Combination Vaccines
Partners in Prevention Coalition of Dodge
County and City of Watertown
Spring 2014
Betsy Peterson, MD
Objectives
• Identify common combination
vaccines used in practice
• Understand indications and
contraindications to combinations
• Understand differences in schedules
when patients have had combination
vaccines
Combination Vaccines
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)
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
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**
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”
Pentacel –
- DTaP
- HiB
- IPV
Given at –
- 2mo
- 4mo
- 6mo
- 15mo
*** Baby will get the 4th dose of IPV (polio) at 15mo,
But still needs a dose after 4th birthday. ***
HiB options
• Pedvax Hib (Merck) – 3 doses at 2mo, 4mo, 1215mo
• ActHib (Sanofi) – 4 doses at 2mo, 4mo, 6mo, 1215mo
• Pentacel (Sanofi) – 4 doses at 2mo, 4mo, 6mo, 1215mo
• Hiberix (GSK) – 12-15mo booster dose only
• ComVax (Merck) – includes Hep B, 3 doses at 2mo,
4mo, 12-15mo
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)
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
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
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
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
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)
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”
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
Why Combo vaccines?
• Less pokes!
• If no combo vaccines were used
(when available) –
–
–
–
–
–
DTaP 5 doses
Polio 4 doses
HiB 3-4 doses
Hep B 3 doses
Prevnar 4 doses
- MMR 2 doses
- Varicella 2 doses
- Hep A 2 doses
- Influenza 6 doses*
28-32 injections by age 5!
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
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.
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
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)
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!
Pentacel
• Pentacel – one vial is DTaP-polio, 2nd
vial is Hib – NEED BOTH!
• Missing component needs to be
repeated - wrong diluent (repeat
both) vs. only gave liquid
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
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.
Questions?