1. Adolescent and Adult ACIP Update
Immunization Coordinators Meeting
May 10, 2012

2. Overview Adult ACIP Updates Adult and Adolescent ACIP Updates
Hepatitis B vaccine for adults with diabetes
Adult and Adolescent ACIP Updates
Tdap Recommendations
Quadrivalent HPV vaccine for males
Adolescent ACIP Update
ACIP MCV4 for Adolescents
Pertussis Booster Requirement
Adolescent Immunization Data
Hello everyone. Before we start our discussion about specific partnerships, I want to highlight changes in adolescent and adult iz recommendationda.

3. Adults with Diabetes and Hepatitis B

4. Background
Since 1996, 25 of 29 outbreaks of hepatitis B infection in long-term care facilities were reported to CDC involving adults with diabetes receiving assisted blood glucose monitoring
Infection control initiatives alone have not been successful in halting outbreaks
Hepatitis B virus is environmentally stable and easily transmissible through percutaneous exposure
Hepatitis vaccines work group of ACIP to evaluate risk for HBV among those with diabetes.
Hepatitis B vaccine is safe in general population and LTC residents but issue with declining seroprotection with age.
Increased risk in general population of those with diabetes and appears to be associated with assisted blood glucose monitoring
Risk estimate for those in LTC not available but outbreaks suggest that it could be substantial.

5. Hepatitis B Vaccine Safety and Efficacy
Hepatitis B vaccination appears safe at any age but is less efficacious and less-cost effective among older adults.
Decision by treating clinician based on patient’s likelihood of acquiring hepatitis B infection, including risk by need for assisted blood-glucose monitoring in LTC facilities, likelihood of chronic sequelae of hepatitis B infection and the declining immunologic response.
Hepatitis B vaccine appears safe after review of studies in the general population and long term care residents
Concern about declining seroconversion after the hepatitis B vaccine series with increasing age

6. ACIP Recommendations: Hepatitis B Vaccine and Adults with Diabetes
Hepatitis B vaccination should be administered to unvaccinated adults with diabetes who are aged 19 through 59 years of age.
Complete series as soon as feasible after diagnosis.
Hepatitis B vaccination may be administered to unvaccinated adults with diabetes who are ≥ 60 years of age at the discretion of the treating clinician.
Assessing their risk and the likelihood of an adequate immune response to vaccination
Seroprotection remains high in the majority of adults to age 60 years
• Younger age, fewer co-morbidities
– Vaccination soon after diabetes diagnosis maximizes protection
• Fewer adults ≥60 years fully protected
• No special safety concerns
For 19 through 59 years: Recommendation category A: evidence type 2.
For 60 years and older: Recommendation category B; evidence type 2.
2009–2010 from eight Emerging Infections Program (EIP) sites constituting approximately 17% of the U.S. population. The analysis was restricted to persons aged ≥23 years because of high rates of vaccination among younger persons. In multivariate analyses that considered persons without hepatitis B–related risk behaviors (i.e., injection-drug use, male sex with a male, and sex with multiple partners), persons aged 23 through 59 years with diabetes had 2.1 (95% confidence interval [CI] = 1.6–2.8) times the odds of developing acute hepatitis B as those without diabetes; the odds were 1.5 (CI = 0.9–2.5) times as likely for persons aged ≥60 years. The annual incidence of reported cases of acute HBV infection among adults with diabetes was 1.8 per 100,000 (CI = 1.5–2.2) (2). Acute HBV infection incidence is underestimated; an additional 10.5 new cases of infection likely occurred for each reported, confirmed case (3).
Data for the period 1999–2010 from the National Health and Nutrition Examination Survey (NHANES), a nationally representative sample of the noninstitutionalized U.S. population, indicated a 60% (p<0.001) higher seroprevalence of antibody to hepatitis B core antigen (indicative of past or present HBV infection) overall among persons aged ≥18 years with diagnosed diabetes compared with those without diabetes. Stratified by age, the estimated prevalence ratios were 1.7 (CI = 1.3–2.2) for persons aged 18 through 59 years and 1.3 (CI = 1.0–1.6) for those aged ≥60 years (CDC, unpublished data, 2011).
In 2008, 2/3 of adult diabetes diagnoses were made before age 60 years; median age 53 years.
Recommendation category A: a recommendation that applies to all persons in an age or risk-based group
Recommendation category B: a recommendation for individual clinical decision making
Evidence type 1: randomized controlled trials, or overwhelming evidence from observational studies
Evidence type 2: randomized controlled trials with important limitations, or exceptionally strong evidence from observational studeies.
Evidence type 3: observational studies, or randomized controlled trials with notable limitations.
Evidence type 4: clinical experience and observations, observational studies with important limitations, or randomized controlled trials with several major limitations.
incorporate consideration of the patient’s likelihood of acquiring HBV infection, including the risk posed by an increased need for assisted blood-glucose monitoring in LTC facilities, the likelihood of experiencing chronic sequelae if infected with HBV, and the declining immunologic responses to vaccines that are associated with frailty.
MMWR. December 23, 2011; 60 (50):

7. HPV Vaccine

8. Updated ACIP Recommendations: Quadrivalent HPV Vaccine (HPV4) for Males
ACIP recommends routine vaccination of males aged 11 or 12 years with a 3 dose series of HPV4.
The vaccination series can be started beginning at age 9 years.
MMWR. December 23, 2011; 60 (50):

9. Updated ACIP Recommendations: Quadrivalent HPV Vaccine for Males
HPV4 vaccination is recommended for males aged 13 through 21 years who have not been vaccinated previously or who have not completed the 3-dose series.
HPV4 vaccination is recommended for men who have sex with men (MSM) and immunocompromised males who are aged 22 through 26 years who haven’t been vaccinated previously or who have not completed the 3-dose series.
Other males aged 22 through 26 years may also be vaccinated.

10. VFC Eligibility: HPV Vaccine
For VFC-eligible patients:
Gender
Age
Bivalent HPV Vaccine
Quadrivalent HPV Vaccine
Females
9 through 18 years
Eligible
Males
Not Eligible

11. Meningococcal Conjugate Vaccine (MCV4)

12. ACIP Recommendations: Meningococcal Conjugate Vaccine Booster
Routine immunization age at 11 – 12 years
Booster dose recommended at age 16 years for those who received a dose at age 11 through 12 years
If vaccinated at age 13 through 15 years, they should receive a one-time booster at age 16 through 18 years
Routine vaccination of healthy (non-high risk) persons is not recommended after age 21 years

13. ACIP Recommendations: Meningococcal Conjugate Vaccine
MCV4 is recommended for high-risk persons ages 9 months through 55 years
Two-Dose MCV4 Primary Series is recommended for persons:
9 through 23 months of age
Who have functional or anatomic asplenia, persistent complement deficiency or who are HIV positive (with an indication for MCV4 vaccination)
If primary series 9 through 23 months, then two doses 3 months apart
2 years and older and 2 dose primary, 2 months apart.
Wait until age 2 years for persons with asplenia due to concern of interference with PCV13 (and at least 4 weeks after completion of PCV13 series).

14. ACIP Updated Tdap Recommendations

15. ACIP Recommendations: Tdap
Adolescents should routinely receive a dose of Tdap at age years.
All adolescents through age 18 years should receive a dose of Tdap if they have not yet received Tdap.

16. ACIP Recommendations: Tdap
Children age 7 through 10 years who are not fully vaccinated against pertussis and who don’t have a contraindication, should receive Tdap for pertussis protection.
Guidance on use of Tdap products for adults aged 65 years and older
Providers should not miss an opportunity to vaccinate persons aged 65 years and older with Tdap, and may administer the vaccine that they have available.
When feasible, for adults aged 65 years and older, Boostrix should be used; however, either vaccine product administered to a person aged 65 years and older provides protection and is considered valid.

17. ACIP Recommendations: Tdap
For adults aged 19 years and older who previously have not received a dose of Tdap, a single dose of Tdap should be given.   
Includes persons 65 years and older
Tdap should be administered regardless of interval since the last tetanus or diphtheria toxoid-containing vaccine. 
Adults should receive a Tdap dose if the dose is recommended and no record of previous administration exists.
Guidance on use of Tdap products for adults aged 65 years and older
Providers should not miss an opportunity to vaccinate persons aged 65 years and older with Tdap, and may administer the vaccine that they have available.
When feasible, for adults aged 65 years and older, Boostrix should be used; however, either vaccine product administered to a person aged 65 years and older provides protection and is considered valid.

18. ACIP Recommendations: Tdap
Pregnant females who have not previously received Tdap should receive a dose of Tdap, preferably after 20 weeks gestation.
If not administered during pregnancy, Tdap can be administered immediately postpartum.
Tdap may be given at any time after a prior dose of Td to provide pertussis protection. There is no minimum interval.   

19. Adolescent Immunizations and Pertussis Booster Requirement

20. Pertussis Booster Requirement
Thanks for your work to implement the pertussis booster requirement for 7th -12th grades for
Starting and annually thereafter, the requirement for a pertussis booster (Tdap) for all students before admission to 7th grade will continue.
Remind parents and providers to immunize their 6th graders now!

21. Pertussis Booster Requirement Tools for Schools and Providers www
Pertussis Booster Requirement Tools for Schools and Providers

23. Recommended Immunizations and Preventive Health Care
Preteen Health Visit
Visit early during 6th grade school year
Avoid a back-to-school rush during summertime
Can provide early documentation to schools
All recommended immunizations—Tdap, MCV4, HPV, influenza
Catch-up immunizations—2 varicella, 3 hep B, 2 MMR, etc.
Recommended preventive care

24. National Immunization Survey Teen, 13-17 Years, California – 2009 and 2010
Vaccine
Rate 2009
Rate 2010
1 Tdap
53.1% ( )
71.2% ( )
1 MCV4
58.4% ( )
66.7% ( )
1 HPV
49.2% ( )
56.1% ( )
3 HPV
21.8% ( )
32.0% ( )
2 MMR
87.2% ( )
87.9% ( )
3 Hep B
89.6% ( )
89.0% ( )
VAR disease
40.0% ( )
40.1% ( )
1 VAR*
88.0% ( )
90.8% ( )
2 VAR*
56.9% ( )
57.3% ( )
Disease or 2 VAR
74.1% ( )
74.4% ( )
Influenza** -
54.0% ( )
*If no disease
**6 mos –17 years
Interim results
thru Feb 2011
( ) 24

25. Completed HPV series*§
National Immunization Survey Teen, Recommended Adolescent Immunization by Age (13-17 Years) -- U.S
13 years
14 years
15 years
16 years
17 years
Tdap
73.7%
( )
77.2%
( )
72.0%
( )
65.4%
( )
54.6%
( )
MCV4
63.8%
( )
66.6%
( )
64.0%
( )
61.8%
( )
57.1%
( )
1 HPV*
38.9%
( )
48.5%
( )
51.1%
( )
51.7%
( )
53.1%
( )
3 HPV*
23.2%
( )
30.5%
( )
31.9%
( )
36.9%
( )
37.5%
( )
Completed HPV series*§
64.1%
( )
68.2%
( )
65.6%
( )
74.3%
( )
74.6%
( )
Note that most preteen vaccines with highest rates at the younger age (due to recent implementation/recommendations) EXCEPT FOR HPV vaccine. Remember it is a preventive vaccine so should be given PRIOR to sexual activity.
*Females only
§For those who had at least 24 weeks between first dose and interview

26. Source: Unpublished Behavioral Risk Factor Surveillance System, 2010
Vaccine coverage for specific vaccines recommended for adults- 2007, 2010
Vaccination
Age groups CA US
Influenza
18-49 yrs
50-64 yrs
65+ yrs
22.3% (21.0% %)
36.0% (34.3% %)
57.6% (55.8% %)
30.5% (29.9% %)
44.5% (43.9% %)
66.6% (66.0% %)
Pneumococcal, ever (2010)
18-64 yrs (HR)
55.5% (53.7% %)
32.8% (27.1% %)
65.6% (62.6% %)
Tetanus in past 10 yrs
65+
62.3% (59.8% %)
63.0% (60.2% %)
54.3% (51.5% %)
57.2% (54.0% %)
57.2% (53.8% %)
44.1% (40.7% %)
Tdap in past 2 yrs
18-64 yrs
2.1% (1.5% - 2.9%)
Source: Unpublished Behavioral Risk Factor Surveillance System, 2010
National Health Interview Survey, 2007

27. Source: Unpublished Behavioral Risk Factor Surveillance System, 2010
Vaccine coverage for specific vaccines recommended for adults- 2007, 2010
Vaccination
Age groups CA US
Zoster/shingles
60+ yrs
---
0.8% (0.3% - 1.8%)
1.9% (1.3% - 2.8%)
Hep A 2+ doses, ever
18-49 yrs
12.1% (9.8% %)
Hep B 3+ doses, ever
23.4% (20.5% %)
HPV 1+ doses, ever
18-26 yrs, females
9.9% (4.9% %)
Source: Unpublished Behavioral Risk Factor Surveillance System, 2010
National Health Interview Survey, 2007

28. Questions?