1. Immunizations for Adults Stephen J. Gluckman, M.D.

2. Immunizations  Where do the recommendations come from?  Advisory Committee on Immunization Practices  Approved by:  American Academy of Family Physicians  American College of Obstetricians and Gynecologists  American College of Physicians

3. Definitions  Active  Toxoid  Live, Attenuated  Killed, Inactivated  Recombinant  Pre-Exposure  Passive  Immune Globulin  Specific high titer preparations  Post-Exposure

4. General Rules: Administration  Give it the way it is recommended.  The buttock is generally not recommended.  Recommended intervals between doses are the minimal ones.  Shorter may lead to decreased antibody levels  Longer will not  Can administer most vaccines simultaneously.

5. General Rules: Contraindications and Precautions  The live vaccines are measles, mumps, rubella, yellow fever, oral polio, varicella, zoster, oral typhoid, BCG  Pregnant woman  Immunocompromised patients  Vaccines made in eggs are measles, mumps, influenza - both, yellow fever  True egg allergy  Vaccines containing neomycin are measles, mumps, rubella, zoster  None contain penicillin

6. General Rules: Misconceptions I The following are not contraindications to vaccination  Local or mild-moderate reactions to previous vaccination  Mild acute URI or gastroenteritis  Current antimicrobial therapy  Breast Feeding

7.  Personal history of “allergies”  Family history of adverse reactions to an immunization  Pregnancy, unless live vaccine  Pregnancy in a household member of vaccinee General Rules: Misconceptions II

8. General Rules: Misconceptions III  Mercury  Thimerosal in vaccines since the 1930’s  No evidence that it has caused any harm  Ethyl mercury not methyl mercury  Essentially removed from all vaccines today  Trace amounts in some formulations of Influenza, Td, TDaP  Autism  Fraudulent study  Poorly supported anecdote

9. REPORT SEVERE REACTION TO PROPER AUTHORITIES http://vaers.hhs.gov/index 1-800-822-7967

10. Immunization record  The patient’s chart should contain a notation including the:  Date  Type of Immunization  Dose  Site  Lot number  Manufacturer  Identification of the person who administered

11. Pre-Exposure Immunization  All Adults  Tetanus/Diphtheria (Td)  Every 10 years  One of these should be: tetanus, diphtheria, acellular pertussis (Tdap)  This should be given if no Td within 5 years  Many Adults  Measles, Mumps, Rubella, Influenza, Pneumococcus, Hepatitis B, Varicella, Hepatitis A, HPV, Zoster  Selected Groups  Travelers, Health Care Workers, College Students, Nursing Home Residents

12. Post-Exposure Immunizations  Hepatitis A  Hepatitis B  Tetanus  Rabies  Varicella

13. MMR  Measles and Mumps  Made in Eggs, Live  One dose indicated for all persons born after 1956 unless  One or more documented prior immunizations  (+) serology  HCW documented disease  Medical contraindication  Second dose  Recently exposed  HCW  International traveler  College Student

14. Rubella  Rubella  Live, no eggs  One dose indicated for  All women of child bearing potential  All HCW’s  unless  History of vaccination  (+) serology »A history of rubella is not reliable

15. Rubella: Vaccine  Live attenuated virus is shed but there is no transmission  Adverse reactions:  Arthralgias and arthritis  Fever  Rash

16. Rubella  What if pregnant at the time of immunization? “The risk of vaccine associated with defects is so small as to be negligible and should not ordinarily be a reason to interrupt pregnancy” - CDC Registry

17. Rubella  Can a breast feeding woman get Immunized?  Yes  Can a household member of a pregnant woman get immunized?  Yes

18. Influenza  Two Types of Vaccines - equal efficacy  Live Vaccine (FluMist ® )  Advantages  No injection  Disadvantages  Expensive  Nasal stuffiness, rhinitis  Shed virus  Only approved for 18-49 year olds  No contact with immunocompromised persons  Inactivated Vaccine  Parenteral  Latex free »Fluzone ®, Fluvirin ®  Contains latex »Fluarix ®

19. Influenza: Vaccine  Changes from year to year based on the “best guess” of which strains will be circulating  Patients need to know  About 70% efficacy  Prevents influenza, a bad disease, not URI’s

20. Influenza: Whom to Vaccinate with the Seasonal Vaccine?  All adults  Particularly indicated for:  Otherwise healthy persons > 50 years of age  Adults chronic cardiopulmonary disorders  Adults with chronic metabolic diseases  Pregnant women  Health care workers  Persons with HIV infection  Residents of chronic care facilities

21. Pneumococcal Vaccine  PPV  23 capsular polyvalent polysaccharide antigens of 90% of bacteremic infections  Healthy adults respond to 80% of the serotypes  PCV  Conjugated vaccine for infants and children (Prevnar ® )

22. Pneumococcal Vaccination  Whom to vaccinate?  All adults 65 and over and those high risk groups at any age  CSF leaks and cochlear implants  Asplenic  Chronic cardiopulmonary, alcoholism or metabolic diseases  Revaccination?  For most people only a single vaccination is recommended  Consider revaccination for:  high risk groups  Those immunized > 5 years ago and were < 65 at the time

23. Hepatitis B WW hy vaccinate? 2200-300,000 new cases annually 110% chronic carrier IImmediate and late mortality

24.  Recombinant  >95% of healthy adults make antibody  Schedule options  0,1,4 months  With hepatitis A (Twinrix):  0,1,6 months  0,7,21 days and 12 months  High dose vaccine for dialysis and immunocompromised patients

25. Hepatitis B: Recommendations AA ll Newborns AA ll Adolescents SS elected (Almost all) Adults OOccupational, e.g. Health Care Workers HHemodialysis patients IInjection drug users SSexually active, Non-monogamous SSexual partner of a known carrier IInmates of long-term correctional facility RRecipients of blood products PPersons with chronic liver disease HHousehold contacts

26.  Management of non-responder?  0.1 - 0.25 ml intradermal at 0,2,4 weeks*  Revaccinate with dialysis dose (40 mcg)*  Need for booster?  Not recommended  Pre and post immunization serological testing?  Not recommended *Not FDA approved but supported in the literature Hepatitis B Areas of Concern

27. Hepatitis A  Vaccine  Formalin inactivated  No antibiotics  Single dose is 99% protective; second dose at > 6 months confers more long lasting immunity  Indications  All children  High risk adults  International travelers  Persons living in areas of high endemicity  Persons working in day care centers  Persons with chronic liver disease  Post exposure prophylaxis (14 days)

28. Hepatitis A  Three equally effective options  Hepatitis A alone (Vaqta or Havrix)  0, > 6 months  Twinrix (Combined with Hepatitis B)  0,1,6 months  0,7,21 days and 12 months

29. Varicella Vaccine  Live, attenuated, neomycin  99% seroconversion rate after two doses  Protective for at least 10 years  Breakthrough infections occur, but are mild  Transmission rates of the vaccine to susceptible contacts are very low.

30. Varicella  Who is Susceptible?  A history of varicella is very reliable  A negative history of varicella is not  Cost effective to measure antibodies in a person who says that they did not have varicella  Indications  All susceptible

31. Varicella Vaccine  Dosage and administration  Children 12 mos to 13 yrs - two doses at > 3 months apart  Greater than 13 yrs - two doses at 4-8 week intervals  Routine testing for immunity after vaccination is unnecessary  Adverse effects: local discomfort

32. An 18 year old woman comes to your office for pre-college immunizations. If she does NOT already have known immunity, for which of the following should she be immunized? (select all that apply) CASE  Measles, mumps, rubella  Hepatitis B  HPV  Meningococcus

33. Meningococcal Vaccine  Two types  Conjugate (Menactra, Menveo)  Age 2-55  Polysaccharide (Menomune)  > Age 55

34. Meningococcal Vaccine  Only effective against serogroups A,C,Y, W-135.  About 30% caused by group B – not in the vaccine

35. Meningococcal Vaccine  Recommended (1 dose)  All children age 11-12  1 st year college students living in dormitories and military recruits (if not given earlier)  Persons at increased risk ages 2-55 years  Travelers to endemic or epidemic areas  Persons on a Hajj (required)  Asplenic patients  Persons with terminal complement deficiencies

36.  Relative Risks for meningococcal disease (per 100,000)  Endemic risk 1-1.5  All college students0.6  Freshman1.7  Freshman in dorm5.4 Meningococcal Vaccine

37.  What is the absolute risk?  About 88 cases of meningococcal meningitis a year in USA  About 30 cases in college students  Vaccine about 90% effective  Vaccine only covers about 70% of the strains  10% mortality, 10% severe sequellae  Therefore: the vaccine will prevent about 18 cases a year in college students and about 4 deaths or severe sequellae  However, it is safe (expensive)

38. Human Papillomavirus (HPV) Vaccine  Indicated for women and suggested for men, 9-26 years  99% make antibodies to the serotypes  ACIP: aim at 11-12 year olds with “catch-up” of older  Two vaccines  Gardasil ® HPV Types 16,18: 70% of types that cause cervical cancer  HPV Types 6,11: 90% of types that cause warts  3 doses: x, x+2m, x+6m  Cervarix ®  Types 16,18  3 doses: x, x+1, x+6

39. Human Papillomavirus (HPV) Vaccine  FAQ  Should woman be screened before being vaccinated  No  What about vaccinating men?  Consider to prevent warts, not cancers or transmission  Should pregnant woman get vaccinated?  No, appears to be safe but…..  How long does the protection lasts?  Unknown. At least 5 years

40. Herpes Zoster Vaccine  Single dose  Live  Neomycin  Studied in 60 years old and older  Prevented disease in 50%  Breakthrough infections were generally milder  Decreased efficacy with increasing age  History of zoster is not a contraindication

41. Pre-Exposure, Selected Groups

42. Nursing Home Patients  Influenza  Pneumococcus  Tetanus/Diphtheria (Tdap)

43. College Students  Measles, Mumps, Rubella  Tetanus/Diphtheria/Pertussis  Hepatitis B  Meningococcal  HPV

44. Health Care Workers  Hepatitis B  Influenza  Varicella  Measles, Mumps, Rubella

45. Questions?