Practical Challenges to Adolescent ImmunizationSociety for Adolescent Health and Medicine Conference, Los Angeles 2015

Presenters/Facilitators Nneka Holder, MD, MPH

Akron Children’s Hospital Avril Melissa Houston, MD, MPH, FAAP

Dept. of Health and Human Services Health Resources and Services Administration

Jessica Kahn, MD, MPH Cincinnati Children’s Hospital Medical Center

Lea Widdice, MD Cincinnati Children’s Hospital Medical Center

Educational Objectives Describe the latest recommendations for utilizing

adolescent vaccines in special populations Identify common legal issues that impact an

adolescent’s right to provide self-consent for vaccination

Discuss at least three strategies for managing challenges in vaccinating adolescents, including vaccine refusal, vaccine hesitancy, and parental or adolescent lack of understanding of vaccine safety and efficacy

Describe two evidence-based strategies for enhancing vaccine administration among adolescent patients

Adolescent Immunization Schedule 2015

ACIP Adolescent Immunization Schedule

Vaccines 11-12 yrs.

13-15 yrs.

16-18 yrs.

HPV

Tdap

MCV4

Influenza

Tdap: tetanus, diphtheria, and acellular pertussis vaccineMCV4: meningococcal conjugate vaccineACIP: Advisory Committee on Immunization Practices

booster

3-dose series

1st dose

Annual immunization

1 dose

Range of recommended ages for all children

Range of recommended ages for catch-up immunization

Immunizations and Pregnancy

Adapted from Centers for Disease Control and Prevention: National Center for Immunization and Respiratory Diseases, Immunization Services Division

Vaccine Before During After Type

Hep A Yes Yes Yes Inactivated

Hep A Yes Yes Yes Inactivated

HPV Yes No Yes Inactivated

Influenza IIV

Yes Yes Yes Inactivated

Influenza LAIV

Yes, avoid conception for 4 wks.

No Yes, avoid conception for 4 wks. Live

MMR Yes, avoid conception for 4 weeks

No Yes, immediately postpartum if susceptible to Rubella

Live

MCV Yes Yes Yes Inactivated

PSV Yes Yes Yes Inactivated

Tdap Yes Yes (27-36 wks. gestation)

Yes, immediately postpartum, if not received previously

Inactivated/toxoid

Td Yes Yes, Tdap preferred

Yes Toxoid

Varicella Yes, avoid conception for 4 wks.

No Yes, immediately postpartum if susceptible

Live

Immunizations and Primary Immune Deficiencies

Category Specific Immunodeficiency

Contraindicated Risk-Specific Recommended Vaccines

Effectiveness & Comments

B-lymphocyte (Humoral)

Severe (X-linked agammaglobulinemia)Less severe (IgA deficiency)

LAIV PneumococcalMMRVaricella

Efficacy uncertain (in severe forms) as it depends on the humoral response; IVIG interferes with immune response Immune response may be attenuated

T-lymphocyte (cell-mediated and humoral)

Complete (SCID, complete DiGeorge)

Partial (Wiscott-Aldrich, most DiGeorge)

LAIVMMRVaricella

LAIVMMRVaricella

Pneumococcal

PneumococcalMeningococcal

Efficacy uncertain

Efficacy depends on immune response

Complement Complement or Factor B

None PneumococcalMeningococcal

Likely effective

Phagocytic function Chronic Granulomatous Dz, Leukocyte adhesion defect

Live bacterial vaccines (such as BCG, S. typhi vaccine)

Pneumococcal Likely safe and effective

Immunizations and Secondary Immune Deficiencies

Specific Immunodeficiency

Contraindicated vaccines

Risk-specific recommendations

Effectiveness and Comments

HIV/AIDS OPVMMR, Varicella (if severe)LAIV

PneumococcalHibMeningococcal

Vaccines might be effectiveIG should be given after exposure to measles

Malignant neoplasm, s/p transplant, XRT

Live and bacterial vaccines

Pneumococcal Efficacy depends of degree of immune suppression

Asplenia None PneumococcalMeningococcalHib

Routine vaccines likely effective

Chronic Renal Disease LAIV PneumococcalHepatitis

Routine vaccines likely effective

Adapted ACIP, Jan 2011