1 / 42

Adult Immunization: 2013 Update

Adult Immunization: 2013 Update . Robert H. Hopkins, Jr., MD, FACP, FAAP Professor of Internal Medicine and Pediatrics Director, Division of General Internal Medicine Director, Internal Medicine-Pediatrics Residency UAMS College of Medicine. Opportunity and Reward.

hewitt
Download Presentation

Adult Immunization: 2013 Update

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. Adult Immunization:2013 Update Robert H. Hopkins, Jr., MD, FACP, FAAP Professor of Internal Medicine and Pediatrics Director, Division of General Internal Medicine Director, Internal Medicine-Pediatrics Residency UAMS College of Medicine

  2. Opportunity and Reward • Immunization rates are far below goal levels • Commonly identified measure of quality preventive care • Many elements in process which can be ‘attacked’ to make improvements • Front desk • Nursing/MA • Physician • Checkout • Improvement can result in better health for your patients!

  3. Adult Vaccination Rates= POOR! Data: , NFS 2012, NHIS 2011 http://www.cdc.gov/flu/professionals/vaccination/nfs-survey-march2012.htm http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6204a2.htm?s_cid=mm6204a2_e

  4. Goals: 2013 AI Update • Review current ACIP Adult Immunization recommendations • Office/Clinic Practice • Hospital Practice • Healthcare Workers • Quality improvement re: VPD • No discussion of therapeutic and other vaccines

  5. 2013 Adult Schedule [Age-Based]

  6. 2013 Adult Schedule [Disease/Indication Based]

  7. Patients: Office and Hospital “Universals” “Selectives” Pneumococcal [PCV13] Meningococcal Hepatitis A Hepatitis B HPV [HPV4, HPV2] Women Men MMR Varicella • Influenza • Pneumococcal [PPS23] • Tdap • Zoster

  8. Influenza • Influenza: Orthomyxoviridae family [enveloped RNA virus] • 3 types based on surface Ag [HA, NA] + internal structure • A: Multiple hosts- Birds, Mammals [Man]. Many HA , NA types • ‘Highly Pathogenic’ and ‘Mild’ strains • B: Human host. 1 HA and 1 NA • C: Human host. Mild illness ‘URI’ • 30-50K deaths annually in US from Influenza • 200K+ assoc. hospitalizations, chronic illnesses exacerbations • > 90% seasonal influenza morbidity/mortality in persons > 65 years • Vaccination is most effective intervention to reduce illness and death.. • Multiple vaccines avail. in US • Effectiveness variable from year/year, different patient groups http://www.cdc.gov/flu/avian/gen-info/flu-viruses.htm

  9. US Influenza Vaccines • IIV: =‘Inactivated’ and replaces ‘TIV’, IM admin. “All comers” 6 mo.+ • Multiple vaccines varied indications [age, etc.]. 2013-14 most Trivalent--Limited supply of quadrivalent inactivated vaccine expected to be available • IntradermalIIV [Approved May 2011 for 18-64 years--smaller needle] • High-Dose IIV for 65+ population# [first avail 2010-11] • Same production as TIV, higher Ag content ~~ More local reactions • Phase 3 trials: Seroconversion, seroprotection rates > TIV for A,B strains • ‘Real world’ efficacy data not yet published • New Cell culture vaccine approved 2013- option in egg-allergic [2013-14] • NewRecombinant HA Vaccine approved 2013- higher HA content, no NA • LAIV: Live-attenuated, cold-adapted nasal. Quadrivalent [2A2B] 2013-14 Indicated only for healthy people 2-49 yrs. # Falsey, et.al. J ID 2009, June9 [Epub]; C. Bridges CDC Personal Comm. 3/2013

  10. Influenza Vaccine changes annually, recommend yearly vaccination! • Vaccine production: ~9 months • Egg-based [all but new recombinant HA, cell-culture vaccines] • Strain choice (Feb) reflects antigenic drift [Prior season + S. Hemisphere] • US Vaccination season: Vaccine avail. to ‘disease passed’…[Sept-April?] • Predominant strain types [Dz and Vax] since 1977: A H1N1, A H3N2, B • 2012-13 Vaccine strains: • Influenza A/California/7/09 (H1N1)-like virus [Since 2009 Pandemic] • Influenza A/Victoria/361/2011 (H3N2)-like virus • Influenza B/Wisconsin/1/2010-like virus (B/Yamagata lineage). • 2/3 strains changed from 2011-12, likely at least B will change for 2013-14 http://www.cdc.gov/vaccines/recs/acip/downloads/mtg-slides-feb09/04-1-flu.pdf

  11. Influenza Vaccine Priorities • ALL 6 MONTHS AND OLDER + DON’T WANT THE FLU • HEALTHCARE WORKERS • High risk for disease (symptomatic and asymptomatic) • High risk for transmission • If sick not available to provide healthcare… • PATIENTS @ Highest Risk severe illness/spread • Pregnant women • Newborns and Children < 2 years • Elderly • “Medical Comorbidities” (including Obesity) • Household contacts of high-risk • Long-term care/institutionalized, Crowded living conditions http://www.cdc.gov/vaccines/pubs/vis/downloads/vis-flu.pdf

  12. Influenza ‘Nuts and Bolts’1 http://www.cdc.gov/vaccines/pubs/vis/downloads/vis-flu.pdf http://www.premierinc.com/all/safety/safety-share/12-05-downloads/03-shea-hcw-flu-position-paper.pdf http://www.uptodate.com/contents/influenza-vaccination-in-individuals-with-egg-allergy • IIV: 1 dose for adults • Incl: QIV, TIV, sqTIV, hdTIV, LAIV, ccTIV, rHA(Flublock) • Kids < 9 years, first vaccine season: 2 doses 4+ weeks apart • LAIV can be safely used in MOST HC settings as alt. to TIV2 • Egg allergy: ACIP, AAAI: NO contraindication. • Anaphalaxis EXCEEDINGLY rare [~1 in 4 million doses] • History is key: Hives= higher risk, consider allergy referral • Risk/benefit of disease vs. vaccineusually favors vaccine… • When vaccinating egg-alergic, observe in office ~ 30 minutes

  13. Influenza • Vaccine effectiveness is multifactorial • Match with ‘disease’ strains • Vaccine availability and timing • Patient ‘substrate’: • ‘Healthy young < 65’ @ ~60-80% v. ‘Sick older > 65’@ 30-40% • Ongoing vaccine research • Adjuvants • Newer production methods • Higher Ag content http://www.cdc.gov/flu/professionals/antivirals/index.htm http://www.cdc.gov/flu/professionals/diagnosis/

  14. Pneumococcal • > 2000 Adults 65+ die from invasive Pneumococcal Disease yearly • Primary adult vaccine is purified capsular polysaccharide [PPS23] • 23 types- cause of 88 % bacteremic PNC dz • 60-70% efficacy vs. invasive disease [IPD] • IPD= Pneumococcal meningitis, bacteremia • Does not ‘prevent pneumonia’ • Immunity lasts at least 5 yr. following 1 dose • ROUTINE REVACCINATION ONCE @ 5+ yr. + age 65 ACCEPTED • RECOMMEND SELECTED Revaccination: • Vax > 5 yrs before, AND Asplenia, Immunosupressed, CKD or Nephrotic Syndrome • Local reactions- only common AE http://www.cdc.gov/vaccines/recs/schedules/downloads/adult/2009/adult-schedule-bw.pdf

  15. PPS 23 Vaccine Effectiveness Fine, et.al. ArchivesIM 1994(154): 2666. Hutchinson et.al. CanJFP 1999(45): 2381. Watson, et.al. Vaccine 2002(20): 2166. Conaty, et.al. Vaccine 2004(22): 3214. Dear, et.al. Cochrane DB Syst Rev 2004, Issue 3. Moberley , et.al. Cochrane DB Syst Rev 2008, Issue 1. Moberly, et.al. Cochrane DB Syst Rev 2013, Issue 1. • 7 Meta-Analyses of RCT [Most recent Cochrane 1/2013] • Conclusions inconsistent re: cause specific outcomes • Agreement: REDUCTION in IPD; NO reduction ALL CAUSE mortality, pneumonia • 3 Meta-Analyses of OBS studies • Consistent results: vaccine is effective for prevention of IPD • Recent RCT Results • IPD: Odds ratio [consistent] 0.26 (CI 0.25-0.46) • Pneumonia: Odds ratio [signif. heterogeneity] 0.71 (CI 0.52-0.97) • Mortality: Odds ratio 0.87 (CI 0.69-1.10) • Summary • Data supports PPS to prevent IPD, not compelling for Pneumonia, Mortality

  16. Pneumococcal Recommendations PPS23 is recommended1 for: • Adults 65+ • Cigarette Smokers [Since 2009] • Chronic conditions: • Diabetes • Heart, Lung, Liver, Kidneydisease • Including Asthma [Since 2009] • Immunocompromise[PCV13+PPS Since 2012] • Disease-based: Solid tumor, Hematologic malig, Myeloma, HIV,… • Iatrogenic: Steroids, Organ transplants, BMT, … • Anatomic/functional asplenia [Sickle Cell, etc.][PCV13+PPS Since 2012] • CSF Leak, Cochlear Implant [PCV13+PPS Since 2012] MMWR 2008;57(53). Scott, et.al. Vaccine 25 (2007) 6164-6.

  17. PCV13 Vaccine in Adults NEW 2012 • Routine PCV-13 in US infants since 2010 • 2010 FDA approved + ACIP recommended • All children 6 weeks – 71 months [Series- another talk…] • Dec 30, 2011 FDA approves for adults: • Prevention of pneumonia and IPD ≥ 50 years • Based on immunogenicity studies [not clinical efficacy] • Safety in ~6000 adults similar to PPSV23 • June 20, 2012 [Pub Oct 12, 2012] ACIP recommends PCV13 in adults: • Immune compromised adults ≥ 19 years + CSF leak/cochlear implant • Best practice PCV 13 should be administered before PPS23 • 1 Booster in children 6-18 years with immune compromise ACIP. MMWR. 2012:61:394-395.

  18. PCV 13 Recommended in Adults With: • Solid Organ Transplants • Multiple myeloma • Hematologic malignancy [Leukemia, Lymphoma, Hodgkins] • General Malignancy • ESKD, Nephrotic Syndrome • Sickle Cell, hemoglobinopathy • HIV • Immunosuppression/Immunodeficiency • Not-immune-compromised • CSF leak, Cochlear implant

  19. PCV13 Vaccine in Adults NEW 2012 • Pneumococcal (PPS23) vaccine-naïve patients: • Adults ≥ 19 yrs with immunocompromise, CSF leak/Cochlear implant • PCV13 FIRST followed by PPS23 at least 8 weeks later • Booster PPS23 in 5 years • AND boost PPS 23 after 5 years PLUS 65+ years old • Previously PPS23-vaccinated subjects: • Adults ≥ 19 yrs with immunocompromise, CSF leak/cochlear implant • PCV13 should be given 1+ years AFTER PPSV23 • Booster PPS23 in 5 years • AND boost PPS 23 after 5 years PLUS 65+ years old ACIP. MMWR. 2012:61:394-395; ACIP June 20, 2012.

  20. Td >> Tdap • All patients should have primary Tetanus, diphtheria series • 3 doses: 0, 1 m., 6 m. [Yields protective Ab~ all for 10 yrs+] • Many adults > 60 y. never received primary T, d series • Over 50% adults do not have protective T, d Ab’s • Booster Td every 10 years [Many adults do not receive routine boosters] • Most boosters given are ‘episodic trauma-related’ • Replace 1 dose Td with Tdap [In primary series or as ‘booster’] • Tdap need not wait on 10 year interval from last Td • Td/Tdap Contraindications • Severe allergy to vaccine comp., Arthus reaction after prior Tetanus vax. • [Tdap] Encephalopathy < 7 days after pertussis containing vaccine • [Tdap] Unstable neurologic disease, Moderate-severe acute illness http://www.cdc.gov/vaccines/vpd-vac/combo-vaccines/DTaP-Td-DT/Tdap.htm

  21. Td >> Tdap • Pertussis incidence increasing since 1970’s • 2012: CDC Passive Surveillance US >42,000 cases, likely 10+x higher • Community outbreaks: Most in fall, winter and in persons of all ages • Nosocomial Disease: Academic, Community • [Med/Surg, OR, L&D, NICU, Oncology] • Residential Care • Adults/Adolescents do not have ‘classic’ triphasic disease • Most have persistent Cough: Median 4 months [6 studies] • 20-40 % ‘Whoop’, 40-55 % Posttussive emesis • 12-32 % Lymphocytosis • ~10% develop complications [Pneumonia most common] http://www.cdc.gov/vaccines/vpd-vac/pertussis/ http://www.cdc.gov/vaccines/vpd-vac/combo-vaccines/DTaP-Td-DT/Tdap.htm

  22. Td >> Tdap • Tdap Recommendation: All Adults • Single dose to replace one dose Td [Booster or primary] • Current recommendation: subsequent Td q10yr • Research on repeated dosing ongoing • May give any time (< 10 years) following last Td • 2011: Tdap recommendation extended to adults > 65 years • No data to suggest harm • Research in process re: effectiveness • Special emphasis: adults with close infant contact: • HEALTHCARE, Parents, Child Care, etc. • NEW 2013: Tdapintrapartumall women, each pregnancy • Regardless of interval/prior Tdap [ideal @ 27-35 weeks] http://www.cdc.gov/vaccines/vpd-vac/combo-vaccines/DTaP-Td-DT/Tdap.htm

  23. Zoster • Most who have varicella have measureable Ab for life • Zoster occurs when CMI surveillance declines [theoretical] • Reactivation or Varicella exposure re-stimulates CMI [Cycle repeats] • Lifetime risk of Zoster ~33% [99.5% adults serology + prior Varicella] • At 85- lifetime risk ~ 50% • PHN= most common AE • To 1/3 patients with Zoster • More common • Zoster occurs @ 70+ • Immunocompromised • Vaccination stimulatesCMI • Arvin A. NEJM 2005;352:2266-77. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5705a1.htm

  24. Zoster • Vaccinate60+ adults [ACIP: Not immunocompromised] • FDA approved from age 50 [Coverage? Cost/Bene?] • Regardless of prior Zoster [opinion: wait 1 yr] • No need to test for/vaccinate against Varicella first • Contraindications • Pregnancy • Anaphylactic Hypersensitivity to Neomycin, Gelatin • No need to defer for ‘at risk contacts’- transmission risk low • No need to defer if recent transfusion, Ab containing products • Adverse events • Occasional mild varicella-like rash @ vaccine site • Frozen powdered vaccine: Give within 60 minutes, 0.65 ml SQ Deltoid • Duration of protection: At least 4 years. No booster. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5705a1.htm

  25. Zoster Vaccine Efficacy Trial: • 38,546 Veterans: Median age: 69 years • 60-69: 20,747 [Efficacy greatest in this group] • ≥ 70: 17,799 (46%) • ≥ 80: ~2,500 (6.5%) • Excluded: Immunocompromised, prior zoster, < 60 yrs. • Vaccine group had [v. placebo]: • 51% fewer episodes of zoster • Less severe disease • 66% less postherpetic neuralgia • No significant safety issues were identified Oxman MN et al. NEJM. 2005;352:2271-2284.

  26. Varicella • Varicella, Zoster vaccines from OKA-strain attenuated virus • Varicella 1,350 PFU virus/dose • Zoster 20,000-60,000 PFU virus/dose • Varicella recommendations similar to MMR: 2 doses, live virus • Difference: Non-immune born after 1980 • Risk of vaccination in pregnancy lower than MMR; but neither is recommended: Vaccinate non-immune women postpartum • Risk groups • HEALTHCARE WORKERS (need 2 doses unless immune) • Education, Daycare, Institutional Employees • Women of childbearing age [Vaccinate pre-preg., post-partum] • International travel

  27. MMR, Varicella • Contraindications: • Severe immune compromise • Organ transplant • HIV: CD4 < 200 • Allergy to vaccine component [MMR=Egg, Varicella=Neomycin, gelatin] • Acute/severe illness • Recent transfusion [Any immunoglobulin-containing product] • Active untreated TB • Pregnancy • MMR: not pregnant x 3 months after vaccine- prevent NRS • Varicella: Not major risk but avoiding all live vaccines recommended • Live virus vaccines [Var., MMR, Zoster] and Tb skin test • OK same day, otherwise delay skin test > 3 months http://www.cdc.gov/mmwr/preview/mmwrhtml/00053391.htm

  28. MMR CDC Health Advisory Network: June 22, 2011, 16 :00 EST (04:00 PM EST) CDCHAN-00323-11-06-22-ADV-N http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5733a1.htmhttp://www.cdc.gov/mmwr/preview/mmwrhtml/mm5542a3.htm http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5753a6.htm • Disease reports increased since 2005…. • Live-attenuated vaccine, routine childhood in most ‘developed world’ • MMR for Adults: 2 doses in non-immune adults born after 1957 • High Risk • HEALTHCARE WORKERS [Born after 1957- Immune or 2 doses] • College Students, [Prison, military barracks, etc.] • International Travelers • Outbreaks assoc. with international travel, adoptions • Immigrants

  29. Hepatitis A, B • Vaccination currently recommended in all US children • Hepatitis A [2007] • Hepatitis B [1995] • Both have selective recommendations for adults • Do NOT need to start over if completion of series is delayed • Can be given individually or together [Combination vaccine] • HAV: 2 doses @ 6+ month interval • HBV: 3 doses @ 0, 1 m, 6 m. • Dose and alternate regimens are different for Hemodialysis patients • Combination: 3 doses @ 0, 1 m, 6 m. • Accelerated Combo.: 4 doses @ 0, 7 d., 21-30 d., booster @ 1 yr. http://www.cdc.gov/vaccines/recs/schedules/downloads/adult/2009/adult-schedule-bw.pdf

  30. Adult Hepatitis A,B Indications • Hepatitis A • Chronic Liver Disease • Including chronic HBV, HCV • MSM • Injection Drug Users • Travel to endemic area • Recipients of Clotting factors • Lab workers • Dialysis HBV • High dose vaccine: all ESRD pt. • Hepatitis B • Diabetes mellitus [12/2011] • Chronic Liver Disease incl. chronic HCV • MSM • Injection Drug Users • Travel to endemic area/intl. adoption • Recipients of Clotting factors • >1 sexual partner/6 mo, STD clinics • HEALTHCARE WORKERS • HIV • Household and sexual contacts of HBV patients • Male prison inmates, correctional staff • Developmental disability facility patients, staff • AK natives and pacific island natives • Any others that want to prevent HBV http://www.cdc.gov/vaccines/recs/schedules/downloads/adult/2009/adult-schedule-bw.pdf

  31. HPV • Cervical Cancer is consequence of a STD [HPV] • Second most common cause CA death in women • 500,000 cases and 250,000 deaths per year • US: ~10 women die every day of cervical cancer • Cause of anal CA and penile CA in men • 20 million current HPV infections • By age 50, 80% SA women will have acquired genital HPV • Many clear spontaneously • 6.2 million new genital HPV infections/year in US • 74% in women 15-24 years of age • 70% Cervical CA worldwide d/t serotypes 16 [54%], 18 [13%] • >90% Genital Warts due to serotypes 6, 11 http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5602a1.htm

  32. HPV • Vaccines: • Gardasil [MSD]: Types 6,11,16,18 3 dose series @ 0, 2 m., 6 m. • Cervarix [GSK]: Types 16,18 3 dose series @ 0, 1-2 m, 6 m. • Ideally should finish series with same vaccine begun, but mix is OK… • Effective protection at least 5 years based on published data [ongoing] • Effective only for types patient has NOT previously acquired • HPV 2 or 4 Women 11-12 [9-26]: prevent Cervical CA[Pre-CA], Genital Warts • HPV4 Men 9-26 to prevent anal/penile preCA and CA • Contraindications/Cautions: • Local reaction, bronchospasm reported • Not recommended in pregnancy- no proven AE [administer after delivery] • Immunosupression can reduce efficacy • VACCINE DOES NOT CHANGE CERVICAL CANCER SCREENING RECs! http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5602a1.htm

  33. Meningococcal • Highly-contagious gram-negative bacterial infection • Highest mortality in children < 1 year • Recommended for children @ 11-12, pre-college ‘catch up’ • selective adult recommendation based on risk • 4 Current vaccines: A, C, Y, W-135 [no type B vaccine] • MPS4: Polysaccharide vaccine [SQ, 1 dose +?booster] • Available since 1978, fair efficacy, OK if conjugate not available • MCV4 [3 products]: Conjugate vaccines [IM, 1 dose] • Approved 2005, 2010, 2012 • Preferred for primary vaccination • Selective booster dosing after 5 yrs [e.g. if high risk persists/recurs] • MMWR 2005;54(RR-7)

  34. Meningococcal Indications • All Children 11-12 years • College freshmen who will live in dormitory/commune • Not previously vaccinated or vaccinated >5 years previously • Asplenia [anatomic or functional]: Best to vaccinate pre-splenectomy • Terminal complement deficiencies • HIV: Best response if CD4 > 200 • Travelers to ‘at risk areas’: Sub-Saharan Africa, Dec-June • Required for entry into Saudi Arabia/Mecca during Hajj • Microbiologists with potential occupational Meningococcus exposure • MMWR 2005;54(RR-7)

  35. Healthcare Workers

  36. Healthcare Workers • Key in implementation of Adult Immunization • Education • Multiple studies: MD recommendation  increases patient Vax uptake • Need preventive benefits ‘for themselves’ • Potential source for disease transmission • Patients • Other staff • Communities • Families • Potential for VPD to impair patient care • Adversely affect efficiency • Prevent HCW from working with [their] patients http://www.cdc.gov/mmwr/preview/mmwrhtml/00050577.htm

  37. HCW Vaccination • Annual influenza vaccination • Tdap: All should receive 1 dose • MMR, Varicella: Proof of immunity or 2 doses [each vaccine] • HBV: 3 dose series • Titer 1 month after series; repeat series x 1 if titer < 10 IU • No recommendation for screening titer otherwise

  38. HCW Recommendations Adapted from data located at http://www.cdc.gov/vaccines/recs/schedules/adult-schedule.htm * Live Virus Vaccines

  39. Special Populations • Hospitalized [Medical] Patients • Influenza [in season], Pneumococcal year-round • Consider ‘family ring’ Tdap, Influenza prior to L&D discharge • Immune Compromise: Maximal ‘non-live’ vaccination • Steroids: Prednisone 20 mg/d equivalent • HIV: CD4 < 200 • Biologic Immunomodulators • Preop Consult • MeningCV, PCV13 then 8+ week PPS23 Pre-Splenectomy • PCV13 then 8+ week PPS 23 Pre-Cochlear implant • Travel • CDC ‘Yellow Book’, Travel Clinics esp. for ‘specials’

  40. Immunization Improvement Strategies • Reminder-Recall • Telephone, E-mail, Text, Post card,.. • Partnering • Local Pharmacy, Health Unit • Team-based Care [Standing Orders] • Front desk—MA--Nurse—MD • Standing orders for vaccination are approved and endorsed by CMS since 2002 • Regular P-D-S-A Cycling • Internal and External reporting

  41. Tools • ACP Adult Immunization Guide • FREE!! I-phone/I-pad App [Available in App store] • Download complete guide [or sections] from ACP website • CDC Adult Immunization Scheduler • http://www.cdc.gov/vaccines/recs/Scheduler/AdultScheduler.htm • CDC/ACIP Recommendations • http://www.cdc.gov/immunizations • http://www.cdc.gov/vaccines/pubs/ACIP-list.htm • IAC Summary of Adult Immuniztion Recs • http://www.immunize.org/catg.d/p2011.pdf • STFM SHOTS Tools for ‘Smart’ Phones • http://www.immunizationed.org/

  42. Thank you for your attention! Questions???

More Related