Adolescent Immunization: Importance and Recommendations

1. IAP VISION 2007 Adolescent IMMUNIZATION ADOLESCENT FRIENDLY SCHOOL INITIATIVE Adolescent Friendly School Initiative

2. INTRODUCTION What isImmunization? • Administration of all or part of micro organism or modified product. • Resulting in protection against the disease.

3. Prevention and control of disease is important for their healthy growth. They must be provided with the opportunity of healthy growth and development. Routine immunization also provides a chance of a health visit Gives further chance for preventive services and health counseling. Importance of adolescent immunization

4. Success of Immunization Program has resulted in the decrease in incidence of the vaccine preventable diseases. But unimmunized adolescents have become more susceptible. TT is the only vaccine included in the National Immunization Schedule in India. Why adolescents should be immunized?

5. To boost immunity that is decreasing Efforts to decrease disease To have specific Protection To provide recent vaccines available for immunization Why Adolescent Immunization is important?

7. Scenario in West Indian Scenario Current Status

8. http://www.cdc.gov/nip. Accessed May, 26th 2007

9. IAP COI Recommendations…

10. IAP adolescent immunization schedule

11. Td Vaccine Td vaccine has become available, should this vaccine be preferred over TT?

12. Diphtheria in India • Diphtheria - Down but not out S K Kabra AIIMS Indian Ped. 2000 July • Patch remains Nandy et al Indian Pedicatrics 2001 • Diphtheria – Certainly not out Poddar B. Indian Pediatrics 2000

14. At 10 & 16yr instead of TT - Reasonable Cost is little higher (Rs. 5.50 for TT and Rs. 6.10 for Td) Diphtheria toxoid one of the safest vaccines. Td is not much more reactogenic than TT. In some parts of world Td is preferred in place of TT - in pregnancy & adults In India Td should be preferred over TT Is it feasible to incorporate Td in Immunization Schedule?

15. dTap vaccine dTap vaccine is also available, should this vaccine be preferred over dT?

16. There is a need to vaccinate all adolescents & adults against pertussis. Recommended by ; international consensus group on pertussis & global pertussis initiative. Pertussis in adolescents

17. Tdap instead of Td is recommended by many authorities to prevent pertussis in adolescents and adults The major benefit is protection of infants and children from pertussis Cost is major obstacle – 50 times Being used in Canada, Not yet licensed in USA Tdap vaccine

18. Aim is to; prevent congenital rubella syndrome (CRS), and not to prevent rubella infection per se, as it is usually benign and inconsequential. Rubella

19. Haphazard use of rubella vaccine in young children may shift the epidemiology of rubella to the right with more clinical cases occurring in young adults leading to increase in cases of CRS. Rubella

20. Recommended to all adolescents (sp. Girls) – irrespective of previous immunization status – no upper age limit. Many states are likely to include MMR in UIP. MMR

21. There is no difference in efficacy or safety among available different strains. Aseptic Meningitis following vaccination is mild, without any sequel or mortality. No association with either autism or Crohn’s dis. (URABE V/S L.Z.) Mumps

22. WHO has recommended universal Hepatitis B vaccination. In 2002 GOI also initiated incorporation of HB vaccine as universal vaccine – in a phased manner. For previously unvaccinated adolescents 0,1 & 6 mo. is a preferred schedule. No booster. Hepatitis B

23. HBIG provides immediate passive immunity Indications; individuals with recent exposure to hepatitis B virus prevention of mother to child transmission and following sexual exposure like in rape cases. Dose: Adults: 1000-2000 IU; Children:- 32-48 IU/kg body wt. Hepatitis B Immunogloulin (HBIG)

24. Peak in school age children (5-19 yrs) Endemic areas – peak incidence – school children. 33m cases & 5 lac deaths 3 populations are at particularly high risk a. Children in endemic areas b. Travelers to endemic areas c. Clinical microbiology technicians Vi capsular polysaccharide vaccine Typhoid: in endemic areas every 3 yearly. Typhoid

25. The IAP COI opines that varicella vaccine is not recommended for universal immunization in India at present. It may be offered to children from high socio-economic strata of society after explaining the pros and cons to the parents on a one-to-one “named child” basis. Varicella

26. It is indicated for ; In children with chronic lung/heart disease, Humoral immunodeficiencies, HIV infection (but with C4 counts above 15% of the age related norms), Leukemia (but in remission and off chemotherapy for at least 3-6 months) and those on long term salicylates/high dose long term oral steroids. In household contacts of immuno-compromised. In children attending crèches and day care centers. Varicella – IAP COI

27. One dose below 13 year and two doses after that 4 wk apart. For post-exposure – within 72 hrs of exposure. Ensure that adolescent girl is not pregnant and she should not conceive for 4 wk after vaccination Varicella Schedule

28. The IAP COI opines that HA vaccine is not recommended for universal immunization in India at present. It may be offered to children after explaining the parents on a one-to one “named child” basis. . Post exposure – to contacts – with in 10 days. Two doses at 6 mo interval from 2 yr onwards Hepatitis A

29. Who have not had viral hepatitis in past, especially those who are leaving home for further studies. In all sero negative patients with chronic liver disease Family contacts of patients with chronic liver disease. In children attending crèches and day care centers and In travelers from abroad visiting endemic areas. Indications in Adolescents;

30. Proposed immunization schedule

31. Newer and Future Vaccines for Adolescent

32. Further Vaccines ? ? ? Present 2010 - 2020 ? RSV otitis media pneumo conjugate Hib HIV? mening A, C conjugate grpB Strep acP acP hep C? rotavirus H. Pylori mening B DTacP-IPV/Hib HPV malaria Herpes EBV DTacP-HB/Hib dengue new TB hep E DTacP-IPV-HB/Hib ETEC-cholera Shigella (adapted from EPI)

33. Meningococcal Influenza HPV e IPV– Salk Vero cell IPV [v IPV] JE CMV Herpes HIV Vaccines under discussion • EB V • Parvovirus, • Para I • E Coli • Adeno • Malaria • Dengue • Hepatitis E • Cholera • Shigella • Campylobacter • Schistosomiasis

34. Rabies – Pre/post exposure Meningococcal vaccine Pneumococcal Influenza Vaccination in special Situations

35. There are 2 influenza viruses, types A and B. Type A :subtypes based on two surface antigens Hemagglutinin (H) and Neuraminidase (N). eg H1N1 Influenza type B is not categorized into subtypes. There are two vaccines available, The inactivated killed Vaccine & Live attenuated influenza vaccine (LAIV) Both vaccines includes Two type A strains (e.g. H3N2 and H1N1) & One type B strain Influenza vaccine -1 Centers for Disease Control and Prevention. Prevention and control of influenza: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 2005;54 (RR08):1-40

36. Human Papilloma Virus (HPV) • HPV is now implicated as a causative agent > 99% of cervical cancer cases. Also pharyngeal and ano-genital cancers . • Lifetime risk among sexually active men & women - 50%. • Most common sexually transmitted infection in the USA • Genital infections occur via G-G; O-G; H-G and AG contact • The vast majority of infections go unrecognized Richard E. Rupp, ,Susan L. Rosenthal, PhD New Immunization , Strategies for Adolescent Patients A Clinical Guide for Pediatricians,Vol. 19, No. 1 November 2006

37. HPV Vaccines available Quadrivalent HPV vaccine FDA licensed Gardasil, Merck Bivalent vaccine, Cervarix,GSK Biologicals soon Both vaccines protect against HPV types 16 and 18. In clinical phase 2 and 3 trials, both vaccines were found to be safe and effective in females. Quadrivalent vaccine is found to be 100% efficacious against high-grade dysplasia, the predecessor to cervical cancer. Richard E. Rupp, ,Susan L. Rosenthal, PhD New Immunization , Strategies for Adolescent Patients A Clinical Guide for Pediatricians,Vol. 19, No. 1 November 2006

38. HPV vaccine schedule Studies show a rapid rise in ano-genital HPV infections by –15 yrs age hence ensure immunization completed prior to it. 11-12 yrs endorsed by the Society for Adolescent Medicine (SAM), 9-10 yrs left to the discretion of the care provider. 3 doses of HPV given at 0, 2 and 6 months in the Deltoid. Both have stable antibody levels and continued efficacy - 5 years post vaccination. Richard E. Rupp, ,Susan L. Rosenthal, PhD New Immunization , Strategies for Adolescent Patients A Clinical Guide for Pediatricians,Vol. 19, No. 1 November 2006

39. ? ? Parental reaction Major Worry : Stigma related to the sexual transmission of HPV. Vaccine will increase sexual activity among teens. Vaccine will not gain widespread acceptance Studies show Parents decisions based on severity of disease, efficacy and safety of the vaccine; the mode of transmission is less important to them. Once educated about HPV, provided with accurate information in a calm and reassuring way majority of parents have positive response . Diekema DS and the American Academy of Pediatrics Committee on Bioethics. Responding to parental refusals of immunization of children. Clinical Report. Pediatrics. 2005;115:1428-1431

40. How to introduce the topic of HPV vaccine ? • Visit of 10-12 yrs • Open the conversation with parents and adolescents about preventive strategy for all adolescent risk-taking behaviors • Clarify their values about a whole range of subjects (eg, sexuality, drinking) • Be sensitive to parental anxieties and possible discomfort with discussing these subjects. • Then talk of HPV as preventive vaccine for cancer and STD Richard E. Rupp, ,Susan L. Rosenthal, PhD New Immunization , Strategies for Adolescent Patients A Clinical Guide for Pediatricians,Vol. 19, No. 1 November 2006

41. My child is too young to get HPV. Why can’t we wait ? • You could wait. But…Two important reasons to do this now : • The immune response appears to be better in younger girls. • It takes 6 months to be fully immunized and the vaccine has to be given before any risk of exposure. • It makes sense to provide it before any possible exposure might occur.” Diekema DS and the American Academy of Pediatrics Committee on Bioethics. Responding to parental refusals of immunization of children. Clinical Report. Pediatrics. 2005;115:1428-1431

42. Can HPV vaccine be given to boys ? • At present it is only licensed for girls. • The FDA wants more data about boys before they approve it. • Males are a potential target for the vaccine for protection against warts, penile or anal cancer & as a vector for transmission to females. Diekema DS and the American Academy of Pediatrics Committee on Bioethics. Responding to parental refusals of immunization of children. Clinical Report. Pediatrics. 2005;115:1428-1431

43. Don’t you think it will encourage my daughter to having early and risky sex? “Does telling young people to wear bicycle helmets or seatbelts encourage anyone to bicycle or drive recklessly”? Your child may never be at risk for HPV infection, or may not be at risk for many years, but we are recommending that all girls get this before anyone is at risk of infection. It is very effective at this age and vaccinating now eliminates the worry about risk into adulthood. Diekema DS and the American Academy of Pediatrics Committee on Bioethics. Responding to parental refusals of immunization of children. Clinical Report. Pediatrics. 2005;115:1428-1431

44. Risk of serious Pneumococcal disease is relatively low, not recommended for routine use . Recommended in; anatomic or functional asplenia (also sickle cell ),nephritic syndrome, CSF leak, immunosuppression Revaccination :>5 yrs after the 1st dose,highest risk for serious Pneumococcal infection and rapid waning of antibodies, Spleenic dysfunction, Sickle cell disease, HIV infection, Hodgkin’s disease, Lymphoma, Multiple myeloma, Chronic renal failure, Nephritic syndrome, undergoing organ transplantation and receiving chemotherapy Pneumococcal vaccine

45. Establish a platform for adolescent immunization Provider and professional recommendation School based immunization requirements State based immunization laws Education and awareness programs Strategies to increase adolescent immunisationIncreasing Demand

46. Pediatricians need to update periodically about new recommendations Students going abroad will come for advise and certificates Newer vaccines New recommendations for Booster doses Preventive /prophylactic vaccines Key messages

47. Example of Chicken POX coverage in Schools

48. It is an infectious disease caused by the varicella-zoster virus. It results in a blister-like rash, itching, tiredness and fever.  The rash appears first on the trunk and face, but can spread over the entire body causing between 250 to 500 itchy blisters. Most cases of chickenpox occur in persons less than 15 years old. Can cause at least 5-6 days of school loss. Prior to the use of varicella vaccine, the disease had annual cycles, peaking in the spring of each year. CHICKENPOX:IT’S MORE SERIOUS THAN YOU THINKWHAT IT IS ????

49. Bacterial infections which can involve many sites of the body including the skin, tissues under the skin, bone, lungs (pneumonia), joints and the blood. Due to the virus infection directly – include viral pneumonia, bleeding problems and infection of the brain (encephalitis). It may lead to Herpes Zoster later in life – vaccine protects from this as well CHICKENPOX:What are the serious complications from chickenpox?

50. In a recent study, 7 out of 10 children preferred a shot over natural disease. 7 out of 10 children considered chickenpox to be worse than many other common childhood ailments, including colds, earaches, sore throat, and fever. The study also found that 3 out of 4 parents are unaware that death is a potential complication of chickenpox. Do children prefer vaccination over having chickenpox ?