What’s New in Adult Immunization William L. Atkinson, MD, MPH National Immunization Program National Immunization Conference 8 March 2006

Disclosures The speaker has no financial interest or conflict with the manufacturer of any product named in this presentation The speaker will discuss the use of acellular pertussis and Hib vaccines in a manner not approved by the U.S. Food and Drug Administration The speaker will discuss vaccines not currently licensed by the FDA

What’s New in Adult Immunization The schedule Influenza vaccine Pertussis vaccine Meningococcal vaccine Coming attractions

Adult Immunization Schedules, 2002-2003 Age-based Condition-based

Adult Immunization Schedules, 2002-2003 Age-based Condition-based

Adult Immunization Schedules, 2005-2006 Age-based Condition- based

Adult Immunization Schedules, 2005-2006

Adult Immunization Schedule, 2005-2006 Routine use Conditional use

Adult Immunization Schedule, 2005-2006

Adult Immunization Schedules, 2005-2006

Adult Immunization Schedules, 2005-2006

Inactivated Influenza Vaccine Recommendations A new “high risk” medical condition was added in 2005: any condition that can compromise respiratory function or the handling of respiratory secretions

The Pertussis Paradox In 2004, pertussis vaccination levels among children 19-35 months of age were the highest ever recorded In 2004, the largest number of pertussis cases (25,827) was reported since 1959 More than 15,000 cases were among adolescents and adults 96% for 3+ doses, 85% for 4+ doses

Pertussis Among Adults Disease often milder than in infants and children Infection may be asymptomatic, or may present as classic pertussis Adults (19-64 years) accounted for more than 7,000 cases in 2004 Older persons often source of infection for children

Tdap Vaccine AdacelTM (sanofi pasteur) Licensed June 10, 2005 Approved for a single (booster) dose* Approved for persons 11-64 years of age *among persons who received a complete series of 4 or 5 dose of DTP/DTaP

Pertussis Vaccine For Adults Only Adacel brand Tdap approved for adults 19-64 years of age Do not administer to adults 65 years of age or older

Pertussis Vaccine For Adults Provisional ACIP recommendations*: Single dose of Tdap should replace a single routine Td dose Efforts should be made to vaccinate adults who have close contact with an infant <12 months of age (e.g., parents, childcare providers, health-care providers) Full recommendations expected in mid-2006 *available at www.cdc.gov/nip/recs/provisional_recs/default.htm

Minimum Interval Between Td and Tdap Interval between Td and Tdap may be shorter than 5-10 years if protection from pertussis needed ACIP did not define an absolute minimum interval between Td and Tdap Provider will need to decide based on whether the benefit of pertussis immunity outweighs the risk of a local adverse reaction

Tdap For Persons Without A History of DTaP All adults should have documentation of having received a series of DTAP, DTP, DT, or Td Persons without documentation should receive a series of 3 vaccinations Preferred schedule: Single dose of Tdap* Td at least 4 weeks after the Tdap dose Second dose of Td at least 6 months after the Td dose *off-label recommendation; 19-64 years of age

Approved by FDA January 2005 The U.S. meningococcal conjugate vaccine, or MCV, is called Menactra. It is produced by Sanofi Pasteur and was licensed in the United States in January 1005. Approved by FDA January 2005

Meningococcal Vaccines Two meningococcal vaccine are available Menomune (the old vaccine) Menactra (the new, better vaccine) Menactra should be given to everyone with an indication who is 11-55 years of age Menomune should only be given to persons 2-10 years and >55 years or if Menactra is not available

Meningococcal Vaccine Revaccination Revaccination may be indicated for persons at high risk for infection* who received Menomune at least 5 years ago Once a person has received MCV no further meningococcal vaccination is recommended (at this time) *e.g., asplenic persons and those who reside in areas in which disease is endemic (does not include college settings)

(for adults)

MMRV (ProQuad) Combination measles, mumps, rubella and varicella vaccine Approved by FDA in September 2005 for children 12 months through 12 years of age (to age 13 years) ACIP does NOT recommend off-label use of MMRV for persons 13 years and older

Vaccines for Adults on the Horizon Herpes zoster (shingles) Human Papillomavirus (cervical cancer and genital warts) Vaccines for sexually transmitted infections (HSV, GC)

Herpes Zoster Vaccine Administered to persons who had chickenpox to reduce the risk of subsequent development of zoster Higher titer (18x) of varicella vaccine virus than standard Varivax® Results of clinical trial published in NEJM June 2, 2005 Merck has filed BLA

Herpes Zoster Vaccine Trial 36,716 persons 60-80+ years of age followed for average of 3.12 years after vaccination Compared to the placebo group the vaccinated group had 51.3% fewer episodes of HZ Less severe illnesses 66.5% less postherpetic neuralgia No significant safety issues identified Oxman et al, NEJM 2005;352(22):2271-84

“In our country, said Alice, you’d generally get to somewhere else if you ran very fast for a long time. Now here, said the Red Queen, it takes all the running you can do to keep in the same place.” -Through the Looking Glass, 1871