Transcript What’s new with vaccines - University of Wisconsin–Madison

Avoiding Missed Opportunities
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Elaine Rosenblatt NP
Clinical Professor
UW WI-Madison
November 8, 2006
Objectives
• Understand the indications for the new
vaccines available for adults
• Learn how to appropriately administer the
new vaccines
• Identify the controversies surrounding some
of the new vaccines
• No financial disclosures
Cases
• 1. College woman
born in 1982 who
comes to your clinic
for an employment
physical exam. She
will be working in a
health care facility.
You need to assess for:
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__Td/Tdap
__Hepatitis B
__HPV
__Influenza
__Measles
__Meningococcal
__Mumps
__Pneumococcal
__Rubella
__Varicella
__Zoster
Cases
• 1. 65 yo man with no
history of shingles in
your office for a health
assessment. You need
to assess for:
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__Td/Tdap
__Hepatitis B
__HPV
__Influenza
__Measles
__Meningococcal
__Mumps
__Pneumococcal
__Rubella
__Varicella
__Zoster
Cases
• 1. 70 yo with a history
of herpetic neuralgia.
Establishing care with
you. Reports an
allergy to eggs. You
need to assess for:
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__Td/Tdap
__Hepatitis B
__HPV
__Influenza
__Measles
__Meningococcal
__Mumps
__Pneumococcal
__Rubella
__Varicella
__Zoster
Tetanus, Diphtheria and Acellular
Pertussis Vaccine (Tdap)
• Main focus: adolescents ages 11-12
• Adult version approved for ages 11-64
• A one time booster or can be used one time
in a primary series
• Preferably 5 years (minimum 2 years) since
last booster
• Side effects: similar to Td
INFLUENZA: Recommendations
• 50 years of age and older
• Chronic diseases (pulmonary, cardiac, DM,
immune problems, cancer, renal, blood disorders)
• Pregnancy: all trimesters
• Health care workers
• Caretakers of the elderly/frail
• Children ages 6-59 months and close contacts
Influenza recommendations cont.
• Those living in chronic care facilities
• Anyone with a condition that can
compromise respiratory function, the
handling of secretions or increased risk for
aspiration
• Those wishing to reduce likelihood of illness
• Best to give between October and November
but can give during the influenza season
(typically December through March)
Influenza—Nasal Spray
FluMist
• Approved June 17, 2003 by FDA
• Live attenuated vaccine for influenza A and
B viruses
• For healthy children and adults age 5-49
years
• 87% efficacy in reducing influenza among
children in study
• In healthy adults it was effective in reducing
severe illness with fever and URI problems
which may be caused by influenza
FluMist, continued
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Can start to give in August
Keep in freezer, thaw just before using
Kids up to age 9 need 2 doses
No needles
Increased cost—about $10.00 more per dose than
inactivated vaccine
• HMO’s not covering at this time as injection is a
good and more cost effective alternative that
covers a larger population
FluMist, continued
• Do not give to patients who are
immunosuppressed or in contact with
• Safety in patients with moderate to severe
asthma and other reactive airway diseases has
not been established
• Do not administer to patients with therapies
including aspirin, a history of Guillain-Barre
syndrome, chronic diseases, allergies to eggs
or those who are pregnant.
• Most common adverse events: nasal
congestion, runny nose, sore throat, cough.
Meningococcal Vaccine
• For international travel to endemic areas, damaged
spleen or asplenia, terminal complement component
deficiency, and college students (especially freshmen
who live in dorms)
• WisAct 61 2003 “Requiring college students be
informed about meningococcal disease and hepatitis
B and to require colleges to maintain certain records
about the vaccination of students”
• Advise students to seek health care after potential
exposures, whether vaccinated or not
Meningococcal Meningitis Vaccine
• Highly efficacious and well tolerated. The new
conjugated vaccine has longer immunity
• Effective 10 days after vaccination
• Menomune: polysaccharide: age 2 and older
• .5 ml SC in arm. Booster dose at 3-5 years
• Good for 35 days once reconstituted
• Menactra (MCV4): conjugated: preferred
vaccine ages 11-55
• .5 ml IM in deltoid. Booster not yet determined
Controversies with Conjugated
Vaccine (Menactra)
• Shortage in 2006
• Guillain-Barre Syndrome
– As of September 2006 seventeen cases
– Remains unclear if this is rate is higher than in
adolescent population
– CDC and AAP continue to recommend routine
vaccination of at risk populations with conjugated
vaccine
– Contraindicated if history of GBS
– Additional information cdc.gov or
http://aapredbook.aappublications.org/news
Quadrivalent Human Papillomavirus
Vaccine: Gardasil
Prevention of:
– Cervical cancer, genital warts, and the
precancerous lesions, cervical adenocarcinoma in
situ, cervical intraepithelial neoplasia (CIN)
grades 1, 2 and 3
– Vulvar intraepithelial neoplasia grades 2
and 3
– Vaginal intraepithelial neoplasia grades 2 and 3.
HPV
• Of the 40 types of HPV, 18 are considered to be
strongly associated with cervical cancer (“highrisk” types).
• Twelve HPV types classified as “low-risk” for the
development of cervical cancer cause anogenital
warts and mild degrees of cervical dysplasia.
• Most HPV infections clear spontaneously within
1-2 years
• Persistent infections are associated with
precancerous lesions of the cervix.
• About 70% of cases of cervical cancer are caused
by the HPV subtypes 16 and 18
• Vaccine comprised of high-risk HPV types 16 and
18 and the low-risk types 6 and 11.
HPV Vaccine
• Age Range: 9-26
• 0.5 mL intramuscularly for three doses given at 0,
2 and 6 months.
• Monitor for injection site pain and inflammation,
and for signs of hypersensitivity.
• The UWHC cost for a single 0.5-mL syringe is
$116.29. The AWP is $149.69. Three doses at
UWHC would cost approximately $350.00, plus
procedure charges.
• Need for booster dose still being studied, but most
recent data suggest immunity extends beyond 4
years for both vaccines
Vaccine Efficacy
• 90% decrease, in patients receiving vaccine compared
to placebo*, for
– Incidence of persistent HPV infection with the
vaccine types.
– Incidence of disease associated with the vaccine
compared to placebo.
• Women still need to follow current recommendations
for screening for cervical cancer.
*Combined incidence of 0.7 per 100 woman-years at risk vs. 6.7 per 100 women-years,
respectively; p<0.0001.
ACIP Recommendations for HPV
• Girls ages 11 and 12 years old.
• Catch-up vaccination for girls and young women ages
13-26 years.
• Vaccination can start at age 9 at clinician’s discretion.
• The vaccine is recommended in girls and women who
have already been infected with HPV in order to
prevent infection with other types of HPV included in
the vaccine.
• Need to continue regular pap smear testing
Controversial Issues with HPV Vaccine
• Concern from some parental groups that giving
vaccine gives the girls ‘permission’ to have sex
• Expense
• ACIP recommends giving with other age-appropriate
vaccines (Td, meningococcal, hepatitis B), but what
about MMR, which is a live vaccine
• Parents more likely to accept HPV vaccination if they
believe that the vaccine is safe and effective, if the
provider recommends it and if they know how severe
HPV-related disease can be
• Use as opportunity to reinforce safe-sex messages
Herpes Zoster Vaccine (Zostavax)
• Indicated for immunocompetent adults 60 years
of age or older with no history of shingles, who
have had chickenpox.
• Live attenuated vaccine; avoid if
immunosuppressed
• Reactions at injection site mild; can develop
varicella-like rash at injection site
• Contraindicated if history of anaphylactic
reaction to gelatin, neomycin or other
components of the vaccine
Herpes Zoster Vaccine
• Single subcutaneous dose (0.65 mL)
• Costs about $150.00 plus injection fee
• Store frozen and administer immediately
after reconstitution to minimize loss of
potency
• Need for booster remains unclear
Shingles Prevention Study
• Outcomes studied: incidence of herpes zoster
(HZ) and post-herpetic neuralgia (PHN) in
individuals age 60 and older
• Median follow-up 3.1 years
• Effective in preventing HZ 51% overall (64% in
patients 60-69 and 38% in those 70 and older)
• Reduced severity and duration of pain and
discomfort caused by Herpes Zoster by 61%
• Efficacy in preventing PHN 67%, regardless of
age
Cost Effectiveness of a Vaccine to Prevent
Herpes Zoster and Post-herpetic Neuralgia
in Older Adults
by Hornberger and Robertus
• “Vaccination would be more cost-effective in
“younger” older adults (age 60-64 years) than in
“older” older adults (age ≥ 70). Longer life
expectancy and a higher level of vaccine efficacy
offset a lower risk for herpes zoster in the younger
group.”
Controversies Herpes Zoster Vaccine
• Go outside FDA licensure to broader age
group (50 and up)
• Use in persons with history of shingles
• Medicare coverage not decided
• Need for a booster dose
Other New Recommendations
• Mumps vaccine
– 2 doses a minimum of 1 month apart for kids
and high risk adults, eg healthcare workers
Websites
• www.cdc.gov/nip Centers for Disease
Control and Prevention National
Immunization Program
• www.vaccineinformation.org
Immunization Action Coalition
• www.immunize.org
“A vaccine not
given is
100%
ineffective!”