Meg Fisher, MD Medical Director, The Children’s Hospital Vaccine Preventable Diseases and the Healthcare Provider Meg Fisher, MD Medical Director, The Children’s Hospital Monmouth Medical Center An affiliate of the Saint Barnabas Health Care System Long Branch, NJ

I will be mentioning off label uses of vaccines. Disclosures I have no disclosures. I will be mentioning off label uses of vaccines.

List and discuss vaccines needed to prevent these diseases Objectives Describe the vaccine preventable diseases that relate to the healthcare provider in the acute care setting List and discuss vaccines needed to prevent these diseases

Immunization Public health success story Rates of all vaccine preventable illnesses have plummeted: Smallpox, diphtheria, tetanus, polio, measles, mumps, rubella, Haemophilus influenzae type b almost gone in the US

Infection is just a plane ride away! Immunization Rates Don’t get complacent! Infection is just a plane ride away!

Identify these infections Test your knowledge Identify these infections

Courtesy of the American Academy of Pediatrics and the Centers for Disease Control and Prevention

Centers for Disease Control and Prevention Courtesy of the Centers for Disease Control and Prevention

Courtesy of his mother

Centers for Disease Control and Prevention Courtesy of the Centers for Disease Control and Prevention

Centers for Disease Control and Prevention Courtesy of the Centers for Disease Control and Prevention

Courtesy of eMedicine and ADAM

Centers for Disease Control and Prevention Courtesy of the Centers for Disease Control and Prevention

Centers for Disease Control and Prevention Courtesy of the Centers for Disease Control and Prevention

Centers for Disease Control and Prevention Courtesy of the Centers for Disease Control and Prevention

Centers for Disease Control and Prevention Courtesy of the Centers for Disease Control and Prevention

Courtesy of the WHO and the Centers for Disease Control and Prevention

Courtesy of PA AAP

Courtesy of the WHO and the Centers for Disease Control and Prevention

Courtesy of the Centers for Disease Control and Prevention

Vaccine Preventable Diseases Hepatitis B, rotavirus, diphtheria, tetanus, pertussis, polio, Haemophilus influenzae type b, Streptococcus pneumoniae, influenza, measles, mumps, rubella, varicella, hepatitis A, Neisseria meningitidis, human papillomavirus

Shortages? Major dilemma for practitioners Distribution always a problem Web site for vaccine shortages: www.cdc.gov/vaccines/vac-gen/shortages None currently

Vaccine Safety www.cdc.gov/vaccinesafety Concerns are limiting vaccine use Rates in New Jersey have fallen dramatically www.cdc.gov/vaccinesafety

Immunization Safety Starts during development Continues through all stages of licensure and during postlicensure use Vaccine adverse event reporting system Vaccine safety datalink Clinical immunization safety assessment

National Vaccine Injury Compensation Program Established by National Childhood Vaccine Injury Act No fault compensation program http://www.hrsa.gov/vaccinecompensation/ Report suspected adverse events to VAERS

Advisory Committee on Immunization Practices Provides advice for CDC Multidisciplinary panel with many liaisons www.cdc.gov/vaccines/recs/acip Pediatricians well represented

Hepatitis B vaccine All providers with blood exposure Three doses: 0, 1, 6 mo Titers to prove response to vaccine If < 10 mIU/ml, repeat series and titer Older less likely to respond

Exposure to HBsAg + Blood Immune: education re preventing exposures Non-responder or not immunized: HBIG plus education re preventing exposures Immunized but not tested: test and give HBIG if negative

Hepatitis B Vaccine New dilemma: Adolescents immunized as children may have low or no antibody levels at entry to college, nursing schools, medical schools Consider giving one dose and repeat titer If negative, finish the series and repeat titer

“I had a little bird. His name was Enza. I opened the window. And in flew Enza.” A chant popular during the influenza pandemic of 1918

Recommendations All people 6 months of age and older Healthcare personnel: mandates recommended by IDSA, PIDS, AAP and others Formulated yearly on best guess Two A strains, one B Start when you get it and continue all season

Influenza Vaccines A/California/7/2009 (H1N1)-like A/Perth/16/2009 (H3N2)-like B/Brisbane/60/2008-like Inactivated, live cold adapted

Influenza Vaccine Schedule Yearly – start when you get it Children under 3 years: lower dose Child under 9: two doses first season* Contraindicated in persons with anaphylaxis to chicken or eggs

Measles, Mumps, Rubella Measles and rubella no longer endemic in the United States Mumps outbreak over in NJ MMRV combination – more fever We should be immune: born before 1957, + titer or received 2 doses of vaccine

Varicella Vaccine Prevents serious illness Outbreaks persist Second dose now recommended for all Routine at 4-5 years, MMRV Catch up for older

Zoster vaccine Zostavax Approved May 2006 Age 60 and above; now 50 and above Protect yourself when the time comes

Tdap: Boostrix, Adacel Tetanus, diphtheria, pertussis booster For teens (both) and adults (Adacel) Licensed in spring 2005 Should alter epidemiology and protect infants Protect yourself and your staff

Targeted adults Anyone caring for young infants Cocoon the infants by immunizing contacts Healthcare people Pregnant women in late 2nd, 3rd trimester Give to the entire household, preferably before delivery

Latest from ACIP Off label use of the vaccine: Use Tdap for incompletely vaccinated children down to age 7 years Use Tdap in adults over 65 years Pregnant women in the 2nd or 3rd trimester Tdap at any interval following T or Td

Meningococcal vaccines Polysaccharide vaccine rarely used today Conjugate vaccines originally recommended: Adolescents age 11-12 yr (pre-teen visit) Adolescents age 15 yr (high school entry) Incoming college freshmen in dorms High risk groups

Latest Recommendations Booster dose for adolescents: age 16 or 5 years after the first dose Highest risk: initial 2 dose series followed by booster doses every 5 years At risk healthcare: microbiologists only

Rotavirus vaccines The old: Rotashield Rhesus rotavirus reassortant Licensed 8/98 Withdrawn 10/99 Intussusception risk < 1/10,000

Rotavirus vaccines The new: RotaTeq, Rotarix RotaTeq: human-bovine reassortant Well tolerated, effective, over 70,000 Licensed February 2006 Rotarix: monovalent, human strain Licensed and used outside US

Safety Issues Porcine circoviruses: no harm Rates of intussusception among vaccine recipients closely studied; post-licensure studies results vary Benefits greatly outweigh risks

Haemophilus influenzae type b Disease dramatically decreased in US Conjugate vaccine eliminates carriage Keep vaccinating!

Streptococcus pneumoniae Dramatic decrease in US since PCV7 Decrease in adult disease as well PCV13 now replaces PCV7 Polysaccharide vaccine PPSV23 for high risk children and adults

Polio Virus Vaccine Polio eliminated from most of the world But in 2010 spread to over a dozen countries Live oral: not in US since 2000, source of some recent outbreaks Inactivated: safe effective, 4 dose series, last/extra dose at 4 to 6 years

Hepatitis A Vaccines Inactivated Two doses, 6 months apart Prior to 2006: at risk or in high incidence state Now: at risk and all children at age 1 Catch up is reasonable

HPV Vaccines Virus-like particles genetically engineered Quadravalent and bivalent vaccines Well tolerated and immunogenic Three dose series Universal for girls; permissive for boys

Websites www.aap.org www.cdc.gov www.immunizationinfo.org www.vaers.org

Smiling is a contagious condition!