Immunology and Vaccines

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CHAPTER 24 Immunology and Vaccines

I. Introduction: The immune system consists of physical and chemical barriers and specific and nonspecific mechanisms to eliminate antigens.
II. Components of the Immune System

A. Antigen-presenting cells

1. B cells

a. Produce antibodies

2. Monocytes

a. Precursor cell to macrophages
b. Circulate in blood; migrate into tissues
c. Scavenge foreign cells

3. Macrophages

a. Phagocytose and kill microorganisms; activation of T cells and initiation of immune response
b. Secrete cytokines
c. Present antigens to lymphocytes

4. Dendritic cells

a. Activation of T cells and initiation of adaptive immune response
b. Star-shaped

B. Polymorphonuclear leukocytes or neutrophils (PML or PMN)

1. Neutrophils

a. Phagocytose and kill microorganisms; first line of defense
b. Most abundant (40%–70% of white blood cells [WBC])
c. Effector cells of innate immunity
d. Short-lived (half-life of mature neutrophils is 2–3 days)

2. Eosinophils

a. Kill antibody-coated parasites through release of toxic substances, major basic protein, eosinophil cationic protein, and several enzymes
b. ~5% of WBC
c. Protects against parasitic organisms
d. Major source of inflammatory mediators
e. Bind IgE

3. Basophils

a. Rare (<5% of WBC)
b. Unknown function
c. Bind to IgE
d. Source of type I hypersensitivity reactions

4. Mast cells

a. Function: expulsion of parasites from body through release of granules containing histamine and other active agents
b. Occur in different body tissues
c. Generate protective acute inflammatory response
d. Source of type I hypersensitivity reactions
e. Degranulation, major contributor to inflammation and allergies

C. Cytotoxic leukocytes

1. Natural killer cells

a. Kills cells infected with certain viruses
b. Larger than lymphocyte with granular cytoplasm
c. Effector cell of innate immunity

2. Lymphokine-activated killers (LAK)

a. Kill various tumor target cells and abnormal lymphocytes

D. Lymphocytes

1. B cells: produce antibodies
2. T cells: helper, cytotoxic

a. Helper T cells: regulate immune response
b. Cytotoxic T cells: kill altered cells (infected with viruses, tumor cells)

E. Antibodies

1. Ig (immunoglobulin) G: most common antibody in blood

(1) Active in blood against bacteria and viruses
(2) Helps phagocytes eliminate antigens

2. IgM: reacts with certain antigens; found in circulating body fluids
3. IgA: plays a role in mucosal immunity
4. IgD: found on B cells. not released from the cell

a. May be involved in B-cell activation

5. IgE: involved in allergic reactions; stick to mast cells and release inflammatory substances

a. Rare in blood

F. Acute phase reactants

1. Soluble mediators of the immune system
2. Levels increase if infection or tissue damage is present
3. Control tissue injury; increase host resistance to infection; promote tissue repair

G. Cytokines

1. Interferons (IFN): important in controlling viral infections and augmenting immune response

a. Nonspecific immune system
b. Examples: INF-α, INF-β, Interferon-γ

2. Tumor necrosis factors (TNF): produced by macrophages and T lymphocytes; regulate immune response and hematopoiesis

a. Examples: TNF-α, TNF-β

3. Interleukins (IL): mediators between leukocytes

a. Examples: IL-1, IL-2, IL-3, IL-4

4. Chemokines: directed migration of leukocytes during immune response
5. Transforming growth factor (TGF): involved in stem cell differentiation and other functions
6. Hematopoietic colony-stimulating factors (CSF): important in maturation of leukocytes

H. Active and passive immunity

1. Active immunity

a. Response to an infection
b. Immunization (vaccination)

2. Passive immunity

a. Mother-to-baby

(1) IgG crosses placenta
(2) IgA in breast milk

b. Antibody injection into nonimmune person (antiserum)

I. Innate versus adaptive defense system

1. Nonspecific defense mechanism (innate)

a. First line of defense: physical barriers (skin, mucosa)
b. Second line of defense: chemical barriers (phagocytes, natural killer cells, inflammation, fever, antimicrobial proteins)

2. Specific defense mechanisms (adaptive)

a. Third line of defense: immune system (lymphocytes, antibodies)

(1) Protects against infectious agents and abnormal cells
(2) Responsible for most complement activation

J. Antigens

1. Substance from a pathogen or foreign organism capable of inducing a specific immune response
2. When the body is exposed to an antigen for the first time, antibody production is slow and at low levels. If the body is exposed to the same antigen again, the antibody response is more intense and rapid.

III. Immunization/Vaccinations

A. Basic Principles of Vaccination

1. Exposure to antigen will provoke an immune response.
2. Repeated exposure to antigen produces immunological memory.
3. Vaccine strategy: make a vaccine that gives a strong immune response—safely
4. US Centers for Disease Control publish recommended vaccination schedules

B. Common Vaccines (Figures 24-1 and 24-2)

1. Diphtheria, tetanus, pertussis (DTaP, DT, Rd, Tdap) vaccines

a. Daptacel (DTaP) diphtheria, tetanus toxioids, and acellular pertussis

(1) Indicated for infants and children, 6 weeks to 6 years old
(2) Dose is IM injection of 0.5 mL given at 2, 4, 6, and 15–20 months; booster at 4–6 years (total of 5 doses)
(3) How supplied: 0.5 mL suspension for injection
(4) Adverse effects: fever, pain and swelling at injection site, irritability, loss of appetite, drowsiness

b. Pediarix (DTaP-HBV-IPV) diphtheria, tetanus toxoids, and acellular pertussis, hepatitis B (recombinant), inactivated poliovirus vaccine

(1) Indicated for infants and children, 6 weeks to 7 years old
(2) Dose is IM injection of 3 doses of 0.5 mL each, at 6- to 8-week intervals; first dose at minimum age of 6 weeks; not used for booster doses
(3) How supplied: 0.5 mL vial
(4) Adverse effects: fever, pain and swelling at injection site, irritability, loss of appetite
(5) Diphtheria toxoid, tetanus toxoid, and pertussis antigens are the same as Infanrix

c. Infanrix (DTaP; diphtheria, tetanus toxoids, and acellular pertussis)

(1) Indicated for infants and children, 6 weeks to 7 years old
(2) Dose is IM injection of 0.5 mL each at 2, 4, and 6 months; one booster at 15–20 months and another booster at 4–6 years of age (total of 5 doses)
(3) How supplied: 0.5 mL vial
(4) Adverse effects: fever, pain and swelling at injection site, irritability, loss of appetite, drowsiness
(5) Note: Diphtheria toxoid, tetanus toxoid, and pertussis antigens are the same as Pediarix and may be used to complete DTaP immunization with Pediarix.

d. Adacel (Tdap) tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis

(1) Indicated for ages 11–64 years old as an active booster immunization (single-dose)
(2) Dose is IM injection of one dose of 0.5 mL; 5 years should pass since the last tetanus, diphtheria, or pertussis vaccine
(3) How supplied: 0.5 mL vial
(4) Adverse effects: fever, pain and swelling at injection site, headache, rash

e. Boostrix (Tdap) tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis

(1) Approved for ages 10–64 years old as an active booster immunization (single-dose)
(2) Dose is IM injection of one dose of 0.5 mL; 5 years should have passed since the last tetanus, diphtheria, or pertussis vaccine
(3) How supplied: 0.5 mL vial
(4) Adverse effects: fever, pain and swelling at injection site, gastrointestinal upset, headache

2. Haemophilus influenzae vaccines

a. Combivax (Haemophilus b conjugate [meningococcal protein conjugate]) and hepatitis B [recombinant] vaccine)

(1) Indicated for infants 6 weeks to 15 months for Haemophilus influenzae type b and hepatitis B virus (HBsAg-negative mothers)
(2) Dose is IM injection at 2, 4, and 12–15 months (total of 3 doses)

(a) For best response, the interval between the second and third dose should be 8–11 weeks.

(3) How supplied: 0.5 mL vial
(4) Adverse effects: pain and swelling at injection site, fever, erythema, somnolence, rash, diarrhea, anorexia
(5) Note: May be administered concurrently with DTP, OPV, eIPV, Varivax, M-M-R II, and booster of DTaP

b. Pedvax HIB (Haemophilus b conjugate vaccine [meningococcal protein conjugate])

(1) Indicated for children 2–71 months for Haemophilus influenzae type b
(2) Dose is IM injection

(a) 2–10 months: 0.5 mL dose, followed by 0.5 mL dose 2 months later; booster at 12–15 months
(b) 11–14 months: 05 mL dose, followed by 0.5 mL dose 2 months later
(c) 15–71 months: 0.5 mL dose

(3) How supplied: 0.5 mL vial (does not contain thimerosal or lactose)
(4) Adverse effects: pain and soreness at injection site, irritability, diarrhea, erythema, otitis media, rash, upper respiratory tract infection, vomiting
(5) Note: May be administered concurrently with DTP, OPV, eIPV, Varivax, M-M-R II, or Recombivax HB

3. Pneumococcal vaccines

a. Pneumovax 23 (PPV23), pneumococcal vaccine polyvalent

(1) Indicated for 50 years and older, and children 2 years and older who are high risk
(2) Dose is SC or IM injection of 0.5 mL dose
(3) How supplied: single- or multiple-dose vial
(4) Adverse effects: fever, pain at injection site, erythema, warmth, swelling, and local induration

b. Prevnar (PCV pneumococcal 7-valent conjugate vaccine [Diphtheria CRM197 protein]) (capsular serotypes 4, 6B, 9V, 14, 18C, 19F, and 23F)

(1) Indicated for infants and toddlers, 6 weeks to 15 months old, and unvaccinated children through 9 years old
(2) Dose is IM injection of 4 doses; first dose at 2 months, then one at 4, 6, and 12–15 months
(3) How supplied: 0.5 mL vial
(4) Adverse effects: pain and irritation at injection site, fever, drowsiness, rash, weakness, vomiting, and seizures

4. Poliovirus vaccines

a. IPOL (poliovirus vaccine inactivated, type 1 [Mahoney], type 2 [MEF-1], and type 3 [Saukett])

(1) Indicated for infants as young as 6 weeks of age, up to adult
(2) Dose is SC or IM injection
(3) Infants: 3 doses of 0.5 mL at 2 month intervals, followed by a fourth dose of 0.5 mL at 12–15 months (and at least 2 months after the third dose)
(4) How supplied: 0.5 mL
(5) Adverse effects: irritability, erythema, fever, vomiting, anorexia, fatigue

b. Orimune (oral live attenuated poliovirus [OPV], [Sabin strain types 1, 2, and 3])

(1) No longer available in the United States

5. Influenza vaccines

image

Figure 24-1 Recommended immunization schedule for persons aged 0-6 years – United States, 2010.

(From http://www.cdc.gov/vaccines/recs/schedules/)

image

Figure 24-2 Recommended immunization schedule for persons aged 7–18 years — United States, 2010.

(From http://www.cdc.gov/vaccines/recs/schedules/)

NOTE: Other TIV vaccine brands (Agriflu, Flulaval, Fluarix) are available.

a. Fluzone TIV (influenza virus trivalent inactivated vaccine, TIV)

(1) Indicated for infants 6 months and older against influenza virus types A and B
(2) Dose is IM injection

(a) 6–35 months: one or two doses of 0.25 mL; two doses should be administered at least 1 month apart in children younger than 9 years old
(b) 3–8 years: one or two doses of 0.5 mL
(c) 9 years and older: one 0.5 mL dose

(3) How supplied

(a) 0.25-mL prefilled syringe (no preservative)
(b) 0.5-mL prefilled syringe (no preservative)
(c) 0.5-mL single-dose vial (no preservative)
(d) 5-mL multi-dose vial, contains thimerosal

(4) Adverse effects: pain at injection site, fever, malaise, myalgia
(5) Note: Use TIV vaccines with caution in patients with allergy to eggs; may cause anaphylaxis, asthma

b. Fluvirin TIV (influenza virus trivalent inactivated vaccine, TIV)

(1) Indicated for children, 4 years and older against influenza virus types A and B
(2) Dose is IM injection

(a) 4–8 years: one or two doses of 0.5 mL
(b) 9 years and older: one 0.5 mL dose

(3) How supplied

(a) 0.5-mL prefilled syringe, contains thimerosal
(b) 5–mL multi-dose vial, contains thimerosal

(4) Adverse effects: pain at injection site, fever, myalgia, malaise
(5) Note: Use TIV vaccines with caution in patients with allergy to eggs; may cause anaphylaxis, asthma

c. FluMist LAIV (live attenuated influenza vaccine (LAIV) types A and B) intranasal spray

(1) Indicated for 2–49 years
(2) Dose is nasal spray

(a) Children 2–8 years not previously vaccinated: two doses, 1 month apart (one spray in each nostril); previously vaccinated: one dose (one spray in each nostril)
(b) Children and adults 9–49 years: one dose (one spray in each nostril)

(3) How supplied: 0.2 mL prefilled nasal spray; refrigerate
(4) Adverse effects: runny nose, nasal congestion, fever, sore throat
(5) Note: Do not use in patients with asthma or children younger than 5 years with recurrent wheezing

6. Measles, mumps, rubella (MMR) vaccine: live vaccine for measles, mumps, and rubella

a. M-M-R-II

(1) Indicated for 12 months and older
(2) Dose is SC injection of two doses, first dose at 12–15 months, second dose at 4–6 years; use within 30 minutes of reconstitution
(3) How supplied: 0.5 mL vial (lyophilized vaccine) and one 7 mL vial of diluent (sterile water for injection)
(4) Adverse effects: fever, syncope, headache, irritability, atypical measles, panniculitis
(5) Note: Use with caution in patients with egg allergy. However, studies have suggested that it is safe in children with severe egg allergy. It should be given 1 month before or after administration of other live vaccines and may be administered concurrently with Varivax or PedvaxHIB.

7. Varicella virus vaccine (chickenpox vaccine)

a. Varivax (live, attenuated virus vaccine [Oka/Merck strain of varicella])

(1) Indicated for 12 months and older
(2) Dose is SC injection

(a) Children 12 months to 12 years: 0.5 mL; if a second dose is administered, give a minimum of 3 months later; use within 30 minutes of reconstitution
(b) Children 13 years and older: 0.5 mL; second 0.5 mL dose 4–8 weeks later

(3) How supplied: 0.5 mL; reconstitute with diluent
(4) Adverse effects: pain and swelling at injection site, rash, erythema

8. Combined varicella and MMR vaccine

a. ProQuad (combined attenuated live virus vaccine [MMR and varicella])

(1) Indicated for children 12 months to 12 years
(2) Dose is SC injection of 0.5 mL; use within 30 minutes of reconstitution
(3) How supplied: 0.5 mL after reconstitution with sterile water
(4) Adverse effects: pain and swelling at injection site, rash, erythema

9. Meningococcal (meningitis) vaccines

a. Menomune MPSV4 (meningococcal polysaccharide serogroups A, C, Y, and W-135)

(1) Indicated for children 2 years and older
(2) Dose is SC injection of single dose of 0.5 mL; use within 30 minutes of reconstitution; protective antibody levels achieved within 7–10 days after vaccination
(3) How supplied: 0.5 mL vial with 0.78 diluent (no preservative); 0.5 mL (five per package) with 0.78 mL diluent (no preservative); 10 doses with 6 mL vial diluent (contains preservative) for administration with needle and syringe (not to be used with jet injector)
(4) Adverse effects: pain at injection site, erythema, chills, fever, headache

b. Menactra MCV4

(1) Indicated for children and adults, 2–55 years, to prevent meningococcal disease
(2) Dose is IM injection of single dose of 0.5 mL
(3) How supplied: latex free syringe: 0.5 mL BD Luer-Lok
(4) Adverse effects: pain at injection site, irritability, diarrhea, drowsiness, Guillian-Barré syndrome

10. Varicella zoster vaccine

a. Zostavax (live attenuated virus vaccine)

(1) Indicated for adults 60 years and older for prevention of herpes zoster (shingles)
(2) Dose is SC injection of 0.65 mL single dose; use within 30 minutes of reconstitution
(3) How supplied: 0.65 mL lypophlized powder (19,400 plaque-forming units [PFU])
(4) Adverse effects: pain and swelling at injection site, pruritus, erythema
(5) Do not use in patients with AIDS.
(6) Note: DOES NOT TREAT shingles or postherpetic neuralgia

11. Human papillomavirus vaccine (HPV vaccine)

a. Gardasil (human papillomavirus (HPV) quadrivalent (types 6, 11, 16, and 18) vaccine, recombinant

(1) Indicated for girls and women (9–26 years)
(2) Dose is IM injection of three doses, 0.5 mL at 0, 2, 6 months
(3) How supplied: 0.5-mL single-dose vial; protect from light
(4) Adverse effects: pain and swelling at injection site, nausea, fever
(5) Do not use in pregnant women

b. Cervarix (HPV bivalent vaccine)

(1) Indicated in females age 10–25 years
(2) Dose in IM injection of three doses, 0.5 mL at 0, 2, 6 months

12. Rotavirus vaccines

a. RotaTeq (rotavirus vaccine, live, oral, pentavalent)

(1) Indicated for infants and children for prevention of rotavirus gastroenteritis caused by serotypes GI, G2, G3, and G4
(2) Dose: Oral is three doses; first dose at 6–12 weeks, second and third doses at 4- to 10-week intervals
(3) How supplied: 2 mL oral solution; protect from light; do not reconstitute or dilute
(4) Adverse effects: diarrhea, bronchospasm, irritability, nasopharyngitis, otitis media, vomiting

(a) Warning: intussusception

b. Rotarix (rotavirus vaccine, live, oral, of serotypes G1 and non-G2 (G3, G4, and G9)

(1) Indicated for infants and children for prevention of rotavirus gastroenteritis caused by G1 and non-G2 (G3, G4, and G9)
(2) Dose: Oral is two doses of 1 mL administered orally; administer first dose at 6 weeks of age; second dose after an interval of at least 4 weeks and before 24 weeks of age
(3) How supplied: 1-mL oral suspension
(4) Adverse effects: irritability, fever, runny nose, vomiting, fussing

(a) Warning: intussusception

13. Hepatitis A vaccines

a. Vaqta (inactivated virus vaccine)

(1) Indicated for children and adults, persons 12 months and older
(2) Dose: IM injection

(a) Adults (19 years and older): 1 mL (50 units) with booster of 1 mL (50 units) 6–18 months later
(b) Children (12 months to 18 years): 0.5 mL (25 units) with booster of 0.5 mL (25 units) 6–18 months later

(3) How supplied

(a) Adults: Hepatitis A virus antigen 50 units/mL (1 mL) in injection or suspension (preservative free)
(b) Pediatric: Hepatitis A virus antigen 25 units/0.5 mL (0.5 mL) in injection or suspension (preservative free)

(4) Adverse effects: irritability, drowsiness, headache, fever, anorexia, pain and swelling at injection site, erythema, warmth

b. Havrix (inactivated virus vaccine)

(1) Indicated for children and adults, 12 years and older
(2) Dose is IM injection

(a) Adults: 1-mL single injection at day 0 and 1-mL booster dose given between 6 and 12 months later
(b) Children 12 months to 18 years: 0.5 mL single injection and 0.5 mL booster given between 6 and 12 months later

(3) How supplied

(a) Adults: 1 mL (1440 ELISA units of viral antigen)
(b) Children: 0.5 mL (720 ELISA units of viral antigen)

(4) Adverse effects: irritability, drowsiness, headache, fever, anorexia, pain and swelling at injection site, erythema, warmth
(5) Note: Prefilled syringes contain dry natural latex rubber and may cause allergic reactions.

14. Combined hepatitis A and hepatitis B vaccines

a. Twinrix (inactivated virus vaccine [recombinant], a combined hepatitis A and hepatitis B vaccine)

(1) Indicated for adults, 18 years of age or older, against disease caused by hepatitis A virus; active immunization against disease caused by hepatitis A virus and hepatitis B virus (all known subtypes)
(2) Dose is IM injection

(a) Adults: three doses of 1 mL each given on a 0-, 1-, and 6-month schedule. Alternatively, four doses on days 0, 7, and 21–30 followed by a booster dose at month 12 may be used.

(3) How supplied: 1 mL (720 ELISA units of inactivated hepatitis A virus and 20 mcg of hepatitis B surface antigen) prefilled Tip-Lok syringes
(4) Adverse effects: headache, fatigue, soreness and redness at injection site

15. Hepatitis B vaccines

a. Engerix-B (recombinant)

(1) Indicated for all known subtypes of hepatitis B virus; it is expected that hepatitis D will be prevented by Engerix-B
(2) Dose is IM injection

(a) Adults (older than 19 years): three doses at 0, 1, and 6 months in a 20 mcg/mL suspension; first dose given on the elected date, second dose given 1 month later, third dose given 6 months after the first dose
(b) When used for immediate prophylactic intervention (e.g., administration to persons who are wounded in bombings or similar mass casualty events), vaccination should begin within 24 hours and no later than 7 days following the event
(c) Children, adolescents (birth to 19 years): three doses of 10 mcg/0.5 mL
(d) Infants: three doses, recommended to start at birth, second dose given at 1 month, third dose given at 6 months

b. Recombivax HB

(1) Indicated for all known subtypes of hepatitis B virus
(2) Dose is IM injection

(a) Adults (older than 19 years): three doses of a 10-mcg (1-mL) suspension at 0, 1, and 6 months
(b) Birth to 19 years: three doses of 5 mcg (0.5 mL). Note: Two dose schedule is available for those 11–15 years old
(c) Infants: three doses of 5 mcg (0.5 mL) recommended to start at birth, second dose given at 1 month, third dose given at 6 months

(3) Adverse effects: flushing, hypotension, pain at injection site

PATIENT PROFILE

Patient Initials: SV
Sex: Female
Age: 68
Height: 5′ 3″
Weight: 74 kg
Race: White
Allergies: No known drug allergies (NKDA)
Patient Consultation: For recent exacerbations of COPD and community-acquired pneumonia, SV was hospitalized for 5 days and just completed her antibiotic therapies as an outpatient. SV wonders if there are any strategies to help her stay healthy and prevent another hospital admission.
Current Health Conditions:
Hypercholesterolemia
COPD (diagnosed 8 years ago)
Recent Laboratories of Note:
Cholesterol: 220 mg/dL
Serum creatinine: 1.1
Social History: Tobacco use: Former heavy smoker; quit 5 years ago when husband died of lung cancer
Alcohol use: None
Recent immunizations: None in the past 10 years
Pharmacy Medication Profile:
Centrum Silver 1 tablet PO once daily
Spiriva Handihaler 1 capsule inhaled once daily in the morning
Simvastatin 40 mg PO once daily at bedtime
Mucinex 1 tablet PO twice daily
Advair inhaler 1 inhalation twice daily

PATIENT PROFILE QUESTION

1. SV’s pharmacist notes that key vaccinations are missing from her vaccination record and autumn is rapidly approaching. What are two vaccination strategies that could have a great impact on the health of SV and reduce the risk of respiratory-related hospitalizations?

I. Receiving Pneumovax
II. Receiving FluMist
III. Receiving Fluzone
IV. Receiving Zostavax
a. I and II
b. I and III
c. I and IV

Answer: b. Annual influenza vaccination should be given to all patients with COPD. Influenza can lead to COPD exacerbations and respiratory failure. Morbidity and mortality may be decreased as much as 50%. Currently, the best choice for influenza vaccination from the above choices would be immunization with the injectable inactivated virus vaccine Fluzone. FluMist contains live, attenuated virus and is inhaled through the nose; those with reactive airways or who are receiving chronic corticosteroid therapy may need to avoid this form of influenza vaccination. The current adult immunization schedule from the Centers for Disease Control and Prevention shows that the pneumococcal vaccine for all adults with COPD is recommended. A single dose of Pneumovax is sufficient for most patients. If the patient was younger than 65 years old at time of primary vaccination, a second dose is recommended after the age of 65 years. Although Zostavax (herpes zoster vaccine) immunization is also a consideration given her age, it would not be given to prevent respiratory-related illness.

REVIEW QUESTIONS

(Answers and Rationales on page 380.)

1. Which of the following cells produces histamine?

I. Mast cells
II. Basophils
III. Erythrocytes
a. I only
b. III only
c. I and II only
d. II and III only
e. I, II, and III

2. Which of the following represents a normal white blood cell count?

a. 100–200 cells per cubic millimeter
b. 400–500 cells per cubic millimeter
c. 1200–3800 cells per cubic millimeter
d. 4300–10,800 cells per cubic millimeter
e. 32,000–56,000 cells per cubic millimeter

3. Which of the following cell type(s) is/are NOT involved in antibody mediated response?

a. Plasma cells
b. T-cytotoxic cells
c. T-helper cells
d. B lymphocytes
e. All of the above

4. Cells and that produce and secrete antibodies are:

I. plasma cells.
II. T cells.
III. B cells.
a. I only
b. III only
c. I and II
d. II and III
e. I, II, and III

5. Which of the following may cause elevated white blood cells?

a. Viral infection
b. Stress
c. Medication
d. Bacterial infection
e. All of the above

6. Leukocytes expressing CD-8 receptors are:

a. B lymphocytes.
b. T-cytotoxic cells.
c. RBC.
d. Natural killer cells.
e. None of the above

7. Which of the following are live vaccines?

I. Oral polio
II. Mumps
III. Measles
a. I only
b. III only
c. I and II
d. II and III
e. I, II, and III

8. Intussusception is most likely to occur with the use of:

a. RotaTeq
b. Prevnar
c. Comvax
d. Gardasil
e. Varivax

9. Which of the following vaccines need to be reconstituted?

I. Menomune
II. M-M-R-II
III. Pneumovax 23
a. I only
b. III only
c. I and II
d. II and III
e. I, II, and III

10. Which of the following vaccines should not be administered to infants younger than 6 weeks of age?

a. Rotavirus
b. DTaP
c. Hib
d. Pneumococcal
e. All of the above

11. The quadrivalent HPV vaccine contains which of the following pseudovirion antigens?

a. HPV 6, HPV 11, HPV 16, HPV 18
b. HPV 1, HPV 2, HPV 3, HPV 4
c. HPV 16 and HPV 18 only
d. HPV 6 and HPV 11 only
e. None of the above

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