Herpes Simplex Vaccine. Genital disease HSV1 /more commonl

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Adolescent Vaccines

• Swati Y Bhave

Convener IPA ( International Pediatric
Association ) Adol Interest group
Member Technical Steering Committee Child Adol
section WHO HQ Geneva from 2007
Member Regional Technical Advisory Group Adol
section WHO SEARO from 2004
Symposium of IAP Adol Chapter PEDICON 2007
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Vaccines under discussion

• Meningococcal
• Influenza
• HPV
• e IPV
• Salk Vero cell IPV v IPV
• JE
• CMV
• Herpes
• HIV

• EB V
• Parvovirus,
• Para I
• E Coli
• Adeno
• Malaria
• Dengue
• Hepatitis E
• Cholera
• Shigella
• Campylobacter
• Schistosomiasis

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Polysaccharide Meningococcal Vaccine -1

• Capsular polysaccharides vaccines successfully
  protect against
• sero groups A, C, Y and W-135.
• But protection wanes after few years
• Use limited to high-risk populations
• military recruits, travelers, freshman students
  college dormitories.
• Other risk factors
• Cigarette smoking, Bar patronage, Recent URTI

American Academy of Pediatrics, Committee on
Infectious Diseases. Prevention and control of
meningococcal disease recommendations for use of
meningococcal vaccines in pediatric patients.
Pediatrics. 2005116496-505
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Conjugate Meningococcal vaccine -2

• Newer conjugate vaccine links capsular
  polysaccharides ( A, C, Y, and W-135) to a
  protein carrier (diphtheria toxoid)
• Induces immunologic memory, longer-term immunity,
  ? NP carriage ? transmission nonvaccinated in
  the community.
• Unfortunately
• B, C and Y account for most disease in the United
  States.
• B 1/3 of total and nearly 25 of disease in
  11-18 yrs

Centers for Disease Control and Prevention.
Prevention and control of meningococcal disease.
Recommendations of the Advisory Committee on
Immunization Practices (ACIP). MMWR Recomm Rep.
200554 (RR07)1-21
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Meningococcal vaccine schedule -3

• 2005, FDA licensed M conjugate vaccine (MCV4)
  Menactra (Sanofi Pasteur) for people 11 to 55
  yrs.
• AAP and ACIP recommend routine MCV-4 to
  adolescents 11 to 12 yrs and high school entry at
  15 yrs
• The goal is to vaccinate all adolescents at age
  11 by 2008.
• ACIP also recommends immunization of college
  freshman living in dormitories and other
  high-risk groups.
• Possible association between Guillain-Barré
  Syndrome (GBS) and (MCV4) reported in October
  2005.
• ACIP recommends continuation but avoid in GBS
  patients

Richard E. Rupp, ,Susan L. Rosenthal, PhD New
Immunization , Strategies for Adolescent Patients
A Clinical Guide for Pediatricians,Vol. 19, No. 1
November 2006
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Influenza vaccine -1

• There are 2 influenza viruses, types A and B.
• Type A subtypes based on two surface antigens
• Hemagglutinin (H) and Neuraminidase (N). eg H1N1
• Influenza type B is not categorized into
  subtypes.
• There are two vaccines available,
• The inactivated killed Vaccine
• Live attenuated influenza vaccine (LAIV)
• Both vaccines includes Two type A strains (eg
  H3N2 and H1N1) One type B strain

Centers for Disease Control and Prevention.
Prevention and control of influenza
Recommendations of the Advisory Committee on
Immunization Practices (ACIP). MMWR 200554
(RR08)1-40
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Influenza Vaccine -2

• Recommended strains may change annually depending
  on patterns observed from global surveillance.
• Three strains of virus strains expected to
  circulate in the community in the winter
• The inactivated influenza vaccine contains
• killed, partially purified viruses. IM inj .
• All of the groups for which annual influenza
  vaccination is indicated may receive the
  inactivated vaccine
• Medical conditions at increased risk
• Pulmonary or cardiovascular disease,
  Neuromuscular dysfunction, Immuno-suppression,
  Long-term aspirin therapy.

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LAVI (Live Attenuated Influenza Vaccine ) -3

• The LAIV licensed USA- FluMist (MedImmune,
  Inc.).
• The attenuated viruses produce either mild
  symptoms (eg, sore throat) or none at all.
• Intra nasally annually to optimize protection.
• Given only to healthy persons 5 to 49 yrs of age
  who are not in contact with severely
  immuno-suppressed persons.
• Both vaccines are made from viruses grown in eggs
  /avoid in allergy to chicken or egg protein

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JE vaccine GOI/PATH project
IAP recommendation

• Live attenuated SA14-14-2 vaccine from CDIBP,
  China
• Single dose, lyophilized One time campaign
  targeting 1-15 year old
• The available m-b derived vaccine in the country
  will be utilised in AP Tamil Nadu

• JE vaccine should be used for universal
  immunization of all children in 1-3 years in
  endemic areas with 3 primary doses
• Boosters every 2 years till 10-15 years of age.
• JE vaccine is not for out break response during
  epidemics.

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e-IPV for adol and adults

• Booster doses not required endemic countries
• Natural boosting - wild virus -likely to be a
  continual process that maintains immunity.
• WHO recommends travellers industrialized
  countries to endemic area.
• Previously vaccinated
• one additional dose of polio vaccine
• Unvaccinated
• full course of primary vaccination
• Route Site SC or IM in the deltoid region.
• IPV trace amount of streptomycin, neomycin, and
  polymyxin B,

http//www.cdc.gov/nip
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Primary vaccination for adults and adol
Guidelines

• 2 doses 4 to 8 weeks apart, with a third dose
  given 6 to 12 months later.
• If 2 to 3 months remain before protection is
  needed,
• give 3 doses of e-IPV gt4weeks apart.
• If only 1 or 2 months remain,
• give 2 doses of e-IPV 4 weeks apart.
• If lt 4 weeks remains,
• give a single dose of e-IPV.

CDC poliomyelitis Report (IMMP-44)
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Primary vaccination for adults adolGuidelines

• adults increased risk of exposure
• Single dose of e-IPV
• who have completed a primary series with any
  poliovirus vaccine
• Give gt1 dose of e-IPV
• to who have had gt1 dose of OPV,lt3 doses of
  conventional IPV (available before 1988), or a
  combination conventional IPV and OPV totaling lt 3
  doses.
• If time permits, give additional doses needed to
  complete a primary series. Do not count doses
  within the minimum interval, too short an
  interval may interfere with antibody response and
  protection from disease.
• Increasing the interval beyond the recommended
  timing does not affect the ultimate efficacy of
  immunization, waiting does delay achieving
  adequate protection from infection.

ACIP. Supplementary chart Recommended Childhood
Immunization Schedule, United States, Approved
by ACIP, AAP,AAFP
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Human Papilloma Virus (HPV)

• Most common sexually transmitted infection in the
  USA
• Genital infections occur via G-G .O-G H-G and AG
  contact
• Lifetime risk among sexually active men women -
  50.
• The vast majority of infections go unrecognized
• HPV is now implicated as a causative agent gt 99
  of cervical cancer cases
• Also pharyngeal and ano-genital cancers .

• 100 types of HPV identified
• 30 -40 types infect ano-genital region.
• Low-risk and high-risk oncogenic potential
• 15 -20 oncogenic
• HR HPV 16 /18 - 70 cancer LR HPV 6 / 11)

Richard E. Rupp, ,Susan L. Rosenthal, PhD New
Immunization , Strategies for Adolescent Patients
A Clinical Guide for Pediatricians,Vol. 19, No. 1
November 2006
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HPV Vaccines available
Quadrivalent HPV vaccine FDA licensed Gardasil,
Merck Bivalent vaccine, Cervarix,GSK
Biologicals soon Both vaccines protect against
HPV types 16 and 18. Quadrivalent also
contains VLPs for HPV 6/11, genital warts. In
clinical phase 2 and 3 trials, both vaccines were
found to be safe and effective in
females. Quadrivalent vaccine is found to be
100 efficacious against high-grade dysplasia,
the predecessor to cervical cancer
Richard E. Rupp, ,Susan L. Rosenthal, PhD New
Immunization , Strategies for Adolescent Patients
A Clinical Guide for Pediatricians,Vol. 19, No. 1
November 2006
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HPV vaccine schedule
Studies show a rapid rise in ano-genital HPV
infections by 15 yrs age Ensure immunization
completed prior to potential exposure 11-12
yrs endorsed by the Society for Adolescent
Medicine (SAM) 9-10 yrs left to the discretion
of the care provider. Some have argued that
vaccinating at age 11 to 12 is too early, as the
duration of immunity is unknown. 3 doses of HPV
given at 0, 2 and 6 months in the Deltoid.
Both have stable antibody levels and continued
efficacy - 5 years post vaccination. CMI
response long duration of protection 15 years of
age and younger higher titers than older teens
and adults.
Richard E. Rupp, ,Susan L. Rosenthal, PhD New
Immunization , Strategies for Adolescent Patients
A Clinical Guide for Pediatricians,Vol. 19, No. 1
November 2006
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? ? Parental reaction
Major Worry stigma related to the sexual
transmission of HPV. vaccine will increase
sexual activity among teens. vaccine will not
gain widespread acceptance Studies show
Parents decisions based on severity of disease,
efficacy and safety of the vaccine the mode of
transmission is less important to them. Once
educated about HPV, provided with accurate
information in a calm and reassuring way majority
of parents have positive response .
Diekema DS and the American Academy of Pediatrics
Committee on Bioethics. Responding to parental
refusals of immunization of children. Clinical
Report. Pediatrics. 20051151428-1431
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How to broach the topic of HPV vaccine ?

• Visit of 10-12 yrs
• open the conversation with parents and
  adolescents
• preventive strategy for all adolescent
  risk-taking behaviors
• parental communication and supervision.
• Clarify their values about a whole range of
  subjects (eg, sexuality, drinking)
• Be sensitive to parental anxieties and possible
  discomfort with discussing these subjects.
• Then talk of HPV as preventive vaccine for
  Cancer and STD

Richard E. Rupp, ,Susan L. Rosenthal, PhD New
Immunization , Strategies for Adolescent Patients
A Clinical Guide for Pediatricians,Vol. 19, No. 1
November 2006
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My child is too young to get HPV. Why cant we
wait ?

• You could wait. ButTwo important reasons to do
  this now
• The immune response appears to be better in
  younger girls.
• It takes 6 months to be fully immunized and the
  vaccine has to be given
• before any risk of exposure.
• It makes sense to provide it before any possible
  exposure might occur.

Can HPV vaccine be given to boys ?

• At present it is only licensed for girls.
• The FDA wants more data about boys before they
  approve it.
• Males are a potential target for the vaccine for
  protection against warts, penile or anal cancer
  as a vector for transmission to females.

Diekema DS and the American Academy of Pediatrics
Committee on Bioethics. Responding to parental
refusals of immunization of children. Clinical
Report. Pediatrics. 20051151428-1431
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Dont you think it will encourage my daughter
to having early and risky sex?
Does telling young people to wear bicycle
helmets or seatbelts? Encourage anyone to
bicycle or drive recklessly? Your child may never
be at risk for HPV infection, or may not be at
risk for many years. But we are recommending
that all girls get this before anyone is at risk
of infection It is very effective at this age
and vaccinating now eliminates the worry about
risk into adulthood. Most important prevention
strategy for helping teens make wise decisions is
for parents to talk to them about values and for
parents to pay attention to what they are doing
and with whom.
Diekema DS and the American Academy of Pediatrics
Committee on Bioethics. Responding to parental
refusals of immunization of children. Clinical
Report. Pediatrics. 20051151428-1431
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Cytomegalovirus Vaccine status

• Vaccine strategies have included a live
  attenuated virus and the use of viral surface
  glycoproteins.
• The glycoprotein vaccine (CMV gB) is furthest
  along in development,
• a phase 2 clinical trial in adolescent females
  currently underway.
• Speculation about when a CMV vaccine might become
  available is premature at this time.

Schleiss, M. Progress in cytomegalovirus vaccine
development. Herpes. 20051266-75
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Herpes Simplex Vaccine

• Genital disease HSV1 /more commonly HSV2.
• Public health perspective - important that
  vaccine ?frequency magnitude of virus shedding.
• Universal immunization of young girls can ?HSV-2
  both men and women
• The vaccine furthest along in development,
• GSK Biologicals, recombinant truncated HSV-2 g
  D (an envelope glycoprotein)
• Two large trials efficacy of 73 - 74 in
  preventing genital herpes disease in HSV-1 and
  HSV-2 seronegative women,
• But did not provide men or HSV-1 seropositive
  women any protection.

Stanberry LR, Spruance SL, Cunningham AL, et al.
Glycoprotein-D-adjuvant vaccine to prevent
genital herpes. N Engl J Med. 20023471652-61
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Pneumococcal vaccine check vaccine name

• Risk of serious Pneumococcal disease is
  relatively low . Not recommended for routine
  use.
• Recommended in groups higher risk
• anatomic or functional asplenia (also sickle
  cell ), nephritic syndrome, CSF leak,
  immunosuppression.
• Revaccination highest risk for serious
  Pneumococcal infection and rapid waning of
  antibodies ,provided gt 5 years have passed since
  administration of the first dose.
• Spleenic dysfunction, Sickle cell disease, HIV
  infection, Hodgkins disease, Lymphoma, Multiple
  myeloma, Chronic renal failure, Nephritic
  syndrome, undergoing organ transplantation and
  receiving chemotherapy.

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HIV VACCINE

• Feb 2003, Vax Gen announced their product
  AIDSVAX was a failure because the circulating HIV
  strain hides its epitopes in a variety of ways
  that genetically engineered gp 120 proteins do
  not mimic successfully.
• ALVAC-HIV, a genetically engineered HIV vaccine
  composed of a live,attenuated Canary pox virus
  into which parts of genes for non-infectious
  components of HIV are inserted is said to be
  promising. 17 candidates are in phase I/II
  trials.
• National Institute of allergy and infectious
  diseases (NIAID) and Merk Co sponsored trials
  with ALVAC-HIV is expected to be completed in
  four-and-a -half years since January 26, 2005 and
  results are expected by 2010.

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Key messages

• Pediatricians need to update periodically about
  new recommendations
• Students going abroad will come for advise and
  certificates
• Newer vaccines
• New recommendations for Booster doses
• Preventive /prophylactic vaccines