1. Immunizations Rodolfo E. Bégué, MD Chief, Infectious Diseases Pediatrics, LSUHSC rbegue@lsuhsc.edu

2.  Edward Jenner (1749-1823)  Smallpox (1796)  Sarah Nelmes  James Phipps  Blossom

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

6. Constituents in a vaccine  Active immunizing agent  Suspending fluid  Preservatives (thimerosal)  Antibiotics (neomycin, streptomycin, polymyxin B)  Adjuvants (aluminum hydroxide, AS04)  Stabilizers (Tween)

7. Immunizing agents  Live, attenuated organisms  Killed, inactivated organisms  Subparticle (proteins, polysaccharides)

8. Hepatitis B  Subparticle vaccine (HBsAg)  Recombinant  Aluminum hydroxide  IM, 3 doses:0, 1, 6 months 0, 2, 6 months  No boosters

9. Hepatitis B  Infants born to HBsAg(+) mothers in addition should receive HBIG 0.5 ml, IM, 1 dose  Injection site pain and low grade fever (1-6%) safe in pregnancy

10. DTaP  Diphtheriatoxoid (protein) Tetanus toxoid (protein) Pertussisacellular(subparticle) whole cell(killed)

11. DTaP  Detoxified in formaldehyde, aluminum, Tween, thimerosal, no antibiotics  IM, 0.5 mL  Primary series (3): 2, 4, 6 months Booster (2): 12-18 mo, 4-6 years  Efficacy 80%, lasts for ~ 3 years  Boosters q 10 years (Td)

12. DTaP  Common adverse reactions: fever, redness and swelling at site, fretfulness, anorexia, drowsiness

13. 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 o C within 48 hrs  Vaccination might be deferred in children with progressive neurological disorder.

14. Contraindications for DTaP  Anaphylactic reactions  Encephalopathy within 7 days.

15. Polio vaccines  InjectableIPV  OralOPV

16. 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 months Booster: 4-6 yrs  (1 adult booster for travelers)

17. Inactivated Polio Vaccine  Local reactions10 %  Low grade temperature30 %  Precautions/contraindications: allergy to any of the components of the vaccine

18. Live Polio Vaccine Vaccine Paralytic Polio:  1 every 3million doses 8-10 cases per year in the US type 3 more frequent (2, 1) usually after first dose 1/2 recipients, 1/2 contacts  Precaution: immune suppressed patients or contacts

19. Hib vaccine  Subparticle vaccines (PRP) conjugated with protein carrier.  Protein carrier allows for: T-cell dependent antigen Better immunogenicity (infants) Booster effect

20. 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.

21. Pneumococcal Conjugate Vaccine  PCV-13  PCV-7

22. 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

23. 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

24. 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.

25. 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%

26. 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%

27. MMRV  Increase risk of febrile seizures (1‰  2 ‰) after 1 st dose  1 st dose:1) MMR + V2) MMRV  2 nd dose:1) MMRV2) MMR + V

28. 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 %)

29. Rotavirus Vaccines Rota Teq (MSD)  February 2006  Live vaccine  Human-Bovine reassortant  Pentavalent (RV5): G1-G4, P[8]  3 doses: 2, 4, 6 months 1 st 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 months 1 st dose: 6 w - <15 w, q 4 w - 10 w, <8 m  Efficacy: 73% (27, 91)

30. 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

31. 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-older LAIV to healthy 2-49 yr MMWR 2010;vol 59, RR-8

32. Influenza Vaccine Specific Target Groups:  Children at risk of severe influenza disease: Asthma and other chronic pulmonary diseases (eg, CF) Hemodynamically significant cardiac disease Immunosuppresive disorders (congenital, acquired, Tx) Sickle cell and other hemoglobinopathies Long-term aspirin therapy (Kawasaki, JRA) Chronic renal dysfunction Chronic 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 2 nd or 3 rd trimester during influenza season AAP, COID, Pediatrics 2004;113:1441-1447

33. 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%)

34. HPV Vaccines  Gardasil (MSD): HPV4: 6, 11, 16, 18 Cervarix (GSK): HPV2: 16, 18  Gardasil: M/F; Cervarix: F  11-12 years, 9-26 years  IM, 3 doses: 0, 1-2, 6 months

35. Meningococcal Vaccine Conjugate Vaccine (MCV4)  Menactra (Sanofi Pasteur)Menveo (Novartis)  A, C, Y, W-135 (B not included), 4  g each  Indications a) 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 booster b) 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

36. AgeSubgroupPrimary VaccinationBooster 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

37. 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)

38. dTap  Booster  Adolescents (11-12 yr, 13-18 yr)  GlaxoSmithKline (Boostrix) Sanofi Pasteur (Adacel)

39. Special Situations  Prematurity (HBV)  Immune suppressed: self: MMR, VZV family contact: (OPV)  Pregnancy: MMR, VZV  Full doses  Multiple vaccines

40. Impact of Vaccinations DiseaseMaximum2006% decrease Diphtheria30,5080100 Measles763,0945599.9 Mumps212,9326,58496.9 Pertussis265,26915,63294.1 Poliomyelitis21,2690100 Rubella488,79611100 Congenital20,0001100 Smallpox110,6720100 Tetanus6014193.1 Hepatitis A254,51815,29894.0 Hepatitis B74,36113,16982.3 Invasive Hib20,000<5099.9 Invasive Pneumo64,40041,55035.5 Varicella5,358,595612,76888.6 Modified from Roush SW, et al. JAMA 2007;298:2155-2163

42. QUESTIONS?