Dr. Hala Boushra , MRCPCH (U.K.) Senior Pediatric specialist Primary Health Care Ministry of Health – Sharjah

but, instead, a means of prevention.” “When meditating over a disease, I never think of finding a remedy for it, but, instead, a means of prevention.” Louis Pasteur

Ministry of Health Recommendation

Vaccines Aren’t Just for Kids Sometimes vaccines do not provide lifelong protection Sometimes the virus or bacteria changes through time Sometimes the aging immune system becomes susceptible to diseases that were less of a threat at an earlier age

Why adult vaccinations? Immunity wanes over time. As we age, we become more susceptible to serious diseases caused by common infections, such as shingles, flu & pneumonia. This results in otherwise preventable morbidity & mortality. Considerable vaccine-preventable morbidity Excess hospitalization Diminished quality of life (post-herpetic neuralgia) Missed work Medical complications

Why adult vaccinations? Adult deaths from vaccine preventable diseases = 60,000 This is 200-fold greater mortality compared with children (300 children died). From: IOM, Calling the Shots: Immunization Finance Policies and Practices, 2000.

Pneumococcal vaccine ( PCV 13 ) Active immunization for the prevention of invasive disease and pneumonia caused by Streptococcus pneumoniae in adults ≥ 18 years of age and the elderly. Providing protection against Pneumococcal serotypes: 1, 3, 4, 5, 6A, 6B, 7F, 9V, 14, 18C, 19A, 19F, 23F Prevenar 13 is estimated to cover over 90% of serotypes causing antibiotic-resistant Invasive Pneumococcal Diseases.

Dosage and Administration PCV 13 suspension for injection in single dose vial The vaccine is a homogeneous white suspension in a pre filled syringe Shake it well before use

Dosage and Administration Cont. PCV 13 Dosing: 2 years and Older: 1 Dose in a lifetime (No need for booster dose). The vaccine should be given by intramuscular injection at the deltoid muscle of the upper arm in adults.

What Makes a Conjugate Different? Polysaccharide antigens + = Immunogenic carrier protein Conjugate vaccine Presentation Primed Naive B cell T cell B cell References de Roux A, et al. Comparison of Pneumococcal Conjugate Polysaccharide and Free Polysaccharide Vaccines in Elderly Adults: Conjugate Vaccine Elicits Improved Antibacterial Immune Responses and Immunological Memory. Clin Infect Dis. 2008; 46(7):1015-1023. Pollard AJ, et al. Maintaining Protection Against Invasive Bacteria With Protein-Polysaccharide Conjugate Vaccines. Nat Rev Immunol. 2009; 9(3):213-220. Plasma cell Memory B cell Plasma cell T-independent T-dependent The conjugation of a polysaccharide to a carrier protein leads to the interaction with T cells resulting in the release of functional antibodies and production of memory B cells1,2 de Roux A, et al. Clin Infect Dis. 2008; 46(7):1015-1023. Pollard AJ, et al. Nat Rev Immunol. 2009; 9:213-220.

Perceived Limitations of PPV Polysaccharide Antigens PPV effectiveness may decline with age1 PPV may have little to no efficacy for the prevention of IPD in the immunocompromised population1 In older adults, PPV may induce antibodies with diminished effectiveness2 Antibodies may have low opsonic capacity PPV antibody response may decline significantly over 5–7 years1 Decline may be more pronounced in older patients Issues around hyporesponsiveness raise many questions3 Key Points PPV may be less effective in elderly individuals. PPV may not be very effective in immunocompromised individuals. In a hospital-based case control study, when vaccine was given in either its 14-valent or its 23-valent form, its aggregate protective efficacy against infections caused by the serotypes represented in the vaccine was 21% for a subgroup of 175 immunocompromised patients (95% CI, -55% to -60%).1 (Shapiro Abstract and p 1457 table 4) In older adults, PPV may induces antibodies that have diminished effectiveness.2 Antibodies may have low opsonic capacity and also reduced potency. (Schenkein abstract and p 5523 col 2 and table 1) The antibody response may decline significantly 5 to 7 years after immunization, and a more pronounced decline might occur in older vaccinees.1 (Shapiro P1457 col1 para2 + Table 5) References Shapiro ED, et al. The protective efficacy of polyvalent pneumococcal polysaccharide vaccine. N Engl J Med. 1991; 325(21):1453-1460. Schenkein JG, et al. Pneumococcal vaccination in older adults induces antibodies with low opsonic capacity and reduced antibody potency. Vaccine. 2008; 26:5521-5526. Brynjolfsson SF, et al. Hyporesponsiveness Following Booster Immunization With Bacterial Polysaccharides Is Caused by Apoptosis of Memory B Cells. Clin Infect Dis. 2012; 205:422-430. Shapiro ED, et al. N Engl J Med. 1991; 325(21):1453-1460. Schenkein JG, et al. Vaccine. 2008; 26:5521-5526. Brynjolfsson SF, et al. Clin Infect Dis. 2012; 205:422-430.

Differences between Prevenar 13 and PPSV23 Conjugated with a carrier protein Produce more functional antibodies Long term protection PPSV23 Polysaccharide Hypo responsiveness Short term protection

High Risk Groups 50 years and Older. Sickle Cell Disease and Asplenia. Diabetes Mellitus. Chronic Cardiac problems. Chronic Renal and Liver Disease. Chronic Pulmonary Disease (Including Asthma). HIV infection. Smoking. Alcoholism. Immunocompromised Leukemia, Malignancy, Acquired Immunodeficiency, Solid organ transplantation, Immunosuppressive medications)

PCV 13 & PPSV23 Intervals

Influenza vaccination

Influenza vaccination Annual vaccination against influenza is recommended for all persons aged ≥6 months. A list of currently available influenza vaccines can be found at http:// www.cdc.gov/flu/protect/vaccine/vaccines.htm Persons aged ≥6 months, including pregnant women, can receive the inactivated influenza vaccine (IIV). An age-appropriate IIV formulation should be used

Algorithm: Evaluation of an Egg Allergy Preceding Influenza Vaccination Yes Can the person eat lightly cooked (e.g., scrambled egg) without reaction? Administer vaccine per usual protocol No Yes After eating eggs or egg-containing foods, does the person experience ONLY hives? Administer TIV (Inactivated) Observe for reaction for at least 30 minutes after vaccination No Does the person experience other symptoms such as: Cardiovascular changes (e.g., hypertension) Gastrointestinal (e.g., nausea/vomiting) Reaction requiring epinephrine Reaction requiring emergency medical attention Refer to a provider with expertise in management of allergic conditions for further evaluation Yes www.cdc.gov/vaccines/recs/acip/downloads/mtg-slides-feb11/06-5-flu-vac-egg.pdf

Give 1 dose every year in the fall or winter. Begin vaccination services as soon as vaccine is available and continue until the supply is depleted. Continue to give vaccine to unvaccinated adults throughout the influenza season (including when influenza activity is present in the community) and at other times when the risk of influenza exists

Contraindications Previous severe allergic reaction (e.g., anaphylaxis) to this vaccine, to any of its components, including egg protein. Adults with egg allergy of any severity may receive RIV or, adults who experience only hives with exposure to eggs may receive other IIV with additional safety precautions (i.e., observe patient for 30 minutes after receipt of vaccine for signs of a reaction). For LAIV only: pregnancy; immunosuppression; receipt of specific antivirals (i.e., amantadine, rimantadine, zanamivir, or oseltamivir) within the previous 48hrs. Avoid use of these anti-viral drugs for 14d after vaccination.

Tetanus, diphtheria, and acellular pertussis (Td/Tdap) vaccination

Infants too young to be vaccinated are at greatest risk for severe pertussis, including hospitalization and death. The disease can be transmitted from adults to close contacts, especially unvaccinated children.

Tetanus, diphtheria, and acellular pertussis (Td/Tdap) vaccination For people who are unvaccinated or behind, complete the primary Td series (3 doses with an interval of 1–2m between dose #1 and #2, and an interval of 6–12m between dose #2 and #3); substitute a one-time dose of Tdap for one of the doses in the series, preferably the first. Give Td booster every 10 yrs after the primary series has been completed. Tdap should be given regardless of interval since previous Td.

Administer 1 dose of Tdap vaccine to pregnant women during each pregnancy (preferably during 27–36 weeks’ gestation) regardless of interval since prior Td or Tdap vaccination

Adults with an unknown or incomplete history of completing a 3-dose primary vaccination series with Td-containing vaccines should begin or complete a primary vaccination series including a Tdap dose For unvaccinated adults, administer the first 2 doses at least 4 weeks apart and the third dose 6–12 months after the second.

For incompletely vaccinated (i. e For incompletely vaccinated (i.e., less than 3 doses) adults, administer remaining doses. Refer to the ACIP statement for recommendations for administering Td/Tdap as prophylaxis in wound managemen

Contraindications Previous severe allergic reaction (e.g., anaphylaxis) to this vaccine or to any of its components. For Tdap only, history of encephalopathy not attributable to an identifiable cause, within 7d following DTP/DTaP, or Tdap.

Varicella vaccination

Varicella vaccination All adults without evidence of immunity to varicella should receive 2 doses of single-antigen varicella vaccine or a second dose if they have received only 1 dose

Evidence of immunity to varicella in adults includes any of the following: Documentation of 2 doses of varicella vaccine at least 4 weeks apart . History of varicella based on diagnosis or verification of varicella disease by a health care provider . History of herpes zoster based on diagnosis or verification of herpes zoster disease by a health care provider; or Laboratory evidence of immunity or laboratory confirmation of disease.

Contraindications Previous severe allergic reaction (e.g., anaphylaxis) anaphylactic reaction to this vaccine or to any of its components. Pregnancy or possibility of pregnancy within 4 wks. People on long-term immunosuppressive therapy or who are immunocompromised because of malignancy and primary or acquired immunodeficiency, including HIV/AIDS (although vaccination may be considered if CD4+ T-lymphocyte counts are greater than or equal to 200 cells/µL.3 ). People with isolated B-lymphocyte deficiency may receive varicella vaccine

Human papillomavirus (HPV) vaccination Three HPV vaccines are licensed for use in females (bivalent HPV vaccine [2vHPV], quadrivalent HPV vaccine [4vHPV], and 9-valent HPV vaccine [9vHPV]) and two HPV vaccines are licensed for use in males (4vHPV and 9vHPV).

For females, 2vHPV, 4vHPV, or 9vHPV is recommended in a 3-dose series for routine vaccination at age 11 or 12 years and for those aged 13 through 26 years, if not previously vaccinated. For males, 4vHPV or 9vHPV is recommended in a 3-dose series for routine vaccination at age 11 or 12 years and for those aged 13 through 21 years, if not previously vaccinated. Males aged 22 through 26 years may be vaccinated .

A complete HPV vaccination series consists of 3 doses A complete HPV vaccination series consists of 3 doses. The second dose should be administered 4–8 weeks (minimum interval of 4 weeks) after the first dose The third dose should be administered 24 weeks after the first dose and 16 weeks after the second dose (minimum interval of 12 weeks).

Zoster vaccination

Zoster vaccination A single dose of zoster vaccine is recommended for adults aged ≥ 50 years regardless of whether they report a prior episode of herpes zoster. Although the vaccine is licensed by the U.S. Food and Drug Administration for use among and can be administered to persons aged ≥50 years ACIP recommends that vaccination begin at age 60 years

Give 1-time dose if unvaccinated, regardless of previous history of herpes zoster (shingles) or chickenpox. If 2 or more of the following live virus vaccines are to be given – MMR, Var, HZV, and/or yellow fever – they should be given on the same day. If they are not, space them by at least 28d.

Contraindications Previous severe allergic reaction (e.g., anaphylaxis) to any component of zoster vaccine. Primary cellular or acquired immunodeficiency. Pregnancy.

Measles, mumps, rubella (MMR) vaccination All adults should have documentation of 1 or more doses of MMR vaccine unless they have a medical contraindication to the vaccine or laboratory evidence of immunity to each of the three diseases. Documentation of provider-diagnosed disease is not considered acceptable evidence of immunity for measles, mumps, or rubella.

Measles component: A routine second dose of MMR vaccine, administered a minimum of 28 days after the first dose, is recommended for adults who: Are students in postsecondary educational institutions Work in a health care facility, or Plan to travel internationally

Mumps component A routine second dose of MMR vaccine, administered a minimum of 28 days after the first dose, is recommended for adults who: Are students in a postsecondary educational institution Work in a health care facility, or Plan to travel internationally

Rubella component For women of childbearing age, regardless of birth year, rubella immunity should be determined. If there is no evidence of immunity, women who are not pregnant should be vaccinated. Pregnant women who do not have evidence of immunity should receive MMR vaccine upon completion or termination of pregnancy and before discharge from the health care facility .

Contraindications Previous severe allergic reaction (e.g., anaphylaxis) to this vaccine or to any of its components. Pregnancy or possibility of pregnancy within 4 wks. Severe immunodeficiency (e.g., hematologic and solid tumors; receiving chemotherapy; congenital immunodeficiency; long-term immunosuppressive therapy; or severely symptomatic HIV). Note: HIV infection is NOT a contraindication to MMR for those who are not severely immunocompromised (i.e., CD4+ T-lymphocyte counts are greater than or equal to 200 cells/µL) for 6 months.

Hepatitis A vaccination

Hepatitis A vaccination Vaccinate any person seeking protection from hepatitis A virus (HAV) infection and persons with any of the following indications: 1 ) Persons who use injection or noninjection illicit drugs . 2 ) Persons working with HAV-infected primates or with HAV in a research laboratory setting .

3) Persons with chronic liver disease and persons who receive clotting factor concentrates . 4 ) Persons traveling to or working in countries that have high or intermediate endemicity of hepatitis A 5) Postexposure: adults age 40 yrs or younger with recent (within 2 wks) exposure to HAV, give HepA. For people older than age 40 yrs with recent (within 2 wks) exposure to HAV, immune globulin is preferred over HepA vaccine.

Give 2 doses, spaced 6–18m apart (depending on brand). If dose #2 is delayed, do not repeat dose # Just give dose #.

Hepatitis B vaccination

Hepatitis B vaccination Vaccinate any person seeking protection from hepatitis B virus (HBV) infection and persons with any of the following indications: 1) health care personnel and public safety workers who are potentially exposed to blood or other infectious body fluids

2) persons who are aged <60 years with diabetes as soon as feasible after diagnosis; 3 ) persons with diabetes who are aged ≥60 years at the discretion of the treating clinician based on the likelihood of acquiring HBV infection, including the risk posed by an increased need for assisted blood glucose

4 ) Persons with end-stage renal disease (including patients receiving hemodialysis). 5 ) Persons with HIV infection . 6 ) Persons with chronic liver disease .

7) Household contacts and sex partners of hepatitis B surface antigen– positive persons . 8) clients and staff members of institutions for persons with developmental disabilities, and international travelers to regions with high or intermediate levels of endemic HBV infection .

Give 3 doses on a 0, 1, 6m schedule Administer missing doses to complete a 3-dose series of hepatitis B vaccine to those persons not vaccinated or not completely vaccinated If the series is delayed between doses, DO NOT start the series over. Continue from where the schedule was interrupted.

Haemophilus influenza type b (Hib) vaccination Not routinely recommended for healthy adults One dose of Hib vaccine should be administered to persons who have anatomical or functional asplenia or sickle cell disease or are undergoing elective splenectomy if they have not previously received Hib vaccine. Hib vaccination 14 or more days before splenectomy is suggested

Recipients of a hematopoietic stem cell transplant (HSCT) should be vaccinated with a 3-dose regimen 6–12 months after a successful transplant, regardless of vaccination history; at least 4 weeks should separate doses. Hib vaccine is not recommended for adults with HIV infection since their risk for Hib infection is low

Meningococal Conjugate (MCV4) & Meningococcal polysaccharide (MPSV4) 1 ) People with anatomic or functional asplenia or persistent complement component deficiency. 2 ) People who travel to or reside in countries in which meningococcal disease is hyperendemic or epidemic (e.g., the “meningitis belt” of Sub-Saharan Africa).

3 ) Microbiologists routinely exposed to isolates of N. meningitidis 3 ) Microbiologists routinely exposed to isolates of N. meningitidis. 4 ) First-year college students through age 21 yrs who live in residence halls and who have not been previously vaccinated or who received their first dose prior to age 16 yrs.

Science Hopes a Vaccine for every Disease

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