Vaccination in the elderly - Dr Bhakti Vasant Public Health Physician - Brisbane South PHN

Vaccination in the elderly

Dr Bhakti Vasant
Public Health Physician
                          Source of image: http://www.cidrap.umn.edu/news-perspective/2013/10/early-
                          results-large-trial-affirm-high-dose-flu-vaccine-seniors

Outline

• Recommended vaccines in the elderly
• Influenza vaccine
• Pneumococcal vaccine
• Zoster vaccine
• Diphtheria, tetanus and acellular pertussis
  (dTPa) vaccine
• Conclusion

Recommended vaccines in the elderly
• Funded vaccines
         • Influenza vaccine (in ≥65y)
         • Pneumococcal vaccine (in ≥65y)
         • Zoster vaccine (in 70y and catch up for 71–79y
           until Oct 2021)
• Recommended (but not funded) vaccines
         • dTPa vaccine (esp if in close contact with infants)
         • Others depending on history
Source of text: Australian Government Department of
Health. Vaccination for seniors. Available from URL:
https://beta.health.gov.au/topics/immunisation/immunisati
on-throughout-life/immunisation-for-seniors, Source of
image: WHO 2017. Available from URL:
http://www.who.int/topics/vaccines/en/

INFLUENZA

   Source of image: http://www.co.delaware.pa.us/intercommunity/flu.html

Influenza vaccination of the elderly (≥65y)

• Vaccination is the most effective means to
  prevent influenza and its complications
• Annual influenza vaccination of the elderly is
  recommended by:
              • The Australian Department of Health
              • The Centers for Disease Control and Prevention
              • The World Health Organization
              • The NHS
Source: Australian Government Department of Health. Vaccination for seniors. Available from:
https://beta.health.gov.au/topics/immunisation/immunisation-throughout-life/immunisation-for-seniors , CDC. What you should
know and do this flu season if you are 65 years and older. Available from: https://www.cdc.gov/flu/about/disease/65over.htm ,
WHO. Influenza (seasonal). Available from: http://www.who.int/mediacentre/factsheets/fs211/en/, NHS. Who should have a flu
jab? Available from URL: https://www.nhs.uk/conditions/vaccinations/who-should-have-flu-vaccine/

Influenza vaccination of healthcare workers
• HCWs are at high risk of contracting influenza and
  transmitting the disease to their patients or the
  general population.
• Annual influenza vaccination of HCWs is recommended
  by:
             • The Australian Immunisation Handbook
             • The Advisory Committee on Immunization Practices (ACIP),
               CDC
             • The World Health Organization
             • The NHS

Source: The Australian Government Department of Health. The Australian Immunisation Handbook, Available from URL:
http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook10-home~handbook10part4~handbook10-
4-7, Shefer A, et al. Immunisation of Healthcare Personnel: Recommendations of the Advisory Committee on Immunisation
Practices. MMWR 201; 60(RR07): 1–45, WHO. Influenza (seasonal). Available from:
http://www.who.int/mediacentre/factsheets/fs211/en/, NHS. Who should have a flu jab? Available from URL:
https://www.nhs.uk/conditions/vaccinations/who-should-have-flu-vaccine/

Role of unvaccinated staff in spreading flu

Source: http://www.australiandoctor.com.au/news/latest-news/unvaccinated-staff-spread-flu-in-nursing-homes?t=635958785047595488

Enabling factors and barriers to HCW
vaccination
• Enabling factors
         • Desire to protect themselves, their families, their friends and
           their patients
         • Convenience (e.g. free vaccination clinics)
• Barriers
         • Perception that influenza is not a serious illness
         • Perception of low risk of infection
         • Perception that inactivated flu vaccine causes flu
         • Perception of poor vaccine efficacy
         • Poor awareness of guideline recommendations
         • Lack of convenience (free vaccination clinics can help)
Source: Stuart MJ. Review of strategies to enhance the uptake of seasonal influenza
vaccination by Australian healthcare workers. CDI 2012; 36(3): E268–E276

The goal for RACF annual flu vaccine coverage
• “Facilities should aim for vaccination coverage of
  95% or more, in both residents and staff”

Source of text: Communicable Diseases Network Australia. Guidelines for the prevention, control and public health management of influenza
outbreaks in residential care facilities in Australia. CDNA 2017. Available from
http://www.health.gov.au/internet/main/publishing.nsf/Content/27BE697A7FBF5AB5CA257BF0001D3AC8/$File/RCF_Guidelines.pdf , source of
image: ECDC. Infographic. Why I need a flu vaccine every year? ECDC 2016. Available from: https://ecdc.europa.eu/en/seasonal-
influenza/prevention-and-control/vaccination-infographic

The 2018 flu vaccine

• The WHO-recommends that the quadrivalent flu
  vaccine used in the 2018 Southern Hemisphere
  flu season contains:
            • an A/Michigan/45/2015 (H1N1)pdm09-like virus
            • an A/Singapore/INFIMH-16-0019/2016 (H3N2)-like
              virus
            • a B/Phuket/3073/2013-like virus
            • B/Brisbane/60/2008-like virus
Source: WHO. Recommended composition of the influenza virus
vaccines used in the 2018 Southern Hemisphere flu season.
Available from URL:
http://www.who.int/influenza/vaccines/virus/recommendations/2018
_south/en/

Interim vaccine effectiveness estimates:
2017 quadrivalent flu vaccine

Age group                        Vaccine effectiveness (95% CI)

All ages                                     33% (17 to 46)

Children

Interim vaccine effectiveness estimates 2:
    2017 quadrivalent flu vaccine

Type                                             Vaccine effectiveness (95% CI)

A/Michigan/45/2015 (H1N1)pdm09 like              50% (8 to 74)
virus

A/Hong Kong/4801/2014 (H3N2) like virus 10% (-16 to 31)

B/Brisbane/60/2008 like virus                    Not estimated due to low
                                                 numbers

B/Phuket/3073/2013 like virus                    45% (22 to 62)
    Source: Sullivan SG et al. Eurosurveillance 2017; 22(43). Available from URL:
    http://eurosurveillance.org/content/10.2807/1560-7917.ES.2017.22.43.17-
    00707

Other flu vaccines for the elderly

Type of flu vaccine           TGA             Vaccine efficacy /

                              registered      effectiveness vs standard

High dose flu vaccine              Yes        24.2% (95% CI 9.7 to 36.5%)

Flu vaccine with adjuvant          Yes        60.1% (95% CI −1.3 to 84.3%)

Recombinant flu vaccine            No         30% (95% CI 10 to 47%)

   Source: DiazGranados CA, et al. N Engl J Med 2014; 371(7): 635–645,
   Domnich A et al. Vaccine 2016; 35(4): 513–520, Dunkle et el. NEJM 2017; 376:
   2427–2436

Source: Prime Minister of Australia. Available from URL: https://www.pm.gov.au/media/ground-breaking-flu-vaccines-protect-millions-aussies

Pneumococcal disease

Source of image: CDC. Pneumococcal photos. Available from URL:
https://www.cdc.gov/pneumococcal/about/photos.html

Burden of pneumococcal disease in the
elderly

• Increased risk of pneumococcal pneumonia and
  invasive pneumococcal disease
• Complications include:
       • long term cognitive and functional impairment
       • cardiovascular dysfunction

• 30-day case fatality rate of pneumococcal
  pneumonia between 2004 and 2012, Australia: 8.1%
Source: Earle K et al. Pneumonia 2016; 8:9

All cause pneumonia hospitalisations for
2001–2012 in adults 65–74y, 75-84y & ≥85y

Source: Earle K et al. Pneumonia 2016; 8:9

Pneumococcal vaccine recommended for
the elderly

• 23-valent pneumococcal polysaccharide
    (23vPPV) recommended for non-Indigenous
    adults ≥65y

    (single dose if nil increased risk of IPD)

• 23vPPV recommended for Indigenous adults
    ≥50y, with an additional dose after 5y
Source: The Australian Immunisation Handbook. 4.13 Pneumococcal disease. Available from URL:
http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook10-
home~handbook10part4~handbook10-4-13#4-13-7

Pooled results: Meta-analysis of RCTs of 23vPPV
versus placebo in people aged ≥60y

Pooled vaccine efficacy (with exclusion of biased
studies): 64% (95%CI: 35–80%)
Source: Falkenhorst G, et al. PlosOne 2017; DOI:10.1371/journal.pone.0169368

ZOSTER

 Source of image: https://www.pinterest.com.au/pin/325948091766450293/

Herpes Zoster: Intro
• Shingles usually a self-limiting vesicular rash
• Most common complication: post-herpetic neuralgia
• Decline in cell-mediated immunity with age
• Annual incidence 2002–2012: 5.6 per 1000 persons
     (15.3 per 1000 persons in 70-79 yr age group)

Source of text: http://www.ncirs.edu.au/assets/provider_resources/fact-sheets/zoster-vaccine-fact-sheet.pdf,
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4416021/, source of image: http://www.zostavax.com/shingles-photos.xhtml

Age-specific hospitalisations for Herpes Zoster

Source: MacIntyre R et al. Increasing trends of Herpes Zoster in Australia. PlosOne
2015; 10(4): e0125025

Zostavax®
• A live attenuated viral vaccine
• Same varicella zoster virus strain as Varilrix®
• 14 times the potency of Varilrix®
• Availability of Zostavax®
    
 Funded from Nov 2016
    
 Age 70y
    
 Catch up for 71–79
        until Oct 2021

Source of text: http://www.ncirs.edu.au/assets/provider_resources/fact-
sheets/zoster-vaccine-fact-sheet.pdf, source of image:
http://www.zostavax.com/pdc/zostavax/faqs.xhtml

Efficacy of Zoster vaccine

• Oxman and colleagues (NEJM 2005; 352: 2271–84)

• Randomised double-blind placebo controlled trial

• The use of Zoster vaccine in participants ≥60y:

   – Reduced burden of illness of Herpes Zoster: 61.1%

   – Reduced incidence of post-herpetic neuralgia: 66.5%

   – Reduced incidence of Herpes Zoster: 51.3%
Source: Oxman et al. NEJM 2005; 352: 2271–84

Zostavax® is contraindicated in patients
with compromised immune function

Source: TGA (2017). Zostavax vaccine safety advisory – not to be used in
patients with compromised immune function. Available from URL:
https://www.tga.gov.au/alert/zostavax-vaccine

Herpes Zoster subunit vaccine

• Not a live vaccine

• Vaccine efficacy against Herpes Zoster in ≥70y (compared
   with placebo): 89.8% (95% CI, 84.2 to 93.7%)

• Vaccine efficacy against post herpetic neuralgia: 88.8%
   (95% CI, 68.7 to 97.1%)

• Only contraindication is history of severe allergic
   reaction to any vaccine component

• Not yet TGA registered

Source: Cunningham et al. N Engl J Med 2016; 375: 1020–32

Diphtheria, tetanus, acellular pertussis
vaccine

Source of image: CDC. Photos of pertussis. Available
from URL: https://www.cdc.gov/pertussis/about/photos.html

Diphtheria, tetanus and acellular pertussis
vaccine
• Increased risk of tetanus with older age
           • Increased mortality with advanced age

           • Serological waning of immunity

           • Some older individuals may not be vaccinated

• Pertussis affects elderly people
           • Associated with increased morbidity

           • Source of infection for infants
Source: Gnanasekaran G. Clin Geriatr Med 2016; 32: 609–625, Moughty A. Emerg Med J 2013; 30:
1009–1011, source of image: https://www.cdc.gov/tetanus/about/photos.html , Ridda I. Vaccine 2012;
30(48): 6745–6752

dTPa vaccine recommendations for the elderly
• Due to the increased morbidity associated with pertussis
    in the elderly, adults aged ≥65 years should be offered a
    single dTPa booster if they have not received one in
    the previous 10 years.
• Adult household contacts and carers (e.g grandparents)
    of infants

Conclusions

• Vaccination plays an important role in reducing

  the burden of disease in the elderly.

• RACFs should aim for at least 95% flu vaccine

  coverage in both residents and staff.

Contact email: Bhakti.Vasant@health.qld.gov.au
Source of image: http://www.powerpointhintergrund.com/uploads/thank-you-background-powerpoint-22.jpeg