Liza Chapman, Pharm.D. GPhA Annual Meeting Immunization Update 2013 Liza Chapman, Pharm.D. GPhA Annual Meeting

Faculty disclosure Liza Chapman has no disclosures to declare at this time

objectives Review the changes/developments made to the immunization recommendations during the past year Discuss cases and provide vaccine recommendations based upon the ACIP/CDC current schedules Identify new developments in practice that impact immunizing pharmacists’ practices

U.S Adult vaccination Rates, 2011 Vaccine (Target Group) Vaccination Rate (%) Influenza (50–64 years) 47.2 Influenza (>65 y/o) 64.9 Influenza (health care personnel (HCP)) 66.9 Pneumococcal (>65 y/o) 64.5 Pneumococcal (19-64 y/o high risk) 20.1 Tdap in past 6 years (19–49 y/o) 12.5 Tdap (HCP) 2005-2011 26.8 Hepatitis B (> 3 doses 19-49 y/o 35.9 Hepatitis B (HCP) 63.2 HPV Females (>1 dose) 21.5 Zoster vaccine (>60 y/o) 15.8 APhA IMZ CTP, 04.2013 National Health Interview Survey –2011 (http://www.cdc.gov/mmwr/pdf/wk/mm62e0129.pdf) National Immunization Survey 2011-2012 http://www.cdc.gov/MMWR/preview/mmwrhtml/mm6138a1.htm

Recent Disease Outbreaks Measles Outbreak (2011)1 222 cases reported Five times the number of cases in 2007 28,000 cases in Europe Mumps Outbreak (2011)2 29 Mumps cases on University campus in California Source – unvaccinated student – all cases linked 22 (76%) vaccinated with 2 doses MMR 2 with 3 doses, 2 with 1 dose, and 2 unknown Pertussis Epidemic3 41,880 cases reported in 2012 18 related deaths 4,783 in Washington State (965 in 2011) 18,719 cases total reported in U.S. in 2011 27,555 in 2010 APhA IMZ CTP, 04.2013 1. Measles. www.cdc.gov/measles 2. MMWR Morb Mortal Wkly Rep. 2012;61:986-989 3. CDC Pertussis Report (www.cdc.gov/pertussis)

Recap from 2013 National adult and Influenza Immunizations Summit

Hepatitis b

New ACIP recommendation Hepatitis b Target groups for HBV Infants Adolescents who have not been previously vaccinated High-risk adults Multiple sex partners Patients seeking treatment for STDs HIV patients IV drug users Dialysis patients Patients with chronic liver disease Health care providers All diabetics 19-59 years old Diabetics >60 years (permissive) New ACIP recommendation

Self-Assessment How many doses must a patient receive to complete the Hepatitis B series? 1 Dose 2 Doses 3 Doses 4 Doses

Self-Assessment It is October and R.J. is 82 y.o. male patient that is moving into an ALC. His medical conditions include: CHF, COPD, and T2DM. R.J.’s PCP cannot locate his vaccination records. Which vaccines would you recommend R.J. receive? Influenza Pneumococcal Zoster Hepatitis B All of the above

Influenza

Review of 2013-13 Influenza Season

HCPs and Influenza vaccinations http://www.cdc.gov/flu/fluvaxview/hcp-ips-nov2012.htm

HCPs and Influenza vaccinations http://www.cdc.gov/flu/fluvaxview/hcp-ips-nov2012.htm

HCPs and Influenza vaccinations http://www.cdc.gov/flu/fluvaxview/hcp-ips-nov2012.htm

HCPs and Influenza vaccinations http://www.cdc.gov/flu/fluvaxview/hcp-ips-nov2012.htm

2013-14 Influenza Vaccine Strains Influenza vaccine contains: A/California/7/2009 (H1N1)–like virus A/Texas/50/2012 (H3N2)–like virus B/Massachusetts/2/2012–like virus Yamagata lineage Quadrivalent Addition: B/Brisbane/60/2008-like virus Victoria lineage

2013-14 Influenza presentations Vaccine (manufacturer) Approved Age Indications Inactivated Influenza Vaccine Fluzone (sanofi pasteur) >6 months Fluvirin (Novartis) >4 years Fluarix (GSK) >3 years FluLaval (GSK) >18 years Afluria (CSL Biotherapies) >9 years Agriflu (Novartis) Fluzone High-Dose (sanofi pasteur) >65 years Fluzone Intradermal (sanofi pasteur) 18-64 years Flucelvax (Novartis) – cell cultured (not eggs) Flublok (Protein Sciences Corp) -recombinant 18-49 years Live Attenuated Influenza Vaccine FluMist (MedImmune) 2 years to 49 years http://www.cdc.gov/flu/protect/vaccine/vaccines.htm

New Manufacturing Technologies Cell cultured vaccine Recombinant HA vaccine

Selecting the best product for your patient It is up to the health care provider to determine the best influenza vaccine product for the patient based on patients’ needs Patient Age Preservative vs. preservative free Administration ID IM IN IIV3 or IIV4

Influenza Vaccine and Egg Allergies According to ACIP, individuals who have only reported hives as a result of vaccination with influenza vaccine should be vaccinated by following these safety measures: Use IIV rather than LAIV Vaccine should be administered by a health care professional familiar with egg allergies Observation after vaccination should be at lease 30 minutes http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6132a3.htm#egg_allergy

Influenza Vaccine and Egg Allergies APhA IMZ CTP, 04.2013

Self-assessment Which influenza vaccine would you recommend for R.J.? LAIV IIV3 IIV4 Fluzone HD Fluzone ID

Meningitis

Meningococcal Vaccine As of March, 2013, now an recommended vaccine for high-risk infants Complement deficiencies Asplenia Travel to certain countries Community outbreaks Not recommended for routine use FDA approved vaccines for infant use Menactra (sanofi-pasteur) – high risk infants only 2 dose series 8 weeks apart (9-23 months of age) Dose 0.5mL IM Menhibrix (GSK) 4 dose series (2,4,6,12-15 months of age) Dose: 0.5 mL IM Used if Hib vaccine needed Not for travel (only 2 serotypes) Community outbreaks only if serotypes C and Y If used, must complete all 4 doses http://www.cdc.gov/mmwr/pdf/rr/rr6202.pdf

Pneumococcal

Pneumococcal Vaccine PCV 13 (Prevnar) Indicated for the active immunization of children ages 6 weeks to 5 years old For the prevention of invasive disease caused by 13 Streptococcus pneumoniae serotypes For the prevention of otitis media caused by 7 Streptococcus pneumoniae serotypes FDA approved for adults aged 50 years and older (Not ACIP recommended for routine use) Dose and route: 0.5 mL IM

PCV 13 Target groups for vaccination Infants and children Routine schedule: 2, 4, 6, 12–15 months Any PCV series begun with PCV7 should be completed with PCV13 Administer a single supplemental dose of PCV13 for: Children aged 14–59 months who have received an age-appropriate series of PCV7 Children aged 60–71 months with underlying medical conditions who have received an age-appropriate series of PCV7 APhA IMZ CTP, 04.2013

PCV 13 and Adults FDA Approved adults >50 years Approval based upon serology ACIP No recommendations for routine use in all adults at this time Not enough data to evaluate Studies currently ongoing Recommended for: Immunocompromising conditions Functional or anatomical asplenia CSF leaks Cochlear implants APhA IMZ CTP, 04.2013

PCV 13 and Immunocompromised Adults It is possible that these patients could receive three doses of PPSV23 in their lifetime. APhA IMZ CTP, 04.2013

Self-Assessment If a patient has already had PPSV23 for a high-risk condition and also needs PCV13 for the same condition, how long should you wait before administering PCV13? No wait 4 weeks 8 weeks 12 weeks

Tdap

Pertussis Surveillance http://www.cdc.gov/pertussis/images/incidence-graph-age.jpg

Pertussis Outbreaks http://www.cdc.gov/pertussis/images/pertussis-graph-2012-lg.jpg

Tdap Age of Patient Recommendation 6 weeks to 6 years old Use DTaP to complete the primary series 7 years to 10 years old who are not fully vaccinated against pertussis Give a single dose of Tdap 11 to 64 years old If there is no record of a Tdap dose, give a single dose of Tdap followed by one dose of Td every 10 years >65 years old If there is no record of a Tdap dose, give a single dose of Tdap followed by one dose of Td every 10 years Health Care Providers If there is no record of a Tdap dose, give a single dose of Tdap. Pregnant women (every pregnancy) Give a dose of Tdap after 20 weeks of gestation. (27-36 weeks optimal)

Self-assessment Some women have closely spaced pregnancies. Should Tdap be given during each pregnancy, even if it means such women would get 2 doses within 12 months? Yes No

Travel vaccines Japanese Encephalitis (Ixiaro) Approved age now includes children 2 months and over 2 Dose vaccine series 0 and 28 days 2 months to 35 months 0.25 ml 36 months and older 0.5 ml Yellow Fever (YF-VAX) WHO has determined there is no need for booster vaccination

Make sure you are up to date www.cdc.gov MMWR Epidemiology and Prevention of Vaccine-Preventable Diseases 2012 Yellow Book www.immunize.org IAC Express Current VISs www.pharmacist.com/immunization-center

Questions Liza Chapman liza.chapman@kroger.com