Transcript Slide 1

Vaccines are for adults too..and what’s new!
Dr. Taj Jadavji
Professor, Departments of Microbiology,
Immunology & Infectious Diseases and
Paediatrics
Faculty of Medicine
University of Calgary
Infectious Disease Consultant – Alberta Health Services
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Vaccines are for adults too..and what’s new!
Disclosure:
1.
Have received Honoraria from:
- Glaxo Smith Kline
- MSD
- Abbott
- Sanofi Pasteur
- Novartis
- Roche
- Pfizer
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10 Great Public Health Achievements –
Industrialized Countries
•
•
•
•
Vaccination
• Safer and healthier
foods
Motor-vehicle safety
• Healthier
mothers and
Safer
Inworkplaces
the last 50 years
Immunization
babies
Control
of infectious
has
saved more lives
than any
• Family planning
diseases other health intervention
• Decline in deaths from • Fluoridation of
drinking water
coronary heart
disease and stroke
• Recognition of
tobacco as a health
hazard
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US Dept of Health and Human Service, MMWR 1999;48:241
Vaccines are for adults too!
In the United States why do
a 100 fold more adults die of
vaccine-preventable
diseases than do children?
From Reid KC, Grizzard TA, Poland GA.
4 Mayo Clin Proc. 1999;74:377–384
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Vaccines & Older Adults
Immunosenescence is one of
the main reasons for the increase
in infections in the older adult.2
Although childhood vaccines
usually prevent clinical illness…..
Most adult vaccines do not
prevent illness but lessen the
severity of infection.2
1.
2.
Fulop, T, and Gemmill, I, Clinical update on adult immunization.
2007
Aw, D., et al, Immunosenescence: emerging challenges for an
5 Immunology 2007. 120, 435–446.
ageing population.
May 2014
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HPV
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The Annual Burden of HPV in
Canada
~510 deaths from cervical, vulvar and
vaginal cancers6
~1835 newly diagnosed cases of
cervical, vulvar and vaginal cancers2,3
77,000 newly diagnosed cases of
genital warts, VIN VAIN 4,5
>325,000 abnormal Pap tests1
>4 million Pap tests 1
1. Akom E, Venne S. November 2002. 2. Statistics Canada. Table 103-0513. CANSIM [Canadian Cancer Registry].
3. Canadian Cancer Society / National Cancer Institute. Canadian Cancer Statistics 2005:88-9. 4. BC Cancer Agency,
2006. 5. Statistics Canada. Accessed at http://www.40.statcan.ca/101/cst01/demo02.htm.
6. Statistics Canada. Table
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102-0522. CANSIM [Vital Statistics – Death Database].
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70%
Cancer Causes Control (2012) 23:1343–1348
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NACI Recommendations
CCDR 2007 Feb vol 33
Vaccine recommended to:
• 9-13 yr olds primary program
• 14 yrs-26 yrs. catch
• permissive use > 26yrs.
• Including those with cervical
abnormalities and genital warts
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Mid-Adult Women Are At Continued Risk
for Acquiring HPV Infection/Disease
Incidence of New Genital Warts in Women by Age in US
Rate of New Genital Warts
per 1000 Person-Years
7
6
5
4
3
2
1
0
<10
10-14
15-19
Insinga RP. Clin Inf Dis. 2003;36:1397-1403.
20-24
24-29
30-34
Age (years)
11
35-39
40-44
45-49
50+
Primary Efficacy Results
Combined Incidence of HPV 6/11/16/18-Related Persistent Infection or
Cervical/Vulvar/Vaginal Disease – Per Protocol Efficacy Population
Population
Vaccine
Placebo
%
95% CI P-value
Reduction
Cases
PYR
Cases
PYR
4
2,721
41
2,654
91%
74, 98
<0.001
24 to 34
Year-Olds
2
1,329
24
1,301
92%
67, 99
<0.001
35 to 45
Year-Olds
2
1,393
17
1,353
89%
52, 99
<0.001
All
Subjects
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PYR = person years at risk; CI = confidence interval.
Luna, IPV Nov 2009
Reduction in any Cervical
Procedure due to any Causal HPV
type
18,150 16-26 yr olds, RPCT x 3yrs
↓42%
↓22%
↓19%
Colposcopy
Cases Placebo
Cases Vaccine
1077
869
Cervical Biopsy
950
741
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Definitive therapy
230
132
NACI recommendations on HPV
vaccine in males Jan 2012
1. HPV4 (Gardasil) recommended in males 9 -26 years
of age for the prevention of anal ,penile, perineal
intraepithelial neoplasia ,cancers and anogenital warts
2. HPV4 (Gardasil) recommended in males who have
sex with males (MSM) ≥9 years of age
3. HPV2 (Cervarix) not recommended in males at this
time (NACI Recommendation Grade I).
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Australia
Free 12-18 yrs &< 26yr
2007-2009
Sex.Trans.infect 2011
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Sex.Trans.infect
2011
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5
Take home points
• HPV is on rise at both ends of the
GI track
• For cancer protection we have 2
excellent anti-cancer vaccines that
are not comparable
1 word summary:immunize!
• Gardasil only vaccine that
prevents genital warts.
• ‘Best vaccine’ is the one that a
patient takes!
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Influenza
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N Engl J Med 2008;359.
340  3rd trimester RDBPC influenza vs
23 valent pneumococcal vaccine
63% reduction of influenza in infants
for up to 6 months and 36% reduction of febrile respiratory illnesses in mothers
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Seasonal influenza mortality UK
2001-2009
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Vaccine 2013 xxx-xxx
•
282 participants; most in long-term care & >85 yrs ;open label ;
pcr confirmation of influenza
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Fluad and TIV vaccine; each given in a different district in BC
•
Results: - Fluad 60% effective
- TIV not effective
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2
0
Clinical Infect Dis 2012 55:951
Case control study 2010-11 season
your vs
parents
and grandparents is less likely to protect them than
N=Immunizing
1040 influenza
3700 controls
immunizing yourself
DO BOTH!
Efficacy: 69 % 6m-8yrs
51 % 9-64yrs
38 % >65 yrs
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21
2
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Take home points
• Influenza vaccine , especially for high risk
groups including pregnant women, babies
and bubies
• 3 new vaccines: intranasal (live) ,intradermal
(killed) & adjuvented
• new vaccines for elderly are here; they are
more immunogenic but are they more
effective than TIV?
• influenza vaccine may prevent MI
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Pneumococcus
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Major Clinical Forms of Pneumococcal Disease
Pneumococcal
Disease
Noninvasive
(Mucosal)
Invasive
Meningitis
Bacteremia
Pneumonia
Acute
Otitis Media
Sinusitis
• Pneumococcal disease can be broadly grouped into categories of invasive disease and
noninvasive (also termed mucosal) disease1
• Noninvasive forms of disease may become invasive
(eg, pneumonia when accompanied by bacteremia)2
• Serotype is associated with disease severity and invasiveness3
1. WHO. Acute Respiratory Infections (Update September 2009).
www.who.int/vaccine_research/diseases/ari/en/print.html. Accessed December 20, 2010.
2. CDC. Epidemiology and prevention of vaccine-preventable diseases. 11th ed. 2009;217-230.
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3. Jansen AG et al. Clin Infect Dis. 2009;49:e23-e29.
S. pneumoniae disproportionately affects those at
the extremes of age
Cases of IPD/100,000
Incidence of IPD and Associated Mortality Rates (USA, 2010)
Age (years)
IPD = invasive pneumococcal disease, and includes meningitis, bacteremia, and pneumonia when accompanied by bacteremia.
Centers for Disease Control and Prevention. 2012. Active Bacterial Core surveillance Report,
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Emerging Infections Program Network, Streptococcus pneumoniae, 2010.
IPD rate per 100,000
Incidence rate (per 100,000) of invasive pneumococcal
disease by age group, Canada, 2011
An Advisory Committee Statement (ACS) National Advisory Committee on Immunization (NACI)
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Statement on the Use of Conjugate Pneumococcal Vaccine – 13 valent in Adults (Pneu-C-13), April 4th, 2013
Reported number of cases and incidence rate of invasive
pneumococcal disease, Canada, 2001-2011
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Canadian Notifiable Disease Surveillance System
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Risk Factors for Invasive Pneumococcal Disease (IPD)
Host Factors
Age
≥ 65
years
*
Immunocompetent
Immunocompromised
Chronic heart disease
Chronic lung disease *
Diabetes mellitus
Chronic liver disease
Cerebrospinal fluid
leaks
• Asthma
• HIV (Human
Immunodeficiency Virus)
infection
• Chronic renal failure,
nephrotic syndrome
• Cancer (solid,
hematologic)
• Solid organ transplantation
• Autoimmune diseases
• Immunosuppressive
therapy, corticosteroids
• Primary
immunodeficiencies
• Functional or anatomic
asplenia
•
•
•
•
•
External
Factors
Socioeconomic
Environmental
•Preceding viral
respiratory
infection
(e.g., influenza)
•Residence in
an institution (eg,
nursing home)
Including chronic obstructive pulmonary disease, emphysema, and asthma.
1.
2.
3.
4.
CDC. Morb Mortal Wkly Rep. 2010;59(34):1102-1106.
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Rahier JF et al. Rheumatology (Oxford). 2010;49(10):1815-1827.
CDC. Prevention of Pneumococcal Infections Secondary to Seasonal and 2009 H1N1 Influenza Viruses Infection. 2009.
CDC. Morb Mortal Wkly Rep. 2001;50(33):707-710.
Behavioral
Factors
• Smoking
• Alcohol
abuse
Current vaccine options
Two types of pneumococcal vaccines
licensed for adults in Canada
(3 products)
Type
Description
Options
Serotypes
Pneumococcal
polysaccharide
vaccines
Polysaccharide
antigens
PPSV23
Polysaccharide
antigens joined
to a protein
(conjugated)
PCV13*
23®
Pneumo
,
®
Pneumovax 23
Antigens of 23 pneumococcal serotypes:
1, 3, 4, 5, 6B, 7F, 9V, 14, 18C, 19A, 19F, 23F,
2, 8, 9N, 10A, 11A, 12F, 15B, 17F, 20, 22F, 33F
(PPSV)
Pneumococcal
conjugate
vaccine (PCV)
Prevnar 13®
Antigens of 13 pneumococcal serotypes:
1, 3, 4, 5, 6B, 7F, 9V, 14, 18C, 19A, 19F, 23F,
6A**
The two types of vaccine contain 12 serotypes in common
* PCV13 replaced the previous version of PCV, known as PCV7, which included 7 pneumococcal serotypes.
** 6A serotype is unique to PCV13
Lang Kau, Cheryl A. Sadowski, Christine Hughes. Vaccinations in older adults: Focus on pneumococcal, influenza
and herpes zoster infections. Canadian Pharmacists Journal.
292011, 144(3):132-141.
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NACI Recommendations:
PPSV23 for High Risk Individuals
≥ 2 yrs of age with co-morbidities:
Immuno-competent
•
•
•
•
•
•
•
Immuno-compromised
Plus: ≥ 18 yrs
≥ 65 yrs
With these factors
All persons
• Functional or anatomic
• Residents of long
asplenia, sickle cell,
term care
hemoglobinopathies
facilities
• HIV infection
• Homelessness,
• Immune deficiencies
alcoholism,
• Immune suppression due
smokers, illicit
to disease or treatment
drug use
• Hematopoietic stem cell • asthma
transplant (recipient)
(if associated
• Solid organ or islet
with COPD,
transplant
emphysema or
• Malignant neoplasms,
prolonged
including leukemia and
systemic
Including chronic obstructive pulmonary disease, emphysema, and asthma.
lymphoma
corticosteroid)
• Chronic renal disease
Chronic heart disease
Chronic lung disease
Diabetes mellitus
Chronic liver disease
Cerebrospinal fluid leaks
Cochlear implants
Chronic neurologic
condition that may
impair clearance of oral
secretions
•
1. National Advisory Committee on Immunization (NACI).
30Canadian Immunization Guide, Public Health Agency of
Canada, 2012. Accessed Feb 2, 2013 at http://www.phac-aspc.gc.ca/publicat/cig-gci/p04-pneu-eng.php#ru
PCV13 vaccine for adults: Current status
 In Canada, PCV13 was approved in January 2012 1
• indicated for active immunization for the prevention of
invasive pneumococcal disease (sepsis, meningitis,
bacteraemic pneumonia, pleural empyema and bacteraemia),
• in adults 50 years of age and older,
• caused by Streptococcus pneumoniae serotypes
1, 3, 4, 5, 6A, 6B, 7F, 9V, 14, 18C, 19A, 19F and 23F. 1
 In Jan 2014 the indication was expanded to include2
• Children, Adolescents and Adults.
1. Pneumococcal 3-valent Conjugate Vaccine (Diphtheria CRM197 Protein) Product Monograph. Pfizer Canada, Jan
2012
2. Health Canada. Notice of Compliance. Accessed July 10, 2013 at http://webprod5.hc-sc.gc.ca/nocac/info.do?no=14512&lang=eng
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Always give PCV13 before polysaccharide 23;
follow with polysaccharide 2 mo-2 yrs later
Non-naive: wait 1 year before PCV13
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3
2
Oct 2012
“for adults >18 with
immunocompromising
conditions...PCV13 should be
administered in addition to PPSV23”
(off label <50yrs.)
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ACIP Feb .12
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3
4
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Varicella
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Shingles risk factors
Advancing age:
- Decreased CMI with age
Immunosuppression:
- HIV-AIDS
- Organ transplants
- Malignancy
- Immunosuppressive therapy
- autoimmune rheumatic diseases
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Shingles: Canadian
epidemiology
30% lifetime risk
*
15% of cases
Post-herpetic
neuralgia (PHN) of whom 70%
*
have moderate to severe pain
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*
Brisson M. CIC 2004
33%
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Frequency of PHN (> 3mo) and
duration of Pain Increase With Age
Percent of patients
reporting pain
100
80
>1 yr
6 - 12 mo
1 - 6 mo
<1 mo
15
30
40
60
40
20
0
0-19 20-29 30-39 40-49 50-59 60-69 ≥79
Age (years)
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Kost R et al. N Engl J Med. 1996;355:32-42.
Treatment of Herpes Zoster
Antivirals(given early):
- modestly shortens the rash
- do NOT prevent PHN
Once zoster develops treatment
does not prevent PHN
Corticosteroids:
- decreases severity of acute pain
- do NOT prevent PHN
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The Shingles Prevention Study
Vaccine Efficacy: HZ Incidence by age
Efficacy 51.3%
63.9%
Incidence of HZ
14
37.6%
Vaccine
Placebo
12
10
8
6
*
4
2
0
All
60-69 yr
 70 yr
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*P <0.001
Adapted from Oxman M et al. N Engl J Med. 2005;352:2271-2284.
The Shingles Prevention Study
Vaccine Efficacy: PHN Incidence
Incidence of PHN
Efficacy
66.5%
2.5
65.7%
66.8%
Vaccine
Placebo
2.0
1.5
1.0
0.5
*
0.0
All Subjects
60-69 yr
 70 yr
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*P <0.001
Adapted from Oxman M et al. N Engl J Med. 2005;352:2271-2284.
The Shingles Prevention Study
Vaccine Efficacy: Severity/duration
Illness
Efficacy 61.1%
65.5%
55.4%
HZ burden of illness
9
8
Vaccine
Placebo
7
6
5
4
3
*
2
1
0
*P <0.001
All
60-69
yr
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 70 yr
Adapted from Oxman M et al. N Engl J Med. 2005;352:2271-2284.
Clinical Infectious Diseases 2012;55(10):1320
N= 38,500 SPS vs.14,000 STPS over 7 years
Comparison SPS vs STPS
SPS (2.5 y) STPS (7y)
HZ
51%
40%
PHN
66%
60% N/S
PHN BOI 61%
50%
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Contraindications
Who can I give Zostavax to?
lymphoproliferative disorders : NO
YES
Solid tumour cancers :
MAYBE
immunosuppressants:
NO
immune modulators :
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NACI January 2014
• Herpes zoster vaccine is recommended for the prevention
of herpes zoster and its complications in persons 60 years
and older
• Herpes zoster vaccine may be used in patients aged 50 to
59 years
• Herpes zoster vaccine may be administered to individuals ≥
50 years old with a prior history of herpes zoster
• Herpes zoster vaccine can be administered concomitantly
with pneumococcal vaccine
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7
Take home points
• Shingles is increasing and is a BAD
disease esp in older population
• PHN lasts for months to years
• Zostavax provides at least 50%
protection against infection, incidence
and severity of PHN.
• mild immunosuppression not C/I
• Now approved >50 yrs. of age esp. prior
to immunosuppression
• Recommended over 60 yrs.
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Pertussis
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Vaccine efficacy decreased by 42% each year after 5 years
N Engl J Med 2012;367:1012-9.
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5
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Clinical Infectious Diseases 2004; 39:1581–2
Approximately 13%–20% of prolonged
cough illnesses in adolescents and adults
are due to B. pertussis infection
Average duration= 8-12 weeks
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Ped Infect Dis J.2004;23:985-9
Pertussis in 616 infants in 4 US states:
mothers 32%
family 43%
75% household contacts
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5
2
“administer a dose of Tdap in the
3rd trimester of each pregnancy
irrespective of the patient’s prior
history of receiving Tdap”
53
53
5
3
Potential new parents and their
families should
receive one dose of TdaP
54
Take home points
• Pertussis is on the rise
• Every adult needs one Tdap
anytime
• Should your target group for Tdap
be parents and families of infants
or infants-to-be?
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5
5
Immunize children to
prevent illness
Immunize adults
to prevent severe
illness and death
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6
Conclusion
• All who deal with immunzation have
the responsibility to be
knowledgeable about
immunizations, to be aware of their
benefits and risks, and to be able to
advocate effectively and clearly for
their appropriate use.
• COMPLACENCY IN THIS MATTER
WILL BE DETRIMENTAL TO OUR
SOCIETY
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THANK YOU
ANY QUESTIONS?
[email protected]
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