Why is there new emphasis on immunizing males against HPV?


Data show that HPV4 in males is a very safe vaccine with minimal side effects.7 It also protects males (as well as females) against genital warts caused by HPV types 6 and 11. In addition, HPV4 provides protection against anal and penile cancers in males, which account for approximately 4,200 new cases combined annually.8 Immunizing males against HPV will reduce spread of the disease, resulting in a lower rate of cervical cancer among females.



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Many preteens and teens fail to complete the HPV vaccine series. What are some strategies for increasing series completion?


HPV vaccination is considered to be complete, and therefore protective, only after receipt of all three doses. According to CDC data, less than one-third of females had completed the HPV vaccine series in 2009.9 For the vaccine to confer herd immunity, a far higher percentage of the eligible population must complete the series.

When patients receive the first HPV vaccine, clinicians should inform their caregivers of the recommended series and institute a reminder system to ensure series completion. Consider scheduling return visits at the initial appointment time; sending reminders via telephone, e-mail and text message; and providing refrigerator magnets that light up when it is time to return for subsequent shots.


Is invasive meningococcal disease a major concern for teens?


Bacterial meningitis is a potentially deadly disease caused by the gram-negative diplococcus Neisseria meningitidis, also called meningococcus. The peak incidence of bacterial meningitis occurs during the first year of life. However, an increased incidence of N. meningitis infection is seen between ages 10 and 20 years.

Groups B, C and Y are responsible for the majority of bacterial meningitis cases. Bacterial meningitis often presents diagnostic challenges due to its similar presentation to other more common illnesses, such as influenza. In many cases, it is too late to render effective treatment by the time a diagnosis is reached. Even with early diagnosis and treatment, approximately 10% of cases of invasive meningococcal disease — and a staggering 40% of cases of meningococcemia — are fatal.10


Why is it important to immunize preteens and teens against meningococcal disease?


Since there is a peak incidence in the early teens, it is crucial that a child receive his or her first meningococcal vaccine by age 12 years. Similar to other vaccines, the meningococcal vaccine can only work if given before exposure to the pathogen.



What is the difference between the meningococcal vaccines currently on the market?


There are two currently available quadrivalent meningococcal conjugate vaccines — MenACWY (Menactra, Sanofi Pasteur) and MCV4 (Menveo, Novartis). MenACWY was first licensed in 2005 and MCV4 in 2010.

The first meningococcal vaccines, developed in the 1970s, were polysaccharide vaccines. Their protection tended to wane faster than these newer meningococcal conjugate vaccines. Polysaccharide vaccines against meningococus are not routinely used in children and adolescents.

Both quadrivalent conjugate vaccines contain serotypes A,C,Y and W-135. There is no preference for one brand over the other.


Is a booster dose of MCV4 necessary? If so, who should be boosted?


The need for a booster dose depends on age of the patient. When the quadrivalent conjugate vaccine was first introduced, a booster dose was not thought to be necessary. However, subsequent studies showed that protective antibody levels decrease significantly three to five years after initial vaccination.

Although there are very few cases of meningitis among individuals vaccinated with either MenACWY or MCV4, the ACIP has determined that a booster dose is necessary for optimal protection against invasive meningococcal disease.

If a child receives his or her first meningitis vaccination at the recommended age of 11 to 12 years, a booster dose will be required at age 16 years. If a child receives his or her first dose between ages 13 and 15, a booster dose will be required at age 18 years. If a child receives his or her first dose at age 16 years or later, no booster is needed.11


If a patient is entering college and has never received a meningococcal vaccine, when should he or she receive a booster dose of MCV4?


Such a patient should receive one dose of meningococcal conjugate vaccine immediately and will not need a booster dose.11 The booster dose recommendations listed above depend solely on the patient’s age at the time of the first immunization.


What is behind the sudden focus on pertussis?


Pertussis has received media attention recently due to the massive increase in the number of cases in some states. Wisconsin, Washington, Montana, Vermont, Minnesota and Iowa have the highest pertussis incidence in 2012, each having between four to 10 times higher incidences than the general population average. Washington state alone saw a 1,300% increase in pertussis cases through the first six months of 2012, compared with 2011.12

Why is pertussis on the rise?


Not all children are receiving a pertussis-containing vaccine on the recommended schedule. In fact, only about 85% of children have received the four recommended doses of diphtheria, tetanus, and pertussis (DTaP) vaccine by age 3 years.13

Parents who delay or refuse immunizations have contributed to the pertussis outbreak by weakening herd immunity. Delayed diagnosis is another reason for the rise in pertussis.

Pertussis can be very difficult to diagnose, especially when it first presents. Pertussis can mirror many other common respiratory illnesses, especially in adolescents and adults. Additionally, not enough teens and preteens have been reached with the Tdap vaccine.

In 2010, only 69% of teenagers had received the Tdap vaccine, and only 81% had received either tetanus and diphtheria (Td) or Tdap.9 Finally, and perhaps most disturbingly, we are seeing waning immunity of pertussis vaccines.

Children must receive the Tdap booster as close to age 11 to 12 years as possible. At this time, Tdap is approved for a single dose only. However, studies are underway to determine if a booster of Tdap will be needed.


What is the difference between the Tdap vaccines on the market?


Adacel (Sanofi Pasteur) and Boostrix (GlaxoSmithKline) were approved for use in 2006. Boostrix is approved for individuals aged 10 years and older, and Adacel is approved for those aged 11 to 64 years. Either vaccine may be used without preference for brand.



Can a patient who received a Td vaccine within the past two years get a Tdap vaccine?


As long as the patient is in the recommended age range and has not received a Tdap vaccine previously, he or she should receive a Tdap vaccine. There is no minimum interval necessary between Td and Tdap vaccines.



Is it true that some children aged 7 to 10 years and some adults older than age 65 years should get the Tdap vaccine?


In certain circumstances, the ACIP recommends using the Tdap vaccine outside of the FDA-approved age indications. Children aged 7 to 10 years who have not been immunized with DTaP or whose immunization history is unknown should receive a Tdap vaccine.

All adults aged 19 years and older who have not previously received a Tdap vaccine should also receive a single dose of Tdap. Even adults aged 65 years and older who need a Tdap vaccine should receive one. The CDC recommends giving Boostrix to adults aged 65 years and older when feasible but permits Adacel to be used as well. This is likely due to licensing restrictions, but the CDC permits off-label use in these circumstances.14


Should pregnant women receive the Tdap vaccine?


Pregnant women should receive a Tdap vaccine during each pregnancy, preferably during the third or late second trimester. Receiving the vaccine during pregnancy will protect the mother from contracting pertussis and transmitting the disease to her baby, and confers some pertussis protection to the infant until he or she can start getting DTaP vaccines.


Who else should get a Tdap vaccine?


Vaccination is advisable for anyone who is going to be in close contact with an infant. This includes health-care providers and office staff, grandparents, other family members, daycare employees, nannies and babysitters.



What can be done to increase immunization rates of teens and preteens?


Use any office visit as an opportunity for immunization. If a child is due for an immunization and has an injury or minor illness, that child may safely receive an immunization. Be emphatic in your recommendation.


Set up a system to get children into the office for their well-child visits. As noted earlier, only a small percentage of preteens and teens present for regular well-child visits. At every appointment, note if the patient has had a well-child visit in the previous 12 months; if not, recommend scheduling one.

Make the front office staff aware so they can schedule an appointment before the patient leaves. Use electronic medical records to run a report on children who have not had a well-child visit in the past 12 months. Use postcards, phone calls and e-mails to remind caretakers to schedule their child’s well-child appointment. 


The Internet is a wonderful way to keep abreast of the most up-to-date information on vaccines. The CDC’s Vaccines & Immunizations page (www.cdc.gov/vaccines/) provides excellent information on disease epidemiology.

The CDC also offers resources for addressing caregivers and patients who are hesitant about receiving vaccines (www.cdc.gov/vaccines/hcp/patient-ed/conversations/index.html). The Immunization Action Coalition (www.immunize.org) is another reliable source of easy-to-find information on vaccines, vaccine-preventable diseases and current vaccine information statements in a variety of languages.

Finally, the American Academy of Pediatrics Childhood Immunization Support Program (www2.aap.org/immunization/) provides a great deal of useful information for clinicians and caregivers.

Christopher Barry, PA-C, MMSc, practices at Jeffers, Mann, & Artman Pediatrics in Raleigh, N.C.


References


  1. Centers for Disease Control and Prevention (CDC). National and state vaccination coverage among adolescents aged 13-17 years-United States, 2011. MMWR Morb Mortal Wkly Rep. 2012;61:671-677.
  2. Rand CM, Shone LP, Albertin C, et al. National health care visit patterns of adolescents: implications for delivery of new adolescent vaccines. Arch Pediatr Adolesc Med. 2007;161:252-259. 
  3. Satterwhite CL, Torrone E, Meites E, et al. Sexually transmitted infections among US women and men: prevalence and incidence estimates, 2008. Sex Transm Dis. 2013;40:187-193.

  4. Centers for Disease Control and Prevention (CDC). Human papillomavirus-associated cancers-United States, 2004-2008. MMWR Morb Mortal Wkly Rep. 2012;61:258-261.
  5. Widdice LE, Brown DR, Bernstein DI, et al. Prevalence of human ­papillomavirus infection in young women receiving the first quadrivalent vaccine dose. Arch Pediatr Adolesc Med. 2012;166:774-776.

  6. Liddon NC, Leichliter JS, Markowitz LE. Human papillomavirus vaccine and sexual behavior among adolescent and young women. Am J Prev Med. 2012;42:44-52.

  7. Gardasil [Human Papillomavirus Quadrivalent (Types 6, 11, 16, and 18) Vaccine, Recombinant] package insert. Merck & Co., Inc.; 2011.
  8. American Cancer Society. Cancer Facts and Figures 2013. Available at www.cancer.org/Research/CancerFactsFigures/CancerFactsFigures/ACSPC-036845.

  9. Centers for Disease Control and Prevention (CDC). National and state vaccination coverage among adolescents aged 13 through 17 years-United States, 2010. MMWR Morb Mortal Wkly Rep. 2011;60:1117-1123.
  10. Centers for Disease Control and Prevention. Epidemiology and prevention of vaccine-preventable diseases. In: The Pink Book: Course Textbook -12th Edition Second Printing.
  11. Centers for Disease Control and Prevention (CDC). Updated recommendations for use of meningococcal conjugate vaccines—Advisory Committee on Immunization Practices (ACIP), 2010. MMWR Morb Mortal Wkly Rep. 2011;60:72-76.
  12. Centers for Disease Control and Prevention (CDC). Pertussis epidemic-
Washington, 2012. MMWR Morb Mortal Wkly Rep. 2012 Jul 20;61(28):517-22.
  13. Centers for Disease Control and Prevention (CDC). National, state, and local area vaccination coverage among children aged 19-35 months—United States, 2009. MMWR Morb Mortal Wkly Rep. 2010;59:1171-7. 
  14. Centers for Disease Control and Prevention (CDC). Updated recommendations for use of tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccine in adults aged 65 years and older-Advisory Committee on Immunization Practices (ACIP), 2012. MMWR Morb Mortal Wkly Rep. 2012;61:468-470.

All electronic documents accessed April 11, 2013.