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Adult Immunization 2010 Tetanus, Diphtheria and Pertussis Segment

Adult Immunization 2010 Tetanus, Diphtheria and Pertussis Segment . This material is in the public domain This information is valid as of May 25, 2010.

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Adult Immunization 2010 Tetanus, Diphtheria and Pertussis Segment

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  1. Adult Immunization 2010 Tetanus, Diphtheria and Pertussis Segment This material is in the public domain This information is valid as of May 25, 2010

  2. NOTE:Participants are strongly encourage to have a copy of the current adult immunization schedule available during this program. The current schedule can be downloaded from the CDC Vaccines and Immunizations website at:http://www.cdc.gov/vaccines/recs/schedules/adult-schedule.htm

  3. Tetanus and Diphtheria Immunity • More than 50% of adults 20 years of age and older in the U.S. do not have a protective level of antibody against tetanus and diphtheria • Many adults 60 years of age and older have not received a primary series of tetanus- and diphtheria-containing vaccine • Many adults of all ages do not receive routine Td booster doses every 10 years

  4. Reported Pertussis by Age Group, 1990-2008

  5. Tetanus and DiphtheriaVaccines for Adults • Tetanus and Diphtheria Toxoid (Td) • formalin-inactivated toxins • 3 doses induces protective antibody in nearly everyone • protection for at least 10 years • Tdap

  6. Tdap Vaccines • Boostrix (GlaxoSmithKline) • single dose • approved for persons 10 through 64 years of age • Adacel (sanofi pasteur) • single dose • approved for persons 11 through 64 years of age

  7. General Principles for Useof Tdap and Td • No brand preference • Tdap preferred to Td to provide protection against pertussis • Approved as a single booster dose in persons who have previously received a full series of pediatric DTaP or DTP

  8. Persons Without Documentation of Pertussis Vaccination • All adults should have documentation of having received a series of DTaP, DTP, DT, or adult Td • Adults without documentation should receive or complete a series of 3 doses • Preferred schedule*: • single dose of Tdap • Td at least 4 weeks after the Tdap dose • second dose of Td at least 6 months after the Td dose *off-label recommendation. See MMWR 2006;55(RR-17)

  9. Minimum Interval BetweenTd and Tdap • ACIP did not define an absolute minimum interval between Td and Tdap • Provider will need to decide based on whether the benefit of pertussis immunity outweighs the risk of a local adverse reaction MMWR 2006;55(RR-17)

  10. Tdap and Pregnancy • Td is generally preferred during pregnancy • All women should receive a dose of Tdap in the immediate postpartum period • Any woman who might become pregnant is encouraged to receive a single dose of Tdap • A clinician may choose to administer Tdap to a pregnant woman in certain circumstances, such as during an outbreak of pertussis in the community • Pregnancy is not a contraindication to vaccination with Tdap MMWR 2008;57(RR-4)

  11. Tdap and HealthcarePersonnel (HCP) • Healthcare personnel who work in hospitals or ambulatory care settings and have direct patient contact should receive a single dose of Tdap as soon as feasible • Priority should be given to vaccination of healthcare personnel who have direct contact with infants 12 months of age and younger • Other HCP should receive a single dose of Tdap to replace the next scheduled Td MMWR 2006;55(RR-17)

  12. Tdap Contraindications • Severe allergic reaction to a vaccine component or following a prior dose • Encephalopathy within 7 days of administration of a pertussis vaccine that is not attributable to another identifiable cause

  13. Tdap Precautions • History of an Arthus-type reaction following a previous dose of tetanus or diphtheria toxoid-containing vaccine • Progressive neurologic disorder, uncontrolled epilepsy, or progressive encephalopathy until condition stabilized • History of Guillain-Barré syndrome (GBS) within 6 weeks after a previous dose of tetanus toxoid-containing vaccine • Moderate or severe acute illness

  14. Tdap/Td Adverse Reactions • Pain • Redness • Swelling • Temperature (100°F or higher) • Systemic 66% - 75% 23% - 24% 21% 3% - 5% 30% - 40%

  15. Adult Immunization 2010 Influenza Segment This material is in the public domain This information is valid as of May 25, 2010

  16. Impact of Influenza • Approximately 36,000 influenza-associated deaths during each influenza season • Persons 65 years of age and older accounted for more than 90% of deaths • The number of deaths and cost to society from influenza is likely to increase as the nation’s population ages MMWR 2009;58 (RR-8)

  17. Influenza Virus Strains • Type A • moderate to severe illness • affects all age groups • affects humans and other animals (particularly migratory waterfowl) • Type B • milder disease • primarily affects children • humans only

  18. Type of nuclear material Neuraminidase Hemagglutinin A/Fujian/411/2002 (H3N2) Virus type Geographic origin Strain number Year of isolation Virus subtype Influenza Virus

  19. Influenza A (H1N1) • A previously unknown strain of H1N1 influenza virus appeared in April 2009 • Many outbreaks in April and May • Pandemic declaration in June • Second wave of illness occurred in the fall and winter of 2009

  20. Impact of Pandemic H1N1 Virus – United States, April 2009-March 2010 • 60 million infections • 270,000 hospitalizations • 13,000 deaths http://www.cdc.gov/h1n1flu/estimates_2009_h1n1.htm

  21. Influenza Vaccines • Live attenuated vaccine (LAIV) • intranasal • Approved only for persons 2 through 49 years of age who are healthy and not pregnant • Inactivated subunit (TIV) • intramuscular • split virus or purified surface antigen MMWR 2009;58(RR-8)

  22. Fluzone HD Vaccine (sanofi pasteur) • Contains 4 times the amount of hemagglutinin than in regular Fluzone TIV • Approved by the FDA only for persons 65 years and older • ACIP has not stated a preference for Fluzone HD or other TIV brand among persons 65 years and older MMWR 2010;59 (in press)

  23. Influenza Vaccines • Trivalent (H3N2, H1N1, B) • Efficacy varies • Duration of immunity 1 year or less for TIV • Duration of immunity at least 1 year for LAIV MMWR 2009;58(RR-8)

  24. Inactivated Influenza Vaccine (TIV) Efficacy • 70%-90% effective among healthy persons <65 years of age • 30%-40% effective among persons 65 years and older with underlying medical conditions • Prevents complications and death from influenza among those who get the disease MMWR 2009;58(RR-8)

  25. Influenza Vaccination Recommendation • Annual influenza vaccination is recommended for every person in the United States 6 months of age and older • Make a special effort to vaccinate persons at increased risk of complications of influenza and their close contacts • persons with underlying medical illnesses • persons 65 years of age and older • pregnant women • children younger than 2 years of age MMWR 2010;59 (in press)

  26. Inactivated Influenza Vaccine Recommendations • Medical conditions that increase the risk of complications of influenza • Pulmonary • Cardiovascular • Metabolic • Renal dysfunction • Hemoglobinopathy • Immunosuppression • any condition that can compromise respiratory function or the handling of respiratory secretions or that can increase the risk of aspiration MMWR 2009;58(RR-8)

  27. Pregnancy and Influenza Vaccine • Excess deaths from influenza among pregnant women were documented during the pandemics of 1918-1919 and 1957-1958 • Pregnant women were at increased risk of complications of influenza during the 2009 H1N1 influenza pandemic • ACIP recommends vaccination with inactivated influenza vaccine for ALL women who will be pregnant during influenza season • inactivated vaccine only • LAIV contraindicated for pregnant women MMWR 2009;58(RR-8)

  28. Inactivated Influenza VaccineContraindications and Precautions • Severe allergic reaction to a vaccine component or following a prior dose • Moderate or severe acute illness • History of Guillain-Barre´ syndrome within 6 weeks following a previous dose of influenza vaccine MMWR 2006;55(RR-3)

  29. Live Attenuated Influenza VaccineContraindications and Precautions • Severe allergic reaction to a vaccine component or following a prior dose • Underlying medical conditions • Immunosuppression • Pregnancy • History of Guillain-Barre´ syndrome within 6 weeks following a previous dose of influenza vaccine • Moderate or severe acute illness MMWR 2006;55(RR-3)

  30. TIV Adverse Reactions Local reactions 15%-20% (pain, redness) Systemic reactions uncommon (fever, malaise) Severe allergic Rarereactions Neurological reactions Very rare MMWR 2006;55(RR-3)

  31. LAIV Adverse Reactions • Increased rate of cough, coryza, nasal congestion, sore throat, chills • No increase in fever • No serious adverse reactions have been identified MMWR 2006;55(RR-3)

  32. Administration of LAIV • Severely immunosuppressed persons should not administer LAIV • Persons who have a contraindication to receipt of LAIV may administer LAIV • Gloves and masks are not required MMWR 2006;55(RR-3)

  33. Adult Immunization 2010 Pneumococcal Segment This material is in the public domain This information is valid as of May 25, 2010

  34. Annual Burden of Pneumococcal Disease in the United States • More than 40,000 invasive infections • More than 4,500 deaths • Incidence of pneumococcal disease rises steadily with increasing age • Drug resistant strains of pneumococcus are becoming more common http://www.cdc.gov/abcs/reports-findings/surv-reports.html

  35. Pneumococcal Polysaccharide Vaccine • Purified capsular polysaccharide antigen from 23 types of pneumococcus • Account for 88% of bacteremic pneumococcal disease • Cross-react with types causing additional 8% of disease MMWR 1997;46(RR-8)

  36. Pneumococcal Polysaccharide Vaccine • 60% to 70% efficacy against invasive disease • Duration of immunity at least 6 years • Schedule 1 dose, selective revaccination (at least 5 years after the first dose) MMWR 1997;46(RR-8)

  37. Pneumococcal Polysaccharide Vaccine Recommendations • Adults 65 years of age and older • Adults of any age with a normal immune system who have chronic illness • cardiovascular disease • pulmonary disease • diabetes • alcoholism, cirrhosis • cerebrospinal fluid leak • cochlear implant MMWR 1997;46(RR-8)

  38. Pneumococcal Polysaccharide Vaccine Recommendations* • Adults 19 years of age and older • asthma • cigarette smoking *provisional recommendation, October 2008 http://www.cdc.gov/vaccines/recs/provisional/

  39. Pneumococcal Polysaccharide Vaccine Recommendations • Adults who are immunocompromised • asplenia (functional or anatomic) • chronic renal failure • nephrotic syndrome • Hodgkin’s disease • lymphoma • multiple myeloma • Persons with HIV infection MMWR 1997;46(RR-8)

  40. Pneumococcal Polysaccharide Vaccine Revaccination Recommendations • Routine revaccination of immunocompetent persons is NOT recommended • Revaccination is recommended for persons at highest risk of serious pneumococcal infection • Revaccinate once • 5 years or longer after first dose (interval applies to persons of all ages) MMWR 1997;46(RR-8)

  41. Candidates for Pneumococcal Revaccination • Functional or anatomic asplenia • Immunosuppression • Chronic renal failure • Nephrotic syndrome • First dose before 65 years of age and >5 years since first dose • First dose at >65 years of age AND later develop a condition for which revaccination is recommended AND at least 5 years since the first dose MMWR 1997;46(RR-8)

  42. Pneumococcal Polysaccharide VaccineContraindications and Precautions • Severe allergic reaction to a vaccine component or following a prior dose • Moderate or severe acute illness MMWR 1997;46(RR-8)

  43. Pneumococcal Polysaccharide Vaccine Adverse Reactions • Local reactions 30% -50%(pain, redness) • Systemic reactions <1%(fever, malaise) • Severe adverse Rarereactions MMWR 1997;46(RR-8)

  44. Adult Immunization 2010 Herpes Zoster (Shingles) Segment This material is in the public domain This information is valid as of May 25, 2010

  45. Herpes Zoster (shingles) • Caused by reactivation of a latent varicella zoster virus infection • Can occur years or decades after illness with chickenpox • Generally associated with normal aging and with anything that causes reduced immunocompetence • Lifetime risk of 32% in the United States • Estimated 1 million cases zoster diagnosed annually in the U.S.

  46. Herpes Zoster Vaccine(Zostavax) • Contains live attenuated varicella virus in an amount that is approximately 14 times greater than that in regular varicella vaccine • Approved for persons 60 years of age and older • Administered by the subcutaneous route

  47. Zostavax Clinical Trial • Compared to the placebo group the vaccine group had: • 51% fewer episodes of zoster • less severe disease • 66% less postherpetic neuralgia • No significant safety issues were identified NEJM 2005;352(22):2271-84.

  48. ACIP Recommendations for Zoster Vaccine • Single dose of zoster vaccine for adults 60 years of age and older whether or not they report a prior episode of shingles • Persons with a chronic medical condition may be vaccinated unless a contraindication or precaution exists for their condition MMWR 2008;57(RR-5)

  49. Screening for Zoster Vaccine Eligibility • Screening for a history of varicella disease is NOT necessary or recommended to administer zoster vaccine to a person 60 years of age or older • Persons born in the U.S. before 1980 can be assumed to have had chickenpox regardless of their recollection of chickenpox MMWR 2008;57(RR-5)

  50. Screening for Zoster Vaccine Eligibility • Do NOT test the person for varicella antibody • Negative test is more likely to indicate waning antibody level rather than true susceptibility • Seronegative persons should receive 2 doses of single-antigen varicella vaccine MMWR 2008;57(RR-5)

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