Transcript 10-17-07 Flu 2007-2008 Jacobi IM.ppt

Influenza Immunization Update
2007-2008
Sheila L. Palevsky, MD MPH
Bureau of Immunization
New York City Department of Health and Mental Hygiene
October 17, 2007
Impact of Influenza
• It is estimated that 10-20% of all adults and up
•
to 40% of children in the U.S. are infected with
influenza each year
~226,000 hospitalizations annually
– About half among those in persons >65 years of age
– Rates of influenza hospitalization in children <5 years
similar to rates in adults >65 years
• >36,000 deaths during each influenza season
– More than 90% are in adults >65 years
Influenza Virus
• Orthomyxoviridae family
• 3 types: A, B, C
• Only influenza A and B cause epidemic human
disease
• Influenza A viruses categorized into subtypes on
the basis of two surface antigens:
– hemagglutinin
– neuraminidase
Influenza Virus
Type of nuclear
material
Neuraminidase
Hemagglutinin
A/Fujian/411/2002 (H3N2)
Virus
type
Geographic
origin
Strain
number
Year of
isolation
Virus
subtype
CDC
Influenza Antigenic Changes
Influenza viruses undergo genetic changes
Drift
Shift
• Minor changes, same subtype
• Major change,new subtype
• Genetic point mutations
• Exchange of gene segments
• Occurs in A and B subtypes
• Occurs only in A subtypes
• May cause yearly epidemics t
• May cause periodic pandemics
⇛ Occurs frequently
⇛ Occurs infrequently
The Next Antigenic Shift
The question is not if, but when
…nor do we know what kind it will be
Immunity to Influenza Antigens
• Immunity to the surface antigens, especially the
hemagglutinin, reduces the likelihood of infection
• Antibody against one influenza virus type or
subtype confers limited or no protection against
another type or subtype of influenza
• Antibody to one antigenic type or subtype might
not protect against infection with a new antigenic
variant of the same type or subtype
Influenza – Clinical Features
•
•
•
•
Respiratory transmission of virus
Contagious prior to the onset of symptoms
Incubation period 1-5 days (average 2 days)
Abrupt onset of fever, myalgia, sore throat,
nonproductive cough, headache (vomiting and diarrhea
may be seen in childhood illness)
• Severity of illness depends on prior experience
with antigenically related variants
All that is called the “flu” is not influenza
Influenza - Complications
• Pneumonia
– Primary influenza
– Secondary bacterial
•
•
•
•
Otitis media (children)
CNS complications including Reye Syndrome
Myocarditis / myositis / rhabdomyolysis
Exacerbations of underlying medical
condition(s)
• Death 0.5 – 1 per 1,000 cases (for all ages)
Important to Remember
• Influenza is spread by coughing, sneezing – through
droplet spread
• Individuals are contagious for 1-4 days before the onset
of symptoms and for 5-10 days after the first symptoms
• Children may shed virus for >10 days after onset of
symptoms
• About 50% of infected individuals do not have any
symptoms but are still contagious
Differentiating Respiratory Illnesses
• Difficult to distinguish influenza from other respiratory
illnesses on the basis of signs and symptoms
– Young children less likely to have typical symptoms of cough
and fever
– Older adults may not have typical symptoms
• The absence of symptoms of influenza-like illness (ILI)
does not effectively rule out influenza
Use laboratory tests to confirm the diagnosis
Influenza Vaccine Efficacy
• Dependent upon:
– Age and immunocompetence of the vaccine recipient
– The degree of similarity between virus in the vaccine and
those in circulation
– Outcomes being measured
•
•
•
•
•
Medically attended acute respiratory illness (MAARI)
Laboratory confirmed influenza
Prevention of influenza-associated hospitalization or death
Seroconversion to circulating vaccine strains
Seroconversionto circlutaing virus strains
Influenza Vaccine Efficacy
Healthy Adults
• For healthy adults <65 years of age:
– 70%-90% effective in preventing clinical illness in healthy
adults when vaccine matches circulating strains of virus
– 50%-77% against laboratory-confirmed illness when vaccine
strains were antigenically dissimilar to circulating strains
– Protection against healthy adults against influenza-related
hospitalization was 90%
You cannot get “the flu” from the flu shot
Influenza Vaccine Efficacy
Adults With Chronic Disease
• For adults <65 years of age with chronic disease:
– Vaccine generally less effective than in healthy adults
– In adults 50-64 years of age, when circulating strain and
vaccine were not well matched (2003-2004), vaccine efficacy:
• 60% for healthy adults vs. 48% among high-risk adults in
preventing laboratory confirmed illness
• 90% for healthy adults vs. 36% among high-risk adults in
preventing hospitalization
You cannot get “the flu” from the flu shot
Influenza Vaccine Efficacy
Older Adults
• For adults >65 years, the goal is to prevent secondary
complications and reduce the risk for influenza-related
hospitalization and death
– Among non-institutionalized persons >60 years, ~60% effective
in preventing clinical illness (lower efficacy in those >70 years)
– 30%-70% effective in preventing hospitalization in noninstitutionalized seniors
– In older nursing home residents:
• 20-40% effective in preventing MAARI
• ~80% effective in preventing death
You cannot get “the flu” from the flu shot
Flu Vaccine
• Although the efficacy of flu vaccine in the elderly
may be less than desired, it is the best protection
against influenza and its complications
• The risk of hospitalization and death due to flu is
high in the elderly (about 5% of deaths)
• Preventing spread of the flu is important !
Flu Vaccine in Children
• Influenza vaccine is effective in children >6 months of age
• Children 6 months <9 years of age should receive 2 doses of
flu vaccine in the first season they receive vaccine
– Among children <9 years of age who have never received
influenza vaccine before and who received only 1 dose of
vaccine in their first year of vaccination, vaccine is less effective
as compared with children who received 2 doses in their first
year of being vaccinated.
Influenza Vaccine (TIV) Adverse Reactions
Local reactions*
15% - 20%
Fever, malaise*
uncommon
Allergic reactions
Neurological reactions
rare
very rare
You cannot get “the flu” from the flu shot
*Local rxns and fever may be more common in young children
The Flu Shot (TIV)
• Contraindications - anaphylactic reaction to
a previous dose or to egg protein, gelatin,
or other vaccine component
• Precaution – moderate to severe illness
– Vaccinate if minor illness: diarrhea, upper
respiratory tract illness (including otitis media) with
or without fever or on current antimicrobial therapy
• Precaution – history of GBS within 6 weeks
of receipt of a dose of flu vaccine
Month of Peak Influenza Activity
United States, 1976-2006
50%
45%
45%
40%
35%
30%
25%
19%
20%
13%
15%
13%
10%
5%
3%
3%
3%
Apr
May
0%
Nov
MMWR 2007:56(RR6)
Dec
Jan
Feb
Mar
CDC
2007-2008 Influenza Vaccine
• A/Solomon Islands/3/2006(H1N1) - like
• A/Wisconsin/67/2005 (H3N2) - like
• B/Malaysia/2506/2004 - like
Strains included in the vaccine change every year based on surveillance data
You need this year’s flu vaccine to protect against this year’s flu!!
Vaccine supply information will be available at www.cdc.gov/nip/flu
Flu Vaccine Availability and
Timing of Vaccination
• Influenza vaccine is being received in offices
now!
• Vaccine is usually most plentiful later in the
calendar year – in November and December –
prior to the peak of influenza activity
• Influenza peaks in late winter; vaccine should
continue to be given well into the spring
• Keep vaccinating so long as supply is available
• If indicated, give pneumococcal (and any other
indicated) vaccine(s) along with flu vaccine
1
Recommendations for Influenza Vaccine: 2007-2008
• All persons, including school-aged children, who want to
reduce the risk of becoming ill with influenza or of
transmitting influenza to others
• All children 6-59 months of age
• All persons >50 years
• Children and teens (6 months -18 years) on long-term
aspirin therapy
• Women who will be pregnant during influenza season
• Children and adults with chronic pulmonary (asthma),
cardiovascular, renal, hepatic, hematological or metabolic
disorders (diabetes mellitus)
• Children and adults with immunosuppression (medication, therapy,
human immunodeficiency virus)
CDC
2
Recommendations for Influenza Vaccine: 2007-2008
• Children and adults who have any condition that
compromise respiratory function or handling of secretions
(cognitive dysfunction, spinal cord injuries, seizures, neuromuscular disorders)
• Residents of nursing homes or other chronic care facilities
who are at least 6 months of age
• Health care personnel
• Healthy contacts including children and caregivers of
children <5 years and adults >50 years, with emphasis on
contacts of children <6 months of age
• Healthy household contacts (including children) and
caregivers of persons with medical conditions that
predispose to complications from influenza
CDC
Influenza Vaccine Recommendations
Chronic Illness*
•
•
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Pulmonary disorders (includes emphysema and asthma)
Heart disease
Metabolic disease (e.g., diabetes)
Renal dysfunction
Hemoglobinopathies
Immunosupression
– HIV/AIDS
– Medications and other treatments
• Conditions that compromise respiratory function
or the the handling of secretions or increase the
risk of aspiration
* >6 months of age
LAIV Indications
• Healthy* persons 2 - 49 years of age
– Health care workers, except those who have direct
contact with severely immunocompromised
patients who require protective isolation
– Contacts of those at high risk (including contacts
of infants and young children)
– Persons who wish to reduce their own risk of
influenza
* Persons who do not have medical conditions
that increase their risk for complications of influenza
Administration of LAIV
• Persons at increased risk for influenza
complications* may administer LAIV
• Gloves and masks are not required
*e.g., pregnant women, persons with asthma and
persons 50 years of age or older
Pregnancy and Influenza
• Risk of hospitalization due to complications of the
flu is 4 times higher than in non-pregnant women
• Risk of complications comparable to nonpregnant women with high-risk medical conditions
• Vaccination (with TIV) is recommended if
pregnant during influenza season
• Vaccination can occur during any trimester
• Vaccinate all contacts of pregnant women
HIV Infection and Influenza
• Persons with HIV at increased risk of
complications of influenza
• TIV induces protective antibody titers in many
HIV infected persons
• Transient increase in HIV replication reported
• TIV will benefit many HIV-infected persons
• Vaccinate all contacts of HIV-infected persons
Influenza Vaccines 2007-2008
Vaccine
Dose / Presentation
Age
Doses
Route
INACTIVATED VACCINE (TIV)
0.25 ml pre-filled syringe*
6-35 mos
1 or 2†
IM
0.5 ml pre-filled syringe*
>36 mos
1 or 2†
IM
0.5 ml vial*
>36 mos
1 or 2†
IM
5.0 ml multi-dose vial*
> 6 mos
1 or 2†
IM
Fluvirin (Novartis)
5.0 ml multi-dose vial
>4 yrs
1 or 2†
IM
Fluarix (GSK)
0.5 ml pre-filled syringe
>18 yrs
1
IM
FluLuval (GSK)
5.0 ml multi-dose vial
>18 yrs
1
IM
Afluria (CSL Limited)
0.5 ml pre-filled syringe
>18 yrs
1
IM
5.0 ml multi-dose vial
>18 yrs
1
IM
2-49 yrs
1 or 2¶
Intra-nasal
Fluzone
(sanofi pasteur)
LIVE, ATTENUATED (LAIV)
FluMist (LAIV)
0.1 ml spray in each nostril
*vaccines approved for children younger than 4 years
† two doses administered at least one month apart for children 6 months <9 yrs who are receiving influenza vaccine for the first time;
children <9 years who received only one dose in their first season of vaccination should receive 2 doses in the next year
¶ two doses administered at least one month apart for children 2 yrs <9 yrs who are receiving influenza vaccine for the first time;
children 2 yrs <9 yrs who received only one dose in their first season of vaccination should receive 2 doses in the next year
Vaccination of Health Care Personnel
• All physicians, nurses, other health care personnel
in all hospital and out-patient settings, including
emergency rooms, and all home care attendants
should receive vaccine annually
• But - - -
• in the 2004 National Health Interview Survey, only
•
42% of health care workers reported receiving
influenza vaccine in the previous 12 months; and
in 2005, only 33% of health care workers in NYC
reported they got a flu vaccine!
What about you ???
Benefits of Influenza Vaccination
of Health Care Workers
• Reduction in nosocomial influenza and
influenza-related deaths
• Reduction in staff illness and illnessrelated absenteeism
• Reduction of direct medical costs and
indirect costs from work absenteeism
MMWR. 2006;55 (RR-2)
Reasons Health Care Workers Do
Not Receive Influenza Vaccine
• Concern about vaccine adverse events
• Perception of a low personal risk of
influenza virus infection
• Insufficient time or inconvenience
• Reliance on homeopathic medications
• Avoidance of all medications
• Fear of needles
• Mistrust of government recommendations
MMWR. 2006;55 (RR-2)
Factors Facilitating Health Care
Worker Influenza Vaccination
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Desire for self-protection
Previous receipt of influenza vaccine
Desire to protect patients
Perceived effectiveness of the vaccine
Legislative and regulatory mandates
– Effective January 2007, JCAHO requires facilities
to offer flu vaccine on site to staff as part of
employee health programs
MMWR. 2006;55 (RR-2)
Barriers to Vaccination
• Health care workers’ misconceptions
about influenza as a disease
• Lack of understanding by health care
workers that influenza can be deadly for
patients and contacts
“flu is not a serious disease”
Barriers to Vaccination
• Perception of a low personal risk of
contracting influenza
“I don’t get sick; I don’t need it”
“absenteeism vs. presenteeism”
Barriers to Vaccination
• Failure of health care workers to explain
vaccine efficacy and safety
“the flu vaccine will make me sick”
“I don’t think the vaccine really works”
Barriers to Vaccination
• Health care workers are poor role
models
Did you have your flu vaccine last year?
Influenza in Healthcare Workers
• Healthcare workers
– Implicated in introducing influenza into and
causing outbreaks among patients in health
care settings
• ICU, neonatal intensive care units, nursing homes
– Often work while ill, exposing vulnerable
patients and their coworkers to influenza
– May be able to spread influenza if infected, but
not symptomatic
• Can shed virus before symptoms develop
• About half of all influenza infections asymptomatic
Barriers to Vaccination
• Need for annual vaccination
“I had the flu shot before, I don’t
need it again”
Barriers to Vaccination
• Need to address popular myths –
taking of vitamins, never get sick,
etc.
“home remedies and preventives are better”
“I don’t need foreign substances in my body”
Barriers to Vaccination
• Fear of needles
LAIV is a good alternative, if eligible
Barriers to Vaccination
• There are many excuses offered to
avoid vaccine – don’t give in to
them
“I don’t eat eggs”
“I am taking medications”
“now isn’t convenient -I’ll get it later”
Barriers to Vaccination
• Low reimbursement
Reimbursement
• Medicare covers flu vaccine and includes an
administration fee
• All Medicaid managed care plans will cover
influenza vaccine for at-risk adults 19-64 years
• Commercial insurance plans should provide
coverage for at-risk patients
• Commercial insurance must cover children with
an indication for flu vaccine
• Influenza vaccine is available through the Vaccines
for Children program for eligible children and teens
Barriers to Vaccination
• Missed opportunities
Use every encounter
as an opportunity to vaccinate
Cultural and Ethnic Issues
• Understand and address different
cultural beliefs of health and sickness
• Address socio-political issues such
as distrust of governmental
recommendations and the memory of
Tuskegee
Getting Ready for Flu Season
• Order sufficient vaccine
• Vaccinate all office staff
• Develop protocols within the health care setting
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–
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–
Have patient information available (posters, flyers)
Flag charts of high-risk patients
Use standing orders
Have special designated vaccination hours
Make every encounter an opportunity to vaccinate
Use signed declination forms if is vaccine refused
• Offer vaccine once available: continue
vaccinating into the spring
Influenza Vaccine: Strategies to Increase Coverage
• Expand use of standing orders
• For employees:
– Vaccination sessions
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•
•
•
Institute vaccination days
Use traveling teams – take the vaccine to the employee
Use incentives
Monitor and report influenza vaccination levels in the facility
– Education
• Education, education, education, education, education
Get documentation if vaccine was given at another location
Pneumococcal Disease
• Pneumococcal pneumonia is a common
complication of influenza
• Rates of severe pneumococcal infection
and death are highest in the elderly
Incidence of Invasive Pneumococcal Disease
in Adults >18 yrs, US 1999-2000
Category
Incidence rate
(cases/100,000 persons)
Healthy
8.8
Diabetes
51.4
Chronic heart disease
93.7
Chronic lung disease
62.9
Solid cancer
300.4
HIV/AIDS
422.9
Hematological cancer
503.1
Alcohol abuse
100.4
Adapted from Kyaw, et al., JID. 2005;192:377-386.
Age-Specific Incidence, by Race, of Invasive Pneumococcal
Disease in Adults (>18 yrs) with No Reported Underlying Illness
United States, 1999-2000
Kyaw, et al., JID. 2005;192:377-382.
Rates of Death or Intensive Care Unit (ICU) Admission,
by Pneumococcal Vaccination Status and Age
Johnstone, J. et al. Arch Intern Med 2007;167:1938-1943.
PPV23 Recommendations
• All adults >65 years of age
• Persons >2 years with
– certain chronic illness
– functional or anatomic asplenia
– immunocompromised (disease, chemotherapy,
radiation therapy, high-dose steroids)
– HIV infection
– cerebrospinal fluid leaks and cochlear implants
– environments or settings with increased risk
PPV 23 Vaccination: Chronic Illness*
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•
•
•
•
•
•
Diabetes or other metabolic disease
Chronic heart disease
Chronic respiratory disorders
Chronic liver disease including alcoholism
Kidney failure, ESRD, hemodialysis
Hemoglobinopathies
Immunosupression
– HIV/AIDS
– cancer
– medications and other treatments
* >2 years of age
PPV23 Revaccination
• Routine revaccination of immunocompetent persons is not recommended
• Revaccination recommended for
persons age >2 years at highest risk of
serious pneumococcal infection
• Single revaccination dose >5 years after
first dose
PPV23 Candidates for Revaccination
• Persons >2 years of age with:
– the highest risk of complications from IPD
– persons whose antibodies decline rapidly
• functional or anatomic asplenia
• immunosuppression
• chronic renal failure
• nephrotic syndrome
• transplant recipients
• Persons vaccinated at <65 years of age
PPV23 Revaccination
• Revaccination once, 5 years after 1st
dose for those aged >65 years:
– if received vaccine >5 years ago, and
– were aged <65 years at the time of
vaccination
PPV23 Vaccination and Revaccination
• If previous vaccination is uncertain
– no available record or date of vaccine
VACCINATE
do not miss the opportunity
There are no contraindications
to simultaneous administration
of any vaccines
Give influenza and pneumococcal vaccines
at the same visit if both are indicated
VPD Surveillance
Report suspected cases of
vaccine preventable diseases
to
212-676-2284/88
after hours: 212-POISONS
Vaccine Adverse Events
Report
suspected
vaccine adverse events
(VAERS)
800-822 7967
or
www.vaers.org
or call 212-676-2284
A vaccine not given
is
100% not effective
Sheila L. Palevsky, MD MPH
Provider Liaison
Chief, Professional Education Unit
New York City Department of Health and Mental Hygiene
2 Lafayette Street – 19th floor - CN21
New York, NY 10007
Phone: 212-676-2264
Fax: 212-442-8091
Email: [email protected]