Immunization
Recommendation
Updates
SEMIC Immunization Conference
April 27, 2017
Disclosures
•
No conflicts of interest
•
Will discuss off-label use
 Tdap
 Meningococcal B vaccine
Measles 2017
•
Case count: 26
 25/26 had 0 MMR
 Between ages 0-5
 25 cases in Hennepin, 1 in Stearns
•
Index case unknown
•
High number of children exposed
 In emergency departments and urgent care
 In childcare settings
•
Hennepin Co. and MDH
 Exposure notification and exclusion recommendations
 Case investigation
 Community outreach
MMR Recommendations during
Outbreak
MMR Doses by Week
5000
4500
4000
MMR Doses
3500
3000
2500
2000
1500
1000
500
0
1
2
3
4
5
6
7
8
9
Week
*Data from MIIC updated weekday mornings
10
11
12
13
14
15
16
Influenza Activity
Influenza
Mid-season Vaccine Effectiveness (VE)
Overall: 48% (CI 37-57%)
 Influenza A H3N2 43% (CI 29-54%) VE
 Influenza B 73% (54-84%) VE
•
VE varies by age group
•
ACIP and CDC continue to explore why VE is lower for
H3N2 comparatively
MMWR 2017 (RR-6);66:167–171.
ACIP Discussion of LAIV
•
Live attenuated influenza vaccine (LAIV) should not be used in the
2016-2017 influenza season
•
Continue to investigate VE issues with the H1N1 strain
 Thermostability
 Serologic studies
•
Challenge: getting enough data to look at VE
 ACIP has no current plans to recommend LAIV in upcoming (2017-18) season
 Discussion of data compelling enough in place of VE
•
Most recent coverage estimates for children are at approximately 50%
 December 2016
 Not lower than previous seasons
https://www.cdc.gov/vaccines/acip/meetings/downloads/slides-2017-02/influenza-04-bright-mallory.pdf
Egg allergy and Influenza Vaccine
•
Residual egg protein in flu vaccine is not likely to induce an
allergic reaction, even in severely allergic people
 The amount of egg protein is actually undetectable (less than 0.5 µg) and it is
thought that at least 130 µg is needed for a reaction to occur
•
Anaphylaxis can occur with any vaccine, to any component
•
Data is reassuring and compelling
•
2700 published studies involving more than 4100 allergic subjects,
including known anaphylaxis to egg ingestion
 Received influenza vaccination without serious reactions, including respiratory
distress or hypotension
 Minor reactions such as hives, mild wheezing, but seen equally among non-egg
allergic controls
MMWR 2016;65(RR-5): 29-30
Vaccinating Egg Allergic Patients
Risk of anaphylaxis due to egg allergy small compared to risk of hospitalization and
death due to influenza
•
People experiencing reactions to egg of any severity (hives to angioedema) may
receive any licensed and recommended influenza vaccine (i.e. IIV, RIV) that is
otherwise appropriate for the recipient’s age and health status.
•
Vaccine administration should be supervised by a health care provider who is able
to recognize and manage severe allergic conditions.
•
A previous severe allergic reaction to influenza vaccine, regardless of the
component suspected of being responsible for the reaction, is a contraindication to
future receipt of the vaccine.
MMWR 2016;65(RR-5): 29-30
Hepatitis B
Strengthening the safety net:
•
Monovalent Hepatitis B vaccine should be administered within
24h of birth for medically stable infants weighing ≥2000 g born to
HBsAg-negative mothers.
•
Preterm infants weighing <2000 g born to HBsAg-negative
mothers should receive the first dose of vaccine 1 month after
birth of at hospital discharge.
•
A new statement will be published to incorporate
recommendations for specific populations and permissive
language will be removed.
https://www.cdc.gov/vaccines/acip/meetings/downloads/slides-2016-10/hepatitis-02-schillie-october-2016.pdf
Meningococcal Vaccines
•
HIV infection was added as a risk indication for MenACWY
(MCV4) vaccination.
 2 months and older
 Dosing is dependent on series initiation and vaccine type, check the schedule
footnotes
 Revaccinate every 5 years
•
Meningococcal B: High risk indication for 10 and older and
permissive recommendations for 16-23 years
•
MenB: MenB-FHbp (Trumenba)
 Now licensed for a 2-dose series in persons without a risk indication
 3-dose for persons with risk indications (includes outbreak situation)
https://www2.cdc.gov/vaccines/ed/pickup/ciinc/2017/CIINC_3_29_2017.pdf
High-Risk Indications Meningitis
Risk Indications
Meningococcal ACWY
Meningococcal B
Complement component
deficiency
Yes
Yes
Anatomic/fuctional
asplenia
Yes
Yes
Living with HIV
Yes
No
Travel
Yes, quadrivalent
product
No
Microbiologist working
with N. Meningitidis
Yes
Yes
Community Outbreak
Yes, for outbreaks
involving serogroups
ACWY
Yes, for outbreaks
involving serogroup B
Meningococcal Vaccines
Meningococcal serogroup(s)
involved
ACWY
Vaccine type
Conjugated ACWY, CY
Polysaccharide ACWY
 At risk age 2 months and older  At-risk over age 55 years
 Routine adolescent:
 11-12 years;
 Booster at 16 years#
MenACWY-crm: Menveo
MPSV4: Menomune
Recommended age indications*
Vaccine names and associated
brand
Immunization requirement?
MenB

MenACWY-D:
Menactra
MenC/Y-Hib:
MenHibrix
Yes, grades 7-12

Not applicable
MenB
 At-risk 10 y and older
 Option for anyone 16-23
years#
MenB-4C:
Bexsero
MenB-FHbp: Trumenba

No
Risk Indications for Meningococcal Vaccines
Risk indications
Meningococcal ACWY (MenACWY)
Meningococcal B (MenB)
Complement component deficiency
Yes
Yes
Anatomic / functional asplenia
Yes
Yes
HIV infected
Yes
No
Yes, quadrivalent product
No
Yes
Yes
Yes, for outbreaks involving serogroups
ACWY
Yes, for outbreaks involving serogroup B
Travel
Microbiologist working with N. Meningitidis
Community Outbreak
Meningococcal Vaccines
Serogroup(s)
involved
Vaccine type
Recommended
age
indications*
Vaccine names
and associated
brand
ACWY
Conjugated ACWY,
CY
Routine adolescent:
11-12 y; booster at 16 y
At-risk 2 months and
older
Polysaccharide
ACWY
MenC/Y-Hib: MenHibrix
MenB
At-risk 10 y and older
At-risk over age 55 years
MenACWY-crm: Menveo
MenACWY-D: Menactra
MenB
MPSV4: Menomune
Option for anyone 16-23
years
MenB-4C: Bexsero
MenB-FHbp: Trumenba
* Recommended by the Advisory Committee on Immunization Practices (ACIP), see FDA-approved package insert for licensed age indication
Tetanus, Diphtheria and Pertussis
(Tdap)
•
For persons aged 7 through 10 years who receive a dose of Tdap as part of
the catch-up series, an adolescent Tdap vaccine dose may be given at age 11
through 12 years
 In line with guidance of children for which Tdap is inadvertently administered
https://www2.cdc.gov/vaccines/ed/pickup/ciinc/2017/CIINC_3_29_2017.pdf
Tdap Vaccination in Pregnancy
•
Maternal vaccination strategy is very promising!
 Data presented to ACIP show 78-91% efficacy
 Large study recently published: 90%+ in first 2 months of life (Baxter et al,
2017)
•
Tdap should be given in the earlier part of the 27-36 weeks
gestation period for vaccination of pregnant women. Evidence
suggests that this timeframe allows for greater maternal
pertussis antibody transfer.
 Data presented that show higher serological biomarkers in infant cord-blood
 May suggest longer exposure may be more important than peak transfer
•
Safety data continue to be reassuring, including for repeated
doses
https://www2.cdc.gov/vaccines/ed/pickup/ciinc/2017/CIINC_3_29_2017.pdf and
https://www.cdc.gov/vaccines/acip/meetings/downloads/slides-2016-10/pertussis-02-liang.pdf
Polio
•
MMWRs published 1/13/17 and 2/17/17 provide additional
guidance regarding assessment of poliovirus vaccination
status and vaccination of children who have received
poliovirus vaccine outside the U.S.
 If both OPV and IPV were administered as part of a series, the total
number of doses needed to complete the series is the same as that
recommended for the U.S. IPV schedule.
 A minimum interval of 4 weeks should separate doses in the series, with
the final dose administered on or after the fourth birthday and at least 6
months after the previous dose.
 If only OPV was administered, and all doses were given before age 4
years, 1 dose of IPV should be given at 4 years or older and at least 6
months after the last OPV dose.
 Only trivalent OPV (tOPV) counts toward the U.S. vaccination
requirements
https://www2.cdc.gov/vaccines/ed/pickup/ciinc/2017/CIINC_3_29_2017.pdf
Human Papilloma Virus (HPV)
Recommendation for 2 Doses
•
First recommended for girls 11-12 years in 2006
•
Routinely recommended for boys 11-12 years in 2011
•
9 valent vaccine licensed in 2015
•
Move from 3 to 2 doses:





Immunogenicity
Post-hoc analysis of efficacy trials
Post licensure effectiveness
Health economic models
Duration of protection
HPV Vaccine: Basics
9vHPV vaccine was approved for a 2-dose series (0, 6 months).
2 doses now recommended for:
- Healthy adolescents beginning the series before 15th birthday
- Adolescents who have begun series but not completed three doses:
- Series was started before age 15 and doses were at least 5
months apart
3 doses recommended for:
- Adolescents/young adults beginning the series after 15th birthday
- Adolescents with an immunocompromising condition
Any combination of 2vHPV, 4vHPV, or 9vHPV is acceptable for both
the 2-dose and 3-dose series.
20
Update: ACIP Recommends
2 HPV Doses for Younger Adolescents
9-14 Years of Age at First Dose
Previous Doses
Doses Needed
None
2 doses
(interval: 0,6-12 months)
1 dose
1 dose
(6-12 months after first dose)
2 doses given less than 5
months apart
1 dose
(12 weeks after the second dose, and at least
5 months after the first dose)
2 doses given 5 or more
months apart
0 doses
(Series complete!)
*If the patient is immunocompromised, give 3 doses at 0, 1-2, and 6 months
Note: Any combination of 2vHPV, 4vHPV, and 9vHPV vaccine products spaced at the
recommended intervals is acceptable
3 Doses of HPV Recommended for
Adolescents 15 years and older
15 Years or Older at First Dose
Previous Doses
Doses Needed
None
3 doses
(0, 1-2, 6 months)
1 dose
2 doses
(At 1-2, and 6 month intervals
from first dose)
2 doses given 4 or more weeks
apart
1 dose
(12 weeks after second dose, and
at least 5 months after first dose)
23
24
HPV Coverage in Minnesota
90
80
78%
74%
70
60
52%
50
40
30
20
10
0
Tdap
MCV4
13-17 year olds, MIIC data April 2017
HPV
References:
•
Baxter, R., Bartlett, J., Fireman, B., Lewis, E., & Klein, N. P. (2017). Effectiveness of Vaccination
During Pregnancy to Prevent Infant Pertussis. Pediatrics, e20164091.
•
Bright, H., Malloy, R. (2017). Update on Status of Investigation of Reduced LAIV Effectiveness.
February 2017. https://www.cdc.gov/vaccines/acip/meetings/downloads/slides-2017-02/influenza04-bright-mallory.pdf
•
Flannery, B. (2017). Interim estimates of 2016–17 seasonal influenza vaccine effectiveness—
United States, February 2017. MMWR. Morbidity and Mortality Weekly Report, 66.
•
Grohskopf, L. A. (2016). Prevention and control of seasonal influenza with vaccines. MMWR.
Recommendations and Reports, 65.
•
Liang, J. (2016). Guidance on the use of Tdap during pregnancy. October 2016.
https://www.cdc.gov/vaccines/acip/meetings/downloads/slides-2016-10/pertussis-02-liang.pdf
•
Robinson, C. Kim, D. (2017). Current Issues in Immunization Netconference. March 2017.
https://www2.cdc.gov/vaccines/ed/pickup/ciinc/2017/CIINC_3_29_2017.pdf
•
Schillie, S. (2016). Revised ACIP Hepatitis B (HepB) Vaccine Recommendations. October 2016.
https://www.cdc.gov/vaccines/acip/meetings/downloads/slides-2016-10/hepatitis-02-schillie-october2016.pdf