1. What’s Up With All Those Other Vaccines?
William L. Atkinson, MD, MPH
National Immunization Program
Feel free to customize.
Hepatitis Coordinator’s Conference
San Antonio, Texas
January 29, 2003

2. What's New in Immunization
The Schedule
General Recommendations
New vaccines
Influenza vaccine for children
Meningitis in cochlear implant recipients
Meningococcal vaccine recall
Adult harmonized schedule
Smallpox vaccine redux

3. The 2003 schedule, released in January 2003
The 2003 schedule, released in January The only obvious change is the inclusion of “and adolescent” to the title. All other changes were in the footnotes.

4. The 2003 footnotes.

5. 2003 Hepatitis B Footnote
Makes explicit that 4 doses can be administered if there is a birth dose
Combination vaccines cannot be given before 6 weeks
In 2002, the statement was that “four doses of vaccine may be administered if combination vaccine is used”. For 2003, the birth dose is specifically mentioned.
2. In 2002, the statement was the “except for Hib-containing vaccine which cannot be administered before age 6 weeks. This change was made to include Pediarix, which does not contain Hib.

6. 2003 Hepatitis B Footnote
The last dose should not be administered before 6 months for infants born to HBsAg+ mothers
These infants should be tested at 9-15 months for HBsAg and anti-HBs
For infants born to HBsAg unknown mothers, blood should be drawn from mother ASAP, 2nd dose at 1-2 months, 3rd dose no sooner than 6 months
In 2002, the footnote said “…the vaccination series should be completed (third or fourth dose) at age 6 months”. No mention was made of the minimum age for the 3rd dose, or the need for post-vaccination serologic testing.
2. In 2002, the footnote said to draw blood “at the time of delivery”. The timing and minimum ages for the second and third doses was not mentioned in 2002 in the HBsAg unknown section of the footnote.

7. 2003 Hepatitis A Footnote
Children and adolescents in high risk states, regions or groups can begin hepatitis A at any visit
The 2 doses should be administered at least 6 months apart
In 2002, no mention was made of children and adolescents, only “…recommended for use in selected states and regions”. Wording that vaccination can begin at any visit, and minimum spacing of doses was not included in the 2002 footnote.

8. 2003 Influenza Footnote
Includes a recommendation for vaccine for household members of persons with high risk medical conditions such as asthma, cardiac diseases, sickle cell disease, HIV and diabetes
Encourages vaccination for healthy children 6 to 23 months of age
Inclusion of household members of high risk persons is new in Encouraging vaccination of healthy children 6-23 months of age is new and identical to wording in 2002 ACIP influenza statement.

9. Detail of catch-up table for children 4 months through 6 years of age.

10. New Vaccines

11. DAPTACELTM DTaP Vaccine
4-component DTaP produced by Aventis Pasteur Ltd (Canada)
Approved May 2002 for first 4 doses of the series
Does not contain thimerosal
NIP recommends applying rules for other DTaP products to DAPTACEL, particularly 4th dose at months (licensed for months), and use for 5th dose if no other DTaP is available. See MMWR Notice to Readers for details.

12. DAPTACELTM DTaP Vaccine
Licensed for the 4th dose at months of age
Not licensed for 5th dose
Apply same schedule as for other DTaP vaccines

13. DTaP Schedule
4th dose recommended at months but may be given earlier if:
child is 12 months of age, and
6 months since DTaP3, and
unlikely to return at months
Interchangeability (including 5th dose)
complete series with same brand of vaccine if possible
use different brand if necessary

14. Pediarix Has Arrived
DTaP – Infanrix
Hep B – Engerix B
IPV

15. Injections in the Pediatric Schedule
At 2 Month Visit
By 18 Months
By 18 Years
Single antigens 5
19-20
23-24
With Pediarix 3
13-15
17-19
20-21
With COMVAX 4
16-17

16. Indications for Pediarix
Minimum age 6 weeks
3 doses at 2, 4 and 6 months
Not approved for booster doses
May be used interchangeably with other pertussis-containing vaccines if necessary

17. Indications for Pediarix
Can be given at 2, 4, and 6 months in infants who received a birth dose of hepatitis B vaccine
May be used in infants whose mothers are HBsAg positive or status unknown

18. Response to Hepatitis B Component
Anti-HBsAg
% >10 mIU/ml
GMC
Components
Separate
100
805
Pediarix
100
1661
Source: Pediarix package insert

19. COMVAX Minimum age 6 weeks
Not approved for use in infants whose mothers are HBsAg positive or status unknown
ACIP VFC vote gave de facto approval for off-label use to complete the hepatitis B series with COMVAX if mother HBsAg positive or unknown

20. Influenza Vaccination of Children
Annual vaccination of persons >6 month with chronic illnesses is recommended
For :
Vaccination of healthy children 6-23 months is “encouraged when feasible”
Vaccination of household contacts and out-of-home caretakers is encouraged
A recommendation for routine annual vaccination of all children <24 months of age is expected within 3 years. Providers should start now to acclimate their practices to annual recall of all young children.

21. PCV Shortage Greater than expected demand for vaccine
Delays in release of some lots
Shortage may continue through first quarter of 2003

22. PCV Recommendations in Shortage Situation
Continue routine vaccination of high-risk children <5 years of age with full PCV series
Defer all doses for health children >24 months of age
Reduce the number of doses for healthy children <24 months of age

23. PCV Recommendations When Supplies Improve
Children who received a reduced number of doses during the shortage should be “caught up”
Most will probably not need a total of 4 doses because of age
Use “lapsed schedule” from ACIP statement
As a practices’ supply increases, children with deferred doses should be recalled and “caught up”. Because the number of doses in a “lapsed” schedule decreases as the child ages, most children will not need a total of 4 doses. The number of doses needed to complete the series should be based on the child’s CURRENT age, not the age when they started the series. Table 11 in the PCV ACIP statement (2000) addresses lapsed schedules.

24. Lapsed PCV Schedule Current Age (mos) 7-11 Prior Vaccination
12-23
24-59
Prior Vaccination
1 dose
2 doses
1 dose at <12 mos
2 doses at <12 mos
Any incomplete
schedule
Doses Needed
1 + booster
2 doses*
1 dose*
1 dose
Summary of PCV ACIP Table 11 for lapsed schedule. Booster doses are given at months. Children now months of age should receive 2 doses separated by at least 2 months. Those who received 2 doses at <12 months of age need only a single dose, which should be given at least 2 months after the previous dose. Unvaccinated children months of age with high risk conditions should receive 2 doses separated by 2 months.
*separated by >2 months. MMWR 2000;49(9):24

25. Pneumococcal Disease High Risk Conditions
Sickle cell disease
Functional or anatomic asplenia
HIV infection
Immunocompromise
Chronic illness
Cochlear implants

26. Meningitis Among People with Cochlear Implants
Ongoing CDC and FDA investigation of the association between one or more types of cochlear implants and bacterial meningitis
52 cases reported in U.S.
33 (63%) patients <7 years of age

27. Vaccine Recommendations for People with Cochlear Implants
Manage as high-risk for invasive pneumococcal disease
PCV and/or PPV, depending on age
See ACIP statements or NIP website for details and schedules

28. National Immunization Program
Hotline (800)
Website
*download or order ACIP statements
online from the NIP website