Meg Fisher, MD

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Vaccine Preventable Diseases and the Healthcare
Provider

• Meg Fisher, MD
• Medical Director,
• The Childrens Hospital

Long Branch, NJ
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Disclosures

• I have no disclosures.
• I will be mentioning off label uses of vaccines.

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Objectives

• Describe the vaccine preventable diseases that
  relate to the healthcare provider in the acute
  care setting
• List and discuss vaccines needed to prevent these
  diseases

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Immunization

• Public health success story
• Rates of all vaccine preventable illnesses have
  plummeted
• Smallpox, diphtheria, tetanus, polio, measles,
  mumps, rubella, Haemophilus influenzae type b
  almost gone in the US

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Immunization Rates

• Dont get complacent!
• Infection is just a plane ride away!

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Test your knowledge

• Identify these infections

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Courtesy of the American Academy of Pediatrics
and the Centers for Disease Control and
Prevention
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Courtesy of the Centers for Disease Control and
Prevention
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Courtesy of his mother
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Courtesy of the Centers for Disease Control and
Prevention
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Courtesy of the Centers for Disease Control and
Prevention
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Courtesy of eMedicine and ADAM
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Courtesy of the Centers for Disease Control and
Prevention
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Courtesy of the Centers for Disease Control and
Prevention
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Courtesy of the Centers for Disease Control and
Prevention
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Courtesy of the Centers for Disease Control and
Prevention
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Courtesy of the WHO and the Centers for Disease
Control and Prevention
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Courtesy of PA AAP
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Courtesy of the WHO and the Centers for Disease
Control and Prevention
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Courtesy of the Centers for
Disease Control and Prevention
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Vaccine Preventable Diseases

• Hepatitis B, rotavirus, diphtheria, tetanus,
  pertussis, polio, Haemophilus influenzae type b,
  Streptococcus pneumoniae, influenza, measles,
  mumps, rubella, varicella, hepatitis A, Neisseria
  meningitidis, human papillomavirus

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Shortages?

• Major dilemma for practitioners
• Distribution always a problem
• Web site for vaccine shortages
• www.cdc.gov/vaccines/vac-gen/shortages
• None currently

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Vaccine Safety

• Concerns are limiting vaccine use
• Rates in New Jersey have fallen dramatically
• www.cdc.gov/vaccinesafety

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Immunization Safety

• Starts during development
• Continues through all stages of licensure and
  during postlicensure use
• Vaccine adverse event reporting system
• Vaccine safety datalink
• Clinical immunization safety assessment

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National Vaccine Injury Compensation Program

• Established by National Childhood Vaccine
  Injury Act
• No fault compensation program
• http//www.hrsa.gov/vaccinecompensation/
• Report suspected adverse events to VAERS

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Advisory Committee on Immunization Practices

• Provides advice for CDC
• Multidisciplinary panel with many liaisons
• www.cdc.gov/vaccines/recs/acip
• Pediatricians well represented

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Hepatitis B vaccine

• All providers with blood exposure
• Three doses 0, 1, 6 mo
• Titers to prove response to vaccine
• If lt 10 mIU/ml, repeat series and titer
• Older less likely to respond

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Exposure to HBsAg Blood

• Immune education re preventing exposures
• Non-responder or not immunized HBIG plus
  education re preventing exposures
• Immunized but not tested test and give HBIG if
  negative

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Hepatitis B Vaccine

• New dilemma
• Adolescents immunized as children may have low or
  no antibody levels at entry to college, nursing
  schools, medical schools
• Consider giving one dose and repeat titer
• If negative, finish the series and repeat titer

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I had a little bird. His name was Enza. I opened
the window. And in flew Enza.
A chant popular during the influenza pandemic of
1918
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Recommendations

• All people 6 months of age and older
• Healthcare personnel mandates recommended by
  IDSA, PIDS, AAP and others
• Formulated yearly on best guess
• Two A strains, one B
• Start when you get it and continue all season

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Influenza Vaccines

• A/California/7/2009 (H1N1)-like
• A/Perth/16/2009 (H3N2)-like
• B/Brisbane/60/2008-like
• Inactivated, live cold adapted

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Influenza Vaccine Schedule

• Yearly start when you get it
• Children under 3 years lower dose
• Child under 9 two doses first season
• Contraindicated in persons with anaphylaxis to
  chicken or eggs

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Measles, Mumps, Rubella

• Measles and rubella no longer endemic in the
  United States
• Mumps outbreak over in NJ
• MMRV combination more fever
• We should be immune born before 1957, titer or
  received 2 doses of vaccine

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Varicella Vaccine

• Prevents serious illness
• Outbreaks persist
• Second dose now recommended for all
• Routine at 4-5 years, MMRV
• Catch up for older

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Zoster vaccine

• Zostavax
• Approved May 2006
• Age 60 and above now 50 and above
• Protect yourself when the time comes

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Tdap Boostrix, Adacel

• Tetanus, diphtheria, pertussis booster
• For teens (both) and adults (Adacel)
• Licensed in spring 2005
• Should alter epidemiology and protect
  infants
• Protect yourself and your staff

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Targeted adults

• Anyone caring for young infants
• Cocoon the infants by immunizing contacts
• Healthcare people
• Pregnant women in late 2nd, 3rd trimester
• Give to the entire household, preferably before
  delivery

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Latest from ACIP

• Off label use of the vaccine
• Use Tdap for incompletely vaccinated children
  down to age 7 years
• Use Tdap in adults over 65 years
• Pregnant women in the 2nd or 3rd trimester
• Tdap at any interval following T or Td

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Meningococcal vaccines

• Polysaccharide vaccine rarely used today
• Conjugate vaccines originally recommended
  Adolescents age 11-12 yr (pre-teen visit)
  Adolescents age 15 yr (high school entry)
  Incoming college freshmen in dorms High risk
  groups

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Latest Recommendations

• Booster dose for adolescents age 16 or
  5 years after the first dose
• Highest risk initial 2 dose series followed by
  booster doses every 5 years
• At risk healthcare microbiologists only

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Rotavirus vaccines

• The old Rotashield
• Rhesus rotavirus reassortant
• Licensed 8/98
• Withdrawn 10/99
• Intussusception risk lt 1/10,000

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Rotavirus vaccines

• The new RotaTeq, Rotarix
• RotaTeq human-bovine reassortant
• Well tolerated, effective, over 70,000
• Licensed February 2006
• Rotarix monovalent, human strain
• Licensed and used outside US

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Safety Issues

• Porcine circoviruses no harm
• Rates of intussusception among vaccine recipients
  closely studied post-licensure studies results
  vary
• Benefits greatly outweigh risks

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Haemophilus influenzae type b

• Disease dramatically decreased in US
• Conjugate vaccine eliminates carriage
• Keep vaccinating!

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Streptococcus pneumoniae

• Dramatic decrease in US since PCV7
• Decrease in adult disease as well
• PCV13 now replaces PCV7
• Polysaccharide vaccine PPSV23 for high risk
  children and adults

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Polio Virus Vaccine

• Polio eliminated from most of the world
• But in 2010 spread to over a dozen countries
• Live oral not in US since 2000, source of some
  recent outbreaks
• Inactivated safe effective, 4 dose series,
  last/extra dose at 4 to 6 years

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Hepatitis A Vaccines

• Inactivated
• Two doses, 6 months apart
• Prior to 2006 at risk or in high incidence state
• Now at risk and all children at age 1
• Catch up is reasonable

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HPV Vaccines

• Virus-like particles genetically engineered
• Quadravalent and bivalent vaccines
• Well tolerated and immunogenic
• Three dose series
• Universal for girls permissive for boys

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Websites

• www.aap.org
• www.cdc.gov
• www.immunizationinfo.org
• www.vaers.org

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Smiling is a contagious condition!