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Immunizations for Preteens

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Immunizations for Preteens INVITED COMMENTARY Immunizations for Preteens Emmanuel B. Walter, Richard J. Chung As a part of health supervision visits, all preteens should figure 1. receive the combined tetanus, diphtheria, and pertussis vac- Immunizations Universally Recommended for North cine, the meningococcal conjugate vaccine, the human pap- Carolina Preteens 11-12 Years of Age illomavirus vaccine series, and an annual influenza vaccine. Because levels of vaccine coverage among preteens are gen- Meningococcal conjugate vaccine First dose (to be followed by a second dose at age 16 years). erally suboptimal, strategies for improving coverage should Tetanus, diphtheria, pertussis vaccine be devised and implemented. Human papillomavirus vaccine 3 doses mmunizations are a major component of health supervi- Females – either HPV4 or HPV2 Ision visits for children and adolescents. Because immuni- Males – HPV4 zation recommendations change frequently, Bright Futures, Influenza vaccine an initiative of the American Academy of Pediatrics (AAP) Yearly that promotes the health of children and adolescents, has 2010 [3, 4]. In 2010, only 14 cases were reported in North issued guidelines that refer providers to the Web sites of the Carolina, and 11 of those cases were caused by serogroups Centers for Disease Control and Prevention (CDC) [1] and included in the current vaccine [4]. Although meningococ- the AAP [2] for the most up-to-date immunization sched- cal disease is uncommon, vaccination is critical, because the ules. For no other age group have routine immunization rec- consequences of infection can be devastating. ommendations evolved more rapidly in the past 8 years than In 2005 the US Food and Drug Administration (FDA) for preteens. (See Figure 1 for a list of vaccines recommended approved the first of the 2 currently licensed quadrivalent for those 11-12 years of age.) This advancement resulted from meningococcal conjugate (MCV4) vaccines, which target the development of a number of novel vaccines, including serogroups A, C, Y, and W-135. Either of the 2 vaccines can meningococcal conjugate vaccine; tetanus, diphtheria, per- be used to routinely immunize children 11 or 12 years of age. tussis vaccine; and human papillomavirus vaccine. In addi- It was subsequently recognized that immunity following a tion, an annual influenza vaccine is now recommended for single dose of MCV4 administered at this age is short-lived, everyone, including preteens. The discussion that follows will leaving some older adolescents unprotected from meningo- highlight the rationale for recommending vaccines during the coccal infection when exposed. Therefore, in 2011 the CDC preteen period. Challenges for immunizing North Carolina began recommending a second dose of MCV4 vaccine for preteens will also be described, and potential strategies for routine administration starting at age 16 years [5]. improving preteen vaccine coverage will be considered. Pertussis Meningococcal Disease Pertussis most frequently manifests in preteens as a Meningococcal disease, caused by Neisseria meningiti- prolonged and severe cough illness [6]. The early phase dis bacteria, most commonly presents as meningitis but of the illness, characterized by rhinorrhea, low-grade fever, may also present with bacteremia or septicemia. The case- and mild cough, is indistinguishable from upper respiratory fatality rate of invasive disease is about 10%, and survivors infections from other causes. As the illness progresses, the often suffer from such sequelae as hearing loss, limb loss, preteen child will typically experience coughing fits and or neurologic impairment [3]. Disease incidence is highest post-tussive emesis. Sleep is often disrupted, and school among children during the first year of life and climbs again absenteeism is common. Over the course of many weeks to during the teenage years. Serogroups C, Y, and W-135 cause about 75% of disease among persons 11 years of age or older Electronically published February 8, 2013. [3]. The vast majority of disease among teens can be pre- Address correspondence to Dr. Emmanuel B. Walter, Duke Children’s vented by vaccination. Prior to 2000, the annual number of Primary Care Clinic, 4020 N Roxboro St, Durham, NC 27704 (chip.wal- reported cases of invasive meningococcal disease in the US [email protected]). N C Med J. 2013;74(1):66-71. ©2013 by the North Carolina Institute of ranged from 1,300 to 3,500. Since 2001, the annual number Medicine and The Duke Endowment. All rights reserved. of cases has steadily decreased from 2,333 in 2001 to 833 in 0029-2559/2013/74115 66 NCMJ vol. 74, no. 1 NCMJ vol. 74, no. 1 ncmedicaljournal.com ncmedicaljournal.com several months, the coughing fits become less frequent and assure protection across the lifespan. Improved vaccines eventually resolve. that induce long-lasting protection against pertussis also A key concern related to pertussis infection in preteens is need to be developed. transmission of infection to school classmates and younger siblings. This may result in classroom and school outbreaks. Human Papillomavirus Furthermore, infected preteens can serve as a reservoir of Human papillomavirus (HPV) infection is the most com- infection, posing risk to infants and newborns, who are most mon sexually transmitted infection in the United States. vulnerable to severe infection. More than 6 million persons in the United States become Since the early 1980s, the incidence of pertussis has grad- infected with HPV each year, with the vast majority of new ually increased [4]. A recent outbreak in California resulted infections occurring among persons 15-24 years of age [3]. in more than 9,000 cases, 809 hospitalizations, and 10 Although infection is typically transient, persistent infection infant deaths [7]. High rates of disease were noted among with oncogenic HPV types is the most important risk fac- preteens, and a recent evaluation of data from that outbreak tor for development of precancerous or malignant lesions of suggests that the protection from disease conferred by a fifth the cervix, anus, or genitals [10]. HPV types 16 and 18 cause dose of diphtheria, tetanus, and acellular pertussis (DTaP) approximately 70% of cancers of the cervix, anus, or geni- vaccine is short-lived [8]. Data from the North Carolina tals [3]. There is also increasing recognition that many head Electronic Disease Surveillance System show that 2012 has and neck cancers are associated with HPV infection [11]. so far witnessed the largest number of pertussis cases seen Other HPV types, in particular types 6 and 11, are respon- in the state during the past 6 years, with the majority occur- sible for 90% of genital warts [3]. ring in children and adolescents 6-17 years of age, many of In the United States, there are more than 12,000 inci- whom were appropriately vaccinated (Figure 2). dent cervical cancer cases and 4,000 deaths due to cervical Current measures for controlling pertussis include vac- cancer annually [12]. In North Carolina, the rate of cervical cination of infants and preschool-age children with DTaP cancer is consistent with the national average, but within according to the recommended childhood immunization the state there are 20 counties with a disease incidence that schedule, as well as routine vaccination of preteens and is higher than the highest rate estimated for any of the 50 unvaccinated adolescents and adults with tetanus toxoid, states [13]. The best methods of preventing cervical cancer reduced diphtheria toxoid, and acellular pertussis (Tdap) include cervical cancer screening and vaccination. Given vaccine. Since 2006, 2 Tdap vaccines have been approved pockets of higher disease incidence, more intensive efforts and recommended for preteens 11-12 years of age. In 2008, at increasing vaccination and screening in some North the state of North Carolina mandated that all children Carolina counties is warranted. enrolled in public school receive a dose of Tdap vaccine A quadrivalent human papilloma virus (HPV4) vac- before entering sixth grade, or by age 12 years for those not cine was approved by the FDA in 2006 and quickly recom- attending public schools [9]. Further studies are needed mended for routine administration to females starting at to elucidate the optimal timing for pertussis vaccination to age 11-12 years. Although a permissive recommendation for figure 2. Pertussis Cases Reported in North Carolina During the First 8 Months of 2012, by Age and Vaccination Status Source: Data are from the North Carolina Electronic Disease Surveillance System provided by the North Carolina Immunization Branch. NCMJ vol. 74, no. 1 NCMJ vol. 74, no. 1 67 ncmedicaljournal.com ncmedicaljournal.com Coping With a Pertussis Outbreak in Alamance County, North Carolina Kathleen Shapley-Quinn At its peak prevalence in the United States in the 1930s, definition for pertussis. Laboratory testing with culture pertussis (whooping cough) affected as many as 265,000 and/or polymerase chain reaction technology was used people per year, killing thousands of infants [1]. With the whenever possible to confirm diagnoses. Contacts in ad- introduction of a combination vaccine for diphtheria, per- ditional schools were identified, and additional unrelated tussis, and tetanus (DPT) in the mid 1940s, the number of (not epidemiologically linked) cases of pertussis in the annual cases gradually decreased, until fewer than 2,000 community were found by health care providers. A total were being recorded in the 1970s [1]. Since that time, of 166 cases were diagnosed between December 2011 and though, the incidence of pertussis has been on the rise, August 2012, most of them children in the Alamance-Burl- and more than 30,000 cases were reported during the ington school system. A total of 24 schools were affected. first 9 months of 2012 [2]. Inadequate vaccination rates are often blamed for such Why the resurgence? DPT vaccine, which contains outbreaks, so it is notable that school records showed whole-cell pertussis, is very effective but also has an unac- that 100% of students in the Alamance-Burlington school ceptable side-effect profile.
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