Disclosures. Immuniza(on Update Vaccina(ng All Ages. Learning Objec(ves. Test Your Knowledge. Test Your Knowledge. Test Your Knowledge 4/28/17

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1 Immuniza(on Update Vaccina(ng All Ages Jayme Garcia, PharmD Pa#ent Care Coordinator Smith s Food & Drug UPhA Board Member Disclosures Dr. Garcia declares no conflicts of interest, real or apparent, and no financial interests in any company, product, or service men#oned in this program, including grants, employment, gifs, and stock holdings. The Utah Pharmacy Associa#on is accredited by the Accredita#on Council for Pharmacy Educa#on as a provider of con#nuing pharmacy educa#on. Learning Objec(ves At the conclusion of this program, the par#cipa#ng pharmacist or technician will be able to: 1. Summarize the vaccina#on recommenda#ons in childhood and adulthood made by the Advisory CommiNee on Immuniza#on Prac#ces (ACIP). 2. Recognize major changes in recommenda#ons made by ACIP in the past year. 3. Describe the appropriate immuniza#on techniques for infants, children and adults. 4. Understand the role of the pharmacy in improving immuniza#on rates. Which is the most predominant flu strain seen in the flu season? A. Influenza A (H1N1) B. Influenza A (H3N2) C. Influenza B (Victoria lineage) D. Influenza B (Yamagata lineage) A two- dose series of HPV vaccine is recommended for most pa#ents in which pa#ent popula#on? A. Female pa#ents 9 to 26 years old B. Male pa#ents 11 to 21 years old C. Pa#ents ini#a#ng the series before age 15 D. All eligible pa#ents Which vaccine(s) will be discon#nued in the United States afer this year? Select all that apply. A. Menveo B. Zostavax C. Cervarix D. Gardasil E. All of the above 1

2 Test Your Knowledge Who should receive a two- dose series of meningococcal ACWY vaccine with revaccina#on every 5 years? A. B. C. D. E. Asplenic pa#ents Pa#ents with HIV Pa#ents on hemodialysis A & B All of the above ACIP Mee(ng Votes 2017 Schedule Changes June 2016 Approval of recommenda#on that live anenuated influenza vaccine (LAIV) not be used for the flu season Approval of cholera vaccine recommenda#on for those traveling to high risk areas Approval of recommenda#on for meningococcal quadrivalent (ACWY) be given rou#nely to pa#ents > 2months of age with HIV October 2016 Approval of changes to 2017 child/adolescent and adult immuniza#on schedules Approval of 2- dose HPV series for most pa#ents 9-14 years. February 2017 Child/Adolescent Specific (18 years and younger) Hepa##s B: Footnote now states to administered first dose within 24 hours of birth Previously stated before hospital discharge Polio: Addi#onal guidance given for when the fourth dose is administered inadvertently early Meningococcal: Need for booster dose at age year old plajorm added Pneumococcal: References to the 7- valent pneumococcal vaccine have all been removed New chart of recommenda#ons based on medical indica#ons Approval of influenza strains for the flu season 2017 Schedule Changes Adult Specific (19 years and older) 2016 Hepa##s B: Chronic liver disease condi#ons updated Inac#vated influenza virus (IIV): Egg allergy revised for flu vaccine New table for contraindica#ons and precau#ons Both Child/Adolescent and Adult LAIV: Removed from the figure and footnote Tdap: Footnote now states to give in pregnancy preferably during the early part of gesta#onal weeks 27 through 36 MenACWY: Recommended for pa#ents with HIV MenB- FHbp: 2- dose (Trumenba) schedule HPV: 2- dose schedule 2

3 Influenza Influenza Vaccina(on Coverage Among Adults - Utah GOAL = 90% for high risk adults GOAL = 80% GOAL = 90% Reported U.S. Flu Posi(ve Tests Flu Vaccine Effec(veness (VE) Any Vaccine Overall adjusted VE = 47% A/H1N1: 41% A/H3N2: 45% B/Yamagata: 55% B/Victoria: 55% IIV Overall adjusted VE = 49% A/H1N1: 44% A/H3N2: 43% B/Yamagata: 59% B/Victoria: 58% Es(mates Any Vaccine Overall adjusted VE ~ 48% A/H3N2: 43% Influenza B: 73% Flu Season World Health Organiza#on (WHO) pick for flu season A/Michigan/45/2015 (H1N1)pdm09- like virus A/Hong Kong/4801/2014 (H3N2)- like virus B/Brisbane/60/2008- like virus B/Phuket/3073/2013- like virus NEW Trivalent Quadrivalent ACIP Flu Recommenda(on Annual vaccina#on for all people ages 6 months and older who do not have a contraindica#on to the vaccine Children 6 months to 8 years of age receiving influenza vaccine for the first #me should receive two doses at least 4 weeks apart Flumist (LAIV) not likely to be recommended for the flu season 3

4 Handling Egg Allergy in Adults Meningococcal Dependent on Reac#on Type Hives only Pa#ent should receive age- appropriate IIV or recombinant influenza vaccine (RIV) Severe egg allergy (angioedema, respiratory distress, lightheadedness or recurrent emesis or who require epinephrine) Pa#ent can be vaccinated in any inpa#ent or outpa#ent medical sepng under the supervision of a vaccine provider who can recognize signs and symptoms of severe allergic reac#on (e.g. anaphylaxis) MenACWY Vaccines Meningococcal Quadrivalent Conjugate Vaccine (MenACWY) Available formula#ons: Menveo & Menactra Preferred for ages 2 or 9 months respec#vely to 55 years May be given to people age 56 years or older Meningococcal Quadrivalent Polysaccharide Vaccine (MPSV4) Available formula#on: Menomune but not for long Will be discon#nued this year. Last lots expire Sept Tradi#onally preferred for adults 56 years and older MenACWY ACIP Recommenda(ons Rou#ne vaccina#on with 2- dose series given at years and 16 years old Pa#ents with the following risk factors should receive a 2 to 4 dose series dependent on age: HIV infec#on NEW Anatomical or func#onal asplenia Persistent component deficiency Travelers to meningococcal disease epidemic areas First- year college student up through age 21 who are living in residence halls Microbiologist who are rou#nely exposed to isolates of Neisseria meningi#dis Military recruits Adults with con#nued risk factors should receive a booster every 5 years Meningococcal B Trumenba (MenB- FHbp) 1st MenB vaccine FDA approved October 2014 Approved for ages years 2 components 2 or 3 dose IM series NEW Bexero (MenB- 4c) 2 nd MenB vaccine FDA approved January 2015 Approved for ages years 4 components 2 dose IM series Revised Men B Vaccine Schedule For persons at increased risk of meningococcal B disease 2 doses of Bexsero (0 and 1 month) OR 3 doses of Trumenba (0, 2, 6 months) Persistent complement component deficiencies Anatomic or func#onal asplenia Microbiologists rou#nely exposed to isolates of Neisseria meningi#dis Persons iden#fied to be at increased risk because of MenB outbreaks (i.e. college students) For persons not at increased risk of meningococcal B disease 2 doses of Bexsero (0 and 1 month) OR 2 doses of Trumenba (0 and 6 months) NEW NOT rou#nely recommended for college students, interna#onal travelers, HIV+ pa#ents 4

5 Human Papilloma Virus (HPV) Cancer preven#on! HPV vaccina#on protects: Females: cervical, vulvar and vaginal cancer Males: penile cancer Both: anal and oropharyngeal cancer Gardasil 9 (9vHPV) FDA approved December 2014 Covers serotypes 6, 11, 16, 18, 31, 33, 45, 52, 58 coverage rates for cervical cancer to 90% S#ll covers 90% of genital warts Cervarix (2vHPV) and Gardasil (4vHPV) No longer marketed in the U.S. ACIP HPV Recommenda(on ACIP recommends rou#ne HPV vaccina#on ini#ated at age 11 or 12 years for ALL males and females The series may be ini#ated at the age of 9 A two dose series (0 and 6 months) is approved if ini#ated before 15 years old NEW Doses MUST be separated by at least 5 months otherwise defaults to 3 dose series (0, 1-2 and 6 months) ALL females ages years old Who did not get any or all doses when they were younger (catch- up) ALL males ages years old Who did not get any or all doses when they were younger (catch- up) HPV Vaccine Special Popula(ons Children with a history of sexual abuse or assault Rou#ne HPV vaccina#on beginning at age 9 years Men who have sex with men (MSM) 3 dose series through age 26 years Immunocompromised pa#ents 3 dose series through age 26 years Transgender persons Vaccina#on through age 26 years New FDA Approved Vaccines New FDA Approved Vaccines Influenza Afluria Quad 18 years Fluad Trivalent Adjuvanted 65 years Flucelvax Quad 4 years Flublok Quad Recombinant FluLaval Quad 6 months Cholera Vaxchora HPV Vaccina(on Coverage in Utah Es#mated vaccina#on coverage for adolescents years old in 2015 HPV Full Series U.S Utah Female 42% 25% Male 28% 20% Healthy People 2020 Goal = 80% Administra(on by the Intramuscular (IM) Route Vaccines in the Pipeline Ebola RSV Zoster inac#vated Dengue Zika Oral dose years 5

6 Tips for Vaccina(ng Children Administra(on by the Subcutaneous (SQ) Route Comfor(ng Restraint Distrac(on Techniques The Cough Trick When using the count to three method, give the shot on two then inject on three Lots of praise Let the child be in control Remove other siblings from the room if possible Minimizing Pain in Children Administer vaccines with a rapid injec#on technique rather than slow push Ask children to relax shoulders Inject the most painful vaccine last (MMR, Prevnar?) Rubbing or applying pressure around the injec#on site before and during vaccine administra#on Parent led distrac#on may reduce distress For children age 3 or older - slow, deep breathing and blowing during vaccina#on DO NOT tell children it will not hurt Sweet tas#ng sucrose solu#ons administered during vaccina#on Breast feeding in infants up to 12 months of age Insufficient evidence: Ice packs NSAIDS or APAP Pharmacists Role Collect immuniza#on history from pa#ent, prescriber, Utah Statewide Immuniza#on Informa#on System (USIIS) Assess which vaccines are needed based on age, condi#on(s), lifestyle Plan to ensure product availability, immunizer comfort level and efficient pharmacy workflow Implement. Vaccinate. Vaccinate. Vaccinate! Follow- up: Monitor and Evaluate. Do addi#onal vaccines need to be scheduled for series comple#on? Provide strong recommenda#ons and remain the source of truth for your pa#ents! Immuniza(on References Immuniza#on Ac#on Coali#on (IAC) Utah Statewide Immuniza#on Informa#on System (USIIS) Centers for Disease Control and Preven#on (CDC) Test Your Knowledge Which is the most predominant flu strain seen in the flu season? A. B. C. D. Influenza A (H1N1) Influenza A (H3N2) Influenza B (Victoria lineage) Influenza B (Yamagata lineage) SmartPhone App Pink Book Vaccine Informa#on Statements (VIS) 6

7 A two- dose series of HPV vaccine is recommended for most pa#ents in which pa#ent popula#on? A. Female pa#ents 9 to 26 years old B. Male pa#ents 11 to 21 years old C. Pa#ents ini#a#ng the series before age 15 D. All eligible pa#ents Which vaccine(s) will be discon#nued in the United States afer this year? Select all that apply. A. Menomune B. Zostavax C. Cervarix D. Gardasil E. All of the above Who should receive a two- dose series of meningococcal ACWY vaccine with revaccina#on every 5 years? A. Asplenic pa#ents B. Pa#ents with HIV C. Pa#ents on hemodialysis D. A & B E. All of the above The current quadrivalent meningococcal vaccine covers all of the following serotypes EXCEPT A. A B. B C. C D. Y Need More Informa(on? Jayme Garcia, PharmD Patient Care Coordinator Smith s Food & Drug, Inc. UPhA Board Member jayme.garcia@sfdc.com 7