Vaccine Preventable Diseases-Why Worry
and What Is New: The Best Available
Evidence from The Centers for Disease
Control and Prevention 2015
Mary Koslap-Petraco DNP, PNP-BC, CPNP, FAANP
NAPNAP North Carolina chapter
22nd Annual Pediatric Nurse Practitioner Symposium
William and Ida Friday Center
Chapel Hill, NC
October 9, 2015
Disclosures
 Dr. Mary Koslap-Petraco has nothing to declare
Objectives
 Analyze the best available evidence for immunization practice
for children and adolescents
 Explain the science behind the most current immunization
recommendations for children and adolescents
 Change immunization practice in light of new evidence for
children
 Identify signs and symptoms of vaccine preventable diseases
that have recently recurred
So What Is New
 New columns to stress availability of inactivated influenza vaccine
and live-attenuated influenza vaccine starting at age 2 years
 Need for 2 doses of influenza vaccine for children 6 months to 8
years who receive influenza vaccine for the first time
 Children 9 years and older will need only 1 dose
 Children 6 months to 8 years who did not receive an H1N1
containing vaccine previously still need 2 doses of influenza vaccine
this year
 No preference for LAIV over IIV for children
So What is New
 For children 6 months to less than 12 months who are traveling
outside the U.S. a single dose of MMR vaccine is required
 Noted on the ACIP schedule by a purple bar
 Clarifying changes were made to the wording in the footnotes
for DTaP and pneumococcal vaccine
 Extensive revisions were made to the footnotes for
meningococcal vaccine to clarify appropriate dosing schedules
for high risk infants and children and for the use of different
vaccines
ACIP Recommendations
 This schedule includes recommendations in effect as of
January 1, 2015
 Any dose not administered at the recommended age
should be administered at a subsequent visit, when
indicated and feasible
 The use of a combination vaccine generally is preferred
over separate injections of its equivalent component
vaccines
 Vaccination providers should consult the relevant Advisory
Committee on Immunization Practices (ACIP) statement
for detailed recommendations, available online at
http://www.cdc.gov/vaccines/hcp/acip-recs/index.html.
Resources for Catch-up
 CDC has developed job aids for
 DTaP/Tdap/Td
 Hib
 PCV13
 Pneumococcal Conjugate Vaccine (PCV) Catch-Up Guidance for Children 4
Months through 18 Years of Age
 Haemophilus Influenzae type b-Containing Vaccines Catch-Up Guidance for
Children 4 Months through 18 Years of Age
 Hib Vaccine Products: ActHIB, Pentacel, MenHibRix, or Unknown
 Hib Vaccine Products: Pedvax and Comvax Vaccines Only
 Diphtheria, Tetanus, and Pertussis-Containing Vaccines Catch-Up Guidance
for Children 4 Months through 18 Years of Age
 http://www.cdc.gov/vaccines/schedules/hcp/child-adolescent.html
Pertussis
 Prolonged cough (3 months or longer)
 Post-tussive vomiting (pathognomonic in adults)
 Multiple medical visits and extensive medical evaluations
Pertussis Among
Adolescents
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Complications
Hospitalization
Medical costs
Missed school and work
Impact on public health system
Tdap/Td for Persons Without
Documentation of Pertussis
Vaccination
 Preferred schedule:
 0, 1, & 6 months
 Single dose of Tdap
 Td at least 4 weeks after the Tdap dose
 Second dose of Td at least 6 months after the prior Td dose
 For those who received 4 or 5 dose DTaP series Tdap is given at age
11-12 years
Case Study
 An 8 year old child received 4 doses of DTaP before
the 4th birthday. The child was given Td a week ago.
 Is this child appropriately immunized?
 What is your course of action?
Tdap and Pregnancy
 Updated recommendation:
 Tdap should be given during EACH pregnancy
 Preferred during 27-36 week of pregnancy
 Vaccinate during third trimester or late in second trimester
(after 20 weeks gestation)
 Vaccinating at this time maximizes transfer of antibodies to
baby to protect baby before baby is able to begin DTaP series
 Use Tdap for routine tetanus and diphtheria booster or
wound management if no prior Tdap dose
Case Study
 An 17 year old adolescent just delivered a baby. She
did not get Tdap during pregnancy. She received
Tdap 2 years ago.
 Is the adolescent appropriately immunized?
 What is your course of action?
DTaP
 Diphtheria and tetanus toxoids and acellular
pertussis vaccine (DTaP).
 The fourth dose may be administered as early as
age12 months, provided at least 6 months have
elapsed since the third dose.
Case Study
 A 9-year old child has received DTaP? What should you
do?
 A 6 year old child receives Tdap. What should you do?
HPV Vaccination Coverage
 Vaccination uptake has stalled
 Latest studies indicate that parents do not see need for HPV
vaccine
 Parents also question safety of vaccine after severe side
effects were reported by the press
 None of these reported side effects were found to be valid
 Nearly 50% of teen girls have begun HPV vaccine series
 Almost 1 in 3 does not complete vaccine series
 Only 1/3 of girls 13 through 17 years complete the 3-dose
series
Numbers of Cancers and Genital Warts
Attributed to HPV Infections, U.S.
CDC. Human papillomavirus (HPV)-associated cancers. Atlanta, GA: US Department of Health and Human
Services, CDC; 2013. Available at http://www.cdc.gov/cancer/hpv/statistics/cases.htm
HPV-Associated Cervical Cancer Incidence Rates
by State, United States, 2006-2010
www.cdc.gov/cancer/npcr
Rates of HPV-Associated Cancer and Median Age at
Diagnosis Among Females, United States, 2004–2008
*The vaginal cancer statistics for women between the ages of 20 and 39 is not shown because there were fewer than 16 cases.
Watson et al. Human papillomavirus-associated cancers—United States, 2004-2008. MMWR 2012;61:258-261.
ACIP Recommendation and
AAP Guidelines for HPV Vaccine
Routine HPV vaccination recommended for both
males and females ages 11-12 years
 Vaccine can be given starting at age 9 years of age for
both males and females; vaccine can be given ages 2226 years for males
 February 2015 ACIP recommended use of 9 valent
HPV vaccine
 No HPV boosters necessary beyond 3 dose series
(February, 2015)
CDC. Quadrivalent Human Papillomavirus Vaccine: Recommendations of ACIP. MMWR 2007;56(RR02):1-24.
HPV Vaccination Schedule
 ACIP Recommended schedule is 0, 1-2*, 6 months
 Following the recommended schedule is
preferred
 Minimum intervals
 4 weeks between doses 1 and 2
 12 weeks between doses 2 and 3
24 weeks between doses 1 and 3
 Administer IM
CDC. Quadrivalent Human Papillomavirus Vaccine: Recommendations of ACIP. MMWR 2007;56(RR02):1-24.
HPV Vaccine is an Anti-Cancer Vaccine
Reduction in prevalence of vaccine-type HPV by 56%
in girls age 14-19 with vaccination rate of just ~30%
Our low vaccination rates will lead to 50,000 girls
developing cervical cancer – that would be
prevented if we reach 80% vaccination rates
For every year we delay increasing vaccination rates
to this level, another 4,400 women will develop
cervical cancer
Markowitz et al. JID 2013;208:385-393. CDC unpublished model – H. Chesson et al - for girls in US <13 at present,
diff. betw 30% vs. 80% 3-dose coverage, lifetime cerv. ca. risk
HPV Vaccine Is Safe, Effective, and
Provides Lasting Protection
 HPV Vaccine is SAFE
 Safety studies findings for HPV vaccine similar to safety
reviews of MCV4 and Tdap vaccines
 HPV Vaccine WORKS
 High grade cervical lesions decline in Australia (80% of
school aged girls vaccinated)
 Prevalence of vaccine types declines by more than half in
United States (33% of teens fully vaccinated)
 HPV Vaccine LASTS
 Studies suggest that vaccine protection is long-lasting; no
evidence of waning immunity
Garland et al, Prev Med 2011; Ali et al, BMJ 2013; Markowitz JID 2013; Nsouli-Maktabi MSMR 2013
Inadvertent Administration
of HPV Vaccine during Pregnancy
 No safety concerns* raised by HPV4 in pregnancy registry
 CDC/FDA continue to monitor the safety of HPV vaccine, including
reports in pregnant women through VAERS
 A retrospective analysis of pregnancy-associated HPV4 VAERS reports is
in progress (2005-2012)
 >85% of reports were submitted from the Merck Pregnancy
Registry so anticipate a similar safety profile
 For VSD, descriptive data of adverse events following inadvertent
exposure to HPV4 during pregnancy by 2015
*death, life-threatening illness, hospitalization, prolongation of existing
hospitalization, persistent or significant disability, congenital malformations
HPV Vaccine
Duration of Immunity
 Studies suggest that vaccine protection is longlasting; no evidence of waning immunity
 Available evidence indicates protection for
at least 8-10 years
 Multiple cohort studies are in progress to
monitor the duration of immunity
Romanowski B. Long term protection against cervical infection with the human papillomavirus: review of
currently available vaccines. Hum Vaccin. 2011 Feb;7(2):161-9.
HPV Vaccine Impact:
HPV Prevalence Studies
 NHANES Study
 National Health and Nutrition Examination Survey (NHANES)
data used to compare HPV prevalence before the start of the
HPV vaccination program with prevalence from the first four
years after vaccine introduction
 In 14-19 year olds, vaccine-type HPV prevalence decreased 56
percent, from 11.5 percent in 2003-2006 to 5.1 percent in 20072010
 Other age groups did not show a statistically significant
difference over time
 The research showed that vaccine effectiveness for prevention
of infection was an estimated 82 percent
Cummings T, Zimet GD, Brown D, et al. Reduction of HPV infections through
vaccination among at-risk urban adolescents. Vaccine. 2012; 30:5496-5499.
HPV Vaccine Impact:
HPV Prevalence Studies, continued
 Clinic-Based Studies
 Significant decrease from 24.0% to 5.3% in HPV vaccine
type prevalence in at-risk sexually active females 14-17
years of age attending 3 urban primary care clinics from
1999-2005, compared to a similar group of women who
attended the same 3 clinics in 2010
 Significant declines in vaccine type HPV prevalence in
both vaccinated and unvaccinated women aged 13-26
years who attended primary care clinics from 2009-2010
compared to those from the pre-vaccine period (20062007)
Kahn JA, Brown DR, Ding L, et al. Vaccine-Type Human Papillomavirus and Evidence
of Herd Protection After Vaccine Introduction. Pediatrics. 2012; 130:249-56.
Impact of Bivalent HPV Vaccine
on Oral HPV Infection
 Of 7,466 women 18-25 years of age randomized to receive
HPV vaccine or hepatitis A vaccine, 5,840 provided oral
specimens at the final 4-year study visit
 Oral prevalence of identifiable mucosal HPV was relatively
low (1.7%)
 There were 15 HPV 16/18 infections in the hepatitis A
comparison group and 1 in the HPV vaccine group, for an
estimated vaccine efficacy of 93.3%
 These results suggest that the vaccine provides strong
protection against oral HPV 16/18 infection and may prevent
HPV 16/18-associated oropharyngeal cancers
Herrero R, et al. Reduced prevalence of oral human papillomavirus (HPV) 4 years after bivalent HPV vaccination in
a randomized clinical trial in Costa Rica. PLOS ONE 2013;8:e68329
31
Strong Start?
Adolescent Immunization Coverage, US 13-17 year olds
National Immunization Survey-Teen (NIS-Teen) 2006 vs. 2007
50
40
32.4
30.4
30
25.1
20
11.7
10
10.8
0
MCV4
Tdap
HPV (females
only)
CDC. National and State Vaccination Coverage Among Adolescents Aged 13–17 Years — United States, 2012
MMWR 2013; 62(34);685-693.
2006
2007
Impact of Eliminating Missed Opportunities
by Age 13 Years in Girls Born in 2000
Percent Vaccinated
100
80
60
91
40
20
47
0
HPV-1 (girls)
Vaccine
Missed opportunity: Healthcare encounter when some, but not all ACIP-recommended vaccines are given. HPV-1:
Receipt of at least one dose of HPV.
MMWR. 63(29);620-624.
Actual
Achievable
Evidence-based strategies to improve
vaccination coverage
 Reminder/recall system
 Provider level (e.g., EMR prompts)
 Parent/patient level (e.g., postcards, telephone calls,
text messaging)
 Standing orders
 Provider assessment and feedback
 Assessment of vaccination coverage levels within the
practice and discussion of strategies to improve vaccine
delivery
 Utilizing immunization information systems
www.thecommunityguide.org/vaccines/universally/index.html
Impact of Reminder/Recall on Vaccination
Rates among Adolescents
60
50
49.5*
40.8
*p<0.05
44.3*
Percent
40
29.5
30
Intervention
26.5*
Control
20
15.3
10
0
Tdap
MCV4
Vaccine
Suh C et al. Pediatrics 2012;129:e1437-45
HPV-1
Evidence-Based Messages
PARENTS SHOULD:
 Realize HPV vaccine is CANCER PREVENTION
 Understand HPV vaccine is best at 11- 12 years old
 Immune response is more robust when given at 11-12 years old
 Recognize importance of getting all 3 shots
HEALTHCARE PROFESSIONALS SHOULD:
 Be familiar with all of the indications for HPV vaccine
 Make strong recommendations for receiving vaccine at 11 or 12
 Be aware of, and interested in, systems that can improve practice
vaccination rates
HPV Vaccine Communications During the
Healthcare Encounter
 HPV vaccine is often presented as ‘optional’ whereas other
adolescent vaccines are recommended
 Some expressed mixed or negative opinions about the
‘new vaccine’ and concerns over safety/efficacy
 When parents expressed reluctance, providers were
hesitant to engage in discussion
 Some providers shared parents’ views that teen was not at
risk for HPV and could delay vaccination until older
Goff S et al. Vaccine 2011;10:7343-9
Hughes C et al. BMC Pediatrics 2011;11:74
Goff S et al. Vaccine 2011;10:7343-9
Hughes C et al. BMC Pediatrics 2011;11:74
What’s in a recommendation?
 Studies consistently show that a strong
recommendation from you is the single
best predictor of vaccination
 In focus groups and surveys with moms,
having a doctor recommend or not
recommend the vaccine was an important
factor in parents’ decision to vaccinate their
child with the HPV vaccine
 Not receiving a recommendation for HPV
vaccine was listed a barrier by mothers
Unpublished CDC data, 2013.
Just another adolescent vaccine
 Successful recommendations group all of the adolescent
vaccines
 Recommend the HPV vaccine series the same way you
recommend the other adolescent vaccines
 Moms in focus groups who had not received a provider’s
recommendation stated that they questioned why they had
not been told or if the vaccine was truly necessary
 Many parents responded that they trusted their child’s
provider and would get the vaccine for their child as long as
they received a recommendation from the provider
Unpublished CDC data, 2013.
Review
1.
Give a STRONG recommendation
 Ask yourself, how often do you get a chance to prevent cancer?
2.
Start conversation early and focus on cancer prevention
 Vaccination given well before sexual experimentation begins
 Better antibody response in preteens
3.
Offer a personal story
 Own children/Grandchildren/Close friends’ children
 HPV-related cancer case
4. Welcome questions from parents, especially about safety
 Remind parents that the HPV vaccine is safe and not associated with
increased sexual activity
Tools for your Practice
Tips for Talking to Parents
about HPV Vaccine
cdc.gov/vaccines/hpv-tipsheet
Case Study
 A 14 year old male had his first HPV vaccine 2 months
ago and had a second dose today. What is the next
step for this adolescent in this series?
Measles
Measles in the United States
 2014
 644 cases from 27 states
 23 measles outbreaks in 2014, including one large outbreak of
383 cases, occurring primarily among unvaccinated Amish in OH
January 1 to January 15, 2015
• 102 cases reported
 Majority not vaccinated
 Reported in 14 states: CA, CO, IL, MN, MI, NB, NY, OR, PA, SD, TX,
UT, and WA
 Current outbreak related to suspected US traveler who was
unimmunized and traveled to endemic area
 Infected individual visited Disneyland….and the rest is history!!!!!
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Measles U.S. 2014*
216 cases reported from 15 states including 15 outbreaks
45 importations
22 from the Philippines
38 (85%) US residents
96% cases import-associated
38 cases (17%) hospitalized
Cases in US residents (N=207)
63% unvaccinated
25% unknown vaccination status (90% of those adults)
12% vaccinated (including 8% with 2 or more doses)
Among unvaccinated
83% were personal belief exemptors
6% unvaccinated travelers age 6-15 mos
7% too young to be vaccinated
* Provisional reports to CDC through May 16, 2014
Global Burden of Measles
 Prior to Vaccine: 5-8 million deaths/year
 77% decrease in incidence from 2000 to 2012
 78% decrease in deaths from 2000 to 2012 (90% since 1985)
122,000 deaths in 2012 (~14 deaths/hour)
 Remains a leading cause of Vaccine Preventable Deaths in
young children Most deaths in children under 5 years old
What is Measles
 Febrile rash illness
 Most contagious of the vaccine preventable diseases
 Highly effective vaccine part of the routine immunization
schedule
Clinical Presentation
Rash ~14 days after exposure (range 7-21 days)
 Fever (up to 105oF)
 Cough, Coryza, and/or Conjunctivitis
 Follows prodrome lasting 2-4 days
 Prodrome may include Koplick Spots
Erythematous maculopapular eruptions Spreads from
head to trunk to extremities
 Initially blanching
Fades in order of appearance
Measles Complications
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Condition
Diarrhea
Otitis media
Pneumonia
Encephalitis
Death
Percent reported
8
7-9
1-6
0.05-0.1
0.1-0.2 (2-15 in
developing
countries)
 Subacute Sclerosing Panencephalitis (SSPE) 0.001
Measles and Immune Suppression
 Those infected with measles are vulnerable to other infections for
up to 3 years
 Before vaccine was introduced virus was responsible for about 50
of deaths
 Including those caused by other childhood diseases
 Measles binds to cells that are meant to ‘remember’ past
infections
 Virus actually resets the immune system
 Effectively wipes out previous immunity causing ‘immune amnesia’
 Explains why measles vaccination programs are associated with
reduction in childhood deaths from other disease
 Mina, M. J., Metcalf, C. J. E., de Swart, R. L., Osterhaus, A. D. M. E., & Grenfell, B. T. (2015). Longterm measles-induced immunomodulation increases overall childhood infectious disease
mortality. Science, 348(6235), 694-699.
Measles-Mumps-Rubella
Recommendations
 Children – 2 doses at ages 12-15 months and 4-6 years
 For catch-up doses must be separated by 28 days
 CDC recommends that MMR be given at the earliest
opportunity
Travel Recommendations for
Measles
 Persons aged ≥12 months should receive 2 doses
 Includes providing a 2nd dose to children prior to age 4-6 years
 Children aged 6-11 months should receive 1 dose
 Purple bar added to 2015 ACIP schedule
 If vaccinated at age 6-11 months, still need 2 subsequent doses
at age ≥12 months
Keys to Elimination in the U.S.
 High 2-dose MMR vaccine coverage
 High quality surveillance
 Rapid identification of and response to measles cases
 Reportable within 24 hours per Council of State and Territorial
Epidemiologists (CSTE) guidelines local health department and
CDC
 Aggressive outbreak control measures
 Information sharing tools (Epi-X, HAN)
Varicella Vaccine
 Minimum age: 12 months
 The second dose may be administered before age 4 years,
provided at least 3 months have elapsed since the first
dose
 For children aged 12 months through 12 years the
recommended minimum interval between doses is 3
months
 If the second dose was administered at least 4 weeks after
the first dose, it can be accepted as valid
 For persons aged 13 years and older, the minimum interval
between doses is 4 weeks
Case Study
 A 5 year old needs MMR and VAR. MMRV (Proquad)
is available.
 What vaccine/vaccines will you choose?
 Are there any increased risks for administering
Proquad?
PPSV23 Indications for High Risk
Children
 PPSV23 at least 8 weeks after last dose of PCV13 for
children aged 2 years or older with the following
conditions:
 Immunocompetent children with chronic heart disease
(particularly cyanotic, congenital heard disease and
cardiac failure, chronic lung disease (including asthma if
treated with high-dose oral corticosteroids), diabetes
mellitus, CSF leaks, cochlear implant
 Immunocompromising conditions: HIV infection, chronic
renal failure & nephrotic syndrome, diseases associated
with treatment with immunosuppressive drugs or
radiation therapy including malignant neoplasms,
leukemias, lymphomas and Hodgkins disease, or solid
organ transplantation and congenital immunodeficiency
Pneumococcal Vaccine for High Risk
Children 6-18 years
 1. If neither PCV13 nor PPSV23 has been received
previously, administer 1 dose of PCV13 now and 1 dose of
PPSV23 at least 8 weeks later
 2. If PCV13 has been received previously but PPSV23 has
not, administer 1 dose of PPSV23 at least 8 weeks after the
most recent dose of PCV13
 3. If PPSV23 has been received but PCV13 has not,
administer 1 dose of PCV13 at least 8 weeks after the most
recent dose of PPSV23
PPSV23 Indications for High Risk
Children
 Children with atomic or functional asplenia including
sickle cell disease and other hemoglobinopathies
congenital or acquired asplenic or splenic dysfunction
 A single dose of PPSV23 should be administered 5
years after the first dose to these children
Pneumococcal Vaccine (PCV13)
Indications for Children
 Pneumococcal vaccine 13 valent. (Minimum age: 6 weeks
for pneumococcal conjugate vaccine [PCV13]
 PCV13 is recommended for all children aged younger than
5 years
 Administer 1 dose of PCV13 to all healthy children aged 24
through 59 months who are not completely vaccinated for
their age.
Case Study
Your patient is a 16 year old who is going for a cochlear
implant. The adolescent has never received
pneumococcal vaccine.
What is your course of action?
Influenza Vaccine 2015-16
 Composition of 2015-16 Influenza vaccine
 will contain hemagglutinin (HA) derived from an
A/California/7/2009 (H1N1)-like virus, an
A/Switzerland/9715293/2013 (H3N2)-like virus, and a
B/Phuket/3073/2013-like (Yamagata lineage) virus
 Represents changes in the influenza A (H3N2) virus
and the influenza B virus as compared with the 2014–
15 season
 http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6430a3.htm
2014-16 Influenza Vaccine
 Quadrivalent influenza vaccines will contain these
vaccine viruses, and a B/Brisbane/60/2008-like
(Victoria lineage) virus, which is the same Victoria
lineage virus recommended for quadrivalent
formulations in 2013–14 and 2014–15
 Emphasis on giving oseltamivir and zanamivir
especially for high risk individuals
 Oseltamivir only antiviral approved for children
Timing of Influenza Vaccination
 In more than 80% of influenza seasons, peak activity has not
occurred until January or later
 In more than 60% of seasons, the peak was in February or later
 Immunization providers should begin offering vaccine as soon as
it becomes available each season
 Providers should offer vaccine during routine healthcare visits or
during hospitalizations whenever vaccine is available
Timing of Influenza Vaccination
 Continue to offer influenza vaccine throughout the
influenza season, especially to healthcare personnel
and those at high risk of complications
 Continue to vaccinate even after influenza activity has
been documented in the community
Inactivated Influenza Vaccines
and Egg Sensitivity
 Allergy to eggs must be distinguished from allergy to
influenza vaccine
 Severe egg allergy is neither a precaution nor a
contraindication for influenza vaccine
Influenza Vaccine Administration for
Children
 ACIP recommends that children aged 6 months through 8 years
who have previously received ≥2 total doses of trivalent or
quadrivalent influenza vaccine before July 1, 2015, require only 1
dose for 2015–16
 The two previous doses need not have been given during the
same season or consecutive seasons
 Children in this age group who have not previously received a
total of ≥2 doses of trivalent or quadrivalent influenza vaccine
before July 1, 2015 require 2 doses for 2015–16
 The interval between the 2 doses should be at least 4 weeks
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6430a3.htm
Influenza Vaccine and Egg
Sensitivity
 All vaccines should be administered in settings where personnel
and equipment are available for rapid recognition and treatment
of anaphylaxis

 All vaccination providers should be familiar with office emergency
plan
 Staff should be prepared with:
 CPR certification
 epinephrine, and
 equipment for maintaining an airway
Inactivated
Influenza Vaccine (IIV)
Dosage
Age Group
Dosage
6 through 35 months
0.25 mL
3 years of age and older
0.5 mL
Schedule
Age Group
Number of Doses
6 months through 8 years
1 or 2 doses
9 years of age and older
1 dose
Meningitis Vaccine in ChildrenClarifications
 Hib-MenCY – (MenHibrix) Minimum age 6 weeks –
combination meningitis and Hib vaccine
 Indicated for children younger than 19 months of age
with anatomic or functional asplenia including sickle
cell disease)
 Administer at 2,4,6, and 12-15 months
Meningitis Vaccine for Children
 Children aged 2 through 18 months with persistent
complement component deficiency
 Administer infant series of Hib-MenCY at 2,4,6 and 12-15
months OR
 Starting at 9 months MCV4-D (Menactra) 2 dose primary
series with at least 8 weeks between doses
 Children 19-23 months with persistent complement
component deficiency who have not received a complete
series of Hib-MenCY or MCV4-D
 Administer 2 dose primary series of MCV4-D at least 8 weeks
apart
Meningitis Vaccine in Children
 Children 24 months and older with persistent complement
component deficiency or anatomic or functional asplenia
(including sickle cell disease) who have not received a
complete series of HibMenCY or MCV4-D (Menactra)
 Administer 2 dose primary series of MCV4-D or MCV4-CRM
(Menveo)
 If MCV4-D is administered to child with asplenia (including
sickle cell disease) do not administer MCV4-D until 2 years old
and at least 4 weeks after completion of all PCV13 doses
Meningitis Vaccine in Children
 Children aged 9 months and older who travel to countries in the
African meningitis belt or to the Haij, administer age appropriate
formulation and series of MCV4 for protection against
serogroups A and W-13
 Prior receipt of Hib-MenCY is not sufficient for children traveling
to the meningitis belt or Haij
 Children aged 9 months-6 years at increased risk are
recommended to be revaccinated 3 years after their primary
series, and then at 5 year intervals if they remain at risk
MCV4 for children 7 to 18 years and
Older
 Administer MCV4 at age 11 through 12 years with a booster dose
at age 16 years
 Administer 1 dose at age 13 through 18 years if not previously
vaccinated
 Persons who received their first dose at age 13 through 15 years
should receive a booster dose at age 16 through 18 years.
 Administer 1 dose to previously unvaccinated college freshmen
living in a dormitory
 Persons with HIV infection who are vaccinated with MCV4
should receive 2 doses at least 8 weeks apart
Meningitis B history
 B, C, and Y strains are the cause of meningitis in the US
 MCV4 covers A, C, Y, W135 strain
 B strain is not contained in MCV4 because when added to vaccine
inactivates vaccine for other strains
 B strain is the cause of outbreaks in colleges




NJ (Princeton)
PA (Drexel University associated case with Princeton)
CA (University of California Santa Barbara)
RI (Providence University) most recent outbreak
Meningitis B history
 More than 13,000 doses of a serogroup B vaccine were
administered at Princeton University through an FDA
investigational new drug application
 More than 17,000 UCSB students received a serogroup B
vaccine through an FDA investigational new drug
application
 CDC collaborated with local health departments to contain
and control outbreaks
Meningitis B Vaccine
 On October 29, 2014, the Food and Drug Administration
(FDA) licensed the first serogroup B meningococcal
vaccine (Trumenba®)
 Approved for 10-25 years of age as a 3-dose series
 0, 2, and 6 months
 On January 23, 2015, FDA licensed a second serogroup B
meningococcal vaccine (Bexsero®)
 Approved for 10-25 years of age as a 2-dose series
 0 and at least 1 month
Meningitis B Vaccine
 ACIP voted unanimously on 2/26/15 meeting
 Limited recommendation for vaccine passed for controlling
outbreaks of serogroup B meningococcal disease and for
those at high risk
 Those with low immunity
 College students threatened with outbreak
 On 6/12/15 ACIP voted to approve a permissive
recommendation for Meningitis b vaccine
 Providers can use these vaccines for people 10-25 years of age
consistent with the labeled indication

Use of Serogroup B Meningococcal (MenB) Vaccines in Persons Aged ≥10 Years at Increased Risk for
Serogroup B Meningococcal Disease: Recommendations of the Advisory Committee on Immunization
Practices, 2015
Vaccine Messaging
 Effective provaccine messages to curb the dangerous trend of
vaccine refusal is needed
 Prior research on vaccine attitude change suggests that it is difficult
to persuade vaccination skeptics and that direct attempts to do so
can even backfire
 People’s antivaccination attitudes were successfully countered by
making them appreciate the consequences of failing to vaccinate
their children (using information provided by the Centers for
Disease Control and Prevention)
 This intervention outperformed another that aimed to undermine
widespread vaccination myths.

Horne, Z., Powell, D., Hummel, J., & Holyoak, K. (2015). Countering antivaccination attitudes. Crossmark, Early Edition
 > Zachary Horne, doi: 10.1073/pnas.1504019112
VAERS
Vaccine Adverse Event Reporting System – passive system
 VAERS is a post-marketing safety surveillance program,
collecting information about adverse events (possible side
effects) that occur after the administration of vaccines licensed
for use in the United States
 VAERS provides a nationwide mechanism by which adverse
events following immunization may be reported, analyzed, and
made available to the public
 VAERS also provides a vehicle for disseminating vaccine safetyrelated information to parents and guardians, health care
providers, vaccine manufacturers, state vaccine programs, and
other constituencies
 What are your responsibilities?
 Report any clinically significant adverse event noted following
administration
Storage and Handling-Vaccine Cold
Chain
Improper temperatures can make vaccines less
effective
 A temperature-controlled environment used to
maintain and distribute vaccines in optimal condition:
1.
2.
3.
4.
Cold storage unit at the vaccine manufacturing plant
Transport of vaccine to the distributor
Delivery to the provider
Ends with administration of the vaccine to the patient
Vaccine Cold Chain
 Proper storage temperatures must be
maintained at every link in the chain
Provider Vaccine Cold Chain
Management
1. Effectively trained personnel
2. Appropriate storage equipment
3. Efficient vaccine management procedures
4. Vaccine Storage and Handling Took Kit
http://www.cdc.gov/vaccines/recs/storage/toolkit/defau
lt.htm
Screening Questions
 Immunization Action Coalition web site
 www.immunize.org
 Has wealth of information in easy to access format
 http://www.immunize.org/catg.d/p4060.pdf
Evidence-Based Strategies
 Examples:
 standing orders
 reminder and recall
 AFIX: assessment, feedback, incentive, and eXchange
References

American Academy of Pediatrics. (2012). Mesles. In Pickering, L.K., Baker, C.J., Kimberlin, D.W., Long, S.S. (Eds.), Red
Book: Report of the Committee on Infectious Diseases, 29th ed. (pp. 489-489). Elk Grove Village, IL: American
Academy of Pediatrics.

Centers for Disease Control and Prevention. (updated January 26, 2015). Retrieved from the web at
http://www.cdc.gov/meningococcal/outbreaks/vaccine-serogroupb.htm l

Centers for Disease Control and Prevention. (2013). Human papillomavirus (HPV)-associated cancers. Atlanta, GA: US
Department of Health and Human Services, Available at
http://www.cdc.gov/cancer/hpv/statistics/cases.htm

Centers for Disease Control and Prevention. (2007) Quadrivalent Human Papillomavirus Vaccine: Recommendations
of ACIP. MMWR. 56(RR02):1-24.

Centers for Disease Control and Prevention. (2013). Prevention and control of meningococcal diseaseRecommendations of the Advisory Committee on Immunization Practices. MMWR. 62(RR.#2):1-27.

Centers for Disease Control and Prevention. (2012). Vaccine storage and handling. Atkinson, W. L., Wolf, S. (Eds.).
Epidemiology and prevention of vaccine preventable diseases-The Pink Book. 12th ed. (second printing).
Atlanta, GA: The Public Health Foundation. http://www.cdc.gov/vaccines/pubs/pinkbook/vac-storage.html
References
Centers for Disease Control and Prevention. (2014). Prevention and control of
seasonal influenza with vaccines: Recommendations of the Advisory
Committee on Immunization Practices, United States 2014-15 influenza
season. MMWR. August 15, 2014: 63(32);691-697.
CDC. (2013 ). National and State Vaccination Coverage Among Adolescents Aged 13–
17 Years — United States, 2012. MMWR; 62(34):685-693.
Centers for Disease Control and Prevention. (2012). VAERS. Retrieved from
http://www.cdc.gov/vaccines/programs/vfc/providers/
reports.html
Cummings T, Zimet GD, Brown D, et al. (2012 ). Reduction of HPV infections through
vaccination among at-risk urban adolescents. Vaccine. 30:5496-5499.
Federal Drug Administration. (2013). Flublok. Retrieved from
http://www.fda.gov/BiologicsBloodVaccines/Vaccines
/ApprovedProducts/ucm335836.htm
Federal Drug Administration. (2012). Flucelvax. Retrieved from
http://www.fda.gov/BiologicsBloodVaccines/Vaccines//approvedProducts
/ucm328629.htm
References

Grohskopf, L., Olsen, S., Sokolow, L., Bresee, J., et. al. (2014). Prevention and Control of Seasonal
Influenza with Vaccines: Recommendations of the Advisory Committee on
Immunization Practices (ACIP) — United States, 2014–15 Influenza Season: MMWR. 6391-7.

Herrero R, et al. (2013). Reduced prevalence of oral human papillomavirus (HPV) 4 years after bivalent HPV
vaccination in a randomized clinical trial in Costa Rica. PLOS ONE;8:e68329.

Kahn JA, Brown DR, Ding L, et al. (2012). Vaccine-Type Human Papillomavirus and Evidence of Herd
Protection After Vaccine Introduction. Pediatrics. (130)249-56.

McNeil LK, Zagursky RJ, Lin SL, et al. Role of factor H binding protein in Neisseria meningitidis virulence and
its potential as a vaccine candidate to broadly protect against meningococcal disease. Microbiol
Mol Biol Rev. 2013;77(2):234‐252

Romanowski B. (2011 ). Long term protection against cervical infection with the human
papillomavirus: review of currently available vaccines. Human Vaccine. Feb;7(2):161-9.

Strikas, R. (2015). Advisory Committee on Immunization Practices (ACIP),* (2015). ACIP
Child/Adolescent Immunization Work Group. (2015). Advisory Committee on
Immunization Practices Recommended Immunization Schedules for Persons Aged 0 Through 18
Years United States, MMWR; 64, 93-94.
Watson et al. Human papillomavirus-associated cancers—United States, 2004-2008.(2012). MMWR. 61:258-26.
Sources for Immunization Schedules,
Changes, & Information
 Center for Disease Control www.cdc.gov/vaccines
 http://www.cdc.gov/vaccines/schedules/hcp/child-adolescent.html
 Contains all schedules for child, adolescent, and adult immunization
schedules
 American Academy of Pediatrics
www.aap.org
 ACIP Advisory Committee on Immunization Practices
 http://www.cdc.gov/vaccines/recs/acip
 The Red Book
 CDC vaccine storage and handling took kit
http://www.cdc.gov/vaccines/recs/storage/toolkit/storage-handlingtoolkit.pdf