2. Adult Immunization Original by Dr. Ari Robicsek Updated by T.Cook 21 Mar 2003

3. Objectives To know which vaccines to recommend to which patients To know why Sources Canadian Immunization Guide, 6th ed Health Canada Weblink Health Canada Weblink CDC National Immunization Program Weblink Up To Date, vaccine manufacturer websites

4. Some thoughts: When was the last time you asked a patient about their immunization record? Prevention of disease should be the domain of specialists as well as primary care physicians.

5. Vaccine Regimens Pediatric (not discussed)Adult Traveler (future seminar)

6. R ecommended A dult I mmunization S chedule U nited S tates, 2002-2003 and R ecommended I mmunizations for A dults with M edical C onditions Summary of Recommendations Published by The Advisory Committee on Immunization Practices Department of Health and Human Services Centers for Disease Control and Prevention Based on the Recommendations of the Advisory Committee on Immunization Practices, Centers for Disease Control and Prevention

7. For persons with medical / exposure indications Recommended Adult Immunization Schedule, United States, 2002-2003 Approved by the Advisory Committee on Immunization Practices (ACIP), and accepted by the American College of Obstetricians and Gynecologists (ACOG) and the American Academy of Family Physicians (AAFP) This schedule indicates the recommended age groups for routine administration of currently licensed vaccines for persons 19 years of age and older. Licensed combination vaccines may be used whenever any components of the combination are indicated and the vaccine’s other components are not contraindicated. Providers should consult the manufacturers' package inserts for detailed recommendations. Report all clinically significant post-vaccination reactions to the Vaccine Adverse Event Reporting System (VAERS). Reporting forms and instructions on filing a VAERS report are available by calling 1-800-822-7967 or from the VAERS website at http://www.vaers.org.http://www.vaers.org For additional information about the vaccines listed above and contraindications for immunization, visit the National Immunization Program Website at http://www.cdc.gov/nip/ or call the National Immunization Hotline at 800-232-2522 (English) or 800-232-0233 (Spanish).http://www.cdc.gov/nip/ *Covered by the Vaccine Injury Compensation Program. For information on how to file a claim call 1-800-338-2382. Please also visit http://www.hrsa.osp.gov/vicp accessed February 21, 2002. To file a claim for vaccine injury write: U.S. Court of Federal Claims, 717 Madison Place, N.W., Washington D.C. 20005. (202) 219-9657.http://www.hrsa.osp.gov/vicp Measles, Mumps, Rubella (MMR)* 65 years and older50-64 years 19-49 years Vaccine Tetanus, Diphtheria (Td)* Influenza Pneumococcal (polysaccharide) Hepatitis B* Hepatitis A Varicella* Meningococcal (polysaccharide) Catch-up on childhood vaccinations For all persons in this age group Age 1 dose booster every 10 years 1 1 annual dose 1 dose annually for persons with medical or occupational indications, or household contacts of persons with indications 2 1 dose revaccination 4 1 dose for persons with medical or other indications. (1 dose revaccination for immunosuppressive conditions) 3,4 3 doses (0, 1-2, 4-6 months) for persons with medical, behavioral, occupational, or other indications 5 2 doses (0, 6-12 months) for persons with medical, behavioral, occupational, or other indications 6 1 dose if measles, mumps, or rubella vaccination history is unreliable; 2 doses for persons with occupational, geographic, or other indications 7 2 doses (0, 4-8 weeks) for persons who are susceptible 8 1 dose for persons with medical or other indications 9 See Footnotes for Recommended Adult Immunization Schedule on the back cover. Asplenia including elective splenectomy and terminal complement component deficiencies Contraindicated Recommended Immunizations for Adults with Medical Conditions, United States, 2002-2003 *Covered by the Vaccine Injury Compensation Program. G. Hemodialysis patients: Use special formulation of vaccine (40 ug/mL) or two 1.0 mL 20 ug doses given at one site. Vaccinate early in the course of renal disease. Assess antibody titers to hep B surface antigen (anti-HBs) levels annually. Administer additional doses if anti- HBs levels decline to <10 milliinternational units (mlU)/ mL. H. Also administer meningococcal vaccine. I. Elective splenectomy: vaccinate at least 2 weeks before surgery. J. Vaccinate as close to diagnosis as possible when CD4 cell counts are highest. K. Withhold MMR or other measles containing vaccines from HIV-infected persons with evidence of severe immunosuppression. MMWR 1996; 45: 603-606, MMWR 1992; 41 (RR-17): 1-19. A.If pregnancy is at 2 nd or 3 rd trimester during influenza season. B.Although chronic liver disease and alcoholism are not indicator conditions for influenza vaccination, give 1 dose annually if the patient is > 50 years, has other indications for influenza vaccine, or if the patient requests vaccination. C.Asthma is an indicator condition for influenza but not for pneumococcal vaccination. D.For all persons with chronic liver disease. E.Revaccinate once after 5 years or more have elapsed since initial vaccination. F.Persons with impaired humoral but not cellular immunity may be vaccinated. MMWR 1999; 48 (RR-06): 1-5. Renal failure / end stage renal disease, recipients of hemodialysis or clotting factor concentrates Pregnancy Medical Conditions Diabetes, heart disease, chronic pulmonary disease, chronic liver disease, including chronic alcoholism Congenital immunodeficiency, leukemia, lymphoma, generalized malignancy, therapy with alkylating agents, antimetabolites, radiation or large amounts of corticosteroids HIV infection For all persons in this group For persons with medical / exposure indications Catch-up on childhood vaccinations Vaccine Tetanus- Diphtheria (Td)* Measles Mumps Rubella (MMR)* Hepatitis B* Hepatitis A D Varicella * Influenza A Pneumo- coccal (poly- saccharide ) G E, H, I E, J F B K C 1 dose for unvaccinated persons 3 E E

8. Footnotes for Recommended Adult Immunization Schedule 1.Tetanus and diphtheria (Td): A primary series for adults is 3 doses: the first 2 doses given at least 4 weeks apart and the 3 rd dose, 6-12 months after the second. Administer 1 dose if the person had received the primary series and the last vaccination was 10 years ago or longer. MMWR 1991; 40 (RR-10): 1-21. The ACP Task Force on Adult Immunization supports a second option: a single Td booster at age 50 years for persons who have completed the full pediatric series, including the teenage/young adult booster. Guide for Adult Immunization. 3 rd ed. ACP 1994: 20. 1.Influenza vaccination: Medical indications: chronic disorders of the cardiovascular or pulmonary systems including asthma; chronic metabolic diseases including diabetes mellitus, renal dysfunction, hemoglobinopathies, immunosuppression (including immunosuppression caused by medications or by human immunodeficiency virus [HIV] ), requiring regular medical follow-up or hospitalization during the preceding year; women who will be in the second or third trimester of pregnancy during the influenza season. Occupational indications: health care workers. Other indications: residents of nursing homes and other long-term care facilities; persons likely to transmit influenza to persons at high-risk (in-home care givers to persons with medical indications, household contacts and out-of-home caregivers of children birth to 23 months of age, or children with asthma or other indicator conditions for influenza vaccination, household members and care givers of elderly and adults with high-risk conditions); and anyone who wishes to be vaccinated. MMWR 2002; 51 (RR-3): 1 -31. 3. Pneumococcal polysaccharide vaccination: Medical indications: chronic disorders of the pulmonary system (excluding asthma), cardiovascular diseases, diabetes mellitus, chronic liver diseases including liver disease as a result of alcohol abuse (e.g., cirrhosis), chronic renal failure or nephrotic syndrome, functional or anatomic asplenia (e.g., sickle cell disease or splenectomy), immunosuppressive conditions (e.g., congenital immunodeficiency, HIV infection, leukemia, lymphoma, multiple myeloma, Hodgkins disease, generalized malignancy, organ or bone marrow transplantation), chemotherapy with alkylating agents, anti-metabolites, or long-term systemic corticosteroids. Geographic/other indications: Alaskan Natives and certain American Indian populations. Other indications: residents of nursing homes and other long-term care facilities. MMWR 1997; 47 (RR-8): 1-24. 4. Revaccination with pneumococcal polysaccharide vaccine: one time revaccination after 5 years for persons with chronic renal failure or nephrotic syndrome, functional or anatomic asplenia (e.g., sickle cell disease or splenectomy), immunosuppressive conditions (e.g., congenital immunodeficiency, HIV infection, leukemia, lymphoma, multiple myeloma, Hodgkins disease, generalized malignancy, organ or bone marrow transplantation), chemotherapy with alkylating agents, anti-metabolites, or long-term systemic corticosteroids. For persons 65 and older, one-time revaccination if they were vaccinated 5 or more years previously and were aged less than 65 years at the time of primary vaccination. MMWR 1997; 47 (RR-8): 1-24. 5. Hepatitis B vaccination: Medical indications: hemodialysis patients, patients who receive clotting-factor concentrates. Occupational indications: health- care workers and public-safety workers who have exposure to blood in the workplace, persons in training in schools of medicine, dentistry, nursing, laboratory technology, and other allied health professions. Behavioral indications: injecting drug users, persons with more than one sex partner in the previous 6 months, persons with a recently acquired sexually-transmitted disease (STD), all clients in STD clinics, men who have sex with men. Other indications: household contacts and sex partners of persons with chronic HBV infection, clients and staff of institutions for the developmentally disabled, international travelers who will be in countries with high or intermediate prevalence of chronic HBV infection for more than 6 months, inmates of correctional facilities. MMWR 1991; 40 (RR-13): 1-25. (www.cdc.gov/travel/diseases/hbv.htm)www.cdc.gov/travel/diseases/hbv.htm

9. 6. Hepatitis A vaccination: For the combined HepA-HepB vaccine use 3 doses at 0, 1, 6 months). Medical indications: persons with clotting-factor disorders or chronic liver disease. Behavioral indications: men who have sex with men, users of injecting and noninjecting illegal drugs. Occupational indications: persons working with HAV-infected primates or with HAV in a research laboratory setting. Other indications: persons traveling to or working in countries that have high or intermediate endemicity of hepatitis A. MMWR 1999; 48 (RR-12): 1-37. (www.cdc.gov/travel/diseases/hav.htm)www.cdc.gov/travel/diseases/hav.htm 7. Measles, Mumps, Rubella Vaccination (MMR): Measles component: Adults born before 1957 may be considered immune to measles. Adults born in or after 1957 should receive at least one dose of MMR unless they have a medical contraindication, documentation of at least one dose or other acceptable evidence of immunity. A second dose of MMR is recommended for adults who:  are recently exposed to measles or in an outbreak setting  were previously vaccinated with killed measles vaccine  were vaccinated with an unknown vaccine between 1963 and 1967  are students in post-secondary educational institutions  work in health care facilities  plan to travel internationally Mumps component: 1 dose of MMR should be adequate for protection. Rubella component: Give 1 dose of MMR to women whose rubella vaccination history is unreliable and counsel women to avoid becoming pregnant for 4 weeks after vaccination. For women of child-bearing age, regardless of birth year, routinely determine rubella immunity and counsel women regarding congenital rubella syndrome. Do not vaccinate pregnant women or those planning to become pregnant in the next 4 weeks. If pregnant and susceptible, vaccinate as early in postpartum period as possible. MMWR 1998; 47 (RR-8): 1-57. 8. Varicella vaccination: Recommended for all persons who do not have reliable clinical history of varicella infection, or serological evidence of varicella zoster virus (VZV) infection; health-care workers and family contacts of immunocompromised persons, those who live or work in environments where transmission is likely (e.g., teachers of young children, day care employees, and residents and staff members in institutional settings), persons who live or work in environments where VZV transmission can occur (e.g., college students, inmates and staff members of correctional institutions, and military personnel), adolescents and adults living in households with children, women who are not pregnant but who may become pregnant in the future, international travelers who are not immune to infection. Note: Greater than 90% of U.S. born adults are immune to VZV. Do not vaccinate pregnant women or those planning to become pregnant in the next 4 weeks. If pregnant and susceptible, vaccinate as early in postpartum period as possible. MMWR 1996; 45 (RR-11): 1-36, MMWR 1999; 48 (RR-6): 1-5. 9. Meningococcal vaccine (quadrivalent polysaccharide for serogroups A, C, Y, and W-135). Consider vaccination for persons with medical indications: adults with terminal complement component deficiencies, with anatomic or functional asplenia. Other indications: travelers to countries in which disease is hyperendemic or epidemic (“meningitis belt” of sub-Saharan Africa, Mecca, Saudi Arabia for Hajj). Revaccination at 3-5 years may be indicated for persons at high risk for infection (e.g., persons residing in areas in which disease is epidemic). Counsel college freshmen, especially those who live in dormitories, regarding meningococcal disease and the vaccine so that they can make an educated decision about receiving the vaccination. MMWR 2000; 49 (RR-7): 1-20. Note: The AAFP recommends that colleges should take the lead on providing education on meningococcal infection and vaccination and offer it to those who are interested. Physicians need not initiate discussion of the meningococcal quadravalent polysaccharide vaccine as part of routine medical care.

12. Strategies to Improve Vaccine Delivery to Adults Despite favourable attitudes among Canadian physicians towards the use of vaccines in adults, such vaccines are underused. It is estimated that only 45% of high-risk individuals receive influenza vaccine annually. An organized systematic approach to vaccine delivery is required. Physicians play a major role in the identification of adults in need of immunization. Methods of identification include reminder notices in patient records, pre-employment medical examinations, school and college entry questionnaires, employee health nurse visits and letter reminders. Emergency rooms, public health clinics, hospitals and other health care institutions may also play an important role in vaccine delivery. Health visits of recent immigrants can identify this particular population at risk. When people are offered vaccines, high rates of compliance are usually noted. Adult immunization can be successful if well-organized provincial/territorial/institutional programs are established and maintained.

13. C. Opportunity for Immunization in Acute Care Institutions Taking an immunization history from those admitted to hospital provides an important opportunity to maintain up-to-date immunization for all patients. For patients without regular sources of care or those followed in specialized clinics, the only opportunities for immunization may be during hospital outpatient visits or hospitalization. The admission of elderly patients and others at high risk of influenza complications should be regarded as an opportunity to ensure that these people are immunized against influenza. Programs to immunize such patients before discharge will ensure that these very high-risk patients will not miss immunization in the community because of hospitalization during influenza season. The routine presence of standing orders or delegated acts for immunization in these institutions, along with clear departmental protocols, can help to reduce administrative barriers to incorporating these preventive acts in an institution traditionally preoccupied with treatment. Pneumococcal vaccine should be administered before discharge to unvaccinated patients 65 years of age and those with chronic health problems for which immunization is recommended. All pregnant women should be screened for hepatitis B surface antigen (HBsAg), and the newborn of an HBsAg positive woman should be given hepatitis B immune globulin (HBIG) and started on a course of vaccine. Women susceptible to rubella should receive vaccine post-partum, before discharge from hospital.

14. Immunization Guidelines Immunization services should be readily available. There should be no barriers or unnecessary prerequisites to the receipt of vaccines. Providers should use all clinical encounters to screen for needed vaccines and, when indicated, vaccinate Providers should educate in general terms about immunization.

15. Guidelines Cont’d Providers should: inform in specific terms about the risks / benefits of vaccines they are to receive. recommend deferral or with- holding of vaccines for true contraindications only administer all vaccine doses for which a patient is eligible at the time of each visit. ensure that all vaccinations are accurately and completely recorded. maintain easily retrievable summaries of the vaccination records to facilitate age- appropriate vaccination.

16. Providers should report clinically significant adverse events following vaccination promptly, accurately, and completely report all cases of vaccine-preventable diseases as required under provincial / territorial legislation. adhere to appropriate procedures for vaccine management. maintain up-to-date, easily retrievable protocols at all locations where vaccines are administered. maintain ongoing education regarding vaccines operate a tracking system.

17. ISSUES WITH SPECIFIC VACCINES Td MMR Pneumococcal Influenza Hepatitis B

18. Tetanus/Diphtheria Bacterial diseases with high mortality, both entirely vaccine preventable “Td” is a toxoid vaccine (bacterial toxins adsorbed to aluminum) primary vaccination done early in life adverse effects minimal in adults

19. Tetanus/Diphtheria How often should Td be administered? If primary vaccination has been done, including the booster at age 14-16, there are two acceptable approaches: 1. Booster at ten-year intervals. 2. Just one booster at age 50 if not done in 40’s. Note: Vaccinate after a dirty wound if last vaccination was more than five years earlier.

20. MMR Serious complications of Measles: Mumps: Rubella: Resurgence of measles in U.S. in late ‘80’s; seems that 5-20% of people don’t respond to intial vaccination in childhood New recommendations are for two-time MMR to protect against measles Meningitis/other CNS disease, sterility Pneumonia, meningoencephalitis, SSPE Congenital rubella

21. MMR Which adults should get MMR? Any who are not immune:  Born after 1970 AND no documentation of immunization (or infection) either by paper evidence or serology Most importantly:  women of childbearing years  health care workers  college students  travellers to epidemic areas

22. MMR Post exposure prophylaxis: vaccination post-exposure protects against measles if given within 72 hours not protective against mumps or rubella Safe in pregnancy? Probably, but we don’t use it if a woman is found to be serologically negative in pregnancy, we immunize after delivery before she leaves hospital

23. MMR Contraindications: egg anaphylaxis is NOT a contraindication even though measles grown in eggs neomycin allergy IS a contraindication HIV is NOT a contraindication unless very immunosuppressed Adverse Effects: rubella component causes arthralgia in > 40% of women; some even have arthritis; this happens 1- 3 weeks post vaccination

24. Streptococcus pneumoniae Risk of invasive pneumococcal infections increases with age 7/100,000 in young adults 61/100,000 in adults 65 or older; 3x increased mortality for pneumococcal pneumonia compared to young adults 46 times higher than controls in HIV patients in pre-HAART era other RF’s for pneumococcal pneumonia are haem CA, EtOH, smoking, Black/First Nations, asplenia

25. Streptococcus pneumoniae First pneumococcal vaccine tested pre Great War; vaccine to polysaccharide capsular antigens introduced in 1945 but widely ignored due to high Abx efficacy now ~10% of clinical isolates Canada-wide have some PEN-resistance (which correlates with other- Abx resistance) polyvalent (= made up of antigens from multiple strains) capsular-polysaccharide based vaccine first championed in 70’s by MD who found high protective efficacy vs. pneumococcal pneumonia in South African miners Since then, efficacy has been a lot harder to demonstrate

26. Streptococcus pneumoniae Does the polyvalent polysaccharide pneumococcal vaccine “work’? Yes and No

27. Streptococcus pneumoniae Vaccine has NOT been shown to consistently reduce rate of pneumococcal pneumonia in anyone. Studies have been hampered by poor ability to discriminate between pneumococcal and non-pneumococcal pneumonia. RCT’s have not had enough power to assess efficacy against bacteremia or meningitis. Evidence of reduction in invasive disease DOES exist; - meta-analysis of 9 RCT’s found reduction of bacteremic pneumonia in low-risk groups (perhaps ~80%) - case control studies have shown 75% effectiveness vs. invasive disease in the elderly, and benefit in DM, asplenia, chronic lung disease

28. Streptococcus pneumoniae Evidence is more controversial in HIV very questionable benefit -- even possibility of harm -- if CD4 < 200

29. Streptococcus pneumoniae Standard of Care Pneumovax 23, Pneumo 23 and Pnu-Immune 23 are available vaccines with approval for adult use all have antigens from the 23 pneumococcal strains which account for 90% of bacteremia and meningitis don’t use in kids < 2 because it doesn’t work

30. Streptococcus pneumoniae Standard of Care Which people  65 should get the vaccine? Everyone Which people < 65 should get the vaccine? Patients with: - questionable splenic function - chronic disease of heart, liver, kidneys, lungs (not asthma) - alcoholism, DM - immunosuppression, including HIV

31. When do you revaccinate? Streptococcus pneumoniae Standard of Care We don’t know. May be a good idea to revaccinate ONE time, five years post initial vaccination, in - patients over 65 who were vaccinated before they were 65 - patients with immunocompromise or other high risk

32. Streptococcus pneumoniae Adverse effects: about 1/3 have local pain and swelling systemic reactions are rare Can you give the flu vaccine at the same time? Sure. Just use a different spot.

34. Influenza Epidemics described by Hippocrates; “influenza” Italian for “influence” -- disease felt to be due to ‘influence’ of atmospheric factors Actually caused by respiratory orthomyxoviruses (Influenza A, B, C) small-droplet aerosol spread (coughs and sneezes) mainly active late fall -- early winter antigenic shift prevents natural or vaccine immunity from carrying over from year to year can cause endemic, epidemic and pandemic disease; disastrous Spanish flu was responsible not only for making Edvard Munch look as terrible as he did in the previous slide: (Self-portrait after Spanish influenza, 1919), it also caused 21 million deaths bacterial pneumonia is its most important severe complication

35. Influenza Vaccines we use are inactivated viruses grown in hen’s eggs each year a new formulation is prepared based on last year’s popular antigens effectiveness of the vaccine depends on how close those antigens are to the ones in circulation this season

36. Influenza Does the vaccine work? Yes (we’re pretty sure.) Evidence mainly not from RCT’s. Meta-analysis of 20 cohort studies suggested 50-60% efficacy in flu reduction. Nursing home residents have 50-60% reduction in pneumonia, and possibly higher reduction in mortality. May even benefit household contacts of vaccinees.

37. Influenza Standard of Care When (in the year) should you vaccinate? Protection starts two weeks after vaccination, and lasts at least 6 months (perhaps less in the elderly.) Best to start in September; but best time for the elderly, given quicker loss of immunity, might be November. It’s OK to vaccinate even after flu season has started.

38. Influenza Standard of Care Whom should you vaccinate? 1. People at high risk: -  65 years of age (anyone) - living in a medical institution - severe heart or lung disease (this is the biggest risk factor for flu-related death) - other chronic disease (eg: DM) - immunocompromise - young folks on chronic ASA (Reye’s risk) - pregnant women at any stage of pregnancy 2. People who might give the virus to high-risk patients: - health care workers 3. May be worth vaccinating all working adults to prevent disruption during flu season.

39. Influenza Adverse effects: local stuff some formulations cause 1-2 days of fever, especially in flu-vaccine virgins; this is actually uncommon, though no proven Guillain-Barre with current generation (unlike old one) Contraindications? Egg anaphylaxis

40. Hepatitis B Vaccines highly effective Most of the world is still using vaccines derived from plasma of HBV carriers We use HBV S Antigen particles grown in recombinant yeast; our vaccinees will be HBSAb positive but HBCAb negative attempts at only vaccinating “high-risk” individuals were failures; we have now instituted universal vaccination for kids

41. Hepatitis B rate of seroconversion is 95% in healthy adults progressively less with age; <50% seroconversion in sixth decade also lower in patients with chronic disease rate of seropositivity decays with time, but as long as an antibody response was elicited initially, protection is likely still good for at least 15 years

42. Hepatitis B Who gets vaccinated? All Canadian kids at age 9-13; (neonates born to carriers are vaccinated and treated with HBIG at birth.) Adults who are: - health care workers - engaging in high-risk sexual activity or IVDU - household contacts of HBV patients - on chronic hemodialysis - getting repeated transfusions

43. Hepatitis B Adverse Effects: local stuff 1-3% have low-grade fever, myalgia, arthralgia, etc. despite some claims, no evidence of a link to multiple sclerosis SAFE in pregnancy

44. Hepatitis B Vaccine administered as three doses, at months 0, 1 and 6 usually given IM, but intradermal injection of a higher-than-usual dose may increase response rate in immunocompromised patients routine post-vaccination seroconversion testing only if at high risk; if negative revaccinate and retest (50% chance of working the second time)

45. HIV Pnemococcal vaccination if CD4 > 200 ONE revaccination at five years Flu yearly HBV for all; HAV if concurrent HBV or HCV infection Meningococcal vaccine if asplenic, travelling, living in dorms

46. Asplenia Pneumococcal vaccination 2 weeks pre elective splenectomy 2 weeks post emergency splenectomy (Ab’s work better in patients whose vaccination is slightly delayed post-op) revaccination at five years HIB vaccine most adults have antibodies, but we give it anyway Meningococcal vaccine Flu yearly

47. Health Care Workers Same as everyone else (Td) PLUS: HVB (with titer check 1-2 months after third dose) Flu MMR: immune status should be checked (documents or titers) for measles in all, rubella in women vaccines relating to special exposures (eg: BCG, typhoid, Hep A)

48. Bottom Line In our regular practice, we should be at least considering pneumococcal and influenza vaccination status of our outpatients and inpatients everyone over 65 should have both sick people should have both no flu if egg anaphylaxis