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Adolescent Vaccines

Adolescent Vaccines . Convener IPA ( International Pediatric Association ) Adol Interest group . Swati Y Bhave . Member Technical Steering Committee Child & Adol section WHO HQ Geneva from 2007 . Member Regional Technical Advisory Group Adol section WHO SEARO from 2004 .

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Adolescent Vaccines

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  1. Adolescent Vaccines Convener IPA ( International Pediatric Association ) Adol Interest group Swati Y Bhave Member Technical Steering Committee Child & Adol section WHO HQ Geneva from 2007 Member Regional Technical Advisory Group Adol section WHO SEARO from 2004 Symposium of IAP Adol Chapter PEDICON 2007

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

  3. Polysaccharide Meningococcal Vaccine -1 • Capsular polysaccharides vaccines successfully protect against • sero groups A, C, Y and W-135. • But protection wanes after few years Use limited to high-risk populations military recruits, travelers, freshman students college dormitories. Other risk factors Cigarette smoking, Bar patronage, Recent URTI American Academy of Pediatrics, Committee on Infectious Diseases. Prevention and control of meningococcal disease: recommendations for use of meningococcal vaccines in pediatric patients. Pediatrics. 2005;116:496-505

  4. Conjugate Meningococcal vaccine -2 • Newer conjugate vaccine links capsular polysaccharides ( A, C, Y, and W-135) to a protein carrier (diphtheria toxoid) • Induces immunologic memory, longer-term immunity, ↓ NP carriage ↓ transmission – nonvaccinated in the community. Unfortunately • B, C and Y account for most disease in the United States. • B :1/3 of total and nearly 25% of disease in 11-18 yrs Centers for Disease Control and Prevention. Prevention and control of meningococcal disease. Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2005;54 (RR07):1-21

  5. Meningococcal vaccine schedule -3 • 2005, FDA licensed M conjugate vaccine (MCV4) [ Menactra (Sanofi Pasteur)] for people 11 to 55 yrs. • AAP and ACIP recommend routine MCV-4 to adolescents 11 to 12 yrs and high school entry at 15 yrs • The goal is to vaccinate all adolescents at age 11 by 2008. • ACIP also recommends immunization of college freshman living in dormitories and other high-risk groups. Possible association between Guillain-Barré Syndrome (GBS) and (MCV4) reported in October 2005. ACIP recommends continuation but avoid in GBS patients Richard E. Rupp, ,Susan L. Rosenthal, PhD New Immunization , Strategies for Adolescent Patients A Clinical Guide for Pediatricians,Vol. 19, No. 1 November 2006

  6. Influenza vaccine -1 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 (eg H3N2 and H1N1) & One type B strain 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

  7. Influenza Vaccine -2 Recommended strains may change annually depending on patterns observed from global surveillance. Three strains of virus strains expected to circulate in the community in the winter The inactivated influenza vaccine contains killed, partially purified viruses. IM inj . • All of the groups for which annual influenza vaccination is indicated may receive the inactivated vaccine Medical conditions at increased risk – Pulmonary or cardiovascular disease, Neuromuscular dysfunction, Immuno-suppression, Long-term aspirin therapy.

  8. LAVI (Live Attenuated Influenza Vaccine ) -3 • The LAIV licensed USA- FluMist (MedImmune, Inc.). • The attenuated viruses produce either mild symptoms (eg, sore throat) or none at all. • Intra nasally annually to optimize protection. • Given only to healthy persons 5 to 49 yrs of age who are not in contact with severely immuno-suppressed persons. • Both vaccines are made from viruses grown in eggs /avoid in allergy to chicken or egg protein

  9. IAP recommendation JE vaccine – GOI/PATH project • Live attenuated SA14-14-2 vaccine from CDIBP, China • Single dose, lyophilized One time campaign targeting 1-15 year old • The available m-b derived vaccine in the country will be utilised in AP & Tamil Nadu • JE vaccine should be used for universal immunization of all children in 1-3 years in endemic areas with 3 primary doses • Boosters every 2 years till 10-15 years of age. • JE vaccine is not for out break response during epidemics.

  10. e-IPV for adol and adults Booster doses not required endemic countries – Natural boosting - wild virus -likely to be a continual process that maintains immunity. WHO recommends travellers industrialized countries to endemic area. Previously vaccinated one additional dose of polio vaccine Unvaccinated full course of primary vaccination Route & Site: SC or IM in the deltoid region. IPV trace amount of streptomycin, neomycin, and polymyxin B, http://www.cdc.gov/nip

  11. Primary vaccination for adults and adol Guidelines 2 doses 4 to 8 weeks apart, with a third dose given 6 to 12 months later. If 2 to 3 months remain before protection is needed, • give 3 doses of e-IPV >4weeks apart. If only 1 or 2 months remain, • give 2 doses of e-IPV 4 weeks apart. If < 4 weeks remains, • give a single dose of e-IPV. CDC poliomyelitis Report (IMMP-44)

  12. Primary vaccination for adults & adolGuidelines adults : increased risk of exposure Single dose of e-IPV who have completed a primary series with any poliovirus vaccine Give >1 dose of e-IPV to who have had >1 dose of OPV,<3 doses of conventional IPV (available before 1988), or a combination conventional IPV and OPV totaling < 3 doses. • If time permits, give additional doses needed to complete a primary series. Do not count doses within the minimum interval, : too short an interval may interfere with antibody response and protection from disease. • Increasing the interval beyond the recommended timing does not affect the ultimate efficacy of immunization,: waiting does delay achieving adequate protection from infection. ACIP. Supplementary chart: Recommended Childhood Immunization Schedule, United States, Approved by ACIP, AAP,AAFP

  13. Human Papilloma Virus (HPV) • Most common sexually transmitted infection in the USA • Genital infections occur via G-G .O-G H-G and AG contact • Lifetime risk among sexually active men& women - 50%. • The vast majority of infections go unrecognized • HPV is now implicated as a causative agent > 99% of cervical cancer cases • Also pharyngeal and ano-genital cancers . • 100 types of HPV identified • 30 -40 types infect ano-genital region. • Low-risk and high-risk oncogenic potential • 15 -20 oncogenic • HR HPV 16 /18 - 70% cancer LR HPV 6 / 11) Richard E. Rupp, ,Susan L. Rosenthal, PhD New Immunization , Strategies for Adolescent Patients A Clinical Guide for Pediatricians,Vol. 19, No. 1 November 2006

  14. 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. Quadrivalent also contains VLPs for HPV 6/11, genital warts. 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

  15. HPV vaccine schedule Studies show a rapid rise in ano-genital HPV infections by –15 yrs age Ensure immunization completed prior to potential exposure 11-12 yrs endorsed by the Society for Adolescent Medicine (SAM) 9-10 yrs left to the discretion of the care provider. Some have argued that vaccinating at age 11 to 12 is too early, as the duration of immunity is unknown. 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. CMI response long duration of protection 15 years of age and younger higher titers than older teens and adults. Richard E. Rupp, ,Susan L. Rosenthal, PhD New Immunization , Strategies for Adolescent Patients A Clinical Guide for Pediatricians,Vol. 19, No. 1 November 2006

  16. ?? 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

  17. How to broach the topic of HPV vaccine ? • Visit of 10-12 yrs • open the conversation with parents and adolescents • preventive strategy for all adolescent risk-taking behaviors • parental communication and supervision. • 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

  18. 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.” 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

  19. 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. Most important prevention strategy for helping teens make wise decisions is for parents to talk to them about values and for parents to pay attention to what they are doing and with whom. 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

  20. Cytomegalovirus Vaccine status • Vaccine strategies have included a live attenuated virus and the use of viral surface glycoproteins. • The glycoprotein vaccine (CMV gB) is furthest along in development, • a phase 2 clinical trial in adolescent females currently underway. • Speculation about when a CMV vaccine might become available is premature at this time. Schleiss, M. Progress in cytomegalovirus vaccine development. Herpes. 2005;12:66-75

  21. Herpes Simplex Vaccine • Genital disease HSV1 /more commonly HSV2. • Public health perspective - important that vaccine ↓frequency & magnitude of virus shedding. • Universal immunization of young girls can ↓HSV-2 : both men and women • The vaccine furthest along in development, • GSK Biologicals, : recombinant truncated HSV-2 g D (an envelope glycoprotein) • Two large trials efficacy of 73% - 74% in preventing genital herpes disease in HSV-1 and HSV-2 seronegative women, • But did not provide men or HSV-1 seropositive women any protection. Stanberry LR, Spruance SL, Cunningham AL, et al. Glycoprotein-D-adjuvant vaccine to prevent genital herpes. N Engl J Med. 2002;347:1652-61

  22. Pneumococcal vaccine check vaccine name Risk of serious Pneumococcal disease is relatively low . Not recommended for routine use. Recommended in groups higher risk anatomic or functional asplenia (also sickle cell ), nephritic syndrome, CSF leak, immunosuppression. Revaccination : highest risk for serious Pneumococcal infection and rapid waning of antibodies ,provided > 5 years have passed since administration of the first dose. Spleenic dysfunction, Sickle cell disease, HIV infection, Hodgkin’s disease, Lymphoma, Multiple myeloma, Chronic renal failure, Nephritic syndrome, undergoing organ transplantation and receiving chemotherapy.

  23. HIV VACCINE • Feb 2003, Vax Gen announced their product AIDSVAX was a failure because the circulating HIV strain hides its epitopes in a variety of ways that genetically engineered gp 120 proteins do not mimic successfully. • ALVAC-HIV, a genetically engineered HIV vaccine composed of a live,attenuated Canary pox virus into which parts of genes for non-infectious components of HIV are inserted is said to be promising. 17 candidates are in phase I/II trials. • National Institute of allergy and infectious diseases (NIAID) and Merk & Co sponsored trials with ALVAC-HIV is expected to be completed in four-and-a -half years since January 26, 2005 and results are expected by 2010.

  24. Key messages • 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

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