Combination 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 vaccination

Per 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?