Updates focus on new indications for 2011-2012 vaccines

NEW YORK — New indications for vaccines included in the routine immunization schedule were discussed at the 24th Annual Infectious Diseases in Children Symposium.

Michael T. Brady, MD, chair of the department of pediatrics at The Ohio State University/ Nationwide Children’s Hospital, and chair of the AAP’s Red Book committee, provided an update on new indications associated with the meningococcal conjugate vaccine; influenza, including information about egg allergies; and the human papillomavirus.

Meningococcal vaccine

This year, there were three key updates for meningococcal vaccines from the Advisory Committee on Immunization Practices, Brady said. The first was related to vaccination of patients at prolonged risk for the disease, such as those with complement deficiency, asplenia or HIV infection.

“For those who are at prolonged risk due to immunodeficiency and who have only received one primary does, a second dose should be given at first convenience as long as it is at least 2 months or more from the first dose,” Brady said.

If the child was aged 2 to 5 years when last vaccinated against meningococcal disease, there should be a 3-year interval between revaccination. Boosters for patients aged older than 5 years should be spaced 5 years apart, he said.

The second update referred to the FDA’s April approval of MCV4 (Menactra, Sanofi-Pasteur) as a two-dose primary series for children aged 9 to 23 months. Brady said although it is the first meningococcal vaccine licensed in the United States for children aged younger than 24 months, “there is no current routine recommendation for Menactra in infants.”

In general, the vaccine is recommended for infants aged 9 months or younger with persistent complement deficiency and those who travel or reside in meningococcal endemic locations. The vaccine is also indicated for children who are asplenic. But the vaccine is not recommended until 24 months of age because of a potential interference of the meningococcal vaccine and the pneumococcal conjugate vaccine.

According to Brady, there is evidence of interchangeability of the two products: “You should try to give the same, but it is possible to give two different vaccines.”

Brady also said there were concerns with current adolescent meningococcal vaccine recommendations; namely, that the antibodies have been shown to wane before peak incidence of the disease.

“Breakthrough cases are as severe as in those who never received the vaccine,” he said, adding that anamnestic response occurs but is not rapid enough to prevent invasive disease.

Influenza vaccine

The seasonal influenza vaccine for this influenza season is the same vaccine antigenically as last year, but Brady said it is important to inform patients that they should still be vaccinated for the 2011-2012 influenza season.

“Universal immunization of children 6 years of age or older is recommended, even though this year’s seasonal influenza vaccine strains are identical to last year’s strains,” he said.

For patients with egg allergy, all vaccines for 2011-2012 have ovalbumin of less than 0.7 mcg/0.5 mL, and skin testing is no longer necessary before administering the vaccine. After the administration of a single dose to those with egg allergy, patients should be observed for 30 minutes; the two-step graded challenge is no longer recommended, Brady said.

As for the increased rate of febrile seizures reported last year in concurrent administration of influenza and 13-valent pneumococcal conjugate vaccines, Brady said available data indicate that there is no need to give them at separate dates.

HPV and males

In October, ACIP recommended that males be routinely vaccinated against HPV. With this vaccine, there is efficacy in preventing HPV infection in males, Brady said. Similar to females, there is “no evidence of efficacy” in males already infected with HPV. In females, post-vaccine titers are significantly higher in 9- to 15-year-olds vs. 16- to 26-year-olds. This is expected to be the same in males. The most common adverse event was injection site reaction.

“The AAP statement is expected in March 2012 and will support the ACIP recommendation,” he said.

Regarding severe adverse reactions related to HPV vaccines, Brady said other than syncopy, studies have shown that “some events may be temporally related, but they are not causally related.” – by Whitney McKnight

Disclosure: Dr. Brady reports no relevant financial disclosures.

Paul A. Offit

Dr. Brady summarized several issues for vaccines that are important for the practitioner. First: Although one meningococcal vaccine is licensed for infants, more are on the way. Currently, the only recommendation for infant meningococcal vaccination is for infants at highest risk, such as those with complement deficiencies or those about to travel to sub-Saharan Africa, where the disease is prevalent. It will be interesting to see how the CDC and AAP respond when two other meningococcal vaccines are licensed for infants at 2, 4, 6 and 12 months of age. It is unclear whether either will receive a routine recommendation. Second: It is comforting to know that advances in protein purification have led to the production of influenza vaccines that now contain levels of egg proteins that are sub-immunogenic. Severely egg allergic children no longer need to be desensitized prior to receiving influenza vaccine. Given that about 0.5% of the population is severely allergic to egg proteins, this should make administering influenza vaccine programs much easier. Finally, we now have a recommendation to vaccinate boys and young men with HPV vaccine. This recommendation was a long time in coming. Males benefit from HPV vaccine because 1) HPV causes thousands of cases of oropharyngeal and anal and genital cancers every year in men; 2) HPV causes about 500,000 cases of anal and genital warts, which, although not fatal, are disfiguring and emotionally crippling; 3) women get HPV from men; and 4) men who have sex with men don't benefit from a female-only recommendation.

Paul A. Offit, MD
Infectious Diseases in Children Editorial Board member

Disclosure: Dr. Offit reports no relevant financial disclosures.

For more information:

• Brady M. Vaccines 2011-2012: An Update on New Indications. Presented at: the 24th Annual Infectious Diseases in Children Symposium; Nov. 19-20, 2011; New York.

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