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Adult Vaccines

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  1. Adult Vaccines

  2. Educational Learning Objectives At the conclusion of this presentation, the participant should be able to: Discuss the indications and recommendations for the most current immunization schedules for childhood, adolescent, and adult populations Respond to frequently encountered questions and situations during patient discussions including 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 2010 CDC. MMWR Morb Mortal Wkly Rep. 2010;59(1).

  4. Gaps Persist Between Vaccination Rates and Goals US Goals: Elderly: 90% HR < 65: 60% HR denotes High Risk Schiller J, et al. http://www.cdc.gov/nchs/data/hestat/vaccine_coverage.htm. Accessed September 2009.

  5. Adult Immunization Schedule: US 2010 CDC. MMWR Morb Mortal Wkly Rep. 2010;59(1).

  6. Tdap If overall risk/benefit is favorable, discount risk of local rxns and immunize *Only if no previous Tdap received CDC. MMWR Recomm Rep. 2006; 55(RR3):1-34. CDC. MMWR Recomm Rep. 2006;55(RR17);1-33. CDC. MMWR Morb Mortal Wkly Rep. 2009;58(14):374-375.

  7. Pertussis Challenges for Those Providing Care for Adults • Modified, less “classic” illness • Respiratory infection • Persistent cough • Laboratory diagnosis inadequate • Treatment reduces severity only if given very early (usually before pertussis is considered) • Out of sight; out of mind

  8. Adult Immunization Schedule: US 2010 CDC. MMWR Morb Mortal Wkly Rep. 2010;59(1).

  9. 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 Oct 2009.

  10. HPV – ACIP RecommendationsQuadrivalent HPV (HPV4) and Bivalent HPV (HPV2) • Routine vaccination of females aged 11-12 years with 3 doses of HPV vaccine • 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, precancers and dysplastic lesions • Vaccination with HPV4 for additional prevention against genital warts • Monitor patients for 15 minutes following vaccination for syncopal episodes ACIP Schedules. www.cdc.gov/vaccines/recs/schedules/default.htm. Accessed Jan 2010.

  11. HPV Vaccination and Pregnancy • HPV vaccines are not recommended for use in pregnant women • Initiation of the vaccine series should be delayed 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 • If a vaccine dose has been administered during pregnancy, there is no indication for intervention • Two vaccine in pregnancy registries have been established. Patients and health care providers should report: • Quadrivalent HPV vaccine/pregnancy: 800-986-8999 • Bivalent HPV vaccine/pregnancy: 888-452-9622 CDC. http://www.cdc.gov/vaccines/recs/provisional/downloads/hpv-vac-dec2009-508.pdf. Accessed March 2010.

  12. HPV Quadrivalent Vaccine in Males • FDA approved quadrivalent HPV vaccine for prevention of genital warts due to HPV types 6 and 11 in boys and men ages 9 through 26 • ACIP: Permissive HPV vaccine for males • Cost effectiveness • Priority vaccinating females to reduce overall disease/cancer burden • Quadrivalent HPV vaccine most effective when given before exposure to HPV through sexual contact FDA News Release. http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm187003.htm. Accessed Oct 2009. Dunne E. ACIP Meeting Oct 2009. http://www.cdc.gov/vaccines/recs/acip/downloads/mtg-slides-oct09/02-9-hpv.pdf. Accessed Oct 2009.

  13. Quadrivalent HPV Vaccine for Women 27–45 yearsUnder FDA Review ACIP Considerations • As women age from their mid 20s • HPV prevalence decreases • HPV incidence decreases • Likelihood of having acquired HPV infection increases • Disease outcomes (genital warts, CIN 2/3) peak among women in their mid to late 20s, potential benefit of vaccinating women in late 20s to early 40s would be minimal • 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 March 2010. Haupt R. http://www.cdc.gov/vaccines/recs/acip/downloads/mtg-slides-feb10/02-2-hpv.pdf. Accessed March 2010.

  14. Adult Immunization Schedule: US 2010 CDC. MMWR Morb Mortal Wkly Rep. 2010;59(1).

  15. Shingles (Herpes Zoster) CDC. http://www.cdc.gov/vaccines/vpd-vac/shingles/photos.htm. Accessed September 2009.

  16. Zoster (Shingles) Vaccine • Single-dose vaccine licensed for persons 60+ years of age • High potency live, attenuated varicella vaccine • Boosts immunity • Off-label use in patients under 60 • Shingles – localized rash due to reactivation of latent chicken pox (varicella) virus • Postherpetic neuralgia – extreme, debilitating pain lasting for months CDC. MMWRRecomm Rep. 2008;57(RR5):1-30.

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

  18. Zoster Vaccine Cost Issues • Routine vaccination not covered by Medicare part B • Eligible for reimbursement by Medicare part D • In the office, check that insurance can be billed directly through the computer billing system or through pharmacy, otherwise patient will have to pay full amount and claim for reimbursement • Outside the office, ensure vaccine administered at a pharmacy or other location covered by insurance CDC. http://www.cdc.gov/vaccines/vpd-vac/shingles/vac-faqs.htm. Accessed September 2009. AAFP. http://www.aafp.org/fpm/20070700/33bill.html. Accessed September 2009.

  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% • 60-69 years ↓64% • ≥ 70 years ↓38% • Incidence of post-herpetic 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. Adult Immunization Schedule: US 2010 CDC. MMWR Morb Mortal Wkly Rep. 2010;59(1).

  21. Seasonal Influenza Has a Huge Annual Impact in the United States *Average of all causes, 1976-77 through 1998-99. †Average of all causes, 1990-91 through 1998-99. CDC. MMWRRecomm Rep.2003;52(RR-8):1-36. Thompson WW, et al. JAMA. 2003;289:179-186. Adams PF, et al. Vital Health Stat10. 1999;200:1-203.

  22. Annual Influenza Vaccine is Recommended for: All people age 6 months and older! CDC. http://www.cdc.gov/vaccines/recs/provisional/downloads/flu-vac-mar-2010-508.pdf. Accessed March 2010.

  23. Trivalent Inactivated Virus (TIV) versus Live Attenuated Influenza Virus (LAIV) Vaccines TIV • Licensed for use in persons age ≥6 mos • Intramuscular injection • TIV contains purified viral particles that have been chemically inactivated • Purified components from 3 WHO-recommended annual strains • Immunity developed against disrupted/denatured viral proteins, not against intact virus LAIV • Licensed for use among nonpregnant persons aged 2-49 years • Administered by nasal spray • LAIV contains intact virus that has been propogated in eggs at 25ºC • Cold-adaptation results in restricted replication at body temp • More mild flu symptoms • Contains same 3 WHO-recommended annual strains as TIV CDC. MMWRRecomm Rep. 2009;58(RR08):1-52. Flumist Prescribing Information. www.flumist.com. Accessed Oct 2009.

  24. N = 5499 N = 5231 Percentage Year Influenza Vaccination During Most Recent Pregnancy – Georgia & Rhode Island §95% confidence Interval †2007 data for Georgia were not available CDC. MMWR Morb Mortal Wkly Rep. 2009;58(35):969-992.

  25. 2009–2010 Seasonal Influenza Vaccines • 2009–2010 seasonal influenza vaccine formulation: • A/Brisbane/59/2007(H1N1)-like virus • A/Brisbane/10/2007 (H3N2)-like virus • B/Brisbane/60/2008-like antigens • Vaccines Trivalent Inactivated, Injectable Influenza Vaccine • Fluzone® (sanofi): age ≥ 6 months • Fluvirin® (Novartis): age ≥ 4 years • Fluarix® (GSK): age ≥ 3 years • FluLaval™ (ID Biomedical/GSK): age ≥ 18 years • Afluria® (CSL): age ≥ 6 months Live Attenuated, Nasal Spray Influenza Vaccine • FluMist® (MedImmune): age 2 through 49 years (healthy, non-pregnant) • Seasonal 2009 influenza vaccine does not protect against 2009 (pandemic) H1N1 influenza CDC. MMWR Recomm Rep. 2009;58(RR8):1-52. CDC. http://www.fda.gov/BiologicsBloodVaccines/Vaccines/ApprovedProducts/ucm094045.htm. Accessed March 2010.

  26. 2009 H1N1 (Pandemic) Influenza Vaccines As of November 11, 2009: 4 monovalent inactivated vaccines approved • CSL Limited • Age 6-35 mos: Two 0.25 mL IM doses (4 wk interval) • Age 36 mos to 9 yrs: Two 0.5 mL IM doses (4 wk interval) • Age ≥ 10 yrs: Single 0.5 mL IM injection • Adults ≥ 18 yrs: Single 0.5 mL IM injection • Novartis Vaccines and Diagnostics Limited • Age 4-9 yrs: Two 0.5 mL IM doses (4 wk interval) • Age 10-17 yrs: Single 0.5 mL IM injection • Age ≥ 18 yrs: Single 0.5 mL IM injection • Sanofi Pasteur, Inc. • Age 6-35 mos: Two 0.25 mL IM doses (4 wk interval) • Age 36 mos to 9 yrs: Two 0.5 mL IM doses (4 wk interval) • Age ≥ 10 yrs: Single 0.5 mL IM injection • Adults ≥ 18 yrs: Single 0.5 mL IM injection • ID Biomedical/GSK • Adults ≥ 18 yrs: Single 0.5 mL IM injection 1 live attenuated (nasal administration) • MedImmune LLC • Age 2-9 yrs: Two 0.2 mL doses (0.1 mL per nostril), 4 week interval • Age 10-49 yrs: Single 0.2 mL dose (0.1 mL per nostril) Prescribing information available at: http://www.cdc.gov/h1n1flu/vaccination/dosage.htm#table1. Accessed December 2009.

  27. 2009 H1N1 Influenza SummaryBetween April 2009 and February 13, 2010 • Cases of H1N1 Influenza • 42–86 million • Mid-level: 59 million • H1N1-related Hospitalizations • 188,000–389,000 • Mid-level: 265,000 • H1N1-related Deaths • 8,520–17,620 • Mid-level: 12,000 • Vaccination Coverage • ~86 million people received 97 million doses of H1N1 vaccine CDC. http://www.cdc.gov/h1n1flu/estimates_2009_h1n1.htm. Accessed March 2010.

  28. Percentage of Visits for Influenza-like Illness; National Summary Oct 2006–Feb 2010 Finelli L, et al. http://www.cdc.gov/vaccines/recs/acip/downloads/mtg-slides-feb10/05-2-flu-vac.pdf. Accessed March 2010.

  29. 2009–2010 College Influenza-like Illness Finelli L, et al. http://www.cdc.gov/vaccines/recs/acip/downloads/mtg-slides-feb10/05-2-flu-vac.pdf. Accessed March 2010.

  30. Influenza Hospitalizations, Sep 2009–Feb 2010 Finelli L, et al. http://www.cdc.gov/vaccines/recs/acip/downloads/mtg-slides-feb10/05-2-flu-vac.pdf. Accessed March 2010.

  31. Aggregate Hospitalizations 2009–H1N1 April 2009–Feb 2010 Finelli L, et al. http://www.cdc.gov/vaccines/recs/acip/downloads/mtg-slides-feb10/05-2-flu-vac.pdf. Accessed March 2010.

  32. Influenza Deaths, Sep 2009–Feb 2010 Finelli L, et al. http://www.cdc.gov/vaccines/recs/acip/downloads/mtg-slides-feb10/05-2-flu-vac.pdf. Accessed March 2010.

  33. Deaths 2009–H1N1 Influenza April 2009–Feb 2010 Finelli L, et al. http://www.cdc.gov/vaccines/recs/acip/downloads/mtg-slides-feb10/05-2-flu-vac.pdf. Accessed March 2010.

  34. Influenza Vaccination (H1N1, Seasonal or Both) by mid-January 2010 Data from National 2009 H1N1 Flu Survey (NHFS) Singleton J. http://www.cdc.gov/vaccines/recs/acip/downloads/mtg-slides-feb10/05-4-flu-vac.pdf Accessed March 2010.

  35. 2010–2011 Influenza Season • Universal Influenza Vaccination • All people 6 months and older are now recommended to receive annual influenza vaccination • 2010-2011 Trivalent Influenza Vaccines • A/California/7/2009(H1N1)-like virus • Same strain as in the 2009 H1N1 monovalent vaccine • A/Perth/16/2009(H3N2)-like virus • New strain for northern hemisphere vaccine • Same strain as 2010 southern hemisphere seasonal strain • B/Brisbane/60/2008-like virus • No change CDC. http://www.cdc.gov/vaccines/recs/provisional/downloads/flu-vac-mar-2010-508.pdf. March 2010.

  36. 2010–2011 Influenza Season Continued Emphasis on High-risk Groups: • Children aged 6 months through 4 years • Adults ≥ 50 years • Women who will be pregnant during the influenza season • Persons who have chronic pulmonary, cardiovascular, renal, hepatic, neurological, neuromuscular, hematological or metabolic disorders • Persons who have immunosuppression (including caused by medication or HIV) • Residents of nursing homes and other chronic-care facilities • Health care personnel • Household contacts and caregivers of children aged < 5 year and adults aged ≥ 50 years, with particular emphasis on vaccinating contacts of children < 6 months • Household contacts and caregivers of persons with medical conditions that put them at higher risk for severe complications from influenza CDC. http://www.cdc.gov/vaccines/recs/acip/downloads/mtg-slides-feb10/05-7-flu-vac.pdf. Accessed March 2010.

  37. Flu Shots May Also Reduce Hospitalizations for Cardiovascular Disease • 2-year cohort study of elderly members of 3 HMOs • 1998–1999 and 1999–2000 seasons with > 140,000 elderly members in each year’s cohort • After multivariable analysis, vaccination cohort showed a reduced risk of death and hospitalization Nichol KL, et al. N Engl J Med. 2003;348:1322-1332.

  38. Rationale for Vaccinating HCWs • “First do no harm” • Reduce the risk for nosocomial transmission from staff to patient • Reduce staff absenteeism and preserve health care capacity • May be cost saving for the health care org • Personal benefits to HCWs • (? Increase awareness & likelihood of HCWs vaccinating patients)

  39. 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.

  40. Not Vaccinated Vaccinated 40.1 59.9 Health Care Workers Should Be Immunized HCW Influenza Vaccination Rates NHIS, 2003

  41. Pneumococcal Polysaccharide Vaccine (PPSV23) • Contains polysaccharide surface antigens expressed on S. pneumoniae • Over 90 known serotypes • Vaccine contains 23 polysaccharide serotypes from S. pneumoniae • 1-4, 5, 6B, 7F, 8, 9N, 9V, 10A, 11A, 12F, 14, 15B • 17F, 18C,19F,19A, 20, 22F, 23F, 33F • Included in PCV7 • New conjugate vaccine • PCV13 (Serotypes 1, 3, 4, 5, 6A, 6B, 7F, 9V,14,18C,19A,19F, 23F) CDC. http://www.cdc.gov/vaccines/pubs/pinkbook/downloads/pneumo.pdf. Accessed March 2010. CDC. MMWR Morb Mortal Wkly Rep. 2010;59(9):258-261.

  42. Pneumococcal Polysaccharide Vaccine (PPSV23) • Single dose recommended for: • All ≥ 65 years • 2–64 years: chronic cardiovascular disease, chronic pulmonary disease, diabetes, alcoholism, chronic liver disease, CSF leaks, asplenia, cochlear implants • > 2 years and immunocompromised • Asthmatics and smokers age 19-64 years • Proposed language for one-time revaccination: • “A second dose of PPSV23 is recommended 5 years after the first dose of PPSV23 for persons aged ≥ 2 years who are immunocompromised, have sickle cell disease, or functional or anatomic asplenia” ACIP Schedules. http://www.cdc.gov/vaccines/recs/schedules/default.htm. Accessed September 2009. CDC. http://www.cdc.gov/vaccines/recs/provisional/downloads/pneumo-oct-2008-508.pdf. Accessed Oct 2009.

  43. PPSV23 and Smokers Higher RR of invasive pneumococcal disease among smokers. Current smoker RR = 4.1. Passive exposure RR = 2.5. There is a dose response relation to number of cigarettes per day and pack years smoked Risks among smokers comparable to those of diabetes, asthma and other known risks 50/100,000/yr incidence rate NNV is 10,700 for age 18-44, 4000 for age 45-64 Nuorti J, et al. N Engl J Med. 2000;342:681-689. ACIP Meeting Oct 2008. http://www.cdc.gov/vaccines/recs/acip/downloads/min-oct08.pdf. Accessed September 2009.

  44. 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.

  45. Adult Immunization Schedule: US 2010 CDC. MMWR Morb Mortal Wkly Rep. 2010;59(1).

  46. Hepatitis A Postexposure Prophylaxis • For healthy persons 12 months through 40 years of age who have not previously received HepA vaccine • Take into account patient characteristics, including chronic liver disease • Immunoglobulin and/or single-antigen hepatitis A vaccine should be administered as soon as possible after exposure • Vaccine preferred for those of age 12 mos to 40 yrs • Ig preferred for age < 12 mos, those with vaccine allergies, or those with immunosuppression or liver disease • Ig preferred for age > 40 but vaccine may be used if Ig unavailable • HepA and Ig may be administered simultaneously • Efficacy of Ig or HepA when administered > 2 weeks postexposure is unknown CDC. MMWR Morb Mortal Wkly Rep. 2007;56(41):1080-1084. CDC. MMWR Morb Mortal Wkly Rep. 2009;58(36):1006-1007.

  47. Hepatitis A Vaccine International Travel • For healthy persons 40 years of age or younger • 2 doses 6 months apart prior to departure • The first dose of Hepatitis A vaccine should be administered as soon as travel is considered • 1 dose of single-antigen vaccine administered at any time before departure • Consider both HAV and Ig for • Persons age > 40 with chronic illness traveling in less than 2 weeks and only receiving one dose of HAV • Persons at risk of severe disease from hepatitis A virus planning to travel in 2 weeks or sooner CDC. MMWR Morb Mortal Wkly Rep.2007;56(41):1080-1084.

  48. Hepatitis B Vaccine Expanded Indications • A patient’s “acknowledgment of a specific risk factor should not be a requirement for vaccination” • For all “sexually active persons who are not in a long-term mutually monogamous relationship” • Past indications: • Universal for ages birth–18 years • Being evaluated for STD • Being treated for STD • Men who have sex with men • Sex partners of HBs Ag-positive persons • Prisoners • Health care workers CDC. MMWR Recomm Rep. 2006;55(RR16):1-33.

  49. Hepatitis B Vaccine Hepatitis B. http://www.cdc.gov/vaccines/pubs/pinkbook/downloads/hepb.pdf. Accessed Oct 2009.

  50. HBV Protection* by Age Group and Dose *Anti-HBs antibody titer of 10 mIU/mL or higher **Preterm infants less than 2 kg have been shown to respond to vaccination less often ***Factors that may lower vaccine response rates are older than 40 years, male gender, smoking, obesity, and immune deficiency Hepatitis B. http://www.cdc.gov/vaccines/pubs/pinkbook/downloads/hepb.pdf. Accessed Oct 2009.