Combination and Special Circumstance Vaccines Rita Rossi-Foulkes MP Monthly Meeting May, 2018

Pediarix Vaccine (DTaP, IPV, Hep B) 3 dose primary series: ages 2, 4, and 6 months. Licensed by the FDA for only the first 3 doses of the DTaP series. Only ages 6 weeks to 7 years Using Pediarix for DTaP #4 is off-label and not recommended, thus should not be given to children who are overdue for DTaP #4, IPV #3, and HepB #3. If a dose was inadvertently given, there is no need to repeat if proper intervals between each component is maintained. PCG uses Pediarix

Pentacel (DTaP, Hib, IPV)  4-dose primary series at ages 2, 4, 6, and 15–18 months It should not be used for any dose in the primary series for children age 5 years or older or as the booster dose for children ages 4-6 years We do not carry Pentacel in the PCG.

Pentacel If a patient received Pentacel for the primary series to a child at ages 2, 4, 6, and 15–18 months, the child receives a total of 4 doses of inactivated polio vaccine (IPV). Does the child still need a booster dose of IPV before entering kindergarten? Yes! ACIP recommends that children receive at least 1 dose of IPV at age 4 through 6 years, even if they have previously received 4 doses

Kinrix (DTaP-IPV) Approved for the fifth dose of DTaP and the fourth dose of IPV for ages 4 - 6 years who received DTaP (Infanrix) and/or DTaP-HepB-IPV (Pediarix) as the first three doses and DTaP (Infanrix) as the fourth dose. It should not be given to children younger than age 4 years. Although it is preferable to use the same manufacturer's DTaP vaccine for all of the doses in the series, you can give Kinrix as the fifth dose of DTaP and fourth dose of IPV at age 4 through 6 years if the previous brand is unknown or if Kinrix is the only product stocked. PCG carries Kinrix

Quadracel (DTaP IPV) For ages 4 - 6 years of age as the fifth dose in the DTaP series, and as the fourth or fifth dose in the IPV series in children who have received 4 doses of Pentacel (DTaP-IPV-Hib, Sanofi Pasteur) and/or Daptacel (DTaP, Sanofi Pasteur) vaccine ACIP recommends the same brand of DTaP be used for all doses but that a different brand can be used if necessary. So Quadracel can be used in a series with another brand of DTaP if necessary. PCG does not carry Quadracel

Twinrix (HepB HepA) Contains half of the Havrix (Hep A vaccine) adult dose and the full Engerix-B (Hep B) adult dose 18 years or older if at risk for both hepatitis A and hepatitis B, (certain international travelers, MSM, illegal drug users), or to people who simply want to be immune to both diseases. A Twinrix series consists of 3 doses given intramuscularly on a 0, 1, and 6 month schedule. Minimum intervals for Twinrix are 4 weeks between dose #1 and dose #2, and 5 months between dose #2 and dose #3. if someone needs protection sooner (e.g., imminent foreign travel), you can give it as a 4-dose series at intervals of 0, 7, and 21–30 days, followed by a fourth dose at 12 months.

MMRV (ProQuad) 12 months to 12 years during the 5–12 day post-vaccination period, approximately one additional febrile seizure occurred among every 2,600 children ages 12 through 23 months vaccinated with a first dose of MMRV vaccine compared with children in the same age group vaccinated with separate first doses of MMR vaccine and varicella vaccine administered during a single office visit. Unless the parent or caregiver expresses a preference for MMRV vaccine, CDC recommends that providers administer MMR vaccine and varicella vaccine for the first dose in this if aged 12-47 months, and then MMRV for the second dose. PCG carries MMRV

Hib Vaccination Infants 2 through 6 months of age should receive a 3-dose series of ActHIB, Hiberix, Pentacel, or MenHibRix or a 2-dose series of PedvaxHIB Pedvax HIB is the vaccine PCG stocks so the 6 month dose is not necessary HIB must be dosed again on or after the 12 month birthday.

HPV Ages 9-15: 2 dose series separated by 6-12 months Ages 16-16 or h/o cancer or immune suppression: 3 dose series: 0, 1-2 and,6 months.

PCG Children Typical Schedule 2 months: Pediarix, Pedvax Hib, Prevnar, Rotavirus 4 months: Pediarix, Pedvax Hib, Prevnar, Rotavirus 6 months: Pediarix, Prevnar, Rotavirus (no Hib), flu#1. Flu #2 in 1 month* and annually 12 months: Pedvax Hib, MMR, Varicella or MMR-V, Hepatitis A Prevnar now or at 15 month visit 15 months: Prevnar if not given at 12 months, DTaP 18 months: Hepatitis A 4 years: MMRV and Kinrix (DTaP-Hib) *First time flu shots under 7 years, needs two doses 1 month apart and only one dose in subsequent seasons.

PCG Adolescents Typical Schedule 11 years: TdaP, HPV #1, Menactra. 2nd HPV due in 6 months 16 years: Menactra #2. If HPV not completed by age 15, will need 3 doses. HPV #1 now, #2 in 2 months and #3 in 6 months. Annual flu

Shingles Vaccine Recombinant zoster vaccine (RZV, Shingrix) is recommended for immunocompetent adults 50 years of age and older (2 doses, 2-6 months apart) RZV is recommended for the prevention of herpes zoster and related complications for immunocompetent adults who previously received zoster vaccine live (ZVL) ZVL remains a recommended vaccine for prevention of herpes zoster and its complications in immunocompetent adults 60 years of age and older. However, RZV is preferred over ZVL in this age group.

Adults with Asplenia Hib: 1 dose Pneumococcal: Prevnar (PCV13) first, followed by 1 dose of Pneumovax at least 8 weeks later, booster dose of Pneumovax 5 years after first dose. If received 1 or 2 doses of Pneumovax younger than age 65, will need another dose at age 65 or older, provided at least 5 years have passed since previous dose of Pneumovax Both Below Vaccinations are recommended and can be given same day. Meningococcal B (serotype B, Bexsero, Trumenba): 2 or 3 doses, depending on the brand Meningococcal ACWY Conjugate (Menactra, Menveo): 2 doses separated by 8 weeks, then a booster dose every 5 years thereafter. Meningococcal Polysaccharide Vaccine (MPSV, Menomune) also protects against ACWY strains but less effective in children.

Planning Splenectomy Splenectomy: Prevnar (PCV13), Haemophilus influenzae type b vaccine, MenACWY, and meningococcal B vaccine should be given 14 days before splenectomy, if possible. Doses given during the 14 days before surgery can be counted as valid. If the doses cannot be given prior to the splenectomy, they should be given as soon as the patient's condition has stabilized after surgery

Meningococcal Vaccination for Children with Functional or Anatomic Asplenia or Immune Compromised or Certain Conditions* 2 months and older as (1) those with persistent complement component deficiency (including children taking eculizumab [Soliris]), (2) those with functional or anatomic asplenia, (3) those traveling to or residing in an area of the world where meningococcal disease is hyperendemic or epidemic (such as sub-Saharan Africa and Saudi Arabia) or (4) are at risk during a community outbreak attributable to a vaccine serogroups. MenACWY-CRM (Menveo) is approved for children age 2 months and older. MenACWY-D (Menactra) is approved for children age 9 months and older For functional or anatomic asplenia, MenACWY-D should not be administered until at least 4 weeks after the pneumococcal conjugate vaccine (PCV13, Prevnar13, Pfizer) vaccination series is completed. Children at increased risk for meningococcal disease should receive booster doses as long as they remain at increased risk (see Booster Doses section below). Data show that the MenACWY-D may interfere with the immunologic response to PCV13 if these two vaccines are given too close together. So ACIP recommends that MenACWY-D not be administered until at least 4 weeks after completion of the age-appropriate PCV13 series. MenACWY-CRM (Menveo) does not affect the immune response to pneumococcal vaccine so can be given at any time before or after PCV13

Pneumococcal Vaccination for Children with Functional or Anatomic Asplenia or Immune Compromised or Certain Conditions* Give 1 dose of PPSV23 at age 2 years or older and at least 8 weeks after last dose of PCV13 Give 1 additional dose of PPSV23 at least 5 years following the first PPSV23; the next recommended dose would be at age 65 years Revaccination with PPSV 23 5 years following first is not needed for : Chronic heart disease (particularly cyanotic congenital heart disease and cardiac failure); chronic lung disease (including asthma if treated with prolonged high-dose oral corticosteroids); diabetes mellitus; cerebrospinal fluid leak; cochlear implan Immune Compromised includes: HIV infection, Chronic renal failure and nephrotic syndrome, Diseases associated with treatment with immunosuppressive drugs or radiation therapy (e.g., malignant neoplasms, leukemias, lymphomas, and Hodgkin disease; or solid organ transplantation), Congenital immunodeficiency (includes B- [humoral] or T-lymphocyte deficiency; complement deficiencies, particularly C1, C2, C3, or C4 deficiency; and phagocytic disorders [excluding chronic granulomatous disease])

Meningococcal Vaccination for Children with Functional or Anatomic Asplenia or Immune Compromised or Certain Conditions* If younger than age 7 years when receiving the second dose of the primary series, should receive first booster dose 3 years after completing the primary series. Should then receive a booster dose every five years thereafter. If age 7 years or older when receiving the second primary dose should receive first booster dose 5 years after the completing the primary series and every five years thereafter. HIV-infected people 2 months of age and older should routinely receive an age-appropriate MenACWY series People age 2 years and older with HIV infection who have not been previously vaccinated should receive a 2-dose primary series of MenACWY (doses separated by 8–12 weeks). People with HIV infection who have previously received one dose of MenACWY should receive a second dose at the earliest opportunity (at least 8 weeks after the previous dose) and then receive booster doses at the appropriate intervals . ACIP does not recommend routine meningococcal serogroup B vaccination of people with HIV infection.

Can combination vaccines be used with children who have fallen behind with their vaccinations? If so, what schedule should we follow? Combination vaccines may be used when any of the components are indicated and none are contraindicated. The minimum interval between doses is the greatest interval between any of the individual antigens. For example, the minimum interval between the first and second doses of MMR is 4 weeks and the minimum interval between the first and second doses of varicella vaccine is 12 weeks. When the two vaccines are combined in MMRV (ProQuad) the minimum interval between MMRV dose #1 and dose #2 is 12 weeks, which is the greatest of the minimum intervals of the two vaccines if given separately.

Switching between Combination Vaccines Switching between combination and single-antigen vaccines poses no problem as long as you maintain the recommended minimum intervals for all vaccines and the vaccines are licensed for the age of the patient. CDC recommends that whenever feasible, only one manufacturer's DTaP product be used for the entire pertussis series, but that vaccinations should not be deferred if the DTaP product previously given is unavailable or unknown

Size Matters Be sure to know the dose based on age for different vaccinations. Recombivax HB (Merck): Dose 0 through 19 yrs is 0.5 mL and requires 3 doses. Dose for 11 through 15 yrs is 1.0 ml and requires 2 doses. Dose for 20 yrs and older is 1.0 mL and requires 3 doses. For adult dialysis patients, dose is 2.0 ml and requires 3 doses.

For Vaccine Questions http://www.immunize.org/