health and wellness for all arizonans azdhs.gov influenza and influenza vaccines karen lewis, m.d....
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Health and Wellness for all Arizonansazdhs.gov
INFLUENZA AND INFLUENZA VACCINES
Karen Lewis, M.D.
Medical Director
Arizona Immunization Program Office
November 18, 2011
Health and Wellness for all Arizonansazdhs.gov
INFLUENZA VIRUS BIOLOGY• Influenza A, B & C• Subtypes (A)
– Hemagglutinin– Neuraminadase
Antigenic drift (mutation)
Antigenic shift (reassortment)
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20th Century Influenza Pandemics
• Spanish flu H1N1 (1918-1919)
• Asian flu H2N2 (1957-1958)
• Hong Kong flu H3N2 (1968-1969)
• Swine flu H1N1 (2009-2010)
30
35
40
45
50
55
60
65
70
75
80
1900 1920 1940 1960 1980 2000
Male Female
US Life Expectancy 1900-2000
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Seasonal Influenza in the US
• Every winter• Attack rates: 10-40 %• Deaths: ~ 3,000-49,000/yr.• Hospitalizations: ~224,000/yr.
Most at risk: Elderly, children, those with medical conditions
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Deaths from Seasonal Influenza in US
Age groups
Deaths % Mortality Rate/
100,000 Person Years
< 1 yo 13 < 1 % 2.2
1-4 yo 25 < 1 % 1.1
5-49 yo 272 3 % 1.5
50-64 yo 461 6 % 12.5
> 65 yo 7,326 91 % 132.5
Total 8,097 100 % 19.6
JAMA January 8, 2003
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Bacterial Pneumonia Complicating Influenza
Etiologic agent Preceding year
(no influenza)
During flu season 1968-1969
Pneumococci 103 (62%) 52 (48%)
S. aureus 10 (6%) 21 (19%)
Staph & others 7 (4%) 7 (7%)
H. influenzae 14 (8%) 12 (11%)
Other Gram negative species
32 (20%) 16 (15%)
Total 167 108Schwarzmann et al. Arch Intern Med 1971: 127; 1037-1041.
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SYMPTOMS OF INFLUENZA• Rapid onset• High fever, chills• Extreme exhaustion• Muscle aches• Dry cough• Runny nose• Sore throat
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COMPLICATIONS OF INFLUENZA
• Viral pneumonia• Secondary bacterial pneumonia • Encephalitis• Heart and lung disease worsening• Hospitalization• Death
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Influenza Testing
• Culture• PCR• DFA or IFA
• Influenza season– If rapid test +, influenza likely
• Summer– If rapid test +, could be false +
A NEGATIVE INFLUENZA TEST DOES NOT EXCLUDE THE DIAGNOSIS OF INFLUENZA
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CDCInfluenzaTesting
Algorithm
www.cdc.gov/flu/professionals/diagnosis/testing_algorithm.htm
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SURGICAL MASK for DROPLET SPREAD
PATIENTPATIENTHEALTH CARE WORKERSHEALTH CARE WORKERS
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Influenza Antiviral Principles• Treatment
– Best within 48 hours– Give for 5 days– Especially
• Hospitalized• Pneumonia (lab +)• Bacterial
coinfection• High risk of
complications
• Prevention– Outbreak in closed
institutional settings– Post exposure– High risk (?)
• 2 wks after vaccine• Immunosuppressed• Poor vaccine/virus
match
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Patients at Higher Risk for Complications from Influenza
• > 65 years• < 2 years old• Pregnant women• Chronic lung disease
– Asthma
• Heart Disease
• Renal Disease• Liver Disease• Neurologic disease• Metabolic disease
– Diabetes
• Immunosuppression• Morbid obesity
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Antivirals: Neuraminadase InhibitorsTreatment Prophylaxis Form
Oseltamivir (Tamiflu®)OralAdult Dose 75 mg BID** 75 mg once a day**
Age > 1 year old > 1 year old
Zanamivir (Relenza®)InhaledDose 2 puffs q 12 hours 2 puffs once a day
Age > 7 years old > 5 years old
Peramivir * 600 mg daily N/A IV
**Reduce dose with CrCl 10-30 mL/min
*Not FDA licensed
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Side Effects of Neuraminadase Inhibitors
• Oseltamivir– Nausea—10%– Vomiting—9%– Transient
neuropsychiatric events
• Zanamivir– Brochospasm
• Peramivir– Diarrhea– Nausea/vominting– Neutropenia
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Influenza Vaccine Summary1. Give as soon as available
2. Give to everyone > 6 months High-risk patients Pregnant women Health care providers
3. Give throughout influenza season
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Trivalent Influenza Vaccine (TIV) Inactivated
Intramuscular
Component Adult and > 36 mo
6 mo-35 mo
H1N1 15 mcg 7.5 mcgH3N2 15 mcg 7.5 mcg
B 15 mcg 7.5 mcg
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Adverse Events after Influenza Shots
www.immunize.org
• Common–Local reaction
• Uncommon–Tired–Achy–Low fever
www.immunize.org
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Intradermal Influenza Vaccine (TIV)• 18-64 years old• Smaller needle• Less antigen
– 9 mcg instead of 15 mcg
• Same antibody response
• Local reaction more visible
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High-dose IM Influenza Vaccine Now Licensed for > 65 Years Old
Component Standard Fluzone® High-Dose
H1N1 15 mcg 60 mcg
H3N2 15 mcg 60 mcg
B 15 mcg 60 mcg
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Inactivated Influenza Vaccine (TIV) Contraindications and PrecautionsContraindication
• Anaphylactic reaction after previous vaccine
• Egg allergy is no longer a contraindication
Precaution• Moderate-severe
illness with or without fever
• GBS within 6 weeks of influenza vaccine
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New Recommendations
Egg Allergy & Flu Vaccine
• Mild egg allergy is no longer a contraindication to TIV influenza vaccine
• A previous severe allergic reaction to influenza vaccine is still a contraindication
MMWR Aug. 26, 2011
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Live Attenuated Influenza Vaccine (LAIV)
• Trivalent • Cold adapted—
Cannot grow at normal body temperature
• + stuffy nose
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Live Attenuated Influenza Vaccine
• Indications– 2-49 year old– Healthy– Not pregnant– Avoid contact with
severely immune compromised patients for 7 days
• Contraindicated– Egg allergy– Pregnancy– Immunosuppressed– Close contact of
SEVERELY immunosuppressed
• Precaution– Moderate/severe illness– GBS within 6 weeks of
influenza vaccine
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Health Benefits to Adults from Trivalent Inactivated Influenza Vaccine (TIV)
Vaccine Placebo Effectiveness in Reducing…
P value
N 422 424
URI Illnesses 105 140 25% <0.001
Sick leave due to URIs 70 122 43% 0.001
Visits to MDs for URIs 31 55 44% 0.004
Days of URIs 780 974 20% 0.034
Days of sick leave
for all illnesses
129 203 36% 0.004
Nichol KL, et al. NEJM Oct. 5, 1995
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Group 2008-09 (%) 2009-10 (%) 2010-11(%)
Overall (persons aged > 6 mos) N/A 41.3 42.8
Children, 6 mos-17 years 24.0 42.3 49.0
6 mos-4 years 32.0-40.9 N/A 61.3
Persons > 18 years 36.2 40.5 40.9
Persons 18-49 years, all 24.8 30.3 30.2
Persons 50-64 years 41.8 44.8 45.6
Persons ≥ 65 years 67.1 68.9 68.6
Seasonal Influenza Vaccination Coverage by Age: 2008-09 -- 2010-11 Seasons
MMWR, June 10, 2011 & Carolyn Bridges Webinar 9/15/2011
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Providers % Locations %
All HCPs 63.5 Hospital based 71.1
MD or dentist 84.2 Outpatient 61.5
Nurse 82.6 Dentist office 54.6
Allied health workers
64.4 Long term care facility
64.4
Administration 57.2 Home health 53.6
Which Health Care Providers Got Influenza Vaccine in 2010-2011?
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Influenza Vaccination of HCWs Protects LTC Patients in UK
Vaccine Offered Vaccine Not Offered
Patients 749 688
HCW Vaccine coverage 50-59% 4-9%
Patients tested 258 269
Culture + flu A 3 9
Culture + flu B 3 1
PCR + flu A 10 17
PCR + flu B 4 1
Deaths 17 30
Autopsy + for Influenza 0 6
Carman, Lancet 2000
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Effect of Policy on HCP Influenza Vaccine Receipt
Policy Vaccinated
Seasonal vaccine
Required 97.6%
Recommended 64.5%
None 23.5%
2009 H1N1 vaccine
Required 87%
Recommended 43%
None 11.3%
MMWR April 2, 2010
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ALL PREGNANT WOMEN NEED INFLUENZA VACCINE
• Any trimester• Vaccine decreases
– Maternal complications– Premature births– Infant influenza
• Infant cocooning– Family– Caretakers
MMWR Aug. 6, 2011
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Commonly Heard Reasons for Not Getting Influenza Vaccine
• I never get the flu• The flu’s not that bad• I am healthy so I don’t need vaccination• I always get sick after vaccination• I get sicker the years that I get vaccinated• Vaccines are often poorly matched • Vaccines not safe
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Excess GBS Cases per Million
1976 Swine Flu Vaccine 101977-1991 Seasonal Vaccines No increased risk
1992-1993 and 1993-1994Seasonal Influenza Vaccines
~1
2009 H1N1 VaccinesMMWR 2010 ~0.8
NEJM 2011 (China)0BMJ 2011 (Europe)0
IDSA 2011 (Kaiser Permanente) No increased risk
Risks from Influenza and Influenza Vaccines
GBS after Influenza vs Vaccine4-7 times higher risk
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Thimerosal Timeline• 1930’s—Preservative (~50% Ethyl mercury)• 1968—CFR required use• 1997—FDA Modernization Act• 1999—Recommend reduction or removal• 2001—Routine infant/children vaccines
without thimerosal (or trace) except for some influenza vaccines in multidose vials
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Autism Rates in Denmark after 1992 Thimerosal Removal from Vaccines
Madsen et al. Pediatrics 2003
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US Vaccine Safety Monitoring• Vaccine Adverse Events Reporting System
(VAERS)• Vaccine Safety Datalink
– Real time link with EHRs• Clinical Immunization Safety Network
– Columbia, Boston U, Stanford, Vanderbilt, John Hopkins, Kaiser Permanente
• Vaccine Assessment Unit– Dept. of Defense