Vaccines are for adults too..and what

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Vaccines are for adults too..and whats new!

• Dr. Taj Jadavji
• Professor, Departments of Microbiology,
  Immunology Infectious Diseases and Paediatrics
• Faculty of Medicine
• University of Calgary
• Infectious Disease Consultant Alberta Health
  Services

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Vaccines are for adults too..and whats new!

• Disclosure
• Have received Honoraria from
• - Glaxo Smith Kline
• - MSD
• - Abbott
• - Sanofi Pasteur
• - Novartis
• - Roche
• - Pfizer

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10 Great Public Health Achievements
Industrialized Countries

• Vaccination
• Motor-vehicle safety
• Safer workplaces
• Control of infectious diseases
• Decline in deaths from coronary heart disease and
  stroke

• Safer and healthier foods
• Healthier mothers and babies
• Family planning
• Fluoridation of drinking water
• Recognition of tobacco as a health hazard

In the last 50 years Immunization has saved more
lives than any other health intervention
US Dept of Health and Human Service, MMWR
199948241
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Vaccines are for adults too!

• In the United States why do a 100 fold more
  adults die of vaccine-preventable diseases than
  do children?

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From Reid KC, Grizzard TA, Poland GA. Mayo Clin
Proc. 199974377384
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Vaccines Older Adults

• Immunosenescence is one of the main reasons for
  the increase in infections in the older adult.2
• Although childhood vaccines usually prevent
  clinical illness..
• Most adult vaccines do not prevent illness but
  lessen the severity of infection.2

1. Fulop, T, and Gemmill, I, Clinical update on
   adult immunization. 2007
2. Aw, D., et al, Immunosenescence emerging
   challenges for an ageing population. Immunology
   2007. 120, 435446.

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May 2014
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HPV
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The Annual Burden of HPV in Canada
510 deaths from cervical, vulvar and vaginal
cancers6
1835 newly diagnosed cases of cervical, vulvar
and vaginal cancers2,3
77,000 newly diagnosed cases of genital warts,
VIN VAIN 4,5
gt325,000 abnormal Pap tests1
gt4 million Pap tests 1
1. Akom E, Venne S. November 2002. 2. Statistics
Canada. Table 103-0513. CANSIM Canadian Cancer
Registry. 3. Canadian Cancer Society / National
Cancer Institute. Canadian Cancer Statistics
200588-9. 4. BC Cancer Agency, 2006. 5.
Statistics Canada. Accessed at http//www.40.statc
an.ca/101/cst01/demo02.htm. 6. Statistics
Canada. Table 102-0522. CANSIM Vital Statistics
Death Database.
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9
70
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Cancer Causes Control (2012) 2313431348
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NACI RecommendationsCCDR 2007 Feb vol 33

• Vaccine recommended to
• 9-13 yr olds primary program
• 14 yrs-26 yrs. catch
• permissive use gt 26yrs.
• Including those with cervical abnormalities
  and genital warts

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Mid-Adult Women Are At Continued Risk for
Acquiring HPV Infection/Disease
Incidence of New Genital Warts in Women by Age in
US
7
6
5
4
Rate of New Genital Warts per 1000 Person-Years
3
2
1
0
lt10
10-14
15-19
20-24
24-29
30-34
35-39
40-44
45-49
50
Age (years)
Insinga RP. Clin Inf Dis. 2003361397-1403.
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Primary Efficacy Results
Combined Incidence of HPV 6/11/16/18-Related
Persistent Infection or Cervical/Vulvar/Vaginal
Disease Per Protocol Efficacy Population
Population Vaccine Vaccine Placebo Placebo Reduction 95 CI P-value
Population Cases PYR Cases PYR Reduction 95 CI P-value
All Subjects 4 2,721 41 2,654 91 74, 98 lt0.001
24 to 34Year-Olds 2 1,329 24 1,301 92 67, 99 lt0.001
35 to 45Year-Olds 2 1,393 17 1,353 89 52, 99 lt0.001
Approved for ages 9-45yrs
PYR person years at risk CI confidence
interval.
Luna, IPV Nov 2009
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Reduction in any Cervical Procedure due to any
Causal HPV type
18,150 16-26 yr olds, RPCT x 3yrs
?42
?22
?19
Colposcopy
Cervical Biopsy
Definitive therapy
Cases Placebo 1077
950 230
Cases Vaccine 869
741 132

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NACI recommendations on HPV vaccine in males Jan
2012
1. HPV4 (Gardasil) recommended in males 9 -26
years of age for the prevention of anal ,penile,
perineal intraepithelial neoplasia ,cancers and
anogenital warts   2. HPV4 (Gardasil)
recommended in males who have sex with males
(MSM) 9 years of age   3. HPV2 (Cervarix) not
recommended in males at this time (NACI
Recommendation Grade I).  
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Australia
Free 12-18 yrs lt 26yr 2007-2009
Sex.Trans.infect 2011
Sex.Trans.infect 2011
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Take home points

• HPV is on rise at both ends of the GI track
• For cancer protection we have 2 excellent
  anti-cancer vaccines that are not comparable
• Gardasil only vaccine that prevents genital
  warts.
• Best vaccine is the one that a patient takes!

1 word summaryimmunize!
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Influenza
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N Engl J Med 2008359.
340 ? 3rd trimester RDBPC influenza vs 23 valent
pneumococcal vaccine
63 reduction of influenza in infants for up to
6 months and 36 reduction of febrile respiratory
illnesses in mothers
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Seasonal influenza mortality UK 2001-2009
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Vaccine 2013 xxx-xxx

• 282 participants most in long-term care gt85
  yrs open label pcr confirmation of influenza
• Fluad and TIV vaccine each given in a different
  district in BC
• Results - Fluad 60 effective
• - TIV not effective

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Clinical Infect Dis 2012 55951
Case control study 2010-11 season N 1040
influenza vs 3700 controls Efficacy 69
6m-8yrs 51 9-64yrs
38 gt65 yrs
Immunizing your parents and grandparents is less
likely to protect them than immunizing
yourself DO BOTH!
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Take home points

• Influenza vaccine , especially for high risk
  groups including pregnant women, babies and
  bubies
• 3 new vaccines intranasal (live) ,intradermal
  (killed) adjuvented
• new vaccines for elderly are here they are more
  immunogenic but are they more effective than TIV?
• influenza vaccine may prevent MI

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Pneumococcus
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Major Clinical Forms of Pneumococcal Disease
PneumococcalDisease
Noninvasive(Mucosal)
Invasive
Meningitis
Bacteremia
Pneumonia
Sinusitis
Acute Otitis Media

• Pneumococcal disease can be broadly grouped into
  categories of invasive disease and noninvasive
  (also termed mucosal) disease1
• Noninvasive forms of disease may become invasive
  (eg, pneumonia when accompanied by bacteremia)2
• Serotype is associated with disease severity and
  invasiveness3

1. WHO. Acute Respiratory Infections (Update
   September 2009).www.who.int/vaccine_research/dise
   ases/ari/en/print.html. Accessed December 20,
   2010.
2. CDC. Epidemiology and prevention of
   vaccine-preventable diseases. 11th ed.
   2009217-230.
3. Jansen AG et al. Clin Infect Dis. 200949e23-e29.

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S. pneumoniae disproportionately affects those at
the extremes of age
Incidence of IPD and Associated Mortality Rates
(USA, 2010)
Cases of IPD/100,000
Deaths associated with IPD/100,000
Age (years)
IPD invasive pneumococcal disease, and includes
meningitis, bacteremia, and pneumonia when
accompanied by bacteremia.
Centers for Disease Control and Prevention. 2012.
Active Bacterial Core surveillance Report,
Emerging Infections Program Network,
Streptococcus pneumoniae, 2010.
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Incidence rate (per 100,000) of invasive
pneumococcal disease by age group, Canada, 2011
IPD rate per 100,000
An Advisory Committee Statement (ACS) National
Advisory Committee on Immunization
(NACI) Statement on the Use of Conjugate
Pneumococcal Vaccine 13 valent in Adults
(Pneu-C-13), April 4th, 2013
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Reported number of cases and incidence rate of
invasive pneumococcal disease, Canada, 2001-2011
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Canadian Notifiable Disease Surveillance System
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Risk Factors for Invasive Pneumococcal Disease
(IPD)
Age Host Factors Host Factors External Factors Behavioral Factors
Age Immunocompetent Immunocompromised External Factors Behavioral Factors
65 years Chronic heart disease Chronic lung disease Diabetes mellitus Chronic liver disease Cerebrospinal fluid leaks Asthma HIV (Human Immunodeficiency Virus) infection Chronic renal failure, nephrotic syndrome Cancer (solid, hematologic) Solid organ transplantation Autoimmune diseases Immunosuppressive therapy, corticosteroids Primary immunodeficiencies Functional or anatomic asplenia Socioeconomic Environmental Preceding viral respiratory infection (e.g., influenza) Residence in an institution (eg, nursing home) Smoking Alcohol abuse

• Including chronic obstructive pulmonary
  disease, emphysema, and asthma.
• CDC. Morb Mortal Wkly Rep. 201059(34)1102-1106.
  
• Rahier JF et al. Rheumatology (Oxford).
  201049(10)1815-1827.
• CDC. Prevention of Pneumococcal Infections
  Secondary to Seasonal and 2009 H1N1 Influenza
  Viruses Infection. 2009.
• CDC. Morb Mortal Wkly Rep. 200150(33)707-710.

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Current vaccine options
Two types of pneumococcal vaccines licensed for
adults in Canada (3 products)
Type Description Options Serotypes
Pneumococcal polysaccharide vaccines (PPSV) Polysaccharide antigens PPSV23 Pneumo 23 , Pneumovax 23 Antigens of 23 pneumococcal serotypes1, 3, 4, 5, 6B, 7F, 9V, 14, 18C, 19A, 19F, 23F, 2, 8, 9N, 10A, 11A, 12F, 15B, 17F, 20, 22F, 33F
Pneumococcal conjugate vaccine (PCV) Polysaccharide antigens joined to a protein (conjugated) PCV13 Prevnar 13 Antigens of 13 pneumococcal serotypes1, 3, 4, 5, 6B, 7F, 9V, 14, 18C, 19A, 19F, 23F, 6A
The two types of vaccine contain 12 serotypes in
common
PCV13 replaced the previous version of PCV,
known as PCV7, which included 7 pneumococcal
serotypes. 6A serotype is unique to PCV13
Lang Kau, Cheryl A. Sadowski, Christine Hughes.
Vaccinations in older adults Focus on
pneumococcal, influenza and herpes zoster
infections. Canadian Pharmacists Journal. 2011,
144(3)132-141.
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NACI Recommendations PPSV23 for High Risk
Individuals
2 yrs of age with co-morbidities 2 yrs of age with co-morbidities Plus 18 yrs 65 yrs
Immuno-competent Immuno-compromised With these factors All persons
Chronic heart disease Chronic lung disease Diabetes mellitus Chronic liver disease Cerebrospinal fluid leaks Cochlear implants Chronic neurologic condition that may impair clearance of oral secretions Functional or anatomic asplenia, sickle cell, hemoglobinopathies HIV infection Immune deficiencies Immune suppression due to disease or treatment Hematopoietic stem cell transplant (recipient) Solid organ or islet transplant Malignant neoplasms, including leukemia and lymphoma Chronic renal disease Residents of long term care facilities Homelessness, alcoholism, smokers, illicit drug use asthma (if associated with COPD, emphysema or prolonged systemic corticosteroid)

• Including chronic obstructive pulmonary disease,
  emphysema, and asthma.

1. National Advisory Committee on Immunization
   (NACI). Canadian Immunization Guide, Public
   Health Agency of Canada, 2012. Accessed Feb 2,
   2013 at http//www.phac-aspc.gc.ca/publicat/cig-g
   ci/p04-pneu-eng.phpru

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PCV13 vaccine for adults Current status

• In Canada, PCV13 was approved in January 2012 1
• indicated for active immunization for the
  prevention of invasive pneumococcal disease
  (sepsis, meningitis, bacteraemic pneumonia,
  pleural empyema and bacteraemia),
• in adults 50 years of age and older,
• caused by Streptococcus pneumoniae serotypes
  1, 3, 4, 5, 6A, 6B, 7F, 9V, 14, 18C,
  19A, 19F and 23F. 1
• In Jan 2014 the indication was expanded to
  include2
• Children, Adolescents and Adults.

1. Pneumococcal 3-valent Conjugate Vaccine
   (Diphtheria CRM197 Protein) Product Monograph.
   Pfizer Canada, Jan 2012
2. Health Canada. Notice of Compliance. Accessed
   July 10, 2013 at http//webprod5.hc-sc.gc.ca/noc
   -ac/info.do?no14512langeng

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Always give PCV13 before polysaccharide 23
follow with polysaccharide 2 mo-2 yrs
later Non-naive wait 1 year before PCV13
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Oct 2012
for adults gt18 with immunocompromising
conditions...PCV13 should be administered in
addition to PPSV23 (off label lt50yrs.)
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ACIP Feb .12
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(No Transcript)
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Varicella
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Shingles risk factors

• Advancing age
• - Decreased CMI with age
• Immunosuppression
• - HIV-AIDS
• - Organ transplants
• - Malignancy
• - Immunosuppressive therapy
• - autoimmune rheumatic diseases

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Shingles Canadian epidemiology

• 30 lifetime risk
• 15 of cases Post-herpetic neuralgia
  (PHN) of whom 70 have moderate to severe pain

Brisson M. CIC 2004
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Frequency of PHN (gt 3mo) and duration of Pain
Increase With Age
100
gt1 yr
6 - 12 mo
80
1 - 6 mo
40
30
lt1 mo
15
60
Percent of patients reporting pain
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20
0
0-19
20-29
30-39
40-49
50-59
60-69
79
Age (years)
Kost R et al. N Engl J Med. 199635532-42.
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Treatment of Herpes Zoster

• Antivirals(given early)
• - modestly shortens the rash
• - do NOT prevent PHN
• Corticosteroids
• - decreases severity of acute pain
• - do NOT prevent PHN

Once zoster develops treatment does not prevent
PHN
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The Shingles Prevention Study Vaccine Efficacy
HZ Incidence by age
Efficacy 51.3 63.9 37.6
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Vaccine
Placebo
12
10
Incidence of HZ
8

6
4
2
0
All
60-69 yr
70 yr
P lt0.001
Adapted from Oxman M et al. N Engl J Med.
20053522271-2284.
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The Shingles Prevention Study Vaccine Efficacy
PHN Incidence
Efficacy 66.5 65.7 66.8

P lt0.001
Adapted from Oxman M et al. N Engl J Med.
20053522271-2284.
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The Shingles Prevention Study Vaccine
Efficacy Severity/duration Illness

Efficacy 61.1 65.5 55.4

P lt0.001
Adapted from Oxman M et al. N Engl J Med.
20053522271-2284.
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Clinical Infectious Diseases 201255(10)1320
N 38,500 SPS vs.14,000 STPS over 7 years
Comparison SPS vs STPS
SPS (2.5
y) STPS (7y) HZ 51
40 PHN 66 60
N/S PHN BOI 61 50
Conclusion complete vaccine efficacy for 5
yrs.
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Contraindications

• Who can I give Zostavax to?
• lymphoproliferative disorders
• Solid tumour cancers
• immunosuppressants
• immune modulators

NO
YES
MAYBE
NO
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NACI January 2014

• Herpes zoster vaccine is recommended for the
  prevention of herpes zoster and its complications
  in persons 60 years and older
• Herpes zoster vaccine may be used in patients
  aged 50 to 59 years
• Herpes zoster vaccine may be administered to
  individuals 50 years old with a prior history
  of herpes zoster
• Herpes zoster vaccine can be administered
  concomitantly with pneumococcal vaccine

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Take home points

• Shingles is increasing and is a BAD disease esp
  in older population
• PHN lasts for months to years
• Zostavax provides at least 50 protection against
  infection, incidence and severity of PHN.
• mild immunosuppression not C/I
• Now approved gt50 yrs. of age esp. prior to
  immunosuppression
• Recommended over 60 yrs.

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Pertussis
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Vaccine efficacy decreased by 42 each year after
5 years
N Engl J Med 20123671012-9.
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Clinical Infectious Diseases 2004 3915812
Approximately 1320 of prolonged cough
illnesses in adolescents and adults are due to B.
pertussis infection Average duration 8-12 weeks
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Ped Infect Dis J.200423985-9
Pertussis in 616 infants in 4 US states mothers
32 family 43
75 household contacts
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administer a dose of Tdap in the 3rd trimester
of each pregnancy irrespective of the patients
prior history of receiving Tdap
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Potential new parents and their families should
receive one dose of TdaP
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Take home points

• Pertussis is on the rise
• Every adult needs one Tdap anytime
• Should your target group for Tdap be parents and
  families of infants or infants-to-be?

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Immunize children to prevent illness

• Immunize adults
• to prevent severe
• illness and death

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Conclusion

• All who deal with immunzation have the
  responsibility to be knowledgeable about
  immunizations, to be aware of their benefits and
  risks, and to be able to advocate effectively and
  clearly for their appropriate use.
• COMPLACENCY IN THIS MATTER WILL BE DETRIMENTAL TO
  OUR SOCIETY

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THANK YOU
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