combination vaccines partners in prevention coalition of dodge county and city of watertown spring...
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Combination VaccinesCombination Vaccines
Partners in Prevention Coalition of Dodge County and City of Watertown
Spring 2014Betsy Peterson, MD
Objectives• Identify common combination
vaccines used in practice• Understand indications and
contraindications to combinations• Understand differences in
schedules when patients have had combination vaccines
Combination Vaccines
Infant Vaccines• 2mo, 4mo, 6mo:
– DTaP = Diphtheria, Tetanus, Pertussis (no available individual vaccines)
– IPV = Polio– Hep B = Hepatitis B– HiB-OMP (Pedvax HiB, 3 doses) OR HiB-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)
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
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**
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”
Pentacel – - DTaP - HiB - IPVGiven at – - 2mo - 4mo - 6mo - 15mo
*** Baby will get the 4th dose of IPV (polio) at 15mo, But still needs a dose after 4th birthday. ***
HiB options• Pedvax Hib (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
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)
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
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
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
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
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)
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, offVFC 4/1/14, private “early 2015”
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
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!
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
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.
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 vaccinationPer 2500 infants vaccinated; 7-8/10,000 vs. 3-4/10,000
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)
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!
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
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
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.
Questions?