An 18-year-old man seeks advice before going to central Africa for a class project at his university. He was diagnosed with Crohn disease 3 years ago but currently feels well and has been asymptomatic on methotrexate and adalimumab for the last year. A review of medical records shows documentation of meningococcal polysaccharide vaccine at age 11. The patient has had no vaccines since then but believes that he received all of the recommended childhood vaccinations prior to that. His vital signs and physical examination are normal. Which of the following vaccines should be recommended for this patient?

Question

An 18-year-old man seeks advice before going to central Africa for a class project at his university.  He was diagnosed with Crohn disease 3 years ago but currently feels well and has been asymptomatic on methotrexate and adalimumab for the last year.  A review of medical records shows documentation of meningococcal polysaccharide vaccine at age 11.  The patient has had no vaccines since then but believes that he received all of the recommended childhood vaccinations prior to that.  His vital signs and physical examination are normal.  Which of the following vaccines should be recommended for this patient?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d27d_cfbd_bc81_8933725da5da_MD0003_00 Meningococcal vaccination with a quadrivalent (serotypes A, C, Y, W135) conjugate vaccine is recommended for all adolescents. This patient received primary vaccination at the recommended age (age 11-18; preferred age 11-12). However, he would benefit from a booster vaccine for several reasons: In general, a booster vaccine should be provided at age 16 (up to age 21) if the primary vaccine was at age <16. Meningococcal vaccination is also recommended before travel to highly endemic environments, such as most of sub-Saharan Africa and the Muslim hajj pilgrimage to Mecca, Saudi Arabia. In addition, an increased risk of meningococcal meningitis is found among young adults in large groups living in close proximity, such as military recruits and first-year college students residing in dormitories (although the details of this patient's arrangements are unknown). Primary vaccination can also be given to adults age >18 who are at increased risk for invasive meningococcal disease (eg, complement deficiency, functional or anatomic asplenia). (Choices A, B, and D) The safety of live-attenuated vaccines in those receiving tumor necrosis factor (TNF) antagonists (eg, adalimumab) is unknown, and these vaccines should be avoided in such patients. Examples include the intranasal influenza, varicella, and measles/mumps/rubella (MMR) vaccines. Influenza vaccination should be offered to all individuals annually, especially to those at increased risk of infection. However, the intranasal vaccine is likely less effective than the inactivated (intramuscular) vaccine and is contraindicated in immunosuppressed patients. live-attenuated vaccines (Choice E) Vaccination for yellow fever is recommended prior to travel to some countries in central Africa, many of which require evidence of vaccination for entry. However, contraindications to this live-attenuated vaccine include: Allergy to vaccine components (eg, eggs) AIDS (CD4 <200/mm³), certain immunodeficiencies (including those associated with thymus disorder), recent stem cell transplantation Immunosuppressive therapy (eg, TNF antagonists, high-dose systemic corticosteroids), as with this patient Individuals with these conditions who must travel to an endemic area should be provided with a medical waiver (documented in an international certificate of vaccination) and counseled on mosquito-protective measures. Educational objective: Meningococcal vaccination should be provided to all adolescents at age 11-12, with a booster recommended at age 16. Meningococcal vaccination is especially important for patients with complement deficiency or asplenia, military recruits, college students living in dormitories, and travelers to sub-Saharan Africa. Live-attenuated vaccines should be avoided in patients receiving tumor necrosis factor antagonists. References: Meningococcal meningitis: an emerging infectious disease. (http://www.ncbi.nlm.nih.gov/pubmed/20131137)

An 18-Year-Old Man Seeks Advice Before Going to Central Africa