1. Combination Vaccines Partners in Prevention Coalition of Dodge County and City of Watertown Spring 2014 Betsy Peterson, MD

2. Objectives Identify common combination vaccines used in practice Understand indications and contraindications to combinations Understand differences in schedules when patients have had combination vaccines

4. Combination Vaccines

9. Infant Vaccines 2mo, 4mo, 6mo: –DTaP = Diphtheria, Tetanus, Pertussis (no available individual vaccines) –IPV = Polio –Hep B = Hepatitis B –HiB-OMP (Pedvax HiB, 3 doses) OR HiB-PRPT (ActHib, 4 doses) = Hemophilus influenza, Type B –Prevnar 13 = Pneumococcus, 13 serotypes –RV5 = Rotateq (5 serotypes, 3 doses) OR RV1 = Rotarix (1 serotype, 2 doses)

10. DTaP Daptacel – Sanofi, 6wk to <7yr Infanrix – GSK, 6wk to <7yr Pediarix – also includes IPV, Hep B; GSK, 6wk to <7yr Pentacel – also includes IPV, HiB; Sanofi, 6wk to <7yr Kinrix – also includes IPV; GSK, 4yr to <7yr

11. Tdap Boostrix – GSK, single dose*, 10yr “and older” Adacel – Sanofi, single dose*, 10yr to 64yr **off-label used for 7-10yr if previously undervaccinated; off label for use with each pregnancy**

12. Pediarix – - Hep B - DTaP - IPV Given at – - 2mo - 4mo - 6mo ** Baby will get 4 doses of Hep B, which is acceptable. MUST have 16 weeks between dose 1 and 3 (or 4) AND be At Least 24 weeks old for dose 3 (or 4). **Dose 3 of 4 is marked “invalid”

13. Pentacel – - DTaP - HiB - IPV Given at – - 2mo - 4mo - 6mo - 15mo *** Baby will get the 4 th dose of IPV (polio) at 15mo, But still needs a dose after 4 th birthday. ***

14. HiB options Pedvax Hib (Merck) – 3 doses at 2mo, 4mo, 12- 15mo ActHib (Sanofi) – 4 doses at 2mo, 4mo, 6mo, 12- 15mo Pentacel (Sanofi) – 4 doses at 2mo, 4mo, 6mo, 12- 15mo Hiberix (GSK) – 12-15mo booster dose only ComVax (Merck) – includes Hep B, 3 doses at 2mo, 4mo, 12-15mo

15. An aside about buying groups… Vaccines are expensive Buying groups allow offices or companies to save significant money by agreeing to purchase certain types of vaccines Examples – –GSK “when available” (Pediarix, Rotarix, Havrix, Kinrix, Boostrix), choose a Hib brand. –Merck/Sanofi “when available” (Pentacel, Rotateq, ActHib OR PedvaxHib, Adacel, Vaqta)

16. Sample Pediarix schedule Birth – Hep B 2mo – Pediarix (DTaP-Hep B-IPV), Prevnar 13, Hib-OMP, Rotarix 4mo – Pediarix, Prevnar 13, Hib-OMP, Rotarix 6mo – Pediarix, Prevnar 13 15mo – Infanrix (DTaP), Hib-OMP

17. Sample Pentacel schedule Birth – Hep B 2mo – Pentacel (DTaP-HiB-IPV), Prevnar 13, Hep B, Rotateq 4mo – Pentacel, Prevnar 13, Rotateq 6mo – Pentacel, Prevnar 13, Hep B, Rotateq 15mo - Pentacel

18. But what about…? Shortages Kids who move/transfer to a different clinic Occasionally clinics will have certain combo vaccines for private vs. VFC When your office is changing from one combo to another

19. Kindergarten age Due for – –DTaP (#5) – Infanrix, Daptacel, or Kinrix (DTaP-IPV) –IPV (#4) – IPOL or Kinrix –MMR (#2) – MMRII or Proquad –Varicella (#2) – Varivax or Proquad

20. MMR and Varicella – Separate** or as Proquad DTaP and IPV – Separate or as Kinrix ***MMR and Varicella (and FluMist) can be given – On the same day, or separated by 28 days (4wk)

22. ComVax HiB plus Hep B – Merck, 3 doses 2mo, 4mo, 12-15mo Less common with Pediarix and Pentacel, but may appear on historical records Discontinued production, off VFC 4/1/14, private “early 2015”

23. TwinRix Hep A and Hep B – GSK, 3 doses For 18 years and older Given as 0, 1 and 6mo doses For adults who have not completed either Hep A or Hep B series

24. Why Combo vaccines? Less pokes! If no combo vaccines were used (when available) – –DTaP 5 doses - MMR 2 doses –Polio 4 doses - Varicella 2 doses –HiB 3-4 doses - Hep A 2 doses –Hep B 3 doses - Influenza 6 doses* –Prevnar 4 doses 28-32 injections by age 5!

25. Why Combo vaccines? At 2, 4, 6mo – 2-3 injections vs. 5 each visit (plus one for flu at 6mo) At kindergarten – 2-3 instead of 4! 20-24 injections (vs. 28-32) by age 5

26. Why not Combo vaccines? Immunization administration fees have classically been “per injection” –More pokes = more money Now <19yr has administration codes for “per component, with counseling” –Pediarix = 5 components, DTaP = 3 components, HiB = 1 component, etc.

27. What about safety? Immunizations are very closely regulated and monitored for safety –ProQuad has an advisory of slightly increased risk of febrile seizures when given at 12-23mo compared to MMR and Varicella given separately on the same day at 12-23mo. No difference seen with the booster dose. 1 additional febrile seizure at 5-12 days after vaccination Per 2500 infants vaccinated; 7-8/10,000 vs. 3-4/10,000

28. Historical/Future Combos TriHibit – DTaP and HiB-PRP – Sanofi, discontinued 2011 (Pentacel) Hexaxim – DTaP-IPV-Hep B-HiB – Sanofi, approved for WHO use outside US and Europe (no reconstitution required)

30. A note about errors… Double check – the components, age (<7?), minimum intervals, right patient, route of admin (IM/SQ), dilution liquid, storage, lot numbers Computers are good, but not perfect – if it doesn’t match up or gives an error message, ASK!

31. Pentacel Pentacel – one vial is DTaP-polio, 2 nd vial is Hib – NEED BOTH! Missing component needs to be repeated - wrong diluent (repeat both) vs. only gave liquid

32. ProQuad MMR-V contains varicella, so needs to be in the freezer – pay attention to what the shipping container says! MMR and varicella and ProQuad are given sub-Q, not IM

33. Kinrix Approved for 4-<7 years Dose does NOT need to be repeated if given outside of this range, counts as valid, but higher risk of side effects.

34. Questions?