Adult Immunization:

1

• Adult Immunization
• Lifespan Clinical Issues

Donna L. Weaver, RN, MN National Immunization
Program
Greensboro, NC October 2, 2003
2

• The sponsor of this event has not contributed to
  the content of this presentation. The content
  was developed entirely by the National
  Immunization Program of the Centers for Disease
  Control and Prevention. The presenter receives
  no financial support of any kind from the sponsor.

3

• The use of trade names and commercial sources
  during this presentation is for identification
  only, and does not imply endorsement by the U.S.
  Department of Health and Human Services, the U.S.
  Public Health Service, or the Centers for Disease
  Control and Prevention.

4
Disclosures

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

5
Vaccine Preventable Diseases in Adults

• VPD's kill hundreds of times more adults than
  children every year
• More than 45,000 deaths per year - 6,000 from
  invasive pneumococcal disease - 36,000 from
  influenza - 4,000 - 5,000 from hepatitis B
• Coverage levels generally low

6
Adult Immunization Schedule

• Published in MMWR in October 2002
• Lists vaccines recommended by age and underlying
  medical condition (pregnancy, immuno-suppression,
  asplenia, HIV infection, etc)
• www.cdc.gov/nip/recs/adult-schedule.htm

7
(No Transcript)
8
(No Transcript)
9
(No Transcript)
10
(No Transcript)
11
Vaccines for Many Adults
Vaccine
Indications

• Tetanus and diphtheria All-every 10 yrstoxoids
• Influenza Vaccine All gt50 yrs
• Underlying Illness
• Contacts
• Pneumococcal Vaccine All 65 yrs
• Underlying Illness

12
Vaccines for Some Adults
Vaccine
Indications

• Hepatitis B Vaccine Increased Risk
• MMR Vaccine Born 1956
• Varicella Vaccine Susceptible

13
Vaccines for a Few Adults
Vaccine
Indications

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

14
http//www.cdc.gov/nip/flu/
Influenza Vaccine
15
Impact of Influenza

• 36,000 excess deaths per year
• gt90 of deaths among persons gt65 years of age
• Average of 114,000 influenza-related excess
  hospitalizations per year
• 57 of all hospitalizations among persons gt65
  years of age

16
www.cdc.gov/mmwr/preview/mmwrhtml/rr5208a1.htm
17
Influenza ACIP Statement 2003

• Influenza recommendations
• Timing of influenza vaccination by age and risk
  group
• 2003-2004 vaccine virus strains
• Availability of doses with reduced thimerosal
  content

18
Adult Influenza Vaccine Recommendations

• All persons gt50 years of age
• Persons with chronic illness
• Immunocompromised
• Residents of long-term care facilities
• Women at least 3 months pregnant during flu season

19
Influenza Vaccine Recommendations

• Healthcare workers
• Household contacts and caretakers of those at
  high risk
• Persons who provide essential community services
• Anyone who wants to decrease their risk of
  infection with influenza

20
Timing of Influenza Vaccine, 2003

• The first doses of your first shipment of
  inactivated influenza vaccine should be
  administered to you and your entire staff

21
Influenza Vaccine Recommendations, 2003-2004

• Vaccination can proceed for all high-risk and
  healthy persons, individually and through mass
  campaigns, as soon as vaccine is available
• Tiered influenza vaccination schedule is not
  necessary in 2003

22
Timing of Peak Influenza Activity
1980-1999 data
23
Timing

• Continue to offer influenza vaccine in December,
  especially to high-risk persons and health care
  providers
• Continue to vaccinate throughout influenza season

24
2003-2004 Influenza Vaccine

• Same strains as the 2002-2003 influenza vaccine
• Do NOT use 2002-2003 vaccine during 2003-2004
  influenza season (it is expired!)
• You still need a dose this year even if you had
  one last year

25
Vaccines
Live attenuated vaccine Intranasal Trivalent
Inactivated subunit Intramuscular Trivalent
26
(No Transcript)
27
Live Attenuated Influenza Vaccine

• FluMistTM
• Licensed by FDA June 17,2003
• Administered by nasal spray
• Approved for use ONLY among healthy persons 5-49
  years of age

28
Live Attenuated Influenza VaccineIndications

• Healthy persons 5 49 years of age
• Household contacts of persons at increased risk
  of complications of influenza (except
  immuno-suppression)
• Persons who wish to reduce their own risk of
  influenza

Persons who do not have medical conditions that
increase their risk of complications of influenza
29
Live Attenuated Influenza VaccinePersons Who
Should NOT Be Vaccinated

• Children lt5 years of age
• Persons gt50 years of age
• Persons with underlying medical conditions
• asthma, reactive airways disease or other chronic
  pulmonary condition
• cardiovascular disease
• metabolic diseases (e.g. diabetes)
• renal disease
• hemoglobinopathy (e.g. sickle cell disease)

These persons should receive inactivated
influenza vaccine
30
Live Attenuated Influenza VaccinePersons Who
Should NOT Be Vaccinated

• Pregnant women
• Persons immunosuppressed from disease (including
  HIV) or drugs
• Children or adolescents receiving chronic therapy
  with aspirin or other salicylates
• Severe (anaphylactic) allergy to egg or other
  vaccine components
• History of Guillian-Barre syndrome

These persons should receive inactivated
influenza vaccine
31
Live Attenuated Influenza VaccinePersons Who
Should NOT Be Vaccinated

• No data regarding transmission from adults
  vaccinated with LAIV to immunosuppressed persons
• ACIP prefers the use of inactivated influenza
  vaccine for persons with household or other close
  contact with immunosuppressed persons, including
  healthcare workers

32
Live Attenuated Influenza VaccineAdverse
Reactions

• Children
• no significant increase in URI symptoms, fever,
  or other systemic symptoms
• significantly increased risk of asthma or
  reactive airways disease children 12 to 59 months
  of age
• Adults
• significantly increased rate of cough, runny
  nose, nasal congestion, sore throat, and chills
  reported among vaccine recipients
• no increase in the occurrence of fever
• No serious adverse reactions identified

33
http//www.immunize.org/catg.d/2015pne.pdf
Pneumococcal Polysaccharide Vaccine
34
PPV23 Recommendations

• Adults gt65 years of age
• Persons gt2-64 years of age with normal immune
  systems who have chronic illness or cochlear
  implant
• Immunocompromised (disease or treatment/medication
  , includes sickle cell disease, functional or
  anatomic asplenia, HIV infection
• Persons in environments or settings with
  increased risk

35
PPV23 Revaccination

• Routine revaccination of immunocompetent persons
  is not recommended
• Revaccination recommended for those at highest
  risk of serious pneumococcal infection

36
Candidates for PPV23 Revaccination

• Asplenia
• Immunosuppression
• Chronic renal failure
• Nephrotic syndrome
• Persons vaccinated at lt65 years of age

37
http//www.cdc.gov/hepatitis
Hepatitis B Vaccine
38
Hepatitis B Vaccine Adolescent and Adult Schedule
Minimum Interval --- 1 month 2
months
Usual Interval --- 1 month 5 months

• Dose
• Primary 1
• Primary 2
• Primary 3

The third dose should be given no less than 4
months after dose 1
39

• Hepatitis B Vaccine

Booster doses are NOT routinely recommended for
any group.
40

• Hepatitis B Vaccine

If the hepatitis B vaccine series is interrupted
do not restart or add doses. Complete the series
on schedule.
41
Long-term Efficacy

• Immunologic memory following vaccination
• Anamnestic response on exposure
• Chronic infection rarely documented among vaccine
  responders

42
Post-vaccination Testing
Recommended for

• Infants born to HBsAg women
• Dialysis patients
• Immunodeficient persons
• Certain healthcare workers

43
Management of Nonresponders

• Complete a second series of three doses
• Should be given on the usual schedule of 0, 1 and
  6 months
• Retest 1 to 2 months after completing the second
  series

44
Persistent Nonresponders to Hepatitis B Vaccine

• lt5 of vaccinees do not develop anti-HBsAg after
  6 valid doses
• May be nonresponder or "hyporesponder"
• Check HBsAg status
• If exposed, treat as nonresponder with post
  exposure prophylaxis

45
TwinRix

• Combination hepatitis A (pediatric dose) and
  hepatitis B vaccine (adult dose)
• 3 dose series at 0, 1, 6-12 months
• Licensed only for persons gt18 years of age

46
National Immunization Program

• Hotline [phone]
• Email nipinfo_at_cdc.gov
• Website www.cdc.gov/nip

download or order ACIP statements online from
the NIP website
47
(No Transcript)
48
(No Transcript)
49
www.cdc.gov/mmwr/preview/mmwrhtml/00025228.htm
50
ftp//ftp.cdc.gov/pub/Publications/mmwr/rr/rr4204
.pdf
51
www.cdc.gov/nip/publications/HSCTRecs.pdf
52
www.cdc.gov/mmwr/PDF/rr/rr5005.pdf
53
www.cdc.gov/nip/publications/preg_guide.htm
54
www.cdc.gov/mmwr/PDF/rr/rr5012.pdf
55
ftp//ftp.cdc.gov/pub/Publications/mmwr/rr/rr4618
.pdf
56
www.cdc.gov/mmwr/PDF/rr/rr4808.pdf
57
www2.cdc.gov/nchstp_od/PIWeb/NIPorderform.asp
58
Immigrant Immunization Requirements
http//www.cdc.gov/ncidod/dq/health.htm
59
www.cdc.gov/nip/publications/adultstrat.htm
60
www2.cdc.gov/nchstp_od/PIWeb/NIPorderform.asp
61
www2.cdc.gov/nchstp_od/PIWeb/NIPorderform.asp
62
www.cdc.gov/mmwr/PDF/rr/rr4901.pdf
63
www.cdc.gov/nip/publications/Long-term-care.pdf
64
www.immunize.org/catg.d/4036need.pdf
65
www.immunize.org/catg.d/p4065scr.pdf
66
www.immunize.org/catg.d/p2023b.pdf
67
https//www.immunize.org/smallpoxizcards/index.ht
m
68
For adult medicine health professionals. To
subscribe, call [phone] or send email to
admin_at_immunize.org
69
for OB/Gyn providersCall [phone]
70
www.jfponline.com/supplements/jan_03_supplement.a
sp
71
Questions???