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Immunization Update


Stanley E. Grogg, DO, FACOP Professor of Pediatrics Liaison Member of the Advisory Committee for Immunization Practices (ACIP) Have spoken for the following ... – PowerPoint PPT presentation

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Title: Immunization Update

Immunization Update 2007
Stanley E. Grogg, DO, FACOP Professor of
Pediatrics Liaison Member of the Advisory
Committee for Immunization Practices (ACIP)
I have the following disclosures
  • Have spoken for the following pharmaceutical
    companies in the last 6 months
  • AstraZeneca
  • GlaxoSmithKline
  • Merck
  • MedImmune
  • Novartis
  • Primary Investigator in clinical vaccine
    research for the following companies
  • MedImmune
  • Merck
  • Sanofi-Pasture
  • GlaxoSmithKline
  • Wyeth

Objectives and references
  • You will be able to list and recommend new
    vaccines available for public use
  • You will be able to employ the new vaccines into
    daily practice
  • http//

The Okie Good News
  • Improved from 44th in the nation in 2005 to 25th
    in 2006
  • OK Department of Health
  • 80.4 of OK children ages 19 months through 35
    months were immunized against 10 potentially
    deadly diseases (2006)

Available Vaccines
  • Pertussis
  • Pneumococcal
  • Polio Rabies
  • Rotavirus Rubella
  • Smallpox Tetanus
  • Typhoid
  • Yellow fever
  • More to come?
  • Anthrax BCG
  • Chickenpox Cholera
  • Diphtheria Hepatitis A
  • Hepatitis B Hib
  • HPV Influenza
  • Japanese encephalitis
  • Measles Mumps
  • Meningococcous

Which of the following patients should generally
NOT be given a live vaccine?
  • A. Pregnant women
  • B. Patients on chemotherapy
  • C. Patients currently on high corticosteroid
    doses for at least 14 days
  • D. All of the above

All of the following are live virus vaccines
  • 1. FluMist
  • 2. RotaTeq
  • 3. Varivax and Zostavax
  • 4. MMR II
  • 5. IPV   

Advantages of Live Vaccines
  • Often protective after the first dose
  • Immunity is usually long-lasting 
  • A second dose is NOT really a booster but to
    stimulate immunity for those who did not react

In general avoid most live vaccines in patients
who are immunosuppressed
  • Avoid live vaccines until 3 months after stopping
  • Wait one month after high daily steroid doses
    (i.e. prednisone 20 mg, or 2 mg/kg) in patients
    taking them for at least 14 days
  • It's not necessary to avoid live vaccines while
    using inhaled steroids, steroid tapers or oral
    courses for less than 14 days
  • Antivirals can interfere with live vaccines
  • Wait 24 hours after stopping a herpes antiviral
    (i.e. acyclovir) to give Varivax and 2 weeks
    after giving FluMist to give an influenza
    antiviral if possible   

Avoid most live vaccines in patients who are
immuno-suppressed EXCEPTIONS
  • Household contacts
  • Can give MMR, Varivax, RotaTeq, and Zostavax to
    healthy people living with someone who is
  • Pregnancy
  • Avoid live vaccines during pregnancy because of a
    theoretical risk of infection to the fetus
  • Use the inactivated flu vaccine during pregnancy
  • Timing of vaccinations
  • If LIVE INJECTABLE vaccines can't be given on the
    same day, give them at least 28 days apart

Religious exemptions for shots on the
rise Tulsa World, Oct. 20, 2007
  • All states have some requirement for
  • Allow parents to opt out for medical or religious
    reasons (Kansas, Missouri)
  • Allow parents to cite personal or philosophical
    reasons (Arkansas, Colorado, Oklahoma, Texas)
  • Allow only medical exemptions (Mississippi)

AAPs Vaccine Refusal Form
  • http//
  • AAPs Childhood Immunization Support Program
  • If my child does not receive the vaccine(s), the
    consequences may include
  • -contracting the illness the vaccine should
  • -transmitting the disease to others
  • -the need for my child to stay out of child care
    or school during disease outbreaks

True or False
  • Routine immunization is NO longer needed for
    polio, measles, mumps, varicella, pertussis,
    diphtheria, tetanus

2006 Outbreak prompts change to recommendations
on mumps
  • ACIP/AAP June 2006
  • Recommended routine MMR at 12-15 months ______
    AND specify that students attending colleges and
    other post-high school institutions receive _
    doses of MMR

Up Date Varicella How many doses are recommended?
  • August 2006
  • ACIP recommends 2nd dose of varicella
  • Children aged 4-6 years
  • Children, adolescents and adults who previously
    received only 1 dose
  • Outbreak situations

Rational for 2nd varicella dose
  • 20 of children who have received 1 dose are not
    fully protected
  • One dose may not provide protection into
    adulthood when infection with zoster virus is
    more severe

Recent Immunization Schedule Changes
  • HepB needs to be given at birth
  • Can be delayed only if health care provider order
    to withhold
  • Tdap adolescent
  • Hepatitis A
  • Meningococcal (MPSV4) conjugate vaccine

Recent Immunization Schedule Changes contd
  • Influenza vaccine for gt 6-59 months of age
  • Rotavirus (RotaTeq by Merck) for infants
  • HPV for adolescents

What disease is known as the 100 Day Cough?
  • RSV
  • Adenovirus
  • Rhinovirus
  • SARS
  • Pertussis

Tdap Recommendations
  • Use in place of Td as booster at 11 and 12 yrs
  • Use for 13-18 yr old who missed the 11 to 12 yrs
    dose of Td
  • 11-18 yrs of age who have already been vaccinated
    with Td are encouraged to receive a dose of Tdap
    to protect against pertussis if gt 2 years since
  • ( June 30, 2005)

Reasons for new Tdap recommendations
  • Pertussis still manages to cycle its way through
  • 2000-2005
  • 100 pertussis-related deaths US
  • 25,616 cases reported in 2005
  • Disease uncomfortable for anyone who has it
  • Cough for weeks

  • Recommended in adults who are in close contact
    with infants younger than 12 months of age
  • Parents
  • Child care providers

Tdap for Pregnant Women
  • Tdap can be given instead of Td booster if
    increased risk of Pertussis or needs immediate
    protection (tetanus)
  • Source for Pertussis infection 15-20 of infants

So, Heath Care Providers?
  • Every time you see a newborn, you should ensure
    that the entire immediate family have all been
    immunized for pertussis

What should be given for wound prophylaxis for an
  • Ages 11-18

  • Should a teen who has had pertussis be vaccinated
    with Tdap?

  • What is the maximum age DTaP can be administered?
  • 3 years
  • 4 years
  • 5 years
  • 6 years
  • 7 years

For what age is the Hepatitis A now approved?
  • Can be given as young as
  • gt6 months of age
  • gt9 months of age
  • gt12 months of age
  • gt18 months of age
  • gt2 years of age

What would you recommend for an infant under one,
traveling to Mexico?
  • A. Risk prevention
  • Dont drink the water, etc.
  • B. Gamma globulin
  • C. Hep A to the adults in close contact with
  • D. All of the above
  • E. Only A and C above
  • Remember infants do not get significant clinical
    disease, thus discuss risk prevention and
    immunize those over 12 months traveling?

Cocoon Effect
  • Vaccinating one group to protect another
  • HepA in children to protect adults
  • Tdap in adolescents/adults to protect infants

ACIP New Recommendations for Hep A
  • Can be used as post-exposure prophylaxis rather
    than GG if given within 2 weeks of exposure
  • Can be given on the way to the airport if
    patient is traveling to high risk area

Twinrix by GSK Combination of A and B
  • For use 18 years of age and older
  • Saves 2 injections ?
  • Cannot be used as on the way to airport
    injection because the amount of A antigen is ½ of
    that in Havrix

Menactra (MCV4) (Sanofi) Indications (ACIP 2007)
  • Routine vaccination for all adolescent between
    11-18 years
  • College freshman living in dorms
  • Revaccination only if gt 5 years since Menomune
    (MPSV4) if student is at high risk
  • To be added to Vaccine Injury Compensation Program

Menactra (MCV4) (Sanofi) Indications (ACIP 2007)
  • Now approved and recommended down to 2 years of
    age for those at risk for meningococcal
  • ACIP recommends using Menactra rather than
    Menomune (MPSV4)
  • Conjugated vaccines stimulates both humoral and
    cellular responses

Guillain-Barre Syndrome (GBS) and Menactra
  • Vaccination still recommended
  • Not a greater than expected number of GBS events

Syncope and Menactra
  • Syncope is common among adolescents?
  • No specific relation to Menactra or any other

Menactra (MC4) (Sanofi)Vaccine
  • What N meningitidis serogroup is NOT in vaccine?
  • A
  • B
  • C
  • Y
  • W 135

Annual Influenza Vaccine
  • Recommended for 6-59 month-olds
  • In-home and out-of- home caregivers of children
    ages 2-5 years of age
  • And of course, all healthcare providers!

FluMist (LAIV) (MedImmune) Indications
  • 2-49 years, non-pregnant, healthy persons
  • Contraindicated in asthmatics
  • Do not use for workers in transplant units

New FluMist (2007-08 season)
  • 2-49 y/o (September 28, MMWR) healthy children
  • Reduction in volume of vaccine (.1) mL per
  • Reduction in minimum dose spacing to 4 weeks for
    children who require 2 doses
  • Temperature requirements for storage 35-46
    degrees F

Flu Guidance (CDC) Partially Immunized lt 9 yrs of
age for 2007-08 season
  • Children 6 months-9 years should receive 2 doses
    separated by at least 1 month
  • NEW If the child lt 9 yrs received only one dose
    of influenza vaccine the first season they were
    immunized, they should receive 2 doses the
    following season

RotaTeq (Merck) Pentavalent live oral vaccine
  • ACIP recommendation
  • Infants should receive three doses of the oral
    vaccine at two, four, and six months of age to
    prevent moderate to severe Rotaviral infection
  • Children should receive the first dose of the
    vaccine by 12 weeks of age and should receive all
    doses of the vaccine by 32 weeks of age

Human Papillomavirus Virus Vaccination (HPV)
  • June 2006, ACIP recommendations
  • Be routinely given to girls at 11-12 year check
  • Allows for vaccination of girls beginning at 9
    years of age
  • Vaccination of girls and women 13-26 years of age

Human Papillomavirus Virus Vaccination (HPV)
  • June 2006, ACIP recommendations
  • Vaccination is NOT recommended during pregnancy
  • Can be given to lactating women
  • Cervical cancer screening recommendations do not

HPV the infection
  • Oncogenic (Protects against types 16 and 18)
  • Nononcogenic (Protects against types 6 and 11)

(No Transcript)
Pneumococcal Vaccines
  • Pneumovax-23
  • Pneumococcal polyvalent (23) polysaccharide
  • Cannot be given before 2 years of age
  • Protects against most common serotypes causing
    pneumonia in adults
  • Prevnar-7
  • Conjugate pneumococcal polyvalent (7) vaccine for
    infants and toddlers for protection of
    bacteremia, meningitis, pneumonia and some otitis

Cost of New Vaccines
Who is Eligible to Receive VFC (age 18 or younger)
  • 1. Medicaid eligible
  • 2. Uninsured
  • 3. American Indian/Alaska Native
  • 4. Underinsured (has health insurance benefit
    plan that does NOT include vaccination
  • Only at Federally Qualified Health Center or
    Rural Health Clinic

Case a 11 y/o girl comes to your office in
October for a routine evaluation.
  • Her last set of immunizations was at age 5 years
    and she was up to date. Which of the following
    vaccinations would you recommend today?
  • Tdap
  • Menactra
  • Varivax
  • HPV
  • Influenza
  • Up date
  • HepB
  • MMR
  • HepA

The Future
  • New combinations
  • Avian (H5N1) vaccines by Sanofi is FDA approved,
    April 17, 2007
  • OSU-Clinical Vaccine Research
  • RSV/PIV-3 (MedImmune)
  • PCV-13 (includes 19A serotype) (Wyeth)
  • New MMRV (GSK)
  • Newer adjuvants (such as GSKs ASO4)
  • Personalized vaccine delivery system

Number one question by parents
  • What if I miss an appointment? Does my baby have
    to get the shots all over again?

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