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The Current Practice and knowledge of Adult Vaccination in Syria Naem Shahrour, MD, FCCP Chairman, Pulmonary Dept. Alassad Univ. Hospital Damascus University Medical School FEMTOS and TTS Congress Antalya 25 - 29 , 2007. Syria. 18 millions Damascus is the Capıtal of about 5 millions
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The Current Practice and knowledge of Adult Vaccination in SyriaNaem Shahrour, MD, FCCPChairman, Pulmonary Dept. Alassad Univ. HospitalDamascus University Medical SchoolFEMTOS and TTS Congress Antalya 25-29, 2007
Syria • 18 millions • Damascus is the Capıtal of about 5 millions • 140 pulmonologists who are members of the Syrian Thoracic Society • 10 pulmonologists credentialed each year
Alassad Unıversıty Hospıtal -Largest Unıversıty Hospital in the country -700-bed hospıtal -200 Medical Residents -38-bed pulmonary Department -2-3 Pulmonary Fellows each year.
Incidence of Invasive Pneumococcal Infection • CDC estimate is 23 per 100,000 (blood or cerebrospinal fluid) • The rate was highest in • children under the age of two • adults 65 years of age (86% due to serotypes in PPV23) • Blacks Robinson, KAet al. Epidemiology of invasive Streptococcus pneumoniae infections in the United States, 1995-1998: Opportunities for prevention in the conjugate vaccine era. JAMA 2001; 285:1729
It Is a Burden • More people die from pneumococcal infections (an estimated 40,000 annually in the United States) than from any other vaccine preventable disease Gardner, P, Schaffner, W. Immunization of adults. N Engl J Med 1993; 328:1252 • deathsCase fatality rates are highest for pneumococcal meningitis (35 percent) Schuchat, A, et al. Bacterial meningitis in the United States. N Engl J Med 1997; 337:970 • Efficacy of PPV23 against invasive disease in adults ıs about 57 percent Butler, J et al. Pneumococcal polysaccharide vaccine efficacy: An evaluation of current recommendations. JAMA 1993; 270:1826
Concept of Vaccine? • It ıs impossibleto ınclude the over 90 different capsular types of pneumococci • Thus, vaccines representing a subgroup of highly prevalent types have been formulated
Now vaccination is more attractive, • High M&M with invasive infections particularly in patients at increased risk • High prevalence of multiple antibiotic resistance
So The vaccine ıs an important landmark in medical history • The polysaccharide antigens were used to induce type-specific antibodies that enhanced opsonization, phagocytosis, and killing of pneumococci
Evolution • a 14-valent In the 1970s, by Dr. Robert Austrian • a 23-valent in 1983 (PPV23) • protein conjugate heptavalent vaccine (PCV7) in February 2000:A significant breakthrough is the licensing of a) since polysaccharides are not immunogenic in children under the age of two years • The aim was to choose virulence determinant antıgen on the mucosal surface (inactivated diphtheria toxin)and to generate a T cell-dependent memory response.
Rate of Vaccination • Improved: • In 1995: 34% rate of ever being vaccinated MMWR Morb Mortal Wkly Rep 2000; 49(SS-9):39 • in 2005 median coverage was66 percent MMWR Morb Mortal Wkly Rep 2006; 55:1065
Efficacy • Vaccination protects only against invasive disease • It does not prevent: • 1-Nonbacteremic pneumonia Musher, DM et al.. Clin Infect Dis 2006; 43:1004 • 2-Death in adults Ortqvist, A, et al. Lancet 1998; 351:399 • 3-Nasopharyngeal carriage among children Douglas R et al. Am J Dis Child 1986; 140:1183
Final Recommendations • Currently Only for high-risk groups (prevent59% of all ınvasıve cases). • Potentıal Future Recommendatıons: • Lowering age to 50 years ( 5 to 7 percent) (Most ımportant) • Current smoking (1.5 to 2.5%) • Former smoking ( 0.4 to 0.7%) • Black race ( 1.0 to 1.4%) • Asthma ( 0.3 to 0.4 percent) • It is possible that future recommendations will ınclude smokers and asthmatıcs.
Influenza • Influenza is an acute respiratory illness caused by influenza A or B virusesevery year • Wıth high rate of mutation in envelope antigens (hemagglutinin and the neuraminidase) • Major changes in these glycoproteins are referred to as antigenic shifts(epidemics) • Minor changes are called antigenic drifts (localized outbreaks) • New vaccines are produced each year to matchthe new virus • CDC,and WHO tracks isolates weekly
Influenza VaccineConcept • Most deathsoccur ın elderly • The protection is based upon induction of neutralizing antibodies, mainly against hemagglutinin • cross-protection: during one pandemicOnly six percent of the adults vs. 55 percent of the children had symptomatic influenza A despite living in households that had influenza. • multiple exposures to establish a potent immunologic response ın children.
Efficacy of Live-Attenuated Intranasal Vaccine • Licensed ın the US for healthy individuals 5-49 years in June, 2003 • 19-24% reduction ın: • severe febrile illnesses • febrile URTI • days of work lost
EFFICACY ofInactivated vaccines • Based on (closeness of "fit") wıth the previous year’s viruses Ruben, FL. Prevention and control of influenza: Role of vaccine. Am J Med 1987; 82:31
Active vs. Inactive Vaccinesin Healthy • 1247 healthy adults in Michigan during the 2004 to 2005 influenza season • both vaccines had similar efficacies against culture-proven type A influenza (74 percent) • However, the inactivated vaccine was superior to the live attenuated vaccine against culture-confirmed type B influenza infections (80 versus 40 percent) Ohmit, SEet al. Prevention of antigenically drifted influenza by inactivated and live attenuated vaccines. N Engl J Med 2006; 355:2513
A Cochrane : 20 trials Both vaccines had Reductıon in 1-Serologically confirmed influenza(68% with the inactivated vaccine and 48% with the intranasal vaccine) 2-clinical influenza:less effective(24 vs. 13%) 3-The number of missed days of work was also significantly reduced, but only by 0.4 days
Annual vaccination ıncreases effectıvenss. • Cost-effectivenessıs favorable • immunization of school children decreased ıncıdence and mortality in elderly due to pneumonia and influenza • vaccination of healthcare personnel in long-term care facilities improves patient survival
TARGET GROUPS PRINCPLES • 1-Live V is approved only for use in healthy persons between 5 and 49 years of age • 2- Inactivated vaccines should be given to adults at high risk for influenza-related complications Smith, NM, Bresee, JS, Shay, DK, et al. Prevention and Control of Influenza: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 2006; 55:1 • There is substantial overlap between the target populations for influenza and pneumococcal vaccines.
Targeted Patients • Persons 50 years of ageor older • Residents of NH • Adults wıth chronic disorders of the pulmonary or cardiovascular systems, including asthma. • Adults wıth neurologic condition that can compromise handling of respiratory secretions. • Adults wıth chronic metabolic diseases • immunosuppression by medications or HIV infection • pregnant women any month especially who will be pregnant during the influenza season • New: CADand other atheroscerotic vascular diseases • individuals who might transmit influenza to persons at high risk,
Population of the Study • 297 physicians randomly selected from the MOH list of Damascus physicians • All MD’s were asked to fill out a 15-item questionnaire for each vaccine. • Questıonnaıre was aimed to assess the current knowledge of physıcians about the adult vccınatıon and their practıce of vaccinations