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INFLUENZA AND INFLUENZA VACCINES

INFLUENZA AND INFLUENZA VACCINES. Karen Lewis, M.D. Medical Director Arizona Immunization Program Office November 18, 2011. INFLUENZA VIRUS BIOLOGY. Influenza A, B & C Subtypes (A) Hemagglutinin Neuraminadase Antigenic drift (mutation) Antigenic shift ( reassortment ).

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INFLUENZA AND INFLUENZA VACCINES

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  1. INFLUENZA AND INFLUENZA VACCINES Karen Lewis, M.D. Medical Director Arizona Immunization Program Office November 18, 2011

  2. INFLUENZA VIRUS BIOLOGY • Influenza A, B & C • Subtypes (A) • Hemagglutinin • Neuraminadase • Antigenic drift (mutation) • Antigenic shift (reassortment)

  3. 20th Century Influenza Pandemics • Spanish flu H1N1 (1918-1919) • Asian flu H2N2 (1957-1958) • Hong Kong flu H3N2 (1968-1969) • Swine flu H1N1 (2009-2010) US Life Expectancy 1900-2000

  4. Seasonal Influenza in the US • Every winter • Attack rates: 10-40 % • Deaths: ~ 3,000-49,000/yr. • Hospitalizations: ~224,000/yr. • Most at risk: Elderly, children, those with medical conditions

  5. Influenza Activity in Arizona 1997-2006

  6. Deaths from Seasonal Influenza in US JAMA January 8, 2003

  7. 10/22/2011

  8. ARIZONA (10/15/2011)

  9. Bacterial Pneumonia Complicating Influenza Schwarzmann et al. Arch Intern Med 1971: 127; 1037-1041.

  10. SYMPTOMS OF INFLUENZA • Rapid onset • High fever, chills • Extreme exhaustion • Muscle aches • Dry cough • Runny nose • Sore throat

  11. COMPLICATIONS OF INFLUENZA • Viral pneumonia • Secondary bacterial pneumonia • Encephalitis • Heart and lung disease worsening • Hospitalization • Death

  12. Influenza Testing • Culture • PCR • DFA or IFA • Influenza season • If rapid test +, influenza likely • Summer • If rapid test +, could be false + A NEGATIVE INFLUENZA TEST DOES NOT EXCLUDE THE DIAGNOSIS OF INFLUENZA

  13. www.cdc.gov/flu/professionals/diagnosis/testing_algorithm.htmwww.cdc.gov/flu/professionals/diagnosis/testing_algorithm.htm CDCInfluenzaTestingAlgorithm

  14. SURGICAL MASK for DROPLET SPREAD PATIENT HEALTH CARE WORKERS

  15. Influenza Antiviral Principles • Treatment • Best within 48 hours • Give for 5 days • Especially • Hospitalized • Pneumonia (lab +) • Bacterial coinfection • High risk of complications • Prevention • Outbreak in closed institutional settings • Post exposure • High risk (?) • 2 wks after vaccine • Immunosuppressed • Poor vaccine/virus match

  16. Patients at Higher Risk for Complications from Influenza • > 65 years • < 2 years old • Pregnant women • Chronic lung disease • Asthma • Heart Disease • Renal Disease • Liver Disease • Neurologic disease • Metabolic disease • Diabetes • Immunosuppression • Morbid obesity

  17. Antivirals: Neuraminadase Inhibitors *Not FDA licensed **Reduce dose with CrCl 10-30 mL/min

  18. Side Effects of Neuraminadase Inhibitors • Oseltamivir • Nausea—10% • Vomiting—9% • Transient neuropsychiatric events • Zanamivir • Brochospasm • Peramivir • Diarrhea • Nausea/vominting • Neutropenia

  19. Current Influenza Vaccine Process

  20. Influenza Vaccine Summary • Give as soon as available • Give to everyone > 6 months • High-risk patients • Pregnant women • Health care providers • Give throughout influenza season

  21. Trivalent Influenza Vaccine (TIV) Inactivated Intramuscular

  22. Adverse Events after Influenza Shots • Common • Local reaction • Uncommon • Tired • Achy • Low fever www.immunize.org www.immunize.org

  23. Intradermal Influenza Vaccine (TIV) • 18-64 years old • Smaller needle • Less antigen • 9 mcg instead of 15 mcg • Same antibody response • Local reaction more visible

  24. High-dose IM Influenza Vaccine Now Licensed for > 65 Years Old

  25. Inactivated Influenza Vaccine (TIV) Contraindications and Precautions Contraindication Precaution Moderate-severe illness with or without fever GBS within 6 weeks of influenza vaccine • Anaphylactic reaction after previous vaccine • Egg allergy is no longer a contraindication

  26. New RecommendationsEgg Allergy & Flu Vaccine • Mild egg allergy is no longer a contraindication to TIV influenza vaccine • A previous severe allergic reaction to influenza vaccine is still a contraindication MMWR Aug. 26, 2011

  27. Trivalent Cold adapted—Cannot grow at normal body temperature + stuffy nose Live Attenuated Influenza Vaccine (LAIV)

  28. Live Attenuated Influenza Vaccine • Indications • 2-49 year old • Healthy • Not pregnant • Avoid contact with severely immune compromised patients for 7 days • Contraindicated • Egg allergy • Pregnancy • Immunosuppressed • Close contact of SEVERELY immunosuppressed • Precaution • Moderate/severe illness • GBS within 6 weeks of influenza vaccine

  29. Health Benefits to Adults from Trivalent Inactivated Influenza Vaccine (TIV) Nichol KL, et al. NEJM Oct. 5, 1995

  30. Seasonal Influenza Vaccination Coverage by Age: 2008-09 -- 2010-11 Seasons MMWR, June 10, 2011 & Carolyn Bridges Webinar 9/15/2011

  31. Which Health Care Providers Got Influenza Vaccine in 2010-2011?

  32. Influenza Vaccination of HCWs Protects LTC Patients in UK Carman, Lancet 2000

  33. Effect of Policy on HCP Influenza Vaccine Receipt MMWR April 2, 2010

  34. ALL PREGNANT WOMEN NEED INFLUENZA VACCINE • Any trimester • Vaccine decreases • Maternal complications • Premature births • Infant influenza • Infant cocooning • Family • Caretakers MMWR Aug. 6, 2011

  35. Commonly Heard Reasons for Not Getting Influenza Vaccine • I never get the flu • The flu’s not that bad • I am healthy so I don’t need vaccination • I always get sick after vaccination • I get sicker the years that I get vaccinated • Vaccines are often poorly matched • Vaccines not safe

  36. Risks from Influenza and Influenza Vaccines GBS after Influenza vs Vaccine4-7 times higher risk

  37. Thimerosal Timeline • 1930’s—Preservative (~50% Ethyl mercury) • 1968—CFR required use • 1997—FDA Modernization Act • 1999—Recommend reduction or removal • 2001—Routine infant/children vaccines without thimerosal (or trace) except for some influenza vaccines in multidose vials

  38. Autism Rates in Denmark after 1992 Thimerosal Removal from Vaccines Madsen et al. Pediatrics 2003

  39. US Vaccine Safety Monitoring • Vaccine Adverse Events Reporting System (VAERS) • Vaccine Safety Datalink • Real time link with EHRs • Clinical Immunization Safety Network • Columbia, Boston U, Stanford, Vanderbilt, John Hopkins, Kaiser Permanente • Vaccine Assessment Unit • Dept. of Defense

  40. Additional Influenza Resources • Advisory Committee on Immunization Practices (ACIP) • MMWR Aug. 6, 2010 & Aug. 26, 2011 • CDC website • www.cdc.gov/influenza • Immunization Action Coalition www.immunize.org • World Health Organization www.who.int

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