AAP IMMUNIZATION INITIATIVES NEWSLETTER

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1 October 2014 AAP IMMUNIZATION INITIATIVES NEWSLETTER Inside this issue: Updates & Alerts 1 Events 2 Red Book Online 2 Resources 2 Featured Research Findings 3 Pediatrics in Practice 4 CDC s Spotlight on Childhood Immunizations 6 Special Section Influenza 7 Links to AAP Resources: AAP Immunization Web site The Bookstore Red Book Online The Childhood Immunization Support Program (CISP) is a cooperative agreement between the CDC and AAP. (Cooperative Agreement: 5U38OT ) Updates and Alerts CDC Publishes NIS Data for Childhood and Adolescent Vaccines Childhood The Centers for Disease Control and Prevention (CDC) has published data from the National Immunization Survey (NIS) ( showing that while rates of vaccine doses given in the first year of life are generally above Healthy People 2020 goals, rates for series that include the vaccines due past 12 months of age, while steady, are below national goals. An infographic depicting this is available at: html. CDC suggests practice-based interventions such as reminder and recall systems, and use of immunization information systems. To learn more about these strategies, see the AAP Immunization Training Guide at: Adolescent The NIS teen data show that rates for the first dose of Tdap and meningococcal vaccine are increasing, but rates for HPV vaccine in boys and girls remain well below national goals. The CDC s MMWR on HPV vaccination data is available at: To view the full results of the NIS, visit: The AAP offers the following resources to help improve rates in your practice: Adolescent Immunizations - Strategies for increasing Immunization Rates ngcoverage.pdf CDC Tips and Time-savers for Talking with Parents About HPV Vaccine Education in Quality Improvement for Pediatric Practices Measles Outbreaks in US The Centers for Disease Control and Prevention are reporting 592 cases of measles in 18 separate outbreaks in the United States (US) through August 29, This is the largest number of cases the US has seen since 2000 when the disease was declared eliminated in the US. The majority of the people who got measles are unvaccinated. For updates on measles outbreaks in the US, visit: FDA Approves Menactra for Meningococcal Booster in Teens Last month the FDA extended the license for Menactra to include use in teens and adults ages 15-55, as a booster, as long as it has been at least 4 years since the last dose of MCV4. To view the approval letter, visit: htm. For the new package insert, see: ts/ucm pdf.

2 Upcoming Events Advisory Committee on Immunization Practices Meeting October 29-30, 2014 Tom Harkin Global Communications Center (Building 19) Kent "Oz" Nelson Auditorium Atlanta, GA The ACIP holds three meetings each year to review scientific data and vote on vaccine recommendations. Meetings are open to the public and available online via live webcast. During committee meetings, members present findings and discuss vaccine research and scientific data related to vaccine effectiveness and safety, clinical trial results, and manufacturer's labeling or package insert information. Specific topics at this meeting include the childhood and adult schedules, meningococcal vaccine, influenza, HPV, vaccine safety and more. For more information visit: National Foundation for Infectious Diseases Fall Clinical Vaccinology Course November 7-9, 2014 Houston, TX Topics covered at this educational meeting include immunization strategies and challenges, ACIP updates, influenza vaccines, travel vaccines and more. For more information and to register, visit: fall-cvc.html#sthash.knzjtk7z.dpuf Children s Hospital of Philadelphia (CHOP) Vaccine Webinar Series Paul Offit, MD, Director, Vaccine Education Center, CHOP will be presenting on current vaccine issues. o November 19, 2014 For more information and to register visit: Red Book Online Red Book Online Is Improving! Watch for some exciting new updates and features planned for Red Book Online as we launch a new state-of-the-art digital platform coming soon, making your access to this indispensable infectious disease resource easier and better than ever. New features include: A new, clean look and feel with improved site navigation New, robust searching utilizing the latest in semantic search technology Responsive design adjusting automatically to your favorite device New streamlined log-in process for easy access at the point of care Red Book Online will continue to provide you with the quickest, easiest way to keep pace with all the latest infectious disease developments and AAP clinical guidelines with the same content that you trust. AAP members receive Red Book Online as their enhanced Red Book member benefit. For more information, visit Thank you for your continued support of Red Book Online. Resources CDC The CDC offers resources that help parents navigate the recommended immunization schedule for children. These include family-friendly vaccine schedules for children, preteens and teens, and adults. Children: Preteens and Teens: Adults: Texas Children's Hospital Texas Children s Hospital has released a video that conveys the importance of receiving the flu vaccine. Three families share their experiences with influenza disease with the hope of convincing other families of the need for flu vaccine. View the video at: Immunization Action Coalition (IAC) IAC has updated education for providers about Vaccine Information Statements Current Dates of Vaccine Information Statements It's Federal Law! You must give your patients current Vaccine Information Statements

3 Featured Research Findings Long-term Study of a Quadrivalent Human Papillomavirus Vaccine Daron Ferris, MD, Rudiwilai Samakoses; MD, Stan L. Block, MD; Eduardo Lazcano-Ponce, MD; Jaime Alberto Restrepo, MD; Keith S. Reisinger, MD, MPH; Jesper Mehlsen, MD; Archana Chatterjee, MD, PhD; Ole-Erik Iversen, MD; Heather L. Sings, PhD; Qiong Shou, PhD; Timothy A. Sausser, BS; and Alfred Saah, MD Researchers evaluated the long-term evidence of immunity for HPV strains 6, 11, 16, and 18 as found in the quadrivalent HPV vaccine (HPV4) Gardasil. They also estimated the vaccine s effectiveness in preventing morbidity due to the same strains of HPV. Authors used a randomized, double-blind, placebo-controlled baseline study that assessed the safety and initial immune-response of the HPV4 vaccine among 9- to 15-year-old boys and girls over a 1 year period. One cohort (Early Vaccination Group [EVG]) was given on-time doses of the vaccine at months 0, 2, and 6. The other cohort (Catch-up Vaccination Group [CVG]) was given placebo doses at 0, 2, and 6 months, and the actual vaccine at months 30, 32, and 36. The study presents data from 42 to 96 months after the first HPV vaccine or placebo dose. Participants in the trial were excluded from analysis if they did not receive all 3 doses of vaccine before sexual debut and did not present for at least 1 follow up appointment after the 3 rd vaccine dose. At follow-up points, genital swabs were performed to look for disease, which was decided by a 4-member pathology panel analyzing the swab. Persistent infection was defined as detection of the same HPV type in genital swabs at 2 consecutive visits spaced 4 months apart (pre-specified endpoint) or 12 months apart (post hoc analysis) or the presence of disease associated with the relevant type with DNA for that same type found in the swab at the visit directly before or after the biopsy. A total of 1,116 subjects from the EVG had follow-up to check immunogenicity. On average, this follow-up occurred at years after their 3 vaccine dose. In the CVG, participants had follow-up in years on average. Researches found that antibodies induced by the vaccine lasted through the 96-month follow-up for both boys and girls, but by then levels had fallen compared to levels at the 7 month follow up. No antibody threshold for immunity has been established, so the clinical relevance of this is unclear. Of 256 females and 173 males followed from the EVG, no cases of disease were discovered, and only 2 cases of HPV16-related persistent infection of 4 months duration were detected in females, and 2 cases (1 HPV 6 and 1 HPV 16) of persistent infection of 4 months duration were found in males. No cases of persistent infection of 12 months were found in either sex in this group. In the CVG, 2 cases of HPV16-related persistent infection and 4 cases of HPV18- related persistent infection were found in females. The 4 cases of HPV18-related persistent infection were persistent infections that lasted 12 months. In the male CVG participants, there was 1 case of HPV6-related persistent infection of <12 months duration seen. The study found 1 serious adverse event (AE) follow vaccination that investigators determined to be vaccinerelated. The AE was cranial nerve paralysis that lasted 2.7 weeks duration, was treated, and from which the patient fully recovered. Authors concluded that the HPV4 vaccine demonstrated lasting protection against the 4 HPV strains for over 8 years. Significant serious AEs were not observed for 8 years after vaccination in both genders. This information supports the recommendation to vaccinate all preadolescents and young adolescents with HPV vaccine. Pediatrics Published online August 18, (Login may be required) To learn more about being the key to cancer prevention, a Webinar is available at:

4 Pediatrics in Practice Vaccine Administration Errors While vaccine administration errors happen, there are ways you can help prevent them in your office. Preventing these errors is important in order to make sure children are properly protected against as many diseases as possible. Providing the right dose, the right way, also saves your practice the time of revaccinating, the cost of a lost vaccine, and the embarrassment of needing to explain the error to patients and get them in the office for revaccination. The CDC Pink Book describes 7 Rights of Medication Administration that should be applied to vaccine administration encounters. They include: the right patient; the right vaccine or diluent; the right time (includes administering at the correct age, the appropriate interval, and before vaccine or diluent expires) the right dosage; the right route (oral, intramuscular [IM], subcutaneous [SC], nasal, etc), needle length, and technique; the right site (upper arm, thigh, etc.); and, the right documentation. Some of the most common vaccine administration errors include: Providing the wrong vaccine (DTaP vs. Tdap) Administering vaccine via the wrong route (SC instead of IM) Administering the wrong dose Mixing vaccine with the wrong diluent Giving expired vaccine Not following contraindications (giving 2 live vaccines less than 4 weeks apart and not on the same day, etc.) There are many resources available to help train office staff on proper vaccination techniques. Handouts: AAP Immunization Training Guide: CDC Pink Book (Appendix D Vaccine Administration): IAC Vaccine Administration Clinic Resources IAC Technically Speaking Article California VFC Program Vaccine administration tools Videos: CDC Managing Patient Safety, One Injection at a Time CDC Check Your Steps! Make Every Injection Safe California Department of Public Health - Immunization Techniques: Best Practices with Infants, Children and Adults. This 25-minute DVD is available for a nominal charge from the IAC. Order this video at: If you have vaccine administration questions CDC at nipinfo@cdc.gov or IAC at admin@immunize.org for answers.

5 CDC s Spotlight on Childhood Immunizations Pertussis Cases on the Rise Help Keep Your Patients Protected Pertussis used to be thought of as a disease of the past, but it s making a comeback. In fact, between January 1st and August 16th of this year, 17,325 cases of whooping cough have been reported to the CDC, with cases in all 50 states and Washington, D.C. This is 30% more cases than last year at this same time, and we know that many more cases go unreported. You can help provide children and families with the best protection against this disease by making sure everyone who needs vaccines, gets vaccinated. You and parents that you talk to may wonder why the United States has had this resurgence of pertussis, and although we don t know for sure exactly why it s happening, we know several factors are involved. First, DTaP and Tdap vaccines do not protect people for as long as we would like. As immunity wanes, children and adults can get infected with pertussis and spread it to others. Also, doctors are more aware that pertussis is still around and affecting communities. This raised awareness, along with better tests to diagnose patients, has contributed to an increase in the number of whooping cough cases being diagnosed and reported. Finally, the bacteria that cause pertussis are always changing at a genetic level. Research is underway to determine if any of the recent changes in the bacteria may be related to the increase in disease. Pertussis can take a toll on any of your patients, but it can be deadly for the young infants you see. Most pertussis deaths are in infants too young to be protected by their own vaccination. But, we can provide these babies with some protection by making sure their moms get their Tdap vaccine during the 3rd trimester of each pregnancy. CDC revised the immunization schedule in 2013 to include the recommendation that pregnant women get Tdap vaccine, preferably between 27 and 36 weeks gestation. The antibodies passed to the baby in utero will help provide protection until he is old enough to receive his first pertussis vaccine, and the mother will be protecting herself so she won t spread pertussis to her newborn. However, we know that not all pregnant women have heard about this recommendation, and we need your help. You are parents most trusted source for health information about their children. When a mother comes to your office seeking medical care for her child, and she is pregnant, CDC encourages you to recommend she talk to her ob-gyn about the Tdap vaccine. Let her know that you will be caring for her baby in the future too, and you want to make sure he or she is born with some pertussis protection. You can also recommend Tdap to first-time moms who are pregnant and trying to learn more about your practice as they select a pediatrician for their baby. To learn more about the pregnancy dose of Tdap, visit Of course, you will then continue to protect these babies when you vaccinate them with their DTaP vaccine beginning at 2 months. Moms should understand that each subsequent dose of DTaP is important for best disease protection. Your pre-teen patients need Tdap at 11 or 12 years old since the protection the DTaP vaccine provided them when they were younger decreases over time. Thank you for your help protecting your current and future patients from pertussis! To see the current DTaP and Tdap recommendations visit:

6 Influenza Season Vaccine Formulation The vaccine strains have not changed from last year. Also like last year, both trivalent (three component), and quadrivalent (formulated to protect against four flu viruses) are available. Neither the quadrivalent nor the trivalent formula of the inactivated influenza vaccine (IIV) is preferred over the other. Intramuscular (IM), intradermal, and nasal spray vaccines will all be available. Nasal spray vaccines are a live attenuated influenza vaccine (LAIV) and are quadrivalent. LAIV should be considered for healthy children 2 through 8 years of age who have no contraindications or precautions to the intranasal vaccine. Visit the Preparing Your Practice for Providing Influenza Vaccines to learn more about vaccines available, product codes, and payment information at: Providing-Influenza-Vaccines.aspx. Vaccine Supply Manufacturers have projected that they will produce between 151 million and 159 million doses of influenza vaccine for use in the United States during the influenza season. Several vaccine manufacturers have announced a slow start in the shipping of flu vaccine, leading to physician offices receiving vaccine later than originally projected. Recent projections suggest offices will receive vaccine in mid to late September through the end of October. AAP has assembled information regarding expected ship dates for specific vaccine manufactures here: us/professional-resources/practice-support/vaccine-financing-delivery/pages/private/influenza-vaccine- Supply-Update.aspx Available formulations and a series of briefs on supply and demand can be found, at The CDC offers a table of influenza vaccines at: Healthcare Worker Vaccination AAP - Recommendations for Mandatory Influenza Immunizations of All Health Care Personnel: AAP - Implementation Guidance for Physicians on Mandatory Influenza Vaccination of Healthcare Workers: Influenza Vaccination Coverage Among Health Care Personnel: The CDC and AAP continue to recommend that all health care personnel get vaccinated against influenza. Vaccination rates are highest for physicians, nurse practitioners, and nurses. Information on a CDC healthcare worker influenza survey, including online reports with the data broken out by region/state, is available on FluVaxView at

7 Resources Influenza Season AAP Recommendations for Prevention and Control of Influenza in Children, policy AAP Influenza Guidance: CDC Seasonal Influenza CDC What You Should Know for the Influenza Season National Influenza Vaccine Summit: Earn Your Stripe Poster Template Vaccine Information Statements In English: o Inactivated influenza vaccine (IIV) o Live attenuated influenza vaccine (LAIV) In Spanish: o IIV o LAIV American Lung Association: or (for Spanish language materials) Reminder/Recall Strategies and Resources: Families Fighting Flu: Got an idea about a topic you d like us to cover? Contact us at cispimmunize@aap.org