VACCINE DIALOGUE AIDC 2017

Transcription

1 VACCINE DIALOGUE AIDC 2017

2 Idea is Not to discuss about each vaccine Discuss about when to use- clinical situations Allaying the fears

3 ADULT VACCINES

4 Question What are the current CDC recommendations on adult Immunisations?

5 CDC 2017

6 As per underlying medical conditions

7 Recommended adult vaccines Influenza Pneumococcal Tdap Hepatitis B Hepatitis A Meningococcal HPV MMR Varicella Zoster Indian scenario- typhoid, others- JE vaccine, cholera in endemic regions. Dengue and malaria vaccine- not yet.

8 Case 65 year old lady comes for preventive health check. She is a diabetic for the past 20 years. What vaccines should be administered to her?

9 Vaccines for diabetics Annual flu vaccine Pneumococcal Others: Hepatitis B

10 Influenza vaccine What is the type of vaccine that we use? When is the best time to give the influenza vaccine in India?

11 Types of vaccine Inactivated tri-valent or quadri-valent split virion vaccine Live-attenuated vaccine-nasal- not recommended in flu season, as it was found less effective throughout

12 When to vaccinate

13 Influenza What are the current vaccine strains? Which one should we use?

14 Trivalent virus vaccines for use in the Northern Hemisphere influenza season A/California/7/2009 (H1N1)pdm09-like virus A/Hong Kong/4801/2014 (H3N2)-like virus B/Brisbane/60/2008-like virus WHO recommends that quadrivalent vaccines containing two influenza B viruses contain the above three viruses and a B/Phuket/3073/2013-like virus.

15 Trivalent virus vaccines for use in the 2017 Southern Hemisphere influenza season A/Michigan/45/2015 (H1N1)pdm 09-like virus A/Hong Kong/4801/2014 (H3N2)-like virus B/Brisbane/60/2008-like virus WHO recommended that quadrivalent vaccines containing two influenza B viruses should contain the above three viruses and a B/Phuket/3073/2013- like virus.

16 No special composition of flu vaccine for the tropics From an antigenic evolution perspective, there is no evidence to suggest the need for a 3rd recommendation for vaccine composition specifically for the tropics and subtropics, and the most recent WHO influenza virus vaccine recommendation should be used, independent of the hemisphere in which the country is situated.

17 Questions What are the other risk groups for influenza? Should we repeat the vaccine every year?

18 Other risk groups for Influenza Indicated for all ages beyond 6 months Prioritize- pregnant women, underlying co-morbidities, health care workers, extremes of age.

19 Case.. The 65 year old diabetic lady is accompanied by her 8 year old grand-daughter who is an asthmatic. Does she need the flu vaccine? If so, what should be the dosing schedule?

20 Children Children at high risk: 6months- 5 years IAP recommendation: Congenital or acquired immunodeficiency (including HIV infection) Chronic comorbidities-cardiac, pulmonary, renal, neuromuscular, endocrine Children on long term steroids, salicylates, immunosuppressive or radiation therapy During disease outbreaks

21 Dose in children Age 6-35 months 3-8 years >8 years Dose 0.25 ml 0.5 ml 0.5 ml No. of doses 2* 2* 1 *For previously vaccinated children, one dose should be sufficient.

22 Pneumococcal vaccines Which one to use? When? How to give sequentially?

23 Pneumococcal vaccine for diabetics Age>65 Pneumococcal conjugate vaccine (PCV-13) followed one year later by Your text here Pneumococcal polysaccharide vaccine (PPSV-23) Age<65 Pneumococcal polysaccharide vaccine (PPSV-23) If CKD, PCV-13 followed by PPSV-23

24 Efficacy- PPSV-23 in people aged 65 years or older PPSV-23 showed low to moderate effectiveness against vaccine serotype pneumococcal pneumonia. 33 5% (5 6 to 53 1) against PPSV23 serotypes Lancet ID Volume 17, No. 3, p , March 2017

25 Efficacy of PCV % against vaccine-type pneumococcal pneumonia and 75% efficacy against vaccine-type invasive pneumococcal disease (CAPiTA trial)

26 Hepatitis B What are the recommendations in adults? Do all diabetics need Hepatitis B vaccine?

27 In adults, it is an optional vaccine and recommended for special populations HCW CLD CKD Diabetes HIV High risk sexual behaviour Close contact/ family member of a Hep B patient

28 Hepatitis B vaccine for diabetics. Essential if doing finger stick glucose monitoring or on insulin Dosing- 3 doses 0,1, 6 for immuno-competent adult. Check antihbs levels 4 weeks after the last dose.

29 Case A 31 year old surgeon has a needle stick injury while closing up a laparotomy wound. The source case is known to be Hepatitis B positive. The surgeon has taken 3 doses of Hepatitis B vaccine during his undergrad days. He recalls that he had protective anti-hbs titre then but is not aware of his current titre. What are the recommendations?

30 Anti HBs titres Responder/Non-responder

31 Post exposure prophylaxis in Hepatitis B

32 Case A 23 year old primigravida comes for routine second trimester antenatal check up. Does she need any vaccines? Are vaccines safe in pregnancy?

33 Vaccines in Pregnancy Tdap Influenza Avoid live vaccines

34 CDC recommends

35 IAP guidelines- statement

36 Tdap One dose of Tdap during each pregnancy, in the third trimester Elderly who anticipate or have close contact with infants aged less than 12 months of age (to protect against pertussis) cocoon effect

37 Case A 28 yr old male comes to ER with a clean wound. He had his last immunization at 13 years of age. Does he need tetanus vaccine? Which one to use?

38 Categories History of adsorbed tetanus toxoid (doses) less than 3 or unknown 3 or more doses Clean minor wounds Tdap or Td Clean minor wounds TIG All other wounds Tdap or Td yes no yes yes no** no no no All other wounds TIG ** Yes, if it has been 10 years or longer since the last dose. Yes, if it has been 5 years or longer since the last dose. More frequent boosters are not needed and can accentuate side effects.

39 Tdap Preferred over TT Has TT + dt (low dose) + acellular pertussis For adults- one dose of Tdap, followed by Td every 10 yrs Contraindications- encephalopathy related to vaccine in the past

40 Vaccines for health care workers What are the recommendations for vaccinations of HCW?

41 Annual influenza vaccine Hepatitis B vaccine for HCW with risk of exposure Varicella vaccine MMR Typhoid and Hepatitis A vaccine food handlers

42 Childhood vaccines

43 Question What s in the current UIP schedule?

44 UIP schedule

45 UIP schedule Eligibility Vaccines universally administered Select vaccines Birth BCG, bopv-0, Hepatitis B ( ) 6 weeks bopv-1 (25/04/16) Pentavalent-1 (DTP+Hib+HepB ) (2011) IPV- 1 (Southern states) (Fractional, Intradermal) (Nov 2015) 10 weeks bopv-2 Penta-2 Rotavirus-1 (AP, Orissa, Haryana, HP) (2016) PCV-1 HP, Bihar, UP (May 2017) Rotavirus-2 PCV-2 14 weeks bopv -3, Penta- 3, IPV-2 Rotavirus- 3 PCV-3 IPV- 1 dose i.m

46 UIP schedule Eligibility Vaccines universally administered Select vaccines 9 months Measles containing vaccine- 1 (MCV-1) months MCV- 2 (2010) DPT booster JE vaccine (endemic areas-113 districts, 15 states) ( ) JE vaccine (endemic areas) 5-6 years DPT booster 10 and 16 years TT boosters

47 JE VACCINE COVERAGE

48 Question What about IAP recommendations? Is it any different?

49 IAP schedule

50 Age Vaccine Birth BCG, OPV-0, Hep B-1 6 weeks DTwP 1, IPV 1, Hep-B 2, Hib 1 Rotavirus 1 PCV 1 10 weeks DTwP 2, IPV 2, Hib 2 Rotavirus 2 PCV 2 14 weeks DTwP 3, IPV 3, Hib 3 Rotavirus 3 PCV 3

51 6 months OPV -1 Hep B -3 9 months OPV-2 MMR months Typhoid conjugate vaccine 12 months Hep A months MMR-2, Varicella- 1, PCV booster months DTwP B1/DTaP B1 IPV B1 Hib B1

52 18 months Hepatitis A -2 (inactivated) 2 years TCV booster 4-6 years DTwP B2/DTaP B2 OPV 3 Varicella 2 MMR years Tdap/Td HPV

53 Case A 40 year old lady and her 11year old daughter have come for advise regarding HPV vaccine. The grandmother died of cervical cancer and is hence worried. How to advise them regarding the same?

54 Bi, quadri and 9-valent HPV vaccines 0, 1-2, 6 month schedule for those above 15 yrs and 2 doses for those less than 15 yrs Girls- 11 to 26 yrs Boys- 11 to 21 yrs

55 Efficacy HPV vaccine In women- 100% preventing cervical cancer In men % preventing genital warts and anal precancers

56 Efficacy HPV vaccine In women- 100% preventing cervical cancer In men % preventing genital warts and anal precancers

57 What s with the MR vaccine? Why has MR vaccine been introduced?

58 Why MR? WHO SEARO goal Burden of Measles Rubella : 10-30% of adolescent females and 12-30% of women in the reproductive age-group are susceptible to rubella infection in India CRS Dewan, P. & Gupta, P. Indian Pediatr (2012) 49: 377

59 Vaccine schedule IAP : Measles at 9 months, MMR -1 at months and MMR-2 at 4-5 years. UIP : Measles 1 st dose at 9 month and Measles 2 nd dose at months (2010)

60 MEASLES VACCINE COVERAGE

61 Why MR, why not MMR vaccine?

62 MR vaccine Vaccine effectiveness of measles and rubella vaccine Peak antibody response -6 to 8 weeks after infection or vaccination Immunity : persist for at least 20 years and is generally thought to be lifelong for most individuals.

63 MMR MMR Vaccine effectiveness (Jeryl Lynn strain)is about 78% for 1 dose and 88% for second dose Waning immunity with age Antigenic variation in the virus Outbreaks still occurred in US with > 95% coverage with 2 doses. Not a deadly disease

64 Miscellaneous

65 Vaccines for students travelling abroad What the vaccines usually required?

66 Meningococcal vaccine Tdap MMR Varicella

67 Zoster Vaccine Live vaccine (Zostavax) CDC recommends single dose for all persons over the age of 60 years FDA has approved for yrs Even if the patient reports negative history for varicella (unless they lack serological evidence of varicella, where varicella vaccine have to be offered and not zoster) Even if the patient had previous zoster Vaccine immunity wanes over 5 yrs

68 Queries on vaccine administration, multiple vaccines at a time...

69 Multiple vaccination 2 different parenteral live vaccines if not given on the same day, should be delayed for 4 weeks after 1 live vaccine 2 different oral live vaccines may be given at any interval Oral live vaccines can be scheduled any time after parenteral live vaccines Multiple inactivated vaccines can be given at any intervals

70 Postpone live vaccines Who received blood products or immune globulin during the previous 3 to 11 months Pregnant women

71 3 simple steps Talk about vaccination to your patient, a vaccine councillor will help Record the vaccination and schedule further doses Checklist for specific contra-indication

72 Apollo Vaccine and Travel Clinic All vaccines administered One stop processing Monitoring Record keeping Counselling Patient initiated Physician initiated Via primary care provider Via referral to Dept of Infectious Disease

73 Thank you