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Combination VaccinesCombination Vaccines
Partners in Prevention Coalition of Dodge County and City of Watertown
Spring 2014Betsy Peterson, MD
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Objectives• Identify common combination
vaccines used in practice• Understand indications and
contraindications to combinations• Understand differences in
schedules when patients have had combination vaccines
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Combination Vaccines
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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)
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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
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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**
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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”
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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. ***
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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
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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)
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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
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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
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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
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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
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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)
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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”
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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
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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!
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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
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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.
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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
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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)
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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!
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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
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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
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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.
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Questions?