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

2. 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.

3. Off-Label
Tdap in adults
Adjuvant Shingles Vaccine

4. 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

5. 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?

6. 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

7. 70 year old female thinks she is up to date on all vaccines.

8. 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)

9. Pneumococcal Vaccines
Pneumovax PPSV23 Polysaccharide 1980s 23 Valent
Prevnar® PCV13 Conjugated protein to Polysaccharide PCV PCV types
sugar
sugar
sugar
protein
sugar
sugar
sugar

10. PPVS23
PCV13
Efficacy
Range of Serotypes

11. 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

12. 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.

14. 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.

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

16. 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

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

19. 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

20. 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

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

22. Which P-Vax

23. 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.

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

25. <65 and No Chronic Conditions
No pneumococcal vaccines

26. 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.

27. <65 and at increased risk PPSV23 only
Chronic heart disease
Chronic lung disease (Asthma)
Diabetes mellitus
Alcoholism
Chronic liver disease
Cigarette smoking
PPSV23 only

28. 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

29. >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

30. 46 year old with Hodgkin's Lymphoma in remission after chemotherapy
CASE 5
46 year old with Hodgkin's Lymphoma in remission after chemotherapy

31. 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

32. 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

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

34. 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

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

37. Uncheck to remove top box from overall view.

38. Table View

40. List view

43. Which 2 HPV types cause the vast majority of cancers?

44. Carcinogenic

45. 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

46. Case 6
Dana is a 16 year old female who received 3 HPV4 doses with appropriate intervals between age Should she repeat the series with HPV9?

47. HPV Types
Erickson, Am J Obst & Gyn 2013

48. 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

49. Dana is a 16 year old female who received 3 HPV4 doses at appropriate intervals between age Should she repeat the series with HPV9
The HPV9 series is not recommended for persons who have received a full HPV4 series.

50. 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.

51. 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

52. 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

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

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

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

57. 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);

58. 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);

59. 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

61. 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.

62. 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:
N Engl J Med. 2016;375:
N Engl J Med 2005; 352:

63. 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

64. 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.

65. 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.

66. # Mumps/Measles cases by Year

67. 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

68. … we ought to be debating the science.

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

70. Questions/Comments

71. 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:

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

73. Prevnar® (PCV13) CAPiTA TrialDx
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

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

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

76. 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

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

78. PCV13 CAPiTA Trial Dx Efficacy 95%CI p AAR NNT CAP 5.1% -5.1,14.2 0.32
Pneumococcal
39.6%
.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%
Bonten NEJM 2015

79. 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

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

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

82. 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