Vaccination in women from adolescence to menopause

1. Vaccination in
Women-
Adolescence to
Menopause
Dr Meenakshi Sharma
MD (Obs & Gynae) (AIIMS), FICMCH
Senior Consultant Obs & Gynae
Yashoda Superspeciality Hospitals, Kaushambi
Shanti Mukund Hospital, Delhi

2. References
•ACIP 2017
•FOGSI 2014
•CDC
•ACOG 2014
•WHO 2014

3. Adolescence

4. Vaccination in adolescence
• Vaccination important for adolescents and adults
• 80-85% effective in preventing infectious
diseases
• One third of unimmunised children in world live
in India
• Vaccination coverage – 60-65% in India till 2014
• Mission Indradhanush launched to immunise all
children in 2015 - Target 90% coverage by 2020
• Diphteria and pertusis still endemic in country

5. Adolescence
• Routine Vaccination
• Tdap
• HPV
• Influenza*
• Meningococcal Vaccine*
• Catchup Vaccination
• Hepatitis B
• MMR
• Varicella
• Hepatitis A
• Vaccine in certain
situations
• Pneumococcal
conjugate
• H. Influenza B (Hib)
• Hepatitis A
• Meningococcal
• Pnemococcal
conjugate
ACIP 2017
*Influenza and Meningococcal vaccine to be given in certain
situation according to IAP 2016

6. Vaccination in adolescents IAP
2016
• Routine Vaccination
• Tdap
• HPV
• Vaccine in High risk
children
• Influenza Vaccine
• Meningococcal Vaccine
• Japanese Encephalitis
Vaccine
• Cholera Vaccine
• Rabies Vaccine
• Yellow Fever Vaccine
• Pneumococcal
Polysaccharide vaccine
(PPSV 23)
• High Risk Children
• HIV
• Chronic pulmonary,
renal, hematological,
diabetic
• Immunosuppressive Rx
• Malignancies
• Functional / anatomic
asplenia or hyposplenism
• Children with pets at
home
• Travellers
• Disease outbreak

7. Tetanus Diptheria and acellular
Pertusis (Tdap)
Routine vaccination:
• Administer 1 dose of Tdap vaccine to all adolescents
aged 11 through 12 years.
• Tdap may be administered regardless of the interval
since the last tetanus and diphtheria toxoid–
containing vaccine.
• Administer 1 dose of Tdap vaccine to pregnant
adolescents during each pregnancy (preferably during
the early part of gestational weeks 27 through 36),
regardless of time since prior Td or Tdap vaccination.

8. Tetanus Diptheria and acellular
Pertusis Tdap
Catch–up vaccination:
• Persons aged 7 years or more who are not fully immunized
with DTaP vaccine should receive Tdap vaccine as 1 dose
(preferably the first) in the catch–up series; if additional
doses are needed, use Td vaccine.
• For children 7-10 yrs who receive a dose of Tdap as part of
the catch–up series, an adolescent Tdap vaccine dose at
age 11-12 yrs may be administered.
• Persons aged 11-18 yrs who have not received Tdap vaccine
should receive a dose, followed by tetanus and diphtheria
toxoids (Td) booster doses every 10 years thereafter.
• Inadvertent doses of DTaP vaccine to an adolescent 11-18
yrs, the dose should be counted as the adolescent Tdap
booster.

9. HPV Vaccination
• FOGSI, ACIP, ACOG, RCOG recommends HPV
vaccination in all adolescents for protection
against cancer cervix.
• 9-14 years two dose schedule – 0 and 6 month
• 14 years and above - three dose schedule

10. HPV Vaccine ACIP (2017)
Routine Vaccination
• Administer a 2–dose series of HPV vaccine on a
schedule of 0, 6–12 months to all adolescents aged 11
or 12 years. The vaccination series can start at age 9
years
Catchup vaccination
• Age of initiation of vaccine < 15 years – 2 dose
schedule – 0, 6-12 months
• Age of initiation of vaccine >15 years – 3 dose
schedule -0, 1-2 and 6 months

11. HPV Vaccine ACIP (2017)
2 Dose schedule 3 Dose schedule
Dose Min interval Dose Min Interval
1st & 2nd 5 mth 1st & 2nd 4 wks
2nd & 3rd 12 wks
1st & 3rd 5 mths
If the 2nd dose is administered at a shorter
interval, a 3rd dose should be administered a
min of 12 wks after the 2nd dose and a min
of 5 mths after the1st dose.
If a vaccine dose is administered at a shorter
interval, it should be readministered after another
minimum interval has been met since the most
recent dose
A vaccine dose administered at a shorter interval should be
readministered at the recommended interval.
Special populations:
For children with h/o sexual abuse or assault, administer HPV vaccine beginning
at age 9 yrs.
Immunocompromised persons, including those with HIV should receive a 3–dose
series at 0, 1–2, and 6 months, regardless of age at vaccine initiation

12. HPV Vaccine ACIP 2017
• HPV Vaccine
• Bivalent (Cervarix)– HPV 16 and 18
• Quadrivalent (Gardasil)– HPV 6,11,16 and 18,
• 9-valent (Gardasil9) – HPV types 6,11,16,18, 31, 33,
45, 52, and 58.
• All three vaccines have been approved for
administration in a 3-dose series
• In October 2016 FDA also approved 9vHPV for use
in a 2-dose series for 9-14 yrs
MMWR 2016

13. Rationale of 2 dose schedule -
HPV
• Immunogenicity of 2 dose schedule is non-inferior to
3 dose schedule in age group 9-14 years for 9vHPV,
4vHPV and 2vHPV in various studies
JAMA, 2016, CDC, 2016
• 9vHPV may be used to continue or complete vaccine
schedule of 4vHPV or 2vHPV
• Interrupted schedule- if the schedule is interrupted it
does not need to be restarted. The number of
recommended dose depend on the age of initiation
MMWR, 2017

14. Immunogenicity and HPV infection after one, two,
and three doses of quadrivalent HPV vaccine in
girls in India: a multicentre prospective cohort
study
Unmarried girls aged 10-18 years recd 4HPV from
Sept 1, 2009 to Apr 8, 2010 in 9 centres, 188
clusters, 17,729 girls
• Three doses 0, 60, 180 days –n- 4348 (25%)
• Two doses 0 and 180days-n- 4979 (28%)
• Two doses by default 0 and 60 days- n- 3542 (19%)
• One dose only by default- n-4950 (28%)
Sahnkarnarayan R et al, Lancet, 2016

15. Immunogenicity and HPV infection after one, two,
and three doses of quadrivalent HPV vaccine in
girls in India: a multicentre prospective cohort
study
• Immune response in the two-dose HPV vaccine
group was non-inferior to the three-dose group
(median fluorescence intensity ratio for HPV 16 1·12 [95% CI 1·02–
1·23] and for HPV 18 1·04 [0·92–1·19]) at 7 months, but
was inferior in the two-dose default (0·33 [0·29–0·38]
for HPV 16 and 0·51 [0·43–0·59] for HPV 18) and one-dose
default (0·09 [0·08–0·11] for HPV 16 and 0·12 [0·10–0·14] for HPV
18) groups at 18 months.
Sahnkarnarayan R et al, Lancet, 2016

16. • The geometric mean avidity indices after fewer than
three doses by design or default were non-inferior to
those after three doses of vaccine.
• Fewer than three doses by design and default
induced detectable concentrations of neutralising
antibodies to all four vaccine-targeted HPV types, but
at much lower concentration after one dose.
• The testing of at least two samples from 838
participants showed that there was no persistent HPV
16 or 18 infections in any study group at a median
follow-up of 4·7 years (IQR 4·2–5·1).

17. The Lancet Oncology 2016 17, 67-77DOI: (10.1016/S1470-2045(15)00414-3)
Copyright © 2016 International Agency for Research on Cancer. Published by Elsevier Ltd/Inc/BV. All
rights reserved. Terms and Conditions

18. Influenza – ACIP 2017
• Influenza more severe in <5 years, >65 years,
pregnant women and person with underlying illness
• Administer 1 dose of Inactivated influenza vaccine to
all children more than 9 years
• LAIV is not recommended for influenza 2016-1017
• Both Trivalent IIV3 and quadrivalent IIV4 are
recommennded
• IIV3 – influenza A/california/7/2009(H1N1) like virus,
A/Hongkong/4801/2014(H3N2) and
B/Brisbane/60/2008 like virus, Victoria lineage
• IIV4 – additional influenza B virus strain
B/Phuket/3073/2013 Yamagata lineage
MMWR, 2016

19. Influenza Vaccine Preparation
Vaccine Strains Manufacturer Dose &
Route
Age
Vaxigrip Trivalent Sanofi 15mcg each
HA strain IM
>3 years
Vaxiflue Quadrivalent Zydus 15mcg each
HA strain IM
>3 years
Fluzone Trivalent high
dose
Sanofi 60mcg each
HA strain IM
>65 yrs
Fluzone Quadrivalent Sanofi 9mcg each
HA strain ID
18-64 years

20. Meningococcal Vaccine IAP 2016
• Recommended only for certain high risk group of
children, during outbreaks, and international
travelers to Hajj and sub-Sahara Africa.
• Meningococcal vaccine available in India
• Conjugate vaccines (Quadrivalent MenACWY-D,
Menactra® by Sanofi Pasteur and Monovalent group A,
PsA–TT, MenAfriVac® by Serum Institute of India)
• Polysaccharide vaccines (bi- and quadrivalent)
• Conjugate vaccines have potential for herd protection
and their increased immunogenicity, particularly in
children <2 years of age.
• Quadrivalent conjugate and polysaccharide vaccines
are recommended only for children 2 years and
above. Monovalent group A conjugate vaccine, PsA–TT
can be used in children above 1 year of age.

21. Catch up vaccination Adolescence
– Hepatitis B
• Administer the 3-dose series to those not previously
vaccinated
• Vaccine monovalent Hepatitis B- Recombivax HB
(Merck & Co), Engerix B (GlaxoSmithKline)
• Unvaccinated - 0.5 ml (paediatric dose)
• 0,1-2 month, 6 month
• 0, 1, 4 month
• 0, 2, 4 month
• Engerix 0,1,2,12 month is approved for all ages
• Children 11-15 years – Hep B – 2 dose schedule ( adult
dose Recombivax HB )- (0, 1 month)

25. Measles,Mumps and Rubella
vaccination
• Live attenuated vaccine
• MMR 2 doses 4 weeks apart (Priorix by GSK)
• Adverse reactions rare
• Mild rash
• Fever
• Pain
• Lymphadenitis
• Thrombocytopenia
• Serious allergic reactions very rare
• Avoid Pregnancy for three month
• If pregnancy occurs within 4 weeks of vaccination there is
a very small chance of the fetus being born with CRS and
usually follow and close monitoring with USG is advised
instead of pregnancy termination .
FOGSI 2014

26. Catchup Vaccination - MMR
vaccine
• Ensure that all school-aged children and adolescents have had
at least 2 doses of MMR vaccine (3 doses if the 1st dose is
received before 12 months) ;
• The minimum interval between the 2 doses is 4 weeks.
IAP 2016
• MMR not required if
• Proof of vaccination with live attenuated vaccine
• Proof of exposure to measles, mumps and rubella
• MMR not to be given
• Pregnancy
• h/o life threatening allergic reaction to vaccine, gelatin and
neomycin
• h/o HIV, immunocompromised state, cancer drugs, steroid
treatment, blood disorder, moderate or severe illness,

27. Catchup vaccination – Hepatitis A
• Pre vaccination screening for Hepatitis A
antibody is recommended in children older than
10 years as at this age the estimated sero-
positive rates exceed 50%
• Inactivated HepA vaccine – 0, 6-12 months
• Live attenuated H2-strain Hepatitis A vaccine -
Single dose

28. Catchup Vaccination - Typhoid
• Recommended throughout the adolescent period, i.e.
up to 18 years of age
• Typhoid conjugate vaccines (Vi-PS): single dose
• Typbar-TCV®
• Pedatyph®
• Vi-PS (polysaccharide) vaccines: single dose every 3
years;
• An interval of at least 4 weeks with the MMR vaccine
• Vi conjugate typhoid vaccine should be preferred
over Vi-PS vaccine wherever feasible
• The need and exact timing of the booster doses are
not yet determined

29. Vaccine Dose Type of vaccine Comment
Cholera Two doses 2 weeks Vaxchora –Oral, live
attenuated
Only in highly endemic areas and
traveling to areas where risk of
transmission is very high like Kumbh
mela, etc
Rabies Post-exposure prophylaxis
- 0, 3, 7, 14, and 30 days
Pre- exposure -0, 7 and
28
Human Diploid Cell Vaccine
(HDCV), Purified Chick
Embryo Cell (PCEC) vaccine,
Purified Duck Embryo Vaccine
(PDEV); 0.5 ml for Purified
Vero Cell Vaccine (PVRV).
significant contact with dogs, cats,
cows, buffaloes, sheep, goats, pigs,
donkeys, horses, camels, foxes,
jackals, monkeys, mongoose,
squirrel, bears and others. Domestic
rodent (rat) bites do not require
post exposure prophylaxis in India
Japanese
encephalitis
2 doses 4 weeks apart Inactivated cell culture
derived SA-14-14-2 (JEEV® by
BE India)
Inactivated Vero cell culture-
derived Kolar strain,
821564XY, JE vaccine
(JENVAC® by Bharat Biotech)
Endemic areas or outbreaks only
Varicella 2 doses 4 weeks apart Varivax, live attenuated With no evidence of immunity
Pneumoccal Single dose PPSV 23 Immunocompromised state
Vaccination in certain situations -
Adolescents

32. Preconception

33. Preconception - Vaccines
Window of opportunity to vaccinate susceptible
individuals
• MMR
• Varicella
• HPV
• Influenza
• Tdap/Td
• Hepatitis B

34. Preconception counselling – Key
Points
• Determining immune status for Rubella, varicella and
Hepatitis B is an important component of
Preconception counselling
• Unvaccinated women must be vaccinated for MMR,
Varicella, Hepatitis B, and Tdap to prevent perinatal
infection
• Catchup vaccination should be given for HPV prior to
conception
• Women receiving Live viral vaccines should be
advised to avoid pregnancy for 4 weeks to avoid
theoretical risk of live virus reaching fetus

35. Preconception immunization
• Rubella infection in susceptible women in pregnancy
leads to CRS
• First trimester – 85% CRS
• 13-16 weeks – 54% CRS
• Late second trimester – 25%
• Varicella infection in pregnancy
• Increased perinatal and maternal morbidity and mortality
• FVS occurs in 0.9% in first trimester and upto 50% of
newborns get infected and 23% develop congenital
varicella if infection occurs within 1-4 weeks of delivery

36. Preconception or adults -Hepatitis
• Hepatitis B –Monovalent Recombivax HB or Engerix B
• Hepatitis A and B – Twinrix (Glaxo) licenced from
2001, alternate schedule from 2007 in >18 years
• Recombinant Hep B and inactivated Hep A
• Dose schedule – 1ml each dose
• 0, 1, 6 month
• Alternate schedule 0, 7, 21-30 days and 12 months
• For immunocompromised alternate schedule with 2ml
• Efficacy of First three doses of alternate schedule is
as effective as single dose of monovalent Hep A and 2
doses of Hep B – effective for people travelling

37. Pregnancy

38. Immunisation in Pregnancy
• Vaccine preventable diseases significant maternal and
perinatal morbidity and mortality
• Immunogenicity of vaccine affected by maternal
immune response
• Immature immune system of neonates and preterms
vulnerable to infections
• Immunization of mother protects fetus and infant
directly against vaccine preventable diseases
• Limited evidence of safety of vaccines in pregnancy
as pregnant women not included in trials
Safety of immunization during pregnancy – a review of evidence,
Global Advisory Committee on Safety of Vaccine, WHO 2014

39. Considered safe if
otherwise
indicated
Contraindicated
during
pregnancy or safety
not established
Special
recommendations
pertain
Tetanus and
diphtheria
toxoids (Td)
Tdap
Hepatitis B
Influenza
Meningococcal
Rabies
BCG*
Measles*
Mumps*
Rubella*
Varicella*
Anthrax
Hepatitis A
Japanese
encephalitis
Pneumococcal
Polio (IPV)
Typhoid (parenteral
and Ty21a*)
Vaccinia*
Yellow fever*
Immunizations During Pregnancy
*—Live, attenuated vaccine.
BCG = bacille Calmette-Guérin; IPV = inactivated polio virus.
Adapted from Guidelines for vaccinating pregnant women. Recommendations of the Advisory
Committee on Immunization Practices (ACIP). Atlanta, Ga.: Centers for Disease Control and
Prevention, 2002

42. Influenza vaccination in
pregnancy
• Influenza is pandemic in India and worldwide
• Pregnant women are at high risk for influenza
with 3-4 times higher rate of hospitalisation and
4-5 times higher chances of ICU admission
• Perinatal mortality 39/1000, 33% loss of
pregnancy and 33% higher maternal mortality
• Most of influenza is caused by Influenza A
(H1N1), (H3N2) and Influenza B
• Antigenic drift–Seasonal influenza,Influenza A B C
• Antigenic shift – Pandemic, Influenza A

44. Non-adjuvanted inactivated trivalent
seasonal and monovalent pandemic
influenza vaccines
• Inactivated influenza vaccine is safe and have
adequate immune response in pregnancy with
adequate transfer of transplacental antibody transfer
• The excellent and robust safety profile of multiple
inactivated influenza vaccine preparations over many
decades, and the potential complications of influenza
disease during pregnancy, support WHO
recommendations that pregnant women should be
vaccinated.
• Recommended in 2nd and 3rd trimester and protects
baby till 6 months of age
GACVS, WHO 2014

45. Influenza vaccination in
pregnancy
• CDC, RCOG, ACOG and ACIP recommends annual
influenza vaccine to all pregnant mothers
• Influenza vaccine is an essential component in
preconception, prenatal and postnatal care of
women and should be offered to women who are
or will be pregnant in influenza season
ACOG committee Opinion, 2014
• FOGSI recommends Inactivated Influenza Vaccine
from 26 weeks onwards and can be given earlier
in pandemic at least 2 weeks prior to delivery
FOGSI 2014

46. Influenza vaccination in
pregnancy
• Newer Quadrivalent Vaccine (Vaxiflu)available
contains two strains of Influenza A and two
strains of Influenza B (Yamagata and Victoria)

47. Tetanus Toxoid Vaccines
• 59000 neonatal death in 2008 – 92% reduction from 1980
• 34 countries still not eliminated tetanus till 2012
• WHO recommends 2 TT doses in pregnancy 4 weeks apart with
last dose at least 2 weeks before delivery
• VARES database 2005-2010 search found Tdap to be safe in
pregnancy and can be safely recommended in place TT in
Pregnancy
• There are moderate local reaction to Tdap but because of the
potential benefits of maternal pertussis immunization (ACIP) has
recently recommended that pregnant women receive Tdap
boosters during each pregnancy
ACIP 2012
• ACIP, ACOG and FOGSI recommends Tdap in place of second TT in
pregnancy
GACVS, WHO 2014

48. Pertusis vaccination in Pregnancy
• Substantial increase in pertusis in children in
2012
• 41,880 pertusis cases and 14 infant death in 2012
• Maternal antibodies transported across placenta
provides passive immunity to newborn before
he/she can be vaccinated
• Vaccines are well tolerated and immunogenic in
pregnant women and their neonates
• Tdap has been found safe to be used in
pregnancy with no adverse fetal effects
CDC 2012

50. Tdap in third trimester
• Tdap may be administered any time during pregnancy, but
vaccination during the third trimester would provide the
highest concentration of maternal antibodies to be
transferred closer to birth
• After Tdap, a minimum of 2 weeks is required to mount a
maximal immune response to the vaccine antigens.
• Active transport of maternal IgG does not substantially
take place before 30 weeks of gestation
• One study of pregnant women who received Tdap within
the prior 2 years noted that maternal antibodies waned
quickly; even women immunized during the first or second
trimester had low levels of antibodies at term.
• ACIP concluded that pregnant women should be vaccinated
with Tdap during the third trimester to optimize
transplacental transfer of maternal antibodies
MMWR, 2013

52. ACIP update on Tdap in pregnancy
• Antibody levels in in non pregnant adults peak within
first month with substantial decay after 1 year
• Maternal antibodies from women immunized before
pregnancy waned quickly and the concentration of
maternal antibodies was unlikely to be high enough to
provide passive protection to infants
• Because antibody levels wane substantially during the
first year after vaccination, ACIP concluded a single
dose of Tdap at one pregnancy would be insufficient
to provide protection for subsequent pregnancies.
MMWR, 2013
ACIP recommends Tdap in every pregnancy

53. Impact of Tdap in Pregnancy
Annual mean Cases prevented by Tdap
n(range)
Antenatal Tdap Postpartum Tdap
Infant Pertusis cases 906 (595–1,418) 549 (361–860)
Hospitalisation 462 (261–736) 219 (124–349)
Death 9 (4–17) 3 (1–6)
Tdap in pregnancy versus postpartum Tdap
CDC, unpublished data, 2012, MMWR, 2013

54. Live attenuated Vaccines in
Pregnancy
• Live Viral Vaccines has potential to cross
placenta and affect fetus, they are
contraindicated in pregnancies
• Inadvertent exposure in pregnancy raises safety
concerns

55. Safety of Monovalent Rubella and MMR live
attenuated vaccines exposure in pregnancy
• CRS was not seen after inadvertent exposure of vaccine in
pregnancy in a review of more than 680 Rubella susceptible
women conceived within 3 month of vaccination.
ACIP 2006
• In Latin America, 2894 women rubella susceptible who
conceived within 1 month of Rubella or MMR vaccine were
evaluated for Rubella IgM and features of CRS in fetus.
Cord Rubella IgM was positive in 70 women (3.5%) but none
developed CRS.
Vaccines, 2006
• On the basis of these data, a maximum theoretical risk for
CRS of 0.2% was estimated following inadvertent
vaccination with rubella vaccine during pregnancy
• Inadvertent administration of MMR vaccines is not
considered an indication for termination of the pregnancy,
as there is no evidence of harm to the fetus
GACVS, WHO 2014

56. Post natal
Vaccination

57. Postnatal vaccination
• Good window of opportunity to vaccinate and
protect mother and future progeny

58. Postnatal Vaccination
FOGSI recommends postnatal vaccinations to all
non immunized postnatal mothers
• MMR
• Hepatitis B
• Varicella
• Influenza
• Tetanus
• HPV

60. Post Natal Vaccination
• Both inactivated and Live Vaccines (except Small
Pox and Yellow Fever) are safe for lactating
mothers
• Three vaccines should be given before discharge
to susceptible mothers to protect themselves
and their baby
• MMR
• Varicella
• Tdap

61. Vaccination in
adult and elderly

63. ACIP 2017 Vaccination in certain medical situations

64. Vaccination in adults and elderly
FOGSI recommends vaccination for women of all
ages
• HPV – licensed upto 45 years
• Tetanus ,diphtheria – TT/dT every 10 years,
women more than 65 years in contact with
infant should be given Tdap instead of TT/dT
• Influenza – annual flu shots throughout life,
live attenuated upto 49 years

65. Influenza vaccination in elderly
>65 years – ACIP 2017
• Annual one dose influenza vaccine prior to
innfluenza season
• Fluzone - high dose IIV3 vaccine -60mcg of each
HA strain, total 180mcg should be recommended

67. ACIP recommendations for HPV
2017
• Age <15 years – 2 doses atleast 5 month apart
• Age >15 years – 3 doses
• Adult female through 26 years who have not received
any vaccination should receive 3 doses- 0,1-2,6
months
• Adult female who received 2 vaccines prior to 15
years are considered adequately vaccinated
• Adult female who initiated vaccination prior to 15
years but received only 1 dose or 2 dose less than 5
months apart should receive 1 dose of HPV

68. Vaccine Dose Comments Guideline
Influenza
Inactivated
CDC, ACOG,
FOGSI
Td 0,4 weeks and
6 month
In unknown or
incomplete
immunization
CDC, ACOG,
FOGSI
Tdap one dose 27-
36 weeks
CDC
Vaccine Recommended for use in Pregnancy

69. Vaccine Dose Comments Guidelines
Hepatitis A
Hepatitis B
PCV 13 No
recommendation
CDC
PPSV23 Safety in first
trimester not
established
CDC
Polio IPV May be given if
increased risk of
exposure
CDC
Vaccine to be given in pregnancy if benefit more than the risk

70. Vaccine Dose Comments Guidelines
Influenza (LAIV) CDC, FOGSI, ACOG
MMR CDC, FOGSI, ACOG
Varicella CDC, FOGSI, ACOG
Zoster CDC, FOGSI, ACOG
HPV
Vaccines not recommended or Contraindicated in Pregnancy