1. Adult Vaccines

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

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

4. Gaps Persist Between Vaccination Rates and Goals US Goals: Elderly: 90% HR < 65: 60% HR denotes High Risk Schiller J, et al. http://www.cdc.gov/nchs/data/hestat/vaccine_coverage.htm. Accessed September 2009.

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

6. Tdap 10 to 18 years of age19 to 64 years of age Replaces Td booster for 11 ­ 12-year-olds Catch-up for 13-18 yrs (5-year interval from Td encouraged) If no previous DPT series, give as 1 Tdap + 2 Td Give with MCV4 if both vaccines are indicated Replaces Td booster; wound management* 2-year interval from Td for adults in contact with infants; health care workers Anyone who wants to decrease risk of disease The safety and effectiveness of Tdap have not been established in pregnant women CDC. MMWR Recomm Rep. 2006; 55(RR3):1-34. CDC. MMWR Recomm Rep. 2006;55(RR17);1-33. CDC. MMWR Morb Mortal Wkly Rep. 2009;58(14):374-375. If overall risk/benefit is favorable, discount risk of local rxns and immunize * Only if no previous Tdap received

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

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

9. Available HPV Vaccines Quadrivalent Merck - Gardasil ® Bivalent GSK - Cervarix ® Licensed in the US 20062009 Virus-like Particle Types HPV 6, 11, 16, 18HPV 16, 18 Protection against HPV 16/18 related CIN2+ ≥ 98%≥ 93% Protection against HPV 6/11 related genital lesions ~99%--- Hypersensitivity-related contraindication YeastLatex Age ranges Routine 11 or 12 yrs, as young as 9 yrs; catch-up 13-26 yrs Routine 11 or 12 yrs, as young as 10 years; catch-up 13-25 yrs Schedule 0, 2, 6 months0, 1, 6 months Markowitz L. ACIP Meeting Oct 2009. http://www.cdc.gov/vaccines/recs/acip/downloads/mtg-slides-oct09/02-2-hpv.pdf. Accessed Oct 2009. CIN2+: cervical intraepithelial neoplasia grade 2 or higher and adenocarcinoma in situ

10. HPV – ACIP Recommendations Quadrivalent HPV (HPV4) and Bivalent HPV (HPV2) Routine vaccination of females aged 11-12 years with 3 doses of HPV vaccine –Catch-up 13-26 yrs (HPV4); 13-25 yrs (HPV2) ACIP: no preference for either vaccine HPV4 or HPV2 vaccination for prevention of HPV 16/18- related cervical cancers, precancers and dysplastic lesions Vaccination with HPV4 for additional prevention against genital warts Monitor patients for 15 minutes following vaccination for syncopal episodes ACIP Schedules. www.cdc.gov/vaccines/recs/schedules/default.htm. Accessed Jan 2010.

11. HPV Vaccination and Pregnancy HPV vaccines are not recommended for use in pregnant women Initiation of the vaccine series should be delayed until after completion of pregnancy If a woman is found to be pregnant after initiating the vaccination series, delay remaining doses until after the pregnancy If a vaccine dose has been administered during pregnancy, there is no indication for intervention Two vaccine in pregnancy registries have been established. Patients and health care providers should report: –Quadrivalent HPV vaccine/pregnancy: 800-986-8999 –Bivalent HPV vaccine/pregnancy: 888-452-9622 CDC. http://www.cdc.gov/vaccines/recs/provisional/downloads/hpv-vac-dec2009-508.pdf. Accessed March 2010.

12. HPV Quadrivalent Vaccine in Males FDA approved quadrivalent HPV vaccine for prevention of genital warts due to HPV types 6 and 11 in boys and men ages 9 through 26 ACIP: Permissive HPV vaccine for males –Cost effectiveness –Priority vaccinating females to reduce overall disease/cancer burden –Quadrivalent HPV vaccine most effective when given before exposure to HPV through sexual contact FDA News Release. http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm187003.htm. Accessed Oct 2009. Dunne E. ACIP Meeting Oct 2009. http://www.cdc.gov/vaccines/recs/acip/downloads/mtg-slides-oct09/02-9-hpv.pdf. Accessed Oct 2009.

13. Quadrivalent HPV Vaccine for Women 27–45 years Under FDA Review ACIP Considerations As women age from their mid 20s –HPV prevalence decreases –HPV incidence decreases –Likelihood of having acquired HPV infection increases Disease outcomes (genital warts, CIN 2/3) peak among women in their mid to late 20s, potential benefit of vaccinating women in late 20s to early 40s would be minimal Questions on natural history of incident infections in adult women Greatest benefit from vaccinating females in early adolescence Clinical trial data (women 24–45 years) –Efficacy against HPV 6/11/16/18-related persistent infection, CIN, external genital lesions –Well tolerated Dunne E. http://www.cdc.gov/vaccines/recs/acip/downloads/mtg-slides-feb10/02-3-hpv.pdf. Accessed March 2010. Haupt R. http://www.cdc.gov/vaccines/recs/acip/downloads/mtg-slides-feb10/02-2-hpv.pdf. Accessed March 2010. CIN: cervical intraepithelial neoplasia

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

15. Shingles (Herpes Zoster) CDC. http://www.cdc.gov/vaccines/vpd-vac/shingles/photos.htm. Accessed September 2009.

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

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

18. Zoster Vaccine Cost Issues Routine vaccination not covered by Medicare part B –Eligible for reimbursement by Medicare part D  In the office, check that insurance can be billed directly through the computer billing system or through pharmacy, otherwise patient will have to pay full amount and claim for reimbursement  Outside the office, ensure vaccine administered at a pharmacy or other location covered by insurance CDC. http://www.cdc.gov/vaccines/vpd-vac/shingles/vac-faqs.htm. Accessed September 2009. AAFP. http://www.aafp.org/fpm/20070700/33bill.html. Accessed September 2009.

19. Varicella-Zoster Vaccine Shingles Prevention Study Randomized, placebo-controlled, double-blind vaccine trial –Study population  38,546 volunteers at 22 sites; adults 60+ years  95% of volunteers completed study –Follow-up: median duration 3.12 years Vaccine recipients:  Overall incidence of herpes zoster reduced by 51% 60-69 years ↓64% ≥ 70 years ↓38%  Incidence of post-herpetic neuralgia reduced by 67%  Injection site reactions were more frequent in the vaccine group Oxman MN, et al. N Engl J Med. 2005;352:2271-2284.

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

21. Seasonal Influenza Has a Huge Annual Impact in the United States *Average of all causes, 1976-77 through 1998-99. † Average of all causes, 1990-91 through 1998-99. CDC. MMWR Recomm Rep. 2003;52(RR-8):1-36. Thompson WW, et al. JAMA. 2003;289:179-186. Adams PF, et al. Vital Health Stat 10. 1999;200:1-203. Cases25–55 million+ cases Days of Illness100–200 million days Work loss days10’s of millions Hospitalizations100,000–300,000 Deaths35,000*–50,000 † CostsBillions of dollars

22. Annual Influenza Vaccine is Recommended for: All people age 6 months and older! CDC. http://www.cdc.gov/vaccines/recs/provisional/downloads/flu-vac-mar-2010-508.pdf. Accessed March 2010.

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

24. Influenza Vaccination During Most Recent Pregnancy – Georgia & Rhode Island § 95% confidence Interval † 2007 data for Georgia were not available CDC. MMWR Morb Mortal Wkly Rep. 2009;58(35):969-992. N = 5499 N = 5231 Year Percentage

25. 2009–2010 Seasonal Influenza Vaccines 2009–2010 seasonal influenza vaccine formulation: –A/Brisbane/59/2007(H1N1)-like virus –A/Brisbane/10/2007 (H3N2)-like virus –B/Brisbane/60/2008-like antigens Vaccines Trivalent Inactivated, Injectable Influenza Vaccine  Fluzone ® (sanofi): age ≥ 6 months  Fluvirin ® (Novartis): age ≥ 4 years  Fluarix ® (GSK): age ≥ 3 years  FluLaval™ (ID Biomedical/GSK): age ≥ 18 years  Afluria ® (CSL): age ≥ 6 months Live Attenuated, Nasal Spray Influenza Vaccine  FluMist ® (MedImmune): age 2 through 49 years (healthy, non-pregnant) Seasonal 2009 influenza vaccine does not protect against 2009 (pandemic) H1N1 influenza CDC. MMWR Recomm Rep. 2009;58(RR8):1-52. CDC. http://www.fda.gov/BiologicsBloodVaccines/Vaccines/ApprovedProducts/ucm094045.htm. Accessed March 2010.

26. 2009 H1N1 (Pandemic) Influenza Vaccines As of November 11, 2009: 4 monovalent inactivated vaccines approved CSL Limited –Age 6-35 mos: Two 0.25 mL IM doses (4 wk interval) –Age 36 mos to 9 yrs: Two 0.5 mL IM doses (4 wk interval) –Age ≥ 10 yrs: Single 0.5 mL IM injection –Adults ≥ 18 yrs: Single 0.5 mL IM injection Novartis Vaccines and Diagnostics Limited –Age 4-9 yrs: Two 0.5 mL IM doses (4 wk interval) –Age 10-17 yrs: Single 0.5 mL IM injection –Age ≥ 18 yrs: Single 0.5 mL IM injection Sanofi Pasteur, Inc. –Age 6-35 mos: Two 0.25 mL IM doses (4 wk interval) –Age 36 mos to 9 yrs: Two 0.5 mL IM doses (4 wk interval) –Age ≥ 10 yrs: Single 0.5 mL IM injection –Adults ≥ 18 yrs: Single 0.5 mL IM injection ID Biomedical/GSK –Adults ≥ 18 yrs: Single 0.5 mL IM injection 1 live attenuated (nasal administration) MedImmune LLC –Age 2-9 yrs: Two 0.2 mL doses (0.1 mL per nostril), 4 week interval –Age 10-49 yrs: Single 0.2 mL dose (0.1 mL per nostril) Prescribing information available at: http://www.cdc.gov/h1n1flu/vaccination/dosage.htm#table1. Accessed December 2009.

27. 2009 H1N1 Influenza Summary Between April 2009 and February 13, 2010 Cases of H1N1 Influenza  42–86 million  Mid-level: 59 million H1N1-related Hospitalizations  188,000–389,000  Mid-level: 265,000 H1N1-related Deaths  8,520–17,620  Mid-level: 12,000 Vaccination Coverage  ~86 million people received 97 million doses of H1N1 vaccine CDC. http://www.cdc.gov/h1n1flu/estimates_2009_h1n1.htm. Accessed March 2010.

28. Percentage of Visits for Influenza-like Illness; National Summary Oct 2006–Feb 2010 Finelli L, et al. http://www.cdc.gov/vaccines/recs/acip/downloads/mtg-slides-feb10/05-2-flu-vac.pdf. Accessed March 2010.

29. 2009–2010 College Influenza-like Illness Finelli L, et al. http://www.cdc.gov/vaccines/recs/acip/downloads/mtg-slides-feb10/05-2-flu-vac.pdf. Accessed March 2010.

30. Influenza Hospitalizations, Sep 2009–Feb 2010 Finelli L, et al. http://www.cdc.gov/vaccines/recs/acip/downloads/mtg-slides-feb10/05-2-flu-vac.pdf. Accessed March 2010.

31. Aggregate Hospitalizations 2009–H1N1 April 2009–Feb 2010 Finelli L, et al. http://www.cdc.gov/vaccines/recs/acip/downloads/mtg-slides-feb10/05-2-flu-vac.pdf. Accessed March 2010.

32. Influenza Deaths, Sep 2009–Feb 2010

33. Deaths 2009–H1N1 Influenza April 2009–Feb 2010 Finelli L, et al. http://www.cdc.gov/vaccines/recs/acip/downloads/mtg-slides-feb10/05-2-flu-vac.pdf. Accessed March 2010.

34. Influenza Vaccination (H1N1, Seasonal or Both) by mid-January 2010 Data from National 2009 H1N1 Flu Survey (NHFS) Singleton J. http://www.cdc.gov/vaccines/recs/acip/downloads/mtg-slides-feb10/05-4-flu-vac.pdf Accessed March 2010.

35. 2010–2011 Influenza Season Universal Influenza Vaccination –All people 6 months and older are now recommended to receive annual influenza vaccination 2010-2011 Trivalent Influenza Vaccines –A/California/7/2009(H1N1)-like virus Same strain as in the 2009 H1N1 monovalent vaccine – A/Perth/16/2009(H3N2)-like virus New strain for northern hemisphere vaccine Same strain as 2010 southern hemisphere seasonal strain –B/Brisbane/60/2008-like virus No change CDC. http://www.cdc.gov/vaccines/recs/provisional/downloads/flu-vac-mar-2010-508.pdf. March 2010.

36. Continued Emphasis on High-risk Groups: –Children aged 6 months through 4 years –Adults ≥ 50 years –Women who will be pregnant during the influenza season –Persons who have chronic pulmonary, cardiovascular, renal, hepatic, neurological, neuromuscular, hematological or metabolic disorders –Persons who have immunosuppression (including caused by medication or HIV) –Residents of nursing homes and other chronic-care facilities –Health care personnel –Household contacts and caregivers of children aged < 5 year and adults aged ≥ 50 years, with particular emphasis on vaccinating contacts of children < 6 months –Household contacts and caregivers of persons with medical conditions that put them at higher risk for severe complications from influenza 2010–2011 Influenza Season CDC. http://www.cdc.gov/vaccines/recs/acip/downloads/mtg-slides-feb10/05-7-flu-vac.pdf. Accessed March 2010.

37. Flu Shots May Also Reduce Hospitalizations for Cardiovascular Disease 2-year cohort study of elderly members of 3 HMOs –1998–1999 and 1999–2000 seasons with > 140,000 elderly members in each year’s cohort After multivariable analysis, vaccination cohort showed a reduced risk of death and hospitalization Nichol KL, et al. N Engl J Med. 2003;348:1322-1332.

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

39. Nosocomial Influenza Is Well Documented Nosocomial outbreaks documented on –Solid organ transplant units –Oncology units –Neonatal ICU –Pediatric units –Long term care facilities –General medical wards Results: morbidity for patients & staff, increased costs for institution & impaired capacity to provide care Vectors for transmission include staff, visitors, patients Stott DJ, et al. Occup Med (Lond). 2002;52:249-253. Encourage hygiene etiquette amongst staff and patients

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

41. Pneumococcal Polysaccharide Vaccine (PPSV23) Contains polysaccharide surface antigens expressed on S. pneumoniae –Over 90 known serotypes Vaccine contains 23 polysaccharide serotypes from S. pneumoniae –1-4, 5, 6B, 7F, 8, 9N, 9V, 10A, 11A, 12F, 14, 15B –17F, 18C, 19F, 19A, 20, 22F, 23F, 33F Included in PCV7 New conjugate vaccine –PCV13 (Serotypes 1, 3, 4, 5, 6A, 6B, 7F, 9V,14,18C,19A,19F, 23F) CDC. http://www.cdc.gov/vaccines/pubs/pinkbook/downloads/pneumo.pdf. Accessed March 2010. CDC. MMWR Morb Mortal Wkly Rep. 2010;59(9):258-261.

42. Pneumococcal Polysaccharide Vaccine (PPSV23) Single dose recommended for: All ≥ 65 years 2–64 years: chronic cardiovascular disease, chronic pulmonary disease, diabetes, alcoholism, chronic liver disease, CSF leaks, asplenia, cochlear implants > 2 years and immunocompromised Asthmatics and smokers age 19-64 years Proposed language for one-time revaccination: “A second dose of PPSV23 is recommended 5 years after the first dose of PPSV23 for persons aged ≥ 2 years who are immunocompromised, have sickle cell disease, or functional or anatomic asplenia” ACIP Schedules. http://www.cdc.gov/vaccines/recs/schedules/default.htm. Accessed September 2009. CDC. http://www.cdc.gov/vaccines/recs/provisional/downloads/pneumo-oct-2008-508.pdf. Accessed Oct 2009.

43. PPSV23 and Smokers Higher RR of invasive pneumococcal disease among smokers. Current smoker RR = 4.1. Passive exposure RR = 2.5. There is a dose response relation to number of cigarettes per day and pack years smoked Risks among smokers comparable to those of diabetes, asthma and other known risks 50/100,000/yr incidence rate NNV is 10,700 for age 18-44, 4000 for age 45-64 Nuorti J, et al. N Engl J Med. 2000;342:681-689. ACIP Meeting Oct 2008. http://www.cdc.gov/vaccines/recs/acip/downloads/min-oct08.pdf. Accessed September 2009.

44. Effectiveness of Pneumococcal Polysaccharide Vaccine in Older Adults: The VSD Cohort Study 3-year cohort study of 47,365 members of Group Health Coop (Seattle) PPV was associated with lower rates of bacteremia: –HR 0.56 (95% CI 0.33 to 0.93) PPV was not associated with lower rates of pneumonia –HR 1.07 (95% CI 0.99 to 1.14) HR = hazard ratio. Jackson LA, et al. N Engl J Med. 2003;348:1747-1755.

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

46. Hepatitis A Postexposure Prophylaxis For healthy persons 12 months through 40 years of age who have not previously received HepA vaccine –Take into account patient characteristics, including chronic liver disease Immunoglobulin and/or single-antigen hepatitis A vaccine should be administered as soon as possible after exposure –Vaccine preferred for those of age 12 mos to 40 yrs –Ig preferred for age < 12 mos, those with vaccine allergies, or those with immunosuppression or liver disease –Ig preferred for age > 40 but vaccine may be used if Ig unavailable –HepA and Ig may be administered simultaneously Efficacy of Ig or HepA when administered > 2 weeks postexposure is unknown CDC. MMWR Morb Mortal Wkly Rep. 2007;56(41):1080-1084. CDC. MMWR Morb Mortal Wkly Rep. 2009;58(36):1006-1007.

47. Hepatitis A Vaccine International Travel For healthy persons 40 years of age or younger –2 doses 6 months apart prior to departure –The first dose of Hepatitis A vaccine should be administered as soon as travel is considered –1 dose of single-antigen vaccine administered at any time before departure Consider both HAV and Ig for –Persons age > 40 with chronic illness traveling in less than 2 weeks and only receiving one dose of HAV –Persons at risk of severe disease from hepatitis A virus planning to travel in 2 weeks or sooner CDC. MMWR Morb Mortal Wkly Rep. 2007;56(41):1080-1084.

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

49. Hepatitis B Vaccine CompositionRecombinant HBsAg Efficacy95% (Range, 80%-100%) Duration of immunity20 years or more Schedule3 doses Hepatitis B. http://www.cdc.gov/vaccines/pubs/pinkbook/downloads/hepb.pdf. Accessed Oct 2009.

50. DoseInfants**Teens and Adults*** 116%-40%20%-30% 280%-95%75%-80% 398%-100%90%-95% HBV Protection* by Age Group and Dose *Anti-HBs antibody titer of 10 mIU/mL or higher **Preterm infants less than 2 kg have been shown to respond to vaccination less often ***Factors that may lower vaccine response rates are older than 40 years, male gender, smoking, obesity, and immune deficiency Hepatitis B. http://www.cdc.gov/vaccines/pubs/pinkbook/downloads/hepb.pdf. Accessed Oct 2009.

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

52. HepA-HepB Combination Vaccine (Twinrix) Approved for persons 18 years and older –Combination HepA vaccine (pediatric dose) and HepB (adult dose) First licensed schedule: 0, 1, and 6 months –Alternate schedule 2007: Doses at 0, 7, 21-30 days and a booster dose at 12 months The first 3 doses of the new schedule provide equivalent protection to: –The first dose in the standard single-antigen adult hepatitis A vaccine series –The first 2 doses in the standard adult hepatitis B vaccine series Seroconversion is nearly 100% after either 3 doses of the combination vaccine on the new schedule or a single dose of single-antigen adult hepatitis A vaccine –Duration of protection 4 yrs against HepA No increased benefit of the new schedule for the hepatitis B component compared to administration of 2 hepatitis B vaccine doses 1 to 2 months apart CDC. MMWR Morb Mortal Wkly Rep. 2007:56(40):1057.

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

54. Meningococcal Conjugate Vaccines Recommended for adolescents aged 11-18 years and others at increased risk for meningococcal disease –MCV4-D (Menactra ®, Sanofi): licensed for persons 2-55 years; Serogroups A, C, Y, W-135; diphtheria toxoid conjugate –MenACWY-CRM 197 (Menveo ®, Novartis): licensed for persons 11-55 years; Serogroups A, C, Y, W-135; diphtheria CRM 197 conjugate Revaccination for Persons at Increased Risk –Previous vaccination (meningococcal conjugate vaccine or MPSV4) at 2-6 years, revaccinate 3 years after initial meningococcal vaccine –Previous vaccination (meningococcal conjugate vaccine or MPSV4) at ≥ 7 years, revaccinate 5 years after initial meningococcal vaccine –This includes:  Persons with persistent complement component deficiencies  Persons with anatomic or functional asplenia  Microbiologists who are routinely exposed to isolates of N. meningitidis  Frequent travelers to or people living in areas with high rates of meningococcal disease (African meningitis belt) Meissner HC. http://www.cdc.gov/vaccines/recs/acip/downloads/mtg-slides-feb10/08-1- mening.pdf. Accessed March 2010. CDC. MMWR Morb Mortal Wkly Rep. 2009;58(37):1042-1043.

55. MMR Evidence of Immunity for Health Care Personnel: Mumps, Measles & Rubella Documented administration of two doses of live measles virus vaccine or Laboratory evidence of immunity or laboratory confirmation of disease or Born before 1957* ACIP Provisional Recommendations. http://www.cdc.gov/vaccines/recs/provisional/downloads/mmr-evidence- immunity-Aug2009-508.pdf. Accessed September 2009. *For unvaccinated personnel with no documentation or laboratory evidence of immunity, facilities should consider 2 doses of MMR for measles/mumps, and 1 MMR dose for rubella. Recommended during outbreaks.

56. Strategies for Improving Adult Immunization Rates

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

58. Provider Recommendation Can Overcome Negative Attitudes Among Patients Vaccination Rates Among High Risk Patients With Negative Attitudes Nichol KL, et al. J Gen Intern Med. 1996;11:673-677.

59. Improving Vaccination Rates – Provider Issues Know the facts Recommend vaccinations to your patients Get organized and use systems approaches –Ensure offering and administration of vaccine Automatic processes that empower nurses are effective Address convenience, efficiency, durability Evaluate and provide feedback Consider new paradigms –New venues –Extend vaccination season Practice what we preach (get vaccinated!) Nichol KL. Cleve Clin J Med. 2006;73:1009-1015.

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

61. Factors Associated With Very Strongly Recommending Vaccinations to Elderly Patients Adjusted OR Influenza Vacc. Adjusted OR PPV Monitor vaccination rates in practice as part of CI1.791.72 Vaccination cost saving2.022.92 Having received flu shot1.912.41 Indicating that systemic symptoms uncommon1.57— Number of system strategies used in practice—2.03 V important for HCW to get flu shot3.41.94 Male sex0.580.57 Generalist physician (vs subspecialist)—1.53 Patients risk for disease2.422.38 Concerns about drug resistance—1.46 Vaccine effectiveness1.42— Expert group recommendations—1.43 Having sufficient time to counsel—1.43 Liability issues2.041.64 Ease of targeting high risk groups1.73— Nichol KL, et al. Arch Intern Med. 2001;161:2702-2708.

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

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

64. Where Flu Shots Are Received (Often Not the Doctor’s Office) Singleton J, et al. Am J Infect Control. 2005;33:563-570.

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

66. Standing Orders Are Among the Most Effective Strategies Nonphysicians offer and administer vaccinations –No direct MD involvement at the time of the visit Established with physician approved policies and protocols Locations: –Clinics and hospitals CDC. http://www.cdc.gov/vaccines/recs/rate-strategies/adultstrat.htm. Accessed September 2009. McKibbin LJ, et al. MMWR Recomm Rep. 2000;49 (RR1):15-26.

67. Multifaceted Program Improved Success and Sustainability Increase DemandAnnual reminder to pts Enhance AccessWalk-in Clinics Address Provider BarriersInstitutional Policy Standing Orders Standardized Forms Efficient Clinic Flow Ongoing Measurement and Evaluation

68. Success of Standing Orders as Part of a Multifaceted Program Education Standing Orders Nichol KL. Am J Med. 1998;105:385-392. Influenza Vaccination Rates for Elderly Patients in General Medicine Clinics

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

70. Resources

71. PROTECT TM Website: http://www.francefoundation.com/protect/

72. Resources for Patients and Parents Guide to evaluating information on the web www.cdc.gov/vaccines/vac-gen/evalwebs.htm CDC Vaccine Information Statements (VISs) http://www.cdc.gov/vaccines/pubs/vis/default.htm Vaccine Safety www.cdc.gov/Features/VaccineSafety National Network for Immunization Information (NNII) www.immunizationinfo.org Allied Vaccine Group www.vaccine.org Immunization Action Coalition (IAC) www.immunize.org Vaccine Education Center at CHOP www.vaccine.chop.edu TCH Center for Vaccine Awareness and Research www.texaschildrens.org/carecenters/vaccine/default.aspx

73. Resources for Providers Immunization Schedules www.cdc.gov/vaccines/recs/schedules/ ACIP recommendations & provisional recommendations www.cdc.gov/vaccines/pubs/ACIP-list.htm www.cdc.gov/vaccines/recs/provisional/default.htm The Guide to Community Preventive Services. Vaccine recommendations www.thecommunityguide.org/vaccines/index.html Assessment, Feedback, Incentives, and Exchange (AFIX) www.cdc.gov/vaccines/programs/afix/default.htm National Foundation for Infectious Diseases www.nfid.org Centers for Medicare & Medicaid Services www.cms.hhs.gov

74. Resources for Providers, Parents, and Patients The Immunization Action Coalition: vaccine information for the public and health professionals www.vaccineinformation.org The Immunization Action Coalition: directory of immunization coalitions www.izcoalitions.org