Download Confronting the Challenge of Respiratory Tract Infections

Vaccines in
Pulmonary Medicine
Julio A. Ramirez, MD, FACP
Professor of Medicine
Chief, Infectious Diseases University of Louisville
Chief, Infectious Diseases Veterans Affairs Medical Center
Louisville, Kentucky, USA
Vaccines in Pulmonary Medicine
1 Introduction to Vaccines
2 Vaccine Immunology
3 Current Adult Vaccines
Introduction to Vaccines
Viral & Bacterial Pathogens
1. Influenza Virus
1. C. tetani
2. Varicella-Zoster Virus
2. C. diphtheriae
3. Human Papillomavirus
3. B. pertussis
4. Measles Virus
4. N. meningitidis
5. Mumps Virus
5. H. influenzae
6. Rubella Virus
6. S. pneumoniae
7. Hepatitis A Virus
7. M. tuberculosis
8. Hepatitis B Virus
8. S. typhi
Introduction to Vaccines
Viral & Bacterial Pathogens
1. Influenza Virus
1. C. tetani
2. Varicella-Zoster Virus
2. C. diphtheriae
3. Human Papillomavirus
3. B. pertussis
4. Measles Virus
4. N. meningitidis
5. Mumps Virus
5. H. influenzae
6. Rubella Virus
6. S. pneumoniae
7. Hepatitis A Virus
7. M. tuberculosis
8. Hepatitis B Virus
8. S. typhi
Variola Virus: Smallpox
1796
Introduction to Vaccines
Viral & Bacterial Pathogens
1. Influenza Virus
1. C. tetani
2. Varicella-Zoster Virus
2. C. diphtheriae
3. Human Papillomavirus
3. B. pertussis
4. Measles Virus
4. N. meningitidis
5. Mumps Virus
5. H. influenzae
6. Rubella Virus
6. S. pneumoniae
7. Hepatitis A Virus
7. M. tuberculosis
8. Hepatitis B Virus
8. S. typhi
Variola Virus: Smallpox
1796
Introduction to Vaccines
Smallpox (Variola Virus)
Human Disease
Variola Virus
Inhalation
Smallpox
Mortality
30 to 40%
Introduction to Vaccines
Smallpox (Variola Virus)
Human Disease
Variola Virus
Inhalation
Smallpox
Mortality
30 to 40%
1980
Introduction to Vaccines
Smallpox
Human Disease
Human Disease
Variola Virus
Variola Virus
Inhalation
Inoculation
Smallpox
Smallpox
Mortality
30 to 40%
Mortality
1 to 2%
Introduction to Vaccines
Smallpox: E. Jenner 1796
Human Disease
Cow Disease
Variola Virus
Cowpox Virus
Inhalation
Smallpox
Mortality
30 to 40%
Human Cowpox
Introduction to Vaccines
Smallpox: E. Jenner 1796
Human Disease
Human Disease
Cow Disease
Variola Virus
Variola Virus
Cowpox Virus
Inhalation
Inhalation
Human Cowpox
Smallpox
Mortality
30 to 40%
Vaccination
No Smallpox
Introduction to Vaccines
Smallpox: E. Jenner 1796
Human Disease
Human Disease
Cow Disease
Variola Virus
Variola Virus
Cowpox Virus
Inhalation
Inhalation
Human Cowpox
Cow
Disease
Smallpox
Latin
for Cow: Vacca
CowpoxVaccine
Virus
Vaccination
English:
Mortality
30Spanish:
to 40% Vacuna No Smallpox
Introduction to Vaccines
Smallpox: E. Jenner 1796
Inoculation
Vaccination
Introduction to Vaccines
Tuberculosis
Human Disease
M tuberculosis
Inhalation
No TB
Introduction to Vaccines
Tuberculosis
Human Disease
M tuberculosis
Inhalation
Cow Disease
M bovis
No TB
Introduction to Vaccines
Tuberculosis
Human Disease
M tuberculosis
Inhalation
Cow Disease
M bovis
Vaccination
More TB
Introduction to Vaccines
Tuberculosis
Human
with ID
Isolation
Pathogen
Inactivation
Human
without
ID
Vaccination
Introduction to Vaccines
Tuberculosis
Human
with ID
Isolation
M. bovis
Pathogen
Inactivation
Bacillus
Calmette
Guerin
Human
without
ID
Vaccination
BCG Vaccine
Since 1921
3 billion
Introduction to Vaccines
TB Vaccine Efficacy: Outcome Variable
“Outcome”
“Efficacy”
Latent Infection
20% Protection
Active Disease
“Pulmonary TB”
50% Protection
Active Disease
“TB Meningitis”
75% Protection
Active Disease
“Death due to TB”
85% Protection
Introduction to Vaccines
TB Vaccine
Protection for 10 to 15 years
Partial Protection 50 to 60 years
Prior exposure to mycobacteria may limit BCG
replication (efficacy)
No booster effect
Childhood BCG is not a major cause of PPD (+) in
adulthood
Vaccines in Pulmonary Medicine
1 Introduction to Vaccines
2 Vaccine Immunology
3 Current Adult Vaccines
Vaccine Immunology
Vaccine Development
Human
with ID
Pathogen
Isolation
Live
attenuated
Inactivation
Killed
Pathogen
Toxoid
Human
without
ID
Protein
Vaccination
PS-Protein
PS
PathogenAssociated
Molecular
Patterns
Vaccine Immunology
Host Immune Response
A
Vaccine Immunology
Host Immune Response
A
Ag
Pathogen-Associated
Molecular Patterns
Vaccine Immunology
Host Immune Response
A
Pattern Recognition Receptor
B
Ag
Ag
Ag
Pathogen-Associated
Molecular Patterns
Ag
Vaccine Immunology
Host Immune Response
A
Pattern Recognition Receptor
B
Ag
Ag
Ag
Ag
Ag
Pathogen-Associated
Molecular Patterns
Ag
Ag
DC
Vaccine Immunology
Host Immune Response
A
Pattern Recognition Receptor
B
Ag
Ag
Ag
Ag
Ag
Pathogen-Associated
Molecular Patterns
Ag
Ag
DC
C
Ag
Ag
Lymph nodes
Ag
Ag
DC
Spleen
Vaccine Immunology
Host Immune Response
D
Ag
Ag
Ag
Ag
DC
Ag
B cell activation
B
Vaccine Immunology
Host Immune Response
D
Ag
Ag
Ag
Ag
DC
Ag
B cell activation
B
PC
PC
PC
Plasma cells
IgM
IgA
IgG
Vaccine Immunology
Host Immune Response
E
MHC II
Ag Ag
Th
Ag
DC
Ag
B
Vaccine Immunology
Host Immune Response
E
MHC II
Ag Ag
Germinal Center Response
Th
Ag
DC
Ag
Activated
B cell
B
B
Follicular
helper T cells
Follicular
Dendritic cells
Vaccine Immunology
Host Immune Response
E
MHC II
Ag Ag
Germinal Center Response
Th
Ag
DC
Ag
Activated
B cell
Follicular
helper T cells
Follicular
Dendritic cells
B
Plasma cells
B
PC
PC
PC
IgM
IgA
IgG
Vaccine Immunology
Host Immune Response
E
MHC II
Ag Ag
Germinal Center Response
Th
Ag
DC
Ag
Activated
B cell
Follicular
helper T cells
Follicular
Dendritic cells
B
Plasma cells
B
PC
PC
PC
Bm
Bm
Memory B cells
IgM
IgA
IgG
Vaccine Immunology
Host Immune Response
F
MHC II
Ag Ag
DC
Ag
MHC I
Germinal Center Response
Th
Ag
Activated
B cell
Follicular
helper T cells
Follicular
Dendritic cells
B
Plasma cells
B
PC
CD8
PC
PC
Bm
Bm
Memory B cells
IgM
IgA
IgG
Vaccine Immunology
Host Immune Response
F
MHC II
Ag Ag
DC
Ag
MHC I
Germinal Center Response
Th
Activated
B cell
Ag
Follicular
helper T cells
Follicular
Dendritic cells
B
Plasma cells
B
PC
CD8
T cytotoxic cells
PC
Tc
PC
Tc
Bm
Bm
Memory B cells
IgM
IgA
IgG
Vaccine Immunology
Host Immune Response
F
MHC II
Ag Ag
Germinal Center Response
Th
DC
Ag
MHC I
Activated
B cell
Ag
Follicular
helper T cells
Follicular
Dendritic cells
B
Plasma cells
B
PC
CD8
T cytotoxic cells
PC
Tc
PC
Tc
Bm
Tm
Tm
Bm
Memory T cells
Memory B cells
IgM
IgA
IgG
Vaccine Immunology
Host Immune Response
F
MHC II
Ag Ag
Germinal Center Response
Th
DC
Ag
MHC I
Activated
B cell
Ag
Follicular
helper T cells
Follicular
Dendritic cells
B
Plasma cells
B
PC
CD8
T cytotoxic cells
PC
Tc
PC
Tc
Bm
Tm
Tm
Bm
Memory T cells
Memory B cells
IgM
IgA
IgG
PC
Bone
Marrow
Vaccine Immunology
Host Immune Response
Neutrophils
Vaccine
Monocytes
Dendritic cells
B cells
PC
Bm
T cells
Th
Tc
Vaccine Immunology
Host Immune Response
Neutrophils
Vaccine
Monocytes
Dendritic cells
PS
B cells
PC
Bm
T cells
Th
Tc
Vaccine Immunology
Host Immune Response
Neutrophils
Vaccine
Monocytes
Dendritic cells
PS
PS-Protein
Protein
Toxoid
Killed
B cells
PC
Bm
T cells
Th
Tc
Vaccine Immunology
Host Immune Response
Neutrophils
Vaccine
Monocytes
Dendritic cells
PS
PS-Protein
Protein
Toxoid
Killed
Live
B cells
PC
Bm
T cells
Th
Tc
Vaccine Immunology
Host Immune Response
Neutrophils
Vaccine
Monocytes
Dendritic cells
PS
PS-Protein
Protein
Toxoid
Killed
Live
Duration
of
protection?
B cells
PC
Bm
T cells
Th
Tc
Vaccines in Pulmonary Medicine
1 Introduction to Vaccines
2 Vaccine Immunology
3 Current Adult Vaccines
Current Adult Vaccines
Viral & Bacterial Pathogens
1. Influenza Virus
1. C. tetani
2. Varicella-Zoster Virus
2. C. diphtheriae
3. Human Papillomavirus
3. B. pertussis
4. Measles Virus
4. N. meningitidis
5. Mumps Virus
5. H. influenzae
6. Rubella Virus
6. S. pneumoniae
7. Hepatitis A Virus
7. M. tuberculosis
8. Hepatitis B Virus
8. S. typhi
Current Adult Vaccines
Influenza Vaccine
Recommended antigens for the 2014-2015 influenza season
A/California/7/2009 (H1N1)
A/Texas/50/2012 (H3N2)
B/Massachusetts/2/2012
B/Brisbane/60/2008
Virusneutralizing
antibodies:
IgA
IgM
IgG
Current Adult Vaccines
Influenza Vaccine
Recommended antigens for the 2014-2015 influenza season
A/California/7/2009 (H1N1)
Virusneutralizing
antibodies:
IgA
IgM
IgG
A/Texas/50/2012 (H3N2)
B/Massachusetts/2/2012
B/Brisbane/60/2008
Trivalent
Quadrivalent
Inactivated
Live-attenuated
Intramuscular
Intradermal
Intranasal
Low dose
Regular dose
High dose
Eggs
Cell-based
DNA
Current Adult Vaccines
Influenza Vaccine
Recommended antigens for the 2014-2015 influenza season
A/California/7/2009 (H1N1)
Virusneutralizing
antibodies:
IgA
IgM
IgG
A/Texas/50/2012 (H3N2)
B/Massachusetts/2/2012
B/Brisbane/60/2008
Effectiveness of Influenza Vaccine
Viral strains in the vaccine
Viral strains in the outbreak
Current Adult Vaccines
Influenza Vaccine Effectiveness for the Prevention of
Hospitalizations Due to Influenza Pneumonia
Current Adult Vaccines
Influenza Vaccine Effectiveness for the Prevention of
Hospitalizations Due to Influenza Pneumonia
B/Brisbane/60/2008
Current Adult Vaccines
Influenza Vaccine Effectiveness for the Prevention of
Hospitalizations Due to Influenza Pneumonia
Current Adult Vaccines
Zoster (Shingles)
Adults
Rash / Acute Neuritis
Complications
Postherpetic neuralgia
Ocular complications
Motor neuropathy
Encephalitis
Stroke syndromes
Live Attenuated Zoster Vaccine (single dose)
Current Adult Vaccines
Zoster
Adult: Immunocompromising Conditions
Cancer Drugs Pregnancy HIV <200 HIV >200 Asplenia
Contraindicated
?
1 dose
Adult: Chronic Conditions
Lung Heart Liver Kidney Diabetes Alcoholism Smoking
1 dose
Adult: No Modifying Conditions
18 years
No
50 years
60 years
FDA: Yes?ACIP: No
1 dose
Current Adult Vaccines
H. Influenzae
H. influenzae nonencapsulated: nontypeable
H. influenzae encapsulated: serotypes a, b, c, d, e, f
H. influenzae serotype b (Hib) polysacharide vaccine
H. influenzae serotype b (Hib) polysacharide
conjugate vaccine
Current Adult Vaccines
H. influenzae
Indications for Adults
Hib vaccine may be used in persons with:
Asplenia
Complement component deficiencies
Sickle cell disease
HIV
Most respiratory infections in adults are caused by
nontypeable H. influenzae (NTHi)
Type b Polysaccharide Conjugate Vaccine (1 dose)
Current Adult Vaccines
Pneumococcal
S. pneumoniae:
more than 90 serotypes
Pneumococcal Polysaccharide Vaccine
(PPSV 23 serogroups)
Pneumococcal Polysaccharide Conjugated Vaccine
(PCV 13 serogroups)
Vaccines for Adults
1 Principles of Immunization
2 Introduction to Vaccines
3 Vaccine Immunology
4 Current Adult Vaccines