HIT ME WITH YOUR BEST SHOT: UPDATE ON IMMUNIZATIONS. Karen Hoang, PharmD Clinical Pharmacy Specialist, MTM Services UPMC Health Plan

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1 HIT ME WITH YOUR BEST SHOT: UPDATE ON IMMUNIZATIONS Karen Hoang, PharmD Clinical Pharmacy Specialist, MTM Services UPMC Health Plan

2 DISCLOSURES vno financial or other conflicts to disclose

3 LEARNING OBJECTIVES Explain the current state of pharmacist immunization providers Discuss recent changes to immunization recommendations in the United States Describe appropriate immunizations for patient-specific indications

4 EXPLAIN THE CURRENT STATE OF PHARMACIST IMMUNIZATION PROVIDERS

5 CURRENT STATE OF PHARMACIST IMMUNIZATION PROVIDERS vpharmacist immunization authorization governed by individual state laws vprescribing regulations vwritten or verbal prescriptions vstanding orders vprotocols, collaborative agreements v48 states allow pharmacists to administer any type of vaccine v28 states allow pharmacists to provide immunizations to patients of any age v17 states allow for children v7 states allow for adults only

6 PENNSYLVANIA REGULATIONS vpharmacists permitted to administer influenza to children 9 years old vparental consent needed if under 18 vimmunization schedule must adhere to Centers for Disease Control and Prevention (CDC) schedule vminimum of $1,000,000 liability insurance vmust notify primary care physician within 48 hours

7 DISCUSS RECENT CHANGES TO IMMUNIZATION RECOMMENDATIONS IN THE UNITED STATES

8 INFLUENZA VACCINE

9 INFLUENZA VACCINE vlive, attenuated influenza vaccine (LAIV4) not recommended for season vlack of efficacy during and season vreduced effectiveness in previous seasons was caused by reduced reproductive fitness of the A(H1N1) strain used vemphasize vaccination of high-risk groups vchildren < 5 years vadults 50 years vchronic disease vimmunocompromised vpregnant women vchildren receiving ASA vnursing home residents vamerican Indian/Alaska Natives vextreme obesity (BMI 40)

10 INFLUENZA VACCINE PRODUCTS FOR SEASON Fluzone (Sanofi Pastuer) IIV4 Vaccine (manufacturer) Approved Age 6+ months Fluvirin (Seqirus) IIV3 4+ Fluarix (GSK) IIV4 FluLaval (GSK) IIV4 6+ months 6+ months Afluria (Seqirus) IIV3 5+ Afluria (Seqirus) IIV4 5+ Fluzone High-Dose (Sanofi Pasteur) IIV3 65+ Fluzone Intradermal (Sanofi Pasteur) IIV Flucelvax (Seqirus)-cell cultured (not eggs) cciiv4 4+ Flublok (Protein Sciences) RIV3 & RIV4 18+ Fluad (Seqirus) aiiv3 65+

11 VACCINE COMPOSITION vtrivalent va/michigan/45/2015 (H1N1)pdm09 like virus va/hong Kong/4801/2014 (H3N2) like virus vb/brisbane/60/2008 like virus (Victoria lineage) vquadrivalent vall of the above and B/Phuket/3073/2013 like virus (Yamagata lineage)

12 CDC RECOMMENDATIONS FOR EGG ALLERGY vable to eat lightly cooked egg vunlikely to be egg-allergic vegg allergy with hives only vcan receive any influenza vaccine including RIV vegg allergy with reaction other than hives vmay receive any influenza vaccine vshould be administered in medical setting under supervision of provider who can recognize and manage severe allergic conditions vprevious severe allergic reaction is contraindication

13 PNEUMOCOCCAL VACCINES

14 PREVNAR 13 vpneumococcal conjugate 13 valent vaccine (PCV13, Prevnar 13) vrecommended for adult use in 2010 vasplenia vimmunocompromising conditions vcongenital or acquired immunodeficiency vhiv vchronic renal failure vleukemia, lymphoma, Hodgkin disease vsolid organ transplant vimmunosuppression or radiation therapy vrecommended for adults 65 years in 2014

15 PNEUMOVAX vpneumococcal polysaccharide -23 valent vaccine (PPSV23, Pneumovax ) vadults 65 years old vpersons 2-64 years old at risk for pneumococcal disease v Chronic heart disease (not hypertension) v Chronic lung disease v Smokers v Diabetes v Alcoholism v Cirrhosis v Cochlear implants v CSF leaks v Other diseases or conditions that lower the body s resistance to infection

16 COMPARISON Conjugate vaccine PCV13 Indicated for immunocompromised young adults Give at least 1 year after prior Pneumovax 23 dose All adults age 65 years old Only one single dose in adulthood PPSV23 Polysaccharide vaccine Indicated for smokers and young adults with certain chronic diseases and immunocompromised young adults If need second dose, give 5 years after first dose Give 8 weeks after prior Prevnar 13 dose All adults age 65 years old 1-2 doses <65 and/or 1 dose 65

17 SCHEDULE vpcv13 v1 lifetime dose vadults 65: all adults vadults 19-64: with indication vppsv23 v1, 2, or 3 lifetime doses vadults 65: 1 dose at least 1 year after PCV13 and 5 years after previous PPSV23 vadults with indication: 1 or 2 doses v1 dose <65 y/o in cerebrospinal fluid leaks, cochlear implants, chronic heart disease, chronic lung disease, chronic liver disease, alcoholism, diabetes, cigarette smokers, and nursing home/long-term care facility residents v2 doses <65 y/o in immunocompromised, HIV infection, kidney failure, ESRD, HD recipient, asplenia

18 DOSE TIMING vrecommended intervals for sequential use of PCV13 and PPSV23 for immunocompetent adults aged 65 years Advisory Committee on Immunization Practices, United States Kobayashi M. MMWR. 2015;64(34):944-7.

19 TETANUS, DIPTHERIA, PERTUSSIS VACCINE (TDAP)

20 TETANUS, DIPHTHERIA, PERTUSSIS vavailable vaccines vboostrix 10+ years old vadacel years old vtdap vaccine approved for adults in 2005 vrecommended by CDC in 2006 vexpanded indication for pregnancy in 2013 vgestational weeks 27-36

21 MENINGOCOCCAL VACCINES

22 AVAILABLE VACCINES vmeningococcal conjugate 4 valent vaccine (MCV4, MenACWY, Menveo, Menactra ) vmeningococcal serogroup B vaccine (MenB, Trumemba [MenB, FHbp], Bexero [MenB-4C)

23 MENINGOCOCCAL 4-VALENT VACCINES (MENINGOCOCCAL A/C/Y/W-135) vrecommended in adults for: vasplenia v2-dose primary series vrevaccinate every 5 years vhiv v2-dose primary series vrevaccinate every 5 years vmilitary recruits v1-dose primary series vrevaccinate every 5 years, if risk remains vfirst-year college students 21 years v1 dose, if not previously vaccinate since age 16 years

24 MENINGOCOCCAL B VACCINES v[menb-fhbp] (Trumemba ) and MenB-4C (Bexero ) are not interchangeable vrecommended in adults for: vasplenia vserogroup B meningococcal outbreak vmay be administered to healthy adolescents age years who are not at risk for disease (preferred age 16-18)

25 HUMAN PAPILLOMAVIRUS VACCINE (HPV)

26 HUMAN PAPILLOMAVIRUS VACCINE (HPV) vgardasil 9 vrecommended for: vfemales age 11 years through 26 years vmales age 11 years through 21 years (22-26 years based on individual clinical decision) v9-14 years old: 2 doses vdoses separated by 6-12 months v15+ years old: 3 doses vsecond dose 1-2 months after first dose vthird dose 6 months after first dose

27 HAEMOPHILUS INFLUENCE VACINE (HIB)

28 HAEMOPHILUS INFLUENZAE TYPE B (HIB) v2014 Adult Recommendations v1 booster dose recommended for: vasplenia (functional or anatomical) vsickle cell disease v3-dose series recommended for: vhematopoeitic stem cell transplant vno longer recommended for HIV or immunodeficiency

29 HERPES ZOSTER VACCINE

30 HERPES ZOSTER VACCINE vzostavax (Merck) - Food and Drug Administration (FDA) approved for patients age 50+ vcdc recommends for age 60+ vlive vaccine contraindicated for certain conditions: vpregnancy vimmunocompromised conditions vhiv with CD4+ <200 cells/µl vvaccine efficacy wanes over time

31 ZOSTER VACCINE RECOMBINANT, ADJUVANTED (SHINGRIX ) vnon-live, recombinant zoster vaccine (does not need to be frozen) vantigen reconstituted with AS01 B adjuvant suspension vdemonstrated 90% efficacy rate in clinical trials vstudied in >50, >70, and >80 years vpersistent after 4-year follow-up vdemonstrates similar response in patients who previously received liveattenuated zoster vaccine

32 ZOSTER VACCINE RECOMBINANT, ADJUVANTED (SHINGRIX ) vapproved by FDA October 20, 2017 vrecommended for patients 50+ vrevaccination with Shingrix recommended for those who received Zostavax vpreference for Shingrix over Zostavax vdosing v0.5 ml IM injection v2-dose series vadminister at month 0 and month 2-6

33 OTHER UPDATES vrecommendation for use of a third dose of measles mumps rubella (MMR) vaccine during a mumps outbreak v2018 adult immunization schedule approved released February 2018 vshoulder Injury Related to Vaccine Administration (SIRVA) increasingly is being reported vcdc has developed a handout to help educate providers on correct administration of injections vnew hepatitis B vaccination (Heplisav-B) recommended by ACIP

34 DESCRIBE APPROPRIATE IMMUNIZATIONS FOR PATIENT-SPECIFIC INDICATIONS

35 PATIENT CASE #1 vjs is a 65 yo M who has asthma. Which of the following vaccines would you recommend? va) Meningococcal (ACYW-135) vb) Meningococcal B vc) Herpes Zoster vd) Hib ve) HPV

36 PATIENT CASE #2 vnw is a 56 yo M who was recently diagnosed with diabetes. Which of the following vaccines would you recommend? va) Tdap vb) HPV vc) PCV13 vd) Meningococcal (ACYW-135) ve) None of the above

37 PATIENT CASE #3 vdk is a 23 yo F patient with asplenia. Which of the following vaccines would you recommend? va) Influenza vb) PCV13 vc) PPSV23 vd) Hib ve) All of the above

38 PATIENT CASE #4 vtb is a 74 yo F who has kidney failure. Which of the following vaccines would you recommend? va) Hib vb) PCV13 vc) PPSV23 vd) B & C ve) All of the above

39 PATIENT CASE #5 vmp is a 21 yo M with HIV. Which of the following vaccines would you recommend? va) Influenza vb) Tdap vc) Meningococcal (ACYW-135) vd) HPV ve) All of the above

40 RESOURCES vppa Immunization Toolkit vhttp:// vcenters for Disease Control and Prevention vwww.cdc.gov/vaccines/schedules/hcp/index.html vadvisory Committee on Immunization Practices (ACIP) vwww.cdc.gov/vaccines/acip/ vimmunization Action Coalition vwww.immunize.org/

41 REFERENCES v Pharmacist Administered Vaccines. (2015). Washington, DC: American Pharmacists Association. Available at: [Accessed 7 Jan. 2018]. vpennsylvania Code. (2015). CHAPTER 27. STATE BOARD OF PHARMACY. [online] Available at: [Accessed 7 Jan. 2018]. vgrohskopf LA, Sokolow LZ, Broder KR, et al. Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices United States, Influenza Season. MMWR Recomm Rep 2017;66(No. RR-2):1 20. DOI: vcenters for Disease Control and Prevention. (2017). Pneumococcal Vaccination. [online] Available at: [Accessed 7 Jan. 2018]. vkobayashi M, Bennett NM, Gierke R, Almendares O, Moore MR, Whitney CG, et al. Intervals between PCV13 and PPSV23 vaccines: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR. 2015;64(34): vcenters for Disease Control and Prevention. (2016). Diphtheria, Tetanus, and Pertussis Vaccine Recommendations. [online] Available at: [Accessed 7 Jan. 2018]. vcenters for Disease Control and Prevention. (2017). Meningococcal Vaccine Recommendations. [online] Available at: [Accessed 7 Jan. 2018]. vcenters for Disease Control and Prevention. (2016). HPV Vaccine Recommendations. [online] Available at: [Accessed 7 Jan. 2018]. vcenters for Disease Control and Prevention. (2016). Hib Vaccine Recommendations. [online] Available at: [Accessed 7 Jan. 2018]. vcenters for Disease Control and Prevention. (2017). Shingles/Herpes Zoster Vaccine Recommendations. [online] Available at: [Accessed 7 Jan. 2018]. vshingrix (Zoster Vaccine Recombinant, Adjuvanted) [package insert]. Research Triangle Park, NC: GlaxoSmithKline Biologicals; vfoster, SL. (2017). CDC s ACIP recommends preferred use of new herpes zoster vaccine. [online] American Pharmacists Association. Available at: [Accessed 7 Jan. 2018].

42 QUESTIONS?