Immunization of Adults in High Risk Populations. Carol A. Kurbis MD, CCFP, FRCPC WRHA Medical Officer of Health

Transcription

1 Immunization of Adults in High Risk Populations Carol A. Kurbis MD, CCFP, FRCPC WRHA Medical Officer of Health

2 OBJECTIVES To review recommendations for immunization in adult populations, with a focus on vaccine issues of particular relevance for populations with sexually transmitted and blood borne infections. To examine current immunization rates and trends in specific populations of relevance. To highlight certain issues in the provision of immunization services in Manitoba, such as storage and handling of vaccines and the Manitoba Immunization Monitoring System.

3 AGENDA Vaccine Eligibility Specific Vaccines: Hepatitis B vaccine Hepatitis A vaccine Human papillomavirus vaccine Pneumococcal polysaccharide vaccine Influenza vaccine Other Considerations: Storage and Transport of Vaccines MIMS Resources

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5 CONSIDER HALO H Health (high risk medical conditions) Hib Hep A Hep B Hep A/B IPV Men C-C Men C-ACYW-135 Men P-ACYW-135 Var A Age HBV Born during or after 1989 HPV Born during or after 1997 Men C Born during or after 1995 Varicella Born during or after 1995

6 CONSIDER HALO L- Lifestyle Risks Hep A Hep B Hep A/B Pneu-P-23 O Occupation Rabies Hepatitis B *Eligibility criteria for high-risk medical conditions are as per the current Canadian Immunization Guide (CIG) and the most current National Immunization Committee on Immunization (NACI) statements available at:

7 NON-PUBLICLY FUNDED VACCINES New vaccines: Herpes Zoster Vaccine Specific NACI recommendations e.g.: Acellular pertussis parent/caregiver of infants HPV - Females between the ages of 14 and 26 years HBV Travelers, Persons new to Canada

8 For each adult being immunized, consider their HALO** (Health Factors, Age Factors, Lifestyle Factors and Occupation) that may guide further immunization decisions. Health Factors Age Factors Lifestyle Factors Occupational and Other Susceptible or not previously immunized *High risk medical conditions Pregnant History of STD Immunosuppressed Including HIV Cochlear Implant Asplenia Age 65 Women born after 1997 Born During or after 1989 Women of Reproductive age Persons new to Canada Men who have sex with Men Sexual activity risk factors Illicit drug use International Traveler Parent /Caregiver of Young Child Healthcare Worker Adults in Institutions Acellular pertussis YES (YES) (YES) HPV NO (YES) YES (YES) Varicella/Zoster (YES) YES NO (contra) MMR YES NO (contra)?? (YES) (YES) (YES) (YES)?? YES YES YES YES Influenza YES YES YES YES YES YES YES YES YES IPV (previously unimmunized only) (YES) (YES) (YES) Pneumococcal YES YES YES YES YES (YES) YES HAV YES (YES) YES YES YES (YES) HBV YES YES YES (YES) YES YES YES (YES) (YES) YES Meningococcal YES YES YES (YES) Hib YES YES YES () not covered by provincial vaccination program?? Refer to CIG for recommended use in immunocompromised conditions. See vaccine specific recommendations by medical condition. Contraindicated if severe immunodeficiency. *Refer to CIG for vaccine specific high risk medical conditions (differ by vaccine). **Modelled on HALO method Immunization Action Coalition ( page 41) Source: CIG Canadian Immunization Guide aspc.gc.ca/publicat/cig gci/index eng.php

9 HEPATITIS B VACCINE ELIGIBILIITY Individuals born during or after 1989 (current age 21 years). Individuals with high-risk medical conditions Hemophilia, chronic renal failure, chronic liver disease or on hepatotoxic drugs, hepatitis C, hematopoietic stem cell transplantation Sexual exposure men having sexual contact with men; those who have unprotected sex with new partners; those who have had more than one sexual partner in the previous 6 months; those with a history of sexually transmitted infections (STI); persons attending an STI clinic or who otherwise engage in risky sexual practices.

10 HEPATITIS B VACCINE ELIGIBILIITY Current or recent illicit drug use Residents in correctional facilities and residents in institutions for the developmentally challenged. Post-exposure: Percutaneous or mucosal exposure to blood Sexual and household contacts of HBsAgpositive persons

11 ADULTS AT RISK FOR HBV INFECTION Non-publicly funded NACI recommended groups: international travelers to regions with high levels of endemic HBV infection; HCW s, emergency services, and other occupations with risk for exposure to blood or body fluids; populations or communities in which HBV is highly endemic. CMAJ Canadian Guidelines for Immigrant Health Screen adults and children from countries where hepatitis B is prevalent ( 2% hepatitis BsAg positive) for prior immunity to hepatitis B (anti-hbc, anti-hbs), and vaccinate those found to be susceptible (negative for all three markers of HBsAg, anti-hbc and anti-hbs) to decrease morbidity and mortality and transmission of hepatitis B.

12 HEPATITIS B VACCINE IMMUNIZATION COVERAGE 2008 Hepatitis B Vaccine Coverage in MIMS % coverage WHR WHR- Inner City MB 0 Age 11 Age 17

13 PREVACCINATION SEROLOGIC TESTING Not indicated before routine vaccination of infants or children Recommended for Pregnant women Adopted children at high risk from countries, geographic regions, or family situations with a high prevalence of HBV infection Groups with high risk of HBV infection e.g. individuals from settings with a high prevalence of HBV infection; MSM; IDU; incarcerated persons; household, sex, and needle-sharing contacts of HBsAg-positive persons.

14 POSTVACCINATION SEROLOGIC TESTING Not routinely recommended following vaccination of infants, children, adolescents, or most adults. Recommended when important to ensure there is protection against a continual known or repeated exposure to hepatitis B. E.g.: Infants born to HBsAg+ women Sexual partners and household contacts of chronic carriers of HBV Certain healthcare personnel

15 POSTVACCINATION SEROLOGIC TESTING Test for anti-hbs 1 to 2 months after completion of the 3- dose series. If protective antibody documented, no need for further testing, even when an exposure occurs (immune memory persists). If testing done beyond 6 months post-immunization, may indicate either primary vaccine failure or waning antibody. anti-hbs concentrations decline rapidly within the first year and more slowly thereafter. 15%-50% of children have low or undetectable concentrations of anti-hbs 5 to 15 years after vaccination.

16 MANAGEMENT OF NONRESPONSE TO HEPATITIS B VACCINE If post-vaccination serology done within 1-6 months of immunization: Complete a second series of three doses Should be given on the usual schedule of 0, 1 and 6 months Retest 1-2 months after completing the second series

17 PERSISTENT NONRESPONSE TO HEPATITIS B VACCINE May be nonresponder or "hyporesponder. Unlikely to respond to further doses. Check HBsAg status If exposed, treat as nonresponder with postexposure prophylaxis

18 HEPATITIS A VACCINE ELIGIBILITY Individuals 12 months or older with high-risk medical conditions Persons with chronic liver disease or who are receiving hepatotoxic medications, including persons infected with hepatitis C. People with hemophilia A or B receiving plasmaderived replacement clotting factors. Individuals with life-style risks for infection Men who have sex with men Persons who use illicit drugs

19 ADULTS AT RISK OF HEPATITIS A Non-publicly funded: Persons with occupational risk E.g. Members of the Canadian armed forces, emergency relief workers in areas with high rates of HAV infection, workers involved in research on HAV who may be exposed to HAV. International travelers Residents of communities that have high endemic rates of HAV or are at risk of HAV outbreaks

20 HEPATITIS A and B HAHB may be made available to individuals meeting the criteria for hepatitis A and B immunization, provided the individual is still susceptible to both hepatitis A and hepatitis B (i.e. no prior infection with hepatitis A or B, no prior immunization with hepatitis A or B).

21 HUMAN PAPILLOMAVIRUS VACCINE ELIGIBILITY All Grade 6 females only (school-based program). Females who missed the vaccine in Grade 6 and are born on or after January 1, 1997 (current age 14 years).

22 NACI HPV RECOMMENDATIONS Females between 9 and 13 years of age. Females between the ages of 14 and 26, even if they are already sexually active, as they may not yet have HPV infection and are very unlikely to have been infected with all four HPV types in the vaccine.

23 NACI HPV RECOMMENDATIONS Females between the ages of 14 and 26 years who have had previous Pap abnormalities, including cervical cancer, or have had genital warts or known HPV infection. These women may not have had infection with the HPV types included in the vaccine and are very unlikely to have been infected with all four HPV types. However, they should be advised that there are no data to suggest that the vaccine will have any therapeutic effect on existing cervical lesions.

24 NACI HPV RECOMMENDATIONS Females > 26 years. Studies of Gardasil vaccine use in women > 26 years are ongoing. No recommendations at this time, although its use can be considered in individual circumstances. Females < 9 years of age. The vaccine is not recommended for this age group. Males. Not recommended for males at this time.

25 NACI HPV RECOMMENDATIONS Immunocompromised persons. Can be administered to persons who are immunosuppressed; however, the immunogenicity and efficacy are not known, and individuals should be aware that immune response to the vaccine might be less than that in persons who are immunocompetent. Pregnancy. Not recommended for use in pregnancy.

26 HPV VACCINATION SCHEDULE Routine schedule is 0, 2, 6 months Intramuscular injection in the deltoid Minimum intervals 4 weeks between doses 1 and 2 12 weeks between doses 2 and 3

27 HPV VACCINE IMMUNIZATION COVERAGE Uptake in WHR Schools HPV Grade % coverage (3 Doses) dose 3 doses / / /11

28 PNEUMOCOCCAL POLYSACCHARIDE VACCINE - PNEU-P increase in IPD in Winnipeg. 98 cases of IPD in WHR in 2010, compared to average 55 cases over previous 3 years. increase in 12F serotype unimmunized year old inner city adults, including homeless individuals. More gradual increase in 19A serotype populations typically at risk for IPD (very young and very old).

29 PNEUMOCOCCAL POLYSACCHARIDE VACCINE Outreach immunization campaign in inner city in Feb outreach clinics in settings for vulnerable population 696 clients assessed 449 PPV23 vaccines 377 influenza vaccines

30 PNEU-P-23 ELIGIBILITY Seniors 65 years of age or older Residents of PCH or LTC facility Persons 2 to 64 years of age at high risk of IPD

31 PNEU-P-23 HIGH RISK MEDICAL CONDITIONS chronic medical conditions (e.g., chronic cardiac and pulmonary disease, diabetes mellitus, chronic renal disease or CSF leak) functional or anatomic asplenia HIV infection, immunocompromising conditions sickle cell disease and other sickle cell hemoglobinopathies, cochlear implants cirrhosis and alcoholism

32 NACI PNEU-P-23 RECOMMENDATIONS Additional populations recommended: Those who smoke Homeless Illicit drug use

33 PNEU-P-23 VACCINE At present, routine re-immunization is not recommended. Consider re-immunization for those at highest risk of invasive infection, including those with functional or anatomic asplenia or sickle cell disease; hepatic cirrhosis, chronic renal failure or nephrotic syndrome; HIV infection; and immunosuppression related to disease or therapy. If re-immunization is carried out, only a single reimmunization is recommended after 5 years in those aged > 10 years at the time of initial immunization and after 3 years for those who received the initial vaccine when they were 10 years of age.

34 PNEU-P-23 VACCINE Re-immunization of healthy adults < 2 years after the initial dose is associated with increased local and systemic reactions. Subsequent studies have suggested that revaccination after intervals of 4 years is not associated with an increased incidence of adverse side effects. Severe local reactions are rare.

35 INFLUENZA VACCINE ELIGIBILITY All eligible in 2010/11 Universal program Targeted to those at high risk: Seniors age 65 or older Children age six months to four years Those with chronic illness Pregnant women Health care workers and first responders Individuals of Aboriginal ancestry People who are severely overweight or obese

36 INFLUENZA VACCINE COVERAGE 25.0% 20.0% 15.0% 10.0% 5.0% 2008/ / /11 0.0% MANITOBA WHR

37 MANITOBA IMMUNIZATION MONITORING SYSTEM - MIMS 1988 first immunization registry in Canada Initially, MIMS only recorded immunizations provided to children (born after 1980). In 2000, adult immunizations were added to the registry.

38 MIMS Immunization events are captured in two ways: publicly-funded immunizations administered by physicians are entered into the system via the physician billing system; all other immunizations, such as those provided by public health nurses, are recorded by data entry staff in the regions. Captures type of vaccine administered, date of administration and service provider.

39 MIMS Issues: Gaps in data Access for all providers Population-based work e.g. schools Real-time and remote access Future EHR, Panorama Public health surveillance system If unable to access WRHA community area offices can obtain records

40 VACCINE STORAGE AND HANDLING lth/cdc/coldchain.html

41 IMMUNIZATION RESOURCES Public Health Agency of Canada Canadian Immunization Guide NACI statements Manitoba Health Fact sheets Schedules, eligibility, information for health professionals

42 IMMUNIZATION RESOURCES WRHA Immunization Manual (under construction) ual.php

43 QUESTIONS?