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					  Immunizations

 Rodolfo E. Bégué, MD
Chief, Infectious Diseases
  Pediatrics, LSUHSC
  rbegue@lsuhsc.edu
 Edward Jenner
 (1749-1823)
 Smallpox (1796)
 Sarah Nelmes
 James Phipps
 Blossom
                 Immunizations

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

 Active immunizing agent
 Suspending fluid
 Preservatives (thimerosal)
 Antibiotics (neomycin, streptomycin, polymyxin B)
 Adjuvants (aluminum hydroxide, AS04)
 Stabilizers (Tween)
              Immunizing agents

 Live, attenuated organisms
 Killed, inactivated organisms
 Subparticle (proteins, polysaccharides)
                  Hepatitis B

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

 Diphtheria   toxoid       (protein)
 Tetanus       toxoid       (protein)
 Pertussis     acellular    (subparticle)
               whole cell   (killed)
                        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)
                       DTaP

 Common adverse reactions:
 fever, redness and swelling at site, fretfulness,
 anorexia, drowsiness
               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 oC within 48 hrs
 Vaccination might be deferred in children with
 progressive neurological disorder.
        Contraindications for DTaP

 Anaphylactic reactions
 Encephalopathy within 7 days.
               Polio vaccines

 Injectable   IPV
 Oral         OPV
          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)
         Inactivated Polio Vaccine

 Local reactions            10 %
 Low grade temperature      30 %
 Precautions/contraindications:
 allergy to any of the components of the vaccine
              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
                    Hib vaccine

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

 PCV-13
 PCV-7
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
   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
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.
            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%
                     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%
                      MMRV

 Increase risk of febrile seizures (1‰2 ‰)
 after 1st dose
 1st dose:       1) MMR + V      2) MMRV
 2nd dose:       1) MMRV         2) MMR + V
                  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 %)
                     Rotavirus Vaccines
 Rota Teq (MSD)                    Rotarix (GSK)
 February 2006                     April 2008
 Live vaccine                      Live vaccine
 Human-Bovine reassortant          Human
 Pentavalent (RV5): G1-G4, P[8]    Monovalent (RV1): G1, P[8]
 3 doses:                          2 doses:
  2, 4, 6 months                     2, 4 months
  1st dose: 6 w - <15 w,             1st dose: 6 w - <15 w,
  q 4 w - 10 w, <8 m                 q 4 w - 10 w, <8 m
 Efficacy: 74% (67, 80)            Efficacy: 73% (27, 91)
                 Influenza Vaccines

TIV                            LAIV

 Inactivated, split-virus      Live, cold-adapted
 Chick embryo                  Chick embryo
 Tri-valent (two A, one B),    Tri-valent (two A, one B),
  reformulated yearly            reformulated yearly

 IM, 1 or 2 doses              Intranasal, 1 or 2 doses
 All subjects 6 months and     Healthy, 2-49 years
  older
                   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
                          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 2nd or 3rd trimester during influenza season


                                                  AAP, COID, Pediatrics 2004;113:1441-1447
        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%)
                 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
                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
Age               Subgroup                                   Primary Vaccination               Booster Dose

9 through 23      Children with complement deficiencies;     Two doses of MCV4,                If first dose received at age 9months
months of                                                    three months apart                through 6 years and remain at increased
age, with high    Children with HIV, if another indication   Two doses of MCV4,                risk for meningococcal disease, should
risk conditions   for vaccination exists                     three months apart                receive an additional dose of MCV4 three
                  All others in this age group               Two doses of MCV4,                years after primary vaccination. Boosters
                                                                                               should be repeated every five years
                  recommended for vaccination (travelers     three months apart
                                                                                               thereafter.
                  to the Meningitis Belt, etc)               (infants receiving the vaccine
                                                             prior to travel can receive the   If first dose received at age 7 years or
                                                             doses as early as two months      older and remain at increased risk for
                                                             apart)                            meningococcal disease, should receive
                  Children with complement deficiencies;     Two doses of MCV4, two            an additional dose of MCV4 five years after
2 through 18
                                                                                               primary vaccination. Boosters should be
years of age,     functional or anatomic asplenia;           months apart
                                                                                               repeated every five years thereafter.
with high risk    Children with HIV, if another indication   Two doses of MCV4,
conditions        for vaccination exists                     two months apart
                  All others in this age group               Single dose of MCV4
                  recommended for vaccination (travelers
                  to the Meningitis Belt, etc)
All other                                                    Routine vaccination with MCV4     If vaccinated at age 11 through 12 years,
children 11-18                                               at ages 11 through 12 years       should receive a one-time booster dose at
years of age                                                                                   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
            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)
                       dTap

 Booster
 Adolescents (11-12 yr, 13-18 yr)
 GlaxoSmithKline (Boostrix)
 Sanofi Pasteur (Adacel)
               Special Situations

 Prematurity (HBV)
 Immune suppressed:
     self:             MMR, VZV
     family contact:   (OPV)
 Pregnancy: MMR, VZV
 Full doses
 Multiple vaccines
             Impact of Vaccinations
Disease            Maximum         2006       % decrease
Diphtheria          30,508           0             100
Measles             763,094         55            99.9
Mumps               212,932        6,584          96.9
Pertussis           265,269       15,632          94.1
Poliomyelitis       21,269           0             100
Rubella             488,796         11             100
 Congenital         20,000           1             100
Smallpox            110,672          0             100
Tetanus               601           41            93.1
Hepatitis A         254,518       15,298          94.0
Hepatitis B         74,361        13,169          82.3
Invasive Hib        20,000          <50           99.9
Invasive Pneumo     64,400        41,550          35.5
Varicella          5,358,595     612,768          88.6
                    Modified from Roush SW, et al. JAMA 2007;298:2155-2163
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