FPO-Faculty Disclosure Click to add subtitle
Table of Contents PROTECTTMSupPorting AppROpriate ImmunizaTions Across the AgE SpeCTrum Childhood Childhood Vaccines Combination Vaccines Addressing Parental Concerns Strategies for Improving Childhood Immunization Rates Adolescent Adolescent Vaccines Strategies for Improving Adolescent Immunization Rates Adult Adult Vaccines Strategies for Improving Adult Immunization Rates General Immunization Information for All Age Groups Vaccine-preventable Diseases General Strategies for Improving Immunization Rates Resources
Educational Learning Objectives At the conclusion of this presentation, the participant should be able to: Discuss the indications and recommendations for the most current immunization schedules for childhood, adolescent, and adult populations Respond to frequently encountered questions and situations during patient discussions including safety, efficacy, and possible misinformation Implement strategies for improving immunization rates within one’s clinical practice, taking into account current immunization schedules and guidelines
Routine Childhood Immunization Schedule, 1983 DTP DTP DTP DTP Td DTP VACCINE OPV OPV OPV* OPV OPV MMR DTP = Diphtheria, tetanus, pertussis OPV = Oral polio (trivalent) MMR = Measles, mumps, rubella *A third dose of OPV is optional but may be given in areas of high endemicity for poliomyelitis CDC. MMWR Morb Mortal Wkly Rep. 1983;32(1):1-8,13-17.
2010 Child Immunization Schedule HepB = Hepatitis B; RV = Rotavirus; DTaP = Diphtheria, Tetanus, Pertussis; Hib = Haemophilus influenzae type b; PCV = Pneumococcal; IPV = Inactivated Poliovirus; MMR = Measles, Mumps, Rubella; HepA = Hepatitis A; MCV = Meningococcal; PPSV = Pneumococcal Polysaccharide ACIP Schedules. http://www.cdc.gov/vaccines/recs/schedules/default.htm. Accessed Jan 2010.
Childhood Catch-up Schedule ACIP Schedules. http://www.cdc.gov/vaccines/recs/schedules/default.htm. Accessed Jan 2010.
Vaccination Coverage Children 19–35 Months, United States, N = 18,430 100 2004 2005 90 2006 2007 2008 80 70 60 50 Vaccination Coverage (%) 40 30 20 10 * 0 DTaP/DT DTaP/DT Poliovirus MMR ≥ 1 Dose Hib ≥ 3 Doses Hepatitis B ≥ 3 Doses Varicella PCV7 PCV7 Hepatitis A ≥ 3 Doses ≥ 4 Doses ≥ 1 Dose ≥ 3 Doses ≥ 4 Doses ≥ 2 Doses *Data for previous years not available CDC. MMWR Morb Mortal Wkly Rep. 2009;58(33):913-940.
2008–2010 Changes in Child Schedule Influenza Universal annual vaccination ≥ 6 months Rotavirus Two schedules available: age 2, 4 mos and age 2, 4, and 6 months Polio Emphasize importance of booster dose at age ≥ 4 yrs Meningococcal Conjugate Vaccine Two vaccines now approved; MCV4-D (Menactra®) and MenACWY-CRM197 (Menveo®) Booster Hib Booster reinstatement, shortage issues are over Pneumococcal Addition of PCV13 Booster for PPSV23
Immunization Timelines • 8% of children immunized too early to be valid • 58% of children received at least one vaccine later than recommended • Thirty-five million adolescents may be missing at least one recommended vaccination Luman ET, et al. Pediatrics. 2002;110:935-939.
Hepatitis B • Dose 3 should be administered ≥ 16 wk after dose 1 • Combination vaccines cannot be used for the birth dose * HB Immunoglobulin should also be administered at birth for infants whose mothers are HBsAg positive Adapted from Table 1, ACIP General Recommendations on Immunization: MMWR Recomm Rep. 2006;55(RR-15):1-48.
Hepatitis B Perinatal Transmission* • If mother positive for HBsAg and HBeAg • 70%–90% of infants infected • 90% of infected infants become chronically infected • If positive for HBsAg only • 5%–20% of infants infected • 90% of infected infants become chronically infected *in the absence of postexposureprophylaxis
Why Rotavirus? > 400,000 physician visits > 200,000 ED visits > 50,000 hospitalizations > $1 billion in total health care costs CDC. MMWR Recomm Rep. 2006;55(RR12):1-13.
Rotavirus Vaccines and Schedules CDC. MMWR Recomm Rep. 2009;58(RR2):1-25.
Rotavirus Vaccine Harmonized Recommendations “..vaccination should not be deferred because the product used for previous dose(s) is not available or is unknown. In these situations, the provider should continue or complete the series with the product available. If any dose in the series was RV5, or the vaccine product is unknown for any dose in the series, a total of 3 doses of rotavirus vaccine should be administered.” CDC. MMWR Recomm Rep. 2009;58(RR2):1-25.
Rotarix−FDA Advisory • The FDA is recommending that health care providers temporarily suspend the use of Rotarix vaccine for rotavirus immunization in the United States while the agency learns more about components of an extraneous virus detected in the vaccine. • An independent research team using a novel technique found DNA from porcine circovirus 1 (PCV1) in Rotarix. • PCV1 is not known to cause illness in humans or other animals. Rotarix has been studied extensively before and after approval, and found to have an excellent safety record. There is no current evidence of a safety risk; the temporary suspension is a precautionary move. • Children with incomplete Rotarix series should complete the series with RV5 (RotaTeq). This will require 3 total rotavirus vaccine doses to be a complete series. FDA. http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm205625.htm. Accessed March 2010.
Rotavirus Contraindications History of serious allergic reaction to a previous dose of vaccine History of severe hypersensitivity to any component of the vaccine Precautions Altered immunocompetence Moderate to severe illness, including acute gastroenteritis Preexisting chronic gastrointestinal disease Previous history of intussusception CDC. MMWR Recomm Rep. 2009;58(RR2):1-25.
Family Physicians and Rotavirus Vaccine 2008 Survey* 45% provided rotavirus vaccine on site ½ rate of other vaccines 35% referred elsewhere 24% did neither 3x rate of other vaccines *Campos-Outcalt D, et al. Immunization Practices of Family Physicians. 43rd National Immunization Conference, Dallas TX, March 31, 2009. Abstract PS19.
DTaP • Dose 5 not needed if dose 4 is given after age 4 yrs Adapted from Table 1, ACIP General Recommendations on Immunization. CDC. MMWR Recomm Rep. 2006;55(RR15):1-48.
Hib • Dose at 6 mo of age not necessary if first 2 doses are PRP-OMP • Fewer doses required if series initiated at ≥ 7 mo of age • Supply shortage over, reinstate 12-15 mo booster and catch-up • Approved products • –PedvaxHib (Merck) • –ActHIB (Sanofi) • –Hiberix (GSK)---booster only CDC. MMWR Morb Mortal Wkly Rep. 2009;58(24):673-674.
Summer 2009 HIB Updated Recommendations Re-institute routine booster Catch up on those who missed their booster at their next regular check up No recall of all those who missed booster immediately Changed in late summer to recall of those who missed CDC. http://www.cdc.gov/vaccines/vac-gen/shortages/downloads/hib-hcp-ltr-7-30-09.pdf. Accessed September 2009. CDC, personal communication.
Hib Products *Can immunize through age 59 months Haemophilus influenzae type b. http://www.cdc.gov/vaccines/pubs/pinkbook/downloads/hib.pdf. Accessed September 2009. HIBERIX PI. http://www.fda.gov/downloads/BiologicsBloodVaccines/Vaccines/ ApprovedProducts/UCM179530.pdf. Accessed September 2009.
PCV7 ACIP Schedules. http://www.cdc.gov/vaccines/recs/schedules/default.htm. Accessed Sept 2009.
13-Valent Pneumococcal Conjugate Vaccine(PCV13) • Licensed by FDA on February 24, 2010 • Serotypes in PCV13 • PCV7 types: 4, 6B, 9V, 14, 18C, 19F, 23F • Additional serotypes: 1, 3, 5, 6A, 7F, 19A • Approved for use in children 6 weeks through 5 years (before the 6th birthday) • 4-dose series at ages 2, 4, 6, and 12-15 months • Indications • Prevention of invasive pneumococcal disease (IPD) caused by the 13 vaccine serotypes • Prevention of otitis media caused by PCV7 serotypes CDC. MMWR Morb Mortal Wkly Rep. 2010;59(9):258-261.
PCV13 Recommended Schedules for Children < 24 months CDC. http://www.cdc.gov/vaccines/recs/provisional/downloads/pcv13-mar-2010-508.pdf. Accessed March 2010.
Transition from PCV7 to PCV13 According to Number of Doses Previously Received *No additional PCV13 doses are indicated for children 12-23 months who received 2 or 3 doses or PCV7 before age 12 months and at least 1 dose of PCV13 at age ≥ 12months **For children with underlying medical conditions, a supplemental PCV13 dose is recommended through 71 months of age CDC. MMWR Morb Mortal Wkly Rep. 2010;59(9):258-261.
PCV13 Recommended Schedules for Children ≥ 24 months *For children who have underlying medical conditions, a supplemental PCV13 dose is recommended through 71 months of age CDC. http://www.cdc.gov/vaccines/recs/provisional/downloads/pcv13-mar-2010-508.pdf. Accessed March 2010.
PCV13 – Children 6 through 18 Years of Age with High-risk Conditions • A single dose of PCV13 may be administered for children 6 through 18 years of age who are at increased risk for invasive pneumococcal disease because of their sickle cell disease, HIV infection or other immunocompromising condition, cochlear implant or cerebrospinal fluid leaks, regardless of whether they have previously received PCV7 or PPSV23 This recommendation is an off-label use of PCV13, which is indicated for children 6 weeks through 5 years of age (prior to the 6th birthday) CDC. http://www.cdc.gov/vaccines/recs/provisional/downloads/pcv13-mar-2010-508.pdf. Accessed March 2010.
PPSV23 After PCV13 for Children ≥ 2 years of Age with Underlying Medical Conditions Doses of PCV13 should be completed before PPSV23 is given. No more than 2 PPSV23 doses are recommended. CDC. http://www.cdc.gov/vaccines/recs/provisional/downloads/pcv13-mar-2010-508.pdf. Accessed March 2010.
Transition from PCV7 to PCV13 • When PCV13 is available in office, unvaccinated and incompletely vaccinated children should receive PCV13 (not PCV7) • If only PCV7 is available in office, unvaccinated and incompletely vaccinated children should receive PCV7; these children should complete the series with PCV13 at subsequent visits • Children for whom the supplemental PCV13 dose is recommended should receive it at their next medical visit. Active recall is not being recommended CDC. MMWR Morb Mortal Wkly Rep. 2010;59(9):258-261.
PPSV23 • Second dose recommended for individuals at highest risk • Second dose is recommended 5 years after first dose in age ≥ 2 years who are immunocompromised, have sickle cell disease, or functional or anatomic asplenia • Routine use not recommended for Alaskan Native or American Indian • children ages 24-59 months • – May be recommended by local health departments based on community epidemiology Adapted from Table 1, ACIP General Recommendations on Immunization. MMWR Recomm Rep.2006;55(RR15):1-48. ACIP Provisional Recommendations.www.cdc.gov/vaccines/recs/provisional/ downloads/pneumo-Oct-2008-508.pdf. Accessed September 2009.
IPV • *In first 6 months of age, 2 mo intervals are recommended unless • accelerated dosing is needed (eg, travel) • Last dose after age 4 • - 6 mo minimum interval from penultimate dose • DTaP-IPV-Hib (Pentacel): 4 doses at age 2, 4, 6, and 15-18 mos will require a 5th dose at 4-6 years with an age-appropriate IPV vaccine Adapted from Table 1, ACIP General Recommendations on Immunization. MMWR Recomm Rep.2006;55(RR15):1-48. CDC. MMWR Morb Mortal Wkly Rep. 2009;58(30):829-830.
Annual Influenza Vaccine is Recommended for: All people age 6 months and older! CDC. http://www.cdc.gov/vaccines/recs/provisional/downloads/flu-vac-mar-2010-508.pdf. Accessed March 2010.
Seasonal Influenza Vaccination Status of Children 6–23 mos & 2–4 yrs, United States 2007–08 season: 6–23 months, N = 302,333; 2–4 years, N = 808,711 2008–09 season: 6–23 months, N = 263,597; 2–4 years, N = 767,422 CDC. MMWR Morb Mortal Wkly Rep. 2009;58(38):1059-1090.
TIV • *Two doses (4 wks apart) are given for children 6 mo through 8 yr of age who are receiving influenza vaccine for the first time • If 2nd dose is missed during first vaccination season, • administer two doses during next season • Seasonal influenza products will not confer protection against • pandemic H1N1 strains • Pandemic H1N1 vaccine available CDC. MMWR Recomm Rep. 2009;58(RR8):1-52.
LAIV • * Two doses are given for children 2 through 8 yr of age who are receiving influenza vaccine for the first time • If 2nd dose is missed during first vaccination season, administer two doses during next season CDC. MMWR Recomm Rep. 2009;58(RR8):1-52.
Trivalent Inactivated (TIV) and Live Attenuated Influenza Virus (LAIV) Vaccines CDC. MMWR Recomm Rep. 2009;58(RR8):1-52.
Two Doses for Children Under 9 Years of Age Regardless of whether a child receives LAIV or TIV, those younger than 9 years of age who are receiving influenza vaccine for the first time should receive 2 doses, 4 weeks apart. If a child received only 1 dose in the first year, he or she should receive 2 doses, 4 weeks apart, the following year. CDC. MMWR Recomm Rep. 2009;58(RR8):1-52.
Trivalent Inactivated Virus (TIV) versus Live Attenuated Influenza Virus (LAIV) Vaccines TIV • Licensed for use in persons age ≥6 mos • Intramuscular injection • TIV contains purified viral particles that have been chemically inactivated • Purified components from 3 WHO-recommended annual strains • Immunity developed against disrupted/denatured viral proteins, not against intact virus LAIV • Licensed for use among nonpregnant persons aged 2-49 years • Administered by nasal spray • LAIV contains intact virus that has been propogated in eggs at 25ºC • Cold-adaptation results in restricted replication at body temp • More mild flu symptoms • Contains same 3 WHO-recommended annual strains as TIV CDC. MMWR Recomm Rep. 2009;58(RR8):1-52. Flumist Prescribing Information. www.flumist.com. Accessed Oct 2009.
2009–2010 Seasonal Influenza Vaccines • 2009–2010 seasonal influenza vaccine formulation: • A/Brisbane/59/2007(H1N1)-like virus • A/Brisbane/10/2007 (H3N2)-like virus • B/Brisbane/60/2008-like antigens • Vaccines Trivalent Inactivated, Injectable Influenza Vaccine • Fluzone® (sanofi): age ≥ 6 months • Fluvirin® (Novartis): age ≥ 4 years • Fluarix® (GSK): age ≥ 3 years • FluLaval™ (ID Biomedical/GSK): age ≥ 18 years • Afluria® (CSL): age ≥ 6 months Live Attenuated, Nasal Spray Influenza Vaccine • FluMist® (MedImmune): age 2 through 49 years (healthy, non-pregnant) • Seasonal 2009 influenza vaccine does not protect against 2009 (pandemic) H1N1 influenza CDC. MMWR Recomm Rep. 2009;58(RR8):1-52. CDC. http://www.fda.gov/BiologicsBloodVaccines/Vaccines/ApprovedProducts/ucm094045.htm. Accessed March 2010.
2009 H1N1 (Pandemic) Influenza Vaccines As of November 11, 2009: 4 monovalent inactivated vaccines approved • CSL Limited • Age 6-35 mos: Two 0.25 mL IM doses (4 wk interval) • Age 36 mos to 9 yrs: Two 0.5 mL IM doses (4 wk interval) • Age ≥ 10 yrs: Single 0.5 mL IM injection • Adults ≥ 18 yrs: Single 0.5 mL IM injection • Novartis Vaccines and Diagnostics Limited • Age 4-9 yrs: Two 0.5 mL IM doses (4 wk interval) • Age 10-17 yrs: Single 0.5 mL IM injection • Age ≥ 18 yrs: Single 0.5 mL IM injection • Sanofi Pasteur, Inc. • Age 6-35 mos: Two 0.25 mL IM doses (4 wk interval) • Age 36 mos to 9 yrs: Two 0.5 mL IM doses (4 wk interval) • Age ≥ 10 yrs: Single 0.5 mL IM injection • Adults ≥ 18 yrs: Single 0.5 mL IM injection • ID Biomedical/GSK • Adults ≥ 18 yrs: Single 0.5 mL IM injection 1 live attenuated (nasal administration) • MedImmune LLC • Age 2-9 yrs: Two 0.2 mL doses (0.1 mL per nostril), 4 week interval • Age 10-49 yrs: Single 0.2 mL dose (0.1 mL per nostril) Prescribing information available at: http://www.cdc.gov/h1n1flu/vaccination/dosage.htm#table1. Accessed December 2009.
2010–2011 Influenza Season • Universal Influenza Vaccination • All people 6 months and older are now recommended to receive annual influenza vaccination • 2010-2011 Trivalent Influenza Vaccines: • A/California/7/2009(H1N1)-like virus • Same strain as in the 2009 H1N1 monovalent vaccine • A/Perth/16/2009(H3N2)-like virus • New strain for northern hemisphere vaccine • Same strain as 2010 southern hemisphere seasonal strain • B/Brisbane/60/2008-like virus • No change CDC. http://www.cdc.gov/vaccines/recs/provisional/downloads/flu-vac-mar-2010-508.pdf. March 2010.
2010–2011 Influenza Season Continued Emphasis on High-risk Groups: • Children aged 6 months through 4 years • Adults ≥ 50 years • Women who will be pregnant during the influenza season • Persons who have chronic pulmonary, cardiovascular, renal, hepatic, neurological, neuromuscular, hematological or metabolic disorders • Persons who have immunosuppression (including caused by medication or HIV) • Residents of nursing homes and other chronic-care facilities • Health care personnel • Household contacts and caregivers of children aged < 5 year and adults aged ≥ 50 years, with particular emphasis on vaccinating contacts of children < 6 months • Household contacts and caregivers of persons with medical conditions that put them at higher risk for severe complications from influenza CDC. http://www.cdc.gov/vaccines/recs/acip/downloads/mtg-slides-feb10/05-7-flu-vac.pdf. Accessed March 2010.
MMR • May be administered as MMRV if 12 mo-12 yr of age, but minimal interval • is 3 mo ACIP Summary Recommendations. www.immunize.org/catg.d/p2010.pdf. Accessed Oct 2009.
Varicella Varicella photo. http://www.cdc.gov/vaccines/vpd-vac/varicella/photos.htm. Accessed September 2009.
Varicella • Second dose At ≥ 3 months if 1st dose for age < 13 yrs At ≥ 4 weeks if 1st dose for age > 13 yrs • “MMRV vaccine can be used in place of trivalent MMR vaccine and monovalent varicella vaccine to implement the recommended 2-dose vaccine policies for prevention of measles, mumps, rubella, and varicella” • Note: a two-fold increase in the risk of febrile seizures is associated with MMRV versus MMR and Varicella vaccines administered separately and simultaneously CDC MMWR Recomm Rep. 2007;56(RR04):1-40. CDC. MMWR Morb Mortal Wkly Rep. 2008;57(10);258-260 Broder K, et al. Presented at the ACIP June 25, 2009.
Hepatitis A • New recommendations for families of international adoptees ACIP Summary Recommendations. http://www.immunize.org/catg.d/p2010.pdf. Accessed September 2009. CDC. MMWR Morb Mortal Wkly Rep. 2009;58(36):1006-1007.
Hepatitis A: Families of International Adoptees • Hepatitis A vaccination is recommended for all previously unvaccinated persons who anticipate close personal contact with an international adoptee from countries of high or intermediate endemicity during the first 60 days following arrival in the US. • The first dose of hepatitis A vaccine should be administered as soon as adoption is planned. Ideally, the first dose of hepatitis A vaccine should be administered at least two weeks prior to the arrival of the adoptee. CDC. MMWR Morb Mortal Wkly Rep. 2009;58(36):1006-1007.
General Principles • The only vaccines that cannot be given at the same time are smallpox and varicella • Minimal intervals apply to • Doses of the same inactivated vaccine • Doses of the same live vaccine • Doses of different live vaccines not given simultaneously, except • Oral typhoid Ty21a vaccine • Rotavirus vaccine • Minimal intervals do not apply to doses of different inactivated vaccines • Minimal intervals define catch-up schedules • A 4-day grace period is granted to all vaccine doses • Rabies vaccine is an exception • Local regulations may not allow a grace period Marshall, GS. The Vaccine Handbook: A Practical Guide for Clinicians. West Islip, NY:Professional Communications, Inc.;2008.