Immunizations Updates in Family Medicine 2017

Transcription

1 Immunizations Updates in Family Medicine 2017 Joyce Sanchez, MD, FACP Assistant Professor of Medicine Division of Infectious Diseases 2017 MFMER slide-1

2 No disclosures 2017 MFMER slide-2

3 Learning Objectives Describe updates in the following vaccinations Pneumococcal vaccine Meningococcal vaccine MMR HPV Influenza Herpes Zoster 2017 MFMER slide-3

4 Case 1 A family medicine colleague who has been vaccinating patients 65 years of age and older with PPSV-23 asks you to explain the main benefit of PCV-13. Which of the following best describes the role of PCV-13 in elderly patients? A. It provides protection for multiple serogroups not covered by PPSV-23 B. It has been shown to decrease the incidence of pneumonia caused by the contained vaccine serotypes C. It has been shown to decrease mortality in this age group D. It has no role in patients who have received PPSV MFMER slide-4

5 PCV13 Vaccine and Pneumonia Bonten et al. N Engl J Med 2015; 372: MFMER slide-5

6 PCV-13 vaccine 46% efficacy in preventing pneumonia 75% efficacy in preventing invasive pneumococcal disease by vaccine-contained serotypes No different in mortality PPSV-23 has not shown similar reductions in those aged 65 and older 2017 MFMER slide-6

7 Case 2 A 65-year-old man who has hypertension and hyperlipidemia presents for his annual physical. He has felt well, and his only medication is lisinopril. He has never received the pneumococcal vaccine. The patient appears well. Temperature is 37.1 C (98.8 F), pulse rate is 71 per minute, respirations are 15 per minute, and blood pressure is 120/80 mm Hg. Oxygen saturation is 99% on room air. Physical examination reveals no gross abnormalities MFMER slide-7

8 Which of the following pneumococcal vaccine (PPSV-23 and/or PCV-13) immunization schedules should you recommend for this patient? A. PPSV-23 now and PCV-13 in one year B. PCV-13 and PPSV-23 now C. PCV-13 now and a second dose in one year D. PCV-13 now and PPSV-23 in one year E. PPSV-23 now and a second dose in 5 years 2017 MFMER slide-8

9 Pneumococcal Vaccine Schedule for Adults 65 years June 2015: ACIP proposed this interval change to 1 year June 2015: ACIP proposed this interval change to 1 year Tomczyk S. MMWR 2014; 63: MFMER slide-9

10 Pneumococcal vaccine schedule Routine vaccination with PCV-13 and PPSV-23 for all persons 65 years PPSV23 VACCINE HISTORY 0 PCV13 ALL ADULTS AGED 65 years * PPSV23 12 months later** PPSV23 age 65 years PCV13 1 year after PPSV23 PPSV23 age <65 years PCV13 1 year after PPSV23 PPSV23 12 months later*** * Without immunocompromising conditions ** PPSV can be given later than 12 months after PCV13 if this window is missed *** A one-time booster dose of PPSV23 should be administered 5 years after the first PPSV23 dose 2017 MFMER slide-10

11 Case 3 A 19 year old man is recently diagnosed with nephrotic syndrome of uncertain etiology. He has received all his childhood vaccines. He has no allergies or other medical conditions. He presents to your clinic for a pre-employment physical and preventive health maintenance MFMER slide-11

12 Which of the following is the most appropriate recommendation regarding pneumococcal (PCV-13 and/or PPSV-23) vaccination for this patient? A. PCV-13 alone B. PPSV-23 alone C. PCV-13 followed by PPSV-23 after at least 8 weeks D. PCV-13 followed by PPSV-23 after at least 1 year E. PPSV-23 followed by PCV-13 after at least 1 year 2017 MFMER slide-12

13 Pneumococcal vaccination PPSV23 should be administered at least 1 yr after PCV13, except among adults with predisposing condition), for whom the interval should be at least 8 wks Adults yrs should get PPSV23 chronic heart disease (including CHF and cardiomyopathies, excluding HTN), chronic lung disease, chronic liver disease, alcoholism, or diabetes mellitus, or who smoke cigarettes: administer 2017 MFMER slide-13

14 Adults yrs 1= chronic heart/lung disease, DM, alcoholism, cirrhosis, asthma, cigarette smoking 2=cochlear implant, CSF leak 3=Immunocompromised or asplenia Congenital/acquired immunodeficiency HIV CKD; nephrotic syndrome Malignancy Solid organ transplant Iatrogenic immunosuppression 2017 MFMER slide-14

15 Case 4 In which of the following situations is the use of meningococcal group B vaccine most appropriate? A. A college outbreak to eliminate the carrier state B. A traveler to the meningococcal "belt" in equatorial Africa C. A patient with terminal complement deficiency D. All healthcare workers 2017 MFMER slide-15

16 MenACWY-D (Menactra) Two serogroup B meningococcal vaccines have been licensed by the FDA Recommended for people 10 years who are at increased risk for serogroup B meningococcal infections: Serogroup B meningococcal disease outbreak Damaged or absent spleen Persistent complement component deficiency Patients on eculizumab Microbiologists who work with N. meningitidis 2017 MFMER slide-16

17 Serogroup B Meningococcal Vaccines MFMER slide-17

18 Case 5 A 30-year-old Muslim man is going on a pilgrimage to Mecca (including the Hajj) with his father. He thinks he needs some vaccines before he goes. He was born and raised in Minnesota and received all childhood vaccinations. He has never traveled outside the US before MFMER slide-18

19 Regarding meningococcal vaccination. What do you recommend? A. MenACWY-D (Menactra) B. Serogroup B meningococcal vaccine C. A and B D. No meningococcal vaccine needed E. Tell me where I can found out 2017 MFMER slide-19

20 Meningitis risk in travelers Meningitis Belt Greatest risk: dry season (Dec. - June) Risk of travelers: 0.4/100,000 Hajj pilgrimage to Saudi Arabia associated with outbreaks of meningococcus group A (not group B) Hajj pilgrims must have had the meningococcal vaccine 3 years and 10 days before arriving in Saudi Arabia MFMER slide-20

21 2017 MFMER slide-21

22 Case 6 For which of the following groups is a second MMR vaccination recommended? A. Travelers to Tanzania B. All adults older than 19 years of age C. Pregnant women who are in the third trimester D. Persons who are immunosuppressed as a result of taking chronic corticosteroids E. All adults 65 years of age and older 2017 MFMER slide-22

23 MMR Vaccination Children need 2 doses of MMR vaccine: 1 st dose age months, 2 nd dose age 4-6 years Teens and adults should be up to, especially: Students at post-high school educational institutions International travelers Healthcare professionals Women of childbearing age who are not pregnant People who care for/around immunocompromised HIV infected without severe immunosuppression Pregnancy, immunosuppression: relative contraindications 2017 MFMER slide-23

24 Case 7 A 9 year old girl with a history of ADD presents for her yearly physical with her mother. Her mother regretfully reports that her daughter was sexually molested by a close male family member 2 months ago. She underwent an emergency evaluation at the time of the incident. The offender is now incarcerated after a formal investigation MFMER slide-24

25 What do you recommend regarding HPV vaccination in this child? A. Vaccinate now and give booster in 6 months B. Vaccinate now with subsequent boosters in 1 month and 6 months C. At age 11, give 2 shots 6 months apart D. At age 11, give 3 shots over 6 months E. At age 14, 3 shots over 6 months 2017 MFMER slide-25

26 HPV Vaccine Children starting at age 9 with a history of sexual abuse All children years: 2 shots 6-12 months apart Children 14 years: 3 shots over 6 months All young men through age 21 The following through age 26 Women MSM (including gay or bisexual) Transgender Immunocompromising conditions (including HIV) 2017 MFMER slide-26

27 HPV Vaccine MFMER slide-27

28 Case 8 A 28 year old woman of 20 weeks gestation with her second child presents to your clinic in February. She is healthy and has no acute concerns. She has never received the influenza vaccine. She completed her childhood DTaP series and received Tdap vaccination at the time of delivery of her first child three years ago. She has no known allergies MFMER slide-28

29 Regarding vaccinations, which of the following should you advise? A. Influenza vaccination now B. Tdap vaccination now C. Tdap and influenza vaccination now D. Tdap and influenza vaccination shortly after delivery E. Influenza vaccination now, and routine Td 10 years after her previous Tdap dose 2017 MFMER slide-29

30 Tdap and Pregnancy CDC recommends Tdap with each pregnancy after 20 weeks gestation regardless of previous vaccination history Provides maternal antibodies to the infants during the time that they are most vulnerable to disease (first 2 months) 2017 MFMER slide-30

31 Influenza Vaccine (inactivated) Everyone 6 months old Especially pregnant women Contraindications: Severe allergic reaction to vaccine or vaccine component (including egg protein) Precautions: Moderate or severe acute illness Guillain-Barré Syndrome within 6 weeks of previous flu vaccine 2017 MFMER slide-31

32 Live attenuated Influenza Vaccine In season: Not effective (3%)!!! ACIP and CDCrecommendations LAIV4 should not be used for the influenza season MFMER slide-32

33 Herpes Zoster in Immunocompromised Current live-attenuated vaccine contraindicated in immunocompromised Nearly 3 fold higher risk of zoster in 42 days after vaccine Subunit vaccine effective in older adults, phase 3 study. Approval expected later in MFMER slide-33

34 Thank you! 2017 MFMER slide-34

35 Ebola Vaccine 2017 MFMER slide-35

36 Zika Vaccine Low variation between strains vaccine against one strain could possibly protect against other strains Several approaches being studied Inactivated Live attenuated Subunit DNA Vector-based 2017 MFMER slide-36

37 Zika Vaccines in Development Institute Vaccine Platform(s) Status Inovio DNA Vaccine In clinical trials in PR NIH Bharat DNA Vaccine Live VZV recombinant Live attenuated ZIKV Purified inactivated virus VLP expressing polyprotein In clinical trials Preclinical/animal studies NewLink Purified inactivated virus Preclinical/animal studies Novavax Protein nanoparticle vaccine Preclinical/animal studies Replikins Synthetic peptide vaccine Preclinical/animal studies Pharos Biologicals DNA vaccine Preclinical/animal studies 2017 MFMER slide-37

38 Zika Vaccines in Development Institute Vaccine Platform(s) Status Bio-Manguinhos Butantan US CDC Purified inactivated virus YF17DD chimera VLP DNA Dengue recombinant Purified Inactivated virus VLP expressing ZIKV DNA Live attenuated recombinant Early stage research Early stage research Early stage research CureVac Thermostabile mrna-based vaccine Early stage research Geovax Live MVA recombinant Early stage research GSK Self-amplifying mrna platform Early stage research Hawaii Biotech Alhydrogel + recombinant protein Early stage research Oxford University Live adenovirus recomninant Early stage research Protein Sciences Recombinant E protein Early stage research Sanofi YF17D chimera Early stage research Sementis Live poxvirus recombinant Early stage research Themis Bioscience Live measles recombinant Early stage research Valneva Purified inactivated virus Early stage research Mayo Vaccine Research Group HLA-presented, natuarally processed and presented ZIKV peptides packaged with biodegradable nanoparticles Early stage research 2017 MFMER slide-38