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Prevention of Influenza and Pertussis Through Immunization

Prevention of Influenza and Pertussis Through Immunization. Randall J Nett, MD, MPH. CDR, United States Public Health Service Career Epidemiology Field Officer — assigned to Montana DPHHS Montana Immunization Regional Meetings Spring 2013. Office of the Director.

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Prevention of Influenza and Pertussis Through Immunization

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  1. Prevention of Influenza and Pertussis Through Immunization Randall J Nett, MD, MPH CDR, United States Public Health Service Career Epidemiology Field Officer — assigned to Montana DPHHS Montana Immunization Regional Meetings Spring 2013 Office of the Director Career Epidemiology Field Officer Program

  2. One Thing to Remember Do everything you can to make sure every child and adult patient is up-to-date on their pertussis and influenza immunizations

  3. Pertussis http://diseasespictures.com/wp-content/uploads/2012/10/Whooping-cough-3.jpg

  4. http://www.cdc.gov/pertussis/about/photos.htmland http://www.vaccineinformation.org/video/pert_4.ram

  5. Pertussis • Bordetella pertussis • Catarrhal stage • Mild upper respiratory tract symptoms (similar to common cold) • 1–2 weeks • Paroxysmal stage • Prolonged cough, inspiratory whoop, cough often followed by vomiting • 1–6 weeks • Convalescent stage • Symptoms gradually wane • Weeks to months American Academy of Pediatrics. Pertussis (whooping cough). In: Pickering LK, Baker CJ, Kimberlin DW, Long SS, eds. Red Book : 2012 Report of the Committee on Infectious Diseases. Elk Grove Village, IL: American Academy of Pediatrics: 553–66.

  6. Clinical Manifestations • Fever often absent or minimal • Cough in previously immunized children and adults ranges from mild to typical of pertussis • Duration of illness: 6–10 weeks • Illness most severe in children aged <6 months (especially severe in pre-term and unimmunized infants) • Short catarrhal stage • Gagging • Gasping • Bradycardia • Absence of “whoop” • Prolonged convalescence American Academy of Pediatrics. Pertussis (whooping cough). In: Pickering LK, Baker CJ, Kimberlin DW, Long SS, eds. Red Book : 2012 Report of the Committee on Infectious Diseases. Elk Grove Village, IL: American Academy of Pediatrics: 553–66.

  7. Disease Information • Humans only known hosts • Transmission occurs by aerosolized droplets • Incubation period typically 7–10 days (range 5–21 days) • Diagnosis made by: • Clinical symptoms • Signs • PCR and culture American Academy of Pediatrics. Pertussis (whooping cough). In: Pickering LK, Baker CJ, Kimberlin DW, Long SS, eds. Red Book : 2012 Report of the Committee on Infectious Diseases. Elk Grove Village, IL: American Academy of Pediatrics: 553–66.

  8. 2013 Advisory Committee on Immunization Practices (ACIP) Recommended Immunization Schedule for DTaP • Minimum spacing between doses 1, 2, and 3 is 4 weeks • Minimum spacing between doses 3 & 4 and 4 & 5 is 6 calendar months • Minimum age for dose 4 is 12 months • Minimum age for dose 5 is 4 years • The 4th dose can be administered as early as 12 months of age, provided at least 6 calendar months have elapsed since the 3rd dose • The minimum recommended interval between the 3rd and 4th dose is 6 calendar months. However, the 4th dose need not be repeated if administered at least 4 months after the 3rd dose. CDC. Advisory Committee on Immunization Practices (ACIP) Recommended Immunization Schedule for Persons Aged 0 Through 18 Years — United States, 2013. MMWR. 2013;62(01):2–8.

  9. DTaP efficacy • 6 efficacy trials (n = 46,283 participants) • 52 safety trials (n = 136,541 participants) • Multi-component (≥3) vaccines • ~85% efficacy in preventing typical pertussis disease • (≥21 days of paroxysmal cough with confirmation of B. pertussis infection by , appropriate serology, or contact with a household member who has culture confirmed pertussis) • 71–78% efficacy in preventing mild pertussis disease • (≥7 consecutive days of cough with confirmation of B. pertussis infection by culture or appropriate serology) Zhang L, Prietsch SO, Axelsson I, Halperin SA. Acecullar vaccines for preventing whooping cough in children. Cochrane Database Syst Rev. 2012;3:CD001478.

  10. DTaP — Waning Immunity Klein NP, Bartlett J, Rowhani-Rahbar A, Fireman B, Baxter R. Waning protection after fifth dose of acellular pertussis vaccine in children. NEJM. 2012;367:1012–9.

  11. DTaP — Waning Immunity Klein NP, Bartlett J, Rowhani-Rahbar A, Fireman B, Baxter R. Waning protection after fifth dose of acellular pertussis vaccine in children. NEJM. 2012;367:1012–9.

  12. 2013 Advisory Committee on Immunization Practices (ACIP) Recommended Immunization Schedule for Tdap • ACIP recommends children aged 7 through 10 years who are not fully vaccinated* against pertussis and for whom no contraindication to pertussis vaccine exists should receive a single dose of Tdap to provide protection against pertussis • *Fully vaccinated is defined as 5 doses of DTaP or 4 doses of DTaP if the 4th dose was administered on or after the 4th birthday • Tdap is recommended in this age group because of its reduced antigen content compared with DTaP, resulting in reduced reactogenicity. • If additional doses of tetanus and diphtheria toxoid-containing vaccines are needed, then children aged 7 through10 years should be vaccinated according to catch-up guidance, with Tdap preferred as the first dose CDC. Advisory Committee on Immunization Practices (ACIP) Recommended Immunization Schedule for Persons Aged 0 Through 18 Years — United States, 2013. MMWR. 2013;62(01):2–8.

  13. 2013 Advisory Committee on Immunization Practices (ACIP) Recommended Immunization Schedule for Tdap for Adults • Adults 19 years of age and older who have not previously received a dose of Tdap, a single dose should be administered. • Providers should not miss an opportunity to vaccinate persons aged 65 years and older with Tdap. Therefore, providers may administer the Tdap vaccine they have available. When feasible, Boostrix should be used for adults aged 65 years and older; however, ACIP concluded that either vaccine administered to a person 65 years or older is immunogenic and would provide protection. A dose of either vaccine may be considered valid. CDC. Advisory Committee on Immunization Practices (ACIP) Recommended Immunization Schedule for Adults Aged 19 Years and Older — United States, 2013. MMWR. 2013;62(01):9–19

  14. Tdap Continued • Tdap vaccine can be administered regardless of the interval since the last tetanus and diphtheria toxoid-containing vaccine • Currently, Tdap is recommended only for a single dose across all age groups (except during pregnancy) CDC. Advisory Committee on Immunization Practices (ACIP) Recommended Immunization Schedule for Adults Aged 19 Years and Older — United States, 2013. MMWR. 2013;62(01):9–19

  15. Tdap in Pregnancy • Administer one dose of Tdap vaccine to pregnant women during each pregnancy (preferred during 27–36 weeks’ gestation), regardless of number of years since prior Td or Tdap vaccination. http://www.cdc.gov/vaccines/schedules/downloads/adult/mmwr-adult-schedule.pdf

  16. Tdapfor Wound Management • Use tetanus toxoid–containing vaccine for wound management in adults aged ≥19 years if ≥5 years have elapsed since last receiving Td • If tetanus booster is indicated, Tdappreferred over Td in adults aged ≥19 years who have not received Tdappreviously

  17. Tdap efficacy in adolescents • Australian study • 85.4% (95% CI: 83.0–87.5%) efficacy for laboratory-confirmed cases • 78.0% (95% CI: 60.7–87.6%) efficacy for all study cases • Pertussis outbreak in St. Croix school (2007) • Calculated RR for unvaccinated:vaccinated = 2.9 (no CI reported) • In U.S., targeted use of Tdap among adolescents associated with reduced incidence of disease from 2005–2009 in those aged 11–18 years Bechini A, Tiscione E, Boccalini S, Levi M, Bonanni P. Acellular pertussis vaccine use in risk groups (adolescents, pregnant women, newborns and healthcare workers): A review of evidences and recommendations. Vaccine. 2012;30:5179–90.

  18. http://www.cdc.gov/pertussis/outbreaks.html

  19. Why the Resurgence of Pertussis? • Increased awareness of pertussis  increased reporting • Public • Physicians who care for adults • Public health • PCR assays • DTaP vaccines less potent than DTP vaccines • Genetic changes in circulating strains of B. pertussis (???) Cherry JD. Epidemic pertussis in 2012 — the resurgence of a vaccine-preventable disease. NEJM. 2012;367(9):785–7.

  20. When is a Case of Pertussis Not Really Pertussis? • Outbreak of pertussis-likeillness occurred May 2010–May 2011 in Ohio • 918 confirmed, probable, suspected cases reported(80 cases per 100,000 pop) • 29% of specimens with identified Bordetella specieswere B. holmesii Rodgers L, et al. Epidemiologic and laboratory features of a large outbreak of pertussis-like illnesses associated with cocirculatingBordetella holmesiiand Bordetella pertussis—Ohio, 2010–2011. Clin Infect Dis. 2013;56:322–31.

  21. 2011 National Immunization Survey (19–35 months) — Montana’s rank and opportunity to improve http://www.cdc.gov/mmwr/pdf/wk/mm6135.pdf

  22. 2011 National Immunization Survey (13–17 years) — Montana’s rank http://www.cdc.gov/mmwr/pdf/wk/mm6134.pdf

  23. Should we continue to vaccinate against pertussis? • Absolutely!!!! • U.S. incidence is about 4% of what it was during an epidemic year in 1930s • Less severe disease in fully immunized • Better vaccines needed • Possible alternative schedule needed Cherry JD. Epidemic pertussis in 2012 — the resurgence of a vaccine-preventable disease. NEJM. 2012;367(9):785–7.

  24. influenza http://phil.cdc.gov/phil/details.asp

  25. Influenza Basics • Influenza virus (A, B, C) • Types A and B cause seasonal epidemics • Type A viruses divided into subtypes based on two surface proteins • Hemagglutinin (17 different subtypes) • Neuraminidase (10 different subtypes) • Type A viruses further broken down by strains http://www.cdc.gov/flu/about/viruses/types.htm

  26. Influenza Naming Convention • The antigenic type (e.g., A, B, C) • The host of origin • Swine, equine, chicken, etc. • For human-origin viruses, no host of origin designation is given • Geographical origin (e.g., Denver, Taiwan, etc.) • Strain number (e.g., 15, 7, etc.) • Year of isolation (e.g., 57, 2009, etc.) • For influenza A viruses, the hemagglutinin and neuraminidase antigen description in parentheses [e.g., (H1N1), (H5N1)] • Examples • A/duck/Alberta/35/76 (H1N1) for a virus from duck origin • A/Perth/16/2009 (H3N2) for a virus from human origin http://www.cdc.gov/flu/about/viruses/types.htm

  27. http://upload.wikimedia.org/wikipedia/commons/thumb/7/7a/Influenza_nomenclature.svg/590px-Influenza_nomenclature.svg.pnghttp://upload.wikimedia.org/wikipedia/commons/thumb/7/7a/Influenza_nomenclature.svg/590px-Influenza_nomenclature.svg.png

  28. Influenza Epidemics and Pandemics • Antigenic drift • Small changes in the virus that happen continuously over time • Produces new viruses that might not be recognized by body’s immune system  reinfection • Seasonal epidemics • Antigenic shift • Abrupt, major changes in influenza A viruses • New hemagglutinin (H) or new neuraminidase (N) proteins • New influenza A subtype OR new H/N combination that evolved from animal population so different from same subtype in humans • Pandemics http://www.cdc.gov/flu/about/viruses/types.htm

  29. http://www.chinadaily.com.cn/english/doc/2004-06/09/xin_020601080903455246635.jpghttp://www.chinadaily.com.cn/english/doc/2004-06/09/xin_020601080903455246635.jpg

  30. Clinical Manifestations • Sudden onset of fever and other clinical symptoms • Non-productive cough • Sore throat • Runny or stuffy nose • Muscle or body aches • Headaches • Vomiting and diarrhea (sometimes occurs, more common in children) American Academy of Pediatrics. Pertussis (whooping cough). In: Pickering LK, Baker CJ, Kimberlin DW, Long SS, eds. Red Book : 2012 Report of the Committee on Infectious Diseases. Elk Grove Village, IL: American Academy of Pediatrics: 553–66.

  31. Disease Information • Transmission occurs primarily by respiratory droplets through coughing/sneezing but also by contacting contaminated surfaces • Incubation period typically 1–4 days (avg. 2 days) • Diagnosis made by: • Viral culture • Immunofluorescent antibody testing (IFA) • PCR American Academy of Pediatrics. Pertussis (whooping cough). In: Pickering LK, Baker CJ, Kimberlin DW, Long SS, eds. Red Book : 2012 Report of the Committee on Infectious Diseases. Elk Grove Village, IL: American Academy of Pediatrics: 553–66.

  32. Influenza-related Morbidity and Mortality • Pneumonia • Bronchitis • Sinus infections • Otitis media • Asthma exacerbations • Febrile seizures • Encephalopathy • Invasive secondary bacterial infections • Death (0.5–1 death per 1000 cases) http://www.cdc.gov/flu/about/disease/symptoms.htm

  33. High-risk Populations • Children aged <5 years, especially those aged <2 years • Adults aged ≥65 years • Pregnant women • American Indians and Alaska Natives • Persons with the following medical conditions • Neurological and neurodevelopmental conditions • Asthma • Chronic lung disease • Chronic heart disease • Blood, endocrine, kidney, liver, or metabolic disorders • Immunocompromised • Those aged <19 years on chronic aspirin therapy • Morbid obesity (BMI ≥40) http://www.cdc.gov/flu/about/disease/high_risk.htm

  34. Influenza Vaccination • All persons aged ≥6 months should receive routine annual influenza vaccination • Vaccination should occur before onset of influenza activity in the community • Providers should offer influenza vaccination as soon as vaccine is available and throughout influenza season • Special emphasis should be placed on vaccinating high-risk populations and healthcare professionals http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6033a3.htm

  35. Influenza Vaccines for 2013/2014 IIV = inactivated influenza vaccine; LAIV = live-attenuated influenza vaccine

  36. Influenza Vaccines for 2013/2014

  37. Influenza Vaccine • Inactivated influenza vaccine (IIV) 3 • Intramuscular or intradermal route • Contains 3 inactivated influenza viruses (2013/2014) • A/California/7/2009 (H1N1)pdm09-like virus; • A/Texas/50/2012 (H3N2)-like virus; • B/Massachusetts/2/2012-like virus (B/Yamagata lineage) http://www.cdc.gov/flu/professionals/vaccination/index.htm

  38. Influenza Vaccine • IIV4 and live-attenuated intranasal vaccine (LAIV) 4 • Contains 4 viral strains for 2013/2014 • A/California/7/2009 (H1N1)pdm09-like virus • A/Texas/50/2012 (H3N2) • B/Massachusetts/2/2012-like (B/Yamagata lineage) • B/Brisbane/60/2008-like (B/Victoria lineage) http://www.cdc.gov/flu/professionals/vaccination/index.htm

  39. Influenza Vaccine and Children http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6132a3.htm#fig1

  40. Seasonal Influenza Vaccine Effectiveness Estimates (2012–2013) • Overall effectiveness of influenza vaccine is moderate and varies from year to year, and by population • Influenza A (H3N2 only) = 47% (95% CI = 35–58) • 6 mos–17 years = 58% (95% CI = 38–71) • 18–49 years = 46% (95% CI = 20–63) • 50–64 years = 50% (95% CI = 15–71) • ≥65 years = 9% (95% CI = -84 to 55) • Influenza B only = 67% (95% CI = 51–78) http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6207a2.htm?s_cid=mm6207a2_w

  41. LAIV vs. TIV Effectiveness • Few studies directly compare LAIV vs. TIV • Results differ for children vs. adults • Children: 3 RCTs found LAIV had better protection than TIV • Adults: One RCT among predominantly college-age healthy adults found TIV was more efficacious in preventing influenza • Not enough data to make conclusive recommendation • CDC does not recommend one vaccine over another http://www.cdc.gov/flu/professionals/vaccination/effectivenessqa.htm

  42. 2012-2013 Influenza Vaccination Coverage http://www.cdc.gov/flu/fluvaxview/nifs-estimates-nov2012.htm

  43. 2012-2013 Influenza Vaccination Coverage Among Healthcare Professionals http://www.cdc.gov/flu/fluvaxview/hcp-ips-nov2012.htm

  44. Vaccinating Healthcare Workers Against Influenza • 1981 — ACIP recommends all healthcare workers (HCW) receive annual seasonal influenza vaccination • Healthy People 2020 objective — 90% coverage for HCW • Influenza vaccination rates for HCW below national goals • Unvaccinated HCW contribute to nosocomial influenza outbreaks in healthcare settings • Increase morbidity and mortality • Increase worker illness rate and absenteeism • Increase economic costs to the healthcare system Stewart AM, Cox MA. State law and influenza vaccination of health care personnel. Vaccine. 2013;31:827–832.

  45. Vaccinating Healthcare Workers Against Influenza • 20 (39%) of 51 states have enacted laws requiring certain healthcare employers (HCEs) to develop and implement influenza vaccination programs (includes District of Columbia) • 16 of 20 states include all facility employees • 5 of 20 states regulate both residential healthcare facilities and acute care hospitals • 16 of 20 states require employers to ‘provide’, ‘arrange for’, ‘ensure’, ‘require’, or ‘offer’ influenza vaccinations to HCWs • 3 of 20 states outline how to address noncompliant HCWs • 15 of 20 states allow exemption possibilities • No law exists in Montana requiring mandatory influenza vaccination for HCWs Stewart AM, Cox MA. State law and influenza vaccination of health care personnel. Vaccine. 2013;31:827–832.

  46. Vaccinating Healthcare Workers Against Influenza • Mandatory influenza vaccination policies recommended by multiple professional organizations • More effective at improving vaccination coverage levels of HCWs compared with voluntary programs • Facilities with mandatory policies have reported coverage levels up to 99.3% • Existing labor laws do not allow mandatory vaccination programs of union employees (subject to collective bargaining) Stewart AM, Cox MA. State law and influenza vaccination of health care personnel. Vaccine. 2013;31:827–832.

  47. 2012-2013 Influenza Vaccination Coverage Among Pregnant Women http://www.cdc.gov/flu/fluvaxview/pregnant-women-2012.htm

  48. 2011-2012 Influenza Vaccination Coverage in Montana http://www.cdc.gov/flu/professionals/vaccination/reporti1112/reporti/index.htm

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