1 / 58

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

tracy
Download Presentation

Immunization May Prevent Non -infectious Diseases in Older Adults

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. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. 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

  2. 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.

  3. 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.

  4. 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

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

  6. 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.

  7. Tdap in Older Adults

  8. 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.

  9. 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?

  10. 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

  11. 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.

  12. 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.

  13. TdaP Post-Data Questions What is recommendation? What is the uptake? What are the ID benefits? What are the potential non-ID benefits?

  14. Influenza in Older Adults

  15. 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].

  16. Chronic Conditions Associated with Influenza Disease Green = children; Blue = Adults

  17. Influenza Pre-Data Questions What is recommendation? What is the uptake? What are the ID benefits? What are the potential non-ID benefits?

  18. 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.

  19. 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

  20. 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).

  21. Healthy People 2020 Goals vs. RI Performance in 2012-13 Season * Represent the women who had a baby in 2011

  22. Hospital Data (Inpt and Outpt)Age Breakdown \ * 2 patients with unknown age

  23. Non-ID Benefits of Influenza Vaccine 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.

  24. Major Adverse CV Events Udell JA, et al. JAMA. 2013;310(16):1711-1720.

  25. Major Adverse CV Events Udell JA, et al. JAMA. 2013;310(16):1711-1720.

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

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

  28. High Dose(HD) IIV ACIP 10/13 • 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.

  29. Influenza Post-Data Questions What is recommendation? What is the uptake? What are the ID benefits? What are the potential non-ID benefits?

  30. This is your brain with Pneumococcus

  31. Pneumococcal Background • 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].

  32. Pre-Data Questions What is recommendation? What is the uptake? What are the ID benefits of vaccine? What are the potential non-ID benefits?

  33. This is your lung with Pneumococcus5% mortality

  34. This is your blood with Pneumococcus20% mortality

  35. This is your brain with Pneumococcus 30% mortality

  36. Pneumococcal Recommendations – 8/2014 65 yo+: No or unknown history Give PCV13  6-12 months  PPSV23 65 yo+: PPSV23 > 1 year ago, no PCV13 history Give PCV13

  37. Sept 2012 Provisional RecommendationsPCV13 and PPSV23 Immunize.org/ Accessed 9/25/12.

  38. Pneumococcal Uptake • Percent vaccinated in US in 2012 (PPSV23) • 20% 19-64 yo high risk • 59.9% >65 yo • MMWR 2014; 63(5):96-97.

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

  40. Non-ID Benefits of Pneumococcal Vaccine? 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.

  41. Post-Data Questions What is recommendation? What is the uptake? What are the ID benefits? What are the potential non-ID benefits?

  42. Herpes Zoster

  43. Herpes Zoster Background • 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.

  44. Zoster Pre-Data Questions What is recommendation? What is the uptake? What are the ID benefits of vaccine? What are the potential non-ID benefits?

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

  46. VZV Pathogenesis 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

  47. CV Risks After Herpes Zoster *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.

  48. Non-significant 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.

  49. 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.

More Related