Immunization may prevent non infectious diseases in older adults
Download
1 / 58

Immunization May Prevent Non -infectious Diseases in Older Adults - PowerPoint PPT Presentation


  • 80 Views
  • Uploaded on

Immunization May Prevent Non -infectious Diseases in Older Adults. “Fundamental Concepts in Age-Related Health and Wellness.” 15 September 2014 - 1:15-2:15 pm Sheraton Providence Airport Hotel, Warwick, RI. Jeffrey Bratberg, PharmD, BCPS Clinical Professor of Pharmacy Practice

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about ' Immunization May Prevent Non -infectious Diseases in Older Adults' - tracy


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.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
Immunization may prevent non infectious diseases in older adults

Immunization May Prevent Non-infectious Diseases in Older Adults

  • “Fundamental

  • Concepts in Age-Related Health and Wellness.”

  • 15 September 2014 - 1:15-2:15 pm

  • Sheraton Providence Airport Hotel, Warwick, RI

Jeffrey Bratberg, PharmD, BCPS

Clinical Professor of Pharmacy Practice

University of Rhode Island College of Pharmacy

Adjunct Clinical Associate Professor of Medicine

Alpert Medical School of Brown University


Disclosures
Disclosures

Jef Bratberg, PharmD, BCPS has financial relationships to report with the following pharmaceutical manufacturers:

Merck and Co. – speakers bureau, expert panel

Sanofi-Pasteur – speakers bureau

Pfizer – Unrestricted educational grant

There is no commercial support associated with this CME/CE presentation.

I will not allow affiliations or financial relationships to bias or otherwise influence my presentation.


Objectives
Objectives

1. Describe core components of successfully aging in older adults.

2. Distinguish age-related and non-age-related changes.

3. Determine strategies to resist the effects of age-related changes.

4. Discuss the evidence supporting the possible non-infectious disease benefits of administering adult vaccines to the geriatric population.

5. Discuss interventions for the risks and protective factors that influence geriatric mental health.

6. Describe the benefits of regular physical activity for older adults.


Background
Background

Weinberger B, et al. Vaccines in the elderly. Clin Microbiol Infect 2012; 18 (Suppl. 5): 100–108.

Hurley LP, et al. U.S. Physicians’ perspective of adult vaccine delivery. Ann Intern Med. 2014;160:161-170.

Dorrinton MG, et al. Immunosenescenceand novel vaccination strategies for the elderly. Frontiers in Immunology 2013; 4:1-10.

  • Challenges to elderly vaccination

    • Access

    • Co-morbidities

    • Documentation

    • Physician reimbursement

    • Immunosenescence


Immunosenescence

Dorrinton MG, et al. Immunosenescenceand novel vaccination strategies for the elderly. Frontiers in Immunology . 2013; 4:1-10.


Background1
Background

  • Challenges to elderly vaccination

    • Access

    • Co-morbidities

    • Documentation

    • Physician reimbursement

    • Immunosenescence

  • Solutions

    • Bring vaccines to them

    • Target caregivers

    • Establish adult registry

    • Pharmacoeconomic analyses

    • Adjuvants

    • Higher dose antigens

Weinberger B, et al. Vaccines in the elderly. Clin Microbiol Infect 2012; 18 (Suppl. 5): 100–108.

Hurley LP, et al. U.S. Physicians’ perspective of adult vaccine delivery. Ann Intern Med. 2014;160:161-170.

Dorrinton MG, et al. Immunosenescenceand novel vaccination strategies for the elderly. Frontiers in Immunology 2013; 4:1-10.


Tdap in older adults
Tdap in Older Adults


Pertussis background
Pertussis Background

  • Disease etiology

    • Bordetella pertussis gram positive bacteria

  • Transmission – respiratory droplets are highly contagious

  • Epidemiology

    • 13.3 cases/100,000 incidence (n=140)

    • 24,231 cases in 2013 in US

    • Under-reported

    • Outbreaks occur in skilled nursing facilities

  • Clinical manifestations in adults 65 + yo

    • Cough (86%)

    • Whoop (33%)

    • Apnea (32%)

    • Post-tussive vomiting (27%)

  • Hospitalizations higher than in younger groups

    (> 5%)

  • Death via cough syncope

Weston WM, et al. Vaccination of adults 65 years of age and older with tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine: Results of two randomized trials. Vaccine 2012; 30:1721-1728.


Pre data questions
Pre-Data Questions

What are the recommendations for vaccination

What percent of > 65 yo receive vaccine?

What are the ID benefits of vaccine?

What are the potential non-ID benefits?


June 29 2012 tdap acip recommendations
June 29, 2012 Tdap ACIP Recommendations

Guidance on use of Tdap products for adults aged 65 years and older

Providers should not miss an opportunity to vaccinate persons aged 65 years and older with Tdap

Either vaccine can be used, though Boostrix preferred


October 24 2012 acip tdap recommendations
October 24, 2012 ACIP Tdap Recommendations

  • Use Tdap with every pregnancy

  • Can be given anytime, ideally 27-36 weeks

    • Regardless of receipt of previous Tdap

    • Regardless of time since last Tdap

  • If not during pregnancy  post-partum

  • Cocooning – contacts of < 12 month old

    • Parents, siblings, grandparents

    • Childcare and healthcare personnel

    • Tdap then Td every 10 years

MMWR. 62(7): 131-135.


Tdap uptake
Tdap Uptake

  • Percent vaccinated in US in 2012

    • 14.2 % > 19 yo

    • 15.6 % 19-64 yo

    • 8% >65 yo

  • MMWR 2014; 63(5):96-97.


Tdap post data questions
TdaP Post-Data Questions

What is recommendation?

What is the uptake?

What are the ID benefits?

What are the potential non-ID benefits?



Influenza background
Influenza Background

  • Disease etiology

    • Influenza A & B viruses

  • Transmission – respiratory droplets are highly contagious

  • 5-20% of population becomes infected / yr

  • Clinical Manifestations

    • Fever/chills

    • Cough

    • Fatigue

    • Muscle aches

    • Sore throat

    • Headache

  • 36,000 excess hospitalizations

  • 22,000 excess deaths

  • Highest risk conditions

    • >65 yo

    • Pregnancy

    • Children

    • Immunocompromised

    • Chronic diseases

Efficacy of High-Dose versus Standard-Dose

Influenza Vaccine in Older Adults

DiazGranados, CA, et al. NEJM 2014.

CDC.gov/flu [Acessed on 15 August 2014].



Influenza pre data questions
Influenza Pre-Data Questions

What is recommendation?

What is the uptake?

What are the ID benefits?

What are the potential non-ID benefits?


Vaccination recommendation
Vaccination Recommendation

All persons > 6 months of age should receive an influenza vaccine

No preference for which type of inactivated vaccine in > 65 yo age group

“Although delaying vaccination might permit greater immunity later in the season, deferral might result in missed opportunities to vaccinate and difficulties in vaccinating a population within a limited time. Vaccination programs should balance maximizing likelihood of persistence of vaccine-induced protection through the season with avoiding missed opportunities to vaccinate or vaccinating after influenza virus circulation begins.”

MMWR August 15, 2014 / 63(32);691-697.


2013 14 influenza interim vaccine effectiveness
2013-14 Influenza Interim Vaccine Effectiveness

  • Overall vaccine effectiveness against medically attended acute respiratory illness (outpatient medical visits)

  • Adjusted for age, site, race/ethnicity, self-rated health, days from illness onset to enrollment

  • Influenza A (pH1N1) – 62% (53-69%)

  • Influenza overall – 61% (CI 52%-68%)

    MMWR February 2014


Flu Vaccination Rates among Adults RI, NE, US, 2012-13 Season

HP 2020 Goal= 90%

HP 2020 Goal= 80%

Data Source: CDC, Behavioral Risk Factor Surveillance System (BRFSS).


Healthy People 2020 Goals vs. RI Performance in 2012-13 Season

* Represent the women who had a baby in 2011


Hospital Data (Inpt and Outpt) RI Performance in 2012-13 SeasonAge Breakdown

\

* 2 patients with unknown age


Non id benefits of influenza vaccine
Non-ID Benefits of Influenza Vaccine RI Performance in 2012-13 Season

Influenza disease associated with higher incidence of cardiovascular (CV) events

Hospitalization rates for MI and MI mortality spike during flu seasons compared to non-flu

Vaccination reduced CV risk by up to 45%

Stroke risk reduced by 25% in small trials

ACA and AHA recommend vaccination for heart disease patients similar to blood pressure and cholesterol control recs (2006-present)

Worzella SL, Hayney MS. JAPhA 2014; 54:446-448.


Major adverse cv events
Major Adverse CV Events RI Performance in 2012-13 Season

Udell JA, et al. JAMA. 2013;310(16):1711-1720.


Major adverse cv events1
Major Adverse CV Events RI Performance in 2012-13 Season

Udell JA, et al. JAMA. 2013;310(16):1711-1720.


Cv mortality events
CV Mortality Events RI Performance in 2012-13 Season

Udell JA, et al. JAMA. 2013;310(16):1711-1720.


Cv mortality events1
CV Mortality Events RI Performance in 2012-13 Season

Udell JA, et al. JAMA. 2013;310(16):1711-1720.


High dose hd iiv acip 10 13
High Dose(HD) IIV ACIP 10/13 RI Performance in 2012-13 Season

  • Pre-published results Phase III trial

  • 126 centers enrolled 32,000 seniors

    • ‘11-12 mildseason

    • ‘12-13 moderately severe

  • 1:1 randomization

  • High dose trivalent IIV 24.2% (CI 9.7-36.5%) more effective than standard dose for lab-confirmed flu (NP swabs)

  • > 9.1% FDA lower limit

  • 227 (1.43%) vs 300 (1.89%)

  • 4.6 cases / 1000 injections

Efficacy of High-Dose versus Standard-Dose

Influenza Vaccine in Older Adults

DiazGranados, CA, et al. NEJM 2014.


Influenza post data questions
Influenza Post-Data Questions RI Performance in 2012-13 Season

What is recommendation?

What is the uptake?

What are the ID benefits?

What are the potential non-ID benefits?


This is your brain RI Performance in 2012-13 Season

with

Pneumococcus


Pneumococcal background
Pneumococcal Background RI Performance in 2012-13 Season

  • Disease etiology

    • Streptococcus pneumoniae

      gram positive bacteria

  • Transmission – respiratory droplets are highly contagious

  • Two vaccines approved

    • PPSV23

    • PCV13

  • Overall

    • 4 million episodes

    • 445,000 hospitalizations

    • 22,000 deaths

  • Epidemiology - > 65 yo

    • 37 cases/100,000

    • 5.61 deaths/100,000

http://www.cdc.gov/vaccines/pubs/surv-manual/chpt11-pneumo.html. [Accessed on 16 August 2014].


Pre data questions1
Pre-Data Questions RI Performance in 2012-13 Season

What is recommendation?

What is the uptake?

What are the ID benefits of vaccine?

What are the potential non-ID benefits?


This is your lung with pneumococcus 5 mortality
This is RI Performance in 2012-13 Season your lung with Pneumococcus5% mortality


This is your blood with pneumococcus 20 mortality
This is RI Performance in 2012-13 Seasonyour blood with Pneumococcus20% mortality


This is your brain RI Performance in 2012-13 Season

with

Pneumococcus

30% mortality


Pneumococcal recommendations 8 2014
Pneumococcal Recommendations – 8/2014 RI Performance in 2012-13 Season

65 yo+: No or unknown history

Give PCV13  6-12 months  PPSV23

65 yo+: PPSV23 > 1 year ago, no PCV13 history

Give PCV13


Sept 2012 provisional recommendations pcv13 and ppsv23
Sept 2012 Provisional Recommendations RI Performance in 2012-13 SeasonPCV13 and PPSV23

Immunize.org/ Accessed 9/25/12.


Pneumococcal uptake
Pneumococcal Uptake RI Performance in 2012-13 Season

  • Percent vaccinated in US in 2012 (PPSV23)

    • 20% 19-64 yo high risk

    • 59.9% >65 yo

  • MMWR 2014; 63(5):96-97.


http://openi.nlm.nih.gov/detailedresult.php?img=2118281_jem2030813f01&req=http://openi.nlm.nih.gov/detailedresult.php?img=2118281_jem2030813f01&req=4. [Accessed on 16 August 2014].


Non id benefits of pneumococcal vaccine
Non-ID Benefits of Pneumococcal Vaccine?http://openi.nlm.nih.gov/detailedresult.php?img=2118281_jem2030813f01&req=

Mouse models: Antibodies to oxidized low-density lipoprotein (oxLDL) inversely associated with atherosclerotic burden; data limited in humans

Correlation between antipneumococcal antibody level, anti-oxLDL antibody production in humans

Cardioprotective effect not seen in prospective three-year study of ischemic stroke

PCV13 results in significantly higher antibody titers than PPSV23

Large, randomized, prospective trials required to establish link of either vaccine

Worzella SL, Hayney MS. JAPhA 2014; 54:446-448.


Post data questions
Post-Data Questionshttp://openi.nlm.nih.gov/detailedresult.php?img=2118281_jem2030813f01&req=

What is recommendation?

What is the uptake?

What are the ID benefits?

What are the potential non-ID benefits?


Herpes zoster

Herpes Zosterhttp://openi.nlm.nih.gov/detailedresult.php?img=2118281_jem2030813f01&req=


Herpes zoster background
Herpes Zoster Backgroundhttp://openi.nlm.nih.gov/detailedresult.php?img=2118281_jem2030813f01&req=

  • Disease etiology

    • Varicella zoster virus spontaneous re-activation

  • Transmission – NONE

  • Clinical manifestations

    • Painful dermatome rash

    • Post-herpetic neuralgia

    • HZ ophthalmicus (HZO)

  • Epidemiology

    • 99.5% of adults > 40 yo have anti-VZV antibodies

    • 1 million episodes/yr

    • 1 in 3 people will develop in lifetime

  • Epidemiology – older adults

    • 70% of cases in > 50 yo

    • Over 50% have developed by age 85 yo

  • Vaccine approved > 50 yo+

Harpaz R, et al. MMWR 2008;57:1-30.


Zoster pre data questions
Zoster Pre-Data Questionshttp://openi.nlm.nih.gov/detailedresult.php?img=2118281_jem2030813f01&req=

What is recommendation?

What is the uptake?

What are the ID benefits of vaccine?

What are the potential non-ID benefits?


Gildenhttp://openi.nlm.nih.gov/detailedresult.php?img=2118281_jem2030813f01&req= D, et al. Varicella zoster virus vasculopathies: diverse clinical manifestations, laboratory features, pathogenesis, and treatment. Lancet Neurol2009; 8(8): 731.


Vzv pathogenesis
VZV Pathogenesishttp://openi.nlm.nih.gov/detailedresult.php?img=2118281_jem2030813f01&req=

Nagel, et al. Update on varicella zoster virus vasculopathy. CurrInf Dis Rep 2014;16:407-8.

Breuer J, et al. Herpes zoster as a risk factor for stroke and TIA: A retrospective cohort study in the UK. Neurology 2014;82:206–212.

Gilden D, et al. Varicella zoster virus vasculopathies: diverse clinical manifestations, laboratory features, pathogenesis, and treatment. Lancet Neurol2009; 8(8): 731.

At autopsy, viral inclusions, DNA, &antigen present in cerebral arteries

VZV vasculopathyis associated with stroke and TIA

Taiwanese cohort studies - 1.3 HR – HZ, 4.5 HR – HZO for stroke


Cv risks after herpes zoster
CV Risks After Herpes Zosterhttp://openi.nlm.nih.gov/detailedresult.php?img=2118281_jem2030813f01&req=

*Hazard Ratios were adjusted for sex, age, BMI > 30, hypertension, diabetes,

ischemic heart disease, atrial fibrillation, intermittent claudication, carotid stenosis, valvular heart disease, smoking, and elevated cholesterol.

** P < 0.05

Breuer J, et al. Herpes zoster as a risk factor for stroke and TIA: A retrospective cohort study in the UK. Neurology 2014;82:206–212.


Non-significanthttp://openi.nlm.nih.gov/detailedresult.php?img=2118281_jem2030813f01&req=

Breuer J, et al. Herpes zoster as a risk factor for stroke and TIA: A retrospective cohort study in the UK. Neurology 2014;82:206–212.


Breuer J, et al. Herpes zoster as a risk factor for stroke and TIA: A retrospective cohort study in the UK. Neurology 2014;82:206–212.


Breuer J, et al. Herpes zoster as a risk factor for stroke and TIA: A retrospective cohort study in the UK. Neurology 2014;82:206–212.


Risk of stroke following herpes zoster a self controlled case series study
Risk of Stroke Following Herpes Zoster: and TIA: A retrospective cohort study in the UKA Self-Controlled Case-Series Study

Langan S, et al. Risk of Stroke Following Herpes Zoster: A self-controlled case-series study. Clin Inf Dis 2014;58(11):1497–503.


Risk of Stroke Following Herpes Zoster: and TIA: A retrospective cohort study in the UKA Self-Controlled Case-Series Study

Langan S, et al. Risk of Stroke Following Herpes Zoster: A self-controlled case-series study. Clin Inf Dis 2014;58(11):1497–503.


Risk of Stroke Following Herpes Zoster: and TIA: A retrospective cohort study in the UKA Self-Controlled Case-Series Study

Langan S, et al. Risk of Stroke Following Herpes Zoster: A self-controlled case-series study. Clin Inf Dis 2014;58(11):1497–503.


Zoster uptake
Zoster Uptake and TIA: A retrospective cohort study in the UK

  • Percent vaccinated in US in 2012

    • 20.1% >60 yo

  • MMWR 2014; 63(5):96-97.


Herpes zoster hz working group acip 10 2013
Herpes Zoster (HZ) and TIA: A retrospective cohort study in the UK Working Group ACIP 10/2013

  • FDA: approved 50+ years old

  • ACIP: Approved 60+ years old

  • Supply stable since 2012

  • Risk for HZ incr. 200% between 60 and 80 yo

  • NO change to age rec.

  • Shingles Prevention Study (SPS) extensions

    • VE 40% HZ

    • VE 60% PHN

    • Long-term – even lower VE

  • Cost Effectiveness by vaccination age

    • 70 yo – PHN 

    • 60 yo – HZ 

    • 50 yo –  cost-effective


Post data questions1
Post-Data Questions and TIA: A retrospective cohort study in the UK

What is recommendation?

What is the uptake?

What are the ID benefits?

What are the potential non-ID benefits?


Immunization may prevent non infectious diseases in older adults1

Immunization May Prevent and TIA: A retrospective cohort study in the UKNon-infectious Diseases in Older Adults

  • “Fundamental

  • Concepts in Age-Related Health and Wellness.”

  • 15 September 2014 - 1:15-2:15 pm

  • Sheraton Providence Airport Hotel, Warwick, RI

Jeffrey Bratberg, PharmD, BCPS

Clinical Professor of Pharmacy Practice

University of Rhode Island College of Pharmacy

Adjunct Clinical Associate Professor of Medicine

Alpert Medical School of Brown University


ad