Microsoft powerpoint - barb bancroft ho.vaccine veritysueshea2010.pptx

• Of the 30 years of added life expectancy Americans have enjoyed since 1990, only 5 years were added by advances in clinical medicine • Most of the gains in life expectancy were the result of public health interventions such as improvements in water quality, sanitation, and food safety and in the development of a broad array of vaccines (Bartecchi) To develop immunity you either suffer the important fundamental aspects of infection control and prevention • 10th century B.C. Chinese and “sowing the • Edward Jenner, the milkmaid and the cowpox (aka vaccinia) (1796)—claimed that smallpox will be eradicated within 10 years • The annual average number of disease cases in the pre-vaccine era for the 8 vaccinations recommended before 1980—1,027,958* • The annual average number of cases in the post- • The annual average number of disease cases in the pre-vaccine era for the 5 vaccines first recommended after 1980—4,351,752** • The annual average number of cases in the post- • Annual pre-vaccine deaths from all 13 • Annual post-vaccine deaths from all 13 • Annual post-vaccine deaths, excluding strep • Kids receive a plethora of vaccines prior to the age of 2 to prevent a myriad of childhood diseases… • 28 doses to be exact if they get the complete schedule of immunizations recommended by the CDC • H. flu meningitis—what are the numbers? 40-100 cases/100,000 of invasive H. flu in 1989; vaccine in 1990— • 1.4 cases/100,000 today• Strep pneumoniae meningitis—what are the numbers? 77% decline in kids; 60% decline in adults • Lumbar punctures in kids—before, during, Why suffer from the flu when you can get the • Why do you need a new flu vaccine every The flu virus…avian flu, swine flu, human flu, • Hemagglutinin (H)—helps the virus “stick” to • Neuraminidase (N)—the enzyme that “eats” • Oseltamivir (Tamiflu) and zanamivir (Relenza) Mixing the virus…usually “mixed” in • Migratory birds as the natural host for the flu Pigs as the natural host for the flu virus • How does the flu virus change it’s appearance • H1N1 (Spanish flu—1917-1918)—pandemic• H1N1—the swine flu of 2009• H5N1 (Avian flu virus)—has not yet adapted to replicate easily in humans; person-to-person transmission is rare • Only 340 documented cases • What should you do if the “bird flu” hits your • Don’t PANIC• Know the signs and symptoms • Signs of symptoms of the flu—usually respiratory with a high • Generalized inflammation—achy bones, skin, teeth, hair—you • “I don’t know if I have ever had the flu or not…” • In older patients with underlying heart disease, the flu vaccine reduces the risk of a myocardial infarction by 66% and a stroke by 20% (by reducing inflammation) • the flu in the elderly…50% efficacy ≥60; 23% in ≥70 • H1N1, the “swine flu”—outbreak in Southern California and San Antonio, Texas (week of April 22, 2009); first case of last year’s outbreak was in a 6-year-old child in Mexico • Gardasil is a quadrivalent vaccine-- HPV 16, 18 responsible for over 70% of all cases of cervical cancer and genital warts caused by HPV-6 and11 • Approved for boys and girls—9 to 26 • Cervarix is a bivalent vaccine—HPV 16 and 18 Cervical cancer is the number 2 cause of death in women worldwide (273,000 women died worldwide, 6500 in U.S. in 2002)there are over 100 types of HPV, 30 of which invade mucous membranesroughly three quarters of U.S. adults have had at least one HPV infectionIs it 100% effective? HPV naïve, yes; already + HPV with above types? Not effective…Why should I have my daughter get the HPV vaccine? She tells me… So, you think oral sex is “less risky” than usual method? People who perform oral sex on more than five partners in their lifetime have a 250percent higher risk of developing throat cancer. Pharyngeal infections with HPV increase the risk of throat cancer by 32-fold. (N Engl J Med, May 6, 2007) The good news? Cancer of the throat caused by HPV responds to treatment better than throat cancer related to smoking, alcohol, or other causes.
• Increased rise in oropharyngeal squamous cell cancer—specifically the lingual base and palatine tonsils in white men 40 to 55 years of age with no history of ETOH and/or tobacco use; 60% of oropharyngeal cancers in the US are HPV; greater than 90% are HPV-16; (15 types of HPV have oncogenic potential) • HPV prevalence in cervical rather than penile tissue might boost the chances of HPV infection when performing oral sex on females, contributing to the higher rate of HPV-associated oropharyngeal cancer in men • Does the HPV vaccine prevent oropharyngeal • Dunno yet…but HPV-16 is part of the vaccine • Don’t believe everything you read on the Internet… • Madsen KM Et al. A population-based study of measles, mumps, and rubella vaccination and autism. N Engl J Med 2002 Nov 7;347:1477-82.
The incidence of autism has increased since the • Schechter R and Grether JK. Continuing increases in autism reported to California’s developmental services system: Mercury in retrograde. Arch Gen Psych 2008 Jan; 65:19 • The US Government will NOT give cash to the 5000 families who believe that thimerosol causes autism. There is absolutely NO PROOF for that or for the MMR as a cause of autism • Now the campaigners against vaccines have started blaming the sheer numbers of vaccines • Why do we need boosters? Booster shots boost the • Pneumococcal vaccine, tetanus boosters • If vaccine is presented to the B cell it is a shorter- • Bacterial antigens are presented to the B cell system—think pneumoccocal and meningococcal vaccines • Vaccines presented to T cells tends to be longer- • The pneumococcal vaccine is given at 50 to 65 and • Meningococcal vaccine and college students—the old meningococcal vaccine (Menommune) was good for only 3-5 years (B cell presentation only) • The newer conjugated meningococcal vaccines (Menactra, Menveo) last 8-10 years—(B and T cell presentation) • There are five main disease-producing serotypes of N. meningitides (A, B, C, Y, W-135). Two main “meningitis spikes” occur—in the first year of life (primary serotype B) and in the young adult years (serotypes C and Y often predominate in college outbreaks). Menactra (the newer vaccine), and the older meningococcal vaccine, Menomune, offer protection against all types except serotype B. WHY not B? • B serotype has similar properties to peripheral nervous system myelin—increased risk of GBS • As of February 25, 2008, more than 15 million doses of Menactra have been distributed, and the Vaccine Adverse Event Reporting System (VAERS) has received 26 confirmed case reports of GBS within 6 weeks of receipt of MCV4 Menactra meningococcal vaccination. Causal relationship only.
• However, if hx of GBS, do not give Menactra— • If presented to the T cell (cell-mediated immunity), the vaccine will last much longer • Usually viral antigens or “conjugated” • Only 1 in 4 Americans aged 50 to 64 regularly take advantage of preventive services such as screening and immunizations.
• Td (tetanus toxoid, reduced diphtheria toxoid) – every 10 • Why every 10 years? The diphtheria portion wears off in 11 years; the tetanus doesn’t wear off for 19 years…but, since they are given together is better to err on the safe side and give it every 10 • What are the two most common causes for tetanus (lockjaw) • Severe burns, tooth infections, animal bites, + the proverbial • Tdap (Td + and acellular pertussis)Boostrix (ages 10-18) and Adacel (ages 11 to 64)— one time booster • Pertussis “whooping cough” (Bordetella pertussis)— introduced in the 1940s; average of 175,000 cases per year; 1980-1990 an average of 2,900 cases per • On the rise—9,771 cases in 2002; over a million immunity waning (wears off after 5-10 years); kids not getting vaccinated because of the “fear” of autism, parental denial of continuing risks of • Highest risk in infants who have not yet been • Flu vaccine every year in the Fall--this year’s flu vaccine has already been formulated and will contain the antigens to protect against the swine flu… • Pneumococcal vaccine at age 65; chronic illness necessitates the vaccine at an earlier age—asthma, COPD, functional or anatomic asplenia, CKD, DM; vaccine before 65? Need a 2nd one after 5 years • Influenza and pneumonia represent the fifth • 20,000 to 40,000 deaths per year from the seasonal flu; over 90% occur among those 65 and older • Flu vaccine reduces hospitalizations by 27 to • 40,000 deaths from strep pneumonia; 50% • Hepatitis B (x3)(if you haven’t had it as a child)• 1,000,000 Americans with chronic Hep B• 200,000 new cases per year• 4,000-5,000 die each year• Hepatitis B vaccine series (Engerix-B, preservative • In the arm or leg, not the buttocks• Immunity is waning in adolescents—do we need boosters? 95% of 6-year-olds have immunity but only 60% of 14-year-olds (newest CDC recommendations didn’t address this issue) • Traveling to certain foreign countries? Hepatitis A vaccine and other vaccines for specific countries (check the CDC recommendations) at least 6 months before you travel • Traveler’s returning with fever of unknown origin—3% due to vaccine preventable diseases • Zostavax after age 60 to prevent shingles (14x stronger than Varivax—the kids version) • With aging population, the absolute # of herpes zoster cases is increasing dramatically; Why? • Because cell-mediated immunity; killer T cells are responsible for CMI (keeping the herpes virus latent)and the function of killer T cells decreases with age • Lifetime incidence is 10-20% with greater than FYI: Percent of individuals with shingles, by • 10—0.5%• 20—1.3%• 30—2.7%• 40—4.8%• 50—7.5%• 60—11.9%• 70—19.7%• 80—31.8%• 90—46.1%• Donahue JG, et al. Archives of Internal Medicine, • Increased risk with monoclonal antibodies to tumor necrosis factor – alpha—infliximab (Remicade), adalimumab (Humira), certolizumab (Cimzia)—multi-dermatomal; severe in more than 20%; ophthalmic involvement is common • SUGGESTION: patients receive Zostavax at least 3 weeks before beginning treatment with anti-TNFα therapy or after treatment has been discontinued for at least 5 half-lives (Strangfeld) • Hematologic malignancy—rate of HZ is 5-25% • HIV/AIDS increases risk by 12-17 fold (T cell • Depression and significant stress within past 6 • Ophthalmic complications 10-25% (keratitis, iritis, retinitis, optic neuritis with vision loss and blindness) • AIRBONE precautions for disseminated herpes zoster • Acyclovir (Zovirax)—800 mg/day po 5x/day x 7-10 days; significant reduction in severity, duration and • Famciclovir (Famvir)—500 mg po 3x/day x 7 days—as effective as Zovirax in reducing acute pain and • Valacyclovir HCl (Valtrex)—1000 mg/po 3x/d x 7 days provides an improved benefit over acyclovir in reducing the severity and duration of PHN in patients • Start treatment within 48 to 72 hours of rash onset; • 500,000 to 1 million episodes per year • PHN – vaccine reduces incidence of HZ by 51% and decreases incidence of PHN by 66%; decreases morbidity by 61% • Patients older than 50 have a 14.7-fold higher incidence of chronic pain 30 days after the onset of rash than patients under age 50 • PHN in 70% of untreated elderly HZ patients • Pain persisting for greater than 3 months • 59% of PHN patients were prevented from pursing usual ADLs for as long as 16 years; average 1.4 years • Mean hospitalization rate is 9.3/100,000 for patients • Treatment? Nortriptyline/gabapentin (Neurontin) • Vaccines to prevent amyloid plaque formation in the brain (in clinical trials)—prevention of Alzheimer’s disease • Vaccines to prevent UTIs, STDs (Chlamydia), • Bartecchi CE and Schrier RW. Living Healthier and Longer: What Works, What Doesn’t. MFTP Publications, 2008.
• Koutsky LA et al. A controlled trial of human papillomavirus type 16 vaccine. N Engl J Med 2002 Nov 21;347:1703-5.
• Carleson LH. Immunization Update. The Nurse Practitioner • D’Souza G et al. Case-control study of human papillomavirus and oropharyngeal cancer. N Engl J Med 2007 May 10; 356:1944-56 • Jamieson DJ et al. H1N1 2009 influenza virus infection during pregnancy in the USA. Lancet 2009 Aug 8; 374-451.
• Marur S et al. HPV-associated head and neck cancer: a virus-related cancer epidemic. The Lancet Oncology 2010 (August);11(8) • Roush SW et al. Historical comparisons of morbidity and mortality for vaccine-preventable diseases in the United States. JAMA 2007 Nov 14; 298:2155.

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