Adult Immunization. Dr. Purnima Parthasarathy Senior Consultant, Infectious Diseases KTPH November 21, 2015

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1 Adult Immunization Dr. Purnima Parthasarathy Senior Consultant, Infectious Diseases KTPH November 21, 2015 S

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3 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 daylabel 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

4 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

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8 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

9 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

10 MOH Influenza Vaccine / Medisave S Persons 65 years approved 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

11 Flu vaccines in Singapore S Parenteral Trivalent S Parenteral Tetravalent S Intradermal Trivalent ages ContraindicationTrivalent flu shot anaphylaxis to egg/ chicken proteins, gentamicin, kanamycin, neomycin, h./o GBS after flu shot

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

13 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

14 Incidence of IPD highest in age 55+ group, 2013

15 Pneumoccocal vaccination S PPSV23 (polysaccaride 23-valent) pneumovax S Covers 88% of bacteremia producing strains S Newer: Conjugate 13 valent and 7 valent (peds)

16 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).

17 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

18 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:

19 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/noninvasive 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

20 ACIP June 2014

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22 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.

23 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

24 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)

25 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

26 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 (2 nd ) 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

27 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

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30 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

31 Thank you!!