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The Evolving Adult Immunization Platform

The Evolving Adult Immunization Platform. William Schaffner, MD Vanderbilt University School of Medicine Nashville, TN. When meditating over a disease, I never think of finding a remedy for it, but, instead, a means of preventing it. Louis Pasteur

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The Evolving Adult Immunization Platform

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  1. The Evolving AdultImmunization Platform William Schaffner, MD Vanderbilt University School of Medicine Nashville, TN

  2. When meditating over a disease, I never think of finding a remedy for it, but, instead, a means of preventing it. Louis Pasteur (1822-1895)

  3. Infant/Childhood immunization – one of the top public health success stories of the 20th century Diphtheria, tetanus, measles, mumps, rubella, polio, H. influenzae B, hepatitis B reduced by over 99% Pertussis, hepatitis A, select pneumococcal, varicella, rotavirus, influenza being reduced

  4. Invigoration of Adult Immunization • Build on success of infant/childhood, adolescent program • New vaccines targeted at adults • Recognition of the burden of adult vaccine-preventable disease

  5. Burden of Adult Vaccine-Preventable Disease Influenza: 10-20% of US population affected annually 200,000 hospitalizations 36,000 deaths (average) Pneumococcal: 2,000-5000 meningitis 40,000+ bloodstream infections 150,000-300,000 pneumonia Pertussis: 1 million Cervical cancer: 10,000 Shingles: 1 million Adult deaths from vaccine-preventable diseases: 43,000

  6. Reported Pertussis Cases ≥ 19 yrs 11–18 yrs < 11 yrs Reported Pertussis Cases • 2004 provisional data

  7. Tdap VaccineTetanus-Diphtheria – acellular Pertussis Licensed as one-time booster dose through age 64 Use Tdap at time of regular 10-year booster • Individual protection against pertussis, tetanus, diphtheria • Reduce community outbreaks • Interrupt transmission to vulnerable infants by vaccinating adults (cocoon)

  8. Human Papillomavirus Vaccine(Cervical Cancer) • Licensed vaccine against 4 virus types (6, 11, 16, 18) for females 9-26 years • Papillomavirus infection is precursor to cervical cancer • Types 16, 18 account for 70% of cervical cancers • Virus is transmitted by sexual contact • Over half of women are infected during their lifetime • Three-dose series

  9. Natural History of HPV Infection and Potential Progression to Cervical Cancer1 0–1 Year 0–5 Years 1–20 Years Invasive Cervical Cancer InitialHPV Infection ContinuingInfection CIN 2/3 CIN 1 Cleared HPV Infection (~80%) 1. Pinto AP, Crum CP. Clin Obstet Gynecol. 2000;43:352–362.

  10. HPV Vaccine Trial • Randomized, placebo-controlled, double blind • 27,000 volunteers • 100% effective vs. CIN 2/3

  11. Human Papillomavirus Vaccine CDC’s Advisory Committee on Immunization Practices (ACIP) June 29, 2006 Recommendations: • Routine immunization of females at 11-12 years • May be started as young as 9 years at discretion of provider/parent • Vaccination of females up to age 26

  12. Herpes Zoster (shingles) Vaccine • Licensed for persons 60+ years of age • Shingles – localized rash due to reactivation of latent chickenpox (varicella) virus • Post-Shingles pain – extreme, debilitating pain lasting for months • Vaccine licensed for persons 60+ years of age • High potency live, attenuated varicella vaccine • Boosts immunity

  13. Shingles Prevention Study - 1 • Randomized, placebo-controlled, double blind vaccine trial • 38,546 volunteers at 22 sites; adults 60+

  14. Shingles Prevention Study - 2 • 95% of volunteers completed study • Follow-up <1 - 4.9 years; average 3 years • Shingles reduced 51% • 60-69 years 64% • 70-79 years 41% • 80+ 18% • Post-shingles pain: 67%

  15. Reported Acute Hepatitis B Incidence By Age Group: United States, 1990-2004 ≥20 years 94% decline 71% decline 12-19 years Cases per 100,000 <12 years Year

  16. Reported Acute Hepatitis B Incidence By Age and Sex: United States, 2004 0.1 0.1 <5 Female Male 0.0 0.1 5-9 0.1 0.1 10-14 1.1 0.4 15-19 3.1 3.1 20-24 5.2 4.2 25-29 4.9 4.0 30-34 Age Group (Yrs) 4.4 5.4 35-39 3.6 4.9 40-44 2.7 4.0 45-49 2.0 3.2 50-54 1.3 2.9 55-59 0.8 1.4 60+ Rate per 100,000

  17. Hepatitis B Vaccine: ACIP Recommendations Expanded Risk Groups Sexual Transmission • All sexually active persons not in a mutually monogamous relationship • Persons evaluated or treated for STDs • Men who have sex with men • Sex partners of HBsAg-positive persons

  18. Adult Immunization Influenza Tdap Pneumococcal HPV (cervical cancer) Hepatitis BShingles Special circumstances, e.g. Travel, Health Care Worker

  19. Adult Immunization Challenges • Inadequate payment for vaccines and administration in both public programs and private medical insurance • Lack of knowledge – both patients and providers • Poor public health and private infrastructure for vaccine delivery

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