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Adult Immunization Dr. Purnima Parthasarathy Senior Consultant, Infectious Diseases
KTPH November 21, 2015
http://www.forbes.com/sites/matthewherper/2013/02/19/a-graphic-
that-drives-home-how-vaccines-have-changed-our-world/
General Rules
S For adults- give vaccines during any visit for any reason- otherwise missed opportunities
S OK to give most vaccines together on the same day- label separate sites
S EXCEPTION: PCV and Meningococcal Conjugate vaccine- these should be given 4 weeks apart
S Live parenteral vaccines should be given either together or 4 weeks part
S Live oral vaccines can be given at the same time or before or after each other
What adult vaccines are we talking
about?
S Influenza
S Pneumococcus (23- Polyvalent and newer
Conjugate)
S Herpes Zoster (Shingles)
S Td, measles
S Meningococcus
2 Flu seasons in Singapore
S December and June have peaks of Influenza
illness and ARI
S The Southern Hemisphere vaccine protects
against the 3 common strains of influenza
(A/H1N1/A/H3N2and Influenza B)
S Should be given at least one month before
travel abroad
Influenza: Recommendations
S Who? Age 6 months and above
S How often? Yearly
S Efficacy:
S Children (80%) and adults (65-70)
S Elderly >65 (50%)
S Varies year to year- match
MOH Influenza Vaccine / Medisave
approved S Persons≥65 years
S Children ≥ 6 months to less than 5 years (i.e. 59 months)
S Adults and children with chronic disorders of the lung or heart systems, including asthma
S Adults and children with chronic metabolic diseases (including diabetes mellitus), renal, neurologic, liver, or blood disorders, or immunosuppression (HIV or meds)
S Children and adolescents aged 6 months to 18 years on long-term aspirin therapy (risk for Reye syndrome after influenza infection)
S Women at all stages of pregnancy
S Residents of nursing homes and intermediate and long term care facilities
Flu vaccines in Singapore
S Parenteral Trivalent
S Parenteral Tetravalent
S Intradermal Trivalent – ages 18-64
ContraindicationTrivalent flu shot anaphylaxis to egg/
chicken proteins, gentamicin, kanamycin, neomycin,
h./o GBS after flu shot
New Types of Flu Vaccines
S Quadrivalent- 2 B strains, better coverage when B strains predominate (2012)
S Recombinant Influenza Vaccine- egg free process (age 18 older)
S A quadrivalent (live attenuated) nasal spray vaccine, approved for people 2 through 49 years of age
S High dose Flu vaccine for Elderly (Fluzone® High-Dose; Sanofi Pasteur, Inc)
S An intradermal quadrivalent shot, which is injected into the skin instead of the muscle and uses a much smaller needle than the regular flu shot. It is approved for people 18 through 64 years of age.
Pneumococcal disease
Singapore
S Invasive S. pneumoniae (Blood and CSF)
reportable disease -MOH
S 166 laboratory confirmed cases of invasive
pneumococcal infection in 2013
S Increase of 1.8% compared to 163 cases in
2012
Incidence of IPD highest in age 55+ group, 2013
Pneumoccocal vaccination
S PPSV23 (polysaccaride 23-valent)
“pneumovax”
S Covers 88% of bacteremia producing
strains
S Newer: Conjugate 13 valent and 7
valent (peds)
Pneumovax
S A meta-analyses shows no decrease in
pneumonia incidence as a result of
vaccination, however it has been shown
to be about 60-70% effective in
preventing invasive disease (meningitis,
bacteremia).
ACIP Recommendation
Pneumococcal Conjugate Vaccine –PCV 13
S Conjugate vaccines- more
immunogenic, longer lasting
immmunity
S 13 Valent available in Singapore and
approved for infants
S Soon, will likely be approved for older
adults
CAPiTA Trial
S Community-Acquired Pneumonia Immunization Trial
in Adults
S Parallel-group, randomized, placebo-controlled,
double-blind trial in which subjects
S 84,496 subjects aged 65 years and older were randomly
assigned to receive a single dose of either Prevnar 13
or placebo.
S Julius Clinical, an academic research organization
affiliated with the University Medical Center Utrecht
(UMCU) in the Netherlands, 59 sentinel sites
N Engl J Med. 2015;372:1114-1125.
CAPiTA Trial
S 45.6 % fewer first episodes of vaccine-type CAP among Prevenar 13-vaccinated subjects than in subjects who received placebo (P<0.001)- PRIMARY ENDPOINT
S the Prevenar 13 group experienced 45.0 percent fewer first episodes of non-bacteremic/non-invasive vaccine-type CAP (P=0.007) – SECONDARY ENDPOINT
S 75.0 percent fewer first episodes of vaccine-type IPD (P<0.001) compared with the placebo group -SECONDARY ENDPOINT
ACIP June 2014
H. Zoster/Shingles Vaccine
• Licensed 2006
• Attenuated live virus vaccine
• FDA approved for age 50+
• ACIP recommends its use for adults 60 years of age
and older.
Zostavax®
S Single dose
S Immunity wanes after about 5 years- so don’t give
before age 60
S Recommended even if pt. has had Zoster/Shingles
S This vaccine reduces the risk of developing shingles
by 51%
S Reduces risk of post- herpetic neuralgia (PHN) by
67%.
S $$$ SD250
Vaccinations for Hajj
S Influenza/pneumococcal for high risk patients
S Typhoid vaccines
S Hepatitis A and B
S All adults and children >2 yrs single dose of meningococcal
quadrivalent A/C/Y/W-135 vaccine (must have proof of
vaccination on a valid International Certificate of Vaccination or
Prophylaxis)
S Children between 3 months - 2 years of age must show proof of
vaccination with 2 doses of meningococcal A monovalent vaccine
with a 3-month interval between the doses (≤3 years and ≥10 days
before arriving in Saudi Arabia)
http://wwwnc.cdc.gov/travel/yellowbook/2016/select-destinations/saudi-arabia-hajj-pilgrimage
Meningococcal vaccines in
Singapore
S Quadrivalent Polysaccharide
S Quadrivalent Conjugate Vaccine
S Both protect against Serotypes A, C, Y and
W-135
S Protective in 90% of healthy recipients
Singapore is surrounded by measles
S Outbreaks in Indonesia and Philippines ! 58,000 cases in
2014 in Philippines.
S In 2012, 38 cases of measles, 64 cases of rubella and 521
cases of mumps reported in Singapore.
S Give a booster (2nd) dose of MMR if a person has only
one one dose
S Vaccinate anyone (maids, etc..) naïve persons with 2
doses a month apart
S MMR is a live vaccine
Routine updates
S TD once every 10 years
S Substitute TDap once for Td booster
S Some of the older adults were only vaccinated with one dose of MMR vaccine in childhood
S In Singapore 2 doses of MMR vaccine have been made compulsory since 1998
S Hep B vaccine to high risk adults, ESRD, DM, partners of Heb B infected persons
Adult Immunization
S Singapore is ready for this!!
S Focus on high risk groups and the elderly
S Medisave now covers Pneumococcal and
Influenza vaccines in adults for specific
indications
S Special groups: Hajj, Post- Splenectomy,
Pregnancy
Thank you!!