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Adult Immunization Update

Adult Immunization Update. Michelle McDonald, MD Chief Medical Officer Pima County Health Department Michelle.Mcdonald@pima.gov. Adult Immunization Schedule. Disease Burden in Adults is Substantial.

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Adult Immunization Update

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  1. Adult Immunization Update Michelle McDonald, MD Chief Medical Officer Pima County Health Department Michelle.Mcdonald@pima.gov

  2. Adult Immunization Schedule

  3. Disease Burden in Adults is Substantial • Annual deaths from influenza ~36,000 per year, at least 90% in those >65 years. Pneumococcal next most common cause of death (~3400 per year) from VPDs, also majority elderly • Increasing immunocompromise due to disease or to medications • Diseases previously controlled in US (measles, mumps) are not controlled world wide, even in developing countries – increasing risk for importation into US

  4. Influenza and Pneumoccal Vaccine Rates are Low

  5. Patient Issues for Vaccination • Awareness -Disease -Vaccine -Personal risk • Provider Recommendation* • Access & Ability to pay • Misconceptions/fears -About Vaccine -About Health Care System Kristin Nichol, MD, MPH, MBA Clinical Vaccinology Conference Nov. 2007

  6. Improving Vaccination Rates – Provider Issues • Know the facts and recommend vaccinations to your patients • Get organized and use systems approaches -Standing Orders (no direct MD involvement at time of visit) -Walk-In Clinics -Reminder Notices • Ongoing measurement and evaluation • Practice what we preach – get vaccinated!!

  7. Interventions that Improve Vaccination Rates for Adults Component OR Organizational change 16.0 Provider reminder 3.8 Pt financial incentive 3.4 Provider education 3.2 Pt reminder 2.5 Pt education 1.3 Annal Intern Med 2002;136:641-51

  8. Pneumoccal Vaccine • PPV23 contains antigen from 23 capsular types that cause 88% of bacteremic pneumoccal disease, with cross reactivity for a few more that cover an additional 8% of bactermic disease (96% total) • >80% of healthy adults develop antibodies within 2-3 weeks of vaccination – less in older adults and those with chronic disease. Elevated antibody levels persist at least 5 years in healthy adults, decline more rapidly in elderly and those with chronic disease. • Overall 60-70% effective in preventing invasive disease – has NOT been demonstrated to provide protection against pneumococcal pneumonia nor against carriage. • Conjugate vaccines generally considered more effective – looking at development of adult conjugate vaccine.

  9. Pneumoccal Vaccine 2 • Indications: -all adults > 65 years -persons > 2 years at ↑risk for pnemococcal disease due to immunosuppression – splenic dysfunction or absence, Hodgkin disease, lymphoma, multiple myeloma, chronic renal failure, nephrotic syndrome, immunosuppression from organ transplant, chemotherapy, high dose corticosteroids, asymptomatic or symptomatic HIV infection -immunocompetent persons >2 years with chronic illness including cv disease, pulmonary disease, diabetes, alcoholism, cirrhosis, csf leak, cochlear implant

  10. MMWR 1997:46 (RR-08)

  11. Meningococcal Vaccine • Covers serogroups A, C, Y, W-135 -from 1996-2001 in US 21% serogroup Y 31% serogroup B (accounted for 65% of cases in children <1) 42% serogroup C • Recommendations in adults based on risk • Conjugate vaccine has advantages of longer duration of immunity and reduction in carriage rates – can be used in ages 11-55; over 55 use polysaccharide vaccine

  12. Meningococcal Vaccine • Indications in adults: -microbiologists routinely exposed to isolates of N. meningitidis -military recruits -persons traveling to or residing in countries where N. meningitidis is hyperendemic or epidemic -terminal complement component deficiency -functional or anatomic asplenia • Adverse events -mostly local (48% for MPSV and 59% for MCV) -concern re GBS within 6 weeks – now 22 cases analyzed through VAERS – no statistically significant increase in risk in 11-19 year olds generally, but possible small increase in risk in older subset of 15-19 year olds – analysis ongoing

  13. Pertussis • Adolescents and adults recognized as reservoir of transmission to susceptible infants at greatest risk of disease complications • Vaccine and disease immunity wanes over 5-10 years • Secondary attack rate up to 80% in non immune • Tdap recommended as single dose to replace Td for booster, and is especially recommended for adults with close contact with infants (childcare and healthcare personnel, parents, grandparents) • Boostrix (GLK) ages 10-18; Adacel (SP) ages 11-64 • ACIP has recommended a minimal 5 year interval since last Td dose; there is good evidence for safety for intervals as short as 2 years. Intervals as short as 12 months have been used without significant adverse events.

  14. Herpes Zoster • Primary usefulness is in prevention/reduction of postherpetic neuralgia (PHN), for which there is essentially no treatment Antiviral therapy Modestly shortens rash duration if initiated early Even used early does not prevent PHN Corticosteroids Decrease severity of acute pain Do not reduce incidence or severity of PHN Side effects and toxicity argue against use (esp in elderly) Pain medications Even narcotics have limited effectiveness against PHN

  15. HZ Vaccine (Zostavax) • In initial study with over 18,000 individuals in both vaccine and placebo group efficacy in prevention of shingles 51% 63.9% effective in age 60-69 37.6% effective in age >70 efficacy in prevention of PHN 66.5% 65.7% effective in age 60-69 66.8% effective in age >70 NEJM 2005;352(22):2271-84

  16. HZ Vaccine (Zostavax) • Indicated for adults aged 60 and over • If no memory of hx of varicella disease, give in preference to varicella vaccine (extremely high likelihood they were infected earlier, very large safety margin in the vaccine) • No usefulness in checking serology – available commercial assays lack sensitivity to reliably detect vaccine induced immunity • Fragile! Keep frozen at -15ºC or lower; must use in 30 minutes. Problem as now Medicare Part D only – do not write prescription for patient to fill at pharmacy and bring back to your office – will not be effective

  17. HPV Vaccine • Currently licensed Gardasil (Merck) protects against oncogenic types 16 & 18 and wart producing types 6 and 11 • 99% efficacy in prevention of pre-malignant cervical disease in naïve population, 99.5% of participants developed an antibody response to all 4 HPV subtypes 1 mo after series completion, 99% efficacy against genital warts from the 4 strains. (Bivalent vaccine 90% effective in prevention of premalignant cervical disease.) • Unknowns: duration of protection, need for boosters, efficacy in males, other genotypes

  18. HPV Vaccine • Recommended for -Routine vaccination of 11-12 yo girls (can be used as young as 9 years) -Catch up vaccination of adolescent and young women ages 13-26 not previously vaccinated • Safety – mostly local reactions. Otherwise, syncope seems common (?the targeted group). VAERS data shows 13 reported cases of GBS, lower than baseline rate, and 2 deaths from influenza. Reports of thrombosis were in concurrent users of OCPs.

  19. Older Vaccines with Adult Indications • Influenza!!! • Varicella • Measles • Mumps • Rubella • Hepatitis A • Hepatitis B

  20. Vaccinations for Health Care Workers • Influenza!!! • Hepatitis B • Varicella • Measles • Mumps (MMR) • Rubella • Pertussis

  21. Resources • “Pink Book” Epidemiology and Prevention of Vaccine-Preventable Diseases, CDC • www.CDC.gov/vaccines

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