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Is it a new concept? . or an old concept revisited?
Chronology of Vaccines Discovery
It all started with adult range of vaccines!!!
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The need to revisit the concept
There is no structured data on the burden of vaccinepreventable disease amongst adults.
However:
Chronic liver disease secondary to Hepatitis B - 600,000 deaths in 2002
Annual incidence of invasive Pneumococcal disease (e.g., bacteraemia and
meningitis) in developed countries is 1520 cases/100,000 persons of all
ages & 50 cases per 100,000 elderly adults (65 years) with an overall case
fatality of 20-60%
Influenza afflicts 5%-10% of adult population annually and accounts for
deaths rate of 30-150/100 000 population aged >65 years
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Available at: http://www.who.int/vaccines-documents/DocsPDF05/GIVS_Final_EN.pdf
GIVS Global Immunization vision & strategy 2006-2015.
WHO-UNICEF
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The hurdles in the path
The misconceptions: Vaccines are primarily meant for children
Vaccines received in childhood provide life-long protection
Tetanus?
Pertussis?
Typhoid?
Influenza?
Unrealistic expectations:
Complete protection rather than partial protection and reduction in severity of
disease and associated morbidity and mortality
Lack of national goals and of public health programs
Lack of training on preventive medicine as part of existingpostgraduate curriculum
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The Range of Vaccines for Adolescents and Adults
Currently Available
Tetanus Toxoid
Hepatitis B Vaccine
Influenza Vaccine
Rabies Vaccine MMR
Hepatitis A Vaccine
Typhoid Vaccine
Chicken Pox Vaccine
Polysaccharide Pneumococcal Vaccine
Polysaccharide Meningococcal Vaccine
Yellow Fever Vaccine
Japanese Encephalitis Vaccine
Licensed abroad, NA in India
1. Reduced diphtheria antigen (d)
containing dT, dTaP
2. Zoster Vaccine
3. HPV Vaccine
4. Conjugate Meningococcal Vaccine
In Late stage Development
1. Dengue Vaccine
2. Malaria Vaccine
3. Kala-Azar Vaccine
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The Suggested Approach
Assess Need, the H.A.L.O. Style
H - Health Condition
A - Age
L - Lifestyle
O - Occupation
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An Example of H.A.L.O. checklist followed in US
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What an Indian H.A.L.O. could look like?
Resident of
Endemic zoneInfluenza X X X X X X
PPV X X X X
Hep B X X X X X X X X X X X
Hep A X X X X X X X X
Typhoid X X X X X X X X X X
Varicella/Zoster X X X X
Meningococcal X X X X X
dT X X X X X X X X X X X X
MMR X
JE X
Rabies X
Yellow fever X
Food handler Animal handler Laboratory
worker
Military
personnel
Adolescent &
young adults
Elderly International
traveler
HostellersChronic disease Immunodeficiency Pregnancy
Health Factors Age Lifestyle Occupation
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The Two Vaccines that are:
Old, used over decades
Well established usage and extensive clinical application
in the practice of Internal Medicine
Well documented advantages health & economic
Strongly recommended by authorities like WHO, CDC etc.
Freely available
But,Grossly under-discussed and under-utilized
Influenza Vaccine Pneumococcal Vaccine
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Influenza
The virus and the disease
The available vaccine
Vaccination in adult population
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Influenza Virus
Single stranded, RNA virus of Orthomyxoviridae family
3 types causing disease in man: Types A, B & C
Type A
There are 1-16 HA & 1-9 NA types distributed in Human, Animals &Birds
HA- Helps in attachment with Host cell, NA- Releases the toxins
Moderate-severe illness as outbreaks, epidemics & pandemics
In Humans we find Hemagglutinin (H1,H2,H3) & Neuraminidase(N1,N2)
Type B
Antigenic drift uncommon; antigenic shift not seen
Mild-moderate disease as small outbreaks only
Humans only
Type C
Very uncommonly implicated in clinical disease
Neuraminidase
(NA)
Hemagglutinin
(HA)
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Patho-physiology
Binding and destruction of epithelial cells fromnasopharynx to alveoli
SYSTEMIC BODY REACTIONFever, muscle pain, etc.
LOCAL INFLAMMATORY REACTIONUpper respiratory infection
Bodyresponse
Droplets
Aymard M. Vaccine 1995: 4770.
Healthy Ciliated RespiratoryEpithelium
Damaged RespiratoryEpithelium
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Marked Systemic Symptoms Differentiate Traditional
Flu from Cold
JAMA 2000; 284 (13): 1740
Influenza afflicts 5%-10% of adult population annually and
accounts for deaths rate of 30-150/100 000 population aged >65
years
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Complicated Influenza
Bacterial superinfections Otitis media, Sinusitis
Exacerbation of asthma/COPD
Bronchiolitis, Croup
Secondary bacterial pneumonia
Decompensation of chronic diseases
Pulmonary disease
Heart disease (Congestive heart failure Myocarditis, pericarditis) Renal insufficiency
Metabolic disease (Keto-acidosis in diabetics)
Nicholson KG. Semin Respir Infect 1992; 7: 2637.
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Groups at higher risk of complications
Elderly (>60 yrs.), especially in residential care units
Children & teenagers receiving long-term aspirin therapy
Pregnant women belonging to high-risk groups
Patients with Immuno-suppression & Chronic diseases:
Eur J Clin Res 1992; 3: 11738.
Chroni c renaldys unction
Chronic pulmonary(includi ng asthm a)
aemoglobinopat hies,immunosuppression
Chroni c metaboli c disease(including diabetesmellit us)
Cardiovasculardisorders
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Age distribution of respiratory complications
Betts FR et al. In: Mandell GL et al., eds. Principles and Practice of Infectious Diseases. 3rd Edn. New York:Churchill Livingstone; 1990: 130625.
0
20
0
60
0
0 59 1019 2039 0 9 5059 5069 0
Age groups (year)
espir
atory
complications(%)
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Influenza Vaccines
Trivalent Inactivated vaccine (TIV), containing one strain*each of:
Type A H1N1 virus
Type A H3N2 virus
Type B virus(*Choice of strain to be included is recommended annually by WHO)
The different types of TIV currently available:
Split virus vaccines good immunogenicity and low reactogenicity
most commonly used type of vaccine
Subunit virus vaccines
moderate immunogenicity and low reactogenicity
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Annual doses of influenza vaccination is required to ensure
continuous protection because:
1. The duration of protection offered by TIV is 1 year.
2. There are annual changes in the composition of Influenza vaccine,
as recommended by WHO on basis of surveillance data.
Influenza Vaccination is required annually
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Benefits of influenza vaccination
Reduction in risk ofillness, hospitalization
and death
Reduction in financialand social cost of
illness
Reduction in risk ofinfecting high risk
contacts
Flu Shot
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Efficacy of influenza vaccination in elderly and
high-risk persons
Prevention of illness and death
Among high-risk adults aged 1864 years, vaccination prevented:
78% of deaths
87% of hospitalisations
26% of GP visits
Among elderly individuals (> 65 years), vaccination
prevented:
50% of deaths
48% of hospitalisations
Hak E et al. Arch Intern Med 2005; 165: 27480
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In a meta-analysis of 20 cohort studies, pooled estimates
of vaccine efficacy demonstrated prevention of morbidity
and mortality during the influenza season
Respiratory illness 56%
Pneumonia 53%
Hospitalisation 50%
Death 68%
Gross PA et al. Ann Intern Med 1995; 123: 51827.
Efficacy of influenza vaccination in elderly
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Years of life bought forUS$1 million
Pap smear every 3 years: 52 life-years
Bypass surgery for left main: 134 life-years
coronary artery disease
Influenza vaccination: 11,100 life-years
Russell LB. Health Aff (Millwood) 1992; 11: 1629.
Cost-Effectiveness of influenza vaccination
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Recommendations of the ACIP (Advisory
Committee on Immunization Practices)
Primary target groups recommended for annual vaccination
Persons at increased risk for influenza-relatedcomplications
Persons aged 5064 years
This group has an elevated prevalence of certainchronic medical conditions
Persons who live with/care for persons at high risk
Harper SA et al. MMWR Recomm Rep 2004; 53: 140.
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Persons at increased risk for complications from influenza: Persons aged > 65 years
Residents of nursing homes or other chronic-care facilities thathouse persons of any age with chronic medical conditions
Adults and children with chronic disorders of the pulmonary orcardiovascular systems, including asthma
Adults and children who have required regular medical follow-up orhospitalisation in the preceding year due to chronic metabolicdiseases
Children and adolescents (6 months18 years) receiving long-term
aspirin therapy
Women who will be pregnant during the influenza season
Children aged 623 months
Recommendations of the ACIP (Advisory
Committee on Immunization Practices)
Harper SA et al. MMWR Recomm Rep 2004; 53: 140.
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Persons who can transmit influenza to those at high risk:
Physicians, nurses, and other personnel in both hospital & outpatient-
care settings, including medical emergency response workers
Employees of nursing homes & chronic-care facilities who have
contact with patients or residents Employees of assisted living & other residences for persons in groups
at high risk
Persons who provide home care to persons in groups at high risk
Household contacts (including children) of persons in groups at high
risk
Vaccination is also recommended for household contacts and
out-of-home caregivers of children aged 023 months
Recommendations of the ACIP (Advisory
Committee on Immunization Practices)
Harper SA et al. MMWR Recomm Rep 2004; 53: 140.
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Country-wise recommendations for annual
influenza vaccination
Age > 65years
Age 5065 years
Agedcareresi-
dents
Contactsof
personsat risk
Peoplewith
chronicillnesses
Youngerhealthypersons
Children624
months
USA Yes Yes Yes Yes Yes No Yes
WHO Yes No Yes Yes Yes No No
Australia Yes No Yes Yes Yes No NoHong Kong Yes No Yes Yes Yes No Yes
Malaysia Yes No Yes Yes Yes No Yes
New Zealand Yes No Yes Yes Yes No No
Philippines Yes Yes Yes Yes Yes No Yes
Republic of
KoreaYes Yes Yes No Yes No Yes
Singapore Yes No Yes Yes Yes No Yes
Taiwan Yes No Yes Yes Yes No Yes
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Current use of influenza vaccine
Many European have high coverage in elderly persons
In the USA, coverage amongst > 65 yrs is 62.7 65.6%
In Australia & New Zealand, coverage in the population
> 65 years is 79.1% and 65%, respectively
In South America (e.g. Argentina, Brazil, Chile, Uruguay)
vaccine use is increasing
The 1999 influenza campaign in Brazil achieved a 72.4%
coverage rate among individuals > 65 years
In Asia, the use of vaccine is still limited
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Influenza immunization rates in 2003
Influenza vaccination coverage rates per 1000 in general population
In India, the coverage is around 0.1 per 1000
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Pneumococcal Infections
The bacterium and the disease
The available vaccine
Vaccination in adult population
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Streptococcus pneumoniae -Bacteriology
Gram positive cocci, Facultative anaerobes,
Capsulated
Capsular polysaccharides help escape non-
immune mediated phagocytosis
Antibody against capsular polysaccharide are
protective
Nature of capsular polysaccharide forms the
basis of classification of Pneumococcus in to
serotypes
90 Serotypes are currently known for
Pneumococcus, of which the 23 serotypes
including in PPV accounts for 85-90% of disease
in India.
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Pathogenesis ofPneumococcal Disease
Non-invasive Sinusitis
Otitis media
Pneumonia
Invasive
Bacteraemia
Meningitis
Endocarditis
Peritonitis
Septic arthritis
Hematogenous
dissemination
Contiguous
Dissemination
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Burden of disease
Annual incidence of Invasive Pneumococcal Disease in developedcountries is 1520 cases/100,000 persons of all ages & 50 cases per
100,000 elderly adults (65 years) with an overall case fatality of 20-80%,
in addition to long term sequelae
Additionally, Pneumococcus is the most common cause of Community
acquired Pneumonia, accounting for more than a third of cases in US, with
high complication rates (Bacteraemia and lung abscess) and case fatality
of >10% in elderly
CDC estimates that in Us only, S. pneumoniae annually causes:
500,000 cases of pneumonia
3,000 cases of meningitis
50,000 cases of bacteraemia
40,000 deaths
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Incidence and Case Fatality Ratio by Age Group
Invasive Pneumococcal Disease
8
8
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Incidence of invasive pneumococcal disease in adults
with selected underlying conditions & healthy adults -
United States, 2000
1143 48 59
92
294
341
432
0
100
200
300
400
500
Healthy Chronic
heart
Diabetes Chronic
lung
Heavy
drinker
Solid
cancer
HIV/AIDS Blood
cancer
Casesper100,0
00
persons
>4 timesincrease in risk
>40 timesincrease in risk
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High risk population forPneumococcal diseases
Children < 2 years of age Elderly > 65 years of age
Children & adults with chronic CV or respiratory diseases
Immunosuppressed hosts
Chronic renal disease
Diabetics
Nephrotic syndrome
Transplant recipients
HIV/AIDS Cancer, particularly hematological malignancies
Chemotherapy or radiotherapy
Asplenia
Sickle cell anemia
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Pneumococcal Vaccines
7 Valent Conjugate vaccine
(PCV)
Capsular polysaccharide of 7
common pathogenic
serotypes conjugated with
non-toxic diphtheria toxin
Indicated in children aged 6
months 5 years only
23 Valent Polysaccharide
Vaccine (PPV)
Unconjugated capsular
polysaccharide of 23 common
pathogenic serotypes
Indicated in Children above 2
years of age (not immunogenic
in younger age group)
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23 Valent Polysaccharide Pneumococcal Vaccine
Indications
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Immunocompromised Cardiopulmonary Nursing Age >Country Asplenia Haematological HIV diabetes, renal Other home 65 years
Austria l - - l l - -Belgium l l l l l l lDenmark l l l l - - lFinland l l l l l - lFrance l l - l l - -Germany l l - l - - -
Icelandl l
-l l l l
Ireland l l l l l - -Italy l - l - - - -Luxembourg l l l l l l lNetherlands l - - - - - -Norway l l l l l - lSweden l l l l l - lSwitzerland l l l l l - -
UK l l l l l - -USA l l l l l l l
Country-wise recommendations for
Pneumococcal vaccination (1 )
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Doses of Pneumococcal vaccine distributed per 10,000 population
*
0 40 80 120 160 200 240 280
Others
USACanada
Austria
Belgium
Denmark
Finland
France
Iceland
Norway
Sweden
Switzerland
UK
Pneumococcal immunization rates in 1 6
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Action points to increase uptake of adult
immunization practices
Inclusion of training in PG curriculum
Inclusion of topics in CMEs
Recommendations & guidelines by academic bodies like API,
RSSDI, CSI etc.
Standing orders in individual hospitals, individual departments
Lobbying with policy makers to include the topic in National
goals towards health. Alignment with WHO
objectives
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Time to think of
adultvaccination!!!