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Immunizations
Rodolfo E. Bégué, MD
Chief, Infectious Diseases
Pediatrics, LSUHSC
[email protected]
 Edward Jenner
(1749-1823)
 Smallpox (1796)
 Sarah Nelmes
 James Phipps
 Blossom
Immunizations
 Vaccines are biologically active agents that induce
the production of specific antibodies to render the
subject protected (immune) against infectious
diseases.
Constituents in a vaccine
 Active immunizing agent
 Suspending fluid
 Preservatives (thimerosal)
 Antibiotics (neomycin, streptomycin, polymyxin B)
 Adjuvants (aluminum hydroxide, AS04)
 Stabilizers (Tween)
Immunizing agents
 Live, attenuated organisms
 Killed, inactivated organisms
 Subparticle (proteins, polysaccharides)
Hepatitis B
 Subparticle vaccine (HBsAg)
 Recombinant
 Aluminum hydroxide
 IM, 3 doses:
 No boosters
0, 1, 6 months
0, 2, 6 months
Hepatitis B
 Infants born to HBsAg(+) mothers
in addition should receive HBIG 0.5 ml, IM, 1 dose
 Injection site pain and low grade fever (1-6%)
safe in pregnancy
DTaP
 Diphtheria
Tetanus
Pertussis
toxoid
toxoid
acellular
(protein)
(protein)
(subparticle)
whole cell
(killed)
DTaP
 Detoxified in formaldehyde, aluminum, Tween,
thimerosal, no antibiotics
 IM, 0.5 mL
 Primary series (3): 2, 4, 6 months
Booster (2): 12-18 mo, 4-6 years
 Efficacy 80%, lasts for ~ 3 years
 Boosters q 10 years (Td)
DTaP
 Common adverse reactions:
fever, redness and swelling at site, fretfulness,
anorexia, drowsiness
Precautions for DTaP
 Convulsions, with or without fever, within 3 d
 Persistent crying for > 3 hrs, within 48 hrs.
 Collapse or shock-like state within 48 hrs.
 Temperature > 40.5 oC within 48 hrs
 Vaccination might be deferred in children with
progressive neurological disorder.
Contraindications for DTaP
 Anaphylactic reactions
 Encephalopathy within 7 days.
Polio vaccines
 Injectable
IPV
 Oral
OPV
Inactivated Polio Vaccine
 Formalin inactivated
 Trivalent (serotype 1, 2, 3)
 Trace amounts of neomycin, streptomycin and
polymyxin B.
 SQ, 0.5 mL
 Primary series: 2, 4, 18 months
Booster: 4-6 yrs
 (1 adult booster for travelers)
Inactivated Polio Vaccine
 Local reactions
10 %
 Low grade temperature
30 %
 Precautions/contraindications:
allergy to any of the components of the vaccine
Live Polio Vaccine
Vaccine Paralytic Polio:
 1 every 3million doses
8-10 cases per year in the US
type 3 more frequent (2, 1)
usually after first dose
1/2 recipients, 1/2 contacts
 Precaution: immune suppressed patients or
contacts
Hib vaccine
 Subparticle vaccines (PRP)
conjugated with protein carrier.
 Protein carrier allows for:
T-cell dependent antigen
Better immunogenicity (infants)
Booster effect
Hib vaccines
 IM, 0.5 mL
 2, 4, 6, 12-15 mo
 No boosters
 Very safe vaccines. Local injection site reactions
occur in 25 % but are very mild. Systemic reactions
are very uncommon.
Pneumococcal Conjugate Vaccine
 PCV-13
 PCV-7
Pneumococcal Conjugate (PCV-13)
• Subparticle (polysaccharide), conjugate
• 13 valent
• IM, , 0.5 mL, 4 doses
• Primary series: 2, 4, 6 months of age
• Booster: 12–15 months
Pneumococcal Conjugate (PCV-13)
Catch-Up (Temporary)
 For those who have received PCV-7 partial series,
complete series with PCV-13
 For those who have completed PCV-7 series, give
one extra dose PCV-13
routine up to 5 yr; underlying conditions up to 18 yr
Pneumococcal Polysaccharide Vaccine (PCV-23)
• In addition to PCV-13, children at high risk for
severe pneumococcal infection should receive one
(or more doses of polysaccharide pneumococcal
vaccine (PCV-23) starting at 24 months of age.
Measles, Mumps, Rubella
 Live attenuated
 Grown in chick embryo,no preservatives,neomycin
 SQ, 0.5 mL
 Series (2 doses):12-18 mo and 4-6 yrs
 Side effects: 5-15% (fever, rash)
 P/C: pregnancy, allergies (egg, neomycin), immune
globulin, immune suppression, HIV OK except for C3 or
CD4<15%
Varicella
 Live attenuated, Oka strain
 Neomycin, no preservatives
 SQ, 0.5 ml
 Side effects 5-10% rash
 Series: 2 doses at 12-15 m, 4-6 y
 P/C: pregnancy, allergies, immune globulin,
salycilates, immunodeficiencies (except humoral),
HIV: OK for CD4>15%
MMRV
 Increase risk of febrile seizures (1‰2 ‰)
after 1st dose
 1st dose:
1) MMR + V
2) MMRV
 2nd dose:
1) MMRV
2) MMR + V
Hepatitis A vaccine
 Formalin inactivated virus
 Aluminum hydroxide as adjuvant
 IM, 2 doses (6-12 months apart)
 12 months - 24 months
 Can be used for Post-Exposure prophylaxis (within 2w)
 Efficacy: 79 - 99 %
 Side effects:
soreness injection site (56 %)
headache (14 %), malaise (7 %)
Rotavirus Vaccines
Rota Teq (MSD)
Rotarix (GSK)
 February 2006
 April 2008
 Live vaccine
 Live vaccine
 Human-Bovine reassortant
 Human
 Pentavalent (RV5): G1-G4, P[8]
 Monovalent (RV1): G1, P[8]
 3 doses:
 2 doses:
2, 4, 6 months
1st dose: 6 w - <15 w,
q 4 w - 10 w, <8 m
2, 4 months
1st dose: 6 w - <15 w,
q 4 w - 10 w, <8 m
 Efficacy: 74% (67, 80)
 Efficacy: 73% (27, 91)
Influenza Vaccines
TIV
LAIV
 Inactivated, split-virus
 Live, cold-adapted
 Chick embryo
 Chick embryo
 Tri-valent (two A, one B),
 Tri-valent (two A, one B),
reformulated yearly
reformulated yearly
 IM, 1 or 2 doses
 Intranasal, 1 or 2 doses
 All subjects 6 months and
 Healthy, 2-49 years
older
Influenza Vaccine
Recommendations:
 Universal immunization for all subjects 6 months and older
 Special emphasis to children < 5 y and all household contacts
and out-of-home caregivers of children < 5 y of age
 TIV to all 6 months-older
LAIV to healthy 2-49 yr
MMWR 2010;vol 59, RR-8
Influenza Vaccine
Specific Target Groups:
 Children at risk of severe influenza disease:
Asthma and other chronic pulmonary diseases (eg, CF)
Hemodynamically significant cardiac disease
Immunosuppresive disorders (congenital, acquired, Tx)
Sickle cell and other hemoglobinopathies
Long-term aspirin therapy (Kawasaki, JRA)
Chronic renal dysfunction
Chronic metabolic diseases (eg, diabetes)
 Persons who are in close contact with high-risk children (household, other care
givers, DCC, HCW).
 Women who will be in 2nd or 3rd trimester during influenza season
AAP, COID, Pediatrics 2004;113:1441-1447
Human Papillomavirus (HPV)
 70% sexually active women
 Cause of cervical carcinoma
especially serotypes 16 and 18 (70%)
 Cause of genital warts
especially serotypes 6 and 11 (90%)
HPV Vaccines
 Gardasil (MSD): HPV4: 6, 11, 16, 18
Cervarix (GSK): HPV2: 16, 18
 Gardasil: M/F; Cervarix: F
 11-12 years, 9-26 years
 IM, 3 doses: 0, 1-2, 6 months
Meningococcal Vaccine
Conjugate Vaccine (MCV4)
 Menactra (Sanofi Pasteur)
Menveo (Novartis)
 A, C, Y, W-135 (B not included), 4 g each
 Indications
a) Routine immunization for 11-18 year olds
emphasis target groups: 11-12 yr, college freshmen
boosters: 11-12 y/16 yr; 13-15 yr/16-18 yr; > 16 yr/no booster
b) At risk groups: 9 months to 55 yr (2 doses)
boosters: 3 years (2-6 yr) and then q 5 years
MMWR 2011;60(3):72-76
Age
Subgroup
Primary Vaccination
Booster Dose
9 through 23
months of
age, with high
risk conditions
Children with complement deficiencies;
Two doses of MCV4,
three months apart
Two doses of MCV4,
three months apart
Two doses of MCV4,
three months apart
(infants receiving the vaccine
prior to travel can receive the
doses as early as two months
apart)
Two doses of MCV4, two
months apart
Two doses of MCV4,
two months apart
Single dose of MCV4
If first dose received at age 9months
through 6 years and remain at increased
risk for meningococcal disease, should
receive an additional dose of MCV4 three
years after primary vaccination. Boosters
should be repeated every five years
thereafter.
Routine vaccination with MCV4
at ages 11 through 12 years
If vaccinated at age 11 through 12 years,
should receive a one-time booster dose at
age 16 years
If vaccinated at age 13 through 15 years,
should receive a one-time booster dose at
age 16 through 18 years
2 through 18
years of age,
with high risk
conditions
All other
children 11-18
years of age
Children with HIV, if another indication
for vaccination exists
All others in this age group
recommended for vaccination (travelers
to the Meningitis Belt, etc)
Children with complement deficiencies;
functional or anatomic asplenia;
Children with HIV, if another indication
for vaccination exists
All others in this age group
recommended for vaccination (travelers
to the Meningitis Belt, etc)
If first dose received at age 7 years or
older and remain at increased risk for
meningococcal disease, should receive
an additional dose of MCV4 five years after
primary vaccination. Boosters should be
repeated every five years thereafter.
www.cdc.gov/vaccines/programs/vfc/downloads/.../06-11mening-mcv.pdf
Meningococcal Vaccine
Polysaccharide (MPSV4):
 Menomune (Sanofi Pasteur)
 A, C, Y, W-135 (B not included), 50 g each, SC
 Children > 2 years at risk
– asplenia, complement deficiency, HIV (opt),
outbreak, traveler to an endemic area
– In all cases MCV4 is prefered over MPSV4)
dTap
 Booster
 Adolescents (11-12 yr, 13-18 yr)
 GlaxoSmithKline (Boostrix)
Sanofi Pasteur (Adacel)
Special Situations
 Prematurity (HBV)
 Immune suppressed:
self:
family contact:
MMR, VZV
(OPV)
 Pregnancy: MMR, VZV
 Full doses
 Multiple vaccines
Impact of Vaccinations
Disease
Maximum
2006
% decrease
Diphtheria
30,508
0
100
Measles
763,094
55
99.9
Mumps
212,932
6,584
96.9
Pertussis
265,269
15,632
94.1
Poliomyelitis
21,269
0
100
Rubella
488,796
11
100
20,000
1
100
110,672
0
100
601
41
93.1
Hepatitis A
254,518
15,298
94.0
Hepatitis B
74,361
13,169
82.3
Invasive Hib
20,000
<50
99.9
Invasive Pneumo
64,400
41,550
35.5
5,358,595
612,768
88.6
Congenital
Smallpox
Tetanus
Varicella
Modified from Roush SW, et al. JAMA 2007;298:2155-2163
QUESTIONS?