Adult Immunization Update Presenter: Amanda Ingemi, PharmD, BCPS
Objectives Describe how vaccines teach the body to fight infections. List vaccines available for adults and the indications. Describe the recent updates for specific vaccines like the pneumococcal vaccines and the tetanus vaccines.
Immunology
Questions How do vaccines teach the body to fight infections? How do we recognize the vaccine? How do we make antibodies? How do we keep the blueprints for next time?
Questions How do vaccines teach the body to fight infections? How do we recognize the vaccine? How do we make antibodies? How do we keep the blueprints for next time?
Immune System Identify self vs. non-self Antigens Immune cells Antigen presenting cells B-cells T-cells Parham P, The Immune System 3 rd ed. New York, NY: Garland Science; 2009
Antigens Types Protein Chain of amino acids Hepatitis B surface antigen Hepatitis B vaccine Tetanus toxoid Polysaccharide Chain of sugar molecules Bacteria cell walls Encapsulated organisms (ex. Streptococcus pneumoniae, Haemophilus influenzae) Pneumovax Centers for Disease Control and Prevention. Epidemiology and Prevention of Vaccine-Preventable Diseases. Atkinson W, Wolfe S, Hamborsky J, eds. 12th ed., second printing. Washington DC: Public Health Foundation, 2012.
Questions How do vaccines teach the body to fight infections? How do we recognize the vaccine? How do we make antibodies? How do we keep the blueprints for next time?
Antibody Production Pollard. Nat Rev Immunol. 2009. 9:213-220.
Immune System Response Infection Primary response Antibodies Long-lasting protection Secondary response Parham P, The Immune System 3 rd ed. New York, NY: Garland Science; 2009.
Primary Response http://www.mims.com/usa/diagnoses/info/1209?q=immunoglobulin%20antibodies%2c%20specific%2c%20seru
Secondary Response http://cnx.org/contents/018e7fef-252c-44f3-8918-eaa58b977963@4.
Questions How do vaccines teach the body to fight infections? How do we recognize the vaccine? How do we make antibodies? How do we keep the blueprints for next time?
Blueprints Immunogenicity How much can the antigen elicit an immune response? Bacteria/virus Vaccine Strength of the immune response T-cell independent response No T-cells involved T-cell dependent response T-cell help Parham P, The Immune System 3 rd ed. New York, NY: Garland Science; 2
Blueprints Pollard. Nat Rev Immunol. 2009. 9:213-220
Blueprints T-cell independent response T-cell does not confirm not-self B-cells cannot create memory B-cells Short-term immunity Polysaccharides Encapsulated organisms Polysaccharide vaccines Parham P, The Immune System 3 rd ed. New York, NY: Garland Science; 2009.
Blueprints Pollard. Nat Rev Immunol. 2009. 9:213-220.
Blueprints T-cell dependent response T-cell confirms not-self B-cells create memory B-cells Long-lasting immunity Peptides Hepatitis B Hepatitis B vaccine Parham P, The Immune System 3 rd ed. New York, NY: Garland Science; 2009
Conjugate Vaccine Combine polysaccharide with peptide Want to protect against polysaccharide Want long lasting response T-cell Recognizes the peptide Helps the B-cell make memory B-cells B-cell Makes antibodies to polysaccharide Memory B-cells made for long-lasting response Pollard. Nat Rev Immunol. 2009. 9:213-220. Parham P, The Immune System 3 rd ed. New York, NY: Garland Science; 200
Summary How do vaccines teach the body to fight infections? How do we recognize the vaccine? B-cells recognize antigens How do we make antibodies? Plasma cells produce antibodies How do we keep the blueprints for next time? Plasma cells for short-term Memory B-cells for long-term
Vaccine Indications
Influenza
Pneumococcal
Tetanus and Hepatitis
Zoster, Meningococcal, H.influenzae, HPV
Vaccine Updates
Pneumococcal Vaccine Pneumovax Prevnar Abbreviation PPSV23 PCV13 Valents 23 13 Vaccine type Polysaccharide Conjugate Immunity Shorter Longer Indication Many disease states Only the most immunocompromising disease states, including age >65 Frequency Every 5 years x 2 till age 65, then another dose if > 65 and 5 years since last dose 1 dose Timing 8 weeks after Prevnar 1 year after Pneumovax CDC.gov/vaccines/sched ules/ Centers for Disease Control and Prevention. Epidemiology and Prevention of Vaccine-Preventable Diseases. Atkinson W, Wolfe S, Hamborsky J, eds. 12th ed., second printing. Washington DC: Public Health Foundation, 2012.
Pertussis Outbreak Pertussis Recent outbreak on the Eastern Shore of Virginia Prevalence
Tetanus Types Td Tdap Indications Tdap Everyone x1 During each pregnancy Td every 10 years CDC.gov/vaccines/schedules/
Hepatitis B Dose Pediatric Adult Dialysis Engerix Recombivax Twinrix 10 mcg 20 mcg --- 5 mcg 10 mcg 40 mcg --- 20 mcg --- Interchangeable Yes Yes No (includes hepatitis A vaccine) Adult frequency 0, 1, and 6 months 0, 1, and 6 months 0, 1, and 6 months Centers for Disease Control and Prevention. Epidemiology and Prevention of Vaccine-Preventable Diseases. Atkinson W, Wolfe S, Hamborsky J, eds. 12th ed., second printing. Washington DC: Public Health Foundation, 2012.
Hepatitis B Serologic testing for response: 1-2 months after completing the 3-dose series Nonresponse: can give a second 3-dose series Antibody titers (not protection) wane over time Centers for Disease Control and Prevention. Epidemiology and Prevention of Vaccine-Preventable Diseases. Atkinson W, Wolfe S, Hamborsky J, eds. 12th ed., second printing. Washington DC: Public Health Foundation, 2012.
Example 1 MM is a 21 year old male with asthma who just got into a car accident and his spleen was removed. He received PPSV23 (Pneumovax ) at age 19 because of diabetes. What do you recommend for pneumococcal? a) Give Pneumovax now b) Give Prevnar now c) Give Prevnar now, then Pneumovax in 3 years d) Wait 4 months, then give Prevnar
Example 2 CR is a 61 year old male with HIV. He has received these vaccines: Influenza- 9/2/14 Tdap- 8/20/07 Hepatitis B series complete (can t remember date) What is CR eligible for? a) Zoster b) Meningococcal c) HPV d) Pneumococcal
Example 3 TM is a 21 year old female that had a kidney transplant last year. Which vaccines is she eligible for?
Immunization Questions
How Many Vaccines Can You Give? How many vaccines may be administered at one visit? I recommend 4 at a time (2 in each arm) No limit Are there any contraindications to giving multiple vaccines at once? Most can be administered at the same time Zoster and pneumococcal vaccines 4 weeks apart Give 2 live vaccines at the same time, if not, separate by 4 weeks
Interval Between Doses of the Same Vaccine Increasing the interval Does not diminish effectiveness Decreasing the interval May interfere with antibody response/protection Bottom line: spacing out your vaccines is ok No need to start over even if there is an extended interval between doses
Virginia Immunization Information System Statewide immunization registry Voluntary, free, web-based database Run by the Virginia Department of Health
Adult Immunization Update Presenter: Amanda Ingemi, PharmD, BCPS
Learning Assessment 1 Vaccines help the body make antibodies. Antibodies are made by a) T-cells b) B-cells, specifically plasma B-cells c) Platelets d) Macrophages
Learning Assessment 2 Which set of vaccines are appropriate for a 45 year old male with COPD and had a splenectomy? The patient has no allergies and is on no immunosuppression. a) Influenza, tetanus, herpes zoster (shingles) b) Influenza, pneumococcal (Pneumovax ) c) Influenza, pneumococcal (Pneumovax and Prevnar ), tetanus, meningococcal d) Influenza, pneumococcal (Pneumovax and Prevnar ), tetanus, meningococcal, H. influenzae
Learning Assessment 3 A 55 year old female who is HIV positive is looking to get up to date with her pneumococcal vaccine. She received Pneumovax 8 months ago. What do you recommend? a) Give Pneumovax again now b) Give Prevnar now c) Check a CD4 count before giving anything d) Wait 4 more months, then give Prevnar