Hospital Corpsman Sickcall Screener's Handbook
BUMEDINST 6550:9A
Naval Hospital Great Lakes
1999

Allotted lesson time:

References:

Terminal Learning Objectives: Given the need to perform immunizations and conduct shot call, the student will be able to do so according to proper procedure.

Enabling Learning Objectives:

1. Be able to identify different classifications of immunizations.

2. Be able to identify different immunizations.

3. Be able to identify dosages of different immunizations.

4. Be able to identify side effects and contraindications of different immunizations.

1. Introduction

   1. Purpose of immunization

      1. Prevention of infection and serious disease.

      2. One way to accomplish this is by exposure to biological material to stimulate the production of antibodies.

      3. To prevent infection, you give antibodies.

2. Live attenuated virus vaccine.

   Operational Medicine CD Text, images, videos and manuals The essential text for military healthcare providers www.brooksidepress.org

   1. Most live attenuated virus vaccines are made from viruses grown in chicken embryo or egg cultures.

      1. They should not be given to anyone who:

         1. has allergies to eggs

         2. history of angioedema

         3. anaphylaxis to eggs

         4. immunocompromised persons

      2. All live viruses can increase risk for heat injury after administration.

      3. Live viruses require special handling. They must be kept in a frozen state (at or near zero degrees Celsius).

   2. Yellow fever

      1. occasionally fatal

      2. transmitted by mosquitoes (Adeis egypti)

      3. 3-6 day incubation period

      4. signs/symptoms

         1. headache

         2. fever

         3. epistaxis

         4. backache

         5. nausea/vomiting

         6. hematemesis

         7. jaundice

      5. The vaccine

         1. Must be used within one hour of reconstitution and the vial and syringes must be destroyed.

         2. Dose is 0.5 cc injection SC or IM with a booster every 10 years.

         3. Given to alert forces and personnel who must travel to endemic areas.

         4. Reactions (normal sensitivity) include mild fever 7-14 days after administration, headache, malaise, & myalgias.

   3. Smallpox

      1. disfiguring

      2. sometimes fatal

      3. signs/symptoms:

         1. sudden onset

         2. fever

         3. malaise

         4. headache

         5. backache

         6. abdominal pain

         7. rash 2-4 days after exposure

      4. The vaccine

         1. Given only upon BUMED authority

         2. Dose is one deep using bifurcated needle to create multiple punctures to the skin.

         3. Requires vaccination site care.

         4. Reactions include:

            • lymphadenopathy

            • post vaccinial encephalitis

            • progressive vaccinia

         5. Do not give to patients with skin diseases such as eczema.

         6. Requires follow up at one week to ensure proper response.

   4. Oral polio

      1. Used to protect against polio.

      2. Signs/symptoms

         1. malaise

         2. headache

         3. G.I. disturbances

         4. neck and back stiffness

         5. in severe cases, paralysis

      3. The vaccine

         1. basic series - consist of 3 doses: (if previously unvaccinated)

            1. 2 gtts by mouth

            2. 2 ggts by mouth 6-8 weeks after first dose

            3. 2 gtts by mouth 1 year later

         2. For previously vaccinated persons, the dose is a one-time dose of 2 gtts

         3. Should not be given to people with a febrile illness.

         4. Not contraindicated in pregnancy

         5. Reactions are rare, but include a neurologic disease simulating paralytic poliomyelitis.

   5. Mumps, Measles, Rubella (MMR)

      1. A combination of attenuated vaccines.

      2. Mumps, measles, and rubella have various signs and symptoms:

         1. headache

         2. malaise

         3. anorexia

         4. coruza

         5. cough

         6. conjuctivitis

         7. rash

      3. The vaccine:

         1. Should never be given in pregnancy.

         2. Is given to recruits not previously immunized twice.

         3. Dose is 0.5 cc SC or IM

         4. Reactions include fever up to 5 to 10 days post immunization.

   6. Adenovirus

      1. Flu-like illness

      2. Can be spread in epidemics

      3. The vaccine

         1. Prevents disease from adenovirus types 4 &7.

         2. Contraindicated in pregnancy.

         3. Dose is 1 tablet by mouth

         4. Should be separated from other immunizations by at least one month.

3. Killed virus and virus protein vaccines

   Operational  Medicine Training Videos Inexpensive Downloads, DVDs, and CDs Many are free. See how to do it. www.brooksidepress.org

   1. Rabies - invariably fatal acute encephalomyelitis caused after exposure to an affected animal.

      1. There is one killed virus vaccine derived from human diploid cell culture (Imonax).

      2. Indicated after suspicious bites along with rabies immune globulin (Hyperab or Imogan)

      3. Dosage, given IM to deltoid; found in BUMEDINST 6220.6

   2. Influenza

      1. Epidemic febrile disease caused by many different strains of the flu virus.

      2. Vaccine varies each year and depends on virus strains likely to cause disease during the flu season.

      3. The vaccine should be

         1. given annually

         2. NOT to be given to those with egg allergies!!

         3. dosage varies, but is given IM or SC

         4. to be given alone

         5. Reactions include: local pain and swelling, fever, headache, malaise, & myalgia.

         6. Pt should be given heat stress precautions.

   3. Hepatitis B

      1. Causes a variety of clinical pictures from asymptomatic infection to fulminating disease and death. Can be transmitted sexually.

      2. Signs/symptoms

         1. myalgia

         2. malaise

         3. nausea

         4. diarrhea

         5. fever

         6. jaundice

      3. Two vaccines exist for hepatitis B:

         1. Recombivax HB

         2. Energix - B

      4. The vaccine should:

         1. Given IM to deltoid

         2. Doses are 1.0 cc for first injection; 1.0 cc one month later, and 1.0 cc six months after first dose

         3. Indicated for health care workers, sexual partners for chronic carriers.

         4. For exposures, hepatitis B immune globulin should be given in addition to Heptavax or Recombivax.

         5. Reactions - site soreness, fatigue, weakness, headache

         6. Serologic prescreening may be indicated because of the high cost of vaccines.

4. Killed Bacteria Vaccines

   1. Killed bacterial vaccines are the vaccines that give the largest number of side effects after injection.

      1. They are made from bacterial cultures that have been killed and suspended in solution.

      2. They all increase risk of heat injuries for up to two weeks after injection.

      3. side effects:

         • fever

         • myalgia

         • site soreness

         • swelling

         • localized lymphadenopathy

         • malaise

         • headache

      4. Do not use jet injectors

      5. May be given with other vaccines.

   2. Typhoid - an infection caused by salmonella typhi characterized by fever, headache, malaise, rose spots on the trunk, enlarged lymph tissues and diarrhea.

      1. Two forms of the vaccine are available. One is a live attenuated oral and the other is an injection.

         1. Injection

            1. series consist of 2 shots given 4 or more weeks apart.

            2. dose is 0.5 cc IM or SC

            3. Booster every 3 years and is 1 dose.

            4. Required for all alert forces.

      2. Oral (tyzla)

         1. Indicated for people with severe reactions to injectable vaccine.

         2. May be used for all personnel.

         3. Must be kept refrigerated.

         4. Initial dose is 4 capsules taken on alternate days with cool liquids no more than 37 degrees C.

         5. Booster is given every 5 years and consist of repeating the 4 dose initial series.

   3. Plague

      1. severe, often fatal disease

      2. Caused by Yersinia pestis transmitted by the bite of an infective rodent flea.

      3. Signs/symptoms

         1. high fever, mental confusion, delirium, coma

         2. shock

         3. petechial hemorrhages

      4. The vaccine:

         1. Basic series is first dose of 1.0 cc IM followed in 2-4 weeks by 0.2 cc IM. This is followed in 6 months by 0.2 cc IM.

         2. Basic series is required when entering a high risk area. Re-immuize with 0.2 cc IM every 6 months.

         3. IM Only

         4. Basic series is no longer required per BUMEDNOTE 6230.12.

   4. Cholera - an acute intestinal infection caused by vitro cholera.

      1. It is characterized by:

         1. sudden onset

         2. vomiting

         3. profuse watery stools

         4. rapid dehydration

         5. acidosis

         6. collapse

      2. The vaccine has a low seroconversion rate and is no longer recommended by the World Health Organization.

   5. Pertusis - (whooping cough) an acute, highly contagious infection of the respiratory tract. It is caused by Bordella pertusis.

      1. Serious in children, mild in adults.

      2. A killed suspension of B-pertusis is part of the DPT shot given to children and is responsible for most reactions.

      3. The pertusis vaccine

         1. Started at 8 weeks

         2. Combined with Diptheria and tetanus toxoids, DPT 3 doses at bimonthly intervals

         3. Boosters given at 18 months and 4 years of age.

         4. Dose is 0.5 cc IM or SC for each shot.

5. Toxoids

   1. Immunity to tetanus and diptheria is related to the level of antibodies to the toxins produced.

      1. A modified toxin that does not cause illness is called a toxoid and is used to stimulate the body to produce antibodies that work against the toxin.

      2. Toxoid, are often given together.

      3. The main shots used are:

         1. Combined diptheria, pertusis, tetanus (DPT) given to children.

         2. Diptheria, tetanus, pediatric (DT) used in children who cannot be given pertusis.

         3. Tetanus, diptheria, adult (TD) given to persons 7 years of age for normal booster shots.

         4. Diptheria toxoid (D) given only to children who have contraindications to combined preparation.

         5. Tetanus toxoid (T) given as a booster shot when diptheria not indicated

   2. Tetanus: caused by Clostridium tetanus a bacteria that produces a neurotoxin.

      1. symptoms:

         1. spasms of jaw muscles (lockjaw)

         2. stiffness of neck, back, and abdominal muscles

         3. muscle contractions

      2. History of skin wounds is common. 2/3 of all US cases come from puncture wounds of the hands and feet.

      3. The vaccine:

         1. Dose is 0.5 cc IM

         2. Basic series given as part of DPT as child, but in an unimmunized person: one shot followed in 4-6 weeks by second shot, followed in 6-12 months by third shot.

         3. Booster is every 10 years

         4. May be given if medically indicated for injury.

         5. Increased wounds for risk are - old, dirty wounds, puncture wounds, animal bites, wounds with jagged edges.

         6. Reactions are rare, usually limited to injection site soreness.

   3. Diptheria - acute upper respiratory infection or skin infection, produced by Corynebacterium diptheria.

      1. The toxin is absorbed and causes destruction of epithelium and an inflammatory response.

      2. Results in grayish pseudomembrane commonly found over tonsils, pharynx or larynx.

      3. Tropical form that is responsible for jungle sores.

6. Bacterial Component Vaccines

   1. Pneumovax 23 and pnu-immune 23 are the trade names of a vaccine made from a mixture of highly purified capsular polysaccharides from the 23 most common or most invasive pneumococcal types.

      1. Used to protect against pneumococcal pneumonia, meningitis and otitis media.

      2. The vaccine:

         1. Used in persons over 2 years old who are at risk.

         2. Those at risk include individuals without a spleen; chronic renal, respiratory, or cardiac disease.

         3. over 50 years old

         4. dose is 0.5 cc IM or SC

         5. booster shot is contraindicated

         6. reactions include injection site pain and rarely fever, malaise, or myalgia.

   2. Hemophilus influenza - used to protect against hemophilus, influenza subtype B infection, the most common cause of bacterial meningitis and a leading cause of serious systemic illness in young children in the U.S.

      1. The vaccine

         1. Is recommended for all children between 18 months and 5 years old.

         2. Dose is 0.5 cc IM or SC and is repeated at 4 & 6 months.

         3. Boosters are given at 12-15 months

         4. Reactions are rare

         5. Recently approved vaccine includes the hemophilus, diptheria, tetanus and pertusis.

Shot Call

1. ACLS person (usually a medical officer) and at least one BCLS qualified provider must be present.

2. Ambulance on call with response time of 8 minutes or less.

3. A defibrillator and spark kit should be available.

4. Persons who administer must be trained in:

   1. procedure

   2. proper use and maintenance of equipment

   3. indications and contraindications

   4. storage requirements

   5. management and reporting of adverse reactions

   6. immunization record maintenance

5. Patients who report to shot call should be:

   1. screened for chronic/acute illness

   2. screened for pregnancy

   3. screened for medications that might interact with immunizations

   4. screened for allergies

   5. Offered Tylenol or aspirin to minimize local and systemic shot reactions.

   6. observed for at least 15 minutes after administration for symptoms of anaphylaxis