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Flu and Pneumo(Vaxigrip and Pneumo23)

Dennis S. Quiambao, MD

Medical and Government Affairs Manager

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Influenza

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Influenza

"An unvarying disease caused by a varying virus"

Kilbourne, 1980

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Influenza

●Worldwide: 10% of the population gets the flu

●USA: more than 200,000 people are hospitalized from flu complications; and about 36,000 people die from flu.

●Philippines:●5th leading cause of morbidity●Rate per 100,000 population: 414.6

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Different Types of Influenza Virus

●Type A ●most serious type●most common form, usually breaking out

every two or three years

●Type B

●Type C

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Why be concerned about influenza?●Absenteeism, income and learning

opportunities lost

●Presenteeism

●Cause complications, hospitalization and death among the high-risk groups

●The looming threat of a pandemic due to a novel virus

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Who should be vaccinated?

● Asthmatics

● Chronic bronchitis patients

● Diabetics

● Kidney and liver disease patients

● >50 years old

● Children 6months – 5 years old

● Immunocompromised

● Health care workers

● Anyone who wishes to be vaccinated

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Annual Flu Vaccination in Adults, Current Local Recommendations:

Recommended by:●Philippine College of Chest Physicians●Philippine Society for Microbiology and

Infectious Diseases●Philippine Foundation for Vaccination

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Contraindication

True allergy to chicken eggs

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Possible adverse events

●Soreness, redness or swelling at the injection site

●Low grade fever

●Muscle aches

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Preventing Influenza

●Each year a new vaccine is prepared which when given can prevent influenza

●WHO recommends which viral strains will be included in the vaccine

●Vaccine is about 89% effective in preventing disease, and for the 11% not covered by the vaccine, the illness caused by the virus is milder because of partial protection from the viral strains in the vaccine (cross protection)

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Southern Hemisphere Recommendation 2012

●an A/California/7/2009 (H1N1)-like virus;

●an A/Perth/16/2009 (H3N2)-like virus;

●a B/Brisbane/60/2008-like virus

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Seasonal Occurrence of Influenza

J F M A M J J A S O N D

Southern hemisphere Tropical Northern hemisphere

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Vaccine Manufacturing Time Lines

M A M J J A S O N D J FF M

WHO(Northern hemisphere)

PRODUCTION

INTERNATIONAL SURVEILLANCE NETWORK

VACCINE MANUFACTURER

MELBOURNE(Southern

hemisphere)

PRODUCTION

Choice of strains Vaccine on time

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Timing of Influenza Vaccination

• Vaccination should be given once a year preferably from February to June

• The Southern Hemisphere vaccine which is made available starting February of each year is recommended to cover the expected increase in influenza activity from June to November.

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Influenza: Frequently Asked Questions

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Can the flu shot give me the flu?

●No, the flu shot cannot cause flu illness.

●The three influenza viruses contained in the flu vaccine are each inactivated (killed), which means they cannot cause infection.

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Why do I need to get vaccinated against the flu every year?

● Vaccine against influenza viruses change from year to year, which means two things. ● First, you can get the flu more than once. The immunity that

is built up from having the flu caused by one virus strain doesn't always provide protection when a new strain is circulating.

● Second, a vaccine made against flu viruses circulating last year may not protect against the newer viruses. That is why the influenza vaccine is updated to include current viruses every year.

● Another reason to get flu vaccine every year is that after you get vaccinated your immunity declines over time and may be too low to provide protection after a year.

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Does the flu vaccine work right away?●No. It takes about two weeks after vaccination

for antibodies to develop in the body and provide protection against influenza virus infection. In the meantime, you are still at risk for getting the flu.

●That's why it's better to get vaccinated early before the flu season really gets under way.

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Pneumococcal Disease

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High Burden of Disease

●Serious pneumococcal infections are a major global health problem

●A leading cause of death and morbidity in all ages, in both developed and developing world

●WHO estimates 11 to 20 M hospitalizations from pneumonia occur each year in developing countries

●At least 1M children die every year from pneumococcal infections – primarily pneumonia and meningitis- including >800,000 children under 5 years old

Steptococcus Pneumoniae: The bacterium

● Also called « pneumococcus »

● It’s polysaccharide capsule protects the bacterium against attack from the immune system

There are at least 90 different serotypes of S. pneumoniae [1]

The 10 most common serotypes are estimated to account for about 62% of invasive diseases worldwide [2]

[1] Fedson and Musher. In: Vaccines, 4th ed., 2004

[2] PINK BOOK. 10th edition February 2007

S. Pneumoniae: Transmission and colonization● Colonization: S. Pneumoniae is common inhabitant of the respiratory tract and may be

isolated from the nasopharynx of 5% to 70% of healthy adults [1a]

● Humans may carry the bacteria without being infected but may still pass on the bacteria to others

● Transmission: Person-to-person via respiratory droplets/secretions OR Autoinoculation in asymptomatic carriers [1b]

Nasopharynx:site of colonization

TracheaInhalation

Patient with pneumococcal disease

Asymptomatic carrier

Aerosol

Nasal cavity

Dissemination

[1] PINK BOOK. 10th edition February 2007

[2] Adapted from Musher DM. Streptococcus pneumoniae 1995

S. Pneumoniae: Pathogenesis

Breachof blood-brainbarrier

Bacteraemia

Sinusitis

CSF leakage

Meningitis

Otitis media

Nasopharyngeal colonization

Pneumonia

Breachof phagocytic defenses

Breach of mucociliarydefenses

Peritonitis Arthritis arc

Adapted from [1] Salyers & Whitt. In: Bacterial Pathogenesis: A Molecular Approach. 1994

Factors predisposing to pneumococcal disease

INCREASED RISK OF SEVERE PNEUMOCOCCAL DISEASE

­ Age-related impairment of the immune system and other defense mechanisms

­ Decreased physical activity­ Chronic diseases­ Poor nutrition

● Age [1]

[1] Musher DM. In Mandell G, Bennett JE, Dolin R editors. Principles and practice of infectious disease.4th ed. New York, USA: Churchill Livingstone, Inc.; 1995. p. 1811-26

Factors predisposing to pneumococcal disease

Cardiovasculardisease

RISK OF DECOMPENSATION OF THE UNDERLYING DISEASEAND INCREASED RISK OF SEVERE PNEUMOCOCCAL

DISEASE

● Chronic illness [1a]

Pulmonary disease

Diabetes Liver cirrhosis

[1] CDC. Prevention of pneumococcal disease. Recommendations of the ACIP. MMWR 1997; 46 (N° RR-8): 1-24

Factors predisposing to pneumococcal disease

● Immunodeficiency [1]

INCREASED RISK OF SEVERE PNEUMOCOCCAL DISEASE

­ Immunosuppressive therapies­ Organ transplantation­ Cancers (e.g. lymphomas, myelomas)

­ HIV Infection­ Sickle cell anaemia­ Haematological neoplasms

[1] Musher DM. In Mandell G, Bennett JE, Dolin R editors. Principles and practice of infectious disease. 4th ed. New York, USA: Churchill Livingstone, Inc.; 1995. p. 1811-26

Factors predisposing to pneumococcal infection

●Environmental factors

Very close contact

PREDISPOSITION TO PNEUMOCOCCAL INFECTION

Nursing homes/ hospitals for

elderly persons

Prisons Shelters for homeless persons

[1] Musher DM. In Mandell G, Bennett JE, Dolin R editors. Principles and practice of infectious disease. 4th ed. New York, USA: Churchill Livingstone, Inc.; 1995. p. 1811-26

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10 Leading Causes of Morbidity2007, FHSIS Data, Philippines

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Pneumococcus: Diversity of Serotypes●There are at least 90 different serotypes of S.

pneumoniae1,2

● Each has a capsule of a different chemical composition

● Each stimulates the production of a different antibody

●Only a minority of serotypes cause most cases of human disease● 8-10 cause two-thirds of serious pneumococcal

infections in adults3

1 Fedson, Musher, in Vaccines, 19942 Henrichsen, J Clin Microbiol, 1995

3 UK DoH, Immunisation Against Infectious Disease, 1996

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Pneumococcal Vaccines: Antigen Composition● 23-valent pneumococcal vaccine contains purified capsular

polysaccharides derived from 23 S. pneumoniae serotypes1

● 1, 2, 3, 4, 5, 6B, 7F, 8, 9N, 9V, 10A,11A, 12F, 14, 15B, 17F, 18C, 19A, 19F, 20,

22F, 23F, 33F

● Serotype coverage2,3

● 85-90% of serotypes responsible for all cases of invasive pneumococcal

disease

● Vaccine includes major serotypes that have developed antimicrobial

resistance

● Cross protection within some serotypes1

● For example, antibody response to serotype 6B protects against serotype

6A, which is not in the vaccine

1 CDC, MMWR, 19892 Fedson, Musher, in Vaccines, 19943 Geslin et al., Méd Mal Infect, 1992

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Pneumococcal Disease Prevention: Vaccination Recommendations

●WHO view (Technical Advisory Group convened by WHO Regional Office for Europe, 1988)1

● Pneumococcal vaccination should be recommended for all elderly persons (aged ³60-65 years) and for persons of any age at high risk of acquiring pneumococcal infection

● National recommendations● Many countries recommend vaccination for specific at-risk

groups or conditions

● Some countries recommend vaccination for elderly persons aged:

• ³60 years: Belgium, Germany, Iceland

• ³65 years: Denmark, Finland, Norway, Sweden, USA, Canada, New Zealand

1 Fedson et al., Infection 1989

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Local associations that recommend pneumococcal vaccination

●Philippine Foundation for Vaccination (PFV)

●Philippine Society for Microbiology and Infectious Diseases (PSMID)

●Philippine College of Chest Physicians (PCCP)

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Pneumococcal Vaccination Recommendation

●Age > 60 yrs (routinely): once

●If < 60 yrs but with the following conditions:●Chronic illnesses (Cardio,COPD, Chronic

Tuberculosis*, Bronchiectasis, diabetics, cirrhosis, CSF leaks)

●Immunocompromised (lymphoma, leukemia)●Chronic renal failure, nephrotic syndrome●Transplant patients●Patients on chemo/ radio therapy●HIV/ AIDS functional or anatomic asplenia