Meg Fisher, MD Medical Director, The Children’s Hospital

1. Monmouth Medical Center An affiliate of the Saint Barnabas Health Care System Vaccine Preventable Diseases and the Healthcare Provider Meg Fisher, MD Medical Director, The Children’s Hospital Long Branch, NJ

2. Disclosures • I have no disclosures. • I will be mentioning off label uses of vaccines.

3. Objectives • Describe the vaccine preventable diseases that relate to the healthcare provider in the acute care setting • List and discuss vaccines needed to prevent these diseases

4. Immunization • Public health success story • Rates of all vaccine preventable illnesses have plummeted: • Smallpox, diphtheria, tetanus, polio, measles, mumps, rubella, Haemophilus influenzae type b almost gone in the US

5. Immunization Rates • Don’t get complacent! • Infection is just a plane ride away!

6. Test your knowledge • Identify these infections

7. Courtesy of the American Academy of Pediatrics and the Centers for Disease Control and Prevention

8. Courtesy of the Centers for Disease Control and Prevention

9. Courtesy of his mother

10. Courtesy of the Centers for Disease Control and Prevention

11. Courtesy of the Centers for Disease Control and Prevention

12. Courtesy of eMedicine and ADAM

13. Courtesy of the Centers for Disease Control and Prevention

14. Courtesy of the Centers for Disease Control and Prevention

15. Courtesy of the Centers for Disease Control and Prevention

16. Courtesy of the Centers for Disease Control and Prevention

17. Courtesy of the WHO and the Centers for Disease Control and Prevention

18. Courtesy of PA AAP

19. Courtesy of the WHO and the Centers for Disease Control and Prevention

20. Courtesy of the Centers for Disease Control and Prevention

21. Vaccine Preventable Diseases Hepatitis B, rotavirus, diphtheria, tetanus, pertussis, polio, Haemophilus influenzae type b, Streptococcus pneumoniae, influenza, measles, mumps, rubella, varicella, hepatitis A, Neisseria meningitidis, human papillomavirus

22. Shortages? • Major dilemma for practitioners • Distribution always a problem • Web site for vaccine shortages: • www.cdc.gov/vaccines/vac-gen/shortages • None currently

23. Vaccine Safety • Concerns are limiting vaccine use • Rates in New Jersey have fallen dramatically • www.cdc.gov/vaccinesafety

24. Immunization Safety Starts during development Continues through all stages of licensure and during postlicensure use Vaccine adverse event reporting system Vaccine safety datalink Clinical immunization safety assessment

25. National Vaccine Injury Compensation Program • Established by National Childhood Vaccine Injury Act • No fault compensation program • http://www.hrsa.gov/vaccinecompensation/ • Report suspected adverse events to VAERS

26. Advisory Committee on Immunization Practices • Provides advice for CDC • Multidisciplinary panel with many liaisons • www.cdc.gov/vaccines/recs/acip • Pediatricians well represented

28. Hepatitis B vaccine • All providers with blood exposure • Three doses: 0, 1, 6 mo • Titers to prove response to vaccine • If < 10 mIU/ml, repeat series and titer • Older less likely to respond

29. Exposure to HBsAg + Blood • Immune: education re preventing exposures • Non-responder or not immunized: HBIG plus education re preventing exposures • Immunized but not tested: test and give HBIG if negative

30. Hepatitis B Vaccine • New dilemma: • Adolescents immunized as children may have low or no antibody levels at entry to college, nursing schools, medical schools • Consider giving one dose and repeat titer • If negative, finish the series and repeat titer

31. “I had a little bird. His name was Enza. I opened the window. And in flew Enza.” A chant popular during the influenza pandemic of 1918

32. Recommendations • All people 6 months of age and older • Healthcare personnel: mandates recommended by IDSA, PIDS, AAP and others • Formulated yearly on best guess • Two A strains, one B • Start when you get it and continue all season

33. Influenza Vaccines • A/California/7/2009 (H1N1)-like • A/Perth/16/2009 (H3N2)-like • B/Brisbane/60/2008-like • Inactivated, live cold adapted

34. Influenza Vaccine Schedule • Yearly – start when you get it • Children under 3 years: lower dose • Child under 9: two doses first season* • Contraindicated in persons with anaphylaxis to chicken or eggs

35. Measles, Mumps, Rubella • Measles and rubella no longer endemic in the United States • Mumps outbreak over in NJ • MMRV combination – more fever • We should be immune: born before 1957, + titer or received 2 doses of vaccine

36. Varicella Vaccine • Prevents serious illness • Outbreaks persist • Second dose now recommended for all • Routine at 4-5 years, MMRV • Catch up for older

37. Zoster vaccine • Zostavax • Approved May 2006 • Age 60 and above; now 50 and above • Protect yourself when the time comes

38. Tdap: Boostrix, Adacel • Tetanus, diphtheria, pertussis booster • For teens (both) and adults (Adacel) • Licensed in spring 2005 • Should alter epidemiology and protect infants • Protect yourself and your staff

39. Targeted adults • Anyone caring for young infants • Cocoon the infants by immunizing contacts • Healthcare people • Pregnant women in late 2nd, 3rd trimester • Give to the entire household, preferably before delivery

40. Latest from ACIP • Off label use of the vaccine: • Use Tdap for incompletely vaccinated children down to age 7 years • Use Tdap in adults over 65 years • Pregnant women in the 2nd or 3rd trimester • Tdap at any interval following T or Td

41. Meningococcal vaccines • Polysaccharide vaccine rarely used today • Conjugate vaccines originally recommended: Adolescents age 11-12 yr (pre-teen visit) Adolescents age 15 yr (high school entry) Incoming college freshmen in dorms High risk groups

42. Latest Recommendations • Booster dose for adolescents: age 16 or 5 years after the first dose • Highest risk: initial 2 dose series followed by booster doses every 5 years • At risk healthcare: microbiologists only

43. Rotavirus vaccines • The old: Rotashield • Rhesus rotavirus reassortant • Licensed 8/98 • Withdrawn 10/99 • Intussusception risk < 1/10,000

44. Rotavirus vaccines • The new: RotaTeq, Rotarix • RotaTeq: human-bovine reassortant • Well tolerated, effective, over 70,000 • Licensed February 2006 • Rotarix: monovalent, human strain • Licensed and used outside US

45. Safety Issues • Porcine circoviruses: no harm • Rates of intussusception among vaccine recipients closely studied; post-licensure studies results vary • Benefits greatly outweigh risks

46. Haemophilus influenzaetype b • Disease dramatically decreased in US • Conjugate vaccine eliminates carriage • Keep vaccinating!

47. Streptococcus pneumoniae • Dramatic decrease in US since PCV7 • Decrease in adult disease as well • PCV13 now replaces PCV7 • Polysaccharide vaccine PPSV23 for high risk children and adults

48. Polio Virus Vaccine • Polio eliminated from most of the world • But in 2010 spread to over a dozen countries • Live oral: not in US since 2000, source of some recent outbreaks • Inactivated: safe effective, 4 dose series, last/extra dose at 4 to 6 years

49. Hepatitis A Vaccines • Inactivated • Two doses, 6 months apart • Prior to 2006: at risk or in high incidence state • Now: at risk and all children at age 1 • Catch up is reasonable

50. HPV Vaccines • Virus-like particles genetically engineered • Quadravalent and bivalent vaccines • Well tolerated and immunogenic • Three dose series • Universal for girls; permissive for boys