1. Flu and Pneumo (Vaxigrip and Pneumo23)
Dennis S. Quiambao, MD
Medical and Government Affairs Manager

2. Influenza

3. "An unvarying disease caused by a varying virus"
Influenza
"An unvarying disease caused by a varying virus"
Kilbourne, 1980

4. Influenza Worldwide: 10% of the population gets the flu
USA: more than 200,000 people are hospitalized from flu complications; and about 36,000 people die from flu.
Philippines:
5th leading cause of morbidity
Rate per 100,000 population: 414.6

5. Different Types of Influenza Virus
Type A
most serious type
most common form, usually breaking out every two or three years
Type B
Type C

6. Why be concerned about influenza?
Absenteeism, income and learning opportunities lost
Presenteeism
Cause complications, hospitalization and death among the high-risk groups
The looming threat of a pandemic due to a novel virus

7. Who should be vaccinated?
Asthmatics
Chronic bronchitis patients
Diabetics
Kidney and liver disease patients
>50 years old
Children 6months – 5 years old
Immunocompromised
Health care workers
Anyone who wishes to be vaccinated

8. Annual Flu Vaccination in Adults, Current Local Recommendations:
Recommended by:
Philippine College of Chest Physicians
Philippine Society for Microbiology and Infectious Diseases
Philippine Foundation for Vaccination

9. Contraindication
True allergy to chicken eggs

10. Possible adverse events
Soreness, redness or swelling at the injection site
Low grade fever
Muscle aches

11. Preventing Influenza
Each year a new vaccine is prepared which when given can prevent influenza
WHO recommends which viral strains will be included in the vaccine
Vaccine is about 89% effective in preventing disease, and for the 11% not covered by the vaccine, the illness caused by the virus is milder because of partial protection from the viral strains in the vaccine (cross protection)

12. Southern Hemisphere Recommendation 2012
an A/California/7/2009 (H1N1)-like virus;
an A/Perth/16/2009 (H3N2)-like virus;
a B/Brisbane/60/2008-like virus

13. Seasonal Occurrence of Influenza

14. Vaccine Manufacturing Time LinesJ S O N D F
WHO
(Northern hemisphere)
PRODUCTION
INTERNATIONAL SURVEILLANCE NETWORK
VACCINE MANUFACTURER
MELBOURNE
(Southern hemisphere)
Choice of strains
Vaccine on time

15. Timing of Influenza Vaccination
Vaccination should be given once a year preferably from February to June
The Southern Hemisphere vaccine which is made available starting February of each year is recommended to cover the expected increase in influenza activity from June to November.

16. Influenza: Frequently Asked Questions

17. Can the flu shot give me the flu?
No, the flu shot cannot cause flu illness.
The three influenza viruses contained in the flu vaccine are each inactivated (killed), which means they cannot cause infection.

18. Why do I need to get vaccinated against the flu every year?
Vaccine against influenza viruses change from year to year, which means two things.
First, you can get the flu more than once. The immunity that is built up from having the flu caused by one virus strain doesn't always provide protection when a new strain is circulating.
Second, a vaccine made against flu viruses circulating last year may not protect against the newer viruses. That is why the influenza vaccine is updated to include current viruses every year.
Another reason to get flu vaccine every year is that after you get vaccinated your immunity declines over time and may be too low to provide protection after a year.

19. Does the flu vaccine work right away?
No. It takes about two weeks after vaccination for antibodies to develop in the body and provide protection against influenza virus infection. In the meantime, you are still at risk for getting the flu.
That's why it's better to get vaccinated early before the flu season really gets under way.

20. Pneumococcal Disease

21. High Burden of Disease
Serious pneumococcal infections are a major global health problem
A leading cause of death and morbidity in all ages, in both developed and developing world
WHO estimates 11 to 20 M hospitalizations from pneumonia occur each year in developing countries
At least 1M children die every year from pneumococcal infections – primarily pneumonia and meningitis- including >800,000 children under 5 years old

22. Steptococcus Pneumoniae: The bacterium
Also called « pneumococcus »
It’s polysaccharide capsule protects the bacterium against attack from the immune system
There are at least 90 different serotypes of S. pneumoniae [1]
The 10 most common serotypes are estimated to account for about 62% of invasive diseases worldwide [2]
Steptococcus Pneumoniae: The bacterium
References:
[1] Fedson DS, Musher D. In: Plotkin A, Orenstein WA editors. Vaccines. 4th ed. Philadelphia, USA: WB Saunders Company; p
[2] National Immunization Program, Centers for Disease Control and Prevention, U.S. Department of Health and Human Services. PINK BOOK. Pneumococcal Disease. Streptococcus pneumoniae. In: Atkinson W and Wolfe C eds. Epidemiology and Prevention of Vaccine-Preventable Diseases. 10th ed. Atlanta (GA): Department of Health & Human Services, Centers for Disease Control and prevention ed; 2007.p
[1] Fedson and Musher. In: Vaccines, 4th ed., 2004
[2] PINK BOOK. 10th edition February 2007 22

23. S. Pneumoniae: Transmission and colonization
Colonization: S. Pneumoniae is common inhabitant of the respiratory tract and may be isolated from the nasopharynx of 5% to 70% of healthy adults [1a]
Humans may carry the bacteria without being infected but may still pass on the bacteria to others
Transmission: Person-to-person via respiratory droplets/secretions OR Autoinoculation in asymptomatic carriers [1b]
Nasopharynx: site of colonization
Trachea
Inhalation
Patient with pneumococcal disease
Asymptomatic carrier
Aerosol
Nasal cavity
Dissemination
S. Pneumoniae: Transmission and colonization
S. pneumoniae is an exclusively human pathogen [1c].
References:
[1] National Immunization Program, Centers for Disease Control and Prevention, U.S. Department of Health and Human Services. PINK BOOK. Pneumococcal Disease. Streptococcus pneumoniae. In: Atkinson W and Wolfe C eds. Epidemiology and Prevention of Vaccine-Preventable Diseases. 10th ed. Atlanta (GA): Department of Health & Human Services, Centers for Disease Control and prevention ed; 2007.p
[2] Musher DM. Streptococcus pneumoniae. In Mandell G, Bennett JE, Dolin R editors. Principles and practice of infectious disease. 4th ed. New York, USA: Churchill Livingstone, Inc.; p
[1] PINK BOOK. 10th edition February 2007
[2] Adapted from Musher DM. Streptococcus pneumoniae 1995 23

24. S. Pneumoniae: Pathogenesis
Breach
of blood-brain
barrier
Bacteraemia
Sinusitis
CSF leakage
Meningitis
Otitis media
Nasopharyngeal colonization
Pneumonia
of phagocytic defenses
Breach of mucociliary
defenses
Peritonitis Arthritis arc
S. Pneumoniae: Pathogenesis
Disease is usually caused by spread from the initial site of colonization.
Pneumococcal proliferation in the middle ear causes otitis media; proliferation in the alveoli of the lungs causes pneumococcal pneumonia. (Both are non-invasive pneumococcal diseases.)
Bacteraemia (invasive pneumococcal disease) occurs when pneumococci gain entry to the blood. Meningitis is caused by pneumococcal invasion of the cerebrospinal fluid (CSF).
Reference:
[1] Salyers AA, Whitt DD. Streptococcus pneumoniae. In: Bacterial Pathogenesis: A Molecular Approach. 2nd ed. Washington, USA: ASM Press; p
Adapted from [1] Salyers & Whitt. In: Bacterial Pathogenesis: A Molecular Approach. 1994 24

25. Factors predisposing to pneumococcal disease
Age [1]
Age-related impairment of the immune system and other defense mechanisms
Decreased physical activity
Chronic diseases
Poor nutrition
Factors predisposing to pneumococcal disease [1]
Many factors may contribute to the increased susceptibility of elderly persons to pneumococcal diseases.
In older people, the immune system is less effective and natural defences to pneumococcal infection such as the cough and gag reflexes may be impaired.
Other factors, such as poor nutrition or underlying chronic illness may further increase the risk of infection.
Reference:
[1] Musher DM. Streptococcus pneumoniae. In Mandell G, Bennett JE, Dolin R editors. Principles and practice of infectious disease. 4th ed. New York, USA: Churchill Livingstone, Inc.; p
INCREASED RISK OF SEVERE PNEUMOCOCCAL DISEASE
[1] Musher DM. In Mandell G, Bennett JE, Dolin R editors. Principles and practice of infectious disease.4th ed. New York, USA: Churchill Livingstone, Inc.; p 25

26. Factors predisposing to pneumococcal disease
Chronic illness [1a]
Cardiovascular disease
Pulmonary disease
Diabetes
Liver cirrhosis
Factors predisposing to pneumococcal disease
Pneumococcal infections are more frequent and more severe in patients with chronic conditions. [1b]
A high number of patients with pneumococcal infection have diabetes mellitus, a condition in which PMN chemotaxis is reduced and phagocytic function is defective, especially if renal insufficiency is also present [2a] .
Susceptibility to pneumococcal infection is also greatly increased in persons with altered pulmonary clearance (e.g. chronic bronchitis, asthma, or chronic obstructive pulmonary disease. [2b]
Prior respiratory viral infection, especially influenza, seems to play an important role in susceptibility to pneumococcal infection, potentially through the enhanced adherence of pneumococci to nasopharyngeal cells of persons with viral infection and their lower clearance from the airways because of viral-induced damage [2c].
Also, clinical and epidemiologic observations strongly support the general belief that smoking predisposes to pneumococcal infection [2d]. In a recent risk-factor study among immunocompetent adults aged years, smoking conferred a greater risk of PID than any other studied factor. People with PID were 4.1 times more likely to be smokers, and the association increased with the number of cigarettes smoked and the number of years of smoking [3].
Chronic alcoholism is also associated with a high risk of pneumococcal infection, probably because of multiple risk factors. [2d]
References
[1] Center for Diseases Control and Prevention. Prevention of pneumococcal disease. Recommendations of the Advisory Committee on Immunization Practices. MMWR 1997; 46 (N° RR-8): 1-24.
[2] Musher DM. Streptococcus pneumoniae. In Mandell G, Bennett JE, Dolin R editors. Principles and practice of infectious disease. 5th ed. New York, USA: Churchill Livingstone, Inc.; p
[3] Whitney CG, Schaffner W, and Butler JC. Rethinking Recommendations for Use of Pneumococcal Vaccines in Adults. Clin Infect Dis, 2001; 33(5):
RISK OF DECOMPENSATION OF THE UNDERLYING DISEASE AND INCREASED RISK OF SEVERE PNEUMOCOCCAL DISEASE
[1] CDC. Prevention of pneumococcal disease. Recommendations of the ACIP. MMWR 1997; 46 (N° RR-8): 1-24 26

27. Factors predisposing to pneumococcal disease
Immunodeficiency [1]
INCREASED RISK OF SEVERE PNEUMOCOCCAL DISEASE
Immunosuppressive therapies
Organ transplantation
Cancers (e.g. lymphomas, myelomas)
HIV Infection
Sickle cell anaemia
Haematological neoplasms
Factors predisposing to pneumococcal disease
A functioning immune system is necessary to protect against Streptococcus pneumoniae. [2]
Defective antibody formation (congenital or acquired and whatever the cause), has the greatest impact on susceptibility to pneumococcal infection [3a].
Immunodeficiency may occur as a result of a specific disease, or as a side effect of a particular therapy. [4] The prevalence of a pneumococal infection is increased among individuals with human immunodeficiency virus (HIV) infection. [1]
HIV infection alters host defense at several points, but defective antibody production probably predominates in the predisposition to pneumococcal infection [3b].
Patients undergoing organ transplantation are given immunosupressive therapy to prevent rejection of the transplant.
References
[1] Musher DM. Streptococcus pneumoniae. In Mandell G, Bennett JE, Dolin R editors. Principles and practice of infectious disease. 4th ed. New York, USA: Churchill Livingstone, Inc.; p
[2] Obaro SK, Monteil MA, Henderson DC. The pneumococcal problem. BMJ Jun 15;312(7045):
[3] Musher DM. Streptococcus pneumoniae. In Mandell G, Bennett JE, Dolin R editors. Principles and practice of infectious disease. 5th ed. New York, USA: Churchill Livingstone, Inc.; p
[4] Center for Diseases Control and Prevention. Prevention of pneumococcal disease. Recommendations of the Advisory Committee on Immunization Practices. MMWR 1997; 46 (N° RR-8): 1-24.
[1] Musher DM. In Mandell G, Bennett JE, Dolin R editors. Principles and practice of infectious disease. 4th ed. New York, USA: Churchill Livingstone, Inc.; p 27

28. Factors predisposing to pneumococcal infection
Environmental factors
Very close contact
Nursing homes/ hospitals for elderly persons
Prisons
Shelters for homeless persons
Factors predisposing to pneumococcal infection
Although not contagious, as is, for example, influenza, the Streptococcus Pneumoniae is easily transmitted between people living in very close contact. [1]
Outbreaks can occur, especially among groups with other predisposing factors for pneumococcal disease (e.g. among elderly persons in nursing homes) and among those living in overcrowded conditions. [2]
Outbreaks do not occur under conditions of ‘normal’ social contact, such as in schools or in the workplace. [1]
References:
[1] Musher DM. Streptococcus pneumoniae. In Mandell G, Bennett JE, Dolin R editors. Principles and practice of infectious disease. 4th ed. New York, USA: Churchill Livingstone, Inc.; p
[2] National Immunization Program, Centers for Disease Control and Prevention, U.S. Department of Health and Human Services. PINK BOOK. Pneumococcal Disease. Streptococcus pneumoniae. In: Atkinson W and Wolfe C eds. Epidemiology and Prevention of Vaccine-Preventable Diseases. 10th ed. Atlanta (GA): Department of Health & Human Services, Centers for Disease Control and prevention ed; 2007.p
PREDISPOSITION TO PNEUMOCOCCAL INFECTION
[1] Musher DM. In Mandell G, Bennett JE, Dolin R editors. Principles and practice of infectious disease. 4th ed. New York, USA: Churchill Livingstone, Inc.; p 28

29. 10 Leading Causes of Morbidity 2007, FHSIS Data, Philippines

30. Pneumococcus: Diversity of Serotypes
There are at least 90 different serotypes of S. pneumoniae1,2
Each has a capsule of a different chemical composition
Each stimulates the production of a different antibody
Only a minority of serotypes cause most cases of human disease
8-10 cause two-thirds of serious pneumococcal infections in adults3
1 Fedson, Musher, in Vaccines, 1994
2 Henrichsen, J Clin Microbiol, 1995
3 UK DoH, Immunisation Against Infectious Disease, 1996

31. Pneumococcal Vaccines: Antigen Composition
23-valent pneumococcal vaccine contains purified capsular polysaccharides derived from 23 S. pneumoniae serotypes1
1, 2, 3, 4, 5, 6B, 7F, 8, 9N, 9V, 10A,11A, 12F, 14, 15B, 17F, 18C, 19A, 19F, 20, 22F, 23F, 33F
Serotype coverage2,3
85-90% of serotypes responsible for all cases of invasive pneumococcal disease
Vaccine includes major serotypes that have developed antimicrobial resistance
Cross protection within some serotypes1
For example, antibody response to serotype 6B protects against serotype 6A, which is not in the vaccine
1 CDC, MMWR, 1989
2 Fedson, Musher, in Vaccines, 1994
3 Geslin et al., Méd Mal Infect, 1992

32. Pneumococcal Disease Prevention: Vaccination Recommendations
WHO view (Technical Advisory Group convened by WHO Regional Office for Europe, 1988)1
Pneumococcal vaccination should be recommended for all elderly persons (aged ³60-65 years) and for persons of any age at high risk of acquiring pneumococcal infection
National recommendations
Many countries recommend vaccination for specific at-risk groups or conditions
Some countries recommend vaccination for elderly persons aged:
³60 years: Belgium, Germany, Iceland
³65 years: Denmark, Finland, Norway, Sweden, USA, Canada, New Zealand
1 Fedson et al., Infection 1989

33. Local associations that recommend pneumococcal vaccination
Philippine Foundation for Vaccination (PFV)
Philippine Society for Microbiology and Infectious Diseases (PSMID)
Philippine College of Chest Physicians (PCCP)

34. Pneumococcal Vaccination Recommendation
Age > 60 yrs (routinely): once
If < 60 yrs but with the following conditions:
Chronic illnesses (Cardio,COPD, Chronic Tuberculosis*, Bronchiectasis, diabetics, cirrhosis, CSF leaks)
Immunocompromised (lymphoma, leukemia)
Chronic renal failure, nephrotic syndrome
Transplant patients
Patients on chemo/ radio therapy
HIV/ AIDS functional or anatomic asplenia