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Adult Vaccines:


Adult Vaccines: Update for Clinicians Iyabode A. Beysolow, M.D., M.P.H. National Center for Immunization and Respiratory Diseases 2009 NC Immunization Conference – PowerPoint PPT presentation

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Title: Adult Vaccines:

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

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

Additional Adult schedule changes
  • PPSV23
  • Asthma and cigarette smoking have been added as
    indications for pneumococcal polysaccharide
  • 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

Abbreviations for U.S. Vaccineshttp//
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

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)

Vaccine Information StatementsNew Since August
  • Pneumococcal polysaccharide
  • includes new indications for this vaccine for
    smokers and adults with asthma
  • Combined Td/Tdap

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

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

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
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

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

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)
Influenza Vaccination Coverage Among Recommended
Groups, 2005
Group gt65 years 18-64 years, high risk 50-64
years Pregnant women HCP 18-49 years
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
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

Inactivated Influenza Vaccines Expected To Be
Available in 2009-2010
Vaccine Package Dose Age Thimerosal
Fluzone (sanofi Multidose vial Age-dependent gt6 mos Yes
pasteur) Single dose syringe 0.25 mL 6-35 mos No
Single dose syringe and vial 0.5 mL gt36 mos No
Fluvirin (Novartis) Multidose vial 0.5 mL gt4 yrs Yes
Fluarix (GSK) Flulaval (GSK) Single dose syringe Multidose vial 0.5 mL 0.5 mL gt18 yrs gt18 yrs Trace Yes
Afluria (CSL) Single dose syringe Multidose vial 0.5 mL 0.5 mL gt18 yrs gt18 yrs No Yes
inactivated vaccines approved for children
younger than 4 years
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)
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)
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

MMWR 200958 (RR-8)
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
  • June 19 - infections reported by all 50 states

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

Seasonal vs. H1N1 age distribution of illness
  • Compare charts

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

Risk Factors for Invasive Pneumococcal Disease
  • 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
Pneumococcal Polysaccharide Vaccine (PPSV23)
  • Adults 65 years and older
  • Persons 2 years and older with
  • chronic illness
  • anatomic or functional asplenia
  • immunocompromised (disease, chemotherapy,
  • HIV infection
  • environments or settings with increased risk
  • Asthmatics and smokers over age 19 yrs

New Pneumococcal Polysaccharide Vaccine (PPSV)
  • 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

Smoking Among Persons With IPD, 2001-2003
CDC. Active Bacterial Core surveillance,
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
  • 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

New Pneumococcal Polysaccharide Vaccine (PPSV)
  • All adults 19 years of age and older who smoke
  • Available data do not support smoking as an
    indication for PPSV among persons younger than 19

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)
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
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

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

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

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

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
  • A history of herpes zoster should not influence
    the decision to vaccinate

MMWR 200857(RR-5)
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)
Varicella Immunity
  • Written documentation of age-appropriate
  • 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)
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

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)
  • 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
  • Off-label use of Tdap in these age groups NOT

Tdap Vaccination of Adults19 Through 64 Years of
  • Single dose of Tdap to replace a single dose of
  • May be given at an interval less than 10 years
    since receipt of last tetanus toxoid-containing
  • Special emphasis on adults with close contact
    with infants (e.g., childcare and healthcare
    personnel, and parents)

MMWR 200655(RR-17)1-37.
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.
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)
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

if they have not previously received Tdap.
MMWR 200655(RR-17)1-37.
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
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
  • persons with end-stage renal disease

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

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
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)

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
  • Certain healthcare personnel

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

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

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

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
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

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

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
Hepatitis A Postexposure Prophylaxis
  • For healthy persons 12 months through 40 years of
  • 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
Vaccine Supply Hepatitis A
  • VAQTA (Merck)
  • adult formulation is not currently being
  • will not be available in 2009
  • Supplies of the adult formulation of Havrix (GSK)
    and Twinrix (GSK) are currently adequate to meet
  • 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

New Twinrix Schedule
  • Doses at 0, 7, 21- 30 days and a booster dose at
    12 months
  • ACIP has no recommendation regarding the new
  • 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

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

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
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

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)

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

Special Populations
ACIP HCP Recommendations
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?
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
  • All HCP have an ethical and professional
    responsibility to be vaccinated against influenza

ACIP HCP Recommendations
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
  • 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

Immunizations During Pregnancy
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Immunizations for Immunocompromised
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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

Prevention of Syncope After Vaccination
  • Vaccine providers should strongly consider
    observing patients for 15 minutes after they are
  • 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
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

Vaccine Storage Handling Update
  • VFC Provider Vacine Management Requirements
  • Vaccine Storage Handling Toolkit

Travel Immunization
CDC Vaccines and ImmunizationContact Information
  • Telephone 800.CDC.INFO
  • (for patients and parents)
  • Email
  • (for providers)
  • Website
  • Vaccine Safety

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