ACTIVE IMMUNIZATION IN ELDERLY

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ACTIVE IMMUNIZATION IN ELDERLY

• 
  By.. Dr.Ing-orn Arunakul.

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Universally recommended vaccinations for
children, adolescents, and adults
Population Vaccination Dosage
All adults All adults aged gt 65 years
Tetanus-diphtheria toxoid Influenza Pneumoco
ccal
1 dose administered every 10 years 1 dose
administered Annually 1 dose
Because rotavirus vaccine was not universally
recommended during the period considered in
this review, it is not reflected in these reviews.
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Estimates of the Impact of Full Utilization
of the Vaccines Currently Advocated for Adults
Disease Estimated Estimated Current
Additional annual vaccine
vaccine preventible
deaths efficacy
utilization deaths/y Influenza
20,000 70
59 5,740 Pneumococcal
40,000 60
37 15,120 infection
Hepatitis B 5,000
90 10
4,050 (1-60) Tetanus/
lt 25 99
40 lt15 diphtheria
Travelers dis lt 10
- -
lt10 (typhoid, cholera
rabies, JE, pdiomyelitis yellow
fever) Adult measles, lt 30 95
variable lt 30 mumps
and rubella
Percentage of target groups who are in
compliance with current recommendation
estimated base on seroprevalance data
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INFLUENZA VACCINE
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Viral biology

• 90 ??????????????????????????????????????????????
  ?????
• ??.2534-2542 ?????????????????????????????????????
  ? 36000 ??
• Influenza virus ??????????????? Orthomyxoviridae
• RNA virus component
• Envelope surface protein Hemagglutinin and
  Neuraminidase (HA, NA)
• Ribonucleoprotein genome protein
• 3 types A , B , C

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• HA (H antigen) 15 subtypes
• In human H1, H2, H3
• Neuraminidase (NA N antigen) 9 subtypes
• In human N1, N2

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Antigenic drift minor changes in HA or NA

• Affects Influenza A and B viruses
• Occurs every year or every few years within an
  influenza subtype
• Mutations affecting RNA amino acids
• Does not result in new subtype
• Can result in significant epidemics

Antigenic shift emergence of a
"new" virus worldwide

• Affects only Influenza A virus
• Major and sudden genetic variations in HA
  and/or NA
• No immunity in population
• Results in pandemics every 10 to 40 years

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• Antigenic drift occurs
  almost every year
• Antigenic shift occurs
  every 10-30 years

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Yearly Incidence of Influenza, Thailand,
1978-2001
cases
70,000
50,000
Incidence per 100,000
30,000
Reported cases of influenza
Incidence of Influenza
Data from Pranee Thawatsupha, National Institute
of Healthand Epidemioogy Div, MOPH
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The different influenza vaccines available
Three types of inactivated vaccines
Whole virion vaccines Split virus vaccines
Subunit virus vaccines
Live attenuated virus vaccine
CAIV-T ( nasal spray influenza vaccine )
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Safety,Efficacy and Effectiveness of the
Influenza Virus Vaccine CAIV-T in Healthy
Children and Healthy Adults

Mendelmen PM, Vaccine 2001
Randomized, double-blind, pracebo controlled
study Healthy children Year 1 ( n 1,602 )
93.4 protection Year 1 ( n 1,358
) 87.4 protection Healthy
children n222
82.8 protection Healthy adults n92
85
protection Healthy adults n4,561
9.7 protection (febrile
illness endpoint) 24.8 reduction of
URI,13-28 reduction of day of missed work
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Influenza Vaccination among Thai Elderly Persons

Pradisuwan R. Double-blind,randomized controlled
trail ( n 635,aged gt 65 yr ) Response rate
97.1 56 ( 95CI 14-78) reduction of
influenza-like illness Influenza Vaccination in
Elderly COPD Patients
Wongsurakiat P. Double-blind,ra
ndomized controlled trail ( n 129,aged gt 60 yr
) Immunogenicity response rate 91.7
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Dosage and administration

• age group type of vaccine
  dose timing route
• 6-35 mo split vaccine
  0.25ml 1/2 im
• 3-8 yr split vaccine
  0.5ml 1/2 im
• 9-12 yr whole or split
  0.5ml 1 im
• gt12 yr whole or split
  0.5ml 1 im
• im ??????????????????????????? (deltoid) ,
  ????????????????????????? (anterolateral of the
  thigh)

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Influenza Vaccination with 1/10th the Full Dose(
IM ) Coolper CL NEJM 2004 Health adults 18-40
yrs , phase Ib Serum Antibody Responses after
Intradermal Vaccination against Influenza Robert
B. Belshe NEJM 2004 In an open-label study ID
containing 6 ug of hemagglutinin for each antigen
(40 percent of the usual dose), and an
intramuscular injection( 15 ug for each
antigen)/different vaccine/. Intradermal
injection of a reduced dose resulted in similarly
vigorous antibody responses among persons 18 to
60 years of age but not among those over the age
of 60 years.
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Dose Sparing with Intradermal Injection of
Influenza Vaccine Richard T. Kenney NEJM
2004 Young adults(18-40 yrs) intradermal
administration of one fifth(0.1ml) the standard
intramuscular dose elicited immunogenicity that
was similar to or better than that elicited by
intramuscular injection
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Indication for vaccination

• ????????????????????????????????????????????? WHO
  ?? 2545 ??????????????????????????????????????????
  ? ???????????? ???.?.2547
• 1.??????????????????????????????? ???????????????
  ??????? (H3N2 and H1N1) ?????????? ?????????
  ??????????????????????????????????????????????????
  WHO

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• 2.?????????????????????????????
• ??????????????????????????????????????????????????
  ????????????????????????? ??????
• ???????????? 65 ???????? (????????????????????????
  ?????????? 55 ??)
• ??????????????????????????????????????????????????
  ???????????????????????????
• ???????????????? ???????????? ????????
  ????????????????????
• ??????????????????????????????????????????????????
  ??????????????????????????????????????????
  ??????? ????? ???????? ???????????????????????????
  ??????? ??????????????????????

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Contraindication

• 1.??????????????????????????? ????????????????????
  ???????????????? ????? ???????????????????????????
  ???? oseltamivir
• 2.??????????????????????????????????????
• 3.??????????????????? ????????????????????????????
  ?????????????? ????????????????????????
  ?????????????????????????? ??????????????????

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Adverse reaction of influenza vaccine

• 1. ??????????????? (?????????????? 1/3
  ????????????)
• 2. ??? ??????????????? ????????????? ?????????
  ????????????????????????????????
  ????????????????????????? 6-12 ??????????????
  ?????????????? 1-2 ???
• 3. ????????????????????? ????????????????????????(
  immediate allergic reaction ???? ????? ???????
  ??????? ?????? systematic anaphylaxis)

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Interaction with other vaccines

• Pneumococcal vaccines ????????????????????
  ??????????????????????????? ??????????????????????
  ??????
• ??????????????????????????????????????????????????
  ????

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Serious complication

• Ascending myelitis
• Guillain-Barre syndrome
• Multiple sclerosis
• Optic neuritis
• Demyelinating neurological disease
• in children age 6-23 month
• Swine influenza H1N1)

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Updated Interim Influenza Vaccination
Recommendations --- 2004--05 Influenza Season
October 2004 MMWR
Priority Groups for Inactivated Influenza
Vaccination All children aged 6--23 months
adults aged gt65 years persons aged 2--64 years
with underlying chronic medical conditions all
women who will be pregnant during the influenza
season residents of nursing homes and
long-term--care facilities children aged 2--18
years on chronic aspirin therapy health-care
workers involved in direct patient care and
out-of-home caregivers and household contacts of
children aged lt6 months. Additional Priority
Groups Areas of Sufficient Supply Out-of-home
caregivers and household contacts of persons in
high-risk groups (e.g., persons aged gt65 years
persons with chronic conditions such as diabetes,
heart or lung disease, or weakened immune systems
because of illness or medication and children
aged lt2 years) and all adults aged 50--64
years. Use of Live, Attenuated Influenza
Vaccination All healthy persons who are aged
5--49 years and are not pregnant, especially
health-care workers and out-of-home caregivers
and household contacts of persons in high-risk
groups.
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PNEUMOCOCCAL VACCINE
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Viral biology

• ??????????????????????????????????????????????????
  ???????????????????????? ????????????????????????
  ?????????????? ????????? ??????????????????
  ???????????????? ?????????? ??????????????
  ???????? ??? ?????????????????
• encapsulated gram positive bacteria diplococci
  ,lancet shape
• 90 serotypes and 42 serogroups (different
  polysaccharides of capsule)

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• ?????????? DRSP (drug-resistant S.pneumoniae)
  ??????????? ????????. 2534-2542 ??? 10.5-69.2
• ????????????????????????? 10.5-51.3
  ,????????????????????? 0-28
• ??????????? pneumococcus ?????????????????????????
  ???? (invasive pneumococcal infection) ??????
  septicemia (70 with pneumonitis), meningitis

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• ?????????????????????????????????? 19-30 ???
  100000 ?? ????????????????? 65 ?? ???????????
  42-57 ??? 100000 ??
• ??????????? ???????????????????? 28-51
• ????????? serotype of pneumococcus
  ???????????????????????????? ???????????? 70-90
  ?????????????? ?????????????? 23-valent
  polysaccharide

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Prevention of Pneumococcal Diseases
Active immunization (pneumococcal vaccine)
- 23-valent polysaccharide
pneumococcal vaccine -
Pneumococcal conjugated vaccine ( 7,9,11 )
- Pneumococcal protein vaccine (
Psp A,Psp C,
pneumolysin,autolysin,pneumococcal surface
adhesin A ) ongoing trial ,future
protection in any serotypes!
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23-valent polysaccharide pneumococcal vaccine

• Pneumovax (MSD) or Aventis Pasteur
• Pneumococcus 23 serotypes (1,2,3,4,5,6B,7F,8,8N,10
  A,11A,12F,14,15B,17F,18C,19A,19F,20, 22F,23F,33F)
• Cover gt90 ????????????????????????
• ????????????????????????serotype
  ????????????????? 6B,14,19F,23F ????????? 68.2

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7-valent polysaccharide pneumococcal vaccine

• Prevanar
• Use in children
• ?????????????????????????

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Polysaccharide Pneumococcal Vaccine

• Antigen in vaccine 25 microgram
• Polysaccharide stimulates B-cells ? clonal
  production of Ab producing cells ? anticapsular
  antibody
• Individual response IgG subclass
• In the elderly , antibody response is lower than
  adult

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Guideline of Pneumococcal Vaccination
Vaccination Revaccination (c) I.)
Immunocompetent persons (gt2 years) - Age gt 65
years (A) Once after 5 years (if first
vaccination was given before age 65 year) -
Age lt 65 years - Asplenia (77)(A) Consider
revaccination after 3-5 years - Medical illness
Not
recommended diabetic
mellitus(84), chronic
cardiovascular eg. congestive heart failure
(69), coronary vascular dis
(73), cardiomyopathies or pulmonary
diseases eg COPD (65)( (A)
- Chronic liver disease or Not recommended
alcoholism, CSF leakage (B)
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Guideline of Pneumococcal Vaccination
Vaccination Revaccination (c) II.)
Immunocompromised persons (gt2 years) - HIV
infection or congenital Once
after 5 years immunodeficiency (C) -
Malignancy multiple myeloma, Once after 5
years chronic lymphocytic leukemia,
lymphoma, leukemia,
generalized maligancy (C) - Immunosuppressive
therapy Once after 5 years or
corticosteroid therapy (C) - Chronic renal
failure (C) Once after 5 years -
Organ or hematopoietic cell Once after 5 years
transplantation (C)
If previous vaccination status is unknown,
vaccine should be given ( ) reflects the
strength of evidence supporting the
recommendations for vaccination (A
strong evidence support, B moderate evidence
support, C effectiveness of vaccination is not
proven but benefit and safety of the vaccine
justify vaccination)
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Polysaccharide Pneumococcal Vaccine

• Children adults
• 0.5 ml intramuscular or subcutaneous
• Revaccination as indicated
• ??????????????????????????????????????????????????
  ????????????????????????????????????????
• Simultaneous administration of other vaccines

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• Side effects adverse reactions
• Mild local reactions (50) local swelling, at
  injection site
• Systemic reactions (rare) fever, headache,
  nausea, vomiting
• Revaccination - same as primary vaccination

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The effectiveness of pneumococcal polysaccharide
vaccines in adultsa systematic review of
observational studies and comparison with results
from randomised controlled trials.
Stephen Conaty Vaccine 2004
13 observational studies the estimate of vaccine
efficacy against invasive disease was 53
(4659) compared with 38 (-4 to 63) from nine
RCTs. Estimates of protection against all-cause
pneumonia were based on fewer, heterogeneous
studies that were not consistent with the
findings from RCTs for this outcome. From five
studies combined efficacy was 32 (750)
compared with 3 (-16 to 19) from 13 RCTs.
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(No Transcript)
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State Trends in Health Risk Factors and Receipt
of Clinical Preventive Services among US Adults
during the 1990s JAMA 2002
Age gt 65 yr 1993
1999 Pneumococcal vaccine 19-39
42-63 Influenza vaccine
42-63 58-77
Pneumococcal vaccine Statistically significant
improved in 44/49 states GOAL 2000 gt 60 8/49
states Influenza vaccina Statistically
significant improved in 48/49 states GOAL 2000
gt 60 48/48 states
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Pneumococcal Vaccination Policies Worldwide

• National recommendation ( 14 countries )
• for elderly persons ( gt 65 yr )
• Increasing rate of vaccination
• Age-based strategy
• Hospitalization and long-term care institution
• Routine care practice

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Reasons for the Low Usage of Pneumococcal
Vaccination

• Lack of understanding of importance of
  pneumococcal diseases
• Inconclusive results from clinical trials
  prevention of pneumococcal pneumonia
• Uncertainly about benefits of vaccination
• Lack of reimbursement for the cost of vaccine
• Problems of adult vaccination
• Evaluation of response of vaccine ?
• Problem of revaccination

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THANK YOU