(Test Bank) Nurse Practitioner Certification Examination and Practice Preparation Testbank by Margaret A. Fitzgerald

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Nurse Practitioner Certification Examination and Practice Preparation Testbank by Margaret A. Fitzgerald Answers Health Promotion and Disease Prevention 1. An example of a primary prevention measure for a 78- year-old man with chronic obstructive pulmonary disease is: A. reviewing the use of prescribed medications. B. conducting a home survey to minimize fall risk. C. checking FEV1 (force expired volume at 1 second) to FVC (forced vital capacity) ratio. D. ordering fecal occult blood test (FOBT). 2. Which of the following is an example of a primary preven - tion activity in a 76-year-old woman with osteoporosis? A. bisphosphonate therapy B. calcium supplementation C. ensuring adequate illumination in the home D. use of a back brace 3. Secondary prevention measures for a 78-year-old man with chronic obstructive pulmonary disease include: A. screening for mood disorders. B. administering influenza vaccine. C. obtaining a serum theophylline level. D. advising about appropriate use of car passenger restraints. 4. Tertiary prevention measures for a 69-year-old woman with heart failure include: A. administering antipneumococcal vaccine. B. adjusting therapy to minimize dyspnea. C. surveying skin for precancerous lesions. D. reviewing safe handling of food. 5. Which of the following products provides passive immunity? 6. Active immunity is defined as: A. resistance developed in response to an antigen. B. immunity conferred by an antibody produced in another host. C. the resistance of a group to an infectious agent. D. defense against disease acquired naturally by the infant from the mother. 7. Which of the following is usually viewed as the most cost-effective form of healthcare? A. primary prevention B. secondary prevention C. tertiary prevention D. cancer -reduction measures 8. An 18-year-old woman with allergic rhinitis presents for primary care. She is sexually active with a male partner and is 1 year post -coitarche; during this time she had had two sex partners. An example of a primary prevention activity for this patient is: A. screening for sexually transmitted infection. B. counseling about safer sexual practices. C. prescribing therapies for minimizing allergy. D. obtaining a liquid -based Papanicolaou (Pap) test. 9. When a critical portion of a community is immunized against a contagious disease, most members of the com- munity, even the unimmunized, are protected against that disease because there is little opportunity for an outbreak. This is known as immunity. A. passive B. humoral C. epidemiologic D. community A. hepatitis B immune globulin (HBIG) B. measles, mumps, and rubella (MMR) vaccine 1. B. 4. B. 7. A. C. pneumococcal conjugate vaccine 2. C. 5. A. 8. B. D. live attenuated influenza vaccine (LAIV) 3. A. 6. A. 9. D. 1 Primary Prevention Measures 1 2 C H A P T E R 1 ■ Health Promotion and Disease Prevention Primary prevention measures include activities provided to individuals to prevent the onset or acquisition of a given disease. The goal of primary prevention measures is to spare individuals the suffering, burden, and cost associated with the clinical condition and is the first level of healthcare. An ex - ample is health -protecting education and counseling, such as encouraging the use of car restraints and bicycle helmets, counseling about safer sexual practices, and providing infor - mation on accident and fall prevention. Given its focus on preventing illness or injury, primary prevention is usually viewed as the most effective form of healthcare. Immunizations and chemoprophylaxis are also exam - ples of primary prevention measures. Active immu nization through the use of vaccines provides long -term protection from disease. In herd or community immunity, a significant portion of a given population has immunity against an infec - tious agent; the likelihood that the susceptible portion of the group would become infected is minimized (Fig. 1 –1). Pas - sive immunity is provided when a person receives select an - tibodies, usually via the administration of immune globulin (IG), after exposure to an infective agent. This immunity is temporary and requires the patient to present post-exposure; the protection provided by IG usually starts within hours of receiving the doses and lasts a number of months. The use of vaccines to produce lasting disease protection is preferred to passive immunization through the use of IG. Another exam - ple of passive immunity is the acquisition of disease protec - tion provided from mother to unborn child via the placenta. Secondary prevention measures include activities provided to identify and treat asymptomatic persons who have risk fac- tors for a given disease or in preclinical disease. Examples in- clude screening examinations for preclinical evidence of cancer, such as mammography and cervical examination with a Papanicolaou test. Other examples of secondary prevention activities include screening for clinical conditions with a pro- tracted asymptomatic period, such as a blood pressure meas - urement to detect hypertension and a lipid profile to detect hyperlipidemia (Table 1–1). See full color images of this topic on DavisPlus at http://davisplus.fadavis.com | Keyword: Fitzgerald Tertiary prevention measures are part of the management of an established disease. The goal is to minimize disease - associated complications and the negative health effects of the conditions to the patient. Examples include medications and lifestyle modification to normalize blood glucose levels in individuals with diabetes mellitus and in conjunction with the treatment of heart failure, aimed at improving or mini - mizing disease -related symptoms. DISCUSSION SOURCES http://www.cdc.gov/excite/skincancer/mod13.htm, Centers for Disease Control and Prevention: Levels of Prevention http://www.niaid.nih.gov/topics/pages/communityimmunity.aspx, National Institute of Allergy and Infectious Disease: Community Immunity 10. When advising a patient about injectable influenza im- munization, the nurse practitioner (NP) considers the following about the use of this vaccine: A. Its use is not recommended in sickle cell anemia. B. Its use is limited to children older than 2 years. C. Its use is limited due to containing live virus. D. Its use is recommended for virtually all members of the population. 11. A middle -aged man with chronic obstructive pul- monary disease who is about to receive injectable in- fluenza vaccine should be advised that: A. it is more than 90% effective in preventing influenza. B. its use is contraindicated in the presence of psoriasis vulgaris. C. localized reactions such as soreness and redness at the site of the immunization are fairly common. D. a short, intense, flulike syndrome typically occurs after immunization. 12. A 44-year-old woman with asthma presents asking for a “flu shot.” She is seen today for an urgent care visit, is diagnosed with a lower urinary tract infection, and is prescribed trimethoprim -sulfamethoxazole. She is without fever or gastrointestinal upset with stable respiratory status. You inform her that she: A. should return for the immunization after complet - ing her antibiotic therapy. B. would likely develop a significant reaction if immu - nized today. C. can receive the immunization today. D. is not a candidate for any form of influenza vaccine. 13. Which of the following statements best describes amantadine or rimantadine use in the care of patients with or at risk for influenza? A. Significant resistance to select strains of influenza limits the usefulness of these medications. B. The primary action of these therapies is in prevent - ing influenza A during outbreaks. C. These therapies are active against influenza A and B. D. The use of these products is an acceptable alternative to influenza vaccine. 14. Which of the following statements best describes zanamivir (Relenza) or oseltamivir (Tamiflu) use in the care of patients with or at risk for influenza? A. Initiation of therapy early in acute influenza illness can help minimize the severity of disease when the illness is caused by a nonresistant viral strain. B. The primary indication is in preventing influenza A during outbreaks. C. The drugs are active only against influenza B. D. The use of these medications is an acceptable alter - native to influenza vaccine. Influenza Immunization Section 1: Preventive Services Recommended by the USPSTF The U.S. Preventive Services Task Force (USPSTF) recommends that clinicians discuss these preventive services with eligible patients and offer them as a priority. All these services have been given “A” or a “B” (recommended) grade from the Task Force. Recommendation Adults Special Populations Men Women Pregnant Women Children Abdominal Aortic Aneurysm, Screening Alcohol Misuse Screening and Behavioral Counseling Interventions Asymptomatic Bacteriuria in Adults, Screening Breast and Ovarian Cancer Susceptibility, Genetic Risk Assessment and BRCA Mutation Testing Breast Cancer, Screening Breastfeeding, Primary Care Interventions to Promote Cervical Cancer, Screening Chlamydial Infection, Screening Colorectal Cancer, Screening Congenital Hypothyroidism, Screening Depression in Adults, Screening Diabetes Mellitus (Type 2) in Adults, Screening Folic Acid to Prevent Neural Tube Defects Gonococcal Ophthalmia Neonatorum, Preventive Medication Figure 1-1 Preventive services recommended by the U.S. Preventive Services Task Force (USPSTF). Available at http://www.ahrq.gov/clinic/ pocketgd2012/gcp12s1.htm. Continued Section 1: Preventive Services Recommended by the USPSTF (continued) Recommendation Adults Special Populations Men Women Pregnant Women Children Gonorrhea, Screening 🗸 🗸 Hearing Loss in Newborns, Screening 🗸 Hepatitis B Virus in Pregnant Women, Screening 🗸 High Blood Pressure (Adults), Screening 🗸 🗸 HIV, Screening 🗸 🗸 🗸 🗸 Iron Deficiency Anemia, Prevention 🗸 Iron Deficiency Anemia, Screening 🗸 Lipid Disorders in Adults, Screening 🗸 🗸 Major Depressive Disorder in Children, Screening 🗸 Obesity in Children and Adolescents, Screening 🗸 Osteoporosis, Screening 🗸 Phenylketonuria, Screening 🗸 Rh (D) Incompatibility, Screening 🗸 Sexually Transmitted Infections, Counseling 🗸 🗸 🗸 Sickle Cell Disease, Screening 🗸 Syphilis Infection, Screening 🗸 🗸 Syphilis Infection in Pregnancy, Screening 🗸 Tobacco Use in Adults and Pregnant Women, Counseling 🗸 🗸 🗸 Visual Impairment in Children Ages 1 to 5, Screening 🗸 Figure 1 -1—cont’d 5 C H A P T E R 1 ■ Health Promotion and Disease Prevention Answers TABLE 1-1 Secondary Prevention Principles Principle Prevalence is sufficient to justify screening. Health problem has significant effect on quality or quantity of life. The target disease has a long asymptomatic period. The natural history of the disease, or how the disease un - folds without intervention, is known. A population -acceptable screening test is available. Comment Routine mammography is appropriate in women but not men. Target diseases for secondary prevention include hyperten - sion, type 2 diabetes mellitus, dyslipidemia, and certain cancers. Treatment is available for the target disease. Providing treatment alters the disease’s natural history. The test should be safe, should be available at a reason - able cost, and have reasonable sensitivity and specificity. Source: http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/preventive -medicine/principles - of-screening/, Principles of Screening 15. When advising a patient about the influenza nasal spray vaccine, the NP considers the following: A. Its use is acceptable during pregnancy. B. Its use is limited to children younger than 6 years. C. It contains live, attenuated virus. D. This is the preferred method of influenza protection in the presence of airway disease. 16. Approximately of healthcare providers receive in - fluenza immunization annually. A. one-quarter B. one-half C. two-thirds D. three -quarters or more 17. The most common mode of influenza virus transmission is via: A. contact with a contaminated surface. B. respiratory droplet. C. saliva contact. D. skin-to-skin contact. 18. In an immunocompetent adult, the length of incuba - tion for the influenza virus is on average: A. less than 24 hours. B. 1 to 4 days. C. 4 to 7 days. D. more than 1 week. 19. Influenza protection options for a 62-year-old man with hypertension, dyslipidemia, and type 2 diabetes mellitus include receiving: A. live attenuated influenza vaccine via nasal spray. B. high -dose trivalent inactivated vaccine (TIV) via in- tramuscular injection C. trivalent inactivated vaccine (TIV) in standard dose via intramuscular injection. D. appropriate antiviral medication as the initial onset of influenza -like illness. 20. Which of the following should not receive vaccination against influenza? A. a 19 year-old with a history of hive-form reaction to eating eggs B. a 24-year-old woman who is 8 weeks pregnant C. a 4-month -old infant who was born at 32 weeks of gestation D. a 28-year-old woman who is breastfeeding a 2 week old. 21. A healthy 6-year-old girl presents for care. Her parents request that she receive vaccination for influenza and report that she has not received this vaccine in the past. How many doses of influenza vaccine should she re - ceive this flu season? A. 1 B. 2 C. 3 D. 4 10. D. 14. A. 18. B. 11. C. 15. C. 19. C. 12. C. 16. D. 20. C. 13. A. 17. B. 21. B. An individual who presents with an abrupt onset of signs and symptoms including fever, myalgia, headache, malaise, non- productive cough, sore throat, and rhinitis typically has un - complicated influenza illness, more commonly known as “the flu.” Children with influenza commonly have acute otitis media, nausea, and vomiting in addition to the aforemen - tioned signs and symp toms. Although the worst symptoms in most uncomplicated cases resolve in about 1 week, the cough and malaise often persist for 2 or more weeks. Individuals with ongoing health problems such as pulmonary 6 C H A P T E R 1 ■ Health Promotion and Disease Prevention or cardiac disease, young children, and pregnant women also have increased risk of influenza -related complications includ - ing pneumonia. Rarely, influenza virus infection also has been associated with encephalopathy, transverse myelitis, myositis, myocarditis, pericarditis, and Reye syndrome. Influenza viruses spread from person to person largely via respiratory droplet from an infected person, primarily through a cough or sneeze. In an immunocompetent adult, the influenza virus has a short incubati on period, with a range of 1 to 4 days (average of 2 days). Adults pass the illness on 1 day before the onset of symptoms and continue to remain infectious for approximately 5 days after the onset of the illness. Children remain infectious for 10 or more d ays after the onset of symptoms and can shed the virus before the onset of symptoms. People who are immunocompromised can remain infectious for up to 3 weeks. Historically, the risks for complications, hospitalizations, and deaths from influenza are higher among adults older than age 65 years, young children, and individuals of any age with certain underlying health conditions than among healthy older children and younger adults. In children younger than 5 years, hospital ization rates for influenza - related illness have ranged from approximately 500/100,000 for children with high -risk medical conditions to 100/100,000 for children without high -risk medical conditions. Hospital - ization rates for influenza -related illness among children younger than 24 months are comparable to rates reported among adults older than 65 years. Influenza strains such as H1N1, an influenza A virus also known as swine flu, and H5N1, an influenza A virus also known as avian flu, appear to cause a greater disease burden in younger adults. Considering these factors, influenza, regardless of the viral strain, is not just a bad cold, but rather a potentially serious illness with significant morbidity and mortality risk across the life span. Even in the absence of complications, this viral illness typically causes many days of incapacitation and suf - fering and the risk of death. The influenza vaccines are about 70% to 80% effective in preventing influenza or reducing the severity of the disease. The injectable vaccine does not contain live virus and is not shed; there is no risk of transmitting an infectious agent to household contacts. Mild to moderate ill - ness or current antimicrobial therapy is not a contraindica - tion to any immunization, including the administration of the influenza vaccine. Immunization rates against influenza for individuals with chronic illness are typically the highest, although there is con- siderable room for improvement. Certain groups have very low immunization rates and should be targeted for improvement. These include persons who live with or care for persons at high risk for influenza -related mortality and morbidity. Persons who provide essential community services should be consid - ered for vaccination to minimize disruption of essential activ - ities during influenza outbreaks. Students and other persons in institutional or other group -living situations should be en- couraged to receive vaccine to minimize the risk of an outbreak in a relatively closed community. According to the recommen - dation of the Centers for Disease Prevention and Control (CDC), all members of the population age 6 months and older should receive annual immunization against seasonal in- fluenza. If supply of influ enza vaccines is limited, certain groups at highest risk of influenza complication or transmis - sion should be prioritized for immunization. (Table 1–2). TABLE 1-2 Advisory Committee on Immunization Practices (ACIP) Recommendations on Influenza Immunization Routine influenza vaccination is recommended for all persons aged 6 months and older. While everyone should get a flu vaccine each flu season, certain patient populations are at high risk of having serious flu-related complications or live with or care for people at high risk for developing flu-related complications. Populations include: • All children aged 6 through 59 months. • Adults and children who have chronic pulmonary (including asthma) or cardiovascular (except isolated hypertension), renal, hepatic, neurological, hematologic, or metabolic disorders (including diabetes mellitus). Individuals age 50 years of age and older. • Persons who have immunosuppression (including immunosuppression caused by medications or by HIV infection). • Women who are or will be pregnant during the influenza season. • Children and adolescents (aged 6 months – 18 years) who are receiving long-term aspirin therapy and who might be at risk for experiencing Reye’s syndrome after influenza virus infection. • Residents of nursing homes and other long-term care facilities. • American Indians/Alaska Natives. • Persons who are morbidly obese (BMI 40) kg/m2. • People who live with or care for those at high risk for complications from flu, including: • Healthcare workers. • Household contacts of persons with medical conditions that put them at high risk for complications from the flu. • Household contacts and out of home caregivers of children aged 59 months and adults aged 50 years, with par - ticular emphasis on vaccinating contacts of children less than 6 months of age. (These children are too young to be vaccinated.) 7 C H A P T E R 1 ■ Health Promotion and Disease Prevention TABLE 1-2 Advisory Committee on Immunization Practices (ACIP) Recommendations on Influenza Immunization —cont’d All children aged 6 months to 8 years who receive a seasonal influenza vaccine for the first time should receive 2 doses spaced 4 weeks apart . There are a variety of vaccines to protect against influenza currently available. • Trivalent inactivated vaccine (TIV) in standard dose administered intramuscularly approved for all ages 6 months who have no other contraindications. This is the typical “flu shot.” A quadrivalent inactivated vaccine is also available. • Intradermal TIV in a lower dose when compared to standard flu vaccine administered IM (9 mcg rather than 15 mcg of each strain per dose) in a smaller volume (0.1 mL rather than 0.5 mL) approved for use in adults 18 to 64 years of age, with a preferred injection site over the deltoid. • Inactivated TIV containing a greater dose of antigen when compared to standard flu vaccine (60 mcg rather than 15 mcg per dose) approved for use in adults age 65 years • Live, attenuated influenza vaccine (LAIV) via nasal spray: A flu vaccine made with live, weakened flu viruses that is given as a nasal spray. The viruses in the nasal spray vaccine do not cause the flu. LAIV (trivalent or quadrivalent) is approved for use in healthy individuals, excluding pregnant women, ages 2 through 49 years. • A trivalent cell culture -based inactivated influenza vaccine, which is indicated for persons aged 18 through 49 years. • A recombinant hemagglutinin (HA) vaccine, which is indicated for persons aged 18 through 49 years. The following recommendations apply when considering influenza vaccination of persons who have or report a history of egg allergy. 1. Persons who have experienced only hives following exposure to egg should receive influenza vaccine. Because little data are available for use of LAIV in this setting, IIV (inactivated influenza vaccine) or RIV (recombinant influenza vaccine) should be used. RIV is egg-free and indicated for persons 18–49 years of age. IIV (egg- or cell-culture -based) can also be used with the following additional safety measures: • Vaccine should be administered by a healthcare provider who is familiar with the potential manifestations of egg allergy. • Vaccine recipients should be observed for at least 30 minutes for signs of a reaction following administration of each vaccine dose. 2. Persons who report having had reactions to egg involving angioedema, respiratory distress, lightheadedness, or recurrent emesis, or persons who required epinephrine or other emergency medical intervention may receive RIV3, if aged 18–49 years and there are no other contraindications. If RIV3 is not available or the recipient is not within the indicated age range, such persons should be referred to a physician with expertise in the management of allergic conditions for further risk assessment before receipt of the vaccine. 3. All vaccines should be administered in settings in which personnel and equipment for rapid recognition and treat- ment of anaphylaxis are available. 4. Some persons who report allergy to egg might not be egg allergic. Those who are able to eat lightly cooked egg (scrambled eggs) without reaction are unlikely to be allergic. Conversely, egg -allergic persons might tolerate egg in baked products (bread, cake other bakery products); tolerance to egg-containing foods does not exclude the possibil - ity of egg allergy. Egg allergy can be confirmed by a consistent medical history of adverse reactions to eggs and egg-containing foods, plus skin and/or blood testing for immunoglobulin E antibodies to egg proteins. 5. For individuals who have no known history of exposure to egg, but who are suspected of being egg-allergic on the basis of previously performed allergy testing, consultation with a physician with expertise in the management of allergic conditions should be obtained prior to vaccination. Alternatively, RIV3 may be administered if the recipient is aged 18–49 years. 6. A previous severe allergic reaction to influenza vaccine, regardless of the component suspected to be responsible for the reaction, is a contraindication to receipt of influenza vaccine. Source: http://www.cdc.gov/flu/professionals/acip/2013 -summary -recommendations.htm The Advisory Committee on Immunization Practices (ACIP), sponsored by the CDC, recommends that healthcare administrators consider the level of vaccination coverage among healthcare personnel (HCP) to be one measure of patient safety quality programs; keeping HCP well and on the job is particularly impor tant, given the increased patient vol - ume and work burden to the healthcare system during flu season. At least three -quarters of all HCP report having had an influenza vaccination during a recent influenza season. This rate of immunization marks a significant improvement 8 C H A P T E R 1 ■ Health Promotion and Disease Prevention Measles, Mumps, and Rubella Immunization from rates in prior decades but falls far short of universal im- munization for this important target population. Highest rates are found in acute care facilities where influenza vaccination is mandatory, whereas lowest rates are noted in long -term care facilities. Injectable trivalent influenza vaccine (TIV), more commonly called the “flu shot,” is available in a variety of forms. (See Table 1–2 for details on candidates for each vaccine). The nasal spray flu vaccine, also known as live attenuated influenza vaccine (LAIV) (FluMist), differs from the in - jectable influenza vaccine. Administered via a well-tolerated nasal mist, LAIV offers an easily administered, noninjection method of influenza immunization. LAIV contains influenza viruses that are sufficiently weakened as to be incapable of causing disease but with enough strength to stimulate a pro- tective immune response. The viruses in the LAIV are cold - adapted and temperature -sensitive. As a result, the viruses can grow in the nose and throat but not in the lower respira - tory tract, where the temperature is higher. LAIV is approved for use in healthy people ages 2 to 49 years old. Individuals who should not receive LAIV include children younger than 2 years; adults older than 49 years; patients with a health con- dition that places them at high risk for complications from influenza, including chronic heart disease, chronic lung dis - ease such as asthma or reactive airways disease, diabetes or kidney failure, and immunosuppression; children or adoles - cents receiving long -term high -dose aspirin therapy; people with a history of Guillain -Barré syndrome; pregnant women; and people with a history of allergy to any of the components of LAIV. Adverse effects of LAIV include nasal irritation and discharge, muscle aches, sore throat, and fever. Two special influenza immunization situations bear men- tion. Children younger than 9 years who are receiving initial influenza immunization need two doses of vaccine separated by 4 or more weeks. Pregnant women should be immunized against influenza; the vaccine can be given regardless of preg - nancy trimester. Because of the change in the respiratory and immune system normally present during pregnancy, in - fluenza is five times more likely to cause serious disease in a pregnant woman when compared with a nonpregnant woman. In addition, women who are immunized against influenza during pregnancy are able to pass a portion of this protection on to the unborn child, providing important pro - tection during the first 6 months of life. Flu vaccine is also safe to give during lactation. Children younger than 9 years who are receiving initial influenza immunization need two doses of vaccine separated by 4 or more weeks. Until recently, egg allergy was considered a contraindica - tion to receiving all forms of influenza vaccine. Current rec - ommendations advise that most individuals who are allergic to eggs can safely receive influenza vaccine (Table 1–2). In the Northern Hemisphere, the optimal time to receive any influenza vaccine is usually in fall months, at least 1 month prior to the anticipated onset of the flu season; this timing is reversed in the Southern Hemisphere. The vaccine is given annually and its contents are reflective of the viruses anticipated to cause influenza for the upcoming flu season. In the United States, four antiviral drugs are approved by the Food and Drug Administration (FDA) for use against in - fluenza: amantadine (Symmetrel), rimantadine (Flumadine), zanamivir (Relenza), and oseltamivir (Tamiflu). The adaman - tane derivatives (amantadi ne and rimantadine) are approved only for treatment and prevention of influenza A, whereas the neuraminidase inhibitor drugs (zanamivir and oseltamivir) are approved for use in influenza A and influenza B. Ongoing CDC viral surveillance has shown high levels of resistance of influenza A viruses to amantadine and similar medications. Because of this significant level of resistance, amantadine and rimantadine are no longer recommended by the CDC for the treatment of influenza. Relatively little resistance to the an - tiviral drugs oseltamivir and zanamivir has been noted in North America, but higher levels have been noted in Asia and other parts of the world. The healthcare provider should keep well informed of these developments. Zanamivir and oseltamivir are used to treat influenza A and B infections caused by susceptible viral strains; if treat - ment with either of these drugs is started during the first 2 days of illness, the time a person feels ill is shortened by approximately 1 day. Zanamivir is inhaled and can cause bronchospasm, especially in patients with asthma or other chronic lung disease. The adverse effects of oseltamivir are largely gastrointestinal; the risk of nausea and vomiting is sig- nificantly reduced if the medication is taken with food. Although many antiviral medications carry indications for the post -exposure prevention of influenza, all have a less favorable adverse reaction profile than influenza vaccine; these products are also significantly more expensive. Active immunization against influenza A and B is the preferred method of disease prevention. DISCUSSION SOURCES Centers for Disease Control and Prevention, http://www.cdc.gov/ flu/index.htm, Seasonal Influenza Centers for Disease Control and Prevention, http://www.cdc.gov/ flu/healthcareworkers.htm, Influenza Vaccination Information for Healthcare Workers / Influenza Vaccination Centers for Disease Control and Prevention, http://www.cdc.gov/ flu/professionals/antivirals/index.htm, Antiviral Drugs 22. When considering an adult’s risk for measles, mumps, and rubella (MMR), the NP considers the following: A. Patients born before 1957 have a high likelihood of immunity against these diseases because of a history of natural infection. B. Considerable mortality and morbidity occur with all three diseases. C. Most cases in the United States occur in infants. D. The use of the MMR vaccine is often associated with protracted arthralgia. 9 C H A P T E R 1 ■ Health Promotion and Disease Prevention 23. Which of the following is true about the MMR vaccine? A. It contains inactivated virus. B. Its use is contraindicated in patients with a history of egg allergy. C. Revaccination of an immune person is associated with risk of significant systemic allergic reaction. D. Two doses at least 1 month apart are recommended for young adults who have not been previously immunized. 24. A 22-year-old man is starting a job in a college health center and needs proof of German measles, measles, and mumps immunity. He received childhood immu - nizations and supplies documentation of MMR vacci - nation at age 1.5 years. Your best response is to: A. obtain rubella, measles (rubeola), and mumps titers. B. give MMR immunization now. C. advise him to obtain IG if he has been exposed to measles or rubella. D. advise him to avoid individuals with skin rashes. 25. Concerning the MMR vaccine, which of the following is true? A. The link between use of MMR vaccine and child - hood autism has been firmly established. B. There is no credible scientific evidence that MMR use increases the risk of autism. C. The use of the combined vaccine is associated with increased autism risk, but giving the vaccine’s three components as separate vaccines minimizes this risk. D. The vaccine contains thimerosal, a mercury derivative. 26. Which of the following is not recommended to receive the MMR vaccination? A. A 1-year-old boy with a history of hive-form reac- tion egg ingestion B. A 24 -year-old woman who is 20 weeks pregnant C. A 4-year-old girl who was born at 32 weeks of gestation D. A 32 -year-old woman who is breastfeeding a 2 week old. (native or wild infection); vaccine against these three for - merly common illnesses was unavailable until the 1960s. As with all vaccines, giving additional doses to patients with an unclear immunization history is safe . (See Figure 1 –2 for adult immunization schedules.) A quadrivalent vaccine, pro - tecting against measles, mumps, rubella, and varicella (chick - enpox), is also available and usually used to immunize younger children. Rubella typically causes a relatively mild, 3 - to 5-day ill - ness with little risk of complication to the person infected. When rubella is contracted during pregnancy, however, the effects on the fetus can be devastating. Immunizing the en - tire population against rubella exploits herd or community immunity and protects pregnant women from contracting rubella and therefore eliminating the risk of congenital rubella syndrome in the unborn. Measles can cause severe illness with serious sequelae, including encephalitis and pneumonia; sequelae of mumps include orchitis and possi - ble decreased male fertility. In the past, a history of egg allergy was considered a con - traindication to receiving MMR vaccine. The vaccine now is deemed safe in people with egg aller gy. However, patients with a history of anaphylactic reaction to neomycin or gelatin should not receive MMR. The MMR vaccine is safe to use during lactation, but its use during pregnancy is discouraged because of the theoretical but unproven risk of congenital rubella syndrome from the live virus contained in the vaccine. MMR vaccine is well tolerated; there have been rare reports of mild, transient adverse reactions such as rash and sore throat. At the request of the CDC and the National Institutes o f Health (NIH), the Institute of Medicine and National Acad - emy of Sciences conducted a review of all the evidence related to the MMR vaccine and autism. This independent panel ex - amined completed studies, ongoing studies, published med- ical and scientific articles, and expert testimony to assess whether or not there was a link between autism and the MMR vaccine. The groups concluded that the evidence reviewed did not support an association between autism and the MMR vaccine. Although the preservative thimerosal, a mercury de- rivative, has been mentioned as a possible autism contributor, the MMR vaccine licensed for use in the United States does not contain this preservative. DISCUSSION SOURCES Centers for Disease Control and Prevention, http://www.cdc.gov/ 22. A. 23. D. 24. B. 25. B. 26. B. vaccines/default.htm, Vaccines and Immunizations Centers for Disease Control and Prevention, http://www.cdc.gov/ vaccines/vpd -vac/measles/default.htm#clinical, Measles The MMR vaccine contains live but weakened (attenuated) virus. Two immunizations 1 month apart are recommended for adults born after 1957 because adults born before then are considered immune as a result of having had these diseases Centers for Disease Control and Prevention, http://www.cdc. gov/vaccines/vpd -vac/rubella/default.htm, Rubella (German measles) Centers for Disease Control and Prevention, http://www.cdc.gov/ vaccines/vpd -vac/mumps/default.htm, Mumps Answers 10 C H A P T E R 1 ■ Health Promotion and Disease Prevention ≥ 200 cells/μL < 200 cells/μL VACCINE x 2,* AGE GROUP ⯈ 19-21 years 22-26 years 27-49 years 50-59 years 60-64 years ≥ 65 years 1 dose annually Tetanus, diphtheria, pertussis (Td/Tdap) 3,* Varicella 4,* Human papillomavirus (HPV) Female 5,* Human papillomavirus (HPV) Male 5,* Zoster 6 Measles, mumps, rubella (MMR) 7,* Pneumococcal 13-valent conjugate (PCV13) 8,* Pneumococcal polysaccharide (PPSV23) 9,10 Meningococcal 11,* Hepatitis A 12,* Hepatitis B 13,* type b (Hib) 14,* Substitute 1-time dose of Tdap for Td booster; then boost with Td every 10 yrs 2 doses 3 doses 3 doses 1 dose 1 or 2 doses 1 dose 1 or 2 doses 1 or more doses 2 doses 3 doses 1 dose 1 or 3 doses Measles, mumps, rubella (MMR) 7,* C ontraindicated 1 or 2 doses Recommended Adult Immunization Schedule —United States - 2014 Note: These recommendations must be read with the footnotes that follow containing number of doses, intervals between doses, and other important information. Figure 1. Recommended adult immunization schedule, by vaccine and age group1 *Covered by the Vaccine Injury Compensation Program For all persons in this category who meet the age requirements and who lack documentation of vaccination or have no evidence of previous infection; zoster vaccine recommended regardless of prior episode of zoster Recommended if some other risk factor is present (e.g., on the basis of medical, occupational, lifestyle, or other indication) No recommendation a VAERS report are available at www.vaers.hhs.gov or by telephone, 800-822-7967. Additional information about the vaccines in this schedule, extent of available data, and contraindications for vaccination i s also available at www.cdc.gov/vaccines or from the CDC -INFO Contact Center at 800-CDC -INFO (800-232-4636) in English and Spanish, 8:00 a.m. - 8:00 p.m. Eastern Time, Monday - Friday, excluding holidays. only and does not imply endorsement by the U.S. Department of Health and Human Services. The recommendations in this schedule were approved by the Centers for Disease Control and Prevention’s (CDC) Advisory Committee on Immunization Practices (ACIP), the American Academy of Family Physicians (AAFP), the American College of Physicians (ACP), American College of Obstetricians and Gynecologists (ACOG) and American College of Nurse -Midwives (ACNM). Figure 2. Vaccines that might be indicated for adults based on medical and other indications1 ually 1 dose IIV or LAIV annually gh age 26 yrs rough age 26 *Covered by the Vaccine Injury Compensation Program For all persons in this category who meet the age requirements and who lack documentation of vaccination or have no evidence of previous infection; zoster vaccine recommended regardless of prior episode of zoster Recommended if some other risk factor is present (e.g., on the basis of medical, occupational, lifestyle, or other indications) No recommendation Figure 1-2 Recommended immunization schedule by vaccine and age group —United States, 2013 These schedules indicate the recommended age groups and medical indications for which administration of currently licensed vaccines is commonly indicated for adults ages 19 years and older, as of February 1, 2014. For all vaccines being recommended on the Adult Immunization Schedule: a vaccine series does not need to be restarted, regardless of the time that has elapsed between doses. Licensed combination vaccines may be used whenever any components of the combination are indicated and when the vaccine’s ot her components are not contraindicated. For detailed recommendations on all vaccines, including those used primarily for travelers or that are issued during the year, consult the manufacturers’ package inserts and the complete statements from the Advisory Committee on Immunization Practices (www.cdc.gov/vaccines/hcp/acip -recs/index.html ). Use of d does not imply endorsement by the U.S. Department of Health and Human Services. s 1 or 3 dose post-HSCT recipients only type b (Hib) 14,* 3 doses Hepatitis B 13,* 2 doses Hepatitis A 12,* ses 1 or more do Meningococcal 11,* s 1 or 2 dose Pneumococcal polysaccharide (PPSV23) 9,10 se 1 do Pneumococcal 13-valent conjugate (PCV13) 8,* yrs ery 10 boost with Td ev oster; then Tdap for Td bo dose of 1-time bstitute Su 1 dose Tdap each pregnancy Tetanus, diphtheria, pertussis (Td/Tdap) 3,* Healthcare personnel Diabetes Chronic liver disease Asplenia (including elective splenectomy and persistent complement component 8,14 Heart disease, chronic lung disease, chronic alcoholism Kidney failure, end-stage renal disease, receipt of hemodialysis Men who have sex with men (MSM) HIV infection CD4+ T lymphocyte count 4,6,7,8,15 Immuno - compromising conditions (excluding human virus [HIV])4,6,7,8,15 Pregnancy INDICATION ⯈ VACCINE x www.hrsa.gov/vaccinecompensation or by telephone, 800-338-2382. 1 dose ontraindicated C Zoster 6 yrs s through age 21 3 dose yrs 3 doses th Human papillomavirus (HPV) Male 5,* yrs s through age 26 3 dose 3 doses throu Human papillomavirus (HPV) Female 5,* ses 2 do ontraindicated C Varicella 4,* IIV annually 1 dose 1 dose IIV or LAIV annually 1 dose IIV ann 2,* 11 C H A P T E R 1 ■ Health Promotion and Disease Prevention Footnotes Recommended Immunization Schedule for Adults Aged 19 Years or Older: United States, 2014 1. Additional information • Additional guidance for the use of the vaccines described in this supplement is available at www.cdc.gov/vaccines/hcp/acip -recs/index.html. • Information on vaccination recommendations when vaccination status is unknown and other general immunization information can be found in the General Recommendations on Immunization at www.cdc.gov/mmwr/preview/mmwrhtml/rr6002a1.htm . • Information on travel vaccine requirements and recommendations (e.g., for hepatitis A and B, meningococcal, and other vaccines) is available at http://wwwnc.cdc.gov/travel/destinations/list . • Additional information and resources regarding vaccination of pregnant women can be found at http://www.cdc.gov/vaccines/adults/rec -vac/pregnant.html . 2. • aged 6 months or older. • Persons aged 6 months or older, including pregnant women and persons vaccine (IIV). An age-appropriate IIV formulation should be used. • (RIV) (FluBlok). RIV does not contain any egg protein. • Healthy, nonpregnant persons aged 2 to 49 years without high-risk medical conditions can receive either intranasally administered live, attenuated for severely immunocompromised persons (i.e., those who require care in a protected environment) should receive IIV or RIV rather than LAIV. • The intramuscularly or intradermally administered IIV are options for adults aged 18 to 64 years. • Adults aged 65 years or older can receive the standard -dose IIV or the high-dose IIV (Fluzone High-Dose). 3. Tetanus, diphtheria, and acellular pertussis (Td/Tdap) vaccination • Administer 1 dose of Tdap vaccine to pregnant women during each pregnancy (preferred during 27 to 36 weeks’ gestation) regardless of interval since prior Td or Tdap vaccination. • Persons aged 11 years or older who have not received Tdap vaccine or for whom vaccine status is unknown should receive a dose of Tdap followed by tetanus and diphtheria toxoids (Td) booster doses every 10 years thereafter. Tdap can be administered regardless of interval since the most recent tetanus or diphtheria -toxoid containing vaccine. • Adults with an unknown or incomplete history of completing a 3-dose primary vaccination series with Td -containing vaccines should begin or complete a primary vaccination series including a Tdap dose. • and the third dose 6 to 12 months after the second. • For incompletely vaccinated (i.e., less than 3 doses) adults, administer remaining doses. • Refer to the ACIP statement for recommendations for administering Td/ Tdap as prophylaxis in wound management (see footnote 1). 4. Varicella vaccination • should receive 2 doses of single -antigen varicella vaccine or a second dose if they have received only 1 dose. • Vaccination should be emphasized for those who have close contact with persons at high risk for severe disease (e.g., health care personnel and family c ontacts of persons with immunocompromising conditions) or are at high risk for exposure or transmission (e.g., teachers; child including correctional institutions; college students; military personnel; adolescents and adults living in households with children; nonpregnant women of childbearing age; and international travelers). • Pregnant women should be assessed for evidence of varicella immunity. dose of varicella vaccine upon completion or termination of pregnancy and before discharge from the health care facility. The second dose should • Evidence of immunity to varicella in adults includes any of the following: — documentation of 2 doses of varicella vaccine at least 4 weeks apart; —U.S.-born before 1980, except health care personnel and pregnant women; — by a health care provider; — zoster disease by a health care provider; or — 5. Human papillomavirus (HPV) vaccination • Two vaccines are licensed for use in females, bivalent HPV vaccine (HPV2) and quadrivalent HPV vaccine (HPV4), and one HPV vaccine for use in males (HPV4). • For females, either HPV4 or HPV2 is recommended in a 3-dose series for routine vaccination at age 11 or 12 years and for those aged 13 through 26 years, if not previously vaccinated. • For males, HPV4 is recommended in a 3-dose series for routine vaccination at age 11 or 12 years and for those aged 13 through 21 years, if not previously vaccinated. Males aged 22 through 26 years may be vaccinated. Figure 1 -2—cont’d 5. Human papillomavirus (HPV) vaccination (cont’d) • HPV4 is recommended for men who have sex with men through age 26 years for those who did not get any or all doses when they were younger. • Vaccination is recommended for immunocompromised persons (including those with HIV infection) through age 26 years for those who did not get any or all doses when they were younger. • A complete series for either HPV4 or HPV2 consists of 3 doses. The second dose should be administered 4 to 8 weeks (minimum interval of 4 weeks) at least 12 weeks). • HPV vaccines are not recommended for use in pregnant women. However, pregnancy testing is not needed before vaccination. If a woman is found to be pregnant after initiating the vaccination series, no intervention is needed; the remainder of the 3-dose series should be delayed until completion of pregnancy. 6. Zoster vaccination • A single dose of zoster vaccine is recommended for adults aged 60 years or older regardless of whether they report a prior episode of herpes zoster. Although the vaccine is licensed by the U.S. Food and Drug Administration for use among and can be administered to persons aged 50 years or older, ACIP recommends that vaccination begin at age 60 years. • Persons aged 60 years or older with chronic medical conditions may be vaccinated unless their condition constitutes a contraindication, such as 7. Measles, mumps, rubella (MMR) vaccination • Adults born before 1957 are generally considered immune to measles and mumps. All adults born in 1957 or later should have documentation of 1 or more doses of MMR vaccine unless they have a medical contraindication to the vaccine or laboratory evidence of immunity to each of the three diseases. Documentation of provider -diagnosed disease is not considered acceptable evidence of immunity for measles, mumps, or rubella. Measles component: • A routine second dose of MMR vaccine, administered a minimum of 28 — are students in postsecondary educational institutions; — work in a health care facility; or — plan to travel internationally. • Persons who received inactivated (killed) measles vaccine or measles vaccine of unknown type during 1963–1967 should be revaccinated with 2 doses of MMR vaccine. Mumps component: • A routine second dose of MMR vaccine, administered a minimum of 28 — are students in a postsecondary educational institution; — work in a health care facility; or — plan to travel internationally. • Persons vaccinated before 1979 with either killed mumps vaccine or mumps vaccine of unknown type who are at high risk for mumps infection (e.g., persons who are working in a health care facility) should be considered for revaccination with 2 doses of MMR vaccine. Rubella component: • For women of childbearing age, regardless of birth year, rubella immunity should be determined. If there is no evidence of immunity, women who are not pregnant should be vaccinated. Pregnant women who do not have evidence of immunity should receive MMR vaccine upon completion or termination of pregnancy and before discharge from the health care facility. Health care personnel born before 1957: • For unvaccinated health care personnel born before 1957 who lack laboratory evidence of measles, mumps, and/or rubella immunity or vaccinating personnel with 2 doses of MMR vaccine at the appropriate interval for measles and mumps or 1 dose of MMR vaccine for rubella. 8. Pneumococcal conjugate (PCV13) vaccination • Adults aged 19 years or older with immunocompromising conditions (including chronic renal failure and nephrotic syndrome), functional or have not previously received PCV13 or PPSV23 should receive a single dose of PCV13 followed by a dose of PPSV23 at least 8 weeks later. • Adults aged 19 years or older with the aforementioned conditions who have previously received 1 or more doses of PPSV23 should receive a dose of PCV13 one or more years after the last PPSV23 dose was received. For be given no sooner than 8 weeks after PCV13 and at least 5 years after the most recent dose of PPSV23. • When indicated, PCV13 should be administered to patients who are uncertain of their vaccination status history and have no record of previ- ous vaccination. • Although PCV13 is licensed by the U.S. Food and Drug Administration for use among and can be administered to persons aged 50 years or older, ACIP recommends PCV13 for adults aged 19 years or older with 12 C H A P T E R 1 ■ Health Promotion and Disease Prevention 9. Pneumococcal polysaccharide (PPSV23) vaccination • • Vaccinate all persons with the following indications: — all adults aged 65 years or older; — adults younger than 65 years with chronic lung disease (including chronic obstructive pulmonary disease, emphysema, and asthma), chronic cardiovascular diseases, diabetes mellitus, chronic renal fail- ure, nephrotic syndrome, chronic liver disease (including cirrhosis), - promising conditions, and functional or anatomic asplenia (e.g., sickle cell disease and other hemoglobinopathies, congenital or acquired asplenia, splenic dysfunction, or splenectomy [if elective splenectomy is planned, vaccinate at least 2 weeks before surgery]); — residents of nursing homes or long -term care facilities; and — adults who smoke cigarettes. • Persons with immunocompromising conditions and other selected conditions are recommended to receive PCV13 and PPSV23 vaccines. See footnote 8 for information on timing of PCV13 and PPSV23 vaccinations. • Persons with asymptomatic or symptomatic HIV infection should be vaccinated as soon as possible after their diagnosis. • When cancer chemotherapy or other immunosuppressive therapy is being considered, the interval between vaccination and initiation of immunosuppressive therapy should be at least 2 weeks. Vaccination during chemotherapy or radiation therapy should be avoided. • Routine use of PPSV23 vaccine is not recommended for American Indians/ Alaska Natives or other persons younger than 65 years unless they have underlying medical conditions that are PPSV23 indications. However, pub- lic health authorities may consider recommending PPSV23 for American Indians/Alaska Natives who are living in areas where the risk for invasive pneumococcal disease is increased. • When indicated, PPSV23 vaccine should be administered to patients who are uncertain of their vaccination status and have no record of vaccination. 10. Revaccination with PPSV23 • - mended for persons aged 19 through 64 years with chronic renal failure or nephrotic syndrome, functional or anatomic asplenia (e.g., sickle cell disease or splenectomy), or immunocompromising conditions. • Persons who received 1 or 2 doses of PPSV23 before age 65 years for any indication should receive another dose of the vaccine at age 65 years or later if at least 5 years have passed since their previous dose. • No further doses of PPSV23 are needed for persons vaccinated with PPSV23 at or after age 65 years. 11. Meningococcal vaccination • Administer 2 doses of quadrivalent meningococcal conjugate vaccine (MenACWY [Menactra, Menveo]) at least 2 months apart to adults of all ages with functional asplenia or persistent complement component MenACWY. If an HIV-infected perso n of any age is vaccinated, 2 doses of MenACWY should be administered at least 2 months apart. • Administer a single dose of meningococcal vaccine to microbiologists routinely exposed to isolates of Neisseria meningitidis , military recruits, persons at risk during an outbreak attributable to a vaccine serogroup, and persons who travel to or live in countries in which meningococcal disease is hyperendemic or epidemic. • First-year college students up through age 21 years who are living in residence halls should be vaccinated if they have not received a dose on or after their 16th birthday. • MenACWY is preferred for adults with any of the preceding indications who are aged 55 years or younger as well as for adults aged 56 years or older who a) were vaccinated previously with MenACWY and are recom - mended for revaccination, or b) for whom multiple doses are anticipated. Meningococcal polysaccharide vaccine (MPSV4 [Menomune]) is preferred for adults aged 56 years or older who have not received MenACWY previ- ously and who require a single dose only (e.g., travelers). • Revaccination with MenACWY every 5 years is recommended for adults previously vaccinated with MenACWY or MPSV4 who remain at increased risk for infection (e.g., adults with anatomic or functional asplenia, per- 12. Hepatitis A vaccination • Vaccinate any person seeking protection from hepatitis A virus (HAV) infection and persons with any of the following indications: — men who have sex with men and persons who use injection or non- injection illicit drugs; — persons working with HAV-infected primates or with HAV in a research laboratory setting; — persons with chronic liver disease and persons who receive clotting factor concentrates; — persons traveling to or working in countries that have high or inter - mediate endemicity of hepatitis A; and Figure 1 -2—cont’d 12. Hepatitis A vaccination (cont’d) — unvaccinated persons who anticipate close personal contact (e.g., household or regular babysitting) with an international adoptee - try with high or intermediate endemicity. (See footnote 1 for more hepatitis A vaccine series should be administered as soon as adoption is planned, ideally 2 or more weeks before the arrival of the adoptee. • Single -antigen vaccine formulations should be administered in a 2 -dose schedule at either 0 and 6 to 12 months (Havrix), or 0 and 6 to 18 months (Vaqta). If the combined hepatitis A and hepatitis B vaccine (Twinrix) is used, administer 3 doses at 0, 1, and 6 months; alternatively, a 4 -dose schedule may be used, administered on days 0, 7, and 21 to 30 followed by a booster dose at month 12. 13. Hepatitis B vaccination • Vaccinate persons with any of the following indications and any person seeking protection from hepatitis B virus (HBV) infection: — sexually active persons who are not in a long-term, mutually monoga - mous relationship (e.g., persons with more than 1 sex partner during the previous 6 months); persons seeking evaluation or treatment for a sexually transmitted disease (STD); current or recent injection drug users; and men who have sex with men; — health care personnel and public safety workers who are potentially — persons with diabetes who are younger than age 60 years as soon as feasible after diagnosis; persons with diabetes who are age 60 years or older at the discretion of the treating clinician based on the likelihood of acquiring HBV infection, including the risk posed by an increased need for assisted blood glucose monitoring in long -term care facili - ties, the likelihood of experiencing chronic sequelae if infected with HBV, and the likelihood of immune response to vaccination; — persons with end-stage renal disease, including patients receiving hemodialysis, persons with HIV infection, and persons with chronic liver disease; — household contacts and sex partners of hepatitis B surface anti- persons with developmental disabilities, and international travelers to countries with high or intermediate prevalence of chronic HBV infection; and — all adults in the following settings: STD treatment facilities, HIV test- ing and treatment facilities, facilities providing drug abuse treatment and prevention services, health care settings targeting services to injection drug users or men who have sex with men, correctional facilities, end-stage renal disease programs and facilities for chronic hemodialysis patients, and institutions and nonresidential day care facilities for persons with developmental disabilities. • Administer missing doses to complete a 3 -dose series of hepatitis B vaccine to those persons not vaccinated or not completely vaccinated. third dose should be given at least 2 months after the second dose (and hepatitis B vaccine (Twinrix) is used, give 3 doses at 0, 1, and 6 months; alternatively, a 4-dose Twinrix schedule, administered on days 0, 7, and 21 to 30 followed by a booster dose at month 12 may be used. • Adult patients receiving hemodialysis or with other immunocompromising conditions should receive 1 dose of 40 mcg/mL (Recombivax HB) administered on a 3-dose schedule at 0, 1, and 6 months or 2 doses of 20 mcg/mL (Engerix -B) administered simultaneously on a 4 -dose schedule at 0, 1, 2, and 6 months. 14. (Hib) vaccination • One dose of Hib vaccine should be administered to persons who have functional or anatomic asplenia or sickle cell disease or are undergoing elective splenectomy if they have not previously received Hib vaccine. Hib vaccination 14 or more days before splenectomy is suggested. • Recipients of a hematopoietic stem cell transplant should be vaccinated with a 3 -dose regimen 6 to 12 months after a successful transplant, regardless of vaccination history; at least 4 weeks should separate doses. • Hib vaccine is not recommended for adults with HIV infection since their risk for Hib infection is low. 15. Immunocompromising conditions • Inactivated vaccines generally are acceptable (e.g., pneumococcal, generally are avoided in persons with immune deficiencies or is available at http://www.cdc.gov/vaccines/hcp/acip -recs/index.html. 13 C H A P T E R 1 ■ Health Promotion and Disease Prevention Answers 27. When advising an adult patient about pneumococcal immunization, the NP considers the following about the vaccine: A. The vaccine contains inactivated bacteria. B. Its use is contraindicated in individuals with asthma. C. It protects against community -acquired pneumonia caused by atypical pathogens. D. Its use is seldom associated with significant adverse reactions. 28. Of the following, who is at greatest risk for invasive pneumococcal infection? A. a 68-year-old man with chronic obstructive pul- monary disease B. a 34-year-old woman who underwent splenectomy after a motor vehicle accident C. a 50-year-old man with a 15-year history of type 2 diabetes D. a 75-year-old woman with decreased mobility as a result of severe osteoporosis 29. All of the following patients received pneumococcal vaccine 5 years ago. Who is a candidate for receiving a second dose of antipneumococcal immunization at this time? A. a 45-year-old man who is a cigarette smoker B. a 66-year-old woman with COPD C. a 35-year-old man with moderate persistent asthma D. a 72-year-old woman with no chronic health problems 30. Identify whether the item has the characteristics of 23-valent pneumococcal polysaccharide vaccine (PPSV23) or 13-valent pneumococcal conjugate vaccine (PCV13). A. Routinely used in early childhood B. Use is associated with greater immunogenicity C. Routinely used in all well adults age 65 years or older D. Not licensed for use in children younger than 2 years of age 27. D. 28. B. 29. B. 30. A = PCV13, B = PCV13, C = PPSV23, D = PPSV23 Pneumococcal disease, caused by the gram -positive diplo - coccus Streptococcus pneumoniae, results in significant mor - tality and morbidity. The pneumococcal polysaccharide vaccine (Pneumovax PPSV23) contains purified polysaccha - ride from 23 of the most common S. pneumoniae serotypes. Pneumococcal conjugate vaccine (Prevnar, PCV13) con - tains purified capsular polysaccharide from 13 serotypes of pneumococcus and is used in select adult populations, particularly the immunocompromised. Use of PCV13 is as - sociated with greater immunogenicity when compared with PPSV23, but it does not provide protection against as many pneumococcal serotypes, and is routinely used in childhood. PPSV23 is not licensed for use in children younger than age 2 years. Whatever the form used, the pneumococcal vaccine prima - rily protects against invasive disease such as meningitis and septicemia associated with pneumonia and disease caused by S. pneumoniae ; this organism is the leading cause of death from community -acquired pneumonia (CAP) in the United States. The polysaccharide form protects from approximately 90% of the bacteremic disease associated with the pathogen, whereas the conjugate form is protective from approximately 70%. These immunizations are ineffective, however, against pneumonia and invasive disease caused by other infectious agents, including Mycoplasma pneumoniae ; Chlamydophila (formerly Chlamydia ) pneumoniae ; Legionella species; and se- lect gram -negative respiratory pathogens such as Haemophilus influenzae, Moraxella catarrhalis, and Klebsiella pneumoniae. Indications for adults to receive pneumococcal vaccine in - clude a variety of chronic health problems such as chronic lung disease (including asthma), chronic cardiovascular dis- eases, diabetes mellitus, chronic liver disease including cirrho - sis, chronic alcohol abuse, cigarette smokers age 19 years or older, malignancy, chronic renal failure or nephrotic syn - drome, functional or anatomic asplenia (e.g., sickle cell disease or splenectomy [if elective splenectomy is planned, vaccinate at least 2 weeks before surgery]), immunocompromising con- ditions or recipient of immunosuppressing medications, select organ transplant, cochlear implants, and cerebrospinal fluid leak. Other individuals for whom vaccination is indicated include residents of nursing homes or other long -term care facilities, and all adults 65 years or older regardless of health status. Consideration should also be given to recommending PPSV23 for Alaska Natives and American Indians ages 50 through 64 years who are living in areas in which the risk of invasive pneumococcal disease is increased. Protection from invasive pneumococcal disease in a person with HIV warrants special mention; the risk of pneumococcal infection is up to 100 times greater in people with HIV infec - tion than in other adults of similar age. Once the diagnosis of HIV infection is made, the patient should receive both PCV13 and PPSV23 vaccines as soon as possible; PCV13 is given first followed by PPSV23 8 weeks later. A second dose of PPSV23 should be administered at least 5 years after the initial dose, and a third dose should be administered at age 65 years if the person was younger than age 65 years at the time of HIV diagnosis. Updated recommendations for all adults age 65 years and above require use of both vaccines. Revaccination after 5 years after the first PPSV23 dose is rec- ommended for individuals older than age 2 years but younger than age 65 years who are at highest risk of pneumococcal infection or are at greatest risk of having a rapid decline in Pneumococcal Immunization 14 C H A P T E R 1 ■ Health Promotion and Disease Prevention antibody levels, including sickle cell disease, splenectomy, chronic renal failure, nephrotic syndrome, immunocompro - mise, generalized malignancy, or on immunosuppressing medications. If initial PPSV23 vaccine was received at age 65 years or older, a repeat dose is not required. This immu - nization, with initial and repeat vaccination, is generally well tolerated (Table 1–3). DISCUSSION SOURCES Centers for Disease Control and Prevention, http://www.cdc. gov/vaccines/vpd -vac/pneumo/vac -PCV13 -adults.htm, PCV13 (Pneumococcal Conjugate) Vaccine Centers for Disease Control and Prevention, http://www.immunize. org/askexperts/experts_pneumococcal_vaccines.asp, Pneumococcal Vaccines (PCV13 and PPSV23) 31. Concerning hepatitis B virus (HBV) vaccine, which of the following is true? A. The vaccine contains live, whole HBV. B. Adults should routinely have anti -hepatitis B sur - face antibody titers measured after three doses of vaccine. C. The vaccine should be offered during treatment for sexually transmitted diseases in unimmunized adults. D. Serologic testing for hepatitis B surface antigen (HBsAg) should be done before hepatitis B vaccina - tion is initiated in adults. TABLE 1-3 Pneumococcal Vaccine Adverse Reactions Local Reactions Including Pain, 32. In which of the following groups is routine HBsAg screening recommended? A. hospital laboratory workers B. recipients of hepatitis B vaccine series C. pregnant women D. college students 33. You see a woman who has been sexually active with a man newly diagnosed with acute hepatitis B. She has not received hepatitis B vaccine in the past. You advise her that she should: A. start a hepatitis B immunization series. B. limit the number of sexual partners she has. C. be tested for hepatitis B surface antibody (HBsAb). D. receive hepatitis B immune globulin (HBIG) and hepatitis B immunization series. 34. Hepatitis B vaccine should not be given to a person with a history of anaphylactic reaction to: A. egg. B. baker’s yeast. C. neomycin. D. streptomycin. 35. Risks associated with chronic hepatitis B include all of the following except: A. hepatocellular carcinoma. B. cirrhosis. C. continued infectivity. D. systemic hypertension. 36. Jason is a healthy 18-year-old who presents for primary care. According to his immunization record, he received two dose of HBV vaccine 1 month apart at age 14 years. Which of the following best describes his HBV vaccination needs? A. He should receive a single dose of HBV vaccine now. B. A three -dose HBV vaccine series should be started during today’s visit. C. He has completed the recommended HBV vaccine Redness Fever, myalgia Severe, potentially life-threatening 30%–50% Polysaccharide (Pneumovax 23-valent polysaccharide vaccine) = Uncommon, <1% Conjugate (Prevnar 13-valent con- jugate vaccine) = 11%–40% in children, significantly less in adults with adverse reaction profile similar to 23 -valent polysaccharide vaccine Rare series. D. He should be tested for HBsAb and further immunization recommendations should be made according to the test results. 37. All of the following individuals have not received vaccination against HBV. The vaccine should not be given in which of the following patients? A. a 35-year-old man with multiple sclerosis B. a 25-year-old woman with a past history of Guillain -Barré syndrome C. a 48-year-old woman with systemic lupus erythematosus D. a 28-year-old man who is acutely ill with bacterial Source: www.cdc.gov/mmwr/preview/mmwrhtml/mm5934a3.htm meningitis Hepatitis B Vaccination