Dr.Ashok Grover

Embed Size (px)

Citation preview

  • 8/9/2019 Dr.Ashok Grover

    1/42

  • 8/9/2019 Dr.Ashok Grover

    2/42

    Is it a new concept? . or an old concept revisited?

    Chronology of Vaccines Discovery

    It all started with adult range of vaccines!!!

  • 8/9/2019 Dr.Ashok Grover

    3/42

    The need to revisit the concept

    There is no structured data on the burden of vaccinepreventable disease amongst adults.

    However:

    Chronic liver disease secondary to Hepatitis B - 600,000 deaths in 2002

    Annual incidence of invasive Pneumococcal disease (e.g., bacteraemia and

    meningitis) in developed countries is 1520 cases/100,000 persons of all

    ages & 50 cases per 100,000 elderly adults (65 years) with an overall case

    fatality of 20-60%

    Influenza afflicts 5%-10% of adult population annually and accounts for

    deaths rate of 30-150/100 000 population aged >65 years

  • 8/9/2019 Dr.Ashok Grover

    4/42

    Available at: http://www.who.int/vaccines-documents/DocsPDF05/GIVS_Final_EN.pdf

    GIVS Global Immunization vision & strategy 2006-2015.

    WHO-UNICEF

  • 8/9/2019 Dr.Ashok Grover

    5/42

    The hurdles in the path

    The misconceptions: Vaccines are primarily meant for children

    Vaccines received in childhood provide life-long protection

    Tetanus?

    Pertussis?

    Typhoid?

    Influenza?

    Unrealistic expectations:

    Complete protection rather than partial protection and reduction in severity of

    disease and associated morbidity and mortality

    Lack of national goals and of public health programs

    Lack of training on preventive medicine as part of existingpostgraduate curriculum

  • 8/9/2019 Dr.Ashok Grover

    6/42

    The Range of Vaccines for Adolescents and Adults

    Currently Available

    Tetanus Toxoid

    Hepatitis B Vaccine

    Influenza Vaccine

    Rabies Vaccine MMR

    Hepatitis A Vaccine

    Typhoid Vaccine

    Chicken Pox Vaccine

    Polysaccharide Pneumococcal Vaccine

    Polysaccharide Meningococcal Vaccine

    Yellow Fever Vaccine

    Japanese Encephalitis Vaccine

    Licensed abroad, NA in India

    1. Reduced diphtheria antigen (d)

    containing dT, dTaP

    2. Zoster Vaccine

    3. HPV Vaccine

    4. Conjugate Meningococcal Vaccine

    In Late stage Development

    1. Dengue Vaccine

    2. Malaria Vaccine

    3. Kala-Azar Vaccine

  • 8/9/2019 Dr.Ashok Grover

    7/42

    The Suggested Approach

    Assess Need, the H.A.L.O. Style

    H - Health Condition

    A - Age

    L - Lifestyle

    O - Occupation

  • 8/9/2019 Dr.Ashok Grover

    8/42

    An Example of H.A.L.O. checklist followed in US

  • 8/9/2019 Dr.Ashok Grover

    9/42

    What an Indian H.A.L.O. could look like?

    Resident of

    Endemic zoneInfluenza X X X X X X

    PPV X X X X

    Hep B X X X X X X X X X X X

    Hep A X X X X X X X X

    Typhoid X X X X X X X X X X

    Varicella/Zoster X X X X

    Meningococcal X X X X X

    dT X X X X X X X X X X X X

    MMR X

    JE X

    Rabies X

    Yellow fever X

    Food handler Animal handler Laboratory

    worker

    Military

    personnel

    Adolescent &

    young adults

    Elderly International

    traveler

    HostellersChronic disease Immunodeficiency Pregnancy

    Health Factors Age Lifestyle Occupation

  • 8/9/2019 Dr.Ashok Grover

    10/42

    The Two Vaccines that are:

    Old, used over decades

    Well established usage and extensive clinical application

    in the practice of Internal Medicine

    Well documented advantages health & economic

    Strongly recommended by authorities like WHO, CDC etc.

    Freely available

    But,Grossly under-discussed and under-utilized

    Influenza Vaccine Pneumococcal Vaccine

  • 8/9/2019 Dr.Ashok Grover

    11/42

    Influenza

    The virus and the disease

    The available vaccine

    Vaccination in adult population

  • 8/9/2019 Dr.Ashok Grover

    12/42

    Influenza Virus

    Single stranded, RNA virus of Orthomyxoviridae family

    3 types causing disease in man: Types A, B & C

    Type A

    There are 1-16 HA & 1-9 NA types distributed in Human, Animals &Birds

    HA- Helps in attachment with Host cell, NA- Releases the toxins

    Moderate-severe illness as outbreaks, epidemics & pandemics

    In Humans we find Hemagglutinin (H1,H2,H3) & Neuraminidase(N1,N2)

    Type B

    Antigenic drift uncommon; antigenic shift not seen

    Mild-moderate disease as small outbreaks only

    Humans only

    Type C

    Very uncommonly implicated in clinical disease

    Neuraminidase

    (NA)

    Hemagglutinin

    (HA)

  • 8/9/2019 Dr.Ashok Grover

    13/42

    Patho-physiology

    Binding and destruction of epithelial cells fromnasopharynx to alveoli

    SYSTEMIC BODY REACTIONFever, muscle pain, etc.

    LOCAL INFLAMMATORY REACTIONUpper respiratory infection

    Bodyresponse

    Droplets

    Aymard M. Vaccine 1995: 4770.

    Healthy Ciliated RespiratoryEpithelium

    Damaged RespiratoryEpithelium

  • 8/9/2019 Dr.Ashok Grover

    14/42

    Marked Systemic Symptoms Differentiate Traditional

    Flu from Cold

    JAMA 2000; 284 (13): 1740

    Influenza afflicts 5%-10% of adult population annually and

    accounts for deaths rate of 30-150/100 000 population aged >65

    years

  • 8/9/2019 Dr.Ashok Grover

    15/42

    Complicated Influenza

    Bacterial superinfections Otitis media, Sinusitis

    Exacerbation of asthma/COPD

    Bronchiolitis, Croup

    Secondary bacterial pneumonia

    Decompensation of chronic diseases

    Pulmonary disease

    Heart disease (Congestive heart failure Myocarditis, pericarditis) Renal insufficiency

    Metabolic disease (Keto-acidosis in diabetics)

    Nicholson KG. Semin Respir Infect 1992; 7: 2637.

  • 8/9/2019 Dr.Ashok Grover

    16/42

    Groups at higher risk of complications

    Elderly (>60 yrs.), especially in residential care units

    Children & teenagers receiving long-term aspirin therapy

    Pregnant women belonging to high-risk groups

    Patients with Immuno-suppression & Chronic diseases:

    Eur J Clin Res 1992; 3: 11738.

    Chroni c renaldys unction

    Chronic pulmonary(includi ng asthm a)

    aemoglobinopat hies,immunosuppression

    Chroni c metaboli c disease(including diabetesmellit us)

    Cardiovasculardisorders

  • 8/9/2019 Dr.Ashok Grover

    17/42

    Age distribution of respiratory complications

    Betts FR et al. In: Mandell GL et al., eds. Principles and Practice of Infectious Diseases. 3rd Edn. New York:Churchill Livingstone; 1990: 130625.

    0

    20

    0

    60

    0

    0 59 1019 2039 0 9 5059 5069 0

    Age groups (year)

    espir

    atory

    complications(%)

  • 8/9/2019 Dr.Ashok Grover

    18/42

    Influenza Vaccines

    Trivalent Inactivated vaccine (TIV), containing one strain*each of:

    Type A H1N1 virus

    Type A H3N2 virus

    Type B virus(*Choice of strain to be included is recommended annually by WHO)

    The different types of TIV currently available:

    Split virus vaccines good immunogenicity and low reactogenicity

    most commonly used type of vaccine

    Subunit virus vaccines

    moderate immunogenicity and low reactogenicity

  • 8/9/2019 Dr.Ashok Grover

    19/42

    Annual doses of influenza vaccination is required to ensure

    continuous protection because:

    1. The duration of protection offered by TIV is 1 year.

    2. There are annual changes in the composition of Influenza vaccine,

    as recommended by WHO on basis of surveillance data.

    Influenza Vaccination is required annually

  • 8/9/2019 Dr.Ashok Grover

    20/42

    Benefits of influenza vaccination

    Reduction in risk ofillness, hospitalization

    and death

    Reduction in financialand social cost of

    illness

    Reduction in risk ofinfecting high risk

    contacts

    Flu Shot

  • 8/9/2019 Dr.Ashok Grover

    21/42

    Efficacy of influenza vaccination in elderly and

    high-risk persons

    Prevention of illness and death

    Among high-risk adults aged 1864 years, vaccination prevented:

    78% of deaths

    87% of hospitalisations

    26% of GP visits

    Among elderly individuals (> 65 years), vaccination

    prevented:

    50% of deaths

    48% of hospitalisations

    Hak E et al. Arch Intern Med 2005; 165: 27480

  • 8/9/2019 Dr.Ashok Grover

    22/42

    In a meta-analysis of 20 cohort studies, pooled estimates

    of vaccine efficacy demonstrated prevention of morbidity

    and mortality during the influenza season

    Respiratory illness 56%

    Pneumonia 53%

    Hospitalisation 50%

    Death 68%

    Gross PA et al. Ann Intern Med 1995; 123: 51827.

    Efficacy of influenza vaccination in elderly

  • 8/9/2019 Dr.Ashok Grover

    23/42

    Years of life bought forUS$1 million

    Pap smear every 3 years: 52 life-years

    Bypass surgery for left main: 134 life-years

    coronary artery disease

    Influenza vaccination: 11,100 life-years

    Russell LB. Health Aff (Millwood) 1992; 11: 1629.

    Cost-Effectiveness of influenza vaccination

  • 8/9/2019 Dr.Ashok Grover

    24/42

    Recommendations of the ACIP (Advisory

    Committee on Immunization Practices)

    Primary target groups recommended for annual vaccination

    Persons at increased risk for influenza-relatedcomplications

    Persons aged 5064 years

    This group has an elevated prevalence of certainchronic medical conditions

    Persons who live with/care for persons at high risk

    Harper SA et al. MMWR Recomm Rep 2004; 53: 140.

  • 8/9/2019 Dr.Ashok Grover

    25/42

    Persons at increased risk for complications from influenza: Persons aged > 65 years

    Residents of nursing homes or other chronic-care facilities thathouse persons of any age with chronic medical conditions

    Adults and children with chronic disorders of the pulmonary orcardiovascular systems, including asthma

    Adults and children who have required regular medical follow-up orhospitalisation in the preceding year due to chronic metabolicdiseases

    Children and adolescents (6 months18 years) receiving long-term

    aspirin therapy

    Women who will be pregnant during the influenza season

    Children aged 623 months

    Recommendations of the ACIP (Advisory

    Committee on Immunization Practices)

    Harper SA et al. MMWR Recomm Rep 2004; 53: 140.

  • 8/9/2019 Dr.Ashok Grover

    26/42

    Persons who can transmit influenza to those at high risk:

    Physicians, nurses, and other personnel in both hospital & outpatient-

    care settings, including medical emergency response workers

    Employees of nursing homes & chronic-care facilities who have

    contact with patients or residents Employees of assisted living & other residences for persons in groups

    at high risk

    Persons who provide home care to persons in groups at high risk

    Household contacts (including children) of persons in groups at high

    risk

    Vaccination is also recommended for household contacts and

    out-of-home caregivers of children aged 023 months

    Recommendations of the ACIP (Advisory

    Committee on Immunization Practices)

    Harper SA et al. MMWR Recomm Rep 2004; 53: 140.

  • 8/9/2019 Dr.Ashok Grover

    27/42

    Country-wise recommendations for annual

    influenza vaccination

    Age > 65years

    Age 5065 years

    Agedcareresi-

    dents

    Contactsof

    personsat risk

    Peoplewith

    chronicillnesses

    Youngerhealthypersons

    Children624

    months

    USA Yes Yes Yes Yes Yes No Yes

    WHO Yes No Yes Yes Yes No No

    Australia Yes No Yes Yes Yes No NoHong Kong Yes No Yes Yes Yes No Yes

    Malaysia Yes No Yes Yes Yes No Yes

    New Zealand Yes No Yes Yes Yes No No

    Philippines Yes Yes Yes Yes Yes No Yes

    Republic of

    KoreaYes Yes Yes No Yes No Yes

    Singapore Yes No Yes Yes Yes No Yes

    Taiwan Yes No Yes Yes Yes No Yes

  • 8/9/2019 Dr.Ashok Grover

    28/42

    Current use of influenza vaccine

    Many European have high coverage in elderly persons

    In the USA, coverage amongst > 65 yrs is 62.7 65.6%

    In Australia & New Zealand, coverage in the population

    > 65 years is 79.1% and 65%, respectively

    In South America (e.g. Argentina, Brazil, Chile, Uruguay)

    vaccine use is increasing

    The 1999 influenza campaign in Brazil achieved a 72.4%

    coverage rate among individuals > 65 years

    In Asia, the use of vaccine is still limited

  • 8/9/2019 Dr.Ashok Grover

    29/42

    Influenza immunization rates in 2003

    Influenza vaccination coverage rates per 1000 in general population

    In India, the coverage is around 0.1 per 1000

  • 8/9/2019 Dr.Ashok Grover

    30/42

    Pneumococcal Infections

    The bacterium and the disease

    The available vaccine

    Vaccination in adult population

  • 8/9/2019 Dr.Ashok Grover

    31/42

    Streptococcus pneumoniae -Bacteriology

    Gram positive cocci, Facultative anaerobes,

    Capsulated

    Capsular polysaccharides help escape non-

    immune mediated phagocytosis

    Antibody against capsular polysaccharide are

    protective

    Nature of capsular polysaccharide forms the

    basis of classification of Pneumococcus in to

    serotypes

    90 Serotypes are currently known for

    Pneumococcus, of which the 23 serotypes

    including in PPV accounts for 85-90% of disease

    in India.

  • 8/9/2019 Dr.Ashok Grover

    32/42

    Pathogenesis ofPneumococcal Disease

    Non-invasive Sinusitis

    Otitis media

    Pneumonia

    Invasive

    Bacteraemia

    Meningitis

    Endocarditis

    Peritonitis

    Septic arthritis

    Hematogenous

    dissemination

    Contiguous

    Dissemination

  • 8/9/2019 Dr.Ashok Grover

    33/42

    Burden of disease

    Annual incidence of Invasive Pneumococcal Disease in developedcountries is 1520 cases/100,000 persons of all ages & 50 cases per

    100,000 elderly adults (65 years) with an overall case fatality of 20-80%,

    in addition to long term sequelae

    Additionally, Pneumococcus is the most common cause of Community

    acquired Pneumonia, accounting for more than a third of cases in US, with

    high complication rates (Bacteraemia and lung abscess) and case fatality

    of >10% in elderly

    CDC estimates that in Us only, S. pneumoniae annually causes:

    500,000 cases of pneumonia

    3,000 cases of meningitis

    50,000 cases of bacteraemia

    40,000 deaths

  • 8/9/2019 Dr.Ashok Grover

    34/42

    Incidence and Case Fatality Ratio by Age Group

    Invasive Pneumococcal Disease

    8

    8

  • 8/9/2019 Dr.Ashok Grover

    35/42

    Incidence of invasive pneumococcal disease in adults

    with selected underlying conditions & healthy adults -

    United States, 2000

    1143 48 59

    92

    294

    341

    432

    0

    100

    200

    300

    400

    500

    Healthy Chronic

    heart

    Diabetes Chronic

    lung

    Heavy

    drinker

    Solid

    cancer

    HIV/AIDS Blood

    cancer

    Casesper100,0

    00

    persons

    >4 timesincrease in risk

    >40 timesincrease in risk

  • 8/9/2019 Dr.Ashok Grover

    36/42

    High risk population forPneumococcal diseases

    Children < 2 years of age Elderly > 65 years of age

    Children & adults with chronic CV or respiratory diseases

    Immunosuppressed hosts

    Chronic renal disease

    Diabetics

    Nephrotic syndrome

    Transplant recipients

    HIV/AIDS Cancer, particularly hematological malignancies

    Chemotherapy or radiotherapy

    Asplenia

    Sickle cell anemia

  • 8/9/2019 Dr.Ashok Grover

    37/42

    Pneumococcal Vaccines

    7 Valent Conjugate vaccine

    (PCV)

    Capsular polysaccharide of 7

    common pathogenic

    serotypes conjugated with

    non-toxic diphtheria toxin

    Indicated in children aged 6

    months 5 years only

    23 Valent Polysaccharide

    Vaccine (PPV)

    Unconjugated capsular

    polysaccharide of 23 common

    pathogenic serotypes

    Indicated in Children above 2

    years of age (not immunogenic

    in younger age group)

  • 8/9/2019 Dr.Ashok Grover

    38/42

    23 Valent Polysaccharide Pneumococcal Vaccine

    Indications

  • 8/9/2019 Dr.Ashok Grover

    39/42

    Immunocompromised Cardiopulmonary Nursing Age >Country Asplenia Haematological HIV diabetes, renal Other home 65 years

    Austria l - - l l - -Belgium l l l l l l lDenmark l l l l - - lFinland l l l l l - lFrance l l - l l - -Germany l l - l - - -

    Icelandl l

    -l l l l

    Ireland l l l l l - -Italy l - l - - - -Luxembourg l l l l l l lNetherlands l - - - - - -Norway l l l l l - lSweden l l l l l - lSwitzerland l l l l l - -

    UK l l l l l - -USA l l l l l l l

    Country-wise recommendations for

    Pneumococcal vaccination (1 )

  • 8/9/2019 Dr.Ashok Grover

    40/42

    Doses of Pneumococcal vaccine distributed per 10,000 population

    *

    0 40 80 120 160 200 240 280

    Others

    USACanada

    Austria

    Belgium

    Denmark

    Finland

    France

    Iceland

    Norway

    Sweden

    Switzerland

    UK

    Pneumococcal immunization rates in 1 6

  • 8/9/2019 Dr.Ashok Grover

    41/42

    Action points to increase uptake of adult

    immunization practices

    Inclusion of training in PG curriculum

    Inclusion of topics in CMEs

    Recommendations & guidelines by academic bodies like API,

    RSSDI, CSI etc.

    Standing orders in individual hospitals, individual departments

    Lobbying with policy makers to include the topic in National

    goals towards health. Alignment with WHO

    objectives

  • 8/9/2019 Dr.Ashok Grover

    42/42

    Time to think of

    adultvaccination!!!