Pediatric vaccination review summer update LAUREN RIDDERIKHOFF, DO – PGY 2 FAMILY MEDICINE LAKE CUMBERLAND REGIONAL HOSPITAL

OBJECTIVES OVERVIEW UPDATED VACCINE SCHEDULE AND GUIDELINES 2017 TYPES OF IMMUNITY TYPES OF VACCINES VACCINE MISCONCEPTIONS TRUE CONTRAINDICATIONS PREVENTABLE DISEASES UPDATED VACCINE SCHEDULE AND GUIDELINES 2017 CATCH UP GUIDELINES TALKING TO YOUR PATIENTS

TYPES OF immunity HERD IMMUNITY1 When the majority of the community has been vaccinated against a contagious disease there is not much opportunity for an outbreak Those who are unable to be vaccinated such as immunocompromised, pregnant women, or infants are also protected to a certain degree because those who are vaccinated decrease the likelihood of an outbreak and therefore decrease the likelihood the unvaccinated will catch a contagious disease The higher the proportion of individuals who are immune, the lower the likelihood that a susceptible person will come into contact with an infected individual. Public health’s general aim is to establish herd immunity in most populations. Complications arise when widespread vaccination is not possible or when vaccines are rejected by a part of the population (e.g. parental refusal to immunize). Since only a small fraction of the population (or herd) can be left unvaccinated for this method to be effective, it is considered best left for those who cannot safely receive vaccines because of a medical condition such as an immune disorder or for organ transplant recipients. (Kashif Iqbal, MPH; Leonard Mayer, PhD; Pamela Srivastava, MS; Nancy Rosenstein Messonnier, MD, MPH; Kristine M. Bisgard, DVM, MPH, Manual for the Surveillance of Vaccine-Preventable Diseases (4th Edition, 2008)).

TYPES OF IMMUNITY ACTIVE IMMUNITY5 Immunity to a disease through creation of antibodies Exposure to the disease organism can occur through infection with the actual disease (natural immunity), or introduction of a killed or weakened form of the disease organism through vaccination (vaccine-induced immunity) If an exposed person comes into contact with that disease in the future, their immune system will recognize it and immediately produce the antibodies needed to fight it Active immunity is long term

Types of immunity ACTIVE IMMUNITY6 Bacteria, virus, or parasite infects a cell The cell expresses the pathogen’s antigen on the cell surface T cells bind to the antigen on the surface of the infected cell Binding activates the T cells Nearby T helper cells release cytokines causing the activated T cells to differentiate into cytotoxic T cells Cytotoxic T cells then lyse the infected cells and promote macrophage phagocytosis B cells also bind to T helper cells The antigen binds to the B cell receptor (antibody) inducing differentiation into memory B cells and plasma B cells which produce antibodies to the antigen

Types of immunity PASSIVE IMMUNITY5 When a person is given antibodies to a disease rather than producing them through his or her own immune system A newborn baby from its mother via the placenta Through antibody-containing blood products (immune globulin), which may be given when immediate protection from a specific disease is needed Protection from the disease is immediate, whereas active immunity takes time (usually several weeks) to develop Passive immunity is short term

Types of vaccines LIVE, ATTENUATED10 Contain a version of the living microbe that has been weakened– it cannot cause the disease Elicit strong cellular and antibody responses that usually provides long term immunity in only 1-2 doses Retains its ability to replicate or mutate Need to be refrigerated Smallpox, MMR, Varicella, Intranasal Influenza, Rotavirus, Zoster, Yellow Fever, Typhoid

Types of vaccines INACTIVATED10 Produced by killing the disease-causing microbe with chemicals, heat, or radiation Stimulate a weaker immune system response than do live vaccines Usually takes booster dosing to maintain a person’s immunity Polio, Hepatitis A, Rabies

Types of vaccines SUBUNIT10 Include only the specific parts of the antigen that antibodies or T cells recognize and bind to in order to stimulate the immune system in a specific way Chances of adverse reactions are lower Hepatitis B, Influenza injection, Haemophilus influenzae type b, Pertussis, Pneumococcal, Meningococcal, HPV Research is ongoing for a recombinant subunit vaccine for Hepatitis C

Types of vaccines TOXOID10 Used when the bacterial toxin is the main cause for an illness Scientists inactivate the bacterial toxin into a toxoid using formalin Diphtheria, Tetanus

Vaccine misconceptions11 “Vaccine-preventable diseases have been virtually eliminated from my country, so there is no need for my child to be vaccinated.” We have reduced many vaccine-preventable diseases to low levels in many countries however many are still prevalent in other countries Anyone travelling may bring a vaccine-preventable disease back to any country and if not protected by vaccines these diseases could quickly spread throughout the population Vaccinate for TWO reasons: To protect ourselves To protect others who cannot be vaccinated

Vaccine misconceptions11 “Vaccines cause many harmful side effects, illnesses, and even death - not to mention possible long-term effects we don't even know about.” Most vaccine adverse advents are minor and temporary More serious adverse events are very rare, some even rare enough that risk is not able to be quantified A child is significantly more likely to be harmed from a vaccine preventable disease than from the vaccine itself For example: According to an analysis of the benefit and risk of DTP immunization, if there was no immunization program in the United States, pertussis cases could increase 71-fold and deaths due to pertussis could increase four-fold

Vaccine misconceptions11 “Giving a child multiple vaccinations for different diseases at the same time increases the risk of harmful side effects and can overload the immune system” Eating food, putting toys in their mouths-examples of things that expose children to foreign antigens every day An upper respiratory viral infection exposes a child to 4-10 antigens, and a case of strep pharyngitis 25-50 antigens Multiple studies have shown that simultaneous vaccination with multiple vaccines has no adverse effect on the normal childhood immune system We want to immunize children as early as possible to give them protection during the most vulnerable part of their lives Giving several vaccinations at the same time will also mean fewer clinic visits for vaccinations- saves parents time and money and can be less traumatic According to "Adverse events Associated with childhood vaccines", a 1994 report from the Institute of Medicine in the United States, "In the face of these normal events, it seems unlikely that the number of separate antigens contained in childhood vaccines . . . would represent an appreciable added burden on the immune system that would be immuno-suppressive

Vaccine misconceptions11 “The majority of people who get disease have been vaccinated” True, no vaccine is 100% effective, however not all vaccinated persons develop immunity Most routine childhood vaccines are effective for 85% to 95% of recipients In the US the number of people who have been vaccinated far outnumbers the amount of those who have not, so if there were to be an outbreak both unvaccinated and vaccinated persons who may have not developed immunity will become infected, as expected As you can see, this doesn't prove the vaccine didn't work — only that most of the children in the class had been vaccinated, so those who were vaccinated and did not respond outnumbered those who had not been vaccinated. Looking at it another way, 100% of the children who had not been vaccinated got measles, compared with less than 1% of those who had been vaccinated.

Do vaccines work? Disease incidence for all vaccine preventable diseases rapidly declined after vaccines were made available for each disease Current US sources of the diseases are foreign born people living in the US who have acquired the disease elsewhere or unvaccinated US citizens

Examples: Measles4 In 1954, John F. Enders and Dr. Thomas C. Peebles collected blood samples from ill students during a measles outbreak in Boston, Massachusetts In 1963, they transformed their Edmonston-B strain of measles virus into a vaccine and licensed it in the United States In 1968, an improved measles vaccine began to be distributed By 1981, the number of reported measles cases decreased by 80% Measles was declared eliminated (absence of continuous disease transmission for greater than 12 months) from the United States in 2000

measles4

Diphtheria3 The United States recorded 206,000 cases of diphtheria in 1921, resulting in 15,520 deaths Starting in the 1920s, diphtheria rates dropped quickly in the United States and other countries with the widespread use of vaccines In the past decade, there were less than five cases of diphtheria in the United States reported to CDC

diphtheria3

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pertussis7 The incubation period of pertussis is commonly 7–10 days, with a range of 4–21 days The most common complication, and the cause of most pertussis-related deaths, is secondary bacterial pneumonia with highest risk to young infants During 2012, 48,277 cases of pertussis were reported to CDC, including 20 pertussis-related deaths-the most reported cases since 1955 During 2014, 32,971 cases of pertussis were reported to CDC-a 15% increase compared 28,639 cases reported during 2013 Potential reasons why we’re seeing more cases including: increased awareness, improved diagnostic tests, better reporting, more circulation of the bacteria, waning immunity, some decrease in vaccination

pertussis7 Whole cell pertussis vaccines are associated with higher rates of minor and temporary side effects such as fever and pain and swelling at the injection site. Rare but serious neurologic adverse reactions, including chronic neurological problems, rarely occurred among children who had recently received whole cell vaccines

True contraindications2 PREGNANCY During pregnancy and up to 4 weeks prior to conception IMMUNOSUPPRESSED HIV patients with CD4 count <200 Long term immunosuppressive therapy (Ex: Prednisone 20mg daily or 2mg/kg for >2 weeks) Congenital immunodeficiency Hematologic and solid tumors Receipt of chemotherapy

True contraindications2 ALLERGY Severe allergic reaction or anaphylaxis after a previous dose or to a vaccine component ENCEPHALOPATHY Encephalopathy within 7 days after administration dose of pertussis-containing vaccine that is not attributable to another identifiable cause

Precautions2 A condition that might increase the risk for a serious adverse reaction, might cause diagnostic confusion, or might compromise the ability of the vaccine to produce immunity (e.g., administering measles vaccine to a person with passive immunity to measles from a blood transfusion administered up to 7 months prior) In general, deferral of vaccination is appropriate when a precaution is present However, a vaccination might be indicated in the presence of a precaution if the benefit outweighs the risk for an adverse reaction Most are vaccine specific

General Precautions2 Presence of a moderate or severe acute illness with or without a fever. (Vaccinations should be deferred for persons with a moderate or severe illness) GBS <6 weeks after a previous dose of a vaccine A recent study found an increased risk for febrile seizures in children 12-23 months who receive MMRV compared with MMR and varicella vaccine Defer until neuro status clarified and stable.

Updated vaccine schedule 20178

Hepatitis B8 Hepatitis B surface antigen (HBsAg)-negative mothers: Administer monovalent HepB vaccine to all medically stable newborns weighing ≥2,000 grams within 24 hours of birth Preterm infants weighing <2,000 g should begin vaccination 1 month after birth or at hospital discharge Hepatitis B surface antigen (HBsAg)-positive mothers Administer HepB vaccine and 0.5 mL of hepatitis B immune globulin (HBIG) within 12 hours of birth regardless of weight HBsAg status unknown Administer HepB vaccine at birth regardless of birth weight Administer additional doses at 4 weeks, 8 weeks, and at least 16 weeks after first dose Catch Up Notes: Unvaccinated persons should complete a 3-dose series A 2-dose series (doses separated by at least 4 months) of adult formulation Recombivax HB is licensed for use in children aged 11-15

rotavirus8 Minimum age of administration: 6 weeks Rotarix-administer 2-dose series at 2 and 4 months RotaTeq-administer 3-dose series at 2, 4, and 6 months Contraindicated in SCID, history of intussusception Precaution in Immunocompromised & HIV infection, Spina bifida or bladder exstrophy Catch Up Notes: The maximum age for the first dose in the series is 14 weeks, 6 days; vaccination should not be initiated for infants aged 15 weeks The maximum age for the final dose in the series is 8 months

Diphtheria and tetanus toxoids and acellular pertussis (DTaP) vaccine8 5-dose series at ages 2, 4, 6, 15-18 months, and 4-6 years. The fourth dose may be administered as early as age 12 months as long as 6 months have passed since the third dose If the fourth dose was administered early, it does not need to be repeated Catch Up Notes: The fifth dose of DTaP vaccine is not necessary if the fourth dose was administered at age 4 years or older

Inactivated polio8 Administer a 4-dose series of IPV at ages 2, 4, 6-18 months, and 4-6 years The final dose in the series should be administered at least 6 months after the previous dose and after the fourth birthday Precaution in pregnancy Catch Up Notes: If four or more doses are administered before age 4 years, an additional dose should be administered at age 4-6 years, at least 6 months after the previous dose

Measles, Mumps, Rubella8 Administer a 2-dose series of MMR vaccine at ages 12-15 months and 4-6 years The second dose may be administered before age 4 years, provided at least 4 weeks have passed since the first dose Administer 1 dose of MMR vaccine to infants aged 6-11 months or 2 doses to infants ages 12 months or older before international travel All school-aged children and adolescents should have 2 doses of MMR; the minimum interval between the two doses is 4 weeks Contraindications: Pregnancy Immunocompromised HIV infection with low CD4 percentage

varicella8 Administer a 2-dose series of VAR vaccine at ages 12-15 months and 4-6 years The second dose may be administered before age 4 years, provided at least 3 months have passed since the first dose For children aged 7-12 years, there is a minimum 3 month interval recommended between doses For persons aged 13 years and older the minimum interval between doses is 4 weeks Contraindications: Pregnancy Immunocompromised HIV infection with low CD4 percentage

Hepatitis A8 Initiate the 2-dose HepA vaccine series at ages 12-23 months with separation of the two doses by 6-18 months Children who have received 1 dose of HepA vaccine before age 24 months should receive a second dose 6-18 months after the first dose Anyone 2 years and older who has not already received the HepA vaccine series, 2 doses of HepA vaccine separated by 6-18 months may be administered if immunity is desired (including international adoptees)

Meningococcal-ACWY8 Administer a single dose of Menactra or Menveo vaccine at age 11-12 years, with a booster dose at age 16 years Catch Up Notes: Administer Menactra or Menveo vaccine at age 13-18 years if not previously vaccinated If the first dose is administered at age 13-15 years, a booster dose should be administered at age 16-18 years, with a minimum interval of at least 8 weeks If the first dose is administered at age 16 years or older, a booster dose is not needed

Meningococcal-acwy in high risk children8 Children with anatomic or functional asplenia (including sickle cell disease), HIV infection, or persistent complement component deficiency Menveo Children who initiate vaccination at 8 weeks-administer doses at ages 2, 4, 6, and 12 months Unvaccinated children who initiate vaccination at 7- 23 months-administer 2 doses, with the second dose at least 12 weeks after the first dose AND after the first birthday Children 24 months and older who have not received a complete series-administer 2 doses at least 8 weeks apart

Meningococcal-acwy in high risk children8 MenHibrix Children who initiate vaccination at 6 weeks-administer doses at 2, 4, 6, and 12-15 months If the first dose is given at or after age 12 months, 2 doses should be given at least 8 weeks apart Menactra: Children with HIV infection Children 24 months and older who have not received a complete series-administer 2 doses at least 8 weeks apart Do not administer Menactra until age 2 years and at least 4 weeks after the completion of all PCV13 doses in HIV infection All high-risk children If Menactra is to be administered to a child at high risk for meningococcal disease, it is recommended that Menactra be given either before or at the same time as DTaP

Meningococcal-b8 Recommended routinely for people 10 years or older who are at increased risk for serogroup B meningococcal infections, including: People at risk because of a serogroup B meningococcal outbreak Asplenia Any person with persistent complement component deficiency Anyone taking a drug called eculizumab (also called Soliris®)

Meningococcal-b8 Young adults aged 16-23 years (preferred age range is 16-18 years) who are not at increased risk for meningococcal disease may be vaccinated with a 2- dose series of either Bexsero (1 month interval) or Trumenba (6 month interval) to provide short-term protection against most strains of serogroup B meningococcal disease The two MenB vaccines are not interchangeable If the second dose of Trumenba is given at an interval of <6 months, a third dose should be given at least 6 months after the first dose; the minimum interval between the second and third doses is 4 weeks

Haemophilus infuenzae type b8 The 3-dose primary series with ActHIB, MenHibrix, Hiberix, or Pentacel should be administered at 2, 4, and 6 months One booster dose (dose 3 or 4, depending on vaccine used in primary series) of any Hib vaccine should be administered at age 12-15 months Comvax has been removed from the market, and Hiberix has been added to the list of primary vaccines Catch Up Notes: If dose 1 was administered at ages 12- 14 months, administer a second dose at least 8 weeks after the first dose, regardless of Hib vaccine used in the primary series For unvaccinated children aged 15–59 months, administer only 1 dose

pneumococcal8 Minimum age: 6 weeks for PCV13 (Prevnar 13), 2 years for PPSV23 (Pneumovax) Administer a 4-dose series of PCV13 at 2, 4, and 6 months and12-15 months All PCV13 doses should be administered before PPSV23 vaccination if possible PCV13 Catch Up Notes: Administer 1 dose of PCV13 to all healthy children aged 24-59 months who are not completely vaccinated for their age

pneumococcal8 PPSV23 is administered to children ages 2-18 years at least 8 weeks after last dose of PCV13 with the following conditions: chronic heart disease, chronic lung disease, diabetes mellitus, CSF leak, cochlear implant, sickle cell disease, anatomic or functional asplenia, HIV infection, chronic renal failure, nephrotic syndrome, malignant neoplasms, leukemias, lymphomas, and Hodgkin disease, multiple myeloma, solid organ transplantation, congenital immunodefciency The 7-valent pneumococcal conjugate vaccine (PCV7) has been removed. All healthy children who received PCV7 as part of a primary series have now aged out of the recommendation for pneumococcal vaccine

Human papillomavirus8 Minimum age: 9 years for 4vHPV Gardasil and 9vHPV Gardasil 9 Administer a 2-dose series of HPV vaccine on a schedule of 0, 6-12 months to all children (female or male) aged 11 or 12 years Initiating vaccination before age 15-give 2 doses of HPV vaccine at 0, 6-12 months Initiating vaccination at15 years or older-give 3 doses of HPV vaccine at 0, 1–2, 6 months

Human papillomavirus8 For children with history of sexual abuse or assault, administer HPV vaccine beginning at 9 years Immunocompromised persons, including those with HIV infection, should receive a 3-dose series at 0, 1–2, and 6 months, regardless of age The vaccination series can be given to children aged 9–10 years, even in the absence of a high-risk condition The bivalent HPV vaccine has been removed from the U.S. market

Tetanus and diphtheria toxoids and acellular pertussis (Tdap) vaccine8 Minimum age: 10 years for both Boostrix and Adacel Administer 1 dose of Tdap vaccine to all children 11-12 years Tdap may be administered regardless of the interval since the last tetanus and diphtheria toxoid-containing vaccine Administer 1 dose of Tdap vaccine to pregnant adolescents during each pregnancy (preferably between 27-36 weeks gestation), regardless of time since prior Td or Tdap vaccination Catch Up Notes: Persons 11-18 years who have not received Tdap vaccine should receive one dose, followed by tetanus and diphtheria toxoids (Td) booster every 10 years

influenza8 Everyone 6 months and older should be vaccinated annually CDC recommends use of injectable influenza vaccines (including inactivated influenza vaccines and recombinant influenza vaccines) Intranasal live attenuated influenza vaccine (FluMist) should not be used during the 2016-2017 influenza season Both trivalent (three-component) and quadrivalent (four-component) flu vaccines will be available Precaution in severe egg allergy other than hives, e.g., angioedema, respiratory distress, lightheadedness, emesis, reaction requiring epinephrine or other emergency medical intervention (may be administered in an inpatient or outpatient medical setting under the supervision of a health care provider) Recent studies show FluMist had lower than expected effectiveness to H1N1 strains during 2013-2016 flu seasons.

Talking to your patients9 COMMUNICATION IS KEY Give strong recommendation to vaccinate Encourage and be open to questioning Educate on importance of vaccines, even for diseases that most may be unfamiliar with “Autism is a burden for many families, but well designed and conducted studies that I can share with you show that MMR vaccine is not a cause of autism.” “There’s no proven danger in getting all the recommended 2-month vaccines today. Any time you delay a vaccine you leave your baby vulnerable to disease so it is best to stay on schedule. If you’re uncomfortable, we can give some vaccines today and schedule you to come back in two weeks for the rest, however this is not recommended.” https://www.cdc.gov/vaccines/hcp/conversations/conv-materials.html Evidence shows giving a strong recommendation to vaccinate increases vaccination rates. Communication manner should be not “directing” but should be an open dialogue acknowledging, without minimizing parental concerns.

resources 1. Community Immunity ("Herd Immunity"). (n.d.). Retrieved July 30, 2017, from https://www.vaccines.gov/basics/protection/index.html 2. Contraindications and Precautions. (n.d.). Retrieved July 31, 2017, from https://www.cdc.gov/vaccines/hcp/acip-recs/general-recs/contraindications.html 3. Diphtheria. (n.d.). Retrieved July 30, 2017, from https://www.historyofvaccines.org/content/articles/diphtheria 4. History of Vaccines. (n.d.). Retrieved July 30, 2017, from https://www.historyofvaccines.org/gallery?field_timeline_categories_target_id%5B%5D=51  5. Immunity Types. (n.d.). Retrieved July 30, 2017, from https://www.cdc.gov/vaccines/vac-gen/immunity-types.htm  6. Janeway CA Jr, Travers P, Walport M, et al.(2001). Immunobiology: The Immune System in Health and Disease (5th ed.). New York: Garland Science. Retrieved July 30, 2017, from https://www.ncbi.nlm.nih.gov/books/NBK10762/.  7. Pertussis Surveillance and Reporting. (n.d.). Retrieved July 30, 2017, from https://www.cdc.gov/pertussis/surv-reporting.html  8. Recommended Immunization Schedule for Children and Adolescents Aged 18 Years or Younger, UNITED STATES, 2017. (n.d.). Retrieved August 1, 2017, from https://www.cdc.gov/vaccines/schedules/downloads/child/0-18yrs-child-combined-schedule.pdf 9. Talking to Parents about Vaccines. (n.d.). Retrieved August 1, 2017, from https://www.cdc.gov/vaccines/hcp/conversations/conv-materials.html 10. Types of Vaccines. (n.d.). Retrieved July 30, 2017, from https://www.vaccines.gov/basics/types/index.html 11. Six common misconceptions about immunization. (n.d.). Retrieved July 30, 2017, from http://www.who.int/vaccine_safety/initiative/detection/immunization_misconceptions/en/