4/7/2017. Audrey Ofir, MD, MBA, FAAP University of Miami Miller School of Medicine Holtz Children Hospital

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1 Audrey Ofir, MD, MBA, FAAP University of Miami Miller School of Medicine Holtz Children Hospital 1

2 9vHPV Tdap MCV LAIV HepB Children with Medical conditions 2

3 9vHPV vaccine HPV infection: Causes cervical, vaginal & vulvar CA in women; penile CA in men; and oropharynx as well as anal CA & genital warts in both men and women. HPV type 16 and 18. Routine vaccination: Since 2006 for females and 2011 for males. The new 9vHPV vaccine was introduced in Dec 2014 and is now the only vaccine distributed in the US. Updated guidelines: 9-10 yrs old may be vaccinated in absence of high-risk conditions A new 2-dose schedule for 9-14 yrsold for both males and females which is 6-12 mointerval (min 5 mo) yrsold and pts with any type of 1ry or 2ry immunocompromising conditions should still follow the 3-dose schedule of 0-1/2-6 mo intervals Tdap vaccine STATS 3

4 Whooping cough Bordetella pertussis Prolonged cough with paroxysms, posttussive V, inspiratory whoop. <1 yr old highest morbidity and mortality. 4

5 Tdap vaccine STATS Reasons: waning immunity, increased recognition, increased Dx testing and reporting. DTaPis routinely recommended at 2, 4, and 6 months, at months, and at 4-6 years. Update: if DTaP#4 given early but 4 mo from #3 and 12 mo old, no need to repeat dose. If 7 yrsold, Tdap* is recommended. Tdap is routinely recommended for yrs old. In Aug 2013, pregnant women recommended to get a dose of Tdapduring each pregnancy, preferably at weeks gestation. Update: vaccinate as early as possible 27-36wks gestation to maximize passive antibody transfer to the infant 5

6 Meningococcal Vaccine Background on the disease Meningococcal vaccine Background: Meningococcal disease can present as meningitis or bacteremia Symptoms: F/HA/purpuric rash/stiff neck 800-1,500 cases/yr in the US Transmitted by respiratory/saliva 10-15% fatal; 11-19% of survivors have lg-term disability (brain damage, deafness, amputation) Bacteria: Neisseria meningitidis (Gm diplococcus) with a polysaccharide capsule. 13 serogroups: A,B, C, W, X & Y invasive disease Risk factors: age, community setting, imunodef, travel picture from 6

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8 Meningococcal vaccine 3 main types vaccines: I. Polysaccharide (A, C, AC, ACWY) II. Conjugate (A, C, ACWY*) III. Serogroup B vaccines 2 MenBvaccines licensed in US: MenB-FHbp(Oct 2014, 2-3 doses**); MenB-4C (Jan 2015, 2 doses). The 2 brands are not interchangeable. Latest update leaves it up to the clinician to recommend the MenB vaccine (category B) Insurance coverage Children with medical conditions. 8

9 Influenza vaccine LAIV should not be used during the influenza season Persons with egg allergy: if only hives adm as routine; if > hives adm Flu vaccine in inptor outpt medical setting and observe for 15 mn. A previous severe allergic reaction to flu vaccine is still a C/I to future doses. 850, Million chronic Hep B in the US Cause for >1,500 deaths/yr NB routine vaccination with HepB vaccine started in % decline in new HBV cases between 1991 and

10 Mat HBsAg- Birth Mat HBsAg+ Mat HBsAg unk HepB#1 w/in 24hrs HBV#1 0.5 ml HBIG w/in 12hrs <2,000gms HepB#1 HBIG w/in 12hrs 2,000gms HepB#2 1-2mo ltr HepB#2 at 1mo HepB#2 at 1 mo HepB#1 w/in 12hrs HepB#3 at 24 wks old HepB#3 At 24 wks old Test: HBsAg/anti- HBs At 9-12 mo old HepB#3 at 2-3 mo HepB#4 at 24 wks old Mat HBsAg- Mat HBsAg+ HBIG w/in 7 days 10

11 Children with medical conditions most children with medical conditions can (and should) be vaccinated according to the routine child/adolescent immunization schedule. See Figure 3 in the latest guidelines. 11

12 High-risk groups Hib: 5 yrsold if asplenicor HIV. PCV13: 6 yrsold if cochlear implant, SS, asplenia, immunodeficiencies, nephrotic syndrome, immunosuppressive Tx. PPSV23: 8 wk interval from PCV13 (same criteria) HepA: travel to endemic areas, chronic liver dis, clotting factor dis, household members of an international adoptee from endemic area. MCV4: asplenia, HIV, complement deficiency, eculizumab Tx. MenB: asplenia, complement def, eculizumabtx, travel to endemic areas, outbreak. 9vHPV: sexual abuse/assault, HIV. 9vHPV Tdap MCV LAIV HepB Children with Medical conditions 12

13 Pain/swelling/erythema at site of injection Fever Fussiness Seizure (febrile) Syncope Rash Intusseption GBS Severe allergic reaction to previous dose or to a vaccine component Seizure or other neuro event within 7 days after DTaP/Tdap dose Severe Immunodeficiency if live vaccine (Fig3) Moderate or severe acute illness with or without fever Progressive neurologic disorder Fever of 105 w/in 48hrs previous DTaP Inconsolable crying for 3 hrs after DTaP GBS within 6 weeks of DTaP/Tdap/Flu 13

14 MMR and autism HepB and mercury 9vHP vaccine The Wakefield and Walker-Smith study (Lancet, 2/28/98): 12 cases The Bowel & Brain syndrome Conflict of interest: Wakefield hired by lawyer Richard Barr at time of study In 2010, Lancet retracted study and Wakefield barred from practicing medicine in UK Multiple studies attesting to vaccine safety Devastating effects still linger 14

15 Alleged link between Thimerosal and autism ( the autism epidemic, Methyl Mercury confusion). July 1999: FDA, CDC and AAP recommended removal of Thimerosal from all vaccines Benefits of Thimerosal Thimerosal in multi-dose vials of Flu vaccines Science Communication and The Cultural Cognition Thesis 15

16 Combination vaccines cause more SE? One visit w/ 4 vaccines or 4 visits w/ 1 vaccine? When do we reschedule vaccination? 16

17 (Immunization Action Coalition) (Needle Tips) icles/ / downloads/supplement.pdf 8Q cs/fullarticle/

18 QUESTIONS? COMMENTS? THANK YOU FOR YOUR ATTENTION! 18