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Combination Vaccines

Combination Vaccines. Partners in Prevention Coalition of Dodge County and City of Watertown Spring 2014 Betsy Peterson, MD. Objectives. Identify common combination vaccines used in practice Understand indications and contraindications to combinations

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Combination Vaccines

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  1. Combination Vaccines Partners in Prevention Coalition of Dodge County and City of Watertown Spring 2014 Betsy Peterson, MD

  2. Objectives • Identify common combination vaccines used in practice • Understand indications and contraindications to combinations • Understand differences in schedules when patients have had combination vaccines

  3. Combination Vaccines

  4. Infant Vaccines • 2mo, 4mo, 6mo: • DTaP = Diphtheria, Tetanus, Pertussis (no available individual vaccines) • IPV = Polio • Hep B = Hepatitis B • HiB-OMP (PedvaxHiB, 3 doses) ORHiB-PRPT (ActHib, 4 doses) = Hemophilus influenza, Type B • Prevnar 13 = Pneumococcus, 13 serotypes • RV5 = Rotateq (5 serotypes, 3 doses) OR RV1 = Rotarix (1 serotype, 2 doses)

  5. DTaP • Daptacel – Sanofi, 6wk to <7yr • Infanrix – GSK, 6wk to <7yr • Pediarix – also includes IPV, Hep B; GSK, 6wk to <7yr • Pentacel – also includes IPV, HiB; Sanofi, 6wk to <7yr • Kinrix – also includes IPV; GSK, 4yr to <7yr

  6. Tdap • Boostrix – GSK, single dose*, 10yr “and older” • Adacel – Sanofi, single dose*, 10yr to 64yr • **off-label used for 7-10yr if previously undervaccinated; off label for use with each pregnancy**

  7. Pediarix – - Hep B - DTaP - IPV Given at – - 2mo - 4mo - 6mo ** Baby will get 4 doses of Hep B, which is acceptable. MUST have 16 weeks between dose 1 and 3 (or 4) AND be At Least 24 weeks old for dose 3 (or 4). **Dose 3 of 4 is marked “invalid”

  8. Pentacel – - DTaP - HiB - IPV Given at – - 2mo - 4mo - 6mo - 15mo *** Baby will get the 4th dose of IPV (polio) at 15mo, But still needs a dose after 4th birthday. ***

  9. HiB options • PedvaxHib (Merck) – 3 doses at 2mo, 4mo, 12-15mo • ActHib (Sanofi) – 4 doses at 2mo, 4mo, 6mo, 12-15mo • Pentacel (Sanofi) – 4 doses at 2mo, 4mo, 6mo, 12-15mo • Hiberix (GSK) – 12-15mo booster dose only • ComVax (Merck) – includes Hep B, 3 doses at 2mo, 4mo, 12-15mo

  10. An aside about buying groups… • Vaccines are expensive • Buying groups allow offices or companies to save significant money by agreeing to purchase certain types of vaccines • Examples – • GSK “when available” (Pediarix, Rotarix, Havrix, Kinrix, Boostrix), choose a Hib brand. • Merck/Sanofi “when available” (Pentacel, Rotateq, ActHib OR PedvaxHib, Adacel, Vaqta)

  11. Sample Pediarix schedule • Birth – Hep B • 2mo – Pediarix (DTaP-Hep B-IPV), Prevnar 13, Hib-OMP, Rotarix • 4mo – Pediarix, Prevnar 13, Hib-OMP, Rotarix • 6mo – Pediarix, Prevnar 13 • 15mo – Infanrix (DTaP), Hib-OMP

  12. Sample Pentacel schedule • Birth – Hep B • 2mo – Pentacel (DTaP-HiB-IPV), Prevnar 13, Hep B, Rotateq • 4mo – Pentacel, Prevnar 13, Rotateq • 6mo – Pentacel, Prevnar 13, Hep B, Rotateq • 15mo - Pentacel

  13. But what about…? • Shortages • Kids who move/transfer to a different clinic • Occasionally clinics will have certain combo vaccines for private vs. VFC • When your office is changing from one combo to another

  14. Kindergarten age • Due for – • DTaP (#5) – Infanrix, Daptacel, or Kinrix (DTaP-IPV) • IPV (#4) – IPOL or Kinrix • MMR (#2) – MMRII or Proquad • Varicella (#2) – Varivax or Proquad

  15. MMR and Varicella – Separate**or as Proquad DTaP and IPV – Separate or as Kinrix ***MMR and Varicella (and FluMist) can be given – On the same day, or separated by 28 days (4wk)

  16. ComVax • HiB plus Hep B – Merck, 3 doses • 2mo, 4mo, 12-15mo • Less common with Pediarix and Pentacel, but may appear on historical records • Discontinued production, off VFC 4/1/14, private “early 2015”

  17. TwinRix • Hep A and Hep B – GSK, 3 doses • For 18 years and older • Given as 0, 1 and 6mo doses • For adults who have not completed either Hep A or Hep B series

  18. Why Combo vaccines? • Less pokes! • If no combo vaccines were used (when available) – • DTaP 5 doses - MMR 2 doses • Polio 4 doses - Varicella 2 doses • HiB 3-4 doses - Hep A 2 doses • Hep B 3 doses - Influenza 6 doses* • Prevnar 4 doses 28-32 injections by age 5!

  19. Why Combo vaccines? • At 2, 4, 6mo – 2-3 injections vs. 5 each visit (plus one for flu at 6mo) • At kindergarten – 2-3 instead of 4! • 20-24 injections (vs. 28-32) by age 5

  20. Why not Combo vaccines? • Immunization administration fees have classically been “per injection” • More pokes = more money • Now <19yr has administration codes for “per component, with counseling” • Pediarix = 5 components, DTaP = 3 components, HiB = 1 component, etc.

  21. What about safety? • Immunizations are very closely regulated and monitored for safety • ProQuad has an advisory of slightly increased risk of febrile seizures when given at 12-23mo compared to MMR and Varicella given separately on the same day at 12-23mo. No difference seen with the booster dose. 1 additional febrile seizure at 5-12 days after vaccination Per 2500 infants vaccinated; 7-8/10,000 vs. 3-4/10,000

  22. Historical/Future Combos • TriHibit – DTaP and HiB-PRP – Sanofi, discontinued 2011 (Pentacel) • Hexaxim – DTaP-IPV-Hep B-HiB – Sanofi, approved for WHO use outside US and Europe (no reconstitution required)

  23. A note about errors… • Double check – the components, age (<7?), minimum intervals, right patient, route of admin (IM/SQ), dilution liquid, storage, lot numbers • Computers are good, but not perfect – if it doesn’t match up or gives an error message, ASK!

  24. Pentacel • Pentacel – one vial is DTaP-polio, 2nd vial is Hib – NEED BOTH! • Missing component needs to be repeated - wrong diluent (repeat both) vs. only gave liquid

  25. ProQuad • MMR-V contains varicella, so needs to be in the freezer – pay attention to what the shipping container says! • MMR and varicella and ProQuad are given sub-Q, not IM

  26. Kinrix • Approved for 4-<7 years • Dose does NOT need to be repeated if given outside of this range, counts as valid, but higher risk of side effects.

  27. Questions?

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