Adolescent Immunization Update William L. Atkinson, MD, MPH National Center for Immunization and Respiratory Diseases

Adolescence Derived from Latin verb adolescere, "to grow into adulthood" Merriam-Webster: period of life from puberty to maturity terminating legally at the age of majority Defined by Society of Adolescent Medicine as 10-19 years of age

Vaccines Adolescents May Need MMR Varicella Hepatitis B Others depending on circumstances, medical conditions Pertussis (Tdap) Human Papillomavirus Meningococcal (MCV) Annual influenza

Pertussis—United States, 1980-2007* Tdap approved *2007 provisional data

Pertussis in the United States >25,000 cases reported in 2004 and 2005 >7,000 reported cases among both adolescents and adults Most severe disease and deaths among children 6 months and younger Source of infection of infants often an older child or adult MMWR 2006;55(RR-3):1-43. Although this recommendation is not new, Tdap coverage is only 56% among adolescents & <6% among adults. MMWR 2010;59;1018—23.; MMWR 2010;59:1302--6.

Pertussis Deaths - US, 2004-2006 Age at onset <3 mos 24 32 13 69 (84%) >3 mos 3 7 13 (16%) Total 27 39 16 82 2004 2005 2006 Total CDC, unpublished data, 2007

Updated Tdap Recommendations SEE http://www.cdc.gov/mmwr/preview/mmwrhtml/ mm6001a4.htm?s_cid=mm6001a4_w ACIP recommends one Tdap dose for Persons aged 11 through 18 years who have completed the recommended childhood DTP/DTaP vaccination series and Adults aged 19 through 64 years

Td and Tdap Minimum Intervals Tdap should be administered regardless of interval since the last tetanus or diphtheria toxoid-containing vaccine. Longer intervals between Td and Tdap vaccination could decrease the occurrence of local reactions, but the benefits of protection against pertussis outweigh the potential risk for adverse events.

HPV http://www.vaccineinformation.org/video/hpv.asp Heather Burcham, a 31-year-old woman from Austin, Texas, suffered from cervical cancer and became a national spokesperson and advocate for human papillomavirus (HPV) vaccination. In her video (link shown below), recorded two months before her death, she urges young women to get the HPV vaccine. http://www.vaccineinformation.org/video/hpv.asp

Cervical Cancer Disease Burden in the United States The National Cancer Institute estimates that in 2008 11,070 new cervical cancer cases 3,870 cervical cancer deaths Almost 100% of these cervical cancer cases will be caused by one of the 40 HPV types that infect the mucosa www.cancer.gov/cancertopics/types/cervical/

Cumulative Incidence of Any HPV Infection Months after sexual initiation 4 years, > 50% This is the best data showing that HPV infection is acquired soon after sexual debut. This is a study in which young college women were followed after sexual initation, and were followed for months and tested for HPV infection. The probability of incident HPV infection increased months after sexual debut, and by 4 years after Sexual intercourse, over 50% of these young women were likely to have infection Winer: Am J Epidemiol, 2003;157

HPV Vaccine Efficacy Among 16-26 Year Old Female Endpoint Efficacy HPV 16/18-related CIN 2/3 or AIS 100% HPV 6/11/16/18-related CIN 95% HPV 6/11/16/18-related genital warts 99% CIN=cervical intraepithelial neoplasia AIS=adenocarcinoma in situ Mao C, Koutsky LA, Ault KA, et al. Obstet Gynecol 2006;107:18--27. Villa LL, Costa RL, Petta CA, et al. Lancet Oncol 2005;6:271--8. Villa LL, Ault KA, Giuliano AR, et al. Vaccine 2006;24:5571--83. Villa LL, Costa RL, Petta CA, et al. Br J Cancer 2006;95:1459--66. Food and Drug Administration. Product approval information---licensing action [package insert]. Gardasil (quadrivalent human papillomavirus types 6,11,16,18). Merck & Co., Whitehouse Station, NJ. Available at http://www.fda.gov/cber/label/HPVmer060806LB.pdf.

Human Papillomavirus Vaccine High efficacy among females without evidence of infection with vaccine HPV types No evidence HPV vaccine had efficacy against existing disease or infection (i.e., it is not therapeutic) Prior infection with one HPV type did not diminish efficacy of the vaccine against other vaccine HPV types

HPV Route, Age, Schedule Intramuscular injection in the deltoid Age Minimum age is 9 years Maximum age is 26 years (may complete series after age 27 if begun before age 27) Schedule Routine schedule is 0, 1-2, 6 months Minimum intervals are the same as routine Use recommended routine dosing intervals for series catch-up (i.e., the second and third doses should be administered at 1 to 2 and 6 months after the first dose).The minimum interval between the first and second doses is 4 weeks.The minimum interval between the second and third doses is 12 weeks, and the third dose should be administered at least 24 weeks after the first dose. Catch-up Immunization Schedule for Persons Aged 4 Months Through 18 Years Who Start Late or Who Are More Than 1 Month Behind—United States • 2011. www.cdc.gov/vaccines

HPV Minimum Intervals Between doses Minimum in weeks 1-2 2-3 1-3 4 (approx 1 mo) 2-3 12 (approx 4 mos) 1-3 24 (approx 6 mos) Catch-up Immunization Schedule for Persons Aged 4 Months Through 18 Years Who Start Late or Who Are More Than 1 Month Behind—United States • 2011. www.cdc.gov/vaccines

HPV Vaccine Interval Violations If the 3-dose series was administered in <24 weeks but at least 16 weeks do not repeat* in <16 weeks repeat 3rd dose at least 12 weeks after the invalid dose *if minimum intervals between doses were observed

HPV Vaccine Interval Violations There is no MAXIMUM interval between HPV vaccine doses If the interval between doses is longer than recommended you should just continue the series where it was interrupted

HPV Vaccine Duration of Immunity The duration of immunity after a complete 3-dose schedule is not known Available evidence indicates protection for at least 5 years Multiple cohort studies are in progress to monitor the duration of immunity

HPV Vaccine and Syncope Increase in # of reports of syncope has been detected by the Vaccine Adverse Event Reporting System (VAERS) Most reported syncope episodes are from adolescent females, many of which received HPV vaccine Clinicians who vaccinate adolescents are advised to have patient seated, and consider a 15-20 minute observation period after vaccination MMWR 2008;57(No. 17):457-60

Cervical Cancer Screening Cervical cancer screening – no change 30% of cervical cancers caused by HPV types not prevented by the quadrivalent HPV vaccine Vaccinated females could subsequently be infected with non-vaccine HPV types Sexually active females could have been infected prior to vaccination Providers should educate women about the importance of cervical cancer screening

Meningococcal Conjugate Vaccine Four-month-old female with gangrene of hand due to meningococcemia Source: Centers for Disease Control and Prevention For more images, see http://www.immunize.org/photos/meningococcal-photos.asp

Rates of Meningococcal Disease Rates of Meningococcal Disease* by Age, 11-30 y/o, United States, 1991-2002 * Serogroups A/C/Y/W135 U.S. Rate CDC Unpublished data. ABCs: Active Bacterial Core surveillance NETSS: National Electronic Telecommunications System for Surveillance

Revised Meningococcal Vaccine Recommendations Revised recommendation to include routine vaccination of all unvaccinated persons 11 through 18 years of age with 1 dose of MCV at the earliest opportunity Reiterated routine vaccination of 11-12 year olds and persons 19-55 years at increased risk of meningococcal disease (including college freshmen living in a dormitory) MMWR 2007;56(No. 31):794-5

Meningococcal Conjugate Vaccine Routine Recommendations (2011) 1 dose at age 11 through 12 years + a booster dose at age 16 years. 1 dose at age 13 through 18 years if not previously vaccinated. 1st dose at age 13 through 15 years -- should get a one-time booster given 5 years after the 1st dose, up to age 21 years 1st dose at age after age 15 years – no booster 1 dose to previously unvaccinated college freshmen living in a dormitory. At its February 2005 meeting the Advisory Committee on Immunization Practices voted to recommend routine meningococcal vaccination for several other groups. Meningococcal conjugate vaccine is recommended for all persons at their preadolescent visit, which should occur at ages 11 or 12 years. This is also the time when most children should receive their first TD booster dose. In order to produce a more rapid reduction of meningococcal disease among adolescents ACIP also recommended that for the next 2 to 3 years teens about to enter high school also be vaccinated, at about age 15 years. College freshmen living in a dormitory should be routinely vaccinated because of their increased risk of invasive disease. Other adolescents who wish to reduce their risk for meningococcal disease may elect to receive vaccine. MCV is preferred for all these groups. Recommended Immunization Schedule for Persons Aged 7 Through 18 Years—United States • 2011. www.cdc.gov/vaccines

Meningococcal Conjugate Vaccine and Guillain-Barré Syndrome (GBS) 25 confirmed case reports* of GBS within 6 weeks after receipt of MCV vaccine 20 of the reports are in persons 15-19 years of age Available data cannot determine if MCV increases the risk of GBS No change in recommendations except that persons with a history of GBS who are not in a high risk group for invasive meningococcal disease should not receive MCV *As of December 31, 2007. CDC unpublished data