ADULT IMMUNIZATIONupdate 2013

Ahmed Saad MD. FACP.Assistant Prof Internal Medicine &

Infectious Diseases Cairo university

DisclosuresI have no financial conflict or interest with

the manufacturer of any product named during this presentation .

I will not discuss vaccines not licensed by the FDA

2013 Vaccine Updates

Influenza

Pneumococcal

Herpes Zoster

T dap

HPV

Meningococcal

Hepatitis Vaccine

Varicella

When dealing with a disease, I never think of finding a remedy for it, but, instead, a means of prevention

Louis Pasteur (1822-1895) A Vision to future of humanity

Why adult vaccinations?

Adult deaths from vaccine preventable diseases =

60,000

From: IOM, Calling the Shots: Immunization Finance Policies and Practices, 2000.

Some adults incorrectly assume that the vaccines they received as children will protect them for the rest of their lives.

Some adults were never vaccinated as children

Newer vaccines were not available when some adults were children

Immunity can begin to fade over time As we age, we become more susceptible to

serious disease caused by common infections (e.g., flu, pneumococcus)

Why some adults need vaccines?

Burden of Adult Vaccine-Preventable Disease

Influenza: 10-20% of US people annually

36,000 deaths (average)Pertussis: 1 millionCervical cancer: 10,000H Zoster : 1 millionPneumococcal: 2,000-5000 meningitis 40,000 bloodstream

infections 150,000-300,000

pneumonia

Incidence rates for invasive PD (IPD) in the Middle East

1. Garcia CR et al. Poster presented at 8th bi-annual International Symposium on Pneumococci and Pneumococcal Diseases (ISPPD8), Iguacu Falls, Brazil (March, 2012).

The conjugation of a polysaccharide to a carrier protein leads to the interaction with T cells resulting in the release of functional antibodies and production of memory B cells 1,2

T-independent

Plasma cell

B cell

Presentation

B cellT cell

Memory B cell T-dependent

Plasma cell

What makes a conjugate different?

Polysaccharide antigens

+ =

carrier protein Conjugate vaccine

1. de Roux A et al. Clin Infect Dis. 2008;46:1015-1023. 2. Pollard AJ et al. Nat Rev Immunol. 2009;9:213-220.

Each year, the Advisory Committee on Immunization Practices (ACIP) reviews the recommended adult immunization schedule to ensure that the schedule reflects current recommendations for the licensed vaccines.

Recommended Adult Immunization Schedule — United States, 2013

From: http://www.cdc.gov/vaccines/recs/schedules/adult-schedule.htm

Influenza Vaccine

Influenza VirusFamily

Orthomyxoviridae

Three main typesType A

Multiple speciesType B

HumansType C

Humans and swine

Influenza updates For the (Live Attenuated Influenza

Vaccine) LAIV, beginning with 2013–14 season, only the quadrivalent formulation will be available and trivalent formulation will stop.

It contains 2 influenza A (H3N2) and (H1N1),

plus 2 influenza B vaccine virus strains Also the name inactivate influenza

vaccine( IIV ) replaced the name trivalent inactivated vaccine ( TIV)

Influenza updates Annual vaccination against influenza is

recommended for all persons aged 6 months or older.

Healthy persons , non pregnant (2-49 y) with no high-risk medical conditions can receive (LAIV) or IIV.

Health care personnel, immunocompromised and pregnant should receive IIV rather than LAIV.

Pneumococcal Vaccine

clinical form of pneumococcal disease

* Acute otitis media** including empyema

Invasive

Non-invasive

1. WHO. Acute Respiratory Infections (Update September 2009). 2. Centers for Disease Control and Prevention. Epidemiology and Prevention of Vaccine Preventable Diseases. The Pink Book. 11th Edition. May 2009.

29

• The US Advisory Committee on Immunization Practise (ACIP) recommends vaccination of:− All adults aged 65 years and over

− Adults aged 19-64 years with the following underlying medical conditions:

ACIP risk groups for pneumococcal infection

1- Immunocompetent persons Chronic heart disease Chronic lung disease Diabetes mellitus Cerebrospinal fluid leaks Cochlear implant Chronic liver disease

Cigarette smoking2- Functional or anatomic asplenia

Sickle cell disease Splenectomy congenital or acquired asplenia

3-Immunocompromised persons

Congenital or acquired (HIV) immunodeficiet

C R F & Nephrotic Leukaemias & Lymphomas Generalised malignancy Diseases treated with

immunosuppression( steroids >1 m or Biologics

Solid organ transplantation

(ACIP) recommends vaccination of: All adults aged 65 years and over Adults aged 19-64 years with the following underlying medical conditions:

1. Centers for Disease Control and Prevention. MMWR. Prevention of Pneumococcal Disease. ACIP Recommendations 2010;59:1102–1106.

Pneumococcal VaccineAdults aged 19 years or older with underlying medical conditions should receive a single dose of PCV13 followed 8 weeks later by a dose of PPSV23

Prevenar 13 (PCV13):

23F19F18C149V6B4

19A7F6A531

1.Prevenar EPAR. 2. Prevenar 13 Summary of Product Characteristics March 2012. 3. Centers for Disease Control and Prevention. Update: Haemophilus influenzae type b vaccine. MMWR. 1989;38:14. http://www.cdc.gov/mmwr/preview/mmwrhtml/00001330.html. Accessed May 24, 2011.

Using CRM197 , the same carrier protein as Prevenar 1,2, with more than 20 years of experience in vaccines 3

Herpes Zoster

SHINGLES(HERPES ZOSTER)

Effect Of Herpes Zoster Vaccine

Herpes Zoster / ShinglesLive attenuated VZV in amount 14 times

greater in minimum potency than varicella vaccine ,to elicit a significant increase in the CMI to VZV among older adults

Since 2006, the ACIP/CDC recommends to vaccinate all people > 60 y regardless of history of shingles.

CDC has recommendation and both Zoster & Pneumococcal vaccines can be administered at the same visit if indicated.

Only single dose.Also persons with

chronic medical conditions Can be vaccinated

Herpes zoster vaccination

H zoster use in immunocompromised

H ZOSTER for immunocompromised Retrospective study of 463,541 with age >60 y

with 1 of the following autoimmune diseases: rheumatoid arthritis, psoriasis, psoriatic arthritis, ankylosing spondylitis, or inflammatory bowel disease.

19,000 of received zoster vaccine, of them 633 patients exposed to biologics (551 anti TNF) .

Incidence of HZ within 42 days post vaccination and follow up period of 2 years.

Demographic Data

immunosuppressive Treatment

H ZOSTER for immunocompromised None of these patients on biologics

developed varicella or HZ in 42 days

Decrease incidence of H zoster by 39 % in vaccinated group in 2 years

ACIP recommended that persons > 60 to receive zoster vaccine with or without immunocomromised conditions .

Human Papilloma Virus

0–1 Year 0–5 Years 1–20 Years

Invasive Cervical Cancer

Cleared HPV Infection (~80%)

1. Pinto AP, Crum CP. Clin Obstet Gynecol. 2000;43:352–362. cervical intraepithelial neoplasia (CIN).

CIN 1

InitialHPV

Infection

ContinuingInfection

CIN 2/3

Natural History of HPV Infection and Potential Progression to Cervical Cancer

Recurrent Respiratory Papillomatosis

Routine immunization of females at 11-12 years

Vaccination of females up to age 26

3 Dose 0, 1, 6 months

Human Papilloma virus Vaccine- Recommendations Age & Dose

Meningoccal Disease

Meningococcal vaccine should be administered to persons with the following indications:

1-Medical: A 2-dose series of meningococcal conjugate vaccine (8 w apart ) is recommended for adults with anatomic or functional asplenia, or persistent complement component deficiencies.

2-Adults with HIV infection : to receive a routine 2-doses The 2 doses should be administered at 0 and 2 months

Meningococcal vaccination

Administer a single dose to1- Microbiologists routinely exposed to N

meningitidis2- Military recruits, 3- Those who travel to or live in countries in which

meningococcal disease is hyperendemic or epidemic.

Revaccination with MCV4 every 5 years is recommended for adults who remain at increased risk for

Meningococcal vaccination

Tetanus, diphtheria & Acellular pertussis (Tdap)

Tetanus, Diphtheria & Pertussis (Tdap), cont

Adults are recognized as a reservoir of transmission of Pertussis to a susceptible infants at greatest risk of complications

Updated schedule for Tdap adults 19-64 y to receive a one dose of Tdap

followed Td booster every 10 years

Pregnant women: Tdap during 3rd trimester of every pregnancy

T dap

Varicella

All adults without evidence of immunity to varicella should receive 2 doses (1 month apart )

Evidence of immunity to varicella in adults includes any of the following:

1- Documentation of 2 doses of varicella vaccine at least 4 weeks apart

2-History of varicella diagnosed by healthcare provider

Varicella vaccination

Hepatitis vaccination

Vaccinate any person seeking protection from hepatitis

A virus (HAV) or persons with any of the following

— Persons with chronic liver disease or who is receiveing clotting factor concentrates.

— Persons who use injection or non injection illicit drugs.

— Persons traveling to or working in countries that have high endemicity of hepatitis A

Hepatitis A vaccination

Hepatitis A vaccination2 doses at 0 and 6 months (Havrix )

Or Twinrix (Hepatitis A+B)0-1-6

Or Twinrix a 4-dose schedule (days 0, 7, and 21 ) followed by a booster dose a 12 month .

Hemodialysis and Hepatitis B Vaccination For hemodialysis or immunocompromised 2 doses of 20 μg/mL (Engerix-B) administered simultaneously on a 4-dose schedule( 0, 1, 2, and 6 months)

Measles Mumps Rubella

Women of childbearing age rubella immunity should be checked . If no immunity, and not pregnant should be vaccinated.

Pregnant women with no immunity should receive MMR vaccine upon completion or termination of pregnancy and before discharge from the hospital

Rubella component

Conclusion Our immunocompromised patients should vaccinated with Influenza , Pneumococcal , H Zoster ,Tdap , Hepatitis , Human Papilloma virus