Presentation on theme: "Immunizations Across the Ages: What to DO?"— Presentation transcript:
1Immunizations Across the Ages: What to DO? Stanley E. Grogg, DO, FACOP, FAAPProfessor of PediatricsAssociate Dean of Clinical ResearchOklahoma State University Center for Health SciencesAOA Liaison Member ACOPTulsa, Oklahoma
3Faculty DisclosureIt is the policy of The University of Nebraska Medical Center, Center for Continuing Education and The France Foundation to ensure balance, independence, objectivity, and scientific rigor in all its sponsored educational activities. All faculty, activity planners, content reviewers, and staff participating in this activity will disclose to the participants any significant financial interest or other relationship with manufacturer(s) of any commercial product(s)/device(s) and/or provider(s) of commercial services included in this educational activity. The intent of this disclosure is not to prevent a person with a relevant financial or other relationship from participating in the activity, but rather to provide participants with information on which they can base their own judgments. The University of Nebraska Medical Center, Center for Continuing Education and The France Foundation have identified and resolved any and all faculty conflicts of interest prior to the release of this activity.
4Disclosures Vaccine Research Grants Speaker’s Bureau Consultant GSK MerckNovartisSanofiGSKMerckNovartisMedImmunePfizerSanofiConsultantMerck (HPV for males)Novartis (meningitis)
6Educational Learning Objectives At the conclusion of this presentation, the participant should be able to:Acknowledge the indications and recommendations for current vaccines and vaccine schedules across childhood, adolescent, and adult populations including HCPAddress immunization barriers frequently encountered during patient/caregiver communications regarding safety, efficacy, and possible misinformationImplement strategies for improving immunization rates within one’s clinical practice, taking into account current immunization schedules and guidelines
7For the People Who Are Starting College Next Fall Popcorn has always been microwaved
8Vaccination Coverage Children 19–35 Months, United States, National Immunization Survey CDC. MMWR Morb Mortal Wkly Rep. 2010;59(36):
10Shots Immunization App - Free For iPhone/iPod, iPad, Android, Blackberry, and PCSelect vaccine name for information onHigh risk indicationsAdverse reactionsContraindicationsCatch-upAdministrationRisk communicationEpidemiologyContent includes Childhood, Adolescent, and Adult Immunization Schedules for the US
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13Why Rotavirus Vaccine? > 400,000 physician visits > 200,000 ED visits> 50,000 hospitalizations> $1 billion in total health care costsCDC. MMWR Recomm Rep. 2006;55(RR12):1-13.
14RotavirusRotavirus vaccines (RV5 and RV1) have been shown to be safe and effective at preventing severe diarrheaIn March 2010, it was learned that a virus (or parts of a virus) called porcine circovirus (PCV) is present in both rotavirus vaccinesNo evidence that porcine circovirus is a safety risk or causes illness in humansFDA.Accessed Dec 2010.
15Rotavirus (Added to VIS) ContraindicationSevere Combined Immunodeficiency Disease (SCID)WarningIntussusception (have you heard this story before!)Postmarketing data conducted in Mexico suggest an increased risk of intussusception in the 31-day period following administration of the first dose of ROTARIXCDC. MMWR Wkly Rep. 2010;59(22):Accessed Dec 2010.
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17Meningococcal Conjugate Vaccine, Quadrivalent (MCV4*) Booster dose at age 16 yearsContinue Routine vaccination of adolescents with MCV4 beginning at age 11 through 12 years at the pre-adolescent vaccination visitFor those vaccinated at age 13–15 yearsBooster dose at age 16 through 18 yearsNo booster needed if primary dose on or after age 16 yearsApproved for VFC*Menactra® or Menveo®CDC. MMWR Morb Mortal Wkly Rep. 2011;60(3):72-76.
18Recommendation for MCV4* in Immunocompromised Persons with persistent complement component deficiency (C3, properidin, factor D, and late component), and aspleniaTwo dose primary series of MCV4 (0, 2 months) starting at age twoPersons with HIV11-18 years should receive a two-dose primary series (0, 2 months)*MCV4 (Both Menactra® and now Menveo® approved or 2-55 yrsCDC. MMWR Morb Mortal Wkly Rep. 2011;60(3):72-76.
19Pertussis: California Experience 10 Known Deaths
20Case DTaP, Td or TdapA 7 y/o comes to your office with his mother and wants to start immunizations (was home- schooled) including the diphtheria, tetanus and pertussis if possible. What should you recommend for the first vaccine?1. DTaP2. Td3. Tdap4. None
21New: Tdap Children 7-10 Years of Age (cont) Undervaccinated children ages 7 to 10 yearsShould receive a single-dose of TdapIf additional doses of tetanus and diphtheria are needed, vaccinate according to catch-up scheduleNever been vaccinatedTdap today, followed by a dose of Td > 4 weeks, another dose of Td 6-13 months laterNote: If not administered as the first dose, Tdap can be substituted for any of the other Td doses in the series CDC. MMWR Morb Mortal Wkly Rep. 2011;60:13-15.
22Time interval between Td, DTaP and Tdap? If an 8 y/o child had received a Td one month ago, how long do you have to wait to give the Tdap?1. Give today2. 2 month3. 6 month4. 1 year5. 5 yearsRemoval of interval since the last tetanus or diphtheria containing vaccine
23Case again DTaP, Td or Tdap A 7 y/o comes to your office with his mother and wants to start immunizations (was home-schooled) including the diphtheria, tetanus, and pertussis if possible. What should you recommend for the first vaccine?1. DTaP2. Td3. Tdap4. None
24Recommendations Tdap for Adolescents RoutineAdolescents should receive Tdap at a preventive care visit at 10 to12 years of age (if the recommended childhood DTP/DTaP vaccination series completed)CDC. MMWR Morb Mortal Wkly Rep. 2011;60:13-15.
25Tdap Motion for Health Care Personnel Health care personnel (HCP), regardless of age, should receive a single dose of Tdap as soon as feasible if they have not previously received Tdap and regardless of the time since last Td doseAfter receipt of Tdap, HCP should receive routine booster immunization against tetanus and diphtheria (Td) according to previously published guidelinesACIP. Accessed March 2011.
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27Childhood 2011 Immunization Schedule ACIP Schedules.Accessed Feb 2011.
280-6 Years Primary Footnote Changes Hep BFinal dose administered no earlier than age 24 weeksPCV 13Complete series with 13-valent (PCV-13)Single dose of PCV13 is recommended for all children aged monthsSupplemental doses of PCV13 should be administered at least 8 weeks after the previous dose of PCV7ACIP Schedules.Accessed Feb 2011.
29Revaccination with PPSV23 PPSV23 After PCV13 for Children ≥ 2 Years of Age with Underlying Medical ConditionsGroupSchedule for PPSV23Revaccination with PPSV23Children who have sickle cell disease, functional or anatomic asplenia, HIV-infection, or other immunocompromising condition1 dose of PPSV23 administered at age ≥ 2 yrs and ≥ 8 weeks after last indicated dose of PCV131 dose 5 years after the first dose of PPSV23Immunocompetent children with chronic illnessNot recommendedDoses of PCV13 should be completed before PPSV23 is given. No more than 2 PPSV23 doses are recommended.CDC. MMWR Recomm Rep. 2010;59(RR11):1-19.
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31Influenza: 0-6 Years Footnote Changes Children aged 6 months through 8 years who received no doses of monovalent 2009 H1N1 vaccine should receive 2 doses of vaccineACIP Schedules.Accessed Feb 2011.
32Vaccines for Children (< 18 years) Route of Administration 2010–2011 Influenza SeasonVaccines for Children (< 18 years)VaccineTrade NameAge GroupRoute of AdministrationTIVFluzone; Sanofi≥ 6 monthsIntramuscularFluvirin; Novartis≥ 4 yearsFluarix; GSK≥ 3 yearsAfluria*; CSL≥ 9 yearsLAIVFluMist; MedImmune2–49 yearsIntranasalTIV: trivalent inactivated influenza vaccine; LAIV: live attenuated influenza vaccine*FDA-approved for use ≥ 6 months; however ACIP does not recommend use in children 6 months–8 years due to increased risk of fever and febrile seizures reported among young children < 5 years who received a similar vaccine in Australia 2010.CDC. MMWR Recomm Rep. 2010;59(RR8):1-62.CDC. MMWR Morb Mortal Wkly Rep. 2010;59(31):
33Trivalent Inactivated Influenza Vaccine (TIV) and Live Attenuated Influenza Vaccine (LAIV) CategoryTIVLAIVAdministrationIMIntranasalPrimary immune responseSerum antibodiesSerum & mucosal antibodiesFormulationInactivatedLive attenuatedApproved age and risk groups≥ 6 mo (healthy & high risk)2–49 yrs (healthy)StorageRefrigeratedTwo basic types of influenza vaccines are available: A trivalent vaccine made from inactivated viruses, and a vaccine developed from live-attenuated virus. Influenza viruses for both TIV and LAIV are initially grown in embryonated hen’s eggs, and, therefore, might contain limited amounts of residual egg protein. Persons with a history of severe hypersensitivity, such as anaphylaxis, to eggs should not receive influenza vaccine.CDC. MMWR Recomm Rep. 2009;58(RR8):1-52.33
34Influenza USA 2011 Serotypes (Vaccine is well matched) 13% A-H1N154% A-H3N233% BHigh level resistance A to adamantanes persistsA and B remain susceptible to neuraminidase inhibitorsNext year vaccine will be same composition
35Influenza -You May Have Heard??? Toddlers between 6 to 23 months had a “questionable higher incidence of benign febrile seizures when given the influenza vaccine” (Fluzone by Sanofi)Remains to be determine; CDC is checking Vaccine Safety Data (VSD)Note: Certain vaccines have higher association with febrile seizures (ie, MMRV, whole cell pertussis)CDC.Accessed March 2011.
36New Adolescent Schedule ACIP Schedules.Accessed Feb 2011.
37Adolescent Vaccines Schedule Primary Changes HPVIn 33 million doses, no new adverse event identifiedUptake remains < 40% (financial primary barrier)HPV4 efficacious in malesHPV4 approved for prevention of anal cancerMCV4Added booster dose at 16 yearsFor those vaccinated at age 13–15 yearsBooster dose at age 16 through 18 yearsACIP Schedules.Accessed Feb 2011.
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40Catch-up Hib1 dose of Hib-vaccine should be considered for persons aged 5 years or older for:Sickle cell diseaseHIV infectionLeukemiaHad a splenectomyACIP. Accessed Dec 2010.
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422011 Adult Schedule Additional Language to Include Use of Tdap CDC. MMWR Morb Mortal Wkly Rep. 2011;60(4).
43Tdap-Adult Adults ages 18 through 64 years Should receive a single dose of Tdap in place of one tetanus and diphtheria toxoids (Td) vaccine doseAdults ages 65 years and olderWho have close contact with an infant ages less than 12 months (eg, grandparents, child-care providers, and HCP) should receive a single dose of TdapAdults any ageA single dose of Tdap vaccine may be given in place of a tetanus and diphtheria toxoids, (Td) vaccine, in persons who have not previously received TdapCDC. MMWR Morb Mortal Wkly Rep. 2011;60(4).
44Hepatitis B (information only, no vote) 8.3% of adults with diabetes have evidence of Hepatitis B Infection vs 5.2% without diabetesShould all diabetics be immunized with Hep B?ACIP. Accessed Dec 2010.
45Hepatitis A: Families of International Adoptees All previously unvaccinated persons who anticipate close personal contact with an international adoptee from countries of high or intermediate endemicity during the first 60 days following arrival in the USFirst dose of Hep A vaccineAs soon as adoption is plannedIdeally at least two weeks prior to the arrival of the adopteeCDC. MMWR Morb Mortal Wkly Rep. 2009;58(36):
46HCP DefinitionChange in standard terminology from health care worker (HCW) to health care personnel (HCP): Includes all persons involved in health care
47Hepatitis B for HCP Hepatitis B Give 3-dose series (dose #1 now, #2 in 1 month, #3 approximately 5 months after #2). Give IMObtain anti-HBs serologic testing 1–2 months after dose #3IAC. Accessed March 2011.
48Influenza for HCP Only 62% of HCP vaccinated 2011 Give 1 dose of influenza vaccine annuallyGive inactivated injectable influenza vaccine intramuscularly or live attenuated influenza vaccine (LAIV) intranasally (2-49 years)IAC. Accessed March 2011.
49MMR For HCP Born Prior to 1957 Although birth before 1957 generally is considered acceptable evidence of measles, mumps, and rubella immunityHealth care facilities should consider recommending 2 doses of MMR vaccine routinely to unvaccinated HCP born before 1957 who do not have laboratory evidence of disease or immunity to MMRIf no evidence of immunity, recommend 2 doses of MMR vaccine during an outbreak of measles or mumps and 1 dose during an outbreak of rubellaCDC. MMWR Morb Mortal Wkly Rep. 2011;60(4).
50MMR for HCP Born after 1957For health care personnel (HCP) born in or later without serologic evidence of immunity or prior vaccination, give 2 doses of MMR, 4 weeks apartIAC. Accessed March 2011.
51Varicella for HCPIf no serologic proof of immunity, prior vaccination, or history of varicella disease (chickenpox)Give 2 doses of varicella vaccine, 4 weeks apartIAC. Accessed March 2011.
52Tdap for HCPGive a 1-time dose of Tdap to HCP of all ages with direct patient contactIAC. Accessed March 2011.
53Other Vaccines for HCPHepatitis A, typhoid, and polio vaccines are not routinely recommended for HCP who may have on-the-job exposure to fecal materialHerpes Zoster is not routinely recommendedIAC. Accessed March 2011.
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55Are There any Vaccine Preventable Diseases still Present? CDC warns of possible measles exposure on several US flightsWhen?19541977199020102011
56USA-Today: Feb 28 2011 8:43 AM 27-year-old New Mexico woman Flew from London Heathrow to Washington Dulles on Feb. 20She flew from Baltimore/Washington to Albuquerque via Denver on Feb. 22The traveler became sick and was later confirmed to have measles, prompting concern for others passengers who might have crossed paths with the woman
572011 Measles UpdateAs of February 11, 2011, there were 20 confirmed cases of measles17 (85%) were linked to travel outside the United States, including travel to the Dominican Republic, France, India, and the United KingdomCDC. Accessed March 2011.
58Public Confidence in Vaccines Public confidence in vaccines is affected by:Product safety and efficacyAnecdotal experience/informationPrevalence of diseaseRecommendations by governmental committees and professional societiesPhysician recommendationsMedia coverageVaccine monitoring and surveillance systems
59Nailed: Dr Andrew Wakefield and the MMR – Autism Fraud Trigger for what would become a worldwide controversySingle scientific research paper, published in Lancet (February 1998)Written by a Dr Andrew Wakefield, and co-authored by a dozen other doctorsReport of 12 anonymous children with developmental disorders, who were admitted to a pediatric bowel unit at the Royal Free hospital in Hampstead, north London, between July 1996 and February 1997
61Antigen Burden Vaccine 1960 1980 2000 2010 Smallpox 200 Diphtheria 1 TetanusPertussis30005Polio15MMR24Hib2Varicella69PCV7/PCV13814HepBHepA4HPV4Rotavirus20MCV4Influenza12Total32173041126177Marshall G. The Vaccine Handbook. PCI Books: 2010.
62Omnibus Autism Proceedings Theories of general causationMMR and thimerosal-containing vaccines combine to cause autismThimerosal-containing vaccines cause autismMMR causes autism (dropped)Three test cases per theoryALL THREE REJECTED
63Autism Incidence After Vaccine Formulation Changes Thimerosal-containingvaccines removedAutism Incidence per 10,000Madsen KM, et al. Pediatrics. 2003;112:
64Refusal to Vaccinate (AAP form) http://www. aap I have read the Vaccine Information Statement from the Centers for Disease Control and Prevention explaining the vaccine(s) and the disease(s) it prevents. I have had the opportunity to discuss this with my child’s doctor or nurse, who has answered all of my questions regarding the recommended vaccine(s), etc.Parent’s initials ________ Date ________
65Evidence-based Methods for Improving Immunization Rates Reducing client out-of-pocket costsVaccination programs in schoolsVaccination programs in WIC settingsClient reminder and recall systemsVaccination requirements for child care and schoolProvider reminder systems when used aloneStanding orders when used aloneProvider assessment and feedback The Community Guide html. Accessed Nov 2010.Briss PA, et al. Am J Prev Med. 2000;18(suppl 1):35-43.
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67Resources for Providers www.cdc.gov Immunization SchedulesACIP Recommendations & Provisional RecommendationsImmunization Action Coalition (IAC)The Guide to Community Preventive Services. Vaccine recommendationsAssessment, Feedback, Incentives, and Exchange (AFIX)National Foundation for Infectious DiseasesCenters for Medicare & Medicaid Services
68Resources for Patients and Parents Guide to Evaluating Information on the WebCDC Vaccine Information Statements (VISs)Vaccine SafetyNational Network for Immunization Information (NNII)Allied Vaccine GroupThe Immunization Action Coalition: Vaccine Information for the Public and Health ProfessionalsVaccine Education Center at CHOP
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