4/7/13. Vaccinations for Adults and Adolescents. Effect of Full Use of Adult Immunizations. General Vaccine Information

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1 Vaccinations for Adults and Adolescents Nicholas A. Daniels, MD MPH Department of Medicine Professor of Clinical Medicine Declaration of full disclosure: No conflict of interest 2 Effect of Full Use of Adult Immunizations Deaths/yr Efficacy Current Use PrevDeaths/yr Influenza 36,000 70% 60% 18,000 Pneumococcal 40,000 60% 50% 20,000 HBV 6,000 90% 30% 4,000 Tetanus-Diph < 25 99% 80% < 15 MMR < 30 95% varies < 30 General Vaccine Information Live virus vaccines MMR Varicella Zoster FluMist Yellow Fever Multiple live vaccine administrations should be separated by 4 weeks because of possible interference Inactivated vaccines Td/Tdap Influenza Pneumococcal Polio (IPV) Hepatitis B 3 4 1

2 Pregnant Women and Vaccines Do not use live vaccines in pregnant women. These include: Measles Mumps Rubella Varicella Zoster FluMist Combined Tetanus, Diphtheria, and Pertussis (Tdap) Vaccine Tdap vaccine elicits robust immune response, while exhibiting overall safety profile similar to Td vaccine JAMA Vol. 293: Data support routine use of Tdap vaccine: all adolescents and adults who have not received Tdap, regardless of interval since Td persons age 65 years and older all pregnant women during late-second or third trimester or immediately postpartum during each pregnancy ACIP Pertussis Incidence Pertussis Incidence 7 8 2

3 Flu Pandemics Spanish flu in killed 500,000 Americans. Nearly half were young, healthy adults Asian flu in , first identified in China. Claimed 70,000 American lives Hong Kong flu in caused 34,000 American deaths New Influenza Vaccine Recommendations Everyone 6 months of age and older Persons with chronic medical conditions Residents of nursing homes and long-term care facilities Pregnant women during influenza season FDA approved a quadrivalent influenza vaccine that contains two influenza A and two influenza B virus strains to increase the likelihood that the vaccine provides crossreactive antibody against a higher proportion of circulating influenza B viruses 9 10 Influenza Vaccine Recommendations for groups that can transmit to High Risk Persons Physicians, nurses, other health care workers with patient contact Employees of chronic care and assisted living facilities Household members of persons in highrisk groups 11 Should flu vaccinations be required for health care workers? Rate >90% required to prevent outbreaks Mandatory programs increased vaccination rates from 38% to 95% Law suits filed after mandatory programs Patient safety vs. Employee rights Financial considerations in the Affordable Healthcare Act : to continue receiving government funding, healthcare facilities required to have a 90% compliance with employees receiving vaccinations 12 3

4 The Flu Vaccine Gives Me the Flu Influenza vaccine composed of inactivated virus and hence cannot cause the flu Canadian study confirmed (N=281) oculorespiratory syndrome 78% reported eye symptoms 81% reported respiratory symptoms 76% systemic symptoms (F/C/M) Median onset 4 hrs after vaccination, 24 hrs median duration Clin Infect Dis 2003 Mar 15;36: Influenza Vaccination Can Prevent Cardiac & Cerebrovascular Events Study pooled data from 3 managed care organizations (N=140,000) comparing vaccinated vs. unvaccinated cohorts Vaccination cohort: 50% less likely to die 20% fewer hospitalizations for cardiac and cerebrovascular events 30% less likely to be hospitalized for pneumonia or influenza N Engl J Med;348: Guillain-Barre Syndrome Risk After Flu Vaccine Guillain-Barre Syndrome (GBS) is rare GBS reported after flu vaccination particularly after swine flu vaccine 1976 median onset 13 days after shot Number of reported cases has declined since 1990: cases/year Flu vaccine made from chicken eggs; campylobacter is known cause of GBS Decline of GBS coincided with stepped up food safety interventions and 28% decline in campylobacter infections Influenza Vaccination Talking Points Urge patients to get vaccinated; doctor recommendation is a strong motivator Vaccination prevents days of illness, days lost from work, fewer clinic/hospital visits, decreased absence rates among HCWs Flu vaccination clearly cost-effective JAMA;292;

5 Treatment for Influenza: Neuraminidase Inhibitors Reportedly effective < 48 hrs of onset Billions of dollars spent to stockpile Oseltamivir for use in possible flu pandemic Controversy as drug effectiveness questioned and Roche refuses to release data Oseltamivir (Tamiflu) 75 mg bid for 5 days Reduces viral titers, viral shedding, symptom scores, duration, severity of illness 17 Case: Audience Response 52 yo woman with atrial fibrillation and heart failure requests a flu shot. She takes warfarin for atrial fibrillation. She reports a milk allergy. Which of the following is most appropriate approach? 1. Inactivated influenza vaccine 2. Live attenuated influenza vaccine 3. No influenza vaccine 4. Neuraminidase inhibitor therapy 18 Answer 1. Inactivated influenza vaccine 2. Live attenuated influenza vaccine 3. No influenza vaccine 4. Neuraminidase inhibitor therapy Pneumococcal Polysaccharide Vaccine (PPSV23-valent) Indications 23 serotypes in vaccine account for 85-90% of invasive disease (bacteremia and meningitis). More than 80 known serotypes of pneumococcus Despite appropriate antimicrobial therapy and intensive medical care Overall case-fatality rate for pneumococcal bacteremia is 15-20% Among elderly patients, rate 30-40%

6 Pneumococcal Polysaccharide Vaccine (PPSV23-valent) Indications Vaccinate: All persons >65 years One-time revaccination if received before age 65 (>5 yrs elapsed) Chronic conditions: Give 2 doses for PPSV23 before age 65 (NEW) Cardiopulmonary disease Diabetes mellitus Cirrhosis, alcoholism Anatomic or functional asplenia [including sickle cell disease] HIV infection (risk of infection 100 times greater) Immunosuppressed persons (ESRD) 21 Rethinking Recommendations for Use of Pneumococcal Vaccines in Adults Target people at high risk for invasive pneumococcal disease Vaccine effective against invasive disease in immunocompetent persons, but less effective in immunodeficient High risk also identified for African- Americans (2.0 times the risk of invasive disease) and cigarette smokers (2.6 times the risk for invasive disease) Clin Infect Dis;33(5): Cost-Effectiveness of Pneumococcal Vaccination in Elderly Persons PNEUMOCOCCAL VACCINE IN ADULTS RCTs showed no decrease in death or bacteremia Meta-analysis of 13 RCTs: 50% decrease in pneumonia Prospective study: 57% mortality reduction Case-control studies: 60-70% protective efficacy for bacteremia Vaccination is cost-saving reduces medical expenses

7 PNV and Hospitalized Patients Patients hospitalized with CAP Patients with prior history of pneumococcal vaccination had 40% lower adjusted rate of ICU admission compared to those not previously vaccinated Johnstone, Arch Intern Med;167: Pneumococcal Conjugate Vaccine 13-valent pneumococcal vaccine (Prevnar 13, PCV13) Limited number of serotypes High immunogenicity >90% efficacy Vaccine formulations based on most prevalent serotypes of invasive disease New recommendation: use both vaccines (PCV13, PPSV23) in high-risk adults MMWR Pneumococcal Disease Vaccines Pneumococcal vaccine: CDC: reduces rates of invasive disease Reduces potentially fatal pneumococcal bloodstream infections by 44-47% Newer protein-conjugated vaccines used in children, and now in adults, reduces invasive pneumococcal disease in adults; more effective vaccine Strategies to Improve Vaccination Rates Increase physician discussions Standing orders for nurses in clinics and hospitals Alternative methods through pharmacies, churches, work sites, and other nontraditional sites Conjugated adult vaccine now FDA approved; recommend increased use

8 Varicella (Chickenpox) Vaccine A history of chickenpox or zoster considered adequate evidence of Varicella immunity If no reliable history serologic testing cost effective since most with negative or uncertain history are immune Document immunity in all persons (by history or serology) Varicella (Chickenpox) Vaccine Recommended for all susceptible adults adults 2% of cases, 50% of deaths 15% of persons develop Zoster Live-attenuated virus: two doses needed Two SQ dose 4 to 8 weeks apart JAMA;278: Varicella Vaccination Decline in Varicella mortality after implementation of vaccination observed in all groups under age 50 Vaccination may play key role in preventing Zoster (Shingles) The Shingles Prevention study examined Zoster vaccine in elderly Zoster Vaccine 38,546 adults 60 years of age or older in a randomized trial of attenuated VZV vaccine ("zoster vaccine, zostavax"). Zoster vaccine reduced: incidence of herpes zoster by 51percent (P<0.001) burden of illness by 61 percent (P<0.001) incidence of postherpetic neuralgia by 66 percent (P<0.001) Conclusion: Zoster vaccine reduces morbidity from herpes zoster and postherpetic neuralgia among older adults

9 Case: Audience Response 22 yo nursing school graduate is evaluated during pre-employment physical for job in children s hospital. She has SLE which is well controlled with prednisone, 10 mg daily. She has no recollection of having had chickenpox as a child, results of a varicella titer are negative. Case: Audience Response Which of the following is the most appropriate recommendation? 1. No vaccination 2. Single vaccination, clear for work 3. Single vaccination, delay work for 4 weeks 4. Two-dose vaccination series over 6 weeks, clear for work 5. Two-dose vaccination series over 6 weeks, delay work for 4 weeks Answer: Audience Response 1. No vaccination 2. Single vaccination, clear for work 3. Single vaccination, delay work for 4 weeks 4. Two-dose vaccination series over 6 weeks, clear for work 5. Two-dose vaccination series over 6 weeks, delay work for 4 weeks Hepatitis B vaccine 6000 deaths/year >90% vaccine efficacy > 4000 preventable deaths All adolescents and high risk adults Sex partners of positive persons IVDUs Persons with history of multiple sexual partners Men who have sex with men Recently acquired another STD Health care workers Diabetics

10 Hepatitis B Vaccination: Does Protection Last? Antibody (HBsAb) levels decline to undetectable by 6 years in up to 50% no documented case of clinical hepatitis in vaccine recipients with adequate antibody response initially Long incubation of HBV allows triggering of T-cell memory (1-3 mos) Boosters not routinely recommended Hepatitis B Revaccination Check post-vaccination serology 1-2 mos after series Health care workers Hemodialysis patients, HIV patients, Liver disease patients, other immunosuppressed patients Vaccinate/Revaccinate with 3-dose series twice Initial non-responders re-vaccinated with: One more dose 25-50% response Three more doses 50-75% response Non-responder (failed to produce adequate anti-hbs after two full vaccine series) consider HBIG after possible exposure Hepatitis A Vaccine 75% of adults > 50 years have antibodies 25% of adults years lack antibodies Two shot series 96% protected in 1 mo after shot Booster at 6 to 12 months 40 to 80x protective antibody levels Hepatitis A Vaccine Recommendations People who travel outside the U.S. to endemic areas Persons with chronic liver disease, including chronic hepatitis B and C infections Men who have sex with men Consider vaccinating all foodhandlers

11 Prophylaxis for travel: Hepatitis A Two highly immunogenic, inactivated vaccines (Havrix & Vaqta) Single dose administered 2 to 4 wks before travel; confers 95% protection for 1 yr Two doses 6-12 mo apart provide long-term immunity Combined Hepatitis A and B vaccine (Twinrix) Three doses, given on 0-, 1-, and 6-mo schedule Same schedule used for hep B For imminent travel: vaccine and immune globulin may be administered at same time Meningococcal disease vaccine 1000 cases annually (down from 3000), 10-15% fatal Vaccinate: College freshmen who live in dorms have 6 times higher risk All kids year olds (NEW) Travelers to endemic areas (Sub-Saharan Africa, S. Asia, and Middle East) Anatomic or functional asplenia or terminal complement component deficiency Meningococcal disease vaccine Contains four serogroups: Menactra (MCV4) N. meningitidis A, C, Y, W-135 (no B) Given as a single or 2 dose vaccination (2 doses for highest risk patients: asplenic, complement deficiencies, and HIV patients) May be administered at same time as other vaccines Revaccination with MCV4 every 5 years for high risk HPV Vaccine GARDASIL vaccine may help guard against diseases that are caused by human papillomavirus (HPV4) Types 6, 11, 16, and 18; and HPV2 (Types 16 and 18) Approved for girls and women ages 13 to 26 Approved for boys and young men Given as 3 injections over 6 months: First dose Second dose: 2 months after the first dose Third dose: 6 months after the first dose

12 HPV Vaccine Studies Immunizations Post-Splenectomy Pneumococcal Vaccination PPSV23 PCV13 Meningococcal Vaccination Haemophilus influenza type B (Hib) Influenza Vaccine Booster vaccines recommended Cleveland Clinic Journal of Medicine Jan Future of Vaccines Next wave of Adolescent/Adult vaccines: ETEC vaccine Dengue vaccine Herpes simplex virus-2 vaccine Meningococcal serogroup B Malaria vaccine Future Challenges in Adult Immunizations Increase vaccine production, utilization and insurance coverage of newer vaccines Reduce vulnerability of vaccine supply Improve use of systems to help clinicians: standing orders and computer reminders Implement vaccination in the hospital, clinics, and non-traditional settings

13 Summary 40,000-50,000 adults die annually from vaccine-preventable diseases in the US Evidence-based impact on individual and public health Be proactive with adult vaccine use Strong physician recommendations remain important 49 13

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