Immunizations

Rodolfo E. Bégué, MD

Chief, Infectious Diseases

Pediatrics, LSUHSC

rbegue@lsuhsc.edu

Edward Jenner(1749-1823)

Smallpox (1796)

Sarah Nelmes

James Phipps

Blossom

Immunizations

Vaccines are biologically active agents that induce the production of specific antibodies to render the subject protected (immune) against infectious diseases.

Constituents in a vaccine

Active immunizing agent

Suspending fluid

Preservatives (thimerosal)

Antibiotics (neomycin, streptomycin, polymyxin B)

Adjuvants (aluminum hydroxide, AS04)

Stabilizers (Tween)

Immunizing agents

Live, attenuated organisms

Killed, inactivated organisms

Subparticle (proteins, polysaccharides)

Hepatitis B

Subparticle vaccine (HBsAg)

Recombinant

Aluminum hydroxide

IM, 3 doses: 0, 1, 6 months0, 2, 6 months

No boosters

Hepatitis B

Infants born to HBsAg(+) mothersin addition should receive HBIG 0.5 ml, IM, 1 dose

Injection site pain and low grade fever (1-6%)safe in pregnancy

DTaP

Diphtheria toxoid (protein)Tetanus toxoid (protein)Pertussis acellular (subparticle)

whole cell (killed)

DTaP

Detoxified in formaldehyde, aluminum, Tween, thimerosal, no antibiotics

IM, 0.5 mL

Primary series (3): 2, 4, 6 monthsBooster (2): 12-18 mo, 4-6 years

Efficacy 80%, lasts for ~ 3 years

Boosters q 10 years (Td)

DTaP

Common adverse reactions:fever, redness and swelling at site, fretfulness, anorexia, drowsiness

Precautions for DTaP

Convulsions, with or without fever, within 3 d

Persistent crying for > 3 hrs, within 48 hrs.

Collapse or shock-like state within 48 hrs.

Temperature > 40.5 oC within 48 hrs

Vaccination might be deferred in children with progressive neurological disorder.

Contraindications for DTaP

Anaphylactic reactions

Encephalopathy within 7 days.

Polio vaccines

Injectable IPV

Oral OPV

Inactivated Polio Vaccine

Formalin inactivated

Trivalent (serotype 1, 2, 3)

Trace amounts of neomycin, streptomycin and polymyxin B.

SQ, 0.5 mL

Primary series: 2, 4, 18 monthsBooster: 4-6 yrs

(1 adult booster for travelers)

Inactivated Polio Vaccine

Local reactions 10 %

Low grade temperature 30 %

Precautions/contraindications:allergy to any of the components of the vaccine

Live Polio Vaccine

Vaccine Paralytic Polio:

1 every 3million doses8-10 cases per year in the UStype 3 more frequent (2, 1)usually after first dose1/2 recipients, 1/2 contacts

Precaution: immune suppressed patients or contacts

Hib vaccine

Subparticle vaccines (PRP) conjugated with protein carrier.

Protein carrier allows for:T-cell dependent antigenBetter immunogenicity (infants)Booster effect

Hib vaccines

IM, 0.5 mL

2, 4, 6, 12-15 mo

No boosters

Very safe vaccines. Local injection site reactions occur in 25 % but are very mild. Systemic reactions are very uncommon.

Pneumococcal Conjugate Vaccine

PCV-13

PCV-7

Pneumococcal Conjugate (PCV-13)

• Subparticle (polysaccharide), conjugate

• 13 valent

• IM, , 0.5 mL, 4 doses

• Primary series: 2, 4, 6 months of age

• Booster: 12–15 months

Pneumococcal Conjugate (PCV-13)

Catch-Up (Temporary)

For those who have received PCV-7 partial series, complete series with PCV-13

For those who have completed PCV-7 series, give one extra dose PCV-13 routine up to 5 yr; underlying conditions up to 18 yr

Pneumococcal Polysaccharide Vaccine (PCV-23)

• In addition to PCV-13, children at high risk for severe pneumococcal infection should receive one (or more doses of polysaccharide pneumococcal vaccine (PCV-23) starting at 24 months of age.

Measles, Mumps, Rubella

Live attenuated

Grown in chick embryo,no preservatives,neomycin

SQ, 0.5 mL

Series (2 doses):12-18 mo and 4-6 yrs

Side effects: 5-15% (fever, rash)

P/C: pregnancy, allergies (egg, neomycin), immune globulin, immune suppression, HIV OK except for C3 or CD4<15%

Varicella

Live attenuated, Oka strain

Neomycin, no preservatives

SQ, 0.5 ml

Side effects 5-10% rash

Series: 2 doses at 12-15 m, 4-6 y

P/C: pregnancy, allergies, immune globulin, salycilates, immunodeficiencies (except humoral), HIV: OK for CD4>15%

MMRV

Increase risk of febrile seizures (1‰2 ‰)after 1st dose

1st dose: 1) MMR + V 2) MMRV

2nd dose: 1) MMRV 2) MMR + V

Hepatitis A vaccine

Formalin inactivated virus

Aluminum hydroxide as adjuvant

IM, 2 doses (6-12 months apart)

12 months - 24 months

Can be used for Post-Exposure prophylaxis (within 2w)

Efficacy: 79 - 99 %

Side effects: soreness injection site (56 %)headache (14 %), malaise (7 %)

Rotavirus Vaccines

Rota Teq (MSD) February 2006

Live vaccine

Human-Bovine reassortant

Pentavalent (RV5): G1-G4, P[8]

3 doses:2, 4, 6 months1st dose: 6 w - <15 w, q 4 w - 10 w, <8 m

Efficacy: 74% (67, 80)

Rotarix (GSK) April 2008

Live vaccine

Human

Monovalent (RV1): G1, P[8]

2 doses:2, 4 months1st dose: 6 w - <15 w, q 4 w - 10 w, <8 m

Efficacy: 73% (27, 91)

Influenza Vaccines

TIV

Inactivated, split-virus

Chick embryo

Tri-valent (two A, one B), reformulated yearly

IM, 1 or 2 doses

All subjects 6 months and older

LAIV

Live, cold-adapted

Chick embryo

Tri-valent (two A, one B), reformulated yearly

Intranasal, 1 or 2 doses

Healthy, 2-49 years

Influenza Vaccine

Recommendations:

Universal immunization for all subjects 6 months and older

Special emphasis to children < 5 y and all household contacts and out-of-home caregivers of children < 5 y of age

TIV to all 6 months-olderLAIV to healthy 2-49 yr

MMWR 2010;vol 59, RR-8

Influenza Vaccine

Specific Target Groups:

Children at risk of severe influenza disease:Asthma and other chronic pulmonary diseases (eg, CF)Hemodynamically significant cardiac diseaseImmunosuppresive disorders (congenital, acquired, Tx)Sickle cell and other hemoglobinopathiesLong-term aspirin therapy (Kawasaki, JRA)Chronic renal dysfunctionChronic metabolic diseases (eg, diabetes)

Persons who are in close contact with high-risk children (household, other care givers, DCC, HCW).

Women who will be in 2nd or 3rd trimester during influenza season

AAP, COID, Pediatrics 2004;113:1441-1447

Human Papillomavirus (HPV)

70% sexually active women

Cause of cervical carcinoma especially serotypes 16 and 18 (70%)

Cause of genital warts especially serotypes 6 and 11 (90%)

HPV Vaccines

Gardasil (MSD): HPV4: 6, 11, 16, 18Cervarix (GSK): HPV2: 16, 18

Gardasil: M/F; Cervarix: F

11-12 years, 9-26 years

IM, 3 doses: 0, 1-2, 6 months

Meningococcal Vaccine

Conjugate Vaccine (MCV4)

Menactra (Sanofi Pasteur) Menveo (Novartis)

A, C, Y, W-135 (B not included), 4 g each

Indicationsa) Routine immunization for 11-18 year olds emphasis target groups: 11-12 yr, college freshmen

boosters: 11-12 y/16 yr; 13-15 yr/16-18 yr; > 16 yr/no boosterb) At risk groups: 9 months to 55 yr (2 doses)

boosters: 3 years (2-6 yr) and then q 5 years

MMWR 2011;60(3):72-76

Age Subgroup Primary Vaccination Booster Dose

9 through 23 months of age, with high risk conditions

Children with complement deficiencies; Two doses of MCV4, three months apart

If first dose received at age 9months through 6 years and remain at increased risk for meningococcal disease, should receive an additional dose of MCV4 three years after primary vaccination. Boosters should be repeated every five years thereafter.  If first dose received at age 7 years or older and remain at increased risk for meningococcal disease, should receive an additional dose of MCV4 five years after primary vaccination. Boosters should be repeated every five years thereafter.

Children with HIV, if another indication for vaccination exists

Two doses of MCV4, three months apart

All others in this age group recommended for vaccination (travelers to the Meningitis Belt, etc)

Two doses of MCV4, three months apart (infants receiving the vaccine prior to travel can receive the doses as early as two months apart)

2 through 18 years of age, with high risk conditions

Children with complement deficiencies; functional or anatomic asplenia;

Two doses of MCV4, two months apart

Children with HIV, if another indication for vaccination exists

Two doses of MCV4, two months apart

All others in this age group recommended for vaccination (travelers to the Meningitis Belt, etc)

Single dose of MCV4

All other children 11-18 years of age

Routine vaccination with MCV4 at ages 11 through 12 years

If vaccinated at age 11 through 12 years, should receive a one-time booster dose at age 16 years If vaccinated at age 13 through 15 years, should receive a one-time booster dose at age 16 through 18 years

www.cdc.gov/vaccines/programs/vfc/downloads/.../06-11mening-mcv.pdf

Meningococcal Vaccine

Polysaccharide (MPSV4):

Menomune (Sanofi Pasteur)

A, C, Y, W-135 (B not included), 50 g each, SC

Children > 2 years at risk

– asplenia, complement deficiency, HIV (opt), outbreak, traveler to an endemic area

– In all cases MCV4 is prefered over MPSV4)

dTap

Booster

Adolescents (11-12 yr, 13-18 yr)

GlaxoSmithKline (Boostrix)Sanofi Pasteur (Adacel)

Special Situations

Prematurity (HBV)

Immune suppressed:self: MMR, VZVfamily contact: (OPV)

Pregnancy: MMR, VZV

Full doses

Multiple vaccines

Impact of VaccinationsDisease Maximum 2006 % decrease

Diphtheria 30,508 0 100

Measles 763,094 55 99.9

Mumps 212,932 6,584 96.9

Pertussis 265,269 15,632 94.1

Poliomyelitis 21,269 0 100

Rubella 488,796 11 100

Congenital 20,000 1 100

Smallpox 110,672 0 100

Tetanus 601 41 93.1

Hepatitis A 254,518 15,298 94.0

Hepatitis B 74,361 13,169 82.3

Invasive Hib 20,000 <50 99.9

Invasive Pneumo 64,400 41,550 35.5

Varicella 5,358,595 612,768 88.6

Modified from Roush SW, et al. JAMA 2007;298:2155-2163

QUESTIONS?