1. The Current Practice and knowledge of Adult Vaccination in SyriaNaem Shahrour, MD, FCCPChairman, Pulmonary Dept. Alassad Univ. HospitalDamascus University Medical SchoolFEMTOS and TTS Congress Antalya 25-29, 2007

5. Syria • 18 millions • Damascus is the Capıtal of about 5 millions • 140 pulmonologists who are members of the Syrian Thoracic Society • 10 pulmonologists credentialed each year

16. Alassad Unıversıty Hospıtal -Largest Unıversıty Hospital in the country -700-bed hospıtal -200 Medical Residents -38-bed pulmonary Department -2-3 Pulmonary Fellows each year.

17. Incidence of Invasive Pneumococcal Infection • CDC estimate is 23 per 100,000 (blood or cerebrospinal fluid) • The rate was highest in • children under the age of two • adults 65 years of age (86% due to serotypes in PPV23) • Blacks Robinson, KAet al. Epidemiology of invasive Streptococcus pneumoniae infections in the United States, 1995-1998: Opportunities for prevention in the conjugate vaccine era. JAMA 2001; 285:1729

18. It Is a Burden • More people die from pneumococcal infections (an estimated 40,000 annually in the United States) than from any other vaccine preventable disease Gardner, P, Schaffner, W. Immunization of adults. N Engl J Med 1993; 328:1252 • deathsCase fatality rates are highest for pneumococcal meningitis (35 percent) Schuchat, A, et al. Bacterial meningitis in the United States. N Engl J Med 1997; 337:970 • Efficacy of PPV23 against invasive disease in adults ıs about 57 percent Butler, J et al. Pneumococcal polysaccharide vaccine efficacy: An evaluation of current recommendations. JAMA 1993; 270:1826

19. Concept of Vaccine? • It ıs impossibleto ınclude the over 90 different capsular types of pneumococci • Thus, vaccines representing a subgroup of highly prevalent types have been formulated

20. Now vaccination is more attractive, • High M&M with invasive infections particularly in patients at increased risk • High prevalence of multiple antibiotic resistance

21. So The vaccine ıs an important landmark in medical history • The polysaccharide antigens were used to induce type-specific antibodies that enhanced opsonization, phagocytosis, and killing of pneumococci

22. Evolution • a 14-valent In the 1970s, by Dr. Robert Austrian • a 23-valent in 1983 (PPV23) • protein conjugate heptavalent vaccine (PCV7) in February 2000:A significant breakthrough is the licensing of a) since polysaccharides are not immunogenic in children under the age of two years • The aim was to choose virulence determinant antıgen on the mucosal surface (inactivated diphtheria toxin)and to generate a T cell-dependent memory response.

23. Rate of Vaccination • Improved: • In 1995: 34% rate of ever being vaccinated MMWR Morb Mortal Wkly Rep 2000; 49(SS-9):39 • in 2005 median coverage was66 percent MMWR Morb Mortal Wkly Rep 2006; 55:1065

24. Efficacy • Vaccination protects only against invasive disease • It does not prevent: • 1-Nonbacteremic pneumonia Musher, DM et al.. Clin Infect Dis 2006; 43:1004 • 2-Death in adults Ortqvist, A, et al. Lancet 1998; 351:399 • 3-Nasopharyngeal carriage among children Douglas R et al. Am J Dis Child 1986; 140:1183

25. Final Recommendations • Currently Only for high-risk groups (prevent59% of all ınvasıve cases). • Potentıal Future Recommendatıons: • Lowering age to 50 years ( 5 to 7 percent) (Most ımportant) • Current smoking (1.5 to 2.5%) • Former smoking ( 0.4 to 0.7%) • Black race ( 1.0 to 1.4%) • Asthma ( 0.3 to 0.4 percent) • It is possible that future recommendations will ınclude smokers and asthmatıcs.

27. Influenza • Influenza is an acute respiratory illness caused by influenza A or B virusesevery year • Wıth high rate of mutation in envelope antigens (hemagglutinin and the neuraminidase) • Major changes in these glycoproteins are referred to as antigenic shifts(epidemics) • Minor changes are called antigenic drifts (localized outbreaks) • New vaccines are produced each year to matchthe new virus • CDC,and WHO tracks isolates weekly

28. Influenza VaccineConcept • Most deathsoccur ın elderly • The protection is based upon induction of neutralizing antibodies, mainly against hemagglutinin • cross-protection: during one pandemicOnly six percent of the adults vs. 55 percent of the children had symptomatic influenza A despite living in households that had influenza. • multiple exposures to establish a potent immunologic response ın children.

29. Efficacy of Live-Attenuated Intranasal Vaccine • Licensed ın the US for healthy individuals 5-49 years in June, 2003 • 19-24% reduction ın: • severe febrile illnesses • febrile URTI • days of work lost

30. EFFICACY ofInactivated vaccines • Based on (closeness of "fit") wıth the previous year’s viruses Ruben, FL. Prevention and control of influenza: Role of vaccine. Am J Med 1987; 82:31

31. Active vs. Inactive Vaccinesin Healthy • 1247 healthy adults in Michigan during the 2004 to 2005 influenza season • both vaccines had similar efficacies against culture-proven type A influenza (74 percent) • However, the inactivated vaccine was superior to the live attenuated vaccine against culture-confirmed type B influenza infections (80 versus 40 percent) Ohmit, SEet al. Prevention of antigenically drifted influenza by inactivated and live attenuated vaccines. N Engl J Med 2006; 355:2513

32. A Cochrane : 20 trials Both vaccines had Reductıon in 1-Serologically confirmed influenza(68% with the inactivated vaccine and 48% with the intranasal vaccine) 2-clinical influenza:less effective(24 vs. 13%) 3-The number of missed days of work was also significantly reduced, but only by 0.4 days

33. Annual vaccination ıncreases effectıvenss. • Cost-effectivenessıs favorable • immunization of school children decreased ıncıdence and mortality in elderly due to pneumonia and influenza • vaccination of healthcare personnel in long-term care facilities improves patient survival

34. TARGET GROUPS PRINCPLES • 1-Live V is approved only for use in healthy persons between 5 and 49 years of age • 2- Inactivated vaccines should be given to adults at high risk for influenza-related complications Smith, NM, Bresee, JS, Shay, DK, et al. Prevention and Control of Influenza: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 2006; 55:1 • There is substantial overlap between the target populations for influenza and pneumococcal vaccines.

35. Targeted Patients • Persons 50 years of ageor older • Residents of NH • Adults wıth chronic disorders of the pulmonary or cardiovascular systems, including asthma. • Adults wıth neurologic condition that can compromise handling of respiratory secretions. • Adults wıth chronic metabolic diseases • immunosuppression by medications or HIV infection • pregnant women any month especially who will be pregnant during the influenza season • New: CADand other atheroscerotic vascular diseases • individuals who might transmit influenza to persons at high risk,

36. Population of the Study • 297 physicians randomly selected from the MOH list of Damascus physicians • All MD’s were asked to fill out a 15-item questionnaire for each vaccine. • Questıonnaıre was aimed to assess the current knowledge of physıcians about the adult vccınatıon and their practıce of vaccinations

37. Sample of Physicians

38. Percentage of MD Using the Vaccine

39. Percentage of Users of Infl. V.According to Specialty

40. Percentage of Users of Pneu V.According to Specialty

41. 1-How Long Have You Been Using the Infl. Vaccine?

42. How Long Have you Been Using the Pneu Vaccine?

43. 2-Whom Would You Recommend The Infl Vaccine To?

44. Whom Would You Recommend The Pneu Vaccine To?

45. 3- Are You convinced of The Benefits of the Influenza Vaccine ?

46. Are convinced of The Benefit of the Pneu Vaccine?

47. 4-Is It Hard To Convince Pts of Infl V.?

48. Is It Hard To Convince Pts of Pneu V.?

49. 5-Percentage of Patients benefiting from Infl Vaccination?

50. Percentage of Patients benefiting from Pneu Vaccination?