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Updates from the Advisory Committee on Immunization Practices February Meeting

March 6, 2018 2 comments
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Photo Credit: James Gathany, Centers for Disease Control and Prevention

The Advisory Committee on Immunization Practices (ACIP) held its first meeting of 2018 on February 21st and 22nd.  The Committee consists of a panel of immunization experts that advise the Centers for Disease Control and Prevention (CDC).  Part of their charter is to continually evaluate new data and update or change vaccine recommendations as warranted. 

The agenda for the February 2018 meeting included presentations pertaining to several different diseases and vaccines, to include hepatitis, influenza, anthrax, HPV, pneumococcal, meningococcal and Japanese encephalitis.

A overview of the meeting is provided below, with details on presentations in the order they occurred: 

Hepatitis B

The committee voted unanimously to approve a non-preferential recommendation for a new Hepatitis B vaccine (Dynavax’s HEPISLAV-B™) to their list of recommended vaccines for adults 18 years and older against infections caused by all known subtypes of Hepatitis B.

This vote came following the presentation of data showing that the new two-dose vaccine generates a more rapid and higher antibody response than the standard 3 dose vaccine.

Hepatitis B is a viral disease of the liver that can become chronic and lead to cirrhosis, liver cancer and death. The hepatitis B virus is 50 to 100 times more infectious than HIV, and transmission is on the rise. In 2015, new cases of acute hepatitis B increased by more than 20 percent nationally and 850,000-2.2 million persons are estimated to be living with infection in the U.S.

Since there is no here is no cure for hepatitis B, vaccination is our best chance at preventing the disease. While about 90% of people are infected during infancy, in adults, hepatitis B is most often spread through contact with infected blood and through unprotected sex with an infected person. Some individuals who are especially susceptible include those who are immunosuppressed or living with diabetes. The CDC recommends vaccination for those at high risk for infection due to their jobs, lifestyle, living situations and travel to certain areas.

The Working Group summary suggested that this new vaccine option is likely to improve vaccine series completion and result in earlier protection, which is especially beneficial in persons with anticipated low adherence such as injection drug users.  Additionally, the improved immunogenicity in populations with typically poor vaccine response such as the elderly, diabetics and those on dialysis, is promising.  The ACIP will continue to review post-marketing surveillance studies and additional data to ensure safety and cost-effectiveness considerations.

Hepatitis A

The committee voted unanimously to pass three recommendations pertaining to Hepatitis A.

  • Hepatitis A vaccines should be administered for post-exposure prophylaxis for all persons 12 months of age or older.
  • Hepatitis A vaccine or immune globulin (IG) may be administered to persons 40 years of age or older, depending on the providers’ risk assessment.
  • Hepatitis A vaccine should be administered to infants age 6-11 months of age traveling outside the US when protection against hepatitis A is recommended. This recommendation takes into consideration the fact that infants under 12 months who will be traveling internationally will typically also need an MMR vaccine.  Since Hepatitis A immune globulin and MMR vaccine should not be administered simultaneously, these children should receive a single dose of HepA vaccine. It’s important to note that infants should then complete the full, 2 doses of MMR and HepA vaccines at 12 months of age as recommended.

Influenza

The Committee heard five presentations specific to influenza.

The first two were reports of current season data; one detailing flu surveillance, the other providing early influenza vaccine effectiveness data.

According to the update, the majority of circulating flu strains are similar to those contained in the 2017-2018 vaccine.  The only virus clearly showing antigenic drift was the B/Victoria lineage viruses which represents less than 1% of circulating viruses.  So far this season, influenza A (H3N2) has been dominant, with influenza B activity starting to increase more recently. Activity has been the highest we’ve seen since 2009, and while final severity can’t be determined until the end of the season, hospitalization rates and mortality could be similar to or exceed those send during the severe 2014-2015 season.

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Based on data from 4,562 children and adults with acute respiratory illness enrolled during November 2, 2017–February 3, 2018, at five study sites, the overall estimated effectiveness of the 2017–18 seasonal influenza vaccine for preventing medically attended, laboratory-confirmed influenza virus infection was 36%. The percentage differs by age group and by virus.  A detailed report can be found here.

The most notable news out of the Committee last week was the vote to restore the live attenuated influenza virus (LAIV) vaccine as an option for the 2018-19 season. LAIV is commonly known as the nasal spray flu vaccine or by its brand name, FluMist This renewed ACIP recommendation offers FluMist as one of several vaccine options for non-pregnant people who are 2-49 years of age during the 2018-2019 season, but does not indicate any preference for FluMist over injectable flu vaccines.

While FluMist has not been recommended for the past two flu seasons due to reduced effectiveness against the H1N1 flu strain in children, the Committee heard three presentations specific to LAIV vaccine efficacy in children prior to taking a vote on future recommendations for LAIV.  The first reported on the efficacy of Fluarix Quadrivalent in children 6-35 month of age. Another presented the results of a randomized trial of a new H1N1 LAIV strain in U.S. children. The third was a review LAIV in children 2-17 years of age.  

The possible root cause of the poor effectiveness of LAIV against H1N1 was discussed and poor replication of the H1N1 selected strain was thought to be the likely problem. A new strain selection process is now in place in cooperation with the Food & Drug Administration (FDA) and it suggested that the antibody responses of the latest reformulated version of the quadrivalent vaccine, which includes the new 2017-18 post-pandemic 2009 H1N1 LAIV strain (A/Slovenia), will perform significantly better than what was previously observed when the vaccine included the 2015-16 post-pandemic LAIV strain (A/Bolivia).  Immunogenicity and viral shedding data in small trials supported this notion, but no efficacy data is available at this time.

The Committee was therefore forced to a vote using only the science available to date. There was a lively discussion among members who expressed various concerns. While flu vaccine effectiveness is a serious issue, some committee members expressed concern that they may be holding FluMist to a higher standard than other influenza vaccines, yet all have efficacy challenges from year to year.  Other members were concerned with how the vaccine may perform in an H1N1 dominated season. Until the vaccine is used, further effectiveness assessments are performed, and a prominent H1N1 year occurs, a certain level of uncertainty will remain.

While members voted overwhelmingly (12-2) to reinstate LAIV on the immunization schedule, a second vote to give other flu vaccines a preferential recommendation over LAIV failed (11-3).  So, while the ACIP will not indicate a preference for any one type of flu vaccine over another, the public will ultimately determine whether there will be high uptake of this particular vaccine next season. Read more…

HPV Epidemic – Someone You Love Film – Watch It, Share It!

July 16, 2015 1 comment
Every Child By Two is pleased to welcome Linn to our social media team. Linn is a student intern who will be sharing her perspectives on vaccines with us through the eyes of a PhD candidate.  We hope you enjoy her first piece of the summer.

The HPV vaccine is recommended for all girls and boys ages 11-12.

This vaccine has the potential to prevent 70% of all cervical cancers and 90% of genital warts.

Why then is there such a low rate of vaccine uptake?

Only about 1/3 of girls aged 13-17 have been fully vaccinated and less than 14% of boys are fully vaccinated.

One study looked to identify the barriers to uptake of HPV vaccine and found that it was not the lack of perceived risk or vaccine safety that kept parents from vaccinating their children, but the perception that it would increase risky sexual behavior in adolescents even though there is no evidence that this will occur.HPV

As a young student, I remember learning about the HPV vaccine in high school. HPV was a sexually transmitted disease that was relatively unknown, but we learned that the vaccine would prevent certain cancers and genital warts. The knowledge that I gained about the ability for this vaccine to prevent these potential diseases prompted me to learn more about the HPV vaccine and increased my desire to receive it.

However, when I discussed it with my mother, an interesting process began to occur. She did not know any information about the HPV vaccine and when I spoke to her about the fact that it prevents a sexually transmitted disease, I could see a shift in her gaze as she narrowed her eyes. I sensed that she was hesitant because of the social stigma that surrounded a female who would get a vaccine that was related to sexual contact.

All of these opinions are related to a negative stigma around sexual behaviors that are not true.  And yet these are the thoughts I sensed were running through my mother’s head as she also considered what her own peers would think, as I am sure many others do.

Back then I perceived that the assumptions that are made about females that get an STD vaccine were:

a) She is promiscuous.

b) She is about to become promiscuous.

c) She wants to be promiscuous.

At the time, I even remember having a discussion with a teacher about the HPV vaccine and her speaking about how she refused to give her child the HPV vaccine because “they should not be giving 11-12 girls a vaccine to prevent a sexually transmitted disease”.   Now I understand that the 11-12 year old visit is the optimal visit, as it eliminates the connection of the vaccine with future sexual contact by integrating it within the routine vaccine schedule, which includes meningitis vaccines and a Tdap booster. In addition, I’ve learned that by waiting to provide the vaccine at a later date, many children fall through the cracks because they do not receive routine health care in their teen years. Read more…

HPV Vaccine is All About Cancer Prevention

January 24, 2013 91 comments

In recognition of Cervical Cancer Awareness Month, Dr. Lara Zibners* has contributed this guest post on the importance of HPV vaccination for both girls and boys.

DrZibnersLast year I went on a cycling weekend out in California with four other women, all of us doctors. We were there to celebrate my dear friend’s recovery from breast cancer. Of course there was the usual debauchery– feather boas included– that takes place when 5 middle-aged women have left their husbands in charge of the children. But there was still a sense of sobriety, knowing why we were all there and wishing that “chemo” and “reconstructive surgery” weren’t the frequent topics of conversation that they were. And with cancer on our minds, this group of five female physicians soon found ourselves talking about—what else?—genital warts.

The OB-Gyn in the group waxed poetically about how excited she was to immunize her patients against HPV—the human papillomavirus. It’s long been known that HPV is responsible for nearly all cases of cervical cancer in women. HPV is a nasty little virus that spreads from skin-to-skin, person-to-person. Often this occurs during sexual contact but can also be passed from mother to child. Many people infected with HPV don’t even realize it, meaning they continue to pass the infection to others. Hence the some 6 million people infected every year with HPV.  And while HPV causes unsightly genital warts, that’s not what bothers physicians about it. What bothers us is that HPV causes cancer. And cancer, to put it bluntly, sucks.

Good news is there’s a vaccine that can protect us from the most common strains of HPV that cause cancer. It is currently recommended that girls between the ages of 11 and 12 receive 3 doses of the vaccine. As of 2011, this was extended to include the routine vaccination of boys. Naturally this caused a stir, since HPV is usually blamed for causing cervical cancer. And a boy isn’t supposed to have a cervix. So what was this? An act of chivalry? A sort of “holding the door” open so cancer wouldn’t whack a girl in the head? Read more…

A Parent Perspective on Preventing HPV

January 4, 2012 3 comments

By Amy Pisani

Recently, my eleven year old son had an appointment for his annual well-visit with his pediatrician.  I strongly believe that these routine visits are one of the most important tasks we, as parents, undertake to ensure that our children are developing properly. 

As I accompanied him on this visit, I couldn’t help but recall my first post-delivery visit to the pediatrician when he was just a precious little baby.  After the full work up, the doctor answered our innumerable questions about caring for our newborn.  But what remains so vivid in my mind is when he stuck out his hand and offered me a hardy congratulation for a job well done.  Self centered as that memory may be, it was the first time someone other than my husband had given me credit for nurturing this tiny human as he grew from an embryo into a ten-fingered, ten-toed, healthy breastfed baby.  It was then that I realized the enormity of being a parent – that my husband and I were completely responsible for the future health and well-being of this child.

As the days and months flew by we visited the pediatrician regularly for his well-baby checkups, which of course included essential vaccinations against dangerous diseases.  Unfortunately, this was before the influenza vaccine was universally recommended and our son had to be hospitalized twice by the time he turned two for complications from bouts of influenza.  We learned how rapidly an infant can succumb to what many people still consider a common and less dangerous disease.  Fortunately he overcame each illness, as well as dozens of other common viruses and respiratory infections over the years.

Now in our twelfth year of parenting I look at this boy, who will undoubtedly surpass me in height within the year, and I recognize that we still have a long road of parenting ahead.    As we teach him right from wrong and lay down the rules of our home, we seek to raise a healthy, wise and well rounded individual who will grow into a happy adult who can contribute to our society in a positive manner.

As his mother, it is difficult to accept that my son is on the cusp of becoming a teenager, and I can only hope that we have set him on a course that will permit him to achieve his greatest dreams.  But what is more difficult to accept is that someday in the future (hopefully the distant future) he will become sexually active.  And so, we must prepare him for this eventuality by protecting him as best we can from diseases such as Herpes, HIV and Human Papilloma Virus (HPV).  Certainly we will teach our son about the need for diligent personal prevention through the use of condoms.  However, with the availability of a safe and effective vaccine to prevent HPV for both our son and his future sexual partner(s), we feel it is also our responsibility to protect him through vaccination as well.   Read more…

HPV Vaccine: What’s Good For the Goose Is Good For the Gander

October 26, 2011 13 comments

There has certainly been a great deal of media coverage regarding yesterday’s vote from the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC) in favor of recommending Human Papillomavirus (HPV) vaccine for boys.

As the mother of five girls, I am happy to hear this.  Although my daughters will all receive the HPV vaccine, I’ve always wondered why females were being tasked with reducing the spread of a virus that can be transmitted through genital contact.   After all, HPV transmission often involves parties from both sexes.  So, while previous recommendations to vaccinate girls have had the potential to lower the rates of HPV transmission, unless there is a large majority of girls vaccinated (which, as of yet, there isn’t), the fact is HPV will continue to be spread among a sexually active population that includes both men and women.

So, a new decision has been made and the ACIP recommendation is to vaccinate boys as well.  But it’s wasn’t such a simple matter.  The recommendation was based on specific evidence that illustrated a cost-benefit of vaccination that will reduce the incidence of certain cancers in males.

What we know about the HPV virus. Read more…