Adolescent Immunizations

Transcription

1 Adolescent Immunizations Preteen Vaccine Week Webinar January 23, 2008 Eileen Yamada, MD, MPH California Department of Public Health Immunization Branch

2 Younger Children AND Adolescents Need Immunizations! Two pediatric schedules: 0-6 and 7-18 years

3 Adolescent Vaccines: Year Old Immunization Visit

4 Which Immunizations Do Adolescents Need? Tdap (tetanus, diphtheria, pertussis booster) One dose recommended for all MCV4 (meningococcal conjugate vaccine) One dose recommended for all HPV (human papillomavirus vaccine) if Female

5 Which Immunizations Do Adolescents Need? Influenza if at high-risk or wish to reduce their risk (or the spread to others) 2 nd Dose of Varicella Vaccine If not already immune Other immunizations if Specific risk factors Contact with high risk persons (including infants) Not up-to-date

6 When Should Adolescents Receive Their Immunizations? Ideally at the year old preteen visit! But if they didn t receive immunizations at that age, then as soon as possible!

7 Pertussis (Whooping Cough) and Tdap Vaccine

8 25,000 20,000 15,000 10,000 5,000 0 reported cases Reported Pertussis Cases, California

9 Percent of Reported Cases > 9 Years of Age is Increasing, California % 20+ years years 80% 1-9 years < 1 year percent of reported case 60% 40% 20% 0% California Dept of Health Services Immunization Branch

10 Whooping cough scare in Palo Alto OAKLAND TRIBUNE, Nov 15, 2006 by Julie Sevrens Lyons It started in September with one student coughing. Soon pertussis, commonly known as whooping cough, hit members of the cross-country team. Now seven cases of the tough, rib-cracking infection have been confirmed at Palo Alto High School; County health officials suspect 37 more. All 1,700 students are being encouraged to get booster shots to keep the disease from spreading. The Santa Clara County health department will hold a free pertussis vaccination clinic on Palo Alto High School's campus Wednesday, and has alerted more than 5,000 local health care providers about the outbreak. There have been no reported outbreaks at schools in San Mateo County.

11 Pertussis in Adolescents Prolonged cough (several weeks to months) a common feature in adolescents Symptoms nonspecific during first week or two Delayed or missed diagnosis Increased opportunity to spread disease Often occurs in outbreaks in middle and high schools Close interaction with large numbers of students with waning immunity Can disrupt usual school functions with significant public health and school efforts to educate families, detect and treat cases, and provide chemoprophylaxis to close contacts

12 The Majority of Severe Pertussis Disease Complications Occur Among Infants 0-2 Months of Age, California Death Encephalopathy number of cases age (months) California Dept of Health Services Immunization Branch

13 Source of Infant Pertussis (n=264) Source* Percent Mother Father Grandparent Sibling 0-4 years 5-9 years 10+ yrs Neighbors, friends *Source identified for 264/616 (43%) of infants in study, Bisgard et al. 2004

14 Cocooning! Tdap vaccination recommended for those anticipating close contact with infants < 12 months E.g., Parents, grandparents, child care providers, health care providers, siblings, and others with close contact with infant) Ideally at least 2 weeks before close contact with the infant Refer client and others with close contact to infant to health care provider if not protected against pertussis

15 2005 ACIP Tdap Recommendations: Adolescents (11-18 Years) Should receive Tdap instead of Td as booster; preferred age years. Should receive Tdap if already given Td Interval 5 years encouraged Interval < 5 years can be used, especially if benefit of providing protection is increased Tetanus prophylaxis, wound management: give Tdap History of pertussis: Still give Tdap

16 Meningococcal Conjugate Vaccine

17 Meningococcal Disease Caused by Neisseria meningitidis Invasive meningococcal disease Meningitis Meningococcemia Pneumonia Other Case fatality rate of 10-14% 11-19% with serious sequelae Deafness, neurologic deficit or limb loss

18 Meningococcal Conjugate Vaccine Menactra Protection against types A, C, Y, and W-135 Given intramuscularly Now licensed for those 2 years -55 years No current vaccine for serogroup B MMWR 2005; 54 (No. RR-7):1-17.

19 rate per 100,000 population Rates of meningococcal disease by age and serogroup California, All Serogroups Serogroups A,C,Y, W age groups < California Dept of Health Services Immunization Branch

20 Meningococcal Disease Among Young Adults, United States, years old 1.4 / 100, years old, not college student 1.4 / 100,000 Freshmen 1.9 / 100,000 Freshmen in dorms 5.1 / 100,000 Bruce et al, JAMA 2001;286;688-93

21 Meningococcal Conjugate Vaccine Revised Recommendations Vaccination with one dose of MCV4 is recommended for all 11 through 18 year olds at the earliest opportunity Persons years old should be routinely vaccinated at the ACIP recommended year old health care visit MMWR 2007; 56 (31);

22 Other Populations at Increased Risk for Meningococcal Disease Routine vaccination is also recommended for persons who are at increased risk for meningococcal disease, including: College freshmen living in dorms Military recruits Microbiologists routinely exposed to N. meningitidis Travelers to, or residents of, countries in which N. meningitidis is hyperendemic or epidemic Persons with terminal complement component deficiencies Persons with anatomic or functional asplenia MMWR 2005; 54 (No. RR-7):1-17.

23 When student has meningococcal disease Report to local health department Preventive antibiotic to CLOSE contacts Kissing, sharing water bottles, household, or prolonged close contact Not merely classroom attendance Reminder: Vaccine recommended for all years If outbreak of meningococcal disease in school Work with local health department! Mass chemoprophylaxis Consider vaccination for protection in mid-to-long term

24 National Immunization Survey Teen Estimated Vaccination Coverage, 2006 Vaccine 13 years Age 17 years yrs Td or Tdap 1 dose 48.3% ( ) 68.6% ( ) 60.1% ( ) Tdap 1 dose 12.7% ( ) 5.1% ( ) 10.8% ( ) MCV4 1 dose 11.3% ( ) 7.1% ( ) 11.7% ( )

25 HPV Vaccine

26 Over 100 HPV Types Dermal (skin) HPV types (nonsexual contact) Common Warts Munoz, NEJM 2003;348: Low-risk types low grade cervical abnormalities genital warts respiratory papillomatosis Mucosal (genital) HPVs (sexual contact) (~40 types identified) High-risk types 6,11,42,43,44 16,18, 31,33,35,39, 45,51,52,56,58 low grade, high grade, & precancerous cervical abnormalities anogenital cancers

27 HPV (6, 11, 16, 18)-associated Conditions HPV 16, 18 Cervical Cancer High grade cervical abnormalities Low grade cervical abnormalities Anal cancer Vulvar/Vaginal/Penile cancers Head and Neck cancer HPV types 6 and 11 Genital warts Low grade cervical abnormalities Recurrent respiratory papillomatosis Estimated Attributable % 70% 50% 30% ~70% ~40% ~10% Estimated Attributable % 90% 10% 90% From presentation at ACIP: Dunne E. Epidemiology of HPV Infection. ACIP Meeting: Atlanta, GA, February 2006

28 HPV Infection is Common Approximately 20 million people are currently infected with HPV Estimated 6.2 million new infections every year among year olds 74% among those years By age 50, an estimated 80% of sexually active women will have acquired genital HPV infection

29 Wright, NEJM Natural History

30 HPV: Background Condom use may reduce the risk for HPV and HPV-associated disease, but is not 100% effective. HPV spread by skin-to-skin contact (mucosal areas not covered by condom)

31 HPV Vaccine Efficacy HPV vaccines are very efficacious if given prior to exposure to HPV HPV vaccines are preventive; they are not effective for treating current HPV infection Garland SM et al. N Engl J Med 2007; 356: Future II Study Group. Lancet 2007; 369: Future II Study Group. NEJM 2007; 356: Joura EA et al. Lancet 2007; 369: Paavonen J et al. Lancet 2007; 369: Harper et al, Lancet, 2006; 367:

32 Quadrivalent HPV Vaccine: Lesions Associated with Vaccine-Type HPV Endpoints HPV 16, and 18- Associated CIN 2/3 or AIS HPV 6, 11, 16, and 18- Associated Genital Warts Per Protocol Efficacy (95% CI) 98% (86,100) 100% (92,100) Intention to Treat Efficacy (95% CI) 44% (26, 58) 76% (61, 86) Future II Study Group. NEJM 2007; 356: Garland SM et al. N Engl J Med 2007; 356:

33 Serum GMT 95% with CI, mmu/ml Antibody Titers by Age at Vaccination Anti-HPV 6 GMTs (Quadrivalent HPV vaccine) Immunogenicity Bridge Efficacy Program Age (Years) Merck, unpublished data, ACIP presentation by Eliav Barr, February 2006

34 Current Status of HPV Vaccines Vaccine Manufacturer Merck (Gardasil ) Quadrivalent 6/11/16/18 GSK (Cervarix ) Bivalent 16/18 Schedule (3 doses over 6 months) 0, 2, and 6 months 0, 1, and 6 months FDA Licensure Status Licensed June 2006 (females ages 9 to 26 years) Submitted March 2007 Expect decision 2008

35 HPV Vaccine Recombinant DNA technology Not live, not infectious Induces type-specific antibody production MMWR 2007; 56 (March 12, 2007): 1-19.

36 ACIP Recommendations: Quadrivalent HPV Vaccine March 2007

37 Recommendations for Use: Quadrivalent HPV Vaccine Routine vaccination of females aged 11 to 12 years Can be started as young as 9 years Catch-up vaccination of females years who haven t been vaccinated or completed the full series 3 dose series given over 6 months Continue routine cervical cancer screening MMWR 2007; 56 (March 12, 2007): 1-19.

38 Special Situations Females may be vaccinated if they have: Equivocal or abnormal Pap test Positive High-Risk HPV Test Genital Warts Or if they are: Lactating Immunocompromised MMWR 2007; 56 (March 12, 2007): 1-19.

39 Quadrivalent HPV Vaccine Not currently recommended for use during pregnancy Limited data Not associated with adverse outcomes of pregnancy or to the fetus MMWR 2007; 56 (March 12, 2007): 1-19.

40 Safety Injection site reactions most common Pain, swelling, redness Mostly mild to moderate in intensity

41 Other Important Vaccines

42 Other Important Vaccines Varicella All adolescents (and children) without evidence of immunity to varicella should have received 2 doses of varicella vaccine. Hepatitis B All unvaccinated adolescents < 19 years should have received hepatitis B vaccine series Measles, Mumps, Rubella (MMR) All adolescents should have documentation of 2 doses of MMR or other evidence of immunity

43 Other Important Vaccines Influenza if: at high-risk or wish to reduce their risk (or the spread to others) NOTE: May have specific influenza vaccine recommendation for 5-18 years in the future Hepatitis A Catch-up immunization (2 doses) Other immunizations based on risk

44 National Immunization Survey Teen Estimated Immunization Coverage, 2006 Age MMR ( 2 doses) Hep B ( 3 doses) Varicella disease Varicella ( 1 dose)* 13 years % (95% CI) 87.0% (82.8, 90.3) 88.6% (84.5, 91.6) 60.5% (55.3, 65.4) 73.3% (66.1, 79.5) 17 years % (95% CI) 85.8% (81.9, 88.9) 77.3% (72.5, 81.4) 82.1% (77.9, 85.7) 46.3% (35.0, 58.1) yrs % (95% CI) 86.9% (85.2, 88.5) 81.3% (79.4, 83.1) 69.9% (67.7, 72.0) 65.5% (61.4, 69.4) *Without a history of varicella disease

45 Preventing Adverse Events Syncope (fainting) can occur after vaccination and might be more common among adolescents and young adults Providers should strongly consider a 15 minute observation period

46 Summary Make sure all adolescents are up-to-date on all their immunizations! Give Tdap, meningococcal conjugate vaccine, and HPV vaccine series (girls) Check other immunizations to make sure they are up-to-date Annual influenza vaccine for those at high risk or who would like to decrease their risk of flu or transmitting it to others

47 Preteen Vaccine Week January 20-26, 2008

48 Resources CDPH/Iz CDPH/Iz/Preteens: C3I (CIC): CDC/NIP: CDC/Preteen: AAP: AAFP: IAC: McCauley MM, et al eds. Strengthening the delivery of new vaccines for adolescents. Pediatrics 2008; 121 (Suppl 1): S1-S87.

49 Questions?

50 Eileen Yamada, MD, MPH Immunization Branch California Department of Public Health