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1 Adolescent and Adult Immunization Update Presentation to: Presented by: Date:

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.

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

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 UNIMMUNIZED INFECTED = immunized

6 Cocooning Strategy

7 20 th Century Peak & Current Morbidity for VPDs Prevaccine (in peak year) 2011% Reduction of Cases Diphtheria30, 5080100 Measles763,09422299.9 Mumps212,93240499.8 Pertussis265,26918,71992.9 Paralytic polio63,3020100 Rubella488,796499.9 Tetanus6013694.0 Hib, type b (age < 5 yrs) 20,000 (yearly average in 1980’s) 4, plus 226 of unknown type >99.8 MMWR (Weekly), August 17, 2012, 61(32); 624-637

8 Indications Recommendations Requirements Indication Information about the appropriate use of the vaccine Information about the appropriate use of the vaccineRecommendation ACIP statement that broadens and further delineates the Indication found in the package insert ACIP statement that broadens and further delineates the Indication found in the package insert Basis for standards for best practice Basis for standards for best practiceRequirement Mandate by a state that a particular vaccine must be administered and documented before entrance to Mandate by a state that a particular vaccine must be administered and documented before entrance to child care and/or school child care and/or school

9 2013 Adult Immunization Schedule 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.

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.

12 Recommended Adult Vaccines Influenza Td/Tdap Varicella HPV Zoster MMR Pneumococcal Meningococcal Hepatitis A Hepatitis B

13 Burden of Seasonal Influenza 36,000 Flu related deaths each year in the US 36,000 Flu related deaths each year in the US ~90% of deaths among persons age 65 and older ~90% of deaths among persons age 65 and older October – November best time to receive flu vaccination October – November best time to receive flu vaccination Takes about 2 weeks to develop antibodies Takes about 2 weeks to develop antibodies December to Spring not too late! December to Spring not too late!

14 Seasonal Influenza Vaccine Influenza Vaccine Strains for the 2012-13 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 2011-2012 influenza vaccine used in the U.S. Recommended for all people age 6 months and older.

15 Inactivated Influenza Vaccines (TIV) Administer by Injection Administer by Nasal spray: MedImmune FluMist ® - for healthy persons 2 through 49 years of age - not for pregnant women Live, Attenuated Influenza Vaccine (LAIV) 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 MMWR / August 17, 2012 / Vol. 61 / No. 32

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

17 Inactivated Influenza Vaccines and Egg Sensitivity All influenza vaccine viruses for the 2012- 2013 season are grown in hen’s eggs Allergy to eggs must be distinguished from allergy to influenza 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?

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 B est to get vaccinated before flu season starts December– March is Not Too Late to get a Flu Vaccination

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

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 Ref: Recommended Adult Immunization Schedule – United States, 2012 MMWR Vol. 61/ No. 4/ February 3, 2012 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

25 Pneumococcal Polysaccharide Vaccine for Adults (PPSV23) – Part two 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. Ref: Recommended Adult Immunization Schedule – United States, 2012 MMWR Vol. 61/ No. 4/ February 3, 2012 A one time revaccination 5 years after the first dose is recommended for those with: chronic renal failure functional/anatomic asplenia immunocompromising conditions

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.

27 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. NEW MMWR Vol. 61/No. 21 June 1, 2012 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.

28 Property Polysaccharide Conjugate B-cell-dependent immune responseYes 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 Advantages of Conjugate Vaccines 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

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.

31 Tdap and Pregnancy June 2011 ACIP votes to recommend Tdap for women > 20 weeks pregnant

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.

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

34 Hepatitis B

35 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 19 through 59 years with diabetes mellitus. All adults seeking protection from HBV infection should be vaccinated according to recommended adult schedule. Transmission: 1. Percutaneous or mucosal exposure to blood or body fluids including contaminated surfaces 2. Perinatal infection from HbSAg + mother.

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

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

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 2 nd series, test for hepatitis B surface antigen

40 Currently Licensed SINGLE ANTIGEN Hepatitis B Vaccines Vaccine Age Group Number of Doses Dose/Volume Engerix B Pediatric Formulation (GLAXO-SmithKline) 0 through 19 yrs 3 10 mcg/ 0.5 ml Engerix B Adult Formulation (GLAXO-SmithKline) 20 years & older 3 20 mcg/ 1.0 ml Recombivax HB Pediatric Formulation (Merck & Co) 0 through 19 yrs 3 5mcg/ 0.5 ml Recombivax HB Pediatric Formulation (Merck & Co) 20 years & older 3 10mcg/ 1.0 ml Recombivax HB Adult Formulation (Merck & Co) 11 through 15 years 2 10mcg/ 1.0 ml Recombivax HB Adult Formultion (Merck & Co) 20 years & older 3 10 mcg/ 1.0 ml

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

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!

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

44 Evidence of Immunity

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.

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)

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

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.

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

50 “Shingles” Shingles is caused by reactivation of varicella zoster Herpes 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 *Ref: Epidemiology and Prevention of Vaccine-Preventable Diseases. 12th Edition, May 2011.

52 Vaccines for Special Circumstances Hepatitis A Meningococcal Rabies HPV Travel

53 Hepatitis A

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

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

56 Hepatitis A Post-Exposure Prophylaxis In 2007, ACIP recommended that people age 1 - 40 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.

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

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.

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 --- 1 mL given IM – Booster dose 6-12 months after 1st dose Children and Adolescents (12 months through 18 years) – 1 dose --- 0.5 mL given IM – Booster dose 6-12 months after 1st dose Havrix® and Vaqta® Both brands are interchangeable

60 Recommended Doses and Schedules of Hepatitis A Vaccine VaccineAge Group Number of doses VolumeSchedule Havrix ® (Glaxo-Smithkline) 12 mos-18 yrs20.5 mL0, 6 - 12 mos 19 yrs and older21 mL0, 6 - 12 mos Twinrix™ Hepatitis A & B combined (Glaxo-Smithkline) 18 yrs and older31 mL0, 1, 6 mos Vaqta ® (Merck & Co.) 12 mos-18 yrs20.5 mL0, 6 - 12 mos 19 yrs and older21 mL0, 6 - 12 mos

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, 21-30 days and booster dose at 12 mos. –First 3 doses of this schedule provide protection = to: 1 st dose in standard single antigen Hep A adult series 1 st 2 doses in standard adult Hep B series

62 Completing series Twinrix ® or with Single Antigen Vaccines DOSE 1DOSE 2DOSE 3 Twinrix ® Adult Hep. A Adult Hep. B (1) Twinrix ® OR (2) Adult Hep. A & Adult Hep. B Twinrix ® Adult Hep. A & Adult Hep. B Adult Hep. A Adult Hep. B Twinrix ® (1) Twinrix ® OR (2) Adult Hep. A & Adult Hep. B

63 Meningococcal Disease

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. 2010 Menveo ® (MenCYW-135) Licensed for persons 11through 55 years of age Administered IM Revaccination indicated All three vaccines protect against serotypes A, C, Y, and W-135 None of the vaccines protect against serotype B

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

66 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

67 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

68 Meningococcal Vaccine Recommendations & Considerations Routine vaccination of 11-18 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

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

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.

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. TypeWomenMen 16 and 1870% of cervical cancer 70% of anal/genital cancer 70% of anal/penile cancer 6 and 1190% of genital warts 90% of RRP* lesions *Recurrent Respiratory Papillomatosis 90% of genital warts 90% of Recurrent lesions Cervarix® (GSK) 16 and 18 only Gardasil® (Merck) 6, 11, 16 and 18

73 HPV4 Vaccine (Gardasil ® ) 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 )* Ref: MMWR; December 23, 2011 / 60(50);1705-8 Recommended for prevention of infection with HPV types 6, 11, 16, 18 in females 9 through 26 years & males 9 through 21years ACIP permissive recommendation for males 22 through 26 years

74 HPV2 Vaccine (Cervarix ® ) 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 )* Licensed for prevention of infection with HPV types 16 & 18 in females ages 10 through 25 years. Ref: MMWR 2010; 59, No. 20: 626 - 631

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

76 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………. FOLLOW ACIP Recommendations!!!

77 Yellow Fever Typhoid Polio

78 Georgia Registry of Immunization Transactions and Services (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 1-888- 223-8644 or e-mail

80 Introduction to GRITS GRITS is Mandated by Official Code Annotated, 31-12-3.1 – 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


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

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

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

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 Ref: General Recommendations on Immunization MMWR 2011; 60 (No. RR-2) January 28, 2011

87 Vaccine Risk Perception 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 Many young adults are not familiar with vaccine- preventable diseases and perceive the risks of a vaccine outweighs the benefit  “I can’t afford to pay for the vaccine”

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

89 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 Important Office Practices

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

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.

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) Are YOU up to date?

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

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!!!

95 On the horizon… Quadrivalent live attenuated influenza vaccine (LAIV) – FluMist Quadrivalent® (MedImmune) approved February 2012 – Anticipated to be available for 2013-2014 US season.

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?

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”

98 Resources Georgia Immunization Program – On Call hotline 404-657-3158 National Immunization Program at CDC – Georgia Adult Immunization Coalition – Immunization Action Coalition –

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

100 Resources for Factual & Responsible Vaccine Information

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


103 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? Test Your Knowledge!

104 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? Test Your Knowledge! Tdap, hepatitis A, hepatitis B, PPSV23, Influenza vaccine MMR?, Varicella?, Zostavax?

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

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

107 Questions??? Georgia Immunization Office

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