Immunizations June 5, 2015 Brenda Ormesher, MD Infectious Disease Peacehealth Medical Group Springfield, OR
Disclosures None
Goals Understand basic public health impact of immunization Recognize types of vaccinations available Identify resources available for identifying CDC recommended immunizations Discuss differences and rationale for use of specific vaccination formulations in practice
Introduction
Vaccine vac cine/vakˈsēn/ (Noun) a substance used to stimulate the production of antibodies and provide immunity against one or several diseases, prepared from the causative agent of a disease, its products, or a synthetic substitute, treated to act as an antigen without inducing the disease.
History One of the great public health achievements in human history Inoculation against smallpox was practiced 2000 years ago but modern concept credited to Edward Jenner (1796) Now 23 FDA approved vaccine-preventable diseases
http://www.immunize.org/catg.d/p4037.pdf
General Characteristics of Vaccines
Components of Vaccine Antigens component derived from disease- causing organism which trigger protective immune response Stabilizers Maintain effectiveness during storage Factors affecting stability include temperature and ph Include magnesium chloride (OPV), magnesium sulfate (RSV, measles), lactose-sorbitol and sorbitolgelatin Adjuvants Added to vaccines to stimulate production of antibodies Several hundred different types Antibiotics Trace amounts used in manufacturing to prevent bacterial contamination of tissue growth cells for viruses Trace amounts (25 micrograms neomycin in MMR and IPV) Preservatives Multidose vaccines to prevent bacterial and fungal growth Include thiomersal, formaldehyde (purification process removes almost all formaldehyde, <0.02% per dose)
Routes of Administration http://vaccine-safety-training.org/adverse-events-causes.html
Types of Vaccines Live, attenuated Inactivated/ killed Toxoid (inactivated toxin) Subunit/ conjugate DNA vaccine Recombinant vector
Live, attenuated Living microbe that has been weakened in the lab Should not be given in immunocompromised host Closest to natural infection Elicit strong cell-mediated and antibody response Life long immunity with only 1 or 2 doses (similar immunogenicity as wild-type pathogen) Examples: MMR (measles, mumps, rubella) Varicella (chickenpox) Influenza nasal spray Rotavirus Zoster (shingles) Yellow fever Tuberculosis (BCG) Oral polio vaccine (OPV)
Live, attenuated Vaccines http://vaccine-safety-training.org/live-attenuated-vaccines.html
Inactivated, killed Produce inactivated vaccine by killing the microbe with chemicals, heat, or radiation More stable and safe than live vaccines (dead microbes cannot mutate) Stimulate a weaker immune system response than live vaccines Requires booster shots to maintain immunity Examples: Polio (IPV) Hepatitis A Whole-cell pertussis (wp) Rabies
Inactivated, killed Vaccines http://vaccine-safety-training.org/inactivated-whole-cell-vaccines.html
Toxoid (inactivated toxin) For bacteria that secrete toxins (toxin must be main cause of illness) Inactivate toxins by treating with formalin To increase immune response the toxoid is absorbed to aluminum or calcium salts (serve as adjuvant) Produces antibodies that lock onto & block the toxin Examples: Diphtheria, tetanus (part of DTaP)
Toxoid Vaccines http://vaccine-safety-training.org/toxoid-vaccines.html
Subunit Protein-based, Polysaccharide, Conjugate Use only part of a target pathogen (no live components) Protein or polysaccharide- Uses part of target pathogen to provoke a response from the immune system Conjugate- Link antigens or toxins that immune system will recognize to the polysaccharide coating of bacteria No guarantee that immunological memory will be formed in correct manner Examples: Influenza (injection) Haemophilus influenza type b (Hib) Pertussis (part of DTaP) Pneumococcal Meningococcal Human papillomavirus (HPV)
Subunit: Polysaccharide versus Conjugate Polysaccharide Little or short-lived impact on carriage of bacteria Decreasing immune response with time (needs boosters) Limited ability to protect children under 2 years Conjugate Enhances the immune response and long term recognition Protective immune response in infants Minimizes hyporesponsiveness Harder to design/ develop
Polysaccharide vs Conjugate Vaccines http://www.nature.com/nri/journal/v9/n3/fig _tab/nri2494_f1.html
Subunit (purified antigen) Vaccines http://vaccine-safety-training.org/subunit-vaccines.html
CDC Immunization Recommendations
Recommended adult immunization schedule, by vaccine and age group CDC 2015 Adult Immunization Schedule
Vaccines that might be indicated for adults based on medical or other indications CDC 2015 Adult Immunization Schedule
There s an app for that Free! Available from App store for ios 5.0 or later or Google Play for Android 2.1 http://www.cdc.gov/vaccines/s chedules/hcp/scheduleapp.html#download
Vaccine Specific Information
Vaccine-Preventable Diseases Adenovirus type 4 & 7 Anthrax Chickenpox (Varicella) Diphtheria Hepatitis A Hepatitis B Hib (Haemophilis influenza type b) HPV (Human Papillomavirus) Influenza Japanese encephalitis Measles Meningococcal Mumps Pertussis (Whooping cough) Pneumococcal Poliovirus Rabies Rotavirus Shingles (Herpes zoster, varicella) Tetanus Tuberculosis Typhoid fever Yellow fever
Influenza http://www.cdc.gov/vaccines/pubs/pinkbook/downloads/appendices/b/us-vaccines.pdf
Which influenza vaccine is right for my patient? That depends.
Does your patient have an egg allergy? Cost $32/ dose http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6332a3.htm#tab
Is your patient a pediatric patient? In pediatrics demonstrated superior efficacy in live attenuated vaccine reduction of 55% in culture confirmed influenza cases in ages 6 to 59 months 52% increased protection in children age 6 to 71 months) http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6332a3.htm
Is your patient age 6 months to 2 years? Give Fluzone In a previously unvaccinated child (< 8 years old) give 2 doses of influenza vaccine at least 4 weeks apart http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6332a3.htm
Is your patient age 2 to 49 years old and have special medical conditions? Pregnant? Immunosuppressed? Egg allergy? Children age 2 to 17 years receiving aspirin? Children age 2 to 4 years who have asthma with wheezing in past 12 months? Influenza antiviral medications in past 48 hours? Care for severely immunosuppressed person who require a protective environment? http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6332a3.htm
Is your patient age 2 to 49 years old and have special medical conditions? Yes: do not give live attenuated vaccine (FluMist), give inactivated influenza vaccine No: give FluMist (cost $22 per dose) http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6332a3.htm
Is your patient over 65 years old? Inactivated influenza vaccine high dose (60 mg of hemagglutinin per strain) induced a significantly higher antibody response and provider better protection against lab-confirmed illness than standard inactivated influenza vaccine (15 mg of hemagglutinin per strain) Cost of high dose influenza vaccine $30 vs $10 for standard dose DiazGranados, C. Et al. Efficacy of High-Dose versus Standard-Dose Influenza Vaccine in Older Adults. NEJM 2014; 371:635-645.
Vaccine Effectiveness Vaccine effectiveness decline post-vaccination By age: Vaccine effectiveness in < 65 years estimated at 44%, vaccine effectiveness > 65 years estimated at 19% By time: Vaccine effectiveness in first 100 days 61%, between 100 and 119 days was 42%, after 120 days was 0% Castilla J, et al. Decline in Vaccine Effectiveness with Time After Vaccination, Navarre, Spain, Season 2011/12. Eurosurveillance, Volume 18, Issue 5, 31Jan2013.
Quadrivalent versus Trivalent Rationale for quadrivalent: historically influenza vaccines contain only one strain of B virus although though there are two different lineages of B strains that circulate most seasons Benefit: improved coverage of B strain which could account for 1-44% of influenza cases (based on data from preceding 10 years) Negative: Cost ($15 for quad vs $10 for tri), supply
Pneumococcal + Pneumovax (PPSV23)- Pneumococcal polyvalent (polysaccharide) vaccine covering 23 serotypes, cost $85/ dose + Prevnar (PCV13)- Pneumococcal conjugate vaccine covering 13 serotypes, cost $150/ dose http://www.cdc.gov/vaccines/pubs/pinkbook/downloads/appendices/b/us-vaccines.pdf
Pneumococcal Recommendations Recommendation for adults 65 years or older: see diagram Recommendations for adults 19 years or older with no history of PCV13: CSF leak, cochlear implant, sickle cell disease, function or anatomic asplenia, congenital or acquired immunodeficiency, HIV infection, chronic renal failure, nephrotic syndrome, leukemia, Hodgkin disease, generalized malignancy, long-term immunosuppressive therapy, solid organ transplant, multiple myeloma Bonten M, Bolkenbaas M, Huijts S, et al. Community Acquired Pneumonia Immunization Trial in Adults (CAPiTA). Abstract no. 0541. Pneumonia 2014;3:95. https://pneumonia.org.au/public/journals/22/publicfolder/abstractbookmasterforwebupdated20-3-14.pdf.
Meningococcal http://www.cdc.gov/vaccines/pubs/pinkbook/downloads/appendices/b/us-vaccines.pdf
Meningococcal Disease- Worldwide http://www.meningitisinfo.com/epidemiology_ssi.aspx
Meningococcal A, C, W-135 and Y Menomune Polysaccharide vaccine Licensed for data on A & C strains (not enough date for W-135, Y) Recommended for adults who require single dose only (travelers, military recruits) Cost $125/ dose Menactra Polysaccharide conjugate vaccine Licensed for A, C, Y, W-135 Asplenia, complement deficiencies, microbiologist, frequent international travelers to high endemic regions (African meningitis belt, Hajj) Cost $100/ dose Menveo polysaccharide conjugate vaccine Licensed for A, C, Y, W-135 Asplenia, complement deficiencies, microbiologist, frequent international travelers to high endemic regions (African meningitis belt, Hajj) Cost $120/ dose
Meningococcal B Trumenba Composed of two recombinant lipidated factor H binding protein (fhbp) variants from N. meningitidis serogroup B, one from fhbp subfamily A and one from subfamily B (A05 and B01, respectively) Series of 3 shots at 0, 2 and 6 months Cost $120/ dose Bexsero Composed of 4 distinct antigens including factor H binding protein (fhbp), Neisserial adhesin A (NadA), Neisserial heparin-binding antigen (NHBA), and PorA P1.4 immunodominant antigen of OMV NZ (strain NZ98/254) Series of 2 shots at least 1 month apart Cost $160/does
Human Papillomavirus Cervarix Viral protein subunit vaccine Covers serotype 16 and 18 (may provide cross protection for 31, 33, 45,52) Contains novel adjuvant so may be responsible for great antibody response (unknown) Series of 3 shots at 0, 1-2 and 6 months Cost $130/ dose Gardasil Viral protein subunit vaccine Covers serotype 6, 11, 16 and 18 (may provide cross protection for 31, 45) Series of 3 shots at 0, 2 and 6 months Cost $150/ dose Gardasil 9 Viral protein subunit vaccine Covers serotype 6, 11, 16, 18, 31, 33, 45, 52 and 58 Series of 3 shots at 0, 2 and 6 months Cost $160/ dose http://www.ganfyd.org/index.php?title=file:hpvcerv icalcancer.png
Questions/ Comments? Email: BOrmesher@peacehealth.org Thank you!