REACHING OUR GOALS: CHILDHOOD & ADOLESCENT IMMUNIZATION 2017 Illinois Chapter, American Academy of Pediatrics
Learning Objectives Provide the updates from 2017 Advisory Committee on Immunizations Practices (ACIP) pediatric vaccination and catch-up schedule Recommend best practices when administering vaccines to children and adolescents Demonstrate correct schedule recommendations for ACIP scheduled vaccines Interpret correct storage and handling of vaccines being administered
Disclosure Slide 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.
Importance of Vaccines Healthy population Prevent infectious diseases Protect those who can t get vaccination Cost/time/emotional savings
What s new in 2017? Layout changes in the immunization schedule figure New 16 yr age column New blue bar for meningococcal & HPV vaccines New or revised ACIP recommendations for: influenza human papillomavirus hepatitis B Haemophilus influenzae type pneumococcal Meningococcal diphtheria and tetanus toxoids and acellular pertussis vaccines New Figure 3 added Vaccines that might be indicated for children and adolescents aged 18 years or younger based on medical indications
Cocooning Babies <6 mo. vulnerable to diseases Whooping cough & flu What can you do? Get vaccinated!
Hepatitis B
Hepatitis B Vaccines 3 types of disease: Acute, chronic, perinatal How common is Hepatitis B? Acute: approx. 19,200 new cases in US in 2014 Chronic: approx. 850,00 2.2mil 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 Symptoms Acute: Most <5yo are asymptomatic; 30-50% 5yo are symptomatic Morbidity/mortality Acute: 0.5-1% case fatality, more severe for >60yo Chronic: 25% of those infected in childhood die prematurely
Hepatitis B Vaccines 2 single-agent vaccines: Recombivax HB Engerix-B 3 combination vaccines: 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). Do NOT freeze. 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.)
Hepatitis B Vaccines Recommended vaccination schedule 3 dose series 1 st dose at birth (use monovalent) Maternal HBsAg Status Newborn Weight - + Unknown 2000 g 1st dose 24 hrs < 2000 g 1st dose 1 mo. after birth or at discharge 1st dose HepB vaccine + 0.5 ml HBIG 12 hrs 1st dose HepB vaccine + 0.5 ml HBIG 12 hrs 1st dose 12 hrs & test maternal status (if + give HBIG) 1st dose HepB vaccine + 0.5 ml HBIG 12 hrs 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 If interrupted, do not need to re-start Adult Recombivax HB: 2 dose series licensed for use in children 11 15yo; 4mo. between dose 1 & 2
Rotavirus
Rotavirus Vaccines How common is it? Highest rates in infants & young children 95% children infected by 5yo, prior to 2006 vaccine 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
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 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
Rotavirus Vaccines 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 (including HIV) Chronic GI disease Spina bifida or bladder exstrophy Refer to new Figure 3 for visual guidance
Diphtheria, Tetanus, & Pertussis
Diphtheria, Tetanus, & acellular Pertussis Vaccines (DTaP) Protects against diphtheria, tetanus, & pertussis Bacterial infections cause disease Diphtheria Spread through coughs, sneezing Children <5 yo can have case fatality rates up to 20% Tetanus Bacteria present in environment, enter through broken skin 10 20% die, even with treatment Pertussis aka whooping cough 3 stages: catarrhal, paroxysmal, convalescent Spread through coughs, sneezing Children <1 yo have highest incidence, and most at risk for severe or fatal outcomes. Children ages 7 10 have 2 nd highest rates.
Diphtheria, Tetanus, & acellular Pertussis Vaccines (DTaP) Pentacel, Infanrix, Daptacel, Pediarix; Kinrix & Quadracel (5 th dose ONLY) Recommended Vaccination Schedule 5 doses: 2, 4, 6, 15 18 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. 2017 Update: Early 4 th dose: if >4mo. after 3 rd & child is 12mo OK Intramuscular injection Store at 2-8 C (36-46 F). Do not freeze. Contraindications & Precautions: Refer to CDC list
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 DT generic (Sanofi Pasteur), Td generic (MassBiologics), Tenivac 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 11 18 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. Inadvertant DTaP dose: depends on age Intramuscular injection Store at 2 C - 8 C (36 F - 46 F). Do not freeze. Contraindications & precautions: Refer to CDC list
Tetanus, diphtheria, & acellular pertussis (Tdap)/Tetanus & diphtheria (Td) Pregnancy and Tdap vaccination Tdap for each pregnancy, at 27 36 weeks (ACIP preference for closer to 27 wks); 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
Haemophilis influenzae type b
Haemophilis influenzae type b Vaccine Hib bacteria infections 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 Range from fever to cough to nausea (depends on infx type) Morbidity/mortality Most invasive Hib infx require hospitalization Up to 20% of Hib meningitis neurological sequelae 3 6% of children with Hib meningitis die
Haemophilis influenzae type b Vaccine Single-agent vaccines ActHIB; PedvaxHib; Hiberix (may be used in primary vax series) Combination vaccines Menhibrix: Hib + Nisseria meningitidis Pentacel: Hib + diphtheria + tetanus + pertussis + poliomyelitis COMVAX: No longer available Recommended Vaccination Schedule ActHIB, MenHibrix, Hiberix, Pentacel: doses at 2, 4, & 6 mo. (min. age 6 wks) PedvaxHib: doses at 2 & 4 mo. Booster dose at 12 15 mo. Catch-up schedule Complex. Follow CDC algorithms: http://www.cdc.gov/vaccines/schedules/downloads/child/job-aids/hibacthib.pdf http://www.cdc.gov/vaccines/schedules/downloads/child/job-aids/hibpedvax.pdf Unvaccinated children 15-59 mo. only need 1 dose Intramuscular injection
Haemophilis influenzae type b Vaccine Protects against Haemophilis influenzae type b (Hib) High-risk patients 12 59 mo. at increased risk for Hib & had 0 1 dose prior to 12 mo. 2 more doses 8 wks apart 12 59 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
Pneumococcal Disease
Pneumococcal Vaccines Most common cause of bacteremia, pneumonia, meningitis, and ear infection in children How common is it? 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 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 Complications Pneumonia: empyema, pericarditis, endobronchial obstruction, atelectasis, abscess, death Meningitis: hearing loss, developmental delay, death Bacteremia: death Ear infection: repeated ear infections Morbidity/mortality Pneumonia: 5% of all pts die Meningitis: 1 in 15 children <5yo die Bacteremia: 1 in 100 children <5yo die
Pneumococcal Vaccines Protect against pneumococcal disease PCV13 = Prevnar13; PPSV23 = Pneumovax23 Recommended Vaccination Schedule PCV13: 4 dose series at 2, 4, 6, 12 15 mo. (min. age 6 wks) PPSV23: only in high-risk cases 2 yo Catch-up schedule: http://www.cdc.gov/vaccines/schedules/downloads/child/jobaids/pneumococcal.pdf
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
Polio
Polio Vaccines (IPV) Not circulating in US, but can be imported Transmitted person to person, fecal-oral or respiratory route 72% have no symptoms, 24% flu-like sxs 2-5 days Complications: Paresthesia, meningitis, paralysis, post-polio syndrome, death 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
New Guidance on Polio Vaccines OPV = oral polio vaccine If both OPV & IPV administered as part of a series total # of doses needed to complete the series is the same as that recommended for the U.S. IPV schedule. Min.4 weeks between doses Final dose 4yo; min. 6 mo. after the previous dose. If only OPV administered & all doses given before age 4 years 1 dose IPV should be given at 4 years or older and at least 6 months after the last OPV dose. This 6-month period is a change from the current footnote which indicates the period is 4 weeks after the last OPV dose. Only trivalent OPV (topv) counts toward the U.S. vaccination requirements Guidance to assess doses documented as "OPV https://www.cdc.gov/mmwr/volumes/66/wr/mm6606a7.htm
Influenza
Influenza Vaccines Protects against influenza 3 types of influenza virus: A, B, 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 2015-2016 season: 31.1 hospitalizations per 100,000 population Pediatric deaths range from 34-171 per season; 74 in 2015-2016
Influenza Vaccines Protects against influenza Video: http://www.vaccineinformation.org/videos/index.asp?vid_cat=0013 Respiratory droplets released from sneeze Emergency hospital during 1918 epidemic Photos: CDC
Influenza Vaccines Protects against influenza IIV vs. LAIV IIV3 & IIV4 (multiple trade names): 6 mo (varies) 2017 Update: LAIV no longer recommended
Influenza Vaccines Protects against influenza Recommended Vaccination Schedule Annual dose for everyone 6 mo, unless contraindicated Catch-up schedule MMWR; August 26, 2016; 65(5);1 54
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 to vaccine component, incl. egg protein Further detail: https://www.cdc.gov/mmwr/volumes/65/rr/rr6505a1.htm Precautions Moderate or severe acute illness with or without fever, history of Guillen-Barre Syndrome within 6 wks of previous dose
Measles, Mumps, & Rubella
Measles, Mumps, & Rubella Vaccine Measles Viral respiratory illness Highly contagious: infects 9 of 10 non-infected Transmitted via respiratory droplets Mumps Pain and swelling in the salivary glands Highly contagious, Spread via respiratory droplets, saliva, sharing items, or by contaminated objects touched by an infected person Rubella aka German measles Viral respiratory illness Spread via respiratory droplets Most serious complications in pregnant women
Measles, Mumps, & Rubella Vaccine Protects against measles, mumps, & rubella M-M-R II & PROQUAD Live, attenuated virus vaccine Recommended Vaccination Schedule 2 doses: 12 15 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
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?
Varicella
Varicella Vaccines Viral infection with varicella-zoster virus How common is it? Prior to vaccine: 4million cases, 100-150 died 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
Varicella Vaccines Protects against varicella (chickenpox) Varivax & PROQUAD Live, attenuated virus vaccine Recommended Vaccination Schedule 2 dose series: 12 15 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
Hepatitis A
Hepatitis A Vaccine Liver infection caused by Hepatitis A virus How common is it? 95% decrease since vaccine 2014: 2,500 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, joint pain, jaundice Complications Rare, can cause liver failure and death Morbidity/mortality 2014: 76 deaths
Hepatitis A Vaccine Protects against Hepatitis A Havrix, Vaqta & Twinrix Recommended Vaccination Schedule 2 doses: 12 23 mo. (separate by 6-18 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
Human Papilloma Virus (HPV)
HPV Vaccine 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, sexually transmitted Symptoms Typically asymptomatic Genital warts, abnormal pap test Complications Cancer, death Morbidity/mortality Cancers: 17,600 in women, 9,300 in men 90%: cervical & anal cancer 70%: vaginal, vulvar & oropharyngeal 60%: penile
HPV Vaccine Important to make strong recommendation for vaccination! Gardasil (4vHPV) & Gardasil 9 (9vHPV) 2017 Update: Cervarix no longer available Recommended Vaccination Schedule 2017 Update: 2 doses: 11 12 yo. (can start at 9 yo) 2017 Update: 6 12 mo. between doses 1 & 2 Catch-up schedule Min. age 9 yo. Recommended max. age: 26yo for women, 21yo for men
HPV Vaccine Protects against Human Papillomavirus (HPV) Special Populations Children with hx of sexual abuse/assault begin vaccine at 9 yo. MSM routine vaccination as for all males through 26 yo Transgender routine vaccination as for all adolescents through 26 yo. Immunocompromised 3 dose series at 0, 1-2, and 6 mo. Pregnancy not recommended, but no evidence of harm
HPV Vaccine Protects against Human Papillomavirus (HPV) 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
Meningococcal Disease
Meningococcal Vaccines 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. & 16 23 yo. 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 10 15 out of 100 cases die 11 19 of survivors have long-term disability
Meningococcal Vaccines Protects against meningococcal disease MenACWY: Menactra, Menveo MenCY + Hib: MenHibrix Recommended Vaccination Schedule Routine: 1 dose Menactra or Menveo at 11 12 yo.; booster at 16 yo. 11 18yo 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, HIV (2017 Update) Catch-up schedule 13 15 yo: 1 dose Menactra or Menveo; booster at 16 yo, 8wks between doses 16 18 yo: 1 dose Menactra or Menveo; no booster
Meningococcal Vaccines Protects against meningococcal disease MenB: Bexsero, Trumenba 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, travel 16 23 yo may get MenB vax, preferably at 16 18 yo Category B recommendation, so it is up to individual clinicians to decide 2017 Update: 2 doses of Trumenba 6 mo. between doses 1 & 2 If <6 mo. 3 rd dose required 6 mo between 1 st & 3 rd dose > 4 wks between 2 nd & 3rd dose
Meningococcal Vaccines 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. Use 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
QUESTIONS/COMMENTS? Thank you!