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1 Immunizations for Children, Adolescents, and Adults MARCH 2015 Immunization Education For Healthcare Providers in Training.

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Presentation on theme: "1 Immunizations for Children, Adolescents, and Adults MARCH 2015 Immunization Education For Healthcare Providers in Training."— Presentation transcript:

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2 1 Immunizations for Children, Adolescents, and Adults MARCH 2015 Immunization Education For Healthcare Providers in Training

3 Presented By: Georgia Chapter - American Academy of Pediatrics Georgia Immunization Program In Cooperation with: Georgia Academy of Family Physicians Georgia Chapter American College of Physicians Georgia OB/Gyn Society

4 Faculty Disclosure Information In accordance with ACCME* Standards, all faculty members are required to disclose to the program audience any real or apparent conflict of interest to the content of their presentation. This presentation will include the most current ACIP recommendations for frequently used vaccines but is not a comprehensive review of all available vaccines. Some ACIP recommendations for the use of vaccines have not currently been approved by the FDA. Detailed information regarding all ACIP Recommendations is available at *Accreditation Council for Continuing Medical Education

5 Objectives At the end of this presentation, you will be able to: Recall the role vaccines have played in preventing diseases Discuss the importance of vaccines for children, adolescents and adults Review the most recent CDC recommendations for storage and handling of vaccines List at least 2 reliable sources for immunization information

6 INFECTIOUS AGENT PERSON EXPOSED CARRIER DISEASE COMPLETE RECOVERY COMPLICATIONS DEATH RECOVERY WITH SEQUELAE COMPLETE RECOVERY NO DISEASE MAY INFECT UNIMMUNIZED RESULTS OF EXPOSURE TO A VACCINE PREVENTABLE DISEASE

7 INFECTIOUS AGENT EXPOSED AND VACCINATED NO DISEASE INDIVIDUAL REMAINS HEALTHY NO TRANSMISSION TO OTHERS NO CARRIER STATE GOALS OF VACCINATING

8 Vaccination Terminology (1) Active Immunity Protection produced by the person’s own immune system Usually permanent from disease May require multiple doses of a vaccine Passive Immunity Protection transferred from another person or animal Temporary protection that wanes with time Ref: Epidemiology and Prevention of Vaccine-Preventable Diseases. 12th Edition, May 2012

9 Vaccination Terminology (2) Antigen A live or inactivated substance (e.g., protein, polysaccharide) capable of producing an immune response Antibody Protein molecules (immunoglobulin) produced by B lymphocytes to help eliminate an antigen Ref: Epidemiology and Prevention of Vaccine-Preventable Diseases. 12th Edition, May 2012

10 Vaccines Live, Attenuated Measles,Mumps & Rubella (MMR) Varicella LAIV Rotavirus Herpes Zoster Inactivated Toxoids (DTaP, Td, Tdap) Whole (Hepatitis A, IPV) Split (Influenza - IIV) Recombinant vaccines (Hepatitis B, HPV4, HPV2) Polysaccharide vaccines (PPSV23, MPSV4) Conjugated vaccines (Hib, PCV13, MCV4) Vaccine - A product that interacts with the immune system to produce active immunity against a disease without the risk of the disease and its potential complications. Ref: Epidemiology and Prevention of Vaccine-Preventable Diseases. 12th Edition, May 2012

11 Disease Average Annual Reported Cases Pre-vaccine* Cases in U.S. 2013** Provisional Cases in U.S. 2014*** Provisional % Reduction In U.S Smallpox48,164Eradicated worldwide in 1980 Diphtheria175,88501>99.9% Measles503, >99.9% Mumps152, , % Pertussis147,27128,63928, % Polio (paralytic)16, % Rubella47,74598>99.9% Congenital Rubella Syndrome % Tetanus1, % H. Influenzae Type b Age<5 years 20, % The Impact of Vaccines *MMWR 48(12); April 2, 1999 ** MMWR 63(32); August 15, 2014 ***MMWR 63(53); January 9, 2015

12 Advisory Committee on Immunization Practices (ACIP) 15 voting members with expertise in one or more of the following:  Vaccinology  Immunology  Infectious diseases  Pediatrics  Internal Medicine  Preventive medicine  Public health  Consumer perspectives and/or social and community aspects of immunization programs Committee develops recommendations and schedules for the use of licensed vaccines

13 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 child care and/or school Mandate by a state that a particular vaccine must be administered and documented before entrance to child care and/or school

14 Immunized individuals block infection from reaching those who are unimmunized Adapted from CDC INFECTED UNIMMUNIZED = IMMUNIZED UNIMMUNIZED Herd Immunity INFECTED

15 2015 Immunization Schedules All staff must use the same immunization schedule Four Schedules:  Children & Adolescents 0 through 18 years  Catch-up schedule for ages 4 months -18 years  Adult 19 years and older  Adult based on medical and other indications READ THE FOOTNOTES

16 MAKING HEADLINES When a vaccine works, it prevents a disease. Prevention does not make headlines. The possibility that a vaccine has an adverse effect, true or false, DOES MAKE A GOOD STORY.

17 Vaccine Risk Perception Concerns Immune system overload Children get too many shots at one visit Vaccines have side effects (adverse reactions) Immunity from the disease is better than immunity from a vaccine (ie. chicken pox) Vaccines cause autism Many parents of young children are not familiar with vaccine-preventable diseases and perceive the risks of vaccines outweigh the benefits

18 Response to Vaccine Safety Concerns Vaccines are among the most thoroughly tested and safest things we put into our bodies Refusing a vaccine means taking the risks of the disease and of spreading the disease to others “Natural immunity” (from disease) may come with complications, permanent damage, or death In Georgia, an unimmunized student may be prohibited from attending school during an epidemic* * State of Georgia -Rules of Department of Human Services: Public Health Consistent reproducible research has shown that autism is NOT caused by: — Thimerosal — Multiple vaccines at one time — MMR vaccine

19 Talking with Parents about Vaccines Start conversations early (prenatal visits) Use language and examples parents can understand Give written information (VIS) prior to the immunization visit Provide your recommendations Draw upon your experiences as a health care provider Solicit and welcome questions Recognize that some parents may be more interested in discussing vaccines than others Adapted from Glen Nowak, PhD. CDC

20 Vaccine Schedules Varying From ACIP/AAP/AAFP Recommendations Dr. Bob’s Selective Vaccine Schedule Dr. Bob’s Alternative Vaccine Schedule Parent/caretaker refuses all vaccines If any of these Alternate Schedules are requested, the health care provider and staff must spend additional time educating the parent/caretaker about the appropriate use of vaccines.

21 Anti-Vaccine Movement Promotes the idea that there is less evidence of disease today and immunizations are no longer needed Sends confusing & conflicting information Uses stories, personal statements, and books to play on the emotional side of concerned parents Encourage parents/patients to: Get the facts Consider the source Discuss their concerns with you

22 Resources for Factual & Responsible Vaccine Information

23 VACCINE PREVENTABLE DISEASES

24 Diphtheria Tetanus Pertussis ©AAP (Whooping Cough)

25 Vaccines Containing Diphtheria & Tetanus Toxoid plus Pertussis Antigens ACIP recommends: DTaP – 2months through 6 years (Multiple doses) Tdap – 10 years and Older (One dose) Td (Use for booster dose when pertussis antigens are not indicated)

26 Cocooning Strategy Siblings Child Care Provider Healthcare WorkerGrandparents Parents

27 Haemophilus influenzae type b (Hib) ACIP recommends Hib vaccine: 3 or 4 doses for children 2 through 15 months of age One dose of Hib may be given to adults with immunocompromising conditions. MMWR, February 28, 2014, Vol 63, #RR01

28 Polio ACIP recommends: Inactivated Polio Vaccine (IPV) 4 doses 2 months through 6 years Persons travelling to countries experiencing polio outbreaks may require a booster dose MMWR, August 7, 2009, Vol 58, #30 MMWR, July 11, 2014,Vol 63 # 27

29 MEASLES Incubation period generally 8 to 14 days from exposure to onset of symptoms. Symptoms are fever, cough, coryza, conjunctivitis, maculopapular rash and Koplik spots. Complications include otitis media, pneumonia, croup, & diarrhea. Acute encephalitis occurs in 1 out of 1,000 cases. Death occurs in 1 to 3 of every 1,000 cases. Measles Vaccine 95% of people develop serum measles antibody after one dose. 99% after 2 doses. 5% or less may lose protection after several years. AAP Red Book, 30 th Edition 2015 Source: American Academy of Pediatrics, Red Book Online Visual Libr ary Source: Centers for Disease Control and Prevention Koplik Spots

30 Measles (M) Mumps (M) Rubella (R) Congenital Rubella (R) Measles, Mumps, Rubella Source: Creative Commons Source: American Academy of Pediatrics Red Book On Line Visual Library

31 MMR Vaccine ACIP recommends a 2 Dose Series for children –Dose 12 through 15 months of age –Dose 4 through 6 years of age Acceptable presumptive evidence of MMR immunity 1 Documentation of age appropriate vaccination with MMR vaccine Laboratory evidence of immunity Laboratory confirmation of disease Birth before 1957 Birth date not acceptable evidence of rubella immunity for women who could become pregnant 1. MMWR, June 14, 2013 Vol 62 RR #04)

32 ACIP recommends: Two doses of varicella vaccine for everyone who has not had chickenpox Varicella (Chickenpox) MMWR, June 22, 2007, Vol 56, #RR-04

33 Herpes Zoster Herpes zoster (HZ), or shingles, occurs through reactivation of latent varicella-zoster virus Typically characterized by prodromal pain and an acute vesicular eruption (rash) accompanied by moderate to severe pain One in three persons will develop zoster during their lifetime Post-herpetic neuralgia (PHN)is a common consequence of zoster Risk for zoster and PHN increases with age Photo courtesy of

34 Varicella ACIP recommends first dose at 12 through 15 months of age and second dose at 4 through 6 years MMRV Combination vaccine with measles, mumps, rubella, and varicella antigens Contains 7 times the varicella component of single antigen varicella vaccine Approved for use in children 12 mos. through 12 years of age Herpes zoster vaccine Contains 14 times the varicella component of single antigen varicella vaccine Vaccine licensed for persons age 50 years and older, for prevention of shingles. ACIP recommends vaccine for persons 60 years and older. Vaccines containing Varicella antigen

35 Pneumococcal Disease Photo courtesy AAP Infection with pneumococcal bacteria may cause pneumonia, bacteremia, meningitis and otitis media resulting in thousands of hospitalizations and deaths each year in the United States Multi-drug resistant pneumococci are common

36 ACIP recommends PCV13 for: − All children starting at 2 months of age − Children and adolescents with medical conditions that increase their risk for pneumococcal infections − Adults with specific medical conditions − All adults 65 years and older ACIP recommends PPSV23 for: − Persons 2 years and older who are at increased risk for pneumococcal infection due to medical conditions and/or cigarette smoking − All persons age 65 years and older Pneumococcal Vaccines PCV13 and PPSV23 MMWR, December 10, 2010, Vo1 59, #RR-11 MMWR, October 12, 2012, Vol 61, #40 MMWR, June 28, 2013, Vol 62, #25

37 IIV (inactivated influenza vaccine) injectable IIV3 vaccines contains 3 strains, 2 Type A and 1 Type B IIV4 vaccines contains 4 strains, 2 Type A and 2 Type B Viral strains usually change yearly Recommended for all persons aged 6 months and older Influenza Vaccines LAIV4 (live attenuated influenza vaccine) nasal spray Contains 4 strains, 2 Type A and 2 Type B Only for healthy persons aged 2 through 49 years Not recommended for pregnant women

38 Composition of Influenza Vaccines for Season in the U.S. Trivalent Vaccines will contain: A/California/7/2009 (H1N1) - like virus A/Texas/50/2012 (H3N2) - like virus B/Massachusetts/2/ like(Yamagata lineage) virus ACIP recommends annual influenza vaccine for all persons 6 months of age and older who do not have contraindications. Quadrivalent Vaccines will also contain: B/Brisbane/60/2008-like (Victoria lineage) virus Ref: Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices (ACIP) Influenza Season MMWR /Vol. 63/ No. 32, August 15, 2014

39 Inactivated Influenza Vaccines (IIV) Administer by Injection: Fluzone ® sanofi-pasteur - 6 months of age and older IIV3 & IIV4 Fluarix ® GSK - 3 years of age and older IIV3 & IIV4 FluLaval ® GSK - 3 years of age and older IIV3 & IIV4 Fluvirin ® Novartis - 4 years of age and older IIV3 Afluria ® CSL - 9 years of age and older IIV3 Flucelvax ® Novartis - 18 years of age and older (ccIIV3)* FluBlok ® Protein Sciences - 18 through 49 years (RIV3)** Fluzone ® Intradermal sanofi-pasteur - 18 through 64 years IIV3 Fluzone ® High-Dose sanofi-pasteur - 65 years and older IIV3 *ccIIV3 = cell culture based trivalent inactivated influenza vaccine **RIV3 = recombinant hemagglutinin influenza vaccine Ref. Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices (ACIP) Influenza Season MMWR /Vol. 63/ No. 32, August 15, 2014

40 Live, Attenuated Influenza Vaccine (LAIV4) Administer by Nasal spray: FluMist® Medimmune - for healthy persons 2 through 49 years of age - not for pregnant women When immediately available, LAIV4 should be used for healthy children aged 2 through 8 years who have no contraindications. If LAIV4 is not immediately available, IIV should be given so that opportunities to vaccinate children are not missed or delayed. FOLLOW UP NOTE During the 2013-'14 influenza season LAIV was not effective against the influenza A H1N1 pandemic strain (H1N1 pdm09) virus when compared with inactivated influenza vaccine (IIV) in children 2 through 8 years of age. (Red Book Online Special Alerts—November 7, 2014) MMWR; August 15, 2014, Vol 63 #32; On February 26, 2015 ACIP voted to recommend either IIV or LAIV as appropriate option. Official recommendation pending publication in MMWR

41 Hepatitis A Fecal-Oral transmission Food borne outbreaks Adults average 27 lost work days per illness Risk factors include child or employee in child care facility and travel Children often asymptomatic – but can infect others Photo Courtesy Immunization Action Coalition

42 ACIP recommends 2 doses for all children: 12 through 23 months of age and Children 2 through 18 years who have not previously received the vaccine, can receive the vaccine at subsequent visits. Hepatitis A Vaccine ACIP recommends the vaccine for adults at high-risk for acquiring hepatitis A infection: Those traveling or working in countries with high or intermediate rates of infection Men Who Have Sex with Men Users of Injecting and Non-Injecting Drugs Contact with adoptees from countries with high rates of hepatitis A if contact will be within 60 days of arrival in U.S. MMWR, May 19, 2006, Vol 55, #RR-07

43 Hepatitis B ACIP Recommends hepatitis B vaccine for: All newborns before discharge from the nursery using single antigen vaccine and completion of the series per schedule. All children and adolescents less than 19 years of age who did not complete the series as an infant. All adults at risk for hepatitis B infection, including those aged 19 through 59 years with diabetes mellitus Persons of any age at risk for infection by sexual exposure All other adults seeking protection from HBV infection. Transmission: 1. Percutaneous or mucosal exposure to blood or body fluids including contaminated surfaces, or exposure by sexual contact 2. Perinatal infection from HBsAg + mother MMWR, December 23, 2005, Vol 54, #RR16 MMWR, December 8, 2006, Vol 55, #RR16

44 Meningococcal Disease Meningitis ~50% of cases 9-10% fatality rate Meningococcemia 5%-20% of cases Up to 40% fatality rate Rash Vascular damage Disseminated intravascular coagulation Multi-organ failure Shock Death can occur in 24 hours Ref: 1. Epidemiology and Prevention of Vaccine-Preventable Diseases. 12th Edition, May AAP Red Book 2012 Photo courtesy CDC: Dr. Brodsky & Mr. Gust 11-19% of survivors have permanent sequelae From Schoeller, T, Schmutzhard E. NEJM 2001;34:1372

45 Meningococcal Conjugate Vaccine (MCV4) (Men A,C,Y, W-135) Menactra  licensed for 9 mos. through 55 years Menveo® licensed for ages 2 mos. through 55 years ACIP Recommendation: One dose at 11 or 12 years of age and a booster dose at 16 yrs. If first dose is at years, give one booster dose 5 years after the first dose or sooner if entering college or technical school If first dose given ≥ 16 years of age, a 2 nd dose is not needed 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. For persons 56 years and older who need meningococcal vaccine, use MPSV4. If MCV4 has been given previously and a booster is needed MCV4 is preferred. MMWR, March 22, 2013, Vol 62, RR #02

46 Serogroup B Meningococcal Vaccine Bexsero® licensed for ages 10 through 25 years (2 dose) Trumenba® licensed for ages 10 through 25 years (3 dose) On February 26, 2015 ACIP voted to recommend serogroup B meningococcal vaccine for: Persons with persistent complement component deficiencies Persons with anatomic or functional asplenia Microbiologists routinely exposed to isolates of Neisseria meningitidis Persons identified to be at increased risk because of a serogroup B meningococcal disease outbreak Official recommendation pending publication in MMWR

47 Types of Human Papilloma Virus (HPV) Mucosal/Genital ~40 types Cutaneous ~60 types Cervical cancer Anogenital cancer Oropharyngeal Cancer Cancer precursors Low grade cervical disease Genital Warts Laryngeal Papillomas Low grade cervical disease Skin warts Hands and Feet High risk types 16, 18, 31, 33, 45, 52, 58 (and others) Low risk types 6, 11 and others Ref: 1.Epidemiology and Prevention of Vaccine Preventable Diseases 12 th Edition, May Red Book – AAP 2012 Report of the Committee on Infectious Diseases

48 HPV Vaccines Cervarix® (HPV2 ) HPV types 16 & 18 Gardasil ® (HPV4) HPV types 6, 11, 16, 18 Gardasil 9 ® (HPV9) HPV types 6, 11, 16, 18, 31, 33, 45, 52, 58 ACIP recommends HPV vaccine starting at age 11 or 12 years for: All females through 26 years of age using HPV2, HPV4 or HPV 9. All males through 21 years of age and males 22 through 26 years with risk factors using HPV4 or HPV9. Non risk males 22 through 26 years may also receive the vaccine. HPV 9 may be used to complete the 3 dose series that was started with HPV2 or HPV4 MMWR, March 27, 2015, Vo1 64, No. 11 Dose 2 should be given at least 1 to 2 months after first dose (1 month minimum) Dose 3 should be given at least 6 months after the first dose (minimum of 3 months between dose 2 and 3)

49 Rotavirus causes severe diarrhea, vomiting, fever, and dehydration, typically in infants and young children. Leading cause of diarrhea in infants and young children in the U.S., easily spreading to other children and adults. Most likely to occur between November and May. Rotavirus ACIP recommends: RotaTeq®: 3 doses; ages 2, 4, 6 months OR Rotarix®: 2 doses; ages 2 and 4 mo n ths MMWR, February 6, 2009, Vol 58, #RR-02

50 Critical Elements for Immunization Services

51 Healthcare Personnel (HCP) Need These Immunizations Annual influenza vaccine Tdap or Td Hepatitis B (exposure risk) Check immunity Validate immune status of: Varicella Measles, Mumps & Rubella (MMR) Are YOU up to date?

52 Appropriate Vaccine Storage & Handling is Very Important Store all vaccines as recommended by manufacturer Monitor and record temperatures of refrigerator and freezer twice daily Take immediate action for all out-of-range temps Implement a vaccine emergency system Maintain temperature log records for 3 years DO NOT STORE ANYTHING ELSE in the refrigerator!

53 Check Expiration Date of Vaccines and Diluents 12/15 12/10/15 Vaccine Expiration Date is 12/10/15 Use through December 10, 2015 Do NOT use on or after December 11, Vaccine Expiration Date is 12/15 Use through December 31, 2015 Do NOT use on or after January 1, Note: Some multidose vials have a specified time frame for use once the vial is entered with a needle. This may vary from the expiration date printed on the vial.

54 The 7 Rights of Vaccine Administration Right Patient Right Vaccine or Diluent Right Time* Right Dosage Right Route, Needle Length, Technique Right Site for route indicated Right Documentation * Correct age, appropriate interval, and administer before vaccine or diluent expires Ref: Epidemiology and Prevention of Vaccine-Preventable Diseases. 12th Edition, May 2012.

55 Intramuscular (IM) DTaP, Tdap, Hib, Td, Hep A, Hep B, PCV13, IIV, MCV4, HPV Subcutaneous (SQ, SC, or sub-Q) MMR, MMRV, Varicella, MPSV4, Herpes Zoster Either intramuscular or subcutaneous IPV, PPSV23 Intranasal LAIV Intradermal IIV (Fluzone) Orally (PO) Rotavirus Sites for Vaccine Administration

56 General Recommendations Published January 2011

57 General Recommendations Contents Timing and spacing of vaccines Contraindications and precautions Vaccine administration Vaccine storage and handling Altered immunocompetence Special situations Vaccination records Reporting adverse events Vaccine information sources

58 Vaccine Information Statements Information sheets produced by the CDC Explanation of risks and benefits of a vaccine Federal law requires that a VIS be handed to patient/parent before each dose of vaccines is given Must be provided for any vaccine that is covered by the Vaccine Injury Compensation Program Available through Immunization Action Coalition (IAC) at

59 Always Document… After vaccine administration document: Publication date of VIS & Date VIS given Date, site, route, antigen(s), manufacturer, lot # Person administering vaccine, practice name and address Vaccine refusals with a signed “Refusal to Vaccinate Form” Accept only written documentation of prior immunizations

60 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

61 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

62 Questions? Check out these links for more immunization information and resources! National Immunization Program ► Hotline 800.CDC.INFO Website Georgia Immunization Program Hotline Website Immunization Action Coalition Phone Website

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64 Schedule for children & adolescents Birth thru 18 years of age


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