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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


7

Eighteenth 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)
19801999: 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)
20002010: 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
1
Behaviour
(travel,
sexual
behaviour)
1. Plotkins,
S. et al, Immunization
in the United
States. Vaccines 2008:1479-1510
2. 2006 Canadian Immunization Guide

Whats 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

Estimated HPV Contribution in Cancer


Cervix

> 99%

Anus

84.2%

Vagina

69.9%

Penis

47.0%

Vulva

40.4%

Oropharynx

35.6%

Oral cavity

23.5%
0

20

40
60
Percentage

80

WHO Information Centre on HPV and Cervical Cancer. Available at:


www.who.int/hpvcentre/statistics/en/.

100

Recommended Use
Group

Recommendation

Comments

Females

Recommended

Efficacy is greatest prior to first sexual


intercourse
Although efficacy not demonstrated,
immunogenicity data imply high
efficacy

Recommended,

Age 1426 years

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

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

Age 913 years

Females

Age 1426 years


with HPV-related
cervical or genital
disease or current
infection

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 sulfate
Approved 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 3deacylated monophosphoryl Lipid A
Approved in Canada February 2010 for females from
10 to 25 yrs of age
3 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.
2.

Older women >26 years of age


Males

http://www.cdc.gov/vaccines/recs/acip/slidesoct09.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
5
men.
Partridge JM, et al. J Infect Dis 2007;196:1128-36.

Saraiya M, et al. Cancer 2008;113 (10 Suppl):2837-40.


Guris D. 25th International Papillomavirus Conference, Malmo. May 2009. Abstract P-27.16
Giuliano A, Palefsky J. 25th International Papillomavirus Conference, Malmo. May 2009. Abstract O-01.07
Palefsky J, Giuliano A. 25th International Papillomavirus Conference, Malmo. May 2009. Abstract O-27.01

4. VARISELA
Direkom 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 Influenz

Imunitas terhadap Vaksinasi Influe


Viru
s
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 dipak


Vaksin virus mati utuh

1.

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 Influen

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. Fitzpatricks Dermatology in General Medicine. 5th ed. Vol 2. New York, NY: McGraw-Hill;

Incidence of Zoster by Age

The incidence of shingles increases significantly with age,


with 67% of cases occurring in persons over 50 years of
age.
Johnson R. et al. JID 2007 11(Suppl 2) S43-48

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

Brisson M. et al. Human Vaccine


2008

~2,000 hospital admissions and 20 deaths

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,
38

MMWR. 2006

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
The Paradigm
Paradigm Has
Has Shifted
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

Tindakan Preventif

Waspada dimusim Flu

Tindakan Preventif

Thank you for your


attention!