Transcript No Slide Title

Adult Immunization
Original by Dr. Ari Robicsek
Updated by T.Cook 21 Mar 2003
Objectives
To know which vaccines to recommend to
which patients
To know why
Sources
Canadian Immunization Guide, 6th ed
Health Canada Weblink
CDC National Immunization Program Weblink
Up To Date, vaccine manufacturer websites
Some thoughts:
When was the last time you asked a
patient about their immunization
record?
Prevention of disease should be the
domain of specialists as well as primary
care physicians.
Vaccine Regimens
Pediatric (not discussed)
Adult
Traveler (future seminar)
Recommended Adult Immunization
Schedule United States, 2002-2003
and
Recommended Immunizations for Adults
with Medical Conditions
Summary of Recommendations Published by
The Advisory Committee on
Immunization Practices
Department of Health and Human Services
Centers for Disease Control and Prevention
Based on the Recommendations of the Advisory Committee on Immunization Practices, Centers for Disease Control and
Prevention
Recommended Adult Immunization Schedule, United States, 2002-2003
For all persons in
this
age group
Age
Vaccine
Catch-up on
childhood vaccinations
19-49 years
For persons with
medical / exposure
indications
50-64 years
Tetanus,
Diphtheria (Td)*
Recommended Immunizations for Adults with Medical Conditions, United States,
2002-2003
For all persons in
this group
Catch-up on
childhood vaccinations
Vaccine
65 years and older
Medical
Conditions
1 dose booster every 10 years1
Pregnancy
Influenza
Pneumococcal
(polysaccharide)
1 dose annually for persons
with medical or occupational
indications, or household contacts
of persons with indications 2
1 annual dose
1 dose for persons with medical or other indications. (1 dose
revaccination for immunosuppressive conditions) 3,4
1 dose for unvaccinated persons 3
1 dose revaccination
4
Hepatitis B*
3 doses (0, 1-2, 4-6 months) for persons with medical, behavioral, occupational, or other indications 5
Hepatitis A
2 doses (0, 6-12 months) for persons with medical, behavioral, occupational, or other indications 6
Measles, Mumps,
Rubella (MMR)*
Varicella*
Meningococcal
(polysaccharide)
1 dose if measles, mumps, or
rubella vaccination history is
unreliable;
2 doses for persons with
occupational, geographic,
or other indications 7
2 doses (0, 4-8 weeks) for persons who are
susceptible8
1 dose for persons with medical or other indications 9
See Footnotes for Recommended Adult Immunization Schedule on the back cover.
*Covered by the Vaccine Injury Compensation Program. For information on how to file a claim call 1-800-338-2382. Please also visit http://www.hrsa.osp.gov/vicp
accessed February 21, 2002. To file a claim for vaccine injury write: U.S. Court of Federal Claims, 717 Madison Place, N.W., Washington D.C. 20005. (202) 219-9657.
This schedule indicates the recommended age groups for routine administration of currently licensed vaccines for persons 19 years of age and older. Licensed combination
vaccines may be used whenever any components of the combination are indicated and the vaccine’s other components are not contraindicated. Providers should consult the
manufacturers' package inserts for detailed recommendations.
Report all clinically significant post-vaccination reactions to the Vaccine Adverse Event Reporting System (VAERS). Reporting forms and instructions on filing a VAERS report
are available by calling 1-800-822-7967 or from the VAERS website at http://www.vaers.org.
For additional information about the vaccines listed above and contraindications for immunization, visit the National Immunization Program Website at http://www.cdc.gov/nip/
or call the National Immunization Hotline at 800-232-2522 (English) or 800-232-0233 (Spanish).
Approved by the Advisory Committee on Immunization Practices (ACIP), and accepted by the American College
of Obstetricians and Gynecologists (ACOG) and the American Academy of Family Physicians (AAFP)
Diabetes, heart disease,
chronic pulmonary
disease, chronic liver
disease, including chronic
alcoholism
For persons with
medical / exposure indications
Tetanus- Influenza Pneumo- Hepatitis
coccal
Diphtheria
B*
(poly(Td)*
saccharide)
Hepatitis Measles
Mumps
A
Rubella
(MMR)*
Varicella
*
A
B
Congenital
immunodeficiency, leukemia,
lymphoma, generalized
malignancy, therapy with
alkylating agents,
antimetabolites, radiation
or large amounts
of corticosteroids
C
E
Asplenia including elective
splenectomy and
terminal complement
component deficiencies
E, H, I
HIV infection
A. If pregnancy is at 2nd or 3rd trimester during influenza season.
B. Although chronic liver disease and alcoholism are not indicator
conditions for influenza vaccination, give 1 dose annually if the patient is
> 50 years, has other indications for influenza vaccine, or if the patient
requests vaccination.
C. Asthma is an indicator condition for influenza but not for pneumococcal
vaccination.
D. For all persons with chronic liver disease.
E. Revaccinate once after 5 years or more have elapsed since initial
vaccination.
F. Persons with impaired humoral but not cellular immunity may be
vaccinated. MMWR 1999; 48 (RR-06): 1-5.
D
E
Renal failure / end stage
renal disease, recipients of
hemodialysis or clotting
factor concentrates
*Covered by the Vaccine Injury Compensation
Program.
Contraindicated
E, J
F
G
K
G. Hemodialysis patients: Use special formulation of vaccine (40 ug/mL)
or two 1.0 mL 20 ug doses given at one site. Vaccinate early in the
course of renal disease. Assess antibody titers to hep B surface
antigen (anti-HBs) levels annually. Administer additional doses if antiHBs levels decline to <10 milliinternational units (mlU)/ mL.
H. Also administer meningococcal vaccine.
I. Elective splenectomy: vaccinate at least 2 weeks before surgery.
J. Vaccinate as close to diagnosis as possible when CD4 cell counts are
highest.
K. Withhold MMR or other measles containing vaccines from HIV-infected
persons with evidence of severe immunosuppression. MMWR 1996; 45:
603-606,
MMWR 1992; 41 (RR-17): 1-19.
Immunization Guidelines
Immunization services should be readily
available.
There should be no barriers or unnecessary
prerequisites to the receipt of vaccines.
Providers should use all clinical encounters to
screen for needed vaccines and, when
indicated, vaccinate
Providers should educate in general terms
about immunization.
Guidelines Cont’d
Providers should:
inform in specific terms about the risks /
benefits of vaccines they are to receive.
recommend deferral or with- holding of
vaccines for true contraindications only
administer all vaccine doses for which a
patient is eligible at the time of each visit.
ensure that all vaccinations are accurately
and completely recorded.
maintain easily retrievable summaries of the
vaccination records to facilitate ageappropriate vaccination.
Providers should
report clinically significant adverse events
following vaccination promptly, accurately,
and completely
report all cases of vaccine-preventable
diseases as required under provincial /
territorial legislation.
adhere to appropriate procedures for vaccine
management.
maintain up-to-date, easily retrievable
protocols at all locations where vaccines are
administered.
maintain ongoing education regarding
ISSUES WITH SPECIFIC VACCINES
Td
MMR
Pneumococcal
Influenza
Hepatitis B
Tetanus/Diphtheria
Bacterial diseases with high mortality,
both entirely vaccine preventable
“Td” is a toxoid vaccine (bacterial toxins
adsorbed to aluminum)
primary vaccination done early in life
adverse effects minimal in adults
Tetanus/Diphtheria
How often should Td be administered?
If primary vaccination has been done, including the booster
at age 14-16, there are two acceptable approaches:
1. Booster at ten-year intervals.
2. Just one booster at age 50 if not done in 40’s.
Note: Vaccinate after a dirty wound if last vaccination was more
than five years earlier.
MMR
Serious complications of



Measles: Pneumonia, meningoencephalitis, SSPE
Mumps: Meningitis/other CNS disease, sterility
Rubella: Congenital rubella
Resurgence of measles in U.S. in late ‘80’s;
seems that 5-20% of people don’t respond to
intial vaccination in childhood
New recommendations are for two-time MMR
to protect against measles
MMR
Which adults should get MMR?

Any who are not immune:
 Born after 1970 AND no documentation of immunization
(or infection) either by paper evidence or serology

Most importantly:
 women of childbearing years
 health care workers
 college students
 travellers to epidemic areas
MMR
Post exposure prophylaxis:
 vaccination post-exposure protects against
measles if given within 72 hours
 not protective against mumps or rubella
Safe in pregnancy?
 Probably, but we don’t use it
 if a woman is found to be serologically negative in
pregnancy, we immunize after delivery before she
leaves hospital
MMR
Contraindications:
 egg anaphylaxis is NOT a contraindication even
though measles grown in eggs
 neomycin allergy IS a contraindication
 HIV is NOT a contraindication unless very
immunosuppressed
Adverse Effects:
 rubella component causes arthralgia in > 40% of
women; some even have arthritis; this happens 13 weeks post vaccination
Streptococcus pneumoniae
Risk of invasive pneumococcal infections
increases with age



7/100,000 in young adults
61/100,000 in adults 65 or older; 3x increased
mortality for pneumococcal pneumonia compared
to young adults
46 times higher than controls in HIV patients in
pre-HAART era
other RF’s for pneumococcal pneumonia are
haem CA, EtOH, smoking, Black/First Nations,
asplenia
Streptococcus pneumoniae
First pneumococcal vaccine tested pre Great War;
vaccine to polysaccharide capsular antigens
introduced in 1945 but widely ignored due to high
Abx efficacy
now ~10% of clinical isolates Canada-wide have
some PEN-resistance (which correlates with otherAbx resistance)
polyvalent (= made up of antigens from multiple
strains) capsular-polysaccharide based vaccine first
championed in 70’s by MD who found high protective
efficacy vs. pneumococcal pneumonia in South
African miners
Since then, efficacy has been a lot harder to
demonstrate
Streptococcus pneumoniae
Does the polyvalent polysaccharide
pneumococcal vaccine “work’?
Yes and No
Streptococcus pneumoniae
Vaccine has NOT been shown to consistently reduce rate of
pneumococcal pneumonia in anyone. Studies have been
hampered by poor ability to discriminate between
pneumococcal and non-pneumococcal pneumonia.
RCT’s have not had enough power to assess efficacy against
bacteremia or meningitis.
Evidence of reduction in invasive disease DOES exist;
- meta-analysis of 9 RCT’s found reduction of bacteremic
pneumonia in low-risk groups (perhaps ~80%)
- case control studies have shown 75% effectiveness vs.
invasive disease in the elderly, and benefit in DM, asplenia,
chronic lung disease
Streptococcus pneumoniae
Evidence is more controversial in HIV
very questionable benefit -- even
possibility of harm -- if CD4 < 200
Streptococcus pneumoniae
Standard of Care
Pneumovax 23, Pneumo 23 and Pnu-Immune
23 are available vaccines with approval for
adult use
all have antigens from the 23 pneumococcal
strains which account for 90% of bacteremia
and meningitis
don’t use in kids < 2 because it doesn’t work
Streptococcus pneumoniae
Standard of Care
Which people  65 should get the
vaccine?
Everyone
Which people < 65 should get the
vaccine?
Patients with:
- questionable splenic function
- chronic disease of heart, liver, kidneys,
lungs (not asthma)
- alcoholism, DM
- immunosuppression, including HIV
Streptococcus pneumoniae
Standard of Care
When do you revaccinate?
We don’t know.
May be a good idea to revaccinate ONE time,
five years post initial vaccination, in
- patients over 65 who were vaccinated
before they were 65
- patients with immunocompromise or
other high risk
Streptococcus pneumoniae
Adverse effects:


about 1/3 have local pain and swelling
systemic reactions are rare
Can you give the flu vaccine at the
same time?
Sure. Just use a different spot.
Hepatitis B
Vaccines highly effective
Most of the world is still using vaccines
derived from plasma of HBV carriers
We use HBV S Antigen particles grown in
recombinant yeast; our vaccinees will be
HBSAb positive but HBCAb negative
attempts at only vaccinating “high-risk”
individuals were failures; we have now
instituted universal vaccination for kids
Hepatitis B
rate of seroconversion is 95% in healthy
adults
progressively less with age; <50%
seroconversion in sixth decade
also lower in patients with chronic disease
rate of seropositivity decays with time, but as
long as an antibody response was elicited
initially, protection is likely still good for at
least 15 years
Hepatitis B
Who gets vaccinated?
All Canadian kids at age 9-13; (neonates born to carriers are
vaccinated and treated with HBIG at birth.)
Adults who are:
- health care workers
- engaging in high-risk sexual activity or IVDU
- household contacts of HBV patients
- on chronic hemodialysis
- getting repeated transfusions
Hepatitis B
Adverse Effects:




local stuff
1-3% have low-grade fever, myalgia,
arthralgia, etc.
despite some claims, no evidence of a link
to multiple sclerosis
SAFE in pregnancy
Hepatitis B
Vaccine administered as three doses, at
months 0, 1 and 6
usually given IM, but intradermal injection of
a higher-than-usual dose may increase
response rate in immunocompromised
patients
routine post-vaccination seroconversion
testing only if at high risk; if negative
revaccinate and retest (50% chance of
working the second time)
HIV
Pnemococcal vaccination if CD4 > 200

ONE revaccination at five years
Flu yearly
HBV for all; HAV if concurrent HBV or
HCV infection
Meningococcal vaccine if asplenic,
travelling, living in dorms
Asplenia
Pneumococcal vaccination
 2 weeks pre elective splenectomy
 2 weeks post emergency splenectomy (Ab’s work
better in patients whose vaccination is slightly
delayed post-op)
 revaccination at five years
HIB vaccine
 most adults have antibodies, but we give it
anyway
Meningococcal vaccine
Flu yearly
Health Care Workers
Same as everyone else (Td) PLUS:




HVB (with titer check 1-2 months after
third dose)
Flu
MMR: immune status should be checked
(documents or titers) for measles in all,
rubella in women
vaccines relating to special exposures (eg:
BCG, typhoid, Hep A)
Bottom Line
In our regular practice, we should be at
least considering pneumococcal and
influenza vaccination status of our
outpatients and inpatients
everyone over 65 should have both
sick people should have both
no flu if egg anaphylaxis