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Adult Vaccines: Increasing Influenza and Pneumococcal vaccination

Adult Vaccines: Increasing Influenza and Pneumococcal vaccination. ACHCA Annual Conference April 2006 James Marx, RN, MS, CIC Broad Street Solutions www.InfectionControl.net. Agenda. Epidemiology of Influenza Epidemiology of Pneumococcal Disease Role of vaccination in disease prevention

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Adult Vaccines: Increasing Influenza and Pneumococcal vaccination

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  1. Adult Vaccines: Increasing Influenza and Pneumococcal vaccination ACHCA Annual Conference April 2006 James Marx, RN, MS, CIC Broad Street Solutions www.InfectionControl.net

  2. Agenda • Epidemiology of Influenza • Epidemiology of Pneumococcal Disease • Role of vaccination in disease prevention • Role of antiviral medication • Infection Control measures • Droplet Precautions • Hand Hygiene • Restriction of Activities and Group Dining

  3. Agenda • Requirement for vaccination of SNF residents (CMS and AB 691) • Standing Orders in SNF- AB 1711 • Minimum Data Set- Section W • Barriers to vaccination • Lack of education • Consent issues • Vital Signs • Billing

  4. Agenda • Monitoring for Performance Improvement • Hospital Core Measures to prevent Community Acquired Pneumonia • Percent of vaccinated staff • Percent of vaccinated SNF residents • Percent of vaccinated eligible inpatients • Group Discussion on improving interfacility transfers

  5. Vaccine preventable diseases • Residents, staff, visitors • Influenza (Oct-Mar) • Tetanus/diphtheria • Residents • Pneumococcal (All year) • Residents and Staff (Selected populations) • Hepatitis B • Varicella (chickenpox)

  6. Epidemiology Influenza Pneumococcal Disease

  7. Influenza • Sixth leading cause of death • Death in the elderly is about 1/1000 cases or 36,000 deaths per year • Hospitalization in the elderly is about 1/250 cases

  8. Institutional outbreaks • To date this season, respiratory outbreaks have been reported in seven long-term care and developmental facilities in Santa Clara, Marin, Orange and Santa Cruz counties. • Five outbreaks were associated with influenza A; in two an etiology was not identified.

  9. Influenza Nomenclature • A/New York/55/2004/(H3N2) • Influenza A • First isolated in New York • Strain number 55 • First isolated in 2004 • Hemagglutinin type 3 • Neuraminidase type 2

  10. Influenza peak in past 26 seasons

  11. Influenza Basics • Influenza A and B • Influenza A subgroups, H and N • Antigenic drift and shift • Results of viral mutation over time • Transmitted person-to-person via respiratory secretions • Incubation 1-4 days, 2 days average

  12. Endemic  Epidemic  Pandemic

  13. The Two Mechanisms whereby Pandemic Influenza Originates Belshe, R. B. N Engl J Med 2005;353:2209-2211

  14. Influenza Patterns • Sporadic  year round, A, B, and C • Seasonal  December to February, mostly Influenza A (annual) • Epidemic  Exaggeration of the seasonal pattern, involves a geographic region with an attack rate of 10 to 40 % (299 in recorded history- last one was 1997) • Pandemics  Global impact (31 in recorded history- last in 1968)

  15. How big is a seasonal outbreak? • Clinical illness in 16,000,000 per year in the US • 4,500,000 cases in the elderly • 3,600,000 doctors visits • May result in 40,000 excess deaths

  16. How Big is Epidemic Influenza ? • An epidemic but not pandemic year may infect 15 to 35% of the population • 90,000 to 210,000 deaths • 310,000 to 730,000 hospitalizations

  17. How Big is Pandemic Influenza ? • Pandemic influenza could infect 60% of the world’s population • If no more lethal than current H3N2 • 150,000 to 450,000 deaths • If as lethal as swine flu (1917) • 450,000 to 750,000 deaths • If as lethal as avian H5N1 • 75,000,000 deaths

  18. Current status of pandemic

  19. Influenza Basics • Infectious period is 1 day before and 5 days after symptoms appear, in adults • In children and the elderly, infectious period may be 6 days before and 10 days after symptoms appear

  20. Influenza signs and symptoms • Abrupt onset with • Fever • Myalgia • Headache • Severe malaise • Nonproductive cough • Sore throat • Runny nose

  21. Pathogenesis of Influenza • Mucosal epithelia are the most heavily infected cells • Disrupts host cell protein synthesis • May trigger apoptosis • Protein epitopes are similar to peptides toxic to neutrophils

  22. Complications of Influenza • Progressive pneumonia (rare) • Bronchial mucosal sloughing • Loss of ciliated epithelia • Alteration to white cell function • Bronchoconstriction • Bacterial superinfection

  23. Influenza Vaccine • Technology developed in the 1940s • Virus is inoculated into embryonated chicken eggs • Each egg produces enough virus for 1 to 3 doses of vaccine • At least 9 months are needed to produce adequate amounts of any given strain

  24. Intramuscular Vaccine • Inactivated virus, grown in chicken eggs • Protection in 2 weeks after vaccination • 2005-6 vaccine contains • A/California/7/2004 (H3N2) • A/New Caledonia/20/99 (H1N1) • B/Shanghai/361/2002 • Selection each year is a guess made in April; vaccine made in summer

  25. Vaccine effectiveness • Adults < 65 years • 70-90% protection against influenza • Adults > 65 years • 58% protection against influenza • 50-60% effective in preventing hospitalization • 80% effective in preventing death

  26. Vaccine Administration • Intramuscular; 1 inch or longer needle • 0.5 ml • Soreness at the site occurs < 65% of the time and lasts < 2 days

  27. Vaccine Administration • Fever, malaise and myalgia occurs within 6-12 hours of administration and occurs most often in first time vaccinees • Anaphylaxis and Guillain-Barré Syndrome are extremely rare • Can be given at the same time as other vaccines, at different sites

  28. New influenza vaccine • Intranasal, live vaccine (FluMist) • Ages 5-49 only • Transmission of vaccine virus to others is possible • Close contact with people at high risk of influenza should be avoided for 21 days after vaccine is given • Nasal swab may be positive for up to 3 weeks after vaccine • Not recommended for pregnant women • In 2005-2006 CDC changed recommendations to include healthcare workers

  29. Live Vaccine • Recombinants with less virulent strains • Cold adapted virus • DNA vaccines

  30. Cost effective in staff • Influenza vaccine • Reduces physician office visits 34-44% • Reduces lost work days 32-45% • Reduces antibiotic use 25% • $60 - 4,000/illness averted among healthy persons aged 18--64 years

  31. Vaccine recommendations: High Risk • Persons aged >65 years • Residents of nursing homes and other chronic-care facilities that house persons of any age who have chronic medical conditions • Adults and children who have chronic disorders of the pulmonary or cardiovascular systems, including asthma (hypertension is not considered a high-risk condition) • Adults and children who have required regular medical follow-up or hospitalization during the preceding year because of chronic metabolic diseases (including diabetes mellitus), renal dysfunction, hemoglobinopathies, or immuno-suppression (including immunosuppression caused by medications or by human immunodeficiency virus [HIV])

  32. Vaccine recommendations: High Risk • Adults and children who have any condition (e.g., cognitive dysfunction, spinal cord injuries, seizure disorders, or other neuromuscular disorders) that can compromise respiratory function or the handling of respiratory secretions or that can increase the risk for aspiration • Children and adolescents (aged 6 months--18 years) who are receiving long-term aspirin therapy and, therefore, might be at risk for experiencing Reye syndrome after influenza infection • Women who will be pregnant during the influenza season • Children aged 6--23 months

  33. Vaccine Recommendations: Transmitters • Employees of assisted living and other residences for persons in groups at high risk • Persons who provide home care to persons in groups at high risk • Household contacts (including children) of persons in groups at high risk • Healthcare Workers (HCWs)

  34. Vaccine Recommendations: Other • Persons aged 50-64 • Healthy young children • Travelers • General population

  35. Define a influenza case • Use a written definition (A McGeer, AJIC, 1991) • Sudden onset of fever (>100.4° F) plus three or more of the following symptoms (Dec-Mar only): • Headache or eye pain • Myalgia(Muscle aches) • New or increased dry cough • Chills • Sore throat • Malaise or loss of appetite • Laboratory confirmed influenza

  36. Define an influenza outbreak • One laboratory confirmed and two suspect cases of influenza in a 48-72 hour period among staff, residents, or visitors (SHEA position paper) • Ten percent (10%) of residents meet written definition of influenza in a 7 day period (SHEA position paper) • Write the outbreak definition in your policy

  37. Outbreak activities • Reinforce hand hygiene • Increase availability of tissue and disposal containers • Institute droplet precautions for residents with symptoms; standard surgical masks • Remind staff to stay home if they have symptoms consistent with influenza • Consider use of antiviral prophylaxis • Consider restriction of admissions, groups activities, dining and visitation • Notify reporting agencies

  38. Mechanism of Action of Neuraminidase Inhibitors Moscona, A. N Engl J Med 2005;353:1363-1373

  39. Selected Treatment Trials of Neuraminidase Inhibitors Moscona, A. N Engl J Med 2005;353:1363-1373

  40. Avian Influenza • Causes influenza in birds • Has been transmitted to humans • Rare human-to-human transmission (1 case) • Future mutations could effect humans

  41. Selected Trials of Prophylaxis with the Use of Neuraminidase Inhibitors Moscona, A. N Engl J Med 2005;353:1363-1373

  42. Pneumococcal Disease • Pneumonia • Bacteremia • has a 40% mortality • Meningitis

  43. Pneumococcal Disease and Vaccination • Basics • Vaccine protects from invasive Streptococcus pneumoniae • Pneumonia • Bacteremia • Meningitis • More than 80 different subtypes of this bacteria • 5%- 70% of people are carriers of this bacteria in their nose, mouth, and lungs • Pneumococcal pneumonia is the most common cause of pneumonia in adults

  44. Pneumococcal pneumonia • Symptoms • fever, chills, shaking, chest pain, productive cough, shortness of breath, rapid heart beat, and general weakness • More than 50,000 cases occur each year • The overall death rate is 20% but in the elderly it may be as high as 60%

  45. Vaccine efficacy • This vaccine provides protection against 23 serotypes of St. pneumoniae • Protection usually lasts from 5-10 years or longer in healthy individuals • No recommendation for revaccination in most people • Reduces death by 50% • Uncertain vaccine status??- VACCINATE!

  46. Vaccine administration • May be given at same time a influenza vaccine • For IM injection administer vaccine at a 90° angle with a 1 to 2 inch 22-25-gauge needle in the deltoid • For SC injections, administer vaccine at a 45° angle with a 5/8-inch, 23-25-gauge needle into the subcutaneous tissue of the upper-outer arm.

  47. Vaccine recommendations • Older than 65 years of age • Anatomic or functional asplenia, CSF leak, diabetes mellitus, alcoholism, cirrhosis, chronic renal insufficiency, chronic pulmonary disease, or advanced cardiovascular disease • multiple myeloma, lymphoma, Hodgkin's disease, HIV infection, organ transplantation, or chronic use of glucocorticosteroids

  48. Vaccine recommendations • Persons who are genetically at increased risk, such as Alaskan and Native Americans • Persons who live in special environments where outbreaks may occur, such as nursing homes

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