Immunization For Elderly

Ashok Grover
PHYSICIAN

Pushpanjali Crosslay Hospital

Pushpanjali Medical Centre
Shri Mahavir Clinic – Madhuban
Max Balaji Hospital
Is it a new concept? ……. or an old concept revisited?
Chronology of Vaccines’ Discovery

It all started with adult range of vaccines!!!

The need to revisit the concept

• There is no structured data on the burden of vaccine

preventable 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 ≥15–20 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
GIVS Global Immunization vision & strategy 2006-2015.
WHO-UNICEF

Available at: http://www.who.int/vaccines-documents/DocsPDF05/GIVS_Final_EN.pdf

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 existing
postgraduate curriculum
The Range of Vaccines for Adolescents and Adults

Currently Available Licensed abroad, NA in India

• Tetanus Toxoid
1. Reduced diphtheria antigen (d)
• Hepatitis B Vaccine
containing dT, dTaP
• Influenza Vaccine
2. Zoster Vaccine
• Rabies Vaccine
• MMR 3. HPV Vaccine

• Hepatitis A Vaccine 4. Conjugate Meningococcal Vaccine

• Typhoid Vaccine
• Chicken Pox Vaccine In Late stage Development
• Polysaccharide Pneumococcal Vaccine
1. Dengue Vaccine
• Polysaccharide Meningococcal Vaccine
2. Malaria Vaccine
• Yellow Fever Vaccine
3. Kala-Azar Vaccine
• Japanese Encephalitis Vaccine
The Suggested Approach –
Assess Need, the H.A.L.O. Style

• H - Health Condition
• A - Age
• L - Lifestyle
• O - Occupation
An Example of H.A.L.O. checklist followed in US
 What an Indian H.A.L.O. could look like?

Health Factors Age Lifestyle Occupation

Chronic disease Immunodeficiency Pregnancy Adolescent & Elderly International Hostellers Resident of Food handler Animal handler Laboratory Military
young adults traveler Endemic zone worker personnel
Influenza 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
 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

 Influenza
• The virus and the disease
• The available vaccine
• Vaccination in adult population
 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)
Neuraminidase
• Type B (NA)
• Antigenic drift uncommon; antigenic shift not seen
• Mild-moderate disease as small outbreaks only
Hemagglutinin
• Humans only
(HA)
• Type C
• Very uncommonly implicated in clinical disease
Patho-physiology

Binding and destruction of epithelial cells from

nasopharynx to alveoli
Droplets

LOCAL INFLAMMATORY REACTION Body

Upper respiratory infection response

SYSTEMIC BODY REACTION

Fever, muscle pain, etc.

Healthy Ciliated Respiratory Damaged Respiratory

Epithelium Epithelium

Aymard M. Vaccine 1995: 47–70.

Marked Systemic Symptoms Differentiate Traditional
Flu from Cold

Influenza afflicts 5%-10% of adult population annually and

accounts for deaths rate of 30-150/100 000 population aged >65
years
JAMA 2000; 284 (13): 1740
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: 26–37.

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:

Chronic pulmonary Chronic renal

(including asthma) dysfunction

Chronic metabolic disease Cardiovascular

(including diabetes mellitus) disorders

Haemoglobinopathies,
immunosuppression

Eur J Clin Res 1992; 3: 117–38.

Age distribution of respiratory complications

80
complications (%)

60
Respiratory

40

20

0
0–4 5–9 10–19 20–39 40–49 50–59 50–69 > 70

Age groups (year)

Betts FR et al. In: Mandell GL et al., eds. Principles and Practice of Infectious Diseases. 3rd Edn. New
York: Churchill Livingstone; 1990: 1306–25.
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
Influenza Vaccination is required
annually

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.

Benefits of influenza vaccination

Flu Shot

Reduction in risk of Reduction in risk of Reduction in financial

illness, hospitalization infecting high risk and social cost of
and death contacts illness
Efficacy of influenza vaccination in elderly and
high-risk persons

• Prevention of illness and death

– Among high-risk adults aged 18–64 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: 274–80

Efficacy of influenza vaccination in elderly

• 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: 518–27.

Cost-Effectiveness of influenza vaccination

Years of life bought for

US$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: 162–9.

Recommendations of the ACIP (Advisory
Committee on Immunization Practices)

Primary target groups recommended for annual vaccination

– Persons at increased risk for influenza-related

complications
– Persons aged 50–64 years
• This group has an elevated prevalence of certain
chronic medical conditions
– Persons who live with/care for persons at high risk

Harper SA et al. MMWR Recomm Rep 2004; 53: 1–40.

Recommendations of the ACIP (Advisory
Committee on Immunization Practices)

Persons at increased risk for complications from influenza:

– Persons aged > 65 years
– Residents of nursing homes or other chronic-care facilities that
house persons of any age with chronic medical conditions
– Adults and children with chronic disorders of the pulmonary or
cardiovascular systems, including asthma
– Adults and children who have required regular medical follow-up or
hospitalisation in the preceding year due to chronic metabolic
diseases
– Children and adolescents (6 months–18 years) receiving long-term
aspirin therapy
– Women who will be pregnant during the influenza season
– Children aged 6–23 months

Harper SA et al. MMWR Recomm Rep 2004; 53: 1–40.

Recommendations of the ACIP (Advisory
Committee on Immunization Practices)

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 0–23 months

Harper SA et al. MMWR Recomm Rep 2004; 53: 1–40.

Country-wise recommendations for annual
influenza vaccination

Aged Contacts People Younger Children

Age > 65 Age 50– care of with healthy 6–24
years 65 years resi- persons chronic persons months
dents at risk illnesses
USA Yes Yes Yes Yes Yes No Yes
WHO Yes No Yes Yes Yes No No
Australia Yes No Yes Yes Yes No No
Hong 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 Yes Yes Yes No Yes No Yes
Korea
Singapore Yes No Yes Yes Yes No Yes
Taiwan Yes No Yes Yes Yes No Yes
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

Influenza immunization rates in 2003

Influenza vaccination coverage rates per 1000 in general population

In India, the coverage is around 0.1 per 1000

 Pneumococcal Infections
• The bacterium and the disease
• The available vaccine
• Vaccination in adult population
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.
Pathogenesis of Pneumococcal Disease

Non-invasive
Contiguous
Dissemination
• Sinusitis
• Otitis media
• Pneumonia

Invasive
• Bacteraemia
Hematogenous
dissemination
• Meningitis
• Endocarditis
• Peritonitis
• Septic arthritis
Burden of disease

• Annual incidence of Invasive Pneumococcal Disease in developed

countries is ≥15–20 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
Incidence and Case Fatality Ratio by Age Group
Invasive Pneumococcal Disease

Case fatality ratio Incidence

180 30

Case fatality ratio (%)

(cases/100,000 pop)

160
25
140
Incidence

120 20
100
15
80
60 10
40
5
20
0 0

Age group, years

Incidence of invasive pneumococcal disease in adults
with selected underlying conditions & healthy adults -
United States, 2000
>40 times
increase in risk
500 432
Cases per 100,000 persons

400 341
294
>4 times
300 increase in risk

200
92
100 43 48 59
11
0
Healthy Chronic Diabetes Chronic Heavy Solid HIV/AIDS Blood
heart lung drinker cancer cancer
High risk population for Pneumococcal 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
 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)
23 Valent Polysaccharide Pneumococcal Vaccine

Indications
Country-wise recommendations for
Pneumococcal vaccination (1997)
Immunocompromised Cardiopulmonary Nursing Age >
Country Asplenia Haematological HIV diabetes, renal Other home 65 years
Austria  - -   - -
Belgium       
Denmark     - - 
Finland      - 
France   -   - -
Germany   -  - - -
Iceland   -    
Ireland      - -
Italy  -  - - - -
Luxembourg       
Netherlands  - - - - - -
Norway      - 
Sweden      - 
Switzerland      - -
UK      - -
USA
Pneumococcal immunization rates in 1996

USA
Canada
Belgium
UK
Sweden
Norway
Finland
Iceland
Austria
France
Switzerland
Denmark
Others *

0 40 80 120 160 200 240 280

Doses of Pneumococcal vaccine distributed per 10,000 population
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
Time to think of
adult
vaccination!!!