Practical Advise on Adult Immunizations Melissa Martinez MD Practical Advise on Adult Immunizations Family Medicine Resident School February 15, 2017

Disclosure 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.

Off-Label Tdap in adults Adjuvant Shingles Vaccine

By 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 vaccines Determine the correct timing of HPV doses to complete a series Change Power Chart Immunizations settings to facilitate ease of practice Anticipate possible changes in vaccine recommendations

22 year old female who had all of her childhood, adolescent vaccines 22 year old female who had all of her childhood, adolescent vaccines. What vaccines should you recommend for her?

22 year old female who had all of her childhood, adolescent vaccines 22 year old female who had all of her childhood, adolescent vaccines. What vaccines should you recommend for her? Tdap/Td and Influenza

70 year old female thinks she is up to date on all vaccines.

70 year old female thinks she is up to date on all vaccines 70 year old female thinks she is up to date on all vaccines. Tdap/Td, influenza, pneumococcal X2 and Shingles (Varicella in certain circumstances)

Pneumococcal Vaccines Pneumovax PPSV23 Polysaccharide 1980s 23 Valent Prevnar® PCV13 Conjugated protein to Polysaccharide PCV7 -1998 PCV13 2009 13 types ® sugar sugar sugar protein sugar sugar sugar

PPVS23 PCV13 Efficacy Range of Serotypes

20-60% of school age kids colonized Theory: PCV13 deceases asymptomatic carriage rates 20-60% of school age kids colonized 5-10% of adults without children colonized CDC pink book 2015 By decreasing carriage we get herd immunity

ACIP Routine use of PCV13 among adults >age 65 in series with PPSV23 The recommendations for routine PCV13 use among adults aged ≥65 years will be re-evaluated in 2018 and revised as needed.

66 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.

Rule 1 Over 65 PCV13 PPSV23 One Year If possible PCV13 first

66 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

Case 2 66 year old female treated with mastectomy, chemotherapy and radiation for breast cancer at age 50. Given PPSV23 at age 55

Timeline Age 55 PPSV23 Age 66 PCV13 Age 67 PPSV23 # 2 >1 year 1 year after PSV13 and 5 years after PPSV23 Age 67 PPSV23 # 2

Case 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

Rule 2 Repeat PPSV23 in 5 years if patient received PPSV23 prior to age 65.

Which P-Vax

CASE 3 66 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.

Blood Brain Barrier disruption Under 65 Immuno-compromised No chronic conditions Increased Risk Blood Brain Barrier disruption

<65 and No Chronic Conditions No pneumococcal vaccines

CASE 4 66 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.

<65 and at increased risk PPSV23 only Chronic heart disease Chronic lung disease (Asthma) Diabetes mellitus Alcoholism Chronic liver disease Cigarette smoking PPSV23 only

66 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

>65 No PneumoVaccine PCV 13 1 year PPSV 23 Received PPSV 23 before 65 (if 5 years since last PPSV 23) Received PPSV 23 after 65

46 year old with Hodgkin's Lymphoma in remission after chemotherapy CASE 5 46 year old with Hodgkin's Lymphoma in remission after chemotherapy

Immuno-compromised PCV13 first PPSV23 8 weeks later Hemoglobinopathies Asplenia Chronic Renal Failure Nephrotic Syndrome Generalize Malignancy Leukemia Lymphoma Hodgkins HIV/Immunocompromised Immunosuppression Solid Organ Transplant Multiple Myeloma PCV13 first PPSV23 8 weeks later Or If PPSV23 first, PCV13 in one year Repeat PPSV23 in 5 years

46 year old with Hodgkin's Lymphoma in remission after chemotherapy CASE 5 46 year old with Hodgkin's Lymphoma in remission after chemotherapy PCV13 first PPSV23 8 weeks later Repeat PPSV23 in 5 years

Blood Brain Barrier Disruption Cochlear Implant CSF Leak PCV13 first PPSV23 8 weeks later

Age 19-64 Determine medical conditions No chronic medical condition Chronic medical condition indicates to receive both pneumococcal vaccines or just PPSV23 Do not give pneumococcal vaccine until age 65 Both – PCV13 first PPSV23 only 8 weeks After 12 months, give PPSV23 Reassess for PCV13 and PPSV23 booster at 65 years old 5 years Second PPSV23 five years after first dose or at age 65 for immunocompromised only

First click Immunizations on tool bar, then Properties from the drop down.

Uncheck to remove top box from overall view.

Table View

List view

Which 2 HPV types cause the vast majority of cancers?

Carcinogenic

HPV 2 Cervarix® 16/18 $128.75 HPV 4 Gardasil 4® 6/11 /16/18 $160.70 Vaccine Coverage Cost per dose HPV 2 Cervarix® 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

Case 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?

HPV Types Erickson, Am J Obst & Gyn 2013

HPV 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 oral female 51 Saraiya JNCI 2015

Dana 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.

Case 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.

Case 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

How many doses of HPV Dose 1 Dose 2 Dose 1 Dose 2 Dose 3 9-15 years Immunocompetent 15 years or more Immunocompromised Dose 1 Dose 2 Dose 1 Dose 2 Dose 3 2 months 6-12 months 6-12 months

Which vaccines should you avoid in a women who is pregnant or might become pregnant in the next six months?

Pregnancy and Vaccines MMR Varicella Live Attenuated Intra nasal flu LAIV HPV not live, but not recommended in pregnancy

CASE 8 Robert is a healthy 45 year old male who comes in for a well check. He had Tdap vaccine 11 years ago.

Adults Td/Tdap Boosters Primary Series Dose 1 Tdap once Td q 10 year 4 weeks Dose 2 6-12 months Dose 3 *One dose Tdap Tdap once Td q 10 year MMWR 2011 / 60(37);1279-1280

Repeat 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

CASE 8 Robert 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 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.

New Shingles Vaccine HZV (Zostavax) HSV Sub unit Herpes Zoster Efficacy 51.3% 4 years duration Post Herpetic Neuralgia Efficacy 66.5% Herpes Zoster Efficacy 89.9% (over 70) 3.7 years and going Post Herpetic Neuralgia Efficacy 89% Shorter durination 4 year N Engl J Med. 2015;372:2087-96 N Engl J Med. 2016;375:1019-32. N Engl J Med 2005; 352: 2271-84.

HZV sub unit More reactions: 2 Doses Vaccine 79.0% Placebo 29.5% 2 Doses Study of immunocompromised underway Questions Price Previous HZV Long term duration and safety

Martha 25 yo Patient Care Tech with a history of celiac Martha 25 yo Patient Care Tech with a history of celiac. She received the Hep B series but her titers are low.

Martha 25 yo patient care tech Martha 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.

# Mumps/Measles cases by Year

Conclusions Tdap and Influenza for all adults under 65 Tdap, influenza, pneumococcal and shingles for all adults over 65 Over 65 PCV13 first then PPSV23 one year Under 65: put patient in a group Do not repeat HPV At least 6 months between HPV Okay to give Tdap in place of Td Stay tuned on new shingles vaccine Gluten free diet for non-responders to Hep B vaccine

… we ought to be debating the science.

Get Involved Adult Immunization Task Force AAFP Grants to Clinics Immunization Practices Advisory Committee Influenza Clinics

Questions/Comments MLMartinez@salud.unm.edu

Thimerosal Ethyl mercury Methyl mercury Toxic Threshold 200mcg/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:

PCV13 CAPiTA Trial 84,496 age 65+ in Netherlands Placebo=42,250 Mean follow up 3.97 years Bonten NEJM 2015

Prevnar® (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

CAP IPD 5.1% 48.5% 10 20 -10 30 40 50 60

PPSV23 Meta-analysis Selection Criteria Subjects age 50+ Outcomes CAP or IPD Kraicer-Melamed Vaccine 2016

PPSV23 Meta-analysis Dx Efficacy 95%CI p ARR NNT CAP cohort 17% -26,45 Case Co 7 -10,21 IPD 50% 21,69 54% 32,69

CAP IPD 17% 5.1% 48.5% 50% 10 20 -10 30 40 50 60

PCV13 CAPiTA Trial Dx Efficacy 95%CI p AAR NNT CAP 5.1% -5.1,14.2 0.32 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 Bonten NEJM 2015

CAP pneumococcal CAP 39.6% 45.5 %CAP Vaccine type 17% 10 20 -10 30 40 5.1% 10 20 -10 30 40 50 60

IPD vaccine type 75.% 48.5% 50% 40 50 20 30 60 70 80 90

PPSV23 immunization uptake 50-70% Pneumococcal Incidence for 65+ ABCS /CDC PPSV23 immunization uptake 50-70% PCV 13 in kids Year

20-60% of school age kids colonized 5-10% of adults without children colonized 20-60% of school age kids colonized CDC pink book 2015