Presentation is loading. Please wait.

Presentation is loading. Please wait.

PROTECTTM SupPorting AppROpriate ImmunizaTions Across the AgE SpeCTrum

Similar presentations


Presentation on theme: "PROTECTTM SupPorting AppROpriate ImmunizaTions Across the AgE SpeCTrum"— Presentation transcript:

1 PROTECTTM SupPorting AppROpriate ImmunizaTions Across the AgE SpeCTrum

2 FPO-Faculty Disclosure
Click to add subtitle

3 PROTECTTM SupPorting AppROpriate ImmunizaTions Across the AgE SpeCTrum
Table of Contents PROTECTTM SupPorting AppROpriate ImmunizaTions Across the AgE SpeCTrum Childhood Childhood Vaccines Combination Vaccines Addressing Parental Concerns Strategies for Improving Childhood Immunization Rates Adolescent Adolescent Vaccines Strategies for Improving Adolescent Immunization Rates Adult Adult Vaccines Strategies for Improving Adult Immunization Rates General Immunization Information for All Age Groups Vaccine-preventable Diseases General Strategies for Improving Immunization Rates Resources

4 Educational Learning Objectives
At the conclusion of this presentation, the participant should be able to: Discuss the indications and recommendations for the most current immunization schedules for childhood, adolescent, and adult populations Respond to frequently encountered questions and situations during patient discussions including safety, efficacy, and possible misinformation Implement strategies for improving immunization rates within one’s clinical practice, taking into account current immunization schedules and guidelines

5 Childhood Vaccines

6 Routine Childhood Immunization Schedule, 1983
Birth 1 mo 2 4 6 12 mo 15 mo 18 mo 24 mo 4-6 y 11-12 y 14-16 y DTP DTP DTP DTP DTP Td VACCINE OPV OPV OPV* OPV OPV MMR DTP = Diphtheria, tetanus, pertussis OPV = Oral polio (trivalent) MMR = Measles, mumps, rubella *A third dose of OPV is optional but may be given in areas of high endemicity for poliomyelitis CDC. MMWR Morb Mortal Wkly Rep. 1983;32(1):1-8,13-17.

7 2010 Child Immunization Schedule
HepB = Hepatitis B; RV = Rotavirus; DTaP = Diphtheria, Tetanus, Pertussis; Hib = Haemophilus influenzae type b; PCV = Pneumococcal; IPV = Inactivated Poliovirus; MMR = Measles, Mumps, Rubella; HepA = Hepatitis A; MCV = Meningococcal; PPSV = Pneumococcal Polysaccharide ACIP Schedules. Accessed Jan 2010.

8 Childhood Catch-up Schedule
ACIP Schedules. Accessed Jan 2010.

9 Vaccination Coverage Children 19–35 Months, United States, N = 18,430
100 2004 2005 90 2006 2007 80 2008 70 60 Vaccination Coverage (%) 50 40 30 20 10 * DTaP/DT DTaP/DT Poliovirus MMR ≥ 1 Dose Hib ≥ 3 Doses Hepatitis B ≥ 3 Doses Varicella PCV7 PCV7 Hepatitis A ≥ 3 Doses ≥ 4 Doses ≥ 1 Dose ≥ 3 Doses ≥ 4 Doses ≥ 2 Doses *Data for previous years not available CDC. MMWR Morb Mortal Wkly Rep. 2009;58(33):

10 2008–2010 Changes in Child Schedule
Influenza Universal annual vaccination ≥ 6 months Rotavirus Two schedules available: age 2, 4 mos and age 2, 4, and 6 months Polio Emphasize importance of booster dose at age ≥ 4 yrs Meningococcal Conjugate Vaccine Two vaccines now approved; MCV4-D (Menactra®) and MenACWY-CRM197 (Menveo®) Booster Hib Booster reinstatement, shortage issues are over Pneumococcal Addition of PCV13 Booster for PPSV23 10

11 Immunization Timelines
8% of children immunized too early to be valid 58% of children received at least one vaccine later than recommended Thirty-five million adolescents may be missing at least one recommended vaccination Luman ET, et al. Pediatrics. 2002;110:

12 Hepatitis B Dose # Recommended Age Minimum Age Recommended Interval
Minimum Interval 1 Birth* Birth 1-4 mo 4 wk 2 1-2 mo 2-17 mo 8 wk 3 6-18 mo 24 wk Dose 3 should be administered ≥ 16 wk after dose 1 Combination vaccines cannot be used for the birth dose * HB Immunoglobulin should also be administered at birth for infants whose mothers are HBsAg positive Adapted from Table 1, ACIP General Recommendations on Immunization: MMWR Recomm Rep. 2006;55(RR-15):1-48.

13 Hepatitis B Perinatal Transmission*
If mother positive for HBsAg and HBeAg 70%–90% of infants infected 90% of infected infants become chronically infected If positive for HBsAg only 5%–20% of infants infected *in the absence of postexposure prophylaxis

14 Why Rotavirus? > 400,000 physician visits > 200,000 ED visits
> 50,000 hospitalizations > $1 billion in total health care costs CDC. MMWR Recomm Rep. 2006;55(RR12):1-13.

15 Rotavirus Vaccines and Schedules
CDC. MMWR Recomm Rep. 2009;58(RR2):1-25.

16 Rotavirus Vaccine Harmonized Recommendations
Dose # RV1 (Rotarix) RV5 (RotaTeq) ACIP Recommendation Usual schedule 2, 4 mo 2, 4, 6 mo Same 1 Earliest Latest 6 wk 20 wk 12 wk 14 wk 6 day 2 10 wk 24 wk 32 wk 8 mo 0 day 3 --- 14 wk Note: for 2nd and 3rd dose latest age for both is 32 weeks. When the 2nd dose is delayed, this may result in only 2 doses being given. “..vaccination should not be deferred because the product used for previous dose(s) is not available or is unknown. In these situations, the provider should continue or complete the series with the product available. If any dose in the series was RV5, or the vaccine product is unknown for any dose in the series, a total of 3 doses of rotavirus vaccine should be administered.” CDC. MMWR Recomm Rep. 2009;58(RR2):1-25.

17 Rotarix−FDA Advisory The FDA is recommending that health care providers temporarily suspend the use of Rotarix vaccine for rotavirus immunization in the United States while the agency learns more about components of an extraneous virus detected in the vaccine. An independent research team using a novel technique found DNA from porcine circovirus 1 (PCV1) in Rotarix. PCV1 is not known to cause illness in humans or other animals. Rotarix has been studied extensively before and after approval, and found to have an excellent safety record. There is no current evidence of a safety risk; the temporary suspension is a precautionary move. Children with incomplete Rotarix series should complete the series with RV5 (RotaTeq). This will require 3 total rotavirus vaccine doses to be a complete series. FDA. Accessed March 2010.

18 Rotavirus Contraindications Precautions
History of serious allergic reaction to a previous dose of vaccine History of severe hypersensitivity to any component of the vaccine Precautions Altered immunocompetence Moderate to severe illness, including acute gastroenteritis Preexisting chronic gastrointestinal disease Previous history of intussusception CDC. MMWR Recomm Rep. 2009;58(RR2):1-25.

19 Family Physicians and Rotavirus Vaccine
2008 Survey* 45% provided rotavirus vaccine on site ½ rate of other vaccines 35% referred elsewhere 24% did neither 3x rate of other vaccines *Campos-Outcalt D, et al. Immunization Practices of Family Physicians. 43rd National Immunization Conference, Dallas TX, March 31, Abstract PS19.

20 DTaP Dose # Recommended Age Minimum Age Recommended Interval
Minimum Interval 1 2 mo 6 wk 4 wk 2 4 mo 10 wk 3 6 mo 14 wk 6-12 mo 4 15-18 mo 12 mo 3 yr 5 4-6 yr 4 yr Dose 5 not needed if dose 4 is given after age 4 yrs Adapted from Table 1, ACIP General Recommendations on Immunization. CDC. MMWR Recomm Rep. 2006;55(RR15):1-48.

21 Hib Dose # Recommended Age Minimum Age Recommended Interval
Minimum Interval 1 2 mo 6 wk 4 wk 2 4 mo 10 wk 3 6 mo 14 wk 6-9 mo 8 wk 4 12-15 mo 12 mo Dose at 6 mo of age not necessary if first 2 doses are PRP-OMP Fewer doses required if series initiated at ≥ 7 mo of age Supply shortage over, reinstate mo booster and catch-up Approved products – PedvaxHib (Merck) – ActHIB (Sanofi) – Hiberix (GSK)---booster only CDC. MMWR Morb Mortal Wkly Rep. 2009;58(24):

22 Summer 2009 HIB Updated Recommendations
Re-institute routine booster Catch up on those who missed their booster at their next regular check up No recall of all those who missed booster immediately Changed in late summer to recall of those who missed CDC. Accessed September 2009. CDC, personal communication.

23 Hib Products Product Description Primary Series Booster
PedvaxHIB (Merck) Monovalent Hib vaccine 2,4 months 12-15 months* Comvax (Merck) Combined Hib/hepatitis B vaccine Act HIB (Sanofi Pasteur) 2,4,6 months TriHIBit DTaP/Hib vaccine Not licensed for this age group 15-18 months* HIBERIX (GSK) Hib conjugate (tetanus toxoid conjugate) --- 15 months* *Can immunize through age 59 months Haemophilus influenzae type b. Accessed September 2009. HIBERIX PI. ApprovedProducts/UCM pdf. Accessed September 2009.

24 PCV7 Dose # Recommended Age Minimum Age Recommended Interval
Minimum Interval 1 2 mo 6 wk 4 wk 2 4 mo 10 wk 3 6 mo 14 wk 8 wk 4 12-15 mo 12 mo ACIP Schedules. Accessed Sept 2009.

25 13-Valent Pneumococcal Conjugate Vaccine (PCV13)
Licensed by FDA on February 24, 2010 Serotypes in PCV13 PCV7 types: 4, 6B, 9V, 14, 18C, 19F, 23F Additional serotypes: 1, 3, 5, 6A, 7F, 19A Approved for use in children 6 weeks through 5 years (before the 6th birthday) 4-dose series at ages 2, 4, 6, and months Indications Prevention of invasive pneumococcal disease (IPD) caused by the 13 vaccine serotypes Prevention of otitis media caused by PCV7 serotypes CDC. MMWR Morb Mortal Wkly Rep. 2010;59(9):

26 PCV13 Recommended Schedules for Children < 24 months
Age at Examination (mos) Vaccination History: Total PCV7 and/or PCV13 Doses Received Previously Recommended PCV13 Regimen 2 through 6 mos 0 doses 3 doses, 8 wks apart; 4th dose at age mos 1 dose 2 doses, 8 wks apart; 4th dose at age mos 2 doses 1 dose, 8 wks after the most recent dose; 4th dose at age mos 7 through 11 mos 2 doses, 8 wks apart; 3rd dose at mos 1 or 2 doses before age 7 mo 1 dose at age 7-11 mos, 2nd dose at mos, ≥ 8 wks later 12 through 23 mos 2 doses, ≥ 8 wks apart 1 dose before age 12 mo 1 dose at ≥ 12 mo 1 dose, ≥ 8 wks after the most recent dose 2 or 3 doses before age 12 mo 4 doses of PCV 7 or other age-appropriate, complete PCV7 schedule 1 supplemental dose, ≥ 8 wks after the most recent dose CDC. Accessed March 2010.

27 Transition from PCV7 to PCV13 According to Number of Doses Previously Received
Primary Infant Series Booster Dose Supplemental PCV13 Dose 2 mos 4 mos 6 mos ≥ 12 mos* 14-59 mos** PCV7 PCV13 -- *No additional PCV13 doses are indicated for children months who received 2 or 3 doses or PCV7 before age 12 months and at least 1 dose of PCV13 at age ≥ 12months **For children with underlying medical conditions, a supplemental PCV13 dose is recommended through 71 months of age CDC. MMWR Morb Mortal Wkly Rep. 2010;59(9):

28 PCV13 Recommended Schedules for Children ≥ 24 months
Age at Examination (mos) Vaccination History: Total PCV7 and/or PCV13 Doses Received Previously Recommended PCV13 Regimen Healthy children 24 through 59 mos Unvaccinated or any incomplete schedule 1 dose, ≥ 8 wks after the most recent dose 4 doses of PCV7 or other age-appropriate, complete PCV7 schedule 1 supplemental dose, ≥ 8 wks after the most recent dose Children 24 through 71 mos with underlying medical conditions Unvaccinated or any incomplete schedule of < 3 doses 2 doses, one ≥ 8 wks after the most recent dose and another dose ≥ 8 wks later Any incomplete schedule of 3 doses 4 doses of PCV 7 or other age-appropriate, complete PCV7 schedule 1 supplemental dose, ≥ 8 wks after the most recent dose* *For children who have underlying medical conditions, a supplemental PCV13 dose is recommended through 71 months of age CDC. Accessed March 2010.

29 PCV13 – Children 6 through 18 Years of Age with High-risk Conditions
A single dose of PCV13 may be administered for children 6 through 18 years of age who are at increased risk for invasive pneumococcal disease because of their sickle cell disease, HIV infection or other immunocompromising condition, cochlear implant or cerebrospinal fluid leaks, regardless of whether they have previously received PCV7 or PPSV23 This recommendation is an off-label use of PCV13, which is indicated for children 6 weeks through 5 years of age (prior to the 6th birthday) CDC. Accessed March 2010.

30 Revaccination with PPSV23
PPSV23 After PCV13 for Children ≥ 2 years of Age with Underlying Medical Conditions Group Schedule for PPSV23 Revaccination with PPSV23 Children who have sickle cell disease, functional or anatomic asplenia, HIV-infection, or other immunocompromising condition 1 dose of PPSV23 administered at age ≥ 2 yrs and ≥ 8 weeks after last indicated dose of PCV13 1 dose 5 years after the 1st dose of PPSV23 Immunocompetent children with chronic illness Not recommended Doses of PCV13 should be completed before PPSV23 is given. No more than 2 PPSV23 doses are recommended. CDC. Accessed March 2010.

31 Transition from PCV7 to PCV13
When PCV13 is available in office, unvaccinated and incompletely vaccinated children should receive PCV13 (not PCV7) If only PCV7 is available in office, unvaccinated and incompletely vaccinated children should receive PCV7; these children should complete the series with PCV13 at subsequent visits Children for whom the supplemental PCV13 dose is recommended should receive it at their next medical visit. Active recall is not being recommended CDC. MMWR Morb Mortal Wkly Rep. 2010;59(9):

32 PPSV23 Dose # Recommended Age Minimum Age Recommended Interval
Minimum Interval 1 2 yr 5 yr 2 7 yr Second dose recommended for individuals at highest risk Second dose is recommended 5 years after first dose in age ≥ 2 years who are immunocompromised, have sickle cell disease, or functional or anatomic asplenia Routine use not recommended for Alaskan Native or American Indian children ages months – May be recommended by local health departments based on community epidemiology Adapted from Table 1, ACIP General Recommendations on Immunization. MMWR Recomm Rep.2006;55(RR15):1-48. ACIP Provisional Recommendations.www.cdc.gov/vaccines/recs/provisional/ downloads/pneumo-Oct pdf. Accessed September 2009.

33 IPV Dose # Recommended Age Minimum Age Recommended Interval
Minimum Interval 1 2 mo 6 wk 4 wk* 2 4 mo 10 wk 2-14 mo 3 6-18 mo 14 wk 3-5 yr 6 mo 4 4-6 yr 18 wk *In first 6 months of age, 2 mo intervals are recommended unless accelerated dosing is needed (eg, travel) Last dose after age 4 - 6 mo minimum interval from penultimate dose DTaP-IPV-Hib (Pentacel): 4 doses at age 2, 4, 6, and mos will require a 5th dose at 4-6 years with an age-appropriate IPV vaccine Adapted from Table 1, ACIP General Recommendations on Immunization. MMWR Recomm Rep.2006;55(RR15):1-48. CDC. MMWR Morb Mortal Wkly Rep. 2009;58(30):

34 Annual Influenza Vaccine is Recommended for:
All people age 6 months and older! According to the Advisory Committee on Immunization Practices (ACIP) of the US Centers for Disease Control and Prevention (CDC), several groups of people should be primary targets for vaccination during the influenza season. These are groups who are at high risk of morbidity or mortality due to influenza. CDC. Accessed March 2010. 34

35 Seasonal Influenza Vaccination Status of Children 6–23 mos & 2–4 yrs, United States
2007–08 season: 6–23 months, N = 302,333; 2–4 years, N = 808,711 2008–09 season: 6–23 months, N = 263,597; 2–4 years, N = 767,422 CDC. MMWR Morb Mortal Wkly Rep. 2009;58(38):

36 TIV Dose # Recommended Age Minimum Age Recommended Interval
Minimum Interval 1 Yearly 6 mo 4 wk 4 wk* 2 *Two doses (4 wks apart) are given for children 6 mo through 8 yr of age who are receiving influenza vaccine for the first time If 2nd dose is missed during first vaccination season, administer two doses during next season Seasonal influenza products will not confer protection against pandemic H1N1 strains Pandemic H1N1 vaccine available CDC. MMWR Recomm Rep. 2009;58(RR8):1-52.

37 LAIV Dose # Recommended Age Minimum Age Recommended Interval
Minimum Interval 1 Yearly 2 yr 4 wk 4 wk* 2 * Two doses are given for children 2 through 8 yr of age who are receiving influenza vaccine for the first time If 2nd dose is missed during first vaccination season, administer two doses during next season CDC. MMWR Recomm Rep. 2009;58(RR8):1-52.

38 Trivalent Inactivated (TIV) and Live Attenuated Influenza Virus (LAIV) Vaccines
Category TIV LAIV Administration IM Intranasal Primary immune response Serum antibodies Serum & mucosal antibodies Formulation Inactivated Live attenuated Approved age and risk groups ≥ 6 mo (healthy & high risk) 2–49 yrs (healthy) Storage Refrigerated Two basic types of influenza vaccines are available: A trivalent vaccine made from inactivated viruses, and a vaccine developed from live-attenuated virus. Influenza viruses for both TIV and LAIV are initially grown in embryonated hen’s eggs, and, therefore, might contain limited amounts of residual egg protein. Persons with a history of severe hypersensitivity, such as anaphylaxis, to eggs should not receive influenza vaccine. CDC. MMWR Recomm Rep. 2009;58(RR8):1-52. 38

39 Two Doses for Children Under 9 Years of Age
Regardless of whether a child receives LAIV or TIV, those younger than 9 years of age who are receiving influenza vaccine for the first time should receive 2 doses, 4 weeks apart. If a child received only 1 dose in the first year, he or she should receive 2 doses, 4 weeks apart, the following year. CDC. MMWR Recomm Rep. 2009;58(RR8):1-52.

40 Trivalent Inactivated Virus (TIV) versus Live Attenuated Influenza Virus (LAIV) Vaccines
Licensed for use in persons age ≥6 mos Intramuscular injection TIV contains purified viral particles that have been chemically inactivated Purified components from 3 WHO-recommended annual strains Immunity developed against disrupted/denatured viral proteins, not against intact virus LAIV Licensed for use among nonpregnant persons aged 2-49 years Administered by nasal spray LAIV contains intact virus that has been propogated in eggs at 25ºC Cold-adaptation results in restricted replication at body temp More mild flu symptoms Contains same 3 WHO-recommended annual strains as TIV CDC. MMWR Recomm Rep. 2009;58(RR8):1-52. Flumist Prescribing Information. Accessed Oct 2009.

41 2009–2010 Seasonal Influenza Vaccines
2009–2010 seasonal influenza vaccine formulation: A/Brisbane/59/2007(H1N1)-like virus A/Brisbane/10/2007 (H3N2)-like virus B/Brisbane/60/2008-like antigens Vaccines Trivalent Inactivated, Injectable Influenza Vaccine Fluzone® (sanofi): age ≥ 6 months Fluvirin® (Novartis): age ≥ 4 years Fluarix® (GSK): age ≥ 3 years FluLaval™ (ID Biomedical/GSK): age ≥ 18 years Afluria® (CSL): age ≥ 6 months Live Attenuated, Nasal Spray Influenza Vaccine FluMist ® (MedImmune): age 2 through 49 years (healthy, non-pregnant) Seasonal 2009 influenza vaccine does not protect against 2009 (pandemic) H1N1 influenza CDC. MMWR Recomm Rep. 2009;58(RR8):1-52. CDC. Accessed March 2010.

42 2009 H1N1 (Pandemic) Influenza Vaccines
As of November 11, 2009: 4 monovalent inactivated vaccines approved CSL Limited Age 6-35 mos: Two 0.25 mL IM doses (4 wk interval) Age 36 mos to 9 yrs: Two 0.5 mL IM doses (4 wk interval) Age ≥ 10 yrs: Single 0.5 mL IM injection Adults ≥ 18 yrs: Single 0.5 mL IM injection Novartis Vaccines and Diagnostics Limited Age 4-9 yrs: Two 0.5 mL IM doses (4 wk interval) Age yrs: Single 0.5 mL IM injection Age ≥ 18 yrs: Single 0.5 mL IM injection Sanofi Pasteur, Inc. ID Biomedical/GSK 1 live attenuated (nasal administration) MedImmune LLC Age 2-9 yrs: Two 0.2 mL doses (0.1 mL per nostril), 4 week interval Age yrs: Single 0.2 mL dose (0.1 mL per nostril) Prescribing information available at: Accessed December 2009.

43 2010–2011 Influenza Season Universal Influenza Vaccination
All people 6 months and older are now recommended to receive annual influenza vaccination Trivalent Influenza Vaccines: A/California/7/2009(H1N1)-like virus Same strain as in the 2009 H1N1 monovalent vaccine A/Perth/16/2009(H3N2)-like virus New strain for northern hemisphere vaccine Same strain as 2010 southern hemisphere seasonal strain B/Brisbane/60/2008-like virus No change CDC. March 2010.

44 2010–2011 Influenza Season Continued Emphasis on High-risk Groups:
Children aged 6 months through 4 years Adults ≥ 50 years Women who will be pregnant during the influenza season Persons who have chronic pulmonary, cardiovascular, renal, hepatic, neurological, neuromuscular, hematological or metabolic disorders Persons who have immunosuppression (including caused by medication or HIV) Residents of nursing homes and other chronic-care facilities Health care personnel Household contacts and caregivers of children aged < 5 year and adults aged ≥ 50 years, with particular emphasis on vaccinating contacts of children < 6 months Household contacts and caregivers of persons with medical conditions that put them at higher risk for severe complications from influenza CDC. Accessed March 2010.

45 MMR Dose # Recommended Age Minimum Age Recommended Interval
Minimum Interval 1 12-15 mo 12 mo 3-5 yr 4 wk 2 4-6 yr 13 mo May be administered as MMRV if 12 mo-12 yr of age, but minimal interval is 3 mo ACIP Summary Recommendations. Accessed Oct 2009.

46 Varicella Varicella photo. Accessed September 2009.

47 Varicella Dose # Recommended Age Minimum Age Recommended Interval
Minimum Interval 1 12-15 mo 12 mo 3-5 yr 12 wk (age < 13) 4-8 wk (age ≥ 13) 2 4-6 yr 15 mo Second dose At ≥ 3 months if 1st dose for age < 13 yrs At ≥ 4 weeks if 1st dose for age > 13 yrs “MMRV vaccine can be used in place of trivalent MMR vaccine and monovalent varicella vaccine to implement the recommended 2-dose vaccine policies for prevention of measles, mumps, rubella, and varicella” Note: a two-fold increase in the risk of febrile seizures is associated with MMRV versus MMR and Varicella vaccines administered separately and simultaneously CDC MMWR Recomm Rep. 2007;56(RR04):1-40. CDC. MMWR Morb Mortal Wkly Rep. 2008;57(10); Broder K, et al. Presented at the ACIP June 25, 2009.

48 Hepatitis A Dose # Recommended Age Minimum Recommended Interval
Minimum Interval 1 12-23 mo 12 mo 6-18 mo 6 mo 2 18-41 mo 18 mo New recommendations for families of international adoptees ACIP Summary Recommendations. Accessed September 2009. CDC. MMWR Morb Mortal Wkly Rep. 2009;58(36):

49 Hepatitis A: Families of International Adoptees
Hepatitis A vaccination is recommended for all previously unvaccinated persons who anticipate close personal contact with an international adoptee from countries of high or intermediate endemicity during the first 60 days following arrival in the US. The first dose of hepatitis A vaccine should be administered as soon as adoption is planned. Ideally, the first dose of hepatitis A vaccine should be administered at least two weeks prior to the arrival of the adoptee. CDC. MMWR Morb Mortal Wkly Rep. 2009;58(36):

50 General Principles The only vaccines that cannot be given at the same time are smallpox and varicella Minimal intervals apply to Doses of the same inactivated vaccine Doses of the same live vaccine Doses of different live vaccines not given simultaneously, except Oral typhoid Ty21a vaccine Rotavirus vaccine Minimal intervals do not apply to doses of different inactivated vaccines Minimal intervals define catch-up schedules A 4-day grace period is granted to all vaccine doses Rabies vaccine is an exception Local regulations may not allow a grace period Marshall, GS. The Vaccine Handbook: A Practical Guide for Clinicians. West Islip, NY: Professional Communications, Inc.;2008.

51 Principles of Catch-up Schedules
Age Doses administered prior to minimum age should not be considered valid Reduce number of doses according to age and schedule (eg, Hib, PCV) Do not administer beyond maximum age Dose intervals Minimum Do not administer subsequent doses at less than minimum intervals Unnecessary to repeat series; diminution of immunity is not expected in the short term Check formula interchangeability

52 Erroneous Contraindications
The following are NOT contraindications: Mild acute illness Mild-moderate local reaction Concurrent antibiotic therapy Convalescent phase of illness Prematurity Recent exposure to illness History of non-vaccine allergies Family history of allergies, SIDS, seizures Desensitization shots Breastfeeding Positive TST Pregnant household contact (except OPV and smallpox) Asymptomatic or mildly symptomatic HIV infection Allergic to eggs but can eat egg-containing products Mild latex allergy Autoimmune disease

53 Combination Vaccines

54 MMRV: New Issues Increased risk of febrile seizures among 12- to 23-month-olds receiving dose 1 of MMRV vs MMR and varicella vaccines at the same visit Limited availability of MMRV due to manufacturing constraints ACIP position Age 12 through 47 months for first dose: no preference Dose 2 and any dose at age > 48 months The use of combinations generally is preferred. Considerations should include provider assessment, patient preference, and the potential for adverse events. Footnote= Provider assessment should include storage costs, number of injections, vaccine availability, vaccination status, likelihood of improved coverage, and likelihood of patient return visits. CDC. MMWR Morb Mortal Wkly Rep. 2008;57(10): Resolution No. 06/09-3. resolutions/0606mmrv.pdf. Accessed September 2009. 54

55 Current US Combination Vaccines
Product TriHIBit Comvax Twinrix Pediarix ProQuad DTaP Tripedia Infanrix IPV Hib conj ActHIB PedvaxHIB Hep-A Havrix Hep-B Recom-HB Engerix-B Measles MMRII Mumps Rubella Varicella Varivax

56 Current US Combination Vaccines
Product Pentacel Kinrix DTaP (Daptacel) Infanrix IPV Poliovax Hib conj ActHIB Hep-A Hep-B Measles Mumps Rubella Varicella

57 Combination Vaccine Rule
The minimum intervals between doses of a combination vaccine are dictated by the single antigen with the longest minimum intervals

58 Addressing Parental Concerns Safety

59 Public Confidence in Vaccines
Public confidence in vaccines is affected by a number of factors, including: Product safety and efficacy Anecdotal experience/information Prevalence of disease Recommendations by governmental committees and professional societies Physician recommendations Media coverage Vaccine monitoring and surveillance systems

60 Alternative Vaccination Schedules
The Dr. Bob Sears’ alternative schedule Dr. Bob Sears’ strategy for addressing parent concerns Dr. Paul Offit’s analysis of this strategy

61 Dr. Bob Sears’ Alternative Vaccine Schedule
Sears RW. The Vaccine Book. New York, NY: Little Brown & Company: 2007.

62 Dr. Bob Sears’ Alternative Vaccine Schedule
Parameter Dr. Bob Sears ACIP Total visits to completion 15 visits 4 or 5 visits Age at completion 42 months 15 or 18 months Marshall G. The Vaccine Quarterly. 2009;3[1]:17.

63 Critique of Dr. Bob Sears’ Alternative Schedule
Argument The Truth Doctors do not understand vaccines. Parents can educate themselves to know more than doctors. Doctors may not always review the primary data, but the advisory committees that do are composed of experts whose record has been spot-on. Government and pharmaceutical companies conspire to misrepresent data. There is no evidence of conspiracy. Vaccine-preventable diseases are not that serious and are often not seen in practice. Vaccine-preventable diseases are serious and can result in death. Anecdotal experience in practice does not trump national surveillance data. Natural immunity is better than vaccine-induced immunity. The cost of natural immunity is the risk of serious disease or death. Vaccines are not adequately tested for safety. Vaccines are among the most thoroughly tested pharmaceuticals. The post-licensure safety net is robust. Offit PA, Moser CA. Pediatrics. 2009;123(1):e164-e169.

64 Critique of Dr. Bob Sears’ Alternative Schedule
Argument The Truth Vaccines are recommended for protection of the public at large, not individuals. Every individual benefits from receiving vaccines– they become immune to the disease and, as long as others are immunized, they have less chance of exposure. Parents’ fears should be indulged by offering alternative schedules. Parents’ fears should be assuaged by explaining the scientific findings. Reports in VAERS and language in the Package Insert (PI) constitute accurate profiles of vaccine side effects. VAERS reports do not establish causality and the PI lists any reported events, whether causally related or not. There is a middle ground between causality and coincidence. This logic is flawed–either vaccines do or don’t cause certain adverse events. Science fails because it cannot prove there is no connection between vaccines and certain adverse events. Science doesn’t work that way– one can only reject or fail to reject the null hypothesis. For more discussion on this alternative schedule, visit Offit PA, Moser CA. Pediatrics. 2009;123(1):e164-e169.

65 Institute of Medicine Immunization Safety Reviews
2004 “…the body of epidemiological evidence favors rejection of a causal relationship between the MMR vaccine and autism… [and] favors rejection of a causal relationship between thimerosal-containing vaccines and autism.” 1. Immunization Safety Review: Accessed September 2009. 2. Immunization Safety Review: Accessed September 2009. 3. Immunization Safety Review: Accessed September 2009.

66 US Measles Cases Cases of imported measles* as a proportion of all measles cases–US 1997 to July 2008 Cases of measles by vaccination status (2008) Measles increase in 2008 not due to a greater number of imported cases, but was the result of greater transmission after importation CDC. MMWR Morb Mortal Wkly Rep. 2008;57(33):

67 Danish Cohort Study The Past The Present Relative risk:
Population of Denmark Children born between 01/01/91 and 12/31/98 The Past MMR 1,647,504 person-yr No MMR 482,360 person-yr The Present Autism: 263 ASD: 345 Autism: 53 ASD: 77 Relative risk: Autism: 0.92 ( ) ASD: 0.83 ( ) Madsen KM, et al. N Engl J Med. 2002;347:

68 Danish Cohort Study The Past The Present Autism: 104 ASD: 321
Population of Denmark Children born between 01/01/90 and 12/31/96 The Past Thimerosal 1,220,006 person-yr No thimerosal 1,660,159 person-yr The Present Autism: 104 ASD: 321 Autism: 303 ASD: 430 Relative risk: Autism: 0.85 ( ) ASD: 1.12 ( ) Hviid A, et al. JAMA. 2003;290:

69 Mercury Levels After Thimerosal-Containing Vaccines
2-month-old infants Pichichero ME, et al. Pediatrics. 2008;121:e208-e214.

70 Autism Incidence After Vaccine Formulation Changes
Thimerosal-containing vaccines removed Autism Incidence per 10,000 Persons Madsen KM, et al. Pediatrics. 2003;112:

71 Autism in California Schechter R, Grether JK. Arch Gen Psychiatry. 2008;65:19-24.

72 Thimerosal Status of Current Vaccines
Trade Name Status Diphtheria, tetanus, pertussis Infanrix Daptacel Tripedia Free ≤ 0.3 mcg Hg/0.5mL PCV-7 Prevnar Polio IPOL Hepatitis B Recombivax HB Engerix-B Hib conjugate ActHIB PedvaxHIB HibTITER Free (single dose) Hib/Hepatitis B Comvax MMR M-M-R-II Varicella Varivax DTaP/Hep-B/IPV Pediarix Influenza Fluzone T-free Fluvirin P-free < 1.0 mcg Hg/0.5 mL FluMist Hepatitis A* *updated 3/14/08 Vaqta Havrix Thimerosal in Vaccines. Accessed September 2009.

73 Vaccine Adverse Event Reporting System
Postmarketing surveillance system Mandatory reporting by health care providers Occurrence of events listed as contraindications Occurrence of events listed in the Reportable Events Table Voluntary reporting: any event by any one Intent: hypothesis generation not hypothesis testing Marshall GS, et al. The Vaccine Handbook. Lippincott Williams + Wilkins; 2004. VAERS reporting. Accessed September 2009. CDC. MMWR Morb Mortal Wkly Rep. 1988;37(13):

74 Vaccine Safety Datalink Study
MMRV MMR plus V Number of subjects 43,353 314,599 Rate of febrile seizures 9 per 10,000 4 per 10,000 CDC. MMWR Morb Mortal Wkly Rep. 2008;57(10):

75 Adjudication of Febrile Seizure Incidence Following MMRV
Pre-adjudicated Seizure Reports Adjudicated Seizure Data Adjudication panel: Drs S. Michael Marcy, Robert Riewerts, and Suresh Gurbani – Reviewed medical records (blinded to vaccination dates) – Confirmed seizure diagnosis based on Brighton Collaboration criteria Post-adjudication seizure data for days 5-12 postvaccination: – MMRV: 0.70/1000 – MMR + V: 0.32/1000 – Relative risk = 2.2 (95% CI = 1.04, 4.65) Jacobsen SJ, et al. Vaccine. 2009;27:

76 Aluminum Adjuvants: Review of the Evidence
Hydroxide vs No Adjuvant (children up to 18 months of age) Any Aluminum vs No Adjuvants (children years) Jefferson T, et al. Lancet Infect Dis. 2004;4:84-90.

77 Strategies for Improving Childhood Immunization Rates

78 Evidence-based Methods for Improving Immunization Rates
Community Preventive Services Task Force Recommended Strategies Reducing client out-of-pocket costs Vaccination programs in schools Vaccination programs in WIC settings Client reminder and recall systems Vaccination requirements for child care, school, and college attendance Provider reminder systems when used alone Standing orders when used alone Provider assessment and feedback  The above recommendations have all been upgraded to ‘strong evidence’ based on systematic reviews The Community Guide.http://www.thecommunityguide.org/vaccines/universally/index.html. Accessed September 2009. Briss PA, et al. Am J Prev Med. 2000;18(suppl 1):35-43.

79 Adolescent Vaccines

80 Definition of ‘Adolescent’
7th birthday until the 19th birthday Per CDC adolescent immunization schedule Society of Adolescent Medicine defines adolescent as yrs

81 2010 ACIP Adolescent Immunization Schedule
Minimum age 9 years ACIP Schedules. Accessed Jan 2010.

82 Adolescent Catch-up Schedule
ACIP Schedules. Accessed Jan 2010.

83 Adolescent (13–17 yrs) Vaccination Coverage, United States 2007–2008
100 90 2007 N = 2947 2008 N = 17,835 80 70 60 Vaccination Coverage (%) 50 40 30 20 10 MMR Hepatitis B Varicella Varicella Td or Tdap Tdap MCV4 HPV4* HPV4* ≥ 2 Doses ≥ 3 Doses ≥ 1 Dose ≥ 2 Doses ≥ 1 Dose ≥ 1 Dose ≥ 1 Dose ≥ 1 Dose ≥ 3 Doses * Percentages for females only CDC. MMWR Morb Mortal Wkly Rep. 2009;58(36):

84 Tdap Boostrix Adacel Approved for use ages 10-64 years
--- recommended catch-up Boostrix Approved for use ages years Adacel Approved for use ages years Two FDA-approved Tdap vaccines available Both contain the same acellular pertussis component as their respective DTaP products FDA recommended one-time use of Tdap only For year olds, replaces Td booster if no previous Tdap Catch-up for yrs (5-year interval from last Td encouraged) MCV4 contains diphtheria conjugate protein carrier If both are indicated, administer MCV4 and Tdap simultaneously CDC. MMWR Recomm Rep. 2006;55(RR03):1-34.

85 Tdap 10 to 18 years of age 19 to 64 years of age
Replaces Td booster for 11­12-year-olds Catch-up for yrs (5-year interval from Td encouraged) If no previous DPT series, give as 1 Tdap + 2 Td Give with MCV4 if both vaccines are indicated Replaces Td booster; wound management* 2-year interval from Td for adults in contact with infants; health care workers Anyone who wants to decrease risk of disease The safety and effectiveness of Tdap have not been established in pregnant women If overall risk/benefit is favorable, discount risk of local rxns and immunize Note: Give MCV4 and Tdap simultaneously if both are indicated; carrier protein for MCV4 is diphtheria toxoid, avoid injection site reactions from sequential vaccination. * Only if no previous Tdap received CDC. MMWR Recomm Rep. 2006;55(RR3):1-34. CDC. MMWR Recomm Rep. 2006;55(RR17):1-33. CDC. MMWR Morb Mortal Wkly Rep. 2009;58(14):

86 Available HPV Vaccines
Quadrivalent Merck - Gardasil® Bivalent GSK - Cervarix® Licensed in the US 2006 2009 Virus-like Particle Types HPV 6, 11, 16, 18 HPV 16, 18 Protection against HPV 16/18 related CIN2+ ≥ 98% ≥ 93% Protection against HPV 6/11 related genital lesions ~99% --- Hypersensitivity-related contraindication Yeast Latex Age ranges Routine 11 or 12 yrs, as young as 9 yrs; catch-up yrs Routine 11 or 12 yrs, as young as 10 years; catch-up yrs Schedule 0, 2, 6 months 0, 1, 6 months CIN2+: cervical intraepithelial neoplasia grade 2 or higher and adenocarcinoma in situ Markowitz L. ACIP Meeting Oct Accessed Oct 2009.

87 HPV – ACIP Recommendations Quadrivalent HPV (HPV4) and Bivalent HPV (HPV2)
Routine vaccination of females aged years with 3 doses of HPV vaccine Catch-up yrs (HPV4); yrs (HPV2) ACIP: no preference for either vaccine HPV4 or HPV2 vaccination for prevention of HPV 16/18-related cervical cancers, precancers and dysplastic lesions Vaccination with HPV4 for additional prevention against genital warts Monitor patients for 15 minutes following vaccination for syncopal episodes ACIP Schedules. Accessed Jan 2010.

88 HPV Vaccination and Pregnancy
HPV vaccines are not recommended for use in pregnant women Initiation of the vaccine series should be delayed until after completion of pregnancy If a woman is found to be pregnant after initiating the vaccination series, delay remaining doses until after the pregnancy If a vaccine dose has been administered during pregnancy, there is no indication for intervention Two vaccine in pregnancy registries have been established. Patients and health care providers should report: Quadrivalent HPV vaccine/pregnancy: Bivalent HPV vaccine/pregnancy: CDC. Accessed March 2010.

89 HPV Quadrivalent Vaccine in Males
FDA approved quadrivalent HPV vaccine for prevention of genital warts due to HPV types 6 and 11 in boys and men ages 9 through 26 ACIP: Permissive HPV vaccine for males Cost effectiveness Priority vaccinating females to reduce overall disease/cancer burden Quadrivalent HPV vaccine most effective when given before exposure to HPV through sexual contact FDA News Release. Accessed Oct 2009. Dunne E. ACIP Meeting Oct 2009.

90 Avg Annual Incidence (#)
HPV-associated* Invasive Squamous Cell Carcinomas in Women and Men, 1998–2003 Anatomic Area Avg Annual Incidence (#) Incidence (per 100,000) 95% CI Cervix 10,846 8.9 8.9,9.0 Vagina 601 0.5 0.4,0.5 Vulva 2266 1.7 1.7,1.7 Anus/Rectum 1935 1.5 1.5,1.5 Oropharynx/OC 1702 1.3 1.3,1.4 Total Females 17,350 14.0 13.8,14.0 Penis 828 0.8 0.8,0.8 1083 1.0 1.0,1.0 5658 5.2 5.1,5.2 Total Males 7568 7.0 6.9,7.0 *Defined by histology and anatomic site Watson M, et al. Cancer. 2008;113(10suppl): Data source: National Program of Cancer Registries and SEER, covering 83% coverage of US population. ACIP Meeting February Accessed Oct 2009.

91 HPV Vaccine Parental Concerns
Many parents uncomfortable addressing subjects related to child sexuality, especially at such young ages Be sensitive to discussing this issue Communicate the importance of completing the 6-month immunization series before the adolescent becomes sexually active Vaccination does not imply current sexual activity, nor will it encourage it Protection against HPV acquired by involuntary sexual intercourse Improved immunogenicity at younger ages Educate parents and adolescents regarding the ubiquitous nature of HPV and its association with cervical dysplasia and cancer Parents who received education on human papillomavirus and HPV vaccine more likely to accept vaccination of their child than those who received no educational intervention Communicate the universality of the vaccine recommendation to avoid feelings of being stigmatized/singled out Rosenthal SL. J Adolesc Health. 2005;37:

92 HPV Postlicensure Safety Data- VAERS
Review of 12,424 adverse event reports following immunization (AEFI) with quadrivalent HPV Vaccine from the Vaccine Adverse Event Reporting System (VAERS): 6/31/06 through 12/31/08 Disproportional reporting of syncope and venous thromboembolism Increased risk among teens yrs Serious injuries have resulted Providers should strongly consider observing patients for 15 minutes after they are vaccinated Quadrivalent HPV was the only vaccine administered in: 74% of syncope/vasovagal reports 73% of dizziness reports 78% of nausea reports Slade BA, et al. JAMA. 2009;302(7): Calugar A. Oct 2008 ACIP meeting. Accessed Oct 2009.

93 Meningococcal Conjugate Vaccines
Recommended for adolescents aged years and others at increased risk for meningococcal disease MCV4-D (Menactra®, Sanofi): licensed for persons 2-55 years; Serogroups A, C, Y, W-135; diphtheria toxoid conjugate MenACWY-CRM197 (Menveo®, Novartis): licensed for persons years; Serogroups A, C, Y, W-135; diphtheria CRM197 conjugate Revaccination for Persons at Increased Risk Previous vaccination (meningococcal conjugate vaccine or MPSV4) at 2-6 years, revaccinate 3 years after initial meningococcal vaccine Previous vaccination (meningococcal conjugate vaccine or MPSV4) at ≥ 7 years, revaccinate 5 years after initial meningococcal vaccine This includes: Persons with persistent complement component deficiencies Persons with anatomic or functional asplenia Microbiologists who are routinely exposed to isolates of N. meningitidis Frequent travelers to or people living in areas with high rates of meningococcal disease (African meningitis belt) Meissner HC. Accessed March 2010. CDC. MMWR Morb Mortal Wkly Rep. 2009;58(37):

94 Annual Influenza Vaccine is Recommended for:
All people age 6 months and older! According to the Advisory Committee on Immunization Practices (ACIP) of the US Centers for Disease Control and Prevention (CDC), several groups of people should be primary targets for vaccination during the influenza season. These are groups who are at high risk of morbidity or mortality due to influenza. CDC. Accessed March 2010. 94

95 Trivalent Inactivated Virus (TIV) versus Live Attenuated Influenza Virus (LAIV) Vaccines
Licensed for use in persons age ≥6 mos Intramuscular injection TIV contains purified viral particles that have been chemically inactivated Purified components from 3 WHO-recommended annual strains Immunity developed against disrupted/denatured viral proteins, not against intact virus LAIV Licensed for use among nonpregnant persons aged 2-49 years Administered by nasal spray LAIV contains intact virus that has been propogated in eggs at 25ºC Cold-adaptation results in restricted replication at body temp More mild flu symptoms Contains same 3 WHO-recommended annual strains as TIV CDC. MMWR Recomm Rep. 2009;58(RR8):1-52. Flumist Prescribing Information. Accessed Oct 2009.

96 2009–2010 Seasonal Influenza Vaccines
2009–2010 seasonal influenza vaccine formulation: A/Brisbane/59/2007(H1N1)-like virus A/Brisbane/10/2007 (H3N2)-like virus B/Brisbane/60/2008-like antigens Vaccines Trivalent Inactivated, Injectable Influenza Vaccine Fluzone® (sanofi): age ≥ 6 months Fluvirin® (Novartis): age ≥ 4 years Fluarix® (GSK): age ≥ 3 years FluLaval™ (ID Biomedical/GSK): age ≥ 18 years Afluria® (CSL): age ≥ 6 months Live Attenuated, Nasal Spray Influenza Vaccine FluMist® (MedImmune): age 2 through 49 years (healthy, non-pregnant) Seasonal 2009 influenza vaccine does not protect against 2009 (pandemic) H1N1 influenza CDC. MMWR Recomm Rep. 2009;58(RR8):1-52. CDC. Accessed March 2010.

97 2009 H1N1 (Pandemic) Influenza Vaccines
As of November 11, 2009: 4 monovalent inactivated vaccines approved CSL Limited Age 6-35 mos: Two 0.25 mL IM doses (4 wk interval) Age 36 mos to 9 yrs: Two 0.5 mL IM doses (4 wk interval) Age ≥ 10 yrs: Single 0.5 mL IM injection Adults ≥ 18 yrs: Single 0.5 mL IM injection Novartis Vaccines and Diagnostics Limited Age 4-9 yrs: Two 0.5 mL IM doses (4 wk interval) Age yrs: Single 0.5 mL IM injection Age ≥18 yrs: Single 0.5 mL IM injection Sanofi Pasteur, Inc. Age ≥10 yrs: Single 0.5 mL IM injection ID Biomedical/GSK 1 live attenuated (nasal administration) MedImmune LLC Age 2-9 yrs: Two 0.2 mL doses (0.1 mL per nostril), 4 week interval Age yrs: Single 0.2 mL dose (0.1 mL per nostril) Prescribing information available at: Accessed December 2009.

98 2010–2011 Influenza Season Universal Influenza Vaccination
All people 6 months and older are now recommended to receive annual influenza vaccination Trivalent Influenza Vaccines A/California/7/2009(H1N1)-like virus Same strain as in the 2009 H1N1 monovalent vaccine A/Perth/16/2009(H3N2)-like virus New strain for northern hemisphere vaccine Same strain as 2010 southern hemisphere seasonal strain B/Brisbane/60/2008-like virus No change CDC. March 2010.

99 2010–2011 Influenza Season Continued Emphasis on High-risk Groups:
Children aged 6 months through 4 years Adults ≥ 50 years Women who will be pregnant during the influenza season Persons who have chronic pulmonary, cardiovascular, renal, hepatic, neurological, neuromuscular, hematological or metabolic disorders Persons who have immunosuppression (including caused by medication or HIV) Residents of nursing homes and other chronic-care facilities Health care personnel Household contacts and caregivers of children aged < 5 year and adults aged ≥ 50 years, with particular emphasis on vaccinating contacts of children < 6 months Household contacts and caregivers of persons with medical conditions that put them at higher risk for severe complications from influenza CDC. Accessed March 2010.

100 PPSV23 Single dose recommended for:
7–10 years 11-12 years 13–18 years for certain high-risk groups Single dose recommended for: All ≥ 65 years 2–64 years: chronic cardiovascular disease, chronic pulmonary disease, diabetes, alcoholism, chronic liver disease, CSF leaks, asplenia, cochlear implants >2 years and immunocompromised Asthmatics and smokers age years Proposed language for one-time revaccination: “A second dose of PPSV23 is recommended 5 years after the first dose of PPSV23 for persons aged >2 years who are immunocompromised, have sickle cell disease, or functional or anatomic asplenia” ACIP Summary Recommendations. Accessed Oct 2009. ACIP Provisional Recommendations. Accessed Oct 2009.

101 PPSV23 and Alaskan Natives, American Indians
“Routine use of PPSV23 is not recommended for Alaska Native or American Indian persons younger than 65 years old unless they have underlying medical conditions that are PPSV23 indications. However, in special situations, public health authorities may recommend PPSV23 for Alaska Natives and American Indians aged 50 through 64 years who are living in areas in which the risk of invasive pneumococcal disease is increased." ACIP Provisional Recommendations. Accessed Oct 2009.

102 HepA Routine vaccination recommended for all children ages 12-23 mos
7–10 years 11-12 years 13–18 years for certain high-risk groups Routine vaccination recommended for all children ages mos In areas without existing Hep A vaccination programs, catch-up of unvaccinated children 2-18 yrs old may be considered Recommendations for age ≥2 yrs depend on risk and vary according to state programs Dosing: VAQTA® For all persons age ≥12 mos 2 doses at 0 and 6-18 mos HAVRIX® 2 doses at 0 and 6-12 mos CDC. MMWR Morb Mortal Wkly Rep. 2006;55(RR7):1-23. CDC Resolution No. 06/07-1. Accessed Oct 2009.

103 Hepatitis A Vaccine International Travel
For healthy persons 40 years of age or younger 2 doses 6 months apart prior to departure The first dose of Hepatitis A vaccine should be administered as soon as travel is considered 1 dose of single-antigen vaccine administered at any time before departure Consider both HAV and Ig for Persons age > 40 with chronic illness traveling in less than 2 weeks and only receiving one dose of HAV Persons at risk of severe disease from hepatitis A virus planning to travel in 2 weeks or sooner CDC. MMWR Morb Mortal Wkly Rep. 2007;56(41):

104 Hepatitis A Postexposure Prophylaxis
For healthy persons 12 months through 40 years of age who have not previously received HepA vaccine Take into account patient characteristics, including chronic liver disease Immunoglobulin and/or single-antigen hepatitis A vaccine should be administered as soon as possible after exposure Vaccine preferred for those of age 12 mos to 40 yrs Ig preferred for age <12 mos, those with vaccine allergies, or those with immunosuppression or liver disease Ig preferred for age >40 but vaccine may be used if Ig unavailable HepA and Ig may be administered simultaneously Efficacy of Ig or HepA when administered >2 weeks postexposure is unknown CDC. MMWR Morb Mortal Wkly Rep. 2007;56(41): CDC. MMWR Morb Mortal Wkly Rep. 2009;58(36):

105 Hepatitis A: Families of International Adoptees
Hepatitis A vaccination is recommended for all previously unvaccinated persons who anticipate close personal contact with an international adoptee from countries of high or intermediate endemicity during the first 60 days following arrival in the US. The first dose of hepatitis A vaccine should be administered as soon as adoption is planned. Ideally, the first dose of hepatitis A vaccine should be administered at least two weeks prior to the arrival of the adoptee. CDC. MMWR Morb Mortal Wkly Rep. 2009;58(36):

106 HepB Multiple schedules
7–10 years 11-12 years 13–18 years catch-up Multiple schedules Children 1-10 yrs 0, 1, and 6 mos 0, 2, and 4 mos 0, 1, 2, and 12 mos Adolescents yrs 0, 1, and 4 mos* 0, 2, and 4 mos* 0, 12, and 24 mos* 0 and 4-6 mos (2 dose schedule uses adult 10ug formulation, Recombivax-HB)** No combination HepB vaccines approved for use in ages yrs * These schedules provide equivalent seroprotection in adolescents **No long-term data are available for antibody persistence- when second dose is to be administered at age >15 yrs, consider switching to a 3-dose schedule using pediatric formulation CDC. MMWR Recomm Rep. 2005;54(RR16):1-23.

107 HepA-HepB Combination Vaccine (Twinrix)
Approved for persons 18 years and older Combination HepA vaccine (pediatric dose) and HepB (adult dose) First licensed schedule: 0, 1, and 6 months Alternate schedule 2007: Doses at 0, 7, days and a booster dose at 12 months The first 3 doses of the new schedule provide equivalent protection to: The first dose in the standard single-antigen adult hepatitis A vaccine series The first 2 doses in the standard adult hepatitis B vaccine series Seroconversion is nearly 100% after either 3 doses of the combination vaccine on the new schedule or a single dose of single-antigen adult hepatitis A vaccine Duration of protection 4 yrs against HepA No increased benefit of the new schedule for the hepatitis B component compared to administration of 2 hepatitis B vaccine doses 1 to 2 months apart CDC. MMWR Morb Mortal Wkly Rep. 2007;56(40):1057.

108 Varicella Universal recommendation for routine vaccination is 2 doses
7–10 years 11-12 years 13–18 years catch-up Universal recommendation for routine vaccination is 2 doses Given 3 months apart for those under 13 years old 4 to 8 weeks apart for those ≥ 13 years old Second dose is still valid if >8 week interval Formulations Varivax licensed ages 12 mos and older Proquad (Combination MMRV) not licensed ≥13 years CDC. MMWR Recomm Rep. 2007;56(RR04):1-40.

109 Adolescent Immunization: Goals and Objectives
Effective adolescent vaccine delivery and monitoring are critical Adolescents lag far behind preschoolers in immunization coverage Healthy People 2010 objective for adolescents aged years is 90% coverage with the following: 3 or more doses of hepatitis B vaccine 2 or more doses of MMR vaccine 1 or more doses of Td* vaccine 1 or more doses of varicella vaccine *Healthy People 2010 objectives were set prior to licensure of Tdap, meningococcal, and HPV vaccines. 109

110 Strategies for Improving Adolescent Immunization Rates

111 Healthy People 2010 Adolescent Immunization Goals
Increase the proportion of young children and adolescents who receive all vaccines that have been recommended for universal administration for at least 5 years Increase routine vaccination coverage levels for adolescents For yrs olds, 90% coverage rates for ≥ 3 hepatitis B, ≥ 2 MMR, ≥ 1 varicella, ≥ 1 TD Flu vaccine recommendation is new; no specific goal established Healthy People 14-27.htm. Accessed September 2009.

112 Parents Are a Key Influence
Parental perception of vaccination is an important factor in adolescents’ vaccination decisions1,2 Parents influence adolescent acceptance Providers influence parental acceptance Parental consent for immunization is the most cited barrier to immunizing students at school-based vaccination initiatives3,4 Rosenthal SL, et al. J Adolesc Health. 1995;17: Rosenthal SL. J Adolesc Health. 2005;37: Guajardo AD, et al. J Sch Health. 2002;72: Deeks SL, Johnson IL. Can J Public Health. 1998;89:

113 Patient and Provider Factors That Influence Adolescent Immunization
Education/ Knowledge Self-Efficacy Patient Provider Insurance/ Reimbursement Time Provider likelihood to administer immunization Patient likelihood to access immunization ADOLESCENT IMMUNIZATION Middleman AB. J Adolesc Health. 2007;41:

114 Available Reimbursement for Adolescent Vaccination
Public funding for eligible children up to but not including the 19th birthday Vaccines for Children Program (VFC) Many insurers follow VFC lead State Children’s Health Insurance Program (SCHIP) Funding for adolescents > 19 years: Federal Vaccination Assistance Act, Section 317 Inadequate for large-scale immunization strategies

115 Establishing Adolescent Immunization Platforms
Need exists for standard immunization visits during adolescence ACIP recommendations geared to 11- to 12-year-old age group Younger adolescents have higher rates of accessing preventive health care than older adolescents Rand CM, et al. J Adolesc Health. 2005;37:87-93.

116 Establishing Adolescent Immunization Platforms (cont)
Society for Adolescent Medicine position statement 11- to 12-year visit: primary immunization platform 14- to 15-year visit: catch up on missed vaccines or complete multidose regimens 17- to 18-year visit: update vaccinations that were missed or are newly recommended Middleman AB, et al. J Adolesc Health. 2006;38: IDSA. Clin Infect Dis. 2007;44:e104-e108.

117 Advantages of Building an Adolescent Immunization Platform Structure
Puts focus on disease prevention among this age group Presents opportunities for improved comprehensive care that includes other health issues (eg, screening and prevention of risk behaviors) Creates parental and provider expectation of compliance with established adolescent immunization visits IDSA. Clin Infect Dis. 2007;44:e104-e108.

118 Adolescent Vaccination Coverage: Who Is Measuring?
The National Committee for Quality Assurance (NCQA) Healthcare Effectiveness Data and Information Set (HEDIS) update: NCQA eliminated measures in 2008; Web site indicates development of updated measures for 2009 National Immunization Survey (NIS) 2006: First year of data collection for adolescents 13 to 17 years of age NIS-Teen: Includes provider-reported information HPV not reported (recommended in 2007) Now conducted annually

119 NIS-Teen Results Vaccine Coverage 2006+ 2007^ 2008*
≥ 1 dose Tdap after 10 years of age 10.8% 30.4% 40.8% ≥ 1 dose Td/Tdap after 10 years of age 60.1% 72.3% 72.2% ≥ 3 doses HepB vaccine 81.3% 87.6% 87.9% ≥ 2 doses MMR vaccine 86.9% 88.9% 89.3% ≥ 1 dose of Varicella vaccine (no disease history) 65.5% 75.7% 81.9% ≥ 2 doses of Varicella vaccine (no disease history) 18.8% 34.1% MCV4 vaccine 11.7% 32.4% 41.8% HPV 4 ≥ 1 dose 25.1% 37.2% +n = adolescents ^n = 2947 adolescents *n = 17,835 adolescents CDC. MMWR Morb Mortal Wkly Rep. 2008;57(40): CDC. MMWR Morb Mortal Wkly Rep. 2009;58(36):

120 Adolescent Immunization Rates: Strategies to Hit the Target
Public Policy Providers National State Education re immunizations Use of recall systems Education re: provision of preventive care for adolescents Use of standing orders Mandates for school entry Development of standard immunization platforms by ACIP, professional organizations Use of immunization information systems Development of specific vaccination “quick visits” if other services not needed Use of screening tools Bull’s-eye! Shots in Adolescent Arms State review of “consent” procedures Attend vaccination “quick visits” if other preventive services not required Education re need for preventive care of adolescents Reimbursement/ funding (currently SCHIP) Use of alternative site if no medical home or if need to complete a series of vaccinations Reimbursement/ funding (currently VFC, 317) Enrollment in immunization information systems Education re: immunizations Funding and support for immunization information systems Patients Funding and support for immunization information systems State legislation allowing immunization at alternative sites Insurance reform Middleman AB. J Adoles Health. 2007;41:

121 Benefits of Using a Computerized Immunization Information System (IIS)
Recommended by National Vaccine Advisory Committee (NVAC) and National Immunization Program (NIP) Consolidates fragmented records Keeps track of patients needing recommended or catch-up vaccination Provides automated reminder and recall Assists in management of vaccine supply Generates vaccination records for parents, schools, other Yawn BP, et al. Am J Manag Care. 1998;4: Glazner JE, et al. Ambul Pediatr. 2004;4:34-40.

122 Are Providers Seeing Adolescents?
HEDIS data: 34% of adolescents who participate in health plans have annual preventive visits1 NCHS (CDC) data: 86% of 6- to 17-year-olds and 76% of 18- to 24-year-olds report at least one doctor’s office, ED, or home visit within past year2 88–92% of adolescents report having an identified source of primary care3,4 HEDIS = Health Plan Employer Data and Information Set; NCHS = National Center for Health Statistics McInerny TK, et al. Pediatrics. 2005;115: National Center for Health Statistics. Health, United States, 2005. Klein JD, et al. Arch Pediatr Adolesc Med. 1998;152: Klein JD, et al. J Adolesc Health. 1999;25:

123 Provider-based Strategies to Improve Adolescent Immunization Rates
Standing orders Recommended by CDC (strong evidence) to increase adult immunization Would likely decrease missed vaccination opportunities in adolescents Screening tools (NVAC recommends annual review) Reminder/recall systems (often with IIS) Recommended (strong evidence) by CDC to increase adult, adolescent, and childhood immunizations Complex for adolescents (eg, changing phone numbers, waning effect of calls) Vaccination “quick visits” Understanding other adolescent issues/care IIS: immunization information systems The Community Guide. Accessed September 2009. Szilagyi PG, et al. Arch Pediatr Adolesc Med. 2006;160:

124 The Goal: To Increase the Adolescent Immunization Rate
Healthy People 2010 Adolescent immunization coverage goal: 90% Increase number of providers who measure vaccination coverage level every 2 years among children in their practice Free assistance from public health departments (CoCASA software) Vaccines for Children quality improvement activities (eg, AFIX) Healthy People 2010 Immunization and Infectious Disease. Accessed Oct 2009. CoCASA. Accessed Oct 2009. AFIX. Accessed Oct 2009.

125 Standing Orders Are Among the Most Effective Strategies
Nonphysicians offer and administer vaccinations No direct MD involvement at the time of the visit Established with physician approved policies and protocols Locations: Clinics and hospitals CDC. Accessed September 2009. McKibbin LJ, et al. MMWR Recomm Rep. 2000;49 (RR1):15-26.

126 Success of Standing Orders as Part of a Multifaceted Program
Influenza Vaccination Rates for Elderly Patients in General Medicine Clinics Standing Orders Education Nichol KL. Am J Med. 1998;105:

127 Adult Vaccines

128 Adult Immunization Schedule: US 2010
CDC. MMWR Morb Mortal Wkly Rep. 2010;59(1).

129 Gaps Persist Between Vaccination Rates and Goals
US Goals: Elderly: 90% HR < 65: 60% HR denotes High Risk Schiller J, et al. Accessed September 2009.

130 Adult Immunization Schedule: US 2010
CDC. MMWR Morb Mortal Wkly Rep. 2010;59(1).

131 Tdap 10 to 18 years of age 19 to 64 years of age
Replaces Td booster for 11­12-year-olds Catch-up for yrs (5-year interval from Td encouraged) If no previous DPT series, give as 1 Tdap + 2 Td Give with MCV4 if both vaccines are indicated Replaces Td booster; wound management* 2-year interval from Td for adults in contact with infants; health care workers Anyone who wants to decrease risk of disease The safety and effectiveness of Tdap have not been established in pregnant women If overall risk/benefit is favorable, discount risk of local rxns and immunize Note: Give MCV4 and Tdap simultaneously if both are indicated; carrier protein for MCV4 is diphtheria toxoid, avoid injection site reactions from sequential vaccination. * Only if no previous Tdap received CDC. MMWR Recomm Rep. 2006; 55(RR3):1-34. CDC. MMWR Recomm Rep. 2006;55(RR17);1-33. CDC. MMWR Morb Mortal Wkly Rep. 2009;58(14):

132 Pertussis Challenges for Those Providing Care for Adults
Modified, less “classic” illness Respiratory infection Persistent cough Laboratory diagnosis inadequate Treatment reduces severity only if given very early (usually before pertussis is considered) Out of sight; out of mind

133 Adult Immunization Schedule: US 2010
CDC. MMWR Morb Mortal Wkly Rep. 2010;59(1).

134 Available HPV Vaccines
Quadrivalent Merck - Gardasil® Bivalent GSK - Cervarix® Licensed in the US 2006 2009 Virus-like Particle Types HPV 6, 11, 16, 18 HPV 16, 18 Protection against HPV 16/18 related CIN2+ ≥ 98% ≥ 93% Protection against HPV 6/11 related genital lesions ~99% --- Hypersensitivity-related contraindication Yeast Latex Age ranges Routine 11 or 12 yrs, as young as 9 yrs; catch-up yrs Routine 11 or 12 yrs, as young as 10 years; catch-up yrs Schedule 0, 2, 6 months 0, 1, 6 months CIN2+: cervical intraepithelial neoplasia grade 2 or higher and adenocarcinoma in situ Markowitz L. ACIP Meeting Oct 2009. Accessed Oct 2009.

135 HPV – ACIP Recommendations Quadrivalent HPV (HPV4) and Bivalent HPV (HPV2)
Routine vaccination of females aged years with 3 doses of HPV vaccine Catch-up yrs (HPV4); yrs (HPV2) ACIP: no preference for either vaccine HPV4 or HPV2 vaccination for prevention of HPV 16/18-related cervical cancers, precancers and dysplastic lesions Vaccination with HPV4 for additional prevention against genital warts Monitor patients for 15 minutes following vaccination for syncopal episodes ACIP Schedules. Accessed Jan 2010.

136 HPV Vaccination and Pregnancy
HPV vaccines are not recommended for use in pregnant women Initiation of the vaccine series should be delayed until after completion of pregnancy If a woman is found to be pregnant after initiating the vaccination series, delay remaining doses until after the pregnancy If a vaccine dose has been administered during pregnancy, there is no indication for intervention Two vaccine in pregnancy registries have been established. Patients and health care providers should report: Quadrivalent HPV vaccine/pregnancy: Bivalent HPV vaccine/pregnancy: CDC. Accessed March 2010.

137 HPV Quadrivalent Vaccine in Males
FDA approved quadrivalent HPV vaccine for prevention of genital warts due to HPV types 6 and 11 in boys and men ages 9 through 26 ACIP: Permissive HPV vaccine for males Cost effectiveness Priority vaccinating females to reduce overall disease/cancer burden Quadrivalent HPV vaccine most effective when given before exposure to HPV through sexual contact FDA News Release. Accessed Oct 2009. Dunne E. ACIP Meeting Oct 2009. Accessed Oct 2009.

138 Quadrivalent HPV Vaccine for Women 27–45 years Under FDA Review ACIP Considerations
As women age from their mid 20s HPV prevalence decreases HPV incidence decreases Likelihood of having acquired HPV infection increases Disease outcomes (genital warts, CIN 2/3) peak among women in their mid to late 20s, potential benefit of vaccinating women in late 20s to early 40s would be minimal Questions on natural history of incident infections in adult women Greatest benefit from vaccinating females in early adolescence Clinical trial data (women 24–45 years) Efficacy against HPV 6/11/16/18-related persistent infection, CIN, external genital lesions Well tolerated CIN: cervical intraepithelial neoplasia Dunne E. Accessed March 2010. Haupt R. Accessed March 2010.

139 Adult Immunization Schedule: US 2010
CDC. MMWR Morb Mortal Wkly Rep. 2010;59(1).

140 Shingles (Herpes Zoster)
CDC. Accessed September 2009.

141 Zoster (Shingles) Vaccine
Single-dose vaccine licensed for persons 60+ years of age High potency live, attenuated varicella vaccine Boosts immunity Off-label use in patients under 60 Shingles – localized rash due to reactivation of latent chicken pox (varicella) virus Postherpetic neuralgia – extreme, debilitating pain lasting for months CDC. MMWR Recomm Rep. 2008;57(RR5):1-30.

142 Zoster Vaccine Contraindications and Precautions
Single dose vaccine Contraindications Previous severe allergic reaction to a vaccine component Immunocompromised persons Persons with HIV, AIDS, leukemia, lymphoma, or other malignant neoplasms Persons on immunosuppressive therapy, including high-dose corticosteroids Persons receiving immune mediators/modulators, such as etanercept, infliximab, and adalimumab Pregnancy or planned pregnancy within 4 weeks Precautions Moderate or severe acute illness CDC. MMWR Recomm Rep. 2008;57(RR5):1-30.

143 Zoster Vaccine Cost Issues
Routine vaccination not covered by Medicare part B Eligible for reimbursement by Medicare part D In the office, check that insurance can be billed directly through the computer billing system or through pharmacy, otherwise patient will have to pay full amount and claim for reimbursement Outside the office, ensure vaccine administered at a pharmacy or other location covered by insurance CDC. Accessed September 2009. AAFP. Accessed September 2009.

144 Varicella-Zoster Vaccine Shingles Prevention Study
Randomized, placebo-controlled, double-blind vaccine trial Study population 38,546 volunteers at 22 sites; adults 60+ years 95% of volunteers completed study Follow-up: median duration 3.12 years Vaccine recipients: Overall incidence of herpes zoster reduced by 51% 60-69 years ↓64% ≥ 70 years ↓38% Incidence of post-herpetic neuralgia reduced by 67% Injection site reactions were more frequent in the vaccine group Oxman MN, et al. N Engl J Med. 2005;352:

145 Adult Immunization Schedule: US 2010
CDC. MMWR Morb Mortal Wkly Rep. 2010;59(1).

146 Seasonal Influenza Has a Huge Annual Impact in the United States
Cases 25–55 million+ cases Days of Illness 100–200 million days Work loss days 10’s of millions Hospitalizations 100,000–300,000 Deaths 35,000*–50,000† Costs Billions of dollars *Average of all causes, through †Average of all causes, through CDC. MMWR Recomm Rep. 2003;52(RR-8):1-36. Thompson WW, et al. JAMA. 2003;289: Adams PF, et al. Vital Health Stat ;200:1-203.

147 Annual Influenza Vaccine is Recommended for:
All people age 6 months and older! According to the Advisory Committee on Immunization Practices (ACIP) of the US Centers for Disease Control and Prevention (CDC), several groups of people should be primary targets for vaccination during the influenza season. These are groups who are at high risk of morbidity or mortality due to influenza. CDC. Accessed March 2010. 147

148 Trivalent Inactivated Virus (TIV) versus Live Attenuated Influenza Virus (LAIV) Vaccines
Licensed for use in persons age ≥6 mos Intramuscular injection TIV contains purified viral particles that have been chemically inactivated Purified components from 3 WHO-recommended annual strains Immunity developed against disrupted/denatured viral proteins, not against intact virus LAIV Licensed for use among nonpregnant persons aged 2-49 years Administered by nasal spray LAIV contains intact virus that has been propogated in eggs at 25ºC Cold-adaptation results in restricted replication at body temp More mild flu symptoms Contains same 3 WHO-recommended annual strains as TIV CDC. MMWR Recomm Rep. 2009;58(RR08):1-52. Flumist Prescribing Information. Accessed Oct 2009.

149 Influenza Vaccination During Most Recent Pregnancy – Georgia & Rhode Island
Year Percentage §95% confidence Interval †2007 data for Georgia were not available CDC. MMWR Morb Mortal Wkly Rep. 2009;58(35):

150 2009–2010 Seasonal Influenza Vaccines
2009–2010 seasonal influenza vaccine formulation: A/Brisbane/59/2007(H1N1)-like virus A/Brisbane/10/2007 (H3N2)-like virus B/Brisbane/60/2008-like antigens Vaccines Trivalent Inactivated, Injectable Influenza Vaccine Fluzone® (sanofi): age ≥ 6 months Fluvirin® (Novartis): age ≥ 4 years Fluarix® (GSK): age ≥ 3 years FluLaval™ (ID Biomedical/GSK): age ≥ 18 years Afluria® (CSL): age ≥ 6 months Live Attenuated, Nasal Spray Influenza Vaccine FluMist® (MedImmune): age 2 through 49 years (healthy, non-pregnant) Seasonal 2009 influenza vaccine does not protect against 2009 (pandemic) H1N1 influenza CDC. MMWR Recomm Rep. 2009;58(RR8):1-52. CDC. Accessed March 2010.

151 2009 H1N1 (Pandemic) Influenza Vaccines
As of November 11, 2009: 4 monovalent inactivated vaccines approved CSL Limited Age 6-35 mos: Two 0.25 mL IM doses (4 wk interval) Age 36 mos to 9 yrs: Two 0.5 mL IM doses (4 wk interval) Age ≥ 10 yrs: Single 0.5 mL IM injection Adults ≥ 18 yrs: Single 0.5 mL IM injection Novartis Vaccines and Diagnostics Limited Age 4-9 yrs: Two 0.5 mL IM doses (4 wk interval) Age yrs: Single 0.5 mL IM injection Age ≥ 18 yrs: Single 0.5 mL IM injection Sanofi Pasteur, Inc. ID Biomedical/GSK 1 live attenuated (nasal administration) MedImmune LLC Age 2-9 yrs: Two 0.2 mL doses (0.1 mL per nostril), 4 week interval Age yrs: Single 0.2 mL dose (0.1 mL per nostril) Prescribing information available at: Accessed December 2009.

152 2009 H1N1 Influenza Summary Between April 2009 and February 13, 2010
Cases of H1N1 Influenza 42–86 million Mid-level: 59 million H1N1-related Hospitalizations 188,000–389,000 Mid-level: 265,000 H1N1-related Deaths 8,520–17,620 Mid-level: 12,000 Vaccination Coverage ~86 million people received 97 million doses of H1N1 vaccine CDC. Accessed March 2010.

153 Percentage of Visits for Influenza-like Illness; National Summary Oct 2006–Feb 2010
Finelli L, et al. Accessed March 2010.

154 2009–2010 College Influenza-like Illness
Finelli L, et al. Accessed March 2010.

155 Influenza Hospitalizations, Sep 2009–Feb 2010
Finelli L, et al. Accessed March 2010.

156 Aggregate Hospitalizations 2009–H1N1 April 2009–Feb 2010
Finelli L, et al. Accessed March 2010.

157 Influenza Deaths, Sep 2009–Feb 2010
Finelli L, et al. Accessed March 2010.

158 Deaths 2009–H1N1 Influenza April 2009–Feb 2010
Finelli L, et al. Accessed March 2010.

159 Influenza Vaccination (H1N1, Seasonal or Both) by mid-January 2010
Data from National 2009 H1N1 Flu Survey (NHFS) Singleton J. Accessed March 2010.

160 2010–2011 Influenza Season Universal Influenza Vaccination
All people 6 months and older are now recommended to receive annual influenza vaccination Trivalent Influenza Vaccines A/California/7/2009(H1N1)-like virus Same strain as in the 2009 H1N1 monovalent vaccine A/Perth/16/2009(H3N2)-like virus New strain for northern hemisphere vaccine Same strain as 2010 southern hemisphere seasonal strain B/Brisbane/60/2008-like virus No change CDC. March 2010.

161 2010–2011 Influenza Season Continued Emphasis on High-risk Groups:
Children aged 6 months through 4 years Adults ≥ 50 years Women who will be pregnant during the influenza season Persons who have chronic pulmonary, cardiovascular, renal, hepatic, neurological, neuromuscular, hematological or metabolic disorders Persons who have immunosuppression (including caused by medication or HIV) Residents of nursing homes and other chronic-care facilities Health care personnel Household contacts and caregivers of children aged < 5 year and adults aged ≥ 50 years, with particular emphasis on vaccinating contacts of children < 6 months Household contacts and caregivers of persons with medical conditions that put them at higher risk for severe complications from influenza CDC. Accessed March 2010.

162 Flu Shots May Also Reduce Hospitalizations for Cardiovascular Disease
2-year cohort study of elderly members of 3 HMOs 1998–1999 and 1999–2000 seasons with > 140,000 elderly members in each year’s cohort After multivariable analysis, vaccination cohort showed a reduced risk of death and hospitalization Nichol KL, et al. N Engl J Med. 2003;348:

163 Rationale for Vaccinating HCWs
“First do no harm” Reduce the risk for nosocomial transmission from staff to patient Reduce staff absenteeism and preserve health care capacity May be cost saving for the health care org Personal benefits to HCWs (? Increase awareness & likelihood of HCWs vaccinating patients)

164 Nosocomial Influenza Is Well Documented
Nosocomial outbreaks documented on Solid organ transplant units Oncology units Neonatal ICU Pediatric units Long term care facilities General medical wards Results: morbidity for patients & staff, increased costs for institution & impaired capacity to provide care Vectors for transmission include staff, visitors, patients Encourage hygiene etiquette amongst staff and patients Stott DJ, et al. Occup Med (Lond). 2002;52:

165 Health Care Workers Should Be Immunized
HCW Influenza Vaccination Rates NHIS, 2003 Vaccinated 40.1 Not 59.9

166 Pneumococcal Polysaccharide Vaccine (PPSV23)
Contains polysaccharide surface antigens expressed on S. pneumoniae Over 90 known serotypes Vaccine contains 23 polysaccharide serotypes from S. pneumoniae 1-4, 5, 6B, 7F, 8, 9N, 9V, 10A, 11A, 12F, 14, 15B 17F, 18C, 19F, 19A, 20, 22F, 23F, 33F Included in PCV7 New conjugate vaccine PCV13 (Serotypes 1, 3, 4, 5, 6A, 6B, 7F, 9V,14,18C,19A,19F, 23F) CDC. Accessed March 2010. CDC. MMWR Morb Mortal Wkly Rep. 2010;59(9):

167 Pneumococcal Polysaccharide Vaccine (PPSV23)
Single dose recommended for: All ≥ 65 years 2–64 years: chronic cardiovascular disease, chronic pulmonary disease, diabetes, alcoholism, chronic liver disease, CSF leaks, asplenia, cochlear implants > 2 years and immunocompromised Asthmatics and smokers age years Proposed language for one-time revaccination: “A second dose of PPSV23 is recommended 5 years after the first dose of PPSV23 for persons aged ≥ 2 years who are immunocompromised, have sickle cell disease, or functional or anatomic asplenia” ACIP Schedules. Accessed September 2009. CDC. Accessed Oct 2009.

168 PPSV23 and Smokers Higher RR of invasive pneumococcal disease among smokers. Current smoker RR = 4.1. Passive exposure RR = 2.5. There is a dose response relation to number of cigarettes per day and pack years smoked Risks among smokers comparable to those of diabetes, asthma and other known risks 50/100,000/yr incidence rate NNV is 10,700 for age 18-44, 4000 for age 45-64 Nuorti J, et al. N Engl J Med. 2000;342: ACIP Meeting Oct Accessed September 2009.

169 3-year cohort study of 47,365 members of Group Health Coop (Seattle)
Effectiveness of Pneumococcal Polysaccharide Vaccine in Older Adults: The VSD Cohort Study 3-year cohort study of 47,365 members of Group Health Coop (Seattle) PPV was associated with lower rates of bacteremia: HR 0.56 (95% CI 0.33 to 0.93) PPV was not associated with lower rates of pneumonia HR 1.07 (95% CI 0.99 to 1.14) HR = hazard ratio. Jackson LA, et al. N Engl J Med. 2003;348:

170 Adult Immunization Schedule: US 2010
CDC. MMWR Morb Mortal Wkly Rep. 2010;59(1).

171 Hepatitis A Postexposure Prophylaxis
For healthy persons 12 months through 40 years of age who have not previously received HepA vaccine Take into account patient characteristics, including chronic liver disease Immunoglobulin and/or single-antigen hepatitis A vaccine should be administered as soon as possible after exposure Vaccine preferred for those of age 12 mos to 40 yrs Ig preferred for age < 12 mos, those with vaccine allergies, or those with immunosuppression or liver disease Ig preferred for age > 40 but vaccine may be used if Ig unavailable HepA and Ig may be administered simultaneously Efficacy of Ig or HepA when administered > 2 weeks postexposure is unknown CDC. MMWR Morb Mortal Wkly Rep. 2007;56(41): CDC. MMWR Morb Mortal Wkly Rep. 2009;58(36):

172 Hepatitis A Vaccine International Travel
For healthy persons 40 years of age or younger 2 doses 6 months apart prior to departure The first dose of Hepatitis A vaccine should be administered as soon as travel is considered 1 dose of single-antigen vaccine administered at any time before departure Consider both HAV and Ig for Persons age > 40 with chronic illness traveling in less than 2 weeks and only receiving one dose of HAV Persons at risk of severe disease from hepatitis A virus planning to travel in 2 weeks or sooner CDC. MMWR Morb Mortal Wkly Rep. 2007;56(41):

173 Hepatitis B Vaccine Expanded Indications
A patient’s “acknowledgment of a specific risk factor should not be a requirement for vaccination” For all “sexually active persons who are not in a long-term mutually monogamous relationship” Past indications: Universal for ages birth–18 years Being evaluated for STD Being treated for STD Men who have sex with men Sex partners of HBs Ag-positive persons Prisoners Health care workers CDC. MMWR Recomm Rep. 2006;55(RR16):1-33.

174 Hepatitis B Vaccine Composition Recombinant HBsAg Efficacy
95% (Range, 80%-100%) Duration of immunity 20 years or more Schedule 3 doses Hepatitis B. Accessed Oct 2009.

175 HBV Protection* by Age Group and Dose
Infants** Teens and Adults*** 1 16%-40% 20%-30% 2 80%-95% 75%-80% 3 98%-100% 90%-95% *Anti-HBs antibody titer of 10 mIU/mL or higher **Preterm infants less than 2 kg have been shown to respond to vaccination less often ***Factors that may lower vaccine response rates are older than 40 years, male gender, smoking, obesity, and immune deficiency Hepatitis B. Accessed Oct 2009.

176 Hepatitis B Vaccine Adult Schedule
Several approved 3-dose schedules for adults age ≥ 20 years 0, 1, and 6 months* 0, 1, and 4 months 0, 2, and 4 months 0, 1, 2, and 12 months** “Providers should select the vaccine schedule they consider necessary to achieve completion of the vaccine series” No apparent effect on immunogenicity has been documented when minimum spacing of doses (ie, 4 weeks between doses 1 and 2, 8 weeks between doses 2 and 3, and 16 weeks between doses 1 and 3) is not achieved precisely. * Approved Twinrix schedule ** A 4-dose schedule of Engerix-B is licensed for all age groups CDC. MMWR Recomm Rep. 2006;55(RR16):1-25.

177 HepA-HepB Combination Vaccine (Twinrix)
Approved for persons 18 years and older Combination HepA vaccine (pediatric dose) and HepB (adult dose) First licensed schedule: 0, 1, and 6 months Alternate schedule 2007: Doses at 0, 7, days and a booster dose at 12 months The first 3 doses of the new schedule provide equivalent protection to: The first dose in the standard single-antigen adult hepatitis A vaccine series The first 2 doses in the standard adult hepatitis B vaccine series Seroconversion is nearly 100% after either 3 doses of the combination vaccine on the new schedule or a single dose of single-antigen adult hepatitis A vaccine Duration of protection 4 yrs against HepA No increased benefit of the new schedule for the hepatitis B component compared to administration of 2 hepatitis B vaccine doses 1 to 2 months apart CDC. MMWR Morb Mortal Wkly Rep. 2007:56(40):1057.

178 Adult Immunization Schedule: US 2010
CDC. MMWR Morb Mortal Wkly Rep. 2010;59(1).

179 Meningococcal Conjugate Vaccines
Recommended for adolescents aged years and others at increased risk for meningococcal disease MCV4-D (Menactra®, Sanofi): licensed for persons 2-55 years; Serogroups A, C, Y, W-135; diphtheria toxoid conjugate MenACWY-CRM197 (Menveo®, Novartis): licensed for persons years; Serogroups A, C, Y, W-135; diphtheria CRM197 conjugate Revaccination for Persons at Increased Risk Previous vaccination (meningococcal conjugate vaccine or MPSV4) at 2-6 years, revaccinate 3 years after initial meningococcal vaccine Previous vaccination (meningococcal conjugate vaccine or MPSV4) at ≥ 7 years, revaccinate 5 years after initial meningococcal vaccine This includes: Persons with persistent complement component deficiencies Persons with anatomic or functional asplenia Microbiologists who are routinely exposed to isolates of N. meningitidis Frequent travelers to or people living in areas with high rates of meningococcal disease (African meningitis belt) Meissner HC. Accessed March 2010. CDC. MMWR Morb Mortal Wkly Rep. 2009;58(37):

180 MMR Evidence of Immunity for Health Care Personnel: Mumps, Measles & Rubella
Documented administration of two doses of live measles virus vaccine or Laboratory evidence of immunity or laboratory confirmation of disease or Born before 1957* *For unvaccinated personnel with no documentation or laboratory evidence of immunity, facilities should consider 2 doses of MMR for measles/mumps, and 1 MMR dose for rubella. Recommended during outbreaks. ACIP Provisional Recommendations. Accessed September 2009.

181 Strategies for Improving Adult Immunization Rates

182 Evidence-based Methods for Improving Immunization Rates
Community Preventive Services Task Force Recommended Strategies Reducing client out-of-pocket costs Vaccination programs in schools Vaccination programs in WIC settings Client reminder and recall systems Vaccination requirements for child care, school, and college attendance Provider reminder systems when used alone Standing orders when used alone Provider assessment and feedback  The above recommendations have all been upgraded to ‘strong evidence’ based on systematic reviews The Community Guide. Accessed September 2009. Briss PA, et al. Am J Prev Med. 2000;18(suppl 1):35-43.

183 Provider Recommendation Can Overcome Negative Attitudes Among Patients
Vaccination Rates Among High Risk Patients With Negative Attitudes Nichol KL, et al. J Gen Intern Med. 1996;11:

184 Improving Vaccination Rates – Provider Issues
Know the facts Recommend vaccinations to your patients Get organized and use systems approaches Ensure offering and administration of vaccine Automatic processes that empower nurses are effective Address convenience, efficiency, durability Evaluate and provide feedback Consider new paradigms New venues Extend vaccination season Practice what we preach (get vaccinated!) Nichol KL. Cleve Clin J Med. 2006;73:

185 Clinician Barriers to Adult Immunizations
Knowledge about bad diseases, good vaccines Generally OK May underestimate disease burden and overestimate side effects Don’t always strongly recommend Frequently don’t use proven systems strategies Core elements for success: Education, measurement, systems approaches Other issues Ultimate success may require collaboration of many stakeholders and new paradigms

186 Factors Associated With Very Strongly Recommending Vaccinations to Elderly Patients
Adjusted OR Influenza Vacc. PPV Monitor vaccination rates in practice as part of CI 1.79 1.72 Vaccination cost saving 2.02 2.92 Having received flu shot 1.91 2.41 Indicating that systemic symptoms uncommon 1.57 Number of system strategies used in practice 2.03 V important for HCW to get flu shot 3.4 1.94 Male sex 0.58 0.57 Generalist physician (vs subspecialist) 1.53 Patients risk for disease 2.42 2.38 Concerns about drug resistance 1.46 Vaccine effectiveness 1.42 Expert group recommendations 1.43 Having sufficient time to counsel Liability issues 2.04 1.64 Ease of targeting high risk groups 1.73 See reference pdf in bottom corner of slide (just outside slide display area). See table 4. Nichol KL, et al. Arch Intern Med. 2001;161:

187 Why Don’t Health Care Providers Use These Strategies?
No time / forget / logistics / resources I am already doing it Not included in CI activities / not measured PCPs should be doing it Lack of knowledge about effective strategies Missed opportunities and lack of system approaches

188 Other Issues Reimbursement levels State laws
In some states, pharmacists and other health care workers can immunize under standing orders Regulations for vaccinations in long term care facilities Patient concerns for vaccine safety Vaccine immunogenicity (especially for inpatients) Nontraditional settings

189 Where Flu Shots Are Received (Often Not the Doctor’s Office)
Singleton J, et al. Am J Infect Control. 2005;33:

190 Vaccinations in Nontraditional Settings
Potential advantages Cost Access/convenience Increased public awareness and demand New providers and new strategies For flu, pneumo, ??? other vaccines CDC. MMWR Recomm Rep. 2000;49 (RR1):1-13.

191 Standing Orders Are Among the Most Effective Strategies
Nonphysicians offer and administer vaccinations No direct MD involvement at the time of the visit Established with physician approved policies and protocols Locations: Clinics and hospitals CDC. Accessed September 2009. McKibbin LJ, et al. MMWR Recomm Rep. 2000;49 (RR1):15-26.

192 Multifaceted Program Improved Success and Sustainability
Increase Demand Annual reminder to pts Enhance Access Walk-in Clinics Address Provider Barriers Institutional Policy Standing Orders Standardized Forms Efficient Clinic Flow Ongoing Measurement and Evaluation

193 Success of Standing Orders as Part of a Multifaceted Program
Influenza Vaccination Rates for Elderly Patients in General Medicine Clinics Standing Orders Education Nichol KL. Am J Med. 1998;105:

194 Targeting Hospitalized Patients Makes Sense
Hospitalization is a marker for increased risk Hospitalized patients may be less likely to be immunized Providers often miss opportunities to immunize Organized programs work in the inpatient setting

195 General Immunization Information for All Age Groups

196 Vaccination Pearls There is no harm in vaccinating individuals who have had the disease Poor immunogenicity of natural infection (Hib under 2 yr of age) Waning immunity (pertussis) Multiple serotypes (pneumococcus) Didn’t really have the disease (varicella) There is no recommendation for maximum number of injections per limb Each injection must be separated 1 inch on same limb There is no recommendation for maximum number of vaccinations per day

197 Erroneous Contraindications
Mild acute illness Mild-moderate local reaction Concurrent antibiotic therapy Convalescent phase of illness Prematurity Recent exposure to illness History of non-vaccine allergies Family history of allergies, SIDS, seizures Desensitization shots Breastfeeding Positive Tuberculin Skin Test (TST) Pregnant household contact (except Oral polio Vaccine (OPV) and smallpox) Asymptomatic or mildly symptomatic HIV infection Allergic to eggs but can eat egg-containing products Mild latex allergy Autoimmune disease

198 General Safety Concerns
Post vaccination syncope most common among adolescents/young adults Approximately 12% result in hospitalization Serious injuries include Skull fractures Cerebral bleeding Car accidents 89% of episodes occur ≤ 15 minutes CDC. MMWR Recomm Rep. 2002;51(RR2);1-36.

199 Vaccine-preventable Diseases

200 Measles Clinical Presentation Complications Transmission
Fever, runny nose, rash Complications Ear infection 1 in 10 Pneumonia 1 in 20 Encephalitis 1 in 1000 Death 1 in 1000 Transmission Respiratory secretions Vaccine Formulations MMR-II Live-attenuated measles virus Live B-level strain mumps virus Live-attenuated rubella virus Unvaccinated persons at increased risk for disease College students Health care workers Women of childbearing age International travelers CDC. Accessed September 2009.

201 Measles CDC. Accessed September 2009.

202 Mumps Clinical Presentation Complications Transmission
Swollen parotid salivary glands Fever, headache, muscle aches, fatigue Complications Encephalitis/meningitis Permanent deafness Spontaneous abortion Orchitis, oophoritis, mastitis Transmission Saliva, respiratory secretions, airborne Unvaccinated persons at increased risk for disease College students Health care workers Women of childbearing age International travelers CDC. Accessed September 2009.

203 Mumps CDC. Accessed September 2009.

204 Rubella Clinical Presentation Complications Transmission
2-3 day fever, rash Complications Birth defects if acquired during pregnancy: deafness, cataracts, heart defects, mental retardation, liver/spleen damage Transmission Respiratory secretions Unvaccinated persons at increased risk for disease College students Health care workers Women of childbearing age International travelers CDC. Accessed September 2009. Rubella. Accessed Oct 2009.

205 Rubella CDC. Accessed September 2009.

206 Tetanus Clinical Presentation Complications Transmission
Early: lockjaw, stiffness in neck and abdomen, difficulty swallowing First symptoms may appear up to 3 weeks post-infection Late: severe muscle spasms, generalized tonic seizure-like activity, severe autonomic system disorders Complications Bone fractures, arrythmia, death in 10-20% of cases Transmission Bacterial infection, usually via exposure of a skin break to dust, soil, or manure Groups at increased risk for disease Unvaccinated individuals CDC. Accessed September 2009.

207 Tetanus CDC. Accessed September 2009.

208 Diphtheria Clinical Presentation Complications Transmission
Sore throat, low-grade fever, fatigue Membranous pharyngitis Bull neck in 10% of cases Occasional skin lesions Complications Airway obstruction, cardiac complications, coma, death if untreated Transmission Respiratory secretions Groups at increased risk for disease Unvaccinated individuals CDC. Accessed September 2009. Dipnet.com Accessed September 2009.

209 Diptheria CDC. Accessed September 2009.

210 Pertussis Clinical Presentation Complications Transmission
Early: Runny nose, sneezing, low grade fever, cough, similar to common cold 1-2 weeks: Paroxysms, whooping cough Complications Bacterial pneumonia, rib fracture Infants are at highest risk for apnea, pneumonia, seizures, encephalopathy, death Transmission Respiratory secretions Groups at increased risk for disease Unvaccinated individuals CDC. Accessed September 2009.

211 Pertussis CDC. Accessed September 2009.

212 Reported Pertussis Cases
Cortese M, et al. Am J Prev Med. 2007;32(3): 212

213 Pertussis Is Increasingly an Adolescent and Adult Disease
2004 18.8 fold 15.5 fold 9000 8000 7000 6000 Average Number of Cases / Year 5000 4000 In the early 1990s, most of the reported pertussis cases were in infants and young children. But in each subsequent time period, more and more pertussis cases have been reported among adolescents and adults.1 Over the last 14 years, there has been a 17-fold increase in pertussis among adolescents and adults. Note that pertussis is widely under-reported, so that the figures you see on this slide are just the tip of the iceberg. Recent studies estimate the annual incidence of pertussis to be approximately 500 per 100,000 persons, or over 1 million cases yearly in the United States, with the majority of these occurring in adolescents and adults.2-5 References: 1. Güris D, et al. Changing epidemiology of pertussis in the United States: increasing reported incidence among adolescents and adults, Clin Infect Dis. 1999;28: 2. CDC. Pertussis -- United States,  2002;51:73-76. 3. CDC. Summary of notifiable diseases—United States, MMWR. 2003;50(53):15 4. CDC. Summary of notifiable diseases—United States, MMWR. 2004;51(53):28. 5. CDC. Summary of notifiable diseases—United States, MMWR. 2005;52(54):28, 72. 6. Pertussis Surveillance Report – 8/12/05, available at Accessed September 2005. 3000 2000 1000 <1 1-4 5-9 10-19 20+ Age Group (years) Güris D, et al. Clin Infect Dis. 1999;28: CDC. MMWR Morb Mortal Wkly Rep. 2005;54(50): Pertussis. Accessed Sept 2009.

214 Viral Hepatitis CDC. Accessed September 2009.

215 Reported Acute Hepatitis B Incidence By Age Group: United States, 1990–2004
≥ 20 years 12-19 years Cases per 100,000 < 12 years Year CDC. MMWR Recomm Rep. 2005;54(RR16):1-31.

216 Age of Infection of Acute and Chronic Hepatitis B Virus Infection
Acute infection Chronic infection CDC Sentinel Sites data. Hepatitis B. Accessed Oct 2009.

217 Risk Factors for Hepatitis B
CDC. MMWR Recomm Rep. 2006;55(RR16):1-25.

218 Haemophilus influenzae
CDC. Accessed September 2009.

219 Epidemic Influenza Has a Huge Annual Impact in the United States
Cases 25–55 million+ cases Days of Illness 100–200 million days Work loss days 10’s of millions Hospitalizations 100,000–300,000 Deaths 35,000*–50,000† Costs Billions of dollars *Average of all causes, through †Average of all causes, through CDC. MMWR Recomm Rep. 2003;52(RR8):1-36. Thompson WW, et al. JAMA. 2003;289: Adams PF, et al. Vital Health Stat ;200:1-203.

220 Influence of Influenza Epidemics on Seasonal Mortality
All Cause P&I: pneumonia and influenza Simonsen L, et al. Am J Public Health. 1997;87:

221 February is #1 for Peak Influenza Activity
CDC. MMWR Recomm Rep. 2008;57(RR7):1-60.

222 Influenza Complications
Pneumonia Ear infection Sinus infection Dehydration Worsening of chronic conditions “The number of pediatric influenza-associated deaths reported during was moderately higher than the number reported during the two previous surveillance years; the number of these deaths in which pneumonia or bacteremia due to S. aureus was noted represents a five-fold increase.” CDC. MMWR Recomm Rep. 2008;57(RR7):1-60. CDC Health Advisory. Accessed Oct 2009. 222

223 2009–2010 Seasonal Influenza Vaccines
2009–2010 seasonal influenza vaccine formulation: A/Brisbane/59/2007(H1N1)-like virus A/Brisbane/10/2007 (H3N2)-like virus B/Brisbane/60/2008-like antigens Vaccines Trivalent Inactivated, Injectable Influenza Vaccine Fluzone® (sanofi): age ≥ 6 months Fluvirin® (Novartis): age ≥ 4 years Fluarix® (GSK): age ≥ 3 years FluLaval™ (ID Biomedical/GSK): age ≥ 18 years Afluria® (CSL): age ≥ 6 months Live Attenuated, Nasal Spray Influenza Vaccine FluMist ® (MedImmune): age 2 through 49 years (healthy, non-pregnant) Seasonal 2009 influenza vaccine does not protect against 2009 (pandemic) H1N1 influenza CDC. MMWR Recomm Rep. 2009;58(RR10):1-8. CDC. Accessed March 2010.

224 2009 H1N1 (Pandemic) Influenza Vaccines
As of November 11, 2009: 4 monovalent inactivated vaccines approved CSL Limited Age 6-35 mos: Two 0.25 mL IM doses (4 wk interval) Age 36 mos to 9 yrs: Two 0.5 mL IM doses (4 wk interval) Age ≥ 10 yrs: Single 0.5 mL IM injection Adults ≥ 18 yrs: Single 0.5 mL IM injection Novartis Vaccines and Diagnostics Limited Age 4-9 yrs: Two 0.5 mL IM doses (4 wk interval) Age yrs: Single 0.5 mL IM injection Age ≥ 18 yrs: Single 0.5 mL IM injection Sanofi Pasteur, Inc. ID Biomedical/GSK 1 live attenuated (nasal administration) MedImmune LLC Age 2-9 yrs: Two 0.2 mL doses (0.1 mL per nostril), 4 week interval Age yrs: Single 0.2 mL dose (0.1 mL per nostril) Prescribing information available at: Accessed December 2009.

225 2009 H1N1 Influenza Summary Between April 2009 and February 13, 2010
Cases of H1N1 Influenza 42–86 million Mid-level: 59 million H1N1-related Hospitalizations 188,000–389,000 Mid-level: 265,000 H1N1-related Deaths 8,520–17,620 Mid-level: 12,000 Vaccination Coverage ~86 million people received 97 million doses of H1N1 vaccine CDC. Accessed March 2010.

226 Percentage of Visits for Influenza-like Illness; National Summary Oct 2006–Feb 2010
Finelli L, et al. Accessed March 2010.

227 2009–2010 College Influenza-like Illness
Finelli L, et al. Accessed March 2010.

228 Influenza Hospitalizations, Sep 2009–Feb 2010
Finelli L, et al. Accessed March 2010.

229 Aggregate Hospitalizations 2009–H1N1 April 2009–Feb 2010
Finelli L, et al. Accessed March 2010.

230 Influenza Deaths, Sep 2009–Feb 2010
Finelli L, et al. Accessed March 2010.

231 Deaths 2009–H1N1 Influenza April 2009–Feb 2010
Finelli L, et al. Accessed March 2010.

232 Influenza Vaccination (H1N1, Seasonal or Both) by mid-January 2010
Data from National 2009 H1N1 Flu Survey (NHFS) Singleton J. Accessed March 2010.

233 2010–2011 Influenza Season Universal Influenza Vaccination
All people 6 months and older are now recommended to receive annual influenza vaccination Trivalent Influenza Vaccines: A/California/7/2009(H1N1)-like virus Same strain as in the 2009 H1N1 monovalent vaccine A/Perth/16/2009(H3N2)-like virus New strain for northern hemisphere vaccine Same strain as 2010 southern hemisphere seasonal strain B/Brisbane/60/2008-like virus No change CDC. Accessed March 2010.

234 2010–2011 Influenza Season Continued Emphasis on High-risk Groups:
Children aged 6 months through 4 years Adults ≥ 50 years Women who will be pregnant during the influenza season Persons who have chronic pulmonary, cardiovascular, renal, hepatic, neurological, neuromuscular, hematological or metabolic disorders Persons who have immunosuppression (including caused by medication or HIV) Residents of nursing homes and other chronic-care facilities Health care personnel Household contacts and caregivers of children aged < 5 year and adults aged ≥ 50 years, with particular emphasis on vaccinating contacts of children < 6 months Household contacts and caregivers of persons with medical conditions that put them at higher risk for severe complications from influenza CDC. Accessed March 2010.

235 Extending Vaccination Season Will Reduce Missed Opportunities
Percent of Maximum Vaccine demand Influenza cases Week CDC. MMWR Morb Mortal Wkly Rep. 2007;56(31):

236 Changes in Overall Invasive Pneumococcal Disease, 1998–2007
PCV7 introduced Age Group vs baseline (years) (% reduction) 120 < 5 76 100 5–17 43 18–49 40 80 50–64 18 Cases/100,000 population ≥ 65 37 60 40 20 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 Year Pilishvili T, et al. J Infect Dis. 2010;201:32-41.

237 Direct Effect of Vaccination: Invasive Pneumococcal Disease Among Children < 5 Years, 1998/99–2007 PCV7 introduced 90 80 Serotype group PCV7 type Non-PCV7 type 19A 70 60 50 Cases/100,000 population *100% reduction in PCV7 serotypes, 2007 vs baseline 40 30 20 10 * 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 Year Pilishvili T, et al. J Infect Dis. 2010;201:32-41.

238 Invasive Pneumococcal Disease Among Adults ≥ 65 Years, 1998/99–2007
PCV7 introduced 40 35 *92% reduction in PCV7 serotypes, 2007 vs baseline 30 25 Cases/100,000 population Serotype group 20 PCV7 type Non-PCV7 type 15 19A 10 5 * 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 Year Pilishvili T, et al. J Infect Dis. 2010;201:32-41.

239 Percentage of Deaths from Vaccine-preventable Diseases Among Children Aged < 5 Years, 2002
*Other VPDs: Diphtheria, HepB, Japanese encephalitis, meningococcal disease, poliomyelitis, and yellow fever. In 2002, an estimated 2.5 million deaths worldwide under the age of 5 were attributable to diseases for which vaccines were available CDC. MMWR Morb Mortal Wkly Rep. 2006;55(18):

240 HPV/Cancer Disease Burden in the United States
Anogenital HPV is the most common sexually transmitted infection in the US1 Estimated 20 million currently infected 6.2 million new infections/year Common among adolescents and young adults Estimated 80% of sexually active women will have been infected by age 50 Infection also common in men The American Cancer Society estimates that in 2008 11,070 new cervical cancer cases 3,870 cervical cancer deaths Almost 100% of these cervical cancer cases will be caused by one of the 40 HPV types that infect the mucosa Burchell AN. Vaccine. 2006;24(suppl 3):52-61.

241 Human Papillomavirus Types and
Disease Association mucosal/genital (~40 types) nonmucosal/cutaneous (~60 types) high-risk types 16, 18, 31, 45 (and others) low-risk types 6, 11 (and others) skin warts (hands and feet) Low grade cervical abnormalities Cancer precursors Anogenital cancers Low grade cervical abnormalities Genital warts Laryngeal papillomas

242 HPV-Associated Disease
Type Women Men 16/18 70% of cervical cancer 70% of anal/genital cancer 70% of anal cancer Transmission to women 6/11 90% of genital warts 90% of RRP lesions RRP: recurrent respiratory papillomatosis CDC. MMWR Recomm Rep. 2007;56(RR-2):1-23.

243 Meningococcal Disease
CDC. Accessed September 2009.

244 Age-Specific Fatalities From Meningococcal Disease, US, 1997–2002
This bar graph shows the distribution of deaths from meningococcal disease according to age group, as described in the National Vital Statistics Report from the CDC for the years 1997 to It is important to note that 15- to 24-year-olds have substantial mortality from meningococcal disease.1 Twenty percent of survivors in all age groups suffer severe sequelae, which can result in permanent disability, including scarring and limb loss from gangrene, stroke, or central nervous system sequelae including seizures, hearing loss, and cognitive defects.2-6 References: CDC. National Vital Statistics Reports. 2003;52:30; 2004;53:29. Granoff DM, et al. Meningococcal vaccines. In: Plotkin SA, ed. Vaccines. 4th ed. Philadelphia, Pa: WB Saunders Co; 2004: Fellick JM, et al. Neurodevelopmental outcome in meningococcal disease: a case-control study. Arch Dis Child. 2001;85:6-11. Erickson L, De Wals P. Complications and sequelae of meningococcal disease in Quebec, Canada, Clin Infect Dis. 1998;26: Erickson LJ, et al. Complications of meningococcal disease in college students. Clin Infect Dis. 2001;33: Munford RS. Meningococcal infections. In: Braunwald E, et al, eds. Harrison’s Principles of Internal Medicine. 15th ed. New York, NY: McGraw-Hill Professional; 2001: CDC. National Vital Statistics Reports. Accessed Oct 2009.

245 Most Common Clinical Presentations of Meningococcal Disease
Meningitis Fever and headache (flu-like symptoms) Stiff neck Nausea Altered mental status Seizures ~ 50% of cases 3% to 10% fatality rate Meningococcemia Rash Vascular damage Disseminated intravascular coagulation Multiorgan failure Shock Death can occur within 24 hours ~ 5% to 20% of cases Up to 40% fatality rate Rosenstein NE, et al. N Engl J Med. 2001;344:

246 Varicella CDC. Accessed September 2009.

247 General Strategies for Improving Immunization Rates

248 Standing Orders Are Among the Most Effective Strategies
Nonphysicians offer and administer vaccinations No direct MD involvement at the time of the visit Established with physician approved policies and protocols Locations: Clinics and hospitals CDC. Accessed September 2009. McKibbin LJ, et al. MMWR Recomm Rep. 2000;49(RR1):15-26.

249 Multifaceted Program Improved Success and Sustainability
Increase Demand Annual reminder to pts Enhance Access Walk-in Clinics Address Provider Barriers Institutional Policy Standing Orders Standardized Forms Efficient Clinic Flow Ongoing Measurement and Evaluation

250 Success of Standing Orders as Part of a Multifaceted Program
Influenza Vaccination Rates for Elderly Patients in General Medicine Clinics Standing Orders Education Nichol KL. Am J Med. 1998;105:

251 Standing Orders More Effective than Education or MD Reminders for Inpatients
Crouse B, et al. J Fam Pract. 1994;38:

252 Sample Standing Order Immunization Action Coalition. Accessed September 2009.

253 Venues for Vaccination: Where Vaccine Recipients Were Immunized, 2005–2006

254 Physician Practice and Interest in Selected Strategies
Doing Already Would Try Patient reminders 23% 53% Walk-in Vax 67% 19% Policy to Assess 48% 31% Standing Orders 33% 36% Clearer Vax Guidelines 51% Registry 7% 56% Szilagyi PG, et al. Prev Med. 2005;40:

255 Available Reimbursement for Adolescent Vaccination
Public funding for eligible children up to but not including the 19th birthday Vaccines for Children Program (VFC) Many insurers follow VFC lead State Children’s Health Insurance Program (SCHIP) Funding for adolescents > 19 years: Federal Vaccination Assistance Act, Section 317 Inadequate for large-scale immunization strategies

256 Reimbursement Rates Providers often not reimbursed adequately for administration costs “Float” costs are high Some states add taxes to the cost of vaccines Institute of Medicine recommended a universal federal reimbursement system – subsidized mandate for insurance companies Significant correlation between reimbursement rates and 8/16 studied HEDIS measures Childhood immunizations correlation 0.42 Strong relationship with rates of adolescent varicella vaccination (r = 0.53) Low reimbursement rates associated with lower rates of vaccination of adolescents McInerny TK, et al. Pediatrics. 2006;115:

257 Resources

258 PROTECTTM Website: http://www.francefoundation.com/protect/

259 Resources for Patients and Parents
Guide to evaluating information on the web CDC Vaccine Information Statements (VISs) Vaccine Safety National Network for Immunization Information (NNII) Allied Vaccine Group Immunization Action Coalition (IAC) Vaccine Education Center at CHOP TCH Center for Vaccine Awareness and Research

260 Resources for Providers
Immunization Schedules ACIP recommendations & provisional recommendations The Guide to Community Preventive Services. Vaccine recommendations Assessment, Feedback, Incentives, and Exchange (AFIX) National Foundation for Infectious Diseases Centers for Medicare & Medicaid Services

261 Resources for Providers, Parents, and Patients
The Immunization Action Coalition: vaccine information for the public and health professionals The Immunization Action Coalition: directory of immunization coalitions

262 Passive Surveillance: VAERS
National reporting system Jointly administered by CDC and the Food and Drug Administration (FDA) since 1990 Designed to detect: New, unusual or rare events Changes in rates of previously reported AEs Patient risk factors While the information provided is useful, it also may be somewhat limited Causality may not be determined because of limited data CDC. Accessed September 2009.

263

264 Active Surveillance Vaccine Safety Datalink (VSD)
Established in 1990 as collaborative effort between Centers for Disease Control and Prevention (CDC) and 8 geographically diverse health maintenance organizations1,2 Large linked database which covers ~3% of the US population1,2 Links vaccination and health records1,2 Allows identification of possible AEs1,2 1. Iskander J. Current CDC vaccine safety activities. Accessed September 2009. 2. Pickering LK ,Bocchini J. AAP News. 2008;29(5):1.

265 Useful Flu Vaccine Links/Resources
The Childhood Influenza Immunization Coalition (CIIC) The Childhood Influenza Immunization Coalition (CIIC) was established by the National Foundation for Infectious Diseases (NFID) to protect infants, children and adolescents from influenza by communicating with "one strong voice" the need to make influenza immunization a national health priority. The Coalition seeks to address and improve the low influenza immunization rates among children. Members, including SAM, represent more than 25 of the nation's leading public health, medical, patient and parent groups committed to protecting children's health and encouraging wellness. The CIIC Web site provides a variety of excellent educational materials to help promote childhood influenza immunization. Centers for Disease Control and Prevention (CDC) The Centers for Disease Control and Prevention Web site offers of wealth of information and resources, including posters for your office, tracking of reported cases of flu and links to the full ACIP flu recommendations. The National Network for Immunization Information (NNii) The National Network for Immunization Information (NNii) provides up-to-date, science-based information to health care professionals, the media, and the public: everyone who needs to know the facts about vaccines and immunization. Families Fighting Flu (FFF) Families Fighting Flu (FFF) was established for the children who die each year due to the influenza virus (commonly called "the flu"). Each family has experienced first-hand the death of a child due to the flu or has had a child experience severe medical complications from the flu. This non-profit organization, made up of families and health care practitioners, is dedicated to educating people about the severity of influenza and the importance of vaccinating children against the flu every year. 265


Download ppt "PROTECTTM SupPorting AppROpriate ImmunizaTions Across the AgE SpeCTrum"

Similar presentations


Ads by Google