Adolescent and Adult Immunization Update Presentation to Presented

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

Disclosure Statements • 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 Program 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 offlabel use of the vaccine package insert guidelines.

Disclosure Statement • To obtain nursing contact hours for this session, you must be present for the entire session and complete an evaluation. • Continuing education will be provided through the Georgia Department of Public Health • Georgia Department of Public Health is an approved provider of continuing nursing education by the Alabama State Nurses Association, an accredited approver by the American Nurses Credentialing Center’s Commission of Accreditation

Objectives At the end of this presentation, participants will be able to: • Recall the role vaccines have played in preventing diseases • Discuss the importance of vaccines for children, adolescents and adults • Discuss the role of a vaccine champion • List at least two reliable sources for immunization information

The Impact of Vaccines Disease Average Annual Reported Cases Pre-vaccine* Smallpox Diphtheria Measles 48, 164 175, 885 503, 282 Mumps Pertussis Polio (paralytic) Rubella Congenital Rubella Syndrome Tetanus 152, 209 147, 271 16, 316 47, 745 823 1, 329 20, 762 0 5 1 5, 311 15, 737 0 5 1 96. 5% 89. 3% 100% >99. 9% 1, 314 20, 000 29 29 33 22 98. 1% 99. 9% H. Influenzae Type b Age<5 years *MMWR 48(12); 243 -248 April 2, 1999 Cases in U. S. 2015** Provisional Cases in U. S. 2016** Provisional % Reduction In U. S. 2016 Eradicated worldwide in 1980 0 0 100% 188 69 >99. 9% **MMWR 64(52), ND-924 -ND-941, January 6, 2017

VPD Vaccination Rate Needed for Herd Immunity Measles 92 -94% Pertussis 92 -94% Diphtheria 83 -85% Rubella 83 -85% Mumps 75 -86% Influenza 30 -75%

Immunization Schedule Updates • All staff must use the same immunization schedule • Schedules: § Children & Adolescents 0 through 18 years § Catch-up schedule for ages 4 months -18 years § Children and Adolescents 18 years or younger based on medical indications § Adult 19 years and older § Adult based on medical and other indications READ THE FOOTNOTES http: //www. cdc. gov/vaccines/schedules/hcp/child-adolescent. html http: //www. cdc. gov/vaccines/schedules/hcp/adult. html

What Does It All Mean? Indication -Information about the appropriate use of the vaccine Recommendation -ACIP statement that broadens and further delineates the Indication found in the package insert -Basis for standards for best practice Requirement -Mandate by a state that a particular vaccine must be administered and documented before entrance to child care and/or school

General Best Practice Guidelines • • • Timing and Spacing of Immunobiologics Contraindications and Precautions Preventing and Managing Adverse Reactions Vaccine Administration Storage and Handling of Immunobiologics Altered Immunocompetence Special Situations Vaccination Records Vaccination Programs Vaccine Information Sources

Test Your Knowledge! If 2 different live injectable vaccines are given < (less than) 28 days apart, the one given second should be what? IAC Ask the Experts - Reviewed July 2014

Test Your Knowledge! If 2 different live injectable vaccines are given < (less than) 28 days apart, the one given second should be what? The second or invalid dose should be repeated greater than or equal to 28 days after the second or invalid dose. IAC Ask the Experts - Reviewed July 2014

Frequently Asked Question? • Why do ACIP recommendations not always agree with vaccine package inserts? There is usually very close agreement between vaccine package inserts and ACIP statements. The Food and Drug Administration (FDA) must approve the package insert, and requires documentation for all claims and recommendations made in the insert. Occasionally, ACIP may use different data to formulate its recommendations, or try to add flexibility to its recommendations, which results in wording different than on the package insert. ACIP sometimes makes recommendations based on expert opinion and public health considerations. Published recommendations of national advisory groups (such as ACIP or AAP's Committee on Infectious Diseases) should be considered equally as authoritative as those on the package insert. Source: IAC’s Ask the Experts www. immunize. org/askexperts/experts_general. asp

Vaccines 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. Live, Attenuated Inactivated • Measles, Mumps & Rubella (MMR) • Toxoids (tetanus, diphtheria) • Varicella • Fractional subunits- (Influenza, acellular pertussis) • LAIV- (Nasal Spray flu) • Rotavirus • Herpes Zoster/Shingles • Whole (Hepatitis A, polio) • Recombinant vaccines (Hepatitis B, HPV) • Polysaccharide vaccines (PPSV 23, MPSV 4) • Conjugated vaccines (Hib, PCV 13, MCV 4)

“It’s The Law”

Influenza Vaccines for 2017 -2018 Season in the U. S. Trivalent Vaccines (IIV 3): • A/Michigan/45/2015 (H 1 N 1) (NEW) • A/Hong Kong/4801/2014 (H 3 N 2)-like virus • B/Brisbane/60/2008 -like virus Quadrivalent Vaccines (IIIV 4) will also include: • B/Phuket/3073/2013 -like virus ACIP recommends annual influenza vaccine for all persons 6 months of age and older who do not have contraindications. Recommendations and Reports Vol. 66 / No. 2 MMWR / August 25, 2017

ACIP VOTE On February 21, 2018 ACIP voted to include the nasal spray flu vaccine among the recommended influenza vaccines for the 2018 -2019 season. • CDC does not currently have a contract for LAIV • LAIV will likely be available for private purchase before it is available on public contracts • Contact the VFC Program for additional information 1 -800 -848 -3868

Influenza Vaccination of Persons with a History of Egg Allergy • Persons with a history of egg allergy who have experienced only urticarial (hives) after exposure to egg should receive influenza vaccine. • Persons who report having had reactions to egg involving symptoms other than urticarial (hives), such as angioedema, respiratory distress, lightheadedness, or recurrent emesis; or who required epinephrine or another emergency medical intervention, may similarly receive any licensed and recommended influenza vaccine (i. e. , any IIV or RIV) that is otherwise appropriate for the recipient’s age and health status. • A previous severe allergic reaction to influenza vaccine is a contraindication to future receipt of the vaccine. Recommendations and Reports Vol. 65 / No. 5 MMWR / August 26, 2016

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

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?

Percent of Ga residents older than 65 yrs. who self-reported receiving an influenza vaccination 2015

Pneumococcal Conjugate Vaccine for Adults (PCV 13) ACIP recommends 1 dose of PCV 13 for: • Adults 19 years and older with the following: § Immunocompromising conditions § Functional or anatomic asplenia § Sickle cell disease § CSF leaks § Cochlear implants • Adults 65 years and older MMWR 2014; Vol. 63 #37: 822 -5 MMWR, 2015 , Vol. 64, #34: 944 -7 PCV 13 – PPSV 23 spacing and timing of doses 65 years and older

Pneumococcal Polysaccharide Vaccine for Adults (PPSV 23) ACIP recommends 1 dose of PPSV 23 for: • Adults 65 years and older • Persons aged 2 through 64 years with medical conditions that increase their risk for pneumococcal infection • Persons 19 through 64 years with asthma • Cigarette smokers 19 years of age and older • Revaccination not recommended for most persons until they reach age 65 Persons at highest risk, such as those with immunocompromising conditions, and/or functional or anatomic asplenia, who received a dose before age 65, should receive a 2 nd dose 5 years after dose 1, and a 3 rd dose at age 65. MMWR, September 3, 2010, Vol 59, #34 MMWR, October 12, 2012, Vol 61 #40

Percent of Ga. residents older than 65 yrs. who self-reported receiving pneumococcal

Diphtheria, Tetanus and Pertussis Vaccines ACIP recommends: A 5 dose series of DTa. P: Administered at 2, 4, 6, 15 -18 months and 4 -6 years (Do not administer after age 6) one dose of Tdap: For children and adolescents starting at 11 or 12 years of age For all adults aged 19 years and older who have not had Tdap previously MMWR, September 23, 2011, Vol 60, #37 MMWR, January 14, 2011, Vol 60, #01 MMWR, June 29, 2012 Vol 61, #25

Tdap for Pregnant Women ACIP recommends: • One dose of Tdap each pregnancy • Optimal timing early in the 27 through 36 week gestation window • If not given during pregnancy; administer immediately postpartum Ref: Advisory Committee on Immunization Practices. Updated ACIP statement for pertussis, tetanus and diphtheria vaccines presented by Jennifer L. Liang, October 19, 2016.

Cocooning Strategy Parents Child Care Provider Healthcare Worker Siblings Grandparents

Test Your Knowledge! Logan is a 7 year old boy who was not fully immunized with DTa. P and received 1 dose of Tdap in the catch-up series. Can he receive an additional dose of Tdap vaccine at 11 through 12 years? Ref: Recommended Immunization Schedule for Children and Adolescents Aged 18 years or younger, United States, 2017

Test Your Knowledge! Logan is a 7 year old boy who was not fully immunized with DTa. P and received 1 dose of Tdap in the catch-up series. Can he receive an additional dose of Tdap vaccine at 11 through 12 years? Yes, he can receive an adolescent Tdap vaccine dose at age 11 through 12 years. Ref: Recommended Immunization Schedule for Children and Adolescents Aged 18 years or younger, United States, 2017

Hepatitis A Vaccine for Adults ACIP recommends hepatitis A vaccine for adults who are at high-risk of acquiring hepatitis A infection: • Those traveling or working in countries with high or intermediate endemicity of infection • Men who have sex with men • Users of injecting and non-injecting drugs • Persons working with HAV positive primates or with HAV in research laboratory settings • Contact with adoptees from countries with high rates of hepatitis A if contact will be within 60 days of arrival in U. S. The first dose of the 2 dose series should be given as soon as adoption is planned. MMWR, May 19, 2006, Vol 55, #RR-07 MMWR, September 18, 2009, Vol 58 #36

Hepatitis A ACIP voted unanimously to pass the following recommendations to Hepatitis A: • Hep A vaccine should be administered for post-exposure for all persons age 12 months or older • Hep A vaccine or IG may be administered to persons age 40 years or older, depending on the provider’s risk assessment • Hep A vaccine should be administered to infants age 611 months traveling outside the U. S. when protection against hepatitis A is recommended

Hepatitis B Transmission: 1. Percutaneous or mucosal exposure to blood or body fluids including contaminated surfaces, or exposure by sexual contact 2. Perinatal infection from HBs. Ag + mother ACIP recommends hepatitis B vaccine for: • All newborns before discharge from the nursery usingle 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. MMWR, December 23, 2005, Vol 54, #RR 16 MMWR, December 8, 2006, Vol 55, #RR 16 MMWR, December 22, 2011 Vol 60 #50

Hepatitis B vaccination and testing guidelines for Healthcare workers

Recommended Healthcare Personnel Vaccinations • Hepatitis B • Influenza • Measles, Mumps, Rubella (MMR) • Varicella (Chickenpox) • Tetanus, Diphtheria, Pertussis (Tdap) • Meningococcal Are YOU up to date? Available at www. immunize. org, P#2017

PRE-EXPOSURE EVALUATION FOR HEALTH-CARE PERSONNEL PREVIOUSLY VACCINATED WITH COMPLETE, ≥ 3 -DOSES OF HEP B VACCINE SERIES WHO HAVE NOT HAD POSTVACCINATION SEROLOGIC TESTING Measure antibody to hepatitis B surface antigen (anti-HBs) anti-HBs <10 m. IU/m. L anti-HBs ≥ 10 m. IU/m. L Administer 1 dose of Hep. B vaccine, postvaccination serologic testing anti-HBs <10 m. IU/m. L anti-HBs ≥ 10 m. IU/m. L Administer 2 more doses of Hep. B vaccine, postvaccination serologic testing anti-HBs <10 m. IU/m. L No Action for Hepatitis B prophylaxis (regardless of source patient hepatitis B surface antigen status) anti-HBs ≥ 10 m. IU/m. L HCP need to receive hepatitis B evaluation for all exposures MMWR, December 20, 2013, Vol 62. RR # 10

Measles, Mumps, Rubella ACIP recommends: • 2 - dose series at ages 12 through 15 months and 4 through 6 years • at least 4 weeks between first and second dose MMWR, June 14, 2013, Vol 62, #RR-04

Varicella ACIP recommends: • 2 -dose series at 12 through 15 months and 4 through 6 years • Second dose may be administered before age 4 years, provided 3 months have elapsed since the first dose • Adults without evidence of immunity should receive 2 doses of single-antigen varicella vaccine 4 -8 weeks apart, or a second dose if they have only 1 dose

Varicella Immunity ACIP considers evidence of immunity to varicella to be: • Documentation of 2 doses of vaccine given no earlier than age 12 months, with at least 3 months between doses for children younger than age 13 years, or at least 4 weeks between doses for people age 13 years and older • U. S. -born before 1980* • A healthcare provider's diagnosis of varicella or verification of history of varicella disease • History of herpes zoster, based on healthcare provider diagnosis • Laboratory evidence of immunity or laboratory confirmation of disease *Note: year of birth is not considered as evidence of immunity for healthcare personnel, immunosuppressed people, and pregnant women. MMWR 2007; 56(RR-4); 16 -17

MMRV (Pro. Quad®) Routine Recommendation • May be administered to children 12 months through 12 years of age • MMRV is not licensed for people 13 years of age or older • A third dose of MMRV might be recommended in certain mumps outbreaks situations*

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 if not given during the same visit – If PPD given first, administer MMR when client returns for skin test reading • Spacing with antibody-containing products such as immune globulin (IG)

Herpes Zoster Vaccine Live (ZVL) • 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 • Postherpetic neuralgia (PHN)is a common consequence of zoster • Risk for zoster and PHN increases with age Photo courtesy of www. webmd. com

Zostavax® Zostavax is licensed for use in persons 50 years and older Overall Efficacy • • • 51% fewer episodes of zoster and less severe disease 66% less post-herpetic neuralgia Protection wanes within the first 5 years and duration of protection beyond 5 years is uncertain ACIP recommends one dose for adults 60 years and older, including those who have experienced previous episodes of shingles. It is not necessary to ask patient about a history of varicella or to do serologic testing for immunity. MMWR, August 22, 2014, Vol 63, #33 30 MMWR (RR) June 6, 2008, Vol 57 #05; 1 -

SHINGRIX (RZV) • Administer 2 doses of recombinant zoster vaccine (RZV) 2 -6 months apart to adults aged 50 years or older regardless of past episode of herpes zoster or receipt of zoster live (ZVL) • Administer 2 doses of RZV 2 -6 months apart to adults who previously received ZVL at least 2 months after ZVL • For Adults aged 60 years or older, administer either RZV or ZVL (RZV is preferred)

SHINGRIX (RZV) SHINGRIX delivered 90% efficacy against shingles Recombinant vaccine; do not freeze For intramuscular administration only Reconstitute and use immediately; reconstituted vaccine is stable for 6 hours refrigerated between 36 -46°F and should be discarded after 6 hours • Contraindicated for a history of severe allergic reaction (e. g. , anaphylaxis) to any component of the vaccine or after a previous dose of SHINGRIX • •

Test Your Knowledge! Hazel is 61 years old. She had major surgery one month ago requiring a blood transfusion. During her visit to your office today she tells you she would like to get the shingles vaccine. How would you respond to her request? Zoster vaccine can be given to persons who have recently received blood products. The amount of antigen in zoster vaccine is so substantial that it overpowers any antibody to herpes zoster that may be in the blood product. Ref: Immunization Action Coalition - Ask the Experts – September 2011

Test Your Knowledge! Sixty five year old Nadine requests the shingles vaccine. In addition, she needs pneumococcal and influenza vaccine. Should she receive all 3 vaccines on the same day? Yes. Although Merck reports one study showing a reduced immune response to Zostavax when administered at the same time as Pneumovax compared to administration 4 weeks apart, ACIP has not made this recommendation.

Is Shingles Contagious? • Shingles cannot be passed from one person to another. • However, a person with shingles can spread the virus to a person who has never had chickenpox. • If the person who has never had chickenpox becomes infected with the virus, he or she will develop chickenpox, not shingles.

Serogroup A, C, W, Y Meningococcal Vaccines Routine Recommendation • 2 -dose series at 11 -12 years and 16 years • Age 13 -15 years administer 1 -dose and booster at age 16 -18 years (minimal interval 8 weeks) • 1 -dose at age 16 -18 years

Meningococcal Vaccines for Special Populations and Situations • Anatomic or functional asplenia, sickle cell disease, HIV infection, persistent complement component deficiency (including eculizumab use) • Children who travel to or live in countries where meningococcal disease is hyperendemic or epidemic, including countries in the African meningitis belt or during the Hajj, or exposure to an outbreak attributable to a vaccine serogroup

Serogroup B Meningococcal Vaccines ACIP Recommendation • May be given at clinical discretion to adolescents 16 -23 years (preferred age 16 -18 years) who are not at increased risk ü Bexsero: 2 doses at least 1 month apart ü Trumenba: 2 doses at least 6 months apart. If 2 nd dose given earlier than 6 months, give 3 rd dose at least 4 months after the 2 nd dose

Serogroup B for Special Populations and Situations Anatomic or functional asplenia, sickle cell disease, persistent complement component deficiency (including eculizumab use), serogroup B meningococcal disease outbreak ü Bexsero: 2 -doses at least 1 month apart ü Trumenba: 3 -dose series at 0, 1 -2, and 6 months Bexsero and Trumenba are not interchangeable

Test Your Knowledge! Simon received MPSV 4 at 5 years of age for international travel and a dose of MCV 4 at age 11. Does he need a booster dose of MCV 4 vaccine at age 16? Yes. Any meningococcal vaccination given prior to the tenth birthday (either with MCV 4 or MPSV 4) does NOT count toward routinely recommended doses. IAC Ask the Experts - Reviewed September 2013

HPV Vaccine • Routine recommendation for adolescents 11 -12 years (can start at age 9) • Number of doses dependent on age at initial vaccination >Age 9 -14 years: 2 -dose series at 0 and 6 -12 months >Age 15 years or older: 3 -dose series at 0, 1 -2 months, and 6 months • Persons who completed a valid series with any HPV vaccine do not need any additional doses • Special Situations >History of sexual abuse or assault: begin series at age 9 years >Immunocompromised: aged 9 -26 years administer 3 -dose series >Pregnancy: vaccination not recommended, but if administered inadvertently while pregnant delay remaining doses until after pregnancy.

HPV Vaccine • At the February 2018 ACIP Meeting they presented a session about harmonizing of HPV vaccination age recommendations for females and males • Considerations for harmonization of upper age recommendations for males and females - would simplify immunization schedule -facilitate reaching males, including high risk

Test Your Knowledge! If dose #1 of HPV vaccine was given before the 15 th birthday and it has been more than a year since that dose was given, would the series be complete with just one additional dose? Yes. Adolescents and adults who started the HPV vaccine series prior to the 15 th birthday and who are not immunocompromised are considered to be adequately vaccinated with just one additional dose of HPV vaccine.

Test Your Knowledge! Will the 2 -dose recommendation be retroactive for children and teens vaccinated prior to 2016? Yes. Any person who ever received 2 doses of any combination of HPV vaccines can be considered fully vaccinated if dose #1 was given before the 15 th birthday and the 2 doses were separated by at least 5 months.

Rabies Vaccine Recommendations Post-exposure prophylaxis l …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. Postexposure prophylaxis would not be warranted for other household members.

Just as a reminder…… • Regardless of: – the availability of vaccine – the funding of the vaccine (VFC, statesupplied, or private stock) – whether the vaccine is required for school or child care or not………. FOLLOW ACIP Recommendations!!!

www. cdc. gov/travel l Yellow Fever l Typhoid l Polio

Challenges to Adult Vaccination Most patients indicate that they are likely to receive a vaccination if their healthcare provider (you) recommends it. Ref: Johnson DR, et al. Am J Med. 2008; 121 (7 Suppl 2): S 28 -S 35.

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, Ph. D. CDC

Important Office Practices • 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

A “Birth to Death” Immunization Registry • Providers administering vaccines in Georgia must provide appropriate information to GRITS. • Create an interface between your system and GRITS that will drastically decrease data entry • 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 • Reminder/recall notices for parents

Improve Access To Immunizations • • • Immunization only visits Walk-ins for immunizations Implement standing orders Early, extended, or weekend hours Mass vaccination clinics

Become a Vaccine Champion!! Critical Elements • Appropriate storage and handling of all vaccines. • Correct administration of vaccines • Education of patients and parents about vaccines • Every office and clinic needs a vaccine champion.

Vaccine Champion Key Characteristics • Lead your immunization team. • Educate all staff about new vaccines and recommendations. • Educate 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.

VAERS Public Health Reports should be faxed or mailed to the State Immunization Program. Fax number (404)657 -1463

Vaccine Injury Compensation Program (VICP) 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”

Resources for Factual & Responsible Vaccine Information www. immunize. org

Stay Current! • Sign up for listserv sites which provide timely information pertinent to your practice www. immunize. org/resources/emailnews. asp – AAP Newsletter – CDC immunization websites (32 in all) – CHOP Parents Pack Newsletter – IAC Express – Websites specific to particular vaccines

Internet Resources Georgia Department of Public Health l http: //dph. georgia. gov/immunization-section l https: //dph. georgia. gov/train-trainer CDC Immunization information l http: //www. cdc. gov/vaccines/ CDC Flu information l http: //www. cdc. gov/flu/ Immunization Action Coalition l www. immunize. org

State Resources • GA Immunization Program Office – On call Help line: 404 -657 -3158 – GRITS Help Line: 1 -866 -483 -2958 – VFC Help Line: 1 -800 -848 -3868 – Website http: //dph. georgia. gov/immunization-section – Your local Immunization Regional Program Consultant (IRC) – Epidemiology: 1 -866 -782 -4584 • GA Chapter of the AAP • GA Academy of Family Physicians

It’s a Team Effort! High Immunization rates begin with a team designed plan! What can your team do to improve rates?