Q and A Session

Moderator: Dr. Humiston, do you have any opening remarks?

Dr. Sharon Humiston: Yes, I just want to welcome folks, and say thank you for staying tuned to the question and answer part of the session.

Moderator: Thank you. Dr. Rudner Lugo, do you have any opening comments?

Dr. Nancy Rudner Lugo: Yes, I want to thank you all for participating; but, also I want to add that we can talk about the technical aspects in vaccination, but the real challenge is getting that needle and the adolescent arm at the same place, at the same time. That is why we really encourage immunizing early and often.

Moderator: Thank you. Our first question comes from our planning committee. If a patient should fail to come in for a follow-up appointment following the initial dose, can the HPV vaccine be administered at intervals greater than 2 and 6 months?

Dr. Rudner Lugo: Yes. Let me take that one. It is just like we did with the hepatitis B series. You do not start the series again. You give it when they are there. The intervals are minimal intervals. So, you need 24 weeks between the first and the last.  But, few adolescents come in that 6 month window. So, it is okay to spread it out, you do not need to start the series again.  And, sometimes there may be a year between the second vaccine and the third, and that is fine.

Dr. Humiston: I think that is a really important point, because you do not want to waste an expensive vaccine.

Dr. Rudner Lugo: And again, the reality with adolescents is that they are moving objects. They are hard to get, and it is helpful that this is a flexible schedule. But, as long as you get the minimal intervals, there is a lot of flexibility. We really still want to encourage those annual visits.

Moderator: Thank you.  Our next question comes from Ohio Pediatrics, Inc. Please go ahead with your question.

Participant: I recently had a conversation with a dentist who was very disappointed that the oral disease process of HPV was not addressed as much as the genital. Can you speak to that?

Dr. Humiston: I think that the oral cancers are much less common than the cervical cancer. And so, from a public health standpoint, more people are going to be worried about cervical cancer than the oral cancers. But, it is not to say that—as you are bringing up—it is not to say that it is the only reason for giving these vaccines. We talked in the slide session about children born through an infected birth canal can also have laryngeal papillomas, which you know are devastating. It is just that the numbers are small—much smaller than for cervical cancer. You bring up a good point.

Moderator: Thank you. Our next question comes from Minute Clinic. Please go ahead with your question.

Participant: Thank you. I am curious to know, what is your opinion on the need for a booster vaccine for the young ones who are receiving the meningococcal vaccine?  Do you think they will need the booster once they move on into their late teens, and move into college?

Dr. Humiston: I am speaking completely without data, because of course we have not had the new conjugate vaccine long enough to test how long it will last. I suspect it will be a long-lasting vaccine because—as we talked about in the slide session—it is a T-dependent vaccine. You know, this conjugation process makes it so that it activates your T-helper cells, and so usually those vaccines end up being long-lasting. So, I am suspecting it will be long-lasting. We also have to look at where is the highest risk of disease after infancy. In the adolescent age group, the peak is in that 17 to 20 years of age group. And, so we want to really make sure that the doses end before they are going to college and going to be living in a dormitory or going into military service and living in barracks.

Participant:  Yes, I agree. I have a follow-up question. Is there an active study pursuing that right now?  To see if a span of 7 years would indicate a revaccination?

Dr. Humiston: I do not know. I suspect that the CDC would be doing long-term surveillance.

Participant: Okay, thank you.

Dr. Rudner Lugo: Any time that a new vaccine comes onto the market, there are post-approval studies that continue. So, it is most likely that there is. And, I also want to add, research points out that meningococcal is a risk for college students and the military. I also have always wondered, well what about adolescents in that same age group, who are living in an apartment together or other close quarters? The problem was just not studied.

Participant: Yes. Well, true of camp, too, where they are 14-year olds, 13-year olds.

Dr. Humiston: Yes. Well, and in New York State, that is enough of an issue that that is part of the law now around meningococcal disease, because a state legislator lost a child or grandchild to meningococcal disease during camp. We also know that certain behaviors increase your risk of meningococcal disease. Smoking and drinking, in particular. So, luckily most of our 13-year olds are not doing that, but a lot of our college freshman are experimenting with those kinds of things.

Moderator: Thank you.  Our next question comes from Kalamazoo, Michigan.  Please go ahead with your question.

Participant: Last year we had a brief outbreak of pertussis in our community, and it influenced us enough that we are now considering giving Tdap to all postpartum moms before they leave the hospital.  And I wondered if your panel had any comments on this?

Dr. Humiston: Yes. ACIP does, they prefer, if a mom is not up-to-date on her tetanus and diphtheria during pregnancy, ACIP—the CDC advisory board—says to use TD. But, even they emphasize that if a woman does not need a routine TD during pregnancy, to definitely use Tdap postpartum. For the very reason you think, it is devastating. There is a story in Immunization Action Coalition's Web site about a mom who had a cough illness. No one suspected pertussis. She passed pertussis to her newborn, and the newborn died. How devastating. And, so it really seems to me, just like we want to protect that newborn through cocooning. We cannot protect him by giving him all the doses necessary to get the infant's immune system completely up to speed. That takes months. So, the best we can do for that infant is to cocoon him by having everybody around him vaccinated. And, this goes, also I have to say, for influenza. That is another thing for me. I think most parents are happy to take this vaccine. And, similar, with influenza, grandparents can take it. We have a little bit more of a problem with pertussis vaccine in grandparents. Because remember, we said there is no pertussis vaccine for anyone 65 years of age or older yet in the United States. So, you get into that discussion, where if you can get a healthcare provider who is willing to give it to an older person. We really need a pertussis vaccine for grandparents.

I also want to say, daycare providers. I think that there should be some kind of quality assurance that lets the parents know whether your daycare provider can be passing pertussis around, you know, an infant room.

Nancy, do you want to add anything?

Dr. Rudner Lugo: I think it goes back to—we have to reduce the prevalence of the disease in the community, so that we can reduce the incidence. The mother who was coughing with her infant, she was symptomatic. But, there are also asymptomatic carriers as well, which is part of the challenge. But, if we can get a cohort of adolescents well-immunized, then we make a dent, because adolescents have so much more contact with other people that they become this pool of passing the virus back and forth. We can really make a dent.

Immunizing—from what we have seen with the influenza recommendation for pregnant women—immunizing adults is always more difficult and the uptake rates are lower.

Moderator: Thank you. Our next question comes from Clark Summit.  Please go ahead with your question.

Participant: Thank you both for your presentation. This is amazing; some of the statistics and information. I wanted to touch base because I know that there has been a recent CDC bulletin out about in regard to measles outbreaks in the United States. Should we be concerned?

Dr. Humiston: Well, I think this is one of those things where there is so much international travel now. And that bulletin just highlighted all the countries that we are importing measles from. You know, it is not just Yemen anymore. And so, I do think we need to be concerned basically on 2 levels. One, we need to make sure that everybody gets their 2-dose series. And I think we are doing a pretty good job of that nowadays. I know, even when I went to graduate school, I had to get my second dose. So, I think we are doing a pretty good job of that.

But then, the other issue is storage and handling of the vaccine. I used to work in Georgia, and the Georgia State Health Department went out and started looking at storage and handling practices in offices and found that there were a lot of problems. And so, because measles, mumps, and rubella vaccine is a live-virus vaccine, you need to treat it with the same tender delicacy that you treat a pet. And, I always say, you would not leave your pet out in the car under all kinds of variable temperatures. Well, similarly you would not leave your MMR vaccine under all different kinds of temperatures because it is a living creature and needs to be handled gently and carefully. I think that that is another thing in terms of things to worry about—and I have a long list—that is one of them. And, your state will gladly come to your office and make sure that you are doing your storage and handling properly.

Dr. Rudner Lugo: My recommendation to you is for any office to have 2 immunization specialists—specialists in terms of the care of the vaccine from the minute it comes to your office. And, that person also—those 2 people could check one another—but also check the rotation of the stock and periodically observe the vaccine being given. A subcutaneous vaccine given IM may not be as effective and the same vice versa. The other part is, for efficiency, some offices they draw up the vaccine and they have it there waiting for that patient. And then, the clinician has a conversation with the patient about something else. And then, by the time someone else comes back, that vaccine has been out too long and it is not really as effective. We have compromised effectiveness.

Dr. Humiston: I live in Rochester, New York where we have real weather conditions. And, not this winter, but the winter before, Buffalo got hit with a snowstorm. There was electricity out everywhere, and so many offices did not have plans for controlling temperature. Again, being an emergency medicine doctor, I believe anything that can go wrong, will go wrong. And, that includes all kinds of disasters. So, having back-up plans, too, to secure your vaccine stock is really important, especially now that your vaccine stock, is worth so much money.

Dr. Rudner Lugo: I would also like to add the CDC has a wonderful tool kit on safety and handling of vaccines. And, on the CDC Web site you will find a lot of resources for vaccine storage and handling. As well as on www.immunize.org, which is the Immunization Action Coalition Web site.

Participant: Can I just ask another question?

Dr. Humiston: Sure.

Participant: In regard to HPV, I know that we talked a lot about adolescents—the preteen ages. I see some studies now that they are starting to look at extending that, and going into the midfifties.

Dr. Humiston: You are right that they are doing studies. This was presented at the National Immunization Conference. There is a lot of interest in vaccinating older women. The fastest rate of rise in sexually transmitted infections is actually in middle-aged women. But, the idea here is that although young women have traditionally been where sexual activity was occurring and, well they also have high risk because of a lot of columnar epithelial cells are exposed.  So, there is a study going on—and I think I mentioned in the slide presentation, too—there is a study going on to look at the use in males; but it is currently not licensed for that use, and obviously, not recommended.

Dr. Rudner Lugo: Well, the immunization schedule is always evolving. I mean, we have recently added the vaccines we are talking about today. If I understand correctly, the ACIP approved influenza vaccine, but now recommends it up to 18 years of age, phasing that in over the next season coming up. When you are using an immunization schedule—you can get them from the CDC Web site—it should come out every December, toward the end of December for the following year. So, be sure that the schedule that you are using has the current year on it.