Health Promotion And Disease Prevention

Front 1

Incubation period of the influenza virus in an immunocompetent adult

Back 1

-Range of 1-4 days (average of 2 days)

-Adults pass the illness on 1 day before the onset of symptoms and continue to remain infectious for approx. 5 days after the onset of illness

-Children remain infectious for 10+ days 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

Front 2

Efficacy of the influenza vaccines in preventing in preventing influenza or reducing the severity of the disease

Back 2

- 70% to 80% effective in preventing influenza or reducing the severity of disease

Front 3

The Injectable vaccine

Back 3

-does not contain live virus and is not shed

-there is no risk of transmitting an infectious agent to household contacts

-mild to moderate illness is not a contraindication to ANY immunization including the administration of the influenza vaccine

Front 4

Influenza vaccine recommended for use in pregnant women

Back 4

-the injectable trivalent influenza vaccine (TIV)

-recommended for all pregnant women

Front 5

Timing of TIV administration

Back 5

-based largely on the vaccines availability b/c a formulation based on predicted influenza strains is produced annually

Front 6

Appropriate age group for TIV administration

Back 6

-can be given to infants 6 months old and older

Front 7

Immunization rates are typically the highest in what group?

Back 7

-Immunization rates against influenza for individuals with chronic illness are typically the highest, although with considerable room for improvement

Front 8

Certain groups have very low immunization rates and should be targeted for improvement. These groups include:

Back 8

-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 considered for vaccination to minimize disruption of essential activities during influenza outbreaks

-students and other persons in institutional or other group-living situations should be encouraged to receive vaccine to minimize the risk of an outbreak in a relatively closed community

-As supply allows, vaccination providers should administer influenza vaccine to any person who wishes to reduce the likelihood of becoming ill with influenza or transmitting influenza to others

Front 9

What is the current rate of immunization for health care providers?

Back 9

-40%

Front 10

Nasal spray flu vaccine (FluMist)

Back 10

-aka live attenuated influenza vaccine (LAIV)

-administered via well-tolerated nasal mist, LAIV offers an easily administered, non-injection method of influenza immunization

-LAIV contains live viruses that are sufficiently weakened as to be incapable of causing disease but with enough strength to stimulate a protective immune response

-the viruses in LAIV are cold-adapted and temperature-sensitive --> as a result, the viruses can grow in the nose and throat, but not in the lower respiratory tract where the temperature is higher

Front 11

For what ages is administration of the LAIV approved for use?

Back 11

-approved for use in healthy people 2 to 49 years old

Front 12

What individuals should not receive LAIV?

Back 12

-children < 2 yrs old

-adults > 50 yrs old

-patients with a medical condition that places them at high risk for complications from influenza, including chronic heart disease, chronic lung disease such as asthma or RAD, DM or kidney failure, and immunosuppression

-children or adolescents receiving long-term high-dose aspirin therapy

-people with a h/o Guillain-Barré syndrome

-pregnant women

-people with a h/o allergy to any of the components of LAIV or to eggs

Front 13

What are adverse effects of LAIV?

Back 13

-nasal irritation and discharge

-muscle aches

-sore throat

-fever

Front 14

In the northern hemisphere when is the optimal time to receive any influenza vaccine?

Back 14

-usually in October or November, about 1 month before the anticipated onset of the flu season

-the timing is reversed in the Southern Hemisphere

*children < 9 yrs old who are receiving initial influenza immunization need two doses of vaccine separated by 4 or more weeks with TIV and 6 or more weeks with LAIV

Front 15

What are the four antiviral drugs approved by the FDA for use against influenza?

Back 15

-amantadine (Symmetrel)

-rimantidine (Flumadine)

-zanamivir (Relenza)

-oseltamivir (Tamiflu)

Front 16

The adamantane derivatives (amantadine and rimantidine are approved for only treatment and prevention of which type(s) of influenza?

Back 16

- amantadine and rimantidine are approved only for treatment and prevention of influenza type A

Front 17

For which type(s) of influenza are the neuraminidase inhibitor drugs (zanamivir and oseltamivir approved?

Back 17

-zanamivir and oseltamivir are approved for use in influenza A and influenza B

Front 18

CDC viral surveillance has shown high levels of resistance of influenza A viruses to what drugs?

Back 18

-amantadine and other similar medications

-because of this significant level of resistance, amantadine and rimantidine have not been recommended for use in more recent U.S. Flu seasons

-less resistance to the antiviral drugs oseltamivir and zanamivir has been noted in North America, but higher levels have been noted in Asia and other parts of the world

Front 19

CDC viral surveillance has shown high levels of resistance of influenza A viruses to what drugs?

Back 19

-amantadine and other similar medications

-because of this significant level of resistance, amantadine and rimantidine have not been recommended for use in more recent U.S. Flu seasons

-less resistance to the antiviral drugs oseltamivir and zanamivir has been noted in North America, but higher levels have been noted in Asia and other parts of the world

Front 20

Zanamivir and oseltamivir

Back 20

-are used to treat influenza A and B infections caused by susceptible viral strains

-treatment with either of these drugs can shorten the time a person infected with influenza feels Ill by approx. 1 day, if treatment is started during the first 2 days of illness

-zanamivir is inhaled and can cause bronchcospasm, 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 significantly reduced if the medication is taken with food

Front 21

CDC viral surveillance has shown high levels of resistance of influenza A viruses to what drugs?

Back 21

-amantadine and other similar medications

-because of this significant level of resistance, amantadine and rimantidine have not been recommended for use in more recent U.S. Flu seasons

-less resistance to the antiviral drugs oseltamivir and zanamivir has been noted in North America, but higher levels have been noted in Asia and other parts of the world

Front 22

Zanamivir and oseltamivir

Back 22

-are used to treat influenza A and B infections caused by susceptible viral strains

-treatment with either of these drugs can shorten the time a person infected with influenza feels Ill by approx. 1 day, if treatment is started during the first 2 days of illness

-zanamivir is inhaled and can cause bronchcospasm, 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 significantly reduced if the medication is taken with food

Front 23

What is the preferred method for immunization against influenza A and B?

Back 23

-although many antiviral meds carry indications for the post exposure prevention of influenza, all have a less favorable adverse reaction profile then the influenza vaccine; active immunization against influenza A and B by administering the flu shot or intranasal spray is the preferred method of disease prevention.

Front 24

Which of the following is true about the MMR Vaccine?

A. It contains inactivated virus

B. Its use is contraindicated in patients w/ a h/o egg allergy

C. Revaccination of an immune person is associated w/ risk of allergic reaction

D. Two doses at least 1 month apart are recommended for young adults who have not been previously immunized

Back 24

D is the correct answer. Two doses at least 1 month apart are recommended for young adults who have not been previously immunized

A is false. The MMR vaccine contains live but weakened (attenuated) virus

B is false. In the past, a h/o egg allergy was considered a C/I to receiving MMR vaccine. The vaccine now seems to be safe in people w/ egg allergy

C is false. Revaccination of an immune person is not assoc. w/ risk of allergic reaction.

As with all vaccines, giving additional doses to patients w/ unclear immunization history is safe

-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 (native or wild infection)

Vaccine against these three formerly common illnesses was unavailable until the 1960's

Front 25

Who should not receive the MMR?

Back 25

-Patients w/ a h/o life-threatening allergic 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 b/c of the theoretical but unproven risk of congenital rubella syndrome from the live virus contained in the vaccine

Front 26

What adverse reactions may occur with administration of the MMR Vaccine?

Back 26

-The MMR is well-tolerated; there have been rare reports of mild, transient adverse reactions such as rash and sore throat

Front 27

Does evidence support an associated between autism and the MMR vaccine?

Back 27

No. Evidence gathered by the NIH (at the request of the CDC) does not support an association between autism and the MMR vaccine

-Although the preservative thimerosal, a mercury derivative, has been mentioned as a possible autism contributor, the MMR vaccine licensed for use in the U.S. does not contain this preservative

Front 28

What risk of complication does Rubella carry for the infected person?

Back 28

-Rubella typically causes a relatively mild, 3- to 5-day illness w/ 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 entire population against rubella protects unborn children from the risk of contracting congenital rubella syndrome

Front 29

What are the sequellae of measles?

Back 29

-Measles can cause severe illness with serious sequellae, including encephalitis and pneumonia

Front 30

What is a sequella of mumps?

Back 30

-Sequellae of mumps include orchitis

Front 31

Examples of Primary Prevention

Back 31

Prevent Disease/Injury/Condtion

Examples:

-Youth violence prevention

-Bullying prevention

-Personal safety promotion (e.g., seatbelts, airbags, helmets)

-Disease prevention (e.g., immunizations, using sunscreen)

-Healthy lifestyle promotion

-Promotion of OSHA laws (e.g., workplace safety) and EPA laws (e.g., clean water, anti-pollution laws)

Front 32

Examples of Secondary Prevention

Back 32

Detect Disease/Condition as early as possible to minimize bodily damage

Examples:

-Any lab test to screen for a disease (e.g., CBC for anemia, TSH for thyroid disease)

-USPSTF screening recommendations (e.g., mammograms, PSA, purified protein derivative [PPD])

-Screening for high-risk behavior (e.g., asking a pt about the # of sexual partners), screening for suicide risk (e.g., assess suicide risk, check for signs and sxs of depression)

-Personal actions to detect cancer (e.g., BSE, GSE)

Front 33

Examples of Tertiary Prevention

Back 33

Limiting further harm and disability (Rehabilitation, Support groups, Education or Equipment)

Examples:

-All types of rehab (e.g., cardiac rehab, PT, OT, speech therapy, addiction/drug rehab)

-Support groups (e.g., breast cancer patients, AA)

-Exercise for an obese person (if the person is healthy, then it is primary prevention)

Front 34

Screening Tests -

Sensitivity

Back 34

-Detect individuals who have the disease

-Highly sensitive tests have higher risk of "false positives"

-For example, the HIV ELISA test has a 99% sensitivity for HIV antibodies, but it is too sensitive and can be "false positive" (especially in low-risk populations

The next step is the Western Blot test, which is very specific for HIV (the confirmatory test)

Front 35

Screening Tests -

Specificity

Back 35

-Detect individuals who do not have the disease

-For example, a positive HIV ELISA result is always "confirmed" w/ the Western Blot test, which is very specific for HIV antibodies

The Western Blot is the "confirmatory test" for HIV. It is better at ruling out a person who does not have the disease

Front 36

Screening for Breast Cancer (USPSTF, 2009)

Back 36

Baseline mammogram: start at age 50 yrs, then every 2 years (biennially) until the age of 74

Age 75 yrs and older: insufficient evidence for routine mammogram. Individualize

*Age 40-49 years (individualize based on risk factors, biennial schedule if done

Against teaching BSE (Grade D rec)

**The American Cancer Society recommends starting routine screening at age 40 yrs

Front 37

Screening for Cervical Cancer

Back 37

-start at age 21 years

-Every 3 years (Pap Smear) until age 65

*Against routine screening if < 21 yrs old

**Age 65 or older or Hysterectomy w/ removal of cervix (benign disease) --> Stop routine screening if h/o adequate screening (and not high risk for cervical cancer); can stop routine pap smear screening

Front 38

Screening for Colon/Colorectal Cancer

Back 38

-Start at age 50

-High-sensitivity FOBT (every year), or sigmoidoscopy (every 5 years), or colonoscopy (every 10 years)

-Age 76-85 years: individualize

-Age older than 85 years: Stop routine screening

Front 39

Against routine screening for:

Back 39

Lung cancer

Skin cancer (insufficient evidence)

Ovarian cancer

Testicular cancer (adolescents or adult males)

Pancreatic cancer

Front 40

What are contraindications for Live Attenuated Inactivated Virus (LAIV) Influenza vaccine?

Back 40

-Pregnancy

-Chronic diseases (i.e., asthma, COPD, renal failure, DM)

-C/I in children on aspirin therapy (age 2 to 17 yrs)

Front 41

What is the youngest age at which flu vaccine (injection) can be given?

LAIV vaccine?

Back 41

TIV: At the age of 6 months

LAIV: 2 to 49 years

Front 42

What types of medications are avoided after receiving the LAIV flu vaccine (nasal form)?

Back 42

-Some antivirals (amantadine, rimantadine, zanamivir, osletamivir) should be avoided 48 hours before and 14 days after vaccination b/c they interfere w/ antibody production

Front 43

Tetanus Vaccine:

Back 43

-Give every 10 years for lifetime

-Boosters: for "dirty"/Contaminated wounds, give a booster if the last dose was more than 5 years prior

-Age 7 yrs and older: Use only tetanus and diptheria (Td) and tetanus, diptheria, and acellular pertussis (Tdap) forms of the vaccine

-Td: Given by IM route. Start using this form at age 7 years

-Tdap: Given by IM route

Front 44

When can the Tdap be used as a booster in adolescents and adults?

Back 44

The Tdap can be substituted for a single dose of Td (once in a lifetime)

Front 45

What is done if a patient has a tetanus-prone wound and vaccination status is unknown?

Back 45

Administer immediate dose of Td vaccine and the tetanus immunoglobulin (TIG) injection

Front 46

Which wounds are considered as highest risk for tetanus infection?

Back 46

Puncture wounds, wounds w/ devitalized tissue, soil-contaminated wounds, crush injuries, others...

Front 47

What vaccine is recommended for persons who are 65 years of age?

Back 47

Give one dose of Pneumovax (lifetime). No booster is needed

Front 48

If a person is vaccinated with the Pneumovax vaccine before the age of 65, what is recommended?

Back 48

-Give a booster dose of Pneumovax 5 years after the initial dose

Front 49

When should the Zoster Vaccine (Zostavax) be given?

Back 49

-Zostavax is a live attenuated virus vaccine

-Administer at age 60 years; one-time dose SC (even if the pt has already had shingles)

-The youngest the age that Zostavax can be given is 50 years of age

*Do not use vaccine if no h/o chickenpox or shingles (seronegative). The patient will become ill w/ chickenpox.

However, if a person had shingles before, the vaccine can still be administered.

*Certain antivirals (acyclovir, famciclovir, valacyclovir) can decrease immunologic response if take 24 hours before or 14 days after vaccination.

**May cause exacerbation of asthma and PMR

C/I:

-pregnancy and breastfeeding

-Leukemia, lymphomas, or other malignancies of the bone/bone marrow

-Immunocompromise (high-dose steroids > 2 wks, anti-TNF meds such as etanercept

Front 50

Varicella Vaccine

Back 50

-Varicella live attenuated virus (Varivax): given by SC route; health teenagers to adults w/ no h/o chickenpox; health care workers

-Need 2 doses (4 to 8 weeks apart)

-Exposure to chickenpox: give w/in 5 days after incident for post-exposure prophylaxis

-Acceptable evidence of varicella infection

-Written documentation of two doses of varicella vaccine (at least 28 days apart)

-Written diagnosis of chickenpox or shingles based on health care provider diagnosis

-Positive laborary varicella titer

-Born in the US before 1980

Front 51

Meningococcal conjugate vaccine quadrivalent (MCV4)

Back 51

Schedule - depends: for adults, give one or two doses (at least 2 months apart)

-First-year college students through age 21 years who will be living in residence halls (give one dose)

Front 52

What is the follow-up if a person w/ a history of Bacille-Calmette-Guerin (BCG) immunization has a positive PPD?

Back 52

-Evaluate the person for S&S of TB

-Rule out latent infection

-Order a CXR and check for S&S of TB such as "chronic" cough, weight loss, and night sweats

-Do not assume the reaction is from the BCG vaccine since the effect of the vaccine declines over time

Front 53

Hepatitis B

Back 53

Schedule: Total of 3 doses

-Hepatitis B titers should be checked w/in 60 days of the third dose.

*If incomplete series do not restart. If had one dose, give the second dose during the visit. If had two doses, give the 3rd dose

Front 54

Health Care Personnel Vaccination Recommendations

Back 54

Td or Tdap: give one-time dose of Tdap for all health care personnel who have not received the Tdap when due for tetanus booster. Continue giving Td boosters every 10 years for a lifetime

MMR: Proof of immunity necessary (born before 1957, laboratory confirmation such as positive titers). If not vaccinated for MMR, need two doses (at least 4 weeks apart)

Varicella: Proof of immunity necessary (positive varicella titer, documentation of two doses of varicella vaccine or diagnosis of varicella by physician/HCP

Hepatitis B: Hep B titers should be checked w/in 60 days of the 3rd dose. If incomplete hep B series (fewer than 3 doses), complete the series (do not restart) and check the titer as recommended

Influenza: all health care personnel should have annual flu shot during the fall/winter

Front 55

What is active immunity?

Back 55

Resistance developed in response to an antigen (infecting agent or vaccine) and usually characterized by the presence of an antibody produced by the host

Onset of protection: Usually w/in 1 month of dose

Duration of protection: Usually years or lifelong

Front 56

What is passive immunity?

Back 56

Immunity conferred by an antibody produced in another host, acquired naturally by an infant from mother, or artificially by administration of an antibody-containing preparation (antiserum or immune globulin [IG])

Onset of protection: usually w/in hours of dose

Duration of protection: time-limited, usually 6-9 mos

Front 57

What is a C/I to Hepatitis B vaccination?

Back 57

Anaphylactic reaction hx to Baker's yeast

Front 58

What are C/I's to varicella vaccination?

Back 58

Anaphylactic reaction hx to Gelatin & Neomycin

Front 59

What are C/I's to MMR vaccination?

Back 59

Anaphylactic reaction hx to Neomycin & Gelatin

Front 60

What are C/I's to IPV vaccination?

Back 60

Anaphylactic reaction hx to Neomycin, polymixin B, streptomycin

Front 61

What is a C/I to vaccinia (smallpox) vaccination?

Back 61

Anaphylactic reaction hx to Neomycin, polymixin B, streptomycin

Front 62

True or False -

While the PPD tuberculin skin test (TST) can be applied before or on the same day that MMR vaccine is given, if MMR vaccine is given on the previous day or earlier, the PPD TST test should be delayed for at least one month

Back 62

True

Front 63

True or False -

A 55-year old woman w/ Asthma is an ideal candidate for live attenuated influenza vaccine (LAIV, FluMist) against seasonal influenza

Back 63

False

Front 64

Calculating Pack-Year History to Quantify Tobacco Use

Back 64

Number of packs-per-day (PPD) x the number of years smoked

Example:

2 PPD x 30 years = 60 pk-yr hx

0.5 PPD x 10 years = 5 pk-yr hx