Timely Immunization Practice Strategies

Transcription

1 Timely Immunization Practice Strategies Mary Wisinski RN BSN Immunization Program Supervisor March 9, 2018

2 Slide Credits Credit for many slides to the Michigan Department of Health and Human Services Immunization Program Staff

3 Updates from MDHHS

4 Proposed Legislation HB 4425 & 4426; Reverses our educational requirement as we have implemented in the administrative rules. Removes the ability of a Health Officer to exclude an individual as a disease control measure unless is it an epidemic. SB 299 & 300 Similar to the Bills above. HB 5162 & 5163 Restricts the department s ability to add new vaccines for schools and childcare.

5 Changes to the Waiver Language 2017 Language on Waiver By signing this waiver, I acknowledge that I have been informed that I may be placing my child and others at risk of serious illness should he or she contract a disease that could have been prevented through proper vaccination Language on Waiver By signing this waiver, I acknowledge I have attended the waiver session and have been informed about vaccines and vaccine preventable diseases. I also understand that my child may be excluded from the school or childcare center if the local health department determines that it is necessary to control the occurrence of a vaccine preventable disease.

6 New Waiver Processes New policy coming out on review of Medical Contraindications New process coming out to deal with FERPA issues being brought up

7 ACIP Released MMWR for Hepatitis B January 12, 2018 Prevention of Hepatitis B Virus Infection in the United States: Recommendations of the Advisory Committee on Immunization Practices Summarizes and consolidates previously published recommendations Universal hepatitis B (HepB) vaccination within 24 hours of birth for medically stable infants weighing 2,000 grams Testing HBsAg-positive pregnant women for hepatitis B virus deoxyribonucleic acid (HBV DNA) Post-vaccination serologic testing (PVST) for infants whose mother s HBsAg status remains unknown indefinitely Single-dose revaccination for infants born to HBsAg-positive women not responding to the initial vaccine series Vaccination of persons with chronic liver disease Removal of permissive language for delaying the birth dose until after hospital discharge Guidance for postexposure prophylaxis following occupational and other exposures If you have any questions, please feel free to contact Pat Fineis, Perinatal Hepatitis B fineisp@michigan.gov MMWR Hepatitis B:

8 Recommendation of the Advisory Committee on Immunization Practices for Use of a Third Dose of Mumps Virus Containing Vaccine in Persons at Increased Risk for Mumps During an Outbreak ACIP Released MMWR for Use of a 3 rd Dose of Mumps January 12, 2018 Persons previously vaccinated with 2 doses of a mumps viruscontaining vaccine who are identified by public health authorities as being part of a group or population at increased risk for acquiring mumps because of an outbreak should receive a 3 rd dose of a mumps virus-containing vaccine A third dose of MMR vaccine has at least a short-term benefit for persons in outbreak settings An ACIP recommendation would allow health departments to make more rapid decisions regarding use of a third dose of MMR because of an outbreak MMRV vaccine may be used when a 3 rd dose mumps vaccination is indicated among children 12 years of age and younger Evidence indicates that a 3 rd dose of MMR vaccine improves protection for persons at increased risk for mumps because of an outbreak No additional dose is recommended for person in outbreak settings who have already received 3 or more doses of a mumps virus-containing vaccine MMWR Mumps:

9 GlaxoSmithKline influenza vaccine Fluarix Quadrivalent was approved by the U.S. Food and Drug Administration (FDA) to extend the age range Influenza Fluarix January 12, 2018 Fluarix Quadrivalent vaccine has been approved for use in all persons 6 months of age and older Prior to FDA approval the vaccine was only approved for use in persons 3 years of age and older At this time, CDC and the ACIP have not released any further recommendations on the use of Fluarix MDHHS has updated all the influenza handouts to reflect the Fluarix change

10 Meningococcal Serogroup B in MCIR & Quick Look at Using Meningococcal Serogroup B Vaccines (MenB)

11 Meningococcal Serogroup B in MCIR January 24, 2018 MCIR drop-down will display Bexsero as MenB-4C (Bexsero) Trumenba as MenB-FHbp (Trumenba) MenB vaccine will be forecasted as a general routine vaccine series for persons 16 through 23 years of age with a due date of the 16th birthday Once dose 1 is given, the vaccine brand will be displayed as MenB-4C (Bexsero) or MenB-FHbp (Trumenba) MCIR will forecast dose 2 at the appropriate interval as DUE based on what MenB vaccine brand was given If both MenB vaccine brands have been given as dose 1 and dose 2, MCIR will forecast the final MenB dose based on the last dose that was given MCIR will display doses given at 10 years and older under Other Administrations There is no second dose forecasting for this age group at this time (MCIR will not forecast for patients with high risk indications)

12 MenB vaccine will display on the MCIR information screen as MenB Cat. B and under the status column Discuss/Due Now will be displayed.

13 On the Immunization Status page it will be displayed as MenB Category B with Discuss/Due Now

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15 Herpes Zoster Vaccine vaccines/hcp/aciprecs/vaccspecific/shingles.html

16 Herpes Zoster Vaccine January 28 th, 2018 Recommendations of the Advisory Committee on Immunization Practices for Use of Herpes Zoster Vaccines An adjuvanted recombinant protein subunit vaccine (previously referred to as HZ/su) There are 2 zoster vaccines *NEW* Shingrix, Recombinant Zoster Vaccine (RZV) Zostavax, Zoster Vaccine Live (ZVL) ACIP recommendations: 1. RZV is recommended for immunocompetent adults 50 years and older 2. RZV is recommended for immunocompetent adults who previously received ZVL 3. RZV is preferred over ZVL

17 Shingrix, Recombinant Zoster Vaccine (RZV) 1) RZV is recommended for immunocompetent adults aged 50 years and older Benefits of RZV: High vaccine efficacy against herpes zoster 97% (50-69 years) 91% (70 years and older) High vaccine efficacy against postherpetic neuralgia (PHN) 91% for 50 years and older Maintained efficacy 85% for 4 years following vaccination in 70 years and older

18 Shingrix, Recombinant Zoster Vaccine (RZV) 2) RZV is recommended for immunocompetent adults who previously received zoster vaccine live (ZVL) RZV is more efficacious than ZVL in all age categories Differences are larger at older ages RZV is significantly more efficacious over 4 years, with VE greater than 97% in the first year, which is maintained at greater than 85% during the first 4 years for all ages

19 Shingrix, Recombinant Zoster Vaccine (RZV) 3) RZV is preferred over ZVL Efficacy RZV estimates of efficacy are significantly higher than ZVL estimates across all age groups: years: 97% vs 64% years: 91% vs 41% 80 years and older: 91% vs 18% RZV appears to wane at a slower rate than ZVL over the first 4 yrs The expected cases of HZ and PHN averted are far greater with RZV compared to ZVL **These vaccines have not been studied in a head to head efficacy trial

20 Further ACIP Recommendations for RZV Recommended populations for RZV include: Adults 50 years and older Adults with chronic medical conditions Chronic renal failure, diabetes mellitus, rheumatoid arthritis, and chronic pulmonary disease Adults taking low-dose immunosuppressive therapy, anticipating or have recovered from immunosuppression Give regardless of prior receipt of varicella vaccine, ZVL, or herpes zoster episode HZ vaccines do not require screening for a history of chickenpox (varicella) ACIP has not made recommendations for the use of RZV with immunocompromised patients This will be discussed at future meetings when more data becomes available

21 RZV Key Points It is stored in the refrigerator and requires reconstitution prior to administration After reconstitution, administer RZV immediately or store between 36º-46ºF (2-8ºC) Must use within 6 hours after reconstitution RZV is given IM as a 2-dose series at 0 and 2-6 months Maybe co-administered with other vaccines Following the first dose of RZV, the second dose should be given 2 6 months later The vaccine series need not be restarted if more than 6 months have elapsed since the first dose If the second dose of RZV is given less than 4 weeks after the first, the second dose should be repeated Two doses of the vaccine are necessary regardless of prior history of herpes zoster or prior receipt of ZVL

22 What will RZV look like in MCIR? Business rules are being reviewed for MCIR now Plan will be to start assessment and forecasting at 50 years of age RZV is the preferred vaccine and MCIR assessment and forecast will reflect this MCIR drop-down will reflect new acronyms Zoster RZV (Shingrix) Zoster ZVL (Zostavax) If ZVL has been administered then RZV will be assessed and forecasted at appropriate intervals Minimum interval from ZVL to RZV is 8 weeks (2 months) Recommended interval is being discussed with CDC subject matter experts Looking at 5 year interval for 50 through 69 years and those 70 years and older would be an 8 week interval

23 Resources for Herpes Zoster Vaccines MDHHS working on the Quick Looks for herpes zoster vaccines. Plan is for two Quick Looks The Vaccine Education Center at CHOP updated its Q&A piece for patients, "Shingles: What You Should Know ccine-education-center-shingles.pdf

24 Updated Vaccine Labels

25 2018 Immunization Schedules

26 A table has been added outlining vaccine type, abbreviation, and brand names for vaccines schedule discussed in the child/adolescent immunization schedule

27 In the catch up figure the maximum ages for the first and last doses in the rotavirus vaccination series were added and the poliovirus rows were edited to clarify the catch-up recommendation. In the medical indication figure a reference was added to the HIV column to give more information and in the pneumococcal conjugate row, stippling was added to heart, lung, liver, and diabetes columns to clarify an additional dose of vaccine might be recommended.

28 Hepatitis B vaccine (Hep B) footnote was revised to include information regarding vaccination of <2,000-g infants born to Hepatitis B virus surface antigen (HBsAg)- negative mothers. Poliovirus vaccine footnote was revised to include guidance for persons who received oral poliovirus vaccine. Influenza vaccine footnote was updated to reflect LAIV should not be used during the flu season

29 The measles, mumps, and rubella vaccine (MMR) footnote was updated to include guidance regarding the use of third dose of mumps viruscontaining vaccine during a mumps outbreak. The meningococcal vaccine footnote has been edited to create separate footnotes for MenACWY and MenB vaccines.

30 Adult Immunization Schedule

31 Tdap or Td vaccines Td/Tdap has been replaced by Tdap or Td on figures 1 and 2 and the text in the indication bar has been revised to 1 dose Tdap, then Td booster every 10 years. In figure 1, the text in the indication bars for HPV vaccine for females and males has been revised to 2 or 3 doses depending on age at series initiation.

32 Administer 1 dose of MMR vaccine to adults who previously received 2 doses of mumpscontaining vaccine and are identified by a public health authority to be at increased risk during a mumps outbreak. The text in the indication bar for Figure 1 for MMR has been changed to 1 or 2 doses depending on indication (If born in 1957 or later).

33 In figures 1 and 2, the text in the indication bar for MenACWY has been revised to 1 or 2 doses depending on indication, then booster every 5 years if risk remains. MPSV4 is no longer available and has been removed from the adult immunization schedule.

34 Adult Immunization Schedule for Zoster Vaccines Administer 2 doses RZV 2 6 months apart to adults aged 50 years or older regardless of past episode of herpes zoster or receipt of 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) ZVL has replaced the term HZV (herpes zoster vaccine) that was used in past adult immunization schedules to refer to the live zoster vaccine A row for RZV was added above the row for ZVL and a dashed line was used to separate RZV and ZVL rows to denote that the 2 zoster vaccines are recommended for the same purpose

35 Upcoming ACIP Meeting Draft Agenda ACIP meeting February 21 st and 22 nd Planned vote with Hepatitis for HEPLISAV-B Discussion around HepA post-exposure prophylaxis with summary and grade Discussion regarding Fluarix Quad for 6-35 months Discussion about the harmonization of the upper age for male and female vaccination with HPV vaccine

36 Storage and Handling Toolkit & Pneumococcal Timing Piece The Vaccine Storage & Handling Toolkit has been updated! A reorganized table of contents to better navigate the toolkit Revised recommendation for monitoring and recording storage unit temperature Updated content to reflect current vaccine products on the market

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38 Michigan Influenza Activity

39 7.1% due to ILI National baseline: 2.2% Peak in the past 15 flu seasons 2009 H1N1 pandemic: 7.8% : 7.6%

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42 Flu Vaccination Coverage; National Estimates from compared to MCIR *MCIR used for numerator and denominator for children; 2016 Census data used for the adult denominators. MCIR data: doses reported from July 1, 2017 through February 4, 2018; adult data entry are voluntary.

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44 Flu Vaccination Coverage, MCIR data*, Mid Season and End of Season Estimates Mid Season Mid Season Mid Season 6mos through 8yrs Up-to-date** mos through 17yrs* 1+ Flu doses yrs and older 1+ Flu doses * Influenza vaccines are required to be reported for children and strongly recommended for adults; underreporting occurs. MCIR data are used for the numerator and denominator for children. Census estimates are used for the adult denominator. ** Based on the number of doses the child is recommended according to their MCIR history (1 or 2 doses).

45 Michigan Vaccination Coverage Data Mid Season MCIR Estimates ( ) Children 6 months through 8 years of age who are recommended 2 doses 5.4% coverage (27,407/507,178) Age Coverage for Kids that Need Two UTD Coverage 6 months to 1 year

46 Flu Vaccine Effectiveness Australian study published October Adjusted VE overall: 33% (95% CI: 17 to 46) A(H1)pdm09: 50% (95% CI: 8 to 74) A(H3): 10% (95% CI: -16 to 31) B: 57% (95% CI: 41 to 69) Canadian study published January Adjusted VE overall: 42% (95% CI: 25 to 55) A(H3): 17% (95% CI: -14 to 40) B: 55% (95% CI: 38 to 68) Good news: Influenza B vaccine may provide some cross-lineage protection US study: ongoing; more information hopefully in the next few weeks Challenges with H3N2 virus selection (Nov study 3) H3N2 viruses grown in eggs acquire adaptive changes that alter antigenicity Wide genetic diversity in circulating H3N2 viruses

47 Summary Current flu season is hitting hard High hospitalization rate High ILI activity Increase in influenza-associated pediatric deaths Michigan is experiencing widespread flu activity Low vaccination coverage in Michigan While influenza vaccine effectiveness needs improvement, some protection is better than none. It s not too late to get your flu vaccine!

48 Update on the Michigan Hepatitis A Outbreak MI Hepatitis A Epi Summary 8/1/16 1/31/18 Number of Confirmed Cases 727 Primary 656 Secondary 71 Hospitalized, n (%) 590 (81.2) Deaths, n (%) 24 (3.3) Median age (range) years 41 (<1 90) Female, n (%) 248 (34.1) Data below excludes secondary cases Documented substance use, n (%) 323 (49.2) Coinfection with hepatitis C, n (%) 180 (27.4) Coinfection with hepatitis B, n (%) 16 (2.4) MSM, n (%) data includes men only 64 (14.3) Homeless/transient living, n (%) 78 (11.9) Recently incarcerated, n (%) 50 (7.6) Healthcare worker, n (%) 19 (2.9) Food Worker, n (%) 28 (4.3) Lost to follow up, n (%) 137 (20.9) Data source: Michigan Disease Surveillance System, MDHHS. Author: Danielle Donovan, Epidemiologist, Division of Communicable Diseases, MDHHS. Non-substance use, non-homeless, n (%) 261 (39.8) Report is a preliminary ad hoc analysis. Information to be considered DRAFT.

49 MI Hep A Outbreak: Analysis of MSM cases Data source: Michigan Disease Surveillance System, MDHHS. Author: Danielle Donovan, Epidemiologist, Division of Communicable Diseases, MDHHS. Risk factors MSM (n=64) Hospitalized, n (%) 57 (89.1) Deaths, n (%) 2 (3.1) Median age (range) years 39.5 (20-76) Documented substance use, n (%) 24 (37.5) Injection, n (%) 6 (9.4) Non-injection, n (%) 18 (28.1) Homeless/transient living, n (%) 2 (3.1) Coinfection with hepatitis C, n (%) 6 (9.4) Coinfection with hepatitis B, n (%) 1 (1.6) Recently Incarcerated, n (%) 3 (4.7) Healthcare worker, n (%) 5 (7.8) Food worker, n (%) 6 (9.4) Non-substance abuse, nonhomeless, n (%) 37 (57.8) Report is a preliminary ad hoc analysis. Information to be considered DRAFT.

50 Hepatitis A Outbreak Resources Information for Public Health and Healthcare Providers MDHHS Strategic Prioritization for Primary Prevention Vaccination (1/24/18)

51 Vaccine Delivery High-risk groups Substance use disorder Men who have sex with men Homeless or transient housing Recently incarcerated Chronic liver disease Access points Local Health Departments Emergency Departments SUD rehab programs LGBTQ-friendly community venues Shelters/soup kitchens/food trucks Jails/Prisons Clinics FQHCs Methadone/pain clinics HIV/PrEP/MSM-friendly clinics Hepatology/Transplant clinics Healthcare outreach to homeless EMT/paramedics? Pharmacists? Opioid epidemic initiatives?

52 Michigan Health Alert Network MDHHS has been given permission from the CDC to expand the vaccination campaign to high risk individuals across the state to prevent additional spread of the hepatitis A outbreak. The high risk groups outlined in the MDHHS Strategic Prioritization for Primary Prevention Vaccination for the hepatitis A outbreak include: Persons who use injection or non-injection drugs Men who have sex with men Persons who are currently homeless or in transient living conditions Persons who have been recently incarcerated Persons with chronic liver disease CDC continues to identify the adult hepatitis A vaccine supplies as constrained. Constrained means the vaccine supplies to the state have been limited by CDC, however, MDHHS has determined there is enough vaccine available to support hepatitis A vaccination efforts statewide both in outbreak and non-outbreak jurisdictions. All LHDs are encouraged to conduct outreach and vaccinate high risk groups. Please note, ACIP recommendations should continue to be followed per standard protocols. There is no change to those routine activities. Additional information can be found on the michigan.gov/hepatitisaoutbreak website.

53 KCHD Response Partnering with PHS for same day vaccination of their eligible client PHS clinic assistants will assess MCIR and register clients Charts will be put in Fuller immunization rack for nurses Fuller clerks/ca s will check client out if admin fee is owed Vaccination will be for Hepatitis A only-can remind client they are due for other vaccines Nurse will counsel the client to call for appointment for second dose in 6-12 months. Not scheduling routinely now due to vaccine constraints

54 Percentage of Michigan Kids Vaccinated at Milestone Ages for the Advisory Committee on Immunization Practices Recommended Vaccines, MCIR Data, January State of Michigan Kent County Hep B Hep B 1 Rota 1 DTaP 1 Hib 1 PCV 1 IPV Hep B 2 Rota 2 DTaP 2 Hib 2 PCV 2 IPV Hep B UTD Rota 3 DTaP UTD Hib 3 PCV 1 IPV 2 Hep B 3 DTaP UTD Hib 4 PCV 2 IPV 1 MMR 1 Var Hep B 4 DTaP UTD Hib 4 PCV 3 IPV 1 MMR 1 Var Hep B 4 DTaP UTD Hib 4 PCV 3 IPV 1 MMR 1 Var 1 MO 3 MO 5 MO 7 MO 16 MO 19 MO 24 MO

55 Thank you!