The Evolving Adult Immunization Platform

1
The Evolving AdultImmunization Platform

• William Schaffner, MD
• Vanderbilt University School of Medicine
• Nashville, TN

2
When meditating over a disease, I never think of
finding a remedy for it, but, instead, a means of
preventing it.
Louis Pasteur
(1822-1895)

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Infant/Childhood immunization one of the top
public health success stories of the 20th
century Diphtheria, tetanus, measles, mumps,
rubella, polio, H. influenzae B, hepatitis B
reduced by over 99 Pertussis, hepatitis A,
select pneumococcal, varicella, rotavirus,
influenza being reduced
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Invigoration of Adult Immunization

• Build on success of infant/childhood, adolescent
  program
• New vaccines targeted at adults
• Recognition of the burden of adult
  vaccine-preventable disease

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Burden of Adult Vaccine-Preventable Disease

• Influenza 10-20 of US population affected
  annually
• 200,000 hospitalizations
• 36,000 deaths (average)
• Pneumococcal 2,000-5000 meningitis
• 40,000 bloodstream
  infections
• 150,000-300,000
  pneumonia
• Pertussis 1 million
• Cervical cancer 10,000
• Shingles 1 million
• Adult deaths from vaccine-preventable diseases
  43,000

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Reported Pertussis Cases
19 yrs
1118 yrs
lt 11 yrs
Reported Pertussis Cases

• 2004 provisional data

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Tdap VaccineTetanus-Diphtheria acellular
Pertussis

• Licensed as one-time booster dose through age 64
• Use Tdap at time of regular 10-year booster
• Individual protection against pertussis, tetanus,
  diphtheria
• Reduce community outbreaks
• Interrupt transmission to vulnerable infants by
  vaccinating adults (cocoon)

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Human Papillomavirus Vaccine(Cervical Cancer)

• Licensed vaccine against 4 virus types (6, 11,
  16, 18) for females 9-26 years
• Papillomavirus infection is precursor to cervical
  cancer
• Types 16, 18 account for 70 of cervical cancers
• Virus is transmitted by sexual contact
• Over half of women are infected during their
  lifetime
• Three-dose series

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Natural History of HPV Infection and Potential
Progression to Cervical Cancer1
01 Year
05 Years
120 Years
Invasive Cervical Cancer
InitialHPV Infection
ContinuingInfection
CIN 2/3
CIN 1
Cleared HPV Infection (80)
1. Pinto AP, Crum CP. Clin Obstet Gynecol.
200043352362.
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HPV Vaccine Trial

• Randomized, placebo-controlled, double blind
• 27,000 volunteers
• 100 effective vs. CIN 2/3

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Human Papillomavirus Vaccine

• CDCs Advisory Committee on Immunization
  Practices (ACIP) June 29, 2006
• Recommendations
• Routine immunization of females at 11-12 years
• May be started as young as 9 years at discretion
  of provider/parent
• Vaccination of females up to age 26

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Herpes Zoster (shingles) Vaccine

• Licensed for persons 60 years of age
• Shingles localized rash due to reactivation of
  latent chickenpox (varicella) virus
• Post-Shingles pain extreme, debilitating pain
  lasting for months
• Vaccine licensed for persons 60 years of age
• High potency live, attenuated varicella vaccine
• Boosts immunity

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Shingles Prevention Study - 1

• Randomized, placebo-controlled, double blind
  vaccine trial
• 38,546 volunteers at 22 sites adults 60

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Shingles Prevention Study - 2

• 95 of volunteers completed study
• Follow-up lt1 - 4.9 years average 3 years
• Shingles reduced 51
• 60-69 years 64
• 70-79 years 41
• 80 18
• Post-shingles pain 67

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Reported Acute Hepatitis B Incidence By Age
Group United States, 1990-2004
20 years
71 decline
94 decline
12-19 years
Cases per 100,000
lt12 years
Year
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Reported Acute Hepatitis B Incidence By Age and
Sex United States, 2004
0.1
0.1
lt5
Female
Male
0.1
0.0
5-9
0.1
0.1
10-14
0.4
1.1
15-19
3.1
3.1
20-24
5.2
4.2
25-29
4.9
4.0
30-34
Age Group (Yrs)
5.4
4.4
35-39
4.9
3.6
40-44
4.0
2.7
45-49
3.2
2.0
50-54
2.9
1.3
55-59
1.4
0.8
60
Rate per 100,000
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Hepatitis B Vaccine ACIP Recommendations
Expanded Risk Groups

• Sexual Transmission
• All sexually active persons not in a mutually
  monogamous relationship
• Persons evaluated or treated for STDs
• Men who have sex with men
• Sex partners of HBsAg-positive persons

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Adult Immunization

• Influenza Tdap
• Pneumococcal HPV (cervical cancer)
• Hepatitis B Shingles
• Special circumstances, e.g. Travel, Health Care
  Worker

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Adult Immunization Challenges

• Inadequate payment for vaccines and
  administration in both public programs and
  private medical insurance
• Lack of knowledge both patients and providers
• Poor public health and private infrastructure for
  vaccine delivery