Jon Temte, MD/PhD Chair Wisconsin Council on Immunization Practices Professor of Family Medicine and Community Health

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1 Jon Temte, MD/PhD Chair Wisconsin Council on Immunization Practices Professor of Family Medicine and Community Health University of Wisconsin School of Medicine and Public Health Grand Rounds September 27, 2017

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3 Consulting GSK Vaccines (new vaccine) Disclosures

4 Understand current ACIP recommendations for adults Appreciate the existing gaps between existing vaccine recommendations and vaccine coverage Recognized and implement the Standards for Adult Immunization Practice

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6 44.7 million Americans are 65 years or older (14.1% of the U.S. population) 11,000 seniors become eligible for Medicare daily in the U.S. 1.8 million live in this nation's 16,000 nursing homes Additional 900,000 live in assisted living facilities Petit AB, Bramer C, Jacobs M et al. Adult Influenza Vaccinations Reported to the Wisconsin Immunization Registry by Retail Pharmacies, JPSWI 2015

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8 What are the gaps? Where are the gaps? How do we close the gaps?

9 ACIP Recommended Immunization Schedule is available at

10 One out of every 344 People aged 65+ years

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12 4x-increase (60mcg) in the dose of hemagglutinin antigen for each of the three influenza strains A postlicensure study of effectiveness compared with standard dose TIV (Fluzone) was begun in 2009 and completed in 2013 High dose showed ~25% relative risk reduction in influenza cases Absolute RR = ~ 4 cases per 1000 Attack rate = 1.43% w/ high dose Attack rate = 1.89% w/ regular dose DiazGranados CA, et al. Efficacy of high-dose versus standard-dose influenza vaccine in older adults. N Engl J Med 2014;371: CDC/Richard Duncan

13 282 eligible participants were enrolled (84 cases) 136 were in a long term care facility and 132 were 85 years of age or older Vaccine effectiveness decreased with increasing age In a variety of multivariate analyses, ATIV was significantly protective at around 60% (p = 0.02) VE increased in non-long term care residents. In multivariate analyses TIV was ineffective. Van Buynder JL, et al. The comparative effectiveness of adjuvanted and unadjuvanted trivalent Inactivated influenza vaccine (TIV) in the elderly. Vaccine 2013; 31:

14 7.7 Influenza B Victoria is not in trivalent vaccine 18.8 A[H1N1] A[H3N2] B-Yamagata 13.2 B-Victoria 60.3 Data from:

15 Influenza B Yamagata is not in trivalent vaccine 21.2 A[H1N1] A[H3N2] B-Yamagata B-Victoria 68.2 Data from:

16 RCT to explore utility of RIDT in LTCFs Highly Vaccinated population 81-98% of residents immunized in each facility Interim data assessment following season 51 cases of influenza identified in LTCF residents Attack rate = 7.8% 18 cases of influenza A[H3N2] 33 cases of influenza B 100% of B cases were of the Yamagata lineage

17 Influenza Vaccine age years 42.2%

18 Influenza Vaccine age 65 years 77.3%

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20 All adults should receive Tdap Pregnancy Administer Tdap between 27 and 36 weeks gestation for each pregnancy If not provided during pregnancy, administer Tdap immediately postpartum Adults 65 years and older Image: CDC Routinely Recommended Grandparents, child-care providers, and health-care practitioners who have/anticipate close contact with an infant less than 12 months of age and who previously have not received Tdap No indication for revaccination outside of pregnancy

21 66.9% 68.2%

22 Vaccine licensed for use for age 50+ years Single dose of zoster vaccine is recommended for adults aged 60 years and older regardless of whether they report a history of chickenpox or a prior episode of herpes zoster Vaccinate persons with chronic medical conditions unless their condition is a contraindication Limited by decreasing immunogenicity with age Waning immunity over time Source: CDC/ Judy Schmidt

23 70 Vaccine Efficacy (%) years 70 + years Data from: Oxman MN, Levin MJ; Shingles Prevention Study Group. Vaccination against herpes zoster and postherpetic neuralgia. J Infect Dis 2008; 197:S Levin MJ, Oxman MN, Zhang JH et al.; Veterans Affairs Cooperative Studies Program Shingles Prevention Study Investigators. Varicella-zoster virus-specific immune responses in elderly recipients of a herpes zoster vaccine. J Infect Dis 2008; 197:

24 Tseng, HF, Harpaz R, Luo Y et al. Declining effectiveness of herpes zoster vaccine in adults 60 years and older. J Infect Dis

25 41.1% 42.1%

26 Age 65 years If < 65 years chronic lung disease immunocompromising conditions; including chronic renal failure nephrotic syndrome including asthma chronic cardiovascular diseases diabetes mellitus chronic liver diseases cirrhosis chronic alcoholism functional or anatomic asplenia sickle cell disease splenectomy cochlear implants cerebrospinal fluid leaks HIV persons who smoke cigarettes

27 One-time revaccination after 5 years for persons aged 19 through 64 years with chronic renal failure or nephrotic syndrome; functional or anatomic asplenia (e.g., sickle cell disease or splenectomy) persons with immunocompromising conditions. 65 years plus: one-time revaccination if vaccinated 5 or more years previously and less than 65 years at the time of primary vaccination

28 55.7% 55.0%

29 ACIP recommends routine use PCV13 for adults 65 years and older Pneumococcal vaccine naïve elders PCV13, followed by PPSV23, 12 months later Prior PPSV23 recipients at age 65+ PCV13 at least one year after the most recent PPSV23 When an additional dose of PPSV23 is indicated additional dose 12 months after PCV13 and at least 5 years after most recent dose of PPSV23

30 ACIP recommends routine use PCV13 for adults 19 years and older with: immunocompromising conditions functional or anatomic asplenia cerebrospinal fluid (CSF) leaks cochlear implants PCV13 is administered in addition to PPSV23 vaccine naïve individuals PCV13 followed by PPSV23 at least 8 weeks later previously been vaccinated with PPSV23 PCV13 one or more years after the last PPSV23 dose

31 40.7% 56.1%

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33 HBV vaccine is recommended for diabetics age 19 through 60 DM associated with 2-fold increased risk of hepatitis B at time of diagnosis for new diabetics as soon as feasible Routine 3 dose schedule HBV vaccine may be provided to diabetics > 60 years Non-significant 45% increase in risk

34 What are the gaps? Where are the gaps? How do we close the gaps?

35 Survey of 954 primary care physicians in 2012 General Internists (79% response rate) Family Physicians (62% response rate) For a 67 year-old patient how important is % indicating very important Influenza Pneumococcal Tdap/Td Herpes Zoster Data from: Hurley LP, Bridges CB, Harpaz R et al. Physician attitudes toward adult vaccines and other preventive practices, United States, Public Health Rep 2016; 131:

36 80 Medical Home 70 No Medical Home Influenza Pneumococcal Td Zoster Data from: Williams WW, Lu P-J, O Halloran A et al. Surveillance of Vaccination Coverage Among Adult Populations United States, 2014 MMWR Surveill Summ 2016;65(No. SS-1):1-36.

37 Influenza Vaccine (in previous year) % (95% C.I.) Pneumococcal Vaccine (ever) % (95% C.I.)

38 Tdap Vaccine (in the past 9 years) % (95% C.I.) Hepatitis B (3+ doses ever) % (95% C.I.)

39 Zoster Vaccine (ever) % (95% C.I.)

40 80 White 70 Black Influenza Pneumococcal Td Zoster Data from: Williams WW, Lu P-J, O Halloran A et al. Surveillance of Vaccination Coverage Among Adult Populations United States, 2014 MMWR Surveill Summ 2016;65(No. SS-1):1-36.

41 What are the gaps? Where are the gaps? How do we close the gaps?

42 Tools for self-ref lection

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49 National Vaccine Advisory Committee (NVAC) revised the Standards for Adult Immunization Practice in 2013

50 National Vaccine Advisory Committee. Recommendations from the National Vaccine Advisory Committee: Standards for Adult Immunization Practice. Public Health Reports / March April 2014 / Volume 129:

51 ASSESS immunization status of all your patients at every clinical encounter Stay informed. Get the latest CDC recommendations for immunization of adults. Implement protocols and policies. Ensure that patients' vaccine needs are routinely reviewed and patients get reminders about vaccines they need.

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54 Strongly RECOMMEND vaccines that patients need Share tailored reasons why vaccination is right for the patient. Highlight positive experiences with vaccination. Address patient questions and concerns. Remind patients that vaccines protect them and their loved ones against a number of common and serious diseases. Explain the potential costs of getting sick.

55 Free Download of pdf at:

56 ADMINISTER needed vaccines or REFER your patients to a vaccination provider. Offer the vaccines you stock. Refer patients to providers in the area that offer vaccines that you don't stock.

57 Petit AB, Bramer C, Jacobs M et al. Adult Influenza Vaccinations Reported to the Wisconsin Immunization Registry by Retail Pharmacies, JPSWI 2015

58 DOCUMENT vaccines received by your patients Participate in your state's immunization registry. Help your office, your patients, and your patients' other providers know which vaccines your patients have had. Follow up. Confirm that patients received recommended vaccines that you referred them to get from other immunization providers.

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60 Increasingly aging population Increasingly diverse population Gaps exist Attitudes Access to a medical home Disparities due to race and ethnicity Immunosenescence Standards for Adult Immunization Practice Assess Recommend Administer Document

61 Contact Information Jonathan L. Temte, MD/PhD Chair Wisconsin Council on Immunization Practices Professor of Family Medicine and Community Health University of Wisconsin School of Medicine and Public Health