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Immunizations Rodolfo E. Bégué, MD Chief, Infectious Diseases Pediatrics, LSUHSC email@example.com 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 Monovalent (RV1): G1, P 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 QUESTIONS?
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