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1 Cancer Survivorship Protecting Against Vaccine Preventable Diseases Heidi Loynes BSN, RN Immunization Nurse Educator Michigan Department of health and Human Services (MDHHS)

2 Are Vaccine-Preventable Diseases Still Out There? Images courtesy of CDC. 2

3 Despite the U.S. immunization program s success, according to CDC officials, 189 people in the U.S. have been reported to have measles this year in 5 outbreaks, as of May 1, 2015 April 1,

4 More Headlines Nonmedical Vaccine Exemptions and Pertussis in California, 2010, Atwell et al, Pediatrics 2013;132:

5 Importance of Vaccinating the Immunocompromised The number of patients with immunosuppression is increasing People with compromised immune systems (cancer, HIV infection, Crohn s, etc.) are vulnerable to illness Vaccination rates tend to be lower in patients with compromised immune systems Partly because the provider may be concerned about safety and effectiveness Resource: Clinical Practice Guideline for the Vaccination of the Immunocompromised Host, Clinical Infectious Diseases, Infectious Disease Society of America (IDSA) at: Vaccination of immunocompromised patients, Clinical Microbiology and Infection Volume 18, Supplement 5, October

6 Why Vaccinate Cancer Survivors? Vaccination are important Survivors are at elevated risk for infection because of cancer treatment Adults with cancer are recommended to receive appropriate vaccinations as part of standard practice In 2009, only 57.8% of adult cancer survivors reported receiving an influenza vaccination Only 48.3% reported receiving an pneumococcal vaccination People who are compromised are at increased risk for flu and pneumococcal disease National guidelines recommend certain vaccines (e.g., inactivated influenza vaccine and pneumococcal vaccines) specifically for cancer survivors NCCN guidelines recommend that all cancer survivors be considered for appropriate vaccinations Medscape, New Cancer Survivorship Guidelines Issued by NCCN ; Crystal S. Denlinger, MD,

7 Challenges to Vaccination of Cancer Survivors Vaccines as a strategy to prevent infection in cancer and transplant survivors can have challenges May not trigger protective immune responses Especially in actively immunocompromised individuals or survivors with residual immune deficits Some vaccines (Zoster, MMR) are contraindicated in actively immunocompromised individuals Ideally providers should administer all indicated vaccines to patients before initiation of cancer treatment Should recommend and encourage the administration of all inactivated vaccines Medscape, New Cancer Survivorship Guidelines Issued by NCCN ; Crystal S. Denlinger, MD,

8 Give a Strong Recommendation Studies consistently show that provider recommendation is the strongest predictor of vaccination Adults who are initially reluctant, are likely to receive a vaccination when the health care provider s opinion of the vaccine is positive Atkinson, William, et al. Epidemiology and Prevention of Vaccine Preventable Diseases, 12th Ed MMWR 2010;Vol 59(08);1-62

9 Vaccinating Cancer Survivors Vaccines are especially critical for people with health conditions such as a weakened immune system

10 Preparing to Vaccinate Determination of altered immunocompetence is important to the vaccine provider Why? Incidence or severity of some vaccine-preventable diseases is higher in persons with altered immunocompetence Vaccines might be less effective during the period of altered immunocompetence Vaccinating a Cancer Survivor involves: Screening (for precautions and contraindications) Physician, PA, NP in clinical decision Risk versus benefit Determining which vaccines to administer (assessment)

11 Recommended Schedule for Adults 2015 Recommended vaccinations indicated for adults based on medical and other indications 11

12 Recommending Vaccines to Cancer Survivors Specialist caring for the immunocompromised share responsibility with the primary care provider Ensure appropriate vaccination to the immunocompromised Recommend appropriate vaccinations of household contacts Vaccines considered safe for cancer, transplant survivors & close contacts: Pneumococcal vaccine (both types) Pneumococcal Conjugate (PCV13) Pneumococcal Polysaccharide (PPSV23) Inactivated Influenza Vaccine (IIV3, IIV4) Tetanus, diphtheria, pertussis (Tdap, Td, DTaP) Hepatitis A and Hepatitis B Inactivated poliovirus (IPV) Haemophilus Influenza type b (Hib) Meningococcal Conjugate (MCV4) Human papillomavirus (HPV) Resource: Clinical Practice Guideline for the Vaccination of the Immunocompromised Host, Clinical Infectious Diseases, Infectious Disease Society of America (IDSA) at:

13 Vaccines Contraindicated in Actively Immunocompromised Survivors Live attenuated vaccines Influenza---Live, Attenuated Influenza Vaccine (LAIV) Measles, Mumps, Rubella (MMR) Varicella Zoster Oral Polio Rotavirus Oral Typhoid Yellow Fever

14 Pneumococcal Vaccines Most common pneumococcal disease is pneumococcal pneumonia which is a frequent complication of influenza Accounts for an estimated 400,000 hospitalizations per year Case fatality rate 5-7%, higher in elderly There are 2 Pneumococcal vaccines PCV13 (Pneumococcal Conjugate Vaccine) Brand name: Prevnar13 Given IM to ages 2 months and older PPSV23 (Pneumococcal Polysaccharide Vaccine) Brand name: Pneumovax Given IM to ages 2 years and older If both vaccines are recommended: Do not give these 2 vaccines at the same visit Administer PCV13 first (preferred) then PPSV23 Intervals between PCV13 & PPSV23 based on age and risk 20

15 PCV13 and PPSV23 PCV13 (Prevnar13 ) For Persons 6 Years and Older For persons with a high risk indication and no previous dose of PCV13: Administer 1 dose to persons aged 6-64 years with: CSF leaks, cochlear implants Immunosuppression caused by disease or medications, HIV, functional or anatomic asplenia, sickle cell, general malignancy Routinely administer 1 dose to all persons aged 65 years and older with no previous dose of PCV13 PPSV23 (Pneumovax ) For persons with a high risk indication: Administer 1 dose to persons aged years who Smoke cigarettes or have asthma Administer 1 dose to persons aged 2-64 years with: Chronic pulmonary, kidney or heart disease, diabetes mellitus, alcoholism, CSF leaks, or cochlear implants Administer 2 doses to persons aged 2-64 years with: Immunosuppression caused by disease or medications, HIV, functional (sickle cell) or anatomic asplenia, malignancy Minimum interval between 2 doses is 5 years Routinely administer 1 dose to all persons age 65 years or older Final PPSV23 dose regardless of risk factor

16 Administering PCV13 and PPSV23 Age Group 19 years 65 years Underlying Conditions High-risk immunocompetent (CSF leak, cochlear implant) Functional or anatomic asplenia Immunocompromised Immunocompetent not in a risk group listed under 19 years Recommended Intervals PCV13 to PPSV weeks PPSV23 to PCV13 12 months 12 months 12 months 1 Recommended: PCV13 be given prior to PPSV23 (red box) 24

17 Burden of Influenza Disease Difficult to predict severity or timing 5%-20% of U.S. population infected Range of 3,000-49,000 (average 23,600) influenzarelated deaths annually in the U.S. Rates of serious illness & death greatest in: Persons aged 65 years and older Children less than 2 years of age Persons (any age) with medical conditions that put them at high risk for complications from influenza Having or surviving cancer does not put you at an increased risk for getting the flu It does put you at an increased risk of complications from the flu virus Such as: pneumonia, hospitalization, and even death

18 Flu Coverage in High Risk Adults High-risk adults aged years: U.S. 39.3% MI 43.4% (+12.8% from ) High-risk adults aged years: U.S. 47.6% MI 46.9% (+6.1% from )

19 Immunization Recommendations: Everyone! Every Year! All persons 6 months of age and older should be given flu vaccine every year Continue to ensure that persons at higher risk for influenza-related complications are vaccinated If you are a cancer survivor, you are still at higher risk for flu-related complications Vaccinate close contacts of those at high risk to provide another layer of protection including: Healthcare Personnel (HCP) Parents & contacts of infants less than 6 months of age

20 Two Types of Inactivated Influenza Vaccine (IIV) Inactivated Influenza Vaccine, Trivalent Inactivated Influenza Vaccine, Quadrivalent IIV3 (flu shot, IM) IIV4 (flu shot, IM) 3 flu strains: 2 A, 1 B 4 flu strains: 2 A, 2 B Age 6 months/older** Age 6 months/older** For persons who: - Are healthy - Have any underlying medical condition - Are pregnant For persons who: - Are healthy - Have any underlying medical condition - Are pregnant **Age indication varies by vaccine brand Live attenuated influenza vaccine (LAIV4) is contraindicated in the immunocompromised

21 Influenza Vaccines IIV: Inactivated Influenza Vaccine, trivalent (IIV3) or quadivalent (IIV4) LAIV4: Live, Attenuated, Influenza Vaccine, quadrivalent cciiv3: Cell Culture-based Inactivated Influenza Vaccine, trivalent RIV3: Recombinant Influenza Vaccine, trivalent Vaccine Type Brand Age Indication Manufacturer TRIVALENT (IIV3) IIV3 *Fluzone 6 months and older sanofi pasteur IIV3 Fluvirin 4 years & older Novartis IIV3/Jet Injector¹ Afluria 9 years & older biocsl IIV3 High Dose Fluzone High Dose 65 years & older sanofi pasteur cciiv3 Flucelvax 18 years & older Novartis RIV3 Flublok 18 years & older Protein Sciences QUADRIVALENT (IIV4 & LAIV4) IIV4 *Fluzone Quadrivalent 6 months and older sanofi pasteur IIV4 *Fluarix Quadrivalent 3 years & older GlaxoSmithKline IIV4 *FluLaval Quadrivalent 3 years & older GlaxoSmithKline IIV4 ID Fluzone Intradermal 18 through 64 years sanofi pasteur LAIV4 Contraindicated *FluMist Quadrivalent Healthy, non-pregnant persons 2 through 49 years MedImmune *Available for VFC Providers ¹Afluria was approved by the Food and Drug Administration for intramuscular administration with the PharmaJet Stratis needle-free jet injector system for persons 18 through 64 years of age

22 Hematopoietic Stem Cell Transplant (HSCT) Recipients At increased risk for certain vaccine-preventable diseases Including diseases caused by encapsulated bacteria (i.e., pneumococcal, meningococcal and Hib infections) HCT recipients should be revaccinated Regardless of the source of the transplanted stem cells Most inactivated vaccines should be initiated 6 months after the HCT Follow minimum intervals between doses References: Tomblyn M, Chiller T, Einsele H, et al. Guidelines for Preventing Infectious Complications among Hematopoietic Cell Transplantation Recipients: A Global Perspective, Biol Blood Marrow Transplant 15: ;2009 Rubin, LG, Levin MJ, Ljungman P., et. Al IDSA Clinical Practice Guidelines for Vaccination of the Immunocompromist Hot. Clin. Infect. Dis. 2014; 58: e

23 Vaccination of HSCT Recipients Inactivated influenza vaccine (IIV) Administer at least 6 months after HSCT and annually thereafter May administer as early as 4 months post HSCT if community outbreak as defined by the local health department However, 2 nd dose should be considered if flu vaccine given before 6 months post HSCT (at least 4 weeks later) Tetanus, diphtheria acellular pertussis vaccines Start series 6 months after HSCT DTaP is preferred (3 doses) Alternatively, if only Tdap available (give one Tdap followed by 2 doses of DT or Td for a total of 3 doses) Hib vaccine Administer 3 doses 6-12 months post HSCT; at least 1 month should separate the doses

24 Protecting Our At-Risk Population Goal is to ensure we vaccinate against vaccine-preventable diseases To help provide protection for our vulnerable (at-risk ) population We do this by: Recommending and administering vaccines for our cancer patients and cancer survivors Ensuring that household contacts are vaccinated Why is vaccinating household contacts and the general population important? Because Herd immunity (cocooning) makes a difference Implies that disease risk will be reduced for susceptible persons by the presence & proximity of immune individuals ( indirect protection )

25 Continue the Survivorship Vaccinate to Protect our At-Risk

26 Thank You Heidi Loynes BSN, RN Immunization Nurse Educator Michigan Department of health and Human Services (MDHHS)

27 Resources 1. Clinical Practice Guideline for the Vaccination of the Immunocompromised Host, Clinical Infectious Diseases, Infectious Diseases Society of America (IDSA) at: 2. General Recommendations on Immunization, Recommendations of the Advisory Committee on Immunization Practices (ACIP), MMWR; Vol.60p; No.2; January 28, What Cancer Patients, Survivors, and Caregivers Should Know About the Flu at: 4. Influenza vaccination for immunocompromised patients: systematic review and meta-analysis by etiology at: 5. Vaccination of immunocompromised patients Clinical Microbiology and Infection Volume 18, Supplement 5, October 2012 at 6. Clinical Practice Guideline for the Vaccination of the Immunocompromised Host, Clinical Infectious Diseases, Infectious Disease Society of America (IDSA) at: 7. Weakened Immune System and Adult Vaccination at: 8. Vaccination of Persons with Primary and Secondary Immune Deficiencies at: 9. Vaccination of Hematopoietic Stem Cell Transplant (HSCT) Recipients at: