Immunizations What to DO

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ImmunizationsWhat to DO

• Stanley E. Grogg, DO, FACOP
• Professor of Pediatrics
• Ok State Univ-COM
• AOAs Liaison to CDCs Advisory Committee on
  Immunization Practices (ACIP)

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Disclosures

• Speakers Bureaus
• AstraZeneca
• GSK
• Merck
• Pfizer
• Sanofipasteur
• Consultant
• Merck
• Novartis

• Primary Investigator in research studies
• Astellas
• GSK
• Merck
• MedImmune
• Novartis
• Sanofipasteur
• Wyeth

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Learning objectives

• After the presentation, the attendee should be
  able to
• Better understand the contraindications/precaution
  s for vaccines
• Know the differences between conjugate and
  polysaccharide vaccines
• Provide recommendations if the wrong vaccine is
  administered
• Communicate to the patient the benefits of
  vaccines
• Feel knowledgeable about the latest ACIP
  recommendations
• Understand pandemic conditions

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Great Web References

• www.cdc.gov
• http//www.cdc.gov/vaccines/recs/acip
• http//www.cispimmunize.org
• http//www.cdc.gov/vaccinesafety
• http//www.cdc.gov/flu/pandemic

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Comment

• Recommended immunization schedule has become
  increasingly complex
• Infants and young children now receive vaccines
  to protect against 14 different infections
• Requiring as many as 26 inoculations by 2 years
  of age
• It is an enormous challenge for health care
  providers to make sure that everyone is immunized
  correctly and on time

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Dr. BobsAlternative Vaccine Schedule
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If a parent is unable to produce documentation
but insists that their child received the vaccine
doses, what should you do?

• Only accept written, dated records as evidence of
  vaccination
• Attempt to locate missing records
• Contact previous healthcare providers
• Review state or local immunization information
  systems
• In general, receiving extra doses of vaccine
  poses no medical problem
• May increase risk of local adverse reaction
• On the other hand, do you ever need to restart a
  series?
• NO just continue where the series left off

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What vaccine preventable disease in 2008 has the
highest incidence since 1997?

• Pertussis
• Rubella
• Mumps
• Chickenpox
• Measles
• And in 2009 H. Flu disease has been reported
• (Infectious Diseases in Children September 2008)

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Thursday, May 01, 2008

• Looks like VHS will be gone long before Measles
• Measles is back...with a bit of an epidemic
  vengeance
• CNN reports 64 cases in 9 states. Not
  surprisingly, all but one were unvaccinated. The
  CDC singles the problem to improper vaccination
  practices abroad

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Comment

• Many vaccine-preventable diseases have been
  completely or virtually eliminated from the USA
• Young parents do not see the diseases they are
  asked to prevent
• So vaccination becomes a matter of faith
• In health care professionals
• In public health officials
• In pharmaceutical companies
• This kind of faith is in short supply we live in
  a cynical, distrustful time

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Anti-vaccine Myths

• Because parents today are much less likely than
  their parents to fear vaccine-preventable
  diseases
• They are much more likely to fear vaccine side
  effects, real or imagined
• The media has not helped here

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All of the following are true of vaccinations
EXCEPT

• Drastically reduced cases of dangerous and
  life-threatening disease
• Directly help to protect an individual against
  diseases
• Indirectly protect an individual by reducing the
  number of people who carry disease-causing
  organisms (herd effect)
• Risks of NOT immunizing far outweigh the risks of
  immunizing
• Children who are not immunized are NOT potential
  carriers of the vaccine preventable diseases

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All of the following are true EXCEPT

• Children encounter LESS immunological components
  from vaccines today than they did 30 years ago
• Giving several vaccines at one time does NOT
  overwhelm a childs immune system
• Delaying vaccines is NOT risky
• The FDA requires extensive safety testing before
  vaccines are licensed
• Vaccines that protect against bacterial diseases
  are made from many components including
  inactivated bacterial proteins (DPT) or bacterial
  sugars called polysaccharides (Hib, pneumococcal)

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AAPs Vaccine Refusal Form

• AAPs 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

http//www.cispimmunize.org/pro/pdf/RefusaltoVacci
nate_revised204-11-06.pdf
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Diseases which should be in the pasthow quickly
we forget?
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Vaccines can be administered in all of the
following except

• Mild acute illness with or without fever
• Mild-to-moderate local reaction (swelling,
  redness, soreness) after previous dose
• Current antimicrobial use
• Serious allergic reaction (e.g. anaphylaxis)
  after a previous vaccine dose
• Lack of previous physical exam in well appearing
  person

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Vaccines can be administered in all of the
following except

• The only real contraindication applicable to all
  vaccines is a history of a severe allergic
  reaction after a previous dose of vaccine or to a
  vaccine constituent
• Unless the recipient has been desensitized

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What would you DO?

• A 4 month-old develops encephalopathy 7 days
  after administration of the 2nd DTaP vaccine.
  What would you administer at 6 months?
• Give a tetanus only (not diphtheria nor
  pertussis)
• Give TD (not pertussis)
• Give DTaP
• Give ½ dose of DTaP
• Not administer vaccines

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Rotavirus Vaccine (RV1, RV5)

• A 3-mon-old comes into your office for his first
  set of immunizations. Would you recommend a RV
  vaccine?
• Yes
• No
• Minimum age for vaccination 6 weeks
• Vaccination should not be started after 15 weeks
  of age
• 3rd dose should not be given after 8 months of
  age

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Harmonized Schedule RV Vaccine
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18 yr-old going to college and living in dormitory

• At age 11, this young lady went on a mission trip
  to sub-Saharan Africa and received a Menomune
  vaccine. She is now going to college (early Oct)
  and will be living in a dormitory. What would you
  recommend?
• Repeat Menomune
• No further meningococcal vaccine is necessary
• Give Menactra vaccine only
• Up date Tdap, influenza, HPV, MMR-V, and Menactra
• IF 5 years since Menomune

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The CDC's Advisory Committee on Immunization
Practices (ACIP Oct. 2008)

• Routine meningococcal vaccination for all
  adolescents 11 through 18 years of age
• The pre-adolescent visit at 11- 12 years of age
  is the best time to vaccinate
• Previously unvaccinated 11 to 18-year olds should
  be immunized at the earliest possible health-care
  visit
• Use Menactra (conjugate, MCV4) instead of
  Menomune (polysaccharide, MPV4)

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Conjugated (created by covalently attaching a
poor antigen to a carrier protein) and
Polysaccharide Vaccines
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Polysaccharide and conjugated vaccines?

• Polysaccharide vaccines
• Menomune
• Pneumovax
• Conjugated vaccines
• Menactra
• Prevnar
• Hib

Conjugate vaccines link polysaccharides to
antigens or toxoids that a baby's immune system
can recognize
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Menactra (MC4) Vaccine

• Which N meningitidis serogroup is NOT in vaccine?
• A
• B
• C
• Y
• W 135

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The CDC recommends routine influenza vaccine for-

• Only 6 months to 5 yrs of age
• Only 2 months to 5 yrs of age
• All children 6 months to 18 yrs of age
• Only 2 yrs 18 yrs of age
• All ages
• Immunizing school-age kids reduces the number who
  will get sick and increases herd immunity
• TIV (Fluzone by Sanofi is approved down to 6
  months)
• LAIV (FluMist by MedImmune) is approved from 2
  yr-49 yr for well children

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Children and Transmission of Influenza
Other children
Family members other close contacts
Daycare, preschool and school-age children
Community incl. high risk populations
Adapted from Elveback LR et al. Am J Epidemiol.
1976103152-65.
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HPV4 (Gardasil) Pearls

• All of the following are true of Gardasil EXCEPT
• Safe
• Active against only HPV types 16 and 18
• Indicated for women aged 9 to 26 years
• Higher incidence of site injection reactions than
  placebo
• Higher incidence of vasovagal syncope than
  placebo
• Gardasil is a quadrivalent vaccine active against
  HPV types 6,11, 16 and 18

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Human Papillomavirus (HPV) Vaccines

• Human Papilloma Virus Vaccine Dosing intervals
• Between1st and 2nd dose is minimum of 4 wks
• Between 2nd and 3rd dose, at least 24 wks after
  1st dose
• Most frequent reported AEs syncope and dizziness
• VAERS is not designed to assess biological or
  epidemiological plausibility of AEs following
  vaccination
• In conclusion
• Safe and effective

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How can you prevent patients from fainting after
vaccination?

• Make sure patient is seated
• Symptoms that precede fainting
• Weakness, dizziness, pallor
• Keep patient seated or reclining for 20-30 minutes

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Gardasil (HPV4) Now indicated for prevention
of-
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Is it necessary to routinely obtain a pregnancy
test before administering any vaccine?

• No
• Females of childbearing age should be asked about
  the possibility of their being pregnant prior to
  being given any vaccine for which pregnancy is a
  contraindication or precaution
• The patients answer should be documented
• If the patient is uncertain, a test should be
  performed before administering live virus vaccines

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Vaccine errors What to DO?

• A four year boy was accidently given Zostavax
  instead of Varivax. What is your recommendation?
• No further chicken pox vaccine is needed?
• Bring the child back in a month, and give a
  Varivax
• Give Varicella Immune Globulin
• Fire the nurse

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Vaccine errors What to DO?

• A 60 year-old man was accidently given Varivax
  instead of Zostavax. What is your
  recom-mendation?
• No further Zostavax vaccine is needed?
• Bring the man back in a month, and give a
  Zostavax
• Give Varicella Immune Globulin
• Again, fire the nurse

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Is it ok to brown-bag zoster vaccine?

• CDC strongly discourages patients transporting
  vaccine from a pharmacy to a doctors office
• Zoster vaccine must be transported on dry ice,
  with strict adherence to stringent vaccine
  transport guidelines

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Should a healthy person age 60 receive zoster
vaccine if they are going to be in contact with
an unvaccinated infant?

• Not a contraindication for Zoster Vaccine

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Is there a HepB shortage?

• Yes
• No
• In February 2009, both Merck and GSK experienced
  an inability to fill orders for pediatric Hep B
  Vaccine
• CDC presently does not recommend any changes in
  the schedules

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Use only the 3 dose series of Hep BBirth, 2
months, 6 months

• A 4 month-old comes to your office. He received a
  Pediarix (DTaP, IPV, HepB) Hib at two months.
  Because of the supply issue with HiB vaccine, you
  have decided to use Pentacel (DTaP, IPV, Hib).
  Can you interchange the vaccine?
• Yes
• N0
• Infant received HepB as newborn and at two
  months, and, thus does not need another HepB at 4
  months-give separately at 6 months with 2nd
  Pentacel

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Combinations

• Comvax
• Hib HepB at 2 and 4 months
• Pediarix
• DTaP IPV HepB at 2, 4, 6, months
• Kenrix
• DTaP IPV at 4-6 yrs
• Pentacel
• DTaP IPV Hib at 2, 4, 6, 18 months
• ProQuad (Not presently available)
• MMR Varivax

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Pneumococcal Polyvalent Polysaccharide Vaccine
(Pneumovax) (PPSV23)ACIP October 2008

• Give to adult cigarette smokers aged 19-64 years
  as well as smoking cessation counseling
• Give to persons aged 19-64 years who have asthma
• Give a 2nd dose 5 years after the first dose of
  Pneumovax (PPSV23) for persons aged 2 yrs or
  greater who are immunocompromised, have sickle
  cell disease, or functional or anatomic asplenia
• Hopefully they already received Prevnar (PCV-7)

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Change in Boostrix (GSK) (Tdap)?

• Yes
• December 4, 2008
• FDA approved Boostrix for one-time booster for
  people ages 10-64 (previously 10-18)
• Tdap (Adacel or Boostrix)
• Use for booster one time is 5yrs since Td
• There is no minimum interval one needs to wait
  between receiving Td and Tdap when it is given to
  protect infants or other vulnerable patients

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Can the parents of a newborn receive a dose of
Tdap right after their childs birth?

• Yes
• No
• Parents should receive a single dose of Tdap as
  soon as possible to protect the baby from
  pertussis
• Other household contacts who are not up to date
  with their pertussis-containing vaccinations
  should also be appropriately vaccinated
• Such as Grandparents

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Will Bird or Swine Flu Cause Another Pandemic?????

• The bird-flu (AH5N1) would need to mutate into a
  strain that can be easily transmitted from human
  to human
• The swine flu (AH1N1) already has?

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Bird-Flu Contd

• Where humans, pigs, and poultry live in close
  quarters, the flu virus can mutate into a form
  that more easily infects humans

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Swine Flu www.cdc.gov/swineflu
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Everyday actions people can take to stay healthy

• Cover nose and mouth with a tissue when you cough
  or sneeze
• Throw the tissue in the trash after you use it
• Wash your hands often with soap and water,
  especially after you cough or sneeze
• Alcohol-based hands cleaners are also effective
• Avoid touching your eyes, nose or mouth

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Try to avoid close contact with sick people

• Influenza is thought to spread mainly
  person-to-person through coughing or sneezing of
  infected people
• If you get sick, CDC recommends that you stay
  home from work or school and limit contact with
  others to keep from infecting them

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What are the signs and symptoms of swine flu?

• Similar to the symptoms of regular human flu
• Fever
• Cough
• Sore throat
• Body aches
• Headache
• Chills
• Fatigue
• Diarrhea and vomiting?

• Severe illnesses
• May cause a worsening of underlying chronic
  medical conditions
• Pneumonia and respiratory failure
• Deaths

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MedicationsBird and Swine Flu

• Two FDA-approved influenza antiviral medications
  are thought to be effective for H5N1 and H1N1
• Oseltamivir (Tamiflu)
• Anamivir (Relenza)

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FDA authorization signed Monday

• Allows physicians to give Tamiflu (Roche), to
  children less than one year old
• Allows the inhalant Relenza, made by
  GlaxoSmithKline, to be used in treating suspected
  cases of swine flu and dispensed to patients in
  hospitals

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The Future

• New combinations
• Avian (H5N1) vaccines by Sanofi is FDA approved,
  April 17, 2007
• OSU-Clinical Vaccine Research
• RSV/PIV-3 (MedImmune)
• PCV-13 (includes 19A serotype) (Wyeth)
• New MMRV (GSK)
• Newer adjuvants (such as GSKs ASO4)
• Personalized vaccine delivery system