The evolving adult immunization platform
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The Evolving Adult Immunization Platform. William Schaffner, MD Vanderbilt University School of Medicine Nashville, TN. When meditating over a disease, I never think of finding a remedy for it, but, instead, a means of preventing it. Louis Pasteur

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The Evolving Adult Immunization Platform

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The evolving adult immunization platform

The Evolving AdultImmunization Platform

William Schaffner, MD

Vanderbilt University School of Medicine

Nashville, TN


The evolving adult immunization platform

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)


The evolving adult immunization platform

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


Invigoration of adult immunization

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


Burden of adult vaccine preventable disease

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


Reported pertussis cases

Reported Pertussis Cases

≥ 19 yrs

11–18 yrs

< 11 yrs

Reported Pertussis Cases

  • 2004 provisional data


Tdap vaccine tetanus diphtheria acellular pertussis

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)


Human papillomavirus vaccine cervical cancer

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


Natural history of hpv infection and potential progression to cervical cancer 1

Natural History of HPV Infection and Potential Progression to Cervical Cancer1

0–1 Year

0–5 Years

1–20 Years

Invasive Cervical Cancer

InitialHPV Infection

ContinuingInfection

CIN 2/3

CIN 1

Cleared HPV Infection (~80%)

1. Pinto AP, Crum CP. Clin Obstet Gynecol. 2000;43:352–362.


Hpv vaccine trial

HPV Vaccine Trial

  • Randomized, placebo-controlled, double blind

  • 27,000 volunteers

  • 100% effective vs. CIN 2/3


Human papillomavirus vaccine

Human Papillomavirus Vaccine

CDC’s 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


Herpes zoster shingles vaccine

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


Shingles prevention study 1

Shingles Prevention Study - 1

  • Randomized, placebo-controlled, double blind vaccine trial

  • 38,546 volunteers at 22 sites; adults 60+


Shingles prevention study 2

Shingles Prevention Study - 2

  • 95% of volunteers completed study

  • Follow-up <1 - 4.9 years; average 3 years

  • Shingles reduced 51%

    • 60-69 years 64%

    • 70-79 years 41%

    • 80+ 18%

  • Post-shingles pain: 67%


Reported acute hepatitis b incidence by age group united states 1990 2004

Reported Acute Hepatitis B Incidence By Age Group: United States, 1990-2004

≥20 years

94% decline

71% decline

12-19 years

Cases per 100,000

<12 years

Year


Reported acute hepatitis b incidence by age and sex united states 2004

Reported Acute Hepatitis B Incidence By Age and Sex: United States, 2004

0.1

0.1

<5

Female

Male

0.0

0.1

5-9

0.1

0.1

10-14

1.1

0.4

15-19

3.1

3.1

20-24

5.2

4.2

25-29

4.9

4.0

30-34

Age Group (Yrs)

4.4

5.4

35-39

3.6

4.9

40-44

2.7

4.0

45-49

2.0

3.2

50-54

1.3

2.9

55-59

0.8

1.4

60+

Rate per 100,000


Hepatitis b vaccine acip recommendations

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


Adult immunization

Adult Immunization

InfluenzaTdap

PneumococcalHPV (cervical cancer)

Hepatitis BShingles

Special circumstances, e.g. Travel, Health Care Worker


Adult immunization challenges

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


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