Latest Childhood Immunization Guidelines and Addressing Vaccine Refusals at Community Health Centers

Transcription

1 Latest Childhood Immunization Guidelines and Addressing Vaccine Refusals at Community Health Centers Hosted by: Illinois Chapter, American Academy of Pediatrics Co-sponsored by: Illinois Primary Healthcare Association

2 Disclosures I have no relevant financial relationships with the manufacturer(s) of any commercial products(s) and/or provider(s) of commercial services discussed within this CME activity. I do NOT intend to discuss an unapproved or investigative use of a commercial product/device in my presentation.

3 Learning Objectives 1. Review 2016 ACIP recommendations for routine childhood and adolescent immunizations 2. Describe vaccine preventable disease epidemiology 3. Identify approaches and communication strategies that providers can use in clinical settings to improve childhood and adolescent vaccination rates 4. Discuss resources to improve the efficiency for delivering immunizations

4 Agenda We will review the ACIP 2016 vaccine recommendations in the order they appear on the immunization schedule We will review the most common vaccine concerns Your recommendations make a difference We will leave 5 mins for FAQ s any questions not answered during the webinar will receive follow up

5 Importance of Vaccines Healthy population Prevent infectious diseases Protect those who can t get vaccination Cost/time/emotional savings

6 Vaccines Work Vaccines are: successful cost-effective public health tools They protect BOTH: vaccinated individuals entire communities

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9 Cocooning Babies <6 mo. vulnerable to diseases Whooping cough & flu What can you do? Get vaccinated!

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11 Hepatitis B

12 Hepatitis B Vaccines 1st dose at birth! Recommended vaccination schedule 3 dose series 1 st dose at birth (use monovalent) 2 nd dose at 1 2 mo. (use monovalent at 6wks); min. 4 wks after 1 st dose 3 rd dose at 6 18 mo.; min. 16 wks after 1 st dose & 8 wks after 2 nd dose Final dose to be given no earlier than 24 weeks Catch-up schedule 3 dose series, following same timing minimums Adult Recombivax HB: 2 dose series licensed for use in children 11 15yo; 4mo. between dose 1 & 2

13 Hepatitis B Vaccines 2 single-agent vaccines: Recombivax HB Engerix-B 3 combination vaccines: Comvax: HepB + Haemophilus influenzae type B Pediarix: HepB + diphtheria + tetanus + acellular pertussis adsorbed + inactivated polio virus Twinrix: HepB + Hepatitis A Intramuscular injection Vaccines from different manufacturers can be used to complete a series All vaccines need to be stored in fridge at 2-8 C (36-46 F). freeze. Do NOT Contraindication: severe allergic reaction to previous dose or vaccine component Precautions: Moderate or severe acute illness, with or without fever Infant weight <2000 grams (4lbs., or 6.4oz.)

14 Hepatitis B Vaccines Protect against Hepatitis B 3 types of disease: Acute, chronic, perinatal How common is Hepatitis B? Acute: approx. 19,700 new cases in US in 2013 Chronic: approx. 700,00 1.4mil in US, 240mil global Perinatal: without vax, 40% of babies born to infected mothers will get chronic HepB Transmission Percutaneous or mucosal contact with infected blood or body fluids NOT through food or water, sharing eating utensils, breastfeeding, hugging, kissing, hand holding, coughing, or sneezing. (CDC)

15 Hepatitis B Vaccines Protect against Hepatitis B Symptoms Include: fever, fatigue, loss of appetite, nausea, vomiting, abdominal pain, dark urine, joint pain, jaundice Acute: Most <5yo are asymptomatic; 30-50% 5yo are symptomatic Chronic: From asymptomatic to range of liver disease Morbidity/mortality Acute: 0.5-1% case fatality, more severe for >60yo Chronic: 25% of those infected in childhood die prematurely Treatment Acute: Only supportive care Chronic: Antiviral drugs, regular monitoring Report to IDPH ( 7d); Nationally notifiable to CDC

16 Hepatitis B Vaccines Normal liver Liver damaged by HepB Liver cancer caused by HepB Protect against Hepatitis B Video: Photos:

17 Rotavirus

18 Rotavirus Vaccines Protect against rotavirus Catch-up schedule Min. age for 1 st dose is 6 wks. Max. age for 1 st dose is 14 wks, 6 days. Do not start after this. Max. age for final dose is 8 mo., 0 days Contraindications: Severe allergic reaction to previous dose or vaccine component Severe combined immunodeficiency (SCID) History of intussusception Precautions: Moderate or severe acute illness, with or without fever Immunodeficiency other than SCID Chronic GI disease Spina bifida or bladder exstrophy

19 Rotavirus Vaccines Protect against rotavirus Given orally RotaTeq (RV5) 6 32 wks; Live virus Store at 2 to 8 C (36 to 46 F), protect from light Rotarix (RV1) 6 24 wks; Live attenuated virus Reconstitute with provided diluent Prior to reconstitution: Store lyophilized vaccine at 2-8 C (36 to 46 F) & protect from light. Store diluent at 2 to 8 C (36 to 46 F) or room temp up to 25 C (77 F) & do NOT freeze. After reconstitution: Use within 24 hrs. Store at 2 to 8 C (36 to 46 F) or room temp up to 25 C (77 F) & do NOT freeze Recommended Vaccination Schedule RotaTeq 2, 4, & 6 mo. Min. of 4 wks between doses Rotarix 2 & 4 mo. Min. of 4 wks between doses

20 Rotavirus Vaccines Protect against rotavirus How common is it? Highest rates in infants & young children 95% children infected by 5yo, prior to 2006 Transmission Highly communicable Fecal-oral route Symptoms Watery diarrhea, Vomiting, Fever, Abdominal pain, Loss of appetite, Dehydration Morbidity/mortality Globally: leading cause of severe diarrhea in children; 453,000 deaths in 2008 Treatment Rehydration therapy Re-infection is possible

21 Rotavirus Vaccines Examples of dehydration caused by Rotavirus Protect against rotavirus Video: Photos:

22 Diphtheria, Tetanus, & Pertussis

23 Diphtheria, Tetanus, & acellular Pertussis Vaccines (DTaP) Protects against diphtheria, tetanus, & pertussis Tripedia (Discontinued), Pentacel, Infanrix, Daptacel, Pediarix, Kinrix & Quadracel (5 th dose ONLY) Recommended Vaccination Schedule 5 doses: 2, 4, 6, mo., 4 6 yo. 1 st dose min. 6 wks; 4 th dose min. 12 mo. Catch-up schedule 4 week min. between doses 1 & 2, doses 2 & 3 6 mo. min. between doses 3 & 4, doses 4 & 5 Don t need 5 th dose if 4 th done at 4 yo. If not complete by 7yo, need to switch to Tdap Intramuscular injection Store at 2-8 C (36-46 F). Do not freeze. Contraindications & Precautions: Refer to CDC list

24 Tetanus, diphtheria, & acellular pertussis (Tdap)/Tetanus & diphtheria (Td) Tdap protects against tetanus, diptheria, & pertussis Adacel, Boostrix (min. age 10 yo) Td booster protects against tetanus and diphtheria MA Public Health Biologic Lab, Decavac, Tenavac Recommended Vaccination Schedule Tdap: 1 dose at 11 12yo, can do 11 18yo Td: 1 dose every 10 years, or as needed Catch-up schedule Tdap: If not done at yo. give anytime, no min. time after last Td Tdap: Can replace the 10 year Td booster If DTaP not completed: use Tdap as 1 dose, Td if needed for rest. If Tdap given, do NOT give the dose at yo. Then Td booster as usual. Intramuscular injection Store at 2 C - 8 C (36 F - 46 F). Do not freeze. Contraindications & precautions: Refer to CDC list

25 Tetanus, diphtheria, & acellular pertussis (Tdap)/Tetanus & diphtheria (Td) Pregnancy and Tdap vaccination Tdap for each pregnancy, at weeks; immediately postpartum Maternal antibodies confer some protection to infants before they can receive DTaP Also helps keep the mother from passing disease to newborn Tdap or DTaP vaccination recommended for all family members/care givers Photo: medscape.org

26 Diphtheria, Tetanus, & acellular Pertussis Vaccines (DTaP) Protects against diphtheria, tetanus, & pertussis Bacterial infection caused by Corynebacterium diphtheriae Bacteria go to respiratory system & produce toxin How common is it? Not common in US, circulating globally Transmission Person to person, respiratory droplet Symptoms Weakness, sore throat, fever, swollen glands in neck Pseudomembrane & difficulty breathing Complications Airway blockage, myocarditis, polyneuropathy, paralysis, skin lesions, pneumonia, respiratory failure, death Morbidity/mortality 5 10% case-fatality rate, with treatment; up to 20% in children <5yo Up to half die without treatment Treatment Antitoxin and antibiotics Report immediately ( 3h) to IDPH; Nationally notifiable to CDC

27 Diphtheria, Tetanus, & acellular Pertussis Vaccines (DTaP) Protects against diphtheria, tetanus, & pertussis Child with swollen neck Child with pseudomembrane in throat Photos: CDC

28 Diphtheria, Tetanus, & acellular Pertussis Vaccines (DTaP) Protects against diphtheria, tetanus, & pertussis Bacterial infection from Clostridium tetani, bacterial toxin causes damage Forms Generalized tetanus, localized tetanus, cephalic tetanus How common is it? Now not common; 233 cases between Adults who didn t receive vaccine or not current on boosters Transmission Bacteria present in environment (soil, dust, manure) Commonly enters through wound Symptoms Initial lockjaw Muscle spasms, headache, jaw cramping, muscle stiffness, trouble swallowing, fever Complications Laryngospasm, bone fracture, hypertension, HAI, pulmonary embolism, difficulty breathing, death Morbidity/mortality Generalized: 10-20% die Treatment Emergency, immediate hospitalization & treatment Tetanus immune globulin, tetanus toxoid booster, muscle relaxants, wound care, antibiotics Report to IDPH ( 7d); Nationally notifiable to CDC

29 Diphtheria, Tetanus, & acellular Pertussis (DTaP) Protects against diphtheria, tetanus, & pertussis Man with contracted jaw and neck muscles Child with muscle spasms Photos: CDC;

30 Diphtheria, Tetanus, & acellular Pertussis Vaccines (DTaP) Protects against diphtheria, tetanus, & pertussis Bacterial infection caused by Bordatella pertussis 3 stages Catarrhal, paroxysmal, convalescent How common is it? 75% decrease from pre-vax era, but 2012 a peak year Babies <1 yo highest incidence Transmission Person to person, respiratory Symptoms Cough that becomes more severe, whoop noise at aspiration, apnea Complications Pneumonia, convulsions, and encephalopathy, death Morbidity/mortality 50% of babies <1 yo require hospitalization & 1% die 5% of teens & adults require hospitalization Treatment Early treatment is critical Antibiotics Report to IDPH ( 24h); Nationally notifiable to CDC

31 Diphtheria, Tetanus, & acellular Pertussis Vaccines (DTaP) Protects against diphtheria, tetanus, & pertussis Video: Many good ones here And here: Child with broken blood vessels in eyes and facial bruising from coughing Baby hospitalized with severe pertussis Photos: CDC

32 Haemophilis influenzae type b

33 Haemophilis influenzae type b Vaccine Protects against Haemophilis influenzae type b (Hib) Single-agent vaccines ActHIB; PedvaxHib; Hiberix (booster dose only) Combination vaccines ActHIB & diluent = TriHIBit: Hib + diphtheria + tetanus + pertussis Menhibrix: Hib + Nisseria meningitidis Pentacel: Hib + diphtheria + tetanus + pertussis + poliomyelitis COMVAX: Hib + Hepatitis B Recommended Vaccination Schedule ActHIB/TriHIBit, MenHibrix, Pentacel: doses at 2, 4, & 6 mo. (min. age 6 wks; 15 mo. For TriHIBit) PedvaxHib, COMVAX: doses at 2 & 4 mo. Booster dose at mo. Hiberix can only be used in 1 4 yo Catch-up schedule Complex. Follow CDC algorithms: Unvaccinated children 15 mo. only need 1 dose

34 Haemophilis influenzae type b Vaccine Protects against Haemophilis influenzae type b (Hib) Diluent ActHIB: saline OR Tripedia TriHIBit MenHibrix & Hiberix: saline Pentacel: DTaP-IPV liquid Storage ActHIB/TriHIBit: 2-8 C (35-46 F). Use in 24 hr. MenHibrix: 2-8 C (35-46 F). Protect from light. Use immediately. Pentacel: 2-8 C (35-46 F). Use immediately. PedavaxHib & Comvax: 2-8 C (35-46 F). Hiberix: 2-8 C (35-46 F). Protect from light. Use in 24 hrs. Do not freeze Intramuscular injection

35 Haemophilis influenzae type b Vaccine Protects against Haemophilis influenzae type b (Hib) High-risk patients mo. at increased risk for Hib & had 0 1 dose prior to 12 mo. 2 more doses 8 wks apart mo. at increased risk for Hib & had 2+ doses prior to 12 mo. 1 more dose <5 yo undergoing chemo or radiation & had dose(s) within 14 days or during tx re-administer the dose(s) 3 mo. after tx HSCT pts 3 dose series 6 12 mo. after transplant Underimmunized 15 mo. & elective splenectomy 1 dose Underimmunized 5 yo & asplenia 1 dose Unvaccinated 5 18 yo & HIV 1 dose Contraindications Severe allergic reaction to previous dose or vaccine component Age < 6 weeks Precautions Moderate or severe acute illness, with or without fever

36 Haemophilis influenzae type b Vaccine Protects against Haemophilis influenzae type b (Hib) Hib bacteria infections Bronchitis, ear infection Pneumonia, bacteremia, meningitis, epiglotittis, cellulitis, infectious arthritis How common is it? Highest rates in children <5yo, but <1 case/100,000 Common in underimmunized & infants Transmission Person-to-person, respiratory Symptoms Pneumonia: fever, cough, SOB, chills, sweating, chest pain + more Bacteremia: fever, chills, abdominal pain, nausea, vomiting, anxiety + more Meningitis: fever, headache, stiff neck, nausea, vomiting, confusion + more Morbidity/mortality Pre-vax: 20,000 children <5yo invasive infx; 1,000 died Most invasive Hib infx require hospitalization Up to 20% of Hib meningitis neurological sequelae 3 6% of children with Hib meningitis die Treatment Antibiotics Invasive infection: Report to IDPH ( 24h); Nationally notifiable to CDC

37 Haemophilis influenzae type b Vaccine Protects against Haemophilis influenzae type b (Hib) Video options: Cellulitis Gangrene secondary to septicemia Photos: CDC;

38 Pneumococcal Disease

39 Pneumococcal Vaccines Protect against pneumococcal disease PCV7 now usually replaced by PCV13 PCV7 = Prevnar7; PCV13 = Prevnar13; PPSV23 = Pneumovax Recommended Vaccination Schedule PCV13: 4 dose series at 2, 4, 6, mo. PPSV23: only in high-risk cases 2 yo Catch-up schedule:

40 Pneumococcal Vaccines Intramuscular injection; Subcutaneous option for PPSV23 Store at 2 C - 8 C (36 F - 46 F). Do not freeze. Contraindication Severe allergic reaction to previous dose or vaccine component Precaution Moderate or severe acute illness, with or without fever

41 Pneumococcal Vaccines Protects against pneumococcal disease Bacterial infection caused by Streptococcus pneumoniae Most common cause of bacteremia, pneumonia, meningitis, and ear infection in children How common is it? Prior to vax: 17,000 case invasive infx, 13,000 cases bacteremia, 700 meningitis, 5mil ear infection, 200 deaths Higher risk pops: <2 yo, group care, certain illnesses, cochlear implants, CSF leave Transmission Person to person via respiratory secretions, 20 60% children are carriers Higher in winter and early spring Symptoms Pneumonia: fever & chills, cough, difficulty breathing, chest pain Meningitis: stiff neck, fever, headache, photophobia, confusion Bacteremia: fever, chills, low alertness Ear infection: ear pain, red/swollen ear drum, fever, sleepiness

42 Pneumococcal Vaccines Protects against pneumococcal disease Complications Pneumonia: empyema, pericarditis, endobronchial obstruction, atelectasis, abscess, death Meningitis: hearing loss, developmental delay, death Bacteremia: death Ear infection: repeated ear infections Morbidity/mortality 2013: 1,171 cases of invasive pneumococal disease in children <5yo Pneumonia: 5% of all pts die Meningitis: 1 in 15 children <5yo die Bacteremia: 1 in 100 children <5yo die Treatment Antibiotics, but resistant to 1+ abx in 30% of cases Invasive infection: Report to IDPH ( 7d) if child is < 5yrs; Nationally notifiable to CDC for all ages

43 Pneumococcal Vaccines Protects against pneumococcal disease Video: vid_id=0001&vid_cat=0018 Bacteria grown from blood culture Brain with purulent meningitis Photos: CDC

44 Polio

45 Polio Vaccines (IPV) Protects against poliomyelitis IPOL, Pediarix, Pentacel; Kinrix & Quadracel (4 th dose) Recommended Vaccination Schedule 4 dose series: 2, 4, 6 18 mo., 4 6 yo Catch-up schedule 4 wks between doses 1 & 2, doses 2 & 3 6 mo. between doses 3 & 4 If 3 rd dose at 4 yo + 6mo after last dose no 4 th dose If 4 doses before 4 yo dose at 4 yo needed Pentacel needs to be reconstituted Intramuscular injection; IPOL can be subcutaneous Store at 2 C - 8 C (35 F - 46 F). Do not freeze. Protect IPOL from light. Contraindications Severe allergic reaction to previous dose or vaccine component Precautions Moderate or severe acute illness, with or without fever Pregnancy

46 Polio Vaccines (IPV) Protects against poliomyelitis Viral infection with poliovirus How common is it? Not circulating in US, but can be brought in from another country Transmission Person to person, fecal-oral or respiratory route More common in infants & young children Symptoms 72% have no symptoms, 24% flu-like sxs 2-5 days Complications Paresthesia, meningitis, paralysis, post-polio syndrome, death Report all cases immediately ( 3h) to IDPH Paralytic polio case: Report to CDC within 4h Non-paralytic polio case: Report to CDC within 24h

47 Photos: CDC Polio Vaccines (IPV) Video: Child paralysed by polio, DRC Young girl with deformed leg due to polio Ward full of iron lung machines in 1952

48 Influenza

49 Universal Recommendation Everyone aged 6 months+, unless contraindicated IAC: Screening Checklists for Contraindications IIV:

50 Influenza Vaccines Protects against influenza Recommended Vaccination Schedule Annual dose for everyone 6 mo, unless contraindicated Catch-up schedule MMWR 2015; 64(30);

51 Timing of Influenza Vaccination Flu season: October May Peak in December - February 2 weeks to make antibodies from vaccine Offer vaccine as soon as it becomes available, by October if possible Providers should offer vaccine during routine healthcare visits or during hospitalizations whenever vaccine is available Vaccinate throughout the entire flu season

52 Types of Vaccines Inactivated Influenza Vaccine (IIV) Trivalent (3 strains) or Quadrivalent (4 strains) Cell culture-based (cciiv4), recombinant (RIV3), high dose (IIV3), adjuvanted (aiiv3) options. Live Attenuated Influenza Vaccine (LAIV) previously available, but NO LONGER RECOMMENDED

53 Influenza Vaccines Protects against influenza IIV: Intramuscular Store at 2 C 8 C (35 F 46 F) Contraindications IIV: Severe allergic reaction to previous dose of IIV or LAIV or to vaccine component, incl. egg protein Precautions IIV: Moderate or severe acute illness with or without fever, history of Guillen-Barre Syndrome within 6 wks of previous dose IIV: mild egg allergy (hives only)

54 Influenza Vaccines Protects against influenza 3 types of influenza virus: Type A, Type B, Type C How common is it? 5 20% US pop. infected/year Young children have highest rates of illness Transmission Person to person, respiratory Seasonal: Oct - May Symptoms Fever/chills, cough, sore throat, runny/stuffy nose, muscle ache, fatigue Complications High-risk groups Pneumonia, bronchitis, sinus infection, worsened chronic illness, death Morbidity/mortality season: 65.5 hospitalizations per 100,000 population Pediatric deaths range from per season; 145 in Treatment Antivirals Reporting Influenza-related hospitalization: Report to IDPH ( 24h); Nationally notifiable to CDC Influenza-associated pediatric death: Report to IDPH ( 7d); Nationally notifiable to CDC Influenza A variant infection: Report immediately to IDPH ( 3h); Nationally notifiable to CDC

55 Influenza Vaccines Protects against influenza Video: Respiratory droplets released from sneeze Emergency hospital during 1918 epidemic Photos: CDC

56 NEW Updates for Season LAIV should NOT be used during the flu season New vaccines: Quadrivalent formulation of Flucelvax (cciiv4) 1 st adjuvanted flu vaccine: FLUAD (aiiv3) Updated recommendations for people with egg allergies Removal of recommendation to observe for 30 minutes post-vaccination Persons with history of severe allergic reaction to egg should be vaccinated in an inpatient or outpatient medical setting, supervised by health care provider

57 ACIP Recommendations - LAIV LAIV should NOT be given CDC conducts vaccine effectiveness (VE) studies each season to estimate flu vaccine effectiveness. VE data showed poor or relatively lower effectiveness of LAIV from Reason for the recent poor performance of LAIV not known LAIV accounts for ~8% of total supply of flu vaccine. Based on manufacturer projections, health officials expect that supply of IIV for the season should be sufficient to meet any increase in demand resulting from the ACIP recommendation. MMWR; August 26, 2016; 65(5);1 54

58 Measles, Mumps, & Rubella

59 Measles, Mumps, & Rubella Vaccine Protects against measles, mumps, & rubella M-M-R II & PROQUAD Live, attenuated virus vaccine Recommended Vaccination Schedule 2 doses: mo., 4 6 yrs. Catch-up schedule 4 wks between doses 1 & 2 If traveling outside US: 6 11 mo.: 1 dose prior to travel + re-vaccination 12+ mo.: 1 dose at 12+ mo., 2 nd dose 4 wks after Subcutaneous injections MMR II: lyophilized + diluent at 2 C - 8 C, reconstituted at 2 C - 8 C. Use in 8 hrs. Do not freeze or expose to light. Contraindications Severe allergic reaction to previous dose or vaccine component Severe immunodeficiency Pregnancy Precautions Moderate or severe acute illness, with or without fever Recent receipt of antibody-containing blood product Hx of thrombocytopenia or thrombocytic purpura Need for tuberculin skin testing

60 Measles, Mumps, & Rubella Vaccine Protects against measles, mumps, & rubella Viral respiratory infection How common is it? 2000: eliminated from US Still common globally Transmission Highly contagious, respiratory route Symptoms Fever, cough, coryza, conjunctivitis (3C s) Koplik spots in mouth Rash Complications High-risk: <5 yo, immunocompromised Bronchopneumonia, ear infection, laryngotracheobronchitis, diarrhea Encephalitis, respiratory & neurologic, subacute sclerosing panencephalitis (SSPE) Morbidity/mortality 2014: 667 cases; 1 death in in 1000 cases die Treatment No antiviral, only supportive care + Vitamin A Report to IDPH ( 24h); Nationally notifiable to CDC

61 Measles, Mumps, & Rubella Photos: CDC Vaccine Protects against measles, mumps, & rubella Video: Face of child with measles Measles rash

62 Measles, Mumps, & Rubella Vaccine Protects against measles, mumps, & rubella Viral infection by paramyxovirus How common is it? Variable, 2010: 2,612 cases vs. 2015: 688 Transmission Respiratory, objects Symptoms Fever, headache, muscle ache, fatigue, loss of appetite, puffy cheeks and swollen jaw Complications Orchitis, oophoritis, mastitis, encephalitis, meningitis, deafness Report to IDPH ( 24h); Nationally notifiable to CDC

63 Measles, Mumps, & Rubella Vaccine Protects against measles, mumps, & rubella Young boy with swollen neck from mumps Photos: CDC

64 Measles, Mumps, & Rubella Vaccine Protects against measles, mumps, & rubella AKA German measles, Viral infection How common is it? 2004: eliminated from US Transmission Person to person, respiratory Symptoms Rash, low fever (<101F) aching joints Complications Congenital Rubella Syndrome: cataracts, heart defects, hearing impairment; miscarriage; stillbirth Rare: hemorraghic manifestations (1/3000) & encephalitis (1/6000) Report to IDPH ( 24h); Nationally notifiable to CDC

65 Photos: CDC Measles, Mumps, & Rubella Vaccine Protects against measles, mumps, & rubella Video: Rash caused by rubella Child with cataracts caused by CRS

66 Measles, Mumps, & Rubella Vaccine Protects against measles, mumps, & rubella Does the MMR vaccine cause autism? No! 1998: Andrew Wakefield published article claiming this Article retracted, Wakefield permanently barred from medicine Further reading in Resources MMR vaccine Autism?

67 Varicella

68 Varicella Vaccines Protects against varicella (chickenpox) Varivax & PROQUAD Live, attenuated virus vaccine Recommended Vaccination Schedule 2 dose series: mo., 4 6 yo. 3 mo between 1 st & 2 nd Catch-up schedule 7 18 yo without evidence of immunity need 2 doses < 13 yo: 3 mo between 1 st & 2 nd 13+ yo: 4 wks between 1 st & 2 nd Subcutaneous injections Refrigerated & frozen formulations Contraindications Severe allergic reaction to previous dose or vaccine component Severe immunodeficiency Pregnancy Precautions Moderate or severe acute illness, with or without fever Recent receipt of antibody-containing blood product Antivirals 24 hrs prior to vaccination

69 Varicella Vaccines Protects against varicella (chickenpox) Viral infection with varicella-zoster virus How common is it? Prior to vaccine: 4million cases, died in US Decreased by 90% Transmission Respiratory, lesions Symptoms Fever, fatigue, loss of appetite, headache Rash blisters scabs Complications High-risk: infants, adolescents, pregnant women, immunocompromised (HIV/AIDS) Most common: bacterial infx in children, penumonia in adults Dehydration, bleeding problems, encephalitis, cerebellar ataxia, sepsis, toxic shock syndrome, joint infections, bone infections, death Treatment At-home and OTC treatments; DO NOT USE ASPIRIN Antivirals Report to IDPH ( 24h); Nationally notifiable to CDC

70 Varicella Vaccine Protects against varicella (chickenpox) Video: Shorter video: Adolescent girl with lesions Secondary infection of lesion Photos: CDC;

71 Hepatitis A

72 Hepatitis A Vaccine Protects against Hepatitis A Havrix, Vaqta & Twinrix Recommended Vaccination Schedule 2 doses: mo. Catch-up schedule 6 mo. Between doses 1 & 2 Intramuscular injection Store at 2-8 C (36-46 F). Do not freeze. Contraindications Severe allergic reaction to previous dose or vaccine component Precautions Moderate or severe acute illness, with or without fever

73 Hepatitis A Vaccine Protects against Hepatitis A Liver infection caused by Hepatitis A virus How common is it? 95% decrease since vaccine 2013: 3,473 cases High-risk: travelers, MSM, drug users, clotting disorders, work with primates Transmission Fecal-oral, contaminated food/water Symptoms Majority of children asymptomatic, but 80% of adults have sxs Nausea, fever, fatigue, abdominal pain, vomiting, dark urine, joint pain, jaundice Complications Rare, can cause liver failure and death Morbidity/mortality 2013: 80 deaths Treatment: None Report to IDPH ( 24h); Nationally notifiable to CDC

74 Hepatitis A Vaccine Protects against Hepatitis A Video: Infected man with jaundice Photo: CDC

75 Human Papilloma Virus (HPV)

76 HPV Vaccine Protects against Human Papillomavirus (HPV) Cervarix, Gardasil & Gardasil 9 (*NEW*) Recommended Vaccination Schedule 3 doses: yo. 1 2 mo. between doses 1 & 2 6 mo. between doses 2 & 3 High risk at 9 years of age Gardasil 9 can be used to begin or finish series Catch-up schedule Min. age 9 yo. Doses 1 & 2: 1 2 mo., Min. 4 wks Dose 3: 24 wks after 1 st dose, 16 weeks after 2 nd dose (min. 12 wks) Recommended: Up to 26yo for women, 21yo for men Intramuscular injection Store at 2-8 C (36-46 F). Do not freeze. Protect Gardasil & Gardasil 9 from light. Contraindications Severe allergic reaction to previous dose or vaccine component Precautions Moderate or severe acute illness, with or without fever Pregnancy

77 HPV Vaccine Protects against Human Papillomavirus (HPV) Viral infection genital warts, cancer How common is it? 79mil infected in US, 14mil new cases/yr. 360,000 get genital warts Transmission Person to person, sexual Symptoms Typically asymptomatic Genital warts, abnormal pap test Complications Cancer, death Morbidity/mortality 33,200 cancers: 20,600 in women, 12,600 in men 90%: cervical & anal cancer 70%: vaginal, vulvar & oropharyngeal 60%: penile Treatment None for HPV Genital warts, Cancer

78 HPV Vaccine Protects against Human Papillomavirus (HPV) Video: Oral HPV warts Photo: CDC

79 Meningococcal Disease

80 Meningococcal Vaccines Protects against meningococcal disease MenACWY: Menactra, Menveo MenCY + Hib: MenHibrix Recommended Vaccination Schedule Routine: 1 dose Menactra or Menveo at yo.; booster at 16 yo yo with HIV: Menactra or Menveo 8 wks between doses 1 & 2 2 mo 18 yo at High Risk: See ACIP Schedule or IAC chart High-risk = Anatomic or functional asplenia, Persistent complement component deficiency, Travel, Outbreak Catch-up schedule yo: 1 dose Menactra or Menveo; booster at 16 yo, 8wks between doses yo: 1 dose Menactra or Menveo; no booster MenB: Bexsero, Trumenba (*NEW*) 10 yo at high risk: 2 doses of Bexsero, 3 doses of Trumenba High-risk = Anatomic or functional asplenia, Persistent complement component deficiency, MenB outbreak, microbiologists yo may get MenB vax, preferably at yo Category B recommendation, so it is up to individual clinicians to decide

81 Meningococcal Vaccines Protects against meningococcal disease Storage Menactra: 2-8 C (36-46 F). Do not freeze. Menveo: Components at 2-8 C (36-46 F). Do not freeze. Reconstituted vax at 77 F (25 C) up to 8 hrs MenHibrix: vaccine at 2-8 C, diluent at 2-25 C. Do not freeze. reconstituted vax immediately. Bexsero & Trumenba: 2-8 C (36-46 F). Do not freeze. Protect Bexsero from light. Intramuscular injection Contraindications Severe allergic reaction to previous dose or vaccine component Precautions Moderate or severe acute illness, with or without fever Use

82 Meningococcal Vaccines Protects against meningococcal disease Bacterial infection caused by Neisseria meningitidis (B, C, & Y) How common is it? Declining since 1990 s, 2013: 550 cases Highest rates in <1 yo. & yo. Seasonal: Jan & Feb High risk groups Transmission Person to person Symptoms Meningococcal meningitis: sudden fever, headache, stiff neck & nausea, vomiting, photophobia, confusion Meningococcal septicemia: fatigue, vomiting, cold hands/feet, chills, ache/pain, rapid breathing, rash Complications Hearing loss, brain damage, loss of limbs, scarring, shock, coma, death Morbidity/mortality out of 100 cases die of survivors have long-term disability Treatment Antibiotics Report to IDPH ( 24h); Nationally notifiable to CDC

83 Meningococcal Vaccines Protects against meningococcal disease Video: 4 mo. old girl with gangrene of hands & legs due to meningococcal septicemia Photo: CDC

84 Common Concerns

85 1. Does MMR cause Autism? History of the controversy - the Wakefield Studies. Scientifically and ethically flawed, now completely discredited Evidence compiled since 1998 overwhelmingly shows no link between MMR and autism Recent (February 2009) developments - vaccine court reveals no link- It is abundantly clear..theories of causation were speculative and unpersuasive Several studies have found against the idea of the light going out Wakefield medical license taken away in May 2010 August 2011 IOM report rejects causal relationship of MMR and autism

86 Examine the Evidence Study in English children before and after 1988 (vaccine introduced) - no difference in autism b/t immunized and unimmunized England - Rate of autism increases 7x, MMR rate same 537,000 Children in Denmark b/t no difference in autism 535,000 Children in Finland - no difference in autism MMR stopped in Japan in Between , immunization rate fell from 70% - 2%, but rate of autism doubled 2004 study in Atlanta - no difference in autism among vaccinated and unvaccinated children California study - b/t , rate of autism increased 373%, immunization coverage only increased by 14% June 2010 study in Pediatrics - Timely vaccination during infancy has no adverse effect on neuropsychological outcomes 7-10 years later

87 2. What is autism? Criteria for diagnosis changed in Much more specific diagnosis: deficits in social communication and interaction restricted, repetitive behaviors, interests, or activities symptoms must be present in early childhood symptoms together limit and impair everyday functioning No more PDD-NOS, no more Asperger s

88 3. What causes autism, and why is it so common? Possible components of cause: Genetics Abnormal Brain Growth Environmental Trigger Prematurity Possible reasons for rise: Calling one diagnosis another Changing criteria for diagnosis Better awareness, earlier diagnosis Social acceptance Over- and misdiagnosis

89 4. Where are the Studies? Institute of Medicine 2011 report on adverse effects of vaccines Very detailed look at all available evidence. Conclusive evidence that MMR (and vaccines in general) do not cause autism. Anyone who wants to see the studies should read this 900 page book

90 5. Where does the schedule come from? ACIP (Advisory Committee on Immunization Practices) 15 voting members, many subcommittees. etings.htm#li - meetings and transcripts are open to the public. Often takes decades for vaccines to get approved

91 6. Should I separate the MMR vaccine? There is no reason to do this Separate components no longer made in US MMR is not, nor has it ever been, linked to autism No country in the world recommends splitting the vaccine The reported rise in autism is due to several factors, none of which involve vaccines We don t know what exactly causes autism, but vaccines have been extensively studied and shown not to be a cause

92 7. What do courts say about vaccines and autism? Vaccine Court - started in 1998, funded by taxes on vaccines, decisions based on preponderance of evidence, not proof beyond reasonable doubt In the summer of 2008, the court compensated the family of a 9 year old girl with an underlying rare medical disorder with symptoms similar to autism, saying that it was possible that vaccines exacerbated the disorder - NOT that vaccines cause autism! 6 is a link to the 2/2009 decisions from the court strongly ruling against any link between MMR, thimerosol, and autism

93 8. Are vaccines safe? If safe = harmless, then no vaccine is 100% safe. But very few things are harmless If safe = preserving from a real danger, then vaccines are very safe For all vaccines, the benefits far outweigh the risks We have seen how quickly vaccines are pulled when true concerns arise (1st rotavirus) There is a system in place (VAERS - where any patient or clinician can report concerns about vaccines

94 9. Are vaccines necessary? Vaccines are a victim of their own success - most people have never seen many of the diseases the vaccines prevent. Vaccines should be given because : Some diseases are so common in this country (pertussis, rotavirus, influenza) that not immunizing children puts them at risk for the disease Some diseases are present at low levels (measles, mumps, rubella) that not immunizing will lead to disease outbreaks and deaths Some diseases have been virtually eliminated from the US (diphtheria, polio), but are present in other parts of the world and could potentially be reintroduced by commonplace international travel

95 10. Are infants too young for immunizations? Infants are immunized because infancy is when they are most vulnerable to many diseases. For example: Almost all of the deaths from pertussis in the US are in children under 6 months Children under 2 years old are 500x more likely to get Hib meningitis if someone with a Hib infection is living in the home 90% of newborns of mothers infected with Hep B will develop chronic liver disease Infants are born with fully responsive immune systems

96 11. Can my baby handle so many shots at once? A baby is born with the potential to make millions and millions and millions of antibodies Babies are exposed to millions of germs every day shot, 200 proteins shots, 3217 proteins shots, 3000 proteins shots, 130 proteins A single bacteria on a toy can produce 3,000 proteins that the immune system needs to react against! Due to new combination vaccines, the number of shots is decreasing There is no difference in immune response to a vaccine if it is given alone or in combination with other vaccines

97 12. Is it better to be naturally infected? Natural infection does almost always cause better immunity than vaccination (except for Hib, pneumococcal, and tetanus), and it does so after just one infection. However, this comes at a much higher price, such as: Paralysis from natural polio Brain damage from natural Hib and pneumococcal infection Liver failure from natural Hep B Deafness and sterility from natural mumps

98 13. Do vaccines weaken the immune system? Natural infection with some viruses and bacteria does make the body less able to fight off infections from other viruses and bacteria This is not the case with vaccines - the viruses and bacteria in vaccines are so disabled that they cannot weaken the immune system Vaccinated children are not at greater risk of other infections than unvaccinated children

99 14. Is it safer to delay or stagger shots? Vaccines are given early in life because, for most of them, the diseases that they prevent can severely affect infants There is no good reason to stagger shots If you want to use the Sears Schedule, you should actually read the book! Sears schedule = 19 office visits, vs. 9 office visits with AAP schedule My problems with Dr. Bob s Alternative Vaccine Schedule Why would spreading out vaccines lead to less adverse events? Salon.com 10/13/2010 Facing Off With the Vaccine Guru

100 15. What else is in the shots? Should vaccines be greener? There are many components to vaccines, and they all serve a purpose. Most are present in much higher amounts in the environment Thimerosol - Not used in vaccines that kids under 2 receive anymore (except some flu vaccine), and the rate of autism keeps increasing Aluminum -There is way more aluminum in formula and breastmilk then there is in vaccines. Vaccines that contain Aluminum cause more soreness and redness, but there is no evidence that there are any other negative effects Formaldehyde - no concerns for bad effects MSG - very small amounts, no bad effects

101 16. How can I prepare myself and my child for shots? Read the Vaccine Information Statements Prepare questions before visit Bring a favorite toy, blanket, book Stay calm, talk softly Distract during shots (talk, sing) Nurse or give bottle after shots Cool washcloths on legs, Tylenol if needed

102 The Problem Nearly half (48.7%) of U.S. children are undervaccinated at some point prior to age 2 The most vulnerable children are unprotected. 1 in 8 (13%) of these children are undervaccinated due to parental choice to delay or refuse certain vaccines We need to learn more about the consequences of these decisions and counsel about them. Glanz et al. A Population-Based Cohort Study of Undervaccination in 8 Managed

103 Final Message Your Recommendation Matters Most!

104 Clear simple messages Get back to basics Presumptive recommendation Vaccinate ON time, EVERY time Vaccines are recommended at certain ages and intervals to: Optimize the immune response Ensure protection when child most at risk Minimize adverse events* *Rowhani-Rahbar et al. Effect of Age on the Risk of Fever and Seizures Following Immunization

105 Tips to improve Create reminder/recall systems in the office All staff give consistent message: Safe to receive multiple vaccines at once Avoid spreading out or delaying vaccines Safe to give vaccines during mild illness For example: OK to vaccinate during ear infection, cold, diarrhea, while taking antibiotics

106 Questions/comments?

107 Resources General Vaccine Scheduling & Information ACIP Recommended Vaccine Schedule & Catch-Up for 0 18 yrs: Create a personalized immunization schedule based on baby s birth date: Abbreviations and acronyms: Guidance on most efficiently scheduling combination vaccines: Reliable sources on vaccine information for clinicians or parents (websites, books, phone #, video): Vaccine Contraindications & Precautions: FDA product inserts for vaccines: htm Manual for the Surveillance of Vaccine-Preventable Diseases: CDC Pink Book:

108 Resources Hepatitis B CDC Hepatitis B Information & Resources: WHO Hepatitis B Fact Sheet: IAC Hepatitis B Information & Resources: Perinatal Transmission of Hepatitis B: Hepatitis B VIS: Rotavirus CDC Rotavirus Information & Resources: WHO Rotavirus Information & Resources: IAC Rotavirus Information & Resources: Complete MMWR with further details on MMR Vaccine Precautions: Rotavirus VIS:

109 Resources Diphtheria CDC Diphtheria Information & Resources: WHO Diphtheria Information & Resources: IAC Diphtheria Information & Resources: Tetanus CDC Tetanus Information & Resources: WHO Tetanus Information & Resources: IAC Tetanus Information & Resources: Pertussis CDC Pertussis Information & Resources: WHO Pertussis Information & Resources: IAC Hepatitis B Information & Resources: Vaccinating Pregnant Patients: DTaP Vaccine Contraindications & Precautions: DTaP VIS: Tdap/Td Vaccine Contraindications & Precautions: Tdap VIS: Td VIS:

110 Resources Haemophilis influenzae type B (Hib) CDC Hib Information & Resources: WHO Hib Information & Resources: IAC Hepatitis B Information & Resources: Hib VIS: Hib Catch-up Schedule Algorithms: Pneumococcal CDC Pneumococcal Information & Resources: IAC Pneumococcal Information & Resources: PCV-specific: PPSV-specific: Pneumococcal VIS: PCV13: PPSV23: Guidance on Using PPSV23 to Vaccinate High-Risk Children: PCV Catch-up Schedule Algorithm:

111 Resources Polio CDC Polio Information & Resources: WHO Polio Information & Resources: IAC Polio Information & Resources: Polio VIS: Influenza CDC Influenza Information & Resources: WHO Influenza Information & Resources: IAC Influenza Information & Resources: Influenza VIS: LAIV: Inactivated: Full list of Influenza Vaccines Available, Season (Table): Vaccination Algorithm for Children Aged 6mo 8 yrs (Figure 1): Recommendations for Influenza Vaccination in Those with Egg Allergy (Figure 2): Vaccination Contraindications:

112 Resources Measles CDC Measles Information & Resources: WHO Measles Information & Resources: IAC Measles Information & Resources: Mumps CDC Mumps Information & Resources: WHO Mumps Information & Resources: IAC Mumps Information & Resources: Rubella CDC Rubella Information & Resources: WHO Rubella Information & Resources: IAC Rubella Information & Resources: MMR VIS:

113 Resources Varicella CDC Varicella Information & Resources: WHO Varicella Information & Resources: IAC Varicella Information & Resources: Varicella VIS: Hepatitis A CDC Hepatitis A Information & Resources: WHO Hepatitis A Fact Sheet: IAC Hepatitis A Information & Resources: Hepatitis A VIS:

114 Resources HPV CDC HPV Information & Resources: Information & Guidance on the New Gardasil 9 Vaccine: HPV and Cancer: WHO HPV & Cervical Cancer Fact Sheet: IAC HPV Information & Resources: HPV VIS: Cervarix: Gardasil: Gardasil 9:

115 Resources Meningococcal CDC Meningococcal Information & Resources: WHO Meningococcal Meningitis Fact Sheet: IAC Meningococcal Information & Resources: Meningococcal VIS: Menactra, Menveo, & MenHibrix: MenB: Guidance on vaccinating high risk children and adolescents: All Current ACIP Meningococcal Vaccine Recommendations: Current ACIP Recommendations for MenB Vaccines: