1 / 80

Tactics for Increasing Immunization Coverage Among Adults

Tactics for Increasing Immunization Coverage Among Adults. Educational Learning Objectives. At the conclusion of this presentation, the participant should be able to: Acknowledge the indications and recommendations for current vaccines and vaccine schedules across adult populations

leroy
Download Presentation

Tactics for Increasing Immunization Coverage Among Adults

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. Tactics for Increasing Immunization Coverage Among Adults

  2. Educational Learning Objectives At the conclusion of this presentation, the participant should be able to: Acknowledge the indications and recommendations for current vaccines and vaccine schedules across adult populations Address immunization barriers frequently encountered during patient/caregiver communications regarding safety, efficacy, and possible misinformation Implement strategies for improving immunization rates within one’s clinical practice, taking into account current immunization schedules and guidelines

  3. Adult Immunization Schedule: US 2011 CDC. MMWR Morb Mortal Wkly Rep. 2011;60(4).

  4. Vaccines For Adults Based on Medical and Other Indications 2011 CDC. MMWR Morb Mortal Wkly Rep. 2011;60(4).

  5. Recent Updates to the Adult Immunization Schedule • Influenza • Pneumococcal • Tdap • CDC. MMWR Recomm Rep. 2010;59(RR8):1-62. • CDC. MMWR Morb Mortal Wkly Rep. 2010;59(34):1102-1106. • ACIP. http://www.cdc.gov/vaccines/recs/default.htm. Accessed Nov 2010.

  6. Adult Immunization CoverageNational Health Interview Survey 2009 ≥ 65 yrs ≥ 65 yrs 50-64 yrs, HR 19-49 yrs, HR 19-64 yrs, HR Sample size→ N = 1,067 N = 1,046 N = 2,444 N = 8,070 N = 5,275 HR: High Risk CDC. http://www.cdc.gov/vaccines/stats-surv/nhis/2009-nhis.htm. Accessed Nov 2010.

  7. Adult Immunization CoverageNational Health Interview Survey 2009 19-49 yrs 50-64 yrs ≥ 65 yrs 19-49 yrs, HR 19-49 yrs 19-26 yrs 19-49 yrs ≥ 60 yrs Sample size→ N = 14,378 6,540 5,132 N = 13,127 N = 1,052 12,454 N = 7,335 N = 1,785 HR: High Risk CDC. http://www.cdc.gov/vaccines/stats-surv/nhis/2009-nhis.htm. Accessed Nov 2010.

  8. These new parents (age 30) both received Td vaccine 3 years ago prior to their marriage. Should they be vaccinated with Tdap in order to protect their young son from pertussis?

  9. Both parents should receive a single dose of Tdap promptly to protect their son from pertussis.

  10. Tdap for Adults • 19 to 64 years: single dose of Tdap in place of Td (if no previous Tdap received) • Especially important for adults around young infants • Parents, grandparents, nannies • ≥ 65 years (no previous Tdap) who have close contact with infants < 12 months* • Tdap can be administered regardless of interval since last Td *Off-label ACIP recommendation; Medicare Part D coverage CDC. MMWR Morb Mortal Wkly Rep. 2009;58(14):374-375. ACIP. http://www.cdc.gov/vaccines/recs/acip/slides-oct10.htm#adult. Accessed Nov 2010.

  11. Self-reported Tetanus and Pertussis Coverage Adults, National Health Interview Survey Tetanus Preceding 10 years Adults ≥ 18 yrs Tdap 2008 Adults 18–64 yrs CDC. MMWR Morb Mortal Wkly Rep. 2010;59(40):1302-1306.

  12. Human Papillomavirus 25-year-olds • Sexually active since age 13 • Multiple partners • Not previously vaccinated for HPV • Not previously sexually active • Now in a monogamous relationship • Not previously vaccinated for HPV Should either of these women receive the HPV vaccine?

  13. Available HPV Vaccines CIN2+: cervical intraepithelial neoplasia grade 2 or higher and adenocarcinoma in situ Markowitz L. ACIP Meeting Oct 2009. http://www.cdc.gov/vaccines/recs/acip/downloads/mtg-slides-oct09/02-2-hpv.pdf. Accessed Nov 2010.

  14. HPV – ACIP RecommendationsQuadrivalent HPV (HPV4) and Bivalent HPV (HPV2) • Routine vaccination of females age 11 to 12 years • Catch-up 13-26 yrs (HPV4); 13-25 yrs (HPV2) • ACIP: no preference for either vaccine • HPV4 or HPV2 vaccination for prevention of HPV 16/18-related cervical cancers, pre-cancers, and dysplastic lesions • Vaccination with HPV4 for additional prevention against genital warts, pre-invasive and invasive lesions of the vagina and vulva ACIP Schedules. www.cdc.gov/vaccines/recs/schedules/default.htm. Accessed Nov 2010. FDA. http://www.fda.gov/BiologicsBloodVaccines/Vaccines/ApprovedProducts/ucm172678.htm. Accessed Nov 2010.

  15. HPV Vaccination and Pregnancy • HPV vaccines are not recommended for use in pregnant women • Delay initiation of vaccination until after completion of pregnancy • If a woman is found to be pregnant after initiating the vaccination series, delay remaining doses until after the pregnancy • Two vaccine in pregnancy registries: • Quadrivalent HPV vaccine/pregnancy: 800-986-8999 • Bivalent HPV vaccine/pregnancy: 888-452-9622 CDC. MMWR Morb Mortal Wkly Rep. 2010;59:626-629.

  16. HPV Quadrivalent Vaccine in Males • FDA approved quadrivalent HPV vaccine for boys and men ages 9 through 26 • ACIP: Permissive HPV vaccine for males CDC. MMWR Morb Mortal Wkly Rep. 2010;59:630-631.

  17. Quadrivalent HPV Vaccine for Women 27 to 45 yearsUnder FDA Review ACIP Considerations • As women age from their mid 20s, reduced prevalence and incidence of HPV • Disease outcomes (genital warts, CIN 2/3) peak among women in their mid to late 20s • Questions on natural history of incident infections in adult women • Greatest benefit from vaccinating females in early adolescence • Clinical trial data (women 24–45 years) • Efficacy against HPV 6/11/16/18-related persistent infection, CIN, external genital lesions • Well tolerated CIN: cervical intraepithelial neoplasia Dunne E. http://www.cdc.gov/vaccines/recs/acip/downloads/mtg-slides-feb10/02-3-hpv.pdf. Accessed Nov 2010. Haupt R. http://www.cdc.gov/vaccines/recs/acip/downloads/mtg-slides-feb10/02-2-hpv.pdf. Accessed Nov 2010.

  18. This 65-year-old recently recovered from a case of shingles. Is he a candidate for the zoster vaccine? If so, how long should he wait before receiving the vaccine?

  19. Varicella-Zoster VaccineShingles Prevention Study • Randomized, placebo-controlled, double-blind vaccine trial • Study population • 38,546 volunteers at 22 sites; adults 60+ years • 95% of volunteers completed study • Follow-up: median duration 3.12 years • Vaccine recipients: • Overall incidence of herpes zoster reduced by 51% • Incidence of postherpetic neuralgia reduced by 67% • Injection site reactions were more frequent in the vaccine group Oxman MN, et al. N Engl J Med. 2005;352:2271-2284.

  20. Varicella-Zoster VaccineShingles Prevention Study Postherpetic Neuralgia Herpes Zoster Oxman MN, et al. N Engl J Med. 2005;352:2271-2284.

  21. Zoster (Shingles) Vaccine • Single-dose vaccine licensed for persons 60+ years of age • Shingles • Postherpetic neuralgia CDC. MMWRRecomm Rep. 2008;57(RR5):1-30. CDC. http://www.cdc.gov/vaccines/vpd-vac/shingles/photos.htm. Accessed Nov 2010.

  22. Zoster VaccineContraindications and Precautions • Contraindications • Previous severe allergic reaction to a vaccine component • Immunocompromised persons • HIV, AIDS, leukemia, lymphoma, or other malignant neoplasms • Persons on immunosuppressive therapy, including high-dose corticosteroids • Persons receiving immune mediators/modulators • Pregnancy or planned pregnancy within 4 weeks • Precautions • Moderate or severe acute illness CDC. MMWRRecomm Rep. 2008;57(RR5):1-30.

  23. A previous case of shingles is not a contraindication for the zoster vaccine. The data are not definitive regarding how long to wait following a case of shingles to vaccinate with the zoster vaccine. Some professionals suggest 5 years.

  24. Zoster Vaccine Cost Issues • Routine vaccination not previously covered by Medicare part B • Eligible for reimbursement by Medicare part D • Patient assistance programs • With health care reform • Private sector health plans ‘1st Dollar Coverage’ • Medicare personalized prevention plan Affordable care act. http://www.healthcare.gov/news/factsheets/affordable_care_act_immunization.html. Accessed Nov 2010. AAFP. http://www.aafp.org/fpm/20070700/33bill.html. Accessed Nov 2010.

  25. Seasonal Influenza Has a Huge Annual Impact in the United States Based on 2003 US population demographics Molinari NA, et al. Vaccine. 2007;25:5086-5096.

  26. Influenza Vaccination Coverage Levels *Data from the Behavioral Risk Factor Surveillance System and National 2009 H1N1 Flu Survey • CDC. MMWR Recomm Rep. 2010;59(RR8):1-62. • CDC. http://www.cdc.gov/flu/professionals/vaccination/coverage_0910estimates.htm. Accessed Nov 2010.

  27. Annual Influenza Vaccine Is Recommended for All people* age 6 months and older! High risk groups include: Adults > 50 yrs Young children Pregnant women People with chronic comorbidities * Without contraindications • CDC. MMWR Recomm Rep. 2010;59(RR8):1-62.

  28. 2010–2011 Influenza Season • 2010-2011 Trivalent Influenza Vaccines • A/California/7/2009(H1N1)-like virus • A/Perth/16/2009(H3N2)-like virus • B/Brisbane/60/2008-like virus • Current information from the CDC and FDA • http://www.cdc.gov/vaccines/vpd-vac/flu/default.htm#ref • http://www.fda.gov/BiologicsBloodVaccines/Vaccines/ApprovedProducts/ucm094045.htm • CDC. MMWR Recomm Rep. 2010;59(RR8):1-62. • CDC. http://www.cdc.gov/vaccines/vpd-vac/flu/default.htm#ref. Accessed Nov 2010. • FDA. http://www.fda.gov/BiologicsBloodVaccines/Vaccines/ApprovedProducts/ucm094045.htm. • Accessed Nov 2010.

  29. Seasonal Influenza Vaccines †Includes medical conditions such as chronic pulmonary, cardiovascular, renal, hepatic, neurologic, hematologic or metabolic disorders; those who are immunosuppressed; those who are or will be pregnant during influenza season; residents of nursing homes and chronic-care facilities *Children ≥ 6 mos–8 yrs without prior influenza vaccination or who only received 1 dose of seasonal influenza vaccine should receive 2 doses TIV: trivalent inactivated influenza vaccine; LAIV: live, attenuated influenza vaccine CDC. MMWR Morb Mortal Wkly Rep. 2010;59(RR8):1-62.

  30. 2010–2011 Influenza Season TIV: trivalent inactivated influenza vaccine; LAIV: live attenuated influenza vaccine *Each 0.5 mL dose contains 60 μg each of the 3 influenza strains CDC. MMWR Recomm Rep. 2010;59(RR8):1-62. CDC. MMWR Morb Mortal Wkly Rep. 2010;59(31):989-992.

  31. Influenza Vaccination Coverage LevelsHealth Care Workers (HCW) • CDC. MMWR Recomm Rep. 2010;59(RR8):1-62. • CDC. MMWR Morb Mortal Wkly Rep. 2010;59(12):357-362.

  32. Nosocomial Influenza Is Well Documented • Nosocomial outbreaks documented on • Solid organ transplant units • Oncology units • Neonatal ICU • Pediatric units • Long term care facilities • General medical wards • Results: morbidity for patients & staff, increased costs for institution & impaired capacity to provide care • Vectors for transmission include staff, visitors, patients Encourage hygiene etiquette amongst staff and patients Stott DJ, et al. Occup Med (Lond). 2002;52:249-253.

  33. Considerations for Those Morbidly Obese High-risk Group for Influenza For Intramuscular (IM) Injections 22-25 gauge needle • CDC. MMWR Recomm Rep. 2010;59(RR8):1-62. • Immunization Action Coalition. http://www.immunize.org/catg.d/p2020A.pdf. Accessed Nov 2010.

  34. This woman is 6 months pregnant and would like to get an influenza vaccine. Should she get the trivalent inactivated vaccine, the live attenuated influenza vaccine, or neither?

  35. Influenza vaccination is recommended for all pregnant women, due to the increased risk for influenza-related complications. She should receive the trivalent inactivated influenza vaccine. Live attenuated influenza vaccine is contraindicated during pregnancy.

  36. Maternal Influenza Immunization and Protection of Infants • Nonrandomized, prospective, observational cohort study • Navajo and White Mountain Apache Indian Reservations • N = 1160 mother infant pairs; birth–6 months Eick A, et al. Arch Pediatr Adolesc Med. 2010 Oct 5. [Epub ahead of print]

  37. Cumulative Cases of Laboratory-Confirmed Influenza in Infants of Moms Who Received Influenza Vaccine Compared with Controls; Bangladesh N = 340 mothers randomized to either inactivated influenza vaccine or 23-valent pneumococcal polysaccharide vaccine Zaman K, et al. N Engl J Med. 2008;359:1555-1564.

  38. Influenza Vaccination Coverage Levels Among Pregnant Women Sample size→ N = 113 N = 177 N = 6,225 N = 5,112 NHIS NHIS PRAMS PRAMS NHIS: National Health Interview Survey PRAMS: Pregnancy Risk Assessment Monitoring System; 10 States • CDC. MMWR Morb Mortal Wkly Rep. 2010;59(47):1541-1545.

  39. Influenza in the Elderly • Serious complications from influenza • Secondary infections • Exacerbations of chronic diseases • Increased hospitalization and death • Influenza vaccination • Reduced hospitalizations and death • CDC. MMWR Recomm Rep. 2010;59(RR8):1-62.

  40. High-Dose Inactivated Influenza Vaccine for Adults ≥ 65 Years, 2010-2011 Influenza Season • Rationale • Higher antigen content • Standard dose • TIV 45 μg total virus hemagglutinin antigen per dose • High-dose TIV • 180 μg total virus hemagglutinin antigen per dose • Higher immune response; clinical ramifications unknown • ACIP: no preference for any specific inactivated trivalent influenza vaccine for use in adults ≥ 65 years CDC. MMWR Wkly Rep. 2010;59(16):485-486.

  41. Extremes of age Comorbidities Certain ethnic groups Immune deficiencies Risk Factors for Invasive Pneumococcal Disease Lynch J, Zhanel G. Semin Respir Crit Care Med. 2009;30(2):189-209.

  42. S. Pneumoniae ABCs Data -2008 45 7 40 6 35 Cases 5 Deaths 30 4 25 Deaths per 100,000 Population Cases Per 100,000 Population 20 3 15 2 10 1 5 0 0 < 1 1 2-4 5-17 18-34 35-49 50-64 ≥ 65 Age (years) CDC ABC Surveillance report. http://www.cdc.gov/abcs/reports-findings/survreports/spneu08.html. Accessed Nov 2010.

  43. Invasive Pneumococcal Disease Among Adults ≥ 65 Years, 1998/99–2007 PCV7 introduced 40 35 *92% reduction in PCV7 serotypes, 2007 vs baseline 30 25 Serotype group Cases/100,000 population 20 PCV7 type Non-PCV7 type 15 19A 10 5 * 0 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 Year Pilishvili T, et al. J Infect Dis. 2010;201:32-41.

  44. Pneumococcal Polysaccharide Vaccine (PPSV23) for Adults • Vaccine contains 23 polysaccharide serotypes from S. pneumoniae • Single dose recommended for: • All ≥ 65 years • Asthmatics and smokers age 19 to 64 years • 19 to 64 years: chronic cardiovascular disease, chronic lung disease, diabetes, alcoholism, chronic liver disease, CSF leaks, asplenia, cochlear implants • Immunocompromised persons CDC. MMWR Morb Mortal Wkly Rep. 2010;59(34):1102-1106.

  45. Revaccination with PPSV23 • 19 to 64 years: one-time revaccination after 5 years • Chronic renal failure or nephrotic syndrome • Functional or anatomic asplenia • Persons with immunocompromising conditions • ≥ 65 years: one-time revaccination if vaccinated ≥ 5 yrs previously and < 65 years at time of primary vaccination ACIP. http://www.cdc.gov/vaccines/recs/acip/slides-oct10.htm. Accessed Nov 2010.

  46. Pneumococcal Polysaccharide Vaccine Coverage –Adults ≥ 65 Years, 1997–March 2010 CDC/NCHS. http://www.cdc.gov/nchs/data/nhis/earlyrelease/201009_05.pdf. Accessed Nov 2010.

  47. Effectiveness of Pneumococcal Polysaccharide Vaccine in Older Adults: The VSD Cohort Study • 3-year cohort study of 47,365 members of Group Health Coop (Seattle) • PPV was associated with lower rates of bacteremia: • HR 0.56 (95% CI 0.33 to 0.93) • PPV was not associated with lower rates of pneumonia • HR 1.07 (95% CI 0.99 to 1.14) HR = hazard ratio. Jackson LA, et al. N Engl J Med. 2003;348:1747-1755.

  48. Effectiveness of PPSV23 in Adults2008 Meta-analysis • 22 studies; 15 randomized controlled trials (RCTs), N = 48,656 patients; 7 non-RCTs, N = 62,294 patients • Results from RCTs • Invasive pneumococcal disease (IPD) • Strong evidence of protection (74%); OR 0.26 (95% CI 0.15–0.46); P < 0.00001 • No statistical heterogeneity • All-cause pneumonia • Inconclusive efficacy (29%); OR 0.71 (95% CI 0.52–0.97); P = 0.029 • Substantial statistical heterogeneity • All-cause mortality • No evidence of protection; OR 0.87 (95% CI 0.69–1.10); P = 0.25 • Adults with chronic illness • Evidence is less clear • Results from non-RCTs • IPD • Evidence of protection (52%); OR 0.48 (95% CI 0.37–0.61); P < 0.00001 Moberley S, et al. Cochrane Database Syst Rev. 2008;(1):CD000422.

More Related