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Adult Immunization Dr. Purnima Parthasarathy Senior Consultant, Infectious Diseases

KTPH November 21, 2015

http://www.forbes.com/sites/matthewherper/2013/02/19/a-graphic-

that-drives-home-how-vaccines-have-changed-our-world/

General Rules

S For adults- give vaccines during any visit for any reason- otherwise missed opportunities

S OK to give most vaccines together on the same day- label separate sites

S EXCEPTION: PCV and Meningococcal Conjugate vaccine- these should be given 4 weeks apart

S Live parenteral vaccines should be given either together or 4 weeks part

S Live oral vaccines can be given at the same time or before or after each other

What adult vaccines are we talking

about?

S Influenza

S Pneumococcus (23- Polyvalent and newer

Conjugate)

S Herpes Zoster (Shingles)

S Td, measles

S Meningococcus

2 Flu seasons in Singapore

S December and June have peaks of Influenza

illness and ARI

S The Southern Hemisphere vaccine protects

against the 3 common strains of influenza

(A/H1N1/A/H3N2and Influenza B)

S Should be given at least one month before

travel abroad

Influenza: Recommendations

S Who? Age 6 months and above

S How often? Yearly

S Efficacy:

S Children (80%) and adults (65-70)

S Elderly >65 (50%)

S Varies year to year- match

MOH Influenza Vaccine / Medisave

approved S Persons≥65 years

S Children ≥ 6 months to less than 5 years (i.e. 59 months)

S Adults and children with chronic disorders of the lung or heart systems, including asthma

S Adults and children with chronic metabolic diseases (including diabetes mellitus), renal, neurologic, liver, or blood disorders, or immunosuppression (HIV or meds)

S Children and adolescents aged 6 months to 18 years on long-term aspirin therapy (risk for Reye syndrome after influenza infection)

S Women at all stages of pregnancy

S Residents of nursing homes and intermediate and long term care facilities

Flu vaccines in Singapore

S Parenteral Trivalent

S Parenteral Tetravalent

S Intradermal Trivalent – ages 18-64

ContraindicationTrivalent flu shot anaphylaxis to egg/

chicken proteins, gentamicin, kanamycin, neomycin,

h./o GBS after flu shot

New Types of Flu Vaccines

S Quadrivalent- 2 B strains, better coverage when B strains predominate (2012)

S Recombinant Influenza Vaccine- egg free process (age 18 older)

S A quadrivalent (live attenuated) nasal spray vaccine, approved for people 2 through 49 years of age

S High dose Flu vaccine for Elderly (Fluzone® High-Dose; Sanofi Pasteur, Inc)

S An intradermal quadrivalent shot, which is injected into the skin instead of the muscle and uses a much smaller needle than the regular flu shot. It is approved for people 18 through 64 years of age.

Pneumococcal disease

Singapore

S Invasive S. pneumoniae (Blood and CSF)

reportable disease -MOH

S 166 laboratory confirmed cases of invasive

pneumococcal infection in 2013

S Increase of 1.8% compared to 163 cases in

2012

Incidence of IPD highest in age 55+ group, 2013

Pneumoccocal vaccination

S PPSV23 (polysaccaride 23-valent)

“pneumovax”

S Covers 88% of bacteremia producing

strains

S Newer: Conjugate 13 valent and 7

valent (peds)

Pneumovax

S A meta-analyses shows no decrease in

pneumonia incidence as a result of

vaccination, however it has been shown

to be about 60-70% effective in

preventing invasive disease (meningitis,

bacteremia).

ACIP Recommendation

Pneumococcal Conjugate Vaccine –PCV 13

S Conjugate vaccines- more

immunogenic, longer lasting

immmunity

S 13 Valent available in Singapore and

approved for infants

S Soon, will likely be approved for older

adults

CAPiTA Trial

S Community-Acquired Pneumonia Immunization Trial

in Adults

S Parallel-group, randomized, placebo-controlled,

double-blind trial in which subjects

S 84,496 subjects aged 65 years and older were randomly

assigned to receive a single dose of either Prevnar 13

or placebo.

S Julius Clinical, an academic research organization

affiliated with the University Medical Center Utrecht

(UMCU) in the Netherlands, 59 sentinel sites

N Engl J Med. 2015;372:1114-1125.

CAPiTA Trial

S 45.6 % fewer first episodes of vaccine-type CAP among Prevenar 13-vaccinated subjects than in subjects who received placebo (P<0.001)- PRIMARY ENDPOINT

S the Prevenar 13 group experienced 45.0 percent fewer first episodes of non-bacteremic/non-invasive vaccine-type CAP (P=0.007) – SECONDARY ENDPOINT

S 75.0 percent fewer first episodes of vaccine-type IPD (P<0.001) compared with the placebo group -SECONDARY ENDPOINT

ACIP June 2014

H. Zoster/Shingles Vaccine

• Licensed 2006

• Attenuated live virus vaccine

• FDA approved for age 50+

• ACIP recommends its use for adults 60 years of age

and older.

Zostavax®

S Single dose

S Immunity wanes after about 5 years- so don’t give

before age 60

S Recommended even if pt. has had Zoster/Shingles

S This vaccine reduces the risk of developing shingles

by 51%

S Reduces risk of post- herpetic neuralgia (PHN) by

67%.

S $$$ SD250

Vaccinations for Hajj

S Influenza/pneumococcal for high risk patients

S Typhoid vaccines

S Hepatitis A and B

S All adults and children >2 yrs single dose of meningococcal

quadrivalent A/C/Y/W-135 vaccine (must have proof of

vaccination on a valid International Certificate of Vaccination or

Prophylaxis)

S Children between 3 months - 2 years of age must show proof of

vaccination with 2 doses of meningococcal A monovalent vaccine

with a 3-month interval between the doses (≤3 years and ≥10 days

before arriving in Saudi Arabia)

http://wwwnc.cdc.gov/travel/yellowbook/2016/select-destinations/saudi-arabia-hajj-pilgrimage

Meningococcal vaccines in

Singapore

S Quadrivalent Polysaccharide

S Quadrivalent Conjugate Vaccine

S Both protect against Serotypes A, C, Y and

W-135

S Protective in 90% of healthy recipients

Singapore is surrounded by measles

S Outbreaks in Indonesia and Philippines ! 58,000 cases in

2014 in Philippines.

S In 2012, 38 cases of measles, 64 cases of rubella and 521

cases of mumps reported in Singapore.

S Give a booster (2nd) dose of MMR if a person has only

one one dose

S Vaccinate anyone (maids, etc..) naïve persons with 2

doses a month apart

S MMR is a live vaccine

Routine updates

S TD once every 10 years

S Substitute TDap once for Td booster

S Some of the older adults were only vaccinated with one dose of MMR vaccine in childhood

S In Singapore 2 doses of MMR vaccine have been made compulsory since 1998

S Hep B vaccine to high risk adults, ESRD, DM, partners of Heb B infected persons

Adult Immunization

S Singapore is ready for this!!

S Focus on high risk groups and the elderly

S Medisave now covers Pneumococcal and

Influenza vaccines in adults for specific

indications

S Special groups: Hajj, Post- Splenectomy,

Pregnancy

Thank you!!