Transcript Immunization for Adults Trish M. Perl, MD, MSc Professor of Medicine, Pathology and Epidemiology Johns Hopkins University Healthsystem Epidemiologist Johns Hopkins Healthsystem [email protected].

Immunization for Adults
Trish M. Perl, MD, MSc
Professor of Medicine, Pathology and
Epidemiology
Johns Hopkins University
Healthsystem Epidemiologist
Johns Hopkins Healthsystem
[email protected]
Disclosures/ Thank you
• Research support: VA and CDC, Merck, Medimmune
• Advisory Boards: Pfizer
• Honorarium: Pfizer, ACP
• Thanks to the ACP Immunization Task Force
Objectives
• Review the recommended immunizations in adults
• Review immunizations in special populations
• Discuss key points about epidemiology, safety, efficacy or
immunogenicity of each recommended immunizations.
Why am I Talking About This?
• Vaccine preventable diseases kill more North, Central and
South Americans annually than traffic accidents, breast
cancer or HIV/Aids
• 2.1% of eligible adults (18-64) have had Tdap in the
previous 2 years
• <2% of >60 have had the shingles vaccine
• 10% of eligible adult women have received the HPV
vaccine
• 36.1% of all adults are vaccinated annually for influenza,
69% of >65 have received the vaccine and 58% of
medicare beneficiaries
• 66.9% of eligible patients have received the pneumococcal
vaccine
http://healthyamericans.org/assets/files/TFAH2010AdultImmnzBrief13.pdf
Barriers to Immunization
•
•
•
•
•
•
•
•
Cost
Lack of infrastructure
Lack of physician support
Need for multiple visits
Need for multiple doses
Inconvenience
Concerns about safety (e.g., autism)
Limited insurance coverage
How Do They Work?
Live attenuated vaccine
• Mimic natural disease
• One or two dose
• Long lived immune response
• Interference from immunoglobulins
• Risk = “wild” type infection
Inactivated vaccines
• Do not cause infection (mostly local
side effects)
• Require multiple doses
• Usually require boosters
• No interference from
immunoglobulins
Ann Intern Med 2015
Why Vaccinate for Influenza
Morbidity and Mortality
> 40,000 deaths annually related to influenza
Increased hospitalizations, medical visits, antibiotic
use
In the US > 1 billion in excess costs
Vaccine prevention
Decreases risk of acquisition of influenza
Decreases the risk of complications
Decreases the severity of illness in some cases
Decreases use of medical infrastructure
Decreases absenteeism
Seasonal Influenza
Formulations/Route:
1) Influenza Trivalent/Quadrivalent inactivated influenza vaccine (TIV)-IM
2) High Dose Trivalent ( > 65 years)
3) Intradermal
4) Cell culture vaccine (egg free)
5) Recombinant HA vaccine (high HA; egg free)
4) Attenuated Live influenza vaccine (LAIV)—intranasal all quadrivalent
Risk groups: Beginning 2014–15
All ages > 6months of age including those without risk factors
LAIV is only approved in non-pregnant healthy ages 2-49
Adults > 65 years may be given TIV/QUAD or high dose TIV
Annual Vaccine
 Give when seasonal infection occurs
Seasonal Influenza
Contraindications
Previous anaphylaxis to the vaccine or components
LAIV: pregnancy, chronic pulmonary disease, cardiovascular, renal,
hepatitis, neurological and neuromuscular, hematologic or metabolic
(diabetes) disorders; immunosuppression (including caused by
medications or HIV)
Precautions:
Moderate or severe acute illness
History of GBS within 6 weeks following vaccine
LAIV: close contact with person with acute leukemia or protective
isolation; receipt of anti-viral agents within 48 hours of vaccine (avoid for
14 days post vaccination.
Considerations
If 2 or more of the following live vaccines are to be given, LAIV, MMR,
varicella or yellow fever—give on the same day, if not space by 28 days
Dispelling Myths: Influenza Vaccine and Egg Allergy
• Retrospective chart-review
• n=261 egg allergic patients 6 mos to 18 yrs --received the vaccine skin test
&/or a 2-dose graded influenza vaccine (n=172) between seasons 2002–
2003 and 2006–2007.
• In 2006–2007, the skin test eliminated and egg allergic patients received
the influenza vaccine.
• 56 patients who received the skin test before the influenza vaccine, 95%
(95% CI: 85.1–98.9) tolerated the vaccine without a serious adverse
reaction.
• Of the 115 patients who received the vaccine without a preceding skin test,
97% (95% CI: 91.3–99.0) tolerated the vaccine without serious adverse
reaction. The tolerance rate ratio was 1.01 (95% CI: 0.97–1.06).
Chung et al. Pediatrics 2010;125:e1024–e1030
Thimerosol
• Mercury in fish
= 1.1 - 41.1 micrograms/ounce
One can of tuna = 29 mcg mercury
Thimerosol
(mercury-containing preservative)
in vaccine
= < 1 microgram/dose
Slide from David Warren
A Mass Vaccination Program in Japan
14
pneumonia and influenza
60
12
50
40
10
all cause mortality
1957
Asian influenza
epidemic claims
8,000 lives
8
30
20
10
6
1962
Program
to vaccinate
schoolchildren
begins
1977
Influenza vaccination
becomes mandatory
1994
Program is
discontinued
1987
Parents allowed to
refuse vaccination
0
Adapted from Reichert TA et al. N Engl J Med. 2001;344:889-896; Slide from David Weber, MD.
4
2
0
Excess Deaths Attributed to Pneumonia and Influenza
(per 100,000 population)
Excess Deaths From All Causes (per 100,000 population)
70
Pneumococcal Polysaccharide (PPSV)
 2 formulations
23 valent, polysaccharide (common capsular serotypes)
–Induces T cell independent B cell responses
–Effectiveness is impeded by poor immune responses
in elderly, immunocompromised & infants < 2years
7 valent (4, 6B, 9V, 14, 18C, 19F and 23F)-covalently
linked polysacchraide-protein conjugate vaccine.
–Strains responsible for 80% of invasive
pneumococcal disease in children
–82% decrease in invasive disease in children and
dramatic impact on herd immunity.
–Emergence of strains not in vaccine (non-vaccine
serogroups)
Pneumococcal Polysaccharide (PPSV)
Formulations/Route: IM (SQ)
I dose if unvaccinated or vaccine hx unknown
Revaccinate if 1st dose given before age 65 yrs and 5 years have
elapsed from 1st dose; age 19-64, at high risk for fatal pneumococcal
infection and 5 years has elapsed since dose #1.
Risk groups:
>65 years older
>19 years with chronic illness or other risk factors (chronic
cardiac/pulmonary disease), asthma, chronic liver disease, ETOH, DM,
functional/anatomic asplenia, immunocompromised (HIV, leukemia,
lymphoma, MM, CRF, nephrotic syndrome, generalize malignancy,
receiving immunosuppressive chemotherapy, SOT or BMT*
CSF leaks, smoker, candidate for chochlear implant,
 Special environments (American Indian, Alaskan native > 50), * At highest risk
for fatal pneumococcal infection
Pneumococcal Polysaccharide (PPSV)
• Decreases noted in vaccine
serogroups (4, 6B, 9V,14, 18C,
19F, 23F); vaccine related
serogroups (6A, 9A, 19 A); but
not in non-vaccine serogroups
(1, 3, 5, 7f, 12 F)-Whitney 2003
Van der Pol and Opal, Lancet Infect Dis 2009:374;1543
Whitney et al NEJM 2003;348 (18);1747
Pneumococcal Polysaccharide (PPSV)
Best Practice
• Give PCV first and then PPSV 23
• Immunity lasts at least 5 years
Tetanus Immunity: US
100
Males
90
Females
% immune to tetanus
80
n=10,618
70
60
50
40
30
20
10
0
6-11 yrs
12-19
yrs
Gergen, PJ NEJM 1995:332;761-6
20-29
30-39
40-49
50-59
60-69
70+
Pertussis: US
n=10,618
Tetanus, Diphtheria, Pertussis
Formulations/Route: Td/Tdap-IM every 10 years
Risk groups:
>18 years who lack written documentation complete primary
series 0, 1-2 mo, 6-12 mo intervals), substitute one dose of
Tdap for one of the doses preferably the 1st.
Repeat Td every 10 years after primary series
Tdap can be given regardless of interval since last Td
For Tdap only, give to adults <65 years or older or any adult
in contact with infants < 12 months old; HCWs who have
direct patient care
pregnant women given in 2nd and 3rd trimester. If not
administered during pregnancy give Tdap immediately postpartum
Tetanus, Diphtheria, Pertussis
Contraindications
Previous anaphylaxis to the vaccine or components
For Tdap only, history of encephalopathy within 7 days
following DTP/Tdap
Precautions
Moderate or severe acute illness
History of GBS w/in 6 wks following previous tet toxoid vac
Unstable neurologic condition
History of arthrus reaction following a previous dose of
tetanus &/or diph toxoid containing vaccine including MCV4
Caveats
Using tetanus toxoid is not recommended
What’s New
• Use a single dose of Tdap to replace Td
• Current recommendation is to give Td every 10 years
• Special populations to consider
–
–
–
–
Healthcare
Parents
Childcare, etc
Intrapartum with each pregnancy regardless of interval.
Ideally should be given at 27-35 weeks gestation
– Provides passive immunity to the infant
)
Risk Factors for Hepatitis B
CDC Sentinel Sites. 2001 data
http://www.cdc.gov/mmwr/PDF/rr/rr5516.pdf
Hepatitis B
Formulations/Route: IM
3 doses, time 0, 1 and 6 months later, or alternative 0, 2, 4 months; 0, 1
4 mo and 0, 1, 2, 12 mo (Engerix only)
Must have 4 wks in between doses 1 and 2 and 8 weeks between doses
2 and 3 and overall 16 weeks between doses 1 and 3. If series is
delayed do NOT start over, continue from where left off.
Risk groups:
All adults who want to be protected from hepatitis B (HBV)
Household contacts & sex partners of HBsAg + people; IVDU, people
seeking STD evaluation or treatment; hemodialysis patients and those
awaiting dialysis, MSM, HCWs & public safety workers who are exposed
to blood; staff working with developmentally disabled; inmates in LT
correctional facilities; certain international travelers, people with chronic
liver disease
Hepatitis B
Contraindications:
Previous anaphylaxis to the vaccine or components
Precautions:
Moderate or severe acute illness
Efficacy:
30-55% after 1st dose in healthy adults <40 yrs, 75% after
2nd dose and 90% after 3rd dose. Efficacy 60% in > 60 yrs
Of non responders (anti Hbs>10 IU/mL) to 1st series; 2550% respond to 4th dose; 44-100% respond to repeat 3
dose vaccine series.
Some studies suggest using high dose vaccine enhances
response
Hepatitis B: New Recommendations
• 2011: Add unimmunized diabetic patients
– Aged 19-59
– > 60 at the discretion of the treating physician
• Why?
– Patients with DM 2 have 2.1 fold increase risk for acute
HBV
– NASH is more common in diabetics and this and other
chronic liver disease increased the risk of HBV associated
morbidity/mortality
Hepatitis B
Efficacy:
Median response 64% (67-86%) of hemodialysis pts
respond
Response is best if vaccine pre-dialysis with creatinine < 4
Caveats:
Provide serologic screening for immigrants from endemic
areas. For sexual partners and household contacts of
HBsAg positive people provide serologic screening and
administer initial dose of Hep B vaccine at same visit.
Vaccine provides long term immunity
Hepatitis B by Year, United States, 1966 - 2000
HBsAg
screening of
pregnant Infant Immunization
recommended
women
recommended
Vaccine
licensed
14
12
OSHA Rule enacted
Cases per 100,000 Population
10
Adolescent
Immunization
recommended
8
6
4
Decline among
MSM & HCWs
2
Decline among
injecting
drug users
0
1967
1969
1971
1973
1975
1977
1979
1981
1983
Year
Source: NNDSS
1985
1987
1989
1991
1993
1995
1997
1999
Annual incidence of occupational
infections has decreased 95%
since hepatitis B vaccine became
available in 1982
Mahoney FJ et al Arch Int Med 1997;157:2601+
Efficacy of Zoster Vaccine
MMWR 2008: 57;1.
Zoster (Shingles)
Efficacy: 55-72%; Duration of immunity under study but at
least 5 years
Formulations/Route: live attenuated strain (Oka) SC
14 times potency of varicella vaccine (>19,400 PFU)—
Zostavax; 7 times the potency of varicella vaccine (9,800
PFU) ProQuad
Risk groups:
People >60 years
MMWR 2008: 57;1
Zoster (Shingles)
Contraindications:
Previous anaphylaxis to the vaccine or components
Primary cellular or acquired immunodeficiency
Pregnancy (?what)
Precautions:
Moderate or severe acute illness
Receipt of specific antivirals (ie acyclovir, valacyclovir 24
hours before vaccination—if possible delay resumption of
these antivirals for 14 days post vaccination.
Zoster (Shingles)
Side effects:
•local reactions (more common in younger patients),
headache, rash (zoster like at injection site in 1% of
recipients, mean time to rash 4 days post vaccination),
rarely herpes zoster
Caveats:
•>2 of the following live vaccines (MMR, Zoster, Yellow
Fever) are to be given on same day—otherwise space by
28 days
•Vials/names of zoster vaccine and varicella can be
confused – warn staff
HPV and Cervical Cancer Prevention
Human Papillomavirus (HPV)
Formulations/Route: inactivated IM
Cervarix – bivalent (HPV 16, 18); Gardasil-quadrivalent
(HPV 16, 18, 6, 11)
3 doses, 0, 2, 6 months, at least 4 weeks between dose 1
and 2 and 12 weeks between dose 2 and 3; 24 weeks
between doses 1 and 3
If possible use the same product for all 3 doses
If dose is delayed, do not restart series, just continue
Risk groups:
All unvaccinated women through age 26 (ages 9-26, usually
given ages 11-12)
Consider in men through age 26
Human Papillomavirus (HPV)
Contraindications:
Previous anaphylaxis to the vaccine or components
Precautions:
Moderate or severe acute illness
Data on vaccination are limited and if possible should be
delayed until the completion of pregnancy
Human Papillomavirus (HPV)
Efficacy:
•Males;> 65.5% overall but 95% if per protocol population
evaluated
•Females; 91.6% against infection and 100% against
persistent infection
Side effects:
•local reactions, fainting, headache, nausea, fever, GBS
(rare)
Caveats:
•Can administer with other vaccines
HPV Efficacy
Guiliani et al NEJM 2011:364;401
Garland et al NEJM 2007:356;1928
MMR
Formulations/Route: SC
1 or 2 doses -described below, if need dose #2 give > 4weeks after dose
1
If pregnant woman rubella susceptible, give dose #1 post partum
Within 72 hours of a measles exposure give 1 dose of post exposure
prophylaxis to susceptible adults
Risk groups:
Born after 1957 (especially outside of North America) should receive at
least 1 dose if no evidence of immunity (lab or documentation of vaccine
after 1 year old)
Women of child bearing age who do not have acceptable evidence of
immunity or vaccination.
HCWs (paid & volunteer), students entering college/post high school
education activities and international travelers should receive 2 doses
MMR
Contraindications:
Previous anaphylaxis to the vaccine or components
Pregnancy or possibility within 4 wks
Severe immunodeficiency (hematologic / solid malignancies
receiving chemo, congenital immunodeficiency, long-term
immunosuppression, severely symptomatic HIV
Note HIV with CD 4 > 200 or not severely compromised is
NOT a contraindication
Precautions:
Moderate or severe acute illness
Blood, plasma, immunoglobulin within last 11 months
HX of TTP or thrombocytopenia
MMR
Caveats:
Born before 1957 considered immune but evidence of
immunity considered critical in HCWs
>2 of the following live vaccines (MMR, Varicella, Zoster,
Yellow Fever) are to be given on same day—otherwise
space by 28 days.
If TST (tuberculosis skin test) and MMR are needed but not
given on the same day, delay TST for 4-6 weeks after MMR.
Routing post vaccination serologic testing is NOT
recommended.
Pregnancy and Immunization
HCP’s and Immunization
•
•
•
•
•
•
Annual influenza vaccination
Tdap
MMR (at least 2 doses)
Varicella or evidence of immunity
HBV – 3 doses
Meningococcal in microbiologists
Conclusions
• Adult vaccination is commonly neglected – we miss the
opportunities
• Adults are either vectors of communicable diseases because of
waning immunity or at risk of the disease and or its complications
• Get vaccinated
• The following vaccinations are recommended for all adults
– Influenza
– Td/Tdap
– MMR*
Conclusions
• The following vaccinations are recommended for certain at risk
groups
–
–
–
–
–
–
Pneumococcal
Meningococcal
HPV
HAV
IPV
Zoster (Shingles)