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Laurene Mascola, M.D., M.P.H. lmascola2@yahoo

IMPORTANCE OF IMMUNIZATION IN ADULTS: WHAT’S NEW?. Laurene Mascola, M.D., M.P.H. lmascola2@yahoo.com. Annenberg Center for Health Sciences at Eisenhower April 5, 2018. DISCLOSURES AND ACKNOWLEDEMENTS. Speaker for Merck Acknowledgement: Dr. Carolyn Bridges, April 12, 2017

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Laurene Mascola, M.D., M.P.H. lmascola2@yahoo

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  1. IMPORTANCE OF IMMUNIZATION IN ADULTS: WHAT’S NEW? Laurene Mascola, M.D., M.P.H. lmascola2@yahoo.com Annenberg Center for Health Sciences at Eisenhower April 5, 2018

  2. DISCLOSURES AND ACKNOWLEDEMENTS • Speaker for • Merck • Acknowledgement: • Dr. Carolyn Bridges, April 12, 2017 • Dr. David Kim, April 26,2017-CDC Net Conference

  3. OBJECTIVES • Background- • Burden among adults for VPDs • Impact of vaccination • 2017 adult immunization schedule updates • Influenza, Zoster, PPSV/PCV 13,Tdap, HPV, Meningococcal • Gaps in vaccination coverage • Strategies to improve adult immunization coverage

  4. OBJECTIVES • Background- • Burden among adults for VPDs • Impact of vaccination • 2017-2018 adult immunization schedule updates • Influenza, Zoster, PPSV/PCV 13,Tdap, HPV,, Meningococcal • Gaps in vaccination coverage • Strategies to improve adult immunization coverage

  5. THE AGING POPULATION AND THE IMPORTANCE OF PREVENTIVE CARE (1) • Centers for Disease Control and Prevention (CDC). Healthy Aging: Helping People to Live Long and Productive Lives and Enjoy a Good Quality of Life: At a Glance 2011. cdc.gov/chronicdisease/resources/publications/aag/pdf/2011/Healthy_Aging_AAG_508.pdf. Accessed July 15, 2013 • CDC. MMWR Recomm Rep. 2008;57(RR-7):1-64. 3. CDC. MMWR Recomm Rep. 1997;46(RR-8):1-24. 4. Harpaz R et al. MMWR Recomm Rep. 2008;57(RR-5):1-30 • Currently, ∞ 80% of older adults live with at least 1 chronic condition1 • 50% of older adults have at least 2 1 • Infectious diseases take a disproportionate toll on older adults1 • Age is an independent risk factor for several infectious diseases- i.e. influenza, pneumococcal disease and shingles2-4

  6. AMERICANS ARE LIVING LONGER THAN EVER (2) • 10,000 turn 65 daily; trend continues through 2030; health care spending will increase by 25% • Between 2012-2050, # adults ≥65 will double in US, reaching 84 million • by 2030, 1/5 Americans will be ≥ 65 • In 2033, these adults will outnumber those < 18 yrs. for first time in US; clinical preventive services more a priority than ever

  7. OBJECTIVES • Background- • Burden among adults for VPDs • Impact of vaccination • 2017-2018 adult immunization schedule updates • Influenza, Zoster, PPSV/PCV 13,Tdap, HPV, Meningococcal • Gaps in vaccination coverage • Strategies to improve adult immunization coverage

  8. Health and Economic Impact of Influenza • Millions of cases per year-this year one of the worst-back to 2014-2015 • 226,000 hospitalizations/year, >75% in elderly • 3,000-49,000 death/year,>90% among adults;2018>84 children died • 2/3rds unvaccinated- half healthy • Direct medical cost-$10.4 million, with loss of work and life-$87 billion

  9. IMPACT OF VACCINATION-INFLUENZA • Vaccine effectiveness varies depending on antigenic match, age and health • 60–70% in younger adults when good match • Adults ≥65yrs 30% for illness if good match • 2017–2018 interim vaccine effectiveness estimate- all types VE 36% (27-44%) • 25%(13-36%) against A(H3N2); 67% (54-76%)against A(H1N1)pdm09 • VE for type B Yamagata 42% (25-56%) • Children 6mo-8 yrs. had VE H3N2 -59%

  10. US LAB- CONFIRMED FLU HOSPITALIZATIONS 2011-2017

  11. INFLUENZA 2017-2018 SEASON TO DATE: March 17,2018 • Began to increase start Nov. –still regional in US and widespread in California • Flu A (H3N2)most frequent: • why season has higher mortality and hospitalization among older adults ( and those 50-64) and children • Outpt ILI levels are highest since pandemic • Hospitalization rates surpassed reports during same week of 2014-2015 season • LAC one peds death; US 133 peds (3/4s no vaccine)-almost as high as pandermic fluwatch@laster.ph.lacounty.gov

  12. PROPORTION OF ILI ED VISTS/WK –LAC 2014-2018 March 2,2018 Fluwatch

  13. To subscribe send email to: fluwatch@listserv.ph.lacounty.gov H1N1

  14. IMPACT INFLUENZA VACCINE-CARDIAC • Effective in preventing major cardiac events among persons with existing cardiovascular disease(1-4) • Meta-analysis of case control studies: (3) • Acute respiratory illness/ILI increases acute MI risk by 2-fold • Influenza vaccination efficacy (VE) 29% (95% CI=9-44%) against acute MI • Meta-analysis randomized studies persons with existing CVD: influenza VE 36% (95% CI=14%-53%) 1. CDC. Prevention and Control of Seasonal Influenza: Recommendations of the ACIP – U.S., 2014-15 Influenza Season. MMWR 2014; 63(32); 691-697. • 2. American College of Cardiology recommendations for secondary prevention of atherosclerotic cardiovascular disease. • 3. Barnes M, et al. Acute myocardial infarction and influenza: a meta-analysis of case–control studies. Heart 2015;101:1738–1747. • 4. Udell JA, et al. Association between influenza vaccination and cardiovascular outcomes in high-risk patients: a meta-analysis. JAMA 2013;310:1711–20.

  15. INFLUENZA VACCINE DURING PREGNANCY PROTECTS INFANTS<6MO FROM INFLUENZA Zaman et al.NEJM359: 1555-64,2008

  16. BURDEN OF ZOSTER AND PHN ON HEALTH RELATED QUALITY OF LIFE • l million cases of zoster annually in US • 10-11/1000 per year in those ≥60 yrs • Life time risk 32% • Thoracic, cervical, ophthalmic most common involvement • ∞ 10-25% with ophthalmicus complication • Risk of severe PHN increases with age-∞ 17-20%

  17. IMPACT OF PHN ON HEALTH-RELATD QOL Drolet M.et al, CMAJ 2010- dk blue at recruitment of pain, light blue after pain stopped

  18. IMPACT OF VACCINATION-PNEUMOCOCCAL (1) • 13-valent pneumococcal conjugate vaccine (PCV13) • 45% against vaccine-type pneumococcal pneumonia and 75% against vaccine-type invasive pneumococcal disease (IPD) among adults ≥65y • 23-valent pneumococcal polysaccharide vaccine (PPSV23) • 74% (95%CI 55,86) in meta-analysis against IPD • Not effective against non-IPD pneumonia • 11 unique serotypes (12 common serotypes with PCV13) caused 38% of IPD among adults ≥65y Bonten MJ,et al.NEJM2015;372:1114-25

  19. IMPACT (2) • Significant reductions in overall and PCV13 serotype IPD among adults since PCV13 introduction • Rates plateaued in 2014-2016, no further reductions in adults≥ 65 yrs. Since 2014 adult PCV 13 recommendations • Despite reductions, IPD rates, including PCV13 serotypes, remained high in adults with HIV

  20. Pertussis

  21. BURDEN OF PERTUSSIS: US AND LAC, 1/1/2016-12/31/2016 • USA-2015-21,000 cases,22% in adults • Most severe for infants: hospitalized-apnea, pneumonia, seizures, death • LAC- 216 cases, 8% hospitalized, no deaths • 16 percent <one year; 35% hospitalized • 32% under ten years • 85% <19 years with only one hospitalization • Complications adults: pneumonia, syncope, rib fracture, etc.

  22. IMPACT OF VACCINATION-Tdap IN PREGNANCY • Vaccinating pregnant women 90% effective in preventing pertussis in infants • From 2000-2011 in US, annual number of pertussis cases in infants ≤ 12 months with maternal Tdap vaccination: • 2746 cases (549 with vaccination after preg, 906 with vaccination during); 1217 hospitalizations prevented and 18 deaths prevented :3 with vaccination after, 9 vaccination during • Vaccinate with each pregnancy

  23. BURDEN OF CERVICAL CANCER INCIDENCE, MORTALITY US 2007-2012 • Assessed recent trends (MMWR. 2014;63:1-6) • Trends in cervical cancer incidence rates have decrease slightly while death rates same • South had highest incidence and death rate, and % of women not screened in past 5 years • 11.4 % of US women had not been screened in past 5 years • Those not screened more likely not to have health insurance

  24. OROPHARYNGEAL CANCER Oropharyngeal cancer has surpassed cervical cancer as most common HPV-related cancer 70% of oropharyngeal cancers are related to HPV One study prevalence of HPV 16 and 18 was 3.9% in sample healthy pop Need to discuss importance of HPV vaccination wrt to this cancer as well

  25. IMPACT OF VACCINATION From 2008-2012,CIN2+incidence decreased from 94 to 5/100,000 in 18-20 yr. old women in Ca. and 450 to 57 in NY Australian model predicted: over 2018-2035 CIN 2/3 and invasive cervical cancer rates to decrease 40-44%, and 42-51% respectively Genital warts already decreased; RLP down In US, within 8 yrs. Of vaccine intro.4HPV types dec. 71% among 14-19 and 61% in 20-24 yr. old women [JID2017:216(1Sept)Oliver et al]

  26. OBJECTIVES • Background- • Burden among adults for VPDs • Impact of vaccination • 2017-2018 adult immunization schedule updates • Influenza, Zoster, Tdap, HPV, Meningococcal, PPSV/PCV 13 use in adults • Gaps in vaccination coverage • Strategies to improve adult immunization coverage

  27. ADULT IMMUNIZATION SCHEDULE • Updated yearly: is current, approved ACIP policy • Designed for implementation of ACIP recs • Contains figures for indications by age ,medical or other conditions; contains notes for each vaccine • Target audience –clinical care providers and pharmacists • Updates approved by • American College of Physicians, AAFP, ACOG, American College of Nurse-Midwives • Published in • MMWR, Annals of Internal Medicine

  28. UPDATES-2018 ADULT IMMUNIZATION SCHEDULE • Influenza vaccination –Jun 2017 • No LAIV in 2017–2018;changed language on egg allergy, Feb 2018 will be different • Zoster vaccine • Use extra MMR in outbreak setting • HPV vaccination –Oct 2016 • Updated dosing schedule • Meningococcal vaccination –Jun and Oct 2016 • Use of MenACWY for adults with HIV infection • Updated dosing schedule for MenB-FHbp

  29. RECOMMENDED IMMUNIZATION SCHEDULE FOR ADULTS AGED ≥19 YEARS US, 2018 BY CONDITION*(1) Ann Intern Med. 2018;168(3):210-220

  30. RECOMMENDED IMMUNIZATION SCHEDULE FOR ADULTS AGED 19 YEARS OR OLDER: US, 2018

  31. Influenza A

  32. FLU VACCINE-UPDATED RECOMMENDATIONS LAIV should not be used in 2017–2018, different for next year If hx of egg allergy and hives-, use any licensed age-appropriate influenza vaccine If egg rxns other than hives, use any age-appropriate flu vaccine (IIV or RIV) Angioedema, respiratory distress, lightheadedness, recurrent vomiting: give in medical setting supervised by HCP MMWR 2016;65(RR-5);29-30

  33. NEW IN INFLUENZA • Safe to vaccinate women during pregnancy with influenza vaccine and suggest protective effect (Regen, et al. CID. 2016;62[10]:1221) • Studied 58,008 births 2012-2013; 5076 vaccinated, 52932 unvaccinated • overall only 8.7% vaccinated - in Australia • The adjusted risk of stillbirth was 51% lower among vaccinated women compared with unvaccinated (aHR-.49;95% CI, .29-.84)

  34. VACCINATION OF ADULTS 65 YEARS AND OLDER High dose flu vaccine inactivated trivalent vaccine – 4 x antigen as standard dose Licensed 2009 based on better immunogenicity wrt to standard for influenza A (H1N1), A (H3N2) and non-inferior immune response for B RCT found efficacy of high-dose relative to standard dose vaccine of 24% (CI 9.7-36.5) against laboratory confirmed influenza Cohort study by CMS comparing persons with a claim for standard versus high dose vaccine found 22% (CI 16-27%) reduction in influenza-related hospitalization

  35. HOT OFF THE PRESS • FluMist will be available next year • ACIP voted on Feb. 22,2018 to put it back on list of available vaccines • Some countries always continued use • Vote came after year where most vaccine effectiveness was low • New strain in FluMist-A/Slovenia • Also, vaccine coverage in children dipped 2% after mist discontinued

  36. INFLUENZA VACCINE STATUS IN ADULTS ≥65 YRS. BY POVERTY STATUS MMWR/Feb.23,2018/vol.67/no7/233

  37. Reducing the Risk of Cervical Cancer and Genital Warts in Girls ,Women and Men HPV 9-The Cancer Vaccine .

  38. HPV 9

  39. ACIP RECOMMENDATION: HPV VACCINATION1,2,a Males HPV Vaccination with HPV4 or HPV9 Females HPV Vaccination with HPV2, HPV4, or HPV9 Routine: 11- or 12-year-olds Catch up: 13- to 21-year-olds Routine: 11- or 12-year-olds Catch up: 13- to 26-year-olds • Males and females: Vaccination series can be started at age 9 years • Vaccination schedule supported by AAP, AAFP, and ACOG 1. Centers for Disease Control and Prevention (CDC). MMWRRecomm Rep. 2015;64(11):300–304. 2. CDC. cdc.gov/vaccines/schedules/downloads/child/0-18yrs-child-combined-schedule.pdf. Accessed February 25, 2016.

  40. HPV VACCINATION –UPDATED RECOMMENDATIONS • 2 HPV vaccines (0, 6–12 mos.) should be given if age <15 • 3 HPV vaccines (0, 1–2, 6 mos.) should be given if age ≥15 • Young adults who did not complete HPV series before age 15 • Did not start –give 3 doses of HPV vaccine • Received 1 dose –give 1 dose HPV vaccine • Received 2 doses but <5 mos. apart –give 1 dose HPV vaccine; if after≥5mo apart- considered adequately vaccinated

  41. MENINGOCOCCAL DISEASE :AN UPDATE

  42. MENINGOCOCCAL VACCINATION –BACKGROUND 1980s –MPSV4 rec for groups at increased risk 2005 –MenACWY rec for persons age 11–55 at risk 2010 –MenACWY booster rec for those still at risk 2015 –MenB vaccines for persons age ≥10 at increased risk; healthy 16–23yrs (preferred age 16–18) may receive MenB 2016 –Evidence indicates HIV infection increases risk of invasive meningococcal disease 2016 –MenB-FHbp dosage change approved by FDA (3 doses at 0, 1–2, 6 mos. and 2 doses at 0, 6 mos.); choice depends on risk

  43. MENINGOCOCCAL VACCINATION –UPDATED RECOMMENDATIONS MenACWY: HIV + adults recommended to receive MenACWY at least 2 months apart, revaccinate every 5 years MenB: persons at increased risk for mening: receive 3 doses of MenB-FHbp at 0, 1–2, 6 months Healthy persons 16–23 not at increased risk may receive 2 doses of MenB-FHbp at 0, 6 months (either MenB-FHbp and MenB-4C) (pub pending)

  44. Herpes Zoster

  45. LESIONS OF ZOSTER

  46. IMPACT OF VACCINATION-ZOSTER (1) • Zoster vaccine live(VZVL) 51% against shingles,66% against PHN-not age dependent in efficacy studies; no serious SAE; 1 dose • 80% against extreme cases of PHN(1) • Between 50-60 years- VE 70% • New inactivated adjuvanted HZ subunit vaccine now preferential over VZVL 1. Oxman MN, et al. NEJM 2005;352:2271–2284,2. Lal H, et al. NEJM 2015,3. Cunningham AL, et al NEJM 2016,4. Presented at February 2017 ACIP meeting

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