Family Medicine Resident School February 15 2017 Melissa Martinez MD Disclosure The AAFP Vaccine Science Fellowship F unded by a grant from Merck amp Co Inc The AAFP has full control over the content of the fellowship and selection of fellows ID: 779112
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Slide1
Practical Advise on Adult Immunizations
Family Medicine Resident School
February 15, 2017
Melissa Martinez MD
Slide2Disclosure
The AAFP Vaccine Science Fellowship
Funded by a grant from Merck & Co Inc.
The AAFP has full control over the content of the fellowship and selection of fellows
.
Slide3Off-Label
Tdap
in adultsAdjuvant Shingles Vaccine
Slide4By the end of this talk you will be able to:
Correctly answer “easy” board questions about vaccines
Explain the rational and timing of two pneumococcal vaccinesDetermine the correct timing of HPV doses to complete a seriesChange Power Chart Immunizations settings to facilitate ease of practice
Anticipate possible changes in vaccine recommendations
Slide522 year old female who had all of her childhood, adolescent vaccines. What vaccines should you recommend for her?
Slide622 year old female who had all of her childhood, adolescent vaccines. What vaccines should you recommend for her?
Tdap/Td and Influenza
Slide770 year old female thinks she is up to date on all vaccines.
Slide870 year old female thinks she is up to date on all vaccines.
Tdap
/Td, influenza, pneumococcal X2 and Shingles(Varicella in certain circumstances)
Slide9Pneumococcal Vaccines
Pneumovax PPSV23
Polysaccharide1980s23 Valent
Prevnar
® PCV13
Conjugated protein to
Polysaccharide
PCV7 -
1998
PCV13
2009
13 types
®
sugar
sugar
sugar
sugar
sugar
sugar
protein
Slide10Efficacy
Range of Serotypes
PPVS23
PCV13
Slide1120-60% of school age kids colonized
5-10% of adults without children colonized
CDC pink book 2015
Theory: PCV13
deceases asymptomatic carriage rates
By decreasing carriage we get herd immunity
Slide12ACIP
Routine use of PCV13 among adults >age 65 in series with PPSV23The recommendations for routine PCV13 use among adults aged ≥65 years will be
re-evaluated in 2018 and revised as needed.
Slide13Slide1466 year old male with type II diabetes, hypertension, low back pain, and elevated cholesterol. Smokes 1 pack per day for 30 years. He has never received a pneumococcal vaccine
.
Slide15Rule 1
Over 65 PCV13 PPSV23
One Year
If possible PCV13 first
Slide1666 year old male with type II diabetes, hypertension, low back pain, and elevated cholesterol. Smokes 1 pack per day for 30 years. He has never received a pneumococcal vaccine.
PCV13 now and PPSV23 twelve months
Slide17Case 2
66 year old female treated with mastectomy, chemotherapy and radiation for breast cancer at age 50. Given PPSV23 at age 55
Slide18Slide19Timeline
Age 55 PPSV23
Age 66 PCV13
Age 67 PPSV23 # 2
>1 year
1 year after PSV13 and 5 years after PPSV23
Slide20Case 2
66 year old female treated with mastectomy, chemotherapy and radiation for breast cancer at age 50. Given PPSV23 at age 55
PCV13 now PPSV23 #2 in one year
Slide21Rule 2
Repeat PPSV23 in 5 years if patient received PPSV23 prior to age 65.
Slide22Which
P-
Vax
Slide2366 56 year old male with type II diabetes, hypertension, low back pain, and elevated cholesterol. Smokes 1 pack per day for 30 years. He has never received a pneumococcal vaccine.
CASE 3
Slide24Under 65
Slide25<65 and No Chronic Conditions
No pneumococcal vaccines
Slide2666
56 year old male with type II diabetes, hypertension, low back pain, and elevated cholesterol. Smokes 1 pack per day for 30 years. He has never received a pneumococcal vaccine.
CASE 4
Slide27<65 and at increased risk
PPSV23 only
Chronic heart diseaseChronic lung disease (Asthma)Diabetes mellitusAlcoholism
Chronic liver disease
Cigarette smoking
PPSV23 only
Slide2866
56 year old male with type II diabetes, hypertension, low back pain, and elevated cholesterol. Smokes 1 pack per day for 30 years. He has never received a pneumococcal vaccine.
PPSV23 only until he turns 65 Then PCV13 followed by PPSV23 in 5 years
Slide29>65
No
PneumoVaccine
PCV 13
1
year
PPSV
23
Received
PPSV 23 before 65
1
year
PCV 13
1
year
PPSV 23
(if 5
years since last PPSV 23)
Received
PPSV 23 after 65
1 year
PCV 13
Slide3046 year old with Hodgkin's Lymphoma in remission after chemotherapy
CASE 5
Slide31Immuno
-compromised
Hemoglobinopathies AspleniaChronic Renal Failure
Nephrotic
Syndrome
Generalize Malignancy
Leukemia
Lymphoma
Hodgkins
HIV/
Immunocompromised
Immunosuppression
Solid Organ Transplant
Multiple Myeloma
PCV13 first
PPSV23
8 weeks
later
If PPSV23 first, PCV13 in
one year
Or
Repeat PPSV23 in 5 years
Slide3246 year old with Hodgkin's Lymphoma in remission after chemotherapy
CASE 5PCV13 first
PPSV23
8 weeks
later
Repeat PPSV23 in 5 years
Slide33Blood Brain Barrier Disruption
Cochlear Implant
CSF LeakPCV13 firstPPSV23 8 weeks
later
Slide34Age 19-64
Determine medical conditions
Chronic medical condition indicates to receive both pneumococcal vaccines or just PPSV23
No chronic medical condition
Both – PCV13 first
After 12 months, give PPSV23
Do not give pneumococcal vaccine until age 65
PPSV23 only
Reassess for PCV13 and PPSV23 booster at 65 years old
Second PPSV23 five years after first dose or at age 65
for immunocompromised only
8 weeks
5 years
Slide35Slide36First click Immunizations on tool bar, then Properties from the drop down.
Slide37Uncheck to remove top box from overall view.
Slide38Table View
Slide39Slide40List view
Slide41Slide42Slide43Which 2 HPV types cause the vast majority of cancers?
Slide44Carcinogenic
Slide45Vaccine
Coverage
Cost per doseHPV 2Cervarix
®
16/18
$128.75
HPV 4
Gardasil
4
®
6/11 /16/18
$160.70
HPV 9
Gardasil
9
®
6/11/16/18
31/33/ 45
/ 52/58
$177.70
Erickson, Am J
Obst
&
Gyn
2013
CDC Vaccine price list
Slide46Case 6
Dana is a 16 year old female who received 3 HPV4 doses with appropriate intervals between age 11-13. Should she repeat the series with
HPV9?
Slide47HPV Types
Erickson, Am J
Obst &
Gyn
2013
Slide48HPV Attributable Cancers in US
Caner
HPV 16/18 %
HPV
31/33/ 45/ 52/58
vaginal
55
18
vulvar
49
14
penile
48
9
anal male
79
4
anal female
80
11
oral male
63
4
oral female
51
9
Saraiya
JNCI 2015
Slide49Dana is a 16 year old female who received 3 HPV4 doses at appropriate intervals between age 11-13. Should she repeat the series with HPV9
The HPV9 series is not recommended for persons who have received a full HPV4 series
.
Slide50Case 7
Ben, age 13, received the first dose of HPV4 followed by a second dose two months later. It has been 6 months since his second dose of HPV and he is now in clinic for a 3rd
dose.
Slide51Case 7
Ben, age 13, received the first dose of HPV4 followed by a second dose two months later. It has been 6 months since his second dose of HPV and he is now in clinic for a 3rd
dose. Give HPV9 as the third dose in the series
Slide52How many doses of HPV
9-15 yearsImmunocompetent
Dose 1Dose 2
15 years or more
Immunocompromised
Dose 1
Dose 2
Dose 3
6-12 months
2 months
6-12 months
Slide53Which vaccines should you avoid in a women who is pregnant or might become pregnant in the next six
months?
Slide54Pregnancy and Vaccines
MMR Varicella Live AttenuatedIntra nasal flu LAIV
HPV not live, but not recommended in pregnancy
Slide55Robert is a healthy 45 year old male who comes in for a well check. He had
Tdap vaccine 11 years ago.
CASE 8
Slide56Slide57Adults Td/Tdap
Primary Series
Dose 14 weeksDose 26-12 monthsDose 3*One dose
Tdap
Boosters
Tdap
once
Td q 10 year
MMWR 2011 / 60(37);1279-1280
Slide58Repeat Tdap in Adults ?
ACIP “No”Unless adult is pregnant
Unless adult is due for Td and only Tdap available
Tdap
Every Pregnancy
MMWR 2011 / 60(37);1279-1280
Slide59Robert is a healthy 45 year old male who comes in for a well check. He had
Tdap vaccine 11 years ago.
Td or Tdap acceptable
CASE 8
Slide60Slide61Case 9
54 year old female on prednisone and azathioprine for SLE. She remembers that her mother had a “terrible” case of shingles and she wants to get the shingles shot.
Slide62New Shingles Vaccine
HZV (Zostavax)
Herpes Zoster Efficacy 51.3%4 years durationPost Herpetic Neuralgia
Efficacy 66.5%
HSV Sub unit
Herpes Zoster
Efficacy 89.9% (over 70)
3.7 years and going
Post Herpetic Neuralgia
Efficacy 89%
N
Engl
J Med. 2015;372:2087-96
N
Engl
J Med. 2016;375:1019-32
.
N
Engl
J Med 2005; 352: 2271-84.
Slide63HZV sub unit
More reactions:Vaccine 79.0% Placebo 29.5%2 Doses
Study of immunocompromised underwayQuestionsPricePrevious HZVLong term duration and safety
Slide64Martha 25 yo Patient Care Tech with a history of
celiac. She received the Hep B series but her titers are low.
Slide65Martha 25 yo patient care tech. She received the
Hep B series but her titers are low.
Celiac=lower response rate compared to controls
Compliance with gluten free diet improved response
Theory: HLA DQ2 common to both
No studies to date of Non-responders and test for celiac or trial of gluten free diet.
Slide66# Mumps/Measles cases by Year
Slide67Conclusions
Tdap and Influenza for all adults under 65Tdap
, influenza, pneumococcal and shingles for all adults over 65Over 65 PCV13 first then PPSV23 one yearUnder 65: put patient in a groupDo not repeat HPVAt least 6 months between HPVOkay to give Tdap in place of Td
Stay tuned on new shingles vaccine
Gluten free diet for non-responders to
Hep
B vaccine
Slide68… we ought to be debating the science.
Slide69Get Involved
Adult Immunization Task Force
AAFP Grants to ClinicsImmunization Practices Advisory CommitteeInfluenza Clinics
Slide70Questions/Comments
MLMartinez@salud.unm.edu
Slide71Thimerosal
Methyl mercury
Ethyl mercury
Toxic
Threshold
200mcg/L
2000mcg/L
Clearance
Slow
Fast
Experience
Neurologic damage in Japan
Banned
in California for 6 years with no difference in autism rates
Pediatrics
. 2008,
J
Pediatr
Pharmacol
Ther
. 2010 , Price
Pediatrics
. 2010,
Offit
Autism's False Prophets:
Slide72PCV13CAPiTA Trial
84,496 age 65+ in Netherlands Placebo=42,250
PCV13=42,240Mean follow up 3.97 yearsBonten NEJM 2015
Slide73Prevnar® (PCV13)CAPiTA Trial
Dx
Efficacy
95%CI
p
ARR
NNT
CAP
5.1%
-5.1,14.2
0.32
IPD
48.5%
20.9,67.0
.006
.0007
1,428
Bonten
NEJM 2015
Slide74-10
0
10
20
30
40
50
60
CAP
IPD
5.1%
48.5%
Slide75PPSV23Meta-analysis
Selection Criteria Subjects age 50+
Outcomes CAP or IPD Kraicer-Melamed Vaccine 2016
Slide76PPSV23Meta-analysis
Dx
Efficacy
95%CI
p
ARR
NNT
CAP
cohort
17%
-26,45
CAP
Case Co
7
-10,21
IPD
cohort
50%
21,69
IPD
Case Co
54%
32,69
Slide77-10
0
10
20
30
40
50
60
CAP
IPD
5.1%
17%
50%
48.5%
Slide78PCV13CAPiTA Trial
Dx
Efficacy
95%CI
p
AAR
NNT
CAP
5.1%
-5.1,14.2
0.32
CAP
Pneumococcal
39.6%
9.8-46.7
.008
.0009
1111
CAP Vaccine
type
45.6%
21-65
<0.001
IPD
48.5%
20.9,
67.0
.006
.001
1000
IPD Vaccine type
75%
41.4-90.8
<0.001
Bonten
NEJM 2015
Slide79-10
0
10
20
30
40
50
60
CAP
45.5 %CAP Vaccine type
5.1%
17%
CAP pneumococcal
39.6%
Slide8020
30
40
50
60
70
80
90
50%
48.5%
IPD vaccine type
75.%
Slide81Pneumococcal Incidence for
65+
PCV 13 in kids
ABCS /CDC
PPSV23 immunization uptake 50-70%
Year
Slide8220-60% of school age kids colonized
5-10% of adults without children colonized
CDC pink book 2015