Childhood Immunization Update - PowerPoint Presentation

Slide1

Childhood Immunization Update

DPH

Audience / Presenter’s Name / Date

2019

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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

Recall two recent immunization updates

Discuss the role of a vaccine champion

Discuss GA Immunization law and DPH rules and regulations for schools and child care attendance

List at least two reliable sources for immunization information

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Topics for Discussion

2019 Immunization Schedule Changes

ACIP Recommendations/Updates

New and future vaccines for potential use in practice

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The Impact of Vaccines in the United States

CDC. National Notifiable Diseases Surveillance System, 2017 Annual Tables of Infectious Disease Data. Available at www.cdc.gov/nndss/infectious-tables.html. NNDSS finalized annual data as of November 28, 2018.

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VPDVaccination RateNeeded for Herd ImmunityMeasles92-94%Pertussis92-94%Diphtheria83-85%Rubella83-85%Mumps75-86%Influenza30-75%

MMWR. 2017 Nov 3; 66(43): 1171–1177

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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 indicationsAdults 19 years and olderAdults based on medical and other indications

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

READ THE NOTES

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

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

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

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

Altered ImmunocompetenceSpecial SituationsVaccination RecordsVaccination ProgramsVaccine Information Sources

Timing and Spacing of

Immunobiologics

Contraindications and Precautions

Preventing and Managing Adverse Reactions

Vaccine Administration

Storage and Handling of

Immunobiologics

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General Best Practice Updates

May 14, 2018Timing and Spacing, LAIV added, MPSV23 removedJuly 18, 2018Hep A/ IG administration changedThree precautions removed from DTaP rowVaricella updated for the use of aspirin or aspirin-containing productstable 4-2 under contraindications and precautions, header changed to conditions“Multiple vaccinations”, HepA and IG- this couplet added to the pairs which should not be administered in the same limbVaccine Administration, RZV Row/Dose Column state that only 0.5cc should be withdrawn even if more vaccine remains in the vial

https://www.cdc.gov/vaccines/hcp/acip-recs/general-recs/general-recs-errata.html

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Diphtheria, Tetanus, and Pertussis Vaccines(DTaP & Tdap)

Routine RecommendationDTaP: 5 dose series administered at 2, 4, 6, 15-18 months and 4-6 yearsTdap: 1 dose administered at 11-12 years of age; administer 1 dose to pregnant adolescent (preferably during the early part of gestational weeks 27-36)Catch-up vaccinationA 5th dose of DTaP is not necessary if dose 4 was administer at age 4 years or olderChildren ages 7 through 10 years who receive DTaP or Tdap inadvertently or as part of a catch-up series should receive Tdap for the routinely recommended adolescent dose at 11-12 years of ageFor other catch-up guidance, please refer to immunization schedule notes

Prevention of Pertussis, Tetanus, and Diphtheria with Vaccines in the United States: Recommendations of the Advisory Committee on Immunization Practices (ACIP), MMWR/ April 27, 2018/ 67 (2); 1-44

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Hepatitis A Vaccine

Routine RecommendationAdminister 2 dose series between the 1st and 2nd birthdays (Havrix 6-12 months apart or Vaqta 6-18 months apart)Catch-up vaccinationAdminister 2 doses to children 2 years of age or older separated by 6 monthsInternational TravelInfants age 6-11 months: 1 dose before departure; revaccinate with 2 doses (separated by 6-18 months), between 12 to 23 months of age.Unvaccinated children age 12 months and older: 1st dose as soon as travel in considered

Prevention of Hepatitis A Through Active or Passive Immunization - Recommendations of the Advisory Committee on Immunization Practices (ACIP) MMWR Vol. 55/No. RR-7 May 19, 2006

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Hepatitis A Vaccine Special Situations

Administer a 2 dose series to at risk populationChronic liver disease, clotting factor disorders, MSM, injection and non injection drug users, homelessness, work with HepA virus (i.e. in research labs or nonhuman primates with HepA infection)Persons who anticipate close, personal contact with an international adoptee during the first 60 days after arrival in the U.S. from a country with high or intermediate endemicity (administer the 1st dose as soon as the adoption is planned, at least 2 weeks before the adoptee’s arrival)Administer for post-exposure for all persons age 12 months or olderHep A vaccine or IG may be administered to persons age 40 years or older, depending on the provider’s risk assessment

MMWR/ February 15, 2019 / 68(6);153–156 MMWR November 2, 2018; 67(43); 1208–1210 MMWR 2018; 67(43); 1216-1220

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Hepatitis B Vaccine

Routine Recommendation

Dose 1 @ birth

Dose 2 @

1-2

months of age

at least 1 month after first dose

Dose 3 @ 6-18 months of age

minimum of 4 months after the first dose

minimum of 2 months after the second dose but not before an infant is 24 weeks of age

Administration of 4 doses is permitted when a combination vaccine containing

HepB

is used after the birth dose

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HEPLISAV-B (HepB-CpG)

Administration2-dose vaccine series administered at least 4 weeks apart (0, 1 month) via IM injectionLicensed for use in persons ≥ 18 yearsDosing ScheduleThe 2-dose series ONLY applies when both doses are HeplisavA series consisting of 1 dose of Heplisav and a different Hep B vaccine, should consist of 3 total doses using the 3-dose schedule minimum intervalsDoses administered at less than the recommended minimum interval should be repeatedSerologic TestingPost vaccination Serologic Testing is recommended 1-2 months after final dose for: hemodialysis patients; immunocompromised persons, including those with HIV; healthcare personnel and/or partners of HBsAg-positive persons

MMWR Recommendations and Reports/ Vol. 67/ No. 15/ April 20, 2018 https://www.cdc.gov/vaccines/schedules/vacc-updates/heplisav-b.html

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Haemophilus influenzae type b (Hib)

Routine Recommendation

4-dose series at 2, 4, 6, and 12-15 months (

ActHIB

,

Hiberix

, or

Pentacel

)

3-dose series at 2, 4, and 12-15 months (

PedvaxHIB

)

Catch-up vaccination

Administer 1 dose for unvaccinated children ages 15-59 months

Refer to catch-up immunization schedule for other catch-up guidance

Special situations

Refer to immunization schedule notes for guidance when vaccinating high risk children with medical indications (i.e. chemo, radiation, HSCT, asplenia, elective splenectomy, HIV and immunoglobulin deficiency, early complement deficiency)

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HPV Vaccine

Routine Recommendation

All adolescents 11-12 years old (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 (minimum interval of 5 months; repeat dose if administered too soon)

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

Through 26 years old, if not previously adequately vaccinated

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HPV Vaccine for Special Population and Situations

Special situations

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

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

Pregnancy: vaccine is not recommended during pregnancy

If administered inadvertently while pregnant, no intervention needed-delay further doses until after pregnancy

Pregnancy testing not needed before vaccination

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Influenza Vaccinesfor 2018-2019 Season in the U.S.

Trivalent Vaccines (IIV3): A/Michigan/45/2015 (H1N1) A/Singapore/INFIMH-16-0019/2016 (H3N2)-like virus (NEW)B/Colorado/06/2017-like virus (Victoria lineage)- like virus (NEW)Quadrivalent Vaccines (IIIV4) will also include: B/Phuket/3073/2013-like virus (Yamagata lineage)- like virusACIP recommends annual influenza vaccine for all persons 6 months of age and older who do not have contraindications

Recommendations and Reports Vol. 67 / No. 3 MMWR / August 24, 2018

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FluMist Medimmune Nasal Spray (LAIV4)

FluMist Medimmune nasal spray is licensed for healthy persons 2 through 49 years of ageAdministration Pre-filled single-use sprayer contains 0.2mL of vaccineEnsure patient is in upright position0.1mL to be sprayed into first nostril, then dose divider clip is removed from the sprayer to administer second half of dose (remaining 0.1mL) into other nostrilContraindications Children 2-4 yrs. of age with a diagnosis of asthma or who have had a history of wheezing in the past 12 months; asthma in people 5 yrs. of age and olderPersons who are immunocompromised, by medication or diseaseClose contacts and caregivers of severely immunosuppressed personsPregnant womenPersons who have received influenza antiviral medications within the previous 48 hrs

MMWR Recommendations & Reports/Vol. 67/No. 3, August 24, 2018

https://www.cdc.gov/flu/about/qa/nasalspray.htm

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Product Updates

FDA licensure and labeling changes:

January 23, 2019 FDA approved use of the 0.5mL dose of Sanofi’s

Fluzone

Quadrivalent influenza vaccine to include children age 6 through 35 months

Approval of Afluria Quadrivalent (Seqirus) and

Flublok

Quadrivalent (Protein Sciences)

Expansion of the age indication for FluLaval Quadrivalent (GSK) and Fluarix Quadrivalent (GSK) to age 6 months and older (previously licensed for persons 3 years and older)

Expansion of the age indication for Afluria (Seqirus) to include persons 5 years and older (previously recommended for persons 18 years and older)

CDC published ACIP’s recommendations for the use of quadrivalent live attenuated influenza vaccine (LAIV4) in the 2018-19 influenza season

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Dosing Algorithm for Children

Recommendations and Reports Vol. 67 / No. 3 MMWR / August 24, 2018

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Measles, Mumps, Rubella

Routine Recommendation

2- dose series at ages 12 through 15 months and 4 through 6 years (dose 2 may be given as early as 4 weeks after the 1

st

dose)

Catch-up vaccination

Unvaccinated children and adolescents: 2 doses at least 4 weeks apart

Special situations

International travel

: 1 dose prior to departure for infants ages 6-11 months followed by routine 2 dose series at 12-15 months (12 months for children in high-risk areas) and dose 2 as early as 4 weeks

Administer a 2 dose series at least 4 weeks apart for unvaccinated children 12 months and older, prior to departure

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Varicella

Routine Recommendation

2-dose series at 12 through 15 months and 4 through 6 years

The 2

nd

dose may be given as early as 3 months after the 1

st

dose (a dose given after a 4-week interval may be counted)

Catch-up vaccination

Administer 2 doses to persons 7-18 years without evidence of immunity

Ages 7-12 years routine interval between doses 3 months (minimum interval: 4 weeks)

Ages 13 years and older minimum interval 4 weeks between doses

The maximum age for use of MMRV is 12 years old

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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

Maximum age for MMRV use is 12 years old

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Spacing of Live Virus Vaccines and Other Products

PPD and live virus vaccineApply PPD at same visit as MMRIf MMR given first, delay PPD 4 weeks or longer if not given during the same visitIf PPD given first, administer MMR when client returns for skin test readingSpacing with antibody-containing products such as immune globulin (IG) with live vaccines

MMWR

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

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Polio

Routine Recommendation4- dose series at 2, 4, 6 through 18 months, and 4 through 6 yearsFinal dose after the fourth birthday and at least 6 months after the previous dose4 or more doses of IPV can be administered before the 4th birthday when a combination vaccine containing IPV is used. However, a final dose after the 4th birthday is still recommendedCatch-up vaccinationFinal dose to be given on or after the 4th birthday and at least 6 months after the previous dose, regardless of the number of previous doses IPV is not routinely recommended for U.S. residents 18 years and older

In the first six months of life, use minimum ages and intervals only for travel to a polio-endemic region or during an outbreak

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Pneumococcal Vaccines (PCV13) (PPSV23)

Routine Recommendation for PCV13

4-dose series at 2, 4, 6, and 12-15 months

Catch-up vaccination for PCV13

1-dose for healthy children 24-59 months with any incomplete* PCV13 schedule

Special situations

High risk conditions include: chronic heart disease, chronic lung disease, diabetes, CSF leak, cochlear implants, asplenia, sickle cell, asplenia, HIV, lymphomas, Hodgkin disease, chronic liver disease, alcoholism, etc.

When both PCV13 and PPSV23 are indicated, administer PCV13 first. PCV13 and PPSV23 should not be administered during the same visit

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Serogroup A, C, W, Y Meningococcal Vaccines

Routine Recommendation

2-dose series to be administered at 11-12 years old and 16 years old

Catch-up vaccination

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 old

Special situations

1 dose for first year college students who live in residential housing (if not previously vaccinated at age 16 years or older) or military recruits

Refer to immunization schedule notes for additional guidance when vaccinating clients with medical indications and/or traveling to hyperendemic or epidemic countries

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Serogroup B Meningococcal Vaccines

Clinical discretion

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

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

Special situations

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

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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Rotavirus Vaccine

Routine Recommendation

Rotarix: 2-dose series at 2 and 4 months

RotaTeq

: 3-dose series at 2, 4, and 6 months

If any dose in the series is either RotaTeq or unknown, default to 3-dose series

Catch-up vaccination

Do not start the series on or after age 15 weeks, 0 days

Maximum age for final dose is 8 months, 0 days

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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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Test Your Knowledge!

Q: We have adolescents in our practice who have received the first 2 doses of the HPV series 1 or 2 months apart according to the 3-dose schedule. Can we consider their HPV vaccine series to be complete or do we need to give these patients a third dose?

A: People who have received 2 doses of HPV vaccine separated by less than 5 months should receive a third dose 6–12 months after dose #1 and at least 12 weeks after dose #2.

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Test Your Knowledge!

Q: Which patients should receive a 2-dose schedule of Trumenba (MenB, Pfizer)?A: Healthy adolescents who are not at increased risk for meningococcal disease should receive 2 doses of Trumenba administered at 0 and 6 months. If the second dose is given at an interval of less than 6 months, a third dose should be given at least 4 months after the 2nd dose.

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

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Test Your Knowledge!

Q: If someone received MPSV4 or MenACWY at age 9 years, will two additional doses of MenACWY be needed?A: Yes. Doses of quadrivalent meningococcal vaccine (either MPSV4 or MenACWY) given before 10 years of age should not be counted as part of the routine 2-dose series. If a child received a dose of either MPSV4 or MenACWY before age 10 years, they should receive a dose of MenACWY at 11 or 12 years and a booster dose at age 16 years.

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

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Requirements for School and Childcare Attendance

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Goal

Vaccines work Goal 100 % compliance rateImmunization Laws work Partnerships work

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JOB AIDS

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3231 REQ

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3231 INS

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School Requirement Updates

3231 INS updated December 2017

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Certificate of Immunization (Form 3231)

Certificate on file at each facility or school

Photocopies acceptable

A licensed Georgia physician, APRN, PA or public health official is responsible for completing the certificate

Only physician offices and health clinics can obtain blank certificates

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Valid Certificates

All certificates must be marked with: Child’s nameBirth dateName and Address of Physician, APRN, PA, Qualified Board of Health official or State Immunization Office OfficialCertified SignatureDate of Issue

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Expiration Date

Expires on the date entered as “Expiration Date”

Must be replaced with a current certificate within 30 days

Required for all children less than age four years

Required for all children ages four through ten years who have not completed K through 6

th

grade requirements or children 10 years and older who have not completed 7

th

grade or higher requirements

Required if a medical exemption for a vaccine(s) is marked

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“Complete for School Attendance”

Issued only to children who:Are four years of age or older; andHave met all the requirements for school attendance as outlined in the Policy Guide 3231REQ; andHave all the required vaccine administration dates or natural immunity dates filled in; andDo not have a “Date of Expiration”

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Exemptions

Medical

Physical disability or condition

Documented in the medical exemption box indicated for each vaccine

Reviewed annually

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Exemptions

ReligiousDocumented on form 2208Form kept on file by the school or facility in lieu of a Certificate of Immunization (form 3231)Do not expire

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School Requirement Updates

DPH Rules and Regulations 511-2-2-.07

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Child Care Requirements

Number of vaccine dosesAlways need more dosesMust have a current “expiration date”

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School Requirements

Any “new entrant” enrolling in a Georgia school at any grade or level, must be age appropriately immunized with required vaccines

Number of doses depends on the child’s age

“Complete for 7

th

Grade or higher ” is marked; certificate is complete

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3

: Completing both boxes: When all requirements have not been met

10: “Complete for School” checked for child under age 4

9: No dose DTaP after 4th birthday

2: Doses Hep B spaced incorrectly

7: 1st dose MMR given before age 1 yr.

6: 1st dose varicella given before age 1 yr.

8: No 2nd dose varicella documented

5: Varicella Immunity not documented by vaccine or hx/dx/serology date

4: Address and/or contact information not completed

1: No physician, APRN or PA signature

11. No dose of Tdap or MCV4 for students born on or after 1-1-2002 entering 7

th

grade or “new entrants”

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Filing of Certificates

Available for inspection by health officialsPhotocopy acceptableSent copy to the new school/facilityIn the case of religious exemption, form 2208 must be on file in lieu of form 3231

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Tickler Filing System

Instructions located in the

Immunization Guidelines for Child Care Facility Operators & School Personnel

(

Form 3258

)

Set up by month and year

Parent reminders

Summary of GA Immunization requirements

Document follow-up

Enforce requirements

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GRITS

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Responsibilities

Physicians and Public Health ClinicsChild Care and School Parent/Caregiver

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Become a Vaccine Champion!!

Critical ElementsAppropriate storage and handling of all vaccinesCorrect 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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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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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)

The 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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Should We Report Vaccine Errors to VAERS?

The Vaccine Adverse Event Reporting System (VAERS) accepts all reports, including reports of vaccination errors

VAERS is primarily for monitoring adverse health events, and we encourage reporting of clinically significant adverse health events following vaccination

Using clinical judgment, healthcare professionals can decide whether or not to report a medical error. For example, a healthcare professional might choose to report a vaccination error if the error might pose a safety risk (e.g., administering a live vaccine to an immunocompromised patient) or the error would be preventable with public health action or education

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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 informationhttps://www.cdc.gov/vaccines/index.html Send your clinical vaccine questions to NIPINFO@cdc.gov CDC Flu informationhttps://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?