Immunizations June 5, 2015 Brenda Ormesher, MD Infectious Disease - - PowerPoint PPT Presentation

Immunizations

June 5, 2015

Brenda Ormesher, MD Infectious Disease Peacehealth Medical Group Springfield, OR

Disclosures

 None

Goals

 Understand basic public health impact of immunization  Recognize types of vaccinations available  Identify resources available for identifying CDC

recommended immunizations

 Discuss differences and rationale for use of specific

vaccination formulations in practice

Introduction

Vaccine

vac·cine/vakˈsēn/ (Noun) a substance used to stimulate the production of antibodies and provide immunity against one or several diseases, prepared from the causative agent

• f a disease, its products, or a synthetic substitute, treated to act as an antigen

without inducing the disease.

History

 One of the great public health achievements in human

history

 Inoculation against smallpox was practiced 2000 years ago

but modern concept credited to Edward Jenner (1796)

 Now 23 FDA approved vaccine-preventable diseases

http://www.immunize.org/catg.d/p4037.pdf

General Characteristics of Vaccines

Components of Vaccine



Antigens



component derived from disease- causing organism which trigger protective immune response 

Stabilizers



Maintain effectiveness during storage



Factors affecting stability include temperature and pH



Include magnesium chloride (OPV), magnesium sulfate (RSV, measles), lactose-sorbitol and sorbitol- gelatin 

Adjuvants



Added to vaccines to stimulate production of antibodies



Several hundred different types



Antibiotics



Trace amounts used in manufacturing to prevent bacterial contamination of tissue growth cells for viruses



Trace amounts (25 micrograms neomycin in MMR and IPV) 

Preservatives



Multidose vaccines to prevent bacterial and fungal growth



Include thiomersal, formaldehyde (purification process removes almost all formaldehyde, <0.02% per dose)

Routes of Administration

http://vaccine-safety-training.org/adverse-events-causes.html

Types of Vaccines

 Live, attenuated  Inactivated/ killed  Toxoid (inactivated toxin)  Subunit/ conjugate  DNA vaccine  Recombinant vector

Live, attenuated

• Living microbe that has been weakened in the lab
• Should not be given in immunocompromised host
• Closest to natural infection
• Elicit strong cell-mediated and antibody response
• Life long immunity with only 1 or 2 doses (similar immunogenicity as wild-type

pathogen)  Examples:

 MMR (measles, mumps, rubella)  Varicella (chickenpox)  Influenza nasal spray  Rotavirus  Zoster (shingles)  Yellow fever  Tuberculosis (BCG)  Oral polio vaccine (OPV)

Live, attenuated Vaccines

http://vaccine-safety-training.org/live-attenuated-vaccines.html

Inactivated, killed

 Produce inactivated vaccine by killing the microbe with chemicals,

heat, or radiation

 More stable and safe than live vaccines (dead microbes cannot

mutate)

 Stimulate a weaker immune system response than live vaccines  Requires booster shots to maintain immunity  Examples:

 Polio (IPV)  Hepatitis A  Whole-cell pertussis (wP)  Rabies

Inactivated, killed Vaccines

http://vaccine-safety-training.org/inactivated-whole-cell-vaccines.html

Toxoid (inactivated toxin)

 For bacteria that secrete toxins (toxin must be main cause of

illness)

 Inactivate toxins by treating with formalin  To increase immune response the toxoid is absorbed to

aluminum or calcium salts (serve as adjuvant)

 Produces antibodies that lock onto & block the toxin  Examples:

 Diphtheria, tetanus (part of DTaP)

Toxoid Vaccines

http://vaccine-safety-training.org/toxoid-vaccines.html

Subunit

Protein-based, Polysaccharide, Conjugate

 Use only part of a target pathogen (no live components)  Protein or polysaccharide- Uses part of target pathogen to provoke a

response from the immune system Conjugate- Link antigens or toxins that immune system will recognize to the polysaccharide coating of bacteria

 No guarantee that immunological memory will be formed in correct

manner

 Examples:

 Influenza (injection)  Haemophilus influenza type b (Hib)  Pertussis (part of DTaP)  Pneumococcal  Meningococcal  Human papillomavirus (HPV)

Subunit:

Polysaccharide versus Conjugate

Polysaccharide

 Little or short-lived impact on

carriage of bacteria

 Decreasing immune response

with time (needs boosters)

 Limited ability to protect

children under 2 years

Conjugate

 Enhances the immune

response and long term recognition

 Protective immune response in

infants

 Minimizes hyporesponsiveness  Harder to design/ develop

Polysaccharide vs Conjugate Vaccines

http://www.nature.com/nri/journal/v9/n3/fig _tab/nri2494_F1.html

Subunit (purified antigen) Vaccines

http://vaccine-safety-training.org/subunit-vaccines.html

CDC Immunization Recommendations

Recommended adult immunization schedule, by vaccine and age group

CDC 2015 Adult Immunization Schedule

Vaccines that might be indicated for adults based on medical or other indications

CDC 2015 Adult Immunization Schedule

“There’s an app for that”

• Free!
• Available from App store for

iOS 5.0 or later or Google Play for Android 2.1

• http://www.cdc.gov/vaccines/s

chedules/hcp/schedule- app.html#download

Vaccine Specific Information

Vaccine-Preventable Diseases



Adenovirus type 4 & 7



Anthrax



Chickenpox (Varicella)



Diphtheria



Hepatitis A



Hepatitis B



Hib (Haemophilis influenza type b)



HPV (Human Papillomavirus)



Influenza



Japanese encephalitis



Measles



Meningococcal



Mumps



Pertussis (Whooping cough)



Pneumococcal



Poliovirus



Rabies



Rotavirus



Shingles (Herpes zoster, varicella)



Tetanus



Tuberculosis



Typhoid fever



Yellow fever

Influenza

http://www.cdc.gov/vaccines/pubs/pinkbook/downloads/appendices/B/us-vaccines.pdf

Which influenza vaccine is right for my patient?

 That depends….

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6332a3.htm#Tab

Does your patient have an egg allergy?

Cost $32/ dose

Is your patient a pediatric patient?

 In pediatrics demonstrated superior efficacy in live

attenuated vaccine

 reduction of 55% in culture confirmed influenza cases in ages 6

to 59 months

 52% increased protection in children age 6 to 71 months)

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6332a3.htm

Is your patient age 6 months to 2 years?

 Give Fluzone  In a previously unvaccinated child (< 8 years old) give 2 doses

• f influenza vaccine at least 4 weeks apart

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6332a3.htm

Is your patient age 2 to 49 years old and have special medical conditions?

 Pregnant?  Immunosuppressed?  Egg allergy?  Children age 2 to 17 years receiving aspirin?  Children age 2 to 4 years who have asthma with wheezing in past

12 months?

 Influenza antiviral medications in past 48 hours?  Care for severely immunosuppressed person who require a

protective environment?

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6332a3.htm

Is your patient age 2 to 49 years old and have special medical conditions?

 Yes: do not give live attenuated vaccine (FluMist), give

inactivated influenza vaccine

 No: give FluMist (cost $22 per dose)

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6332a3.htm

Is your patient over 65 years old?

 Inactivated influenza vaccine high dose (60 mg of

hemagglutinin per strain) induced a significantly higher antibody response and provider better protection against lab-confirmed illness than standard inactivated influenza vaccine (15 mg of hemagglutinin per strain)

 Cost of high dose influenza vaccine $30 vs $10 for standard

dose

DiazGranados, C. Et al. “Efficacy of High-Dose versus Standard-Dose Influenza Vaccine in Older Adults.” NEJM 2014; 371:635-645.

Vaccine Effectiveness

 Vaccine effectiveness decline post-vaccination

 By age: Vaccine effectiveness in < 65 years estimated at 44%,

vaccine effectiveness > 65 years estimated at 19%

 By time: Vaccine effectiveness in first 100 days 61%, between

100 and 119 days was 42%, after 120 days was 0%

Castilla J, et al. “Decline in Vaccine Effectiveness with Time After Vaccination, Navarre, Spain, Season 2011/12.” Eurosurveillance, Volume 18, Issue 5, 31Jan2013.

Quadrivalent versus Trivalent

 Rationale for quadrivalent: historically influenza vaccines

contain only one strain of B virus although though there are two different lineages of B strains that circulate most seasons

 Benefit: improved coverage of B strain which could account for

1-44% of influenza cases (based on data from preceding 10 years)

 Negative: Cost ($15 for quad vs $10 for tri), supply

Pneumococcal

http://www.cdc.gov/vaccines/pubs/pinkbook/downloads/appendices/B/us-vaccines.pdf

₊

Pneumovax (PPSV23)- Pneumococcal polyvalent (polysaccharide) vaccine covering 23 serotypes, cost $85/ dose

₊

Prevnar (PCV13)- Pneumococcal conjugate vaccine covering 13 serotypes, cost $150/ dose

Pneumococcal Recommendations

 Recommendation for adults 65 years

• r older: see diagram

 Recommendations for adults 19 years

• r older with no history of PCV13:
• CSF leak, cochlear implant, sickle cell

disease, function or anatomic asplenia, congenital or acquired immunodeficiency, HIV infection, chronic renal failure, nephrotic syndrome, leukemia, Hodgkin disease, generalized malignancy, long-term immunosuppressive therapy, solid

• rgan transplant, multiple myeloma

Bonten M, Bolkenbaas M, Huijts S, et al. Community Acquired Pneumonia Immunization Trial in Adults (CAPiTA). Abstract no. 0541. Pneumonia 2014;3:95. https://pneumonia.org.au/public/journals/22/PublicFolder/ABSTRACTBOOKMASTERforwebupdated20-3-14.pdf .

Meningococcal

http://www.cdc.gov/vaccines/pubs/pinkbook/downloads/appendices/B/us-vaccines.pdf

Meningococcal Disease- Worldwide

http://www.meningitisinfo.com/Epidemiology_ssi.aspx

Meningococcal A, C, W-135 and Y



Menomune



Polysaccharide vaccine



Licensed for data on A & C strains (not enough date for W-135, Y)



Recommended for adults who require single dose only (travelers, military recruits)



Cost $125/ dose 

Menactra



Polysaccharide conjugate vaccine



Licensed for A, C, Y, W-135



Asplenia, complement deficiencies, microbiologist, frequent international travelers to high endemic regions (African meningitis belt, Hajj)



Cost $100/ dose 

Menveo



polysaccharide conjugate vaccine



Licensed for A, C, Y, W-135



Asplenia, complement deficiencies, microbiologist, frequent international travelers to high endemic regions (African meningitis belt, Hajj)



Cost $120/ dose

Meningococcal B

 Trumenba

 Composed of two recombinant lipidated factor H binding protein

(fHBP) variants from N. meningitidis serogroup B, one from fHBP subfamily A and one from subfamily B (A05 and B01, respectively)

 Series of 3 shots at 0, 2 and 6 months  Cost $120/ dose

 Bexsero

 Composed of 4 distinct antigens including factor H binding protein

(fHbp), Neisserial adhesin A (NadA), Neisserial heparin-binding antigen (NHBA), and PorA P1.4 immunodominant antigen of OMV NZ (strain NZ98/254)

 Series of 2 shots at least 1 month apart  Cost $160/does

Human Papillomavirus



Cervarix



Viral protein subunit vaccine



Covers serotype 16 and 18 (may provide cross protection for 31, 33, 45,52)



Contains novel adjuvant so may be responsible for great antibody response (unknown)



Series of 3 shots at 0, 1-2 and 6 months



Cost $130/ dose 

Gardasil



Viral protein subunit vaccine



Covers serotype 6, 11, 16 and 18 (may provide cross protection for 31, 45)



Series of 3 shots at 0, 2 and 6 months



Cost $150/ dose 

Gardasil 9



Viral protein subunit vaccine



Covers serotype 6, 11, 16, 18, 31, 33, 45, 52 and 58



Series of 3 shots at 0, 2 and 6 months



Cost $160/ dose

http://www.ganfyd.org/index.php?title=File:HPVCerv icalCancer.png

Questions/ Comments? Email: BOrmesher@peacehealth.org Thank you!