CHAMPS 2012 Immunization Update with Iyabode A. Beysolow, M.D., - - PowerPoint PPT Presentation

CHAMPS 2012 Immunization Update

with Iyabode A. Beysolow, M.D., M.P.H.

National Center for Immunization and Respiratory Diseases

Teleconference (HRSA – Region VIII) July 25, 2012

7/19/2012

Disclosures

 Dr. Beysolow has no financial conflict or

interest with the manufacturer of any product named during this course.

 I will not discuss the use of vaccines in a

manner that differs from the product insert with the exception of Tdap and PCV13 vaccines.

 I will not discuss vaccines not licensed by

the FDA

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Objectives

Increase provider knowledge

regarding immunizations and the importance of promoting immunizations in the community.

Explain one recent change to

immunization recommendations coming from the Advisory Committee for Immunization Practices

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What do providers want to know about vaccines?

What are CDC/ACIP Recommendations? What’s new in the vaccine world? What should I tell my patients/parents? Where can I find resources quickly?

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Overview

 Introduction  ACIP overview – who is the ACIP?  2012 Immunization Schedules  Feb 2012 and June 2012 ACIP Meeting Updates  Updated ACIP recommendations

• PCV13 in Immunocompromised Adults
• Tdap – adults and adolescence
• Influenza Updates
• HepB – adults with diabetes
• HPV4 – routine recommendation for males
• Health Care Worker Recommendations

 Vaccine Administration (S and H)  Resources  Q and A

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Who is the ACIP?

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Changes to the Schedules

 Concerns:  Increasing complexity of the schedule  Limited space for footnotes  Solutions:  In order to improve footnote readability:

• Redundancy between footnotes and figures

eliminated

• Reference to respective MMWR documents for

more details

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Changes to the Childhood Schedule

 Providers are asked to use all 3 schedules

and their footnotes together and not separately

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CDC Vaccines Webpage http://www.cdc.gov/vaccines/recs/schedules/ch ild-schedule.htm#printable

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MMWR webpage http://www.cdc.gov/mmwr/

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Changes to the Childhood Schedule

 0-6 year schedule:

• MCV bar extended
• Hep A ‘hashed’ bar clarification
• MMR use in 6 through 11 month olds

7-18 year schedule:

• HPV4 routine use in males

Catch-up Schedule:

• HepA and HepB footnotes removed
• MCV footnotes added

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Changes to Recommended Immunization Schedule for Persons Aged 0 Through 6 years

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Changes to Figure 2. Recommended Immunization Schedule for Persons Aged 7 Through 18 Years

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Changes to the 2012 “Catch-up” Schedule

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Changes to the Adult Schedule

 Table summarizing precautions and

contraindications to vaccination was added.

 HepB Footnote updated to include

recommendation to vaccinate adults younger than 60 years old who have diabetes, as soon as possible after diabetes is diagnosed.

 A new footnote to links for the full ACIP

vaccine recommendations and where to find additional information on specific vaccine recommendations for travelers.

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Overview

 Introduction  ACIP overview – who is the ACIP?  2012 Immunization Schedules  Feb 2012 and June 2012 ACIP Meeting Updates  Updated ACIP recommendations

• PCV13 in Immunocompromised Adults
• Tdap – adults and adolescence
• Influenza Updates
• HepB – adults with diabetes
• HPV4 – routine recommendation for males
• Health Care Worker Recommendations

 Vaccine Administration (S and H)  Resources  Q and A

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February 2012 ACIP Meeting Highlights

 Tdap Vote: Use of Tdap in persons 65 years

and older

 Discussion of PCV13 use in adults 50 yrs and

• lder

 Discussion of meningococcal vaccine for

infants – No vote, no recommendation

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June 2012 ACIP Meeting Highlights

 PCV13 use in immunocompromised males

– vote taken – new recommendation

 Influenza vaccine recommendations –

including dosing for 6 mos thru 8 years old

 Updates on HPV vaccine uptake, Adult

immunizations Meeting slides and minutes: http://www.cdc.gov/vaccines/recs/acip/meetin gs.htm

PCV13 USE IN IMMUNOCOMPROMISED ADULTS

Pneumococcal Conjugate Vaccine (PCV13) for Adults

 On December 30, 2011, PCV13 (Pfizer)

was licensed for use among adults 50 years of age and older

 FDA approved expanded age indications

under the Accelerated Approval Pathway

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Pneumococcal Conjugate Vaccine (PCV13) for Adults

 PCV13 immunogenicity non-inferior to

PPSV23

 Indications

• Prevention of pneumococcal disease,

including pneumonia and invasive disease

• Prevention of disease caused by

Streptococcus pneumoniae serotypes 1, 3, 4, 5, 6A, 6B, 7F, 9V, 14, 18C, 19A, 19F and 23F

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Summary of Feb 2012 ACIP Deliberations: PCV13 for Adults

• Deferred universal recommendation

pending the further collection of data

• Efficacy of PCV13 against

pneumonia (CAPITA trial, results in 2013)

• Indirect (herd) effects of PCV13

use in children

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ACIP Recommendations June 2012 Pneumococcal Vaccine naïve adults

 Adults 19 years of age or older with

immunocompromising conditions, functional

• r anatomic asplenia , CSF leaks or cochlear

implants, and those who have not previously received PCV13 or PPSV23 should receive a single dose of PCV13 followed by a dose of PPSV23 at least 8 weeks later. DRAFT LANGUAGE

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Revaccination with PPSV 23

 A second dose of PPSV23 is recommended 5

years after the first dose for persons aged 19–64 years with functional or anatomic asplenia and for persons with immunocompromising conditions.

 Those who received PPSV23 before age 65 years

for any indication should receive another dose of the vaccine at age 65 years or later if at least 5 years have passed since their previous dose.

 Those who receive PPSV23 at or after age 65

years should receive only a single dose of PPSV23.

DRAFT LANGUAGE 7/19/2012

ACIP June 2012- Adults previously vaccinated with PPSV 23(2)

 Adults 19 years of age or older with

immunocompromising conditions , functional or anatomic asplenia , CSF leaks or cochlear implants, who have previously received one or more doses of PPSV23 receive a dose of PCV13

• ne or more years after the last PPSV23 dose was

received.

 For those that require additional doses of

PPSV23, the first such dose should be given no sooner than 8 weeks after PCV13 and at least 5 years since the most recent dose of PPSV23

DRAFT LANGUAGE 7/19/2012

Potential Scenarios for Adults previously vaccinated with PPSV23

 Draft language

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Adults Previously Vaccinated with PPSV23

 40-year-old male with asplenia who

received PPSV23 three years ago

• administer PCV13 today (at least 1 year

interval since PPSV23)

• administer 2nd PPSV23 in 2 years (at least 5

year interval after last PPSV23 dose and at least 8 weeks after PCV13 dose)

• administer final dose of PPSV23 at 65 years
• f age

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PERTUSSIS VACCINES IN ADOLESCENTS AND ADULTS

PERTUSSIS IN THE U.S. 2012

 As of 7/5/12: 17,000 cases reported  10 deaths reported so far (majority among

infants < 3 months of age)

 Several outbreaks or increased activity in

several states in 2012 so far

 2010: 27,550 cases with 27 deaths (25 of

these in children under a year old). Also increase in cases in 7-10 year olds.

CDC Unpublished data, http://www.cdc.gov/pertussis/outbreaks.html

Why Adolescents and Adults Need Pertussis Vaccine

 Pertussis cases increased in the late

1990s and early 2000s

 2004 – 25,827 pertussis cases:

67% of cases among adolescents or adults

 Severe illness among young infants with

pertussis

 Pertussis immunity wanes in 5-10 years

after vaccination

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Source of Infection for Infants With Pertussis

 Household contact – 71%

• Parent – 55% (mother 37%, father 18%)
• Sibling – 16%

 Non-household contact – 29%

• Aunt/uncle – 10%
• Friend/cousin - 10%
• Grandparent – 6%

N=44 infants <6 months of age. Pediatr Infect Dis J 2007;26(4):293-9. 7/19/2012

Adolescent and Adult Pertussis Vaccination

 Primary objective

• protect the vaccinated adolescent or adult

 Secondary objective

• reduce reservoir of B. pertussis
• potentially reduce incidence of pertussis in
• ther age groups and settings

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General Principles for Use

• f Tdap and Td

 Tdap preferred to Td to provide

protection against pertussis

 Tdap approved only for a single

booster dose in persons who have received a full series of pediatric DTaP

• r DTP
• Tdap is NEITHER approved NOR

recommended for multiple administrations

Tdap

 Tdap reduces the risk of pertussis by

60% - 80%

 Tdap approved ages

• 10 years and older for Boostrix
• 11 through 64 years for Adacel
• Schedule: One time only dose (IM)

Wei SC et al. Clin Infect Dis 2010;51:315-21 7/19/2012

Use of Tdap Among Children 7 Through 10 Years of Age

 Children 7 through 10 years of age who are

not fully vaccinated against pertussis and who do not have a contraindication to pertussis vaccine should receive a single dose of Tdap*

 Either brand of Tdap may be used  No revaccination at age 11-12 years old for

those who received Tdap at ages 7 through 10 years

 Revaccination issue still being evaluated

• *off-label recommendation. MMWR 2011; 60 (No. 1):13-5

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“Not Fully Vaccinated Against Pertussis”

 Having received fewer than 4 doses of

DTaP, or

 Having received 4 doses of DTaP but the

last dose was prior to age 4 years

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Tdap Recommendations for Adolescents

 All adolescents should preferably

receive Tdap at the 11 to 12 year-old preventive healthcare visit

 Persons 11 through 18 years of age

who have not received Tdap should receive a dose followed by Td booster doses every 10 years

 Administer at the same visit as other

indicated vaccines (e.g. MCV, HPV)

MMWR 2011; 60 (No. 1):13-5

Tdap Vaccine in Adolescence

 Tdap/Td interval – removed (NEW!!)

• Can be administered regardless of

interval since the last tetanus- or diphtheria-toxoid containing vaccine

 No booster doses of Tdap

recommended at this time

MMWR: January 14, 2011 / 60(01);13-15

Updated recommendation for use

• f Tdap in Adults

 For adults aged 19 years and older who

previously have not received a dose of Tdap, a single dose of Tdap should be given.

 Tdap should be administered regardless of

interval since the last tetanus or diphtheria toxoid-containing vaccine.

 Adults should receive a Tdap dose if the

dose is recommended and no record of previous administration exists.

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6125a4.htm

Tdap in Adults

 Unchanged recommendations:

• After receipt of Tdap, persons should

continue to receive Td for routine booster vaccination (every 10 years)

• Adolescents and adults (previously

unvaccinated) planning close contact with an infant should receive Tdap (cocooning)

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Tdap in Adults over 65 years old

 Vote taken at ACIP meeting in Feb 2012,

published 6/29/12 Providers should not miss an

• pportunity to vaccinate persons aged 65

years and older with Tdap, and may administer the vaccine that they have available.

http://www.cdc.gov/mmwr/preview/mmwrhtml/m m6125a4.htm

Tdap in Adults over 65 years

• ld(2)

 When feasible, for adults aged 65 years and

• lder, Boostrix should be used; however,

either vaccine product administered to a person aged 65 years and older provides protection and is considered valid.

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6125a4.htm

Case studies

 An 8 year old patient arrives from Botswana

without any immunization records. You decide to vaccinate against Diphtheria, Tetanus and

• Pertussis. Which vaccine would you give this

child today and how many doses:

• DTaP or Tdap or Td?
• When this child turns 11 years old, do you give any more

vaccine against Diphtheria, Tetanus and Pertussis?

 A 14 year old child received Td vaccine at age

13 years old (his first Td dose ever). He now presents to your office for his annual check up and you do not see evidence of him receiving Tdap vaccine in the past. Can you give Tdap vaccine today?

DTaP and Tdap Administration Errors

Error Action DTaP given to person >7 years Count dose as valid Tdap given to child <7 years as DTaP #1, 2, or 3 Do not count dose; give DTaP now Tdap given to child <7 years as DTaP #4 or 5 Count dose as valid

INFLUENZA

Universal Recommendation

 Influenza vaccine is recommended for

everyone 6 months and older (without contraindications to the vaccine)

7/19/2012

Influenza Vaccine strains for the 2012-13 Season

 WHO: Feb 23, 2012 recommendations for

Northern Hemisphere’s 2012-2013 influenza vaccine to contain:

• an A/California/7/2009 (H1N1)pdm09-like

virus;

• an A/Victoria/361/2011 (H3N2)-like virus;
• a B/Wisconsin/1/2010-like virus (from the

B/Yamagata lineage of viruses) FDA (VRBPAC): Feb 28 2012 agreed with recommendation

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DOSING IN CHILDREN 6 MONTHS THROUGH 8 YEARS OF AGE

DRAFT ONLY – SUBJECT TO CHANGE

7/19/2012

 DRAFT ONLY SUBJECT TO CHANGE

7/19/2012

HEPATITIS B VACCINE IN ADULTS WITH DIABETES

HepB vaccine in Adults with DM

• Hepatitis B vaccination should be

administered to unvaccinated adults with diabetes mellitus who are aged 19 through 59 years

• Hepatitis B vaccination may be

administered at the discretion of the treating clinician to unvaccinated adults with diabetes mellitus who are aged ≥60 years

7/19/2012

Human Papillomavirus and HPV Vaccine

Education, Information, and Partnership Branch National Center for Immunization and Respiratory Diseases

ACIP Updated HPV Vaccine Recommendations 10/25/2011

 Only HPV4 (Gardasil) should be administered

to males

• HPV2 is not approved for males of any age

 Routinely administer HPV4 vaccine to boys

ages 11-12 years to prevent HPV and HPV related diseases

• May be administered as young as 9 years of age

 Catch up: Young men 13 through 21 years of

age who have not completed a HPV4 series

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6050a3.htm

ACIP Update HPV Vaccine Recommendations 10/25/2011

 ACIP went on to routinely recommend

HPV4 vaccination for immunosuppressed males 22 through 26 years and MSM through age 26 years

 HPV4 may be administered to healthy

males 22 through 26 years of age

HPV Vaccine “Special Situations”

 Vaccine can be administered to females

with:

• equivocal or abnormal Pap test
• positive HPV DNA test
• genital warts
• immunosuppression
• breastfeeding

MMWR 2010;59(No. 20):626-9

HEALTH CARE WORKER RECOMMENDATIONS

ACIP Recommendations Nov 2011 http://www.cdc.gov/mmwr/preview/mmwrhtml/r r6007a1.htm?s_cid=rr6007a1_e

Pop Quiz

 14 year old previously unvaccinated twins

from Russia (one male, one female) come to your office. You have Tdap, MCV4, HPV2 vaccines available.

 What vaccine(s) should they receive today?

Overview

 Introduction  ACIP overview – who is the ACIP?  2012 Immunization Schedules  Feb 2012 and June 2012 ACIP Meeting Updates  Updated ACIP recommendations – Tdap – adults and adolescence – Influenza Updates

– PCV13 in Immunocompromised Adults

– HepB – adults with diabetes – HPV4 – routine recommendation for males – Health Care Worker Recommendations  Vaccine Administration (S and H)  Resources  Q and A

STORAGE AND HANDLING VACCINE ADMINISTRATION

Cold Chain

 Vaccines are fragile  They must be stored

properly from the time they are manufactured until they are given

• Manufacturer to distributor
• Distributor to office
• Office to patient

Vaccine Storage Equipment

 Do NOT use a

“dormitory” unit for permanent storage of vaccines

• Small combination

freezer/refrigerator unit with one exterior door

• An icemaker

compartment (freezer) within the refrigerator

Knowledgeable Staff

 Assign S&H responsibilities

to a staff person

• Designate a back-up person

 Train all staff on vaccine

storage and handling

• Including new staff
• rientation annually, and
• ngoing updates as needed

Ordering and Accepting Vaccine Deliveries

 Choose vaccines that best

meet the needs of patients the facility serves

 Order enough vaccines to

meet the needs of the facility’s patients

 Store vaccines at the

recommended temperature range IMMEDIATELY on arrival

Temperature Monitoring

• 1. Post a refrigerator and

freezer temperature log

• 2. Read and record the

temperature twice daily

• 3. Store temperature logs for

at least 3 years unless state statutes or rules require a longer period

Take IMMEDIATE Action for Out-of-range Temperature

Vaccine Administration

 The Right Patient  The Right Vaccine  The Right Time  The Right Dosage  The Right Route  The Right Technique  The Right Documentation

Administer the Vaccine Correctly

 Prepare vaccine just

prior to administration

 Choose the correct

vaccine based on patient’s age and health status Check the label 3 times!

Vial mix-up charts: www.eziz.org

Right Route for Right Vaccine

Rotavirus Vaccine Oral Route

LAIV Vaccine Intranasal Route

IMMUNIZATION RESOURCES

General Recommendations on Immunization

The “Pink Book”

Resources

 www.cdc.gov/vaccines  State Immunization Program Website  www.immunize.org

Questions

nipinfo@cdc.gov 1-800-CDC-INFO

Thank You!

 Please complete the online evaluation and CME

• questionnaire. You will receive an email with a link to

the evaluation/questionnaire.

 If you are requesting CME credit, you MUST complete

the evaluation and all the CME questions to receive credit.

 Contact Shannon Kolman, CHAMPS Clinical

Programs Director, at 303-867-9583 or Shannon@CHAMPSonline.org with questions.

7/19/2012

“Provider Resources for Vaccine Conversations with Parents”

 Developed with partners: AAP and AAFP  Primary Target Audience: Healthcare Professionals

• Information to help HCW talk to parents about

vaccines, vaccine-preventable diseases, and vaccine safety

• Dual purpose: resources hcps can provide to

parents  Based on formative, mixed methods research  Using risk communication principles  Extensively reviewed by subject matter experts

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“Talking with Parents about Vaccines for Infants”

• During the Office Visit

– Take time to listen – Solicit and welcome questions – Keep the conversation going – Use a mix of science and personal anecdotes – Acknowledge benefits and risks – Respect parents’ authority

• After the Office Visit

– Document parents’ questions/ concerns – Follow up a few days after the visit

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Materials: Provider Resources for Vaccine Conversations with Parents

 Understanding Vaccines and Vaccine Safety

• How Vaccines Work
• The U.S. Recommended Childhood Immunization Schedule
• Ensuring the Safety of U.S. Vaccines
• Understanding the Vaccine Adverse Reaction Reporting System

(VAERS)

• Understanding MMR Vaccine Safety
• Understanding Thimerosal, Mercury, and Vaccine Safety
• Understanding Vaccine Ingredients
• Understanding the Advisory Committee on Immunization

Practices (ACIP)

 Diseases and the Vaccines that Prevent Them

• 14 vaccine-preventable disease sheets
• 2 versions (one for high-information seeking parents and other plain

language) 83

Provider-Targeted Materials

Topics of concern/interest to providers and parents Summary of key points Co-branded with AAFP and AAP The science Q&A format Date

84

Parent-Targeted Materials

Current stories from families affected by VPDs Vaccine risks and benefits VPD risks Quotes from health care professional s Co-branded with AAFP and AAP References Date

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Parent-Targeted Materials

• Providers requested

more plain-language pieces for parents

• More basic overview
• f disease and

vaccine

• Most have no story

(or an abbreviated version)

• Clearly shows

benefits and risks

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Other Parent-Targeted Resources

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More Parent-Targeted Resources

• Well Child Visit

Tracker

• Growth Chart
• Parent-friendly

immunization schedules

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www.cdc.gov/vaccines/conversations

89

Website

Email alerts sent to subscribers when materials are added to site Feedback requested Comments will inform future plans

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We Can All Make Our Vaccine Conversations More Effective

Start conversations early (prenatal visits) Give resources prior to the vaccination visit Use language parents understand/prefer Layer information Use personal stories Provide your recommendation Use credible resources to reinforce your messages Encourage other health care professionals to talk to parents

7/19/2012

Questions

nipinfo@cdc.gov 1-800-CDC-INFO

Thank You!

 Please complete the online evaluation and CME

• questionnaire. You will receive an email with a link to

the evaluation/questionnaire.

 If you are requesting CME credit, you MUST complete

the evaluation and all the CME questions to receive credit.

 Contact Shannon Kolman, CHAMPS Clinical

Programs Director, at 303-867-9583 or Shannon@CHAMPSonline.org with questions.

7/19/2012