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 Adult Immunization and Quality Improvement for Residents  Adult Immunization and Quality Improvement for Residents

Adult Immunization and Quality Improvement for Residents - PowerPoint Presentation

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Adult Immunization and Quality Improvement for Residents - PPT Presentation

Module 1 The Science of Adult Immunization Overview Module 1 Science of Adult Immunization Adult immunization rates ACIP recommended adult vaccine schedule Vaccination among special populations ID: 775092

vaccine www years cdc vaccine www years cdc http vaccines gov ppsv23 adult risk pcv13 adults dose htm tdap

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Slide1

Adult Immunization and Quality Improvement for ResidentsModule 1 – The Science of Adult Immunization

Slide2

Overview

Module 1 – Science of Adult Immunization

Adult immunization rates

ACIP recommended adult vaccine schedule

Vaccination among special populations:

Diabetics

Healthcare workers

Pregnant women

The elderly

Module 2 – Quality Improvement in Adult Immunization

Slide3

Disclosures

[insert your disclosures here]

Slide4

Opportunity and Reward

Immunization rates are far below HP2020 goalsCommon measure of quality preventive careInpatient, outpatientAdult, obstetric, pediatricPrimary, specialty careMany elements in process which can be improvedFront deskNursing/MAPhysicianCheckout

HP2020 =

Healthy People 2020

www.healthypeople.gov

Slide5

Vaccine [Population]20132014InfluenzaInfluenza – All Adults42.7 %43.2 % [All] 19 – 49 years30.4 %31.5 % [All] 50 – 64 years48.0 %47.7 % > 65 years71.7%71.5 % HCW [All]75.2 %77.3%PPS23 & PCV13 High risk 19 – 49 years21.2 %20.3 % > 65 years59.7 %61.3 %Tetanus [19 – 49 years, received past 10 years]62.9 %62.6 %Tetanus/Pertussis [19+, received in past 8 years]17.2 %20.1 %Shingles – Zoster[Age 60+]24.3 %27.9 %Hepatitis B Vaccine [High risk 19 – 49 years]32.6 %32.2 %HPV Vaccine [Women 19-26 >1 dose]36.8%40.2%HPV Vaccine [Men 19-26, >1 dose]5.9%8.2%

Adult Vaccination Rates = POOR!

Data: NHIS 2014

MMWR Feb 5, 2016/

Vol

65(1).

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6436a1.htm

Slide6

Vaccine [Population]RatePneumococcal [>65 years]All Adults61.3 % Hispanic45.2 % White64.7 % Black49.8 % Asian47.7 %

Disparities and Adult Vaccination Rates

Data: NHIS 2014

MMWR Feb 5, 2016/ Vol 65(1).

“…and, unfortunately, there are similar disparities for most adult vaccines. This is

absolutely unacceptable

in the United States in 2015!!” -RHH, MD 2/15/2015

Slide7

Vaccination Rates for Our Patients Are Not Adequate

Vaccine preventable diseases kill more Americans annually than traffic accidents, breast cancer, or HIV/AIDSAbout 20 % of eligible adults (18 – 64) have had Tdap in past 2 years< 30 % of adults > 60 have had the shingles vaccineAnd lifetime risk of shingles is 1/3, increasing with age!~ 10 % of eligible adult women have received the HPV vaccine seriesHPV causes a majority of cervical and other cancers~ 40 % of all adults are vaccinated annually for influenzaAbout 70 % of > 65 have received the vaccine About 60 % of Medicare beneficiaries~ 60% of patients > 65 have received any pneumococcal vaccine

http://

healthyamericans.org/assets/files/TFAH2010AdultImmnzBrief13.pdf

Slide8

Influenza Vaccination Coverage Among Adults Shows Minimal Recent Improvement (%)

Group 2012 – 132013 – 14Difference Persons > 18 years41.542.2+0.7* Persons 18 – 49 years, all31.132.3+1.2* Persons 18 – 49 years, high risk39.838.70.6* Persons 50 – 64 years45.145.3+0.2* Persons ≥ 65 years66.2 65.0-1.2*

* Statistically significant difference, p<0.05

http://

www.cdc.gov/flu/fluvaxview/index.htm

Slide9

Adult Vaccination Coverage, Selected Vaccines by Age and High-risk (HR) Status, United States

HP2020 Targets: 90% PPV ≥65 years, 60% PPV HR 19-64 years, 30% Shingles

Data Source:

2014 NHIS Data

Slide10

Adult Vaccination Coverage, Hepatitis A and B Vaccines by Age and High – Risk Status, United States

HP2020 Target: 90% Hep B Healthcare Personnel (HCP)

Data Source:

2014 NHIS

Slide11

Non-Influenza Adult Vaccination CoverageVaccines with Increases from 2012 to 2014

43.0%

27.9%

21.5%

Data Source: 2012 and

2014 NHIS

Slide12

http://www.cdc.gov/vaccines/schedules/hcp/imz/adult-conditions.html

Adult Immunization Schedule – 2016, By Age

Slide13

http://www.cdc.gov/vaccines/schedules/hcp/imz/adult-conditions.html

Adult Immunization Schedule – 2016, By Medical Indications

Slide14

“Selectives”

Vaccine Groups

“Universals”

InfluenzaPneumococcal [PCV13, PPSV23]TdapZoster

HPV [HPV9, HPV4, HPV2]MMRVaricellaMeningococcalQuad [MCV4, MPSV4]MenBHepatitis AHepatitis B

Slide15

Case 1

John Francis is a 42 year old man with a history of diabetes and hypertension presenting for a routine diabetes visit. While reviewing his immunization history, you note that he had all of his childhood vaccinations [documented in record]. His last booster shot was over 10 years ago. Which vaccines should you strongly recommend that he receive today?

Slide16

“Selectives”

Vaccine Groups

“Universals”

InfluenzaPneumococcal [PCV13, PPSV23]TdapZoster

HPV [HPV9, HPV4, HPV2]MMRVaricellaMeningococcalQuad [MCV4, MPSV4]MenBHepatitis AHepatitis B

Slide17

Influenza

Influenza: Orthomyxoviridae family [enveloped RNA virus]3 types based on surface Ag [HA, NA] + internal structureA: Multiple hosts – Birds, Mammals [Man]. Many HA, NA types‘Highly Pathogenic’ and ‘Mild’ strains B: Human host. 1 HA and 1 NA C: Human host. Mild illness ‘URI’ 30 – 50K deaths annually in US from Influenza200K+ assoc. hospitalizations, chronic illnesses exacerbations> 90% seasonal influenza M&M in people > 65 yearsVaccination is most effective intervention to reduce illness and death.Multiple vaccines avail. in US [effectiveness variable]

http://www.cdc.gov/flu/avian/gen-info/flu-viruses.htm

Slide18

US Influenza Vaccines

IIV: ‘Inactivated influenza vaccines’, IM admin. “All comers” 6 mo.+ (TRI/QUAD)Multiple vaccines with varied indications by age, production, preservative, etc.Some vaccines are TRIvalent, others QUADrivalentLittle data on which to base a strong recommendation for one vax over other Intradermal IIV: Approved 2011 for 18-64 years – smaller needle (TRI)High-Dose IIV: for 65+ population, first avail 2010-11 (TRI)Same production process as TIV, higher Ag dose = More local reactionsSeroconversion, seroprotection rates > TIV for A,B strainsCell culture vaccine: approved in 2013, essentially egg – free option (TRI)Recombinant HA vaccine: approved 2013, egg free, all HA no NA (TRI)Adjuvanted IIV: MF-59 adjuvant, NEW= approved 2015 for seniors 65+ (TRI)LAIV: Live-attenuated, cold-adapted nasal (QUAD)All Quadrivalent [2A2B] since 2013 – 14 Indicated only for healthy people 2 – 49 years

# Falsey, et.al. J ID 2009, June9 [Epub]; C. Bridges CDC Personal Comm.

3/2013

http://www.nejm.org/doi/full/10.1056/NEJMoa1315727 http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm474295.htm

Slide19

Influenza Vaccine Priorities

ALL 6 MONTHS AND OLDER + DON’T WANT THE FLUHEALTHCARE WORKERSHigh risk for disease (symptomatic and asymptomatic)High risk for transmissionIf sick not available to provide healthcare…PATIENTS @ HIGHEST RISK – SEVERE ILLNESS/SPREADPregnant womenNewborns and children < 2 yearsElderly“Medical Comorbidities” (including obesity)Household contacts of high-riskLong-term care/institutionalized, crowded living conditions

http://

www.cdc.gov/vaccines/pubs/vis/downloads/vis-flu.pdf

Slide20

Influenza Vaccines 2015 - 2016

Slide21

Influenza ‘Nuts and Bolts’

IIV: 1 dose for adultsIncl: QIV, TIV, sqTIV, hdTIV, LAIV, ccTIV, rHA (Flublock), Adjuvanted (Fluad)Kids < 9 years, first vaccine season: 2 doses 4+ weeks apartLAIV can be safely used in MOST HC settings as alt. to TIV2No CLEAR indication to choose 1 IIV over anotherPotential Exception: HD vs TIV in seniors 65+ based NEJM Aug 2014No data [quadrivalent] IIV v [trivalent] IIV. LAIV reasonable but not preferred.Vaccine allergy, availability…Egg allergy: ACIP, AAAI: NO contraindicationConsider Recombinant vaccine if anaphylactic egg sensitivity

http://www.cdc.gov/vaccines/pubs/vis/downloads/vis-flu.pdf

http://www.premierinc.com/all/safety/safety-share/12-05-downloads/03-shea-hcw-flu-position-paper.pdf

.

DiazGranados

, et.al. NEJM 371(7), August 14, 2014.

https://cc.readytalk.com/cc/s/meetingArchive?eventId=rtv7rz2szhrw

Slide22

Influenza

Vaccine effectiveness is multifactorial Match with ‘disease’ strainsVaccine availability and timing2015 – 2016 vaccine efficacy ~ 60%Patient ‘substrate’: ‘Healthy young < 65’ @ ~60 – 80% v. ‘Sick older > 65’ @ 30-40%Ongoing vaccine researchAdjuvantsNewer production methodsHigher Ag contentNew delivery devices ‘New Flu’s’Surveillance and candidate vaccine development: H5N1, H7N3, H9 and others

http://

www.cdc.gov/flu/professionals/antivirals/index.htm

http://www.cdc.gov/flu/professionals/diagnosis

/

Slide23

Pneumococcal Disease

> 2000 Adults/yr. 65+ die from invasive pneumococcal disease (IPD)Bacteremia, sepsis, meningitisPPSV23 = ‘adult standard’ vaccine = purified capsule polysaccharide 23 types  cause of 88 % bacteremic PNC diseasePPSV23 has 60-70% efficacy vs. IPDImmunity lasts at least 5 years following 1 doseLocal reactions – only common AEREVACCINATION if imm. before age 65; NOT ‘routine’ 65+ immunizedPCV13=‘pediatric standard’ vaccine = conjugated to protein13 types  ~50% IPD in immunocompromised adultsNo published efficacy studies in adults [PCV7 data in HIV, reports, etc.]Useful/ACIP recommended – combined strategy with PPSV23 – in adults

http://www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/pneumo.html

Slide24

US Pneumococcal Vaccines

VaccineBodyYearPopulationIndicationCommentsPPS14FDA1977High riskPrevent IPD1st lic PNC vaxPPS23FDA/ACIP1983; ’89; ’97; 9/2010High risk adult, childPrevent IPDInitial then updated recs.PCV7FDA/ACIP2/2000Children < 24 monthsPrevent PNC InfectionNew VaccinePCV13FDA/ACIP3/2010Children 6 week - 71 monthsPrevent PNC InfectionChanged, additional typesPCV13FDA12/2011Adults 50+ yearsPrevent IPD, PneumoniaImmunogenicity and safety dataACIP10/2012Highest Risk AdultsPrevent IPDPCV13/PPSACIP12/2012High Risk Kids > 6 yearsPrevent IPDPCV13/PPSACIP9/19/2014Adults 65+ yearsPrevent IPDBest before PPS23

http://

www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/pneumo.html

Slide25

PPS 23 Vaccine Effectiveness

7 Meta-Analyses of RCT [Most recent Cochrane 1/2013]Conclusions inconsistent re: cause specific outcomesAgreement: REDUCTION in IPDNO reduction ALL CAUSE mortality, pneumonia3 Meta-Analyses of Observational StudiesConsistent results: vaccine is effective for prevention of IPDRecent RCT ResultsInvasive PNC Dz: Odds ratio [consistent] 0.26 (CI 0.25-0.46)Pneumonia: Odds ratio [signif. heterogeneity] 0.71 (CI 0.52-0.97)Mortality: Odds ratio 0.87 (CI 0.69-1.10)SummaryData = PPS prevents IPD, not compelling for Pneumonia, Mortality

Fine, et.al.

ArchivesIM

1994(154): 2666. Hutchinson et.al.

CanJFP

1999(45): 2381. Watson, et.al. Vaccine 2002(20): 2166.

Conaty

, et.al. Vaccine 2004(22): 3214. Dear, et.al. Cochrane DB

Syst

Rev 2004, Issue 3.

Moberley

, et.al. Cochrane DB

Syst

Rev 2008, Issue 1. Moberly, et.al. Cochrane DB

Syst

Rev 2013, Issue 1.

Slide26

PCV13 Adult Vaccine Effectiveness

CAPiTA PC RCT PCV13 unimmunized 65+ aged adults, NetherlandsPCV7 in Dutch infants since 6/2006 -> PCV10 in March 201184,000+ participants PCV13 v PlaceboEnrolled 9/2008-1/2010, follow-up ended 8/2013Primary: 1st bacteremic CAP with vaccine – type PNC-> METSecondary: 1st nonbacteremic 1st CAP, other IPD-> METSerologic and urinary Ag used to identify PNC infectionConsidered by ACIP in making current Pneumococcal recs.No published study to date on sequential PCV13/PPSV23 immunization in adults

http://www.nejm.org/doi/full/10.1056/NEJMoa1408544

Slide27

Pneumococcal

Immunization

NO

NO

PCV 13 + PPSV23

PPSV23 ONLY

NO PNEUMOCOCCAL VACCINE

Slide28

Pneumococcal Immunization I

28

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5934a3.htm http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6140a4.htm

PPSV23 ALONE for INCREASED RISKAll cigarette smokers ≥ 19 years oldChronic conditions ≥19 years oldDiabetesLung disease: asthma, COPDCardiovascular diseaseLiver diseaseKidney disease (except ESRD, nephrotic syndrome – PCV13 recommended)

Immunity lasts at least 5 years following 1

dose

REVACCINATION ONCE

after age 65

[AND

>

5

years after initial dose] for those vaccinated prior to age

65

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

Adults 65 years and older

are

in highest risk

group- addressed in next slides.

Slide29

Pneumococcal Immunization II

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6140a4.htm

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6337a4.htm

SEQUENTIAL PCV13 + PPSV23 for

HIGHEST RISK

Adults 65 and older AGE Indication

Immunocompromised

’ MEDICAL

Indications

Disease:

CA: solid tumors, hematologic malignancies, myeloma, etc.

HIV

Inherited and other immune deficiency (CVID, etc.)

End-stage kidney disease ESRD,

nephrotic

syndrome

Latrogenic:

MEDS: Steroids (20 mg/d or greater), biologic immunomodulators, other

TRANSPLANTS: solid organ, bone marrow, stem cell

Asplenia:

ANATOMIC: splenectomy (best if immunized prior to)

FUNCTIONAL: hemoglobinopathy, sickle cell, other

4. Anatomic:

CSF leak, cochlear implant,

splenectomy

Slide30

Increased Risk Patients:Pneumococcal polysaccharide (PPSV23) – nowPCV/Booster once at 65+ years/5+ years later (only for persons vax before 64)Highest Risk Patients:Pneumococcal (PPSV23) vaccine-naive patients (best practice):PCV13 followed by PPSV23 at least 8 weeks laterBooster PPSV23 in 5 years AND final PPSV23 at 5+ years/65+ yearsPreviously PPSV23 – vaccinated patients:PCV13 at least 1 year after prior dose PPSV23 Booster PPSV23 5 years after prior PPSV23 (must be 8+ weeks after PCV13)Final PPSV23 after 65+ years and at least 5 years after last dose65+ Patients:Give PCV13 first, [if pneumococcal vaccine-naive] followed 1 year by PPSV23If any prior PPSV23, PCV13 must be given at least 1 year after the last PPSV23No additional/booster doses if sole indication is age > 65 yearsACIP recommends PPSV23 12 months after PCV13, CMS [M’CARE] will only pay if administered 11+ months between doses

Pneumococcal ‘Nuts and Bolts’PCV13 [1 dose in adults] PPSV23 [1 – 3 doses based on risk]

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6140a4.htm

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6337a4.htm

Slide31

c/o R. Hopkins, MD, FACP, FAAP UAMS

Slide32

Adult Pneumococcal Vaccine: By The Numbers

T

wo vaccines

PCV13

PPSV23

Three intervals

8 weeks between PCV13 and PPSV23 in highest risk medical conditions

1 year between PCV13 and PPSV23 if PPSV23 first or age is only ‘highest risk’ indication

5 years minimum between doses of PPSV23

Maximum doses in adult lifetime

1 PCV13

3 PPSV23 [If highest risk medical condition and first dose before 59

yr

]

Slide33

Td >> Tdap

All patients should have primary tetanus, diphtheria series3 doses: 0, 1 m., 6 m. [yields protective Ab ~ all for 10 years+]Many adults > 60 y. have never received primary T, d seriesOver 50% adults do not have protective T, d AntibodiesBooster Td every 10 years [many adults do not receive boosters]Most boosters given are ‘episodic trauma-related’Replace 1 dose Td with Tdap [primary series or as ‘booster’]Interval from last Td is unimportantNo harm if > 1 dose Tdap, but not ACIP recommendedTd/Tdap contraindicationsSevere allergy to vaccine comp. or Arthus reaction after T vax.[Tdap] encephalopathy < 7 days after pertussis containing vaccine[Tdap] unstable neurologic disease, moderate – severe acute illness

http://

www.cdc.gov/vaccines/vpd-vac/combo-vaccines/DTaP-Td-DT/Tdap.htm

Slide34

Td >> Tdap

Tdap Recommendation: All Adults Single dose to replace one dose Td [booster or primary]Current recommendation: subsequent Td q10yrResearch on repeated dosing ongoingMay give < 10 years following last TdSpecial emphasis: Adults with close infant contactHEALTHCAREParentsChild Care, etc.Tdap intrapartum all pregnant, every pregnancy [since 2013]Regardless of interval/prior Tdap [ideal @ 27 – 35 weeks]Focus: Protect infants [Highest M&M group] by passive immunity

http://

www.cdc.gov/vaccines/vpd-vac/combo-vaccines/DTaP-Td-DT/Tdap.htm

Slide35

Hepatitis B and Diabetes

October 2011: ACIP recommends Hepatitis B vaccine in unimmunized diabetic patientsAged 19 – 59 yearsAge 60+ is at discretion of the treating physician [Category A, type 2 evidence]Why?Patients with DM2 have 2.1 fold increased risk for acute HBV compared with non – DMNASH more common in diabetics and this and other chronic liver disease increases HBV – associated morbidity/mortalityNHANES: Seroprevalence for HBV [Anti – HBVc IgG] is 60% higher in DM than non-DM

http://

www.cdc.gov/mmwr/pdf/wk/mm6050.pdf

Slide36

Case 2

Maria Alvarez is a 24 year old medical student with no significant past medical history presenting for a routine annual exam. Which vaccines should you make sure she receives? As a healthcare worker in training, what vaccines should she receive?

Slide37

“Selectives”

Vaccine Groups

“Universals”

InfluenzaPneumococcal [PCV13, PPSV23]TdapZoster

HPV

[HPV9, HPV4, HPV2]

MMR

Varicella

Meningococcal

Quad [MCV4, MPSV4]

MenB

Hepatitis A

Hepatitis B

Slide38

HPV

Cervical Cancer is consequence of a STD [HPV]Second most common cause CA death in women500,000 cases and 250,000 deaths per yearUS: ~10 women die every day of cervical cancerCause of anal CA and penile CA in men20 million current HPV infections By age 50, 80% SA women will have acquired genital HPVMany clear spontaneously6.2 million new genital HPV infections/year in US74% in women 15 – 24 years of age70% Cervical CA worldwide d/t serotypes 16 [54%], 18 [13%]>90% Genital warts due to serotypes 6, 11

http://

www.cdc.gov/mmwr/preview/mmwrhtml/rr5602a1.htm

Slide39

Cervical Cancer

Genital Warts

Slide40

HPV Vaccines

http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5602a1.htm

Vaccines:HPV4: Types 6,11,16,18 HPV2: Types 16,18 3 dose series @ 0, 2 m, 6 m.HPV9: plus 31, 33, 45, 52, and 58No need to start over if completion delayedEffective protection at least 8 years based on published data [ongoing]Effective only for types patient has NOT previously acquiredHPV 2, 4, or 9 Women: 9-12 yrs [9-26]: prevent Cx CA [Pre-CA], Genital WartsHPV4 or 9 Men: 9-21 yrs [catch-up to 26] to prevent anal/penile preCA and CAContraindications/Cautions:Local reaction, bronchospasm reportedNot recommended in pregnancy – no proven AE [administer after delivery]Immunosuppression can reduce efficacyVACCINE DOES NOT CHANGE CERVICAL CANCER SCREENING RECOMMENDATIONS!

NOTE: This is a CANCER PREVENTION vaccine, not a sex vaccine!

Slide41

Healthcare Workers

Key in implementation of Adult ImmunizationEducation: Multiple studies show that…STRONG MD recommendation  Increased patient vaccine uptakeHCW need preventive benefits for ‘themselves’Potential source for disease transmissionPatientsOther staffCommunitiesFamiliesPotential for VPD to impair patient careAdversely affect efficiencyPrevent HCW from working with [their] patients

http://

www.cdc.gov/mmwr/preview/mmwrhtml/00050577.htm

Slide42

Healthcare Worker Vaccination

Annual

i

nfluenza vaccination

Tdap: All should receive 1 adult dose

MMR, Varicella: Proof of immunity or 2 doses

[

each]

HBV: 3 dose series

T

iter 1 month after series

R

epeat entire series x 1 if titer < 10 IU

No recommendation to screen/recheck titer otherwise

Slide43

Hepatitis B

Formulations/Route: IM3 and 4 dose schedules over at least 4 month intervalStandard: time 0, 1 and 6 months later [alt1: 0, 2, 4 months; alt2: 0, 1 4 mo; Alt 3: 0, 1, 2, 12 mo (Engerix only)]If series is delayed, no need to restart. Complete series from prior dose(s) High dose vaccine, specific schedule for dialysis patients Risk groups [in addition to HCW, Diabetes]All adults who want to be protected from hepatitis B (HBV)>1 sex partner in 6 mo., Household contacts & sex partners of HBsAg + people; IVDU, people seeking STD evaluation or treatment; hemodialysis patients and those awaiting dialysis, MSM; staff working with developmentally disabled; inmates in LT correctional facilities; certain international travelers, persons with chronic liver disease (including HCV, cirrhosis)

http://

www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/hepb.html

Slide44

Case 3

Christine Pulaski is a 32 year old pregnant woman with no significant past medical history who is presenting for a pre-natal visit in her first trimester.Which vaccinations should she receive? Which vaccinations are contraindicated?

Slide45

“Selectives”

Vaccine Groups

“Universals”

InfluenzaPneumococcal [PCV13, PPSV23]TdapZoster

HPV

[HPV9, HPV4, HPV2]

MMR

Varicella

Meningococcal

Quad [MCV4, MPSV4]

MenB

Hepatitis A

Hepatitis B

Slide46

Vaccines for Pregnant Women

VaccineGuidanceRecommendedInfluenza – InactivatedInactivated version only and recommended during flu season regardless of trimester of pregnancyHepatitis B, ARecommended if other high risk condition presentTdapOptimal administration between 27 – 36 weeks gestation during each and every pregnancy, regardless of prior Tdap vaccinationNot RecommendedHPVIf series begun prior to pregnancy, remainder should be delayed until after pregnancyPneumococcalNo guidelines for PCV13, safety of PPSV23 not studiedContraindicatedInfluenza – LAIVAll live virus vaccines- contraindicated in pregnancyMMRVaricellaZoster

http://www.cdc.gov/vaccines/pubs/preg-guide.htm

Slide47

Case 4

Christopher Watkins is a 68 year old man with a prior 10 – week history of a persistentcough presenting for his annual Medicare wellness visit.Mr. Watkins lives with his daughter and his 2 young grandchildren (ages 6 months and 2 years). Which vaccines should Mr. Watkins receive?

Slide48

“Selectives”

Vaccine Groups…

“Universals”

InfluenzaPneumococcal [PCV13, PPSV23]TdapZoster

HPV

[HPV9, HPV4

, HPV2]

MMR

Varicella

Meningococcal

Quad [MCV4, MPSV4]

MenB

Hepatitis A

Hepatitis B

Slide49

Td >> Tdap

Pertussis incidence increasing since 1970’s2012: US >42,000 cases (CDC Passive Surveillance) 2013: US 28,639 cases (CDC Passive Surveillance)Community outbreaks: Most in fall, winter and in all agesNosocomial Disease: Academic, Community [Med/Surg, OR, L&D, NICU, Oncology]Residential Care Adults/Adolescents do not have ‘classic’ triphasic diseaseMost have persistent Cough: Median 4 months [6 studies]20-40 % ‘Whoop’, 40 – 55 % Posttussive emesis12-32 % Lymphocytosis~10% develop complications [Pneumonia most common]

http://www.cdc.gov/vaccines/vpd-vac/pertussis

/

http://

www.cdc.gov/vaccines/vpd-vac/combo-vaccines/DTaP-Td-DT/Tdap.htm

Slide50

Impact of Pertussis Vaccination

www.cdc.gov/pertussis/outbreaks.html

Slide51

Pertussis 2013 to 2014

46 states report increases since 2011

>25,000 cases reported to the CDC with 13 deathsAs of August 24, 2014

www.cdc.gov/pertussis/outbreaks.html

Slide52

Zoster

Most who have varicella have measureable Ab for lifeZoster occurs when CMI surveillance declines [theoretical]Reactivation or Varicella exposure re-stimulates CMI [Cycle repeats]Lifetime risk of Zoster ~33% [~ 99.5% adults sero + prior Varicella]At 85 – lifetime risk ~ 50%PHN = most common AEUp to 1/3 pt with ZosterMore common > 70 years with ZosterImmunocompromisedVaccination stimulates CMI

Arvin A. NEJM 2005;352:2266-77.

http

://www.cdc.gov/mmwr/preview/mmwrhtml/rr5705a1.htm

Slide53

Zoster

Vaccinate Healthy 60+ adults [ACIP: Not immunocompromised]FDA approved from age 50 differs from ACIP recommendationRegardless of prior episode(s) of Zoster [opinion: wait 1 year]No need to test and/or vaccinate vs. Varicella firstContraindicationsPregnancyAnaphylactic Hypersensitivity to Neomycin, GelatinNo need to defer for ‘at risk contacts’ – transmission risk lowNo need to defer if recent transfusion, Ab containing productsAdverse events Occasional mild varicella – like rash @ vaccine siteFrozen vaccine: Administer w/in 60 minutes, 0.65 ml SQ DeltoidDuration of protection: At least 4 years. No booster.

http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5705a1.htm

Slide54

Summary

Current vaccination rates are well below goal

Vaccines can prevent morbidity and mortality associated with vaccine preventable disease

Adult immunization is

complex, rapidly changing

Physician recommendation is key to patient uptake!

Next steps:

[Add PROGRAM SPECIFIC INFO]

Module 2 will be

[add date]

S

trategies to increase adult immunization in practice!

Slide55

Support

This program is supported by the American College of Physicians, and by an educational grant from Merck & Co., Inc. and Sanofi Pasteur.