immunization update: what providers need to know amelie hollier, dnp, fnp-bc, faanp advanced...
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Immunization Update:What Providers Need to Know
Amelie Hollier, DNP, FNP-BC, FAANPAdvanced Practice Education Associates
Lafayette, LA
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CDC.gov• Recommendations published every January
or February• 17 vaccine preventable diseases in infants,
children, adolescents, and adults
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Biggest Change in a Decade!• 2013 changed to a Single schedule (no
longer has 0-6 yrs., 7-18 yrs., catch-up)• More complex, so footnotes clarify all
recommendations
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10 Adult Recommendations(> 19 years old)
• Influenza• Tdap• Varicella• HPV• Zoster• MMR• PCV 13, PPSV23• Meningococcal• Hepatitis A, B• Hib
Impacting health of communities
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True or False
Egg allergy is a contraindication to receiving the influenza vaccine.
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Influenza Immunization• Flublok: a trivalent seasonal flu
vaccine made without eggs or influenza virus• Adults ages 18-49• $30/dose
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Influenza Immunization• Flublok: a recombinant vaccine;
replication of the viral protein that triggers immunity; not the flu virus• You CANNOT get the flu from this flu
shot!
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CC Influenza Immunization• Some trivalent immunizations grown
in Cell Cultures (Flucelvax)
• Contain little or no egg protein• Not egg free but…..safe for most
patients with egg allergies• Can be made rapidly!• $18.25 per dose
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Influenza Immunization
3 influenza strains vs.
4 influenza strains
Trivalent vs. Quadrivalent?
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True or False
Quadrivalent flu immunization is more protective of influenza than trivalent immunization.
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Influenza Immunization
• Not for adults; maybe for kids! (B strains seem to infect kids more than adults) (Quad contains a 2nd B strain)• No receommendation by CDC for one
vaccine vs another for any specific population• 20 % of vaccines this year are quadrivalent• $6 more expensive
Trivalent vs. Quadrivalent?
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True or False
High dose flu vaccine (Fluzone) is more effective than standard dose vaccine in elderly patients.
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Influenza Immunization
• Risk of getting the flu is reduced about 25% when the high dose is used. (Relative risk, not absolute risk)• Cost: $11 vs $28 (HD)
High dose IM flu vaccine
Lowes R. Fluzone High-Dose foils flu better in seniors, says maker. October 24, 2013. http://www.medscape.com/viewarticle/813203?pa=92kly%2Bz1nWaeVh6vErodGqoM3ThPLDEGYJMeUNrocQFsmh0ZUQjnYgpNe4dbAp0DwrQkx7OxpYMdU0y3IK88IA%3D%3D. (Accessed March 8, 2014).
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“Real Language”
• To prevent one extra case of flu, 218 seniors have to be vaccinated with high dose vaccine vs standard• CDC does not recommend it over
the traditional flu vaccine
High dose IM flu vaccine
Lowes R. Fluzone High-Dose foils flu better in seniors, says maker. October 24, 2013. http://www.medscape.com/viewarticle/813203?pa=92kly%2Bz1nWaeVh6vErodGqoM3ThPLDEGYJMeUNrocQFsmh0ZUQjnYgpNe4dbAp0DwrQkx7OxpYMdU0y3IK88IA%3D%3D. (Accessed March 8, 2014).
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“Herd Immunity”
• When a large enough part of the population is immunized, most members are protected even if not immunized. • Reason: There is little opportunity for an
outbreak.• This is important with contagious
diseases like flu, measles, rotavirus, pneumococcal disease, pertussis
Community Immunity
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10 Adult Recommendations(> 19 years old)
• Influenza• Tdap• Varicella• HPV• Zoster• MMR• PCV 13, PPSV23• Meningococcal• Hepatitis A, B• Hib
Follow CDC Schedules unless….
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Immunocompromised Patients
2014 Guidelines2 Questions: • Is patient
immunocompromised?• To what degree? (low or high)
Rubin LG, Levin MJ, Ljungman P, et al. 2013 IDSA clinical practice guideline for vaccination of the immunocompromised host. Clin Infect Dis 2014;58:e44-100.
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Immunizations Facts• Immunocompromised patients
benefit from immunization• Weaker response than
immunocompetent patient• Possible greater (potential) risk of
infection from live vaccines
http://www.cdc.gov/vaccines/spec-grps/hcw.htm
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True or False
A patient uses inhaled fluticasone BID for asthma. Zostavax immunization is contraindicated.
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General Rules(These do NOT constitute immunocompromised states)
• Use of topical or inhaled steroids• Oral steroids for < 14 days (any
dose)• Steroid injection
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General Rules(Immunocompromised patient)
Inactivated Vaccines• Flu, Tdap, others• Not harmful to administer!• Issue: Patient may not respond
as well as an immunocompetent host
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Best Practice
Inactivated Vaccines and an Immunosuppressed Host• Give at least 2 weeks PRIOR to
immunosuppressive meds when possible
• If not possible, then re-immunize at least 3 months after therapy is discontinued, if immunocompetence is restored
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General Rules
Live Vaccines• Shingles, LAIV, MMR,varicella• Ask yourself the 2 questions:
Is patient immunosuppressed?What level
immunosuppression?
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ImmunocompromisedWhen is someone Immunocompromised?• Primary: cellular or humoral immunity (or
both) issues• Secondary: HIV, cancer chemo, radiation
treatment, immunosuppressive meds (methotrexate, corticosteroids, TNF-alpha inhibitors, rituximab, azathioprine)
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Immunization FactImmunocompromised Individuals• Do not administer live vaccines• Some exceptions (low level
immunosuppression for varicella or zoster vaccines CAN be an exception if benefits outweight risks)
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6002a1.htm),
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Best PracticeImmunosuppressed Host/Live Vaccine• Give at least 4 weeks PRIOR to
immunosuppression (drug therapy, radiation, splenectomy)• Give at least 3 months AFTER
chemotherapy is stopped (if immunocompetence is restored)
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An individual was treated with 20 mg prednisone daily for 30 days for a systemic inflammatory condition. Tapering occurred for 10 days. How soon may she safely receive the shingles immunization?
1. Now2. In 1 week3. In 1 month4. In 4-6 months
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Best Practice
Immunosuppressed Host• Defer live vaccines for at least 1
month after discontinuation of high dose steroid therapy • High dose = >20 mg prednisone
daily for > 14 days
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Low vs. High Levels• Low level immunosuppression:
prednisone < 20 mg/d or alternate steroid therapy; methotrexate < 0.4 mg/kg/week, azathioprine < 3 mg/kg/d• High level immunosuppression:
adalimumab, infliximab, etanercept, rituximab (anti-B-cell antibodies)
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Special Considerations
See vaccine specific info for:• HIV, cancer• Solid organ transplant• Stem cell transplant• Asplenia, sickle cell disease• Antibody deficiencies
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10 Adult Recommendations(> 19 years old)
• Influenza• Tdap• Varicella• HPV• Zoster• MMR• PCV 13, PPSV23• Meningococcal• Hepatitis A, B• Hib
Impacting health of communities
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Pneumococcal DiseaseSimple Fact
Pneumococcal disease kills more people in the US than ALL other vaccine preventable diseases combined.
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Pneumococcal Disease• Pneumococcal disease is caused by
Streptococcus pneumoniae• There are 90 different serotypes (PPSV23
immunizes against 23 serotypes)
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Pneumococcal Disease• Very common!!!!• Pneumococcal disease spread by respiratory
droplet• Pneumococcal disease causes pneumococcal
pneumonia, bacteremia, meningitis• Pneumococcal pneumonia fatality rate is 7%
but higher in elderly, co-morbids• 25-30% of pneumococcal pneumonia patients
get bacteremia
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A 68 year old patient does not know whether he received a pneumococcal vaccine or not. How should this be handled?
1. Don’t administer.2. Administer now.
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PPSV 23: Who?• Age 65 years or older with no or
unknown history of prior receipt of PPSV
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Who else needs PPSV 23?Age 19-64 years with no or unknown history of prior receipt of PPSV and any of the following:
• Cigarette smoker age 19 and older• CV disease ( HF, cardiomyopathies, etc.)• Chronic pulmonary disease (COPD, asthma)• DM, alcoholism, chronic liver disease• Candidate for a cochlear implant, CSF leak• Functional or anatomic asplenia (SCA, splenectomy)• HIV, congenital immunodeficiency, hematologic and solid
tumors (immunocompromising conditions)• Immunosuppressive therapy (alkylating agents, antimetabolites,
long term systemic steroids, radiation therapy)
• Chronic renal failure or nephrotic syndrome; Solid organ or bone marrow transplantation
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PPSV23 and PCV13Who gets a second PPSV 23?
• Functional or anatomic asplenia (SCA, splenectomy)• HIV, congenital immunodeficiency, hematologic or
solid tumors (immunocompromising conditions)• Immunosuppressive therapy (alkylating agents,
antimetabolites, long term systemic steroids, radiation therapy)
• Chronic renal failure or nephrotic syndrome; Solid organ or bone marrow transplantationThese patients need PCV13 also!!!!!!
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A 59 year old female (who is a nurse) was diagnosed with sarcoidosis about 20 years ago. She remembers being on prednisone for about a year. Since then she has had no issues. However, for the past 12 months she has had leg and hip pain and has been diagnosed with sarcoidosis involving the muscles.
She has no recollection of pneumococcal vaccine. Should she receive one today?
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A 59 year old female (who is a nurse) was diagnosed with sarcoidosis about 20 years ago. She remembers being on prednisone for about a year. Since then she has had no issues. However, for the past 12 months she has had leg and hip pain and has been diagnosed with sarcoidosis involving the muscles.
Which one?After the first one, what is given next?When?
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Vaccination Coverage Rates 2012
Pneumococcal Vaccine • Highest risk: 20% fully vaccinated• Adults 19-64: 21%• Adults > 65 years: 59.9%
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6305a4.htm
MMWR: February 7, 2014 / 63(05);95-102
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12 Pediatric Recommendations
• Influenza• Rotavirus• DTaP < 7 years• TdaP > 7 years• Varicella• IPV• MMR• PCV 13, PPSV23• Meningococcal• Hepatitis A, B• Hib• HPV
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What’s new since 2013?Remarkably Little has
Changed• Meningococcal maybe given as early as
2 months for high risk infants• Footnotes have been combined for
routine, catch up and high risk patients• Clarified some footnotes for influenza,
pneumococcal, hepatitis A, and Hib
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Pediatric ChallengesCatch-up Vaccinations
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Rotavirus Vaccine• Oral immunization• Jan 2006-August, 2013• 39 cases of oral vaccine administered by
injection
CDC’s MMWR, March 18, 2014
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Worth Noting…
Pertussis Rates: > 48,000 cases in 2012 (most since 1955)
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What’s Pertussis?
• Major cause of mortality in the 20th century• Serious illness in all ages and can be
life threatening• Whooping cough: sound made when
patient gasps for breath after cough• “100 days of cough”
Bordetella pertussis
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What’s Pertussis?
• Highly contagious!!!• Vaccinating all age groups• Vaccination of pregnant women with
EVERY pregnancy (to protect the infant)!
Bordetella pertussis
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PertussisBordetella pertussis
Stage Length Clinical FeaturesStage 1:
CatarrhalUsually 7-10 days; range = 4-21 days
Runny nose, fever, occasional cough
Stage 2: Paroxysmal
1-6 weeks; maybe up to 10 weeks
Paroxysms of rapid cough (thick mucus in resp tree)Whoop at end of cough
15 attacks/24 hours
Stage 3: Convalescent
7-10 days; range = 4-21
Cough severity lessens
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Pertussis?
• Diagnosis is made by collecting a nasopharyngeal swab• Specimen is used for both culture and PCR
(polymerase chain reaction): rapid test• Collect within first 3 weeks of illness• Culture has better specificity but takes 7
days for results
Diagnosis
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Pertussis?
• Macrolides used for treatment• Azithromycin for 5 days,
clarithromycin for 7 days• TMP-SMX if not able to use
macrolide (14 days of treatment)• No therapy for cough
Treatment
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Pertussis?
• Antibiotic warranted for symptoms up to 4 weeks (general public)• Antibiotics warranted for symptoms
up to 8 weeks if healthcare workers, pregnant women, individuals working with infants
Treatment
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Worth Noting…
When administering live and/or attenuated vaccines….both must be given on the same day OR you must wait 4 weeks to give the one you didn’t administer.
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Worth Noting…
At 12 months: MMR, varicella
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Worth Noting…Unknown Vaccination Status• Provider should only accept written,
dated records as evidence• If no evidence, they are considered
susceptible and should be immunized
What are the two exceptions to this rule?
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ExceptionsUnknown Vaccination Status• Influenza• PPSV
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Alternative to Immunization
Serology• Measles• Rubella• Hepatitis A• Tetanus• Hepatitis B
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Pediatric ChallengesHow do we Improve Immunization Rates?
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What strategy results in the most consistently effective means for increasing immunization rates?
1. Chart reminders2. Computerized record reminders3. Mail and telephone reminders4. Standing orders
http://www2a.cdc.gov/vaccines/ed/whatworks/strategies.asp
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Standing Orders
http://www.immunize.org/standing-orders/
Most consistently effective means to increase immunization rates. Examples found at:
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Strategies to Improve Rates
Only identifies people who are scheduled for an appointment
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Strategies to Improve Rates
Colorful stickers in the charts resulted in highest ratesHealth maintenance reminders
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Strategies to Improve Rates
Mail and telephone reminders
Addresses patients without an office visit
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Worth Noting…
National Childhood Vaccine Injury Act of 1986 requires that Vaccine information statements (VIS) be provided each time a vaccine is administered.
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Thank you!For questions or to contact me:
Amelie [email protected]
Advanced Practice Education Associates
Lafayette, LA