Lockdown E-CME & Webinars - this one is on Pfizer vaccine - Prevenar, We have also discussed the common questions on Pneumonia & how to run clinical practice during COVID shutdown

1. Managing Immunization in
the challenging times
How should one address the situation?
Dr. Gaurav Gupta,
Charak Clinics, Mohali

3. Scope
ACVIP guidelines for immunization during COVID
Pneumonia Vaccines – PCV 10 & 13 in India
Pneumonia Vaccines – above 5 years age
Your FAQs about vaccines
Your OPINIONS about vaccination during COVID

4. ACVIP Guidelines on Immunizations during COVID 19
Pandemic
• Prevention (including immunizations) and management of communicable diseases is considered as
an “Essential Medical service”
• Immunization should be prioritized for the prevention of communicable diseases and safeguarded
for continuity during the COVID-19 pandemic, where feasible
• There is no documented risk of immunizing a well child during the COVID 19 Pandemic.
1. ACVIP Guidelines on Immunizations during COVID 19 Pandemic. Iapindia.org. 2020 [cited 20 May 2020]. Available from: https://iapindia.org/pdf/1455-FINAL-ADVISORY-ACVIP-Guidelines-on-Immunisations-
during-COVID-19-Pandemic-skd.pdf
COVID-19: coronavirus disease 2019
ACVIP: Advisory Committee On Vaccines & Immunization Practices
PP-PNP-IND-0382 29 May 2020

5. General instructions for vaccination clinics
1. Have exclusive vaccination
sessions and exclusive
vaccination rooms.
2. Segregate those with fever
and respiratory symptoms
3. Give vaccinations by
appointment only
4. Digital Payment.
5. Stagger appointments & allow
1-2 attendants, discourage
dada-dadi
6. Do SMS –yourself & pts.
7. Aggressive infection control
8. Adequate PPE, surgical mask
and gloves with scrupulous hand
hygiene.
9. Utilize every healthcare visit
including well baby visits for
immunization.
1. ACVIP Guidelines on Immunizations during COVID 19 Pandemic. Iapindia.org. 2020 [cited 20 May 2020]. Available from: https://iapindia.org/pdf/1455-FINAL-ADVISORY-ACVIP-Guidelines-on-Immunisations-
during-COVID-19-Pandemic-skd.pdf PP-PNP-IND-0382 29 May 2020

6. How to Prioritize vaccines?
• Give first year vaccines on time
• Give multiple vaccines at the same time
• Boosters may be delayed if logistic issues
• Catch-up vaccines whenever child comes to the clinic, or when
conditions favourable

7. Prioritizing Vaccines in routine immunization
1. Vaccinate newborns at birth
before discharge. BCG^,
OPV & Hep-B vaccines.
2. Prioritize primary vaccination
series: DPT, Hep B, Hib,
OPV/IPV, RV vaccines,
PCV, Influenza, Varicella
and MR/MMR..
3. Prioritize pneumococcal and
Influenza vaccine to
vulnerable groups incl HCW.
4. JE at 1 year
5. TCV with influenza vaccine at 6
months or MR/MMR at 9
months.
6. HAV & HPV may be postponed
to a later date if needed.
7. Multiple vaccines in the same
session.
1. ACVIP Guidelines on Immunizations during COVID 19 Pandemic. Iapindia.org. 2020 [cited 20 May 2020]. Available from: https://iapindia.org/pdf/1455-FINAL-ADVISORY-ACVIP-Guidelines-on-Immunisations-
during-COVID-19-Pandemic-skd.pdf
^BCG: Bacille Calmette-Guerin; OPV: Oral poliovirus vaccine #MR-Measles, Rubella * MMR-
Measles,Mumps,rubella
PP-PNP-IND-0382 29 May 2020

8. Summary of ACVIP guidelines
In view of the risks associated with the disruption of
routine immunization activities, the ACVIP
recommends the continuation of routine
immunizations, especially the primary vaccine doses,
to be administered in the first year
1. ACVIP Guidelines on Immunizations during COVID 19 Pandemic. Iapindia.org. 2020 [cited 20 May 2020]. Available from: https://iapindia.org/pdf/1455-FINAL-ADVISORY-ACVIP-Guidelines-on-Immunisations-
during-COVID-19-Pandemic-skd.pdf
ACVIP: Advisory Committee On Vaccines & Immunization Practices
PP-PNP-IND-0382 29 May 2020

9. Managing Immunization
in the challenging times
Prevention with Pneumococcal Conjugate Vaccines: a
relook in the current scenario
“The Content in this presentation is only intended for healthcare professionals in India. The medical information in this presentation is provided as an
information resource only, and is not to be used or relied on for any diagnostic or treatment purpose. “
“The views and opinions mentioned in the presentation is strictly that of the author and the individuals expressing the same and Pfizer may not necessarily
endorse the same. Pfizer (including its parent, subsidiary and affiliate entities) makes no representation or warranties of any kind, expressed or implied; as
to the content used in the presentation and/or the accuracy, completeness of its content.”
These slides are for information or education purposes only and not for distribution or promotion. PP-PNP-IND-0382 29 May 2020

10. Available Pneumococcal Conjugate Vaccines
DT=diphtheria toxoid; PCV=pneumococcal conjugate vaccine 10-valent [PCV10], or 13-valent [PCV13]); TT=tetanus toxoid; PCV – Pneumococcal Conjugate Vaccine.
1. Vesikari T, et al. Pediatr Infect Dis J. 2009;28(4 suppl):S66-S76;
2. Prevenar 13 Local Product Document LPDPRV062019 version 15.. Pfizer Ltd.;
PCV132
4 6B 9V 14 18C 19F 23F 1 5 7F 3 6A 19A
CRM197
PCV101
4 6B 9V 14 18C 19F 23F 1 5 7F
Protein D TT DT Protein D
PP-PNP-IND-0382 29 May 2020

11. Serotype Coverage Difference Is Present between
PCV10 and PCV13 in Recently Reported Studies
Singh J, Sundaresan S, Manoharan A, Shet A. Serotype distribution and antimicrobial susceptibility pattern in children≤ 5 years with invasive pneumococcal disease in India–A systematic review. Vaccine. 2017
Aug 16;35(35):4501-9.
64.2%
64.0%
68.0%
64.0%
61.0%
64.0%
68.0%
87.5%
74.5%
74.0%
76.0%
92.0%
79.0%
78.0%
0.0%
20.0%
40.0%
60.0%
80.0%
100.0%
NisargaR
et.al(2015)
BalajiV
et.al(2015)
ManoharanA
et.al(ASIP,
2016)
MehendaleS
et.al(HBSSBM,
2016)
BalasubramanianS
et.al(2016)
ManoharanA
(BASIS,
2016)
VandanaG
et.al(PIDOPS,
2016)
PCV10 PCV13
67.3%
78.4%
60.0%
65.0%
70.0%
75.0%
80.0%
PCV10 PCV13
Proportion(%)ofIPD
11.10%
Difference Attributable to Serotypes 3, 6A and 19A
PCV- Pneumococcal Conjugate Vaccine
PP-PNP-IND-0382 29 May 2020

12. Serotype Coverage Difference between PCV13 and
PCV10 from an Indian Context
Jayaraman Y, Veeraraghavan B, Purushothaman GK, et.al. Burden of bacterial meningitis in India: Preliminary data from a hospital based sentinel surveillance network. PloS one. 2018 May
16;13(5):e0197198.
Pneumococcal Serotypes Covered
by Licensed PCVs
NVS – Non Vaccine Serotypes.
PCV 7
(59%)
PCV 10
(72%)
PCV 13
(90%)
NVS
(10%)
PCV- Pneumococcal Conjugate Vaccine
PP-PNP-IND-0382 29 May 2020

13. *Canadian province of Quebec and Italian region of Piemonte have initiated PCV vaccination programs with PCV10.
†Both PCVs are available/reimbursed in the NIP or the NIP consists of different PCVs by region. BC=birth cohort.
1.Data on file. Pfizer Inc, New York, NY. 2020.
2.Gavi Alliance Annual Progress Report 2017.http://www.gavialliance.org/results/gavi-progress-reports/. Accessed May 16, 2020 [
3. Sachdeva, A., 2017. Pneumococcal conjugate vaccine introduction in India’s Universal immunization program. Indian Pediatrics, 54(6), pp.445-446.
4. Abhipedia.abhimanu.com. 2020. Haryana Launched Pneumococcal Conjugate Vaccine (PCV) And ANMOL App Daily Current Affairs @ Abhipedia Powered By ABHIMANU IAS. [online]
Available at: <https://abhipedia.abhimanu.com/Article/State/MzMzMwEEQQVVEEQQVV/Haryana-launched-Pneumococcal-Conjugate-Vaccine--PCV--and-ANMOL-App-Haryana-State>
[Accessed 29 May 2020].
PCV13 Is Included in Over 125 NIPs, With
Exclusivity in 121 Countries Worldwide1,2
Currently 6 states
have PCV133,4
PCV13 Only* = 121
PCV13 / PCV10† Shared = 6
(PCV13 covers >50% of total BC)
PCV13 / PCV10† Shared = 1
(PCV13 covers <50% of total BC)
PCV10 Only = 31
PP-PNP-IND-0382 29 May 2020

14. Countries Continue to Value the Impact of
PCV13 When Choosing a PCV for Their NIPs
New PCV National Immunization Programs
PCV13
2015 2016 2017 2018 / 2019 2020
PCV10
2015 2016 2017 2018 / 2019 2020
Spain* Mauritius India†
Cambodia Algeria Romania
Portugal Kyrgyzstan
Namibia
Solomon Islands Iraq
Uzbekistan
Eritrea
Lebanon
Poland Serbia
Switched PCV National Immunization Programs
PCV10 to PCV13
2015 2016 2017 2018 / 2019 2020
PCV13 to PCV10
2015 2016 2017 2018 / 2019 2020
Peru Azerbaijan Chile
Belgium
New
Zealand
Armenia Paraguay
Mozambique
El Salvador
Piemonte‡
Myanmar
Haiti
Mongolia
Seychelles
Albania
Quebec ‡
*Launched formal regional immunization programs in 2015.
†Gavi, 5 states only.
‡Canadian province of Quebec and Italian region of Piemonte have initiated PCV vaccination programs with PCV10.
NIP(s)=national immunization program(s).
Data on file. Pfizer Inc, New York, NY. 2020.
Tunisia
Slovenia
Anguilla
Barbados
Bhutan
Trinidad &
Tobago
North Macedonia
(2019)
Croatia
(2019)
Austria
PP-PNP-IND-0382 29 May 2020

15. Is there a place for the use of
PCVs in the pediatric age
group, beyond 5 years?

16. Disease Burden - Indian Scenario
* Include empyema thoracis, deep seated abscess, pericarditis and arthritis;
Prospective multicentre hospital surveillance of Streptococcus pneumoniae disease in India. Invasive Bacterial Infection Surveillance (IBIS) Group, International Clinical Epidemiology Network (INCLEN). Lancet. 19
99;353(9160):1216‐1221..
Prospective Multicentre Hospital Surveillance of Streptococcus pneumoniae Disease in India
Invasive Bacterial Infection Surveillance (IBIS) Group*, International Clinical Epidemiology Network (INCLEN)
Clinical Syndromes in 314 Patients with Invasive Pneumococcal Infection
Clinical
Syndrome
Age
<2 Months
2 Months –
1.9 Years 2–4.9 Years 5–11.9 Years ≥12 Years Total
Meningitis 2 (67%) 29 (43%) 11 (34%) 15 (28%) 60 (38%) 117 (37.3%)
Pneumonia 1 (33%) 23 (34%) 16 (50%) 13 (25%) 40 (25%) 93 (29.6%)
Septicaemia 0 7 (10%) 1 (3%) 4 (8%) 12 (8%) 24 (7.6%)
Peritonitis 0 0 2 (6%) 11 (21%) 10 (6%) 23 (7.3%)
Others* 0 9 (13%) 2 (6%) 10 (9%) 36 (23%) 57 (18.2%)
Total 3 68 32 53 158 314
There is a disease burden due to Pneumococcal infection, in the pediatric age group,
beyond 5 years as well
PP-PNP-IND-0382 29 May 2020

17. IAP Guidebook on Immunization 2018-19
Healthy Children
• PCV-13 has been licensed for age group of 6–17 years
Shah AK. PNEUMOCOCCAL VACCINES. In: IAP Guidebook on Immunization 2018–2019. 3rd ed. New Delhi: Jaypee Brothers Medical Publishers (P) Ltd; 2020. p. 168–206.
Other highlights
• Based on surveillance studies, PCV-13 appears to have some edge
over PCV-10 in India.
• On May 13th, 2017, PCV-13 was launched in UIP of selected Indian
states of Himachal Pradesh and parts of Bihar (17 out of 38 districts)
and Uttar Pradesh (6 out of 75 districts). Eventually PCV-13 will be
introduced in all states of India in phased manner in the coming
years.
What’s New?
PP-PNP-IND-0382 29 May 2020

18. Is there a place for the use of PCVs in the
pediatric age group beyond 5 years?
• There is a remaining burden of pneumococcal disease in children >
5 years of age 1
• Clinical studies of PCV13 have demonstrated an immune response
in children ≥5 to 17 years of age comparable to that in children <5
years 2
• IAP guidebook on immunization (2018-19) mentions the use of
PCV13 in children 6–17 years of age3
1. Invasive Bacterial Infection Surveillance (IBIS) Group and International Clinical Epidemiology Network. (INCLEN). Lancet. 1999;353:1216-1221
2. Agarkhedkar S, Juergens C, Balasundaram K, Agarkhedkar S, Sundaraiyer V, Le Dren-Narayanin N, Cutler MW, Gruber WC, Scott DA, Schmoele-Thoma B, B1851140 Study Team. Safety and
Immunogenicity of 13-Valent Pneumococcal Conjugate Vaccine in Children 6–17 Years of Age in India: An Open-label Trial. The Pediatric infectious disease journal. 2017 Nov 1;36(11):e283-5.
3. Shah AK. PNEUMOCOCCAL VACCINES. In: IAP Guidebook on Immunization 2018–2019. 3rd ed. New Delhi: Jaypee Brothers Medical Publishers (P) Ltd; 2020. p. 168–206.
4. Prevenar 13 Local Product Document LPDPRV062019 version 15
PP-PNP-IND-0382 29 May 2020

19. Adults need vaccines too1
Vaccines are not just for kids1
1.Centers for Disease Control and Prevention. 2020. Adults Need Vaccines, Too. [online] Available at: <https://www.cdc.gov/features/adultimmunizations/index.html>
[Accessed 27 May 2020].

20. References in the notes section
PCV13 – Adult Vaccine Recommendations in
India
1. Muruganathan A, Mathai D, Sharma SK, editors. Adult Immunization. J Assoc Physicians India; 2014. p. 1-270..
2. Indian Guidelines for Vaccination in Older Adults – A Guide for Geriatricians, Internists, Chest Physicians, Surgeons, Gynaecologists, Diabetologists, Cardiologists, Family Physicians developed by Geriatric Society of India, 2015. Ed. Sharma O.P.
3. Indian Academy of Allergy (2016) Available on http://indianacademyofallergy.com/wp-content/uploads/2017/05/Recommendations-IAACON-2016-Print-version-1.pdf last accessed 18 May 2020
4. Indian Society of Nephrology Guidelines for Vaccination in Chronic Kidney Disease. Indian J Nephrol 2016. Vol 26, Issue 7 (Supplement) Page Nos. 1-30. Available from http://www.indianjnephrol.org/ last accessed on 18 May 2020
5. Mathai, Dilip, et al. "Consensus recommendation for India and Bangladesh for the use of pneumococcal vaccine in mass gatherings with special reference to Hajj pilgrims." Journal of Global Infectious Diseases 8.4 (2016): 129.
6. Bajaj S. RSSDI clinical practice recommendations for the management of type 2 diabetes mellitus 2017, International journal of diabetes in developing countries:2018;38(1):1-115
7. Indian Medical Association, Life course Immunization guidebook Dec 2018 release at National Annual Conference of IMA (NATCON) held in Bangalore, India in 2018
8. Guidebook on Adult Immunization in Occupational Health Settings Healthy Worker: Key to Productivity and Sustainability. Available at: http://occuconindia.com/img/iaoh_book.pdf Accessed on: 18 May 2020
PP-PNP-IND-0382 29 May 2020
Adapted from reference 1-8
1. Association of Physicians of India1
2. Geriatric Society of India (Indian Vaccine
Advocacy Group)2
3. Indian Academy of Allergy3
4. Indian Society of Nephrology4
5. Mass Gathering Advisory Board Consensus
Recommendation5
6. Research Society for the Study of Diabetes in
India6
7. Indian Medical Association7
8. Indian Association of Occupational Health8

21. PCV 13
6 weeks to 5
years
6 to 17 years > 50 years
The First and Only PCV to Help Protect All Individuals
at Increased Risk for Pneumococcal Disease
Summary – The Heritage
1. Prevenar 13 Local Product Document LPDPRV062019 version 15
2. Pneumococcal conjugate vaccine 10-valent product monograph; August 31, 2018 https://ca.gsk.com/media/591956/synflorix.pdf [Last accessed on 06 January 2020]
PP-PNP-IND-0382 29 May 2020

22. Your PCV questions !
What is the max gap between 2 PCV doses?
How many doses to give in case of missed dose (catch-up schedule)?
If 1 Synflorix given before, what to do if parents want Prevenar now.
Indications and choice of PCV vaccine for vaccinating the kids who were left out on
PCV vaccine earlier in their life.
Rationale and efficacy of govt schedule of pcv vaccine 6, 14 weeks and 9 months.
Evidence behind such schedule and can we do the same to cut the cost to family.
Synflorix and nontypable Hib(NTHi), Don't hear much about the NTHi these days. Any
insights ?

23. Your OPINIONS matter… what are we
doing?
Are we screening for fever before vaccination?
How are we sanitizing our clinics?
What PPE are we wearing?
How are we giving appointments- are we segregating vaccines / non-vaccines/ < 1 year ?
Are we seeing children with fever &/or URI?
Are we physically examining children, including throat and chest?
Are we preferring digital payments? How are we handling cash?
Bathing after clinic, washing clothes separately?

24. Missed something ?
Check www.slideshare.com/gauravg
docgaurav@gmail.com
Parent health education
https://www.youtube.com/charakclinics
Acknowledgements: Dr. Gautam Rambhad, Medical Advisor, Pfizer