Vaccination Update

1
Vaccination Update
American College of Physicians, 2007 Missouri
Chapter Meeting September 27, Tan Tar A Resort,
Osage Beach, MO

• Gordon Christensen, M.D., F.A.C.P.
• University of Missouri-Columbia
• 573-882-3107

2
Points to be Covered

• Vaccination Primer
• New adult vaccines
• Varicella (Shingles)
• Human Papillomavirus (HPV)
• Routine adult vaccines
• Pneumococcal
• Influenza
• Hepatitis A
• Hepatitis B
• MMR
• Meningococcal

3
Background

• Active immunization
• Durable immunity
• Primary immune response with
• B-cell proliferation
• Antibody production
• T-cell sensitization

• Passive immunization
• Transient immunity
• Antibody infusion

4
TRUE Contraindications to Vaccination

• Severe hypersensitivity reaction
• Anaphylaxis
• Vaccine specific avoid vaccine
• Eggs avoid measles, mumps, influenza, yellow
  fever
• Neomycin streptomycin avoid MMR
• Severe reaction to past vaccine, seen with
• Cholera, Typhoid, and Plague vaccines
• History of post-vaccine encephalopathy from past
  vaccines
• Live vaccines
• Immunocompromised patients (IP)
• Household members of IP avoid oral polio (but
  not MMR)
• Pregnant women

5
FALSE Contraindications to Vaccination

• Current or recent mild illness, with or without
  fever
• Current or recent antimicrobial therapy
• Previous mild to moderate reaction after any
  vaccination, such as
• Local tenderness
• Redness
• Swelling
• Fever lt 40.5C
• Family history of adverse reaction to immunization

No post-vaccination contraindications for
athletics or alcohol
6
Vaccination Requirements for PROVIDERS

• Follow instructions
• Maintain administration records
• Report adverse events
• Provide vaccine information brochures for
  patients, available from
• CDC National Center for Immunization and
  Respiratory Disease website _at_ www.cdc.gov/nip

7
Schedule Problems

• Off schedule? Do not restart series, just
  pick-up where left off and continue
• Multiple vaccines? Can usually co-administer
  vaccines, such as
• Pneumococcal and influenza travel vaccines
• Exceptions
• Live virus vaccines delay one for a month to
  avoid possible impaired immune response to either
  agent
• Immune globulins should not be given with live
  virus vaccines (exceptions inactivated virus
  vaccines, oral polio, and yellow fever)

8
For Healthy Adults
Vaccine 19-49 50-64 gt65
Td
HPV 3 doses, ?
MMR 1 or 2 doses
Varicella 2 doses 1 dose
Influenza
Pneumococcal 1 dose
Hepatitis A
Hepatitis B
Meningococcal
q 10 yrs
q year
9
For Adults with Health Problems
Vaccine 19-49 50-64 gt65
Td
HPV
MMR
Varicella 2 doses
Influenza q year
Pneumococcal
Hepatitis A
Hepatitis B
Meningococcal
1 dose
1-2 doses
2 doses
3 doses
1 or more doses
10
New Adult Vaccines

• Zoster for adults (Shingles vaccine)
• Human Papillomavirus
• Also
• New intranasal influenza vaccine
• New meningococcal conjugate vaccine
• New hepatitis A B combined vaccine
• (New conjugate pneumococcal vaccine)

11
Varicella (Chickenpox ) Vaccine Varivax

• Live, attenuated, virus vaccine, US license in
  1995
• Contraindicated in pregnancy immunocompromised
• For children (gt12 mos) adults, particularly
  adult
• Health care workers
• Primary school teachers day care workers
• Institutional residents and employees
• Military personnel
• Non-pregnant women of child bearing age
• International travelers
• 2 dose adult schedule 0 4-8 weeks No booster

12
Varicella (Shingles ) Vaccine Zostavax

• Zostavax has 14 times more virus than in
  Varivax
• Licensed 2006 for gt59 y/o to prevent shingles
• Clinical study
• 38,000 adults, 60-80 y/o, followed median of 3
  years
• Vaccine group
• 51 fewer episodes of shingles
• Duration reduced from 24 to 21 days
• 66 less post-herpetic neuralgia
• Efficacy highest for 60-69 _at_ 64
• Efficacy declines with age, 18 for gt80 y/o

13
Varicella (Shingles ) Vaccine Zostavax

• Administer as a single dose
• Contraindicated for
• Anaphylactic reaction to gelatin or neomycin,
• Immunodeficiency states including
• leukemia, lymphomas, neoplasms affecting the bone
  marrow or lymphatic system
• AIDS
• active untreated tuberculosis.
• immunosuppressive therapy including high-dose
  corticosteroids
• women who are or may be pregnant
• Average wholesale price 190

14
Varicella (Shingles ) Vaccine Zostavax

• The Advisory Committee on Immunization Practices
  voted in October 25, 2006 that
• A single dose of zoster vaccine i.e. Zostavax
  is recommended for adults 60 years of age and
  older whether or not they report a prior episode
  of herpes zoster. Persons with chronic medical
  conditions may be vaccinated unless a
  contraindication or precaution exists for their
  condition.
• This recommendation was tentatively set for
  publication in CDC Morbidity and Mortality Weekly
  Report for June 2007, but this did not happen. It
  is still under review by the CDC and the
  Department of Health Human Services.

15
Human Papillomavirus (HPV)

• Double stranded DNA virus more than 100 types
• 60 types ? cutaneous infection ? skin warts
• 40 types ? mucosal genital infection
• Genital, laryngeal, rectal warts cervical
  abnormalities
• No cross protection between types
• Certain types PROMOTE (virus infection is
  necessary but not sufficient to cause) 99 of
  cervical cancer
• Type 16 causes 50 Types 16 18 cause 70
• Type 16 causes 10 of HPV genital infection in ?s
• Causes squamous cell adenocarcinoma
• Types 6 11 ? 90 of anogenital warts

16
Human Papillomavirus (HPV)

• Risk Factors for infections
• Number of sex partners
• Age lt 25y
• Most common STD in the US
• 20 million in US, 6 million new annual infections
• 75 of new infections in 15-24 y/o
• 80 of sexually active women infected by 50 y/o
• 20 of men infected
• Causes 90 anal cancer, 40 of vulvar/vaginal/peni
  le cancer, 12 oral pharyngeal cancer

17
Human PapillomaVirus (HPV) Vaccine

• Quadrivalent Vaccine
• L1 major capsid protein, propagated in yeast
• Self assembles into virus-like-particles
• Vaccine includes types 6, 11, 16, 18
• 99.5 of vaccinees develop antibody to all 4
  types
• Efficacy
• 100 prevention of cervical precancer by types 16
  18
• 99 prevention of vaccine type genital warts
• HPV vaccine released in 2006
• Routine vaccination recommended in 2007

18
Human PapillomaVirus (HPV) Vaccine

• For all women lt27 y/o
• Best if given to before sexual debut
• Can begin at age 9 y/o, recommended for 11-12 y/o
• Sexually active women should still be vaccinated
• Women with genital warts and abnormal PAP can be
  vaccinated
• Not recommended for men
• Complete series 3 doses 0, 2 months, 4 months
• Cost 120 per dose, 360 for the 3 dose series
• Not for pregnant women if pregnancy develops
  during vaccination series, then delay completion
  of series until after delivery

19
Routine Adult Vaccines

• Influenza
• Pneumococcal
• Hepatitis A
• Hepatitis B

• MMR
• Tetanus, Diphtheria, Pertussis
• Meningococcal

20
Influenza 3 Types

• Influenza A
• moderate to severe illness
• epidemic pandemic
• all ages
• humans animals (horse, avian swine)
• Influenza B
• Milder disease
• Children seniors
• Humans only
• Influenza C
• Pigs, rare in humans no epidemics

21
(No Transcript)
22
Influenza Vaccine

• Two types
• Trivalent inactivated vaccine (1940s)
• Trivalent attenuated vaccine (2003)
• Vaccinate in October November
• Recommended composition of influenza virus for
  both vaccines for use in the 2007-2008 northern
  hemisphere influenza season
• A/Solomon Islands/3/2006 (H1N1)-like virus
• A/Wisconsin/67/2005 (H3N2)-like virus
• B/Malaysia/2506/2004-like virus

23
Inactivated Influenza Vaccine

• When the antigenic match between vaccine and
  circulating virus is close, prevents
• lt65 prevents 70-90
• gt65 prevents only 30-40 of clinical illness,
  BUT
• Prevents hospitalization in 50-60
• Prevents death in 80

24
Inactivated Influenza Vaccine

• Annual vaccination indicated for
• Chronic pulmonary disease cardiovascular
  disease
• Chronic metabolic disease (diabetes renal
  failure)
• Immunosuppression HIV
• Aspiration risk (dementia, spinal cord injury,
  seizure)
• Pregnancy
• Health care workers long-term-care-facility
  residents
• Household members of people at risk
• On demand

25
Live-Attenuated Influenza Vaccine

• Not for immunocompromised
• Temperature sensitive, cold-adapted, lives only
  in nasopharynx
• 87 effective in children - 27 reduction in
  otitis
• FluMist (MedImmune)
• For 5-49 y/o healthy patients
• Intranasal administration, half in each nares
• Will test positive for Influenza A B for
  several weeks after vaccination with rapid tests

26
Pneumococcal Vaccine

• gt 90 capsular serotypes known
• Capsular polysaccharide vaccine
• 14 valent licensed in 1977
• 23 valent licensed in 1983
• Active against 88 of bacteremic pneumococcal
  pneumonia
• Cross-reactive for an additional 8 of bacteremic
  disease
• Prevents 60-70 of invasive disease
• Does not prevent pneumococcal pneumonia
• For adults, not effective in children lt 2 y/o

27
Pneumococcal Vaccine

• All gt64 y/o
• Chronic pulmonary disease (except asthma)
• Chronic cardiovascular disease
• Diabetes mellitus
• Chronic liver disease
• Chronic renal failure nephrotic syndrome
• Asplenia functional or anatomical (pre-surgery)
• Immunosuppression HIV
• Neoplasia leukemia, lymphoma, multiple myeloma
• Cochlear implants (pre-placement)
• Special populations Native Americans
  long-term-care-facility residents

28
Pneumococcal Revaccination

• After 5 years for
• Chronic renal failure nephrotic syndrome
• Asplenia functional or anatomical
• Immunosuppression HIV
• Neoplasia leukemia, lymphoma, multiple myeloma
• For gt65 y/o if
• Vaccinated gt5 years ago
• lt65 when first vaccinated

29
Conjugate Pneumococcal Vaccine

• Licensed for children (lt2 y/o) in 2000
• 7 valent capsular polysaccharide linked to
  nontoxic diptheria toxin (AKA CRM197)
• Active versus childhood bacteremia (86),
  meningitis (83), otitis media (65)
• Efficacy
• Reduce invasive disease by serotypes by 97
• Reduce all invasive disease by 89
• Reduce severe pneumonia by 73
• Reduce otitis media by 7 tympanoplasty by 20

30
Hepatitis A Vaccine

• Inactivated, whole cell vaccine
• 95 of adults develop protective antibody in 4
  weeks
• 100 seroconvert after two doses
• Indicated for
• Travelers to areas of high hepatitis A endemicity
• Men who have Sex with Men (MSM) IV Drug abusers
• Patients with chronic liver disease
• Patients who receive clotting factors
• Administer
• 2 dose schedule 0 6-18 months
• Single dose provides 1 year immunity

31
Hepatitis B Vaccine

• HBsAg recombinant vaccine from yeast
• Two vaccines in adult child formulations
• After 3 doses, gt90 of adults are sero-positive
• gt40 y/o 90 respond
• gt60 y/o 75 respond
• Some patients (hemodialysis) may require larger
  more doses to develop a response
• Prevents 80-100 clinical hepatitis

32
Hepatitis B Vaccine Indications

• On demand
• All adults at risk
• People who work or live in areas with high
  endemicity for Hepatitis B
• Health-care workers
• Occupational recreational blood exposure
• Travelers to areas of high hepatitis A endemicity
• Sexual exposure sex partner of hepatitis B
  patient, promiscuous sex (STD clinic patients),
  MSM

33
Hepatitis B Vaccine Schedule

• Usual
• 0 1 month 50-60 protection
• 6 month full protection
• Accelerated
• 0,1 2 months OR 0,1 3 weeks good protection
• 12 month for full protection
• Confirmatory serologic testing not recommended
  for healthy adults is recommended for
  hemodialysis patients health care workers with
  blood exposure
• No booster needed

34
Hepatitis AB Combined Vaccine

• Hepatitis A/B (Twinrix), approved in 2001
• 0 1 month
• adequate against A
• 50-60 protection against B
• Repeat _at_ 6 months for full protection
• 0,1 3 weeks (accelerated schedule)
• good protection
• Repeat _at_ 12 months for full protection
• NO Hepatitis C or E vaccine

35
Measles

• Prior to MMR, Measles nearly universal disease of
  childhood
• Death in adults usually due to encephalitis
• Causes subacute sclerosing pan-encephalitis a
  persistent CNS infection leading to degenerative
  neurological disease
• Worldwide still causes 30 million infections
  454K deaths
• Atypical measles
• 1963-67 600-900K received killed measles vaccine
  (KV)
• KMV sensitizes, but does not protect
• With measles KMV ? polyserositis
• Fever, pneumonia, pleural effusions, edema
• Atypical rash maculopapular, petechial,
  urticarial, pupuric, vesicular

36
Mumps

• Mumps in unvaccinated adults includes
• Commonly orchitis parotitis
• Less commonly meningitis encephalitis
• Rarely pancreatitis, deafness, myocarditis,
  arthritis, nephritis

37
Rubella

• AKA German Measles
• In unvaccinated adults
• Arthralgias arthritis
• Encephalitis, frequently fatal
• In pregnant woman ? congenital rubella syndrome
• Fetal death, spontaneous abortion, prematurity
• Cataracts
• Heart defects
• Deafness, microcephaly, mental retardation
• Bone lesions
• Hepatomegaly splenomegaly

38
Measles/Mumps/Rubella (MMR) Vaccine

• MMR vaccine includes live, attenuated measles,
  mumps, and rubella virus
• Contraindicated for immunosuppressed
• Symptomatic HIV (asymptomatic OK)
• Steroids (gt20 mg/day)
• Congenital immune deficiencies
• Leukemia, lymphoma, advanced malignancy
• Chemotherapy radiation therapy
• ProQuad incorporates live, attenuated Varicella
  into the vaccine for MMRV. Intended for children
  (12m 12y)

39
Measles/Mumps/Rubella (MMR) Vaccine

• Born prior to 1957 considered measles mumps
  immune
• Adults born since 1956 should have at least one
  dose of the two dose series
• One dose for women with either none or uncertain
  immunity
• Do not vaccinate pregnant women or women who
  might become pregnant within 4 weeks of
  vaccination
• Two doses indicated for
• Adults exposed to measles
• Adults vaccinated with killed measles vaccine
• Adult students
• Health care workers without measles or mumps
  immunity
• International travelers
• No booster after 2 doses

40
Tetanus, Diphtheria, acellular Pertussis
Td/Tdap

• Adult primary series
• 3 doses 0, 4 weeks, 6-12 months
• Booster with either Td or Tdap
• Booster primary series plus lt10 years
• lt65? Vaccinate at least 1x with Tdap if not
  previously vaccinated
• Pregnant?
• gt10 years since last boost? vaccinate with Td
  in 2nd or 3rd trimester
• lt10 years since Td? vaccinate with Tdap in
  immediate post-partum period

41
Diphtheria, Tetanus, Pertussis

• Formalin inactivated diphtheria toxin (toxoid)
• Formaldehyde inactivated tetanospasmin (toxoid)
• /-
• Acellular pertussis
  (purified
  subcomponents of Bordetella pertussis cells)
• Routine combined vaccination started in 1940s
• Td for adult booster
• DTaP replaced (1991) old DTP for children Tdap
  for adults

42
Tdap Tetanus/Diptheria/acellular-Pertussis

• Adolescent Adult version of the DPT vaccine
• ONE TIME vaccine in place of a Td booster for
• Adolescents adults lt65 y/o
• Particularly adults with contact with infants lt1
  y/o
• Particularly health-care workers with patient
  contact
• Particularly post-partum women
• Give if last Td boost gt2 yr previous
• Subsequent boosters with Td q 10 years
• Pregnancy is not a contraindication to
  vaccination, vaccinate in a Pertussis outbreak

43
Meningococcal Vaccine

• No vaccine for group B, or groups L, X, Z
• Monovalent polysaccharide vaccine licensed in
  1974
• Quadrivalent polysaccharide vaccine licensed in
  1974
• Menactra quadrivalent, conjugate vaccine
• Bound to diphtheria toxoid
• Active against serotypes A,C,Y, W135
• Licensed in 2005
• Intended for
• Children gt11
• At risk adults (Travelers)
• One dose vaccine, no booster needed

44
Questions? CDC Resources

• CDC Immunization Hotline [phone]
• CDC Info 800-232-4636
• CDC website www.cdc.gov/mmwr
• CDC Division of Immunization 404-639-8225