H. Cody Meissner, M.D. Boston Floating Hospital for Children Tufts - - PowerPoint PPT Presentation

2013 Immunization Schedule & Pertussis Update

• H. Cody Meissner, M.D.

Boston Floating Hospital for Children Tufts University School of Medicine June 6, 2013 Webinar MCAAP & MA Dept of Health

Disclaimers/Disclosures

• I have no relevant financial relationships with

the manufacturer(s) of any commercial product(s) and/or provider of commercial services discussed in this CME activity.

• I do not intend to discuss an

unapproved/investigative use of a commercial product/device in my presentation.

Licensed Vaccines in United States

Routine childhood use:

• Diphtheria, tetanus, pertussis
• Haemophilus influenzae type b
• Hepatitis A
• Hepatitis B
• Human papillomavirus
• Influenza
• Measles, mumps, rubella
• Meningococcal
• Pneumococcal
• Poliomyelitis
• Rotavirus
• Varicella

Special settings:

• Adenovirus
• Anthrax
• Bacille Calmette-Guérin (BCG)
• Herpes zoster (shingles)
• Japanese encephalitis virus
• Rabies
• Typhoid
• Vaccinia (smallpox)
• Yellow fever

Bordetella pertussis Major Antigens and Virulence Factors

• Pertussis toxin (PT), also

known as lymphocytosis- promoting factor (LPF)

• Filamentous hemagglutinin

(FHA)

• Pertactin (PRN), also known as

69 kilodalton protein

• Fimbrial agglutinogens (FIM)

Illness due to B. pertussis is Unique

• Difficult to recognize and diagnose because of atypical

symptoms

• Only major infectious disease not associated with fever
• Symptoms in adults & adolescents may be non-specific
• Between paroxysms of cough there are no abnormal physical findings
• Infants may present with respiratory distress & apnea
• Only respiratory infection in children that is more

common in girls and more often fatal in girls

• Immunity after infection or immunization is short-lived
• People with pertussis can be contagious for up to 3

weeks

• Contagious for up to 5 days after starting treatment
• Diagnostic tests may not be readily available

50,000 100,000 150,000 200,000 250,000 300,000

1922 1930 1940 1950 1960 1970 1980 1990 2000 2010

Number of cases Year

Reported Pertussis Cases – 1922–2010

DTwP

10,000 20,000 30,000 1990 1995 2000 2005 2010

Tdap DTaP

SOURCE: CDC, National Notifiable Diseases Surveillance System and Supplemental Pertussis Surveillance System and 1922-1949, passive reports to the Public Health Service

Pertussis Deaths U.S., 2000-2009

Younger than 3 Months 3 Months and Older Total 175 19 194 (90%) (10%)

Possible Explanations for Increase in Reported Pertussis

(Reasons why DTwP, DTaP, Tdap vaccines fail)

• Greater awareness & reporting of pertussis

– Increased surveillance

• Waning vaccine induced immunity
• Acellular vaccine less potent than whole cell vaccine

– DTwP efficacy > DTaP

• Availability of better diagnostic tests

– Culture, serology, PCR

• Genetic changes in B. pertussis
• True increase in disease burden

Initial DTaP series

• Routine vaccination:

– Minimum age 6 weeks – Administer a 5 dose series at 2,4,6 and 15-18 mon and 4-6 yrs – 4th dose may be administered as early as 12 mon if at least 6 mon after 3rd dose – 5th (booster) dose not indicated if 4th dose administered at ≥4 yrs

Tdap Vaccines: licensure & composition

Trade Name, Manufacturer Age approved for use PT µg FHA µg PRN µg FIM 2&3 µg Diphtheria Lf Tetanus Lf Adacel (Sanofi Pasteur) 11 – 64* 2.5 5 3 5 2 5 Boostrix (GSK) 10 and

• lder*

8 8 2.5 _ 2.5 5 PT - pertussis toxin; FHA - Filamentous haemagglutinin; PRN - pertactin; FIM – fimbriae * 7 years and above

Use of Tdap Among Children 7 Through 10 Years of Age

• Children 7 through 10 years of age who are not fully

vaccinated against pertussis and who do not have a contraindication to pertussis vaccine should receive a single dose of Tdap

• Either brand of Tdap may be used
• Fully vaccinated at 7 years if:

– 5 doses of DTaP or – 4 doses of DTaP if the fourth dose was administered on or after the 4th birthday

Percent of Pertussis PCR Positive tests by Vaccine Type for 1st 4 doses (2010-11)

Pediatr 2013;131:e1716

Current Recommendations for Tdap

• A single Tdap dose

– Adolescents aged 11-18 years, preferred at 11 or 12 yrs – Adults aged 19 and older with focus on:

• Pregnant women are recommended Tdap with every pregnancy
• Health care professionals
• Parents & siblings
• Relatives ≥65 yrs

– Further guidance will be forthcoming on timing of revaccination in persons who have received Tdap previously

• No minimal interval from prior Td
• Decennial Td booster for those who received 1 Tdap

– 5 yrs for wound management

Use of Tdap Among Adults 65 Years of Age or Older

• Adults 65 years of age and older who previously

have not received Tdap, should receive a single dose of Tdap

• When feasible, Boostrix should be used for adults

65 years of age and older

• Administer Adacel if Boostrix is not available

Tdap Recommendations for Pregnant Women

• Administer Tdap to pregnant adolescents and

adults during each pregnancy

– preferably during 27-36 weeks’ gestation – regardless of number of yrs since prior Td or Tdap

• If not administered during pregnancy, Tdap

should be administered immediately postpartum

Precautions & Contraindications to Vaccination

• DTaP

Contraindications

• Severe allergic reaction (anaphylaxis)
• Encephalopathy within 7 days not due to other cause
• Children <1 yr with evolving neurologic disorder

Precautions

• Moderate or severe acute illness
• Temperature ≥40.5ᴼC within 48 hr
• Hypotonic, hyporesponsive episode within 48 hr
• Persistent, inconsolable crying lasting ≥3 hr
• Convulsions within 3 days
• Tdap

Contraindications

• Severe allergic reaction
• Encephalopathy within 7 days not due to other cause

Precautions

• Moderate or severe acute illness
• Guillain-Barré syndrome within 6 wks
• Progressive neurologic disorder
• Severe Arthus reaction