    • In general, severely immunocompromised individuals should not receive live vaccines.
    • Patients with chronic conditions that cause limited immunodeficiency (e.g., renal disease, diabetes, liver disease, and asplenia) and who are not receiving immunosuppressants may receive live attenuated and killed vaccines, as well as toxoids.
    • Patients with active malignant disease can receive killed vaccines or toxoids but should not be given live vaccines.
    • Glucocorticoids may cause suppressed responses to vaccines.
      • Wait 1 month to administer live vaccines if on high-dose corticosteroids or treatment course longer than 2 weeks.
    • HIV patients
      • Responses to live and killed vaccines generally suboptimal for HIV–infected patients and decrease as disease progresses.
    • Transplant patients

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  • General contraindications
    • History of anaphylactic reaction to vaccine or component of vaccine.
    • Unexplained encephalopathy occurring within 7 days of dose of pertussis vaccine is contraindication to future doses.
    • Immunosuppression and pregnancy temporary contraindications to live vaccines.
  • Precautions for diphtheria, tetanus toxoids, and acellular pertussis (DtaP)
    • Hypotonic hyporesponsive episode
    • Fever of ≥40.5°C (≥104.9°F)
    • Crying lasting >3 hours within 48 hours of previous dose
    • Seizures with or without fever ...

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