Imunisasi Pada Orang Dewasa

IMUNISASI PADA ORANG DEWASA DAN LANSIA

Dr. SUHAEMI, SpPD, FINASIM

VACCINATIONS IN ADULTS AND THE ELDERLY

PENDAHULUAN

Imunisasi merupakan salah satu intervensi kesehatan yg paling sukses dan efektif dalam mencegah penyakit.

Imunisasi mampu membasmi CACAR dan menurunkan insidensi POLIO secara global sebesar 99 %.

Imunisasi menurunkan angka morbiditas, kecacatan serta mortalitas akibat penyakit Difteri, Pertusis, dan Campak.

WHO : Imunisasi membantu tercapainya MDGs ( Milleniium Development Goals ) melalui strategi global ttg imunisasi dalam GIVS ( Global Immunization Vision and Strategy 2006-2015 )

IMUNISASI berarti induksi agar terbentuk suatu imunitas dgn berbagai cara baik secara pasif maupun aktif.

VAKSINASI adalah tindakan pemberian vaksin ( antigen ) yg dapat merangsang pembentukan imunitas ( antibodi ) dari sistem imun dalam tubuh manusia.

Vaksin merupakan suatu sediaan biologis yg menimbulkan kekebalan terhadap penyakit.

Vaksin umumnya mengandung sejumlah kecil bahan yg menyerupai organisme patogen.

Agen tsb menginduksi sistem imun. Sistem imun mengenalinya sebagai benda

asing, menghancurkannya dan mengingatnya sehingga pada paparan berikutnya agen tsb dapat dikenali dan dihancurkan.

Vaccines by Period of Development

7Eighteenth century: Smallpox (1798) Nineteenth century: Rabies, Hog cholera, Diphtheria antitoxin,

Cholera, Plague, Typhoid (1896) Early twentieth century: BCG tuberculosis, Pertussis (1926)

Diphtheria (1923), (1927) Influenza (1936) Tetanus toxoid (1927), Yellow fever (1935) Rickettsia (1936), Influenza A (1936)

Post-World War II: Yellow fever (1953) Influenza (1945) Diphtheria toxoid (1949), Tetanus toxoid (1949), Pneumococcus (1976-83), Typhoid (1952), Polio Salk (1955), Meningococcus (1962), Polio, Sabin (1963), Measles (1963), Mumps (1967), Tick-borne encephalitis Rubella (1970), Anthrax (1970), MMR (1971)

1980–1999: Adenovirus, Rabies, (1980, human), Hemophilus influenz b, Hepatitis B (1987) Typhoid (1992), salmonella, Japanese encephalitis, Hepatitis B (1981), Varicella (1995), Pertussis acellular (1993), Lyme disease (1998) Hepatitis A (1995), Rotavirus (1998)

2000–2010: Pneumococcal, meningococcal disease, influenza, parainfluenza, human papillomavirus (HPV)

Future: H. pylori,, streptocococcus, HIV, hepatitis C, adenoviruses

PERTANYAAN :

Mengapa orang dewasa tetap memerlukan imunisasi

FAKTA : 1. Influenza : Kematian 36.000 dan

200.000 rawat inap di USA. 2. Dua strain HPV menyebabkan Ca

cervix 70% 3. Setiap tahun ada 5000 kematian ok

Hep B 4. USA 1.000.000 terkena varicella.

INDIKASI imunisasi pada dewasa Riwayat paparan Risiko penularan Usia Lanjut Imunokompromais Travelling

Adult Immunization: Routinely for All & Specific Groups

Adult immunization programs present new and different challenges relative to

childhood programs

Adult Immunization Schedule Classification: Routinely for All2 Specific Groups2

Age1

Occupation1

Health Status1

Behaviour (travel, sexual behaviour)11. Plotkins, S. et al, Immunization in the United States. Vaccines 2008:1479-1510

2. 2006 Canadian Immunization Guide

What’s New in Immunization?

Herpes Zoster Vaccine Human Papilloma Virus Vaccine

Pneumococcal Vaccine

Influenza Vaccine (2010/2011)

1. Vaksinasi Tetanus, Difteri dan Pertusis aselular : IM

2. Vaksinasi Human Papiloma Virus ( HPV)

rekom : 19-49 thn IM ; 0,1,6 bln.. 3. MMR ( Measles, Mumps, Rubella ) SK ; 1 dosis

WHO Information Centre on HPV and Cervical Cancer. Available at: www.who.int/hpvcentre/statistics/en/.

Estimated HPV Contribution in Cancer

Oropharynx 35.6%

Oral cavity 23.5%

Penis 47.0%

Vulva 40.4%

Anus 84.2%

Vagina 69.9%

Cervix > 99%

Percentage0 10020 806040

Recommended UseGroup Recommendation Comments

Females

Age 9–13 years

Recommended •Efficacy is greatest prior to first sexual intercourse•Although efficacy not demonstrated, immunogenicity data imply high efficacy

Females Age 14–26 years

Recommended, even after onset of sexual activity

•May not have been infected•Very unlikely to have been infected with all 4 vaccine HPV types•Need to be aware that they may already have been infected

Females

Age 14–26 years with HPV-related cervical or genital disease or current infection

Recommended •May not have been infected with vaccine HPV types•Very unlikely to have been infected with all 4 vaccine HPV types•Need to be aware that vaccine probably has no therapeutic effect

15 February 2007Statement on human papillomavirus vaccine. Canada Communicable Disease Report. An Advisory Committee Statement (ACS). Can Commun Dis Rep. 2007;33(ACS-2):1-32.

HPV Vaccines – Available in Canada

Quadrivalent vaccine:Contains HPV Types 6, 18 (20 ug each), 11, 16 (40 ug each)Adjuvant: 225 ug Aluminum hydroxyphosphate sulfateApproved in Canada – May 2006 (initially for females 9 to 26 yrs of age; now expanded indications)

3 i.m. Doses: 0, 2 (± 1 m), and 6 (± 2 m) m Bivalent Vaccine:

Contains HPV Types 16 and 18 (20 ug each)Adjuvant: 500 ug Aluminum hydroxide, 50ug 3-deacylated monophosphoryl Lipid AApproved in Canada – February 2010 for females from 10 to 25 yrs of age3 i.m. Doses: 0, 1 (up to 2.5 m) and 6 (between 5 and 9 m after 1st dose) m

HPV2 and HPV4 – Efficacy

L. Markowitz. CDC. Presented at ACIP Oct 2009

HPV Vaccine: Expanding Indications

1. “Older” women >26 years of age2. Males

http://www.cdc.gov/vaccines/recs/acip/slides-oct09.htm

HPV Vaccine in Men

The incidence of anogenital HPV infection in men is at least as high as in women.1

32% of all HPV-related cancers in the USA occur in men.2

Quadrivalent HPV vaccine is immunogenic in males.3

Preliminary data demonstrate efficacy of quadrivalent HPV vaccine versus infection and disease in both heterosexual4 and homosexual men.5

1. Partridge JM, et al. J Infect Dis 2007;196:1128-36.2. Saraiya M, et al. Cancer 2008;113 (10 Suppl):2837-40.3. Guris D. 25th International Papillomavirus Conference, Malmo. May 2009. Abstract P-27.16 4. Giuliano A, Palefsky J. 25th International Papillomavirus Conference, Malmo. May 2009. Abstract O-01.07 5. Palefsky J, Giuliano A. 25th International Papillomavirus Conference, Malmo. May 2009. Abstract O-27.01

4. VARISELADirekom pd yg kontak erat dgn pasien yg berisiko tinggi terjadinya komplikasi ( petugas kesehatan ) SK : 2 dosis 5. INFLUENZA IM: 1 dosis pertahun

Vaksin Influenza

Sampai saat ini imunisasi masih merupakan cara yang cukup efektif untuk mencegah serta mengurangi

komplikasi akibat penyakit influenza.

Salah satuny

a

PNEUMONIA

Vaksin adalah bahan antigenik yang digunakan untuk menghasilkan kekebalan aktif terhadap suatu penyakit sehingga dapat mencegah atau mengurangi pengaruh infeksi oleh organisme alami atau "liar".

Vaksin dapat berupa galur virus atau bakteri yang telah dilemahkan atau dimatikan.

Virus Influenza

[dimatikan/dilemahkan]

Vaksin Anti Influenza

Struktur Virus Influenza

Pengembangan Vaksin Influenza

Imunitas terhadap Vaksinasi Influenza

Virus

Manusia

Antibody HA

Antibody NA

Menahan virus dengan

menetralisasi infektivitas

Membatasi penyebaran virus

dengan menghambat

lepasnya virion yang baru dirakit dari sel

yang terinfeksi

Vaksin virus yang biasa dipakai

1. Vaksin virus mati utuh sangat berhasil dipakai untuk

mencegah penyakit influenza. Setiap dosisnya mengandung Virus

Influenza A H1N1, H3N2, dan virus influenza B.

efikasi protektivitas 60-90% aman dan ditoleransi dengan baik.

2. Vaksin Sub unit/ Split Vaccine sangat berhasil dipakai untuk mencegah

penyakit influenza. Efikasi untuk mencegah influensi adalah 77% dapat ditoleransi dengan sangat baik dan

aman.

Sasaran vaksinasi Influenza Orang tua > 65 tahun Petugas rumah sakit yang merawat

penderita penyakit kronis Orang dewasa yang dan anak-anak yang

menderita penyakit paru ata sistem kardiovaskuler kronis, termasuk anak yang menderita asma

Orang yang mempunyai gangguan funsi ginjal, diebetes mellitus, hemoglobinopati, dan penyakit penekanan sistem imun

Orang yang mendapat pengobatan aspirin janka panjang

Wanita hamil trimester II dan III pada saat musim influenza

Fakta Studi tentang manfaat vaksinisasi influenza untuk mencegah Pneumonia

Vaksinasi influenzamenurunkan angka perawatan pneumonia di rumah sakit (Nicholson KG, Wood JM, Zambon M. Influenza. Lancet.

2003;362:1733-45) Imunisasi pada penderita penyakit

paru kronis dapat mengurangi angka perawatan rumah sakit sebagai akibat pneumonia sebanyak 52% (Nichol KL, Baken L, Nelson A. Relation between influenza vaccination and outpatient visit, hospitalization, and mortality in elderly person with chronic lung disease. Ann. Intern Med.

1999;130:397-403)

Kelompok yang mendapatkan vaksinasi dua kali (fully vaccinated) dapat mencegah terjadinya influenza dan pneumonia hingga 69-87%, sedangkan kelompok yang dilakukan penyuntikan vaksinasi hanya satu kali tidak menunjukkan efek yang bermakna atau sama dengan anak yang tidak mendapatkan vaksinasi influenza. (Dr. Mandy A. Allison, dari University Utah, Salt Lake City, Journal of

Pediatrics.)

6. Vaksinasi PNEUMONIA SK/IM 1x 5 tahun

7. Vaksinasi HEPATITIS A IM, 2 dosis selang 6 bulan

8. Vaksinasi HEPATITIS B IM, 0,1,6

Adult Immunization Schedule Footnotes: Hepatitis B

The Hepatitis B footnote has been revised to include recommendations to vaccinate:

persons with diabetes younger than 60 years old and

persons 60 years and older based on need for assisted blood glucose monitoring.

9. Vaksinasi MENINGITIS IM, setiap 3 tahun

10. Vaksinasi Zoster SK

VZV: Reactivation

Posterior column

spinal cord

Dorsal root ganglion

Site of VZV replication

Arvin AM. Varicella-zoster virus. In: Knipe DM, Howley PM, eds. Fields Virology. 4th ed. Vol 2. New York, NY: Lippincott Williams & Wilkins; 2001:2731-67

Straus SE, Oxman MN. Varicella and herpes zoster. In: Freedberg IM, Eisen AZ, Wolff K, et al, eds. Fitzpatrick’s Dermatology in General Medicine. 5th ed. Vol 2. New York, NY: McGraw-Hill;

1999:2427-50

Incidence of Zoster by Age

Johnson R. et al. JID 2007 11(Suppl 2) S43-48

The incidence of shingles increases significantly with age, with 67% of cases occurring in persons over 50 years of

age.

Herpes Zoster: Canadian Epidemiology

Estimated ~30% lifetime risk of one VZV reactivation1; ~50% if live to 80 years of age

Estimated 129,882 cases of Shingles per year1

~90% of cases occur in immunocompetent people;

13% of zoster episodes will result in PHN (Defined as Pain >90 days after rash onset)

17,108 episodes/year

~2,000 hospital admissions and 20 deaths per yr

Brisson M. et al. Human Vaccine 2008

Zoster Vaccine in Canada

Recommendations: For prevention of HZ and its complications in persons >60 yrs

without contraindications May be used in patients aged 50 and older No recommendation for those with a past episode of zoster Should be given to patients irrespective of a prior history of

chickenpox or documented prior varicella infection Booster doses are not recommended for healthy pts Individuals who indavertently receive systemic anti-viral

therapy active against VZV within 2 days before and 14 days after vaccine may benefit from a second dose 42 days or later

May be given with influenza vaccine; Pneumovax and zoster vaccine should be given at least 4 weeks apart

National Advisory Committee on Immunization (NACI). CCDR January 2010; vol. 36

Summary

Immunization does not stop at childhood Prevention of infection by immunization

is a lifelong process Health Care Practitioners need to

Empower, Educate, Advocate and Recommend

Infant, Child and Adolescent Immunization Schedule US CDC, MMWR. 2006

38

Autism and Vaccines Theory posed that

MMR vaccine might play a role in autism

Weight of scientific evidence does not support

American Academy of Pediatrics Review and Institute of Medicine Review conclude no association

Mercury and Vaccines Federal Act to reduce

mercury exposure Thimiserol -mercury

based preservative Vaccine schedule prior to

1999 for some infants could exceed 1 federal mercury guideline

No evidence of harm US vaccines now

virtually mercury-free

Emergency hospital during influenza epidemic, Camp Funston, Kansas, 1918

Vaccine Concerns: As Old As Vaccines Themselves

“The Cow Pock – or – the Wonderful Effects of the New Inoculation!”Vide – the Publications of ye Anti-Vaccine Society / J. Gillray, 1802

The Paradigm Has Shifted ...The Paradigm Has Shifted ...

Changing Military Changing Mission Emphasis on Reserve Components Economy / demographics Willing to ask questions

Increasingly health conscious population Wealth of readily available information (good & bad)

Tindakan Preventif

Waspada dimusim “Flu”

Tindakan Preventif

Tindakan Preventif

Thank you for your attention!