Adult Immunization Update

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• Adult Immunization Update

Donna L. Weaver, RN, MN National Center for
Immunization and Respiratory Diseases
Greensboro, NC September, 2007
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Disclosures

• The speaker has no financial conflict with the
  manufacturer of any product named in this
  presentation
• The speaker will discuss the use of certain
  vaccines in a manner not approved by the U.S.
  Food and Drug Administration (off-label ACIP
  recommendations)
• The speaker will not discuss products not
  currently licensed by the FDA

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Adult Immunization Overview

• Disease burden
• Goals standards
• Schedule recommendations
• Barriers
• Strategies
• Resources

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VPD Burden Among Adults in the U.S.

• 50,000 adults die annually from
  vaccine-preventable diseases (VPDs)
• Billions of healthcare costs annually
• Coverage rates for adults much lower than for
  children
• Many adults unnecessarily remain at risk

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Healthy People 2010 Goals
http//www.healthypeople.gov/

• Influenza and pneumococcal
• 90 for adults 65 yrs of age
• 60 for noninstitutionalized high-risk adults
  18-64 yrs of age

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Revised Standards for Immunization Practice
http//www.cdc.gov/nip/recs/rev-immz-stds.htm

• Make vaccines easily accessible
• Effectively communicate vaccination information
• Implement strategies to improve vaccination rates
• Develop community partnerships to reach target
  patient populations

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Vaccines for Many Adults
Vaccine
Indications

• Tetanus and diphtheria All-every 10 yrs
  toxoids
• Influenza Vaccine All 50 yrs
• Underlying Illness
• Contacts
• Pneumococcal Vaccine All 65 yrs
• Underlying Illness

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Tetanus A Risk for the Elderlyhttp//www.cdc.go
v/mmwr/PDF/ss/ss5203.pdf

• The highest average annual incidence of reported
  tetanus was among persons aged 60 years, persons
  of Hispanic ethnicity, and older adults known to
  have diabetes.
• 75 of the deaths were among patients aged 60
  years. No deaths occurred among those who were
  up-to-date with tetanus toxoid vaccination.

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Diphtheria Only a plane ride away!http//www.cd
c.gov/mmwr/preview/mmwrhtml/mm5253a3.htm

• Protective antibody levels drop from 91 in 6-11
  year olds to 30 in 60-69 year olds

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Tetanus, Diphtheria, PertussisVaccine for Adults

• Tdap (Adacel)
• Only Tdap brand approved for adults
• Single IM dose
• Approved for persons 11 through 64 years of age

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Use of Tdap Among Adults

• Single dose of Adacel to replace a single dose of
  Td
• May be given at an interval less than 10 years
  since receipt of last tetanus toxoid-containing
  vaccine
• Special emphasis on adults with close contact
  with infants (e.g., childcare and healthcare
  personnel, and parents)

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Tdap for Persons Withouta History of DTaP

• All adults should have documentation of having
  received a series of DTaP, DTP, DT, or Td
• Adults without documentation should receive or
  complete a series of 3 doses
• Preferred schedule
• single dose of Adacel
• Td at least 4 weeks after the Tdap dose
• second dose of Td at least 6 months after the Td
  dose

off-label recommendation
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Tdap and PregnancyACIP Provisional
Recommendations

• Td is generally preferred during pregnancy
• All women should receive a dose of Tdap in the
  immediate postpartum period
• Any woman who might become pregnant is encouraged
  to receive a single dose of Tdap
• A clinician may choose to administer Tdap to a
  pregnant woman in certain circumstances, such as
  during an outbreak of pertussis in the community
• Pregnancy is not a contraindication to
  vaccination with Tdap

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ACIP Tdap Recommendations
http//www.cdc.gov/mmwr/PDF/rr/rr5517.pdf
http//www.cdc.gov/vaccines/recs/provisional/downl
oads/tdap-preg.pdf
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DTaP and Tdap Administration Errors

• Occur because both types of vaccine stored in the
  same refrigerator, and similarity of appearance
  of packaging
• Errors include
• DTaP (pediatric) given to a person 7 years of age
  or older
• Tdap (adolescent/adult) given to child younger
  than 7 years

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Produced by California Immunization Branch
Available at http//www.dhs.ca.gov/ps/dcdc/izgroup
/pdf/IMM-508.pdf
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HPV Disease Burden in the U.S.

• Anogenital HPV incidence
• 20 million currently infected with HPV
• 6.2 million new HPV infections/year
• Common among adolescents and young adults
• More than 80 of sexually active women will have
  been infected by age 50
• Infection also common in men

Cates, STD 26Supp 1-6 (1999) Meyers et al. Am J
Epidemiol 151 1158-1171 (2000).
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Human Papillomavirus Vaccine for Adults

• HPV (Gardasil)
• Quadrivalent, recombinant vaccine
• 3 IM doses
• Approved for females 9 through 26 years of age

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Quadrivalent HPV Vaccine

• For prevention of the following diseases caused
  by HPV types 6, 11, 16, and 18
• High efficacy among females without evidence of
  infection with vaccine HPV types
• No evidence that the vaccine had efficacy against
  existing disease or infection
• Prior infection with one HPV type did not
  diminish efficacy of the vaccine against other
  vaccine HPV types

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Human PapillomavirusVaccine Recommendations

• Women 19-26 years of age are recommended to
  receive the HPV series if they have not already
  received it regardless of sexual history, prior
  HPV infection, or prior disease
• Administered intramuscularly
• Schedule 0, 2 months, and 6 months
• dose 1-2 4 week minimum interval
• dose 2-3 12 week minimum interval
• Do not restart the series if the schedule is
  interrupted
• Administer at same visit as other age-appropriate
  vaccines (e.g., Tdap, MCV)

http//www.cdc.gov/mmwr/PDF/rr/rr5602.pdf
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Human PapillomavirusVaccine Recommendations

• HPV vaccine should not be administered to males
• No safety or efficacy data
• Not labeled for males by FDA
• Off-label use not recommended
• Safety and immunogenicity studies in males in
  progress now

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Vaccination During Pregnancy

• Initiation of the vaccine series should be
  delayed until after completion of pregnancy
• If a woman is found to be pregnant after
  initiating the vaccination series, remaining
  doses should be delayed until after the pregnancy
   
• If a vaccine dose has been administered during
  pregnancy, there is no indication for
  intervention
• Exposures to vaccine in pregnancy should be
  reported to Merck registry (800.986.8999)

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Cervical Cancer Screening

• Cervical cancer screening no change
• 30 of cervical cancers caused by HPV types not
  prevented by the quadrivalent HPV vaccine
• Vaccinated females could subsequently be infected
  with non-vaccine HPV types
• Sexually active females could have been infected
  prior to vaccination
• Providers should educate women about the
  importance of cervical cancer screening

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HPV VaccineSpecial Situations

• Equivocal or abnormal Pap test
• Positive HPV DNA test
• Genital warts
• Immunosuppression
• Breastfeeding

Vaccine can be administered
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ACIPHPV Recommendations
http//www.cdc.gov/mmwr/PDF/rr/rr5602.pdf
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Impact of Influenza

• 36,000 excess deaths per year
• Highest rates of complications and
  hospitalization among young children and persons
  65 yrs of age
• 90 of deaths among persons 65 years of age

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Influenza Vaccine

• Efficacy varies by age and health status,
  similarity to circulating strain
• TIV
• Trivalent Inactivated Vaccine
• Intramuscular injection
• Persons 6 months of age
• LAIV
• Live Attenuated Influenza Vaccine
• Intranasal spray
• Only healthy, nonpregnant persons 5-49 years of
  age

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ACIP Influenza Recommendations
http//www.cdc.gov/mmwr/PDF/rr/rr5606.pdf
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Influenza Vaccine 2007-2008

• Anticipating about 120 million doses to be
  available from four manufacturers
• H1N1 strain changed from 2006-2007 formulation
• No new recommendations for adults
• In January 2007 FDA approved a refrigerator-stable
  formulation of LAIV

http//www.cdc.gov/flu/
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Pandemic Influenza
http//www.pandemicflu.gov/ www.fda.gov/bbs/topics
/NEWS/2007/NEW01611.html
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Impact of Pneumococcal Disease

• Pneumococcal pneumonia
• 100,000-135,000 hospitalizations per year
• 12 die (most are adults)
• Antibiotic resistance is increasing
• Pneumococcal meningitis
• 3,300 cases per year
• 18 die (most are adults)
• Pneumococcal bacteremia
• 60,000 cases per year
• 9 die (most are adults)

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http//www.cdc.gov/mmwr/PDF/wk/mm5436.pdf
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Pneumococcal Polysaccharide Vaccine
Recommendations

• Adults 65 years of age
• Persons with
• chronic illness
• cardiovascular disease
• pulmonary disease
• Diabetes
• Alcoholism
• Cirrhosis
• CSF leaks
• cochlear implant
• decreased immunologic function
• HIV infection
• environments or settings with increased risk

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PPV23 Revaccination

• Revaccinate once (2 total lifetime doses maximum)
• At least 5 years after first dose
• Candidates for revaccination
• Asplenia
• Immunosuppression
• Chronic renal failure
• Nephrotic syndrome
• Persons vaccinated at younger than 65 years of
  age for any reason

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ACIP PPV23 Recommendations
http//www.cdc.gov/mmwr/PDF/rr/rr4608.pdf
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http//www.immunize.org/catg.d/2015pne.pdf
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Pneumococcal VaccineMissed Opportunities

• 65 of patients with severe pneumococcal disease
  had been hospitalized within preceding 3-5 years
  but had not been immunized
• May be administered simultaneously with influenza
  vaccine

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Adult Hepatitis B Vaccine Candidates

• Men who have sex with men
• Heterosexual with multiple partners
• Persons diagnosed with an STD
• Prostitutes
• Injection drug users
• Male prison inmates
• Persons receiving dialysis

• Staff of institutions for developmentally
  disabled
• Alaskan Natives, Pacific Islanders
• Household members and sexual partners of HBV
  carriers
• Recipients of certain blood products
• Immigrants/refugees
• Adoptees, orphans, unaccompanied minors
• Extended travel to areas of high endemicity

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ACIP Adult Hepatitis B Recommendations
http//www.cdc.gov/mmwr/PDF/rr/rr5516.pdf http//w
ww.cdc.gov/mmwr/PDF/wk/mm5409.pdf
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Evidence of Measles, Mumps, Rubella Immunity

• Born before 1957 measles, mumps, and rubella
  (not rubella for women of childbearing age)
• Physician-diagnosed - measles, mumps
• Serologic evidence of immunity measles, mumps,
  and rubella
• Documentation of adequate vaccination measles,
  mumps, and rubella

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ACIP MMR Recommendations
http//www.cdc.gov/mmwr/PDF/rr/rr4708.pdf
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Presumptive Evidence of Mumps Immunity

• Documentation of adequate vaccination
• 2 doses for adults at high risk of exposure to
  mumps
• Laboratory evidence of immunity
• Birth before 1957
• Documentation of physician-diagnosed mumps

www.cdc.gov/mmwr/preview/mmwrhtml/mm5522a4.htm?s_c
idmm5522a4_e
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Revised Definitions for Evidence of Varicella
Immunity

• Written documentation of age-appropriate
  varicella vaccination
• 2 doses for all adults
• Laboratory evidence of immunity or laboratory
  confirmation of disease
• Born in the U.S. before 1980
• A healthcare provider diagnosis of varicella or
  healthcare provider verification of history of
  varicella disease
• History of herpes zoster based on healthcare
  provider diagnosis

http//www.cdc.gov/mmwr/pdf/rr/rr5604.pdf
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ACIP Recommendations for Zoster Vaccine

• Adults 60 years and older should receive a single
  dose of zoster vaccine
• Routine vaccination of persons younger than 60
  years is NOT recommended
• A history of herpes zoster should not influence
  the decision to vaccinate

Provisional recommendations, October
2006 http//www.cdc.gov/nip/recs/provisional_recs/
zoster-11-20-06.pdf
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Zoster Vaccine

• Dont Ask (about a history of varicella)
• Screening for a history of varicella disease is
  not necessary or recommended to administer zoster
  vaccine to a person 60 years of age or older
• Persons 60 years of age and older can be assumed
  to be immune regardless of their recollection of
  chickenpox (so dont ask)

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Zoster Vaccine

• Dont Test (it will just cause you trouble)
• If tested and seronegative the person should
  receive 2 doses of single antigen varicella
  vaccine (Varivax) separated by at least 4 weeks
• Zoster vaccine is not indicated for a person
  whose immunity is based on vaccination

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Vaccines for a Few Adultshttp//www.cdc.gov/vacci
nes/pubs/ACIP-list.htmhttp//wwwn.cdc.gov/travel/
default.aspx
Vaccine
Indications

• Meningococcal Asplenic
• Travel
• Hib Asplenic
• IPV
• Typhoid
• Hepatitis A Travel
• Yellow Fever
• Other

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Barriers

• Trying to use a one-size fits all approach in
  offices with complex systems
• Varied patient beliefs about immunization that
  include racial and ethnic diversity
• Time pressures on providers
• Limited coordination in assigning responsibilities

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Strategies

• Standing orders
• Computerized record or chart reminder
• Expanding access
• Home visits
• Performance feedback
• Patient reminders education
• Personal health record

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Healthcare Workers Need the Following
Immunizations

• Varicella
• MMR
• Annual influenza

• Hepatitis B - exposure risk
• Td (one-time Tdap) 10-year booster

Are YOU up to date?
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Healthcare Personnel Vaccination Recommendations
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HCP Vaccination For more than Personal Health

• Direct contact from patient to patient
• Contact with infected material from patients
• Transmission of disease throughout healthcare
  settingpatients, staff, visitors
• HCP immunity essential to infection prevention
  and control programs

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Adult Immunization Resources

• Centers for Disease Control and Prevention
• http//www.cdc.gov/vaccines/pubs/default.htmflyer
  s
• http//www.cdc.gov/vaccines/ed/broadcasts.htm5
• http//www.cdc.gov/vaccines/ed/adultimzup06/adult0
  6-resources.htm

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Special PopulationsSpecial Immunization Issues

• Immunocompromised persons
• drugs
• disease
• HSCT/bone marrow transplant
• Pregnant women
• Persons with unknown vaccination history

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Vaccination of Immunocompromised Persons

• Immunocompromised persons may receive
  inactivated, recombinant, subunit, conjugate and
  toxoid vaccines when indicated
• Response to vaccine may be suboptimal
• Persons vaccinated during immunosuppressive
  therapy or radiation should be revaccinated 3
  months after therapy discontinued
• It is preferable to vaccinate an
  immunocompromised person and obtain a
  less-than-optimal response than to withhold the
  vaccine and obtain NO response

http//www.cdc.gov/mmwr/PDF/rr/rr5515.pdf
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Vaccination of Immunocompromised Persons

• Susceptible immunocompromised persons are at
  increased risk of adverse events following live
  vaccines
• Live vaccines may be administered 3 months
  following termination of therapy (1 month after
  high-dose steroids)
• MMR, varicella and rotavirus vaccines should be
  administered to susceptible household and other
  close contacts

http//www.cdc.gov/mmwr/PDF/rr/rr5515.pdf
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Vaccination of Asplenic Persons

• Persons with functional or anatomic asplenia are
  at increased risk of infection with encapsulated
  bacteria
• Vaccines recommended (in addition to those
  routinely recommended for age)
• Pneumococcal polysaccharide (2 doses 5 years
  apart)
• Meningococcal polysaccharide or conjugate (11-55
  years of age)
• Hib (?) (off-label)

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Recommendations for Routine Immunization of
Adults w/ HIV/AIDS

• Documented Td series with booster doses every 10
  years (Tdap once)
• Annual influenza vaccination (TIV)
• Pneumococcal polysaccharide (2 doses separated by
  5 years)
• Hepatitis A and B (and other inactivated
  vaccines) if indicated
• MMR if susceptible, depending on level of
  immunosuppression. Withhold MMR or other
  measles-containing vaccines from HIV-infected
  persons with severe immunosuppression

http//www.cdc.gov/mmwr/PDF/rr/rr5515.pdf
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Vaccination of Hematopoietic Stem Cell Transplant
Recipients

• Antibody titers to VPDs decline during the 1-4
  years after allogeneic or autologous HSCT if the
  recipient is not revaccinated
• HSCT recipients may be at increased risk of some
  VPDs, particularly pneumococcal disease
• Revaccination recommended beginning 6-12 months
  post-transplant

http//www.cdc.gov/mmwr/PDF/rr/rr4910.pdf
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Vaccination in Pregnancy

• Inactivated vaccines
• Routine (influenza)
• Vaccinate if indicated (hep B, Td, MPSV, rabies)
• Vaccinate if benefit outweighs risk (all other)
• HPV vaccine not recommended during pregnancy
• Live vaccine do not administer
• Exception is yellow fever vaccine

http//www.cdc.gov/nip/publications/preg_guide.pdf
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Unknown or Uncertain Vaccination Status

• Self-reported doses of vaccine without written
  documentation should not be accepted
• Accept doses if
• written, dated record
• age, spacing, and timing comparable with that
  recommended in the U.S
• If documentation is unavailable, vaccinate
  according to age
• Judicious use of serologic testing may be
  considered for some antigens (measles, mumps,
  rubella, hepatitis B)

including combination vaccines not approved for
use in the U.S. http//www.cdc.gov/mmwr/PDF/rr/rr5
515.pdf (pages 33-35)
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National Center for Immunization and Respiratory
DiseasesContact Information

• Telephone 800.CDC.INFO
• Email nipinfo_at_cdc.gov
• Website www.cdc.gov/nip
• Vaccine Safety
• http//www.cdc.gov/od/science/iso/