Transcript Adolescent Vaccines

Adolescent Vaccines
Swati Y Bhave
Convener IPA ( International Pediatric Association ) Adol Interest group
Member
Technical Steering Committee Child & Adol section
WHO HQ Geneva from 2007
Regional Technical Advisory Group
Adol section WHO SEARO from 2004
Member
Symposium of IAP Adol Chapter PEDICON 2007
Vaccines under discussion
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Meningococcal
Influenza
HPV
e IPV–
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Salk Vero cell IPV [v IPV]
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JE
CMV
Herpes
HIV
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•EB V
•Parvovirus,
•Para I
•E Coli
•Adeno
•Malaria
•Dengue
•Hepatitis E
•Cholera
•Shigella
•Campylobacter
•Schistosomiasis
Polysaccharide Meningococcal Vaccine -1
Capsular polysaccharides vaccines
successfully protect against
 sero groups A, C, Y and W-135.
 But protection wanes after few years
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Use limited to high-risk populations
military recruits, travelers, freshman students college
dormitories.
Other risk factors
Cigarette smoking, Bar patronage, Recent URTI
American Academy of Pediatrics, Committee on Infectious Diseases. Prevention and control of meningococcal
disease: recommendations for use of meningococcal vaccines in pediatric patients. Pediatrics. 2005;116:496-505
Conjugate Meningococcal vaccine -2
Newer conjugate vaccine links capsular
polysaccharides ( A, C, Y, and W-135) to a
protein carrier (diphtheria toxoid)
 Induces immunologic memory, longer-term
immunity, ↓ NP carriage ↓ transmission –
nonvaccinated in the community.
Unfortunately
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B, C and Y account for most disease in the United
States.
B :1/3 of total and nearly 25% of disease in 11-18 yrs
Centers for Disease Control and Prevention. Prevention and control of meningococcal disease. Recommendations of
the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2005;54 (RR07):1-21
Meningococcal vaccine schedule -3
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2005, FDA licensed M conjugate vaccine (MCV4) [
Menactra (Sanofi Pasteur)] for people 11 to 55 yrs.
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AAP and ACIP recommend routine MCV-4 to
adolescents 11 to 12 yrs and high school entry at 15
yrs
The goal is to vaccinate all adolescents at age 11 by
2008.
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ACIP also recommends immunization of college
freshman living in dormitories and other high-risk
groups.
Possible association between Guillain-Barré Syndrome (GBS) and
(MCV4) reported in October 2005.
ACIP recommends continuation but avoid in GBS patients
Richard E. Rupp, ,Susan L. Rosenthal, PhD New Immunization , Strategies for Adolescent
Patients A Clinical Guide for Pediatricians,Vol. 19, No. 1 November 2006
Influenza vaccine -1
There are 2 influenza viruses, types A and B.
 Type A :subtypes based on two surface antigens
Hemagglutinin (H) and Neuraminidase (N). eg H1N1
 Influenza type B is not categorized into subtypes.
There are two vaccines available,
 The inactivated killed Vaccine &
 Live attenuated influenza vaccine (LAIV)
Both vaccines includes Two type A strains (eg H3N2
and H1N1) & One type B strain
Centers for Disease Control and Prevention. Prevention and control of influenza: Recommendations of the Advisory
Committee on Immunization Practices (ACIP). MMWR 2005;54 (RR08):1-40
Influenza Vaccine -2
Recommended strains may change annually
depending on patterns observed from global
surveillance.
Three strains of virus strains expected to circulate in
the community in the winter
The inactivated influenza vaccine contains
killed, partially purified viruses. IM inj .
 All of the groups for which annual influenza
vaccination is indicated may receive the inactivated
vaccine
Medical conditions at increased risk –
Pulmonary or cardiovascular disease, Neuromuscular
dysfunction, Immuno-suppression, Long-term
aspirin therapy.
LAVI (Live Attenuated Influenza Vaccine ) -3
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The LAIV licensed USA- FluMist
(MedImmune, Inc.).
The attenuated viruses produce either mild
symptoms (eg, sore throat) or none at all.
Intra nasally annually to optimize protection.
Given only to healthy persons 5 to 49 yrs of
age who are not in contact with severely
immuno-suppressed persons.
Both vaccines are made from viruses grown
in eggs /avoid in allergy to chicken or egg
protein
JE vaccine –
GOI/PATH project
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Live attenuated
SA14-14-2 vaccine
from CDIBP, China
Single dose,
lyophilized One time
campaign targeting
1-15 year old
The available m-b
derived vaccine in
the country will be
utilised in AP & Tamil
Nadu
IAP recommendation
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JE vaccine should be
used for universal
immunization of all
children in 1-3 years
in endemic areas with
3 primary doses
Boosters every 2
years till 10-15 years
of age.
JE vaccine is not for
out break response
during epidemics.
e-IPV for adol and adults
Booster doses not required endemic countries –
Natural boosting - wild virus -likely to be a continual
process that maintains immunity.
WHO recommends travellers industrialized
countries to endemic area.
Previously vaccinated
one additional dose of polio vaccine
Unvaccinated
full course of primary vaccination
Route & Site: SC or IM in the deltoid region.
IPV trace amount of streptomycin, neomycin, and
polymyxin B,
http://www.cdc.gov/nip
Primary vaccination for adults and adol
Guidelines
2 doses 4 to 8 weeks apart, with a third dose
given 6 to 12 months later.
If 2 to 3 months remain before protection is
needed,
 give 3 doses of e-IPV >4weeks apart.
If only 1 or 2 months remain,
 give 2 doses of e-IPV 4 weeks apart.
If < 4 weeks remains,
 give a single dose of e-IPV.
CDC poliomyelitis Report (IMMP-44)
Primary vaccination for adults & adol
Guidelines
adults : increased risk of exposure
Single dose of e-IPV
who have completed a primary series with any poliovirus
vaccine
Give >1 dose of e-IPV
to who have had >1 dose of OPV,<3 doses of conventional
IPV (available before 1988), or a combination conventional
IPV and OPV totaling < 3 doses.
 If time permits, give additional doses needed to complete a
primary series. Do not count doses within the minimum
interval, : too short an interval may interfere with antibody
response and protection from disease.
 Increasing the interval beyond the recommended timing
does not affect the ultimate efficacy of immunization,:
waiting does delay achieving adequate protection from
infection.
ACIP. Supplementary chart: Recommended Childhood Immunization Schedule, United States,
Approved by ACIP, AAP,AAFP
Human Papilloma Virus (HPV)
• Most common sexually
transmitted infection in the USA
• Genital infections occur via GG .O-G H-G and AG contact
• Lifetime risk among sexually
active men& women - 50%.
• The vast majority of infections
go unrecognized
• HPV is now implicated as a
causative agent > 99% of
cervical cancer cases
• Also pharyngeal and anogenital cancers .
•100 types of HPV
identified
•30 -40 types infect
ano-genital region.
•Low-risk and high-risk
oncogenic potential
•15 -20 oncogenic
•HR HPV 16 /18 - 70%
cancer LR HPV 6 / 11)
Richard E. Rupp, ,Susan L. Rosenthal, PhD New Immunization , Strategies for Adolescent
Patients A Clinical Guide for Pediatricians,Vol. 19, No. 1 November 2006
HPV Vaccines available
Quadrivalent HPV vaccine FDA licensed Gardasil, Merck
Bivalent vaccine, Cervarix,GSK Biologicals soon
Both vaccines protect against HPV types 16 and 18.
Quadrivalent also contains VLPs for
HPV 6/11, genital warts.
In clinical phase 2 and 3 trials, both vaccines
were found to be safe and effective in females.
Quadrivalent vaccine is found to be 100% efficacious
against high-grade dysplasia, the predecessor to cervical
cancer
Richard E. Rupp, ,Susan L. Rosenthal, PhD New Immunization , Strategies for Adolescent
Patients A Clinical Guide for Pediatricians,Vol. 19, No. 1 November 2006
HPV vaccine schedule
Studies show a rapid rise in ano-genital HPV infections by
–15 yrs age
Ensure immunization completed prior to potential
exposure
11-12 yrs endorsed by the Society for Adolescent Medicine
(SAM)
9-10 yrs left to the discretion of the care provider.
Some have argued that vaccinating at age 11 to 12 is too
early, as the duration of immunity is unknown.
3 doses of HPV given at 0, 2 and 6 months in the Deltoid.
Both have stable antibody levels and continued efficacy - 5
years post vaccination.
CMI response long duration of protection
15 years of age and younger higher titers than older teens
and adults.
Richard E. Rupp, ,Susan L. Rosenthal, PhD New Immunization , Strategies for Adolescent Patients A Clinical Guide for
Pediatricians,Vol. 19, No. 1 November 2006
? ? Parental reaction
Major Worry :
stigma related to the sexual transmission of HPV.
vaccine will increase sexual activity among teens.
vaccine will not gain widespread acceptance
Studies show
Parents decisions based on severity of disease, efficacy
and safety of the vaccine;
the mode of transmission is less important to them.
Once educated about HPV, provided with accurate
information in a calm and reassuring way
majority of parents have positive response .
Diekema DS and the American Academy of Pediatrics Committee on Bioethics.
Responding to parental refusals of immunization of children. Clinical Report. Pediatrics. 2005;115:1428-1431
How to broach the topic of HPV vaccine ?
Visit of 10-12 yrs
•open the conversation with parents and
adolescents
preventive strategy for all adolescent risk-taking
behaviors
•parental communication and supervision.
•Clarify their values about a whole range of
subjects (eg, sexuality, drinking)
•Be sensitive to parental anxieties and possible
discomfort with discussing these subjects.
•Then talk of HPV as preventive vaccine for Cancer
and STD
Richard E. Rupp, ,Susan L. Rosenthal, PhD New Immunization , Strategies for Adolescent Patients A Clinical Guide
for Pediatricians,Vol. 19, No. 1 November 2006
My child is too young to get HPV.
Why can’t we wait ?
•You could wait. But…Two important reasons to do this now:
•The immune response appears to be better in younger girls.
•It takes 6 months to be fully immunized and the vaccine has to be
given
•before any risk of exposure.
•It makes sense to provide it before any possible exposure might
occur.”
Can HPV vaccine be given to boys ?
•At present it is only licensed for girls.
•The FDA wants more data about boys before they approve it.
•Males are a potential target for the vaccine for protection
against warts, penile or anal cancer & as a vector for
transmission to females.
Diekema DS and the American Academy of Pediatrics Committee on Bioethics.
Responding to parental refusals of immunization of children. Clinical Report. Pediatrics. 2005;115:1428-1431
Don’t you think it will encourage my daughter
to having early and risky sex?
“Does telling young people to wear bicycle helmets or
seatbelts? Encourage anyone to bicycle or drive
recklessly?
Your child may never be at risk for HPV infection,
or may not be at risk for many years.
But we are recommending that all girls get this before
anyone is at risk of infection
It is very effective at this age and vaccinating now
eliminates the worry about risk into adulthood.
Most important prevention strategy for helping teens
make wise decisions is for parents to talk to them about
values and for parents to pay attention to what they are
doing and with whom.
Diekema DS and the American Academy of Pediatrics Committee on Bioethics.
Responding to parental refusals of immunization of children. Clinical Report. Pediatrics. 2005;115:1428-1431
Cytomegalovirus Vaccine status
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Vaccine strategies have included a live
attenuated virus and the use of viral surface
glycoproteins.
The glycoprotein vaccine (CMV gB) is furthest
along in development,
a phase 2 clinical trial in adolescent females
currently underway.
Speculation about when a CMV vaccine might
become available is premature at this time.
Schleiss, M. Progress in cytomegalovirus vaccine development. Herpes. 2005;12:66-75
Herpes Simplex Vaccine
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Genital disease HSV1 /more commonly HSV2.
Public health perspective - important that vaccine
↓frequency & magnitude of virus shedding.
Universal immunization of young girls can ↓HSV-2 :
both men and women
The vaccine furthest along in development,
GSK Biologicals, : recombinant truncated HSV-2 g
D (an envelope glycoprotein)
Two large trials efficacy of 73% - 74% in
preventing genital herpes disease in HSV-1 and
HSV-2 seronegative women,
But did not provide men or HSV-1 seropositive
women any protection.
Stanberry LR, Spruance SL, Cunningham AL, et al. Glycoprotein-D-adjuvant vaccine to prevent
genital herpes. N Engl J Med. 2002;347:1652-61
Pneumococcal vaccine check vaccine name
Risk of serious Pneumococcal disease is relatively
low . Not recommended for routine use.
Recommended in groups higher risk
anatomic or functional asplenia (also sickle cell ),
nephritic syndrome, CSF leak, immunosuppression.
Revaccination : highest risk for serious
Pneumococcal infection and rapid waning of
antibodies ,provided > 5 years have passed since
administration of the first dose.
Spleenic dysfunction, Sickle cell disease, HIV
infection, Hodgkin’s disease, Lymphoma, Multiple
myeloma, Chronic renal failure, Nephritic syndrome,
undergoing organ transplantation and receiving
chemotherapy.
HIV VACCINE
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Feb 2003, Vax Gen announced their product
AIDSVAX was a failure because the circulating HIV
strain hides its epitopes in a variety of ways that
genetically engineered gp 120 proteins do not
mimic successfully.
ALVAC-HIV, a genetically engineered HIV vaccine
composed of a live,attenuated Canary pox virus into
which parts of genes for non-infectious
components of HIV are inserted is said to be
promising. 17 candidates are in phase I/II trials.
National Institute of allergy and infectious diseases
(NIAID) and Merk & Co sponsored trials with
ALVAC-HIV is expected to be completed in fourand-a -half years since January 26, 2005 and results
are expected by 2010.
Key messages
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Pediatricians need to update periodically
about new recommendations
Students going abroad will come for advise
and certificates
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Newer vaccines
New recommendations for Booster doses
Preventive /prophylactic vaccines