Vaccines TBL #1

Influenza vaccines

Influenza vaccines

• IIV4

• HD-IIV4 (Fluzone High-Dose®)

• ccIIV4 (Flucelvax®)

• RIV4 (Flublok®)

• aIIV4 (Fluad adjuvanted®)

• LAIV4 (FluMist®)

Influenza vaccine products

• Multi-dose vials

• single-dose vials

• prefilled syringes

Influenza vaccine types

• Inactivated vaccine (IIV4)

• Recombinant vaccine (RIV4)

• Live-attenuated vaccine (LAIV4)

Recommendations for Influenza vaccines

Age > 6 months(depends on brand)

Storage for influenza vaccines

Refrigerate (2 to 8°C) / Protect LAIV from light

Dosing/route of influenza vaccines

• Inactivated vaccine: 0.25-0.5mL IM (refer to package insert or CDC*)

• Live-attenuated vaccine: 0.1 mL each nostril

Children aged 6 months through 8 years, who have only received 1 lifetime dose, require 2 doses > 4 weeks apart

Vaccinate annually, ideally during September/October (may vaccinate throughout season)

Efficacy of influenza vaccines

Median 47% (dependent on age, co-morbidities, and match) – vaccination reduces symptomatic illness, medical visits, hospitalization, and death.

Note: immunity delayed ~ 2 weeks after vaccination

Contraindications of influenza vaccines

IIV4 and LAIV4:

• history of anaphylaxis to the influenza vaccine (ccIIV and RIV may be used with caution if previous reaction was to IIV or LAIV).

• Egg allergy no longer considered a contraindication.

LAIV4 only:

• Pregnancy

• immunocompromise

• children aged 2-4 y w/ asthma

• children/adolescents treated w/ aspirin/salicylates – risk of Reye syndrome

• treatment w/ influenza antivirals w/in past 48 h

ADRs (common) for influenza vaccine

IIV4/ccIIV4/RIV4/HD-IIV4/aIIV4: Transient injection site reactions predominate (e.g., pain lasting 1-2 d up to 65%)

LAIV4: Rhinorrhea and nasal congestion, fever (children aged 2-6 years), sore throat

ADRs (rare) for influenza vaccine

IIV: Febrile seizures in young children; increased risk if given on the same day as PCV13 and DTaP vaccines.

Special considerations for influenza vaccine

IIV4 is recommended for use during pregnancy

HD-IIV4, RIV4, aIIV4 ACIP preferred among patients aged > 65 years

COVID-19 vaccines

• Pfizer-BioNTech (COMIRNATY® 2023-24 version)

• Moderna (SPIKEVAX® 2023-24 version)

• Novavax (2023-24 version)

COVID-19 vaccine products

• COMIRNATY® and SPIKEVAX®: Suspension for injection (single dose)

• COMIRNATY®: Single dose prefilled syringes

COVID-19 vaccine types

• Pfizer and Moderna: mRNA vaccines

• Novavax: Protein subunit recombinant vaccine (spike protein plus adjuvant)

COVID-19 vaccine recommended ages

Pfizer and Moderna: Age > 6 months

Novavax: Age > 12 years

Storage of COVID-19 vaccines

Pfizer*:

1. Store in Ultra-cold freezer until expiration

2. After removing it from the ultra-cold freezer, the vaccine can be stored in a regular refrigerator for a ten weeks.

3. Before administering the vaccine, it should be brought to room temperature for around 12 hours

Moderna*:

1. Put in Freezer until expiration

2. refrigerator† x 30 d

3. before administering put vaccine room temp‡ x 24 h

4. It is Stable for12 h once punctured

Novavax:

1. Refrigerator

2. Protect from light

3. Stable for 12 h at 2 to 25°C once punctured

Dosing / Route for COVID-19 vaccines

Pfizer:

• Age 6 mo-4 years = 0.3mL (yellow cap/label)

• 5-11 y = 0.3mL (blue cap/label)

• 12+ = 0.3mL (gray cap/label) / IM

Moderna:

• Age 6 mo–11 y = 0.25mL (dark blue cap + green label)

• 12+ y = 0.5mL (dark blue cap/label) / IM

Novavax:

• Age > 12 y: 0.5mL IM x 1 (previously vaccinated w/ COVID vaccine) or x 2 doses 3 w apart (vaccine naïve)

Efficacy of COVID-19 vaccines

SPIKEVAX = 93% (preliminary data)

COMIRNATY= 95% (preliminary data)

Novavax=90%

Contraindications

Pfizer and Moderna: history of anaphylaxis or an immediate allergic reaction (e.g., hives, swelling, wheezing), even if not severe, to any ingredient in an mRNA COVID-19 vaccine – includes PEG (Novavax vaccines does not contain PEG)

ADRs (common) for COVID-19 vaccines

Local injection site reactions up to 90% (pain, erythema, swelling), fatigue up to 60-80%

fever up to 20-25%

chills up to 40-50%

headache up to 60-75%

myalgia up to 45-60%

ADRs (rare, but serious) for COVID-19 vaccines

Myocarditis and pericarditis: Chest pain, shortness of breath, feelings of a rapid/fluttering/pounding heart – rare, most common among adolescents and young adult males

Footnotes about COVID-19 vaccines

Do not re-freeze once vial is thawed; ^Temp = -90 to -60°C; †Temp = 2 to 8°C; ‡ Temp = 8 to 25° C; € Temp = -50 to -15°C.

Pneumococcal Vaccines

PCV15 (Vaxneuvance™)

PCV20 (Prevnar 20®)

PPSV23 (Pneumovax 23®)

Pneumococcal Vaccine products

• Vaxneuvance™, Prevnar 20®, Pneumovax 23®: Suspension for injection (0.5 mL dose), single-dose prefilled syringe

Pneumococcal Vaccine types

Conjugate vaccine (PCV) – Conjugated to a diphtheria toxoid protein and contains aluminum as an adjuvant Polysaccharide vaccine (PPSV)

Pneumococcal Vaccine recommended ages

PCV13, PCV15, PCV20: Age > 6 weeks (note: PCV13 no longer recommended, to be discontinued)

PPSV23: Age > 2 years

Pneumococcal Vaccine storage

Refrigerate (2 to 8°C)

Pneumococcal Vaccine dosing/route

PCV15/20: 0.5 mL IM – Refer to CDC/ACIP recommendations, with attention to high-risk conditions/dose spacing

PPSV23: 0.5 mL IM or SC – Refer to CDC/ACIP recommendations, with attention to high-risk conditions/dose spacing

Dosing/ spacing

   Dose 1             Dose 1 to Dose 2 

Minimum Interval                                                                                   Dose 3 to 4

Efficacy of Pneumococcal Vaccines

Pediatric: Since approval of PCV, invasive disease in children caused by serotypes in PCV7 and PCV13 declined 99% and 90%, respectively

Adult: PCV13 – 46% efficacy against vaccine-type pneumonia and 75% efficacy against invasive pneumococcal disease (note: immunogenicity of PCV20 comparable to PCV13)

Pneumococcal Vaccines contradictions

h/o anaphylaxis to the vaccine/components

ADRs (common) for Pneumococcal Vaccines

Injection site reactions predominate (pain, tenderness, swelling, erythema), decreased appetite, fatigue, headache, muscle pain, fever

ADRs (rare, but serious) for Pneumococcal Vaccines

Febrile seizures in young children if given on the same day as IIV

Special considerations for Pneumococcal Vaccines

Patients with functional or anatomic asplenia are at very high risk (up to 50X risk) for invasive pneumococcal disease and therefore require vaccination

Patients with a high-risk medical condition may receive either PCV20 or PCV15 followed by PPSV23 – when both PCV and PPSV are indicated, always administer PCV first.

Vaccines for Tetanus, Diphtheria, and Pertussis

• DTaP (Daptocel®, Infanrix®)

• DT (various)

• Tdap (Adacel®, Boostrix®)

• Td (Tenivac®, Tdvax®)

Vaccines (combination) for Tetanus, Diphtheria, and Pertussis

• DTaP-IPV (Kinrix®, Quadracel®)

• DTaP-IPV-Hib (Pentacel®)

• DTaP-IPV-HepB (Pediarix®)

• DTaP-IPV-Hib-HepB (Vaxelis®)

Product for Tetanus, Diphtheria, and Pertussis

• Single-dose vials: Daptocel® Tdvax®

• Infanrix: Single-dose, prefilled syringes

• Both: Adacel®, Boostrix®, Tenivac®

Vaccine type for Tetanus, Diphtheria, and Pertussis

Tetanus/Diphtheria = Toxoid

Pertussis = Inactivated acellular vaccine. Contains aluminum as an adjuvant.

Recommended age(s) for Tetanus, Diphtheria, and Pertussis

DTaP: Age > 6 weeks to < 7 y (age indications vary for combo vaccines). DT may be use in patients w/ pertussis C/I

Td: Age > 7 years

Tdap: Adacel age 10-64 years

Boostrix age > 10 years

• note: CDC/ACIP permits use of both Tdap vaccines in patients 7-10 years old, and permits use of Adacel in patients aged > 65 years if Boostrix is not available

Storage for Tetanus, Diphtheria, and Pertussis

• Refrigerate (2 to 8°C)

Dosing / Route for Tetanus, Diphtheria, and Pertussis

0.5mL IM – Refer to CDC/ACIP recommendations. Note: Boosters required to maintain immunity

CDC/ACIP recommendations

Efficacy for Tetanus, Diphtheria, and Pertussis

Following 3 doses… Tetanus = 99.99%, Diphtheria = 95%, and Pertussis = 80-85%

Contraindications for Tetanus, Diphtheria, and Pertussis

h/o anaphylaxis to the vaccine/components: Ingredients differ by brand (e.g., may contain latex, yeast, neomycin, polymyxin B, streptomycin)

Encephalopathy w/ unidentified cause < 7 d of DTaP/Tdap vaccination

ADRs (common) for Tetanus, Diphtheria, and Pertussis

DTaP: Local reactions (pain, erythema, swelling) 20-40% ( ↑ed with 4th/5th doses), low-grade fever (3-5%).

Td/Tdap: Pain (66-75%), erythema (25%), swelling (21%), low-grade fever (1-5%)

(Note: Td/Tdap contain a reduced quantity of diphtheria toxoid and pertussis antigens to reduce risk of ADRs in age > 7 years)

ADRs (rare, but serious) for Tetanus, Diphtheria, and Pertussis

Systemic reactions (e.g., fever >105°C, febrile seizures, crying >3 hours, hypotonic-hyporesponsive episodes) rare (<1 in 10,000 doses)

Arthus reactions (exaggerated local reactions such as severe pain, swelling, edema, and possibly necrosis near the injection site) – uncommon but may occur if someone is immunized too frequently

Special considerations for Tetanus, Diphtheria, and Pertussis

Tdap is recommended for use during pregnancy (administer early during 3rd trimester, 27-36 weeks gestation)