adult vaccine updates according to last ACIP 2013

2. Ahmed Saad MD. FACP.
Assistant Prof Internal Medicine &
Infectious Diseases Cairo university

3. Disclosures
 I have no financial conflict or interest with the
manufacturer of any product named during this
presentation .
 I will not discuss vaccines not licensed by the FDA

4. 2013 Vaccine Updates

Influenza
 Hepatitis Vaccine

Pneumococcal
 Varicella

Herpes Zoster

T dap
 HPV

Meningococcal

5. Louis Pasteur
(1822-1895)
A Vision to future of humanity
 When dealing with
a disease, I never
think of finding a
remedy for it, but,
instead, a means of
prevention

6. Why adult vaccinations?
Adult deaths from vaccine
preventable diseases = 60,000
From: IOM, Calling the Shots: Immunization Finance Policies and Practices, 200

7. Why some adults need vaccines?
 Some adults incorrectly assume that the vaccines they




received as children will protect them for the rest of their
lives.
Some adults were never vaccinated as children
Newer vaccines were not available when some adults were
children
Immunity can begin to fade over time
As we age, we become more susceptible to serious disease
caused by common infections (e.g., flu, pneumococcus)

8. Burden of Adult Vaccine-Preventable Disease
Influenza: 10-20% of US people annually
36,000 deaths (average)
Pertussis: 1 million
Cervical cancer: 10,000
H Zoster : 1 million
Pneumococcal: 2,000-5000 meningitis
40,000 bloodstream infections
150,000-300,000 pneumonia

9. Incidence rates for invasive PD
(IPD) in the Middle East
1. Garcia CR et al. Poster presented at 8th bi-annual International Symposium on
Pneumococci and Pneumococcal Diseases (ISPPD8), Iguacu Falls, Brazil (March,
2012).

10. What makes a conjugate different?
Polysaccharide antigens
carrier protein
Conjugate vaccine
+
=
Presentation
B cell
T cell
B cell
Plasma cell
T-independent
Memory B cell
T-dependent
Plasma cell
The conjugation of a polysaccharide to a carrier protein leads to the interaction with T cells
resulting in the release of functional antibodies and production of memory B cells 1,2
1. de Roux A et al. Clin Infect Dis. 2008;46:1015-1023. 2. Pollard AJ et al. Nat Rev Immunol. 2009;9:213-220.

11. Recommended Adult Immunization
Schedule — United States, 2013
 Each year, the Advisory Committee on Immunization
Practices (ACIP) reviews the recommended adult
immunization schedule to ensure that the schedule
reflects current recommendations for the licensed
vaccines.

12. From: http://www.cdc.gov/vaccines/recs/schedules/adult-schedule.htm

15. Influenza Virus
 Family
Orthomyxoviridae
 Three main types
 Type A
 Multiple species
 Type B
 Humans
 Type C
 Humans and swine

16. Influenza updates
 For the (Live Attenuated Influenza Vaccine) LAIV,
beginning with 2013–14 season, only the
quadrivalent formulation will be available and
trivalent formulation will stop.
 It contains 2 influenza A (H3N2) and (H1N1),
plus 2 influenza B vaccine virus strains
 Also the name inactivate influenza vaccine( IIV )
replaced the name trivalent inactivated vaccine
( TIV)

17. Influenza updates
 Annual vaccination against influenza is
recommended for all persons aged 6 months or
older.
 Healthy persons , non pregnant (2-49 y) with no
high-risk medical conditions can receive (LAIV) or
IIV.
 Health care personnel, immunocompromised and
pregnant should receive IIV rather than LAIV.

21. clinical form of pneumococcal
disease
Invasive
Non-invasive
* Acute otitis media
** including empyema
1. WHO. Acute Respiratory Infections (Update September 2009). 2. Centers for Disease Control and Prevention. Epidemiology and Prevention of Vaccine Preventable
Diseases. The Pink Book. 11th Edition. May 2009.

24. ACIP risk groups for pneumococcal infection
 (ACIP) recommends vaccination of:
 All adults aged 65 years on over
• The US Advisory Committeeand Immunization Practise (ACIP) recommends vaccination of:
− All adults aged 65 years and with the following underlying medical conditions:
Adults
19-64 years over
− Adults aged 19-64 years with the following underlying medical conditions:
1- Immunocompetent persons

Chronic heart disease
 Chronic lung disease
Diabetes mellitus
 Cerebrospinal fluid leaks
 Cochlear implant
 Chronic liver disease

 Cigarette smoking
3-Immunocompromised persons
 Congenital or acquired (HIV)




2- Functional or anatomic asplenia
Sickle cell disease
 Splenectomy
 congenital or acquired asplenia


immunodeficiet
C R F & Nephrotic
Leukaemias & Lymphomas
Generalised malignancy
Diseases treated with
immunosuppression( steroids >1 m
or Biologics
Solid organ transplantation
1. Centers for Disease Control and Prevention. MMWR. Prevention of Pneumococcal Disease. ACIP Recommendations
2010;59:1102–1106.
29

25. Pneumococcal Vaccine
Adults aged 19 years or older with
underlying medical conditions
should receive a single dose of
PCV13 followed 8 weeks later by a
dose of PPSV23

26. Prevenar 13 (PCV13):
1
4
3
6B
5
9V
6A
14
7F
18C
19A
19F
23F
Using CRM197 , the same carrier protein as Prevenar 1,2,
with more than 20 years of experience in vaccines 3
1.Prevenar EPAR. 2. Prevenar 13 Summary of Product Characteristics March 2012. 3. Centers for Disease Control
and Prevention. Update: Haemophilus influenzae type b vaccine. MMWR. 1989;38:14.
http://www.cdc.gov/mmwr/preview/mmwrhtml/00001330.html. Accessed May 24, 2011.

30. SHINGLES(HERPES ZOSTER)

33. Effect Of Herpes Zoster Vaccine

34. Herpes Zoster / Shingles
 Live attenuated VZV in amount 14 times greater in
minimum potency than varicella vaccine ,to elicit a
significant increase in the CMI to VZV among older
adults
 Since 2006, the ACIP/CDC recommends to vaccinate
all people > 60 y regardless of history of shingles.
 CDC has recommendation and both Zoster &
Pneumococcal vaccines can be administered at the
same visit if indicated.

35. Herpes zoster vaccination
 Only single dose.
 Also persons with
chronic medical
conditions Can be
vaccinated

36. H zoster use in
immunocompromised

37. H ZOSTER for
immunocompromised
 Retrospective study of 463,541 with age >60 y with 1 of the
following autoimmune diseases: rheumatoid arthritis,
psoriasis, psoriatic arthritis, ankylosing spondylitis, or
inflammatory bowel disease.
 19,000 of received zoster vaccine, of them 633 patients
exposed to biologics (551 anti TNF) .
 Incidence of HZ within 42 days post vaccination and
follow up period of 2 years.

38. Demographic Data

39. immunosuppressive Treatment

40. H ZOSTER for
immunocompromised
 None of these patients on biologics developed
varicella or HZ in 42 days
 Decrease incidence of H zoster by 39 % in
vaccinated group in 2 years
 ACIP recommended that persons > 60 to receive
zoster vaccine with or without immunocomromised
conditions .

43. Natural History of HPV Infection and
Potential Progression to Cervical Cancer
0–1 Year
0–5 Years
Continuing
Infection
Initial
HPV
Infection
1–20 Years
CIN
2/3
Invasive
Cervical
Cancer
CIN 1
Cleared HPV Infection (~80%)
1. Pinto AP, Crum CP. Clin Obstet Gynecol. 2000;43:352–362. cervical intraepithelial neoplasia (CIN).

45. Recurrent Respiratory
Papillomatosis

47. Human Papilloma virus VaccineRecommendations Age & Dose
 Routine immunization of females at
11-12 years
 Vaccination of females up to age 26
 3 Dose 0, 1, 6 months

51. Meningococcal vaccination
 Meningococcal vaccine should be administered to
persons with the following indications:
1-Medical: A 2-dose series of meningococcal conjugate
vaccine (8 w apart ) is recommended for adults with
anatomic or functional asplenia, or persistent
complement component deficiencies.
2-Adults with HIV infection : to receive a routine 2-doses
The 2 doses should be administered at 0 and 2 months

52. Meningococcal vaccination
 Administer a single dose to
1- Microbiologists routinely exposed to N meningitidis
2- Military recruits,
3- Those who travel to or live in countries in which
meningococcal disease is hyperendemic or epidemic.
 Revaccination with MCV4 every 5 years is recommended
for adults who remain at increased risk for

55. Tetanus, Diphtheria & Pertussis (Tdap),
cont
 Adults are recognized as a reservoir of transmission of
Pertussis to a susceptible infants at greatest risk of
complications
 Updated schedule for Tdap
adults 19-64 y to receive a one dose of Tdap followed
Td booster every 10 years
 Pregnant women:
 Tdap during 3rd trimester of every pregnancy

56. T dap

58. Varicella vaccination
 All adults without evidence of immunity to
varicella should receive 2 doses (1 month apart )
 Evidence of immunity to varicella in adults
includes any of the following:
1- Documentation of 2 doses of varicella vaccine at
least 4 weeks apart
2-History of varicella diagnosed by healthcare
provider

62. Hepatitis A vaccination
 Vaccinate any person seeking protection from hepatitis
A virus (HAV) or persons with any of the following
— Persons with chronic liver disease or who is receiveing
clotting factor concentrates.
— Persons who use injection or non injection illicit drugs.
— Persons traveling to or working in countries that have
high endemicity of hepatitis A

63. Hepatitis A vaccination
 2 doses at 0 and 6 months (Havrix )
 Or Twinrix (Hepatitis A+B)0-1-6
 Or Twinrix a 4-dose schedule (days 0, 7,
and 21 ) followed by a booster dose a 12
month .

65. Hemodialysis and Hepatitis B
Vaccination
For hemodialysis or
immunocompromised 2 doses of
20 μg/mL (Engerix-B) administered
simultaneously on a 4-dose
schedule( 0, 1, 2, and 6 months)

69. Rubella component
 Women of childbearing age rubella
immunity should be checked . If no
immunity, and not pregnant should be
vaccinated.
 Pregnant women with no immunity should
receive MMR vaccine upon completion or
termination of pregnancy and before
discharge from the hospital

71. Conclusion
 Our immunocompromised patients
should vaccinated with Influenza ,
Pneumococcal , H Zoster ,Tdap ,
Hepatitis , Human Papilloma virus