Adolescent Immunizations Preteen Vaccine Week Webinar January 23, 2008 Eileen Yamada, MD, MPH California Department of Public Health Immunization Branch
Younger Children AND Adolescents Need Immunizations! Two pediatric schedules: 0-6 and 7-18 years
Adolescent Vaccines: 11-12 Year Old Immunization Visit
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
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
When Should Adolescents Receive Their Immunizations? Ideally at the 11-12 year old preteen visit! But if they didn t receive immunizations at that age, then as soon as possible!
Pertussis (Whooping Cough) and Tdap Vaccine
25,000 20,000 15,000 10,000 5,000 0 reported cases 1913 1917 1921 1925 1929 1933 1937 1941 1945 1949 1953 1957 1961 1965 1969 1973 1977 1981 1985 1989 1993 1997 2001 2005 Reported Pertussis Cases, California 1913 2006 3000 2500 2000 1500 1000 500 0 1976 1981 1986 1991 1996 2001 2006
Percent of Reported Cases > 9 Years of Age is Increasing, California 1990-2005 100% 20+ years 10-19 years 80% 1-9 years < 1 year percent of reported case 60% 40% 20% 0% 1990 1995 2000 2005 California Dept of Health Services Immunization Branch
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.
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
The Majority of Severe Pertussis Disease Complications Occur Among Infants 0-2 Months of Age, California 1995 2006 25 20 20 Death Encephalopathy number of cases 15 10 11 14 5 4 5 0 1 1 0 0 0 0 0 0 0 0 1 2 3 4 5 6 age (months) California Dept of Health Services Immunization Branch
Source of Infant Pertussis (n=264) Source* Percent Mother Father Grandparent Sibling 0-4 years 5-9 years 10+ yrs Neighbors, friends 32 15 8 8 5 6 25 *Source identified for 264/616 (43%) of infants in study, Bisgard et al. 2004
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
2005 ACIP Tdap Recommendations: Adolescents (11-18 Years) Should receive Tdap instead of Td as booster; preferred age 11-12 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
Meningococcal Conjugate Vaccine
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
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.
rate per 100,000 population 5 4 3 2 1 Rates of meningococcal disease by age and serogroup California, 2004-2006 All Serogroups Serogroups A,C,Y, W-135 0 age groups <1 1 2-4 5-9 10-14 15-19 20-24 25-44 45-64 65+ California Dept of Health Services Immunization Branch
Meningococcal Disease Among Young Adults, United States, 1998-1999 18-23 years old 1.4 / 100,000 18-23 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
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 11-12 years old should be routinely vaccinated at the ACIP recommended 11-12 year old health care visit MMWR 2007; 56 (31); 794-795.
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.
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 11 18 years If outbreak of meningococcal disease in school Work with local health department! Mass chemoprophylaxis Consider vaccination for protection in mid-to-long term
National Immunization Survey Teen Estimated Vaccination Coverage, 2006 Vaccine 13 years Age 17 years 13-17 yrs Td or Tdap 1 dose 48.3% (43.1-53.7) 68.6% (63.4-73.4) 60.1% (57.8-62.4) Tdap 1 dose 12.7% (9.6-16.5) 5.1% (3.3-7.7) 10.8% (9.4-12.3) MCV4 1 dose 11.3% (8.6-14.8) 7.1% (5.0-10.0) 11.7% (10.3-13.2)
HPV Vaccine
Over 100 HPV Types Dermal (skin) HPV types (nonsexual contact) Common Warts Munoz, NEJM 2003;348:518-27. 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
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
HPV Infection is Common Approximately 20 million people are currently infected with HPV Estimated 6.2 million new infections every year among 14-44 year olds 74% among those 15-24 years By age 50, an estimated 80% of sexually active women will have acquired genital HPV infection http://www.cdc.gov/std/hpv/stdfact-hpv.htm
Wright, NEJM 2003. Natural History
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)
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: 1928-1943 Future II Study Group. Lancet 2007; 369: 1861-1868. Future II Study Group. NEJM 2007; 356:1915-1927. Joura EA et al. Lancet 2007; 369:1693-1702. Paavonen J et al. Lancet 2007; 369: 2161-2170. Harper et al, Lancet, 2006; 367:1247-1255.
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; 356:1915-1927. Garland SM et al. N Engl J Med 2007; 356: 1928-1943.
Serum GMT 95% with CI, mmu/ml 1600 1500 1300 1100 900 700 500 Antibody Titers by Age at Vaccination Anti-HPV 6 GMTs (Quadrivalent HPV vaccine) Immunogenicity Bridge Efficacy Program 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 Age (Years) Merck, unpublished data, ACIP presentation by Eliav Barr, February 2006
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
HPV Vaccine Recombinant DNA technology Not live, not infectious Induces type-specific antibody production MMWR 2007; 56 (March 12, 2007): 1-19.
ACIP Recommendations: Quadrivalent HPV Vaccine March 2007
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 13-26 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.
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.
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.
Safety Injection site reactions most common Pain, swelling, redness Mostly mild to moderate in intensity
Other Important Vaccines
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
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
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) 13-17 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
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
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
Preteen Vaccine Week January 20-26, 2008
Resources CDPH/Iz www.getimmunizedca.org CDPH/Iz/Preteens: www.mybestshot.org C3I (CIC): www.immunizeca.org CDC/NIP: www.cdc.gov/vaccines CDC/Preteen: www.cdc.gov/vaccines/spec-grps/preteens-adol.htm AAP: www.aap.org AAFP: www.aafp.org IAC: www.immunize.org McCauley MM, et al eds. Strengthening the delivery of new vaccines for adolescents. Pediatrics 2008; 121 (Suppl 1): S1-S87.
Questions?
Eileen Yamada, MD, MPH Immunization Branch California Department of Public Health Eileen.Yamada@cdph.ca.gov 510-620-3763