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Adolescent and Adult Immunization Update

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Presentation on theme: "Adolescent and Adult Immunization Update"— Presentation transcript:

1 Adolescent and Adult Immunization Update
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2 Disclosure Statements
To obtain nursing contact hours for this session, you must be present for the entire presentation and complete an evaluation. Neither the planners of this session nor I have any financial relationship with pharmaceutical companies, biomedical device manufacturers, or corporations whose products and services are related to the vaccines we discuss. There is no commercial support being received for this event. The mention of specific brands of vaccines in this presentation is for the purpose of providing education and does not constitute endorsement. The GA Immunization Office utilizes ACIP recommendations as the basis for this presentation and for our guidelines, policies, and recommendations. For certain vaccines this may represent a slight departure from or off-label use of the vaccine package insert guidelines. [Presenter is required to read this information to the audience before the program begins.] To obtain nursing contact hours for this session, you must be present for the entire hour and complete an evaluation. Neither the planners of this session nor I have any financial relationship with pharmaceutical companies, biomedical device manufacturers, or corporations whose products and services are related to the vaccines we discuss. There is no commercial support being received for this event. The mention of specific brands of vaccines in this presentation is for the purpose of providing education and does not constitute endorsement. The GA Immunization Program utilizes ACIP recommendations as the basis for this presentation and for our guidelines, policies, and recommendations. For certain vaccines this may represent a slight departure from or off-label use of the vaccine package insert guidelines.

3 Objectives Define Herd Immunity and Cocooning Strategy; Current Morbidity for VPDs Discuss Indications, Recommendations, and Requirements; Review Adult Immunization Schedule and Routinely Recommended vaccines for Adolescents and Adults Vaccine Preventable Diseases and Vaccine Antigens Used to Prevent VPDs Overview of GRITS Challenges To Adult Vaccinations Recommended Vaccines for HCW VAERS/NVICP Resources Overview of topics to be discussed: Today’s topics will include: Status of licensure and review of new vaccines an overview of the adult immunization schedule some general vaccination guidelines the vaccines that are routinely recommended for adolescents and adults brief overview of vaccines indicated due to special circumstances: hepatitis A, meningitis, rabies, and certain vaccines for travel purposes a brief overview of the Georgia immunization registry, GRITS a few points about missed opportunities immunization resources

4 Why Do We Immunize? We Immunize To Prevent These Diseases

5 Herd Immunity Immunized individuals block infection from reaching those who are unimmunized
INFECTED INFECTED INFECTED It is probably unrealistic to believe we can immunize everyone appropriately. There will always be young infants who have not received all recommended vaccines because of age and there are a significant number of adults who are not adequately immunized. Herd immunity refers to a situation in which a high percentage of a population is immune to a disease, essentially stopping the disease in its tracks because it cannot find new hosts. The threshold for herd immunity varies, depending on the disease, with more virulent infectious agents requiring vaccination of a higher percentage of the population to create the desired herd immunity. Most vaccination policies are focused on creating herd immunity. The creation of herd immunity is especially important in crowded environments which facilitate the spread of disease, like schools. It is also extremely important to receive regular boosters, as some vaccines lose their efficacy over time, leaving people vulnerable to an outbreak. Herd immunity led to the eradication of smallpox, and it explains why diseases such as polio and diphtheria are rare in developed nations with established vaccination policies. = immunized

6 Cocooning Strategy An infant who is infected with Pertussis under 6 months of age can experience a devastating disease, frequently resulting in death, because the infant can not tolerate the severe inflammation of the respiratory tract. The primary series of DTaP is usually not completed until 6 months of age. Therefore, the best method to prevent the infant from infection with Pertussis is to eliminate exposure to the disease. This is accomplished by immunizing ALL caregivers with Tdap vaccine. This is called the “Cocooning Strategy”.

7 20th Century Peak & Current Morbidity for VPDs
Prevaccine (in peak year) 2011 % Reduction of Cases Diphtheria 30, 508 100 Measles 763,094 222 99.9 Mumps 212,932 404 99.8 Pertussis 265,269 18,719 92.9 Paralytic polio 63,302 Rubella 488,796 4 Tetanus 601 36 94.0 Hib, type b (age < 5 yrs) 20,000 (yearly average in 1980’s) 4, plus of unknown type >99.8 The 2nd column of this chart shows the number of cases in the peak year of the 20th century (prevaccine) for each of the VPDs listed in the 1st column. The 3rd column shows the number of cases reported in 2011. The last column shows the percentage of reduction in those disease cases after the introduction of vaccine. You can clearly see the impact vaccines have made, though we still have a ways to go with pertussis. Of the 222 measles cases in 2010, 142 were indigenous and 80 were imported In addition, it has been estimated that vaccination with 7 of the 12 routinely recommended childhood vaccines prevents an estimated 33,000 deaths and 14 million cases of disease in every birth cohort, saves $10 billion in direct costs in each birth cohort, and saves society an additional $33 billion in costs that include disability and lost productivity.* * Zhou F, Santoli J, Messonnier JL, et al. Economic evaluation of the 7-vaccine routine childhood immunization schedule in the United States, 2001, Archives of Pediatric & Adolescent Medicine, 2005;159(12): MMWR (Weekly), August 17, 2012, 61(32); 7

8 Indications Recommendations Requirements
Information about the appropriate use of the vaccine Recommendation ACIP statement that broadens and further delineates the Indication found in the package insert Basis for standards for best practice Requirement Mandate by a state that a particular vaccine must be administered and documented before entrance to child care and/or school EXAMPLES OF AN INDICATION ADACEL vaccine is indicated for active booster immunization for the prevention of tetanus, diphtheria and pertussis as a single dose in persons 11 through 64 years of age. BOOSTRIX® is indicated for active booster immunization against tetanus, diphtheria, and pertussis as a single dose in individuals 10 through 64 years of age. EXAMPLE OF A RECOMMENDATION Recommendations by ACIP for the routine administration of vaccines. May include other information and guidance on epidemiology of the disease, appropriate timing, dosage, contraindications to the vaccine and guidance for use in special populations. Appears first as “provisional recommendation” but once approved, appears in the MMWR as full recommendation EXAMPLE OF VACCINE REQUIREMENTS FOR ENTRY INTO CHILD CARE FACILITIES IN GEORGIA Consistent with the Recommended Childhood and Adolescent Immunization Schedule Children are required to be age appropriately immunized against each of these diseases: Hepatitis B, Diphtheria, Tetanus, Pertussis, Polio, Hib, Pneumococcus, Measles, Mumps, Rubella, Varicella, Hepatitis A 8

9 Adult Immunization Schedule
2013 Adult Immunization Schedule Figure Changes The bar for MMR vaccine was removed for persons born after 1957 to clarify that persons born after 1957 are considered immune and routine vaccination is not recommended. The bar for Td/ Tdap vaccine was changed to solid yellow to reflect a new recommendation that all persons including those 65 years and older are recommended to receive Tdap vaccination as a substitute for one dose of Td vaccine. A new bar for PCV13 vaccine was added. Footnote Changes Influenza vaccine – Footnote now uses the abbreviation IIV for inactivated influenza vaccine and drops the abbreviation TIV for trivalent inactivated vaccine (TIV). Tdap and Td vaccines - Footnote is updated to include the recommendation to vaccinate pregnant women with Tdap during each pregnancy, regardless of the interval since prior Td/Tdap vaccination. Varicella and HPV vaccines - Footnotes were simplified; no changes in recommendations were made. Additional information was added to the HPV footnote regarding vaccination and pregnancy. MMR vaccine - Footnote was modified to reflect the new recommendation that a provider diagnosis of measles, is no longer considered acceptable evidence of immunity to measles.  A provider diagnosis of mumps and rubella continue not to be acceptable evidence of immunity. Pneumococcal vaccines: Pneumococcal polysaccharide (PPSV23) vaccine and PPSV23 revaccination footnotes clarify that persons with certain medical conditions are recommended to receive 2 doses of PPSV23 before age 65 years and even those who receive 2 doses of PPSV23 before age 65 years are recommended to receive PPSV23 at age 65 years, as long as it has been 5 years since the most recent dose. Pneumococcal conjugate 13-valent (PCV13) vaccine - A new footnote was added for PCV13 vaccine. Also, language was added regarding the timing of PCV13 vaccine relative to PPSV23 for those persons recommended to be vaccinated with both pneumococcal vaccines. Hepatitis A vaccine - Footnote was updated to clarify that vaccination is recommended for persons with a history of noninjection illicit drug use in addition to those with injection drug use. Contraindications Table Changes The inactivated influenza vaccine precautions were updated to indicate that persons who experience only hives with exposure to eggs should receive IIV rather than LAIV. Pregnancy was removed as a precaution for hepatitis A vaccine. This is an inactivated vaccine, and similar to hepatitis B vaccines, is recommended if another high risk condition or other indication is present. Language was clarified regarding the precaution for use of antiviral medications and vaccination with varicella or zoster vaccines. Be sure to review the “Notes” section – many changes

10 2013 Footnote Changes Influenza vaccine –the abbreviation IIV for inactivated influenza vaccine and drops the abbreviation TIV for trivalent inactivated vaccine (TIV). Tdap and Td vaccines - is updated to include the recommendation to vaccinate pregnant women with Tdap during each pregnancy, regardless of the interval since prior Td/Tdap vaccination. MMR vaccine - Footnote was modified to reflect the new recommendation that a provider diagnosis of measles, is no longer considered acceptable evidence of immunity to measles.   Pneumococcal vaccines: Pneumococcal polysaccharide (PPSV23) vaccine and PPSV23 revaccination footnotes clarification. Pneumococcal conjugate 13-valent (PCV13) vaccine - A new footnote was added for PCV13 vaccine. Hepatitis A vaccine - Footnote was updated to clarify that vaccination is recommended for persons with a history of noninjection illicit drug use in addition to those with injection drug use. Footnote Changes Influenza vaccine – Footnote now uses the abbreviation IIV for inactivated influenza vaccine and drops the abbreviation TIV for trivalent inactivated vaccine (TIV). Tdap and Td vaccines - Footnote is updated to include the recommendation to vaccinate pregnant women with Tdap during each pregnancy, regardless of the interval since prior Td/Tdap vaccination. Varicella and HPV vaccines - Footnotes were simplified; no changes in recommendations were made. Additional information was added to the HPV footnote regarding vaccination and pregnancy. MMR vaccine - Footnote was modified to reflect the new recommendation that a provider diagnosis of measles, is no longer considered acceptable evidence of immunity to measles.  A provider diagnosis of mumps and rubella continue not to be acceptable evidence of immunity. Pneumococcal vaccines: Pneumococcal polysaccharide (PPSV23) vaccine and PPSV23 revaccination footnotes clarify that persons with certain medical conditions are recommended to receive 2 doses of PPSV23 before age 65 years and even those who receive 2 doses of PPSV23 before age 65 years are recommended to receive PPSV23 at age 65 years, as long as it has been 5 years since the most recent dose. Pneumococcal conjugate 13-valent (PCV13) vaccine - A new footnote was added for PCV13 vaccine. Also, language was added regarding the timing of PCV13 vaccine relative to PPSV23 for those persons recommended to be vaccinated with both pneumococcal vaccines. Hepatitis A vaccine - Footnote was updated to clarify that vaccination is recommended for persons with a history of noninjection illicit drug use in addition to those with injection drug use. Contraindications Table Changes The inactivated influenza vaccine precautions were updated to indicate that persons who experience only hives with exposure to eggs should receive IIV rather than LAIV. Pregnancy was removed as a precaution for hepatitis A vaccine. This is an inactivated vaccine, and similar to hepatitis B vaccines, is recommended if another high risk condition or other indication is present. Language was clarified regarding the precaution for use of antiviral medications and vaccination with varicella or zoster vaccines.

11 2013 Footnote Changes Contraindications Table Changes
The inactivated influenza vaccine precautions were updated to indicate that persons who experience only hives with exposure to eggs should receive IIV rather than LAIV. Pregnancy was removed as a precaution for hepatitis A vaccine. This is an inactivated vaccine, and similar to hepatitis B vaccines, is recommended if another high risk condition or other indication is present. Language was clarified regarding the precaution for use of antiviral medications and vaccination with varicella or zoster vaccines. Contraindications Table Changes The inactivated influenza vaccine precautions were updated to indicate that persons who experience only hives with exposure to eggs should receive IIV rather than LAIV. Pregnancy was removed as a precaution for hepatitis A vaccine. This is an inactivated vaccine, and similar to hepatitis B vaccines, is recommended if another high risk condition or other indication is present. Language was clarified regarding the precaution for use of antiviral medications and vaccination with varicella or zoster vaccines.

12 Recommended Adult Vaccines
Influenza Td/Tdap Varicella HPV Zoster MMR Pneumococcal Meningococcal Hepatitis A Hepatitis B List of the current Recommended Adult Immunizations. The 2013 Recommended Adult Immunization Schedule indicate the recommended age groups and medical indications for which administration of currently licensed vaccines is commonly indicated for adults ages 19 years and older. When reading the schedule, recommendations must be read with the footnotes that follow containing number of doses, intervals between doses, and other important information.

13 Burden of Seasonal Influenza
36,000 Flu related deaths each year in the US ~90% of deaths among persons age 65 and older October – November best time to receive flu vaccination Takes about 2 weeks to develop antibodies December to Spring not too late! Epidemics of influenza typically occur during the winter months and are responsible for an average of approximately 36,000 deaths per year in the US.* In the pandemic “Spanish flu” in there were an estimated 21 million deaths worldwide. Severe epidemics can cost $12 billion. Rates of infection are highest among children, but rates of serious illness and death are highest among persons ages 65 and older and persons of any age who have medical conditions that place them at increased risk for complications from influenza.* Influenza vaccine can prevent up to 70 percent of hospitalizations and 85 percent of flu related deaths in older adults. During most influenza seasons, 10-20% of the nation’s population is infected with this virus.

14 Seasonal Influenza Vaccine
Influenza Vaccine Strains for the A/California/7/2009 (H1N1)-like antigens A/Victoria/361/2011 (H3N2)-like virus B/Wisconsin/1/2010-like(Yamagata lineage) The H1N1 virus is the same, the H3N2 and B vaccine viruses are different from those in the influenza vaccine used in the U.S. Recommended for all people age 6 months and older. Vaccine Strains for the 2012–13 Influenza Season U.S. influenza vaccines for 2012–13 will contain A/California/7/2009 (H1N1)-like, A/Victoria/361/2011 (H3N2)-like, and B/Wisconsin/1/2010-like (Yamagata lineage) antigens. The influenza A(H3N2) and B antigens differ from the respective 2010–11 and 2011–12 seasonal vaccine antigens (3). The influenza A(H1N1) vaccine virus strain is derived from an influenza A(H1N1)pdm09 (2009[H1N1]) virus and was included in the 2009(H1N1) monovalent pandemic vaccine as well as the 2010–11 and 2011–12 seasonal vaccines. Recommendations for Vaccination Routine annual influenza vaccination is recommended for all persons aged ≥6 months. To permit time for production of protective antibody levels (4,5), vaccination optimally should occur before onset of influenza activity in the community. Therefore, vaccination providers should offer vaccination as soon as vaccine is available. Vaccination should be offered throughout the influenza season (i.e., as long as influenza viruses are circulating in the community). MMWR / August 17, 2012 / Vol. 61 / No. 32 14 14 14 14

15 Inactivated Influenza Vaccines (TIV)
Administer by Injection Fluzone® sanofi-pasteur - 6 months of age and older Agriflu ® Novartis - 18 yrs and older Fluzone® Intradermal – 18 – 64 years Fluzone® High-Dose- 65 years and older (4 times more antigen) Fluarix™ GSK - 3 years of age and older Fluvirin™ Novartis - 4 years of age and older Afluria® CSL – 9 years of age and older Flulaval™ GSK - 18 years of age and older Live, Attenuated Influenza Vaccine (LAIV) TABLE. Influenza vaccine information, by age group — United States, 2012–13 influenza season* Vaccine Trade name Manufacturer Presentation Mercury content (μg Hg per 0.5 mL dose) Ovalbumin content (μg per 0.5mL dose)† Age group No. of doses Route TIV Fluzone Sanofi Pasteur mL prefilled syringe —§ 6–35 mos 1 or 2¶ IM** 0.5 mL prefilled syringe —§ ≥36 mos 1 or 2¶ IM** 0.5 mL vial —§ ≥36 mos 1 or 2¶ IM** 5.0 mL multidose vial —§ ≥6 mos 1 or 2¶ IM** TIV Agriflu Novartis Vaccines 0.5 mL prefilled syringe 0 <0.4 ≥18 yrs 1 IM** TIV Fluvirin Novartis Vaccines 0.5 mL prefilled syringe ≤1 ≤1 ≥4 yrs 1 or 2¶ IM** 5.0 mL multidose vial ≤1 TIV Fluarix GlaxoSmithKline 0.5 mL prefilled syringe 0 ≤0.05 ≥3 yrs 1 or 2¶ IM** TIV FluLaval ID Biomedical Corporation of Quebec (distributed by GlaxoSmithKline) 5.0 mL multidose vial <25.0 ≤0.3 ≥18 yrs 1 IM** TIV Afluria CSL Biotherapies (distributed by Merck) 0.5 mL prefilled syringe ≤1 ≥9 yrs†† 1 IM** 5.0 mL multidose vial ≤1 TIV high- dose§§ Fluzone High-Dose Sanofi Pasteur 0.5 mL prefilled syringe —§ ≥65 yrs 1 IM** TIV intradermal¶¶ Fluzone Intradermal Sanofi Pasteur 0.1 mL prefilled microinjection system 0.0 (per 0.1 mL) —§ 18–64 yrs 1 ID LAIV FluMist*** MedImmune 0.2 mL prefilled intranasal sprayer 0.0 (per 0.2 mL) <0.24 (per 0.2mL)††† 2–49 yrs§§§ 1 or 2¶ IN Reference: Prevention and Control of Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices (ACIP), 2011 MMWR Early Release/Vol. 60 August 18, 2011 Administer by Nasal spray: MedImmune FluMist® - for healthy persons 2 through 49 years of age - not for pregnant women MMWR / August 17, 2012 / Vol. 61 / No. 32 15 15

16 How well does the flu shot work?
70%-90% effective among healthy persons younger than 65 years of age For persons older than 65 yrs 50%-60% effective in preventing hospitalization 80% effective in preventing death Statistics are for seasonal influenza vaccine.

17 Inactivated Influenza Vaccines and Egg Sensitivity
All influenza vaccine viruses for the season are grown in hen’s eggs Allergy to eggs must be distinguished from allergy to influenza vaccine Please refer to next slide for flow chart A previous severe allergic reaction to influenza vaccine, regardless of the component suspected to be responsible for the reaction, is a contraindication to future receipt of the vaccine.

18 FIGURE 2. Recommendations regarding influenza vaccination for persons who report allergy to eggs — Advisory Committee on Immunization Practices, United States, 2012–13 influenza season Influenza Vaccination of Persons with a History of Egg Allergy Severe allergic and anaphylactic reactions can occur in response to a number of influenza vaccine components, but such reactions are rare. All currently available influenza vaccines are prepared by means of inoculation of virus into chicken eggs. The use of influenza vaccines for persons with a history of egg allergy has been reviewed recently by ACIP (16). For the 2011–12 influenza season, ACIP recommended that persons with egg allergy who report only hives after egg exposure should receive TIV, with several additional safety measures, as described in this document. Recent examination of VAERS data indicated no disproportionate reporting of allergy or anaphylaxis after influenza vaccination during the 2011–12 season (21). For the 2012–13 influenza season, ACIP recommends the following: 1. Persons with a history of egg allergy who have experienced only hives after exposure to egg should receive influenza vaccine, with the following additional safety measures (Figure 2): a) Because studies published to date involved use of TIV, TIV rather than LAIV should be used (22); b) Vaccine should be administered by a health-care provider who is familiar with the potential manifestations of egg allergy; and c) Vaccine recipients should be observed for at least 30 minutes for signs of a reaction after administration of each vaccine dose (22). Other measures, such as dividing and administering the vaccine by a two-step approach and skin testing with vaccine, are not necessary (22). 2. Persons who report having had reactions to egg involving such symptoms as angioedema, respiratory distress, lightheadedness, or recurrent emesis; or who required epinephrine or another emergency medical intervention, particularly those that occurred immediately or within a short time (minutes to hours) after egg exposure, are more likely to have a serious systemic or anaphylactic reaction upon reexposure to egg proteins. Before receipt of vaccine, such persons should be referred to a physician with expertise in the management of allergic conditions for further risk assessment (Figure 2). 3. All vaccines should be administered in settings in which personnel and equipment for rapid recognition and treatment of anaphylaxis are available. ACIP recommends that all vaccination providers should be familiar with the office emergency plan (11). 4. Some persons who report allergy to egg might not be egg-allergic. Those who are able to eat lightly cooked egg (e.g., scrambled egg) without reaction are unlikely to be allergic. Egg-allergic persons might tolerate egg in baked products (e.g., bread or cake). Tolerance to egg-containing foods does not exclude the possibility of egg allergy (23). Egg allergy can be confirmed by a consistent medical history of adverse reactions to eggs and egg-containing foods, plus skin and/ or blood testing for immunoglobulin E antibodies to egg proteins. 5. A previous severe allergic reaction to influenza vaccine, regardless of the component suspected to be responsible for the reaction, is a contraindication to future receipt of the vaccine.

19 Frequently Asked Questions
Some of my patients refuse influenza vaccination because they insist they "got the flu" after receiving the injectable vaccine in the past. What can I tell them? How long does immunity from influenza last? In which month is it too late to receive influenza vaccine? My patient came in last February and asked for a “flu” shot. Should I have given it to her? Less than 1% of people who are vaccinated with the injectable vaccine develop flu-like symptoms. These side effects are not the same as having influenza, but people confuse the symptoms. Protective immunity doesn't develop until 1–2 weeks after vaccination. Vaccinees may develop influenza because they were exposed to someone with the virus before they became immune. It is not the result of the vaccination. The influenza vaccine is not 100% effective, especially in older persons. The vaccine is only 30%–40% effective in preventing illness among frail elderly persons (although among elderly persons, the vaccine is 50%–60% effective in preventing hospitalization and 80% effective in preventing death). To many people "the flu" is any illness with fever and cold symptoms. If they get any viral illness, they may blame it on the flu shot or think they got "the flu" despite being vaccinated. Influenza vaccine only protects against certain influenza viruses, not all viruses How long does immunity from influenza last? Protection from influenza vaccine is thought to persist for a year or less because of waning antibody and because of changes in the circulating influenza virus from year to year. In which month is it too late to receive influenza vaccine? Influenza vaccine can be administered whenever influenza is present in the community (generally through the end of MARCH). For maximum protection, flu vaccine should be administered during October and November, prior to the onset of influenza season. My patient came in last February and asked for a “flu” shot. Should I have given it to her? Yes. Influenza vaccine may be given at any time during the influenza season. Healthcare providers should continue to offer influenza vaccine to unvaccinated persons who desire it throughout the influenza season. Source: Ask the Experts: William Atkinson, MD, MPH of the Centers for Disease Control and Prevention provided the answers to these questions.

20 Can you get the flu from the flu shot???
NO!!! NO!!! NO!!! Flu vaccine in the shot is made from killed bits and pieces on influenza virus Some people get a little soreness or redness where they get the shot It goes away in a day or two Serious problems from the flu shot are very rare

21 I got the flu shot and still got the flu…
For healthy persons takes about 2 weeks after the shot before your body makes enough antibodies to be protected You are vulnerable to flu infection during this time Flu vaccination does not protect you from colds, sinus infections, and other respiratory illnesses that also circulate during flu season

22 ‘Flu Season’ Can begin as early as October and last through Spring
In GA, Flu usually peaks mid-February Best to get vaccinated before flu season starts December– March is Not Too Late to get a Flu Vaccination When to Get Vaccinated Against Seasonal Flu Yearly flu vaccination should begin in September, or as soon as vaccine is available, and continue throughout the flu season which can last as late as May. This is because the timing and duration of flu seasons vary. While flu season can begin early as October, most of the time seasonal flu activity peaks in January or later. Need to get vaccination as early as possible. About 2 weeks after vaccination, antibodies that provide protection against influenza virus infection develop in the body. But it’s not too late to get vaccinated in January or later since flu can linger into March or Spring.

23 Pneumococcal Disease Pneumococcal infection may cause pneumonia, bacteremia, meningitis and otitis media resulting in thousands of hospitalizations and deaths each year in the United States As many as 175,000 hospitalizations from pneumococcal pneumonia are estimated to occur annually in the United States. Common bacterial complication of influenza Invasive disease from Streptococcus pneumoniae (pneumococcus) is a major cause of illness and death in the United States, with an estimated 43,500 cases and 5,000 deaths among persons of all ages in 2009 (1). Updated Recommendations for Prevention of Invasive Pneumococcal Disease Among Adults Using the 23-Valent Pneumococcal Polysaccharide Vaccine (PPSV23) Weekly September 3, 2010 / 59(34); The next vaccine we will be discussing is Pneumococcal Polysaccharide Vaccine (PPSV23). Pneumococcal diseases are those such as pneumonia, meningitis, and bacteremia. Approximately half of these deaths potentially could be prevented through use of vaccine. * Pneumococcal pneumonia accounts for 10-25% of all pneumonias leading to hospitalization. *MMWR April 4, 1997/ Vol. 46/ No. RR-8 Pneumococcal pneumonia kills about 1 out of 20 people who get it. Bacteremia kills about 1 person in 5, and meningitis about 3 people in 10. How serious is pneumococcal disease in the U.S? Pneumococcal disease is a serious disease that causes much sickness and death. In fact, pneumococcal disease kills more people in the United States each year than all other vaccine-preventable diseases combined. Influenza predisposes individuals to bacterial community-acquired pneumonia.

24 Pneumococcal Polysaccharide Vaccine for Adults (PPSV23) – Part one
Recommended for all persons with the following: Age 65 years and older without history of PPSV23 vaccine Adults who smoke cigarettes Adults less than 65 years with: Chronic lung disease (including asthma) Chronic cardiovascular disease Chronic liver disease End stage renal disease, kidney failure, hemodialysis Diabetes mellitus Immunocompromising conditions Anatomic/functional a-splenia Alcoholism Cochlear implants Updated recommendations for administration of 23-valent pneumococcal polysaccharide vaccine (PPSV23) among adults aged ≥19 years — Advisory Committee on Immunization Practices (ACIP), United States • PPSV23 should be administered to adults aged 19–64 years with chronic or immunosuppressing medical conditions, including those who have asthma. • Adults aged 19–64 years who smoke cigarettes should receive PPSV23 and smoking cessation guidance. • All persons should be vaccinated with PPSV23 at age 65 years. Those who received PPSV23 before age 65 years for any indication should receive another dose of the vaccine at age 65 years or later if at least 5 years have passed since their previous dose. Those who receive PPSV23 at or after age 65 years should receive only a single dose. • ACIP does not recommend routine revaccination for most persons for whom PPSV23 is indicated. A second dose of PPSV23 is recommended 5 years after the first dose for persons aged 19–64 years with functional or anatomic asplenia and for persons with immunocompromising conditions. ACIP does not recommend multiple revaccinations because of uncertainty regarding clinical benefit and safety. Ref: Updated Recommendations for Prevention of Invasive Pneumococcal Disease Among Adults Using the 23-Valent Pneumococcal Polysaccharide Vaccine (PPSV23) MMWR 2010; 59(34); September 3, 2010 Ref: Recommended Adult Immunization Schedule – United States , 2012 MMWR Vol. 61/ No. 4/ February 3, 2012 On December 30, 2011 the FDA approved the use of Prevnar13 for adults 50 years and older The ACIP has not made a recommendation for the use of PVC13 in this older age group but had lengthy discussions at their October 2011 meeting. 24 24 24

25 Pneumococcal Polysaccharide Vaccine for Adults (PPSV23) – Part two
A one time revaccination 5 years after the first dose is recommended for those with: chronic renal failure functional/anatomic asplenia immunocompromising conditions Individuals who received PPSV23 before age 65 years should receive a second dose of vaccine at age 65 years or later if at least 5 years have passed since the previous dose. Updated recommendations for administration of 23-valent pneumococcal polysaccharide vaccine (PPSV23) among adults aged ≥19 years — Advisory Committee on Immunization Practices (ACIP), United States • PPSV23 should be administered to adults aged 19–64 years with chronic or immunosuppressing medical conditions, including those who have asthma. • Adults aged 19–64 years who smoke cigarettes should receive PPSV23 and smoking cessation guidance. • All persons should be vaccinated with PPSV23 at age 65 years. Those who received PPSV23 before age 65 years for any indication should receive another dose of the vaccine at age 65 years or later if at least 5 years have passed since their previous dose. Those who receive PPSV23 at or after age 65 years should receive only a single dose. • ACIP does not recommend routine revaccination for most persons for whom PPSV23 is indicated. A second dose of PPSV23 is recommended 5 years after the first dose for persons aged 19–64 years with functional or anatomic asplenia and for persons with immunocompromising conditions. ACIP does not recommend multiple revaccinations because of uncertainty regarding clinical benefit and safety. Ref: Updated Recommendations for Prevention of Invasive Pneumococcal Disease Among Adults Using the 23-Valent Pneumococcal Polysaccharide Vaccine (PPSV23) MMWR 2010; 59(34); September 3, 2010 Ref: Recommended Adult Immunization Schedule – United States , 2012 MMWR Vol. 61/ No. 4/ February 3, 2012 On December 30, 2011 the FDA approved the use of Prevnar13 for adults 50 years and older The ACIP has not made a recommendation for the use of PVC13 in this older age group but had lengthy discussions at their October 2011 meeting. 25 25 25

26 Pneumococcal Polysaccharide Vaccine (PPSV23)
My patient doesn’t have a record of receiving PPSV23, but she believes she may have had it in the past. What should I do? Persons with uncertain or unknown vaccination status should be vaccinated. If I give PPSV23 to my patient now, must I wait a month before giving influenza vaccine or Td or Tdap vaccine? Inactivated influenza vaccine and Td or Tdap may be given at the same time as or at any time before or after a dose of PPSV23. There are no minimum interval requirements between the doses of these or any other inactivated vaccines. A frequently asked question: My patient doesn’t have a record of receiving pneumococcal vaccine. What should I do? Providers should not withhold vaccination in the absence of an immunization record or with an incomplete record. The patient’s verbal history should be used to determine prior vaccination status. Persons with uncertain or unknown vaccination status should be vaccinated.* *Reference: NEEDLE TIPS, 5/05, Ask the Experts

27 Pneumococcal Conjugate Vaccine (PCV13)
NEW Pneumococcal Conjugate Vaccine (PCV13) Licensed for adults 50 years and older for: Prevention of pneumonia and invasive disease caused by Streptococcus pneumoniae serotypes 1, 3, 4, 5, 6A, 6B, 7F, 9V, 14, 18C, 19A, 19F and 23F. Indication is based on immune responses elicited by Prevnar 13. No controlled trials available in adults demonstrating a decrease in pneumococcal pneumonia or invasive disease after immunization. ACIP has made a recommendation for use of PCV13 in adults 19 years and older with immunocompromising conditions, functional or anatomic asplenia, CSF leaks or cochlear implants. In December 2011 the Food and Drug Administration approved PCV13 as a single dose for the prevention of pneumonia and invasive disease caused by vaccine serotypes of S. pneumoniae in persons 50 years of age and older. Licensure was  based on serological studies of PCV13 recipients. The effectiveness of PCV13 in preventing pneumonia and invasive disease in this age group has not yet been demonstrated in controlled clinical studies. ACIP has discussed this issue but as of February 2012 has not made a recommendation for use of PCV13 in persons 50 years and older. Underlying medical conditions that are indications for pneumococcal vaccination among children, by risk group Risk Group Condition Immunocompetent children Chronic heart disease*, Chronic lung disease† Diabetes mellitus, Cerebrospinal fluid leaks, Cochlear implant Children with functional or anatomic asplenia Sickle cell disease and other hemoglobinopathies Congenital or acquired asplenia, or splenic dysfunction Children with immunocompromising conditions HIV infection Chronic renal failure and nephrotic syndrome Diseases associated with treatment with immunosuppressive drugs or radiation therapy, including malignant neoplasms, leukemias, lymphomas, and HoHIV infection Diseases associated with treatment with immunosuppressive drugs or radiation therapy, including malignant neoplasms, leukemias, lymphomas, and Hodgkin disease; or solid organ transplantation Congenital immunodeficiency§dgkin disease; or solid organ transplantation Congenital immunodeficiency§ MMWR Vol. 61/No. 21 June 1, 2012 *Particularly cyanotic congenital heart disease and cardiac failure. † Including asthma if treated with prolonged high-dose oral corticosteroids. § Includes B- (humoral) or T-lymphocyte deficiency; complement deficiencies, particularly C1, C2, C3, and C4 deficiency; and phagocytic disorders (excluding chronic granulomatous disease). 27 27 27

28 Advantages of Conjugate Vaccines
Property Polysaccharide Conjugate B-cell-dependent immune response Yes Yes T-cell-dependent immune response No Yes Immune memory No Yes Lack of hyporesponsiveness No Yes Booster effect No Yes Long-term protection No Yes Reduction of carriage No Yes Herd immunity No Yes This slides displays the advantage of conjugate vaccines. Previously characterized conjugate vaccines (ie, Haemophilus influenzae type b (Hib) conjugate, pneumococcal conjugate, and meningococcal serogroup-C conjugate) differ from polysaccharide vaccines because they contain capsular polysaccharides covalently linked to bacterial toxoids. As a result, the immune response induced by these conjugate vaccines utilizes T-cells and B-cells, while the response induced by polysaccharide vaccines utilizes only B-cells. The involvement of T-cells has a number of advantages. For instance, conjugate vaccines induce immunologic memory and booster effects. Conjugate vaccines have also been shown to induce immune responses of long duration, reduce nasopharyngeal carriage, and provide herd immunity. Reference: Granoff DM, Feavers IM, Borrow R. Meningococcal Vaccines. In: Plotkin SA, ed. Vaccines. 4th ed. Philadelphia, PA: WB Saunders Co; 2003: Granoff DM, et al. In: Vaccines. 2004: 959.

29 Adult Recommendations for Tetanus, Diphtheria, and Pertussis vaccine (Tdap)
A single dose of Tdap is recommended for All adults aged 19 years and older who have not yet received a dose of Tdap Td should be administered: As a booster dose every 10 years for persons who have already received 1 dose of Tdap Updated Recommendations for Use of Tetanus Toxoid, Reduced Diphtheria Toxoid, and Acellular Pertussis (Tdap) Vaccine in Adults Aged 65 Years and Older — Advisory Committee on Immunization Practices (ACIP), 2012 In February 2012, ACIP recommended Tdap for all adults aged 65 years and older. This recommendation supersedes previous Tdap recommendations regarding adults aged 65 years and older. Tdap use in adults. ACIP recommends that all adults aged 19 years and older who have not yet received a dose of Tdap should receive a single dose. Tdap should be administered regardless of interval since last tetanus or diphtheria toxoid-containing vaccine. After receipt of Tdap, persons should continue to receive Td for routine booster immunization against tetanus and diphtheria, according to previously published guidelines (1,2). Currently, Tdap is recommended only for a single dose across all age groups.

30 Updated Recommendations for Use of (Tdap) Vaccine
Use Tdap regardless of interval since the last tetanus- or diphtheria-toxoid containing vaccine Use Tdap in under-vaccinated children aged 7 through 10 years. On October 27, 2010, ACIP approved the following additional recommendations: use of Tdap regardless of interval since the last tetanus- or diphtheria-toxoid containing vaccine- Guidance for use. ACIP recommends that pertussis vaccination, when indicated, should not be delayed and that Tdap should be administered regardless of interval since the last tetanus or diphtheria toxoid-containing vaccine. ACIP concluded that while longer intervals between Td and Tdap vaccination could decrease the occurrence of local reactions, the benefits of protection against pertussis outweigh the potential risk for adverse events. use of Tdap in undervaccinated children aged 7 through 10 years. Guidance for use. ACIP recommends that children aged 7 through 10 years who are not fully vaccinated* against pertussis and for whom no contraindication to pertussis vaccine exists should receive a single dose of Tdap to provide protection against pertussis. If additional doses of tetanus and diphtheria toxoid--containing vaccines are needed, then children aged 7 through 10 years should be vaccinated according to catch-up guidance, with Tdap preferred as the first dose

31 Tdap and Pregnancy June 2011 ACIP votes to recommend Tdap for women > 20 weeks pregnant Pertussis is a highly contagious respiratory tract infection.  Although most children are protected against pertussis by vaccination during childhood, immunity wanes over time and leaves adolescents and adults unprotected. Incidence increasing Updated Recommendations for Use of Tetanus Toxoid, Reduced Diphtheria Toxoid and Acellular Pertussis Vaccine (Tdap) in Pregnant Women and Persons Who Have or Anticipate Having Close Contact with an Infant Aged <12 Months --- Advisory Committee on Immunization Practices (ACIP), 2011 The model showed that Tdap vaccination during pregnancy would prevent more infant cases, hospitalizations, and deaths compared with the postpartum dose for two reasons: 1) vaccination during pregnancy benefits the mother and infant by providing earlier protection to the mother, thereby protecting the infant at birth; and 2) vaccination during late pregnancy maximizes transfer of maternal antibodies to the infant, likely providing direct protection to the infant for a period after birth. From a safety perspective, ACIP concluded that administration of Tdap after 20 weeks' gestation is preferred to minimize the risk for any low-frequency adverse event and the possibility that any spurious association might appear causative.

32 Tdap and Pregnancy On October 24, 2012, the ACIP voted to recommend tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine (Tdap) for pregnant women with every pregnancy irrespective of previous Tdap history. Updated recommendation ACIP recommends that providers of prenatal care implement a Tdap immunization program for all pregnant women. Health-care personnel should administer a dose of Tdap during each pregnancy irrespective of the patient’s prior history of receiving Tdap. Guidance on use To maximize the maternal antibody response and passive antibody transfer to the infant, optimal timing for Tdap administration is between 27 and 36 weeks gestation. For women not previously vaccinated with Tdap, if Tdap is not administered during pregnancy, Tdap should be administered immediately postpartum.

33 Use of Tdap in Special Situations
Wound management---1 time dose Tdap History of Pertussis---1 time dose Adults ≥65 years of age---1 time dose For use in wound management---1 time dose Tdap Even if the person has a history of pertussis disease---1 time dose If the person has an unknown/incomplete history of having had a DTaP/Td series: 3 dose primary series with 1 dose as Tdap Adults ≥65 years of age Adults 65 years of age and older who has not had a dose of pertussis containing vaccine Pregnancy/Postpartum: Pregnancy is not a contraindication for Tdap or Td Pregnant women due for tetanus booster. If a tetanus and diphtheria booster vaccination is indicated during pregnancy for a woman who has previously not received Tdap (i.e., more than 10 years since previous Td), then Tdap should be administered during pregnancy, preferably during the third or late second trimester (after 20 weeks' gestation). Wound management for pregnant women. As part of standard wound management care to prevent tetanus, a tetanus toxoid--containing vaccine might be recommended for wound management in a pregnant woman if 5 years or more have elapsed since last receiving Td. If a tetanus booster is indicated for a pregnant woman who previously has not received Tdap, Tdap should be administered. Pregnant women with unknown or incomplete tetanus vaccination. To ensure protection against maternal and neonatal tetanus, pregnant women who have never been vaccinated against tetanus should receive three vaccinations containing tetanus and reduced diphtheria toxoids. The recommended schedule is 0, 4 weeks, and 6 to 12 months. Tdap should replace 1 dose of Td, preferably during the third or late second trimester (after 20 weeks' gestation) of pregnancy.

34 Hepatitis B The woman shown in this slide has severe ascites due to liver damage caused by hepatitis B. Hepatitis B (she is not pregnant) can be prevented by Hepatitis B vaccine, the first vaccine listed on the schedule. When administering Hepatitis B vaccine, it is important that you assess the mother’s hepatitis B surface antigen status so you will know how aggressively to administer the vaccine to the infant and also if you will need to do follow up testing on the infant. All the General Recommendations might apply here except #3 & 4 that deal with live virus vaccines. But of particular importance is #8, because hepatitis B vaccine MUST be administered IM. Data has shown that vaccine efficacy is compromised by administration in the gluteus or by subcutaneous administration. Optional information about Hepatitis B disease: Hepatitis B is a viral disease that attacks the liver and cause severe illness and on going liver damage and/or cancer. It is now the most prevalent form of acute viral hepatitis in the US. It is spread by contact with infected body fluids or blood. Examples of methods of transmission include the following: Using unsterilized needles Sexual contact with a person who has hepatitis B Sharing toothbrushes, razors, or washcloths Babies can be infected during childbirth if the mom is infected Babies and young children can be infected if the infected person pre-chews baby food. Over half of the people who get hepatitis B have no symptoms. For people who do get symptoms, they might include: Loss of appetite, nausea or vomiting Weakness and tiredness Fever and headaches Yellow skin and eyes Being immunized against Hepatitis B is also a requirement for attendance in child care and entry to school in GA.

35 Vaccine Recommendations
Hepatitis B Transmission: 1. Percutaneous or mucosal exposure to blood or body fluids including contaminated surfaces 2. Perinatal infection from HbSAg + mother. Vaccine Recommendations All adolescents less than 19 years of age should receive the hepatitis B vaccine series. All adults at risk for hepatitis B infection, including those aged through 59 years with diabetes mellitus. All adults seeking protection from HBV infection should be vaccinated according to recommended adult schedule. Incubation period from time of infection to onset of symptoms is 45 to 160 days (average, 90 days) Approximately 10% of acute hepatitis B infections progress to chronic Hepatitis B infection. 90% of infants and 30-50% of children 1-5 years of age with acute hepatitis B infection become carriers Many with chronic infection are asymptomatic. Chronic infection may progress to cirrhosis, liver failure & hepatocellular carcinoma The ACIP recommends Hepatitis B vaccine for unvaccinated adults with diabetes mellitus ages 19 through 59 years. Hepatitis B vaccine may be administered to those age 60 years and older at the discretion of the treating clinician. (MMWR/December 23, 2011/Vol.60/No. 50) All pregnant women should be tested routinely for HbsAg 90% of healthy adults & 95% of infants, children & adolescents develop adequate antibody response after a complete series If no antibody response after 6 doses, person is a non-responder and is susceptible to hepatitis B Booster doses NOT recommended for any age group References: 1. A Comprehensive Immunization Strategy to Eliminate Transmission of Hepatitis B Virus Infection in the United States Recommendations of the Advisory Committee on Immunization Practices (ACIP) Part 1: Immunization of Infants, Children and Adolescents MMWR Vol. 54/ No. RR-16 December 23, 2005 2. A Comprehensive Immunization Strategy to Eliminate Transmission of Hepatitis B Virus Infection in the United States 3. Recommendations of the Advisory Committee on Immunization Practices (ACIP) Part 2: Immunization of Adults MMWR Vol. 55/ No. RR-16 December 8, 2006 35 35

36 Every person being evaluated or treated for an STD, who is not already vaccinated, should receive hepatitis b vaccination

37 Hep B Vaccine Recommendations
All Adolescents Adults with at risk conditions: Household contacts and sexual partners of persons with acute and chronic infections Users of street injectable drugs More than one sex partner in 6 months Hemodialysis patients Health care and Public Safety workers Certain international travelers Inmates Clients and staff of institutions for the developmentally disabled All Adolescents--this is due to the virus transmission possibilities inherent in such activities as body piercing, tattoos, sports, and unprotected sex. Adolescents Routine hepatitis B vaccination is recommended for all children and adolescents through age 18 years. All children not previously vaccinated with hepatitis B vaccine should be vaccinated at 11 or 12 years of age with the age-appropriate dose of vaccine. Adults with at risk conditions: Household contacts and sexual partners of persons with acute and chronic infections Users of street injectable drugs More than one sex partner in 6 months Hemodialysis patients Health care and Public Safety workers exposed to blood Certain international travelers Inmates Clients and staff of institutions for the developmentally disabled Notice that persons infected with hepatitis C are NOT routinely recommended to receive hepatitis B vaccination

38 New Hepatitis B Vaccine Recommendations 2011
Hepatitis B vaccination should be administered to unvaccinated adults with diabetes mellitus who are aged 19 through 59 yrs Hepatitis B vaccination may be administered at the discretion of the treating clinician to unvaccinated adults with diabetes mellitus who are aged >60 yrs ACIP Recommendations On the basis of available information about HBV risk, morbidity and mortality, available vaccines, age at diagnosis of diabetes, and cost-effectiveness, ACIP recommends the following: Hepatitis B vaccination should be administered to unvaccinated adults with diabetes mellitus who are aged 19 through 59 years (recommendation category A; evidence type 2). Hepatitis B vaccination may be administered at the discretion of the treating clinician to unvaccinated adults with diabetes mellitus who are aged ≥60 years (recommendation category B; evidence type 2).

39 Management of Non-responders
Complete a second series of three doses Make sure using appropriate needle length. ACIP recommends 1-1½ inches for IM injections Should be given on the usual schedule of 0, 1 and 6 months Retest 1 to 2 months after completing the second series If test results are neg. for antibody after 2nd series, test for hepatitis B surface antigen Complete a second series of three doses Make sure using appropriate needle length. ACIP recommends 1-1½ inches for IM injections Should be given on the usual schedule of 0, 1 and 6 months Retest 1 to 2 months after completing the second series If test results are negative for antibody after the 2nd vaccine series, test for hepatitis B surface antigen, as the person could have infection. Less than 5% of those vaccinated do not develop antibodies after 6 valid doses. They may be a non responder. If the susceptible person is exposed to hepatitis B infection, follow the treatment algorithm for a non responder and give post exposure prophylaxis.* *Reference: Epidemiology and Prevention of Vaccine-Preventable Diseases, 10th edition, pg

40 Currently Licensed SINGLE ANTIGEN Hepatitis B Vaccines
Age Group Number of Doses Dose/ Volume Engerix B Pediatric Formulation (GLAXO-SmithKline) 0 through 19 yrs 3 10 mcg/ 0.5 ml Adult Formulation 20 years & older 20 mcg/ 1.0 ml Recombivax HB (Merck & Co) 5mcg/ 10mcg/ 11 through 15 years 2 Adult Formultion This slide demonstrates the recommended dosages for licensed single antigen hepatitis B vaccines. It is significant to note that the schedule for hepatitis B vaccine is flexible and varies. The vaccines are interchangeable, but it is especially important to use the vaccine that is appropriate for the client’s age. Note that Engerix B, pediatric formulation may only be used for persons age 0-19 years. RecombivaxHB pediatric formulation may be used for persons 20 years of age and older if you double the dose (1ml instead of 0.5ml) Also note that the alternate 2 dose schedule of the adult Recombivax HB for use with year olds is included. Consult the ACIP statement on hepatitis B (12/06), AAP’s 2009 Red Book, the Pink Book, or the package insert for more specific details.

41 Measles, Mumps, & Rubella
Highly contagious viral diseases Respiratory transmission Most cases imported from outside the U.S. Congenital Rubella Syndrome Required for college entrance Measles is a highly contagious viral illness that infected almost all children in the prevaccination era. Approximately 30% of reported measles cases have one of more complications. These are more common in children under 5 and adults over 20. Mumps is also a viral illness that can affect multiple body tissues. Parotitis, the most common manifestation, occurs in only 30-40% of cases. Rubella is another viral illness but symptoms are often mild and 30-50% of cases may be subclinical. The most dangerous aspect of this illness is manifested as congenital rubella syndrome.This refers to the miscarriages, stillbirths, and fetal anomalies that can result when rubella infection occurs during early pregnancy, especially during the first trimester. Since the infections obviously don’t affect just children, adults too should make sure they are protected from these diseases. One opportunity to make sure adolescents are protected before moving into adulthood, is to give a second dose of MMR vaccine. This has been a school requirement for 6th graders since 1994, but in 2000 the second dose was required for school entrance, at any age. In addition, colleges and technical schools now require proof of immunity to measles, mumps, and rubella.

42 Measles, Mumps, & Rubella Vaccine Recommendations
Measles, Mumps, & Rubella vaccines are usually given as the combination MMR vaccine 0.5 mL given subcutaneously First dose should be given after 1st birthday If two doses are needed, doses should be administered at least 28 days apart Egg Allergy is NOT a contraindication! Measles, Mumps, & Rubella vaccines are usually given as the combination MMR vaccine 0.5 mL given subcutaneously First dose should be given after 1st birthday If two doses are needed, doses should be administered at least 28 days apart

43 Measles, Mumps, and Rubella Vaccine Recommendations
Adults born in 1957 or later, if not previously vaccinated, need one dose All women of child bearing age who do not have evidence of rubella immunity need one dose -- Advise to avoid getting pregnant for 28 days after receiving MMR High Risk groups needing 2 doses: exposed persons; those vaccinated with killed or unknown type of vaccine; health care workers; students; and international travelers Adults born in 1957 or later, if not previously vaccinated need one dose. All women of child bearing age who do not have evidence of rubella immunity need one dose. Women should be advised to avoid getting pregnant for 28 days after receiving MMR vaccine. High Risk groups needing a 2nd dose of MMR: adults recently exposed to measles or in an outbreak setting; those previously vaccinated with killed measles vaccine; those vaccinated with an unknown type of measles vaccine during ; health care workers; college students; and international travelers.

44 Evidence of Immunity ACIP Provisional Recommendations Prevention of Measles, Rubella, Congenital Rubella Syndrome (CRS), and Mumps Date of ACIP vote: October 24, 2012 Date of posting of provisional recommendations: December 6, 2012 On October 24, 2012, the ACIP voted to approve revised recommendations for prevention of measles, rubella, congenital rubella syndrome (CRS), and mumps. These recommendations update the previous ACIP statement: Measles, Mumps, and Rubella – Vaccine Use and Strategies for Elimination of Measles, Rubella, and Congenital Rubella Syndrome and Control of Mumps: Recommendations of the Advisory Committee on Immunization Practices (ACIP, 1998). Additional revisions to the 1998 ACIP recommendations previously have been adopted regarding: the interval for avoiding pregnancy after receiving rubella-containing vaccines (ACIP, 2001), adequate mumps vaccination for school-aged children and adults at high risk (ACIP, 2006), and evidence of immunity for health-care personnel (HCP) (ACIP, 2011). A summary of the recommendations approved on October 24, 2012 is as follows: 1. Adequate presumptive evidence of immunity to measles, rubella, and mumps for routine vaccination, for students at post-high school educational institutions, and for international travelers: *May vary depending on current state or local requirements. §The first dose of MMR vaccine should be administered on or after age 12 months; the second dose of measles- or mumps-containing vaccine should be administered no earlier than 28 days after the first dose. ¶ Measles, rubella, or mumps immunoglobulin (IgG) in serum; equivocal results should be considered negative. ††Children who receive a dose of MMR vaccine before age 12 months should be revaccinated with 2 doses of MMR vaccine, the first of which should be administered when the child is aged 12–15 months (12 months if the child remains in a high-risk area) and the second at least 28 days later. §§Women of childbearing age are adolescent girls and premenopausal adult women. Because rubella can occur in some persons born before 1957 and because congenital rubella and congenital rubella syndrome can occur in the offspring of women infected with rubella virus during pregnancy, birth before 1957 is not acceptable evidence of rubella immunity for women who could become pregnant. ¶¶Adults at high risk include students in post-high school educational institutions, health-care personnel, and international travelers.

45 Recommendations for Public Health Employees
Document immune status of each employee for all vaccine preventable diseases Strongly encourage employees born prior to 1957 who lack evidence of immunity to mumps to be vaccinated with two doses of MMR vaccine. On June 24, 2009 the ACIP voted on revised recommendations for measles-mumps-rubella (MMR) ‘evidence of immunity’ requirements for healthcare personnel∗. The Healthcare Infection Control Practices Advisory Committee (HICPAC) has endorsed these changes. Adequate presumptive evidence of immunity to measles, rubella, and mumps for persons who work in health care facilities: Measles: a. Documented administration of two doses of live measles virus vaccine or b. Laboratory evidence of immunity or laboratory confirmation of disease or c. Born before 1957 Rubella a. Documented administration of one dose of live rubella virus vaccine or c. Born before 1957 (except women of childbearing age who could become pregnant) Mumps a. Documented administration of two doses of live mumps virus vaccine or Our recommendation for your PH staff is to know the immune status of your employees for any of the VPDs.

46 Spacing of Live Virus Vaccines and Other Products
PPD and live virus vaccine Apply PPD at same visit as MMR If MMR given first, delay PPD 4 weeks or longer Apply PPD first, then give MMR when skin test read Spacing with antibody-containing products such as immune globulin (IG) PPD and live virus vaccine (using MMR as an example) Apply PPD at same visit as MMR Delay PPD 4 weeks or longer if MMR given first Apply PPD first then give MMR when skin test read This spacing will reduce the possibility of a false negative interpretation of the skin test. Spacing with antibody-containing products such as immune globulin (IG) ---Antibody containing products (for example immune globulin) interact less with inactivated vaccines than with live vaccines. Administering inactivated vaccines either simultaneously or at any time interval before or after receiving an antibody containing product should not impair the immune response. The vaccine and antibody product should be administered at different sites using the standard recommended dose. ---Recommended intervals between receipt of various blood products and measles-containing vaccine and varicella vaccine are listed in Table 4 of the ACIP’s General recommendations on Immunization dated Feb. 8, If a dose of live virus vaccine is administered shorter than the recommended interval in Table 4, the vaccine dose should be repeated. Source: ACIP General Recommendations on Immunization pages Feb. 8, 2002.

47 Varicella Virus is a member of the herpes group
Primary infection results in chickenpox Recurrent infection results in shingles Risk of death due to complications from chickenpox is 25 times greater for adults than children Virus is a member of the herpes group. Primary infection results in chickenpox. Recurrent infection results in shingles. Risk of death due to complications from chickenpox is 25 times greater for adults than children. Documented impact of vaccine: Disease burden decreased by 90% Hospitalizations decreased by 88%

48 The Recommended Schedule For Varicella Vaccine
Varicella vaccination is also recommended in these situations: A 2nd dose catch-up is recommended for all children, adolescents and adults who have had 1 dose. Some HIV-infected children should receive 2 doses of single antigen varicella vaccine spaced at least 3 months apart. Do not use MMRV. Postpartum vaccination of 2 doses for women whose prenatal assessment indicated susceptibility During outbreak, 2nd dose should be given to those who have received only 1 dose, provided the minimal interval has elapsed. At the June, 2006 ACIP meeting, the ACIP approved and recommended 2 doses of varicella vaccine and these recommendations are now included in the GIP manual as follows: Dose 1                                    12 months - 15 months Dose 2                                    years Additionally, varicella vaccination is recommended in following situations: A catch up dose for all children, adolescents, and adults who previously had received one dose. (The varicella footnote #3 has language added to clarify that adults who previously received only 1 dose of vaccine should receive a second dose). Doses administered between ages 12 months and 12 years should be given at least 3 months apart. At age 13 or later, the minimum interval between doses is 1 month. HIV infected children– those in CDC clinical class N, A, B or with CD4+ T- lymphocyte counts of 15 % or greater and without evidence of varicella immunity should receive 2 doses of single antigen vaccine at minimum interval of 3 months. Do not use MMRV for this purpose (15 times higher concentration of varicella than single antigen) Prenatal assessment and postpartum vaccination Women should be assessed prenatally for evidence of varicella immunity. At completion of the pregnancy, women with no evidence of immunity, should then receive the 1st dose of the 2 dose series before being discharged from the healthcare facility, and then the 2nd dose 4-8 wks. later. Recommended for post exposure vaccination. If given within 72 hrs. after exposure, it has been found to be % effective in preventing development of disease.

49 Evidence of Varicella Immunity
Documentation of age-appropriate vaccination: Preschool-aged children > 12 months: 1 dose School-aged children, adolescents and adults: 2 doses Laboratory evidence of immunity or laboratory confirmation of disease Born in US before 1980 A healthcare provider diagnosis of varicella or healthcare provider verification of history of varicella disease. For mild or atypical case: Assessment by physician is recommended to determine: Epidemiological link to typical case Laboratory evidence of immunity if titer done at time of disease History of herpes zoster based on healthcare provider diagnosis Documentation of age-appropriate vaccination: Preschool-aged children > 12 months: 1 dose School-aged children, adolescents and adults: 2 doses Laboratory evidence of immunity or laboratory confirmation of disease Born in US before 1980 EXCEPT for: Healthcare personnel Immunocompromised persons Pregnant women A healthcare provider diagnosis of varicella or healthcare provider verification of history of varicella disease. For mild or atypical case: Assessment by physician is recommended to determine: Epidemiological link to typical case Laboratory evidence of immunity if titer done at time of disease History of herpes zoster based on healthcare provider diagnosis

50 Shingles is caused by reactivation of varicella zoster
Herpes Zoster “Shingles” These are images of different ways shingles can appear. It usually appears on one side of the face or body and last 7-10 days. The main symptom is pain but other symptoms can include fever, headache, chills, and upset stomach. For about 1 person in 5, the severe pain can continue, even after the rash has cleared up. This is called post-herpetic neuralgia. It does not happen commonly but a person who has never had chickenpox, could get chickenpox from contact with a person with shingles. Shingles can occur in anyone with a previous history of chickenpox, but is much more common in persons age 60 and older. Shingles is caused by reactivation of varicella zoster

51 Herpes Zoster (Shingles) vaccine
Zostavax™ One dose recommended for adults 60 years and older, including those who have experienced previous episodes of shingles On March 24, 2011 FDA approved Zostavax for use in ages 50-59 years(ACIP has not made a recommendation for this age group) Burden of Shingles Varicella zoster remains dormant in anyone who has had chickenpox Virus reactivates and travels pathway along nerves to skin Results in skin rash/blisters and pain due to inflamed nerves Shingles vaccine licensed in May 2006 in for adults 60 and older. This past April (2011) licensed for adults 50 and older. Manufactured by Merck Single dose administered SC Licensed for person 50 yrs of age and older (ACIP has not made a recommendation for this age group.) Burden of Shingles Varicella zoster remains dormant in anyone who has had chickenpox Virus reactivates and travels pathway along nerves to skin Results in skin rash/blisters and pain due to inflamed nerves Zostavax® from Merck, licensed for use in persons age 60 and older to prevent shingles . Burden of Shingles Vaccine not indicated for treatment of shingles or PHN (post herpetic neuralgia) Single unit dose given subQ Contraindications: History of anaphylactic reaction to gelatin, neomycin, or other vaccine components. Immunosuppression, including that due to high-dose corticosteroid or other therapy Presence of active, untreated tuberculosis Anyone who is or may be pregnant Precautions: Acute illness with fever > F. Transmission of vaccine virus from a vaccinated person to susceptible individuals was not reported in vaccine trials, so risk of this type of transmission is theoretical. Vaccine uses the same antigen preparation as varicella vaccine but at a much stronger concentration, so Zostavax is not a substitute for varicella vaccination---do not give to anyone, especially children, in lieu of varicella vaccine Use in persons with previous history of zoster has not been studied. ACIP recommendations for Zoster Vaccine: *Ref: Epidemiology and Prevention of Vaccine-Preventable Diseases. 12th Edition, May 2011.

52 Vaccines for Special Circumstances
Hepatitis A Meningococcal Rabies HPV Travel These vaccines have valid indications and recommendations under certain circumstances, but only some of them are supplied by the state.

53 Hepatitis A Now let’s look at hepatitis A vaccine .
The persons on this slide have hepatitis A . Note the jaundice of the skin and the sclera of the eye. This vaccine is now routinely recommended for all children ages months. Optional information: The nature of hepatitis A disease is that it is cyclical. It is spread by fecal/oral transmission. Children plan an important role in HAV transmission. Symptomatic infection is uncommon in children, so they may be a source of infection for household or other close contacts. Almost half of persons with hepatitis A do not have an identified source of their infection. Groups of persons at risk for hepatitis A are international travelers, men who have sex with men, and illegal drug users. Food handlers are not at risk.

54 Hepatitis A Vaccine Recommendations
International travelers Close contact with an adoptee from a country of high or intermediate endemicity Men who have sex with men Persons who use illegal drugs Persons who have a clotting factor disorder Persons with occupational risk Persons with chronic liver disease AcIP recommends that Persons at Increased Risk for Hepatitis A or Severe Outcomes of Infection be Identified and vaccinated.

55 Hepatitis A Vaccine International Travel
The first dose of hepatitis A vaccine should be administered as soon as travel is considered For healthy persons 40 years of age or younger: 1 dose of single-antigen vaccine administered at any time before departure Persons at risk of severe disease from hepatitis A virus planning to travel in 2 weeks or sooner should receive the first dose of vaccine and also can be administered immune globulin Hepatitis A vaccine should be strongly considered for persons 1 year of age and older who are traveling to or working in countries where they would have a high or intermediate risk of hepatitis A virus infection. These areas include all areas of the world except Canada, Western Europe and Scandinavia, Japan, New Zealand, and Australia. The first dose of hepatitis A vaccine should be administered as soon as travel is considered. For healthy persons 40 years of age or younger, 1 dose of single antigen vaccine administered at any time before departure can provide adequate protection.

56 Hepatitis A Post-Exposure Prophylaxis
In 2007, ACIP recommended that people age years recently exposed to HAV, who have not received hepatitis A vaccine previously, should receive hepatitis A vaccine as a preference to receipt of immune globulin. The vaccine should be given as soon as possible after exposure to hepatitis A, but within 14 days of exposure. Reference: Update: Prevention of Hepatitis A After Exposure to Hepatitis A Virus and in International Travelers. Updated Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Vol. 56/No. 41 October 19, p

57 Hepatitis A Vaccine Formerly, the most common type of hepatitis reported in the US Transmitted through fecal-oral route with viral replication in the liver Common modes of infection Person-to-person Contaminated food or water Formerly, the most common type of hepatitis reported in the US. That is now hepatitis B. Together with hepatitis B it infects more than 200,000 Americans each year. It is transmitted through the fecal-oral route with viral replication in the liver. The virus is transmitted from person-to-person between household contacts or sex partners Common-source epidemics may come from contaminated food or water. This is facilitated by poor personal hygiene and poor sanitation. Sharing utensils, cigarettes, or kissing are not believed to transmit the virus. HAV infection is acquired primarily by the fecal-oral route by either person-to-person contact or ingestion of contaminated food or water. because the virus is present in blood during the illness prodrome, HAV has been trans-mitted on rare occasions by transfusion. although HAV may be present in saliva, transmission by saliva has not been demonstrated. waterborne outbreaks are infrequent and are usually associated with sewage-contaminated or inadequately treated water.

58 Hepatitis A Vaccine Recommendations
Persons who travel to high risk areas outside the US People with high risk conditions Clotting disorders Street drug use Men who have sex with men People with chronic liver disease including Hep B & C Persons who live in communities with high rates of Hepatitis A In certain circumstances, the vaccine can now be used for post-exposure prophylaxis instead of IG for persons 12 months-40 years of age. Travel: Basically all countries except Western Europe and Scandinavia, New Zealand, Australia, Canada and Japan. People with high risk conditions include: --people with clotting disorders --street drug users --men who have sex with men --people with chronic liver disease, including those with chronic hepatitis B or C Additional consideration for vaccination may be given to people who work with hepatitis A in experimental lab settings and food handlers when health authorities or private employers determine vaccination to be cost effective. ACIP has recommended that routine vaccination be considered for states, counties or communities where the average annual incidence of hepatitis A during was 10 cases per 100,000 population or more, but less than 20 cases per 100,000 population.* The state supplies vaccine for certain high risk populations. In certain circumstances, the vaccine can now be used for post-exposure prophylaxis instead of IG for persons 12 months-40 years of age. *Reference: Epidemiology and Prevention of Vaccine-Preventable Diseases, 10th edition, pg.203.

59 Single Antigen Hepatitis A Vaccine Schedule
Hepatitis A series 2 doses 6 months minimum interval between doses Adults (19 years and older) 1 dose mL given IM Booster dose 6-12 months after 1st dose Children and Adolescents (12 months through 18 years) 1 dose mL given IM Havrix® and Vaqta® Both brands are interchangeable Let’s look briefly at the recommended schedule for administration. Hepatitis A series 2 doses 6 months minimum interval between doses The recommended schedule for adults is 1 dose followed by a booster dose 6-12 months later. For children and adolescents, ages 12 months through 18 years, the recommended schedule is one dose followed by a booster dose 6-12 months later. Both brands are interchangeable.

60 Recommended Doses and Schedules of Hepatitis A Vaccine
Age Group Number of doses Volume Schedule Havrix® (Glaxo-Smithkline) 12 mos-18 yrs 2 0.5 mL 0, mos 19 yrs and older 1 mL Twinrix™ Hepatitis A & B combined 18 yrs and older 3 0, 1, 6 mos Vaqta® (Merck & Co.) This slide further outlines the dosage recommendations for all brands of vaccine for hepatitis A. Both Havrix and Vaqta have pediatric and adult formulations, but TwinRix is licensed for use only in those 18 years of age or older. The basic schedule for hepatitis A vaccine is 2 doses, one given now and one given 6-12 months later. This applies to both pediatric and adult formulations. These formulations are licensed to be given intramuscularly. TwinRix dosage is different because it is a combination vaccine containing both hepatitis A and hepatitis B vaccines and will be discussed in next slide. The Hepatitis A footnote #9 has additional schedule information for the 4-dose combined hepatitis A/hepatitis B vaccine. If the combined hepatitis A and hepatitis B vaccine (Twinrix™) is used, administer 3 doses at 0,1, and 6 months; alternatively, 1 4-dose schedule administered on day 0,7 and 21 to 30 followed by a booster dose at month 12 may be used.

61 Combination Vaccine for Hepatitis A and B (Twinrix®)
Indications for Twinrix® Combination hepatitis B vaccine (adult dose) and hepatitis A vaccine (pediatric dose) Licensed for persons 18 years of age and older Schedule: given at 0, 1, and 6 months Dose 1 and 2---separated by 4 weeks Dose 2 and 3---separated by at least 5 months Dose 1 and 3---must be separated by at least 6 months Accelerated Schedule Doses at 0,7, days and booster dose at 12 mos. First 3 doses of this schedule provide protection = to: 1st dose in standard single antigen Hep A adult series 1st 2 doses in standard adult Hep B series Indications for Twinrix® Combination hepatitis B vaccine (adult dose) and hepatitis A vaccine (pediatric dose) Licensed for persons 18 years of age and older Schedule: given at 0, 1, and 6 months Dose 1 and 2---separated by 4 weeks Dose 2 and 3---separated by at least 5 months Dose 1 and 3---must be separated by at least 6 months Source: Pink Book, February, 10th edition, p. 205 and 227. Accelerated Schedule Doses at 0,7, days and booster dose at 12 mos. First 3 doses provide protection equal to: 1st dose in standard single antigen Hep A adult series 1st 2 doses in standard adult hep B series If the accelerated schedule is started but the client does not return on time for one of the doses, revert to the standard schedule for timing and spacing of remaining doses.* *Per from NIPINFO 1/08.

62 Completing series Twinrix® or with Single Antigen Vaccines
DOSE 1 DOSE 2 DOSE 3 Twinrix® Adult Hep. A Adult Hep. B (1) Twinrix® OR (2) Adult Hep. A & Adult Hep. A & (1) Twinrix® OR We get many questions about how to complete the hepatitis A and B series with single antigen vaccines when the initial dose was with Twinrix or vice-versa. This table will show the timing and spacing of the 3 doses.* Single-antigen hepatitis A vaccine may be used to complete a series begun with Twinrix and vice versa. A person who receives 1 dose of Twinrix may complete the hep A series with 2 doses of adult formulation hepatitis A vaccine separated by at least 5 months. A person who receives 2 doses of Twinrix may complete the hep A series with 1 dose of adult formulation hep A vaccine or Twinrix 5 months after the 2nd dose. A person who begins the hep A series with single-antigen hep A vaccine may complete the series with 2 doses of Twinrix or 1 dose of adult formulation hep A vaccine. It is important to remember that when using both type of vaccines [combination of Twinrix and the single antigen Hep. A and Hep. B], adults require a total of ≥2 mL adult-equivalent doses of hepatitis A vaccine to complete the series. (For Public Health Only---This information is included in the Combination Vaccine guidelines in the Immunization Program Manual, but I wanted to remind you of it since we are trying to administer more hep A and B to our adult clients. Be sure to refer to the manual Chapter 2, under Combination Vaccine Guidelines in the GA Immunization Program Manual.) *SOURCE: CDC Hepatitis A module from “You Call the Shots.” Accessed 1/19/07

63 Meningococcal Disease
These very graphic photos show the possible results of a meningococcal infection becoming systemic and then infecting bodily tissues. The 4 month old on the left has gangrene of the hands and lower extremities due to meningococcemia. The picture on the right shows similar though not as severe tissue damage in an older child.

64 Meningococcal vaccines
Three vaccines Polysaccharide vaccine Menomune™ (MPSV4) Licensed for persons 2 years and older Administered subQ Revaccination may be indicated for persons at high risk Conjugate vaccine Menactra™ (MCV4) Licensed for persons 9 months through 55 years of age Administered IM Revaccination indicated Conjugate vaccine licensed Feb Menveo ® (MenCYW-135) Licensed for persons 11through 55 years of age All three vaccines protect against serotypes A, C, Y, and W-135 None of the vaccines protect against serotype B There are now three types of vaccines that protect against meningococcal meningitis: A polysaccharide vaccine trade name Menomune or MPSV4. Menomune is not routinely used in the general U.S. population because of its poor immunogenicity in children, short duration of protection, and its inability to induce herd immunity. Licensed for persons 2 years and older Administered subQ Revaccination may be indicated for persons at high risk for infection. These include persons with asplenia and those who reside in areas where the disease is endemic. In Jan a meningococcal conjugate vaccine, Menactra, was licensed. Licensed in April 2011 for persons down to 9 months of age. Licensed as of 2007 for persons 2 – 55 yrs. Administered IM In Feb 2010 another meningococcal conjugate vaccine, Menveo, was licensed. Licesnsed for persons 11 through 55 years of age See following slides on revaccination schedule All three vaccines protect against serotypes A, C, Y, and W-135 None of the vaccines protect against serotype B which is a major cause of meningitis in US.

65 Meningococcal Conjugate Vaccine (MCV4)
Menactra (sanofi pasteur)-- licensed for 9 months through 55 years Menveo® (Novartis)-- licensed for ages 2 through 55 years Both vaccines -Quadrivalent vaccines (A, C, Y, W-135) -Administered by intramuscular injection Recommendation for Routine Vaccination of Persons Aged 11 Through 18 Years After a booster dose of meningococcal conjugate vaccine, antibody titers are higher than after the first dose and are expected to protect adolescents through the period of increased risk through age 21 years. Persons who receive their first dose of meningococcal conjugate vaccine at or after age 16 years do not need a booster dose. Routine vaccination of healthy persons who are not at increased risk for exposure to N. meningitidis is not recommended after age 21 years. CDC Guidance for Transition to an Adolescent Booster Dose Some schools, colleges, and universities have policies requiring vaccination against meningococcal disease as a condition of enrollment. For ease of program implementation, persons aged 21 years or younger should have documentation of receipt of a dose of meningococcal conjugate vaccine not more than 5 years before enrollment. If the primary dose was administered before the 16th birthday, a booster dose should be administered before enrollment in college. The booster dose can be administered anytime after the 16th birthday to ensure that the booster is provided. The minimum interval between doses of meningococcal conjugate vaccine is 8 weeks. No data are available on the interchangeability of vaccine products. Whenever feasible, the same brand of vaccine should be used for all doses of the vaccination series. If vaccination providers do not know or have available the type of vaccine product previously administered, any product should be used to continue or complete the series. Ref. 1.Upated Recommendations for Use of Meningococcal Conjugate Vaccines – Advisory Committee on Immunization Practices (ACIP) MMWR January 28, 2011 / 60(03);72-76 2. Recommendation of the ACIP for Use of Quadrivalent Meningococcal Conjugate Vaccine (MenACWY-D) Among Children Aged 9 Through 23 Months at Increased Risk for Invasive Meningococcal Disease MMWR; October 14, 2011 / 60(40); 65 65 65

66 CDC Guidance for Transition to an Adolescent Booster Dose
MCV4 Recommendations One dose at 11 or 12 years of age and a booster dose at 16 years of age If first dose is at 13, 14 or 15 years, give one booster dose 5 years after the first dose Healthy persons who receive their first routine dose of MCV4 at of after age 16 yrs do not need a booster dose Persons aged 21 years or younger attending school or college should have documentation of one dose of MVC4 not more than 5 years before enrollment Recommendation for Routine Vaccination of Persons Aged 11 Through 18 Years After a booster dose of meningococcal conjugate vaccine, antibody titers are higher than after the first dose and are expected to protect adolescents through the period of increased risk through age 21 years. Persons who receive their first dose of meningococcal conjugate vaccine at or after age 16 years do not need a booster dose. Routine vaccination of healthy persons who are not at increased risk for exposure to N. meningitidis is not recommended after age 21 years. CDC Guidance for Transition to an Adolescent Booster Dose Some schools, colleges, and universities have policies requiring vaccination against meningococcal disease as a condition of enrollment. For ease of program implementation, persons aged 21 years or younger should have documentation of receipt of a dose of meningococcal conjugate vaccine not more than 5 years before enrollment. If the primary dose was administered before the 16th birthday, a booster dose should be administered before enrollment in college. The booster dose can be administered anytime after the 16th birthday to ensure that the booster is provided. The minimum interval between doses of meningococcal conjugate vaccine is 8 weeks. No data are available on the interchangeability of vaccine products. Whenever feasible, the same brand of vaccine should be used for all doses of the vaccination series. If vaccination providers do not know or have available the type of vaccine product previously administered, any product should be used to continue or complete the series. Ref. 1.Upated Recommendations for Use of Meningococcal Conjugate Vaccines – Advisory Committee on Immunization Practices (ACIP) MMWR January 28, 2011 / 60(03);72-76 2. Recommendation of the ACIP for Use of Quadrivalent Meningococcal Conjugate Vaccine (MenACWY-D) Among Children Aged 9 Through 23 Months at Increased Risk for Invasive Meningococcal Disease MMWR; October 14, 2011 / 60(40); 66 66 66

67 CDC Guidance for Transition to an Adolescent Booster Dose
MCV4 Recommendations HIV infection is not currently an indication for MCV4 vaccination Some persons with HIV infection should receive MCV4 for other indications such as international travel Persons with HIV infection who are vaccinated with MCV4 should receive 2 doses at least 8 weeks apart Recommendation for Routine Vaccination of Persons Aged 11 Through 18 Years After a booster dose of meningococcal conjugate vaccine, antibody titers are higher than after the first dose and are expected to protect adolescents through the period of increased risk through age 21 years. Persons who receive their first dose of meningococcal conjugate vaccine at or after age 16 years do not need a booster dose. Routine vaccination of healthy persons who are not at increased risk for exposure to N. meningitidis is not recommended after age 21 years. CDC Guidance for Transition to an Adolescent Booster Dose Some schools, colleges, and universities have policies requiring vaccination against meningococcal disease as a condition of enrollment. For ease of program implementation, persons aged 21 years or younger should have documentation of receipt of a dose of meningococcal conjugate vaccine not more than 5 years before enrollment. If the primary dose was administered before the 16th birthday, a booster dose should be administered before enrollment in college. The booster dose can be administered anytime after the 16th birthday to ensure that the booster is provided. The minimum interval between doses of meningococcal conjugate vaccine is 8 weeks. No data are available on the interchangeability of vaccine products. Whenever feasible, the same brand of vaccine should be used for all doses of the vaccination series. If vaccination providers do not know or have available the type of vaccine product previously administered, any product should be used to continue or complete the series. Ref. 1.Upated Recommendations for Use of Meningococcal Conjugate Vaccines – Advisory Committee on Immunization Practices (ACIP) MMWR January 28, 2011 / 60(03);72-76 2. Recommendation of the ACIP for Use of Quadrivalent Meningococcal Conjugate Vaccine (MenACWY-D) Among Children Aged 9 Through 23 Months at Increased Risk for Invasive Meningococcal Disease MMWR; October 14, 2011 / 60(40); 67 67 67

68 Meningococcal Vaccine Recommendations & Considerations
Routine vaccination of yr. olds Recommended for certain high-risk persons: asplenia terminal complement deficiency some travelers MCV4/MPSV4 and Guillain-Barré Syndrome (GBS) ACIP voted in June 2010 to remove the precaution for use of Menactra in people with a history of GBS. This precaution did not apply to Menveo (Novartis) or Menomune (sanofi pasteur). Board of Regents requirements Meningococcal vaccine is also recommended for for certain high-risk persons: asplenia terminal complement deficiency some travelers to sub-Saharan Africa or parts of the Middle East *Guidance re: Meningococcal vaccine and Guillain-Barré Syndrome (GBS)--- to date, evidence is insufficient to conclude that Meningococcal vaccine causes GBS. But an ongoing known risk for serious meningococcal disease exists. Therefore, CDC is recommending: Continue current vaccine strategies But since it is unknown whether receipt of Meningococcal vaccine might increase the risk for recurrence of GBS, avoid vaccinating persons not at high risk and, Do not vaccinate persons with history of GBS * MMWR Dispatch, “Guillain-Barré Syndrome Among Recipients of Menactra® Meningococcal Conjugate Vaccine---United States, June 2005—September 2006” MCV4 would be the recommended vaccine in these cases (in persons yrs. of age), but MPSV4 is acceptable Not yet required for entrance to school Board of Regents requirements (this policy applies only to GA public colleges): State law requires that all public and private colleges provide new students living in campus housing information about meningococcal disease, risk factors, and available vaccine. Student provides vaccination documentation or signs documentation stating they have received meningococcal information.

69 Meningococcal Revaccination Recommendations
High-risk persons who should be revaccinated with Meningococcal vaccine: persistent complement component deficiency anatomic or functional asplenia HIV infection frequent travelers to or persons living in areas with high rates of meningococcal disease At the June 2009 ACIP meeting, a recommendation was made for revaccination using meningococcal conjugate vaccine for persons who remain at high risk for meningococcal disease after their first vaccination (with either the polysaccharide or the conjugate meningococcal vaccine). These include persons with persistent complement component deficiencies, persons with anatomic or functional asplenia, persons infected with HIV, microbiologists who are routinely exposed to Neisseria meningitidis, and frequent travelers to or people living in areas with high rates of meningococcal disease, such as the African meningitis belt.

70 Rabies Vaccine Recommendations
Post-exposure prophylaxis …can be considered for persons who were in the same room as the bat and who might be unaware that a bite or direct contact had occurred (e.g., a sleeping person awakens to find a bat in the room or an adult witnesses a bat in the room with a previously unattended child, mentally disabled person, or intoxicated person) and rabies cannot be ruled out by testing the bat. Post-exposure prophylaxis would not be warranted for other household members. Post-exposure prophylaxis: Indicated for persons with possible exposure to a rabid animal through a bite or contamination of open wounds, abrasions, mucous membranes, or scratches with saliva or other potentially infectious material from a rabid animal. Postexposure prophylaxis is also recommended in the case where a bat is found in a room where a person is sleeping. The Fall/Winter edition of Needle Tips recommends, “When a bat is found in a dwelling, even in the absence of a known bite or scratch, the recommendation calls for aggressive use of postexposure prophylaxis. If possible the bat should be safely collected and submitted for rabies diagnosis.” Details of these recommendations were published in the MMWR, 1998; Vol. 47, No. 1. Consult your local health department regarding the need for rabies vaccine. Consult your clinic or district protocol for follow-up of rabies cases and/or procuring and administering vaccine.

71 Human Papillomavirus (HPV) Disease Burden
Anogenital HPV is the most common sexually transmitted infection in the US Estimated 20 million currently infected 6.2 million new infections/year American Cancer Society estimates 3,870 cervical cancer death annually Common among adolescents and young adults Estimated 80% of sexually active women will have been infected by age 50 Infection also common in men

72 Human Papillomavirus (HPV)
More than 100 different types of HPV. Certain types cause cervical squamous cell cancer, cervical adenocarcinoma, vulvar and vaginal cancer, and genital warts. Type Women Men 16 and 18 70% of cervical cancer 70% of anal/genital cancer 70% of anal/penile cancer 6 and 11 90% of genital warts 90% of RRP* lesions *Recurrent Respiratory Papillomatosis 90% of Recurrent lesions Additional information on human papillomavirus can be found at the following CDC website: • Cervarix® (GSK) 16 and 18 only • Gardasil® (Merck) 6, 11, 16 and 18 72 72 72

73 HPV4 Vaccine (Gardasil®)
Recommended for prevention of infection with HPV types 6, 11, 16, 18 in females 9 through 26 years & males 9 through 21years ACIP recommended schedule is 0, 2, 6 months Minimum intervals 4 weeks between doses 1 and 2 12 weeks between doses 2 and 3 24 weeks between doses 1 and 3 Minimum age is 9 years Maximum age is 26 years (may complete series after age 27 if begun before age 27)* On December 22, 2010 the FDA approved Gardasil for the prevention of anal cancer and associated precancerous lesions due to HPV types 6, 11, 16, and 18 in people 9 through 26 years. In October 2011 ACIP recommended routine vaccination of males 11 or 12 years of age with HPV4 administered as a 3-dose series. The vaccination series can be started beginning at 9 years of age. Vaccination with HPV4 is recommended for males 13 through 21 years of age who have not been vaccinated previously or who have not completed the 3-dose series. Males aged 22 through 26 years may be vaccinated. *The series should be completed regardless of the age of the patient (i.e., even if the patient is older than 26). In certain situations, some clinicians choose to start the 3-dose HPV series in patients who are older than 26 years. This, however, is an off-label use. References: Recommendations on Use of Quadrivalent HPV in Males MMWR;December 23, 2011 / 60(50);1705-8 2. Quadrivalent Human Papillomavirus Vaccine (HPV4, Gardasil) for Use in Males and Guidance from the ACIP MMWR; May 28, 2010 / 59(20); 3. Quadrivalent Human Papillomavirus Vaccine: Recommendations of the ACIP MMWR; March 12, 2007 / 56(Early Release);1-24 ACIP permissive recommendation for males 22 through 26 years Ref: MMWR; December 23, 2011 / 60(50);1705-8 73 73

74 HPV2 Vaccine (Cervarix®)
Licensed for prevention of infection with HPV types 16 & in females ages 10 through 25 years. ACIP recommended schedule is 0, 2, and 6 months. Minimum intervals 4 weeks between doses 1 and 2 12 weeks between doses 2 and 3 24 weeks between doses 1 and 3 Minimum age is 9 years Maximum age is 26 years (may complete series after age 27 if begun before age 27)* The VIS For Cervarix is different from Gardasil Ref: Bivalent Human Papillomavirus Vaccine (HPV2, Cervarix) for Use in Females and Updated HPV Vaccination Recommendations from the ACIP MMWR; May 28, 2010 / 59(20); *The series should be completed regardless of the age of the patient (i.e., even if the patient is older than 26). In certain situations, some clinicians choose to start the 3-dose HPV series in patients who are older than 26 years. This, however, is an off-label use. Ref: MMWR 2010; 59, No. 20: 74 74

75 HPV Vaccine Special Situations
Vaccine can be administered Equivocal or abnormal Pap test Positive HPV DNA test Genital warts Immunosuppression Breastfeeding

76 FOLLOW ACIP Recommendations!!!
Just as a reminder…… Regardless of: the availability of vaccine the funding of the vaccine (VFC, state-supplied, or private stock) whether the vaccine is required for school or child care or not………. There seems to be some confusion among providers that if there are vaccine shortages or the supply is low because it’s a new vaccine, or if the patient doesn’t fit in a certain funding category, or if the vaccine isn’t required for school or child care: then they don’t feel they need to be concerned about whether to recommend or discuss that vaccine with the client or the parent. But the bottom line is the ACIP recommendation is the most important thing!! For instance, if a vaccine is recommended and the child is not VFC eligible, then give them your private stock of that vaccine if you have it. If not, refer the child out to receive it, but don’t ignore the fact that according to the ACIP Recommended schedule, he should have it. Please be sure to emphasize this to any groups that you are educating about the recommended schedule. FOLLOW ACIP Recommendations!!!

77 www.cdc.gov/travel Yellow Fever Typhoid Polio
Yellow Fever---this is a mosquito-borne disease found in tropical climates. Vaccine would be indicated for travel to certain countries where yellow fever is endemic or where vaccine may be required for entry. The 1st time this vaccine is given it must be administered at least 10 days before entering the country in question, and the traveler must have the vaccination documented in the yellow international vaccination record. For travel in subsequent years, a booster is needed every 10 years. See package insert for dosage and administration information. Typhoid Fever ---this is an illness caused by a particular strain of salmonella bacteria that can contaminate water sources. There are currently 3 types of prevention available for this disease: 2 injectable vaccines, and capsules to be taken orally. Dosage and timing information can be accessed from the package insert. Polio---adolescents and adults who have previously been adequately immunized with either oral or inactivated polio vaccine would not generally need further boosters. However, for adults traveling to areas of the world where polio still exists, a one time dose of injectable polio vaccine may be recommended. To administer, give 0.5 ml subcutaneously. Japanese Encephalitis---this is a mosquito-borne infection found in parts of the Far East, southeast Asia, and the Indian subcontinent. In general, risk of disease is very low but depends on such factors as season, duration and location of travel, and activities. Vaccine may be 2 or 3 doses given at intervals. Refer to package insert for more information. Other vaccines mentioned in earlier portions of the presentation (Hep A, Hep B, MMR, meningitis, etc.) may be needed for travel to certain areas. Travelers should consult a travel clinic or the CDC travel website for information regarding vaccinations recommended for their specific destination.

78 Georgia Registry of Immunization Transactions and Services (GRITS)
We will talk briefly about Georgia’s immunization registry, or GRITS.

79 A “Birth to Death” Immunization Registry
Providers administering vaccines in Georgia must provide appropriate information to GRITS. GRITS personnel can work with your EHR/EMR vendor to create an interface between your system and GRITS that will drastically decrease data entry time for your practice. Contact the GRITS Training Coordinator at or In 2004, House Bill 1526 was passed making the Georgia Immunization Registry a birth to death registry mandating that providers of immunizations in Georgia report those immunizations into the registry database. Immunization data may now be shared by all providers of immunizations to Georgians of any age, and to schools, daycares, colleges and universities, and long term care facilities. The patient (age 18 or older) or parent or legal guardian may OPT-OUT of the registry. Contact GRITS to enroll:   Benefits of GRITS include: accurate immunization records, inventory tracking, reduction in missed opportunities or over-immunization, generation of school entrance forms/college immunization forms, reminder/recall notices for parents, assistance in generating reporting of immunizations to HEDIS/COCASA, and elimination of phone calls to providers for immunization records. The GRITS program is web-based. New users to the system will have to attend a training session and receive a password. Advantages of a statewide registry are as follows: Benefits to the Community Enhance the overall health status by facilitating identification of inadequately immunized segments of the population Decrease occurrence of over-immunization due to inability to locate past records Assist in issuing reminders to patients for pending and overdue immunizations Benefits to Healthcare Providers Reduce staff time needed to obtain complete immunization history of patients Provide printouts of school certificates Provide vaccine information and simplify complex and dynamic immunization schedules Streamline vaccine inventory process Generate HEDIS and other reports Reinforce the concept of a medical home Benefits to Public Health Officials Provide an accurate measure of immunization rates for districts, counties, and the state Allow Georgia healthcare providers to update and exchange immunization information about their patients in a confidential manner Facilitate community outreach programs The Georgia Code , which took affect July 1, 1996 and House Bill 1526, which took affect July 1, 2004 states: Any person who administers a vaccine or vaccines licensed for use by the United States Food and Drug Administration to a person shall, for each such vaccination, provide to the department such data as are deemed by the department to be necessary and appropriate for purposes of the vaccination registry established pursuant to subsection (a) of this Code section… At the present time the mandatory use of GRITS is not being strictly enforced but will be sometime in the future. 79

80 Introduction to GRITS GRITS is Mandated by Official Code Annotated, April 8, 1996 passed as a Childhood Registry July 1, 2004 passed as a Birth to Death Registry Mandates reporting by all providers of immunizations to all Georgians. HIPAA compliant GRITS is Mandated by Official Code Annotated, April 8, 1996 passed as a Childhood Registry July 1, 2004 passed as a Birth to Death Registry Mandates reporting by all providers of immunizations to all Georgians. HIPAA compliant

81 Introduction to GRITS The Benefits of a Statewide Immunization Registry… Reduced missed opportunities to vaccinate at risk individuals Reduction of over immunization of individuals Accurate Vaccine Inventory Tracking by Lot # for privately and public funded vaccine The Benefits of a Statewide Immunization Registry… Reduced missed opportunities to vaccinate at risk individuals Reduction of over immunization of individuals Accurate Vaccine Inventory Tracking by Lot # for privately and public funded vaccine

82 This slide depicts a typical Client Information page from the registry, showing the person’s vaccine history, plus the recommendations for further vaccines, including the earliest age that next vaccine could be administered.

83 Challenges to Adult Vaccination
Most patients indicate that they are likely to receive a vaccination if their healthcare provider (you) recommends it. Ref: Johnson DR, et al. Am J Med. 2008;121 (7 Suppl 2):S28-S35.

84 Challenges to Adult Vaccination
Healthcare Provider Perceptions Side Effects Lack of insurance coverage Lack of knowledge about disease prevention Patient reasons “Doctor hasn’t told me I need it” Not knowing when to get it The belief that a healthy person doesn’t need it Financial concerns were not a deterrent for most The chart shows the reasons consumers acknowledge for not receiving immunizations (specifically Influenza and Pneumococcal Vaccines). The number one reason is “Healthy, don’t need it” and second reason is “the doctor hasn’t told me I need it and third reason is “I may have side effects”. Most patients indicate that they are likely to receive a vaccination if their healthcare provider (you) recommends it Ref: Johnson DR, et al. Am J Med. 2008;121 (7 Suppl 2):S28-S35.

85 Why do we miss opportunities to immunize?
Provider or patient unaware of the need Visits for mild illness, injury, or follow-up Need for multiple vaccines Invalid contraindications The CDC definition of a missed opportunity is, “A health care encounter in which a person is eligible to receive vaccination but is not vaccinated completely. (Epidemiology and Prevention of Vaccine-Preventable Diseases, 12th edition. May HHS, CDC. ) Missing an opportunity to immunize may leave you vulnerable to a lawsuit. Patients who developed vaccine-preventable disease after failing to be immunized (missed opportunities) have filed lawsuits. [see Needletips (1), 1,1994] To avoid missed opportunities: Vaccination records: Keep accurate immunization records in a prominent location in the chart so immunization status can be easily checked at each visit. Mild illness/injury visits/follow-up visits: The CDC recommends immunization with all vaccines for patients even those with low-grade fever, mild diarrhea, mild ear infections, mild acute illness, or upper respiratory infections. There is no evidence of increased risk of adverse events associated with immunizations during the course of a minor illness. The decision to defer immunizations results in a missed opportunity. The procedure for assessing immunization status and giving immunizations at follow-up and sick/injury visits may require more time, necessitating change in your office practice. Multiple vaccinations per visit: More than one vaccine can be administered at one time. There is no limit to the number of vaccines that can be given at one visit. Know the schedules: Post the current schedule and keep staff updated on any changes. Know Contraindications: Be aware of the true/valid contraindications, precautions and invalid contraindications. There are few truly valid contraindications to vaccine administration. Adolescents: Adolescents are a large and healthy part of our population who seek medical care infrequently. Immunization status needs to be assessed at each visit. Adults: Some adults who are healthy may be seen infrequently. Other adults may have multiple medical problems. Immunization status of all adults needs to be assessed at each visit. Some barriers to be overcome regarding adolescents include: Parents may be unaware that there are now more vaccines recommended for adolescents Infrequent medical encounters for adolescent preventive medical services leaves fewer opportunities to immunize Lack of awareness by both physicians and parents that VFC provides recommended vaccines free for the uninsured and underinsured (in Georgia) through age 18. Obtaining parental consent for vaccines is a challenge Failure to vaccinate during sports physicals Lack of reminder/recall systems for adolescents 85 85

86 Invalid Contraindications to Vaccine
Mild illness or injury Antibiotic therapy Disease exposure or convalescence Pregnant woman in household Family history of an adverse event to a vaccine Breastfeeding Prematurity Allergies to products not in vaccine Need for TB skin testing Need for multiple vaccines ANTIBIOTIC THERAPY Antibiotics do not have an effect on the immune response to a vaccine. [Exception: The growth of the live Ty21, a strain of typhoid vaccine, is inhibited in vitro by various antibacterial agents. Some antibacterial agents may interfere with efficacy of Ty21 vaccine. CDC Yellow Book (Health Information for Travelers) recommends delaying vaccine >72 hours after any antibacterial agent. The Typhoid VIS recommends a delay of >24 hours.] DISEASE EXPOSURE OR CONVALESCENCE There is no evidence that either disease exposure or convalescence will affect the response to a vaccine or increase the likelihood of an adverse event. PREGNANCY OR IMMUNOSUPPRESSION IN THE HOUSEHOLD OR BREASTFEEDING Most vaccines, including live vaccines (MMR, varicella, and yellow fever) can be given to infants or children with pregnant or immunosuppressed household contacts, as well as to breast-feeding infants. Breastfeeding does not decrease the response to routine childhood vaccines and does not extend or improve passive immunity to vaccine-preventable disease provided by maternal antibody.  PREMATURE BIRTH Vaccines should be started on schedule based on the child's chronological age. Studies demonstrate that decreased seroconversion rates might occur among certain premature infants with low birth weights (i.e., <2,000 grams) after administration of hepatitis B vaccine at birth. However, by one month chronological age, all premature infants, regardless of initial birthweight or gestational age are as likely to respond as adequately as older and larger infants.  NEED OR REQUIREMENT FOR TUBERCULOSIS SKIN TEST (PPD) All vaccines, including MMR, can be given on the same day as a TB skin test, or any time after a TB skin test is applied. MMR vaccine may decrease the response to a TB skin test, potentially causing a false negative response in someone who actually has an infection with tuberculosis. If MMR has been given and one or more days have elapsed, in most situations it is recommended to wait 4-6 weeks before giving a routine TB skin test. No information on the effect of varicella vaccine on a TB skin test is available. It is prudent to apply rules for spacing measles vaccine and TB skin testing to varicella vaccine." 1. General Recommendations on Immunization, Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 2011; 60 (No. RR-2) January 28, 2011 2. Epidemiology and Prevention of Vaccine-Preventable Diseases, 12th edition May HHS, CDC. (Pink Book). Ref: General Recommendations on Immunization MMWR 2011; 60 (No. RR-2) January 28, 2011 86 86 86

87 Vaccine Risk Perception
Many young adults are not familiar with vaccine-preventable diseases and perceive the risks of a vaccine outweighs the benefit Concerns Belief that healthy adults do not need vaccines Vaccines have side effects (adverse reactions) Immunity from the disease is better than immunity from a vaccine Immune system overload Vaccines cause autism Answers to common concerns about vaccines Healthy adults need appropriate vaccines to make them immune to vaccine preventable diseases Some vaccine recipients will have an adverse reaction to a vaccine but most reactions are local and mild. Reactions also occur with some medications and foods. However, the benefits outweigh the risks. Vaccines do not weaken the immune system (we give a small antigen load even at peak times/ages in the vaccine schedule) Natural immunity is not better than vaccines (ex: shingles in those who have had chicken pox natural illness) Vaccine-preventable diseases are serious illnesses with the possibility of complications and even death Well controlled studies during the past 10 years have failed to show any association between MMR vaccine or thimerasol and autism. However, many anti-vaccine groups continue to promote the association of autism and MMR vaccine and the dangers of thimerasol. For more information about these topics (and others of concern to parents/patients) visit “I can’t afford to pay for the vaccine” Before displaying the last bullet you may want to say “Here is one concern you may frequently hear from patients: “I can’t afford to pay for the vaccine” Ask your audience how the practice responds to this statement 87 87

88 Persons can get vaccinated even if…
They have a mild illness (e.g., diarrhea or minor upper respiratory tract illnesses) They are taking antibiotics They live with someone who is pregnant They are breastfeeding an infant or live with someone who is breastfeeding Ivalid contraindication to vaccination Mild illness (e.g., diarrhea or minor upper respiratory tract illnesses) Antibiotic therapy Pregnancy in the household Breastfeeding Need for TB skin testing

89 Important Office Practices
Use Reminders Electronic health record pop-ups or chart reminders Send patient reminders Recall Recall for routine immunizations Recall when vaccine is available after a vaccine shortage Reminders and Recall For providers: A reminder communicating to the health care provider that a patient needs an immunization can be as simple as a chart clip, “sticky note” on the immunization record/ patient record, or a flag on the electronic medical record For patients: A reminder is a message notifying a patient/parent of an upcoming appointment and/or a need for an immunization A recall is a message notifying a patient that they are past due for an appointment and/or immunization These can be automated or manual, computerized, telephonic, or written If one member of a family is scheduled for an appointment, be sure and check all family member records for up to date immunizations and send reminder home at that time! Reference: General Recommendations on Immunization, Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 60(RR-2); January 28, 2011 Dentists and veterinarians do a much better job with reminders and recalls than physicians 89

90 Talking with Patients about Vaccines
Inform that more vaccines are now available for adults Make your recommendation about vaccines Use language patients can understand Give Vaccine Information Statement (VIS) prior to administering a vaccine Solicit and welcome questions Draw upon your experience as a health care provider for those who are hesitant about receiving a vaccine Adapted from Glen Nowak, PhD. CDC 90

91 Every Office and Clinic Needs A Vaccine Champion!
Lead your immunization team. Educate all staff about new vaccines and recommendations. Teach new staff about vaccine storage, handling, & administration. Initiate processes to improve immunization rates in your practice/facility. Assure immunizations of all staff are up-to-date. Ask your audience “Who is your vaccine champion?” and then “Who is this person’s backup?” The vaccine champion will: Lead your immunization team. Educate all staff about new vaccines and recommendations. Educate new staff about vaccine storage, handling, & administration. Initiate processes to improve immunization rates in your practice/facility. Assure immunizations of all staff are up-to-date. Improving Access to immunizations Immunization only visits Walk-ins for immunizations Implement Standing orders Early, Extended, or Weekend hours Mass vaccination clinics These 5 methods listed above can help patients access immunizations more readily but some of these methods may not be the right fit for some practices. The approach to improving access must be determined by individual practitioners and staff. Each practice must decide which method works best for their situation. In large practices or clinics this may be an administrative decision.   91 91

92 Healthcare Workers Need These Immunizations
Annual influenza vaccine Tdap or Td Hepatitis B (exposure risk) Validate immune status of: Varicella Measles, Mumps & Rubella (MMR) Hepatitis B vaccine is recommended for health care workers with potential exposure to blood or body fluids. Ideally the healthcare workers antibody status and immunity should be checked 1-2 months after the 3rd dose. If person fails to develop an adequate antibody titer after three doses, repeat the series and retest 4-8 weeks after 3rd dose of the second series. Un-immunized Healthcare Workers Un-immunized healthcare workers are at risk of infecting patients, family members and community contacts Immunized Healthcare Workers Protect patients from VPD’s Help offices avoid potential liability cases. (The practice can be liable if an unimmunized healthcare worker becomes infected with a vaccine preventable disease and infects a patient.) Maintain productivity Reduce illness and illness-related absenteeism Evidence of Immunity to MMR Documented administration of two doses of measles and mumps vaccine and one dose of rubella vaccine OR Laboratory evidence of immunity or laboratory confirmation of disease (measles, mumps and rubella) OR Born before 1957 (measles, mumps and rubella) References: 1. General Recommendations on Immunization, Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR (RR-2); January 28, 2011 2. Immunization of Health-Care Personnel: Recommendations of ACIP MMWR; November 25, 2011 / 60(RR07);1-45 Are YOU up to date? 92 92

93 Other Considerations for HCW Immunization Plan/Policy
Immunization/immunity record maintained by the facility on each HCW Catch-up programs for current employees and policies for newly-hired workers Work restriction policies for susceptible workers after exposure Management and control of outbreaks Options for refusal of vaccination by employees Immunization/immunity record maintained by the facility on each HCW This would be useful information in the event of a VPD occurrence among the patients or other HCWs Catch-up programs for current employees and policies for newly-hired workers Work restriction policies for susceptible workers after exposure Have plans for the management and control of outbreaks in the facility Options for refusal of vaccination by employees Some policies recommend having the employee sign a standard form, indicating his/her refusal of a particular vaccine and outlining his/her understanding of the necessary actions of furloughs, temporary reassignment of duties, etc. that may be necessary in the event of a VPD in the facility. Employers are strongly encouraged to access both of the following ACIP statements for more details: US Department of Health and Human Services, CDC, “Immunization of Health-Care Workers, Recommendations of the Advisory Committee on Immunization Practices (ACIP) and the Hospital Infection Control Practices Advisory Committee (HICPAC),” MMWR, December 26, 1997/Vol. 46/No. RR-18 US Department of Health and Human Services, CDC, “Influenza Vaccination of Health-Care Personnel, Recommendations of the Healthcare Infection Control Practices Advisory Committee (HICPAC) and the Advisory Committee on Immunization Practices (ACIP),” MMWR, February 24, 2006/Vol. 55/No. RR-2

94 Set an example Flu and Pertussis might not be severe in healthy adults, but can be DEADLY for infants or those with underlying medical conditions Don’t transmit disease to your patients-- get a Tdap and annual Flu vaccination!!! Points to stress. Healthcare workers need to get a flu shot and Tdap so they don’t transmit influenza and pertussis to their patients. Don’t ask a patient if they want a shot because they will probably say no, rather explain they are at risk for disease, vaccine is available at low or no cost, and they really need the vaccine in order to be protected. Unlike flu, invasive pneumococcal disease can occur anytime of the year so PUSH PPV23 to high risk individuals all year round not only during flu season. Don’t forget about diabetics over 2 yrs, they need a PPV23 dose before they turn 65 yrs

95 On the horizon… Quadrivalent live attenuated influenza vaccine (LAIV)
FluMist Quadrivalent® (MedImmune) approved February 2012 Anticipated to be available for US season. In February 2012, FDA approved a new seasonal quadrivalent LAIV, FluMist Quadrivalent (MedImmune). This vaccine currently is not anticipated to be available until the 2013–14 influenza season, at which time it is expected to replace the currently available seasonal trivalent FluMist formulation (Table). Inactivated quadrivalent influenza vaccines currently are in development. These vaccines will be addressed in the ACIP influenza statement as they are approved and become available commercially. Access the Red Book Online for the Vaccine Status Table to see the status of recently submitted, licensed, and recommended vaccines.

96 Vaccine Adverse Event Reporting System
The Vaccine Adverse Event Reporting System (VAERS) is a national vaccine safety surveillance program co-sponsored by the Centers for Disease Control and Prevention and the Food and Drug Administration. What Can Be Reported to VAERS? Who Reports to VAERS? Does VAERS Provide General Vaccine Information? VAERS provides a nationwide mechanism by which adverse events following immunization may be reported, analyzed, and made available to the public. The primary objectives of VAERS are to: Detect new, unusual, or rare vaccine adverse events; Monitor increases in known adverse events; Identify potential patient risk factors for particular types of adverse events; Identify vaccine lots with increased numbers or types of reported adverse events; and Assess the safety of newly licensed vaccines. What Can Be Reported to VAERS? VAERS encourages the reporting of any clinically significant adverse event that occurs after the administration of any vaccine licensed in the United States. Who Reports to VAERS? Anyone can file a VAERS report, including parents, health care providers, manufacturers, and vaccine recipients. Does VAERS Provide General Vaccine Information? No. VAERS only collects and analyzes adverse event reports. In another example, VAERS determined that there may be a potential for a small increase in risk for  Guillain-Barre syndrome after the meningococcal conjugate vaccine, Menactra. As a result of this finding, a history of Guillain-Barre syndrome became a contraindication to the vaccine and further controlled studies are currently underway to research this issue.

97 National Vaccine Injury Compensation Program (NVICP)
National Vaccine Injury Compensation Program provides compensation to individuals found to be injured by or have died from certain childhood vaccines. Established in 1988 by NCVIA Federal “no fault” system to compensate those injured Claim must be filed by individual, parent or guardian Must show that injury is on “Vaccine Injury Table” On October 1, 1988, the National Childhood Vaccine Injury Act of 1986 created the National Vaccine Injury Compensation Program (VICP). The VICP was established to ensure an adequate supply of vaccines, stabilize vaccine costs, and establish and maintain an accessible and efficient forum for individuals found to be injured by certain vaccines. The VICP is a no-fault alternative to the traditional public legal system for resolving vaccine injury claims that provides compensation to people found to be injured by certain vaccines. The National Childhood Vaccine Injury Act (NCVIA) set forth 3 basic requirements for all vaccination providers, which are: Providers must give the patient (or parent/legal representative of a minor) a copy of the relevant federal "Vaccine Information Statement" (VIS) for the vaccine they are about to receive. Providers must record certain information about the vaccine(s) administered in the patient's medical record or a permanent office log. Providers must document any adverse event following the vaccination that the patient experiences and that becomes known to the provider, whether or not it is felt to be caused by the vaccine, and submit the report to the Vaccine Adverse Event Reporting System (VAERS).

98 Resources Georgia Immunization Program
On Call hotline National Immunization Program at CDC Georgia Adult Immunization Coalition Immunization Action Coalition This is a listing of some of the organizations to access if you have questions about immunization requirements or to order information. These are listed on the Resource Handout included in your packet of information. Georgia Immunization Program: The on call hotline is staffed Monday through Friday 8 am to 5pm. Call and ask for the On Call person The Georgia Adult Immunization Coalition is another source of information on immunization for adults. It also has links to other web sites The CDC website, and their link to Travel Information website Local Health Department (Suggestion: Give out name and phone number of local health department person they could contact regarding immunizations. Also include this as a written handout) Follow with Q&A period Have participants complete the evaluation form and turn in

99 Stay Current! Sign up for listserv sites which provide timely information pertinent to your practice AAP Newsletter CDC immunization websites (32 in all) CHOP Parents Pack Newsletter IAC Express Websites specific to particular vaccines 99

100 Resources for Factual & Responsible Vaccine Information
These are sources for scientific and credible information See information sheet in participant packet This site is a good resource for healthcare providers and for information written specifically for patient and parents. (support and counseling for children with infectious diseases) The Allied Vaccine Group (AVG) (www.vaccine.org) was formed for the purpose of making it easier for patients/parents/providers to find reliable, science-based information about vaccines and immunization on the internet. This web site was designed to counter the many anti-vaccine web sites that are now available on the internet. 100 100

101 Internet Resources Georgia Department of Public Health
CDC Immunization information CDC Flu information Immunization Action Coalition

102 The Immunization Program webpage contains various helpful information. The webpage address is at the top of the slide.

103 Test Your Knowledge! James is a 58 year old accountant. He is an alcoholic with chronic liver disease and smokes 1 pack of cigarettes per day. No other significant medical problems. His last tetanus booster was 12 years ago. He states he has never had measles or chicken pox. Tdap, hepatitis A, hepatitis B, Pneumococcal (PPSV23) Influenza, if in fall or winter MMR? No. Born before 1957 and not at risk. Varicella? No. Born before 1980 Zostavax? Not recommended by ACIP Zostavax was licensed by the FDA in May 2006 for individuals 60 Years of age and older. On March 24, 2011 the FDA approved Zostavax for individuals 50 through 59 years of age. At the June 22, 2011 meeting the ACIP did not consider a vote to recommend Zostavax for people 50 through 59 years. Due to the shortage of Zostavax in mid 2011 the working group felt that a recommendation at this time would decrease the limited supply of the vaccine for those 60 years and older who are at higher risk. Practitioners can legally administer the vaccine to the age group, but some insurance carriers may not reimburse for the vaccine because it has not been recommended by the ACIP. What vaccines does he need? EPIC 2010 EPIC 2010 103 103

104 Test Your Knowledge! What vaccines does he need?
James is a 58 year old accountant. He is an alcoholic with chronic liver disease and smokes 1 pack of cigarettes per day. No other significant medical problems. His last tetanus booster was 12 years ago. He states he has never had measles or chicken pox. What vaccines does he need? Tdap, hepatitis A, hepatitis B, Pneumococcal (PPSV23) Influenza, if in fall or winter MMR? No. Born before 1957 and not at risk. Varicella? No. Born before 1980 Zostavax? Not recommended by ACIP Zostavax was licensed by the FDA in May 2006 for individuals 60 Years of age and older. On March 24, 2011 the FDA approved Zostavax for individuals 50 through 59 years of age. At the June 22, 2011 meeting the ACIP did not consider a vote to recommend Zostavax for people 50 through 59 years. Due to the shortage of Zostavax in mid 2011 the working group felt that a recommendation at this time would decrease the limited supply of the vaccine for those 60 years and older who are at higher risk. Practitioners can legally administer the vaccine to the age group, but some insurance carriers may not reimburse for the vaccine because it has not been recommended by the ACIP. Tdap, hepatitis A, hepatitis B, PPSV23, Influenza vaccine MMR?, Varicella?, Zostavax? EPIC 2010 EPIC 2010 104 104

105 Take away messages Georgia has low pneumonia immunization and flu immunization rates for persons 65 yrs and older Flu vaccination efforts should continue into Spring and later! Administer PPSV23 vaccine YEAR ROUND instead of only during flu season to unvaccinated: Unvaccinated persons 65yrs and older DIABETICS over 19 yrs of age Persons over 19 yrs with asthma Points to stress. Healthcare workers need to get a flu shot and Tdap so they don’t transmit influenza and pertussis to their patients. Don’t ask a patient if they want a shot because they will probably say no, rather explain they are at risk for disease, vaccine is available at low or no cost, and they really need the vaccine in order to be protected. Unlike flu, invasive pneumococcal disease can occur anytime of the year so PUSH PPV23 to high risk individuals all year round not only during flu season. Don’t forget about diabetics over 2 yrs, they need a PPV23 dose before they turn 65 yrs

106 Take away messages Historically, Georgia has high rates of hepatitis B infection so strongly encourage hepatitis vaccination for your family planning and STD clients Strongly Encourage Tdap to all adults age 19 years and older Routinely administer HPV vaccine to adolescent females AND males PUSH state supplied hepatitis vaccines to STD and family planning clinics because Georgia has high rates of hepatitis A AND hepatitis B infections PUSH state supplied Tdap to adults (including staff) who are around children less than 1 yr old. Young children haven’t received their primary series of DTaP and are a great risk for contracting Pertussis. PUSH Tdap to women who could become pregnant PUSH HPV to all adolescent females and males

107 Georgia Immunization Office
Questions??? Georgia Immunization Office


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