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

0

50,000

100,000

150,000

200,000

250,000

300,000

1922 1930 1940 1950 1960 1970 1980 1990 2000 2010

Nu

mb

er

of

case

s

Year

Reported Pertussis Cases – 1922–2010

DTwP

0

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

older*

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