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Vaccination Update American College of Physicians, 2007 Missouri Chapter Meeting September 27, Tan Tar A Resort, Osage Beach, MO Gordon Christensen, M.D., F.A.C.P. University of Missouri-Columbia 573-882-3107 Points to be Covered: Vaccination Primer New adult vaccines:

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vaccination update

Vaccination Update

American College of Physicians, 2007 Missouri Chapter Meeting

September 27, Tan Tar A Resort, Osage Beach, MO

Gordon Christensen, M.D., F.A.C.P.

University of Missouri-Columbia

573-882-3107

points to be covered
Points to be Covered:
  • Vaccination Primer
  • New adult vaccines:
    • Varicella (“Shingles”)
    • Human Papillomavirus (HPV)
  • Routine adult vaccines:
    • Pneumococcal
    • Influenza
    • Hepatitis A
    • Hepatitis B
    • MMR
    • Meningococcal
background
Active immunization:

Durable immunity

Primary immune response with:

B-cell proliferation

Antibody production

T-cell sensitization

Passive immunization

Transient immunity

Antibody infusion

Background
true contraindications to vaccination
TRUE Contraindications to Vaccination
  • Severe hypersensitivity reaction
    • Anaphylaxis
      • Vaccine specific – avoid vaccine
      • Eggs – avoid: measles, mumps, influenza, & yellow fever
      • Neomycin & streptomycin – avoid MMR
    • Severe reaction to past vaccine, seen with:
      • Cholera, Typhoid, and Plague vaccines
    • History of post-vaccine encephalopathy from past vaccines
  • Live vaccines
    • Immunocompromised patients (IP)
    • Household members of IP – avoid oral polio (but not MMR)
    • Pregnant women
false contraindications to vaccination
FALSE Contraindications to Vaccination
  • Current or recent mild illness, with or without fever
  • Current or recent antimicrobial therapy
  • Previous mild to moderate reaction after any vaccination, such as:
    • Local tenderness
    • Redness
    • Swelling
    • Fever < 40.5°C
  • Family history of adverse reaction to immunization

No post-vaccination contraindications for athletics or alcohol

vaccination requirements for providers
Vaccination Requirements for PROVIDERS
  • Follow instructions
  • Maintain administration records
  • Report adverse events
  • Provide vaccine information brochures for patients, available from:

CDC National Center for Immunization and Respiratory Disease website @: www.cdc.gov/nip

schedule problems
Schedule Problems
  • Off schedule? – Do not restart series, just pick-up where left off and continue
  • Multiple vaccines? – Can usually co-administer vaccines, such as:
    • Pneumococcal and influenza & travel vaccines

Exceptions:

    • Live virus vaccines: delay one for a month to avoid possible impaired immune response to either agent
    • Immune globulins should not be given with live virus vaccines (exceptions: inactivated virus vaccines, oral polio, and yellow fever)
slide8

For Healthy Adults:

q 10 yrs

q year

slide9

For Adults with Health Problems:

1 dose

1-2 doses

2 doses

3 doses

1 or more doses

new adult vaccines

New Adult Vaccines

Zoster for adults (“Shingles” vaccine)

Human Papillomavirus

Also:

New intranasal influenza vaccine

New meningococcal conjugate vaccine

New hepatitis A & B combined vaccine

(New conjugate pneumococcal vaccine)

varicella chickenpox vaccine varivax
Varicella (“Chickenpox” ) Vaccine: Varivax®
  • Live, attenuated, virus vaccine, US license in 1995
    • Contraindicated in pregnancy & immunocompromised
  • For children (>12 mos) & adults, particularly adult:
    • Health care workers
    • Primary school teachers & day care workers
    • Institutional residents and employees
    • Military personnel
    • Non-pregnant women of child bearing age
    • International travelers
  • 2 dose adult schedule: 0 & 4-8 weeks – No booster
varicella shingles vaccine zostavax
Varicella (“Shingles” ) Vaccine: Zostavax®
  • Zostavax® has 14 times more virus than in Varivax®
  • Licensed 2006 for >59 y/o to prevent shingles
  • Clinical study:
    • 38,000 adults, 60-80 y/o, followed median of 3+ years
    • Vaccine group:
      • 51% fewer episodes of shingles
      • Duration reduced from 24 to 21 days
      • 66% less post-herpetic neuralgia
    • Efficacy highest for 60-69 @ 64%
    • Efficacy declines with age, 18% for >80 y/o
varicella shingles vaccine zostavax13
Varicella (“Shingles” ) Vaccine: Zostavax®
  • Administer as a single dose
  • Contraindicated for:
    • Anaphylactic reaction to gelatin or neomycin,
    • Immunodeficiency states including:
      • leukemia, lymphomas, neoplasms affecting the bone marrow or lymphatic system
      • AIDS
      • active untreated tuberculosis.
      • immunosuppressive therapy including high-dose corticosteroids
      • women who are or may be pregnant
  • Average wholesale price: $190
varicella shingles vaccine zostavax14
Varicella (“Shingles” ) Vaccine: Zostavax®
  • The Advisory Committee on Immunization Practices voted in October 25, 2006 that:

“A single dose of zoster vaccine [i.e. Zostavax] is recommended for adults 60 years of age and older whether or not they report a prior episode of herpes zoster. Persons with chronic medical conditions may be vaccinated unless a contraindication or precaution exists for their condition.”

  • This recommendation was tentatively set for publication in CDC Morbidity and Mortality Weekly Report for June 2007, but this did not happen. It is still under review by the CDC and the Department of Health & Human Services.
human papillomavirus hpv
Human Papillomavirus (HPV)

Double stranded DNA virus – more than 100 types

  • 60 types  cutaneous infection  skin warts
  • 40 types mucosal & genital infection
    • Genital, laryngeal, rectal warts & cervical abnormalities
    • No cross protection between types
    • Certain types PROMOTE (virus infection is necessary but not sufficient to cause) 99+% of cervical cancer
      • Type 16 causes 50%; Types 16 + 18 cause 70%
      • Type 16 causes 10% of HPV genital infection in ♀s
    • Causes squamous cell & adenocarcinoma
    • Types 6 & 11  90% of anogenital warts
human papillomavirus hpv16
Human Papillomavirus (HPV)
  • Risk Factors for infections:
    • Number of sex partners
    • Age < 25y
  • Most common STD in the US:
    • 20 million in US, 6 million new annual infections
    • 75% of new infections in 15-24 y/o
    • 80% of sexually active women infected by 50 y/o
    • 20% of men infected
  • Causes 90% anal cancer, 40% of vulvar/vaginal/penile cancer, & 12% oral & pharyngeal cancer
human papillomavirus hpv vaccine
Human PapillomaVirus (HPV) Vaccine
  • Quadrivalent Vaccine
    • L1 major capsid protein, propagated in yeast
    • Self assembles into virus-like-particles
    • Vaccine includes types 6, 11, 16, & 18
    • 99.5% of vaccinees develop antibody to all 4 types
    • Efficacy:
      • 100% prevention of cervical precancer by types 16 & 18
      • 99% prevention of vaccine type genital warts
  • HPV vaccine released in 2006
  • Routine vaccination recommended in 2007
human papillomavirus hpv vaccine18
Human PapillomaVirus (HPV) Vaccine
  • For all women <27 y/o
  • Best if given to before sexual debut
    • Can begin at age 9 y/o, recommended for 11-12 y/o
    • Sexually active women should still be vaccinated
    • Women with genital warts and abnormal PAP can be vaccinated
    • Not recommended for men
  • Complete series: 3 doses: 0, +2 months, +4 months
  • Cost: $120 per dose, $360 for the 3 dose series
  • Not for pregnant women – if pregnancy develops during vaccination series, then delay completion of series until after delivery
routine adult vaccines

Routine Adult Vaccines

  • MMR
  • Tetanus, Diphtheria, & Pertussis
  • Meningococcal

Influenza

Pneumococcal

Hepatitis A

Hepatitis B

influenza 3 types
Influenza: 3 Types
  • Influenza A
    • moderate to severe illness
    • epidemic & pandemic
    • all ages
    • humans & animals (horse, avian & swine)
  • Influenza B
    • Milder disease
    • Children & seniors
    • Humans only
  • Influenza C
    • Pigs, rare in humans & no epidemics
slide21

HA - Hemaglutinin

  • Binds virus to cells
  • Antigenic types: H1-H15

Influenza A Virus

  • NA - Neuraminidase
  • Promotes viral entry into cells
  • Antigenic types: N1-9
influenza vaccine
Influenza Vaccine
  • Two types
    • Trivalent inactivated vaccine (1940s)
    • Trivalent attenuated vaccine (2003)
  • Vaccinate in October & November
  • Recommended composition of influenza virus for both vaccines for use in the 2007-2008 northern hemisphere influenza season:
    • A/Solomon Islands/3/2006 (H1N1)-like virus
    • A/Wisconsin/67/2005 (H3N2)-like virus
    • B/Malaysia/2506/2004-like virus
inactivated influenza vaccine
Inactivated Influenza Vaccine

When the antigenic match between vaccine and circulating virus is close, prevents

  • <65: prevents 70-90%
  • >65: prevents only 30-40% of clinical illness, BUT:
    • Prevents hospitalization in 50-60%
    • Prevents death in 80%
inactivated influenza vaccine24
Inactivated Influenza Vaccine

Annual vaccination indicated for:

  • Chronic pulmonary disease & cardiovascular disease
  • Chronic metabolic disease (diabetes & renal failure)
  • Immunosuppression & HIV
  • Aspiration risk (dementia, spinal cord injury, seizure)
  • Pregnancy
  • Health care workers & long-term-care-facility residents
  • Household members of people at risk
  • On demand
live attenuated influenza vaccine
Live-Attenuated Influenza Vaccine
  • Not for immunocompromised
  • Temperature sensitive, cold-adapted, lives only in nasopharynx
  • 87% effective in children - 27% reduction in otitis
  • FluMist (MedImmune)
    • For 5-49 y/o healthy patients
    • Intranasal administration, half in each nares
    • Will test positive for Influenza A & B for several weeks after vaccination with rapid tests
pneumococcal vaccine
Pneumococcal Vaccine
  • > 90 capsular serotypes known
  • Capsular polysaccharide vaccine
    • 14 valent licensed in 1977
    • 23 valent licensed in 1983
      • Active against 88% of bacteremic pneumococcal pneumonia
      • Cross-reactive for an additional 8% of bacteremic disease
      • Prevents 60-70% of invasive disease
      • Does not prevent pneumococcal pneumonia
    • For adults, not effective in children < 2 y/o
pneumococcal vaccine27
Pneumococcal Vaccine
  • All >64 y/o
  • Chronic pulmonary disease (except asthma)
  • Chronic cardiovascular disease
  • Diabetes mellitus
  • Chronic liver disease
  • Chronic renal failure & nephrotic syndrome
  • Asplenia – functional or anatomical (pre-surgery)
  • Immunosuppression & HIV
  • Neoplasia: leukemia, lymphoma, multiple myeloma
  • Cochlear implants (pre-placement)
  • Special populations: Native Americans & long-term-care-facility residents
pneumococcal revaccination
Pneumococcal Revaccination
  • After 5 years for :
    • Chronic renal failure & nephrotic syndrome
    • Asplenia – functional or anatomical
    • Immunosuppression & HIV
    • Neoplasia: leukemia, lymphoma, multiple myeloma
  • For >65 y/o if:
    • Vaccinated >5 years ago &
    • <65 when first vaccinated
conjugate pneumococcal vaccine
Conjugate Pneumococcal Vaccine
  • Licensed for children (<2 y/o) in 2000
    • 7 valent capsular polysaccharide linked to nontoxic diptheria toxin (AKA “CRM197”)
    • Active versus childhood: bacteremia (86%), meningitis (83%), & otitis media (65%)
    • Efficacy:
      • Reduce invasive disease by serotypes by 97%
      • Reduce all invasive disease by 89%
      • Reduce severe pneumonia by 73%
      • Reduce otitis media by 7% & tympanoplasty by 20%
hepatitis a vaccine
Hepatitis A Vaccine
  • Inactivated, whole cell vaccine
  • 95% of adults develop protective antibody in 4 weeks
  • 100% seroconvert after two doses
  • Indicated for:
    • Travelers to areas of high hepatitis A endemicity
    • Men who have Sex with Men (MSM) & IV Drug abusers
    • Patients with chronic liver disease
    • Patients who receive clotting factors
  • Administer:
    • 2 dose schedule: 0 & +6-18 months
    • Single dose provides ~ 1 year immunity
hepatitis b vaccine
Hepatitis B Vaccine
  • HBsAg recombinant vaccine from yeast
  • Two vaccines – in adult & child formulations
  • After 3 doses, >90% of adults are sero-positive
    • >40 y/o: 90% respond
    • >60 y/o: 75% respond
    • Some patients (hemodialysis) may require larger & more doses to develop a response
  • Prevents 80-100% clinical hepatitis
hepatitis b vaccine indications
Hepatitis B Vaccine Indications
  • On demand
  • All adults at risk:
    • People who work or live in areas with high endemicity for Hepatitis B
      • Health-care workers
    • Occupational & recreational blood exposure
    • Travelers to areas of high hepatitis A endemicity
    • Sexual exposure: sex partner of hepatitis B patient, promiscuous sex (STD clinic patients), & MSM
hepatitis b vaccine schedule
Hepatitis B Vaccine Schedule
  • Usual:
    • 0 & 1 month: 50-60% protection
    • + 6 month: full protection
  • Accelerated:
    • 0,1& 2 months OR 0,1& 3 weeks: good protection
    • + 12 month for full protection
  • Confirmatory serologic testing not recommended for healthy adults ~ is recommended for hemodialysis patients & health care workers with blood exposure
  • No booster needed
hepatitis a b combined vaccine
Hepatitis A&B Combined Vaccine
  • Hepatitis A/B (Twinrix®), approved in 2001
    • 0 & 1 month:
      • adequate against A
      • 50-60% protection against B
      • Repeat @ 6 months for full protection
    • 0,1& 3 weeks (accelerated schedule):
      • good protection
      • Repeat @ 12 months for full protection

NO: Hepatitis C or E vaccine

measles
Measles
  • Prior to MMR, Measles nearly universal disease of childhood
    • Death in adults usually due to encephalitis
    • Causes subacute sclerosing pan-encephalitis – a persistent CNS infection leading to degenerative neurological disease
    • Worldwide still causes 30 million infections & 454K deaths
  • Atypical measles
    • 1963-67: 600-900K received killed measles vaccine (KV)
    • KMV sensitizes, but does not protect
    • With measles & KMV  polyserositis
      • Fever, pneumonia, pleural effusions, & edema
      • Atypical rash: maculopapular, petechial, urticarial, pupuric, & vesicular
mumps
Mumps
  • Mumps in unvaccinated adults includes:
    • Commonly: orchitis & parotitis
    • Less commonly: meningitis & encephalitis
    • Rarely: pancreatitis, deafness, myocarditis, arthritis, & nephritis
rubella
Rubella
  • AKA “German Measles”
  • In unvaccinated adults:
    • Arthralgias & arthritis
    • Encephalitis, frequently fatal
  • In pregnant woman  congenital rubella syndrome
    • Fetal death, spontaneous abortion, & prematurity
    • Cataracts
    • Heart defects
    • Deafness, microcephaly, & mental retardation
    • Bone lesions
    • Hepatomegaly & splenomegaly
measles mumps rubella mmr vaccine
Measles/Mumps/Rubella (MMR) Vaccine
  • MMR vaccine includes live, attenuated measles, mumps, and rubella virus
  • Contraindicated for immunosuppressed:
    • Symptomatic HIV+ (asymptomatic OK)
    • Steroids (>20 mg/day)
    • Congenital immune deficiencies
    • Leukemia, lymphoma, advanced malignancy
    • Chemotherapy & radiation therapy
  • ProQuad incorporates live, attenuated Varicella into the vaccine for MMRV. Intended for children (12m – 12y)
measles mumps rubella mmr vaccine39
Measles/Mumps/Rubella (MMR) Vaccine
  • Born prior to 1957 considered measles & mumps immune
  • Adults born since 1956 should have at least one dose of the two dose series
  • One dose for women with either none or uncertain immunity
    • Do not vaccinate pregnant women or women who might become pregnant within 4 weeks of vaccination
  • Two doses indicated for:
    • Adults exposed to measles
    • Adults vaccinated with killed measles vaccine
    • Adult students
    • Health care workers without measles or mumps immunity
    • International travelers
  • No booster after 2 doses
tetanus diphtheria acellular pertussis td tdap
Tetanus, Diphtheria, & acellular Pertussis: Td/Tdap
  • Adult primary series:
    • 3 doses: 0, +4 weeks, +6-12 months
  • Booster with either Td or Tdap
    • Booster: primary series plus <10 years
    • <65? Vaccinate at least 1x with Tdap if not previously vaccinated
    • Pregnant?
      • >10 years since last boost? – vaccinate with Td in 2nd or 3rd trimester
      • <10 years since Td? – vaccinate with Tdap in immediate post-partum period
diphtheria tetanus pertussis
Diphtheria, Tetanus, & Pertussis

Formalin inactivated diphtheria toxin (toxoid)

+

Formaldehyde inactivated tetanospasmin (toxoid)

+/-

“Acellular” pertussis (purified subcomponents of Bordetella pertussis cells)

Routine combined vaccination started in 1940s

Td for adult booster

DTaP replaced (1991) old DTP for children; Tdap for adults

tdap tetanus diptheria acellular pertussis
Tdap: Tetanus/Diptheria/acellular-Pertussis
  • Adolescent & Adult version of the “DPT” vaccine
  • ONE TIME vaccine in place of a “Td” booster for:
    • Adolescents & adults <65 y/o
    • Particularly adults with contact with infants <1 y/o
    • Particularly health-care workers with patient contact
    • Particularly post-partum women
    • Give if last Td boost >2 yr previous
  • Subsequent boosters with “Td” q 10 years
  • Pregnancy is not a contraindication to vaccination, vaccinate in a Pertussis outbreak
meningococcal vaccine
Meningococcal Vaccine
  • No vaccine for group B, or groups L, X, & Z
  • Monovalent polysaccharide vaccine licensed in 1974
  • Quadrivalent polysaccharide vaccine licensed in 1974
  • Menactra®: quadrivalent, conjugate vaccine
    • Bound to diphtheria toxoid
    • Active against serotypes A,C,Y, & W135
    • Licensed in 2005
    • Intended for:
      • Children >11
      • At risk adults (Travelers)
    • One dose vaccine, no booster needed
questions cdc resources
Questions? CDC Resources
  • CDC Immunization Hotline: 800-232-2522
  • CDC Info: 800-232-4636
  • CDC website: www.cdc.gov/mmwr
  • CDC Division of Immunization: 404-639-8225