1 vaccines are for adults too..and what’s new! dr. taj jadavji professor, departments of...
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Vaccines are for adults too..and what’s new!
Dr. Taj Jadavji
Professor, Departments of Microbiology, Immunology & Infectious Diseases and
Paediatrics
Faculty of Medicine
University of Calgary Infectious Disease Consultant – Alberta Health Services
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Vaccines are for adults too..and what’s new!
Disclosure:
1. Have received Honoraria from:- Glaxo Smith Kline- MSD- Abbott- Sanofi Pasteur- Novartis- Roche
- Pfizer
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10 Great Public Health Achievements – Industrialized Countries
• Vaccination• Motor-vehicle safety• Safer workplaces• Control of infectious
diseases• Decline in deaths from
coronary heart disease and stroke
• Safer and healthier foods
• Healthier mothers and babies
• Family planning• Fluoridation of drinking
water• Recognition of tobacco
as a health hazard
US Dept of Health and Human Service, MMWR 1999;48:241
In the last 50 years Immunization has saved more lives than any
other health intervention
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In the United States why do a 100 fold more adults die of vaccine-preventable diseases than do children?
4From Reid KC, Grizzard TA, Poland GA. Mayo Clin Proc. 1999;74:377–384
Vaccines are for adults too!
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Vaccines & Older AdultsImmunosenescence is one of
the main reasons for the increase in infections in the older adult.2
Although childhood vaccines usually prevent clinical illness…..
Most adult vaccines do not prevent illness but lessen the severity of infection.2
1. Fulop, T, and Gemmill, I, Clinical update on adult immunization. 2007
2. Aw, D., et al, Immunosenescence: emerging challenges for an ageing population. Immunology 2007. 120, 435–446.
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May 2014
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HPV
83131
The Annual Burden of HPV in The Annual Burden of HPV in CanadaCanada
>4 million Pap tests 1
>325,000 abnormal Pap tests1
1. Akom E, Venne S. November 2002. 2. Statistics Canada. Table 103-0513. CANSIM [Canadian Cancer Registry].3. Canadian Cancer Society / National Cancer Institute. Canadian Cancer Statistics 2005:88-9. 4. BC Cancer Agency, 2006. 5. Statistics Canada. Accessed at http://www.40.statcan.ca/101/cst01/demo02.htm. 6. Statistics Canada. Table 102-0522. CANSIM [Vital Statistics – Death Database].
~1835 newly diagnosed cases of cervical, vulvar and vaginal cancers2,3
77,000 newly diagnosed cases of genital warts, VIN VAIN 4,5
~510 deaths from cervical, vulvar and vaginal cancers6
9 99
70%
Cancer Causes Control (2012) 23:1343–1348
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NACI RecommendationsCCDR 2007 Feb vol 33
Vaccine recommended to:• 9-13 yr olds primary program• 14 yrs-26 yrs. catch • permissive use > 26yrs.• Including those with cervical
abnormalities and genital warts
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Mid-Adult Women Are At Continued Risk for Acquiring HPV
Infection/Disease
Insinga RP. Clin Inf Dis. 2003;36:1397-1403.
Age (years)
Rate
of
New
Genit
al W
art
s p
er
1000 P
ers
on-Y
ears
Incidence of New Genital Warts in Women by Age in US
0
1
2
3
4
5
6
7
<10 10-14 15-19 20-24 24-29 30-34 35-39 40-44 45-49 50+
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Primary Efficacy Results
Population
Vaccine Placebo%
Reduction
95% CI P-valueCases PYR Cases PYR
All Subjects
4 2,721 41 2,654 91% 74, 98 <0.001
24 to 34Year-Olds
2 1,329 24 1,301 92% 67, 99 <0.001
35 to 45Year-Olds
2 1,393 17 1,353 89% 52, 99 <0.001
Combined Incidence of HPV 6/11/16/18-Related Persistent Infection or Cervical/Vulvar/Vaginal Disease – Per Protocol Efficacy Population
PYR = person years at risk; CI = confidence interval. Luna, IPV Nov 2009
Approved for ages 9-45yrs
Approved for ages 9-45yrs
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Reduction inReduction in any any Cervical Cervical Procedure due to Procedure due to any any Causal HPV Causal HPV
typetype
↓↓19%19%↓↓22%22%
↓↓42%42%
ColposcopyColposcopy Cervical BiopsyCervical Biopsy Definitive therapyDefinitive therapy
Cases Placebo 1077 950 230 Cases Placebo 1077 950 230
Cases Vaccine 869 741 132 Cases Vaccine 869 741 132
18,150 16-26 yr olds, RPCT x 3yrs
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NACI recommendations on HPV vaccine in males Jan 2012
1. HPV4 (Gardasil) recommended in males 9 -26 years of age for the prevention of anal ,penile, perineal intraepithelial neoplasia ,cancers and anogenital warts 2. HPV4 (Gardasil) recommended in males who have sex with males (MSM) ≥9 years of age 3. HPV2 (Cervarix) not recommended in males at this time (NACI Recommendation Grade I).
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Sex.Trans.infect 2011
Sex.Trans.infect 2011
AustraliaFree 12-18 yrs &< 26yr 2007-2009
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Take home points• HPV is on rise at both ends of the
GI track• For cancer protection we have 2
excellent anti-cancer vaccines that are not comparable
• Gardasil only vaccine that prevents genital warts.
• ‘Best vaccine’ is the one that a patient takes!
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1 word summary:immunize!
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Influenza
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N Engl J Med 2008;359.
63% reduction of influenza in infants for up to 6 months and 36% reduction of febrile respiratory illnesses in mothers
340 3rd trimester RDBPC influenza vs 23 valent pneumococcal vaccine
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Seasonal influenza mortality UK 2001-2009
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• 282 participants; most in long-term care & >85 yrs ;open label ; pcr confirmation of influenza
• Fluad and TIV vaccine; each given in a different district in BC
• Results: - Fluad 60% effective
- TIV not effective
Vaccine 2013 xxx-xxx
21 2121
Clinical Infect Dis 2012 55:951
Case control study 2010-11 seasonN= 1040 influenza vs 3700 controls
Efficacy: 69 % 6m-8yrs 51 % 9-64yrs 38 % >65 yrs
Case control study 2010-11 seasonN= 1040 influenza vs 3700 controls
Efficacy: 69 % 6m-8yrs 51 % 9-64yrs 38 % >65 yrs
Immunizing your parents and grandparents is less likely to protect them than immunizing yourself
DO BOTH!
Immunizing your parents and grandparents is less likely to protect them than immunizing yourself
DO BOTH!
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Take home points• Influenza vaccine , especially for high risk
groups including pregnant women, babies and bubies
• 3 new vaccines: intranasal (live) ,intradermal (killed) & adjuvented
• new vaccines for elderly are here; they are more immunogenic but are they more effective than TIV?
• influenza vaccine may prevent MI22
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Pneumococcus
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Major Clinical Forms of Pneumococcal Disease
• Pneumococcal disease can be broadly grouped into categories of invasive disease and noninvasive (also termed mucosal) disease1
• Noninvasive forms of disease may become invasive (eg, pneumonia when accompanied by bacteremia)2
• Serotype is associated with disease severity and invasiveness3
1. WHO. Acute Respiratory Infections (Update September 2009).www.who.int/vaccine_research/diseases/ari/en/print.html. Accessed December 20, 2010.
2. CDC. Epidemiology and prevention of vaccine-preventable diseases. 11th ed. 2009;217-230.3. Jansen AG et al. Clin Infect Dis. 2009;49:e23-e29.
PneumococcalPneumococcalDiseaseDisease
MeningitisMeningitis
InvasiveInvasive
BacteremiaBacteremia
NoninvasiveNoninvasive(Mucosal)(Mucosal)
PneumoniaPneumonia SinusitisSinusitisAcute Acute Otitis MediaOtitis Media
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Dea
ths
asso
ciat
ed w
ith I
PD
/100
,000
Cas
es o
f IP
D/1
00,0
00
Incidence of IPD and Associated Mortality Rates (USA, 2010)
Centers for Disease Control and Prevention. 2012. Active Bacterial Core surveillance Report, Emerging Infections Program Network, Streptococcus pneumoniae, 2010.
Age (years)
S. pneumoniae disproportionately affects those at the extremes of age
IPD = invasive pneumococcal disease, and includes meningitis, bacteremia, and pneumonia when accompanied by bacteremia.
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Incidence rate (per 100,000) of invasive pneumococcal disease by age group, Canada, 2011
An Advisory Committee Statement (ACS) National Advisory Committee on Immunization (NACI)Statement on the Use of Conjugate Pneumococcal Vaccine – 13 valent in Adults (Pneu-C-13), April 4 th, 2013
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Reported number of cases and incidence rate of invasive pneumococcal disease, Canada, 2001-2011
Canadian Notifiable Disease Surveillance System
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Age
Host Factors
External Factors
BehavioralFactorsImmunocompetent Immunocompromised
≥ 65 years
• Chronic heart disease• Chronic lung disease *
• Diabetes mellitus• Chronic liver disease• Cerebrospinal fluid
leaks• Asthma
• HIV (Human Immunodeficiency Virus) infection
• Chronic renal failure, nephrotic syndrome
• Cancer (solid, hematologic)• Solid organ transplantation• Autoimmune diseases• Immunosuppressive
therapy, corticosteroids• Primary
immunodeficiencies• Functional or anatomic
asplenia
Socioeconomic
Environmental•Preceding viral respiratory infection (e.g., influenza)•Residence in an institution (eg, nursing home)
• Smoking• Alcohol
abuse
* Including chronic obstructive pulmonary disease, emphysema, and asthma.
1. CDC. Morb Mortal Wkly Rep. 2010;59(34):1102-1106. 2. Rahier JF et al. Rheumatology (Oxford). 2010;49(10):1815-1827.3. CDC. Prevention of Pneumococcal Infections Secondary to Seasonal and 2009 H1N1 Influenza Viruses Infection. 2009.4. CDC. Morb Mortal Wkly Rep. 2001;50(33):707-710.
Risk Factors for Invasive Pneumococcal Disease (IPD)
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Two types of pneumococcal vaccines licensed for adults in Canada
(3 products)
Current vaccine options
Type Description Options Serotypes
Pneumococcal polysaccharide vaccines (PPSV)
Polysaccharide antigens
PPSV23Pneumo 23® , Pneumovax® 23
Antigens of 23 pneumococcal serotypes:1, 3, 4, 5, 6B, 7F, 9V, 14, 18C, 19A, 19F, 23F,2, 8, 9N, 10A, 11A, 12F, 15B, 17F, 20, 22F, 33F
Pneumococcal conjugate vaccine (PCV)
Polysaccharide antigens joined to a protein (conjugated)
PCV13*Prevnar 13®
Antigens of 13 pneumococcal serotypes:1, 3, 4, 5, 6B, 7F, 9V, 14, 18C, 19A, 19F, 23F,6A**
Lang Kau, Cheryl A. Sadowski, Christine Hughes. Vaccinations in older adults: Focus on pneumococcal, influenza and herpes zoster infections. Canadian Pharmacists Journal. 2011, 144(3):132-141.
* PCV13 replaced the previous version of PCV, known as PCV7, which included 7 pneumococcal serotypes.** 6A serotype is unique to PCV13
The two types of vaccine contain 12 serotypes in common
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• Including chronic obstructive pulmonary disease, emphysema, and asthma.
NACI Recommendations: PPSV23 for High Risk Individuals
1. National Advisory Committee on Immunization (NACI). Canadian Immunization Guide, Public Health Agency of Canada, 2012. Accessed Feb 2, 2013 at http://www.phac-aspc.gc.ca/publicat/cig-gci/p04-pneu-eng.php#ru
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PCV13 vaccine for adults: Current status
In Canada, PCV13 was approved in January 2012 1
• indicated for active immunization for the prevention of invasive pneumococcal disease (sepsis, meningitis, bacteraemic pneumonia, pleural empyema and bacteraemia),
• in adults 50 years of age and older,
• caused by Streptococcus pneumoniae serotypes 1, 3, 4, 5, 6A, 6B, 7F, 9V, 14, 18C, 19A, 19F and 23F. 1
In Jan 2014 the indication was expanded to include2
• Children, Adolescents and Adults.
1. Pneumococcal 3-valent Conjugate Vaccine (Diphtheria CRM197 Protein) Product Monograph. Pfizer Canada, Jan 2012
2. Health Canada. Notice of Compliance. Accessed July 10, 2013 at http://webprod5.hc-sc.gc.ca/noc-ac/info.do?no=14512&lang=eng
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Always give PCV13 before polysaccharide 23; follow with polysaccharide 2 mo-2 yrs later
Non-naive: wait 1 year before PCV13
Always give PCV13 before polysaccharide 23; follow with polysaccharide 2 mo-2 yrs later
Non-naive: wait 1 year before PCV13
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“for adults >18 with immunocompromising
conditions...PCV13 should be administered in addition to PPSV23”
(off label <50yrs.)
“for adults >18 with immunocompromising
conditions...PCV13 should be administered in addition to PPSV23”
(off label <50yrs.)
Oct 2012
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ACIP Feb .12
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Varicella
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Shingles risk factorsAdvancing age:
- Decreased CMI with age Immunosuppression: - HIV-AIDS - Organ transplants - Malignancy - Immunosuppressive therapy - autoimmune rheumatic
diseases
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Shingles: Canadian epidemiology
30% lifetime risk *
15% of cases Post-herpetic neuralgia (PHN) of whom 70% have moderate to severe pain *
* Brisson M. CIC 2004
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33%
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Kost R et al. N Engl J Med. 1996;355:32-42.
Pe
rce
nt o
f pa
tient
s re
port
ing
pa
in
Age (years)
0
100
80
60
40
20
0-19 20-29 30-39 40-49 50-59 60-69 ≥79
>1 yr
<1 mo
6 - 12 mo1 - 6 mo
Frequency of PHN (> 3mo) and duration of Pain Increase With Age
15 30 40
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Treatment of Herpes Zoster
Antivirals(given early): - modestly shortens the rash - do NOT prevent PHN
Corticosteroids: - decreases severity of acute pain - do NOT prevent PHN
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Once zoster develops treatment does not prevent PHN
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The Shingles Prevention Study
Vaccine Efficacy: HZ Incidence by age
Efficacy 51.3% 63.9% 37.6%
0
2
4
6
8
10
12
14
All 60-69 yr ≥70 yr
Inci
den
ce o
f H
Z VaccinePlacebo
*
*P <0.001 Adapted from Oxman M et al. N Engl J Med. 2005;352:2271-2284.
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The Shingles Prevention Study Vaccine Efficacy: PHN Incidence
Efficacy 66.5% 65.7% 66.8%
0.0
0.5
1.0
1.5
2.0
2.5
All Subjects 60-69 yr ≥70 yr
Inci
den
ce o
f PH
N VaccinePlacebo
*
*P <0.001 Adapted from Oxman M et al. N Engl J Med. 2005;352:2271-2284.
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The Shingles Prevention Study Vaccine Efficacy: Severity/duration Illness Efficacy 61.1% 65.5% 55.4%
0
1
2
3
4
5
6
7
8
9
All 60-69 yr ≥70 yr
HZ
burd
en o
f ill
ness Vaccine
Placebo
*P <0.001
*
Adapted from Oxman M et al. N Engl J Med. 2005;352:2271-2284.
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Clinical Infectious Diseases 2012;55(10):1320
N= 38,500 SPS vs.14,000 STPS over 7 years Comparison SPS vs STPS
SPS (2.5 y) STPS (7y)
HZ 51% 40%
PHN 66% 60% N/S
PHN BOI 61% 50%
N= 38,500 SPS vs.14,000 STPS over 7 years Comparison SPS vs STPS
SPS (2.5 y) STPS (7y)
HZ 51% 40%
PHN 66% 60% N/S
PHN BOI 61% 50%
Conclusio
n : complete va
ccine effic
acy fo
r ~
5 yrs.
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Contraindications
Who can I give Zostavax to?
lymphoproliferative disorders :Solid tumour cancers : immunosuppressants:immune modulators :
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NOYES
NO
MAYBE
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• Herpes zoster vaccine is recommended for the prevention of herpes zoster and its complications in persons 60 years and older• Herpes zoster vaccine may be used in patients aged 50 to 59 years• Herpes zoster vaccine may be administered to individuals ≥ 50 years old with a prior history of herpes zoster• Herpes zoster vaccine can be administered concomitantly with pneumococcal vaccine
• Herpes zoster vaccine is recommended for the prevention of herpes zoster and its complications in persons 60 years and older• Herpes zoster vaccine may be used in patients aged 50 to 59 years• Herpes zoster vaccine may be administered to individuals ≥ 50 years old with a prior history of herpes zoster• Herpes zoster vaccine can be administered concomitantly with pneumococcal vaccine
NACI January 2014
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Take home points• Shingles is increasing and is a BAD
disease esp in older population• PHN lasts for months to years• Zostavax provides at least 50%
protection against infection, incidence and severity of PHN.
• mild immunosuppression not C/I• Now approved >50 yrs. of age esp.
prior to immunosuppression• Recommended over 60 yrs.
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Pertussis
50 50
Vaccine efficacy decreased by 42% each year after 5 yearsVaccine efficacy decreased by 42% each year after 5 years
N Engl J Med 2012;367:1012-9.
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Clinical Infectious Diseases 2004; 39:1581–2
Approximately 13%–20% of prolonged cough illnesses in adolescents and adults are due to B. pertussis infection
Average duration= 8-12 weeks
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Pertussis in 616 infants in 4 US states:mothers 32%family 43%
75% household contacts
Pertussis in 616 infants in 4 US states:mothers 32%family 43%
75% household contacts
Ped Infect Dis J.2004;23:985-9
53 5353
“administer a dose of Tdap in the 3rd trimester of each pregnancy irrespective of the patient’s prior history of receiving Tdap”
“administer a dose of Tdap in the 3rd trimester of each pregnancy irrespective of the patient’s prior history of receiving Tdap”
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Potential new parents and their families should
receive one dose of TdaP
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Take home points
• Pertussis is on the rise • Every adult needs one Tdap
anytime • Should your target group for
Tdap be parents and families of infants or infants-to-be?
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Immunize adults to prevent severe illness and death
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Immunize children to prevent illness
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Conclusion
• All who deal with immunzation have the responsibility to be knowledgeable about immunizations, to be aware of their benefits and risks, and to be able to advocate effectively and clearly for their appropriate use.
• COMPLACENCY IN THIS MATTER WILL BE DETRIMENTAL TO OUR SOCIETY
