Adult and Child Immunization Update

1. Adult and Child Immunization Update May 6, 2012 Charlene Graves, MD, FAAP Former Medical Director , ISDH Immunization Program (2000 – 2007) Chairman, INAAP Immunization Committee

2. Disclosure • I became a scientific speaker for vaccines manufactured by GlaxoSmithKline in May of 2008.

3. Today’s Topics • Vaccination to protect adults against: • Pertussis • Influenza • Pneumococcal infection • Shingles • Other: Human papillomavirus, Hepatitis B, measles • Update on childhood and teen vaccination new recommendations from 2011 and 2012 • Strategies to improve adult vaccination rates

4. Recent Data on Adult Vaccination RatesMMWR, Feb. 3, 2012

5. Pertussis Infection Update

6. More on Pertussis • 48% of pertussis cases involve adults and adolescents (2009) • Adults and adolescents are the reservoir for infection in young infants, who have severe disease • 10 infants died of pertussis in California, 27 in U.S., in 2010 • Highly communicable through contact with respiratory droplets • Stages of disease: catarrhal, paroxysmal, convalescent

7. Impact of Pertussis • Adults with pertussis: 61% missed work, for an average, of 10 days • 66% required 2 or more medical visits during their illness • Complications: pneumonia (up to 5%), rib fracture (up to 4%), loss of consciousness (3-6%), hospitalization (up to 3%) • Especially dangerous when infants get infected. In one study, 76% of infant pertussis infections were traced back to adults (56%) or adolescents (20%)

8. Diagnosis and Management • Evaluate anyone with a cough lasting 2 weeks of longer • N-P specimen for PCR +/- culture • Antibiotics for patient and all close contacts • Erythromycin (10 days) • Clarithromycin (7 days) • Azithromycin (5 days) • Begin antibiotics prior to return of lab test results • Not contagious after 5 days of antibiotic treatment

9. Pertussis Vaccination • Two Tdap vaccines licensed by the FDA in 2005 • Boostrix is licensed for age 10 and older (GSK) • Adacel is licensed for ages 11-64 years (SFP) • Tdap vaccine recommended for adolescents and adults up to 65 years of age in 2006 • ACIP recommends that all adults (including senior citizens, as of Feb. 2012)receive a one-time Tdap booster to replace the Td shot needed every 10 years • As of Oct. 2011, ACIP recommends that all pregnant women receive a Tdap vaccination after the 20th week of pregnancy. (revised from previous post-partum, before leaving hospital).

10. Tdap Vaccination • There is NO MINIMUM INTERVAL between Td vaccination and receiving Tdap vaccine • Tdap should be used to replace Td booster in wound management situations • Immunogenicity and safety records for both Tdap vaccines are excellent. • Injection site reactions: pain in 60%, redness and/or swelling in 20%

11. Tdap Vaccination Coverage Rates • As of 2010, only8.2% of U.S. adults had Tdap vaccine** • In contrast, 68.7% of U.S. teens have had Tdap • Indiana: 72.3% of teens have had Tdap • Why is Tdap vaccine so under-utilized? • Role of health care provider recommendation • Need for adult patient education • **NHIS data, MMWR Feb.3, 2012

12. Influenza • Burden of influenza: 3,000-49,000 deaths/year (U.S.) • 90% of deaths in 65 years and older • Pediatric deaths : 282 in 2009-10, 122 in 2010-11 • 225,000 hospitalization per year (U.S.) • Risk of hospitalization equal in young children compared to the elderly • Racial and ethnic disparities in adult vaccination

13. Influenza Vaccination Basics • Everyone 6 months of age and older should be vaccinated • For 6 mos. through 8 yrs. of age, 2 doses given at least 4 weeks apart needed in first season (priming immune system) • Trivalent influenza vaccine (TIV) = injection • Live attenuated influenza vaccine (LAIV) = FluMist • Long list of high-risk conditions meriting flu vaccination

14. Influenza Pandemic of 2009-2010

15. Fluzone High-Dose Vaccine • Licensed by FDA in December of 2009 • Alternative for 65 years or older • 60 micrograms of hemaglutinin vs. usual 15 mcg for each flu strain • Increased local reactions at injection site (36%) compared to Fluzone (24%) • Increased antibody levels, clinical efficacy unknown

16. Fluzone Intradermal Vaccine • Licensed in May of 2011 • For 18-64 years of age • 0.1 ml microinjection syringe • Administration in deltoid preferred • More local reactions, including itching, but resolve in 3 to 7 days

17. FluMist vaccine (LAIV) • Licensed for 2-49 years of age, non-pregnant • Not recommended for 2-4 year-olds with recurrent wheezing or wheezing in past year, or anyone with high risk medical conditions (live attenuated vaccine) • OK for health care workers unless work in stem cell transplant unit • Quadrivalent LAIV • Licensed in March 2012, available for 2012-13 flu season • 2 strains each flu A and flu B • Improved protection against B strains

18. Flu Vaccine and Egg Allergy • Use TIV (not LAIV) in persons with egg allergy, if no history of anaphylactic or severe reaction to eggs • Flu vaccine appears safe to use if a person has onlyhives related to egg allergy • Observe for 30 minutes post-vaccination • Angioedema, respiratory distress, lightheadedness, recurrent emesis, or required epinephrine or emergency care need allergist evaluation • Skin prick testing for egg allergy is poorly predictive of a severe reaction

19. Invasive Pneumoccal Disease (IPD) • About 43,500 cases and 5,000 deaths per year in U.S. • 85% of cases of IPD and nearly all deaths are in adults • PPSV23 Update – added indications for use in smokers and patients with asthma (MMWR 9/3/10) • 2-64 years if heart, lung, sickle-cell disease, diabetes, alcoholism, CSF leak, cochlear implant • Any medical condition, drug or treatment lowering ones resistance to infection • Nursing home/long term care patients

20. Pneumococcal Vaccination • Data from NHIS, 2010 (MMWR Feb.3, 2012) • 19-64 yrs., high risk 18.5% Incr. 1.0% from 2009 • 65 yrs and older 59.7% Decrease 1.0% • Non-Hispanic whites 63.5% • Hispanics 39.0% • Non-Hispanic blacks 46.2% • Non-Hispanic Asians 48.2% • 2020 goal 90%

21. Pneumococcal Vaccines • Pneumococcal polysaccharide (PPSV23) since 1983 • Pneumococcal conjugate (PCV7) since 2000 for 2 to 71 months of age – routine for all 2-59 mos. of age, high-risk 60-71 mos. of age • Marked decrease in IPD (45% drop) and in hospitalizations for both children and adults since introduction of PCV7

22. Pneumococcal Vaccines, continued • PCV13 licensed for children in 2/10 and for adults 50 years and older in 12/11 • PCV13 recommendations in MMWR 3/12/10 – replaces PCV7, same ages and doses for 2-59 mos. of age • MMWR 12/10/10 – Spells out details of use of PCV13 and PPSV23 in infants and children • 4th dose of PCV13 for children is underutilized

23. PCV-13 Considerations for Adults • FDA-licensed for 50 yrs.+…..but not yet recommended by the ACIP – why? • Data is insufficient for this recommendation at this time • Awaiting the outcome of a study in the Netherlands comparing efficacy to PPSV23 in seniors • PCV7 greatly decreased IPD among children and adults • PCV13 possibly shows early decline in IPD in adults

24. Herpes Zoster • Shingles is a common and painful disease • Over 1 million cases/year in U.S. • Vaccine (Zostavax) licensed in 2006 for 60 years+ • Contraindications: primary or acquired immunodeficiency, anaphylactic reaction to gelatin or neomycin, pregnancy • Vaccination with shingles vaccine – only 14.4% of adults 60 years of age or older in 2010 (NHIS; MMWR 2//3/12)

25. More on Zostavax • FDA approved Zostavax for 50-59 years of age in 3/11 • FDA approval for 50 to 59 yrs based on 70% decrease in zoster if vaccinated • However, shortage of vaccine and/or delayed orders have been a problem for Merck • Thus, ACIP declined to recommend it for use in this age group

26. Human Papillomavirus Basics • HPV infection acquired soon after sexual initiation • Persistent infection of 1-2 years leads to precancerous cell changes • HPV types 16 and 18 involved in 70% of cervical cancers • HPV types 6 and 11 involved in 90% of genital warts • HPV type 16 a major player in other HPV-associated cancers: vaginal, vulvar, anal, penile, oropharyngeal

27. HPV-Associated Cancers, U.S., 2004-08 (MMWR, 4/20/12) • Average of 33, 369 such cancers each year • Average of 21,290 in females, 12,080 in males • Estimated NEW CASES of HPV-associated cancers each year = 26,000 (18,000 female, 8,000 male) • Cervical cancer is most common (11,967 per year) but oropharyngeal cancer (11, 726) is a close second • Anal cancer rate is higher in females than males

28. HPV Vaccination Recommendations • Quadrivalent vaccine (Gardasil) licensed in 2006 (HPV types 16, 18, 6 and 11) • Bivalent vaccine (Cervarix) licensed in 2009 (16 and 18) • 3 doses of vaccine needed over a 6 month period • Vaccinate 11-12 year-old females routinely with either vaccine (2006) • Vaccinate 11-12 year-old males routinely with Gardasil • Catch-up vaccination for females, through age 26, for males through age 21 • MSM and HIV-infected vaccinate through age 26

29. Improving HPV Vaccination Rates • HPV vaccination of 13-17 year-old females in U.S. in 2010 was 32% for 3 doses (lags other teen vaccines) • HPV vaccination of women 19-26 years of age was 20.7% in 2010 (MMWR 2/3/12) • Provider recommendation for 11-12 year old females: • Family physicians -26% • Pediatricians – 48% • ObGyns – 36%.........in a 2009 study

30. Improving HPV Vaccination Rates • Provider recommendation for HPV vaccination is a key factor; focus more on youngest patients (11-12 yo) • One approach to families: • HPV infection is a common, serious problem ( cervical cancers, other cancers, genital warts) • Your child is susceptible to HPV infection • HPV infection occurs soon after sexual debut; best immune response to vaccination is at younger ages, PRIOR to sexual activity • HPV vaccination prevents cancers – few vaccines can do that

31. Hepatitis B vaccination and diabetes • Studies show increased risk for acute hepatitis B in diabetic patients and a trend for higher mortality if infected. • Assisted monitoring of blood glucose without correct infection control practices increased exposure to infection • October 2011 ACIP recommended hepatitis B vaccination for diabetic patients below age 60 as soon as possible after diabetes is diagnosed • For diabetic patients aged 60 and older, consider hepatitis B vaccination after assessment of risk and likelihood of immune response

32. Measles in U.S., 2011 (MMWR 4/20/12) • 222 cases (196 in U.S. residents), 17 outbreaks • From 2001-10, annually 37-140 cases, 2-10 outbreaks • Median age of 14 years • 32% hospitalized • 90% of cases were import-associated • 86% of patients were unvaccinated/unknown status • 46% of importations were from Europe • (3 outbreaks in Indiana in past 15 months)

33. Measles, Mumps Immunity Issues • Killed (inactivated) measles vaccine used from 1963 to 1967 • Could affect people now 42 to 50 years of age • If received killed measles vaccine, NOT immune • If health care worker vaccinated with killed mumps vaccine before 1979, also need revaccination • Revaccinate with 2 doses of MMR vaccine, minimum of 28 days apart

34. Indiana Child/Teen Vaccination Rates, National Immunization Survey, 2010

35. Childhood Vaccination Recommendation Updates • Meningococcal conjugate vaccines (MCV4) • Menactra or Menveo • 1/11 – expanded age range to 2 to 55 years of age for high risk patients – (2 doses + boosters, can use either vaccine) • 4/11 – expanded use of Menactra (2 doses + boosters) to 9-23 months of age high-risk patients (MMWR 10/14/11) • High-risk: complement component deficiencies, asplenia, HIV, community meningococcal outbreak, travel to/from hyper-endemic countries.

36. Other Childhood Vaccines • MMR and Varicella Vaccines – separate doses or combined vaccine (ProQuad) • Increased risk (2X) for febrile seizures for ages 12-24 months when ProQuad used, compared to separate vaccines. This risk is NOT present at 4-6 years of age • Rotavirus vaccines: big drop in hospitalizations for gastroent/dehydration. New contraindication is hx of Severe Combined Immunodefic. Disease (2/10) • Polio (IPV) – final dose on or after 4th birthday and at least 6 mos. after previous dose.

37. Barriers to Adult Vaccination • Lack of awareness of recommendations by patients and providers • Adults may see only specialists, preventive care not a priority • Out-of-pocket costs • Adult vaccine schedule complex • Adult vaccine through public health is under-funded, compared to Vaccines For Children program

38. Evidence-Based Strategies to Improve Adult Coverage Rates • Patient-Related Strategies: • Enhance access – home visits, referral to providers, decrease out of pocket costs for patients • Rx for vaccine administration at local pharmacy • Increase community demand for vaccines – patient incentives, reminder/recall methods • Community-based interventions – combos of above

39. Strategies to Improve Coverage Rates • Health Care Provider or System-Based: • Provider reminders – electronic, print • Provider assessment and feedback – CASA-AFIX, benchmarks for preventive care • Standing orders – protocols, see Adult Immunization Standing Order Toolkit (Univ. of Pittsburgh) • Immunization registries (IIS): CHIRP is the Children and Hoosiers Immunization Registry Program

40. Really Important • HEALTH CARE PROVIDER RECOMMENDATION FOR VACCINATION • Think of/review immunization status at every visit • Have an “immunization champion” in your office • Embrace new technologies • Consider text messaging and/or e-mails for reminder/recall • But keep HIPAA rules in mind

41. Resources • www.immunize.org (Immunization Action Coalition) • www.cdc.gov/vaccines • www.vaccinateindiana.org • www.healthychildren.org (AAP) • www.tdapvac.com • www.immunizationed.org (smartphone app by STFM) • www.immunizationinfo.org (National Network for Immunization Information)