Krista D Capehart PharmD MSPharm AEC David G Bowyer R Ph Assistant Professors of Pharmacy Practice University of Charleston School of Pharmacy Objectives Determine the appropriate vaccine recommendations for a patient based on current immunization schedules ID: 750845
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Slide1
Vaccine Update and Refresher for Immunizations: 2012
Krista D. Capehart, PharmD, MSPharm, AE-C
David G. Bowyer, R. Ph.
Assistant Professors of Pharmacy Practice
University of Charleston School of Pharmacy Slide2
Objectives
Determine the appropriate vaccine recommendations for a patient based on current immunization schedules.
Apply individual vaccine characteristics to identify anticipated vaccine adverse events.
Explain the Advisory Committee on Immunization Practices (ACIP) recommendations for vaccines pharmacists can administer in West Virginia.
Summarize critical information needed for the administration of influenza and pneumococcal.
Investigate information about the vaccines added to Title 15 Series 12 of the West Virginia Code for immunization rules.Slide3
Pharmacist Administered Immunizations in WV
HB 3056 passed in 2008 authorizing specially trained pharmacists in WV to administer influenza and pneumococcal polysaccharide
Additional vaccines could be added following joint rule-making with WV Board of Medicine, WV Board of Osteopathy, and WV Board of Medicine
Summer 2011 joint rule-making occurred and was approved by the 2012 Legislature
Pharmacists can now administer Hepatitis A, Hepatitis B, Tetanus, and Herpes Zoster in addition to influenza and pneumococcal vaccinesSlide4
Current Title 15 – Series12
Qualifications for pharmacists to administer immunizations:
Any person ≥ 18 years old
Registered with the Board of Pharmacy (BOP) to administer immunizations
Successfully complete immunization training course approved by the BOP
Maintain current certification to basic life-support
Complete 2 hours annually of continuing education related to immunizationsSlide5
Current Title 15 – Series12
Must have immunization questionnaire and consent form, notify patient’s primary care provider (PCP) within 30 days of administration
Report the administration to the WV Statewide Immunization Information (WVSII) database within 30 days of administration
Must have consent & questionnaire readily retrievable and maintained on file for not less than 5 years
Pharmacists can administer epinephrine and diphenhydramine to manage acute allergic reaction following CDC guidelines
Pharmacists must have readily retrievable emergency response plan as outlined by the CDC and a readily retrievable emergency kit to manage an acute allergic reaction to an immunization administeredSlide6
Pharmacists as Immunizers in WV
As of June 2012, 1663 pharmacists have completed the mandated training course and are registered with the West Virginia Board of Pharmacy as Immunizing Pharmacists.
This represents approximately 50% of the pharmacists practicing in WV.
T
his addition to the immunizing workforce increases the access to immunizations for the public.
Slide7
Updates to Title 15 – Series 12
Adds:
Hepatitis A
Hepatitis B
Herpes Zoster
Tetanus (follows CDC recommendations and permits tetanus-diphtheria (Td) or tetanus-diphtheria-pertussis (Tdap)
Pharmacists must report all adverse events to the Vaccine Adverse Events Reporting System (VAERS) and provide a copy to the BOP
(available at http://vaers.hhs.gov/index)Slide8
Case Study 1
A family comes in to the pharmacy. The mother is a 40yo WF with a 15yo WM and 19 WF children requests immunizations for herself and her family. After discussing with her what she needs, you determine that they all need TIV and her daughter needs Hep B.
What immunizations could the pharmacist currently provide for the family?Slide9
Advisory Committee on Immunization Practices (ACIP)Recommendations for Adult Influenza Immunizations
Vaccination recommended for all adults (including healthy adults 19-49 years without risk factors)
Live attenuated influenza vaccine – only approved for healthy non-pregnant people age 2-49 years
65 years and older can get standard-dose Trivalent inactivated influenza vaccine (TIV) or the high does TIV
Give 1 dose every year in the fall or winter
Begin vaccination as soon as vaccine is available and continue until supply is depleted
If 2 or more live virus vaccine are given – give same day or they must be separated by at least 28 days
Needle Tips from the Immunization Action Coalition Volume 21 Number 3 July 2011 available at www.immunize.orgSlide10
Advisory Committee on Immunization Practices (ACIP)Recommendations for Adult Influenza Immunizations
Mild illness is not a contraindication
Contraindications:
Previous anaphylactic reaction to vaccine, components, or eggs
LAIV only: pregnancy, chronic pulmonary problems, cardiovascular (except hypertension), renal, hepatic, neurological/neuromuscular, hematologic, or metabolic disorders, immunosuppression
Precautions:
Moderate or severe acute illness
History of Guillain-Barre syndrome within 6 weeks of previous influenza
LAIV only: taking antivirals 48 hours before vaccination and avoid using antivirals for 14 days after vaccination
Needle Tips from the Immunization Action Coalition Volume 21 Number 3 July 2011 available at www.immunize.orgSlide11
Estimates of Cumulative Influenza Vaccination Coverage for 2010-2011 Season
West Virginia 48%
United States 43%
Among those ≥ 18 years in US vaccination rate 40.4%
High risk group remains: elderly, young children, pregnant women, and people with chronic conditions
Healthy People 2020 target is:
80% for persons 6 months – 64 years
90% for those ≥ 65 years
Final state-level influenza vaccination coverage estimates for the 2010–11 season–United States, National Immunization Survey and Behavioral Risk Factor Surveillance System, August 2010 through May 2011 available at http://www.cdc.gov/flu/professionals/vaccination/coverage_1011estimates.htmSlide12
Influenza Activity U.S. 2010-2011
Higher rates of hospitalization in ≥ 65 years than in 2011-2012
22% of specimens tested were positive with the virus peaking in February 2011
74% of positive specimens were Type A and 26% were Type B
Proportion of specimens testing positive was <10% during the week ending April 16, 2011
MMWR 2011;60(21):705-712Slide13
Resistance in 2010 to Antivirals
5,758 influenza viral specimens tested for resistance
All 723 influenza B were sensitive to oseltamivir and zanamivir
2 of 806 Influenza A (H3H2) were resistant to oseltamivir
All 784 influenza A (H3H2) were sensitive to zanamivir
Of the 4,229 influenza A (H1N1) 39 were resistant to oseltamivir; of the 771 testes with zanamivir, all were sensitive
High resistance to adamantanes (amantadine and rimantadine)
MMWR 2011;60(21):705-712Slide14
2010-2011 Pneumonia and Influenza Related Mortality
Percentage of deaths attributable to pneumonia and influenza exceeded the epidemic threshold from January 29, 2011 to April 23, 2011
Peaked at 8.9% week ending February 12, 2011
From October 3, 2010 to May 21, 2011 had 311 lab confirmed influenza-associated deaths were reported to CDC
MMWR 2011;60(21):705-712Slide15
Place of Influenza Vaccination Among Adults US 2010-11 Season
Overall: doctor’s office was the most common place (39.8%), followed by “store” (supermarket or drug store) at 18.4%, and workplace 17.4%
Those 65 and older were most likely (51.5%) to be vaccinated at a doctor’s office than a store (24.3%)
High risk individuals were more likely to get their vaccination in a doctor’s office than those without (49.1% vs 35.7%)
MMWR; 60(23): 781-785
.Slide16
Early Estimates of Cumulative Influenza Vaccination Coverage for 2011-2012
Season
Among adults ≥ 18 years, estimated vaccination coverage was 45.5%, an increase from 41.1% the previous season
Estimated 2011-12 coverage among adults 18-49 years increased by 7 percentage points compared to the 2010-11 season.
Estimated coverage among adults increased with each increase in adult age group. Estimated coverage among adults was highest in adults ≥ 65 years (70.8%) and lowest among adults 18-49 years (35.8%).
Estimated coverage among adults 50 to 64 years or ≥ 65 years did not differ when compared to the same time the previous season
.
March
2012 National Immunization Survey and National Flu Survey - United States, 2011-12 Influenza
Season
http://
www.cdc.gov/flu/professionals/vaccination/nfs-survey-march2012.htm accessed 6/6/12Slide17
Place of Vaccination 2011-12
The most common place of vaccination among
adults
(32.5%)
was
a doctor’s office
These
results are similar to results from the 2010-11 season when 31.6% of adults
were
vaccinated in doctor’s offices.
Other common places of influenza vaccination reported for adults during the 2011-12 season included medically related places besides doctor’s offices (24.7%), pharmacies or stores (19.7%), and workplaces (13.8%).
March
2012 National Immunization Survey and National Flu Survey - United States, 2011-12 Influenza Season http://www.cdc.gov/flu/professionals/vaccination/nfs-survey-march2012.htm accessed 6/6/12Slide18
Pneumococcal disease
Pneumococcal disease most often occurs in older people as well as in people with a predisposing condition (e.g., pulmonary disease,
asplenia
).
Pneumococcal disease most commonly presents as a serious infection in the lungs (pneumonia), blood (bacteremia), or brain (meningitis). The annual U.S. case estimate for invasive pneumococcal disease (bacteremia and/or meningitis) is 40,000.
PPSV is 60–70% effective in preventing serious pneumococcal disease; it does not provide substantial protection against all types of pneumonia (viral and bacterial). It is not a “pneumonia” vaccine.
Pneumococcal
Polysaccharide Vaccination Pocket Guide
: http
://
www.immunize.org/ppvguide/pocketguide.pdf; accessed 6/6/12Slide19
Pneumococcal Polysaccharide (PPSV)
Recommended for people 65 years and older; younger than 65 years with chronic illnesses or other risk factors (cardiac, pulmonary, liver disease, alcoholism, diabetes, cigarette smoking); Those at highest risk including asplenia, immunocompromising condition, chemotherapy, or has received organ or bone marrow transplant
Give 1 dose if history is unknown or unvaccinated
Give a 1 time revaccination to:
Age 65 years and older if 1
st
dose was before age 65 years and more than 5 years ago
Age 19-64 years at high risk of fatal pneumococcal infection and 5 years have elapsed since the 1
st
dose
Needle Tips from the Immunization Action Coalition Volume 21 Number 3 July 2011 available at www.immunize.orgSlide20
Estimated proportion of adults
who received Pneumococcal
vaccination 2010
19–64
yrs
, high
risk 18.5
≥65
yrs
59.7
Healthy People 2020 goals call for 90 % of the n
on-institutionalized
adults aged 65 years and
older and 60% of non-institutionalized
high-risk adults aged 18 to 64
years to
be
immunized.
Neither overall coverage nor coverage for any specific age or racial/ethnic group differed significantly from 2009 coverage.
National
Health Interview Survey, United States,
2010-MMWR February
3, 2012 / 61(04);
66-72 accessed 6/6/12Slide21
Case Study 2
A 70 yo male comes into the pharmacy to be immunized for influenza and pneumococcal. He had his last flu shot last year and pneumococcal when he was 60yo.
He asks about the nasal flu vaccine. Is he a candidate? Why or why not?
He asks about the “high dose” flu vaccine. Is he a candidate? Why or why not?
Should he get his PPSV today? Why or why not?Slide22
Herpes Zoster (Shingles) – Give Subcutaneous Injection
For people age 60 years and older
Give 1 time dose if unvaccinated, regardless of history of shingles or chickenpox
If giving 2 or more live vaccines at same time (MMR, Zoster, Yellow fever), should be given on the same day or must be separate by 28 days
Contraindications
Previous anaphylactic reaction to any component of vaccine
Primary cellular or acquired immunodeficiency
Pregnancy
Precautions
Moderate or severe acute illness
Receipt of antivirals 24 hours before vaccination; if possible, delay resuming antivirals for 14 days after vaccination
Needle Tips from the Immunization Action Coalition Volume 21 Number 3 July 2011 available at www.immunize.orgSlide23
Tetanus
Comes as tetanus-diphtheria (Td), tetanus-diphtheria-pertussis (Tdap), or tetanus (TT)
Give intramuscular
All who do not have written documentation of a primary series of at least 3 doses of tetanus and diphtheria
Booster of Td or Tdap may be needed for wound management
In pregnancy, give Td or Tdap if indicated in 2
nd
or 3
rd
trimester. If not given during pregnancy, give Tdap immediate postpartum period
Tdap ONLY:
Adults <65 years who have not already had Tdap
Adults of any agent in close contact with infants < 12 months who have not had a dose of Tdap
Healthcare personnel of all ages
Adults ≥ 65 years without a risk factor may also be vaccinated with Tdap
Needle Tips from the Immunization Action Coalition Volume 21 Number 3 July 2011 available at www.immunize.orgSlide24
Tetanus (cont.)
Schedule
Those unvaccinated or behind, complete the primary Td series (spaced at 0, 1-2months, 6-12 month intervals); substitute a one-time dose of Tdap for one of the doses in the series, preferably the first
Give Td booster every 10 years after primary series has been completed
Tdap can be given regardless of interval since previous Td
Contraindications
Previous anaphylactic reaction to vaccine or components
For Tdap only, history of encephalopathy, not attributable to an identifiable cause, within 7 days following DTP/DTaP
Precautions
Moderate and severe acute illness
Guillian-Barre syndrome within 6 weeks following previous dose of tetanus toxoid containing vaccine
Progressive or unstable neurologic disorder, uncontrolled seizures, or progressive neuropathy
Needle Tips from the Immunization Action Coalition Volume 21 Number 3 July 2011 available at www.immunize.orgSlide25
Hepatitis A (Hep A)
Give Intramuscularly
All who want protection from Hep A and those who work or travel anywhere EXCEPT U.S., Western Europe, New Zealand, Australia, Canada, and Japan
Those with chronic liver disease; injecting & non-injecting drug users; men having sex with men; those getting clotting concentrates; those who work in labs with Hep A; some food handlers
People with close contact with an international adoptee from a country of high or intermediate endemicity during the first 60 days following the adoptee’s arrival in the US
Adults age 40 years or younger with recent (within 2 weeks) exposure to Hep A. For older people (<40years), with recent (within 2 weeks) exposure to Hep A immune globulin is preferred over the Hep A Vaccine
Needle Tips from the Immunization Action Coalition Volume 21 Number 3 July 2011 available at www.immunize.orgSlide26
Hepatitis A (Hep A) cont.
Give 2 doses; minimum interval between doses 1 and 2 is six months
If 2
nd
dose is delayed, don’t repeat the first dose, just give the second dose.
Contraindications:
Previous anaphylactic reaction to this vaccine or to any of its components.
Precautions:
Moderate or severe acute illness
Weigh risk versus benefit in pregnancy
Needle Tips from the Immunization Action Coalition Volume 21 Number 3 July 2011 available at www.immunize.orgSlide27
Hep A and Hep B Combination (Twinrix®)
For 18 years and older
3 doses on 0,1, and 6 month schedule
At least 4 weeks between dose 1 and 2 and 5 months between dose 2 and 3
OR
Alternative schedule: 0, 7day, 21-30 day, and a booster at 12 months
Needle Tips from the Immunization Action Coalition Volume 21 Number 3 July 2011 available at www.immunize.orgSlide28
Hep B
Give intramuscularly
All who want to be protected against Hep B
High risk: household contacts, sex partners, injecting drug users, those not in long term mutually monogamous relationships, men having sex with men, people with HIV, persons seeking STD evaluation or treatment, hemodialysis patients, healthcare personnel and public safety workers, inmates at long term correction facilities, chronic liver disease and certain international travel
Needle Tips from the Immunization Action Coalition Volume 21 Number 3 July 2011 available at www.immunize.orgSlide29
Hep B (cont.)
3 doses on a 0, 1, 6 month schedule
At least 4 weeks between dose 1 and 2, at least eight weeks between doses 2 and 3, at least sixteen weeks between doses 1 and 3
If patients fall behind in schedule, do not start over just pick up where left off
Contraindications: previous anaphylactic reaction to this vaccine or any components
Precautions: Moderate or severe acute illness
Needle Tips from the Immunization Action Coalition Volume 21 Number 3 July 2011 available at www.immunize.orgSlide30
Case study 3
A 70yo patient comes into the pharmacy. She is interested in getting her flu shot, pneumococcal vaccine, and anything else she “needs” before she goes to Arizona to help take care of her new twin granddaughters who are 6 weeks old.
What other information do you need to know?
What vaccinations does she need?
What could the pharmacist give her today?Slide31
References
Needle Tips from the Immunization Action Coalition Volume 21 Number 3 July 2011 available at
www.immunize.org
Final state-level influenza vaccination coverage estimates for the 2010–11 season–United States, National Immunization Survey and Behavioral Risk Factor Surveillance System, August 2010 through May 2011 available at
http://www.cdc.gov/flu/professionals/vaccination/coverage_1011estimates.ht
m
MMWR 2011;60(21):705-712
MMWR 2011; 60(23): 781-785.
MMWR 2011:60(33):1128-1132.
Questions & Answers Fluzone High–Dose Seasonal Influenza Vaccine available at
http://www.cdc.gov/flu/protect/vaccine/qa_fluzone.htm
Intradermal Influenza (Flu) Vaccination available at
http://www.cdc.gov/flu/protect/vaccine/qa_intradermal-vaccine.htm
Vaccines, Blood and Biologics FDA Updated Communication on Use of Jet Injectors with Influenza Vaccines. Available at
http://www.fda.gov/BiologicsBloodVaccines/Vaccines/QuestionsaboutVaccines/ucm276773.htm
accessed on October 26, 2011.