Adult Immunization Update

1
Adult Immunization Update

• Michelle McDonald, MD
• Chief Medical Officer
• Pima County Health Department
• Michelle.Mcdonald_at_pima.gov

2
Adult Immunization Schedule
3
Disease Burden in Adults is Substantial

• Annual deaths from influenza 36,000 per year, at
  least 90 in those 65 years. Pneumococcal next
  most common cause of death (3400 per year) from
  VPDs, also majority elderly
• Increasing immunocompromise due to disease or to
  medications
• Diseases previously controlled in US (measles,
  mumps) are not controlled world wide, even in
  developing countries increasing risk for
  importation into US

4
Influenza and Pneumoccal Vaccine Rates are Low
5
Patient Issues for Vaccination

• Awareness
• -Disease
• -Vaccine
• -Personal risk
• Provider Recommendation
• Access Ability to pay
• Misconceptions/fears
• -About Vaccine
• -About Health Care System

Kristin Nichol, MD, MPH, MBA Clinical Vaccinology
Conference Nov. 2007
6
Improving Vaccination Rates Provider Issues

• Know the facts and recommend vaccinations to your
  patients
• Get organized and use systems approaches
• -Standing Orders (no direct MD involvement at
  time of visit)
• -Walk-In Clinics
• -Reminder Notices
• Ongoing measurement and evaluation
• Practice what we preach get vaccinated!!

7
Interventions that Improve Vaccination Rates for
Adults

• Component OR
• Organizational change 16.0
• Provider reminder 3.8
• Pt financial incentive 3.4
• Provider education 3.2
• Pt reminder 2.5
• Pt education 1.3
• Annal Intern Med 2002136641-51

8
Pneumoccal Vaccine

• PPV23 contains antigen from 23 capsular types
  that cause 88 of bacteremic pneumoccal disease,
  with cross reactivity for a few more that cover
  an additional 8 of bactermic disease (96 total)
• 80 of healthy adults develop antibodies within
  2-3 weeks of vaccination less in older adults
  and those with chronic disease. Elevated
  antibody levels persist at least 5 years in
  healthy adults, decline more rapidly in elderly
  and those with chronic disease.
• Overall 60-70 effective in preventing invasive
  disease has NOT been demonstrated to provide
  protection against pneumococcal pneumonia nor
  against carriage.
• Conjugate vaccines generally considered more
  effective looking at development of adult
  conjugate vaccine.

9
Pneumoccal Vaccine 2

• Indications
• -all adults 65 years
• -persons 2 years at ?risk for pnemococcal
  disease due to immunosuppression splenic
  dysfunction or absence, Hodgkin disease,
  lymphoma, multiple myeloma, chronic renal
  failure, nephrotic syndrome, immunosuppression
  from organ transplant, chemotherapy, high dose
  corticosteroids, asymptomatic or symptomatic HIV
  infection
• -immunocompetent persons 2 years with chronic
  illness including cv disease, pulmonary disease,
  diabetes, alcoholism, cirrhosis, csf leak,
  cochlear implant

10
                                                
                                            
MMWR 199746 (RR-08)
11
(No Transcript)
12
Meningococcal Vaccine

• Covers serogroups A, C, Y, W-135
• -from 1996-2001 in US
• 21 serogroup Y
• 31 serogroup B (accounted for 65 of cases
  in children
• 42 serogroup C
• Recommendations in adults based on risk
• Conjugate vaccine has advantages of longer
  duration of immunity and reduction in carriage
  rates can be used in ages 11-55 over 55 use
  polysaccharide vaccine

13
Meningococcal Vaccine

• Indications in adults
• -microbiologists routinely exposed to isolates
  of N. meningitidis
• -military recruits
• -persons traveling to or residing in countries
  where N. meningitidis is hyperendemic or epidemic
• -terminal complement component deficiency
• -functional or anatomic asplenia
• Adverse events
• -mostly local (48 for MPSV and 59 for MCV)
• -concern re GBS within 6 weeks now 22 cases
  analyzed through VAERS no statistically
  significant increase in risk in 11-19 year olds
  generally, but possible small increase in risk in
  older subset of 15-19 year olds analysis
  ongoing

14
Pertussis

• Adolescents and adults recognized as reservoir of
  transmission to susceptible infants at greatest
  risk of disease complications
• Vaccine and disease immunity wanes over 5-10
  years
• Secondary attack rate up to 80 in non immune
• Tdap recommended as single dose to replace Td for
  booster, and is especially recommended for adults
  with close contact with infants (childcare and
  healthcare personnel, parents, grandparents)
• Boostrix (GLK) ages 10-18 Adacel (SP) ages 11-64
• ACIP has recommended a minimal 5 year interval
  since last Td dose there is good evidence for
  safety for intervals as short as 2 years.
  Intervals as short as 12 months have been used
  without significant adverse events.

15
Herpes Zoster

• Primary usefulness is in prevention/reduction of
  postherpetic neuralgia (PHN), for which there is
  essentially no treatment
• Antiviral therapy
• Modestly shortens rash duration if initiated
  early
• Even used early does not prevent PHN
• Corticosteroids
• Decrease severity of acute pain
• Do not reduce incidence or severity of PHN
• Side effects and toxicity argue against use
  (esp in elderly)
• Pain medications
• Even narcotics have limited effectiveness
  against PHN

16
HZ Vaccine (Zostavax)

• In initial study with over 18,000 individuals in
  both vaccine and placebo group
• efficacy in prevention of shingles 51
• 63.9 effective in age 60-69
• 37.6 effective in age 70
• efficacy in prevention of PHN 66.5
• 65.7 effective in age 60-69
• 66.8 effective in age 70

NEJM 2005352(22)2271-84
17
HZ Vaccine (Zostavax)

• Indicated for adults aged 60 and over
• If no memory of hx of varicella disease, give in
  preference to varicella vaccine (extremely high
  likelihood they were infected earlier, very large
  safety margin in the vaccine)
• No usefulness in checking serology available
  commercial assays lack sensitivity to reliably
  detect vaccine induced immunity
• Fragile! Keep frozen at -15ºC or lower must use
  in 30 minutes. Problem as now Medicare Part D
  only do not write prescription for patient to
  fill at pharmacy and bring back to your office
  will not be effective

18
HPV Vaccine

• Currently licensed Gardasil (Merck) protects
  against oncogenic types 16 18 and wart
  producing types 6 and 11
• 99 efficacy in prevention of pre-malignant
  cervical disease in naïve population, 99.5 of
  participants developed an antibody response to
  all 4 HPV subtypes 1 mo after series completion,
  99 efficacy against genital warts from the 4
  strains. (Bivalent vaccine 90 effective in
  prevention of premalignant cervical disease.)
• Unknowns duration of protection, need for
  boosters, efficacy in males, other genotypes

19
HPV Vaccine

• Recommended for
• -Routine vaccination of 11-12 yo girls
  (can be used as young as 9 years)
• -Catch up vaccination of adolescent and young
  women ages 13-26 not previously vaccinated
• Safety mostly local reactions. Otherwise,
  syncope seems common (?the targeted group). VAERS
  data shows 13 reported cases of GBS, lower than
  baseline rate, and 2 deaths from influenza.
  Reports of thrombosis were in concurrent users of
  OCPs.

20
Older Vaccines with Adult Indications

• Influenza!!!
• Varicella
• Measles
• Mumps
• Rubella
• Hepatitis A
• Hepatitis B

21
Vaccinations for Health Care Workers

• Influenza!!!
• Hepatitis B
• Varicella
• Measles
• Mumps (MMR)
• Rubella
• Pertussis

22
Resources

• Pink Book Epidemiology and Prevention of
  Vaccine-Preventable Diseases, CDC
• www.CDC.gov/vaccines