Additional vaccine topics covered at ACIP meeting

Abstract

The following is the second of two articles covering vaccine topics discussed at the February 2013 Advisory Committee on Immunization Practices (ACIP) meeting. Please see last month's Immunization Update for additional information. The last ACIP recommendation regarding Haemophilus influenza (Hib) vaccine was published in 1993, and no changes to the routine use of Hib have been made since that time. Available vaccines on the U.S. market are the following:■Polysaccharide-protein conjugate (PRP) vaccines. (1) PRP-OMP (Ped- vaxHIB—Merck), 1990: 2, 4 months and booster at 12–15 months; (2) PRP- T (ActHIB—Sanofi Pasteur), 1993: 2, 4, 6 months and booster at 12 to 15 months; (3) PRP-T (Hiberix—Glaxo- SmithKline), 2009: booster only.■Combination vaccines. (1) PRP- OMB/Hep B (Comvax—Merck), 1996: 2, 4, 6 months and booster at 12 to 15 months; (2) PRP-T/DTaP/IPV (Pentacel—Sanofi Pasteur), 2008: 2, 4, 6 months and booster at 15–18 months; (3) PRP-T/MenCY (MenHibRix—GlaxoSmithKline), June 2012: 2, 4, 6 months and booster at 12–15 months booster, only if meningococcal vaccine is indicated. Guidance for special populations, high-risk groups, and chemoprophylaxis for Hib will be clarified in the new statement. HibMenCY was recommended by ACIP for use only in high-risk meningococcal groups. Updates to three sections of the general recommendations were presented. Timing and spacing. Previous recommendations in the section on timing and spacing of immunizations defined the "grace period rule" as a 4-day period in which sequential doses of the same vaccine can be given earlier than the minimum interval or minimum age. However, the grace period does not apply to the administration of two live vaccines—MMR (measles-mumps-rubella) and varicella—as one vaccine may interfere with the other if given before 28 days. Therefore, the live vaccine rule prevents the use of the grace period rule.■ACIP recommended HibMenCY only in meningococcal high-risk groups.■Three sections of the general recommendations on immunization were updated. ■ACIP recommended HibMenCY only in meningococcal high-risk groups.■Three sections of the general recommendations on immunization were updated. Another component of the section on timing and spacing clarifies previous information regarding a slight increase in febrile seizures when influenza vaccine and PCV13 are given simultaneously (one additional occurrence per 2,200 doses given). ACIP felt that because the risk is low and the incidence of disease is high, these vaccines should be given together. One exception to the simultaneous administration of two inactivated vaccines is MenACWY (Menactra—Sanofi Pasteur) with PCV13 in patients with asplenia, as evidence exists of interference of PCV13 response. Contraindications and precautions. Concern exists regarding monitoring hospitalized patients for fever after they have received a vaccine and giving bacterial vaccines before splenectomy. Also, some weak evidence suggests that anesthesia decreases immunity (not to vaccination). Another issue is the administration of vaccine to patients with a previous history of Guillain-Barré syndrome (GBS). No cases have been reported of recurrent GBS following influenza or tetanus vaccination. Therefore, this is a precaution only if the previous GBS occurred within 6 weeks of a vaccine. No contraindication to any vaccine exists if the patient has had GBS in the past. Individuals vaccinated outside the United States. The section on individuals vaccinated outside the United States (in the special situations section) required clarification, especially if the records are not clear. Current recommendations state that self-reporting is sufficient for influenza and polysaccharide pneumococcal vaccine (PPSV). The concern is based on increased incidence of adverse effects if the interval between PPSV doses is less than 5 years. Because the number of countries that administer PPSV is low, the working group felt that self-reporting of PPSV should be dropped. These issues only involved discussion; no voting occurred. The Institute of Medicine (IOM) was tasked to review the childhood immunization schedule and assess outcomes comparing children who did and did not follow the schedule. Safety was a major emphasis. IOM conducted information- gathering meetings with the public and a literature review and recommended the following: (1) the National Vaccine Program Office (NVPO) should assess public concerns with the goal of improving communication; (2) NVPO should clarify and standardize key elements of the schedule and adverse events; (3) the Department of Health & Human Services (HHS) should study the safety of the schedule for epidemiology evidence, biological plausibility, and feasibility; (4) HHS should not perform randomized controlled trials to compare safety for unvaccinated children due to the unethical design; and (5) HHS should fund and support studies of this type.