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Vaccine Update Practical Point Vaccine Update Practical Point Chonnamet Techasaensiri, MD Division of Infectious Diseases Department of Pediatrics Faculty of Medicine Ramathibodi Hospital Type of Vaccines • Live attenuated vaccines: MMR, varicella, JE, OPV, rotavirus • Toxoid vaccines: d/D, T • Component vaccines eg. polysaccharide or polypeptide: Hib, PCV, PPSV • Inactivated (killed) vaccines: rabies, JE, wP, influenza • Surface Ag (recombinant) vaccines: HBV 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 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 BCG • Live-attenuated M. bovis • BCG vaccination schedule depends on epidemiology data in each country • Meta-analyses indicate a consistent BCG-induced protective efficacy in young non-HIV-infected children • 73% (67-79%) against TB meningitis • 77% (58-87%) against miliary disease • Protective effect of BCG against pulmonary disease in childhood is variable BCG Disease • BCG abscess • Osteitis • Osteomyelitis • Regional lymphadenitis • Disseminated disease Potential factors affecting the rate of adverse reactions include the BCG dose, vaccine strain, host (age, immune) and method of vaccine administration. Diphtheria – Tetanus - Pertussis • Whole cell is effective, however • Reactogenic • Rate of serious adverse effects Anaphylaxis 1:100,000 doses Seizure in 48 hours 1:1750 doses HHE 3.5-291:100,000 doses Prolong crying > 3 hours 1:100 doses T > 40.5oC in 48 hours 0.3:100 doses • Not recommend in > 6 year-old • DTwP induced immunity decline 50% in 6-12 years, after childhood vaccine most adults are susceptible • DTaP as efficaceous but less reactogenic DTwP • Diphtheria outbreak in Southern and Northeast Thailand in 2012 • In Thailand pertussis is still present esp. in adolescents and adults, but hard to make diagnosis • Tetanus have been rare in Thailand • TT should have been replaced by dT (10-25% of Thai adolescents and adults are susceptible to diphtheria) • DTwP-HB has been used widely in EPI • Still found problems of adverse events following immunization (AEFI) >> rationale for widely use of DTaP Diphtheria – Tetanus - Pertussis Vaccine Age Recommended DTwP 2 mos – 6 yrs DTaP 2 mos – 6 yrs DT 2 mos – 6 yrs Tdap >7 yrs dT >7 yrs Use of Tdap and Tdap-IPV: Thailand • Tdap or Tdap-IPV can be used as the booster dose at 4-6 years of age • Tdap or TdaP should be offered to all adolescent and adults every 10 years • Administer one dose of Tdap vaccine to pregnant women during each pregnancy (preferred during 27–36 weeks’ gestation), regardless of number of years since prior Td or Tdap vaccination. • Tdap can be administered regardless of interval since the most recent tetanus or diphtheria-toxoid containing vaccine Polio Vaccine OPV IPV Cost Low High Route of administration Oral SC or IM Intestinal immunity Yes No Control outbreak after the 1st dose Yes No Immunocompromised host Contraindicated Safe Vaccine-associated paralytic Possible No poliomyelitis (VAPP) Interfere with enteroviral infection Yes No Polio vaccine 1. Oral polio vaccine (OPV) • Monovalent oral polio vaccines mOPV1 or mOPV3 • Bivalent oral polio vaccine type 1 and 3 • Trivalent oral polio vaccine or Sabin vaccine type 1, 2 and 3 2. Inactivated polio vaccine (IPV) type 1, 2 and 3 Oral polio vaccine or Sabin vaccine Disadvantages • Approx. 1 in every 2.7 million first doses of the vaccine can cause paralysis (VAPP). • Virus in the vaccine may genetically change and start to circulate among a population. These viruses are known as circulating vaccine-derived polioviruses (cVDPV). http://www.polioeradication.org/Polioandprevention/Thevaccines/Oralpo liovaccine(OPV).aspx#sthash.1BTkBIsC.dpuf- 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 MMRV vaccines: risk of febrile convulsions First dose ProQuad™ Priorix-Tetra™ of MMRV 1 additional case in 2,300 1 additional case in 5,882 or doses 2,747 subjects Children 1 (One additional case of febrile convulsion (An additional case of febrile convulsion per 12–23 months 7–10 days post-vaccination for every 2,300 5,882 or 2,747 subjects post-vaccination or doses of MMRV administered, in with MMRV compared with matched 9–30 months2 comparison with controls who received MMR, or MMR + V at separate injection sites1) simultaneous MMR + V vaccinations2) Second dose of MMRV No such link found to date3 Children 4–6 years 1Klein et al. Pediatrics 2010; 126: e1–8; 2GlaxoSmithKline. Priorix-Tetra™ European SmPC 2013; 3Klein et al. Pediatrics 2012; 129: 809–14 HBV Vaccine • Thai MOPH recommends DPT-HBV at 2, 4, 6 months of age • Maternal positive HBsAg: Infant should receive HBV at 1 month of age • Total HBV vaccine = 5 doses • The second dose should be administered at age 1 to 2 months • Monovalent HepB vaccine should be used for doses administered before age 6 weeks • Administration of a total of 4 doses of HepB vaccine is permissible when a combination vaccine containing HepB is administered after the birth dose1 1. MMWR Morb Mortal Wkly Rep. Feb 10, 2012. HBV Vaccine • Infants who did not receive a birth dose should receive 3 doses of a HepB- containing vaccine starting as soon as feasible • The minimum interval between dose 1 and dose 2 is 4 weeks, and between dose 2 and 3 is 8 weeks. The final (third or fourth) dose in the HepB vaccine series should be administered no earlier than age 24 weeks and at least 16 weeks after the first dose MMWR Morb Mortal Wkly Rep. Feb 10, 2012. Testing for Anti-HBs 1-2 Months After Vaccination • Routine: not indicated • Recommended for • Infants: HBsAg +mothers • Hemodialysis patients • HIV-infected persons • People at occupational risk of exposure from needlestick injuries • Immunocompromised patients at risk of exposure to HBV Repeat a series of vaccination in non-responders Shortened interval for postvaccination serology in infants born to HBsAg-positive mothers • In agreement with updated recommendations from the CDC, we now obtain postvaccination serology at age 9-12 months (or 1-2 months after the final dose) rather than at age 9-18 months as previously recommended. • The shortened interval permits earlier revaccination of susceptible infants and may avoid unnecessary revaccination of infants who responded appropriately but whose antibody levels declined with time. Schillie S, et al. Morb Mortal Wkly Rep. 2015; 64:1118. Management of HBV Non-Responders • 4% of vaccinated newborns do not reach a protective antibody level (10 mIU/mL), and 0.4% is a true non-responder even after a 4th dose1 • Recipients who do not respond after 1o series • Reimmunize with 3 additional
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