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  2. 2. LOUIS PASTEUR (1822-1895) A VISION TO FUTURE OF HUMANIT YWhen meditatingover a disease, Inever think offinding a remedyfor it, but,instead, a meansof prevention Dr.T.V.Rao MD 2
  3. 3. WHY SOME ADULTS NEED VACCINES?Some adults incorrectly assume that the vaccines theyreceived as children will protect them for the rest of theirlives. Generally this is true, except that:Some adults were never vaccinated as childrenNewer vaccines were not available when some adultswere childrenImmunity can begin to fade over timeAs we age, we become more susceptible to seriousdisease caused by common infections (e.g., flu,pneumococcus) Dr.T.V.Rao MD 3
  4. 4. INVIGORATION OF ADULT IMMUNIZATIONBuild on success ofinfant/childhood,adolescent programNew vaccines targetedat adultsRecognition of theburden of adultvaccine-preventabledisease Dr.T.V.Rao MD 4
  5. 5. WHY WE NEED ADULT VACCINES VACCINE- BURDEN OF ADULT VACCINE - PREVENTABLE DISEASEInfluenza: 10-20% of US population affected annually 200,000 hospitalizations 36,000 deaths (average)Pneumococcal: 2,000-5000 meningitis 40,000+ bloodstream infections 150,000-300,000 pneumoniaPertussis: 1 millionCervical cancer: 10,000Shingles: 1 millionAdult deaths from vaccine-preventable diseases: 43,000 Dr.T.V.Rao MD 5
  6. 6. RECOMMENDED ADULT IMMUNIZATION SCHEDULE — UNITED STATES, 2011 Each year, the AdvisoryCommittee onImmunization Practices(ACIP) reviews therecommended adultimmunization scheduleto ensure that theschedule reflectscurrentrecommendations forthe licensed vaccines. Dr.T.V.Rao MD 6
  7. 7. Dr.T.V.Rao MD 7
  8. 8. Dr.T.V.Rao MD 8
  9. 9. 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%) Dr.T.V.Rao MD 91. Pinto AP, Crum CP. Clin Obstet Gynecol. 2000;43:352–362.
  10. 10. HUMAN PAPILLOMAVIRUS VACCINE (CERVICAL CANCER)Licensed vaccine against 4 virus types (6, 11, 9-16, 18) for females 9 - 26 yearsPapillomavirus infection is precursor to cervicalcancer Types 16, 18 account for 70% of cervical cancersVirus is transmitted by sexual contact Over half of women are infected during their lifetimeThree-dose series Dr.T.V.Rao MD 10
  11. 11. HUMAN PAPILLOMAVIRUS (HPV) VACCINATIONHPV vaccination with either quadrivalent (HPV4) vaccine or bivalentvaccine (HPV2) is recommended for females at age 11 or 12 years andcatch-up vaccination for females aged 13 through 26 years.Ideally, vaccine should be administered before potential exposure toHPV through sexual activity; however females who are sexually active however,should still be vaccinated consistent with age-basedrecommendations. Sexually active females who have not been infectedwith any of the four HPV vaccine types (types 6, 11 , 16, and 18, all ofwhich HPV4 prevents) or any of the two HPV vaccine types (types 16and 18, both of which HPV2 prevents) receive the full benefit of thevaccination. Vaccination is less beneficial for females who havealready been infected with one or more of the HPV vaccine types. HPV4or HPV2 can be administered to persons with a history of genitalwarts, abnormal Papanicolaou test, or positive HPV DNA test, becausethese conditions are not evidence of previous infection with all vaccineHPV types Dr.T.V.Rao MD 11
  12. 12. VACCINATING MALES HPV4 may be administered to males aged 9 through 26 years to reduce their likelihood of genital warts. HPV4 would be most effective when administered before exposure to HPV through sexual contact Dr.T.V.Rao MD 12
  13. 13. HUMAN PAPILLOMAVIRUS VACCINE- RECOMMENDATIONS CDC’s Advisory Committee on Immunization Practices (ACIP) June 29, 2006Recommendations: Routine immunization of females at 11-12 years May be started as young as 9 years at discretion of provider/parent Vaccination of females up to age 26 Dr.T.V.Rao MD 13
  14. 14. ADMINISTRATION OF DOSESA complete series foreither HPV4 or HPV2consists of 3 doses. Thesecond dose should beadministered 1–2months after the firstdose; the third doseshould be administered6 months after the firstdose. Dr.T.V.Rao MD 14
  15. 15. HERPES ZOSTER VACCINATION Single dose of zoster vaccine is recommended for adults aged 60 years and older regardless of whether they report a previous episode of herpes zoster. Persons with chronic medical conditions may be vaccinated unless their condition constitutes a contraindication Dr.T.V.Rao MD 15
  16. 16. EVIDENCE OF MEASLES, MUMPS, AND RUBELLAIMMUNIT Y FOR HEALTHCARE PERSONNEL (HCP) For unvaccinated personnel born before 1957 who lack laboratory evidence of measles, mumps and/or rubella immunity or laboratory confirmation of disease, healthcare facilities should consider vaccinating personnel with two doses of MMR vaccine at the appropriate interval for measles and mumps, and one dose of MMR vaccine for rubella, respectively Dr.T.V.Rao MD 16
  17. 17. MEASLES, MUMPS, RUBELLA (MMR) VACCINATIONAdults born before 1957 generally are consideredimmune to measles and mumps. All adults born in 1957or later should have documentation of 1 or more doses ofMMR vaccine unless they have a medical contraindicationto the vaccine, laboratory evidence of immunity to eachof the three diseases, or documentation of provider-diagnosed measles or mumps disease. For rubella,documentation of provider-diagnosed disease is notconsidered acceptable evidence of immunity. Dr.T.V.Rao MD 17
  18. 18. WHICH ADULTS NEED MMR VACCINEHealthcare personnel born before 1957: For unvaccinatedhealthcare personnel born before 1957 who lack laboratoryevidence of measles, mumps, and/or rubella immunity orlaboratory confirmation of disease, healthcare facilitiesshould 1) consider routinely vaccinating personnel with 2doses of MMR vaccine at the appropriate interval (for measlesand mumps) and 1 dose of MMR vaccine (for rubella), and 2)recommend 2 doses of MMR vaccine at the appropriateinterval during an outbreak of measles or mumps, and 1 doseduring an outbreak of rubella. Complete information aboutevidence of immunity is available at Dr.T.V.Rao MD 18
  19. 19. MMR VACCINE Measles component: A second dose of MMR vaccine, administered a minimum of 28 days af ter the fir st dose, is recommended for adults who 1) have been recently exposed to measles or are in an outbreak setting; 2) are students in postsecondar y educational institutions; 3) work in a healthcare facility; or 4) plan to travel internationally. Per sons who received inactivated (killed) measles vaccine or measles vaccine of unknown type during 1963–1967 should be revaccinated with 2 doses of MMR vaccine. Dr.T.V.Rao MD 19
  20. 20. RUBELLA COMPONENTRubella component: Forwomen of childbearing age,regardless of birth year,rubella immunity should bedetermined. If there is noevidence of immunity, womenwho are not pregnant shouldbe vaccinated. Pregnantwomen who do not haveevidence of immunity shouldreceive MMR vaccine uponcompletion or termination ofpregnancy and beforedischarge from the healthcarefacility Dr.T.V.Rao MD 20
  21. 21. DEALING WITH RUBELLA OUTBREAKSHealthcare personnel born before 1957: For unvaccinatedhealthcare personnel born before 1957 who lack laboratoryevidence of measles, mumps, and/or rubella immunity orlaboratory confirmation of disease, healthcare facilitiesshould 1) consider routinely vaccinating personnel with 2doses of MMR vaccine at the appropriate interval (for measlesand mumps) and 1 dose of MMR vaccine (for rubella), and 2)recommend 2 doses of MMR vaccine at the appropriateinterval during an outbreak of measles or mumps, and 1 doseduring an outbreak of rubella. Complete information aboutevidence of immunity is available at Dr.T.V.Rao MD 21
  22. 22. Pneumococcal Vaccine: Vaccine Efficacy,Vaccination Effectiveness and Epistemological ConfusionLarge-Large - scale prospective efficacy trials have not beenundertaken in older persons, and the results of smaller meta-trials and their meta - analyses have been inconclusive.Population-based observational studies (case-control,indirect cohort and retrospective cohort) convincinglyshow that pneumococcal vaccination is effective inpreventing hospitalization for invasive disease andpneumonia and in preventing death.Unwillingness to accept the results of observationalstudies reflects scientific bias, not problems intrinsic tothe studies themselves. Dr.T.V.Rao MD 22
  23. 23. PNEUMOCOCCAL POLYSACCHARIDE VACCINATION FOR OLDER ADULTS• The burden of invasive pneumococcal disease among older adults is substantial (50 cases/100,000)• The clinical effectiveness and cost-effectiveness of pneumococcal vaccination to prevent invasive disease in older adults are firmly established• Pneumococcal vaccination has been introduced recently in many countries• Persistent doubts about the effectiveness of pneumococcal vaccination are responsible for the lack of vaccine use in some countries
  24. 24. P N E UM OC OC CAL P OLYSAC C H ARI DE ( P P SV ) VAC C I NATI ONVAC C I NATE A L L P E RSON S W I T H T H E FOL LOW I NG I N DI CATI ONSMedical: Chronic lung disease(including asthma); chroniccardiovascular diseases; diabetesmellitus; chronic liver diseases;cirrhosis; chronic alcoholism;functional or anatomic asplenia(e.g., sickle cell disease orsplenectomy [if electivsplenectomy is planned,vaccinate at least 2 weeks beforesurger y]); immunocompromisingconditions (including chronicrenal failure or nephroticsyndrome); and cochlearimplants and cerebrospinal fluidleaks. Vaccinate as close to HIVdiagnosis as possible. Dr.T.V.Rao MD 24
  25. 25. PNEUMOCOCCAL POLYSACCHARIDE (PPSV) VACCINATION Other: Residents of nursing homes or long- term care facilities and persons who smoke cigarettes. Routine use of PPSV is not recommended for American Indians/Alaska Natives or persons aged less than 65 years unless they have underlying medical conditions that are PPSV indications. Dr.T.V.Rao MD 25
  26. 26. REVACCINATION WITH PPSV One-time revaccination af ter 5 year s is recommended for per sons aged 19 through 64 year s with chronic renal failure or nephrotic syndrome; functional or anatomic asplenia (e.g., sickle cell disease or splenectomy); and for per sons with immunocompromising conditions. For per sons aged 65 year s and older, one-time revaccination is recommended if they were vaccinated 5 or more year s previously and were aged less than 65 year s at the time of primar y vaccination Dr.T.V.Rao MD 26
  27. 27. MENINGOCOCCAL VACCINATIONMeningococcal vaccine shouldbe administered to personswith the following indications:Medical: A 2-dose series ofmeningococcal conjugatevaccine is recommended foradults with anatomic orfunctional asplenia, orpersistent complementcomponent deficiencies.Adults with HIV infection whoare vaccinated should alsoreceive a routine 2-doseseries. The 2 doses should beadministered at 0 and 2months Dr.T.V.Rao MD 27
  28. 28. MENINGOCOCCAL VACCINATION WHO NEEDS MOREOther : A single dose of meningococcal vaccine isrecommended for unvaccinated first-year college studentsliving in dormitories; microbiologists routinely exposed toisolates of Neisseria meningitides; military recruits; andpersons who travel to or live in countries in whichmeningococcal disease is hyper endemic or epidemic(e.g., the “meningitis belt” of sub-Saharan Africa duringthe dry season [December through June]), particularly iftheir contact with local populations will be prolonged.Vaccination is required by the government of Saudi Arabiafor all travelers to Mecca during the annual Hajj. Dr.T.V.Rao MD 28
  29. 29. MENINGOCOCCAL VACCINATIONMeningococcal conjugate vaccine,quadrivalent (MCV4) is preferred foradults with any of the precedingindications who are aged 55 year sand younger; meningococcalpolysacc harid e vaccine (MPSV4) ispreferred for adults aged 56 year sand older. Revaccinati on with MCV4ever y 5 year s is recommended foradults previously vaccinated withMCV4 or MPSV4 who remain atincreased risk for infection (e.g.,adults with anatomic or functionalasplenia, or per sistent complementcomponent deficiencies). Dr.T.V.Rao MD 29
  30. 30. INFLUENZA VACCINATIONAnnual vaccination against influenza is recommended forall persons aged 6 months and older, including all adults.Healthy, nonpregnant adults aged less than 50 yearswithout high-risk medical conditions can receive eitherintranasally administered live, attenuated influenzavaccine (FluMist), or inactivated vaccine. Other personsshould receive the inactivated vaccine. Adults aged 65years and older can receive the standard influenzavaccine or the high-dose (Fluzone) influenza vaccine.Additional information about influenza vaccination isavailable at Dr.T.V.Rao MD 30
  31. 31. TETANUS, DIPHTHERIA, AND ACELLULAR PERTUSSIS (TD/TDAP) VACCINATIONAdminister a one-time dose of Tdap to adults aged less than 65years who have not received Tdap previously or for whom vaccinestatus is unknown to replace one of the 10-year Td boosters, and assoon as feasible to all 1) postpartum women, 2) close contacts ofinfants younger than age 12 months (e.g., grandparents and child-care providers), and 3) healthcare personnel with direct patientcontact. Adults aged 65 years and older who have not previouslyreceived Tdap and who have close contact with an infant aged lessthan 12 months also should be vaccinated. Other adults aged 65years and older may receive Tdap. Tdap can be administeredregardless of interval since the most recent tetanus or diphtheria-containing vaccine Dr.T.V.Rao MD 31
  32. 32. TETANUS, DIPHTHERIA, AND ACELLULAR PERTUSSIS (TD/TDAP) VACCINATIONAdults with uncer tain or incompletehistor y of completing a 3-doseprimar y vaccinati on series with Td-containing vaccines should begin orcomplete a primar y vaccinationseries. For unvaccinated adults,administer the fir st 2 doses at least4 weeks apar t and the third dose 6–1 2 months af ter the second. Ifincompletely vaccinated (i.e., lessthan 3 doses), administer remainingdoses. Substitute a one-time dose ofTdap for one of the doses of Td,either in the primar y series or forthe routine booster, whichevercomes fir st. Dr.T.V.Rao MD 32
  33. 33. TETANUS, DIPHTHERIA, AND ACELLULAR PERTUSSIS (TD/TDAP) VACCINATION If a woman is pregnant and received the most recent Td vaccination 10 or more year s previousl y, administer Td during the second or third trimester. If the woman received the most recent Td vaccination less than 10 year s previously, administer Tdap during the immediate postpar tum period. At the clinician’s discretion, Td may be deferred during pregnancy and Tdap substituted in the immediate postpar tum period, or Tdap may be administered instead of Td to a pregnant woman af ter an informed discussion with the woman . T h e AC I P s t a te m e n t f o r r e c o m me n d a t i o n s f o r a d m i ni s te r i n g T d a s p r o p hy la x is i n wound management is available at h t t p : / / w w w. c d c. g ov / va c ci n e s / p u b s / a c ip - list.htm. Dr.T.V.Rao MD 33
  34. 34. VARICELLA VACCINATIONAll adults without evidence of immunity to varicella should receive2 doses of single-antigen varicella vaccine if not previouslyvaccinated or a second dose if they have received only 1 dose,unless they have a medical contraindication. Special considerationshould be given to those who 1) have close contact with persons athigh risk for severe disease (e.g., healthcare personnel and familycontacts of persons with immunocompromising conditions) or 2)are at high risk for exposure or transmission (e.g., teachers; child-care employees; residents and staf f members of institutionalsettings, including correctional institutions; college students;military personnel; adolescents and adults living in households withchildren; nonpregnant women of childbearing age; andinternational travelers). Dr.T.V.Rao MD 34
  35. 35. VARICELLA VACCINATIONEvidence of immunity to varicella in adults includes anyof the following: 1) documentation of 2 doses of varicellavaccine at least 4 weeks apart; 2) U.S.-born before 1980(although for healthcare personnel and pregnant women,birth before 1980 should not be considered evidence ofimmunity); 3) history of varicella based on diagnosis orverification of varicella by a healthcare provider (for apatient reporting a history of or having an atypical case, amild case, or both, healthcare providers should seekeither an epidemiologic link with a typical varicella caseor to a laboratory-confirmed case or evidence oflaboratory confirmation, Dr.T.V.Rao MD 35
  36. 36. VARICELLA VACCINATION Pregnant women should be assessed for evidence of varicella immunity. Women who do not have evidence of immunity should receive the first dose of varicella vaccine upon completion or termination of pregnancy and before discharge from the healthcare facility. The second dose should be administered 4–8 weeks after the first dose. Dr.T.V.Rao MD 36
  37. 37. HEPATITIS A VACCINATIONVaccinate persons with any of the following indications and anyperson seeking protection from hepatitis A virus (HAV) infection:Behavioral:Behavioral Men who have sex with men and persons who useinjection drugs.Occupational: Persons working with HAV-infected primates or withHAV in a research laboratory setting. Medical: Persons with chronic liver disease and persons who receive clotting factor concentrates.Other: Persons traveling to or working in countries that have high orintermediate endemicity of hepatitis Dr.T.V.Rao MD 37
  38. 38. HEPATITIS A VACCINATION. Single-antigen vaccine formulations should be administered in a 2-dose schedule at either 0 and 6–12 months (Havrix), or 0 and 6– 18 months (Vaqta). If the combined hepatitis A and hepatitis B vaccine (Twinrix) is used, administer 3 doses at 0, 1 , and 6 months; alternatively, a 4-dose schedule may be used, administered on days 0, 7, and 21–30, followed by a booster dose at month 12. Dr.T.V.Rao MD 38
  40. 40. HEPATITIS B VACCINE: ACIP RECOMMENDATIONS Expanded Risk GroupsSexual Transmission All sexually active persons not in a mutually monogamous relationship Persons evaluated or treated for STDs Men who have sex with men Sex partners of HBsAg- positive persons
  41. 41. HEPATITIS B VACCINATION INDICATIONS BEHAVIORALBehavioral : Sexuallyactive persons who are not ina long-term, mutuallymonogamous relationship(e.g., persons with more thanone sex partner during theprevious 6 months); personsseeking evaluation ortreatment for a sexuallytransmitted disease (STD);current or recent injection-drug users; and men whohave sex with men. Dr.T.V.Rao MD 41
  42. 42. OCCUPATIONAL RISK OF HBV INFECTION Occupational : Healthcare personnel and public- safety workers who are exposed to blood or other potentially infectious body fluids. Medical: Persons with end-stage renal disease, including patients receiving hemodialysis; persons with HIV infection; and persons with chronic liver disease . Dr.T.V.Rao MD 42
  43. 43. OTHER INDICATIONS FOR HBV VACCINATIONHousehold contacts and sexpartners of persons with infection;chronic HBV infectionclients and staff membersof institutions for personswith developmentaldisabilities; andinternational travelers tocountries with high orintermediate prevalence ofchronic HBV infection (a listof countries is available at Dr.T.V.Rao MD 43
  44. 44. MAJOR NEED FOR HEPATITIS B VACCINATIONHepatitis B vaccination is recommended for all adults inthe following settings: STD treatment facilities; HIVtesting and treatment facilities; facilities providing drug-abuse treatment and prevention services; healthcaresettings targeting services to injection-drug users or menwho have sex with men; correctional facilities; end-stagerenal disease programs and facilities for chronichemodialysis patients; and institutions and nonresidentialday-care facilities for persons with developmentaldisabilities. Dr.T.V.Rao MD 44
  45. 45. MISSING DOSES IN HBV VACCINATIONAdminister missing doses tocomplete a 3-dose series of hepatitisB vaccine to those per sons notvaccinated or not completelyvaccinated . The second dose shouldbe administered 1 month af ter thefir st dose; the third dose should begiven at least 2 months af ter thesecond dose (and at least 4 monthsaf ter the fir st dose). If the combinedhepatitis A and hepatitis B vaccine(Twinrix) is used, administer 3 dosesat 0, 1 , and 6 months; alternatively,a 4-dose Twinrix schedule,administered on days 0, 7, and 21 to30, followed by a booster dose atmonth 1 2 may be used . Dr.T.V.Rao MD 45
  46. 46. HEMODIALYSIS INCREASES CHANCES OF HEPATITIS B INFECTION Adult patients receiving hemodialysis or with other immunocompromising conditions should receive 1 dose of 40 µg/mL (Recombivax HB) administered on a 3-dose schedule or 2 doses of 20 µg/mL (Engerix-B) administered simultaneously on a 4-dose schedule at0, 1 , 2, and 6 months Dr.T.V.Rao MD 46
  47. 47. REPORTED ACUTE HEPATITIS B INCIDENCE REDUCTION BY AGE GROUP: UNITED STATES, 1990 - 2004 1990- ≥20 years 12Cases per 100,000 94% decline 71% decline 10 12-19 years 8 6 4 <12 years 2 0 Year 1990 1992 1994 1996 1998 2000 2002 2004
  48. 48. SELECTED CONDITIONS FOR WHICHHAEMOPHILUS INFLUENZA T YPE B (HIB) VACCINE MAY BE USED 1 dose of Hib vaccine should be considered for persons who have sickle cell disease, leukemia, or HIV infection, or who have had a splenectomy, if they have not previously received Hib vaccine Dr.T.V.Rao MD 48
  49. 49. IMMUNOCOMPROMISING CONDITIONS NEEDGREATER PROTECTION WITH VACCINATIONS Inactivated vaccines generally are acceptable (e.g., pneumococcal, meningococcal, influenza [inactivated influenza vaccine]) and live vaccines generally are avoided in persons with immune deficiencies or immunocompromising conditions. Information on specific conditions is available at s/pubs/acip-list.htm. Dr.T.V.Rao MD 49
  50. 50. VACCINE RECOMMENDATIONS: HIGH RISKPersons aged >65 yearsResidents of nursing homes and other chronic-care facilitiesthat house persons of any age who have chronic medicalconditionsAdults and children who have chronic disorders of thepulmonary or cardiovascular systems, including asthma(hypertension is not considered a high-risk condition)Adults and children who have required regular medicalfollow-up or hospitalization during the preceding yearbecause of chronic metabolic diseases (including diabetesmellitus), renal dysfunction, hemoglobinopathies, or immune-suppression (including immunosuppression caused bymedications or by human immunodeficiency virus [HIV])
  51. 51. “ORGANIZE IMMUNIZATION FOR ALL HEALTH CARE WORKERS Occupational Health Outbreaks Infection Control Infectious Diseases Patients HCW | Student Public Health University/College Family Physician Student Health Pediatrician Physician/Nurse
  52. 52. Created by Dr.T.V.Rao MD for ‘e’Learning resources for Medical andParamedical Health Workers in the Developing World Email Dr.T.V.Rao MD 52