1. Immunizations: 101 The Basics of Vaccine Administration
Introduce self
Introduce Topic: to review information necessary to the safe and appropriate administration of childhood immunizations.
Beth Meadows, RN
Lori Hall, RN
Regional Immunization Nurse Consultants
NC Immunization Branch

2. Let the Fun Begin
Today I am going to walk you through the general information and issues you need to be aware of, or familiar with, in order to safely and appropriately administer childhood vaccines.
In one short session we can not talk in detail about all of the information needed to properly immunize children.
What I will attempt to do is to raise issues you need to fully understand, and to guide you to information that you need to have at your fingertips as you immunize.
The plan for the next hour and a half is to begin by reviewing general information regarding childhood immunizations. There will be a question and answer session following this presentation, so please feel free to ask any burning questions you may have at that time.
Medical recommendations discussed will follow current medical recommendations of ACIP.

3. When most of us think of vaccines, we simply think of infants being immunized every few months. Most people do not think of the complexities of vaccine administration which can sometimes lead to a great deal of frustration. My hope is that through this presentation, we can eliminate some of these feelings……….

4. …..so we can all feel more confident in our roles to protect North Carolina from Vaccine Preventable Diseases.

5. Impact of Vaccines in 20th Century
Smallpox 48,
Diphtheria 175,
Pertussis 147, ,291
Tetanus 1,
Polio (paralytic) 16,
Measles 503,
Mumps 152, ,528
Haemophilus influenzae
(<5 years) 20,000 (est)
(serotype B or unknown serotype)
First things first. Why are we so passionate about childhood immunizations? It’s because vaccines protect children and their communities from the unnecessary consequences of what are now predominately preventable childhood illnesses.
Smallpox: During ,an average of 48,164 cases with 1528 deaths caused both the severe and milder forms of smallpox were reported each year in the US. In 2010 there were no cases of smallpox in this vaccine preventable age.
Polio: During , an average of 16,316 paralytic polio cases and 1879 deaths from polio were reported each year. In 2010 there Were no cases identified.
Measles: During , an average of 503,282 and 432 measles-associated deaths were reported each year. In 2010 there were 61 cases of measles reported in the US.
HiB: Before the first vaccine was licensed, an estimated 20,000 cases of HiB invasive disease occurred each year, and HiB was the leading cause of childhood bacterial meningitis and postnatal mental retardation.
Rubella 47,745 6
Congenital rubella 823 0

6. Agenda Vaccine Issues Child Related Issues Documentation
State Law and State Vaccine Program
There are 5 agenda items I will cover today.
Issues related to the vaccines themselves
Issues related to the child receiving vaccines
Documentation issues
A brief review of NC State law requirements and the NCIP

7. Vaccine Issues Schedules Product Recognition
Minimum Ages/Minimum Intervals
Administration
Storage/Handling
Vaccine Issues:
Schedules
State Law
Product Recognition
Minimum age/minimum intervals
Administration
Storage and Handling

8. Recommended Schedule 2011 By Vaccine By Ages
Footnotes: Don’t forget the footnotes.
Always read
Always heed
This schedule indicates the recommended ages for routine administration of currently licensed childhood vaccines, as of December 21, 2010 for children 0-6 years. Any dose not given at the recommended age should be given at any subsequent visit when indicated and feasible.

9. Walk through the schedule.
Persons Aged 0-6 Years:
By vaccine group or by age. Use DTaP as example.
Use age 6 months as example.
Highlight Need for Footnotes: read highlighted footnotes as examples
Persons Aged 7-18 Years:
By vaccine group or by age. Point out that Hep B, IPV, MMR and varicella are indicated when a primary series is incomplete.
Read high lighted footnotes.

10. Catch-Up Schedule Children age 4 months through 6 years
Children 7 years through 18 years
The next schedule in your toolbox is a catch-up schedule. The catch up schedule uses minimum intervals between doses in order to quickly immunized those children who are behind. The catch-up schedule gets them protected as quickly as is medically recommended. The catch up schedule is for those that are more than one month behind

11. Catch-Up Schedule
The top half of the catch-up schedule is for those children 4 months through 6 years of age. It gives you the minimum interval between vaccine doses in a series. You never want to administer vaccine doses at less than minimum interval. The dose just might not provide adequate immunity.
There is no need to restart a routine childhood vaccine series regardless of the time that has elapsed between doses.

12. Catch-Up Schedule
The second half of the catch-up schedule is for those children/teens who are 7 through 18 years of age.
Use the schedule appropriate to the child’s age.

13. Footnotes

14. Latest Age and Age Restrictions
HiB Age 5 years PCV13 Age 5 years DTaP Age 7 years DT Age 7 years Polio Age <18 years (US resident) Td Not before age 7 years Tdap ????????
Vaccine products have “latest date” or age restrictions. Review slide.
[Hib and PCV13 ≥ 59 mos. Only for asplenia, immunosuppression, etc ]
Vaccine products look like a vegetable soup sitting on your refrigerator and freezer shelves.
DTaP, DT, Td, Tdap (Boostrix and Adacel),
IPV, IEPV (inactivated enhanced potency vaccine),
Polio, HiB, Hep B, Hep A,
PCV13, PPV23, MCV4,
MPSV4, MMR, MMRV, rotavirus, HPV, varicella
Then sitting on that shelf may also be non-vaccine biologicals: ppd, immune globulin, Synagis (for RSV)
Then each vaccine has a product name:
Tripedia, Infanrix, Daptacel, Pediarix, Decavac, Adacel, Boostrix,
ActHiB, PedvaxHiB, Engerix B, Recombivax B, IPOL, Menactra,
Menomune, (ProQuad), Prevnar, Pneumonvax 23, Varivax,
Review new Tdap recs.

15. Vaccine Issues: Products Diphtheria/Tetanus
DTaP DT Td
Tdap: Boostrix,
Adacel
Combination Vaccines: Pentacel, Pediarix, and Kinrix
One of the most concerning issues occurs when we see health care providers who do not understand which/ when to administer different products.
When you open the refrigerator or freezer, what vial do you pull out?
Do you know the different vaccine products?
Even if you understand the vaccine schedule, do you know which product you just administered?
Example across the country, those using DTaP when they thought they had drawn up ppd.
Talk thru diphtheria and tetanus product differences

16. Vaccine Issues: Products
HiB
Hep
Polio
ppd
PCV 13
PPSV 23
MCV-4
MPSV-4
Dtap
Tdap
Talk thru recognizing:
HiB and Hep B and Hep A
Polio and ppd
PCV 13 and PPV 23
Pneumococcal vs meningococcal
PCV-13 vs PPSV-23
MCV-4 vs MPSV-4
MMR vs MMRV

17. Vaccine Issues: Minimum Age
At Birth
At 4 weeks
At 6 weeks-the case for HiB
Live Virus Vaccines-MMR
Varicella
Rotavirus
We’ve looked at the schedule in general terms. Let’s get down to some important specifics. Minimum age and minimum intervals.
At birth, only hep B; at 4 weeks only hep B;
Walk thru issues especially not administering HiB before age 6 weeks. Causing immunological tolerance
Before the FDA licensure of rotavirus vaccine (Rotateq) we would have said to give no live virus vaccine before 12 months. That is still true for MMR, MMRV and varicella. Rota virus vaccine is a live oral vaccine product.
Because mother may have passed on some circulating immunity to her infant MMR, MMRV and varicella should not be administered before 12 month. If the are a repeat dose would be in order to assure immunity.

18. Vaccine Issues: Minimum Intervals
Recommended Minimum Intervals
Interval between IG/Blood and Live Virus Vaccines
Diphtheria/Tetanus containing vaccines-no more than 6 by 7
Interval between MMR and ppd if not administered same day
Pregnancy and Live Virus Vaccines
Walk thru issues:
Recommended Minimum Intervals
Interval between IG/Blood and Live Virus Vaccines
Diphtheria/Tetanus containing vaccines-no more than 6 by 7
Interval between MMR and ppd if not administered same day: fine to give MMR the same day as a TB skin test, but if vaccine given recently (not day of), the skin test should be delayed for 4 weeks after vaccination.
Pregnancy and Live Virus Vaccines wait one month before becoming pregnant

19. Vaccine Issues: Administration
Standing Orders
For RNs
For LPNs
Explain license requirement for a medical order for licensed personnel- RNs and LPNs. RNs can not “prescribe therapies…”
Explain physician can employ unlicensed personnel under his license. He takes responsibility to teach and to supervise.
National Immunization Coalition’s examples match NC Board of Nursing guidelines. LHDs have stricter requirements for standing orders- LHDs must ensure they follow their agreement addenda with the NCIP.

20. Vaccine Issues: Administration
Anatomical Sites
Legs
Arms
Separation
ACIP and AAP recommend using the anterolateral aspect of the thigh for all infants. Toddlers (over 12 months of age-by time are walking) have deltoid muscles adequate to hold IM vaccine injections.
Buttocks of infants and toddlers are not recommended for vaccine, especially never for hepatitis B (not even for adults).
IM injections given in the same limb are to be separated by 1 inch.

21. Vaccine Issues: Administration
Intramuscular Injections:
Infants
Toddlers
Older Child
Subcutaneous Injections:
Needle length: Walk thru National Immunization Coalition charts pointing out needle length.
“If the subq and muscle tissue are bunched it minimize chance of striking bone, a 1-inch needle is required to ensure IM administration in infants.”
Refer to General Recommendations 12/1/2006
Vaccines containing adjuvants (eg. Aluminum-adsorbed DTaP,DT and Td, hep B, and hep A) must be injected deep into muscle mass. These vaccines should not be administered subq or intracutaneously, because they can cause local irritation inflammation, granuloma formation, and tissue necrosis.

22. Pop Test
What is the appropriate size needle length to use when administering an IM injection to an infant greater than 1 month?
A- 5/8 inch
B- 7/8 inch
C 1 inch
D Whatever is in the drawer

23. C: 1 inch

24. Vaccine Issues: Handling
Diluents
Prefilled syringes
Mixing vaccines
Expiration dates
Diluents: always only use those packaged with the vaccine. Never interchange diluents. [If must, live to live and inactivated to inactivated]
Diluents often have differing expiration dates from the vaccines they are
packaged with. And often have differing storage requirements. Refer to packet insert
Read package inserts!
Pre-filling syringes: never and explain why [mix up which is which; exposure to light and heat; wasted doses]. Differentiate packaged pre-filled vs manual pre-filling.
Never mix vaccines in the same syringe unless packaged together for that purpose.
Rotate vaccines by expiration dates. Can administer up to the last day of the month if marked only with month and year.

25. Vaccine Issues: Storage
Temperatures
Light
Clinic Settings
Disaster
Refrigerator: 2 to 8 degrees C
36 to 46 degrees F
Freezer: (Varicella and MMR and MMRV)
(-) 15 degrees and colder for C
(+) 5 degrees and colder for F
Temps must be checked twice a day and documented!!! This is true even for practices using continuous monitoring systems.
Mark both refrigerator/freezer and breaker box “do not unplug”.
Rotate expiration dates.
No vaccines stored in door shelves OR ON THE FRIDGE FLOOR
Ensure appropriate air flow to the vaccine
Dorm units can only be used for daily storage of a small amount of refrigerated vaccines.
Ensure the Disaster Recovery Plan is completed, updated annually, and posted.
Always contact the immunization branch for out of range temperatures .
Thermometers must be certified. (Keep the certification)

26. What is Wrong?? Dorm unit No air flow MMR in unit Vaccine in doors
Positive- does have water bottle and thermometer

27. Better?

28. Child Related Issues Contraindications Teaching/Counseling After Care
Emergency Care
Child related issues:
Contraindications
Teaching and Counseling
After Care
Emergency Care

29. Contraindications
“Guide to Contraindications and Precautions for Childhood Vaccinations”
“Screening Questionnaire for Child and Teen Immunization”
Package Inserts
Review web site references and importance of reading package inserts!
Point out change in MMR (egg vs gelatin allergy).

30. Contraindications State Law and medical exemptions Screening tools
Explain:
NC Medical exemptions based upon ACIP recognized contraindications.
Review NC medical exemption form and request for medical exemption form. See packet
Next slide:

31. Contraindications Check and Double Check
National Immunization Screening Questionnaire
National Immunization Coalition screening tools
Point out that there is an Adult chart available from National Immunization Coalition

32. Teaching and Counseling
Risks vs Benefits
Adverse Reactions
Law Requirements
The more knowledgeable you are, the more trusting parents will be of your care. Visit the Vaccine Safety web site to have your concerns addressed. And to be able to direct parents to reliable information
[A website of Johns Hopkins University]
And, how about Children’s Hospital of Philadelphia’s Vaccine Education Center:
Discuss VIS federal requirements:
“Before a healthcare provider vaccinates a child or adult with a dose of any vaccine containing: dipth., tetanus, pert., measles, Mumps, rubella, polio, hep A, hep B, HiB, varicella, flu, pneumon. …the provider is required by the National Childhood Vaccine Injury Act to provide a copy of the VIS to either the adult or to the child’s parent.”
Immunizing staff should be prepared to answer questions regarding adverse reactions and benefits of vaccine protection;
Be prepared to explain conditions of state law.

33. After Care Wait or not to Wait? Analgesics? Adverse reactions
Parent: call provider
Provider: notify VAERS
AAP says “that when possible, patients should be observed for an allergic reaction for 15 to 20 minutes after receiving immunizations. Review HPV recommendation related increase in reports of syncope after HPV.
Appendix of Pink Book has a good review materials for care, restraint, and pain control
Suggestions includes: acetaminophen after vaccination (warning not to use aspirin) and cold cloth to limb for swelling redness. “Evidence does not support use of antipyretics before or at the time of vaccination;however, they can be used for the treatment of fever and local discomfort that might occur following vaccination.”
Advise parents if temp up greatly or Sx severe, call!
Review what VAERS is: The National Childhood Vaccine Injury Act of 1986, mandated that health care workers who administer vaccines, and licensed vaccine manufactures, report certain adverse health events following specific vaccinations. VAERS created in 1990 to unify efforts for the collection of all reports of clinically significant adverse events

34. Adverse Reactions Emergency Care Protocols Epinephrine Benadryl
All staff administering vaccines need to be prepared to handle the potential medical emergency arising from a vaccine adverse event up to and including anaphylaxis.
National Immunization Coalition has an example of standing orders for medical management of vaccine reactions at:
www,immunize.org
left index under “standing orders” If standing orders are not in place, a direct order can be taken from a physician. Someone in every office should be designated to ensure standing orders are updated annually and emergency medications are checked monthly for expiration.

35. Administration Errors
Don’t Panic
Inform parent of potential side effects and/or need for revaccination at a later time.
Document the dose
Even if a vaccine was given in error, it was still administered and must be documented.

36. Documentation Issues Permanent Medical Record
Certificate of Immunization
Documentation Issues:
Permanent medical records
Certificate of Immunization required by state law:
Name, DOB, name of vaccine, date admin.,
name and address of provider.

37. Permanent Medical Record
Patient identification
Vaccine Name
Date of Administration
Manufacturer
Lot Number
Site (Anatomical)
Immunizer
VIS offered
VIS publication date
Route
The National Childhood Vaccine Injury Act requires the documentation of: review list
Site and Route required by UCVDP Vaccine Agreement

38. Documentation-continued
Certificate of Immunization
Vaccine Administration Log (VAL)
NC Immunization Registry (NCIR)
Explain state law and certificates of immunizations
Vaccine Administration Log (V. A. L.) or NCIR accountability for state supplied vaccines

39. Importance of Vaccine Histories
Immunizations are built on a foundation. Unless you know what bricks were put into place previously, you do not know where to start.
You must have historical immunization records…not parental word…for the vaccines a child has been given. Explain

40. Historical Record Sources
Provider’s Office(s)
Parent’s Records
NCIR
School Records
What sources can a provider use to obtain historical immunization records? Review
Provider’s Office(s)
Parent’s Records
NCIR
School Records-?? If all the information is present.

41. Vaccine Issues: State Law
NC General Statues
NC Administrative Code “The Rules”
NC’s Public Health Laws governing required immunizations for children are to be find both in the General Statues and in the N. C. Administrative Code. Both documents carry the force of law.
General Statues speak in board terms saying that all children present in NC will be protected against 10 diseases: diphtheria, tetanus, pertussis, measles, rubella, mumps, HiB, Hepatitis B, and varicella.
Give web address
NC Administrative Code gives the details

42. State Law Follow ACIP Recommended Childhood Schedule
Requires Certificate of Immunization presented for Child Care/School enrollment
General Statues require children to be protected but the details of how many doses and by what ages are to be found in the Rules. The Rules follow the ACIP Recommended Schedule by adding one month to the Harmonized Schedule and then requiring that number of vaccine doses a child must have by a given age.
State Laws that you need to be aware of include:
release of immunization records to…..
certifications of immunization required for child care and school
four day rule
Medical and religious exemptions
Powers of local health director for enforcement of Public Hlth Law and CD Laws

43. NCIP Follows current medical recommendations of ACIP
Requires Safeguarding of Vaccines
Requires Fiscal Accountability
Quickly as time allows, review State Vaccine Program:
Follows current medical recommendations of ACIP
Requires Safeguarding of Vaccines
Requires Fiscal Accountability
Pay attention to current NCIP Eligibility Criteria. Just because we send you state supplied vaccine, does not mean you can use that vaccine for all for whom it would be medically recommended. The “family” budget must restrict usage.

44. Additional Resources Immunization Works CDC’s Pink Book AAP’s Red Book
Where else to find information.
National Immunization Coalition
CDC’s Pink Book
AAP’s Red Book

45. Additional Resources: continued
DVDs:
Immunization Techniques: Safe, Effective, Caring

46. Additional Resources: continued
North Carolina Immunization Branch Website:
CDC/National Immunization Program (NIP):
Immunization Action Coalition:

47. Additional Resources: continued
ACIP Recommendations
General Recommendations
Vaccine by Vaccine
ACIP Recommendations
General Recommendations
Vaccine by Vaccine

48. Additional Resources: continued
Regional Immunization Nurse Consultants

49. Questions?