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Immunization Immunization Chonnamet Techasaensiri, MD Division of Infectious Diseases Department of Pediatrics Faculty of Medicine Ramathibodi Hospital Outlines • General principles for immunization • Vaccines for health care providers • Other vaccines for adults • Vaccines related complications General Principles for Immunization Type of Immunization • Passive immunization • Administration of performed antibody that can prevent or treat infectious diseases: • Immune globulin (human origin), antitoxin (animal origin) • Active immunization • Vaccines Immune Globulins Prepared from Human Plasma Nonproprietary Name Abbreviation For intramuscular administration Immune globulin IG Hepatitis B immune globulin HBIG Tetanus immune globulin TIG Varicella-zoster immune globulin VZIG/VariZIG For intravenous administration Immune globulin intravenous IGIV Cytomegalovirus immune globulin intravenous CMV-IGIV Botulism immune globulin intravenous BIG-IGIV Vaccinia immune globulin intravenous VIG-IGIV Antibodies of Animal Origin (Animal Antisera) • Botulism antitoxin • Diphtheria antitoxin • Tetanus antitoxin Type of Vaccines • Live attenuated vaccines: MMR,varicella, JE, OPV, rotavirus, influenza (intranasal) • Toxoid vaccines: d/D, T • Component vaccines eg. polysaccharide or polypeptide: Hib, PCV, MPSV • Inactivated (killed) vaccines: rabies, JE, wP, influenza, Ty • Surface Ag (recombinant) vaccines: HBV SARS-CoV-2 Vaccine Candidates Vaccine Platforms Vaccine Candidates Viral vector DNA (nonreplicating) Coronavirus Other DNA spike gene Viral vector RNA Virus genes (replicating) (some inactive) 10 Viral vector 12 RNA (+ LNPs) Coronavirus (replicating) 14 spike gene 20 Virus genes Viral vector SARS-CoV-2 (some inactive) (nonreplicating) live 16 3 Virus attenuated (inactivated) 8 Protein based (eg, spike) Virus 44 SARS-CoV-2 (attenuated) inactivated Protein based Funk. Frontiers in Pharmacology. 2020; 11:937. Slide credit: clinicaloptions.com Immunization Successes Vaccine Area Smallpox eradication Worldwide Polio elimination Most of world Measles elimination U.S. Rubella elimination U.S. Expanded Program on Immunization and Pilot Project: Ministry of Public Health, Thailand Age Vaccines BCG 2013 Live JE Birth HBV1 2 mos DTP-HB-Hib1, OPV1, Rota 2014 HPV 4 mos DTP-HB-Hib2, OPV2, IPV, Rota 2015-2016 IPV, bOPV 6 mos DTP-HB-Hib3, OPV3, Rota 9 mos MMR1 2019 Hib 1 ½ yrs DTP4, OPV4, JE1, MMR2 2 ½ yrs JE2 2020 Rota 4 yrs DTP5, OPV5 11 yrs HPV 12 yrs (gr 6) dT General Recommendation for Immunization • Facilities for immediate allergic reaction, observation 15-20 mins after immunization for syncope and allergic reaction • Multiple vaccines should be given on separate sites, at least 1 inch apart • 28-day minimum interval for >2 live injectable vaccines if not given at the same visit (except OPV, rotavirus vaccine) CDC. MMWR 2011;60(2):1-61. General Recommendation for Immunization • Minor illness is not a contraindication for immunization • Lapsed immunization • Continue vaccination to complete series • No need for re-immunization • Vaccine doses should not be administered at intervals less than minimum intervals or at an age younger than the minimum age suboptimal immune response CDC. MMWR 2011;60(2):1-61. General Recommendation for Immunization • Vaccine administered <4 d before the minimum interval or age are considered valid except for rabies vaccine • Vaccine administered >5 days earlier than the minimum interval or age • Should not be counted as valid doses • Should be repeated as age appropriate CDC. MMWR 2011;60(2):1-61. Catch-Up Schedule https://www.cdc.gov/vaccines/schedules/downloads/child/0-18yrs-child-combined-schedule.pdf Catch-Up Schedule https://www.cdc.gov/vaccines/schedules/downloads/child/0-18yrs-child-combined-schedule.pdf Recommended Intervals Between Receipt of Blood Products and Administration of Live Vaccine Redbook 2021-2024 32nd Edition Recommended Intervals Between Receipt of Blood Products and Administration of Live Vaccine Redbook 2021-2024 32nd Edition Live Vaccine During Corticosteroid Treatment Corticosteroid Therapy Live virus vaccination Topical, aerosol Yes • With evidence of immune No suppression Physiologic maintenance Yes Low or moderate dose Yes High dose* • <14 days Yes after cessation of steroid treatment • >14 days Yes at >1 mo after cessation Immunocompromised host No * High dose: >2 mg/kg/day prednisolone or its equivalent, or >20 mg/day if BW >10 kg Post-exposure Vaccination • Varicella: <120 hours “may prevent or modify” • Measles: <72 hours “may prevent or modify” • Tetanus: with/without TIG • Rabies: with/without RIG • Hepatitis B: with/without HBIG • Hepatitis A: up to 2 weeks Minimum Intervals for Different Vaccines • Live-live • 4 weeks if not simultaneous • Live-inactivated • No minimum • Inactivated-inactivated • No minimum Interchangeability of Different Brands of Vaccines • Hib • PRP-T, PRP-OMP, HbOC: Interchangeable if use 4 dose regimen • DTaP • When feasible, same brand • Orginal not available or known – any • 4th and 5th: any product • Hep B: Interchangeable on regular schedule • Hep A: Interchangeable Interchangeability of COVID-19 Vaccines • Inactivated – Viral vector vaccines • Viral vector – mRNA vaccines • mRNA – Viral vector vaccines Vaccines for Health Care Providers Vaccines for Health Care Providers • Measles, mumps, rubella vaccine • Varicella vaccine • Hepatitis B vaccine • Tdap vaccine • Influenza vaccine: Annually • COVID-19 vaccine MMR For Health Care Providers • Most individuals born prior to 1977 were likely infected naturally and can generally be presumed immune. • However, for unvaccinated health care providers born after 1977 who lack laboratory evidence of measles immunity, vaccination with 2 doses of MMR given at least 28 days apart should be considered. MMR Vaccines in Thailand Name (Company) Measles Rubella Mumps MMR (Masu) Edmonston- Wistar RA L-Zagreb Zagreb 27/3M strain Priorix (GSK) Schwarz Wistar RA Modified Jeryl 27/3M strain Lynn MMR II (MSD) Ender’s Wistar RA Jeryl Lynn 27/3M strain MMR Efficacy • Seroconversion after MMR vaccination • Measles: 95% after 1 dose, >99% after 2 doses • Rubella >95%, confer long-term immunity, probably lifelong • Mumps • Jeryl-Lynn 61.6-80.7% • Urabe 54.4-73.1% • Rubini 55.3% Ong G, et al. J Infect. 2005;51(4):294-8. Bonnet MC, et al. Vaccine. 2006;24:7037-45. Richard JL, et al. Eur J Epidemiol. 2003;18(6):569-77. Mumps Vaccines: Adverse events Strain Aseptic meningitis Parotitis Jeryl Lynn 0/1,800,000 - 1/950,000 0.5% L-Zagreb 1/55,000 - 1/3,300 3.1% Urabe 1/69,000 – 1/400 1.3% A Review for the Global Advisory Committee on Vaccine Safety. W.H.O. June, 2003 MMR: Contraindications • Previous anaphylactic reaction to MMR or its components • Pregnancy or possibility of pregnancy within 4 wks • Severe immunodeficiency Patient with egg allergy can receive MMR vaccine Varicella Vaccine for health Care Providers • Positive history of varicella: No need for varicella vaccine • Negative history of varicella vaccine and disease: Check varicella IgG • If negative varicella IgG: Varicella vaccine 2 doses, 4-8 weeks apart Product VarilrixTM VarivaxTM Varicella GCCTM Vaccine OKA/ GSK OKA/ Merck MAV/06 strain Indication >12 months of age Schedule 2 doses 1-12 yrs: First dose at 12-15 months Second dose at 2.5-6 years >13 yrs: 4 wks apart Formulation Licensed 19844 Licensed 19955 Refrigerator Form Refrigerator Form Refrigerator Form Since 1994 since 2000 Minimum Expire 2,000 PFU 1,350 PFU 1,400 PFU Date of PFU Thermostability 90 min at 25◦C 30 minutes post 30 minutes post (post 8 hrs at 2-8◦C reconstitution reconstitution reconstitution) 1. VarilrixTM Prescribing Information 2.VarilvaxTM Prescribing Information 3.Varicella GCC TM Prescribing Information 4. Kreth HW, Lee BW, Kosuwon P, Salazar J, Barzaga NG, Bock HL, et al. Sixteen Years of Global Experience with the First Refrigerator-Stable Varicella Vaccine (VarilrixTM). BioDrugs 2008;22:387-402. 5. Marin M, Guris D, Chaves SS, Schmid S, Seward JF, MBBS CDC. Prevention of Varicella Recommendation of the Advisory Committee on Immunization Practice (ACIP), MMWR 2007;56:1-37 6. VarilvaxTM Summary of Product Characteristics 2014 32 Random effects model of 1-dose varicella VE for prevention of all varicella, by vaccine Marin M, et al. Pediatrics. 2016;137(3):e20153741. Random effects model of 1-dose varicella VE for prevention of combined moderate and severe varicella, by vaccine Marin M, et al. Pediatrics. 2016;137(3):e20153741. Marin M, et al. Pediatrics. 2016;137(3):e20153741. In Korea, more than half of all vaccinees were immunized with vaccine A, derived from an MAV/06 strain of varicella isolated from a 33-month-old Korean boy in 1989 Lee YH. J Korean Med Sci 2016; 31: 1897-1901 HBV for Health Care Providers • Prevaccination serology (with anti-HBs, anti-HBcAb, and HBsAg) is indicated in previously non-immunized health care providers born before 1992 • Anti-HBs level is ≥10 mIU/mL: Immunity to Hepatitis B • Anti-HBs titer is <10 mIU/ML: Should receive a dose of HBV and have anti-HBs titers repeated in 1-2 months. • Anti-HBs titer is <10 mIU/ML: Should receive 2 more doses of HBV and have anti-HBs titers repeated in 1-2 months. Follow-Up Testing After Immunization • Anti-HBs in 1-2 months after receiving their final dose of vaccine • Anti-HBs level is ≥10 mIU/mL: Vaccine responder • Anti-HBs titer is <10 mIU/ML: Should receive a course of HBV and have anti-HBs titers repeated in 1-2 months. • If the anti-HBs is still <10mIU/mL, the HCP is considered a vaccine nonresponder and should receive HBIG if postexposure
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