health and wellness for all arizonans azdhs.gov influenza and influenza vaccines karen lewis, m.d....

Health and Wellness for all Arizonansazdhs.gov

INFLUENZA AND INFLUENZA VACCINES

Karen Lewis, M.D.

Medical Director

Arizona Immunization Program Office

November 18, 2011


INFLUENZA VIRUS BIOLOGY• Influenza A, B & C• Subtypes (A)

– Hemagglutinin– Neuraminadase

Antigenic drift (mutation)

Antigenic shift (reassortment)


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


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


Influenza Activity in Arizona 1997-2006


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


10/22/2011


ARIZONA

(10/15/2011)


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.


SYMPTOMS OF INFLUENZA• Rapid onset• High fever, chills• Extreme exhaustion• Muscle aches• Dry cough• Runny nose• Sore throat


COMPLICATIONS OF INFLUENZA

• Viral pneumonia• Secondary bacterial pneumonia • Encephalitis• Heart and lung disease worsening• Hospitalization• Death


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


CDCInfluenzaTesting

Algorithm

www.cdc.gov/flu/professionals/diagnosis/testing_algorithm.htm


SURGICAL MASK for DROPLET SPREAD

PATIENTPATIENTHEALTH CARE WORKERSHEALTH CARE WORKERS


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


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


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


Side Effects of Neuraminadase Inhibitors

• Oseltamivir– Nausea—10%– Vomiting—9%– Transient

neuropsychiatric events

• Zanamivir– Brochospasm

• Peramivir– Diarrhea– Nausea/vominting– Neutropenia


Current Influenza Vaccine Process


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


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


Adverse Events after Influenza Shots

www.immunize.org

• Common–Local reaction

• Uncommon–Tired–Achy–Low fever

www.immunize.org


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


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


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


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


Live Attenuated Influenza Vaccine (LAIV)

• Trivalent • Cold adapted—

Cannot grow at normal body temperature

• + stuffy nose


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


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


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


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?


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


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


ALL PREGNANT WOMEN NEED INFLUENZA VACCINE

• Any trimester• Vaccine decreases

– Maternal complications– Premature births– Infant influenza

• Infant cocooning– Family– Caretakers

MMWR Aug. 6, 2011


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


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


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


Autism Rates in Denmark after 1992 Thimerosal Removal from Vaccines

Madsen et al. Pediatrics 2003


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


Additional Influenza Resources• Advisory Committee on Immunization

Practices (ACIP)– MMWR Aug. 6, 2010 & Aug. 26, 2011

• CDC website– www.cdc.gov/influenza

• Immunization Action Coalition www.immunize.org

• World Health Organization www.who.int

health and wellness for all arizonans azdhs.gov influenza and influenza vaccines karen lewis, m.d....

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