Immunization Update 2007

1. Immunization Update 2007 Stanley E. Grogg, DO, FACOP Professor of Pediatrics Liaison Member of the Advisory Committee for Immunization Practices (ACIP)

2. Have spoken for the following pharmaceutical companies in the last 6 months AstraZeneca GlaxoSmithKline Merck MedImmune Novartis Primary Investigator in clinical vaccine research for the following companies MedImmune Merck Sanofi-Pasture GlaxoSmithKline Wyeth I have the following disclosures

3. Objectivesand references • You will be able to list and recommend new vaccines available for public use • You will be able to employ the new vaccines into daily practice • http://www.vaccineinformation.org/photos • www.vaccineinformation.org • www.cdc.gov www.aap.org • www.nfid.org www.immunize.org

4. The “Okie” Good News • Improved from 44th in the nation in 2005 to 25th in 2006 • OK Department of Health • 80.4% of OK children ages 19 months through 35 months were immunized against 10 potentially deadly diseases (2006)

5. Pertussis Pneumococcal Polio Rabies Rotavirus Rubella Smallpox Tetanus Typhoid Yellow fever More to come Available Vaccines Anthrax BCG Chickenpox Cholera Diphtheria Hepatitis A Hepatitis B Hib HPV Influenza Japanese encephalitis Measles Mumps Meningococcous

6. Which of the following patients should generally NOT be given a live vaccine? • A. Pregnant women • B. Patients on chemotherapy • C. Patients currently on high corticosteroid doses for at least 14 days • D. All of the above

7. All of the following are live virus vaccines EXCEPT • 1. FluMist • 2. RotaTeq • 3. Varivax and Zostavax • 4. MMR II • 5. IPV 

8. Advantages of Live Vaccines • Often protective after the first dose • Immunity is usually long-lasting  • A second dose is NOT really a booster but to stimulate immunity for those who did not react initially

9. In general avoid most live vaccines in patients who are immunosuppressed • Avoid live vaccines until 3 months after stopping chemotherapy • Wait one month after high daily steroid doses (i.e. prednisone 20 mg, or 2 mg/kg) in patients taking them for at least 14 days • It's not necessary to avoid live vaccines while using inhaled steroids, steroid tapers or oral courses for less than 14 days • Antivirals can interfere with live vaccines • Wait 24 hours after stopping a herpes antiviral (i.e. acyclovir) to give Varivax and 2 weeks after giving FluMist to give an influenza antiviral if possible   

10. Avoid most live vaccines in patients who are immuno-suppressed; EXCEPTIONS • Household contacts • Can give MMR, Varivax, RotaTeq, and Zostavax to healthy people living with someone who is immunosuppressed • Pregnancy • Avoid live vaccines during pregnancy because of a theoretical risk of infection to the fetus • Use the inactivated flu vaccine during pregnancy • Timing of vaccinations • If LIVE INJECTABLE vaccines can't be given on the same day, give them at least 28 days apart

11. “Religious exemptions for shots on the rise”Tulsa World, Oct. 20, 2007 • All states have some requirement for immunizations • Allow parents to opt out for medical or religious reasons (Kansas, Missouri) • Allow parents to cite personal or philosophical reasons (Arkansas, Colorado, Oklahoma, Texas) • Allow only medical exemptions (Mississippi)

12. AAP’s Vaccine Refusal Form • http://www.cispimmunize.org/ • AAP’s Childhood Immunization Support Program • If my child does not receive the vaccine(s), the consequences may include: • -contracting the illness the vaccine should prevent • -transmitting the disease to others • -the need for my child to stay out of child care or school during disease outbreaks

13. True or False • Routine immunization is NO longer needed for polio, measles, mumps, varicella, pertussis, diphtheria, tetanus

14. 2006: “Outbreak prompts change to recommendations on mumps” • ACIP/AAP June 2006 • Recommended routine MMR at 12-15 months ______ AND specify that students attending colleges and other post-high school institutions receive _ doses of MMR

15. Up Date: VaricellaHow many doses are recommended? • August 2006 • ACIP recommends 2nd dose of varicella • Children aged 4-6 years • Children, adolescents and adults who previously received only 1 dose • Outbreak situations

16. Rational for 2nd varicella dose • 20% of children who have received 1 dose are not fully protected • One dose may not provide protection into adulthood when infection with zoster virus is more severe

17. Recent Immunization Schedule Changes • HepB needs to be given at birth • Can be delayed only if health care provider order to withhold • Tdap adolescent • Hepatitis A • Meningococcal (MPSV4) conjugate vaccine

18. Recent Immunization Schedule Changes cont’d • Influenza vaccine for > 6-59 months of age • Rotavirus (RotaTeq by Merck) for infants • HPV for adolescents

19. What disease is known as the “100 Day Cough”? • RSV • Adenovirus • Rhinovirus • SARS • Pertussis

20. Tdap Recommendations • Use in place of Td as booster at 11 and 12 yrs • Use for 13-18 yr old who missed the 11 to 12 yrs dose of Td • 11-18 yrs of age who have already been vaccinated with Td are encouraged to receive a dose of Tdap to protect against pertussis if > 2 years since booster • (www.cdc.gov/nip: June 30, 2005)

21. Reasons for new Tdap recommendations • Pertussis still manages to cycle its way through communities • 2000-2005 • 100 pertussis-related deaths US • 25,616 cases reported in 2005 • Disease uncomfortable for anyone who has it • Cough for weeks

22. Tdap • Recommended in adults who are in close contact with infants younger than 12 months of age • Parents • Child care providers • HEALTH CARE PROVIDERS

23. Tdap for Pregnant Women • Tdap can be given instead of Td booster if increased risk of Pertussis or needs immediate protection (tetanus) • Source for Pertussis infection 15-20% of infants

24. So, Heath Care Providers • Every time you see a newborn, you should ensure that the entire immediate family have all been immunized for pertussis

25. What should be given for wound prophylaxis for an adolescent? • Ages 11-18

26. Question • Should a teen who has had pertussis be vaccinated with Tdap?

27. Question • What is the maximum age DTaP can be administered? • 3 years • 4 years • 5 years • 6 years • 7 years

28. For what age is the Hepatitis A now approved? • Can be given as young as • >6 months of age • >9 months of age • >12 months of age • >18 months of age • >2 years of age

29. What would you recommend for an infant under one, traveling to Mexico? • A. Risk prevention • Don’t “drink the water”, etc. • B. Gamma globulin • C. Hep A to the adults in close contact with infant • D. All of the above • E. Only A and C above • Remember infants do not get significant clinical disease, thus discuss risk prevention and immunize those over 12 months traveling

30. Cocoon Effect • Vaccinating one group to protect another • HepA in children to protect adults • Tdap in adolescents/adults to protect infants

31. ACIP “New” Recommendations for Hep A • Can be used as post-exposure prophylaxis rather than GG if given within 2 weeks of exposure • Can be given “on the way to the airport” if patient is traveling to high risk area

32. Twinrix by GSK: Combination of A and B • For use 18 years of age and older • Saves 2 injections  • Cannot be used as “on the way to airport” injection because the amount of A antigen is ½ of that in Havrix

33. Menactra (MCV4) (Sanofi) Indications (ACIP 2007) • Routine vaccination for all adolescent between 11-18 years • College freshman living in dorms • Revaccination only if > 5 years since Menomune (MPSV4) if student is at high risk • To be added to Vaccine Injury Compensation Program

34. Menactra (MCV4) (Sanofi) Indications (ACIP 2007) • Now approved and recommended down to 2 years of age for those at risk for meningococcal meningitis • ACIP recommends using Menactra rather than Menomune (MPSV4) • Conjugated vaccines stimulates both humoral and cellular responses

35. Guillain-Barre Syndrome (GBS) and Menactra • Vaccination still recommended • Not a greater than expected number of GBS events

36. Syncope and Menactra • Syncope is common among adolescents • No specific relation to Menactra or any other vaccine

37. Menactra (MC4) (Sanofi)Vaccine • What N meningitidis serogroupis NOT in vaccine? • A • B • C • Y • W 135

38. Annual Influenza Vaccine • Recommended for 6-59 month-olds • In-home and out-of- home caregivers of children ages 2-5 years of age • And of course, all healthcare providers!

39. FluMist (LAIV) (MedImmune) Indications • 2-49 years, non-pregnant, healthy persons • Contraindicated in asthmatics • Do not use for workers in transplant units • NICU OK

40. New FluMist (2007-08 season) • 2-49 y/o (September 28, MMWR) healthy children • Reduction in volume of vaccine (.1) mL per nostril • Reduction in minimum dose spacing to 4 weeks for children who require 2 doses • Temperature requirements for storage 35-46 degrees F

41. Flu Guidance (CDC)Partially Immunized < 9 yrs of age for 2007-08 season • Children 6 months-9 years should receive 2 doses separated by at least 1 month • NEW: If the child < 9 yrs received only one dose of influenza vaccine the first season they were immunized, they should receive 2 doses the following season

42. RotaTeq (Merck)Pentavalent live oral vaccine • ACIP recommendation • Infants should receive three doses of the oral vaccine at two, four, and six months of age to prevent moderate to severe Rotaviral infection • Children should receive the first dose of the vaccine by 12 weeks of age and should receive all doses of the vaccine by 32 weeks of age

43. Human Papillomavirus Virus Vaccination (HPV) • June 2006, ACIP recommendations • Be routinely given to girls at 11-12 year check up • Allows for vaccination of girls beginning at 9 years of age • Vaccination of girls and women 13-26 years of age

44. Human Papillomavirus Virus Vaccination (HPV) • June 2006, ACIP recommendations • Vaccination is NOT recommended during pregnancy • Can be given to lactating women • Cervical cancer screening recommendations do not change

45. HPV: the “infection” • Oncogenic (Protects against types 16 and 18) • Nononcogenic (Protects against types 6 and 11)

47. Pneumococcal Vaccines • Pneumovax-23 • Pneumococcal polyvalent (23) polysaccharide vaccine • Cannot be given before 2 years of age • Protects against most common serotypes causing pneumonia in adults • Prevnar-7 • Conjugate pneumococcal polyvalent (7) vaccine for infants and toddlers for protection of bacteremia, meningitis, pneumonia and some otitis media

48. Cost of New Vaccines

49. Who is Eligible to Receive VFC (age 18 or younger) • 1. Medicaid eligible • 2. Uninsured • 3. American Indian/Alaska Native • 4. Underinsured (has health insurance benefit plan that does NOT include vaccination • Only at Federally Qualified Health Center or Rural Health Clinic

50. Her last set of immunizations was at age 5 years and she was up to date. Which of the following vaccinations would you recommend today? Tdap Menactra Varivax HPV Influenza Up date HepB MMR HepA Case: a 11 y/o girl comes to your office in October for a routine evaluation.