Reports

This report is based on medical evidence presented at sanctioned medical congress, from peer reviewed literature or opinion provided by a qualified healthcare practitioner. The consumption of the information contained within this report is intended for qualified Canadian healthcare practitioners only.

PRIORITY PRESS - 9th Canadian Immunization Conference (CIC)

Quebec City, Quebec / December 5-8, 2010

Health care professionals (HCPs) with an interest in adult immunization should take advantage of every opportunity to discuss vaccination needs with their patients in order to enhance the likelihood that adults will be both interested in and take advantage of age-appropriate vaccines.

“I think we have a really great opportunity to prevent disease in the elderly that we are missing,” Dr. Shelly McNeil, Canadian Centre for Vaccinology and Associate Professor of Medicine, Dalhousie University, Halifax, Nova Scotia said in an interview during the CIC. While vaccines may not prevent all disease in older adults, “we can reduce their chances of being hospitalized and dying from infectious diseases if we more systematically aim to immunize adults,” she added, “and we need better strategies to get vaccines to them.”

One such strategy may be to broaden opportunities for adults to be immunized by offering services in non-traditional settings such as the pharmacy. In New Brunswick, pharmacists have been providing immunization services since December 2009 and the issue is currently under review by the Nova Scotia legislature. In a poster presented here, Isenor et al. reported on a competency-based program—the Dalhousie University Continuing Pharmacy Education Immunization and Injection Administration Training Program (IIATP)—that is used to train pharmacists to become certified as immunizers. Participants (N=228) in the program were asked to fill out a brief online survey after completing the program. Over 80% of respondents either strongly agreed or agreed that they felt prepared to give medications by injection, including vaccines.

Since November 2009, 300 pharmacists have completed the IIATP program, 131 in New Brunswick, and most will be providing the seasonal influenza vaccine in association with the New Brunswick Public Health Program. “Pharmacists are front-line for the public,” noted Susan Bowles, PharmD, also of Dalhousie University, in an earlier interview. When US pharmacists began offering immunization services about 15 years ago, immunization rates went up disproportionate to the number of people they actually immunized because the level of awareness for the need to immunize rose sharply. “Not only are you increasing the opportunity for patients to get immunized, you are also increasing the overall level of awareness by having pharmacists become immunizers,” Dr. Bowles remarked.

Physicians can also contribute significantly to the uptake of adult vaccines by simply recommending vaccines to adults. “The biggest determinant in whether someone is vaccinated or not is whether their HCP recommends it to them,” Dr. McNeil emphasized. “If we make a point as providers to inform people about the benefits of vaccines for adults and we offer them and recommend them, people will be vaccinated.”

Unfortunately, many adults rely on information gleaned from the Internet about vaccination, much of which is misleading or inaccurate. Physicians therefore are often faced with the challenge of trying to strip away false assumptions about vaccines. This, as discussed by Dr. Noni MacDonald, Professor of Pediatrics and Computer Science, Dalhousie University, is where the art of communication comes in. Trust is critical in getting adults to accept vaccination overall, she noted: “If you are all science and no heart, patients won’t trust you... you need to care about patients, that helps build trust,” she said in an interview.

Physicians should also avoid academic jargon when discussing vaccines and try to make explanations as clear as possible. Details such as relative risks and percentages are too mathematical for most patients to grasp; rather, physicians need to use plain numbers—10 out of 100 patients die of tetanus even if they are treated in the emergency department, not 10% of patients—brings the message home that tetanus kills and that vaccination, with a booster every 10 years in adulthood, prevents.

“Physicians also have to be consistent in their messages,” Dr. MacDonald added, “and that message is very simple: vaccines are safe, they are effective and they save lives.”

Dr. Julie Bettinger, Assistant Professor, Vaccine Evaluation Centre, Child and Family Research Institute, University of British Columbia (UBC), Vancouver, agreed that improved uptake of adult vaccines starts with the HCP.

“All of the literature shows that people look to their HCP for immunization advice. You need to make HCPs aware that adult vaccination is needed and then I think you can educate the public about it,” she stated in an interview.

Can-AVERT

Here at the CIC, Kiberd et al. presented results obtained on the first phase of the Can-AVERT (The Canadian Adult Vaccination Evaluation & Research Team) study. Some 4067 respondents completed a national Web-based survey in which researchers sought to determine respondents’ knowledge of and attitudes towards vaccination.

Survey results showed that slightly under one-quarter of respondents had actually received the seasonal influenza vaccine, with another 17% indicating that they intended to. There was also still some concern that seasonal influenza vaccination could cause influenza, which negatively affected coverage. This is not only inaccurate but, as emphasized by Dr. Janet McElhaney, Professor and Allan McGavin Chair in Geriatrics Research, UBC, physicians can reassure patients that had they not been vaccinated and still got influenza, they would have been a lot sicker than they were. Moreover, when they get the influenza vaccine the next year, they are going to mount a really good immune response). Can-AVERT researchers also found coverage of other adult vaccines such as the herpes zoster (HZ) vaccine is inadequate.

“There seems to be a poor understanding of the impact of the infections that can be prevented or reduced with adult immunization,” researchers wrote. “Fewer than 5% of people felt that pertussis, human papillomavirus, pneumonia, shingles and tetanus were significant infections and less than 20% felt that hepatitis was an important infection. While progress is being made in influenza vaccination uptake, there is a greater need to focus on uptake of other adult vaccines.”

Herpes Zoster Study

The most important new vaccine to be introduced for older adults is the HZ vaccine. The Shingles Prevention Study (SPS) showed that the HZ vaccine reduced the HZ burden of illness score by 61.1% in the overall cohort (Oxman et al. N Engl J Med 2005;352:2271-84). The same vaccine also reduced the incidence of post-herpetic neuralgia (PHN) by 66.5% and the incidence of HZ itself by 51.3%.

Here at the CIC, Benbernou et al. carried out the first Canadian study examining the prodromal phase of HZ in older adults. Investigators identified 251 patients 50 years of age and older who presented within 14 days of rash onset to some 83 physicians across Canada. Results showed that the burden of prodromal pain is considerable, with 74% of the cohort having experienced prodromal pain prior to rash onset at a mean duration of 4.7 days. Forty-six per cent of patients also rated their prodromal pain as severe (=7 on a scale of 10) and 41% reported having pain lasting >18 hours per day.

For each increase of 1 unit in the severity of prodromal pain, researchers also found that the risk of having severe acute pain during the HZ episode increased by 8%. Not surprisingly, those who reported prodromal pain prior to rash onset were more likely to visit the emergency room, seek early consultation (0 to 3 days) and received antiviral medication as well as opiates.

“It is very difficult to diagnose prodromal pain but if patients 50 years of age and older present with severe prodromal pain, physicians can suspect HZ and give them antivirals earlier,” Atika Benbernou, MSc, Unité de recherche en santé des populations, CHAUQ, Université Laval, Quebec City, noted in an interview. “And now, of course, there is the HZ vaccine that helps prevent HZ as well.”