1. Adult Immunization 2010 Tetanus, Diphtheria and Pertussis Segment This material is in the public domain This information is valid as of May 25, 2010

2. NOTE: Participants are strongly encourage to have a copy of the current adult immunization schedule available during this program. The current schedule can be downloaded from the CDC Vaccines and Immunizations website at: http://www.cdc.gov/vaccines/recs/schedules/adult- schedule.htm http://www.cdc.gov/vaccines/recs/schedules/adult- schedule.htm

3. Tetanus and Diphtheria Immunity More than 50% of adults 20 years of age and older in the U.S. do not have a protective level of antibody against tetanus and diphtheria Many adults 60 years of age and older have not received a primary series of tetanus- and diphtheria- containing vaccine Many adults of all ages do not receive routine Td booster doses every 10 years

4. Reported Pertussis by Age Group, 1990-2008

5. Tetanus and Diphtheria Vaccines for Adults Tetanus and Diphtheria Toxoid (Td) –formalin-inactivated toxins –3 doses induces protective antibody in nearly everyone –protection for at least 10 years Tdap

6. Tdap Vaccines Boostrix (GlaxoSmithKline) –single dose –approved for persons 10 through 64 years of age Adacel (sanofi pasteur) –single dose –approved for persons 11 through 64 years of age

7. General Principles for Use of Tdap and Td No brand preference Tdap preferred to Td to provide protection against pertussis Approved as a single booster dose in persons who have previously received a full series of pediatric DTaP or DTP

8. Persons Without Documentation of Pertussis Vaccination All adults should have documentation of having received a series of DTaP, DTP, DT, or adult Td Adults without documentation should receive or complete a series of 3 doses Preferred schedule*: –single dose of Tdap –Td at least 4 weeks after the Tdap dose –second dose of Td at least 6 months after the Td dose *off-label recommendation. See MMWR 2006;55(RR-17)

9. Minimum Interval Between Td and Tdap ACIP did not define an absolute minimum interval between Td and Tdap Provider will need to decide based on whether the benefit of pertussis immunity outweighs the risk of a local adverse reaction MMWR 2006;55(RR-17)

10. Tdap and Pregnancy Td is generally preferred during pregnancy All women should receive a dose of Tdap in the immediate postpartum period Any woman who might become pregnant is encouraged to receive a single dose of Tdap A clinician may choose to administer Tdap to a pregnant woman in certain circumstances, such as during an outbreak of pertussis in the community Pregnancy is not a contraindication to vaccination with Tdap MMWR 2008;57(RR-4)

11. Tdap and Healthcare Personnel (HCP) Healthcare personnel who work in hospitals or ambulatory care settings and have direct patient contact should receive a single dose of Tdap as soon as feasible Priority should be given to vaccination of healthcare personnel who have direct contact with infants 12 months of age and younger Other HCP should receive a single dose of Tdap to replace the next scheduled Td MMWR 2006;55(RR-17)

12. Tdap Contraindications Severe allergic reaction to a vaccine component or following a prior dose Encephalopathy within 7 days of administration of a pertussis vaccine that is not attributable to another identifiable cause

13. Tdap Precautions History of an Arthus-type reaction following a previous dose of tetanus or diphtheria toxoid-containing vaccine Progressive neurologic disorder, uncontrolled epilepsy, or progressive encephalopathy until condition stabilized History of Guillain-Barré syndrome (GBS) within 6 weeks after a previous dose of tetanus toxoid-containing vaccine Moderate or severe acute illness

14. Tdap/Td Adverse Reactions Pain Redness Swelling Temperature (100°F or higher) Systemic 66% - 75% 23% - 24% 21% 3% - 5% 30% - 40%

15. Adult Immunization 2010 Influenza Segment This material is in the public domain This information is valid as of May 25, 2010

16. Impact of Influenza Approximately 36,000 influenza- associated deaths during each influenza season Persons 65 years of age and older accounted for more than 90% of deaths The number of deaths and cost to society from influenza is likely to increase as the nation’s population ages MMWR 2009;58 (RR-8)

17. Influenza Virus Strains Type A –moderate to severe illness –affects all age groups –affects humans and other animals (particularly migratory waterfowl) Type B –milder disease –primarily affects children –humans only

18. Influenza Virus A/Fujian/411/2002 (H3N2) Neuraminidase Hemagglutinin Type of nuclear material Virus type Geographic origin Strain number Year of isolation Virus subtype

19. Influenza A (H1N1) A previously unknown strain of H1N1 influenza virus appeared in April 2009 Many outbreaks in April and May Pandemic declaration in June Second wave of illness occurred in the fall and winter of 2009

20. Impact of Pandemic H1N1 Virus – United States, April 2009-March 2010 60 million infections 270,000 hospitalizations 13,000 deaths http://www.cdc.gov/h1n1flu/estimates_2009_h1n1.htm

21. Influenza Vaccines Live attenuated vaccine (LAIV) –intranasal –Approved only for persons 2 through 49 years of age who are healthy and not pregnant Inactivated subunit (TIV) –intramuscular –split virus or purified surface antigen MMWR 2009;58(RR-8)

22. Fluzone HD Vaccine (sanofi pasteur) Contains 4 times the amount of hemagglutinin than in regular Fluzone TIV Approved by the FDA only for persons 65 years and older ACIP has not stated a preference for Fluzone HD or other TIV brand among persons 65 years and older MMWR 2010;59 (in press)

23. Influenza Vaccines Trivalent (H3N2, H1N1, B) Efficacy varies Duration of immunity 1 year or less for TIV Duration of immunity at least 1 year for LAIV MMWR 2009;58(RR-8)

24. Inactivated Influenza Vaccine (TIV) Efficacy 70%-90% effective among healthy persons <65 years of age 30%-40% effective among persons 65 years and older with underlying medical conditions Prevents complications and death from influenza among those who get the disease MMWR 2009;58(RR-8)

25. Influenza Vaccination Recommendation Annual influenza vaccination is recommended for every person in the United States 6 months of age and older Make a special effort to vaccinate persons at increased risk of complications of influenza and their close contacts –persons with underlying medical illnesses –persons 65 years of age and older –pregnant women –children younger than 2 years of age MMWR 2010;59 (in press)

26. Inactivated Influenza Vaccine Recommendations Medical conditions that increase the risk of complications of influenza –Pulmonary –Cardiovascular –Metabolic –Renal dysfunction –Hemoglobinopathy –Immunosuppression –any condition that can compromise respiratory function or the handling of respiratory secretions or that can increase the risk of aspiration MMWR 2009;58(RR-8)

27. Pregnancy and Influenza Vaccine Excess deaths from influenza among pregnant women were documented during the pandemics of 1918-1919 and 1957-1958 Pregnant women were at increased risk of complications of influenza during the 2009 H1N1 influenza pandemic ACIP recommends vaccination with inactivated influenza vaccine for ALL women who will be pregnant during influenza season –inactivated vaccine only –LAIV contraindicated for pregnant women MMWR 2009;58(RR-8)

28. Inactivated Influenza Vaccine Contraindications and Precautions Severe allergic reaction to a vaccine component or following a prior dose Moderate or severe acute illness History of Guillain-Barre´ syndrome within 6 weeks following a previous dose of influenza vaccine MMWR 2006;55(RR-3)

29. Live Attenuated Influenza Vaccine Contraindications and Precautions Severe allergic reaction to a vaccine component or following a prior dose Underlying medical conditions Immunosuppression Pregnancy History of Guillain-Barre´ syndrome within 6 weeks following a previous dose of influenza vaccine Moderate or severe acute illness MMWR 2006;55(RR-3)

30. TIV Adverse Reactions Local reactions 15%-20% (pain, redness) Systemic reactions uncommon (fever, malaise) Severe allergic Rare reactions Neurological reactions Very rare MMWR 2006;55(RR-3)

31. LAIV Adverse Reactions Increased rate of cough, coryza, nasal congestion, sore throat, chills No increase in fever No serious adverse reactions have been identified MMWR 2006;55(RR-3)

32. Administration of LAIV Severely immunosuppressed persons should not administer LAIV Persons who have a contraindication to receipt of LAIV may administer LAIV Gloves and masks are not required MMWR 2006;55(RR-3)

33. Adult Immunization 2010 Pneumococcal Segment This material is in the public domain This information is valid as of May 25, 2010

34. Annual Burden of Pneumococcal Disease in the United States More than 40,000 invasive infections More than 4,500 deaths Incidence of pneumococcal disease rises steadily with increasing age Drug resistant strains of pneumococcus are becoming more common http://www.cdc.gov/abcs/reports-findings/surv-reports.html

35. Pneumococcal Polysaccharide Vaccine Purified capsular polysaccharide antigen from 23 types of pneumococcus Account for 88% of bacteremic pneumococcal disease Cross-react with types causing additional 8% of disease MMWR 1997;46(RR-8)

36. 60% to 70% efficacy against invasive disease Duration of immunity at least 6 years Schedule 1 dose, selective revaccination (at least 5 years after the first dose) Pneumococcal Polysaccharide Vaccine MMWR 1997;46(RR-8)

37. Pneumococcal Polysaccharide Vaccine Recommendations Adults 65 years of age and older Adults of any age with a normal immune system who have chronic illness –cardiovascular disease –pulmonary disease –diabetes –alcoholism, cirrhosis –cerebrospinal fluid leak –cochlear implant MMWR 1997;46(RR-8)

38. Adults 19 years of age and older –asthma –cigarette smoking Pneumococcal Polysaccharide Vaccine Recommendations* *provisional recommendation, October 2008 http://www.cdc.gov/vaccines/recs/provisional/

39. Pneumococcal Polysaccharide Vaccine Recommendations Adults who are immunocompromised –asplenia (functional or anatomic) –chronic renal failure –nephrotic syndrome –Hodgkin’s disease –lymphoma –multiple myeloma Persons with HIV infection MMWR 1997;46(RR-8)

40. Pneumococcal Polysaccharide Vaccine Revaccination Recommendations Routine revaccination of immunocompetent persons is NOT recommended Revaccination is recommended for persons at highest risk of serious pneumococcal infection Revaccinate once 5 years or longer after first dose (interval applies to persons of all ages) MMWR 1997;46(RR-8)

41. Candidates for Pneumococcal Revaccination Functional or anatomic asplenia Immunosuppression Chronic renal failure Nephrotic syndrome First dose before 65 years of age and >5 years since first dose First dose at >65 years of age AND later develop a condition for which revaccination is recommended AND at least 5 years since the first dose MMWR 1997;46(RR-8)

42. Pneumococcal Polysaccharide Vaccine Contraindications and Precautions Severe allergic reaction to a vaccine component or following a prior dose Moderate or severe acute illness MMWR 1997;46(RR-8)

43. Pneumococcal Polysaccharide Vaccine Adverse Reactions Local reactions 30% -50% (pain, redness) Systemic reactions <1% (fever, malaise) Severe adverse Rare reactions MMWR 1997;46(RR-8)

44. Adult Immunization 2010 Herpes Zoster (Shingles) Segment This material is in the public domain This information is valid as of May 25, 2010

45. Herpes Zoster (shingles) Caused by reactivation of a latent varicella zoster virus infection Can occur years or decades after illness with chickenpox Generally associated with normal aging and with anything that causes reduced immunocompetence Lifetime risk of 32% in the United States Estimated 1 million cases zoster diagnosed annually in the U.S.

46. Herpes Zoster Vaccine (Zostavax) Contains live attenuated varicella virus in an amount that is approximately 14 times greater than that in regular varicella vaccine Approved for persons 60 years of age and older Administered by the subcutaneous route

47. Zostavax Clinical Trial Compared to the placebo group the vaccine group had: –51% fewer episodes of zoster –less severe disease –66% less postherpetic neuralgia No significant safety issues were identified NEJM 2005;352(22):2271-84.

48. ACIP Recommendations for Zoster Vaccine Single dose of zoster vaccine for adults 60 years of age and older whether or not they report a prior episode of shingles Persons with a chronic medical condition may be vaccinated unless a contraindication or precaution exists for their condition MMWR 2008;57(RR-5)

49. Screening for Zoster Vaccine Eligibility Screening for a history of varicella disease is NOT necessary or recommended to administer zoster vaccine to a person 60 years of age or older Persons born in the U.S. before 1980 can be assumed to have had chickenpox regardless of their recollection of chickenpox MMWR 2008;57(RR-5)

50. Screening for Zoster Vaccine Eligibility Do NOT test the person for varicella antibody Negative test is more likely to indicate waning antibody level rather than true susceptibility Seronegative persons should receive 2 doses of single-antigen varicella vaccine MMWR 2008;57(RR-5)

51. Zoster Vaccine Contraindications Severe allergic reaction to a vaccine component or following a prior dose Pregnancy or planned pregnancy within 4 weeks Immunosuppression MMWR 2008;57(RR-5)

52. Zoster Vaccine Contraindications Immunosuppression Leukemia, lymphoma or other malignant neoplasm affecting the bone marrow or lymphatic system –persons whose leukemia or lymphoma is in remission and who have not received chemotherapy or radiation for at least 3 months can be vaccinated AIDS or other clinical manifestation of HIV infection –includes persons with CD4+ T- lymphocyte values less than 200 per mm3 or less than 15% of total lymphocytes MMWR 2008;57(RR-5)

53. Zoster Vaccine Contraindications Immunosuppression High-dose corticosteroid therapy –20 milligrams or more per day of prednisone or equivalent lasting 2 or more weeks –vaccination should be deferred for at least 1 month after discontinuation of therapy MMWR 2008;57(RR-5)

54. Zoster Vaccine Contraindications Immunosuppression Hematopoietic cell transplant recipients –experience is limited –assess the immune status of the recipient on a case-by-case basis –if a decision is made to vaccinate, the vaccine should be administered at least 24 months after transplantation MMWR 2008;57(RR-5)

55. Zoster Vaccine Contraindications Immunosuppression Recombinant human immune mediators and immune modulators –preferable to administer zoster vaccine before treatment –assess the immune status of the recipient on a case-by-case basis –vaccination should be deferred for at least 1 month after discontinuation of treatment MMWR 2008;57(RR-5)

56. Zoster Vaccine Precautions Moderate or severe acute illness Current treatment with an antiviral drug active against herpesviruses –discontinue at least 24 hours before administration of zoster vaccine –should not be taken for at least 14 days after vaccination Recent receipt of a blood product is NOT a precaution MMWR 2008;57(RR-5)

57. Zoster and Pneumococcal Polysaccharide (PPSV) Vaccines Zoster package insert advises that zoster and PPSV should not be administered concurrently Based on a study that showed the titer against VZV was lower in persons who received zoster and PPSV at the same visit compared to persons who received these vaccines 4 weeks apart CDC has not changed its recommendation for either vaccine Zoster and PPSV should be administered at the same visit if the person is eligible for both vaccines

58. Zoster Vaccine Storage and Handling Must be stored at 5 o F (-15 o C) or colder AT ALL TIMES Protect from light Administer within 30 minutes of reconstitution

59. Adult Immunization 2010 Human Papillomavirus Vaccine Segment This material is in the public domain This information is valid as of May 25, 2010

60. Human Papillomavirus More than 100 types – More than 60 cutaneous types  Can lead to skin warts –40 mucosal types  high risk types (particularly 16 and 18) –cervical cell abnormalities –certain anogenital cancers  Low risk types (particularly 6 and 11) –cervical cell abnormalities- usually resolve spontaneously and do not lead to cancer –genital warts –respiratory papillomatosis

61. Within 1 Year1-5 Years Up to Decades Initial HPV Infection Persistent Infection CIN 2/3 Cervical Cancer CIN 1 Cleared HPV Infection Natural History of HPV Infection

62. HPV-associated Conditions HPV 16, 18 Estimated % Cervical cancer 70% High/low grade cervical abnormalities30%-50% Anal, Vulvar, Vaginal, Penile Head and neck cancers 10% HPV 6, 11 Low grade cervical 10% abnormalities Genital warts 90% RRP 90%

63. Human Papillomavirus Vaccines HPV4 (Gardasil) –contains types 16 and 18 (high risk) and types 6 and 11 (low risk) HPV2 (Cervarix) –contains types 16 and 18 (high risk) Both vaccines are supplied as a liquid in a single dose vial or syringe Neither vaccine contains an antibiotic or a preservative

64. Human Papillomavirus Vaccines HPV4 vaccine is approved for –females 9 through 26 years of age for the prevention of cervical cancers, precancers and genital warts –males 9 through 26 years of age for the prevention of genital warts HPV2 vaccine is approved for –females 10 through 25 years of age for the prevention of cervical cancers and precancers –not approved for males or for the prevention of genital warts

65. HPV Vaccine Schedule and Intervals HPV4- 0, 2, 6 months HPV2- 0, 1, 6 months ACIP recommends- 0, 1 to 2, 6 months ACIP has not defined a maximum interval between HPV vaccine doses If the interval between doses is longer than recommended continue the series where it was interrupted

66. Correct and consistent condom use may have a protective effect on HPV acquisition, reduce the risk for HPV-associated diseases, and mitigate the adverse consequences of infection with HPV. This statement is required by section 317 of the Public Health Service Act, 42 U.S.C., 243

67. HPV Vaccine Recommendations Recommended age for routine HPV vaccination is 11 or 12 years Vaccination is recommended for females 13 through 26 years of age not previously vaccinated or who have not completed the full 3-dose series The 3 dose series of HPV4 may be administered to males 9 through 26 years of age to reduce their likelihood of acquiring genital warts

68. HPV Vaccine Special Situations Females 26 years of age or younger with equivocal or abnormal Pap test, positive HPV DNA, or genital warts may be vaccinated –vaccine will have no effect on existing disease or infection Females 26 years of age or younger who are lactating and breastfeeding, or are immunocompromised may be vaccinated Vaccination not recommended for pregnant women –pregnancy testing is not needed before vaccination

69. HPV Vaccine Contraindications and Precautions Severe allergic reaction to a vaccine component or following a prior dose –yeast (HPV4) –latex (HPV2 prefilled syringe) Moderate or severe acute illness

70. HPV Vaccine Adverse Reactions Local reaction 20% - 90% (pain, redness, swelling) Temperature 100°F 10% - 13% or higher Serious adverse events None

71. HPV Vaccine and Cervical Cancer Screening Cervical cancer screening recommendations have NOT changed for females who receive HPV vaccine Females who are vaccinated could subsequently be infected with a high-risk HPV type not in either vaccine Females who were sexually active prior to vaccination could have been infected with a vaccine-type HPV before vaccination Healthcare providers who administer HPV vaccine should educate women about the importance of cervical cancer screening

72. Adult Immunization 2010 Hepatitis B Vaccine Segment This material is in the public domain This information is valid as of May 25, 2010

73. Risk Factors for Hepatitis B CDC Sentinel Sites. 2001 data.

74. Hepatitis B Vaccine Long-Term Efficacy Immunologic memory develops following vaccination Antibody level declines following successful vaccination Anamnestic response upon exposure (antibody level increases quickly) Chronic infection rarely documented among vaccine responders MMWR 2006;55(RR-16)

75. Hepatitis B Vaccine Adult Schedule Dose Primary 1 Primary 2 Primary 3 Usual Interval --- 1 month 4-6 months Minimum Interval --- 4 weeks 8 weeks* *third dose must be separated from first dose by at least 16 weeks MMWR 2006;55(RR-16)

76. Hepatitis B Vaccine Booster doses are NOT recommended routinely for any group MMWR 2006;55(RR-16)

77. Hepatitis B Vaccine Adult Candidates Men who have sex with men Heterosexual with multiple partners Persons seeking evaluation or treatment for a sexually transmitted disease Injection drug users Male prison inmates Persons with end-stage renal disease, including predialysis, hemodialysis, peritoneal dialysis, and home dialysis MMWR 2006;55(RR-16)

78. Hepatitis B Vaccine Adult Candidates Staff and clients in institutions for the developmentally disabled Persons with chronic liver disease Persons with HIV infection Household members and sex partners of persons with chronic HBV infection Persons who travel to HBV-endemic areas MMWR 2006;55(RR-16)

79. Hepatitis B Vaccine Contraindications and Precautions Severe allergic reaction to a vaccine component or following a prior dose Moderate or severe acute illness MMWR 2006;55(RR-16)

80. Hepatitis B Vaccine Adverse Reactions Pain at injection site 13%-29% Mild systemic complaints 11%-17% (fatigue, headache) Temperature > 100 o F 1% Severe systemic reactions rare MMWR 2006;55(RR-16)

81. Adult Immunization 2010 Hepatitis A Vaccine Segment This material is in the public domain This information is valid as of May 25, 2010

82. Hepatitis A Fecal-oral transmission Indistinguishable from other types of hepatitis Does not lead to chronic infection Complications related to the acute disease

83. Hepatitis A Vaccines Inactivated whole virus –HAVRIX –VAQTA Single dose with a booster dose 6 to 18 months after the first dose Supplied as a liquid in prefilled syringes and single dose vials

84. Twinrix Hepatitis B (adult dose) and hepatitis A (pediatric dose) 3-dose series at 0, 1, 6 to12 months 4-dose series at 0, 7, 21 to 30 days, booster at 12 months Approved only for adults 18 years of age and older

85. Schedules That Include Both Twinrix and Hepatitis A Vaccine Adult formulation single-antigen hepatitis A vaccine may be used to complete a schedule begun with Twinrix and vice versa Acceptable schedules –2 Twinrix and 1 hepatitis A –1 Twinrix and 2 hepatitis A Maintain spacing recommended for Twinrix –1 month between doses 1 and 2 –5 months between doses 2 and 3

86. Hepatitis A Vaccine Recommendations International travelers Men who have sex with men Injection and noninjection drug users Persons with occupational risk (limited to certain laboratory personnel and animal handlers) Persons with chronic liver disease MMWR 2006;55(RR-7)

87. Hepatitis A Vaccine Recommendations All previously unvaccinated persons who anticipate close personal contact with an international adoptee from a country of high or intermediate endemicity during the first 60 days following arrival of the adoptee in the United States The first dose should be administered as soon as adoption is planned MMWR 2009;58(36):1006-7

88. Hepatitis A Vaccine International Travel The first dose of hepatitis A vaccine should be administered as soon as travel is considered For healthy persons 40 years of age or younger: –1 dose of single-antigen vaccine administered at any time before departure Persons at risk of severe disease from hepatitis A virus planning to travel in 2 weeks or sooner should receive the first dose of vaccine and also can be administered immune globulin MMWR 2007;56(41):1080-4

89. Hepatitis A Postexposure Prophylaxis For healthy persons 12 months through 40 years of age: –single-antigen hepatitis A vaccine should be administered as soon as possible after exposure For persons older than 40 years: –immune globulin is preferred –vaccine can be used if IG cannot be obtained MMWR 2007;56(41):1080-4

90. Hepatitis A Vaccine Contraindications and Precautions Severe allergic reaction to a vaccine component or following a prior dose Moderate or severe acute illness MMWR 2006;55(RR-7)

91. Hepatitis A Vaccine Adverse Reactions Local reactions 20%-50% Systemic reactions (fever, malaise)<10% No serious adverse reactions reported MMWR 2006;55(RR-7)

92. Adult Immunization 2010 MMR Vaccine Segment This material is in the public domain This information is valid as of May 25, 2010

93. Measles-Mumps-Rubella Vaccine (MMR) Contains live attenuated viruses 1-dose efficacy varies from 80% (mumps) to 95% (measles and rubella) Duration of immunity probably lifelong Schedule is 2 doses All adults born in 1957 or later should have documentation of at least 1 dose (or other evidence of immunity)

94. Adults at High Risk for Measles College students International travelers Healthcare personnel

95. MMR Vaccine Contraindications Severe allergic reaction to vaccine component or following prior dose Pregnancy Immunosuppression

96. Measles Vaccine and HIV Infection MMR recommended for persons with asymptomatic and minimally symptomatic HIV infection NOT recommended for persons with evidence of severe immuno- suppression Prevaccination HIV testing of an otherwise healthy person not recommended

97. MMR Vaccination of Women of Childbearing Age Ask if pregnant or likely to become so in next 4 weeks Exclude those who say "yes“ For others – explain theoretical risks – vaccinate

98. MMR Vaccine Precautions Moderate or severe acute illness Recent receipt of a blood product History of thrombocytopenia or thrombycytopenic purpura

99. MMR Adverse Reactions Fever5%-15% Rash 5% Joint symptoms 25% Thrombocytopenia<1/30,000 doses Parotitis rare Deafness rare Encephalopathy <1/1,000,000 doses

100. Adult Immunization 2010 Varicella Vaccine Segment This material is in the public domain This information is valid as of May 25, 2010

101. Varicella Vaccine Live virus vaccine Efficacy –70%-90% against any varicella disease –95%-100% against severe disease Schedule for adults - 2 doses separated by at least 4 weeks

102. Varicella Vaccine Contraindications Severe allergic reaction to vaccine component or following prior dose Pregnancy Immunosuppression

103. Varicella Vaccine Use in Immunocompromised Adults Most immunocompromised persons should not be vaccinated Vaccine is effective and safe in persons with impaired humoral immunity –passive antibody used to treat the condition may interfere with vaccine Vaccinate persons with isolated humoral immunodeficiency

104. Varicella Vaccine Use in Persons with HIV Infection Consider varicella vaccination for HIV-infected adults with CD4+ T- lymphocyte count of 200 mm 3 or higher 2 doses separated by 3 months

105. Varicella Vaccine Precautions Moderate or severe acute illness Recent receipt of a blood product –administer at least 2 weeks prior to receiving blood product –delay for at least 3 months following administration of blood, immune globulin, or other blood products (see table for guidance)

106. Varicella Vaccine Adverse Reactions Injections site complaints - 20% Rash - 4% - 6% –may be maculopapular rather than vesicular –average 5 lesions Temperature 102°F or higher - 10% - 15%

107. Adult Immunization 2010 Meningococcal Vaccine Segment This material is in the public domain This information is valid as of May 25, 2010

108. Meningococcal Polysaccharide Vaccine (MPSV) - Menomune Quadrivalent (serogroups A, C, Y, W-135) Approved for persons 2 years of age and older Administered by subcutaneous injection

109. MPSV Recommendations Not recommended for routine vaccination of civilians Should be used only for persons at increased risk of infection who are 56 years of age or older, or if meningococcal conjugate vaccine is not available

110. Meningococcal Conjugate Vaccine (MCV) Quadrivalent (serogroups A, C, Y, W- 135) conjugated to diphtheria toxoid Menactra approved for persons 2 through 55 years of age Menveo approved for persons 11 through 55 years of age Administered by intramuscular injection

111. Meningococcal Vaccine Recommendations Use of MCV is preferred for persons 2 through 55 years of age for whom meningococcal vaccine is recommended Meningococcal vaccination is routinely recommended for –adolescents –college freshmen who live in a dormitory –adults at increased risk of infection MMWR 2005;54(RR-7)

112. Meningococcal Vaccine Recommendations Recommended for certain high- risk persons: –persistent complement component deficiency –HIV infection –functional or anatomic asplenia –military recruits –certain research and laboratory personnel –travelers to and U.S. citizens residing in countries in which N. meningitidis is hyperendemic or epidemic MMWR 2005;54(RR-7)

113. Meningococcal Vaccine Revaccination Persons through age 55 years who received a previous dose of meningococcal conjugate or meningococcal polysaccharide vaccine and remain at increased risk should receive an additional dose of meningococcal conjugate five years after the previous dose MMWR 2009;58(37):1042-3

114. Meningococcal Vaccine Revaccination High-risk groups who should be revaccinated –persistent complement component deficiency –persons with anatomic or functional asplenia –microbiologists with prolonged exposure to Neisseria meningitidis –frequent travelers to or persons living in areas with high rates of meningococcal disease MMWR 2009;58(37):1042-3

115. Meningococcal Vaccine Revaccination Revaccination with meningococcal conjugate vaccine is currently not recommended for persons whose only risk factor is living in on-campus housing (i.e., a college student living in a dormitory) MMWR 2009;58(37):1042-3

116. Meningococcal Vaccine Contraindications and Precautions Severe allergic reaction to a vaccine component or following a prior dose Moderate or severe acute illness MMWR 2005;54(RR-7)

117. Meningococcal Vaccines Adverse Reactions Local reactions 3%-29% 11%-59% for 1-2 days Low grade fever 3% 5% Systemic reactions 8%-29% 11%-36% (headache, malaise fatigue) MPSV MCV MMWR 2005;54(RR-7)

118. MCV and Guillain-Barre’ Syndrome GBS is a rare illness and expected background incidence rates are not precisely known The number of reports is similar to the number of cases expected to occur in this age group Since 2007, ACIP has considered a history of GBS to be a precaution to the use of meningococcal conjugate vaccine Meningococcal polysaccharide is an acceptable alternative to MCV ACIP is reconsidering this issue

119. Adult Immunization 2010 Adult Immunization Strategies Segment This material is in the public domain This information is valid as of May 25, 2010

120. Influenza Vaccination Coverage for Adults, 2008 18- 49 years of age with high risk conditions 50-64 years of age HP 2010 goal 30% 34% 60%

121. Influenza Vaccination Coverage for Adults, 2008 18- 49 years of age 30% with high risk conditions 50-64 years of age 34% HP 2010 goal 60%

122. Pneumococcal Vaccination Coverage for Adults, 2008 18- 49 years of age15% with high risk conditions 50-64 years of age31% HP 2010 goal60%

123. Vaccination Coverage for Adults 65 Years and Older Influenza vaccine 67% Pneumococcal vaccine 61% HP 2010 goal 90%

124. One of the most important reasons adults identify for not receiving a vaccine is the lack of a provider recommendation for the vaccine.

125. Interventions to Improve Adult Vaccination Coverage Client reminder and recall systems Provider reminder and recall systems –computer notification –flow sheet or checklist –flagging medical record with sticker or stamp Assessment and feedback for providers

126. Interventions to Improve Adult Vaccination Coverage Standing orders –allow nonphysician personnel to prescribe or deliver vaccines using a protocol Reducing out-of-pocket costs for patients Expanding access –increasing or changing hours when immunization services are offered –“express lane” for immunizations

127. Interventions to Improve Adult Vaccination Coverage Screen for vaccine indications Recommend the vaccines Make the vaccines available in the office Patient reminder and recall Standing order system

128. National Center for Immunization and Respiratory Diseases Contact Information Telephone (800) CDC-INFO Email nipinfo@cdc.govnipinfo@cdc.gov Website http://www.cdc.gov/vaccines/ http://www.cdc.gov/vaccines/ Broadcast Updates and Resources Web Page http://www.cdc.gov/vaccines/ed/webcasts.htm