Adult Immunization                    Dr Abhay Dhanorkar2/15/2013                                1
Scope•   Definition•   Introduction•   Rationale for Adult Immunization (AI)•   Disease burden of VPD in USA & Scenario in...
When meditating over a disease,    I never think of finding a remedy for it,    but, instead, a means of preventing it.   ...
Definition• Immunization refers to the artificial  induction of immunity. It can be by    Active Immunization: the use of...
What is Immunization?             Administration of all or part of micro            organism or modified product resulting...
Introduction• Certain vaccines are routinely  recommended for all infants and  children in India.• These include BCG, Diph...
Vaccine-preventable infectious agents or diseases Draft - Global vaccine action plan May 2012 - WHO 2/15/2013             ...
Introduction cont…  • Smallpox eradicated in 1978 from   India  • On the verge of polio eradication.  • Infant/Childhood i...
Rationale for Adult               Immunization • Build on success of infant/childhood, adolescent   immunization program. ...
Disease BurDen of vpD’s in usa• Influenza    >200,000 hospitalizations per year    36,000 deaths    >90% in persons 65 ...
Disease BurDen usa cont…• Hepatitis B   51,000 new infections/yr; 95% in adults   2,000 – 3,000 deaths/yr    ~1.25 mill...
Disease BurDen usa cont…• Herpes Zoster (Shingles)      Reactivation of varicella zoster virus      Associated with norm...
scenario of vpD’s in indiaDiphtheria• Overall cases of Diphtheria reduces            • 1980 – 39231            • 2005 – 10...
VPD’s in India cont…   Tetanus   • Total cases in India          1980 – 45948 cases          2007 – 7005 cases   • Study...
VPD’s in India cont…   Hepatitis – A   • Study by Mall in 5 cities (Kolkota,     Cochin, Indore, Jaipur & Patna) shows    ...
VPD’s in India cont…   Hepatitis – B   • Hepatitis – B prevalence in India - 1-2%     (Lodha et al)   • Study by Murhekar ...
VPD’s in India cont…   Human Papilloma Virus (HPV) Infection   • Nearly 80% of sexually active women & men are     infecte...
2012 ACIP Adult Immunization Schedule, Age-Based Recommendations - USA   2/15/2013                                        ...
2012 ACIP Adult Immunization Schedule- Medical/Occupational         and Behavior-Based Recommendations (USA)              ...
ACIP Adult Immunization Schedule, Age-Based                Recommendations, INDIAVaccine / Age group               19-26 y...
Adult Immunization based on medical and other indications (INDIA)                                    Immunoco             ...
Adult Immunization recommended in indiaTdap                    MMRInfluenza               PneumococcalHepatitis B         ...
Diphtheria, Tetanus, PertussisVaccines• Two Tdap Vaccines are available for use in those  who are more than 10 years of ag...
Tdap cont… • Health care personnel, especially those in   direct contact with the patients, who have not   received Tdap v...
Tdap cont… • For Pregnant Women          Last dose           Recommendation         > 10 Years      1 dose in 2nd or 3rd t...
Tdap cont… Contraindications • History of anaphylaxis to any component. • History of encephalopathy within 7 days of   pre...
Measles, Mumps And RubellaVaccines• In India the measles, mumps, rubella (MMR) live  attenuated vaccine is manufactured us...
MMR cont…MMR cont… • Adults who are > 18yrs of age should   receive at least one dose of MMR if   there is no serologic pr...
MMR cont…MMR cont… Schedule • One or two doses are needed 4 wks   apart. • If a pregnant woman is found to be   rubella su...
MMR cont…MMR cont… Contraindications • Previous anaphylactic reaction to this vaccine,   or to any of its components. • Pr...
InfluenzaVaccines       Trivalent inactivated influenza vaccine (TIV) and       Live attenuated influenza vaccine (LAIV)...
Influenza cont… Recommendations • People aged > 50 years • Chronic obstructive pulmonary   disease (COPD). • Cardiac disea...
Influenza cont… • August - September is the optimal time to receive an   annual flu shot to maximize protection. • Influen...
Pneumococcal InfectionVaccines• The pneumococcal polysaccharide  vaccine (PPV), contains 25 μg each of purified  capsular ...
PPV cont… • Adults who are 65yrs of age or older. High risk people • Anatomic asplenia        • Chronic renal failure • Si...
PPV cont… • One-time revaccination is recommended 5yrs   later for people with    Rapid antibody loss (e.g., renal diseas...
Hepatitis BVaccines• For immunocompetent adults, 1ml (20 μg) of  recombinant vaccine is administered at 0, 1, and 6  month...
HBV cont… Prevaccination screening • Prevaccination screening in general population has not been    found to be cost effec...
HBV cont… 2/15/2013   40
HBV cont… • Booster doses of HBV vaccine are not indicated   in persons with normal immune status . • For CKD patients, th...
Hepatitis AVaccines• Inactivated-single antigen (HAV antigen) vaccines,       Havrix (GlaxoSmithKline) and       Vaqta (...
Hepatitis A cont… Recommendations • The Expert Group felt that universal immunization   for hepatitis A is not recommended...
Hepatitis A cont… Adults high risk for acquiring hepatitis A:   People who travel to endemic area of Hep A   Persons who...
Hepatitis A cont…        Vaccination schedule for hepatitis A 2/15/2013                                     45
Hepatitis A cont… Contraindications • Previous anaphylactic reaction to this vaccine   or to any of its components. • Mode...
Varicella (Var) (Chickenpox)Vaccines• Two Live attenuated VZV (Oka strain)  vaccines for varicella virus are currently  av...
Varicella cont… Recommendations • All susceptible adults and adolescents should   be vaccinated. • It is especially import...
Varicella cont… • People with reliable histories of chickenpox   (such as self or parental report of disease) can   be ass...
Varicella cont… Contraindications • Previous anaphylactic reaction to this vaccine or to any   of its components. • Pregna...
Human Papilloma Virus• Papilloma virus infection is precursor to cervical  cancer    Types 16, 18 account for 70% of cerv...
HPV cont… Schedule • Gardasil vaccine, 3 doses- 0.5ml IM at   0, 2, and 6 months. • Cervarix vaccine, 3 doses - 0.5 ml IM ...
HPV cont… Recommendations • The vaccine has to be delivered prior to   exposure to the HPV virus. Therefore, the   immuniz...
HPV cont… Contraindications • Pregnancy • Patients with hypersensitivity to any of the   vaccine components. Special situa...
HPV cont… • Several mild self limiting problems may   occur with HPV vaccine:       Pain at the injection site ( 8 people...
HPV cont…                 Natural History of HPV Infection and                Potential Progression to Cervical Cancer    ...
Meningococcal MeningitisVaccines• Types   Polysaccharide vaccines       • Bivalent (A&C)       • Quadrivalent (A,C,Y & W1...
Meningococcal cont… Schedule • A single dose of 0.5 ml SC in deltoid region. • In children between 3 months and 2 years of...
Meningococcal cont… Recommendations • The meningococcal vaccine can be used in   selected        populations      in      ...
Meningococcal cont… • Mass vaccination may be considered   depending on the age-specific attack rate,   geographical distr...
Herpes zoster (shingles)            • Shingles is caused by a reawakening              of the chickenpox virus            ...
Herpes Zoster cont… Vaccines • Zostavax - lyophilized preparation of the Oka   strain of live, attenuated varicella zoster...
Herpes Zoster cont… Recommendations • Recommended for persons > 60 years. • High risk for developing recurrent herpes   zo...
Recommended Vaccines for Healthcare                  Workers• Healthcare workers should maintain an  immunization history ...
Recommended vaccines for travelers to                  IndiaCDC recommends the vaccines according to duration of stay in I...
Adult Immunization Challenges• Inadequate funding for vaccines and  administration in public programs• Lack of knowledge –...
Reasons -Aware but not receiving vaccineSource: Johnson et al, Barriers to Adult Immunization, The American Journal of  2/...
Reasons -Aware but not receiving vaccineSource: Johnson et al, Barriers to Adult Immunization, The American Journal of  2/...
Reasons -Aware but not receiving vaccineSource: Johnson et al, Barriers to Adult Immunization, The American Journal of Med...
Screening Patients for Vaccines• Screen every patient regardless of reason for  visit• Utilize screening tools; H-A-L-O   ...
Documentation• Provide copy of Vaccine  Information Statement (VIS)to  patient• Documents to be maintained      Date vacc...
Vaccine Administration• Health care personnel should get proper  training before administrating vaccine.• Always prepare a...
Standards for Adult Immunization                       Practices• Make immunizations available       Adult immunization s...
Standards for AI cont….• Administer and document immunizations properly       Persons who administer vaccines are properl...
Standards for AI cont….• Implement strategies to improve immunization rates.       Systems are developed and used to remi...
Recommendations (CDC)      Finances      Research on barriers      Public and Provider Education      Standards of Car...
References• Centers for Disease Control and Prevention (CDC). Recommended  adult immunization schedule—United States, 2012...
References• Draft global vaccine action plan for 2010 -2020 by the Secretariat, 65th  World Health Assembly ,11 May 2012.•...
2/15/2013   79
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Seminar adult immunization

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  • Here is the first figure of the Schedule, listing vaccines down the left side, with age groups across the top. Changes for 2012 are circled in red, and include:Vaccination of adults 65 years and older with Tdap recommendedIf they have contact with infants <12 months of ageIs permitted for all other older adultsHPV recommendations are separated by gender, and now state the vaccine is recommended, in addition to females, for Males through 21 yearsMales may be vaccinated if 22-26 years of age
  • Seminar adult immunization

    1. 1. Adult Immunization Dr Abhay Dhanorkar2/15/2013 1
    2. 2. Scope• Definition• Introduction• Rationale for Adult Immunization (AI)• Disease burden of VPD in USA & Scenario in India• Recommendations for Adult Immunization in USA & India• Adult Immunization monograph by API – 2008• Recommended Vaccines in India• Challenges in adult immunization• Standards for Adult Immunization Practices• Recommendations by CDC• References2/15/2013 2
    3. 3. When meditating over a disease, I never think of finding a remedy for it, but, instead, a means of preventing it. Louis Pasteur (1822-1895)2/15/2013 3
    4. 4. Definition• Immunization refers to the artificial induction of immunity. It can be by Active Immunization: the use of live attenuated infectious agents or inactivated toxins, or antigens obtained by genetic recombination OR Passive Immunization: temporary immunity obtained by the administration of immunoglobulins or antitoxins. 2/15/2013 Source : Dictionary of Public Health, J Kishore - 2007 4
    5. 5. What is Immunization? Administration of all or part of micro organism or modified product resulting in protection against the disease.2/15/2013 5
    6. 6. Introduction• Certain vaccines are routinely recommended for all infants and children in India.• These include BCG, Diphtheria, Pertussis and Tetanus vaccine (DPT), Oral Polio Vaccine (OPV),HBV, Measles .• Vaccine against H.Influenza (Hib), JE, Chickenpox, herpes Zoster, Human Papilloma Virus , Rotavirus diarrhea etc. are optional.2/15/2013 6
    7. 7. Vaccine-preventable infectious agents or diseases Draft - Global vaccine action plan May 2012 - WHO 2/15/2013 7
    8. 8. Introduction cont… • Smallpox eradicated in 1978 from India • On the verge of polio eradication. • Infant/Childhood immunization – one of the top public health success stories of the 20th century • The prevalence of Diphtheria, Pertussis, tetanus, measl es, mumps, rubella, poliomyelitis are reduced. 2/15/2013 8
    9. 9. Rationale for Adult Immunization • Build on success of infant/childhood, adolescent immunization program. • Not vaccinated earlier, booster. • New vaccines targeted at adults. • Ageing : more susceptible. • Increasing Antimicrobial Resistance. • Recognition of the burden of adult vaccine- preventable disease. • No equivalent “Vaccines for Adults” program. • Few settings in which vaccination is “required.”2/15/2013 9
    10. 10. Disease BurDen of vpD’s in usa• Influenza >200,000 hospitalizations per year 36,000 deaths >90% in persons 65 years and older with comorbid conditions• Invasive Pneumococcal Disease Cases: 42,000 (14.0/100,000) Deaths: 4,500 (1.5/100,000) Rates higher in elderlyhttp://www.cdc.gov/ncidod/dbmd/abcs/survreports.spneu.2/15/2013 10 pdf
    11. 11. Disease BurDen usa cont…• Hepatitis B 51,000 new infections/yr; 95% in adults 2,000 – 3,000 deaths/yr  ~1.25 million with chronic HBV infection• Human Papillomavirus (HPV) At least 70% of sexually active persons acquire genital HPV infection at some point in their lives ~20 million currently infected 6.2 million new infections/year ~ >11,000 new cervical cancer cases/year2/15/2013 11
    12. 12. Disease BurDen usa cont…• Herpes Zoster (Shingles) Reactivation of varicella zoster virus Associated with normal aging and reduced immunocompetence Lifetime risk of 20% ~ 1 million cases/yr• Pertussis Of >25,000 cases reported in 2009, >7,000 were in adults Source of infant infection often an older child or adult • 71% household contact2/15/2013 12
    13. 13. scenario of vpD’s in indiaDiphtheria• Overall cases of Diphtheria reduces • 1980 – 39231 • 2005 – 10231 • 2009 – 3480• Study in Hyderabad shows that annual incidence increases from 11 to 23/lakh from 2003 to 2006 in 5 – 19 years.• Study for Protective levels of antibodies in Delhi shows  121 pregnant women – 94% have protective Ab titer (>0.125U/ml)  574 adults – 87% have protective Ab titer2/15/2013 13
    14. 14. VPD’s in India cont… Tetanus • Total cases in India  1980 – 45948 cases  2007 – 7005 cases • Study in Pondicherry for protective level of Tetanus Ab (> 0.15U/ml)  21 - 30 years – 50.4% (105/208)  31 – 40 years – 29.4%(58/198)  > 41 years – 2.2% (5/224) Pertusss  1987 -163000 cases  2009 – 55074 cases Meningococcal Meningitis cases (2009) in 9 states  Cases – 6386  Deaths – 460 2/15/2013 14
    15. 15. VPD’s in India cont… Hepatitis – A • Study by Mall in 5 cities (Kolkota, Cochin, Indore, Jaipur & Patna) shows adult population was at risk of HAV as low level of anti HAV antibodies • Study by Dhawan et al – seroprevalance for protective anti HAV antibodies High socioeconomic class – 54.5% Low socioeconomic class – 85% • Study by Jindal in Medicos at Delhi – 66% with low anti HAV antibodies 2/15/2013 15
    16. 16. VPD’s in India cont… Hepatitis – B • Hepatitis – B prevalence in India - 1-2% (Lodha et al) • Study by Murhekar in 2001 at Andaman in healthy people  HBsAg +ve – 1.6% &  Anti HBs +ve – 18% • Overall chronic HBsAg +ve rate in India is 4.7% • Meta-analysis by Biswas D et al. shows prevalence of Hep – B in  Non tribal – 2.4%  Tribal – 15.9% 2/15/2013 16
    17. 17. VPD’s in India cont… Human Papilloma Virus (HPV) Infection • Nearly 80% of sexually active women & men are infected with HPV. World – 5,00,000 new cases/year. (CaCx) India – 1,32,000 new cases & 74,000 deaths per year Pneumococcal • Study by International Clinical Epidemiology Network (INCLEN) shows case fatality rate in south India due to Pneumococcal Pneumonia – 19% Pneumococcal bacterimia – 21% Pneumococcal meningitis – 34% • 23% of IPD patients were > 50 years 2/15/2013 17
    18. 18. 2012 ACIP Adult Immunization Schedule, Age-Based Recommendations - USA 2/15/2013 18
    19. 19. 2012 ACIP Adult Immunization Schedule- Medical/Occupational and Behavior-Based Recommendations (USA) Pregn Immunoco HIV & Men Heart Aspleni Chro Diabete Health having disease, c a Kidney ancy mpromisin CD4 sex hronic includi nic failure, -Care g Count lung liver conditions with diseases, ng ESRD, o perso men elective dise n excluding <200 >200 chronic ases nnel cell/ cell/ (MSM) alcoholic Splenec hemodi HIV µl µl tomy lysis2/15/2013 19
    20. 20. ACIP Adult Immunization Schedule, Age-Based Recommendations, INDIAVaccine / Age group 19-26 yrs 27-49 yrs 50-59 yrs 60-64 yrs > 65 yrs Substitude one time dose of Tdap with Td, Td boosterTetanus, Diptheria, Pertussis (Tdap) every 10 yrs then booster with Td every 10 years Human Pappiloma Vaccine 3 doses Varicella 2 doses Zoster 1 dose Measles, Mumps, Rubella 1 or 2 doses 1 dose Influenza 1 dose annually Pnemococcal (Polysaccharide) 1 or 2 doses 1 dose Hepatitis A 2 doses Hepatitis B 3 doses Meninngicoccal 1 or more doses Recommended if some risk factor is present All persons who meet the age criteria 2/15/2013 20 No recommendation
    21. 21. Adult Immunization based on medical and other indications (INDIA) Immunoco Diabetes, Kidney HIV infection heart Asplenia mpromise failure, end Health Indications with CD4 (excluding Chronic d disease, stage renal care Pregnancy count elective liver conditions chronic disease, on professi splenectomy disease (Excluding <200 >200 lung hemodialysi onals Vaccine ) HIV) cells/ µl cells/ µl disease s Tetanus, Diptheria, Substitute one time dose of Tdap with Td, then booster with Td every 10 Td years Pertussis (Tdap) Human Pappiloma 3 doses for females through age 26 years Vaccine Varicella Contraindication 2 doses Zoster Contraindication 1 doseMeasles, Mumps, Rubella Contraindication 1 or 2 doses 1 dose TIV Influenza 1 dose TIV annually or LAIV Pnemococcal (Polysaccharide) 1 or 2 doses Hepatitis A 2 doses Hepatitis B 3 doses Meninngicoccal 1 or more doses Recommended if some risk factor is present All persons who meet the age criteria 2/15/2013 21 Contraindication
    22. 22. Adult Immunization recommended in indiaTdap MMRInfluenza PneumococcalHepatitis B Hepatitis AVaricella HPV (cervical cancer)Meningococcal Herpes Zoster2/15/2013 22
    23. 23. Diphtheria, Tetanus, PertussisVaccines• Two Tdap Vaccines are available for use in those who are more than 10 years of age.  [i] Adacel contains tetanus toxoid, diphtheria toxoid, and five pertussis antigens;  [ii] Boostrix contains tetanus toxoid, diphtheria toxoid, and three pertussis antigens.• Efficacy of Tdap vaccine - 92% in a recent RCT.Recommendations• For adults in the age group of 18 to 64 years  Three dose series if never vaccinated at 0 and 4 weeks, the third 6-12 months after second  One dose booster of Tdap every 10 years2/15/2013 23
    24. 24. Tdap cont… • Health care personnel, especially those in direct contact with the patients, who have not received Tdap vaccine should receive a single dose of Tdap vaccine if 2 years or more have elapsed since the last dose of Td vaccination. • Women planning pregnancy should receive one dose of Tdap vaccine if they had not received it previously. 2/15/2013 24
    25. 25. Tdap cont… • For Pregnant Women Last dose Recommendation > 10 Years 1 dose in 2nd or 3rd trimester 2-10 years 1 dose immediate postpartum Never 3 doses 0, 1, 6 months • During outbreak if previous unimmunized or Td before 2 years give 1 dose of Tdap 2/15/2013 25
    26. 26. Tdap cont… Contraindications • History of anaphylaxis to any component. • History of encephalopathy within 7 days of previous vaccination of Tdap. • Moderate or severe acute illness, and those with unstable neurologic conditions (e.g., stroke, acute encephalopathies) • Tdap vaccination is to be deferred until the acute illness resolves. 2/15/2013 26
    27. 27. Measles, Mumps And RubellaVaccines• In India the measles, mumps, rubella (MMR) live attenuated vaccine is manufactured using the following strains:  Edmonston Zagreb - Measles,  L-Zagreb - Mumps  Wistar RA27/3 strain - Rubella.• The measles and the rubella components are produced using human diploid cells while the mumps component is produced from chick embryo.• The MMR vaccine should be administered subcutaneously into the upper arm.2/15/2013 28
    28. 28. MMR cont…MMR cont… • Adults who are > 18yrs of age should receive at least one dose of MMR if there is no serologic proof of immunity or documentation of a dose given on or after the first birthday. • Adults in high-risk groups, such as health care workers and international travelers, should receive two doses. • All women of childbearing age who do not have acceptable evidence of rubella immunity or vaccination. 2/15/2013 29
    29. 29. MMR cont…MMR cont… Schedule • One or two doses are needed 4 wks apart. • If a pregnant woman is found to be rubella susceptible, administer MMR postpartum. 2/15/2013 30
    30. 30. MMR cont…MMR cont… Contraindications • Previous anaphylactic reaction to this vaccine, or to any of its components. • Pregnancy or possibility of pregnancy within 4 weeks (use contraception). • Persons immunocompromised due to cancer, leukemia, lymphoma, immunosuppressive drug therapy, including high-dose steroids or radiation therapy. 2/15/2013 31
    31. 31. InfluenzaVaccines  Trivalent inactivated influenza vaccine (TIV) and  Live attenuated influenza vaccine (LAIV)• The TIV contains  A/17/California/2009/38(H1N1),  A/Brisbane/ 10/2007 (H3N2), and  B/Brisbane/60/2008 strains.• Live attenuated influenza vaccine (LAIV) – Nasovac contains  A/17/California/2009/38 like strain• Schedule  The TIV - annual, single dose of 0.5 ml IM.  The LAIV – 0.5 ml intranasal (spray 0.25 ml per nostril)2/15/2013 32
    32. 32. Influenza cont… Recommendations • People aged > 50 years • Chronic obstructive pulmonary disease (COPD). • Cardiac diseases • Diabetes Mellitus, Cancer • Immunodeficiency, Renal Disease • Hemoglobinopathies • Pregnant Women • Health Care Providers • Adult household contacts • Travelers to endemic area 2/15/2013 33
    33. 33. Influenza cont… • August - September is the optimal time to receive an annual flu shot to maximize protection. • Influenza vaccine may be given at any time during the influenza season (typically October to March) or at other times when the risk of influenza exists. • May give with all other vaccines but as a separate injection. Contraindications • Previous anaphylactic reaction to this vaccine, to any of its components, or to eggs. • Moderate or severe acute illness. 2/15/2013 34
    34. 34. Pneumococcal InfectionVaccines• The pneumococcal polysaccharide vaccine (PPV), contains 25 μg each of purified capsular polysaccharide from 23 serotypes of Streptococcus pneumoniae.Schedule A single standard dose (0.5 ml) is administered by the intramuscular or subcutaneous route. This vaccine can be co-administered with live vaccines such as the influenza vaccine.2/15/2013 35
    35. 35. PPV cont… • Adults who are 65yrs of age or older. High risk people • Anatomic asplenia • Chronic renal failure • Sickle cell disease • Nephrotic syndrome • Immunocompromised • Chemotherapy & persons including HIV corticosteroids) • Leukemia, Lymphoma • Organ or bone marrow • Hodgkin’s disease transplant. • Multiple myeloma • Pregnant women with • Generalized malignancy high-risk conditions 2/15/2013 36
    36. 36. PPV cont… • One-time revaccination is recommended 5yrs later for people with Rapid antibody loss (e.g., renal disease) People >65yrs of age if the 1st dose was given prior to age 65 and > 5yrs have elapsed since previous dose. 2/15/2013 37
    37. 37. Hepatitis BVaccines• For immunocompetent adults, 1ml (20 μg) of recombinant vaccine is administered at 0, 1, and 6 months as an intramuscular.• Protection (anti-HBs antibody titer of 10mIU/ml or higher) after recombinant vaccine  After first dose - 20% to 30%  After second dose - 75% to 80%  After third doses - 90% to 95%Recommendations• All unvaccinated adult risk for HBV infection and• All adults seeking protection from HBV infection including post-exposure prophylaxis.2/15/2013 38
    38. 38. HBV cont… Prevaccination screening • Prevaccination screening in general population has not been found to be cost effective in India. • Prevaccination screening may be cost-effective in adult populations with a prevalence of HBV infection of >20% such as  Household or sexual contacts of HBsAg-positive persons;  HIV infected persons  Injection drug users  Men who have sex with men  Patients with chronic liver disease (CLD)  End-stage renal disease (ESRD). 2/15/2013 39
    39. 39. HBV cont… 2/15/2013 40
    40. 40. HBV cont… • Booster doses of HBV vaccine are not indicated in persons with normal immune status . • For CKD patients, the need for booster doses should be assessed by annual anti-HBs antibody titre testing. • A booster dose should be administered when anti-HBs levels decline to less than 10 mIU/ml & <100 mIU/ml in patients on dialysis. Contraindications • Previous anaphylactic reaction to this vaccine or to any of its components. • Moderate or severe acute illness. 2/15/2013 41
    41. 41. Hepatitis AVaccines• Inactivated-single antigen (HAV antigen) vaccines,  Havrix (GlaxoSmithKline) and  Vaqta (Merck & Co)• Combination vaccine  Twinrix ( HAV + HBV antigens GlaxoSmithKline).Schedule• Two doses of 1ml at 6 month interval.• Immune status for hepatitis A should be checked2/15/2013 42
    42. 42. Hepatitis A cont… Recommendations • The Expert Group felt that universal immunization for hepatitis A is not recommended as yet. • Not only is the vaccine costly, more epidemiological data are required to ascertain its benefits. • Adults at risk for acquiring hepatitis A, and adults who are negative for anti-HAV antibodies are likely to benefit most in view of changing epidemiology. 2/15/2013 43
    43. 43. Hepatitis A cont… Adults high risk for acquiring hepatitis A: People who travel to endemic area of Hep A Persons who work with HAV-infected primates or with HAV in a laboratory Who receive clotting factor concentrates Persons infected with other hepatitis viruses Chronic liver disease not immune to HAV Received, or are awaiting a liver transplant Men who have sex with men 2/15/2013 44
    44. 44. Hepatitis A cont… Vaccination schedule for hepatitis A 2/15/2013 45
    45. 45. Hepatitis A cont… Contraindications • Previous anaphylactic reaction to this vaccine or to any of its components. • Moderate or severe acute illness. • Safety during pregnancy has not been determined, so benefits must be weighed against potential risk. 2/15/2013 46
    46. 46. Varicella (Var) (Chickenpox)Vaccines• Two Live attenuated VZV (Oka strain) vaccines for varicella virus are currently available in India. – Varilrix (GlaxoSmithKline, Belgium) and – Okavax (Pasteur Mérieux, France).Schedule – < 13 years - 1 dose - 0.5ml SC – > 13 years - 2 doses are recommended. – Interval between 2 doses should be 4– 8wks.2/15/2013 47
    47. 47. Varicella cont… Recommendations • All susceptible adults and adolescents should be vaccinated. • It is especially important to susceptible persons – Health care workers – Family contacts of immunocompromised persons – High risk of exposure (e.g., teachers, day care employees, military personnel, and international travelers). 2/15/2013 48
    48. 48. Varicella cont… • People with reliable histories of chickenpox (such as self or parental report of disease) can be assumed to be immune. • For adults who have no reliable history, serologic testing may be cost effective since most adults with a negative or uncertain history of varicella are immune. 2/15/2013 49
    49. 49. Varicella cont… Contraindications • Previous anaphylactic reaction to this vaccine or to any of its components. • Pregnancy, or possibility of pregnancy within 1 month. • Immunocompromised persons due to malignancies and primary or acquired cellular immunodeficiency including HIV/AIDS. • Salicylates to be avoided for 6wks after receiving varicella vaccine because of a risk of Reye’s syndrome. 2/15/2013 50
    50. 50. Human Papilloma Virus• Papilloma virus infection is precursor to cervical cancer  Types 16, 18 account for 70% of cervical cancersVaccines• Two types HPV vaccines are available.  Gardasil (Merck, USA), a quadrivalent vaccine containing HPV virus L1 protein like particles of HPV 6,11,16, and 18  Cervarix (GlaxoSmithKline, Belgium) is a bivalent vaccine containing L1 VLPs of HPV 16,18.2/15/2013 51
    51. 51. HPV cont… Schedule • Gardasil vaccine, 3 doses- 0.5ml IM at 0, 2, and 6 months. • Cervarix vaccine, 3 doses - 0.5 ml IM at 0, 1 and 6 months 2/15/2013 52
    52. 52. HPV cont… Recommendations • The vaccine has to be delivered prior to exposure to the HPV virus. Therefore, the immunization must precede the sexual debut. • Age for initiation for vaccination to be 10 - 12 years. • Catch-up vaccination can be advised up to the age of 26 years for Gardasil vaccine and 45 years for Cervarix vaccine. 2/15/2013 53
    53. 53. HPV cont… Contraindications • Pregnancy • Patients with hypersensitivity to any of the vaccine components. Special situations • The HPV vaccine is not contraindicated during lactation. • The vaccine can be administered to immunosuppressed individuals. 2/15/2013 54
    54. 54. HPV cont… • Several mild self limiting problems may occur with HPV vaccine: Pain at the injection site ( 8 people in 10) Redness or swelling at the injection site (1 in 4) Mild fever (100 oF) (1 in 10) Itching at the injection site (1in 30) Moderate fever (102 oF) (1 in 65) 2/15/2013 55
    55. 55. HPV cont… Natural History of HPV Infection and Potential Progression to Cervical Cancer 0–1 Year 0–5 Years 1–20 Years Continuing CIN Invasive Infection 2/3 Cervical Cancer Initial HPV Infection CIN 1 Cleared HPV Infection (~80%) 2/15/2013 AP, Crum CP. Clin Obstet Gynecol. 2000;43:352–362. 1. Pinto 56
    56. 56. Meningococcal MeningitisVaccines• Types Polysaccharide vaccines • Bivalent (A&C) • Quadrivalent (A,C,Y & W135) Conjugate vaccines.• The vaccine does not induce herd immunity and has no effect on nasopharyngeal carriage.• Containing 50 μg of polysaccharide per dose.• After reconstitution use within 8-12 hours.2/15/2013 57
    57. 57. Meningococcal cont… Schedule • A single dose of 0.5 ml SC in deltoid region. • In children between 3 months and 2 years of age, two doses at an interval of 3 months are indicated. 2/15/2013 58
    58. 58. Meningococcal cont… Recommendations • The meningococcal vaccine can be used in selected populations in certain situations, such as During an outbreak (HCW, Lab. worker, Close contacts ) During inter-epidemic period To travelers, pilgrims(Quadrivalent), people attending fairs and festivals(bivalent 10-14 days prior). 2/15/2013 59
    59. 59. Meningococcal cont… • Mass vaccination may be considered depending on the age-specific attack rate, geographical distribution of cases, and the availability of vaccine. • During the inter-epidemic period, to personnel living in dormitories; military recruits; jail inmates; immunocompromised individuals. • Adults with anatomic or functional asplenia, or terminal complement component deficiencies. 2/15/2013 60
    60. 60. Herpes zoster (shingles) • Shingles is caused by a reawakening of the chickenpox virus • Symptoms – rash usually along nerve pathways • Very painful and debilitating • 20-30 % people can expect to get shingles in their lifetime2/15/2013 61
    61. 61. Herpes Zoster cont… Vaccines • Zostavax - lyophilized preparation of the Oka strain of live, attenuated varicella zoster virus (VZV). Schedule • Single 0.65 ml dose subcutaneously in the upper arm. • Each 0.65 ml dose contains a minimum of 19,400 plaque-forming units [PFU]. • The vaccine must be used within 30 minutes after reconstitution. 2/15/2013 62
    62. 62. Herpes Zoster cont… Recommendations • Recommended for persons > 60 years. • High risk for developing recurrent herpes zoster, such as Patients with chronic medical conditions (CKD, diabetes mellitus, rheumatoid arthritis, and chronic pulmonary disease); Persons who are likely to have severe immunosuppression in near future. 2/15/2013 63
    63. 63. Recommended Vaccines for Healthcare Workers• Healthcare workers should maintain an immunization history for: Hepatitis B Influenza * MMR Varicella (chickenpox) Tetanus, diphtheria, pertussis Meningococcal** * Receive annually ** For specific healthcare personnel2/15/2013 64
    64. 64. Recommended vaccines for travelers to IndiaCDC recommends the vaccines according to duration of stay in India.• Tetanus-Diphtheria• Hepatitis A• Yellow Fever < 1 month• Polio• Japanese Encephalitis• Rabies 1- 5 month• Typhoid• Hepatitis B• Tuberculosis > 6 month• Meningitis2/15/2013 65 Source : CDC
    65. 65. Adult Immunization Challenges• Inadequate funding for vaccines and administration in public programs• Lack of knowledge – both patients and providers• Poor public health and private infrastructure for vaccine delivery.• Lack of availability of vaccine.• High cost of vaccine.2/15/2013 66
    66. 66. Reasons -Aware but not receiving vaccineSource: Johnson et al, Barriers to Adult Immunization, The American Journal of 2/15/2013 67Medicine, Vol 121, No 7B, July 2008
    67. 67. Reasons -Aware but not receiving vaccineSource: Johnson et al, Barriers to Adult Immunization, The American Journal of 2/15/2013 68Medicine, Vol 121, No 7B, July 2008
    68. 68. Reasons -Aware but not receiving vaccineSource: Johnson et al, Barriers to Adult Immunization, The American Journal of Medicine, 2/15/2013 69Vol 121, No 7B, July 2008
    69. 69. Screening Patients for Vaccines• Screen every patient regardless of reason for visit• Utilize screening tools; H-A-L-O Health condition Age Lifestyle Occupation2/15/2013 70
    70. 70. Documentation• Provide copy of Vaccine Information Statement (VIS)to patient• Documents to be maintained Date vaccination & next dose Vaccine manufacturer Lot number Dose & site of vaccine Vaccinator’s initials2/15/2013 71
    71. 71. Vaccine Administration• Health care personnel should get proper training before administrating vaccine.• Always prepare and check the following for every vaccination you give: Right Patient Right Drug (vaccine) Right Dose Right Route (intramuscular, SC,intradermal) Right Time (is scheduling correct)2/15/2013 72
    72. 72. Standards for Adult Immunization Practices• Make immunizations available  Adult immunization services are readily available  Barriers to receiving vaccines are identified and minimized  Patient “out-of-pocket” immunization costs are minimized• Assess patients’ immunization status  Health care professionals routinely review the immunization status of patients  Health care professionals assess for valid contraindications• Communicate effectively with patients  Patients are educated about risks and benefits of immunization in easy-to-understand language2/15/2013 73
    73. 73. Standards for AI cont….• Administer and document immunizations properly  Persons who administer vaccines are properly trained  Simultaneous administration of indicated vaccine doses  Immunization records for patients should be accurate  All personnel who have contact with patients are appropriately vaccinated2/15/2013 74
    74. 74. Standards for AI cont….• Implement strategies to improve immunization rates.  Systems are developed and used to remind patients and health care professionals when immunizations are due and to re-call patients who are overdue  Standing orders for immunizations are employed  Regular assessments of immunization coverage levels are conducted in a provider’s practice• Patient oriented and community basedSource : Poland GA, Shefer AM, McCauley M, et al. Standards for adult immunization practices. Am J Prev Med 20032/15/2013 75
    75. 75. Recommendations (CDC) Finances Research on barriers Public and Provider Education Standards of Care Improved vaccines (immunogenicity, safety) Supply of Vaccines Support for programs and partners Legislative and regulatory strategies2/15/2013 76
    76. 76. References• Centers for Disease Control and Prevention (CDC). Recommended adult immunization schedule—United States, 2012. MMWR Morb Mortal Wkly Rep Feb 2012.• Poland GA, Shefer AM, McCauley M, et al. Standards for adult immunization practices. Am J Prev Med 2003;25:144–50.• Guthrie S. Birkhead & Julie Morita, NY, A Pathway to Leadership for Adult Immunization: Recommendations of the National Vaccine Advisory Committee, on June 14, 2011.• World Health Organization (WHO)/UNICEF global estimates for Immunization 2010, May 2012.• K.Park-Park’s Textbook of Preventive and Social Medicine,21st edition, Banarsidas Bhanot Publishers,Jabalpur,India.2/15/2013 77
    77. 77. References• Draft global vaccine action plan for 2010 -2020 by the Secretariat, 65th World Health Assembly ,11 May 2012.• Progress Toward Interruption of Wild Poliovirus Transmission — , Morbidity and Mortality Weekly Report Weekly by CDC / Vol. 61 / No. 19 May 18, 2012.• Fiore AE, Uyeki TM, Broder K et al. Prevention and control of influenza with vaccines: recommendations of the Advisory Committee on Immunization Practices (ACIP), 2010. MMWR Recomm Rep. 2010; 59(RR- 8):1-62.• Sharma SK, Singhal RK, Agarwal AK,Adult Immunization (Monograph),Vol. 1, March 2009.Indian Association of Physicians.• www.who.int/topics/immunization.com• www.cdc.gov/vaccines.com.• www.google.co.in/vaccines/images/index.id2/15/2013 78
    78. 78. 2/15/2013 79
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