Adult Vaccines:

1

• Adult Vaccines
• Update for Clinicians

Iyabode A. Beysolow, M.D., M.P.H. National Center
for Immunization and Respiratory Diseases
2009 NC Immunization Conference Immunizations
Real World, North Carolina August 13-14, 2009
2
Disclosures

• The speaker is a federal government employee with
  no financial interest or conflict with the
  manufacturer of any product named in this
  presentation
• The speaker will not discuss vaccines not
  currently licensed by the Food and Drug
  Administration

3
Whats New in Immunization

• New schedules and VISs
• Revised recommendations
• Specific adult vaccines
• Special Populations

4
Additional Adult schedule changes

• PPSV23
• Asthma and cigarette smoking have been added as
  indications for pneumococcal polysaccharide
  vaccination.
• Clarification for Persons in environments or
  settings with increased risk
• Routine use of PPSV23 is not recommended for
  Alaska Native or American Indian persons younger
  than 65 years unless they have underlying medical
  conditions that are PPSV indications. However
  public health authorities may consider
  recommending PPSV23 for Alaska Natives and
  American Indians 50 through 64 years of age who
  are living in areas in which the risk of
  pneumococcal disease is increased

5
Abbreviations for U.S. Vaccineshttp//cdc.gov/vac
cines/recs/acip/downloads/vac-abbrev.pdf
6
Vaccine Information Statements

• Every healthcare provider, public or private, who
  administers a vaccine covered by the National
  Childhood Vaccine Injury Act is required by law
  to provide a copy of the most current VIS with
  EACH DOSE of vaccine

7
Vaccine Information Statements

• Not required by Federal law to obtain a signature
• Must note in each patients permanent medical
  record or permanent office log or file
• date the VIS is provided
• the VIS edition date (usually located at the
  bottom of the second page of the document)

8
Vaccine Information StatementsNew Since August
2008

• Pneumococcal polysaccharide
• includes new indications for this vaccine for
  smokers and adults with asthma
• Combined Td/Tdap

9
New VIS Policies

• Providers can give parents or patients a
  permanent copy of a VIS to read in the office
  before the vaccination instead of giving each
  person their own individual paper copy
• you should still offer each patient their own
  copy to take home
• Persons with a wireless device, such as an
  iPhone, BlackBerry, or Palm Pre, may now download
  VISs onto these devices in lieu of taking home a
  paper copy

10
Haemophilus influenzae type b VaccineUse in
Older Children and Adults

• Generally not recommended for persons older than
  59 months of age
• Consider for high-risk persons asplenia,
  immunodeficiency, HIV infection
• One pediatric dose of any conjugate vaccine
• 3 doses recommended for all persons who have
  received a hematopoietic stem cell transplant

11
Measles, Mumps and Rubella Immunity

• Documented (in writing) physician diagnosis
  (measles and mumps only), or
• Serologic evidence of immunity, or
• Documentation of 2 doses of measles and mumps
  vaccine and one dose of rubella vaccine on or
  after the first birthday, or
• Born before 1957

except regarding rubella in women of
childbearing age
12
Evidence of Measles, Mumps, and Rubella Immunity
for Healthcare Personnel (HCP)

• Appropriate vaccination against measles, mumps,
  and rubella
• 2 doses of measles and mumps vaccine
• at least 1 dose of rubella vaccine, or
• Laboratory evidence of immunity, or
• Laboratory confirmation of disease
• Physician-diagnosed disease no longer recommended
  as evidence of measles or mumps immunity

13
Evidence of Measles, Mumps, and Rubella Immunity
for Healthcare Personnel (HCP)

• For unvaccinated personnel born before 1957 who
  lack laboratory evidence of measles, mumps and/or
  rubella immunity or laboratory confirmation of
  disease, healthcare facilities should consider
  vaccinating personnel with two doses of MMR
  vaccine at the appropriate interval for measles
  and mumps, and one dose of MMR vaccine for
  rubella, respectively

14
Impact of Influenza, 1990-1999

• Approximately 36,000 influenza-associated deaths
  during each influenza season
• Persons 65 years of age and older accounted for
  more than 90 of deaths
• Average of 226,000 hospitalizations during each
  influenza season

MMWR 200756 (RR-6)
15
Influenza Vaccination Coverage Among Recommended
Groups, 2005
Group gt65 years 18-64 years, high risk 50-64
years Pregnant women HCP 18-49 years
HHC
Coverage (95 C.I.) 60 (58-61) 25
(24-27) 23 (22-24) 16 (11-21) 34
(32-36) 9 (8-10)
National Health Interview Survey, 2005.
household contact of high risk person. MMWR
200756(RR-6)22.
16
Seasonal influenza vaccine2009-2010

• Strain change
• The 200910 trivalent vaccine virus strains are
  A/Brisbane/59/2007 (H1N1)-like,
  A/Brisbane/10/2007 (H3N2)-like, and B/Brisbane
  60/2008-like antigens.
• For the 200910 influenza season, the influenza B
  vaccine virus strain was changed to
  B/Brisbane/60/2008, a representative of the
  B/Victoria lineage) compared with the 200809
  season. The influenza A (H1N1 and H3N2 vaccine
  virus strains were not changed

17
Inactivated Influenza Vaccines Expected To Be
Available in 2009-2010
inactivated vaccines approved for children
younger than 4 years
18
Timing of Influenza Vaccination

• Influenza activity can occur as early as October
• In more than 80 of influenza seasons peak
  activity has not occurred until January or later
• In more than 60 of seasons the peak was in
  February or later

MMWR 200958 (RR-8)
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Timing of Influenza Vaccination

• Immunization providers should begin offering
  vaccine as soon as it becomes available
• Providers should offer vaccine during routine
  healthcare visits or during hospitalizations
  whenever vaccine is available

MMWR 200958 (RR-8)
20
Timing of Influenza Vaccination

• Continue to offer influenza vaccine in December,
  especially to healthcare personnel and those at
  high risk of complications
• Continue to vaccinate throughout influenza season
  (December-March)

MMWR 200958 (RR-8)
21
Novel Influenza A (H1N1) Virus - 2009

• April 15 - first infection confirmed by CDC
• April 26 - public health emergency declared
• June 11 - World Health Organization raises
  pandemic alert to Phase 6 (i.e., pandemic in
  progress)
• June 19 - infections reported by all 50 states

http//www.cdc.gov/h1n1flu/
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Novel Influenza A (H1N1) Virus - 2009

• Virus continues to spread
• Spreading along with seasonal influenza viruses
  in the southern hemisphere
• Virus transmission has continued into the summer
  in the United States

http//www.cdc.gov/h1n1flu/
23
Seasonal vs. H1N1 age distribution of illness

• Compare charts

24
ACIP recommendations for Target Groups

• Pregnant women
• Household and caregiver contacts of children
  younger than 6 months of age
• Healthcare and emergency medical services
  personnel
• Children from 6 months through 24 years of age
• And persons 25 through 64 years who have high
  risk medical conditions.

25
Risk Factors for Invasive Pneumococcal Disease
(IPD)

• Asthma has now been identified as an independent
  risk factor for invasive pneumococcal disease
• Adults with asthma had at least double the risk
  of IPD compared with adults of similar age
  without asthma

N Engl J Med 2005 352(20) 2082-90
26
Pneumococcal Polysaccharide Vaccine (PPSV23)
Recommendations

• Adults 65 years and older
• Persons 2 years and older with
• chronic illness
• anatomic or functional asplenia
• immunocompromised (disease, chemotherapy,
  steroids)
• HIV infection
• environments or settings with increased risk
• Asthmatics and smokers over age 19 yrs

27
New Pneumococcal Polysaccharide Vaccine (PPSV)
Recommendation

• All adults 19 years of age and older with asthma
  regardless of severity
• Available data do not support asthma as an
  indication for PPSV among persons younger than 19
  years

http//www.cdc.gov/vaccines/recs/provisional/defau
lt.htmacip
28
Smoking Among Persons With IPD, 2001-2003
CDC. Active Bacterial Core surveillance,
unpublished
29
Cigarette Smoking and IPD

• Approximately half of adults 65 years of age or
  younger who develop severe pneumococcal disease
  are smokers
• Cigarette smoking is a strong risk factor for
  severe disease
• Many adults who smoke cigarettes also have
  another condition for which PPSV is already
  recommended
• Cigarette smoking is a risk behavior that is easy
  to identify among patients in clinical practice
• Smoking cessation should be part of the
  therapeutic plan regardless of immunization

30
New Pneumococcal Polysaccharide Vaccine (PPSV)
Recommendation

• All adults 19 years of age and older who smoke
  cigarettes
• Available data do not support smoking as an
  indication for PPSV among persons younger than 19
  years

http//www.cdc.gov/vaccines/recs/provisional/defau
lt.htmacip
31
Pneumococcal Polysaccharide Vaccine Revaccination

• Routine revaccination of immuno-competent persons
  is not recommended
• Revaccination recommended for persons 2 years of
  age or older who are at highest risk of serious
  pneumococcal infection
• Revaccination is a 1-time event
• 5 years or longer after first dose (interval
  applies to persons of all ages)

MMWR 199746(RR-8)
32
Pneumococcal Polysaccharide VaccineCandidates
for Revaccination

• Persons 2 years or older with
• Asplenia (functional or anatomic)
• Immunosuppression
• Chronic renal failure
• Nephrotic syndrome
• Persons vaccinated before 65 years of age

MMWR 199746(RR-8)1-24
33
MCV Revaccination Recommendations

• MCV revaccination recommendation does NOT apply
  to children who previously received MCV and who
  will be a freshman living in a dormitory

34
MCV Revaccination Recommendations

• High-risk persons who should be revaccinated with
  MCV
• persistent complement component deficiency
• anatomic or functional asplenia
• HIV infection
• frequent travelers to or persons living in areas
  with high rates of meningococcal disease

35
Herpes Zoster (Shingles)

• Reactivation of varicella zoster virus
• Can occur years or even decades after illness
  with chickenpox
• Generally associated with normal aging and with
  anything that causes reduced immunocompetence
• Lifetime risk of 30 in the United States
• Estimated 500,000- 1 million cases of zoster
  diagnosed annually in the U.S

36
Herpes Zoster Vaccine(Zostavax)

• Administered to persons who had chickenpox to
  reduce the risk of subsequent development of
  zoster and postherpetic neuralgia
• Contains live varicella vaccine virus in much
  larger amount (14x) than standard varicella
  vaccine (Varivax)
• Requires freezer storage AT ALL TIMES

37
ACIP Recommendations for Zoster Vaccine

• Adults 60 years and older should receive a single
  dose of zoster vaccine
• Routine vaccination of persons younger than 60
  years is NOT recommended
• Need for booster dose or doses not known at this
  time
• A history of herpes zoster should not influence
  the decision to vaccinate

MMWR 200857(RR-5)
38
Zoster Vaccine

• It is not necessary to inquire about chickenpox
  or test for varicella immunity before
  administering zoster vaccine
• Persons 60 years of age and older (US born) can
  be assumed to be immune regardless of their
  recollection of chickenpox

MMWR 200857(RR-5)
39
Varicella Immunity

• Written documentation of age-appropriate
  vaccination
• Laboratory evidence of immunity or laboratory
  confirmation of disease
• Born in the United States before 1980
• Healthcare provider diagnosis or verification of
  varicella disease
• History of herpes zoster based on healthcare
  provider diagnosis

MMWR 200757(RR-4)
40
Serologic Testing for Varicella Immunity

• If a person 60 years or older is tested for
  varicella antibody and found to be negative
• Administer 2 doses of regular varicella vaccine
  (not zoster vaccine)
• Zoster vaccine is not indicated for persons whose
  immunity is based upon varicella vaccination

41
Zoster VaccineContraindications and Precautions

• Severe allergic reaction to a vaccine component
  or following a prior dose
• Immunosuppression from any cause
• Pregnancy or planned pregnancy within 4 weeks
• Moderate or severe acute illness
• Recent blood product is NOT a precaution

MMWR 200857(RR-5)
42
Shingles QAwww.immunize.org/catg.d/p4221.pdf
43
Tdap

• Tdap minimum ages
• 10 years for Boostrix
• 11 years for Adacel
• Neither brand of Tdap approved for children 7
  trough 9 years of age, or persons 65 years or
  older
• Off-label use of Tdap in these age groups NOT
  recommended

44
Tdap Vaccination of Adults19 Through 64 Years of
Age

• Single dose of Tdap to replace a single dose of
  Td
• May be given at an interval less than 10 years
  since receipt of last tetanus toxoid-containing
  vaccine
• Special emphasis on adults with close contact
  with infants (e.g., childcare and healthcare
  personnel, and parents)

MMWR 200655(RR-17)1-37.
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Minimum Interval Between Td and Tdap

• ACIP did not define an absolute minimum interval
  between Td and Tdap
• Interval between Td and Tdap may be shorter if
  protection from pertussis needed
• Decision to administer Tdap based on whether the
  benefit of pertussis immunity outweighs the risk
  of a local adverse reaction

MMWR 200655(RR-3)1-43.
46
Use of Tdap Among Pregnant Women

• Td is generally preferred during pregnancy
• Women who have not received Tdap should receive a
  dose in the immediate post-partum period
• Any woman who might become pregnant is encouraged
  to receive a single dose of Tdap
• Clinician may choose to administer Tdap to a
  pregnant woman in certain circumstances (such as
  during a community pertussis outbreak)
• Pregnancy is not a contraindication for Tdap

MMWR 200857 (No. RR-4)
47
Tdap Vaccine and Healthcare Personnel

• Healthcare personnel who work in hospitals or
  ambulatory care settings and have direct patient
  contact should receive a single dose of Tdap as
  soon as feasible
• Priority should be given to vaccination of
  healthcare personnel who have direct contact with
  infants 12 months of age and younger
• An interval as short as 2 years (or less) from
  the last dose of Td is recommended for the Tdap
  dose

if they have not previously received Tdap.
MMWR 200655(RR-17)1-37.
48
Adults at Risk for HBV Infection

• Sexual exposure
• sex partners of HBsAg-positive persons
• sexually active persons not in a long-term,
  mutually monogamous relationship
• persons seeking evaluation or treatment for a
  sexually transmitted disease
• men who have sex with men

persons with more than one sex partner during
the previous 6 months
49
Adults at Risk for HBV Infection

• Percutaneous or mucosal exposure to blood
• current or recent IDU
• household contacts of HBsAg-positive persons
• residents and staff of facilities for
  developmentally disabled persons
• healthcare and public safety workers with risk
  for exposure to blood or blood-contaminated body
  fluids
• persons with end-stage renal disease

50
Adults at Risk for HBV Infection

• Others groups
• international travelers to regions with high or
  intermediate levels (HBsAg prevalence of 2 or
  higher) of endemic HBV infection
• persons with HIV infection

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Hepatitis B Vaccine Adolescent and Adult Schedule
Minimum Interval - - - 4 weeks 8 weeks
Usual Interval --- 1 month 5 months

• Dose
• Primary 1
• Primary 2
• Primary 3

third dose must be separated from first dose by
at least 16 weeks
52
Prevaccination Serologic Testing

• Not indicated before routine vaccination of
  infants or children
• Recommended for
• all persons born in Africa, Asia, the Pacific
  Islands, and other regions with HBsAg prevalence
  of 8 or higher
• household, sex, and needle-sharing contacts of
  HBsAg-positive persons
• HIV-infected persons
• Consider for
• Groups with high risk of HBV infection (MSM, IDU,
  incarcerated persons)

53
Postvaccination Serologic Testing

• Not routinely recommended following vaccination
  of infants, children, adolescents, or most adults
• Recommended for
• Infants born to HBsAg women
• Hemodialysis patients
• Immunodeficient persons
• Sex partners of persons with chronic HBV
  infection
• Certain healthcare personnel

54
Postvaccination Serologic Testing

• Healthcare personnel who have contact with
  patients or blood should be tested for anti-HBs
  (antibody to hepatitis B surface antigen) 1 to 2
  months after completion of the 3-dose series

55
Management of Nonresponse to Hepatitis B Vaccine

• Complete a second series of three doses
• Should be given on the usual schedule of 0, 1 and
  6 months
• Retest 1-2 months after completing the second
  series

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Persistent Nonresponse to Hepatitis B Vaccine

• Less than 5 of vaccinees do not develop anti-HBs
  after 6 valid doses
• May be nonresponder or "hyporesponder"
• Check HBsAg status
• If exposed, treat as nonresponder with
  postexposure prophylaxis

57
Vaccine Supply Hepatitis B

• Merck's adult and dialysis formulations of their
  hepatitis B vaccine will not be available in 2009
• Merck expects to return to full supply in 2010
• Supplies of GlaxoSmithKlines adult formulation
  and hepatitis A/hepatitis B combination vaccine
  are sufficient to meet demand

www.cdc.gov/vaccines/vac-gen/shortages/default.htm
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Hepatitis A Vaccine Recommendations

• International travelers
• Men who have sex with men
• Persons who use illegal drugs
• Persons with occupational risk
• Persons with chronic liver disease

59
Hepatitis A Vaccine Recommendations

• Healthcare workers not routinely recommended
• Child care centers not routinely recommended
• Sewer workers or plumbers not routinely
  recommended
• Food handlers may be considered based on local
  circumstances

60
Hepatitis A VaccineInternational Travel

• The first dose of hepatitis A vaccine should be
  administered as soon as travel is considered
• For healthy persons 40 years of age or younger
• 1 dose of single-antigen vaccine administered at
  any time before departure
• Persons at risk of severe disease from hepatitis
  A virus planning to travel in 2 weeks or sooner
  should receive the first dose of vaccine and also
  can be administered immune globulin

MMWR 200756(No.41)1080-4
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Hepatitis A Postexposure Prophylaxis

• For healthy persons 12 months through 40 years of
  age
• single-antigen hepatitis A vaccine should be
  administered as soon as possible after exposure
• For persons older than 40 years
• immune globulin is preferred
• vaccine can be used if IG cannot be obtained

MMWR 200756(No.41)1080-4
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Vaccine Supply Hepatitis A

• VAQTA (Merck)
• adult formulation is not currently being
  distributed
• will not be available in 2009
• Supplies of the adult formulation of Havrix (GSK)
  and Twinrix (GSK) are currently adequate to meet
  demand

www.cdc.gov/vaccines/vac-gen/shortages/default.htm
63
Twinrix

• Combination hepatitis A vaccine (pediatric dose)
  and hepatitis B (adult dose)
• Schedules
• 0, 1, 6 months, or
• 0, 7, 21- 30 days and a booster dose at 12 months
• Approved for persons 18 years of age and older

64
New Twinrix Schedule

• Doses at 0, 7, 21- 30 days and a booster dose at
  12 months
• ACIP has no recommendation regarding the new
  schedule
• The first 3 doses of the new schedule provide
  equivalent protection to
• the first dose in the standard single-antigen
  adult hepatitis A vaccine series
• the first 2 doses in the standard adult hepatitis
  B vaccine series

65
New Twinrix Schedule

• Seroconversion is nearly 100 after either 3
  doses of Twinrix on the new schedule or a single
  dose of single-antigen adult hepatitis A vaccine
• No increased benefit of the new schedule for the
  hepatitis B component compared to administration
  of 2 hepatitis B vaccine doses 1 to 2 months apart

66
Schedules That Include BothTwinrix and Hepatitis
A Vaccine

• Adult formulation single antigen hepatitis A
  vaccine may be used to complete a schedule begun
  with Twinrix and vice versa
• Acceptable schedules
• 2 Twinrix and 1 hepatitis A (adult formulation
• 1 Twinrix and 2 hepatitis A (adult formulation)
• Maintain spacing recommended for Twinrix

for persons 19 years of age or older
67
Human Papillomavirus (HPV)

• Common sexually transmitted infection
• More than 100 types
• Established cause of cervical and other
  anogenital cancers
• Worldwide cervical cancer causes 233,000 deaths
  per year

68
HPV Clinical Features

• Most HPV infections are asymptomatic and result
  in no clinical disease
• Clinical manifestations of HPV infection include
• Anogenital warts
• Recurrent respiratory papillomatosis
• Cervical cancer precursors (cervical
  intraepithelial neoplasia)
• Cancer (cervical, anal, vaginal, vulvar, penile,
  and some head and neck cancer)

69
HPV Vaccination Schedule

• Routine schedule is 0, 2, 6 months
• Intramuscular injection in the deltoid
• Minimum intervals
• 4 weeks between doses 1 and 2
• 12 weeks between doses 2 and 3
• 24 weeks between doses 1 and 3
• Minimum age is 9 years
• Maximum age is 26 years (may complete series
  after age 27 if begun before age 27)

MMWR 200656(No. RR-2)1-23
70
HPV Vaccine Special Situations

• Vaccine can be administered with
• Equivocal or abnormal Pap test
• Positive HPV DNA test
• Genital warts
• Immunosuppression
• Breastfeeding

71
Special Populations
72
ACIP HCP Recommendations www.cdc.gov/vaccines/pubs
/ACIP-list.htm
73
Healthcare Personnel

• Need the following immunizations
• Annual influenza
• Tdap or Td
• Hepatitis B (exposure risk)
• Validate immunity status of
• Varicella
• Measles, Mumps Rubella (MMR)

Are YOU up to date?
74
Influenza Recommendations for HCP

• Annual influenza vaccination is recommended for
  all persons who work in any medical care facility
  or provide care in any setting to persons at
  increased risk of influenza or complications of
  influenza
• All HCP have an ethical and professional
  responsibility to be vaccinated against influenza
  annually

75
ACIP HCP Recommendations www.cdc.gov/vaccines/pubs
/ACIP-list.htm
76
Healthcare Personnel

• Need the following immunizations
• Annual influenza
• Tdap or Td
• Hepatitis B (exposure risk)
• Validate immunity status of
• Varicella
• Measles, Mumps Rubella (MMR)

Are YOU up to date?
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ACIP Recommendations for Tetanus, Diphtheria,
Pertussis Protection in Pregnant Postpartum
Women Their Infants www.cdc.gov/mmwr/PDF/rr/rr57
04.pdf

• If no previous Tdap, give Tdap dose in immediate
  postpartum period
• Td preferred if needed during pregnancy, although
  Tdap is not contraindicated during pregnancy if
  the benefit outweighs the risk (e.g., pertussis
  outbreak)

79
Immunizations During Pregnancy
www.cdc.gov/vaccines/pubs/images/f_preg_view.gif
www.cdc.gov/vaccines/pubs/images/f_preg_chart_view
.gif
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www.immunize.org/pregnancy/
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Immunizations for Immunocompromised www.cdc.gov/mm
wr/PDF/rr/rr5515.pdf
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Vaccine Administration Errors

• Wrong vaccine or wrong diluent
• Wrong vaccine dosage
• Expired vaccine
• Timing and spacing mistakes
• Wrong site, route, or needle length

86
Prevention of Syncope After Vaccination

• Vaccine providers should strongly consider
  observing patients for 15 minutes after they are
  vaccinated
• If syncope develops, patients should be observed
  until symptoms resolve
• Clinicians should be aware of presyncopal
  manifestations (weakness, dizziness, pallor, etc)
  and take appropriate measures to prevent injuries
  if they occur

MMWR 200857(No. 17)457-60 MMWR
200655(RR-15)19
87
Strategies to Improve Adult Vaccination Rates

• Standing Orders
• Computerized record reminders
• Chart reminders
• Performance Feedback
• Home visits
• Mailed/Telephone reminders
• Expanding Access in Clinical Settings
• Patient education
• Personal health records

88
Vaccine Storage Handling Update

• VFC Provider Vacine Management Requirements
• www.cdc.gov/vaccines/programs/vfc/projects/vacc-mg
  mt-manage.htmproviders
• Vaccine Storage Handling Toolkit
• www.cdc.gov/vaccines/recs/storage/default.htm

89
Travel Immunization Resourceswww.cdc.gov/travel/
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CDC Vaccines and ImmunizationContact Information

• Telephone 800.CDC.INFO
• (for patients and parents)
• Email nipinfo_at_cdc.gov
• (for providers)
• Website www.cdc.gov/vaccines/hcp
• Vaccine Safety
• www.cdc.gov/od/science/iso/

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Adult Immunization Resources
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Adult Immunization Resources
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Adult Immunization Resources
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Adult Immunization Resources
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Adult Immunization Resources