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Vaccine Update 2014

Shireesha Dhanireddy, MD Associate Professor, Department of Medicine Division of Infectious Diseases, University of Washington September 2014. Vaccine Update 2014. Vaccine Update 2014: Outline. Discussion of indications for the following vaccines Pneumococcal Vaccine Tdap

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Vaccine Update 2014

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  1. Shireesha Dhanireddy, MD Associate Professor, Department of Medicine Division of Infectious Diseases, University of Washington September 2014 Vaccine Update 2014

  2. Vaccine Update 2014: Outline • Discussion of indications for the following vaccines • Pneumococcal Vaccine • Tdap • Influenza Vaccine • Zoster vaccine

  3. Washington State • Exemptions dropped from 6.2% in 2009-2010 to 4.7% in 2011-2012 though • Went from 2nd to 8th highest in the country for exemptions MMWR 2012;61(33);647-52

  4. Question: Pneumococcal Vaccine For which of the following patients is the 13 valent pneumococcal conjugate vaccine (PCV13) not indicated currently? • 1 year old child • 25 year old HIV+ man • 67 year old woman • 49 year old female cigarette smoker

  5. Pneumococcal Disease • 4 million cases/year in US • 445,000 hospitalizations/year • 22,000 deaths/year Cox CM. CDC Manual for the Surveillance of Vaccine Preventable Diseases. 2012

  6. Pneumococcal Disease Cox CM. CDC Manual for the Surveillance of Vaccine Preventable Diseases. 2012

  7. Pneumococcal Vaccine in Adults:Who need it? • Persons > 65 years of age • Persons age 19-64 with: • Chronic lung disease (asthma or COPD) • Chronic heart disease (except HTN) • Chronic liver disease • CSF leak • Smokers • Diabetes • Alcoholism • Functional or anatomic asplenia • Immunocompromising conditions MMWR 2010. 59(34);1102-1106

  8. Pneumococcal Vaccine Efficacy • Direct effects of PPSV23 vaccination in the elderly controversial • Cochrane Review • Strong evidence for PPSV23 efficacy against invasive disease • Inconclusive efficacy for pneumonia • Not associated with significant decrease in mortality Moberley S. Cochrane Review. 2008

  9. PCV7 introduction Rates of IPD caused by PCV7 serotypes and additional serotypes in PCV13, adults >65 years, 1998–2009 Moore, IDSA, 2009 & CDC Unpublished

  10. ACIP Meeting FEB 2012

  11. Observed vs. Expected cases of PCV5-type IPD among Adults >65 years old, July 2004-June 2012 47% reduction in IPD Moore. ACIP, OCT 2013

  12. Percent Change in PCV5-type IPD Rates by Age Statistically significant reductions in vaccine-type IPD in all age groups within first 2 years after PCV13 introduction.

  13. Pneumococcal Vaccine Coverage Among US Adults, National Health Interview Survey –2011 % Vaccinated

  14. Pneumococcal Vaccine (PPSV23):Revaccination • Not recommended for most persons • Who should be revaccinated? • Persons aged 19-64 with • Functional or anatomic asplenia • Immunocompromising conditions • Multiple vaccinations not recommended MMWR 2010. 59(34);1102-1106

  15. PPSV23 vs PCV13 • PPSV23 – contains polysaccharide antigens • PCV13 – contains immunogenic proteins conjugated to pneumococcal polysaccharides • Prevnar 13 (PCV13) recommended for some immunocompromised adults • FDA approved for adults age > 50 age 12/2011 • ACIP advisory committee approved use in immunocompromised adults 6/2012 MMWR 2012. 61(21);394-5

  16. Latest Update: PCV13 in Adults • ACIP votes to recommend PCV13 vaccine in adults age > 65 years (8/13/2014) • Not previously vaccinated with PCV13 or unknown vaccine history even if have received PPSV23 • Recommendations will be reevaluated in 2018

  17. Question: Pneumococcal Vaccine For which of the following patients is the 13 valent pneumococcal conjugate vaccine (PCV13) not indicated currently? • 1 year old child • 25 year old HIV+ man • 67 year old woman • 49 year old female cigarette smoker (Give the polysaccharide vaccine)

  18. Question: Tdap A 27 year old pregnant woman presents for her routine obstetrics visit at her 32 week gestation visit . She is G2P1. She has a healthy 2 year daughter at home. Which statement is correct regarding Tdap in pregnancy? • She should receive a Tdap today only if she has not had in the past 5 years. • She should receive Tdap only if she did not receive during her prior pregnancy • She should receive Tdap today

  19. Pertussis • Whooping cough • Highly contagious, caused by Bordetella pertussis • Infected adults reservoir for infection of children • 3 phases • Catarrhal phase – last 1-2 weeks, cold symptoms, including tearing and conjunctival injection • Paroxysmal phase – paroxysmal cough, can last 2-3 month untreated • Convalescent phase - resolution

  20. Pertussis in Washington

  21. Tdap: Recommendations WHO • All adolescents aged 11 through 18 years (age 11-12 preferred) • All adults aged 19 through 64 who have not received a dose • All adults aged > 65 years (2/2012) • All pregnant women during each pregnancy WHAT • Boostrix preferred for adults > 65 years (but either okay) WHEN • Regardless of interval between last Td if has not received Tdap • During each pregnancy for pregnant women – optimum timing is 3rd trimester (27-34 weeks) MMWR 2013;62:131-135

  22. Question: Tdap A 27 year old pregnant woman presents for her routine obstetrics visit at her 32 week gestation visit . She is G2P1. She has a healthy 2 year daughter at home. Which statement is correct regarding Tdap in pregnancy? • She should receive a Tdap today only if she has not had in the past 5 years. • She should receive Tdap only if she did not receive during her prior pregnancy • She should receive Tdap today

  23. Question: Zoster Vaccine A 64 year old woman with a self-reported history of shingles 2 years ago and type II diabetes presents to clinic. What do you recommend regarding the zoster vaccine? • Vaccine is contraindicated given her history of diabetes • Vaccine not indicated given her history of zoster • Check VZV titer to confirm history. If negative, proceed with vaccination • Recommend zoster vaccine

  24. Herpes Zoster • Develops in 30% of people over a lifetime (1million + cases a year in US) • Incidence increases with age • 8-10x more likely in people > 60 • May lead to postherpetic neuralgia (PHN) • “pain that persists more than 30 days after the onset of rash or after cutaneous healing” Kimberlin DW, Whitley RJ. NEJM 2007;356:1338-43 Gann JW, Whitley RJ. NEJM 2002;347:340-6

  25. Zoster Vaccine (Zostavax) Study Design N = 38,546 Adults > 60 Randomized, double-blind Followed for mean 3.1 yrs Single dose vaccine vs placebo Decreased Herpes Zoster by 51.3% Decreased PHN by 66.5% Oxman MN et al. NEJM 2005;352:2271-84

  26. Zoster Vaccine: 2008 ACIP Recommendations Age Specific Recommendations: • All persons > 60 years* • Excludes those with contraindications to live vaccine • Includes those with history of zoster or have chronic medical conditions Dose: • Single dose MMWR 2008;57(RR-5):1-40

  27. Update on Herpes Zoster Vaccine (HZV) • October 2008: the ACIP recommended a dose of HZV for all adults >60 years unless they have contraindications • March 2011: FDA approved use of Zostavax in adults aged 50-59 years • Should we be administering HZV at ages 50-59 years?

  28. Zoster Vaccine (Zostavax):Cost/Implications • Cost: $160/dose • Implications: • Varicella vaccine recipients CDC Vaccine Price List

  29. HZ Incidence by Age: Olmsted County, MN, 1996-2001 Source: Yawn 2007

  30. Proportion of HZ Progressing to PHN*, by Age: Olmsted County, MN, 1996-2001 Source: Yawn 2007 *PHN defined as ≥ 90 days of pain

  31. Rate of HZ-Related Hospitalization by Age: Connecticut, 1986-1995 74% of HZ-related hospitalizations in persons ≥60 years Source: Lin 2000

  32. Herpes Zoster (Shingles) Vaccine Coverage Among US AdultsNational Health Interview Survey, 2008-2012 National Immunization Survey (NIS), 2007; National Health Interview Survey (NHIS), 2008-2012

  33. Cumulative Number of PHN* Cases by Vaccination Strategy Ortega-Sanchez. ACIP OCT 2013 * PHN = moderate to severe pain lasting >90 days

  34. Cost-Effectiveness Summary by Strategy(Societal Perspective) * NC =Cost of Vaccination Program-Savings in Cost-of-Illness from Vaccination ** Does not including indirect cost savings Ortega-Sanchez. ACIP OCT 2013

  35. ACIP HZ Working Group Conclusion • Affirms existing recommendation for routine vaccination of persons 60 years of age and older • Burden of HZ disease in increases with age • HZ vaccine administration should be timed to achieve the greatest reduction in burden of HZ and its complications • There is insufficient evidence for long term protection offered by the HZ vaccine • Providers should counsel persons who are vaccinated at 50-59 years of age that the duration of protection offered by the vaccine is uncertain; therefore they may not be protected when the incidence of HZ and its complications are highest.

  36. Question: Zoster Vaccine A 64 year old woman with a self-reported history of shingles 2 years ago and type II diabetes presents to clinic. What do you recommend regarding the zoster vaccine? • Vaccine is contraindicated given her history of diabetes • Vaccine not indicated given her history of zoster • Check VZV titer to confirm history. If negative, proceed with vaccination • Recommend zoster vaccine

  37. Question: Influenza Vaccine 67 year old man with moderate COPD presents for his routine visit in the fall. Which of the following is most appropriate regarding immunization against influenza? • Live attenuated vaccine should be given as it has been found to be more effective than the inactivated vaccine. • High-dose, trivalent, inactivated vaccine should be administered. • Standard-dose, trivalent, inactivated vaccine should be administered

  38. 2013-14 Influenza Vaccines • 2013–14 U.S. trivalent influenza vaccines will contain an A/California/7/2009 (H1N1)–like virus, an H3N2 virus antigenically like the cell-propagated prototype virus A/Victoria/361/2011, and a B/Massachusetts/2/2012–like virus. • Quadrivalent vaccines will include an additional vaccine virus strain, a B/Brisbane/60/2008–like virus.

  39. High Dose versus Standard Dose • High dose vaccine contains 4 times as much hemagglutinin (HA) as standard • Licensed for persons > 65 years of age in 12/2009 but with requirement to show clinical benefit (had shown safety and superior immunogenicity)

  40. Antibody Response to Standard Dose (SD) Fluzone Influenza Vaccine by Age 18-64 years >65 years GMT HAI Sanofi Pasteur. ACIP OCT 2013

  41. High Dose versus Standard Dose

  42. Fluzone High Dose VaccineEfficacy Study • Randomized, blinded study in US, Canada (N = 32,000) • 2011-12 (mild) & 2012-13 (moderately severe) seasons • Lab confirmed influenza: 1.43% HD vs. 1.89% SD • Relative efficacy 24.2% (9.7, 36.5) OR: • 4-5 fewer cases/1000 vaccinated • 217 vaccinations to prevent one additional case • Cost • HD: ~$25 VS.SD: ~$12 • Safety: AE comparable for HD and SD

  43. Influenza Vaccine Coverage Among US Adults: 2011-12 % Vaccinated BRFSS; *internet panel survey

  44. Question: Influenza Vaccine 67 year old man with moderate COPD presents for his routine visit in the fall. Which of the following is most appropriate regarding immunization against influenza? • Live attenuated vaccine should be given as it has been found to be more effective than the inactivated vaccine. • High-dose, trivalent, inactivated vaccine should be administered. • Standard-dose, trivalent, inactivated vaccine should be administered

  45. Vaccine Update 2014: Outline • Discussion of indications for the following vaccines • Pneumococcal Vaccine • Tdap • Zoster vaccine • Influenza Vaccine

  46. Take Home Points • Consider vaccines at every routine visit, particularly in pregnant patients and elderly patients • For elderly patients over 65 years of age, give PCV13 instead of PPSV23 (consider high dose flu vaccine)

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