Update 2010:Vaccines: HZ, HPV, Pneumococcus

T. Mazzulli, MD, FRCPC, FACP

Department of Microbiology

Mount Sinai Hospital and University Health Network

Learning Objectives:

1.Realize that immunization against adult infectious diseases is one of the most successful interventions to protect the health of Canadians

2.Describe recent clinical updates and what’s new in routine adult immunizations: Zoster, HPV and Pneumococcus

3.Develop procedures to enhance immunization rates based on the most recent clinical guidelines in adult immunizations

Ten Great Public Health Achievements1900 - 19991

1. Vaccination2. Motor vehicle safety3. Safer workplaces4. Control of infectious diseases5. Decline in deaths from coronary heart disease and

stroke6. Safer and healthier foods7. Healthier mothers and babies8. Family planning9. Fluoridation of drinking water10. Recognition of tobacco use as a health hazard

1. MMWR, December 24, 19992. Canadian Coalition for Immunization Awareness & Promotion. 2005

Immunization:– Saved more lives in Canada in the last 50 years

than any other health intervention2

– Single most cost-effective health investment, making immunization a cornerstone of efforts to promote health2

Immunization:– Saved more lives in Canada in the last 50 years

than any other health intervention2

– Single most cost-effective health investment, making immunization a cornerstone of efforts to promote health2

Comparison of Maximum and Current Reported Morbidity:Vaccine-Preventable Diseases in the US

Disease PrevaccineEra*

Year 1999 % Decrease

Diphtheria 206,939 1921 1 99.99

Measles 894,134 1941 100 99.99

Mumps 152,209 1968 391 99.75

Pertussis 265,269 1934 7,288 97.25

Polio (wild) 21,269 1952 0 100.00

Rubella 57,686 1969 267 99.53

Cong. Rubella synd.

20,000+ 1964-65 6 99.96

Tetanus 1,560+ 1948 42 97.31

Invasive Hib disease

20,000+ 1984 1,309 99.65

Total 1,639,066 9,404 99.43

Canadian Cost-Benefit of Adult Vaccination

Cost per Life Year Saved for Selected Vaccine Programs and Other Public Health Interventions

Cost per life year saved

Vaccines

Influenza for adults aged ≥ 65 years of age < 0 ($45 saved per $ spent)

Pneumococcal polysaccharide for adults aged ≥ 65 years

< 0 ($8 saved per $ spent)

Other interventions

Low cholesterol diet for men > 20 yo and cholesterol over 4.65 mmol/L (180 mg/dL)

$360,000

Smoking cessation counseling $1,000-10,000

Annual screening for cervical cancer $40,000

Adapted from 2006 Canadian Immunization Guide

Burden of Vaccine Preventable Diseases

There are 200-300 vaccine preventable deaths in Children in the U.S. each year vs 50,000 Adult vaccine preventable deaths/year in the U.S.3

Total economic burden of treating vaccine preventable diseases in adults in the US is greater than $10 billion/year1

1. Inf Disease Clinics of NA. 15(1):9-19, 2000 Mar2. Poland 2005 Vaccine 23 p 2251-22553. Poland 2003 Am J Prev Med, 25(2): 144-50

Comparison of Pediatric & Adult Immunization Coverage

Pediatric Uptake

Rates1

2 years of age

n=4,988

Adult Uptake Rates 2

18-64 y.o.

Total

n = 2,237

with CMC

n=395

65 +

(n=287)

DTaP or IPV

n( %)

85.5% n=4,265

Influenza* 37.3 % 38.2% 69.9%

Hib n(%) 85.8% n=4,278

Hepatitis A 25.1% 22.7% 10.3%

Meningococcoal Conjugate n(%)

94.2% n=4,701

Hepatitis B 30.2% 29.2% 10.5%

Pneumococcal Conjugate n(%)

83.8%

n=4,181

Pertussis 3.9% 2.4% 2.5%

MMR n(%) 93.0% n=4,641

Tetanus 46.5% 49.1% 28.5%

Varicella n(%) 86.8% n=4,328

Pneumococcal* 29.4%

n=599

16.7%

n=271

38.6%

n=287

1. CCDR: 32 (10 2006 Immunization coverage by age 2 for the five recommended vaccines in the Capital Health Region (Edmonton)2. Canadian Adult National Immunization Coverage Survey 2006

Adult Immunization:

Routinely for All & Specific Groups

Adult immunization programs present new and different challenges relative to childhood programs

Adult Immunization Schedule Classification:

– Routinely for All2 – Specific Groups2

Age1

Occupation1

Health Status1

Behaviour (travel, sexual behaviour)1

1. Plotkins, S. et al, Immunization in the United States. Vaccines 2008:1479-15102. 2006 Canadian Immunization Guide

Adult Immunization: Key Issues

Immunosenescence:

Diminished immune response of both innate and adaptive immune systems

Decline in vaccine efficacy with age

Increasing morbidity & mortality from natural infection

=> Increased burden as we age

Kumar, R, et al, Expert Rev. Vaccines 2008 7(4) 467-479.

What’s New in Immunization?

Herpes Zoster Vaccine

Human Papilloma Virus Vaccine

Pneumococcal Vaccine

Influenza Vaccine (2010/2011)

VZV: Reactivation

Posterior column spinal cord

Dorsal root ganglion

Site of VZV replication

Arvin AM. Varicella-zoster virus. In: Knipe DM, Howley PM, eds. Fields Virology. 4th ed. Vol 2. New York, NY: Lippincott Williams & Wilkins; 2001:2731-67

Straus SE, Oxman MN. Varicella and herpes zoster. In: Freedberg IM, Eisen AZ, Wolff K, et al, eds. Fitzpatrick’s Dermatology in General Medicine. 5th ed. Vol 2. New York, NY: McGraw-Hill; 1999:2427-50

Incidence of Zoster by Age

Johnson R. et al. JID 2007 11(Suppl 2) S43-48

The incidence of shingles increases significantly with age, with 67% of cases occurring in persons over 50 years of age.

Herpes Zoster: Canadian Epidemiology

Estimated ~30% lifetime risk of one VZV reactivation1; ~50% if live to 80 years of age

Estimated 129,882 cases of Shingles per year1

– ~90% of cases occur in immunocompetent people;

13% of zoster episodes will result in PHN (Defined as Pain >90 days after rash onset)

– 17,108 episodes/year

~2,000 hospital admissions and 20 deaths per yr

Brisson M. et al. Human Vaccine 2008

Kost R et al. N Engl J Med. 1996;355:32-42.

Pe

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nt

of

pa

tien

ts

rep

ort

ing

pai

n

Age (years)

0

100

80

60

40

20

0-19 20-29 30-39 40-49 50-59 60-69 ≥79

>1 yr

<1 mo

6 - 12 mo

1 - 6 mo

Prevalence of PHN and Duration of Pain Associated with PHN Increase with Age

Arvin A, NEJM 352:2266, 2005

Varicella Exposure

Silent reactivation?

Zoster vaccination

Zoster Threshold

Varicella Herpes Zoster

Age

Aging & Zoster Risk

VZVT-cells

Arvin A. Aging, Immunity, and the varicella-zoster virus. N Engl J Med 2005;352(22):2266-7.

The Shingles Prevention Study Design

Randomized Double-blind, placebo-controlled, multicenter trial – 1:1 Zoster Vaccine or placebo

(Study Timeline: Nov-1998 to April 2004)

Enrolled 38,546 subjects 60 years of age– Age-stratified (60 to 69 years, 70 years)

Median of 3.12 years of surveillance for Herpes Zoster

Oxman M et al. N Engl J Med. 2005;352:2271-2284.

Shingles Prevention Study Vaccine Efficacy: HZ Incidence by age

Efficacy Efficacy

(95% CI)(95% CI)

51.3% 51.3% (44.2-57.6)(44.2-57.6)

63.9%63.9% 37.6%37.6%

0

2

4

6

8

10

12

14

All 60-69 yr 70 yr

Incid

en

ce o

f H

Z Vaccine

Placebo

*

Adapted from Oxman M et al. N Engl J Med. 2005;352:2271-2284.N=38,546 subjects 60 years of age *P <0.001

Shingles Prevention StudyVaccine Efficacy: PHN Incidence by age

Efficacy Efficacy

(95% CI)(95% CI)

66.5% 66.5% (47.5-79.2)(47.5-79.2)

65.7% 65.7% (20.4-86.7)(20.4-86.7)

66.8% 66.8% (43.3-81.3)(43.3-81.3)

0.0

0.5

1.0

1.5

2.0

2.5

All Subjects 60-69 yr 70 yr

Inci

den

ce o

f P

HN

Vaccine

Placebo

*

*P <0.001N=38,546 subjects 60 years of age

Adapted from Oxman M et al. N Engl J Med. 2005;352:2271-2284.

Safety of Herpes Zoster Vaccine:Serious Adverse Events Among All Subjects

Event Vaccine Group

Placebo Group

No. Subjects 19,270 19,276

Day of Vaccination. To End of Study

Death 218 (2.1%) 246 (2.4%)

Vaccine-related SAE 2 (<0.1%) 3 (<0.1%)

Day of Vaccination. To Day 42

Death 14 (0.1%) 16 (0.1%)

≥1 SAEs 255 (1.4%) 254 (1.4%)

Simberkoff MS, et al. Ann Intern Med 2010May;152(9); Oxman, M, et al, Shingles Prevention Study. NEJM 2005

Safety of Herpes Zoster Vaccine:Adverse events at the inoculation site

Adverse events Zoster Vaccine

N=3326

Placebo

N=3249

>1 Inoculation-site adverse event 48.2% 16.6%

Erythema 35.8% 6.9%

Pain or Tenderness 34.4% 8.5%

Swelling 26.2% 4.5%

Pruritus 7.1% 1.0%

Temperature 38.3o C or higher 0.8% 0.8%

Rash 0.3% 0.1%*p<0.001

Simberkoff MS, et al. Ann Intern Med 2010May;152(9); Oxman, M, et al, Shingles Prevention Study. NEJM 2005

Zoster Vaccine in Patients 50 to 59 yrs

22,439 pts aged 50 to 59 yrs– 2.2 yrs follow-up– Efficacy for prevention of HZ was 69.8%

(95% CI: 54.1 to 80.6)– Adverse events (AE):

72.8% vs 41.5% (injection site AE & headache)

0.6% vs 0.5% for serious AE at 42 days

Schmader K et al. Abstract 1380. IDSA. Vancouver, BC, October 2010

Zoster Vaccine (Oka/Merck)

Live, attenuated, Oka/Merck strain of Varicella-zoster Virus

Single-dose of entire vial (approx. 0.65ml)

S.Q. administration only

Contains at least 14-fold more PFU of VZV Oka/Merck/ dose than the Varicella Vaccine

STORE FROZEN - Average temperature of –15°C or colder until it is reconstituted for injectionDISCARD RECONSTITUTED VACCINE IF NOT USED WITHIN 30 MINS

National Advisory Committee on Immunization (NACI)

Members: Dr. J. Langley (Chairperson), Dr. B.Warshawsky (Vice-Chairperson), Dr. S. Ismail (Executive Secretary), Ms. A. Hanrahan, Dr. K. Laupland, Dr. A. McGeer, Dr. S. McNeil, Dr. B. Seifert, Dr. D. Skowronski, Dr. B. Tan.

Liaison Representatives: Dr. B. Bell (CDC), Dr P. Orr (AMMI Canada), Ms. S. Pelletier (CHICA), Ms. K. Pielak (CNCI), Dr. P. Plourde (CATMAT), Dr. S. Rechner (CFPC), Dr. M. Salvadori (CPS), Dr. D. Scheifele (CAIRE), Dr. N. Sicard (CPHA), Dr. V. Senikas (SOGC).

Zoster Vaccine in Canada

Recommendations:– For prevention of HZ and its complications in persons >60 yrs

without contraindications– May be used in patients aged 50 and older– No recommendation for those with a past episode of zoster– Should be given to patients irrespective of a prior history of

chickenpox or documented prior varicella infection– Booster doses are not recommended for healthy pts– Individuals who indavertently receive systemic anti-viral therapy

active against VZV within 2 days before and 14 days after vaccine may benefit from a second dose 42 days or later

– May be given with influenza vaccine; Pneumovax and zoster vaccine should be given at least 4 weeks apart

National Advisory Committee on Immunization (NACI). CCDR January 2010; vol. 36

Zoster Vaccine in Canada

Contraindications:– History of hypersensitivity to any component of the vaccine,

including gelatin– History of anaphylactic/anaphylactoid reaction to neomycin

(traces)– History of dermatitis due to neomycin is not a contraindication to

receiving live virus vaccines– Primary and acquired immunodeficiency states– Immunosuppressive therapy including high-dose corticosteroids– Active untreated tuberculosis– Pregnancy

National Advisory Committee on Immunization (NACI). CCDR January 2010; vol. 36

HPV Vaccines

WHO Information Centre on HPV and Cervical Cancer. Available at: www.who.int/hpvcentre/statistics/en/.

Oropharynx 35.6%

Oral cavity 23.5%

Penis 47.0%

Vulva 40.4%

Anus 84.2%

Vagina 69.9%

Cervix > 99%

Percentage

0 10020 806040

National Advisory Committee on Immunization (NACI)

•Members: Dr. M. Naus (Chairperson), Dr. S. Deeks (Executive Secretary), Dr. S. Dobson, Dr. B. Duval, Dr. J. Embree, Ms. A. Hanrahan, Dr. J. Langley, Dr. K. Laupland, Dr. A. McGeer, Dr. S. McNeil, Dr. M.-N. Primeau, Dr. B. Tan, Dr. B.Warshawsky.

Liaison Representatives: S. Callery (CHICA), Dr. J. Carsley (CPHA), E. Holmes (CNCI), Dr. B. Larke (CCMOH), Dr. B. Law (ACCA), Dr. D. Money (SOGC), Dr. P. Orr (AMMI Canada), Dr. S. Rechner (CFPC), Dr. M. Salvadori (CPS), Dr. J. Smith (CDC), Dr. J. Salzman (CATMAT), Dr. D. Scheifele (CAIRE).

Recommended UseGroup Recommendation Comments

Females

Age 9–13 years

Recommended •Efficacy is greatest prior to first sexual intercourse

•Although efficacy not demonstrated, immunogenicity data imply high efficacy

Females Age 14–26 years

Recommended, even after onset of sexual activity

•May not have been infected

•Very unlikely to have been infected with all 4 vaccine HPV types

•Need to be aware that they may already have been infected

Females

Age 14–26 years

with HPV-related cervical or genital disease or current infection

Recommended •May not have been infected with vaccine HPV types

•Very unlikely to have been infected with all 4 vaccine HPV types

•Need to be aware that vaccine probably has no therapeutic effect

15 February 2007Statement on human papillomavirus vaccine. Canada Communicable Disease Report. An Advisory Committee Statement (ACS). Can Commun Dis Rep. 2007;33(ACS-2):1-32.

Yuk

BC

NWT

AB SK MB

ON

QC

Nun

One Age Group

Multiple Age Groups

No Public Announcement

NF

PEI

NSNB

Multiple Age Groups (Uptake %) Quebec: Grade 4, Grade 9, and Girls < age 18 (84-87%) British Columbia: Grade 6 and Grade 9. (66%) Alberta: Grade 5 and Grade 9 (starting in 2009). Saskatchewan: Grade 6 with a one year Grade 7 catch-up. New Brunswick: Grade 7 with a one year Grade 8 catch-up. Nova Scotia: Grade 7 with a one year Grade 10 catch-up

(80%) Newfoundland and Labrador: Grade 6 and Grade 9 (83%) Yukon: Grade 5 with a catch-up in Grade 6 and 7

Canadian HPV Vaccine Public ProgramsOne Age Group• Manitoba: Grade 6• Ontario: Grade 8

(55%)• Prince Edward Island:

Grade 6 (80%)

February 2009

HPV Vaccines – Available in CanadaQuadrivalent vaccine:

Contains HPV Types 6, 18 (20 ug each), 11, 16 (40 ug each)Adjuvant: 225 ug Aluminum hydroxyphosphate sulfateApproved in Canada – May 2006 (initially for females 9 to 26 yrs of age; now expanded indications)

3 i.m. Doses: 0, 2 (± 1 m), and 6 (± 2 m) m Bivalent Vaccine:

Contains HPV Types 16 and 18 (20 ug each)Adjuvant: 500 ug Aluminum hydroxide, 50ug 3-deacylated monophosphoryl Lipid AApproved in Canada – February 2010 for females from 10 to 25 yrs of age3 i.m. Doses: 0, 1 (up to 2.5 m) and 6 (between 5 and 9 m after 1st dose) m

HPV2 and HPV4 – Efficacy

L. Markowitz. CDC. Presented at ACIP Oct 2009

HPV Vaccine: Expanding Indications

1. “Older” women >26 years of age

2. Males

http://www.cdc.gov/vaccines/recs/acip/slides-oct09.htm

Quadrivalent HPV Vaccine: Efficacy in Women Aged 24-45 Years: Future III

Population Vaccine (n=1911)

Placebo (n=1908)

Vaccine Efficacy

95% CI

All subjects 4 41 91% 74, 98

24-34 yr 2 24 92% 67, 99

35-45 yr 2 17 89% 52, 99

HPV 16 & 18 4 23 83% 51, 96

HPV 6 & 11 0 19 100% 79, 100

Muñoz N, et al. Lancet 2009; 373:1949-57.

HPV Vaccine in Men

The incidence of anogenital HPV infection in men is at least as high as in women.1

32% of all HPV-related cancers in the USA occur in men.2

Quadrivalent HPV vaccine is immunogenic in males.3

Preliminary data demonstrate efficacy of quadrivalent HPV vaccine versus infection and disease in both heterosexual4 and homosexual men.5

1. Partridge JM, et al. J Infect Dis 2007;196:1128-36.2. Saraiya M, et al. Cancer 2008;113 (10 Suppl):2837-40.3. Guris D. 25th International Papillomavirus Conference, Malmo. May 2009. Abstract P-27.16 4. Giuliano A, Palefsky J. 25th International Papillomavirus Conference, Malmo. May 2009. Abstract O-01.07 5. Palefsky J, Giuliano A. 25th International Papillomavirus Conference, Malmo. May 2009. Abstract O-27.01

Severity

Quadrivalent HPV Vaccine

(n = 1,397)Placebo

(n = 1,408)

% Efficacy 95% CICasesInc. per 100 PY Cases

Inc. per 100 PY

Condyloma 3* 0.1 28 1.0 89.4 65.5, 97.9

PIN 1 0 0.0 2 0.1 -- --

PIN 2/3 0 0.0 1 0.0 -- --

Penile/perineal/ perianal cancer

0 0.0 0 0.0 -- --

Efficacy Against HPV 6/11/16/18 Related External Genital Lesions (EGL) in Men 16-26 yr

n = number of subjects randomized who received at least one injection and have follow-up after month 7 PY = person years; PIN = penile/perianal/perineal intraepithelial neoplasia; case counting began after month 7.

Per-protocol population

*Two cases related to HPV 6 alone, and one case related to HPV 6/11/35

A. Giulano & J Palefsky. IPVC 2009; O-01.07

Use of Quadrivalent HPV Vaccine in Males

Health Canada:Feb. 23rd, 2010 – Approved for use in males between 9 to 26 yrs for prevention of infection caused by HPV types 6, 11, 16 and 18 and genital warts caused by HPV types 6 and 11

http://www.cdc.gov/vaccines/recs/acip/slides-oct09.htm

Adverse Events to the HPV Vaccines

Comparative Trial (Bivalent & Quadrivalent Vaccines) (N=1106):

Local symptoms (pain, redness, swelling) & general symptoms (fatigue, myalgia): Bivalent > Quadrivalent

SAEs similar between both (~7% vs 6.2%)

http://www.fda.gov/AdvisoryCommittees/CommitteesMeetingMaterials/BloodVaccinesandOtherBiologics/VaccinesandRelatedBiologicalProductsAdvisoryCommittee/ucm183835.htm; Einstein et al. Human Vaccines 2009

Duration of Protective Efficacy

Both vaccines induce antibody titers substantially higher than after natural infection– Minimum protective antibody threshold not known– Different antibody assays used in clinical trials – can’t

compare antibody titers between trials

WHO:– Protective efficacy of the 2 vaccines has been

maintained throughout their respective observation periods: 6.4 years (bivalent) and 5 years (quadrivalent)

http://www.who.int/wer/2009/wer8415.pdf

0

20

40

60

80

100

6–10 months 2 year 3 year 4 year

%

99%

71%

61%

100% 100% 100%

68%

Seropositivity and Efficacy of quadrivalent vaccine against HPV 18 related CIN2/3 or AIS in Women 16–26 years

Seropositivity to HPV 18

neutralising antibodies as measured by

cLIA

Efficacy against HPV 18-related CIN 2/3 or AIS

*Seropositivity to HPV 18 neutralizing antibodies to a single neutralizing epitope measured by cLIA

Joura E, et al. Vaccine 2008; 26(52)

41

*In participants naïve to the relevant HPV type from day 1 through month 60.

Adapted from Olsson S-E et al. Vaccine (2007), doi:10.1016/j.vaccine.2007.03.049.4

Demonstration of Immune Memory* with an Antigen Challenge at Month 60 Among Women 16-23 Years of Age (HPV 18)

Similar results seen with HPV 16, 6, and 11

Anti-HPV GMT levels[log10 scale])

60+1week

Immune Immune memory memory

demonstratdemonstrated after ed after immune immune

challengechallenge

10,000

1000

100

10

0 2 3 7 12 18 24 30 36 54 60 61

GARDASIL™ (n=82)

Placebo (Sero and PCR neg) (n=70)

Months

6

Pneumococcal Vaccine

0

500,000

1,000,000

1,500,000

2,000,000

All agesChildren aged <5 years

WHO 2004 Global Immunization Data. http://www.who.int/immunization_monitoring/data/GlobalImmunizationData.pdf. Accessed June 7, 2009.

Pneumococcal Disease Is the Leading Cause of Vaccine-preventable Deaths (WHO)

aPolio, diphtheria, yellow fever.

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Age-Specific Incidence of Invasive Pneumococcal Disease, Toronto, 1995

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Pneumococcal Vaccines

1. 2006 Canadian Immunisation Guide2. Canadian Adult National Immunization Coverage Survey 20063. Ann Intern Med. March 2009

Conjugate vaccine (PCV-7):– Jan. 2005 provincial program in Ontario started– No catch-up; start with birth cohort– Covers >80% of serotypes from blood and CSF of children in the pre-

vaccine era– 75% decrease in IPD in children

23-valent Polysaccharide vaccine:– Oct. 1996 provincial program for routine vaccination of all persons 65

yrs– All persons 5 yrs who are at high risk for IPD including those 19 – 65

yrs with asthma3 – Routine booster not recommended; consider once in high risk group

after 5 years– Covers 90% of serotypes from bacteremia and meningitis in adults– Has not been shown to reduce the incidence of CAP but may be

associated with a decrease risk of bacteremia and death as well as severity

Newer Pneumococcal Conjugate Vaccine

Pneumococcal 10 Conjugate Vaccine (Synflorix):– Licensed in Canada in December 2008 for children 6

weeks up to 2 years of agePrimary series: 4 i.m. doses (2, 4, 6, 12-15 months)

– Conjugated to Non-typeable H. influenzae (NTHi) protein D, Diphteria or tetanus toxid

Pneumococcal 13 Conjugate Vaccine (Prevnar 13):– Licensed in Canada in February 2010 for children 6

weeks through 5 yrs of agePrimary series: 4 i.m. doses (2, 4, 6, 12-15 months)Previous PCV-7: 1 dose in 2nd year of life

– Conjugated to Diphtheria CRM197 protein– Will be licensed for use in adults >55 yrs

PCV7 PCV10 PCV13 PPV23

4 4 4 4 2

6B 6B 6B 6B 8

9V 9V 9V 9V 9N

14 14 14 14 10A

18C 18C 18C 18C 11A

19F 19F 19F 19F 12F

23F 23F 23F 23F 15B

1 1 1 17F

5 5 5 22F

7F 7F 7F 33F

3 3

19A 19A

6A

Pneumococcal Vaccines

Primary Objective: To evaluate the association between pneumococcal

vaccination and the risk of myocardial infarction

Pneumococcal vaccination associated with a decrease of more than 50% in the rate of myocardial infarction 2 years after exposure to vaccine

Influenza Vaccine

Pandemic H1N1 2009: Multiple Waves of Morbidity and Mortality in Canada

National Advisory Committee on Immunization (NACI)

•Members: Dr. J. Langley (Chairperson), Dr. B. Warshawsky (Vice-Chair), Dr. S. Ismail (Executive Secretary), Dr.N. Crowcroft, Ms. A. Hanrahan, Dr. B. Henry, Dr. D. Kumar, Dr. S. McNeil, Dr. C. Quach-Thanh, Dr. B. Seifert, Dr. D. Skowronski, Dr. C. Cooper.

Trivalent Influenza Vaccine 2010/2011

Five vaccines (4 i.m. & 1 intradermal) licensed in Canada containing 3 influenza strains:– 2009 pandemic influenza A California (H1N1) - like– 2009 Influenza A Perth (H3N2) - like– 2008 Influenza B Brisbane – like

None contains an adjuvant

Publicly funded programs will use Fluviral (contains thimerosal but no antibiotics) and Vaxigrip (contains thimerosal and neomycin) vaccines– Can be used in adults and children >6 months of age

National Advisory Committee on Immunization (NACI). CCDR August 2010; vol. 36

Trivalent Influenza Vaccine 2010/2011

Recommended Recipients:1. Adults (including pregnant women) and children

with chronic health conditions2. Residents of nursing homes3. People >65 yrs of age4. Healthy children 6 to 23 mos5. Healthy pregnant women (risk of influenza-related

hospitalization increases with length of gestation)6. People capable of transmitting influenza to those at

high risk (e.g. Healthcare workers, Household contacts, child care workers, etc.)

National Advisory Committee on Immunization (NACI). CCDR August 2010; vol. 36

Trivalent Influenza Vaccine 2010/2011

Recommended Recipients (New for 2010/2011):

1. Persons who are morbidly obese (BMI >40)

2. Aboriginal peoples

3. Healthy children 2 to 4 years of age

The first time children <9 yrs receive TIV, a two-dose schedule is required REGARDLESS of whether or not the child received monovalent pH1N1 vaccine in 2009-2010

National Advisory Committee on Immunization (NACI). CCDR August 2010; vol. 36

What Can Be Done to Improve Adult Immunization Rates?

Adult Immunization:Strategies to Improve Vaccine Uptake

Communication

Explaining the need for immunization

Clearly conveying the risks1

Strong physician/provider recommendation1

1Burns IT, Zimmerman RK. 2005:54:S58-622PHAC 2006 Canadian Adult Immunization Coverage Survey

93

7

88

14

79

24

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GotPneumo

Shot

GotTetanus

Shot

Got FluShot

MedicalRecommendation

No MedicalRecommendation

Recommendation is critical2

Adult Immunization:Strategies to Improve Vaccine Uptake

Patient Visit Strategy Assess vaccination at all visits:

stamped chart reminders Improve tracking system

CCIAP Adult Immunization Wallet Card

Empower patient to become more involved Adult Immunization

Questionnaire

Szilagyi, PG, et al. 2005:40:152-161.

Summary

Immunization does not stop at childhood

Prevention of infection by immunization is a lifelong process

Health Care Practitioners need to Empower, Educate, Advocate and Recommend

Thank you for your attention!

Important Web-sites

Public Health Agency of Canada– www.phac-aspc.gc.ca

Canadian Coalition for Immunization Awareness and Promotion (CCIAP)– www.immunize.cpha.ca

Centers for Disease Control and Prevention – www.cdc.gov

World Health Organization– www.who.int