immunizations: a focus the older adult · 2018-04-01 · •cdc vaccine schedules app –free! in...
TRANSCRIPT
Immunizations: A Focus on the Older Adult
Margaret Williamson, PharmD, BPCSAssistant Clinical Professor of Pharmacy PracticeAuburn University Harrison School of Pharmacy
Disclosure Statement
• Neither I nor my spouse have relationships with pharmaceutical companies, biomedical device manufacturers, or other commercial companies whose products or services are related to the subject matter of the conference topics that could be perceived as a conflict of interest.
Learning Objectives• Understand the challenges associated with the
immune system of an older adult and why vaccination is necessary.
• Review the adult immunization schedule from the Centers for Disease Control to determine which vaccines may be recommended for an older adult.
• Distinguish important screening and counseling points among recommended vaccines.
• Discuss the latest recommendations from the CDC regarding pneumococcal vaccination.
Resources for Today’s Presentation
• CDC Adult Immunization Schedule (effective February 1st)– Copies provided to you
• CDC Vaccine Schedules App– FREE! in the Apple App Store or Google Play
• Epidemiology and Prevention of Vaccine‐Preventable Diseases (Pink Book)– 13th Ed. Published Jan 2015, full text PDF online
Healthy People 2020
• Vaccination rates among adults >65 years of age– Influenza: 66.6% (Goal of 90%)– Pneumococcal: 60% (Goal 90%)– Zoster: 24.2% (Goal 30%)
Healthy People 2020: healthpeople.gov
Why Immunizations in Older Adult
• Increased morbidity and mortality associated with infections
• Concomitant medical conditions that increase risk for complications
• Increased susceptibility to infection due to waning immunity
• Can become reservoirs of certain diseases for infants
Barriers to Vaccinations in the Older Adult
• Missed opportunities to provide multiple vaccinations in one day
• Contraindications versus precautions• Health literacy issues regarding vaccine adverse reactions
• Perceived cost issues
Multiple Vaccines in One Day?
• Data show this does not cause any adverse effects
• Consider how many pathogens are on the surfaces you touch every day– The immune system is designed to handle it!
• Delaying vaccines increases:– Risks of infection and outbreaks– Number of appointments/health care system burden
– Likelihood that the vaccine schedule will not be completed
APhA Pharmacy-Based Immunization Delivery. Certificate Training Program, 13th edition. Live Training Seminar.
False Contraindications
• Minor illness (mild fever, upper respiratory infection, mild diarrhea)– Vaccine should not be given if the patient is ill enough to refer to physician or hospital
• Allergies to products not in the vaccine (e.g., penicillin, bird feathers)
• Allergies that are not immediate and life‐threatening (e.g., other than anaphylaxis or laryngeal edema)
• Pregnancy in the household (even varicella)
INFLUENZA
Influenza Virus
A/California/7/2009 (H1N1)
NeuraminidaseHemagglutinin
Virustype
Geographicorigin
Strainnumber
Year of isolation
Virus subtype
CDC. Epidemiology and Prevention of Vaccine Preventable Diseases. 13th ed., 2015
Influenza Virus Strains
• Type A‐moderate to severe illness all age groups – humans and other animals
• Type B‐milder disease primarily affects children – humans only – more stable than influenza A, with less antigenic drift and consequent immunologic stability
• Type C‐rarely reported in humans no epidemics
CDC. Epidemiology and Prevention of Vaccine Preventable Diseases. 13th ed., 2015
Influenza Disease• Onset
– 2 days (1–4) after exposure– Contagious 1 day before symptomatic and 5–7
days after onset• Symptoms
– Cough (can be severe), fatigue, weakness, headache, myalgias
– Sudden onset of fever– Different presentation than common cold
• Complications– Pneumonia, exacerbation of pulmonary and
cardiac conditions– Hospitalizations and deaths
MMWR Morb Mortal Wkly Rep. 2015;64(RR30):818-25.
Influenza in the Older Adult
• At significantly increased risk for complications due underlying medical conditions, secondary infections (pneumonias), and hospitalizations
• Persons >65 years account for 90% of all flu‐related deaths
• Vaccination is 50‐60% effective in preventing hospitalization among elderly persons and 80% effective in preventing death among elderly persons
CDC. Epidemiology and Prevention of Vaccine Preventable Diseases. 13th ed., 2015
Abbreviations for Influenza Vaccines
• Inactivated influenza vaccine = IIV• Trivalent influenza vaccine (TIV) = IIV3
• Quadrivalent (QIV) = IIV4 Recombinant HA vaccine (Flublok) = RIV/RIV3
• Cell cultured (Flucelvax) = ccIIV3
2015–16 Influenza Vaccine
• Vaccine Composition – A/California/7/2009 (H1N1) pfm09‐like – A/Switzerland9715293/2013(H3N2)‐like (New)
– B/Phuket/3073/2013‐like (Yamagata) (New)
– B/Brisbane/60/2008‐like (Victoria) for quadrivalent
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Quadrivalent vs. Trivalent
• Recommendation to simply be vaccinated‐‐ ACIP does not recommend one over another
• Likely that all seasonal vaccines will transition to quad in the coming years
• Supply has to catch up with demand
Fluzone High Dose
• Approved in 2009 as a new formulation of inactivated influenza
• Approved for adults 65 years of age or older
• Each dose contains 4 times as much hemagglutinin as the regular formulation of Fluzone for adults
• ACIP has not expressed a preference for the high dose Fluzone formulation or any other inactivated vaccine for use in persons 65 years and older
Influenza Contraindications and Precautions
• Patients >49 should not receive LAIV• Contraindications IIV/RIV:
– Severe allergic reaction (e.g., anaphylaxis) after a previous dose of RIV or to a vaccine component. RIV does not contain any egg protein.
• Precautions IIV/RIV:– Moderate or severe acute illness with or without
fever– History of GBS within 6 weeks of previous
influenza vaccination– Persons who experience only hives with exposure
to eggs may receive RIV or, with additional safety precautions, IIV.
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Influenza Vaccination of Persons Who Report Allergy
to Eggs
MMWR Morb Mortal Wkly Rep. 2015;64(RR30):818-25.
2015‐2016 Flu Season
• Started out slow… but picking up• Reports of local outbreaks in AL
ZOSTER
Images taken from: zostavax.com
Herpes Zoster Virus• Lies latent in cells of dorsal root ganglia• Reactivates and travels along neuronal cell
axons– Often associated with advancing age or a
weakened immune system (including immunosuppression)
• Appears as localized rash in dermatomes• Complications
– Postherpetic neuralgia (PHN)– Scarring– Bacterial infection– Ocular involvement
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Zoster Vaccination in the Older Adult
• Lifetime risk of zoster is about 1 in 3• Increasing age and cellular immunosuppression are the most important risk factors
• 50% of persons living to age 85 years develop zoster
Zoster Vaccine
• Zostavax (Merck)– Live attenuated virus vaccine– Higher strength than varicella vaccine– Dose and route
• 0.65 mL (entire contents of vial) SC
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Zostavax Efficacy
• ~50% effective… less effective with advancing age
• In those that develop shingles, vaccine reduced the incidence of PHN by 39%
• Most of the effectiveness in prevention of PHN is due to preventing zoster
• Individuals who have had shingles can still receive the vaccine to prevent future occurrences of the disease, but the vaccine does NOT treat active disease or PHN
Zostavax Vaccination in Persons >50 versus >60
• ACIP target group for vaccination– Adults at least 60 years old
• FDA approved for prevention (not treatment) in: – Adults at least 50 years old
• Note: ACIP recommendations still apply to adults 60 years and older
• Vaccine efficacy wanes within the first 5 years after vaccination
• Studies are ongoing to assess the duration of protection from one dose of zoster vaccine and the need, if any, for booster doses
POP QUIZ
A 66 year old female comes into your pharmacy asking what vaccines she may need. After interview you identify that she is a candidate for herpes zoster and PPSV23. Do you:A. Give both todayB. Wait and space the two vaccines
apart
Zoster Contraindications and Precautions
• Contraindications:– Severe allergic reaction (e.g., anaphylaxis) to a
vaccine component– Known severe cellular immunodeficiency (e.g., from
hematologic and solid tumors, receipt of chemotherapy, or long‐term immunosuppressive therapy or patients with HIV infection who are severely immunocompromised)
• Precautions– Moderate or severe acute illness with or without
fever– Receipt of specific antivirals (i.e., acyclovir,
famciclovir, or valacyclovir) 24 hours before vaccination; avoid use of these antiviral drugs for 14 days after vaccination
Immunization Action Coalition. Available from: www.immunize.org/catg.d/p3072a.pdf
Immunosuppression Recommendations
• New IDSA classification of immunosuppression• Low‐level immunosuppression
– Low dose corticosteroid – Alternate dose corticosteroid therapy – Methotrexate dose of 0.4 mg/kg/week or less– Azothiaprine dose of 3 mg/kg/day or less– 6‐MP dose of 1.5 mg/kg/day or less
• High‐level immunosuppression– Cancer chemotherapy – Prednisone dose of 2 mg/kg/day or less or 20
mg/day for 14 days or more– Immune modulators such as TNF‐alpha inhibitors
or anti‐B cell agents (rituximab)
31ACIP. MMWR. 2011:62:1-66.Rubin LG. Clin Infect Dis. 2014;58:e44-e100.
POP QUIZ!
Can patients who receive the herpes zoster vaccine transmit the varicella zoster virus (chickenpox) to susceptible persons?
• In theory, yes, but transmission of the varicella zoster virus from a vaccinated patient to a susceptible person has not yet been documented
• If patient develops rash, should be covered and susceptible persons should avoid contact with the lesions
TETANUS, DIPHTHERIA, PERTUSSIS
Vaccine‐Preventable Diseases in the 21st Century
34
DiseaseMax.Cases Year
Cases2011
Cases2012
Cases 2013
Case 2014
Diphtheria 206,939 1921 0 1 0 1
Hib ~20,000 1980’s 14 30 18 27
Measles 894,134 1941 220 55 184 628
Mumps 152,209 1968 404 229 438 1151
Pertussis 265,209 1934 18,719 48,277 24,231 28,660
ParalyticPoliomyelitis
21,269 1952 0 0 0 0
Tetanus 601 1948 36 37 19 21Varicella 221,983 1984 14,513 13,447 9,987 9058
APhA Pharmacy-Based Immunization Delivery. Certificate Training Program, 13th edition. Live Training Seminar.
Pertussis (Whooping Cough)• Caused by Bordetella pertussis
– Very contagious
• Symptoms– Paroxysmal cough– Whooping caused by inspiration against a closed glottis
• Clinical Course– Incubation 9‐10 days (range 6‐20)– Catarrhal Stage 1‐2 weeks– Paroxysmal Stage 1‐6 weeks– Convalescent Stage 2‐3 weeks (range weeks to months)
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Pertussis (Whooping Cough)
• Complications– Infants and children
• Pneumonia, seizures, encephalopathy, hypoxia, hospitalizations, death
– Teens and adults• Persistent cough, weight loss, passing out, rib fractures
• Disease is more severe among younger children– Among those <1 year of age, 50% hospitalized and 1.6% die
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Tdap in the Older Adult
• Adults are often reservoirs for pertussis and may not even know they have the disease
• Children are most at risk prior to 6 months (prior to routine vaccination)– Among those <1 year of age, 50% hospitalized and 1.6% die
• Should ideally be vaccinated 2 weeks prior to interacting with grandchildren
Differences Between DTaP and Tdap
• Dose– Tdap has lower diphtheria and acellular pertussis
dose to avoid local reactions in adults• FDA‐approved age indications
– DTaP younger than 7 years– Tdap
• Boostrix (GSK) 10 years or more• Adacel (Sanofi Pasteur) 11 to 64 years
• ACIP Recommendations for individuals 65 years and older – When feasible, use Boostrix– Use Adacel to not miss an opportunity if Boostrix
not available
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Timing of Tdap
If is no record of a Tdap dose, give a single dose of Tdap followed by one dose of Td every 10 years
Contraindications and Precautions
• Contraindications – Severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a vaccine component
– For pertussis‐containing vaccines: encephalopathy (e.g., coma, decreased level of consciousness, prolonged seizures) not attributable to another identifiable cause within 7 days of administration of a previous dose
Contraindications and Precautions
• Precautions:– Moderate or severe acute illness with or without
fever– Guillain‐Barré syndrome (GBS) within 6 weeks
after a previous dose of tetanus toxoid‐containing vaccine
– History of Arthus‐type hypersensitivity reactions after a previous dose of tetanus or diphtheria toxoid‐containing vaccine; defer vaccination until at least 10 years have elapsed since the last tetanus‐toxoid containing vaccine
– For pertussis‐containing vaccines: progressive or unstable neurologic disorder (including infantile spasms for DTaP), uncontrolled seizures, or progressive encephalopathy until a treatment
POP QUIZ!!!
• What is the recommended interval between a dose of Tdap and the last Td booster?
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Tdap can be administered regardless of the interval since the last tetanus and diphtheria toxoid‒containing vaccine
PNEUMOCOCCAL
Pneumococcal Disease• Streptococcus pneumoniae
– Gram‐positive coccobacillus with a polysaccharide cellular capsule
– Colonizes upper respiratory tract as part of normal flora
• Infection result of autoinoculation• A leading cause of vaccine‐preventable illness and death in U.S.
• Frequent cause of secondary bacterial pneumonia following influenza
• Threat exists year‐round, not just in winter• Antibiotic resistance is common
Pneumococcal Disease• More than 90 serotypes based upon
polysaccharide capsules• Disseminated disease
– Bacteremia– Meningitis– Arthritis– Peritonitis
• Lower respiratory tract– Pneumonia
• Upper respiratory tract– Sinusitis– Otitis media
Vaccine Licensure
46
• 1977: 14‐valent Pneumococcal Polysaccharide Vaccine (PPSV14)
• 1983: 23‐valent Pneumococcal Polysaccharide Vaccine (PPSV23)
• 2000: 7‐valent Pneumococcal Conjugate Vaccine (PCV7)
• 2010: 13‐valent Pneumococcal Conjugate Vaccine (PCV13)
PPSV23
• Pneumovax 23 (Merck)– Recommend single dose for
• All people 65 years and older• People 19–64 years old who smoke cigarettes • People 19–64 years old who have asthma• People at least 2 years old with chronic illness
– Contains 11 serotypes not found in PCV13– More efficacious against bacteremia than pneumonia
– Not adequately effective in children younger than 2 years
– Dose and route: 0.5 mL IM (or SC)
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Additional Doses of PPSV23
• Recommend a total of 2 doses 5 years apart for patients younger than 65 years with:– Immunosuppression– Asplenia (includes sickle cell disease)
• Recommend 1 dose of PPSV23 for patients younger than 65 years with:– Cochlear implants– CSF leaks
• Recommend one dose of PPSV23 for patients 65 years and older who received 1 or 2 doses at least 5 years ago and when younger than 65 years
PCV13• Prevnar 13 (Pfizer)
– 1 serotype not in PPSV23 (6A)• Routinely given to children ages 6 weeks
through 5 years• FDA approved for adults aged 50 years and
older • ACIP recommended in all adult 65 years and
older and in patients with – Cochlear implants– CSF leaks – Immunosuppression– Asplenia (includes sickle cell disease)
• Dose and route: 0.5 mL IM
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Pneumococcal Vaccination for Adults over 65 years
• If vaccine‐naïve– Give PCV13 followed by PPSV23 12 months later
• If vaccinated with PPSV23 at age 65 years or older– Give PCV13 at least 12 months after the PPSV23
• PCV13 recommendation to be re‐evaluated by ACIP in 2018– Herd immunity may make vaccine unnecessary
• No additional PCV13 is needed if a dose was given before age of 65
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Pneumococcal Vaccine Decision Tree for Adults >65 Years Old Who Did Not Receive PCV13
If PCV13 was given before age 65 years, no additional PCV13 is needed.
ACIP. MMWR. 2014;63:822-5.
Contraindications and Precautions
• Contraindications:– Severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a vaccine component (including, for PCV13, to any diphtheria toxoid‐containing vaccine)
• Precautions:– Moderate or severe acute illness with or without fever
Patient Case #1
SF is a 67 year old African American Female with no significant PMH. She comes in today asking about the pneumococcal vaccine. She has not been previously vaccinated with any pneumococcal vaccines in the past. All other vaccines are up to date. What is your recommendation?
Prevnar 13 today, Pneumovax 23 in 1 year
Patient Case #2
JJ is a 69 year old Caucasian male with PMH significant for HTN and CAD. He comes in today asking about the pneumococcal vaccine. He received Pneumovax 23 a month ago at his doctor’s office and wants to know when he should get his next shot. All other vaccines are up to date. What is your recommendation?Prevnar 13 1 year from Pneumovax vaccination
Patient Case #3
SP is a 66 year old Hispanic male with PMH significant for HTN and COPD. He comes in today asking about the pneumococcal vaccine. He received Pneumovax 23 six years ago (when he was 60) with his diagnosis of COPD. All other vaccines are up to date. What is your recommendation?
Prevnar 13 today, Pneumovax 23 in 1 year
Wrap‐Up
• Waning immunity makes immunization in the older adult both necessary and complicating
• Each patient encounter is an opportunity to recommend necessary vaccines‐ don’t miss your chance!
• Immunization provides both protection to the older adult and the ones they love
Questions???
Margaret Williamson, PharmD, BCPSAssistant Clinical Professor of Pharmacy PracticeClinical Coordinator of Introductory Pharmacy
Practice ExperiencesAuburn University Harrison School of Pharmacy
[email protected]‐844‐7164