Update on ACIP Recommendations Charlene Graves, MD, FAAP Medical Director, Immunization Program, ISDH 317-233-7164 [email protected] October 2007
Mar 27, 2015
Update on ACIP Recommendations
Charlene Graves, MD, FAAPMedical Director, Immunization Program,
ISDH317-233-7164
[email protected] 2007
Objectives Focus on ACIP Recommendations
from 2005-2007 New vaccines: MCV4, rotavirus,
zoster, TdaP, HPV Revised recommendations:
varicella, hepatitis A, and influenza vaccines
Rationale for the ACIP recommendations
Rates of Meningococcal Disease* by Age, United States, 1991-2002
0
0.5
1
1.5
2
2.5
11 13 15 17 19 21 23 25 27 29
Age (yr)
Rate
s pe
r 100
,000
ABCs NETSS
* Serogroups * Serogroups A/C/Y/W135
U.S. Rate
Meningococcal Conjugate Vaccine (Menactra, MCV4)
Licensed by FDA in January 2005 Age indication: 11-55 years of age Vaccinate all persons 11-18 years old Medical indications: asplenia, terminal
complement deficiencies, HIV Can revaccinate with Menactra 5
years after MPSV4
Pertussis Incidence Indiana, 1995-2006
0
50
100
150
200
250
300
350
400
450
Pertussis Cases - Indiana, 2005Percent by Age Group
<1 yr19%
1-4yrs16%
5-9yrs12%
10-18 yrs24%
19+yrs29%
<1 yr 1-4yrs 5-9yrs 10-18 yrs 19+yrs
Tdap Vaccines
FDA licensed in May & June of 2005 BOOSTRIX (GSK) for 10-18 year olds ADACEL (SFP) for 11-64 year olds Clinical efficacy 92% Local injection site reactions (pain)
in 70-75%
ACIP Tdap Recommendations2/06, 12/06
11-18 year-olds and adults should receive ONE DOSE of Tdap to replace a Td booster dose (includes wound management)
Interval between Td and Tdap: desired as 5 years, but OK to give as close as 18-24 months apart
Do not use (yet) in pregnant women (postpartum OK) or 65 year-olds+
Adult/adolescent priority – households with infant below 12 months of age
Rotavirus Disease
Gastrointestinal symptoms in young children, dehydration common
95%+ children infected by age 5 1st infection more likely to be severe
disease Many are infected more than once $1 billion in medical costs each year Historical: Rotashield, intussception
Rotavirus Vaccine Goal: to prevent SEVERE disease, not
ALL disease Rotateq – FDA licensed 2/06, ACIP 8/06 Live, attenuated, pentavalent vaccine Oral administration, 3 doses: 2,4,6
months of age (6-32 weeks) Not recommended to begin series after
12 weeks of age. Minimum interval between doses is 4 weeks.
Public health price is $52, private purchase is $63.25 (per dose)
Rotateq – Clinical Trials & Follow-Up 70,000 children in 11 countries Efficacy – 74% against ANY disease,
98% against SEVERE disease Hospitalizations– 96% decrease E.D., office visits–94%, 86% decrease Intussception: Post-licensing
monitoring shows less cases than expected for age group 6-35 mos
Vaccinate if breastfeeding or past episode of rotavirus infection
In the future - Rotarix (GSK)
U.S. licensure possible in 2007-08 Live, attenuated vaccine 2 doses: start at age 6 weeks,
minimum of 4 weeks to 2nd dose Trials: 63,000 infants, worldwide Efficacy: severe disease – 85%
decrease; hospitalization – 84 %
Herpes Zoster (Shingles)
Lifetime risk of HZ may be 30% 0.5-1 million cases in U.S. each yr Postherpetic neuralgia (PHN) VZV – resides in neurons of sensory
ganglia after having chickenpox One’s immunity keeps VZV latent With aging, cell-mediated immunity
(CMI) decreases and HZ increases
HZ Vaccine Background Hypothesis: vaccine to boost CMI will
decrease shingles Vaccine is live, attenuated, but 18X
more virus than in varicella vaccine Trials: 38,500 aging (20,750 were 60-69
years old; 17,800 70+ yo) Results: 61% efficacious in preventing
disease; 66% in preventing PHN (4 year follow-up)
Store vaccine in freezer, protect from light, give within 30 minutes of reconstitution
Herpes Zoster Vaccine (Zostavax)Provis. Recommendations 10/06 FDA licensure 5/06, Merck For 60 years+, best immune response
when 60-70 years, less after that Safety profile was good Vaccinate even if had HZ before If born before 1980, assume had
chickenpox, despite no hx of disease Contraindic: immunosuppressed; active
untreated TB, allergic to neomycin, gelatin
Questions: Duration of protection, cost-benefit
HPV Characteristics
> 100 types identified 30-40 anogenital Oncogenic types
16, 18: 70% of cervical cancer
Non-oncogenic types 6, 11 for genital warts
0–1 Year 0–5 Years 1–20 Years
Invasive Cervical Cancer
Cleared HPV Infection
1. Pinto AP, Crum CP. Clin Obstet Gynecol. 2000;43:352–362.
CIN 1
InitialHPV
Infection
ContinuingInfection
CIN 2/3
Natural History of HPV Infection and Potential Progression to Cervical Cancer1
HPV Vaccine Strategies
Vaccinate before onset of sexual activity Vaccinate both males and females Immune response strongest at youngest
ages Unknowns:
What antibody titers are protective How long protection will last Getting vaccine to women rarely tested for
cervical cancer
Gardisil FDA licensed in June 2006 for 9-26 year
old females Quadrivalent vaccine (types 6, 11, 16,
18). Retail purchase at $120 per dose. I.M. injection at starting age, then 2
months and 6 months later 94-100% efficacy for warts, Pap changes,
infection As of March 2007, 5 million doses
distributed in U.S. – ¾ in 9-17 yr olds, ¼ in 18-26 year olds
ACIP Recommendations, 3/07
Routine immunization of females 11-12 years of age
“Catch-up” for females 13-26 years not previously vaccinated
Ideally, vaccinate before sexual activity Pap test, HPV DNA, HPV antibody NOT
recommended before vaccination. No change in cervical cancer screening
recommendations
Varicella Vaccine Recommendations, 6/07
Goal – decrease breakthrough disease and reduce/eliminate outbreaks of varicella
Routine vaccination at 12-15 mos. 2nd dose recommended routinely at
4-6 years of age; 3 months as minimum interval between doses
2nd dose recommended for person of ANY age who have had only 1 dose
13 yrs or older, if not immune – 2 doses at least 4 weeks apart
Why Hepatitis A Vaccine for All?
From 1990-97, 65% of reported cases in states with vaccination recommendations (“endemic”)
In 2004, 63% of cases in states without such recommendations
Disease is asymptomatic in most children less than 6 y.o.
1-2 y.o. have highest rate of transmission to parents
Day care exposure: 9% of cases in 2003
Updated Hepatitis A Vaccine Recommendations
Hepatitis A vaccine for all 1-2 year olds and catch-up vaccination thru 18 years of age (5/06) Twinrix accelerated schedule: give at 0,
7, 21-30 days and 12 months – for travelers, deployment for disasters
Hep A post-exposure prophylaxis(PEP): 1-40 years – vaccine. For 40 years+ use
IG (0.02ml/kg). PEP used up to 2 weeks after exposure (ACIP 6/07)
Updated Recommendations on Influenza Vaccine
Influenza vaccine: Give to all children 6 months-59 months of age, also caregivers of children 6-59 months old. For 6 mos- 8yrs of age, need 2 doses the first year of vaccination
6 mo-8 yrs – if only 1 dose the 1st year given, need 2 doses the next year
FluMist – FDA expanded age indication down to 2 year-olds (9/07)
TIV Dosing Schedule for Children
Age Dose# Doses 6-35 mos 0.25 ml 1 or 2 3-8 yrs 0.50 ml 1 or 2 9 yrs+ 0.50 ml 1 Fluzone is only TIV vaccine for 6-48 mos.
of age; fine for older children also Fluvirin available for 4 yrs+ Fluarix, Flulaval, Afluria available for 18
yrs+
Finding ACIP Recommendations and Meeting Minutes
CDC National Immunization Program www.cdc.gov/vaccines/recs/default.htm
ACIP Meetings – agendas, presentations ACIP Recommendations ACIP Provisional Recommendations VFC Resolutions
That’s It. Any Questions??