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Immunization Update

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Immunization Update Andrew Kroger, MD, MPH National Center for Immunization and Respiratory Diseases North Carolina Statewide Immunization Conference – PowerPoint PPT presentation

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Title: Immunization Update


1
  • Immunization Update

Andrew Kroger, MD, MPH National Center for
Immunization and Respiratory Diseases
North Carolina Statewide Immunization Conference
Greensboro, NC August 10, 2011
2
Disclosures
  • Andrew Kroger is a federal government employee
    with no financial interest or conflict with the
    manufacturer of any product named in this
    presentation
  • Andrew Kroger will not discuss a vaccine not
    currently licensed by the FDA

3
Disclosures
  • Andrew Kroger will discuss off-label uses
    meningococcal conjugate vaccine (MCV4) and
    tetanus-reduced-diphtheria-toxoid acellular
    pertussis vaccine (Tdap)

4
Comparison of 20th Century Annual Morbidity and
Current Morbidity Vaccine-Preventable Diseases
Source JAMA. 2007298(18)2155-2163
Source CDC. MMWR January 7, 201159(52)1704-17
16. (provisional MMWR week 52 data) 16 type
b and 254 unknown serotype (lt 5 years of age)
  • National Center for Immunization Respiratory
    Diseases

5
Whats New in Immunization
  • MCV4 vaccine
  • Measles Outbreaks
  • Influenza Vaccine
  • Tdap vaccine

6
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9
Adult Immunization Schedule Indications by Age
Group - 2011
10
Adult Immunization Schedule Indications by
Condition - 2011
11
Persons at Highest Risk of Meningococcal Disease
or Suboptimal Vaccine Response
  • Complement deficiency
  • High-risk of disease
  • Very high antibody titer required to compensate
    for complement deficiency
  • Asplenia
  • High-risk of disease
  • evidence of suboptimal response

12
Persons with Suboptimal Vaccine Response
  • HIV infection
  • evidence of suboptimal response
  • Single dose primary series may not be sufficient
    to confer protection for persons with these
    high-risk conditions

13
MCV4 Primary Series Recommendation
  • Administer 2 doses of MCV4 at least 8 weeks apart
    to persons with persistent complement component
    deficiency and anatomic or functional asplenia

MMWR 201160(No. 3)72-6.
14
MCV4 Primary Series Recommendation
  • HIV infection is not an indication for MCV4
    vaccination
  • However, some persons with HIV infection should
    receive MCV4 (adolescents, some international
    travelers, microbiologists, etc)
  • Persons with HIV infection who are vaccinated
    with MCV4 should receive 2 doses at least 8 weeks
    apart

MMWR 201160(No. 3)72-6.
15
FDA Approval Menactra
  • June 2011 Menactra approved for high-risk
    infants
  • 2 dose series at 9 months and 12 months

16
New MCV4 Recommendations
  • Certain persons recommended for infant series
  • Persistent complement component deficiency
  • Travelers to high-risk meningococcal areas
  • Persons in a meningococcal outbreak
  • HIV infection (permitted)

17
New MCV4 Recommendations
  • Infant vaccination 2 dose series
  • Dose 1 9 months
  • Dose 2 12 months
  • Minimum interval between doses 2 months

18
Infant Vaccination Asplenia
  • Persons with functional or anatomic asplenia NOT
    recommended for infant vaccination
  • Still recommended for 2 dose series beginning at
    age 2 years

19
Asplenia
  • Persons with asplenia are at higher risk for
    invasive pneumococcal disease
  • Dose of PCV13 recommended at 12 18 months of
    age
  • Evidence of interaction between PCV13 and MCV4
    affecting the immune response to PCV13
  • Because of the risk of interaction, MCV4 not
    recommended for asplenic children when they
    should be receiving PCV13

20
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21
Rates of Meningococcal Disease (C and Y) by Age,
1999-2008
Active Bacterial Core surveillance (ABCs),
1998-2008
22
Meningococcal Conjugate (MCV4) Routine
Revaccination
  • In its 2005 recommendations for MCV, ACIP made no
    recommendation about revaccination pending the
    availability of additional data
  • Serologic data are now available from the
    manufacturer that show significant decline in
    antibody 3-5 years after vaccination although few
    breakthrough cases have been reported

MMWR 200958(No. 37)1042-3
23
Seroprotection Rates Following MCV Vaccination
MMWR 200958(No. 37)1042-3
24
New MCV4 Recommendations
  • administer MCV4 at age 11 or 12 years with a
    booster dose at 16 years of age
  • administer 1 dose at age 13 through 15 years if
    not previously vaccinated
  • for persons vaccinated at age 13 through 15 years
    administer a 1-time booster dose is recommended,
    preferably at or after 16 through 18 years of age

off-label recommendation. MMWR 201160(No.
3)72-6.
25
New MCV4 Adolescent Vaccination Recommendations
  • The minimum interval between doses is 8 weeks
  • A booster dose is not recommended for healthy
    persons if the first dose is administered at
    16-21 years of age
  • The booster dose is generally not recommended
    after the 19th birthday however, both an initial
    dose and/or a booster dose can be given to
    someone entering college between 19 through 21
    years old.
  • Booster dose is permitted if an individual is
    already identified as being in college between 19
    through 21 years old.

26
MCV4 vs MPSV4
  • Conjugate vaccines boost the immune response
  • If MPSV4 is substituted for MCV4 for the booster
    dose, or for a primary series dose in high-risk,
    the dose should be repeated

27
MCV Revaccination Recommendations
  • Other high-risk persons recommended for
    revaccination
  • microbiologists with prolonged exposure to
    Neisseria meningitidis
  • frequent travelers to or persons living in areas
    with high rates of meningococcal disease
  • Revaccinate every 5 years as long as the person
    remains at increased risk
  • Every 3 years if first dose given between 2
    through 6 years of age
  • MCV4 for persons 2 through 55 years of age
  • MPSV for persons 56 years and older

28
Measles
  • As of June 17, 2011
  • Over 156 cases of measles reported in U.S.
  • Highest number since 1996

29
MMR
  • A dose is recommended for travelers between 6
    through 12 months of age
  • Does NOT count toward the two dose routine series
  • High-risk countries France, India (generally
    Europe, Africa, Asia)

30
Influenza
31
2011-2012 Influenza Vaccine Composition
  • Same strains this year as last year
  • A/California/7/2009-like H1N1
  • A/Perth/16/2009-like H3N2
  • B/Brisbane/60/2008

32
Duration of Immunity Following Influenza
Vaccination
  • Protection against viruses that are similar
    antigenically to those contained in the vaccine
    extends for at least 6-8 months
  • There is no clear evidence that immunity declines
    more rapidly in the elderly
  • Additional vaccine doses during the same season
    do not increase the antibody response
  • The frequency of breakthrough infections has not
    been shown to be higher among persons vaccinated
    early in the season
  • Skowronski et al. J Infect Dis 2008197490-502

33
Influenza Vaccination Recommendation
  • Annual influenza vaccination is now recommended
    for every person in the United States 6 months of
    age and older

MMWR 201059(RR-8)
34
Influenza Vaccine Presentations 2011-2012
SDSsingle dose syringe SDVsingle dose vial
MDVmultidose vial
35
Fluzone High-Dose
  • Manufactured by Sanofi Pasteur
  • Contains 4 X amount of influenza antigen than
    regular Fluzone
  • Approved only for persons 65 years and older
  • Produced higher antibody levels slightly higher
    local reactions
  • Studies underway to assess relative effectiveness
  • These expected for the 2012-2013 season
  • No preference stated by ACIP for HD or regular
    influenza vaccination

36
Fluzone Intradermal
  • Licensed by FDA in May 2011
  • Approved only for persons 18 through 64 years of
    age
  • Dose is 0.1 mL administered in the deltoid area
    by a specially designed microneedle and injector
    system
  • Formulated to contain more HA (27 mcg) than a 0.1
    mL dose of regular Fluzone formulation (9 mcg)

37
  • Inactivated Influenza Vaccine Schedule

Age Group 6-35 mos 3-8 yrs 9 yrs and older
No. Doses 1 or 2 1 or 2 1
Dose 0.25 mL 0.50 mL 0.50 mL
38
Influenza Vaccination Schedule
  • One dose is recommended for most people
  • 2 doses are recommended for children 6 months
    through 8 years of age who did not receive
    influenza vaccine during the 2010-2011 season

39
Afluria
  • CSL vaccine associated with febrile seizures
  • Risk seen in children 6 months through 4 years of
    age
  • Risk of fever seen in children 5 years through 8
    years
  • Can use Afluria in high-risk children 5 years
    through 8 years if no other age-approved
    formulation is available

40
Live Attenuated Influenza Vaccine Indications
  • Persons 2 through 49 years of age
  • who are healthy (i.e., do not have an underlying
    medical condition that increases the risk of
    complication of influenza)
  • who are not pregnant
  • who do not have contact with a severely
    immunosuppressed person (hospitalized and in
    isolation)

MMWR 201059(RR-8)
41
Influenza Vaccine Screening
  • Evidence that persons with mild, moderate, or
    severe allergy to eggs can tolerate TIV
  • Quantity of ovalbumin (egg protein) in dose of
    TIV less than 0.7 mcg
  • Severe egg allergy now a precaution, not a
    contraindication for TIV

42
Tdap
  • Tdap reduces the risk of pertussis by 60 - 80
  • Tdap approved ages
  • 10 years and older for Boostrix
  • 11 through 64 years for Adacel
  • Tdap not approved by the Food and Drug
    Administration for children 7 years through 9
    years

Wei SC et al. Clin Infect Dis 201051315-21
43
Tdap Recommendations for Adolescents/Adults
  • Persons 11 through 64 years of age who have not
    received Tdap should receive a dose followed by
    Td booster doses every 10 years
  • Adolescents should preferably receive Tdap at the
    11 to 12 year-old preventive healthcare visit

MMWR 2011 60 (No. 1)13-5
44
New Tdap Recommendation for Adults
  • Persons 65 years old or older who anticipate or
    have close contact with an infant should receive
    a dose of Tdap if not already received
  • This is an off-label recommendation if you use
    Adacel
  • MMWR 2011 60 (No. 1)13-5

45
New Tdap Recommendations for Adolescents
  • Persons 7 through 10 years of age who are not
    fully immunized against pertussis (including
    those never vaccinated or with unknown pertussis
    vaccination status) should receive a single dose
    of Tdap

off-label recommendation. MMWR 2011 60 (No.
1)13-5
46
New Tdap Recommendations for Adolescents
  • Not fully immunized
  • fewer than 4 doses of DTaP
  • 4 doses of DTaP and last dose was prior to age 4
    years

MMWR 2011 60 (No. 1)13-5
47
MMWR 2011 60 (No. 1)13-5
48
Tdap Adverse Event Rates by Interval Since
Previous Td/TT
Talbot et al. Vaccine 2010288001-7
49
New Tdap Interval Recommendations
  • Tdap can be administered regardless of the
    interval since the last tetanus and diphtheria
    containing vaccine
  • ACIP concluded that while longer intervals
    between Td and Tdap vaccination could decrease
    the occurrence of local reactions, the benefits
    of protection against pertussis outweigh the
    potential risk for adverse events

off-label recommendation. MMWR 2011 60 (No.
1)13-5
50
Tdap and Healthcare Personnel (HCP)
  • HCP, regardless of age, should receive a single
    dose of Tdap as soon as feasible if they have not
    previously received Tdap and regardless of the
    time since last Td dose
  • Post-exposure prophylaxis should be provided to
    HCP even if vaccinated, although observation for
    symptoms of pertussis an option if provider does
    NOT see hospitalized neonates or pregnant women

off-label provisional ACIP recommendation.
Approved by ACIP on Feb 23, 2011 on CDC website
51
Tdap and Pregnancy
  • Providers of pregnant women should recommend Tdap
    to their patients if not previously received and
    after 20 weeks gestation
  • ACIP vote June 22, 2011

52
Thank You
  • Hotline 800.CDC.INFO
  • Email nipinfo_at_cdc.gov
  • Website www.cdc.gov/vaccines

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