Upload
others
View
10
Download
0
Embed Size (px)
Citation preview
INFLUENZA VACCINE 2015-2016
Mark H. Sawyer MD
UCSD School of Medicine/Rady Children’s Hospital San Diego
San Diego Immunization Partnership
DISCLOSURES
I have no financial disclosures to make related to this
presentation
My family and I are fully immunized
I already received my influenza vaccine this year
OBJECTIVES
Explain how influenza strains get their names and why you care
Explain the differences between available influenza vaccines so that you can choose the best vaccine for your patients
Describe how we measure influenza vaccine effectiveness so that you can convince your patients that it is not a terrible vaccine
Provide a summary of the effectiveness of the 2014-2015 influenza vaccines so that you will be prepared to compare it to this year's vaccine
Describe what is different about the use of influenza vaccine in children so that you Immunize them correctly
Tell your colleagues how we are doing immunizing our community with influenza vaccine so that they will try harder to get all their patients immunized
INFLUENZA ON EARTH-WHY DUCKS MATTER
Influenza Viral Nomenclature
1. CDC. Atkinson W, et al. Chapter 13: Influenza. In: Epidemiology and Prevention of Vaccine-Preventable Diseases, 4th ed. Department of Health and Human Services, Public Health Service, 1998, 220
A / Sydney / 184 / 93 (H3N2)
Type of Nuclear Material
Virus type
Geographic origin
Strain number
Year of isolation
Hemagglutinin
Virus subtype
Neuraminidase
2015-2016 INFLUENZA VACCINE STRAINS?
THIS?
A/California/7/2009 (H1N1)
A/Texas/50/2012 (H3N2)
B/Massachusetts/2/2012-like (Yamagata)
B/Brisbane/60/2008-like (Victoria)
OR THIS?
A/California/7/2009 (H1N1)
A/Switzerland/9715293/2013
(H3N2)
B/Phuket/3073/2013 (Yamagata)
B/Brisbane/60/2008 (Victoria)
2014-2015 INFLUENZA VACCINES
INFLUENZA VACCINES HOW DO YOU KEEP THEM STRAIGHT?
Is it trivalent or quadrivalent?
Is it injectable or nasal?
Is it made in eggs or in cell culture?
Is it a special product?
What are its age restrictions?
Who makes it/brand name?
IS IT TRIVALENT OR QUADRIVALENT?
Currently there are 4 quadrivalent IIV vaccines expected for
2015-2016.
There are 3 trivalent IIV vaccines that are standard dose and are
not special products or cell culture based
Fluzone (Sanofi) comes in both quadrivalent and trivalent
formulations
LAIV only available as quadrivalent
IS IT INJECTABLE OR NASAL?
IIV-injectable influenza vaccine
o Includes both trivalent (IIV3) and quadrivalent (IIV4) vaccines
o Includes cell culture vaccines
o Includes high dose and intradermal
LAIV-live attenuated influenza vaccine
o Only quadrivalent (LAIV4)
o Only one manufacturer
IS IT MADE IN EGGS?
All are except FluBlok/Protein Sciences Corp and
Flucelvax/Novartis
Flublok is a recombinant vaccine (like Hep B vaccine) and may
be referred to as RIV
Flucelvax is a whole virus vaccine but made in cells and may be
referred to as ccIIV
IS IT A SPECIAL PRODUCT?
IIV High dose-Fluzone High Dose/Sanofi
o Recommended for those 65 years of age and over
o More antigen
o More local side effects
o Slightly better effectiveness in seniors
IIV Intradermal-Fluzone Intradermal/Sanofi
o Licensed for 18-64 years of age
HIGH DOSE INFLUENZA VACCINE
• One industry sponsored randomized trial
• Outcome=laboratory confirmed influenza
• High dose vaccine did decrease study-defined ILI
• No difference in hospitalization rate, pneumonia rate, or exacerbation of cardiopulmonary disease
• ACIP recommendations state no product preference
Diazgranados, N Engl J Med 2014; 371:635
WHAT ARE THE AGE RESTRICTIONS?
Vaccine >6 mon
>3 yrs
>4 yrs
>5 yrs
>18 yrs
2-49 yrs
18-49 yrs
18-64 yrs
>65 yrs
Fluzone/Sanofi X
Fluarix/GSK X Fluvirin/Novartis X
Afluria/CSL X Agriflu/Novartis X
Flucelvax/Novartis X
FluLaval/ID Biomed X
FluMist/MedImmune
X
FluBlok/Protein Sciences
X
Fluzone-Intradermal X
Fluzone-High dose X
CDPH VACCINE TABLE
EZIZ.ORG
CDPH VACCINE TABLE
EZIZ.ORG
CDPH VACCINE TABLE
EZIZ.ORG
INFLUENZA 2014-2015:IT WASN’T A VERY GOOD YEAR
http://www.cdc.gov/flu/weekly/
http://www.cdc.gov/flu/weekly/
http://www.cdc.gov/vaccines/acip/meetings/downloads/slides-2015-06/flu-02-flannery.pdf
CDC.GOV/Vaccines
INFLUENZA VACCINE DIDN’T WORK VERY WELL IN 2014-2015
INFLUENZA VACCINE EFFECTIVENESS DEPENDS ON:
How you decide if someone has influenza
What population you study-most vaccines work less well in the very young
and very old
What you mean by effective:
Prevents death
Prevents hospitalization
Prevents a visit to the doctor or emergency rom
Prevents any symptoms
WHAT IS EFFECTIVENESS?
The same vaccine could be:
100% effective at preventing death
80% effective at preventing hospitalization
60% effective at preventing you from having symptoms and a
positive test for influenza
40% effective at preventing an illness that looks like influenza
20% effective at preventing transmission
IN 2014-2015 INFLUENZA VACCINE WORKED BETTER FOR INFLUENZA B TYPES
Flannery-ACIP presentation February 2015
Flannery-ACIP presentation February 2015
LAIV DIDN’T WORK LAST YEAR!
HOW WELL DOES INFLUENZA VACCINE WORK?
Overall effectiveness
50-70% in healthy adults
< 65 years of age
60% ISN’T VERY GOOD !?!
60% protection from a potentially deadly infection is much better than 0!
EFFECTIVENESS OF THE INTRANASAL INFLUENZA VACCINE FOR CHILDREN
LIVE ATTENUATED INFLUENZA VACCINE (LAIV): CDC 2014-2015 RECOMMENDATION
Preferential use of LAIV over IIV for children 8 years and younger based on older studies that showed better effectiveness
No change in recommendation for older children and adults
Emphasis on not missing opportunities if a provider doesn’t have LAIV
So give what you have but if you have both give LAIV
But wait!!! At the end of the 2013-2014 season…..
MMWR August 15, 2014 / 63(32);691-697
LAIV VACCINE EFFECTIVENESS 2013-2014
29 http://www.cdc.gov/vaccines/acip/meetings/downloads/slides-2014-10/flu-03-flannery.pdf
Data showing LAIV ineffective in young children-June 2014
Previous data showed the opposite
Recommendation for 2014-2015 had to be made in June 2014
IT’S TOUGH TO MAKE PREDICTIONS, ESPECIALLY ABOUT THE FUTURE.
Yogi Berra
LAIV NOT VERY EFFECTIVE IN 2014-2015 EITHER
Flannery-ACIP presentation February 2015
RECOMMENDATIONS FOR 2015-2016
If you’ve seen one influenza season, you’ve seen one influenza season
Continued recommendation for routine immunization of all children
No preference for either IIV or LAIV for this coming flu season
2-doses required for vaccine-naïve children under 9 years of age
Stay tuned for more information on LAIV effectiveness
BASIC INFLUENZA VACCINATION RULES FOR CHILDREN <9 YEARS OF AGE
Need to have had 2 doses of influenza
vaccine to prime the immune system
Now that pandemic H1N1 strain has
been in the vaccine since 2010 we no
longer need to specifically ask about it
Effectiveness of 1 dose is <20%
Everyone 6 months of age and
older!
WHO SHOULD GET A FLU VACCINE?
Table 3. Flu Vaccination Coverage* by Age Group, Adults 18 years and older, United States,† 2014–15 Season Age Group Unweighted
Sample Size %‡ ± 95% CI§ Difference from
the 2013-14 Season ± 95%
CI
≥18 years 323,215 43.6 ± 0.4 1.4 ± 0.6|| 18−64 years 208,124 38.0 ± 0.6 1.3 ± 0.8|| 18−64 years at high risk¶
53,795 47.6 ± 1.2 1.3 ± 1.6
18−64 years not at high risk
152,107 35.3 ± 0.6 1.4 ± 0.8||
18−49 years 105,619 33.5 ± 0.8 1.2 ± 1.0|| 18−49 years at high risk
18,269 39.3 ± 1.8 0.6 ± 2.5
18−49 years not at high risk
86,101 32.6 ± 0.8 1.5 ± 1.1||
50−64 years 102,505 47.0 ± 0.8 1.7 ± 1.0|| ≥65 years 115,091 66.7 ± 0.8 1.7 ± 1.0||
Table 2. Flu Vaccination Coverage* by Age Group, Children 6 months–17 years, United States,† 2014–15 Season
Age Group Unweighted Sample Size
%‡ ± 95% CI§ Difference from the 2013-14
Season ± 95% CI
6 months−17 years 128,143 59.3 ± 0.8 0.4 ± 1.1
6 months−4 years
37,626 70.4 ± 1.3 0.0 ± 1.8
6−23 months 14,126 74.6 ± 1.9 0.3 ± 2.8
2−4 years 23,500 67.8 ± 1.7 -0.3 ± 2.5 5−17 years 90,517 55.8 ± 0.9 0.5 ± 1.3 5−12 years 59,075 61.8 ± 1.1 0.8 ± 1.6
13−17 years 31,442 46.6 ± 1.4 0.2 ± 2.1
WHO GOT THEIR INFLUENZA VACCINE LAST YEAR?
http://www.cdc.gov/flu/fluvaxview/coverage-1415estimates.htm
IMMUNIZATION OF YOUNGER ADULTS PROTECTS SENIORS
Taksler, Clin Infect Dis 2015
HEALTHCARE PERSONNEL INFLUENZA VACCINATION 2010-2015
MMWR 2015; 64:1000-1005
WHY HCWS DO OR DO NOT GET INFLUENZA VACCINE
MMWR 2011; 60:1073-1077
INFLUENZA VACCINE DURING PREGNANCY
CHANGES IN PREGNANCY THAT INCREASE RISK OF INFECTION
Gestation Risk of Hospitalization
1st trimester 7.6/10,000 2nd trimester 15.8/10,000 3rd trimester 26.2/10,000
Modulation of immune
response
Expansion of vascular volume
Decreased lung capacity
Increased oxygen
consumption
Neuzil et al Am J Epidemiol. 1998; 148:1094-1102
IMMUNIZATION OF PREGNANT WOMEN PROTECTS THEIR BABIES
316 mother-infant pairs in Bangladesh in 2004-2005
Mothers immmunized randomly with influenza vaccine or pneumococcal vaccine
63% vaccine effectiveness in
preventing lab-confirmed
influenza in babies
36% reduction in febrile respiratory
illness in mothers Zaman, N Engl J Med 2008; 359
INFLUENZA COVERAGE RATES DURING PREGNANCY
MMWR 2015; 64:1000-1005
I CAN’T GET A FLU SHOT BECAUSE I’M ALLERGIC
TO EGGS….
WRONG!
INFLUENZA VACCINE IN EGG ALLERGIC INDIVIDUALS
CDC.GOV/FLU
SUMMARY
Influenza vaccine and circulating strains of influenza virus change over time
There are multiple influenza vaccines on the marker, some for special characteristics and
intended for specific populations
Influenza vaccine did not work well in 2014-2015
Partial protection from influenza is better than no protection
We can do better at immunizing our community
Pregnant women and healthcare personnel especially need influenza vaccine
WHERE TO GO FOR MORE INFORMATION
San Diego HHSA Immunization Branch (SDIZ.org)
California Department of Public Health (www.cdph.ca.gov)
CDC (cdc.gov/vaccines)
EXTRA SLIDES
WHAT YOU HEAR ABOUT INFLUENZA VACCINE
Influenza vaccine doesn’t work
Influenza vaccine makes me sick
Influenza isn’t that big a deal
Influenza vaccine shouldn’t be
given to pregnant women
LAIV (nasal flu vaccine) can’t be used in healthcare workers because they
might spread the virus
COMMON REACTIONS TO INFLUENZA VACCINE
Usually only seen the first time you are immunized
Begin 6-12 hours after immunization
Mostly local pain and swelling
Do not last more than 2 days
Do not include cough CDC NIP Web site http://www.cdc.gov/flu/professionals
COMMON SYMPTOMS AFTER AN LAIV
Children
Runny nose (48% vs 44% in placebo)
Headache (18% vs 12%)
Vomiting (5% vs 3%)
Myalgia (6% vs 4%)
4 fold increase in wheezing in one study.
Not seen in other studies
Adults
Runny nose (45% vs 27%)
Sore throat (28% vs 17%)
Chills (9% vs 6%)
Tiredness (26% vs 22%)
MMWR 2008 Jul 17; Early Release:1-60.
VACCINE WHO SHOULD NOT RECEIVE IT? Those under 2 and over 50 years of age
Those with underlying health conditions
o Heart and lung disease
o Diabetes
o Asthma
o Immunosuppression
2-4 year old children with wheezing
Pregnant women
USE OF LAIV AMONG CLOSE CONTACTS OF HIGH RISK PERSONS
Inactivated influenza vaccine is preferred for close contacts of severely
immunosuppressed persons who require care in a protective environment
Persons who receive LAIV should refrain from contact with severely
immunosuppressed persons for 7 days after vaccination
Persons who receive LAIV do not need to be excluded from visitation of
patients who are not severely immunosuppressed
MMWR 2007;56 (RR-6)
FOLLOW YOUR HEALTHCARE WORKER’S EXAMPLE