Adult immunizations: The old & the new

1. Adult immunizations:The old & the new Wendy Rosenthal, Pharm.D.

2. Vaccine Fun Facts True or False? Vaccines are among the greatest achievements of biomedical science & public health.

3. Impact of Vaccines Since widespread use of vaccines, the annual number of cases has fallen by: • >99% for diphtheria, measles, poliomyelitis, rubella, smallpox & Haemophilus influenzae type B • >90% for pertussis, tetanus & mumps • >80% for hepatitis A & B & varicella • 34% for pneumococcal disease JAMA 2007;298(18):2155-63

4. Vaccine Science Basics of Immunity

5. Vaccination Active immunity produced by vaccine Immunity and immunologic memory similar to natural infection but without risk of disease Epidemiology and Prevention of Vaccine-Preventable Diseases 9th ed

6. Types of Vaccines Live attenuated Weakened form of the original Must replicate in body to be effective Generally require one dose Severe reactions possible Examples: measles, varicella, intranasal influenza Epidemiology and Prevention of Vaccine-Preventable Diseases 9th ed

7. Types of Vaccines Inactivated Composed for whole viruses or bacteria or fractions Cannot replicate Generally require more than one dose Antibody titer diminishes over time Examples: pneumococcal, HPV, influenza Epidemiology and Prevention of Vaccine-Preventable Diseases 9th ed

8. General Considerations Vaccine Adverse Reactions Local Pain, swelling, redness at injection site Usually mild & self-limited Systemic Fever, malaise, headache Live attenuated vaccines: may produce mild symptoms after incubation period of 7 – 21 days Allergy Due to vaccine components

9. General Considerations Contraindications & Precautions C=contraindication P=precaution V= vaccinate if indicated Condition Live Inactivated Allergy to component C C Severe illness P P Pregnancy C V Immunosuppression C V

10. Storage Issues: The Cold Chain Vaccine Manufacturer Distributor Vaccine* Provider’s Office Vaccine* Vaccine* Patient *Vaccine is transported in a refrigerated or frozen state, as appropriate (refrigerator 35° - 46°F (2° - 8°C); freezer 5° F (-15°C) or colder) , using an insulated container or a refrigerated truck.

11. Storage Issues Maintain freezer temperature at 5°F (-15°C) or colder MMR* Varicella Herpes Zoster DTaP, DT, Td Tdap, Hib, Hepatitis A, Hepatitis B, HPV, Influenza (TIV & CAIV-T) IPV, MMR* Maintain refrigerator temperature at 35-46°F (2-8°C) Meningococcal Pneumoccal (PPV & PCV) *MMR may be stored in either the freezer or refrigerator

12. http://www.cdc.gov/nip/recs/adult-schedule.htm#chart

13. Influenza Vaccine

14. Influenza Almost 16 million cases per year in the U.S. among people <20 years of age About 4.5 million per year in the U.S. among the elderly Influenza-related pulmonary and circulatory deaths 1990–1999: average 36,000 Rates of death/100,000 0.4–0.6 aged 0–49 years 7.5 aged 50–64 years 98.3 aged ≥65 years JAMA. 2003;289:179–86.

15. Influenza Virus Single-stranded RNA virus Three strains Type A Moderate to severe illness All age groups Subtypes determined by surface antigens: hemagglutinin & neuraminidase Type B Milder diseases Primarily affects children Type C Rarely reported in humans

16. Influenza Antigenic Changes Antigenic Shift Occur only in type A Drastic changes in hemagglutinin or neuraminidase Responsible for epidemics & pandemics Antigenic Drifts Occur in all three types Minor change in surface antigens May result in epidemic

17. Vaccine Composition Contains surface proteins of virus strains Most likely to circulate in the coming winter Generally two type A and one type B Epidemiological data reviewed and strains chosen 6–9 months before distribution

18. Influenza Vaccine Composition 2007 - 2008 vaccine A/Solomon Islands/3/2006 (H1N1)–like virus A/Wisconsin/67/2005 (H3N2) -like virus B/Malaysia/2506/2004 -like virus 2008 – 2009 vaccine • A/Brisbane/59/2007 (H1N1)-like virus • A/Brisbane/10/2007 (H3N2)-like virus • B/Florida/4/2006-like virus

19. Influenza Vaccine Trivalent Inactivated Vaccines (TIV): Fluzone® (Sanofi Pasteur) Approved for > 6 mo of age Fluvirin® (Chiron) Approved for > 4 years of age Fluarix® (GlaxoSmithKline) Approved for > 18 years of age FluLaval® (GlaxoSmithKline) Approved for > 18 years of age Afluria (CSL Limited) Approved for > 18 years of age Cold-adapted Influenza Vaccine Trivalent : FluMist® (MedImmune) Approved for 2 to 49 years of age

20. Effectiveness Inactivated influenza vaccine 70 – 90% effective among healthy persons <65 yo 30 – 40% effective among frail elderly 50 – 60% effective in preventing hospitalization 80% effective in preventing death Cold-adapted influenza vaccine-trivalent 87% effective in pediatric population Among healthy adults, 18 – 37% fewer days of healthcare provider visits

21. Adult Target Groups Persons at Increased Risk for Complications Persons aged  50 years Residents of nursing homes and chronic-care facilities Adults with chronic heart or lung disorders, including asthma Adults with: Chronic metabolic disease (e.g., diabetes) Renal dysfunction Hemoglobinopathies Immunosuppression (e.g., HIV)

22. Adult Target Groups Persons at Increased Risk for Complications Adults with conditions that can compromise respiratory function or the handling of secretions or that can increase the risk for aspiration Cognitive disorders Spinal cord injuries Seizure disorders Other neuromuscular disorders Women who will be pregnant during the influenza season MMWR. 2007

23. Adult Target Groups Persons Who Can Transmit the Virus to Those at High Risk Health care workers Employees of chronic-care facilities or residences for persons in groups at high risk Persons providing home care to persons in groups at high risk Household members (including children) of persons at high risk Household contacts and out-of-home caretakers of children aged <2 years MMWR. 2007

24. Cold-adapted Influenza Vaccine-Trivalent (FluMist) Healthy Individuals 2–49 Years of Age Who wish to decrease their risk of influenza Who are in close contact with persons at high risk for influenza-related complications

25. Shift in Thinking Influenza vaccination as personal protection versus Immunization for the greater public good

26. Vaccine Fun Facts Which of the following statements is true regarding the peak month for influenza? There has been great variability over the past 30 years Peak most commonly occurs in February Can peak as late as April & May

27. Timing of Vaccination Inactivated vaccine Staggered administration based on need High risk/health care workers– can get as early as Sept, Oct or Nov is ideal Nursing homes – October or later Healthy – November or later Cold-adapted trivalent Starting in October

28. Administration Inactivated Dose: 0.50 ml IM injection in deltoid Cold-adapted Trivalent Dose: 0.5 mLintranasally Half dose to each nostril No need to inhale No need to repeat if sneezing or coughing occur

29. Adverse Effects Soreness at injection site Fever, malaise, myalgia Immediate allergic reaction Sneezing or cough (intranasal)

30. Contraindications Inactivated vaccine Egg allergy History of anaphylactic reaction to components of the vaccine Cold-adapted trivalent vaccine Egg allergy History of anaphylactic reaction to components of the vaccine Aged <2 years or >50 years Persons with chronic diseases Pregnant women

31. Vaccine Fun Facts True or False? You can contract influenza from the IM vaccine.

32. Herpes Zoster Vaccine

33. Clinical Presentation Varicella – Zoster Virus (VZV) Varicella (Chicken Pox) Herpes Zoster (Shingles)

34. Herpes Zoster (Shingles) Reactivation of dormant varicella zoster virus Likelihood for reactivation related to: Age Immune status

35. Incidence of Herpes Zoster (HZ) 90% of U.S. population has serologic evidence of varicella 50% of persons who live to age 85 will develop herpes zoster More than 500,000 cases occur yearly in U.S.

36. Herpes Zoster (Shingles) Symptoms Sharp, stabbing pain & tenderness along the nerve Lesions appear 3 – 5 days later Papules vesicles pustules Heal in 7 – 10 days Present on only one side of the body Contagious until dry crusts appear: 5 – 10 days Pain can occur during the prodrome and/or eruptive phase

37. Vaccine Fun Facts Based on pain research, which of the following is correct? Labor pain > HZ pain HZ pain > labor pain HZ pain = labor pain

38. Herpes Zoster (Shingles) Serious complications Postherpetic neuralgia (PHN) 90% pain-free 1 month after acute attack; 95% pain-free at 3 months & 97% pain-free after 12 months Incidence & duration directly correlate with patient age Difficult to treat Scarring, bacterial superinfection, cranial and motor neuron palsies, pneumonia, encephalitis, visual impairment, hearing loss

39. Herpes Zoster Vaccine (Zostavax) Live, attenuated varicella-zoster virus Indication: prevention of HZ in individuals 60 and older Stimulates the patient’s immune system to reestablish memory cells Dose: 0.65 ml subQ

40. Herpes Zoster Vaccine (Zostavax) Advisory Committee On Immunization Practices (ACIP) recommendations Routinely administer to all people 60 years of age and older This includes those who have had a previous episode of the disease

41. Vaccine Fun Facts What is the potency of Zostavax compared to Varivax? Zostavax > Varivax Zostavax < Varivax Zostavax = Varivax

42. Herpes Zoster Vaccine Must be kept frozen at -15º C (+5º F) Reconstitute straight from freezer and use immediately Adverse effects: injection site reactions

43. Contraindications History of anaphylactic reaction to gelatin, neomycin, or other component of the vaccine Immunodeficiency (leukemia, lymphomas, other bone marrow or lymphatic neoplasms, HIV) Immunosuppressive therapy Active, untreated tuberculosis Pregnancy

44. Herpes Zoster Vaccine Efficacy Efficacy with respect to incidence of zoster was 63.9% among those 60 – 69 yo compared with 37.6% in those 70 years and older Reduced incidence of postherpetic neuralgia by 67% Duration of time patients experienced pain was significantly lower in those who received the vaccine N Engl J Med 2005:352;2271-84

45. Human Papillomavirus (HPV) Vaccine

46. Human Papillomavirus DNA tumor virus Skin virus About 40 genital types 15 to 18 of these associated with cancer Sexually transmitted disease Intercourse Genital, oral & skin to skin contact

47. Common HPV Types Associated With Benign and Malignant Disease

48. Natural History of Cervical Carcinogenesis HPV Cervical Cancer Infection Progression HPV- Infected Cervix Normal Cervix Invasion Precancer Clearance Regression Mild Cytologic and/or Histologic Abnormalities

49. Most HPV Infections Resolve HPV “clearance” 80 – 90% of infections resolve in 2 years Average duration of infection 9 – 13 months Unclear if eradicated or latent HPV “persistence” 10 – 20% of infections persist Major risk factor for cancer Clearance & persistence are age related

50. HPV 6.2 million new cases of sexually transmitted HPV occur in the U.S. each year 20 million people in the U.S. currently have a detectable genital HPV infection 50% of sexually active men and women acquire genital HPV infection at some point in their lives $1.6 billion in direct annual medical costs for treating symptoms of genital HPV infection