Shireesha Dhanireddy, MDAssociate Professor, Department of MedicineDivision of Infectious Diseases, University of WashingtonSeptember 2014
Discussion of indications for the following vaccines Pneumococcal Vaccine Tdap Influenza Vaccine Zoster vaccine
Exemptions dropped from 6.2% in 2009-2010 to 4.7% in 2011-2012 though
Went from 2nd to 8th highest in the country for exemptions
MMWR 2012;61(33);647-52
For which of the following patients is the 13 valent pneumococcal conjugate vaccine (PCV13) not indicated currently?
A.1 year old childB.25 year old HIV+ manC.67 year old womanD.49 year old female cigarette smoker
4 million cases/year in US445,000 hospitalizations/year22,000 deaths/year
Cox CM. CDC Manual for the Surveillance of Vaccine Preventable Diseases. 2012
Cox CM. CDC Manual for the Surveillance of Vaccine Preventable Diseases. 2012
Age Disease Incidence Cases/100,00 (# of cases)
Death Rate Deaths/100,000(# of deaths)
<1 31.4 (142) 0.22 (1)
1 24.6 (112) 0.22 (1)
2-4 12.6 (171) 0.15 (2)
5-17 2.2 (111) 0.02 (1)
18-34 3.7 (261) 0.26 (18)
35-49 10.3 (670) 0.65 (42)
50-64 19.5 (1,068) 1.86 (102)
> 65 37.0 (1,291) 5.61 (196)
Total 12.9 (3,828) 1.22 (363)
Persons > 65 years of agePersons age 19-64 with:
Chronic lung disease (asthma or COPD) Chronic heart disease (except HTN) Chronic liver disease CSF leak Smokers Diabetes Alcoholism Functional or anatomic asplenia Immunocompromising conditions
MMWR 2010. 59(34);1102-1106
Direct effects of PPSV23 vaccination in the elderly controversial
Cochrane Review Strong evidence for PPSV23 efficacy
against invasive disease Inconclusive efficacy for pneumonia Not associated with significant decrease
in mortality
Moberley S. Cochrane Review. 2008
Rates of IPD caused by PCV7 serotypes and additional serotypes in PCV13, adults >65
years, 1998–2009
Moore, IDSA, 2009 & CDC Unpublished 9
ACIP Meeting FEB 2012
47% reduction in IPD
Moore. ACIP, OCT 2013
12
Age group,
years
Percent Decrease in Rate (95%IE)
2010-11 2011-12
<5 67 (62, 70) 88 (86, 89)
5-17 35 (22, 45) 59 (48, 66)
18-49 33 (26, 38) 65 (60, 68)
50-64 24 (18, 28) 54 (51, 58)
>65 23 (13, 31) 47 (39, 53)
Statistically significant reductions in vaccine-type IPD in all age groups within first 2 years after
PCV13 introduction.
% V
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Not recommended for most personsWho should be revaccinated?
Persons aged 19-64 with▪ Functional or anatomic asplenia▪ Immunocompromising conditions
Multiple vaccinations not recommended
MMWR 2010. 59(34);1102-1106
PPSV23 – contains polysaccharide antigens PCV13 – contains immunogenic proteins
conjugated to pneumococcal polysaccharides
Prevnar 13 (PCV13) recommended for some immunocompromised adults FDA approved for adults age > 50 age
12/2011 ACIP advisory committee approved use in
immunocompromised adults 6/2012
MMWR 2012. 61(21);394-5
ACIP votes to recommend PCV13 vaccine in adults age > 65 years (8/13/2014) Not previously vaccinated with PCV13 or
unknown vaccine history even if have received PPSV23
Recommendations will be reevaluated in 2018
For which of the following patients is the 13 valent pneumococcal conjugate vaccine (PCV13) not indicated currently?
A.1 year old childB.25 year old HIV+ manC.67 year old womanD.49 year old female cigarette smoker (Give the polysaccharide vaccine)
A 27 year old pregnant woman presents for her routine obstetrics visit at her 32 week gestation visit . She is G2P1. She has a healthy 2 year daughter at home. Which statement is correct regarding Tdap in pregnancy?
A.She should receive a Tdap today only if she has not had in the past 5 years. B.She should receive Tdap only if she did not receive during her prior pregnancyC.She should receive Tdap today
Whooping cough Highly contagious, caused by Bordetella
pertussis Infected adults reservoir for infection of
children 3 phases
▪ Catarrhal phase – last 1-2 weeks, cold symptoms, including tearing and conjunctival injection
▪ Paroxysmal phase – paroxysmal cough, can last 2-3 month untreated
▪ Convalescent phase - resolution
WHOAll adolescents aged 11 through 18 years (age 11-12 preferred)All adults aged 19 through 64 who have not received a doseAll adults aged > 65 years (2/2012)All pregnant women during each pregnancy
WHATBoostrix preferred for adults > 65 years (but either okay)
WHENRegardless of interval between last Td if has not received TdapDuring each pregnancy for pregnant women – optimum timing is 3rd trimester (27-34 weeks)
MMWR 2013;62:131-135
A 27 year old pregnant woman presents for her routine obstetrics visit at her 32 week gestation visit . She is G2P1. She has a healthy 2 year daughter at home. Which statement is correct regarding Tdap in pregnancy?
A.She should receive a Tdap today only if she has not had in the past 5 years. B.She should receive Tdap only if she did not receive during her prior pregnancyC.She should receive Tdap today
A 64 year old woman with a self-reported history of shingles 2 years ago and type II diabetes presents to clinic. What do you recommend regarding the zoster vaccine?
A. Vaccine is contraindicated given her history of diabetes
B. Vaccine not indicated given her history of zosterC. Check VZV titer to confirm history. If negative,
proceed with vaccinationD. Recommend zoster vaccine
Develops in 30% of people over a lifetime (1million + cases a year in US)
Incidence increases with age 8-10x more likely in people >
60 May lead to postherpetic
neuralgia (PHN) “pain that persists more than
30 days after the onset of rash or after cutaneous healing”
Kimberlin DW, Whitley RJ. NEJM 2007;356:1338-43Gann JW, Whitley RJ. NEJM 2002;347:340-6
Study DesignN = 38,546Adults > 60Randomized, double-
blindFollowed for mean 3.1
yrsSingle dose vaccine vs
placebo
Oxman MN et al. NEJM 2005;352:2271-84
Decreased Herpes Zoster by 51.3%Decreased PHN by 66.5%
Age Specific Recommendations:All persons > 60 years*
Excludes those with contraindications to live vaccine
Includes those with history of zoster or have chronic medical conditions
Dose:Single dose
MMWR 2008;57(RR-5):1-40
October 2008: the ACIP recommended a dose of HZV for all adults >60 years unless they have contraindications
March 2011: FDA approved use of Zostavax in adults aged 50-59 years
Should we be administering HZV at ages 50-59 years?
Cost: $160/dose
Implications: Varicella vaccine recipients
CDC Vaccine Price List
Source: Yawn 2007
*PHN defined as ≥ 90 days of pain
Source: Yawn 2007
Source: Lin 2000
74% of HZ-related hospitalizations in persons ≥60 years
Herpes Zoster (Shingles) Vaccine Coverage Among US AdultsNational Health Interview Survey, 2008-2012
National Immunization Survey (NIS), 2007; National Health Interview Survey (NHIS), 2008-2012
Ortega-Sanchez. ACIP OCT 2013* PHN = moderate to severe pain lasting >90 days
Vaccinate at 50
Vaccinate at 60
Vaccinate at 70
Net cost* $178.5 Million
$169.0 Million
$162.9 Million
Cost per HZ prevented
$11,255 $8,455 $9,989
Cost per PHN prevented
$61,084 $19,761 $9,607
Cost per QALY saved **
$271,713
$79,967 $38,191
* NC =Cost of Vaccination Program - Savings in Cost-of-Illness from Vaccination
** Does not including indirect cost savings Ortega-Sanchez. ACIP OCT 2013
• Affirms existing recommendation for routine vaccination of persons 60 years of age and older Burden of HZ disease in increases with age HZ vaccine administration should be timed to
achieve the greatest reduction in burden of HZ and its complications
There is insufficient evidence for long term protection offered by the HZ vaccine
Providers should counsel persons who are vaccinated at 50-59 years of age that the duration of protection offered by the vaccine is uncertain; therefore they may not be protected when the incidence of HZ and its complications are highest.
A 64 year old woman with a self-reported history of shingles 2 years ago and type II diabetes presents to clinic. What do you recommend regarding the zoster vaccine?
A. Vaccine is contraindicated given her history of diabetes
B. Vaccine not indicated given her history of zosterC. Check VZV titer to confirm history. If negative,
proceed with vaccinationD. Recommend zoster vaccine
67 year old man with moderate COPD presents for his routine visit in the fall.
Which of the following is most appropriate regarding immunization against influenza?
A. Live attenuated vaccine should be given as it has been found to be more effective than the inactivated vaccine.
B. High-dose, trivalent, inactivated vaccine should be administered.
C. Standard-dose, trivalent, inactivated vaccine should be administered
2013–14 U.S. trivalent influenza vaccines will contain an A/California/7/2009 (H1N1)–like virus, an H3N2 virus antigenically like the cell-propagated prototype virus A/Victoria/361/2011, and a B/Massachusetts/2/2012–like virus.
Quadrivalent vaccines will include an additional vaccine virus strain, a B/Brisbane/60/2008–like virus.
High dose vaccine contains 4 times as much hemagglutinin (HA) as standard
Licensed for persons > 65 years of age in 12/2009 but with requirement to show clinical benefit (had shown safety and superior immunogenicity)
18-64 years >65 years
GM
T
HA
I
Sanofi Pasteur. ACIP OCT 2013
Randomized, blinded study in US, Canada (N = 32,000)
2011-12 (mild) & 2012-13 (moderately severe) seasons
Lab confirmed influenza: 1.43% HD vs. 1.89% SD Relative efficacy 24.2% (9.7, 36.5)OR: 4-5 fewer cases/1000 vaccinated 217 vaccinations to prevent one additional case
Cost HD: ~$25 VS. SD: ~$12
Safety: AE comparable for HD and SD
% V
acci
nat
edInfluenza Vaccine Coverage Among US Adults:
2011-12
BRFSS; *internet panel survey
67 year old man with moderate COPD presents for his routine visit in the fall.
Which of the following is most appropriate regarding immunization against influenza?
A. Live attenuated vaccine should be given as it has been found to be more effective than the inactivated vaccine.
B. High-dose, trivalent, inactivated vaccine should be administered.
C. Standard-dose, trivalent, inactivated vaccine should be administered
Discussion of indications for the following vaccines Pneumococcal Vaccine Tdap Zoster vaccine Influenza Vaccine
Consider vaccines at every routine visit, particularly in pregnant patients and elderly patients
For elderly patients over 65 years of age, give PCV13 instead of PPSV23 (consider high dose flu vaccine)