Objectives 1. Become familiar with current immunization schedules for children

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1 Sarah Matches, DO, FAAP Assistant Professor UNTHSC, Dept. of Pediatrics Objectives 1. Become familiar with current immunization schedules for children 2. Describe the international progress in reducing the incidence of vaccine preventable diseases, and how this impacts us in the United States 3. Discuss the challenges of working with vaccine hesitant patients 4. Discuss new pediatric vaccines and the recommendations for administration Disclosures Sub investigator: Phase III Pediatric Clinical Influenza Study for Novartis 1

2 Current Vaccine Schedule for Children 2

3 There s an App for that! 3

4 Vaccination Rates in TX Vaccine Category Percent completely Vaccinated Conscientious Exemptions % DTaP 97.2% 1.04% Hepatitis A 97.1% 1.02% Hepatitis B 98.0% 1.01% MMR (2 doses) 97.4% 1.11% Polio 97.3% 1.07% Varicella (2 doses) % Focus on Polio, Measles and Pertussis 4

5 Polio One in 200 infections leads to irreversible paralysis and among these, 5% 10% will die Since 1988, there has been a 99% reduction in the numbers of polio cases Pakistan and Afghanistan remain the only two countries in the world with endemic polio As of November 18,2015, there have been 56 cases of wild poliovirus in

6 Measles Highly contagious and the virus remains active and contagious in the air or on infected surfaces for up to 2 hours, is a leading causes of death among young children Among unimmunized, 90% of those exposed to the virus will contract the disease Prior to an available vaccine, caused an estimated 2.6 million deaths each year Measles In 2014, caused 114,900 deaths globally about 314 deaths per day, or 13 deaths per hour 79% drop in measles deaths between 2000 and 2014, short of the 95% reduction goals After 1 dose of vaccine at 12 months, 95% are immune, and 99% of the remaining will be immune after a second dose 6

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9 Pertussis The CDC reports there are an estimated 16 million cases of pertussis per year worldwide It causes an estimated 195,000 deaths in children yearly Most of those deaths occur in young unimmunized infants in the developing world Pertussis in the US Pertussis is endemic in the US: >28,000 cases in 2013, >32,000 cases in 2014 Concerns about adverse events associated with the whole cell vaccine led to its replacement with DTaP in 1997 Protection is high for the first 2 years after vaccination, then wanes The high rates of pertussis among vaccinated year olds during recent outbreaks suggests early waning of immunity from acellular vaccines It is important to note that unvaccinated children have at least an eightfold greater risk for pertussis than those fully vaccinated with DTaP 9

10 Pertussis Vaccination The Global Pertussis Initiative (GPI) has shown that vaccinating pregnant women against pertussis is the best way to protect their newborns 1 dose to pregnant adolescents during EACH pregnancy (preferred weeks) regardless of time since last Td or Tdap is recommended All family members and grandparents should be vaccinated prior to birth of the infant, or soon thereafter Meningococcal Type B Human Papillomavirus 9 serotypes (HPV9) Influenza Meningococcal Disease 13 Serogroups, most invasive are A, B, C, W and Y B, C and Y are the most frequent causes of disease in the US Some individuals will be nasopharyngeal carriers of the n. meningitidis bacteria College students or military recruits are at higher risk due their living in close contact with others in dorms or barracks 10

11 Quadrivalent Meningococcal Vaccines 2 Types available in the US since 2005 cover for serogroups A,C,W and Y Meningococcal polysaccharide vaccine (MPSV4) which has a polysaccharide from the surface of the bacteria Meningococcal conjugate vaccines (MCV4) which has the polysaccharide chemically bonded (conjugated) to a protein to produce a better immune response. One dose of MCV4 is recommended at years of age and a second dose at 16 years of age due to waning immunity and the increased risk until age 21 11

12 Serogroup B Meningococcal Vaccines Two new serogroup B meningococcal (MenB) vaccines were recently licensed MenB FHbp (Trumenba) which is a 3 dose series MenB 4C (Bexsero) which is a 2 dose series The 2 vaccines are NOT interchangeable the same product must be used for all doses Either vaccine may be given at the same time as other vaccines, but should be given at a different anatomic site Serogroup B Meningococcal Vaccines Advisory Committee on Immunization Practices (ACIP) approved new recommendations in June, year olds may be vaccinated to provide shortterm protection Category B recommendations High risk groups carry a Category A recommendation this includes >10 years old with: 1) functional asplenia, 2) persistent complement deficiency, or 3) individuals at risk during an outbreak VFC will not carry MenB vaccines, but Medicaid will reimburse provider if vaccine is given. Insurance should cover if recommendations are followed. Human Papillomavirus HPV is the most common sexually transmitted infection in the US HPV can cause cervical, vulvar, vaginal, penile, anal and oropharyngeal cancers and genital warts 1/3 of HPV associated cancers occur in males Types 16 and 18 account for approximately 70% of cervical cancers worldwide, approx. 64% in US Types 6 and 11 are responsible for approximately 90% of genital warts 5 additional cancer causing types; 31, 33, 45, 52 & 58 account for an additional 10% of cancers in the US 12

13 HPV Vaccine A bivalent HPV vaccine (HPV2) protects against HPV types 16 & 18 and is licensed for use in females only A quadrivalent HPV vaccine (HPV4) protects against HPV types 6, 11, 16, & 18 HPV4 is licensed for males and females 9 26 years The new 9 valent HPV vaccine (HPV9) protects against the types in the HPV4 vaccine as well as 31, 33, 45, 52 & 58 HPV9 Vaccine In 2/2015 the ACIP recommended the 9 valent vaccine (HPV9) as one of three HPV vaccines that can be used for routine vaccination (category A) HPV9 is approved for females 9 26y and males 9 15y Given as a 3 dose series, the 2 nd dose is at least 1 2 months after the first, and the third is at least 6 months after the first Recommend starting at 11 12years HPV9 may be substituted for any other vaccine HPV9 Vaccine (cont.) Most frequent side effects are swelling and redness at the injection If someone has completed HPV4 series, they could get 2 doses of the HPV9. However, not clear insurance would cover this HPV9 is on VFC and is likely covered by most insurances since it is Category A recommendation 13

14 Influenza Quadrivalent influenza vaccine is available this year it includes 2 A strains and 2 B strains Recommended for all children 6 mos and older Children age 6 months 8 years receiving the vaccine for the first time, need 2 doses at least 4 weeks apart If they are 6 mos 8 years and have only had one dose total in all previous years, they should also receive 2 doses of the vaccine this year Live attenuated virus vaccine may be given at 2 years of age 14

15 Why Should I Vaccinate My Child? Parents Reasons to not Vaccinate Vaccines cause autism Too many at one time will overload their bodies These illnesses are rare These illnesses aren t that bad (varicella is common example) Vaccines have severe side effects Vaccines contain dangerous preservatives There is a conspiracy between government and big pharma 15

16 Vaccine Hesitant Parents Many parents will listen to your explanations Studies have shown that if the provider makes the recommendation for the vaccine, most parents will agree to proceed Acknowledge Risks and Benefits While severe side effects happen, they are rare The VIS lists known side effects OK to note that not vaccinating is also risky The C.A.S.E. for Vaccines A new model for talking to parents A mnemonic to organize a rapid, useful response Draws from Aristotelian teaching on rhetoric Created by Alison Singer, MD President, Autism Science Foundation Lacks published studies of its efficacy Nonetheless has face validity, historical roots Lacks competing alternatives The CASE Approach Corroborate: Acknowledge the parents concern and find some point on which you can agree; Set the tone for a respectful, successful talk About Me: Describe what you have done to build your knowledge base and expertise Science: Relate what the science says Explain/Advise: Explain your advice to patient, based on the science 16