Private Market Vaccines 1
What do you recommend Best protection for my child Best protection for adults Best protection for occupational health 2
Not on the national schedule.. Rotavirus Varicella Meningococcal HPV vaccine for men Adult pertussis protection: Boostrix/Adacel Healthcare and early childcare workers Pregnant women Cocoon strategies Pneumococcal: PPV23 and PCV13 3
Rotavirus Death rare 1 in 43 children hospitalised by 5 yrs in NZ For each hospitalisation 8 children seen in primary care > 90% children have RV by 3 yrs no strong ethnic or se gradient, a universal bug! Vaccine 85% efficacy against RV hospitalisation 2 doses 4 weeks apart, complete by 24 weeks $100 (currently) - $160 course exc GST and delivery 4 Lepage P. Pediatr Infect Dis J 2006;25:S5 S6. Grimwood K, Lambert SB. Hum Vaccine 2009;5:57 69 Milne RJ, Grimwood K. Value Health 2009;12:888 898
Rotavirus Vaccine Rotarix - Live oral, attenuated human G1P8-2 doses Contraindications: - Hypersensitivity to any component of the vaccine including latex rubber - uncorrected congenital malformation of the gastrointestinal tract - Severe Combined Immunodeficiency Disease (SCID) - Usual live vaccine precautions Administration in infants suffering from acute diarrhoea or vomiting should be delayed
Varicella vaccines Why use >90% children catch varicella 150-200 hospitalisations/year (2/3 otherwise healthy) 1-2 long term disability Death occasional Skin sepsis?rates When to start 1 dose or 2? Wild boosting in NZ current context Role of MMRV (not yet available in NZ) 12-23 months: = 1 extra febrile seizure for every 2300 doses over MMR + Varicella vaccine. 6 Klein et al Pediatrics July 27 2010
Shingles - Zostavax VE Zoster 51% Post herpetic neuralgia 67% Contraindications Anaphylaxis to any components, neomycin Immunodeficiency/ immunosuppr4essed Pregnancy Active untreated Tb 7 Who to advise Elderly.. Aims Keep independent living Reduce increased fraily with onset of zoster
Problem polysaccharide vaccines Pneumovax 23, Menomune, MENCEVAX, Vivaxim, TYPHIM Vi 3-5 years 3-5 years 3-5 years 3-5 years No induction of immune memory by polysaccharide vaccines Boosters required if protection required life-long antibody persistence (e.g. aspenia) Risk of depletion of the specific B cell pool
Types of meningococcal disease Six capsular groups associated with invasive disease: A, B, C, Y, W-135, X Differ by their exterior polysaccharide capsule The frequency of different types differs from country to country NZ currently major types B and C Is in the community all the time in low numbers Occasional outbreaks
Meningococcal around the world
Nasopharyngeal carriage Can be in the nose/throat for weeks to months Usually cleared by your immune system without getting sick Occasionally invades the bloodstream and causes disease Carriage rate <3% children under 5 years of age 25-35% adolescents 15 24 yrs <10% older ages Higher rates in lower se groups, confined or linked populations eg military recruits, pilgrims, boarding schools, prisoners Lancet Infec Disease 2010:10;853-861 Thomas MG. New Zealand Medical Journal (2004) 117:1200.
Risk factors for meningococcal disease Crowded living conditions, e.g. home or hostel Recent respiratory infection Exposure to cigarette smoke Poor nutrition Inherited (genetic) factors
Meningococcal From: The Epidemiology of Meningococcal disease in New Zealand in 2011 ESR June 2011
Distribution of strain types among meningococcal disease cases, 2011 Strain group Number of cases Percentage Group B 62 62.0 P1.7-2,4 37 37.0 Other group Bs 25 25.0 Group C 38 38.0 P1.5-1,10-8 27 27.0 Other group Cs 5 5.0 Other 6 6.0 Group Y 3 3.0 Group W135 2 2.0 Non-groupable 1 1.0 Total 100 100.0 From: The Epidemiology of Meningococcal disease in New Zealand in 2011 ESR June 2011 14
Meningococcal disease rates by age group, 2007 2011 <1 1-4 5-9 10-14 15-19 20+ Rate per 100 000 population 2007 2008 2009 2010 2011 Year From: The Epidemiology of Meningococcal disease in New Zealand in 2011 ESR June 2011 15
Meningococcal vaccines Currently only private market and outbreak use in NZ Polysaccharides A, C, Y, W-135 Ineffective in younger children Short duration of immunity Possible hyporesponsiveness with multiple use Conjugates C, Quadrivalent Effective in younger children Herd immunity effects 16 B vaccine...close (NB unlikely to be any individual protection left now in NZ community from MeNZB vaccine)
International options for meningococcal vaccination Cheap and cheerful Menactra (Sanofi)=conjugate ACWY Neisvac-C (Baxter)= Conjugate C Menitorix (GSK)= Conjugate Hib and MenC Menveo (Novartis) = Conjugate ACWY Meningitec (Pfizer) = Conjugate C MenAfriVac= (Serum Institute of India) Conjugate A Menomune (Sanofi)=polysaccharide ACWY Mencevax (GSK) =polysaccharide ACWY Rolls Royce *Bexsero (Novartis) Recombinant quadrivalent group B * Licensure applications lodged EMEA and FDA
Number of meningococcal disease cases caused by vaccine-targeted strains by age group, 2011 Vaccine <1 yrs 1-4 yrs 5-9 yrs 10-14 yrs 15-19 yrs 20+ yrs TOT MeNZB 7 12 3 1 1 13 37 C conjugate 3 6 4 3 7 9 32 Quadrivalent 3 7 4 3 8 12 37 From: The Epidemiology of Meningococcal disease in New Zealand in 2011 ESR June 2011 18
Pneumococcal vaccines Polysaccharide: PPV23 (Pneumovax) Broad protection Abs persisting up to 10 years, Can revaccinate Protects against pneumococcal pneumonia and IPD Conjugate:?less protective against noninvasive disease Less effective in older and sicker PCV10 (Synflorix), PCV13 (Prevenar 13) Licensure to 5 and > 50 years (Prevenar 13) Primes for a better immunological response with revaccination Narrower serotype protection Serotype replacement 19 Grabenstein G Clinical Infectious Disease (2012) 55(2):255-258
New Zealand pertussis notifications and hospitalisations ESR Pertussis Report 8 June 2012
Pertussis ESR Pertussis Report 2012/2-3
Pertussis control Unable to eradicate from whole community Most severe in younger children Main target of immunisation strategies KEY: High coverage and timeliness of delivery Other strategies Immunising older children Immunising adults?how often to boost Cocoon strategies Immunising pregnant women 22
Safety of Tdap in pregnant women Not evaluated in pre-licensure studies Pregnancy registers established by manufactures sanofi pasteur (Adacel ) and GSK (Boostrix ) Data from passive reporting systems evaluated VAERS The few serious events unlikely to be caused by the vaccine No elevated frequency or unusual patters of AEFI in pregnant women after 20 weeks' gestation is preferred to minimize the risk for any low-frequency adverse event and the possibility that any spurious association might appear causative. Updated Recommendations for Use of Tetanus Toxoid, Reduced Diphtheria Toxoid and Acellular Pertussis Vaccine (Tdap) in Pregnant Women and Persons Who Have or Anticipate Having Close Contact with an Infant Aged <12 Months --- Advisory Committee on Immunization Practices (ACIP), 2011
Transplacental maternal antibodies Efficiently transferred Cord blood from infants whose mothers vaccinated during or before pregnancy higher Half life of maternal Abs in infant ~6 weeks Effectiveness of these Abs in preventing disease not yet known Vaccinated woman likely protected herself and not transmit to infant Optimise transfer by vaccinating late 2 nd or early 3 rd trimester as circulating Abs peak after several weeks then decline. Gall SA, Myers J, Pichichero M. Maternal immunization with tetanus-diphtheria-pertussis vaccine: effect on maternal and neonatal serum antibody levels. Am J Obstet Gynecol 2011;204:334.e1--5. Leuridan E, Hens N, Peeters N, de Witte L, Van der Meeren O, Van Damme P. Effect of a prepregnancy pertussis booster dose on maternal antibody titers in young infants. Pediatr Infect Dis J 2011;30:608--10. Van Rie A, Wendelboe AM, Englund JA. Role of maternal pertussis antibodies in infants. Pediatr Infect Dis J 2005;24(5 Suppl):S62--5.
What would I currently recommend to patients? Cost versus effectiveness : balance.not simple Pertussis and influenza: pregnancy/cocoon Rotavirus 2 doses 6 and 10 weeks Varicella one dose at a year of age (or two doses) Adults with no history of disease Meningococcal Conjugate C at 1 year, or 2 + 1 Conjugate quadrivalent (or polysacc ) at mid teenager HPV boys: Genital warts Herd immunity Other HPV-cancers (oropharyngeal, anal, penile) 25
Adults Pneumococcal PPV23 or PCV13 + PPV23 High risk Varicella No history of disease Pertussis (Tdap) Pregnancy, cocoon Targeted occupations: HCWs, ECC 26
Private purchase of non-funded vaccines (excl GST and delivery) Vaccine Protects against Manufacturer Price per dose 1 Number of doses required Adacel pertussis, tetanus and diphtheria Sanofi-Pasteur $25.00 1 dose as a booster Can be offered to adults for pertussis protection Boostrix pertussis, tetanus and diphtheria GSK $25.00 1 dose as a booster Can be offered to adults for pertussis protection Gardasil human papillomavirus 6,11,16 and 18 CSL $128.50 3 doses for females 9-45 yrs and males 12-15 yrs NB funded for girls born after 1.1.90 Intanza Influenza Sanofi-Pasteur $150/10 Intradermal vaccine IPOL polio Sanofi-Pasteur $35.32 1 dose as a booster Meningitec meningococcal disease group C Pfizer (Wyeth) $75.00 3 doses before 12 months or 1 dose if given after 12 months NeisVac-C Meningococcal disease group C Baxter $82.00 2 doses before 12 months or 1 dose after 12 months Menactra Meningococcal disease groups A,C,Y, W135 sanofi-aventis $89.95 Single dose aged 2 55 years Booster dose ever 5 years if risk continues Mencevax ACWY Menomune ACYW- 135 meningococcal A, C, W 135 and Y meningococcal A, C, W 135 and Y GSK $30.00 1 dose. Do not use before 2 years Sanofi-Pasteur $30.00 1 dose. Do not use before 2 years Pneumovax 23 pneumococcal disease MSD $40.00 1 dose. Do not use before 2 years Prevenar 13 pneumococcal disease Pfizer (Wyeth) $168.20 1 dose if given after 2 years NB funded for children born after 1.1.08 Rotarix rotavirus GSK $80.00 2 doses (before 24 weeks) Varivax varicella (chickenpox) MSD $50.00 Varilrix varicella (chickenpox) GSK $50.00 Zostavax 1 dose 12 months-12 years or 2 doses if given from 13 years 1 dose 9 months-12 years or 2 doses if given from 13 years Varicella (zoster) MSD $172.42 1 dose form 50 years
Protect others - our ethical obligations to our patients Am I vaccinated as a health professional? Flu Pertussis 28