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THE EVOLVING WORLD OF ADULT VACCINES :: NEW INDICATIONS :: Jessica L. MacLeod, APRN Adult & Gerontology Nurse Practitioner (AGNP) VT Immunization Conference.

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Presentation on theme: "THE EVOLVING WORLD OF ADULT VACCINES :: NEW INDICATIONS :: Jessica L. MacLeod, APRN Adult & Gerontology Nurse Practitioner (AGNP) VT Immunization Conference."— Presentation transcript:

1 THE EVOLVING WORLD OF ADULT VACCINES :: NEW INDICATIONS :: Jessica L. MacLeod, APRN Adult & Gerontology Nurse Practitioner (AGNP) VT Immunization Conference October 28, 2011

2 “WHEN MEDITATING OVER A DISEASE, I NEVER THINK OF FINDING A REMEDY FOR IT, BUT, INSTEAD, A MEANS OF PREVENTION.” LOUIS PASTEUR

3 Learning Objectives 1. Increase confidence around current changes to adult immunizations. 2. Understand importance of adult immunizations. 3. Summarize 2011-2012 Adult Vaccine Updates. 4. Identify three recent immunization recommendations made by Advisory Committee on Immunization Practices (ACIP). 5. Describe two emerging immunization issues. 6. Locate resources that support up-to-date immunization practice.

4 2011-2012 Vaccine Updates  Influenza  Tdap  Zoster  HPV  Meningococcal Conjugate

5 Why adult vaccinations?  Immunity wanes over time.  As we age, we become more susceptible to serious diseases caused by common infections, such as shingles, flu & pneumonia. This results in otherwise preventable morbidity & mortality.  Considerable vaccine-preventable morbidity  Excess hospitalization  Diminished quality of life (post-herpetic neuralgia)  Missed work  Medical complications

6 Why adult vaccinations? Adult deaths from vaccine preventable diseases = 60,000 This is 200-fold greater mortality compared with children (300 children died). From: IOM, Calling the Shots: Immunization Finance Policies and Practices, 2000.

7 Influenza  Rates of infection are highest among persons age 65 and older (and children).  Influenza deaths associated with an annual average of 23,600 deaths from 1976 thru 2007 and approximately 226,000 hospitalizations from 1979 thru 2001.  H1N1 in 2009 was the cause of the first influenza pandemic since 1968; included in 2011-2012 vaccine.  In US, influenza A (H3N2)=predominant virus 2010/2011 season.  Two Types: Trivalent Inactivated Vaccine (TIV), Live Attenuated Influenza Vaccine (LAIV).  Thimerosal preservative (only in multidose vials); thought to be safe.  2010-2011 season introduced:  Fluzone High-Dose TIV (65+). Contains 4 times as much hemagglutinin as the standard formulation of Fluzone for adults. ACIP has NOT stated a preference for this high-dose Fluzone.  May 2011:  Fluzone Intradermal approved (18-64 yo). The intradermal is pre-filled syringe; use deltoid NOT the volar surface of the forearm as is done with TB vaccine. Increased side effects compared with IM vaccine, but resolve in 3-7 days. No preference from ACIP.  LAIV or Flumist; approved for ages 2-49 yo who are not pregnant or immunocompromised; single dose.

8 Influenza, continued  Optimal time to vaccinate?  Since 1970s >80% affected in Jan/Feb; “peak season.”  Offer as soon as vaccine is available; during routine OVs and hospitalizations/ER visits.  Continue to offer in December especially to health-care workers and those at high-risk of complications.  Continue to vaccinate through March per ACIP.  One dose per season (changing vaccine components and bioavailability of vaccine >1 year).  Do vaccinate women who are pregnant with TIV (LAIV contraindicated).  Should HCWs be vaccinated & why?  Often implicated in introducing influenza to patient settings, such as ICU, LTC facilities, internal medicine offices.

9 Contraindications & Precautions Guide to Vaccine Contraindications & Precautions: www.cdc.gov/vaccines/recs/vac- admin/downloads/contraindications-guide-508.pdf

10 Algorithm: Evaluation of an Egg Allergy Preceding Influenza Vaccination Can the person eat lightly cooked (e.g., scrambled egg) without reaction? After eating eggs or egg-containing foods, does the person experience ONLY hives? Does the person experience other symptoms such as: Cardiovascular changes (e.g., hypertension) Gastrointestinal (e.g., nausea/vomiting) Reaction requiring epinephrine Reaction requiring emergency medical attention Administer vaccine per usual protocol Administer TIV (Inactivated) Observe for reaction for at least 30 minutes after vaccination Refer to a provider with expertise in management of allergic conditions for further evaluation No Yes www.cdc.gov/vaccines/recs/acip/download s/mtg-slides-feb11/06-5-flu-vac-egg.pdf

11 Tetanus, Diphtheria & Pertussis (Tdap)  Vaccine has been available since 1940s.  Outbreaks of pertussis continue to occur, despite high vaccination rates.  In 2004 & 2005, >25,000 cases. Increased in 2010 and has been increasing since 1990s.  ACIP contends this is due to vaccine immunity waning from last dose.  Adults with pertussis are a source of infection for others, notably infants.  195,000 world deaths in 2008.  17,000 cases in US in 2009; >40% in adults & adolescents.

12 Tetanus, Diphtheria & Pertussis (Tdap), cont  Two Types: Boostrix & Adacel.  Adacel only FDA-approved up through 64 yo.  Either brand may be used, even though Adacel is off-label.  Updated schedule for Tdap for adults: ACIP recommends that adults 19-64 yo who didn’t receive Tdap before or whose vaccination history is unknown, receive a one-time dose of Tdap to replace the next 10-year Td booster.  In July 2011, FDA expanded age indications to include persons age 65+, meaning all adults 19+ should received a Tdap once in their lifetime.  Also added is the recommendation to administer Tdap regardless of interval since the most recent Td-containing vaccine.  Special Populations; Pregnant women & HCWs:  Tdap ok during 3 rd trimester of pregnancy if no prior Tdap. Also, use Tdap if preggo woman needs booster.  Any woman considering becoming pregnant should be immunized with Tdap. This is to protect young infants through passive immunity in infants too young to received pertussis immunization.  HCWs should get Tdap as soon as possible.

13 Herpes Zoster / Shingles  Caused by a reactivation of a latent varicella zoster virus infection; very painful blistering rash that can result in significant morbidity (blindness).  Associated with normal aging & anything that causes immunosuppression.  Estimated lifetime risk of developing zoster is 32%; increases the older we get.  Estimated approx 1 million cases/year in US  Approx 50% are >60yo  As of 2009, only 10% of adults received vaccine, according to the National Health Interview Survey  Most common complication is post-herpetic neuralgia.

14 Herpes Zoster / Shingles, continued  Vaccine is called Zostavax; administered subcutaneously in single dose.  Live vaccine; containing a weakened varicella zoster virus in an amount approximately 14 times greater than in standard varicella vaccine.  Since 2006, the ACIP/CDC recommends to vaccinate all people > 60yo regardless of history of shingles.  March 2011:  FDA expanded indication to include persons 50-59 yo (based on ZEST clinical trial).  The ACIP declined to recommend this after reviewing the literature—due to evaluation of disease burden, limited vaccine supply, and associated cost of Zostavax.  Risk of Zoster and associated complications increases after age 50, but incidence of Zoster in 70 yo is twice that in persons 50-59 yo. So, ACIP wanted to protect the most vulnerable population of people.  Studies currently in progress to examine the need for more than 1 dose of Zostavax; research shows the vaccine works for a minimum of 4 years, but unknown for how much longer.

15 Herpes Zoster / Shingles, continued  Screening for a h/o varicella disease is not recommended; you can assume the person had chicken pox even if they did not have it. Born prior to 1980 means they had it.  It is not necessary to draw titers/serologic testing.  It is necessary to screen for contraindications, which should be done with all live viruses.  Give with precaution when using with anti-virals.  Refer to ACIP general recommendations for further details on precautions & contraindications.  In June 2011, Merck (manufacture of Zostavax) revised product information & recommended to space out Zostavax & Pneumovax by 4 weeks between administration.  A clinical trial showed reduced efficacy of Zostavax when given simultaneously with Pneumonia vaccine. Another study of 14,000 patients, did not demonstrate this inefficacy.  Thus, CDC has not changed its recommendation and both Zoster & Pneumonia vaccines may be administered at the same visit if indicated.

16 Human Papilloma virus (HPV)  Most common sexually transmitted virus in US with more than 50% of sexually active women & men infected at some point in their lives (~ 20 million currently).  Two types: HPV2 (Cervarix) & HPV4 (Gardasil)  HPV4  3-injection vaccine recommended for girls/women & boys/men aged 11-26 (can start as young as 9yo). In the past CDC did not recommend routine vaccination in boys/men.  Covers types 6, 11, 16, 18.  Guards against genital cancers (cervical, vaginal, vulvar, & anal cancers), genital warts, and precancers.  Goal is to immunize prior to HPV exposure.  If vaccine schedule is interrupted, the series does not need to start over.  Ok with lactating women, people HPV+ or h/o genital warts.  Not recommended for pregnant women.

17 Human Papilloma virus (HPV)  How common are HPV-related health problems in men?  About 1% of sexually active men in the U.S. have genital warts at any one time.  Each year in the U.S. there are about 400 men who get HPV- associated penile cancer.  1,500 men who get HPV-associated anal cancer.  5,600 men who get HPV-associated oropharyngeal cancers (cancers of the back of throat including base of tongue and tonsils).

18 Human Papilloma virus (HPV), continued In the media on Tuesday, 10/25/2011, All Things Considered, NPR News.

19 Meningococal Conjugate  ACIP has made several new recommendations in past 2 years.  Respiratory transmission; most common transmission late winter/early spring.  2,000-3,000 new cases each year, declining to 850 in 2010—might this be due to vaccine? Unclear.  Two available: Meningococcal Polysaccharide Vaccine (MPSVQ) and Meningococcal Conjugate (MCV4) (Menactra & Menveo)  Approved for 9m-55yo, Menactra  Approved 2-55yo, Menveo  Since 2011:  The ACIP recommends a booster dose, for up to 18 yo, single. First dose age 11-12 with booster dose at 16 yo. No booster is needed if person gets first dose 16yo+.  Give a 2-dose series to adults with functional or physical asplenia, persistent complement component deficiencies, as well as adults living with HIV with additional risk factor(s), travelers to high-risk locations of Neisseria meningitidis and certain microbiologists.

20 From: http://www.cdc.gov/vaccines/recs/schedules/adult-schedule.htmhttp://www.cdc.gov/vaccines/recs/schedules/adult-schedule.htm

21 From: healthvermont.gov/hc/imm/documents/vaccine_vt_adult_schedule.pdf

22 Case Study 1

23 Case Study 2

24 Case Study 2, continued

25 Resources Updated from 2006.

26 Resources, cont. CDC “Vaccine Information Statements” or “VISs” www.cdc.gov/vaccines/pubs/vis/ It is the law to offer these to your patients. Can get email updates!

27 Resources, cont. CDC “You call the Shots” www.cdc.gov/vaccines/ed/youcalltheshots.htm Also, the CDC Info Contact Center is available 24/7 to patients, families, and providers: 800-CDC-INFO

28 Resources, cont. State of VT Website: healthvermont.gov/hc/imm/provider.aspx healthvermont.gov/hc/imm/provider.aspx

29 Questions & Answers Thank you for joining me today! Jessica L. MacLeod, APRN jessicam@nchcvt.org


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