Adult Immunization

2. Adult Immunization Original by Dr. Ari Robicsek Updated by T.Cook 21 Mar 2003

3. Objectives • To know which vaccines to recommend to which patients • To know why Sources • Canadian Immunization Guide, 6th ed Health Canada Weblink • CDC National Immunization Program Weblink • Up To Date, vaccinemanufacturer websites

4. Some thoughts: • When was the last time you asked a patient about their immunization record? • Prevention of disease should be the domain of specialists as well as primary care physicians.

5. Vaccine Regimens • Pediatric (not discussed) • Adult • Traveler (future seminar)

6. Recommended Adult Immunization Schedule United States, 2002-2003 and Recommended Immunizations for Adults with Medical Conditions Summary of Recommendations Published by The Advisory Committee on Immunization Practices Department of Health and Human Services Centers for Disease Control and Prevention Based on the Recommendations of the Advisory Committee on Immunization Practices, Centers for Disease Control and Prevention

7. A Recommended Adult Immunization Schedule, United States, 2002-2003 Recommended Immunizations for Adults with Medical Conditions, United States, 2002-2003 For all persons in thisage group Catch-up on childhood vaccinations For persons with medical / exposure indications For all persons inthis group Catch-up on childhood vaccinations For persons with medical / exposure indications Contraindicated Vaccine Age Influenza Varicella* Hepatitis B* Hepatitis A Measles Mumps Rubella (MMR)* 19-49 years 50-64 years 65 years and older Tetanus-Diphtheria (Td)* Pneumo-coccal (poly- saccharide) Vaccine Medical Conditions Tetanus, Diphtheria (Td)* 1 dose booster every 10 years1 Pregnancy 1 dose annually for persons with medical or occupational indications, or household contactsof persons with indications 2 Influenza 1 annual dose Diabetes, heart disease, chronic pulmonary disease, chronic liver disease, including chronic alcoholism B C D 1 dose for unvaccinated persons 3 Pneumococcal (polysaccharide) 1 dose for persons with medical or other indications. (1 dose revaccination for immunosuppressive conditions) 3,4 1 dose revaccination 4 Congenital immunodeficiency, leukemia, lymphoma, generalized malignancy, therapy with alkylating agents, antimetabolites, radiation or large amounts of corticosteroids E F Hepatitis B* 3 doses (0, 1-2, 4-6 months) for persons with medical, behavioral, occupational, or other indications 5 Hepatitis A 2 doses (0, 6-12 months) for persons with medical, behavioral, occupational, or other indications 6 Renal failure / end stage renal disease, recipients of hemodialysis or clotting factor concentrates E G 1 dose if measles, mumps, or rubella vaccination history is unreliable; 2 doses for persons with occupational, geographic, or other indications 7 Measles, Mumps, Rubella (MMR)* Asplenia including elective splenectomy and terminal complement component deficiencies E, H, I 2 doses (0, 4-8 weeks) for persons who are susceptible8 Varicella* Meningococcal (polysaccharide) HIV infection K 1 dose for persons with medical or other indications 9 E, J *Covered by the Vaccine Injury Compensation Program. See Footnotes for Recommended Adult Immunization Schedule on the back cover. G. Hemodialysis patients: Use special formulation of vaccine (40 ug/mL) or two 1.0 mL 20 ug doses given at one site. Vaccinate early in the course of renal disease. Assess antibody titers to hep B surface antigen (anti-HBs) levels annually. Administer additional doses if anti-HBs levels decline to <10 milliinternational units (mlU)/ mL. H. Also administer meningococcal vaccine. I. Elective splenectomy: vaccinate at least 2 weeks before surgery. J. Vaccinate as close to diagnosis as possible when CD4 cell counts are highest. K. Withhold MMR or other measles containing vaccines from HIV-infected persons with evidence of severe immunosuppression. MMWR 1996; 45: 603-606, MMWR 1992; 41 (RR-17): 1-19. • If pregnancy is at 2nd or 3rd trimester during influenza season. • Although chronic liver disease and alcoholism are not indicator conditions for influenza vaccination, give 1 dose annually if the patient is > 50 years, has other indications for influenza vaccine, or if the patient requests vaccination. • Asthma is an indicator condition for influenza but not for pneumococcal vaccination. • For all persons with chronic liver disease. • Revaccinate once after 5 years or more have elapsed since initial vaccination. • Persons with impaired humoral but not cellular immunity may be vaccinated. MMWR 1999; 48 (RR-06): 1-5. *Covered by the Vaccine Injury Compensation Program. For information on how to file a claim call 1-800-338-2382. Please also visit http://www.hrsa.osp.gov/vicpaccessed February 21, 2002. To file a claim for vaccine injury write: U.S. Court of Federal Claims, 717 Madison Place, N.W., Washington D.C. 20005. (202) 219-9657. This schedule indicates the recommended age groups for routine administration of currently licensed vaccines for persons 19 years of age and older. Licensed combination vaccines may be used whenever any components of the combination are indicated and the vaccine’s other components are not contraindicated. Providers should consult the manufacturers' package inserts for detailed recommendations. Report all clinically significant post-vaccination reactions to the Vaccine Adverse Event Reporting System (VAERS). Reporting forms and instructions on filing a VAERS report are available by calling 1-800-822-7967 or from the VAERS website at http://www.vaers.org. For additional information about the vaccines listed above and contraindications for immunization, visit the National Immunization Program Website at http://www.cdc.gov/nip/ or call the National Immunization Hotline at 800-232-2522 (English) or 800-232-0233 (Spanish). Approved by the Advisory Committee on Immunization Practices (ACIP), and accepted by the American College of Obstetricians and Gynecologists (ACOG) and the American Academy of Family Physicians (AAFP)

10. Immunization Guidelines • Immunization services should be readily available. • There should be no barriers or unnecessary prerequisites to the receipt of vaccines. • Providers should use all clinical encounters to screen for needed vaccines and, when indicated, vaccinate • Providers should educate in general terms about immunization.

11. Guidelines Cont’d Providers should: • inform in specific terms about the risks / benefits of vaccines they are to receive. • recommend deferral or with- holding of vaccines for true contraindications only • administer all vaccine doses for which a patient is eligible at the time of each visit. • ensure that all vaccinations are accurately and completely recorded. • maintain easily retrievable summaries of the vaccination records to facilitate age-appropriate vaccination.

12. Providers should • report clinically significant adverse events following vaccination promptly, accurately, and completely • report all cases of vaccine-preventable diseases as required under provincial / territorial legislation. • adhere to appropriate procedures for vaccine management. • maintain up-to-date, easily retrievable protocols at all locations where vaccines are administered. • maintain ongoing education regarding vaccines • operate a tracking system.

13. ISSUES WITH SPECIFIC VACCINES • Td • MMR • Pneumococcal • Influenza • Hepatitis B

14. Tetanus/Diphtheria • Bacterial diseases with high mortality, both entirely vaccine preventable • “Td” is a toxoid vaccine (bacterial toxins adsorbed to aluminum) • primary vaccination done early in life • adverse effects minimal in adults

15. Tetanus/Diphtheria • How often should Td be administered? If primary vaccination has been done, including the booster at age 14-16, there are two acceptable approaches: 1. Booster at ten-year intervals. 2. Just one booster at age 50 if not done in 40’s. Note: Vaccinate after a dirty wound if last vaccination was more than five years earlier.

16. MMR • Serious complications of • Measles: • Mumps: • Rubella: • Resurgence of measles in U.S. in late ‘80’s; seems that 5-20% of people don’t respond to intial vaccination in childhood • New recommendations are for two-time MMR to protect against measles Pneumonia, meningoencephalitis, SSPE Meningitis/other CNS disease, sterility Congenital rubella

17. MMR • Which adults should get MMR? • Any who are not immune: • Born after 1970 AND no documentation of immunization (or infection) either by paper evidence or serology • Most importantly: • women of childbearing years • health care workers • college students • travellers to epidemic areas

18. MMR • Post exposure prophylaxis: • vaccination post-exposure protects against measles if given within 72 hours • not protective against mumps or rubella • Safe in pregnancy? • Probably, but we don’t use it • if a woman is found to be serologically negative in pregnancy, we immunize after delivery before she leaves hospital

19. MMR • Contraindications: • egg anaphylaxis is NOT a contraindication even though measles grown in eggs • neomycin allergy IS a contraindication • HIV is NOT a contraindication unless very immunosuppressed • Adverse Effects: • rubella component causes arthralgia in > 40% of women; some even have arthritis; this happens 1-3 weeks post vaccination

20. Streptococcus pneumoniae • Risk of invasive pneumococcal infections increases with age • 7/100,000 in young adults • 61/100,000 in adults 65 or older; 3x increased mortality for pneumococcal pneumonia compared to young adults • 46 times higher than controls in HIV patients in pre-HAART era • other RF’s for pneumococcal pneumonia are haem CA, EtOH, smoking, Black/First Nations, asplenia

21. Streptococcus pneumoniae • First pneumococcal vaccine tested pre Great War; vaccine to polysaccharide capsular antigens introduced in 1945 but widely ignored due to high Abx efficacy • now ~10% of clinical isolates Canada-wide have some PEN-resistance (which correlates with other-Abx resistance) • polyvalent (= made up of antigens from multiple strains) capsular-polysaccharide based vaccine first championed in 70’s by MD who found high protective efficacy vs. pneumococcal pneumonia in South African miners • Since then, efficacy has been a lot harder to demonstrate

22. Streptococcus pneumoniae • Does the polyvalent polysaccharide pneumococcal vaccine “work’? Yes and No

23. Streptococcus pneumoniae Vaccine has NOT been shown to consistently reduce rate of pneumococcal pneumonia in anyone. Studies have been hampered by poor ability to discriminate between pneumococcal and non-pneumococcal pneumonia. RCT’s have not had enough power to assess efficacy against bacteremia or meningitis. Evidence of reduction in invasive disease DOES exist; - meta-analysis of 9 RCT’s found reduction of bacteremic pneumonia in low-risk groups (perhaps ~80%) - case control studies have shown 75% effectiveness vs. invasive disease in the elderly, and benefit in DM, asplenia, chronic lung disease

24. Streptococcus pneumoniae • Evidence is more controversial in HIV • very questionable benefit -- even possibility of harm -- if CD4 < 200

25. Streptococcus pneumoniaeStandard of Care • Pneumovax 23, Pneumo 23 and Pnu-Immune 23 are available vaccines with approval for adult use • all have antigens from the 23 pneumococcal strains which account for 90% of bacteremia and meningitis • don’t use in kids < 2 because it doesn’t work

26. Streptococcus pneumoniaeStandard of Care • Which people  65 should get the vaccine? Everyone • Which people < 65 should get the vaccine? Patients with: - questionable splenic function - chronic disease of heart, liver, kidneys, lungs (not asthma) - alcoholism, DM - immunosuppression, including HIV

27. Streptococcus pneumoniaeStandard of Care • When do you revaccinate? We don’t know. May be a good idea to revaccinate ONE time, five years post initial vaccination, in - patients over 65 who were vaccinated before they were 65 - patients with immunocompromise or other high risk

28. Streptococcus pneumoniae • Adverse effects: • about 1/3 have local pain and swelling • systemic reactions are rare • Can you give the flu vaccine at the same time? Sure. Just use a different spot.

29. Hepatitis B • Vaccines highly effective • Most of the world is still using vaccines derived from plasma of HBV carriers • We use HBV S Antigen particles grown in recombinant yeast; our vaccinees will be HBSAb positive but HBCAb negative • attempts at only vaccinating “high-risk” individuals were failures; we have now instituted universal vaccination for kids

30. Hepatitis B • rate of seroconversion is 95% in healthy adults • progressively less with age; <50% seroconversion in sixth decade • also lower in patients with chronic disease • rate of seropositivity decays with time, but as long as an antibody response was elicited initially, protection is likely still good for at least 15 years

31. Hepatitis B • Who gets vaccinated? All Canadian kids at age 9-13; (neonates born to carriers are vaccinated and treated with HBIG at birth.) Adults who are: - health care workers - engaging in high-risk sexual activity or IVDU - household contacts of HBV patients - on chronic hemodialysis - getting repeated transfusions

32. Hepatitis B • Adverse Effects: • local stuff • 1-3% have low-grade fever, myalgia, arthralgia, etc. • despite some claims, no evidence of a link to multiple sclerosis • SAFE in pregnancy

33. Hepatitis B • Vaccine administered as three doses, at months 0, 1 and 6 • usually given IM, but intradermal injection of a higher-than-usual dose may increase response rate in immunocompromised patients • routine post-vaccination seroconversion testing only if at high risk; if negative revaccinate and retest (50% chance of working the second time)

34. HIV • Pnemococcal vaccination if CD4 > 200 • ONE revaccination at five years • Flu yearly • HBV for all; HAV if concurrent HBV or HCV infection • Meningococcal vaccine if asplenic, travelling, living in dorms

35. Asplenia • Pneumococcal vaccination • 2 weeks pre elective splenectomy • 2 weeks post emergency splenectomy (Ab’s work better in patients whose vaccination is slightly delayed post-op) • revaccination at five years • HIB vaccine • most adults have antibodies, but we give it anyway • Meningococcal vaccine • Flu yearly

36. Health Care Workers • Same as everyone else (Td) PLUS: • HVB (with titer check 1-2 months after third dose) • Flu • MMR: immune status should be checked (documents or titers) for measles in all, rubella in women • vaccines relating to special exposures (eg: BCG, typhoid, Hep A)

37. Bottom Line • In our regular practice, we should be at least considering pneumococcaland influenza vaccination status of our outpatients and inpatients • everyone over 65 should have both • sick people should have both • no flu if egg anaphylaxis