Dr. Pradeep Katwal presented on adult immunization. He discussed how vaccines have led to the eradication of smallpox and near eradication of diseases like diphtheria. He reviewed the immunological basis of vaccines and highlighted various vaccines recommended for adults including influenza, pneumococcal, hepatitis A/B, HPV and herpes zoster vaccines. Adult immunization is important to reduce the burden of vaccine-preventable diseases and protect high risk groups.

1. ADULT
IMMUNIZATION
PRESENTER-DR.PRADEEP KATWAL
MODERATOR-DR. NAVEEN K. PANDEY

2. • Jenner was an
English doctor, the
pioneer of smallpox
vaccination and the
father of
immunology….

3. “When meditating over
a disease, I never
think of finding a
remedy for it, but,
instead, a means of
prevention.”
Louis Pasteur
A Vision to future of humanity
3

4. Most successful medical
intervention ever developed for
prevention of infectious disease
IMMUNIZATION

5. CONDITION ANNUAL NO.
OF
PREVACCINE
CASES
(AVERAGE)
NO. OF CASES
REPORTED IN
2010A
REDUCTION
(%) IN CASES
AFTER
WIDESPREAD
VACCINATION
SMALLPOX 29,005 0 100
DIPHTHERIA 21,053 0 100
INVASIVE
PNEUMOCOCC
AL INFECTION:
<5 YEARS OF
AGE
16,069 4,167C
74
INVASIVE
PNEUMOCOCC
AL INFECTION:
ALL AGES
63,067 44,000C
30
c
Data are from the CDC's Active Bacterial Core Surveillance Report;
www.cdc.gov/abcs/survreports/spneu08.pdf.
Source: Adapted from Roush et al., with permission.

6. • 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..

7. Immunizing agents
1) Vaccines
• Live attenuated:
Bacterial: BCG, Typhoid, plague
Viral : Oral polio , Yellow fever, Measles, Mumps,
Rubella, Influenza
• Inactivated or killed vaccines
Bacterial: Typhoid, Cholera, Pertusis, Plague
Viral : Rabies, Salk (Polio), Influenza , Hepatitis B,
Japanese encephalitis
2) Toxoids : Diphtheria, Tetanus

8. Physiological basis
ACQUIRED IMMUNITY
– HUMORAL IMMUNITY
– CELL-MEDIATED IMMUNITY

9. Antibody response after exposure

10. Central Role of Helper T Cells

11. ADJUVANTS
A vaccine adjuvant is a component that potentiates the
immune responses to an antigen and/or modulates it
towards the desired immune responses.

12. 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.

13. Why we need adult vaccines ?
Influenza: 10-20% of US population annually
200,000 hospitalizations
36,000 deaths (average)
Burden of Adult Vaccine-Preventable Disease
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

14. WHY ADULTS?
The burden
Vaccination gap
High risk group
Chronic medical conditions

15. Recommendation for adult
immunization
• ACIP(advisory committee on immunization
practices)

18. Influenza vaccine

19. • 2009, update
WHO
199 countries
officially reported
over 482,300
laboratory
confirmed cases of
the influenza H1N1
6,071 deaths

21. • 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

22. 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

23. 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.**

24. Contraindication
 Egg allergy
 ?Pregnant women
 ?Gullian barre syndrome(if within 6 wks)

25. • 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.

27. NRS- 1011/-

28. influvac
A/california/7/2009(H1N1)
A/perth/16/2009(H3N2)
A/victoria/210/2009
B/brisbrane/60/2008
Per 0.5 ml

29. Pneumococcal vaccine

30. Polysaccharide vaccine
(PPV 23)
•CONFLIICTING RESULTS
 T Cell independent
immunity
Revaccinate after 5 yrs
Polysaccharide-protein
conjugate vaccine
• The Difference
• Infants and young
• 7,10,13 serotype
– Invasive pneumococcal
vaccine
– Antibiotic resistant strain

31. Harrison figure
Changes 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 United
States for routine administration to infants and young children during the second half
of 2000. (Reprinted with permission from Pilishvili et al, 2010.)

32. Conclusion
The recent introduction of universal PCV vaccination in children has led
to a change in the epidemiology of IPD in adults. The incidence of IPD
associated with PCV serotypes is expected to decrease and that
associated with other serotypes is expected to increase in adults.
Despite a reduction in the incidence of IPD, vaccinating the elderly and
at-risk adults with PPV23 in Germany against IPD and NBPP remains a
cost-effective strategy because of its broad serotype coverage.

33. RS 1857/-
• Pneumo 23

34. Hepatitis B vaccination

35. BEHAVIOURAL
Sexually active person without long-term non-
monogamous relationship
Person with more than one sexual partner during six
months
Seeking STI evaluation
Current or recent IV drug user
OCCUPATIONAL
Healthcare professionals risk of exposure to
blood or potentially infectious body fluids

36. Post-exposure prophylaxis
• Included in EPI schedule
• 3 IM injections (deltoid, not
gluteal)
• 0,1,6 months
• Contains HBsAg (10 mcg)
Pre-exposure prophylaxis
• Administer both HBIG and HB vaccine

37. Hepatitis B vaccine
RS 177 PER
DOSE

38. 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

39. • 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
COMBINED HEPATITIS A
HEPATITIS B VACCINE

40. Meningococcal Vaccine

41. Single dose is recommended -

42. • 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

43. Meseals Mumps Rubella

44. 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

45. MESEALS MUMPS RUBELLA
OUTBREAK SETTING OUTBREAK SETTING CHILD BEARING AGE
Students of post-
secondary school
Students of post
secondary school
-If Non-pregnant
-IF immune status is
not known
Upon completion and
before discharge
Healthcare facility
workers
Healthcare facility
workers
International travellers International travellers

46. 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

47. • Four strains of human papillomavirus
(HPV) -- HPV-6, 11, 16, and 18

48. Tetanus Diptheria pertusis

49. 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.

50. Varicella vaccination
• All adults without evidence of immunity
2 doses of single-antigen varicella vaccine
A second dose if received only 1 dose
Special consideration
1) close contact with persons at high risk for severe
disease
2)Person with high risk for exposure or transmission.

51. Herpes zooster Vaccine

52. Herpes zooster
• Single dose
• Adults aged 60 years and older
• Regardless of whether they report a
previous episode of herpes zoster
Hib vaccine
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

53. Our senario

54. REFRENCES
• Harrison's 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