Adolescent and Adult Immunization Update - PowerPoint Presentation

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Adolescent and Adult Immunization Update

Presentation to:

Presented by:

Date:

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Disclosure Statements

Neither the planners of this session nor I have any financial relationship with pharmaceutical companies, biomedical device manufacturers, or corporations whose products and services are related to the vaccines we discuss.

There is no commercial support being received for this event.

The mention of specific brands of vaccines in this presentation is for the purpose of providing education and does not constitute endorsement.

The GA Immunization Program utilizes ACIP recommendations as the basis for this presentation and for our guidelines, policies, and recommendations.

For certain vaccines this may represent a slight departure from or off-label use of the vaccine package insert guidelines.

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Disclosure Statement

To obtain nursing contact hours for this session, you must be present for the entire session and complete an evaluation.

Continuing education will be provided through the Georgia Department of Public Health

Georgia Department of Public Health is an approved provider of continuing nursing education by the Alabama State Nurses Association, an accredited approver by the American Nurses Credentialing Center’s Commission of Accreditation

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Objectives

At the end of this presentation, participants

will be able to:

Recall the role vaccines have played in preventing diseases

Discuss the importance of vaccines for children, adolescents and adults

Discuss the role of a vaccine champion

List at least two reliable sources for immunization information

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DiseaseAverage Annual Reported Cases Pre-vaccine*Cases in U.S. 2015**ProvisionalCases in U.S.2016**Provisional% ReductionIn U.S. 2016Smallpox48,164Eradicated worldwide in 1980Diphtheria175,88500100%Measles503,28218869>99.9%Mumps152,2091,3295,31196.5%Pertussis147,27120,76215,73789.3%Polio (paralytic)16,31600100%Rubella47,74555>99.9%Congenital Rubella Syndrome82311>99.9%Tetanus1,314293398.1%H. Influenzae Type bAge<5 years20,000292299.9%

The Impact of Vaccines

*MMWR 48(12);243-248 April 2, 1999

**MMWR 64(52), ND-924-ND-941, January 6, 2017

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VPD

Vaccination Rate

Needed for

Herd Immunity

Measles

92-94%

Pertussis

92-94%

Diphtheria

83-85%

Rubella

83-85%

Mumps

75-86%

Influenza

30-75%

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Immunization Schedule Updates

All staff must use the same immunization scheduleSchedules: Children & Adolescents 0 through 18 yearsCatch-up schedule for ages 4 months -18 yearsChildren and Adolescents 18 years or younger based on medical indicationsAdult 19 years and olderAdult based on medical and other indications

READ THE FOOTNOTES

http://www.cdc.gov/vaccines/schedules/hcp/child-adolescent.html

http://www.cdc.gov/vaccines/schedules/hcp/adult.html

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What Does It All Mean?

Indication

-

Information about the appropriate use of the vaccine

Recommendation

-

ACIP statement that broadens and further delineates the Indication

found in the package insert

-Basis for standards for best practice

Requirement

-

Mandate by a state that a particular vaccine must be administered and documented before entrance to child care and/or school

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General Best Practice Guidelines

Timing and Spacing of Immunobiologics

Contraindications and Precautions

Preventing and Managing Adverse Reactions

Vaccine Administration

Storage and Handling of Immunobiologics

Altered Immunocompetence

Special Situations

Vaccination Records

Vaccination Programs

Vaccine Information Sources

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Test Your Knowledge!

If 2 different live injectable vaccines are given < (less than) 28 days apart, the one given second should be what?

IAC Ask the Experts - Reviewed July 2014

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Test Your Knowledge!

If 2 different live injectable vaccines are given < (less than) 28 days apart, the one given second should be what?

IAC Ask the Experts - Reviewed July 2014

The second or invalid dose should be repeated greater than or equal to 28 days after the second or invalid dose.

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Frequently Asked Question?

Why do ACIP recommendations not always agree with vaccine package inserts?There is usually very close agreement between vaccine package inserts and ACIP statements. The Food and Drug Administration (FDA) must approve the package insert, and requires documentation for all claims and recommendations made in the insert. Occasionally, ACIP may use different data to formulate its recommendations, or try to add flexibility to its recommendations, which results in wording different than on the package insert. ACIP sometimes makes recommendations based on expert opinion and public health considerations. Published recommendations of national advisory groups (such as ACIP or AAP's Committee on Infectious Diseases) should be considered equally as authoritative as those on the package insert.

Source: IAC’s Ask the Experts

www.immunize.org/askexperts/experts_general.asp

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Vaccines

Live,Attenuated Measles,Mumps & Rubella (MMR)VaricellaLAIV- (Nasal Spray flu) RotavirusHerpes Zoster/Shingles

InactivatedToxoids (tetanus, diphtheria)Whole (Hepatitis A, polio)Fractional subunits- (Influenza, acellular pertussis)Recombinant vaccines (Hepatitis B, HPV)Polysaccharide vaccines (PPSV23, MPSV4)Conjugated vaccines (Hib, PCV13, MCV4)

Vaccine

- A product that interacts with the immune system to produce active immunity against a disease without the risk of the disease and its potential complications.

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“It’s The Law”

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Influenza Vaccinesfor 2017-2018 Season in the U.S.

Trivalent Vaccines (IIV3): A/Michigan/45/2015 (H1N1) (NEW)A/Hong Kong/4801/2014 (H3N2)-like virusB/Brisbane/60/2008-like virus

ACIP recommends annual influenza vaccine for all persons 6 months of age and older who do not have contraindications.

Quadrivalent Vaccines (IIIV4) will also include: B/Phuket/3073/2013-like virus

Recommendations and Reports Vol. 66 / No. 2 MMWR / August 25, 2017

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ACIP VOTE

On February 21, 2018 ACIP voted to include the nasal spray flu vaccine among the recommended influenza vaccines for the 2018-2019 season.

CDC does not currently have a contract for LAIV

LAIV will likely be available for private purchase before it is available on public contracts

Contact the VFC Program for additional information

1-800-848-3868

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Influenza Vaccination of Persons with a History of Egg Allergy

Persons with a history of egg allergy who have experienced only urticarial (hives) after exposure to egg should receive influenza vaccine. Persons who report having had reactions to egg involving symptoms other than urticarial (hives), such as angioedema, respiratory distress, lightheadedness, or recurrent emesis; or who required epinephrine or another emergency medical intervention, may similarly receive any licensed and recommended influenza vaccine (i.e., any IIV or RIV) that is otherwise appropriate for the recipient’s age and health status. A previous severe allergic reaction to influenza vaccine is a contraindication to future receipt of the vaccine.

Recommendations and Reports Vol. 65 / No. 5 MMWR / August 26, 2016

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I got the flu shot and still got the flu…

For healthy persons takes about 2 weeks after the shot before your body makes enough antibodies to be protected

You are vulnerable to flu infection during this time

Flu vaccination does not protect you from colds, sinus infections, and other respiratory illnesses that also circulate during flu season

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Frequently Asked Questions

Some of my patients refuse influenza vaccination because they insist they "got the flu" after receiving the injectable vaccine in the past. What can I tell them?

How long does immunity from influenza last?

In which month is it too late to receive influenza vaccine?

My patient came in last February and asked for a “flu” shot. Should I have given it to her?

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Percent of Ga residents older than 65yrs. who self-reported receiving an influenza vaccination 2015

Source: 2015 Behavioral Risk Factor Surveillance Survey (BRFSS)

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Pneumococcal Conjugate Vaccine for Adults (PCV13)

ACIP recommends 1 dose of PCV13 for:Adults 19 years and older with the following: Immunocompromising conditions Functional or anatomic asplenia Sickle cell disease CSF leaks Cochlear implantsAdults 65 years and older

MMWR 2014;Vol. 63 #37:822-5 MMWR, 2015 , Vol. 64, #34:944-7

PCV13 – PPSV23 spacing and timing of doses

65 years and older

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Pneumococcal Polysaccharide Vaccine for Adults (PPSV23)

ACIP recommends 1 dose of PPSV23 for:Adults 65 years and olderPersons aged 2 through 64 years with medical conditions that increase their risk for pneumococcal infection Persons 19 through 64 years with asthma Cigarette smokers 19 years of age and olderRevaccination not recommended for most persons until they reach age 65

Persons at highest risk, such as those with immunocompromising conditions, and/or functional or anatomic asplenia, who received a dose before age 65, should receive a 2nd dose 5 years after dose 1, and a 3rd dose at age 65.

MMWR, September 3, 2010,

Vol

59, #34 MMWR, October 12,2012,

Vol

61 #40

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Percent of Ga. residents older than 65yrs. who self-reported receiving pneumococcal

Source: 2015 Behavioral Risk Factor Surveillance Survey (BRFSS)

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Diphtheria, Tetanus and Pertussis Vaccines

ACIP recommends:A 5 dose series of DTaP: Administered at 2, 4, 6, 15-18 months and4-6 years (Do not administer after age 6)

one dose of Tdap:For children and adolescents starting at 11 or 12 years of age For all adults aged 19 years and older who have not had Tdap previously

MMWR, September 23, 2011, Vol 60, #37 MMWR, January 14, 2011, Vol 60, #01 MMWR, June 29, 2012 Vol 61, #25

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Tdap for Pregnant Women

ACIP recommends:One dose of Tdap each pregnancyOptimal timing early in the 27 through 36 week gestation windowIf not given during pregnancy; administer immediately postpartum

Ref:

Advisory Committee on Immunization Practices. Updated ACIP statement for pertussis, tetanus and diphtheria vaccines presented by Jennifer L. Liang, October 19, 2016.

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Cocooning Strategy

Siblings

Child Care Provider

Healthcare Worker

Grandparents

Parents

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Test Your Knowledge!

Logan is a 7 year old boy who was not fully immunized with DTaP and received 1 dose of Tdap in the catch-up series. Can he receive an additional dose of Tdap vaccine at 11 through 12 years?

Ref: Recommended Immunization Schedule for Children and Adolescents Aged 18 years or younger, United States, 2017

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Test Your Knowledge!

Logan is a 7 year old boy who was not fully immunized with DTaP and received 1 dose of Tdap in the catch-up series. Can he receive an additional dose of Tdap vaccine at 11 through 12 years?

Yes, he can receive an adolescent Tdap vaccine dose at age 11 through 12 years.

Ref: Recommended Immunization Schedule for Children and Adolescents Aged 18 years or younger, United States, 2017

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Hepatitis A Vaccine for Adults

ACIP recommends hepatitis A vaccine for adults who are at high-risk of acquiring hepatitis A infection:Those traveling or working in countries with high or intermediate endemicity of infectionMen who have sex with menUsers of injecting and non-injecting drugsPersons working with HAV positive primates or with HAV in research laboratory settingsContact with adoptees from countries with high rates of hepatitis A if contact will be within 60 days of arrival in U.S. The first dose of the 2-dose series should be given as soon as adoption is planned.

MMWR, May 19, 2006,

Vol

55, #RR-07 MMWR, September 18, 2009,

Vol

58 #36

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Hepatitis A

ACIP voted unanimously to pass the following recommendations to Hepatitis A:

Hep A vaccine should be administered for post-exposure for all persons age 12 months or older

Hep A vaccine or IG may be administered to persons age 40 years or older, depending on the provider’s risk assessment

Hep A vaccine should be administered to infants age 6-11 months traveling outside the U.S. when protection against hepatitis A is recommended

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Hepatitis B

ACIP recommends hepatitis B vaccine for: All newborns before discharge from the nursery using single antigen vaccine and completion of the series per schedule.All children and adolescents less than 19 years of age who did not complete the series as an infant.

All adults at risk for hepatitis B infection, including those aged 19 through 59 years with diabetes mellitus Persons of any age at risk for infection by sexual exposureAll other adults seeking protection from HBV infection.

Transmission: 1. Percutaneous or mucosal exposure to blood or body fluids including contaminated surfaces, or exposure by sexual contact2. Perinatal infection from HBsAg + mother

MMWR, December 23, 2005,

Vol

54, #RR16 MMWR, December 8, 2006,

Vol

55, #RR16 MMWR, December 22, 2011

Vol

60 #50

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Hepatitis B vaccination and testing guidelines for Healthcare workers

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Recommended Healthcare Personnel Vaccinations

Hepatitis BInfluenzaMeasles, Mumps, Rubella (MMR)Varicella (Chickenpox)Tetanus, Diphtheria, Pertussis (Tdap)Meningococcal

Are

YOU up to date?

Available at

www.immunize.org

, P#2017

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Measure antibody to hepatitis B surface antigen (anti-HBs

)

anti-HBs <10 mIU/mL

Administer 1 dose of HepB vaccine,postvaccination serologic testing

anti-HBs <10 mIU/mL

Administer 2 more doses of HepB vaccine,postvaccination serologic testing

anti-HBs <10 mIU/mL

HCP need to receive hepatitis B evaluation for all exposures

anti-HBs ≥10mIU/mL

No Action forHepatitis B prophylaxis(regardless of source patient hepatitis B surface antigen status)

PRE-EXPOSURE EVALUATION FOR HEALTH-CARE PERSONNEL PREVIOUSLY VACCINATED WITH COMPLETE, ≥3-DOSES OF HEP B VACCINE SERIES WHO HAVE NOT HAD POSTVACCINATION SEROLOGIC TESTING

anti-HBs ≥ 10 mIU/mL

anti-HBs ≥ 10mIU/mL

MMWR, December 20, 2013,

Vol

62. RR # 10

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Measles, Mumps, Rubella

ACIP recommends:2- dose series at ages 12 through 15 months and 4 through 6 yearsat least 4 weeks between first and second dose

MMWR, June 14, 2013, Vol 62, #RR-04

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Varicella

ACIP recommends:2-dose series at 12 through 15 months and 4 through 6 yearsSecond dose may be administered before age 4 years, provided 3 months have elapsed since the first doseAdults without evidence of immunity should receive 2 doses of single-antigen varicella vaccine 4-8weeks apart, or a second dose if they have only 1 dose

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Varicella Immunity

ACIP considers evidence of immunity to varicella to be: •Documentation of 2 doses of vaccine given no earlier than age 12 months, with at least 3 months between doses for children younger than age 13 years, or at least 4 weeks between doses for people age 13 years and older •U.S.-born before 1980* •A healthcare provider's diagnosis of varicella or verification of history of varicella disease •History of herpes zoster, based on healthcare provider diagnosis •Laboratory evidence of immunity or laboratory confirmation of disease *Note: year of birth is not considered as evidence of immunity for healthcare personnel, immunosuppressed people, and pregnant women.

MMWR

2007;56(RR-4); 16-17

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MMRV (ProQuad®)

Routine Recommendation

May be administered to children 12 months through 12 years of age

MMRV is not licensed for people 13 years of age or older

A third dose of MMRV might be recommended in certain mumps outbreaks situations*

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Spacing of Live Virus Vaccines and Other Products

PPD and live virus vaccine

Apply PPD at same visit as MMR

If MMR given first, delay PPD 4 weeks or longer if not given during the same visit

If PPD given first, administer MMR when client returns for skin test reading

Spacing with antibody-containing products such as immune globulin (IG)

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Herpes Zoster Vaccine Live (ZVL)

Herpes zoster (HZ), or shingles, occurs through reactivation of latent varicella-zoster virusTypically characterized by prodromal pain and an acute vesicular eruption (rash) accompanied by moderate to severe painOne in three persons will develop zoster during their lifetimePostherpetic neuralgia (PHN)is a common consequence of zosterRisk for zoster and PHN increases with age

Photo courtesy of

www.webmd.com

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Zostavax®

ACIP recommends one dose for adults 60 years and older, including those who have experienced previous episodes of shingles.It is not necessary to ask patient about a history of varicella or to do serologic testing for immunity.

Overall Efficacy51% fewer episodes of zoster and less severe disease66% less post-herpetic neuralgiaProtection wanes within the first 5 years and duration of protection beyond 5 years is uncertain

Zostavax is licensed for use in persons 50 years and older

MMWR, August 22, 2014, Vol 63, #33 MMWR (RR) June 6, 2008, Vol 57 #05; 1-30

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SHINGRIX (RZV)

Administer 2 doses of recombinant zoster vaccine (RZV) 2-6 months apart to adults aged 50 years or older regardless of past episode of herpes zoster or receipt of zoster live (ZVL)

Administer 2 doses of RZV 2-6 months apart to adults who previously received ZVL at least 2 months after ZVL

For Adults aged 60 years or older, administer either RZV or ZVL (RZV is preferred)

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SHINGRIX (RZV)

SHINGRIX delivered 90% efficacy against shingles

Recombinant vaccine;

do not freeze

For intramuscular administration only

Reconstitute and use immediately; reconstituted vaccine is stable for 6 hours refrigerated between 36-46°F and should be discarded after 6 hours

Contraindicated for a history of severe allergic reaction (e.g., anaphylaxis) to any component of the vaccine or after a previous dose of SHINGRIX

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Test Your Knowledge!

Hazel is 61 years old. She had major surgery one month ago requiring a blood transfusion. During her visit to your office today she tells you she would like to get the shingles vaccine.How would you respond to her request?

Zoster vaccine can be given to persons who have recently received blood products. The amount of antigen in zoster vaccine is so substantial that it overpowers any antibody to herpes zoster that may be in the blood product.

Ref: Immunization Action Coalition - Ask the Experts – September 2011

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Test Your Knowledge!

Sixty five year old Nadine requests the shingles vaccine. In addition, she needs pneumococcal and influenza vaccine. Should she receive all 3 vaccines on the same day?

Yes. Although Merck reports one study showing a reduced immune response to Zostavax when administered at the same time as Pneumovax compared to administration 4 weeks apart, ACIP has not made this recommendation.

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Is Shingles Contagious?

Shingles cannot be passed from one person to another.

However, a person with shingles can spread the virus to a person who has never had chickenpox.

If the person who has never had chickenpox becomes infected with the virus, he or she will develop chickenpox, not shingles.

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Serogroup A, C, W, Y Meningococcal Vaccines

Routine Recommendation

2-dose series at 11-12 years and 16 years

Age 13-15 years administer 1-dose and booster at age 16-18 years (minimal interval 8 weeks)

1-dose at age 16-18 years

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Meningococcal Vaccines for Special Populations and Situations

Anatomic or functional asplenia, sickle cell disease, HIV infection, persistent complement component deficiency (including eculizumab use)

Children who travel to or live in countries where meningococcal disease is hyperendemic or epidemic, including countries in the African meningitis belt or during the Hajj, or exposure to an outbreak attributable to a vaccine serogroup

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Serogroup B Meningococcal Vaccines

ACIP Recommendation

May be given at clinical discretion to adolescents 16-23 years (preferred age 16-18 years) who are not at increased risk

Bexsero: 2 doses at least 1 month apart

Trumenba: 2 doses at least 6 months apart. If 2

nd

dose given earlier than 6 months, give 3

rd

dose at least 4 months after the 2

nd

dose

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Serogroup B for Special Populations and Situations

Anatomic or functional asplenia, sickle cell disease, persistent complement component deficiency (including eculizumab use), serogroup B meningococcal disease outbreak

Bexsero: 2-doses at least 1 month apart

Trumenba: 3-dose series at 0, 1-2, and 6 months

Bexsero and Trumenba are not interchangeable

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Test Your Knowledge!

Simon received MPSV4 at 5 years of age for international travel and a dose of MCV4 at age 11.

Does he need a booster dose of MCV4 vaccine at age 16?

Yes. Any meningococcal vaccination given prior to the tenth birthday (either with MCV4 or MPSV4) does NOT count toward routinely recommended doses.

IAC Ask the Experts - Reviewed September 2013

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HPV Vaccine

Routine recommendation for adolescents 11-12 years (can start at age 9)

Number of doses dependent on age at initial vaccination

>Age 9-14 years: 2-dose series at 0 and 6-12 months

>Age 15 years or older: 3-dose series at 0, 1-2 months, and 6 months

Persons who completed a valid series with any HPV vaccine do not need any additional doses

Special Situations

>History of sexual abuse or assault: begin series at age 9 years

>Immunocompromised: aged 9-26 years administer 3-dose series

>Pregnancy: vaccination not recommended, but if administered

inadvertently while pregnant delay remaining doses until after

pregnancy.

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HPV Vaccine

At the February 2018 ACIP Meeting they presented a session about harmonizing of HPV vaccination age recommendations for females and males

Considerations for harmonization of upper age recommendations for males and females

- would simplify immunization schedule

-facilitate reaching males, including high risk

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Test Your Knowledge!

If dose #1 of HPV vaccine was given before the 15th birthday and it has been more than a year since that dose was given, would the series be complete with just one additional dose?

Yes. Adolescents and adults who started the HPV vaccine series prior to the 15th birthday and who are not immunocompromised are considered to be adequately vaccinated with just one additional dose of HPV vaccine.

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Test Your Knowledge!

Will the 2-dose recommendation be retroactive for children and teens vaccinated prior to 2016?

Yes. Any person who ever received 2 doses of any combination of HPV vaccines can be considered fully vaccinated if dose #1 was given before the 15th birthday and the 2 doses were separated by at least 5 months.

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Rabies Vaccine Recommendations

Post-exposure prophylaxis…can be considered for persons who were in the same room as the bat and who might be unaware that a bite or direct contact had occurred (e.g., a sleeping person awakens to find a bat in the room or an adult witnesses a bat in the room with a previously unattended child, mentally disabled person, or intoxicated person) and rabies cannot be ruled out by testing the bat. Post-exposure prophylaxis would not be warranted for other household members.

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Just as a reminder……

Regardless of: the availability of vaccinethe funding of the vaccine (VFC, state-supplied, or private stock)whether the vaccine is required for school or child care or not……….

FOLLOW ACIP Recommendations!!!

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www.cdc.gov/travel

Yellow FeverTyphoidPolio

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Challenges to Adult Vaccination

Ref: Johnson DR, et al. Am J Med. 2008;121 (7 Suppl 2):S28-S35.

Most patients indicate that they are likely to receive a vaccination if their healthcare provider (you) recommends it.

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Talking with Patients about Vaccines

Inform that more vaccines are now available for adultsMake your recommendation about vaccinesUse language patients can understand Give Vaccine Information Statement (VIS) prior to administering a vaccineSolicit and welcome questionsDraw upon your experience as a health care provider for those who are hesitant about receiving a vaccine

Adapted from Glen Nowak, PhD. CDC

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Important Office Practices

Use Reminders

-Electronic health record pop-ups or chart reminders

-Send patient reminders

Recall

-Recall for routine immunizations

-Recall when vaccine is available after a vaccine shortage

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A “Birth to Death” Immunization RegistryProviders administering vaccines in Georgia must provide appropriate information to GRITS.Create an interface between your system and GRITS that will drastically decrease data entry Reduced missed opportunities to vaccinate at risk individualsReduction of over immunization of individualsAccurate Vaccine Inventory Tracking by Lot # for privately and public funded vaccineReminder/recall notices for parents

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Improve Access To Immunizations

Immunization only visits

Walk-ins for immunizations

Implement standing orders

Early, extended, or weekend hours

Mass vaccination clinics

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Become a Vaccine Champion!!

Critical ElementsAppropriate storage and handling of all vaccines.Correct administration of vaccinesEducation of patients and parents about vaccinesEvery office and clinic needs a vaccine champion.

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Vaccine Champion

Key Characteristics

Lead your immunization team.

Educate all staff about new vaccines and recommendations.

Educate new staff about vaccine storage, handling, & administration.

Initiate processes to improve immunization rates in your practice/facility.

Assure immunizations of all staff are up-to-date.

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VAERS

Public Health Reports should be faxed or mailed to the State Immunization Program. Fax number (404)657-1463

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Vaccine Injury Compensation Program (VICP)

National Vaccine Injury Compensation Program

provides compensation to individuals found to be injured by or have died from certain childhood vaccines.

Established in 1988 by NCVIA

Federal “no fault” system to compensate those injured

Claim must be filed by individual, parent or guardian

Must show that injury is on “Vaccine Injury Table”

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Resources for Factual & Responsible Vaccine Information

www.immunize.org

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Stay Current!

Sign up for listserv sites which provide timely information pertinent to your practice www.immunize.org/resources/emailnews.aspAAP NewsletterCDC immunization websites (32 in all)CHOP Parents Pack NewsletterIAC ExpressWebsites specific to particular vaccines

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Internet Resources

Georgia Department of Public Healthhttp://dph.georgia.gov/immunization-sectionhttps://dph.georgia.gov/train-trainerCDC Immunization information http://www.cdc.gov/vaccines/ CDC Flu informationhttp://www.cdc.gov/flu/Immunization Action Coalitionwww.immunize.org

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State Resources

GA Immunization Program OfficeOn call Help line: 404-657-3158GRITS Help Line:1-866-483-2958VFC Help Line:1-800-848-3868Website http://dph.georgia.gov/immunization-sectionYour local Immunization Regional Program Consultant (IRC)Epidemiology: 1-866-782-4584 GA Chapter of the AAPGA Academy of Family Physicians

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It’s a Team Effort!

High Immunization rates begin with a team designed plan!

What can your team do to improve rates?