Adult Immunization Update 2015 Objectives Upon completion of this session, the pharmacist should be able to: Compare and contrast previous versions of the ACIP immunization schedules with the most recent (2015)recommendations. List newly approved vaccines and their indications. Identify patients who are good candidates for vaccines. Recommend the appropriate type of influenza vaccine to patients: inactivated tri or quadrivalent, liveattenuated (intranasal), cell cultured, high dose, or recombinant. Identify adult patients in need of pneumococcal vaccination, and recommend the appropriate vaccine(s) (polysaccharide, conjugate, or both). 1
Adults >18 years Centers for Disease Control. Recommended Adult Immunization Schedule 2015. But the flu shot didn t even work this year! http://gis.cdc.gov/grasp/fluview/main.html 2
But the flu shot didn t even work this year! http://gis.cdc.gov/grasp/fluview/main.html What was in the flu vaccine WHO recommendation for influenza vaccine composition for 2014 2015 A/California/7/2009 (H1N1)pdm09 like virus A/Texas/50/2012 (H3N2) like virus B/Massachusetts/2/2012 like virus B/Brisbane/60/2008 like virus (for quadrivalent vaccines) National or regional control authorities (i.e., CDC, FDA) approve the composition and formulation of vaccines for each country 3
Isn t there some new flu shot stuff? Inactivated influenza vaccine (IIV) Trivalent (IIV3; TIV) Cell culture based (cciiv3) Quadrivalent (IIV4) Available in intramuscular, intradermal, or high dose Live attenuated influenza vaccine (LAIV4) Available in intranasal Recombinant hemagglutinin influenza vaccine (RIV3) Available as intramuscular Cell cultured flu vaccine (Flucelvax) First available this season Not grown in eggs Uses cell culture technology No preservatives or antibiotics FDA approved for 18 years of age 4
What people actually caught Predominant strain: Influenza A H3N2 With up to 80% antigenic drift http://www.cdc.gov/media/releases/2014/p1204 flu season.html http://www.cdc.gov/flu/weekly/index.htm IIV High Dose (Fluzone High Dose) Contains 4x the amount of antigen compared with other IIV Indicated for patients 65y/o No preference given by ACIP for this product over any other DiazGranados CA, Duning AJ, Kimmel M. Efficacy of high dose versus standard dose influenza vaccine in older adults. NEJM 2014; 371: 635 45. 5
IIV Intradermal (Fluzone Intradermal) Microinjection system deposits antigen into dermal layer of skin First approved during 2011 flu season Intradermal Intramuscular Inj. Site reaction 89% 60% Erythema 76% 13% Induration 58% 10% Swelling 57% 8% Pain 51% 54% http://www.sanofipasteur.us/node/12102 http://www.fda.gov/downloads/biologicsbloodvaccines/vaccines/approved%20products/ucm305089.pdf http://www.fda.gov/downloads/biologicsbloodvaccines/vaccines/approved%20products/ucm305080.pdf Recombinant hemagglutinin influenza vaccine (RIV3; Flublok) Doesn t use influenza virus or eggs Indicated for 18 49 years old Shorter shelf life (16 weeks from production) http://www.flublok.com/packinsert.pdf 6
IIV Contraindications Severe allergy to any vaccine component Egg to be discussed Caution in moderate or severe acute illness (with or without fever) Caution of GBS within 6 weeks of previous flu vaccine LAIV Contraindications Severe allergy to any vaccine component Egg to be discussed Pregnancy Immunocompromised Caution in: Moderate or severe acute illness (with or without fever) GBS within 6 weeks of previous flu vaccine Kidney failure, ESRD, hemodialysis Asplenia Chronic liver disease Diabetes Heart disease Chronic lung disease Chronic alcoholism Neurologic disease 7
So what about egg allergy? http://www.cdc.gov/flu/professionals/acip/2013 summary recommendations.htm#figure2 So which one does the patient need? Most patients should get IIV3 or IIV4. LAIV is an alternative if they are 2 49 y/o and have no contraindications High dose is an alternative if they are >65 y/o Give RIV if they have a documented egg allergy Role of Flucelvax? Egg allergy? Those with an issue with preservatives ( mercury ), antibiotics? 8
Adults >18 years Centers for Disease Control. Recommended Adult Immunization Schedule 2015. What s up with the pneumococcal vaccine? Who should be vaccinated with PCV13? Age 65 years Any of the following HIGH RISK (19 64y/o): Immunocompromised (HIV, drug induced, leukemia/lymphoma, etc), renal failure, asplenia, CSF leaks, cochlear implants Centers for Disease Control. Advisory Committee on Immunization Practices Recommended Immunization Schedule for Adults Aged 19 Years or Older United States, 2015. MMWR. 2015; 60(04): 91 2. 9
What s up with the pneumococcal vaccine? Who should be vaccinated with PPSV23? Age 65 years Any of the following (19 64y/o): Heart disease (exc. HTN), chronic lung disease, chronic liver disease, alcoholism, DM, smokers, healthcare workers, nursing home residents Centers for Disease Control. Advisory Committee on Immunization Practices Recommended Immunization Schedule for Adults Aged 19 Years or Older United States, 2015. MMWR. 2015; 60(04): 91 2. What s up with the pneumococcal vaccine? EVERYONE over the age of 65 years needs to have had at least one dose of each. If giving first dose at 65 years, give PCV13 first, then PPSV23 6 12 months later. HIGH RISK need PCV13 (one dose), followed by PPSV23. Then PPSV23 booster in 5 years. Then still give PPSV23 at age 65. Centers for Disease Control. Advisory Committee on Immunization Practices Recommended Immunization Schedule for Adults Aged 19 Years or Older United States, 2015. MMWR. 2015; 60(04): 91 2. 10
Payment for Pneumococcal vaccines Medicare Part B now covers the cost of two recommended doses of pneumococcal vaccine (when administered at least 12 months apart). Centers for Disease Control CPT code for PPSV23: 90732 CPT code for PCV13: 90670 Same HCPCS and diagnosis codes for both (G0009 and V.03.82) http://www.cdc.gov/vaccines/hcp/patient ed/adults/downloads/fs pneumo hcp.pdf Adults >18 years Centers for Disease Control. Recommended Adult Immunization Schedule 2015. 11
So who need a Tdap now? Those 11years who have not had a Tdap Followed by Td booster every 10 years *Pregnant women* With EVERY pregnancy Adults >18 years Centers for Disease Control. Recommended Adult Immunization Schedule 2015. 12
What about Zoster? Recommended for all over 60 years of age EXCEPT: Immunocompromised (Pregnant) Vaccine Storage Frozen 58⁰ + 5 ⁰F ( 50 ⁰ 15 C) May be refrigerated (36 46 ⁰F (2⁰ 8⁰C) for up to 72h prior to reconstitution If not injected within 72 hours, must be discarded! DO NOT REFREEZE! Diluent stored separately, at room temperature or refrigerated. https://www.merckvaccines.com/products/zostavax/pages/storageandhandling/storage Adults >18 years Centers for Disease Control. Recommended Adult Immunization Schedule 2015. 13
Yikes! I was at Disneyland! I need an MMR vaccine! What ADULTS need a MMR vaccine? Those born AFTER 1957 who: Do not have confirmed childhood vaccine SERIES or antigen titers Women of childbearing years should have immune testing for rubella. If no proof of immunity, give MMR vaccine (if not pregnant) WILL WANT TO CHECK WITH THIRD PARTY PRIOR TO ADMINISTRATION RE: PAYMENT! Image from: http://www.motherjones.com/bluemarble/2015/01/measles outbreak disneyland antivaxxers QUESTIONS? 14