Update on Adult Immunization Paul J. Carson, MD, FACP Sanford Health, Infectious Disease NDSU Master of Public Health Program UND School of Medicine and Health Sciences When meditating over a disease, I never think of finding a remedy for it, but instead, a means of preventing it Louis Pasteur (1822-1895) The Aging Population and the Importance of Preventive Care By 2030, there will be 71 million adults > 65 years of age, will make up 20% of the U.S. population Health care spending is projected to increase by 25% because of this demographic shift alone. Increasing the use of clinical preventive services is a major healthcare priority Adult Immunization Rates -2012 U.S. Trends in Influenza and Pneumococcal Immunization Coverage In Adults > 65 yo 100 90 80 70 % of 60 Indicated 50 Group 40 Immunized 30 20 10 0 Percent Vaccinated 100 90 80 70 60 50 40 30 2010 Goal Pneumococcus Influenza Adults 18-64 20 10 0 CDC National Health Interview Survey CDC Behavioral Risk Factor Surveillance System 1
Barriers to Adult Immunization Complex adult vaccination schedule Lack of awareness of recommendations by patients and providers Many adults may not have regular healthcare providers Preventive care may not be priority, especially among specialists Missed Vaccination Opportunities in Adults with Invasive Pneumococcus Retrospective study 1,878 adults with IPD 1,177 had a vaccine indication and health care utilization in prior 2 years 52% (617/1,177) were unvaccinated 92% of unvaccinated cases (566/617) had at least 1 opportunity for vaccination Out of pocket costs for vaccines for many adults and many uninsured adults and few public health resources Nothing like a school mandate for adults 2013 Template and icons provided by The Advisory Board Company. Main Reasons Given for Non-Vaccination in Adults 18-64: NIS -2007 Main Reason Influenza Pneumococcus Tetanus Vaccine cost 4% 2% 1% Not needed 28% 19% 41% Did not know 4% 25% 10% Doctordid not recommend 7% 30% 17% Side-effects 21% 5% 1% Adult Immunization The Good News ACA expected to reduce the number of uninsured adults Efforts to enhance PH departments ability to bill for vaccines may increase opportunity for high risk uninsured 317 funds can be used to address lagging vaccine coverage, including uninsured adults Medicare and Medicaid now include adult immunization Copayments can be a significant cost for vaccines covered by Medicare Part D covered vaccines like Tdap and Zoster Increased access to vaccines at workplaces and retail locations like pharmacies and grocery stores 2
Recommended Vaccines for Adults Routinely Recommended Vaccines in Adults Influenza Virus Live-Attenuated Vaccines Influenza (intranasal) Measles, Mumps, Rubella Varicella Zoster Non-Replicating Vaccines Influenza(IM, ID) Hepatitis A Hepatitis B Human Papillomavirus (HPV) Meningococcal Pneumococcal PS (PPV-23) Pneumococcal Conjugate (PCV-13) Tetanus, diphtheria, pertussis (Td/Tdap) 3
Influenza Burden of Disease Readily spread by respiratory droplets and less often by contaminated surfaces Incubation period: 1-4 days Period of infectivity: 1 day prior to symptom onset up to 7 days after onset Asymptomatic carriers can spread infection Attack rates: 5-20% in the community, up to 50% in closed populations Increased risk: children < 2, adults > 65, chronic medical conditions, pregnancy 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Percent of Respondents Who Believed the Flu Vaccine Could Help Them Online Harris poll of 2,225 adults in October 2015 > 70 yrs old Baby Boomers GenX and Millenials 2013 Template and icons provided by The Advisory Board Company. Percent of Respondents Who Believed that Homeopathic Remedies Could Prevent the Flu 20% Online Harris poll of 2,225 adults in October 2015 15% 10% 5% 0% > 70 yrs old Baby Boomers GenX and Millenials 2013 Template and icons provided by The Advisory Board Company. Influenza In Perspective Indications for Influenza Vaccination # of US Deaths 40,000 30,000 20,000 10,000 0 * Entire epidemic Annual 775 1663 2331 Morbidity: > 200,000 Hospitalizations Per Year 14000 36000 All persons aged 6 mosand older annually Emphasis on those at highest risk of complications Age 6 mosto 4 yrs Age 50 yrsand older Chronic pulmonary, cardiac, renal, hepatic, neurologic, hematologic, or metabolic disease Immunosuppression Are or will be pregnant during season Age 6 mos 18 yrson chronic ASA NH residents AI / Alaskan native Morbidly obese Household contacts and caregivers of anyone with increased risk CDC 4
CDC s Review of Vaccine Efficacy Children s risk of PICU admission reduced by 74% during 2010 2012 flu season 71% reduction in flu-related hospitalizations among adults of all ages and 77% reduction in adults over 50 y.o. in 2011-2012 season Lower cardiac events in vaccinated adults with heart disease Reduced hospitalizations in people with diabetes (79%) and chronic lung disease (52%) Immunizing pregnant women reduced infant hospitalization for flu by 92% Influenza Immunization: What s New? Intradermal flu vaccine Available since 2011 Smaller needle, less antigen, similar efficacy Local injection site reactions more common Quadrivalent vaccine First available in the 2013-2014 season Adds a second strain of Influenza B to vaccine Not necessarily preferred over the trivalent vaccine High dose vaccine for elderly Options for egg allergy http://www.cdc.gov/flu/about/qa/vaccineeffect.htm Current Licensed Influenza Vaccines Abbreviation Description IIV3(was TIV) IIV3 High Dose Inactivated Influenza Vaccine, Trivalent High dose trivalent vaccine (for pts > 65) How Derived Trade Names Egg based Egg based Afluria, Fluarix, FluLaval, Fluvirin, Fluzone, FluzoneID, Fluzone HD cciiv3 Inactivatedtrivalent Cell based Flucelvax IIV4 Quadrivalentinactivated influenza vaccine Egg based FluLaval Fluzone Fluarix RIV3 RecombinantInfluenza Vaccine, trivalent Expressionvector FluBlok LAIV4 Live-attenuatedinfluenza vaccine, quadrivalent Egg based FluMist Towards a Universal Influenza Vaccine What about high dose influenza immunization for the Elderly? 5
Post-Vaccination GMTs with Standard Dose vs High Dose Influenza Vaccine 1 60 mcg of antigen per virus 15 mcg of antigen per virus Notes on RIV3 : - Uses recombinant technology, vaccine is completely egg, abx, and preservative free - 3-5 million doses available in 2013-2014 season. - Protein Sciences is working on a quadrivalentform for 2016 2017 season - Indicated for 18 49 y.o. Notes on cciiv3: - Grown in cell-culture. Licensed in 2012 - No abx or preservatives. Cannot be considered completely egg free, but much lower egg antigen and very low risk for allergic patients - Indicated for age 18 and older Ideal Time to be Vaccinated? Month of Peak Influenza Activity United States: 1976-2008 CDC 6
2013 Template and icons provided by The Advisory Board Company. 1/11/2016 Risk of Vaccine Failure as a Function of Time from Immunization Ideal Time to be Vaccinated? Say boo to the flu! Streptococcus pneumoniae (pneumococcus) CF Rate: 5-7% CF Rate: 20% CF Rate: 30% 7
Pneumococcal Vaccines 1977 1983 14-valent polysaccharide vaccine licensed 23-valent polysaccharide vaccine licensed (PPV23) PCV-7 Introduced PCV-7 Introduced 2000 7-valent polysaccharide conjugate vaccine licensed (PCV7) 2010 13-valent PCV licensed Pneumococcal Immunization in Adults Naïve healthy adult > 65 y.o PCV 13 > 12 mos PPSV23 Adult 19-64 in LTC, smoker, or chronic medical condition PPSV23 Adult > 65 y.o, prior PPSV23 after 65 PPSV23 > 12 mos PCV 13 Adult > 65 y.o, prior PPSV23 before 65 PPSV23 PCV 13 > 12 mos at 65 > 12 mos PPSV23 > 5 yrs Pneumococcal Immunization in Immunocompromised Adults 8
Pertussis Pertussis Vaccine Taxonomy DTP Old whole cell diphtheria, tetanus, and persussisvaccine for children. Available in 1940s, routine starting ~ 1950 DTaP Acellular pertussis. Licensed in 1991, used for all 5 shots in series starting 1997 Tdap Booster licensed in 2005 for adults and children over 10. Has reduced antigen levels for diphtheria and pertussis. Note: Upper case letter = higher antigen level Lower case letter = lower antigen level Pertussis: Why Immunize Adults? Adult whooping cough can cause coughing spells that affect breathing, eating, sleeping. The cough of 100 days Adults and siblings are the most common source of pertussis in infants Infants are at the greatest risk of serious complications 2010, 25 infants died Who: 1x booster for all adults age 19 and over (no qualifications for over 65) 1x booster for all HCPs, priority for those with direct contact with infants under 12 mos Pregnant women between 27-36 weeks and all household contacts, 1 Tdap during each pregnancy Booster can be given regardless of interval since previous Td dose, although shorter intervals may increase risk of local reactions Adult TdapUptake in United States -2012 % Immunized with Tdap 0 20 40 60 80 100 Overall Living w Infant Sanford Pregnant Women Cocooning 9
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Age Adjusted Incidence Ratio for Stroke and MI After Shingles Episode Why We Immunize 2.6 2.4 2.2 Incidence Ratio 2 1.8 1.6 1.4 * P < 0.05 Nick, lost his arms and legs from meningococcal meningitis Jesse, died at age 9 from chickenpox Barry, a veteran fire-fighter, died at age 44 from influenza 1.2 1 1 wk* 2-4 wks* 5-12 wks* 13-26 wks 27-52 wks Kristen, died at age 23 from cervical cancer Ischemic Stroke MI Alana, died at age 5 ½ yrs from influenza Amanda, died at age 4 ½ yrs from influenza Lore, died at age 3 mos from whooping cough Minassian. PLOS 2015. http://shotbyshot.org/story-gallery/ 2013 Template and icons provided by The Advisory Board Company. 2013 Template and icons provided by The Advisory Board Company. 11