Twinrix ® is a combined hepatitis A and hepatitis B vaccine approved in 2001 by the Food and Drug Administration (FDA) for persons 18 years of age or older. Twinrix ® contains 720 EL.U. of hepatitis A antigen and 20 μg of hepatitis B surface antigen. Primary immunization consists of three doses, given on a 0-, 1-, and 6-month schedule, the same schedule as that used for single - antigen hepatitis B vaccine. Immunogenicity of the combined vaccine appears to be similar to that of the single - antigen vaccines when given separately. Twinrix ® can be used for immunization of persons 18 years of age or older who have indications for vaccination against both hepatitis A and hepatitis B, such as users of illicit injectable drugs, men who have sex with men, and persons with clotting factor disorders who receive therapeutic blood products. Formulation for children is available in many other countries. For international travel, hepatitis A vaccine is recommended for travelers to areas of high or intermediate hepatitis A endemicity (see slide 10). Hepatitis B vaccine is recommended for travelers to areas of high or intermediate hepatitis B endemicity who plan to live or work for at least 6 months in highly endemic countries (see slide 9 in hepatitis B slide set at http://www.cdc.gov/ncidod/diseases/hepatitis/slideset/hep_b/slide_9.htm).
ADULTIMMUNIZATION PRESENTER-DR.PRADEEP KATWALMODERATOR-DR. NAVEEN K. PANDEY
• Jenner was an English doctor, the pioneer of smallpox vaccination and the father of immunology….
Louis Pasteur A Vision to future of humanity“When meditating overa disease, I neverthink of finding aremedy for it, but,instead, a means ofprevention.” 3
Most successful medicalintervention ever developed forprevention of infectious disease IMMUNIZATION
CONDITION ANNUAL NO. NO. OF CASES REDUCTION OF REPORTED IN (%) IN CASES PREVACCINE 2010A AFTER CASES WIDESPREAD (AVERAGE) VACCINATIONSMALLPOX 29,005 0 100DIPHTHERIA 21,053 0 100INVASIVE 16,069 4,167C 74PNEUMOCOCCAL INFECTION:<5 YEARS OFAGEINVASIVE 63,067 44,000C 30PNEUMOCOCCAL INFECTION:ALL AGESc Data are from the CDCs Active Bacterial Core Surveillance Report;www.cdc.gov/abcs/survreports/spneu08.pdf.Source: Adapted from Roush et al., with permission.
• Immunization- – Immunization is the process whereby a person is made immune or resistant to an infectious disease, typically by the administration of a vaccine.• Vaccine- A vaccine is any preparation intended to produce immunity to a disease by stimulating the production of antibodies..
ADJUVANTSA vaccine adjuvant is a component that potentiates theimmune responses to an antigen and/or modulates ittowards the desired immune responses.
Aims of immunization• Eradication – State where disease and its causal agent have been removed from natural environment• Elimination – Reduction to zero cases or reduction in indegineous sustained transmission of infection in geographical region.• Control – Reduction of illness outcomes and limitation of the disruptive impacts associated with outbreaks of disease in communities, schools, and institutions.
Why we need adult vaccines ?Burden of Adult Vaccine-Preventable Disease Influenza: 10-20% of US population annually 200,000 hospitalizations 36,000 deaths (average) Pneumococcal: 2,000-5000 meningitis 40,000+ bloodstream infections 150,000-300,000 pneumonia Pertussis: 1 million Cervical cancer: 10,000 Shingles: 1 million Death from vaccine-preventable diseases: 43,000
WHY ADULTS?The burdenVaccination gapHigh risk groupChronic medical conditions
Recommendation for adult immunization• ACIP(advisory committee on immunization practices)
• 2009, update WHO199 countriesofficially reported over 482,300 laboratory confirmed cases of the influenza H1N16,071 deaths
• Annual vaccination• Age 6 months and older• Early autumn before influenza outbreak• Influenza A and influenza B• Influenza type/origin/isolate number/year of isolation/subtype
Live vaccine• Intranasal via spray• 2-49 yrs of age• Non pregnant• Has currently – Circulating Strain of influenza A and b – Cold adapted attenuated master strain• Protection >90% in young children• Don’t give antiviral drugs for 2 weeks
Killed vaccine• Inactivated vaccine• 6 months or older• Has influenza A and B – Previous year circulating strain – Anticipated strain circulating this year• Immunocompromised• Protection 50-80% is expected.**
• Vaccine was found to be 33% effective in preventing total respiratory illness (influenza-like illness and clinically diagnosed pneumonia). In prevention of pneumonia alone, vaccine was 43% effective. The estimate for prevention of pneumonia rose to 55% if the period under consideration was limited to the time of peak influenza activity. Given the number of eligible homes and the cohort methodology used, the results support continuation of current policy, encouraging use of vaccine in all nursing home residents.
Polysaccharide-protein Polysaccharide vaccine conjugate vaccine (PPV 23) • The Difference•CONFLIICTING RESULTS T Cell independent • Infants and youngimmunity • 7,10,13 serotypeRevaccinate after 5 yrs – Invasive pneumococcal vaccine – Antibiotic resistant strain
Harrison figureChanges in invasive pneumococcal disease (IPD) incidence, by serotype group,among children <5 years old (first) and adults >65 years old (second), 1998–2007.*7-Valent pneumococcal conjugate vaccine (PCV7) was introduced in the UnitedStates for routine administration to infants and young children during the second halfof 2000. (Reprinted with permission from Pilishvili et al, 2010.)
ConclusionThe recent introduction of universal PCV vaccination in children has ledto a change in the epidemiology of IPD in adults. The incidence of IPDassociated with PCV serotypes is expected to decrease and thatassociated with other serotypes is expected to increase in adults.Despite a reduction in the incidence of IPD, vaccinating the elderly andat-risk adults with PPV23 in Germany against IPD and NBPP remains acost-effective strategy because of its broad serotype coverage.
BEHAVIOURALSexually active person without long-term non-monogamous relationshipPerson with more than one sexual partner during sixmonthsSeeking STI evaluationCurrent or recent IV drug userOCCUPATIONALHealthcare professionals risk of exposure toblood or potentially infectious body fluids
Pre-exposure prophylaxis• Included in EPI schedule• 3 IM injections (deltoid, not gluteal)• 0,1,6 months• Contains HBsAg (10 mcg) Post-exposure prophylaxis• Administer both HBIG and HB vaccine
Hepatitis A virus• Behavioral: – Men who have sex with men – IV drugs users• Occupational: – Persons working with HAV-infected primates or with HAV in a research laboratory setting.• Medical: – Persons with chronic liver disease – persons who receive clotting factor concentrates.• Other: – Persons traveling to or working in countries that have high or intermediate endemicity of hepatitis A
COMBINED HEPATITIS A HEPATITIS B VACCINE• Approved by the FDA in United States for persons >18 years old• Contains 720 EL.U. hepatitis A antigen and 20 μg. HBsAg• Vaccination schedule: 0,1,6 months• Immunogenicity similar to single-antigen vaccines given separately• Can be used in persons > 18 years old who need vaccination against both hepatitis A and B• Formulation for children available in many other countries
• Serogroups A,C,Y W135 T cell independent Cannot be given in age less than 2 years of age Efficay C component >90% (children) Efficacy A component >95%(all age group) Duration of protection 2-5 yrs
MMR• All adults born in 1957 or later should have documentation of 1 or more MMR vaccine• 2nd dose- 28 days after first dose• Previous diagnosis of – Meseals – Mumps – Rubella
MESEALS MUMPS RUBELLAOUTBREAK SETTING OUTBREAK SETTING CHILD BEARING AGEStudents of post- Students of post -If Non-pregnantsecondary school secondary school -IF immune status is not knownHealthcare facility Healthcare facilityworkers workers Upon completion and before dischargeInternational travellers International travellers
Human papilloma virus• Primary goal is to prevent cervical cancer• All females 11-12 yrs• Catchup vaccination 13-26 yrs• Before sexual activity• Schedule- [0-15days-6 months}• Quadrivalent (HPV4) vaccine or bivalent vaccine (HPV2)• May be administered to males aged 9 through 26 years
• Four strains of human papillomavirus (HPV) -- HPV-6, 11, 16, and 18
Tetanus,Diphtheria & acellular Pertusis• Primary series : 3 dose 1st & 2nd dose : at least 4 wks apart 3rd dose: 6-12 months after the second. Tdap can substitute any one of the 3 doses of Td• Booster dose : every 10 yrs Tdap or Td may be used.• Tdap should replace single dose of Td in adult aged < 65 yrs.• Pregnancy: If last Td vaccine >10 yrs : Td at 2nd or 3rd trimester. If last Td vaccine <10 yrs : Td at immediate post partum period.
Varicella vaccination• All adults without evidence of immunity 2 doses of single-antigen varicella vaccine A second dose if received only 1 doseSpecial consideration1) close contact with persons at high risk for severe disease2)Person with high risk for exposure or transmission.
Herpes zooster • Single dose • Adults aged 60 years and older • Regardless of whether they report a previous episode of herpes zoster Hib vaccine1 dose of Hib vaccine should be considered forpersons who have sickle cell disease, leukemia, or HIVinfection, or who have had a splenectomy
REFRENCES• Harrisons Principles of Internal Medicine, 18th Edition• Guyton and Hall Textbook of Medical Physiology (12th Edn)• http://www.cdc.gov/vaccines/default.htm• http://www.fda.gov/BiologicsBloodVaccines /Vaccines/QuestionsaboutVaccines/ucm070 418.htm