1. Vaccines Not Just for Kids Miriam Klassen Acting Medical Officer of Health Perth District Health Unit

2. No conflict of interest Vaccines: Not Just for Kids

3. Overview  Introduction  Routine vaccinations for all adults/seniors  Special circumstances  Herpes Zoster Vaccine

4. Introduction: Why immunize?  Some adults were not immunized as children  Immunity sometimes fades  Newer vaccines available  Increased susceptibility to some infectious disease

5. Routine vaccinations  Diptheria, tetanus, pertussis, measles (excluding those born before 1970), mumps (excluding those born before 1970), rubella (women of child bearing age), varicella (if no history varicella)  Tetanus: Td q 10 yrs  Influenza: annually  Pneumococcus: once, consider repeat once after 5 years for high risk people who received first dose at 10 yrs of age or older

6. Routine vaccinations Canadian Immunization Guide: Seventh Edition

7. Special circumstances  Travel: - influenza, pneumococcus, cholera, JE, typhoid, yellow fever, rabies, meningococcus  Rabies exposure: - Alberta 2007: 73 year old male died of rabies - Aug 2006 -bitten by bat bite shoulder -he killed and disposed of bat - developed shoulder pain in Feb 2007, which progressed, and was eventually admitted with weakness and anorexia and dysphagia

8. Special circumstances  Health care workers/high risk lifestyles: hepatitis B  Immunocompromised: depends on condition but may include: meningooccus, pneumococcus, varicella, hepatitis A +B, influenza, HIB

9. Herpes Zoster  In 2005, by age 15, 95% of Canadians had chicken pox (infection with wild-type herpes varicella-zoster virus)  ~ 130,000 cases HZ/year  Data from 1979 -1997 rates of HZ: 64/100,000 age 0-4 years to 812/100,000 age 65 years +  Risk of herpes zoster increases with age  Average length of hospital stay in those age ≥ 65 years is 20 days  Epidemiology is changing due to varicella vaccine introduced as part of routine childhood vaccines

10. Herpes Zoster  40% of patients with shingles who do not take antivirals, and 20% of those who do will have post-herpetic neuralgia at 6 months post diagnosis (Weir, 2005)  15% of HZ episodes result in PHN, double in those > 65 (MEN, 2008)  30 -35% of those correctly diagnosed and treated have persistent pain, and one half of those will develop PHN despite antidepressants, anticonvulsants and opioids (MEN, 2008) Bottom line is that morbidity is significant

11. Herpes Zoster  Varicella vaccine may paradoxically increase the risk of herpes zoster among older generations who have had natural varicella  Research suggests that intermittant exposure to varicella boosts cell-mediated immunity and protects against zoster  Also increased proportion of people who are immuno-compromised

12. HZ Vaccine Research  Boosts cell-mediated immunity  At least 14X as potent as vaccines to prevent varicella  Shingles Prevention Study: large double blinded RCT (> 38,500 participants) - After median follow-up of 3 years, incidence of shingles reduced by 51% (5.4 vs 11.1 cases/1000, 95% CI 44% - 58%) - cumulative incidence of zoster in vaccine recipients reduced significantly (p < 0.001) - Of those who did develop shingles, those in the vaccine group reported 61% less burden of disease (less pain and discomfort) CI: 51% - 69% - Vaccine group had significantly greater risk of adverse events during first 42 days (1.9 vs 1.3%) and more adverse events at vaccine site (48.3% vs 16.6%) than placebo

13. HZ Vaccine Research  Excluded immunocompromised, anyone with history of HZ, those with cognitive impairment, severe hearing loss, non- ambulatory and those not expected to survive 5 years  Age ≥ 60 (average age 69) followed 31 days to 4.9 years (median 3.1 yrs)  Pain severity measured on ZBPI (Zoster Brief Pain Inventory)  Both vaccine and placebo group were treated if HZ developed  Diagnosis of HZ: clinical, PCR, culture More recent findings: efficacy maintained for 7 years (40% against HZ and 58% against PHN), no increased risk of serious AVR, and at least as efficacious in those aged 50 - 59 years

14. HZ vaccine (Zostavax)  Live attenuated virus (produced on human diploid cells), gelatin, neomycin, sucrose, sodium chloride, monosodium L-glutamate monohydrate, sodium phosphate dibasic, potassium phosphate monobasic, potassium chloride, residuals (MRC-5 cells, bovine calf serum)  Storage requirements: freeze vaccine at average temperature of -15 °C (diluent stored at room temp or in fridge)  Reconstitute at room temperature and use immediately (within 30 min)  Local reaction: erythema, pain, swelling, warmth, bruising  Systemic reactions; headache, fever, allergic reactions  Contraindications: hypersensitivity to any component, anaphylactoid reaction to neomycin (not contact), immunocompromised, pregnancy, TB  subQ (~ 0.65 ml)

15. HZ vaccine  It can be given in patients with unknown chickenpox history: all seronegative patients tested seroconverted in one large study  Can be given with other inactivated vaccines except pneumococcus  Immunocompromised clearly includes: lymphoproliferative malignancies, chemo-toxic or radiation therapy, organ transplant patients and HIV- infected patients: may be a concern in those receiving > 2 mg/kg of body weight or 20 mg/day of prednisone or equivilent  If someone in the household is immuno- compromised -consider serology

16. HZ Vaccine  Guidelines from CMPA: - HZ vaccine would be come standard of care for those ≥60 -physicians should inform patients and document  CDC recommended for those ≥ 60 years (regardless of history of HZ or chicken pox)  Do not give with 23-valent pneumoccocal vaccine as pneumococcal vaccine (although not influenza) attenuates response to HZ vaccine  $175 - 195/shot

17. HZ vaccine  Licensed by US FDA in December 2005  FDA approval May 2006  Recommended for those ≥ 60 years in 2007 by CDC  Approved in Canada by HC in August, 2008  Became available in Canada September 22, 2009  NACI statement pending

18. HZ vaccine

20. References  CDC. (modified 2009). Vaccine Preventable Adult Diseases. Author  Harpaz, R. et al.. (2008). Prevention of herpes zoster. Recommendations of the advisory committee on immunization practices (ACIP) MMWR. CDC  Medical Education Network (MEN). (2008). Maintained efficacy of herpes zoster vaccine: Corroborative Evidence. 8th Canadian Immunization Conference  Oxman, M. et al.. (2005). A vaccine to prevent herpes zoster and postherpetic neuralgia in older adults. NEJM.  PHAC. (2006) Canadian Immunization Guide. Author.  Vaccine Resource Line. (2008). Clarifying the use of the herpes zoster vaccine. Author.  Weir, E. (2005). Vaccination boosts adult immunity to varicella zoster virus. CMAJ