Vaccination of Adolescents

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Vaccination of Adolescents. Andrew Kroger National Center for Immunization and Respiratory Diseases. National Assembly on School-based Health Care (NASBHC). Disclosure. The speaker is a U.S. government employee and has no conflict or interest with any manufacturer of products
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Vaccination of Adolescents
  • Andrew Kroger
  • National Center for Immunization and Respiratory Diseases
  • National Assembly on School-based Health Care (NASBHC)
  • Disclosure
  • The speaker is a U.S. government employee and has no conflict or interest with any manufacturer of products
  • The speaker will discuss the use of Tdap in a manner that varies from the package insert
  • Adolescent VaccinationThe 11-12 Year Old Visit
  • The recommended age for certain vaccines
  • An opportunity to catch-up on lapsed vaccinations
  • Adolescent Vaccines
  • Recommended
  • Tdap or Td
  • Meningococcal Conjugate
  • Human Papillomavirus
  • Catch-up
  • Hepatitis B
  • MMR
  • Varicella
  • Polio
  • Risk Groups
  • Pneumococcal Polysaccharide
  • Influenza
  • Hepatitis A
  • Meningococcal Polysaccharide
  • Tetanus,reduced-diphtheria, acellular pertussis vaccineTetanus,reduced-diphtheria, acellular pertussis vaccinePertussis Pertussis Clinical Features
  • Stages
  • Incubation period – 5-10 days (21 days rare)
  • Catarrhal Stage – 1-2 weeks
  • Paroxysmal Stage – 1-6 weeks (10 days rare)
  • Convalescent stage – 2-3 weeks
  • Pertussis Clinical Features
  • Complications
  • Secondary bacterial infection pneumonia
  • More often in infants < 6 months
  • Seizures, otitis media, anorexia, dehydration
  • Complications from actual coughing: choking, epistaxis, subdural hematoma, hernia, rib fractures, rectal prolapse
  • Adolescent Pertussis Vaccination Objectives
  • Primary
  • Protect vaccinated adolescents
  • Secondary
  • Reduce B. pertussis reservoir
  • Potentially reduce incidence of pertussis in other age groups
  • Tdap Vaccines
  • AdacelTM (sanofi pasteur)
  • Licensed June, 2005
  • Approved for persons 11-64 years of age
  • Boostrix® (GlaxoSmithKline)
  • Licensed May, 2005
  • Approved for persons 10-18 years of age
  • General Principles for Use ofTdap and Td Among Adolescents
  • Tdap products are interchangeable
  • Tdap preferred to Td to provide protection against pertussis
  • Licensed only for a single dose at this time
  • Tdap not approved or recommended for children 7-9 years of age
  • ACIP Recommendations for Tdap Vaccines
  • Adolescents 11-12 years of age should receive a single dose of Tdap instead of Td*
  • Adolescents 13-18 years who have not received Tdap should receive a single dose of Tdap as their catch-up booster instead of Td*
  • *if the person has completed the recommended childhood DTaP vaccination series, and has not yet received a Td boosterACIP Recommendations for Tdap Vaccines
  • ACIP encourages adolescents who received a Td booster to receive a single dose of Tdap to provide protection against pertussis*
  • A 5-year interval between the Td and Tdap is encouraged to reduce the chance of a local reaction
  • *if the person has completed the recommended childhood DTaP vaccination seriesMinimum Interval Between Td and Tdap
  • ACIP did not define an absolute minimum interval between Td and Tdap
  • Provider will need to decide based on whether the benefit of pertussis immunity outweighs the risk of a local adverse reaction
  • Tdap For Persons Without AHistory of DTaP
  • All adolescents should have documentation of having received a series of DTAP, DTP, DT, or Td
  • Persons without documentation should receive a series of 3 vaccinations
  • Preferred schedule:
  • Single dose of Tdap*
  • Td at least 4 weeks after the Tdap dose
  • Second dose of Td at least 6 months after the Td dose
  • *off-label recommendationTdap Contraindications
  • Severe allergic reaction to a vaccine component or following a prior dose
  • Encephalopathy within 7 days of administration of a pertussis vaccine that is not attributable to another identifiable cause
  • Tdap Precautions
  • History of an Arthus-type reaction following a previous dose of tetanus- or diphtheria-containing vaccine
  • Progressive neurological disorder, uncontrolled epilepsy, or progressive encephalopathy
  • History of Guillain-Barré syndrome (GBS) within 6 weeks after a previous dose of tetanus toxoid-containing vaccine
  • Moderate or severe acute illness
  • Conditions NOT Precautionsfor Tdap
  • Following a dose of DTaP/DTP:
  • Temperature 105o F (40.5o C) or higher
  • Collapse or shock-like state
  • Persistent crying lasting 3 hours or longer
  • Convulsions with or without fever
  • History of an extensive limb swelling reaction
  • DTaP and Tdap Administration ErrorsErrorDTaP given to person >7 yearsTdap given to child <7 years as DTaP #1, 2, or 3Tdap given to child <7 years as DTaP #4 or 5ActionCount dose as validDo not count dose; give DTaP nowCount dose as validMeningococcal Conjugate VaccineMeningococcal Conjugate VaccineMeningococcal Vaccine
  • Recommended for:
  • all persons at the preadolescent visit (ages 11-12 years)
  • persons about to enter high school (age 15 years)
  • college freshmen living in a dormitory
  • other adolescents who wish to reduce their risk for meningococcal disease
  • MMWR 2005;54(RR-7)Meningococcal Disease Among Young Adults, United States, 1998-1999
  • 18-23 years old 1.4 / 100,000
  • 18-23 years old not college student 1.4 / 100,000
  • Freshmen 1.9 / 100,000
  • Freshmen in dorm 5.1 / 100,000
  • Bruce et al, JAMA 2001;286;688-93Meningococcal Vaccine
  • Recommended for certain high-risk persons:
  • military recruits
  • certain research and laboratory personnel
  • travelers to and U.S. citizens residing in countries in which N. meningitidis is hyperendemic or epidemic
  • Meningococcal BeltMeningococcal Vaccine
  • Recommended for certain high-risk persons:
  • complement component deficiency
  • functional or anatomic asplenia
  • HIV infection (“should be considered”)
  • Conjugate vaccine - MCVMenomune – ‘old’4 types – A,C,Y,W-135Approved for >2 yrs of age1 dose, selective revaccinationSubcutaneousinjectionMenactra – new4 types– A,C,Y,W-135Approved for 11-55 years of age1 dose, (currently) no revaccinationIntramuscular injectionMeningococcal VaccinesMeningococcal Conjugate VaccineContraindications and Precautions
  • Contraindications
  • Severe allergic reaction to vaccine component or following prior dose
  • Precautions
  • Moderate or severe acute illness
  • Menactra: prior history of Guillain-Barré if not extremely high risk for meningococcal disease
  • MCV: Extremely High Risk
  • Microbiologists routinely exposed to isolates of Neisseria meningitidis
  • Human Papillomavirus Human Papillomavirus (HPV) Vaccine
  • A vaccine to prevent cervical cancer
  • Licensed for 9-26 year olds as:
  • Gardasil™– Merck- Quadrivalent HPV (Types 6, 11, 16, 18) L1 VLP Vaccine
  • Cervarix™- GlaxoSmithKline (GSK) pending licensure (Types 16 and 18)
  • Human Papillomavirus VaccineHuman Papillomavirus VaccineHPV Prevalence: Population Estimates, U.S.
  • 20 million people are infected
  • 6.2 million new infections each year
  • > 50% of sexually active men & women acquire genital HPV infection
  • 74% of new infections occur in persons 15 – 24 years of age
  • W. Cates, STD April 1999, Weinstock, Perspectives on Sexual and Reproductive Health 2004, Koutsky Am J Med 1997 Human Papillomavirus>100 typesMucosalCutaneous(~40types)(~60 types)“Common”“high-risk”“low-risk”wartstypes(16,18)types (6,11)(hands/feet)
  • low grade cervical abnormalities
  • high grade abnormalities/
  • cancer precursors
  • anogenital cancers
  • low grade cervical abnormalities
  • genital warts
  • respiratory papillomas
  • Skin Warts and TagsBackground: HPV-associated Conditions HPV types 16, 18, 6, 11
  • Clifford GM, BJ Ca 2003, Munoz Int J Cancer 2004; Brown J Clin Micro 1993; Carter Cancer Res 2001;
  • Clifford Cancer Epi Biomarkers Prev 2005; Gissman Proc Natl Acad Science 1983;
  • Kreimer Cancer Epidemiol Biomarkers Prev. 2005
  • * All oncogenic types
  • Cervical Cancer Mortality Rates U.S., 1946-1984Source: Program for Improving Clinical Pap Smear Programs and Management, Office of Population Affairs, DHHS, 1987.Efficacy for Prevention of Clinical HPV Disease Due to HPV 6/11/16/18**Integrated dataset; results in the Per-Protocol Populations Antibody Titers by Age at Enrollment Anti-HPV 6 GMTs (Quadrivalent HPV vaccine)Efficacy ProgramImmunogenicity Bridge1600150013001100900Serum GMT with 95% CI, mMU/mL70050091011121314151617181920212223Age at Enrollment (Years)Merck, unpublished data, ACIP presentation by Eliav Barr, February 2006Potential Unintended Consequences of HPV Vaccine
  • Research shows generally low levels of HPV knowledge
  • Multiple influences on adolescent sexual behavior
  • Fear of STD not apparent major motivation for abstinence
  • Increase in sexual risk unlikely
  • Pediatricians’ Intention to Recommend HPV Vaccine for Female and Male Patients, by AgeKahn J et al. Journal of Adolescent Health 2005Quadrivalent HPV VaccineSummary
  • High efficacy in 16 to 26 year-old females who are naïve to the HPV vaccine type
  • HPV 16,18 related CIN 2/3
  • HPV 6,11,16,18 related CIN
  • HPV 6,11,16,18 related external genital lesions
  • No evidence of efficacy against disease in persons already infected with relevant type
  • Efficacy data available through 5; duration of protection and need for booster unknown
  • Safe; side effects mainly local reactions
  • Recommendations
  • Routine vaccination
  • Catch-up vaccination
  • Special situations
  • Precautions and contraindications
  • Routine VaccinationRecommendation
  • ACIP recommends routine vaccination of females 11-12 years of age with three doses of quadrivalent HPV vaccine
  • The vaccination series can be started as young as 9 years of age
  • Rationale: Routine Vaccination Females at 11-12 Years
  • Routine
  • Prevalent infection, targeting ‘high risk’ groups not possible
  • Modeling shows greater impact
  • 11-12 years
  • Vaccination prior to sexual debut
  • Implementation advantages; consistent with young adolescent health care visit
  • High antibody titers after vaccination at this age
  • Data through 5 years show no evidence of waning immunity; ongoing studies will monitor duration of protection
  • Females 13-26 Years Recommendation
  • Vaccination is recommended for females 13-26 years of age who have not been previously vaccinated
  • Ideally vaccine should be administered before onset of sexual activity, but females who are sexually active should still be vaccinated
  • Rationale: Vaccination of Females 13-26 Years
  • Females not yet sexually active can be expected to have the full benefit of vaccination
  • Sexually active females may not have full benefit of vaccine because they may have been infected with vaccine HPV types, however:
  • Only a small percentage are likely to have been infected with all four vaccine HPV types
  • For those already infected with >1 vaccine HPV types, vaccine would provide protection against disease caused by the other vaccine HPV types
  • Therefore, although overall vaccine effectiveness would be lower, most females will still derive benefit from
  • vaccination Special Situations
  • Equivocal or abnormal Pap test
  • Positive HPV test
  • Genital warts
  • Cervical Cancer Screening
  • Cervical cancer screening – no change
  • 30% of cervical cancers caused by HPV types not in the quadrivalent HPV vaccine
  • Vaccinated females could subsequently be infected with non-vaccine HPV types
  • Sexually active females could have been infected prior to vaccination
  • Decision to vaccinate should not be based on Pap testing, HPV DNA testing or HPV serologic testing
  • Providers should education women about the importance of cervical cancer screening
  • Cervical Cancer Screening RecommendationsUSPSTF – U.S. Preventive Services Task ForceACS – American Cancer SocietyACOG – American College of Obstetricians and GynecologistsConv – Conventional Cervical CytologyLBC – Liquid-based CytologyPrecautions and Contraindications
  • Contraindication: History of immediate hypersensitivity or severe allergic reaction to yeast or to any vaccine component
  • Precaution: Moderate or severe acute illnesses: should be deferred until after the illness improves
  • Vaccination during Pregnancy:Recommendation
  • Initiation of the vaccine series should be delayed until after completion of the pregnancy
  • If a woman is found to be pregnant after initiating the vaccination series, completion should be delayed until after the pregnancy
  • If a vaccine dose has been administered during pregnancy, there is no indication for intervention
  • Questions?
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