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1 Centers for Disease Control and Prevention National Center for Immunization and Respiratory Diseases Annual New York Statewide Immunization Meeting JoEllen Wolicki, RN, BSN Nurse Educator Immunization Services Division Photographs and images included in this presentation are licensed solely for CDC/NCIRD online and presentation use. No rightsare implied or extended for use in printing or any use by other CDC CIOs or any external audiences. Disclosures JoEllen Wolicki is a federal government employee with no financial interest in or conflict with the manufacturer of any product named in this presentation The speaker will discuss the off-label use of hepatitis Aand Tdap vaccines The speaker will not discuss a vaccine not currently licensed by the FDA Disclosures The recommendations to be discussed are primarily those of the Advisory Committee on Immunization Practices (ACIP): Composed of 15 nongovernment experts in clinical medicine and public health Provides guidance on use of vaccines and other biologic products to DHHS, CDC, and the U.S. Public Health Service Watch the live webcast s/webcast-instructions.html Next ACIP meeting June 20 21, 2018 CDC ACIP meeting website

2 Overview 2018 immunization schedule for Children 18 years of age and younger Adults 19 years of age and older Seasonal influenza update Measles and mumps update Recent Advisory Committee on Immunization Practices recommendations Building vaccine confidence Immunization resources ACIP Immunization Recommendations: Seasonal Influenza Vaccine Influenza Season Summary Overall, influenza A(H3N2) viruses have predominated this season A total of 119 influenza-associated pediatric deaths have been reported for the season A total of 24,644 laboratory confirmed, influenza-associated hospitalizations were reported for the And It ain tover tilit s over Yogi Berra CDC Flu website accessed March 19, 2018:

3 Influenza Season ILI Activity for the Week Ending March 10, 2018 ILINetState Activity Indicator Map: Looking Ahead There Are Many Different Influenza Vaccine Products 14 distinct products Indications vary by product including age, formulation, and type More than one might be appropriate for any given recipient ACIP/CDC express no preferences for any one type of influenza vaccine if more than one is appropriate and available Vaccination should not be delayed in order to obtain a specific product Table 1 Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices United States, Influenza Season Influenza Vaccine Strains Trivalent vaccine includes: A/Michigan/45/2015 (H1N1)pdm09-like virus A/Singapore/INFIMH /2016 (H3N2)-like virus B/Colorado/06/2017-like virus (B/Victoria/2/87 lineage) Quadrivalentvaccine includes: A/Michigan/45/2015 (H1N1)pdm09-like virus A/Singapore/INFIMH /2016 (H3N2)-like virus B/Colorado/06/2017-like virus (B/Victoria/2/87 lineage) B/Phuket/3073/2013-like virus (B/Yamagata/16/88 lineage)

4 ACIP Recommendations: Influenza Annual influenza vaccination continues to be recommended for persons 6 months of age and older without contraindications or precautions DRAFT: Immunization providers may choose to administer New! any licensed, age appropriate influenza vaccine product including LAIV, IIV, RIV, or cciiv. DRAFT ACIP recommendations for influenza to be discussed and voted on at the meeting in June and published soon after Recommendations of the Advisory Committee on Immunization Practices (ACIP) are not final until approved by the CDC director and published in the MMWR Seasonal Influenza vote ACIP Meeting 2/2019 Mumps and Measles 2018 U.S. Mumps Cases as of February 24, 2018 AK, AL, AZ, CA, FL, GA, HI, IA, ID, IN, KS, KY, LA, ME, MD, MA, MI, NE, NJ, NM, NY, OH, OR, PA, TN, TX, VA, WA, WI and WV **Preliminary data reported to CDC. Mumps outbreaks are not reportable. Mumps Cases and Outbreaks

5 Measles Cases 2018 January 1 to February 24, 2018: 13 people from 7 states were reported to have measles Arkansas, Illinois, Indiana, New York, Oklahoma, Pennsylvania, and Texas 1.New York 2. New Jersey 3.Detroit *Cases as of February 24, Case count is preliminary and subject to change. Data are updated monthly. Source: Morbidityand Mortality Weekly Report (MMWR), Notifiable Diseases and Mortality Tables New York Post March 15,2018 Guidance for Health Care Personnel Be vigilant about measles, mumps and rubella Ensure EVERONE is up to date on MMR vaccination Staff and patients children, adolescents, and adults Consider disease in patients with clinically compatible symptoms Measles: Febrile rash illness with malaise, cough, coryza, and conjunctivitis Mumps: Pain, tenderness, and swelling in one or both parotid salivary glands Rubella: Mild, maculopapular rash along with lymphadenopathy, and a slight fever Ask patients about: Recent travel internationally Recent travel to domestic venues frequented by international travelers Recent contact with international travelers History of disease in the community Promptly isolate patients with symptoms For health care personnel: Measles: Mumps: Rubella: ACIP Immunization Update Childhood and Adult Mumps Recommendations A third dose of MMR can be administered to adults who previously received 2 or more doses of mumps-containing vaccine and are identified by public health authority to be at increased risk for mumps in an outbreak Recommended Immunization Schedule for Children and Adolescents Aged 18 Years or Younger, ACIP Recommended Immunization Schedule for Adults 19 Years of Age and Older,

6 Advisory Committee on Immunization Practices Immunization Schedules 2018 Recommended Immunization Schedule for Children and Adolescents Aged 18 Years or Younger, 2018 Recommended Immunization Schedule for Children and Adolescents Aged 18 Years or Younger, ACIP Recommended Immunization Schedule for Adults 19 Years of Age and Older, 2018 Download the App ACIP Recommended Immunization Schedule for Adults 19 Years of Age and Older,

7 2018 Immunization Updates Update: Childhood Immunization Schedule Tdap Adolescents who received Tdapinadvertently or as part of the catch-up series between 7 10 years of age may receive the routine adolescent Tdapdose (11 12 years of age) Coming Soon! Foot note 13: Recommended Immunization Schedule for Children and Adolescents Aged 18 Years or Younger, DTaP, PCV13, Hib and HPV too! Update: Childhood Immunization Schedule Polio The poliovirus vaccine footnote was revised to include updated guidance for persons who received inactivated (IPV) and live, attenuated (OPV) polio vaccine as part of their vaccination series Total number of doses needed to complete the series is the same as that recommended for the U.S. IPV schedule

8 Polio Schedule For infants 6 months and younger, minimum age and minimum intervals are only recommended if there is at risk of imminent exposure to circulating poliovirus Minimum interval between doses is 4 weeks If 4 or more doses are administered before age 4 years, an additional dose should be administered at age 4 through 6 years and at least 6 months after the previous dose A fourth dose is not necessary if the third dose was administered at age 4 years or older and at least 6 months after the previous dose Additional Considerations Only IPV is available in the United States For a series with both OPV and IPV: Only trivalent OPV (topv) counts toward the U.S. vaccination requirements If a child completed a valid series of topvin another country, no supplemental doses of IPV are necessary Assessing Doses of OPV OPV doses * administered: Before April 2016 o Count towards a completed series regardless of how the dose is documented Between April 1, 2016 through April 30, 2016 o Count towards a completed series if documented as topv On or after May 2016 oopv doses should not be counted If the dose documentation includes campaign, the dose does NOT count *Must meet minimum age and intervals

9 Hepatitis A Vaccine ACIP Vote February 2018 New! A single dose of hepatitis A vaccine should be administered to infants DRAFT age 6-11 months of age traveling outside the United States when protection against hepatitis A is recommended Infants should restart the 2-dose series of HepAvaccine at 12 months of age or older as recommended Recommendations of the Advisory Committee on Immunization Practices (ACIP) are not final until approved by the CDC director and published in the MMWR HepA vote ACIP Meeting 2/2019 Update: Adult Immunization Schedule Zoster Shingrix(RZV) Administer Shingrixto immunocompetent persons 50 years of age and older Storage: Store vaccine AND diluent in the refrigeratorbetween 2 C and 8 C (36 F and 46 F) Preparation: Reconstitute the vaccine with the diluent supplied by the manufacturer just before administering Schedule: 2 doses 2 to 6 months apart Route: IM Injection Site: deltoid or the thigh may be used if necessary Needle gauge: gauge Needle length: varies by age/weight May administer during the same clinical visit as other needed vaccines. Administer in a separate limb from other vaccines, if possible DoolingKL, GuoA, Patel M, et al. Recommendations of the Advisory Committee on Immunization Practices for Use of Herpes Zoster Vaccines. MMWR MorbMortal WklyRep 2018;67: DOI: RZV (Shingrix) Adverse Reactions Local reactions 49% Local reactions Grade 3 9.4% Systemic reactions (headache, malaise, fatigue) Systemic reactions (headache, malaise, fatigue) Grade % 11% DoolingKL, GuoA, Patel M, et al. Recommendations of the Advisory Committee on Immunization Practices for Use of Herpes Zoster Vaccines. MMWR MorbMortal WklyRep 2018;67: DOI:

10 Clinical Considerations RZV (Shingrix) is preferred to Zostavaxfor persons 60 years and older RZV (Shingrix) is recommended for persons previously vaccinated with Zostavax Wait at least 8 weeks after Zostavax before administering RZV Administer RZV (Shingrix) regardless of previous history of varicella or varicella vaccination DoolingKL, GuoA, Patel M, et al. Recommendations of the Advisory Committee on Immunization Practices for Use of Herpes Zoster Vaccines. MMWR MorbMortal WklyRep 2018;67: DOI: ShingrixErrors Vaccine administration errors we have heard about: Storing the vaccine and/or diluent in the freezer Using the wrong diluent to reconstitute the vaccine Administering the vaccine subcutaneously Staff think only 1 dose is needed and do not schedule/educate patients for a second dose Schedule errors interval violations Vaccine Administration Update

11 Shoulder Injury Related to Vaccine Administration Shoulder injury related to vaccine administration (SIRVA) was added to the Vaccine Injury Compensation Table in March 2017 Shoulder injuries related to vaccine administration are injuries to the musculoskeletal structure of the shoulder, including the ligaments, bursa, and tendons They are thought to occur as a result of the unintended injection of vaccine antigen and/or trauma from the needle going into and around the underlying bursa of the shoulder Symptoms include shoulder pain and limited mobility after the injection Shoulder Injury Related to Vaccine Administration and Vaccine Administration Best Practices When administering a vaccine by intramuscular (IM) injection in the deltoid muscle, use: Proper landmarks and technique to identify the injection site Proper needle length based on the age, patient size, and injection technique Intramuscular Injections and Adults Adults: 19 years of age and older Age group Needle length Site Men and women, <60 kg (130 lbs) 1 inch (25 mm) * Men and women, kg ( lbs) Men, kg ( lbs) Women, kg ( lbs) Men, >118 kg (260 lbs) Women, >90 kg (200 lbs) 1 inch (25 mm) inches (25-38 mm) 1.5 inches (38 mm) Deltoid *Some experts recommend a 5/8-inch needle for men and women who weigh <60 kg Best Practices Guidance of the Advisory Committee on Immunization Practices (ACIP)

12 Clinical Resources for Shoulder Injury Related to Vaccine Administration CDC Vaccine administration webpage for information and materials for health care personnel, including Web-based module with CE Job aids and infographics IM demonstration video Vaccine administration resource library: Vaccine Conversations and Building Vaccine Confidence

13 Communicating About Vaccines There is much research on parents knowledge, attitudes, and beliefs about vaccines Little research on what communication techniques actually change parents behavior Research in this area is complicated We ve been focused on the what more than the how Conventional Wisdom Improve parents knowledge and they will make the right decision This educational approach assumes human decision-making is rational (when research shows it often is not) Behavioral economics: human behavior is influenced by deepseated cognitive biases and heuristics resistant to rational influence O Leary, S. Strategies for Talking to Vaccine-Hesitant Parents. NFID Clinical Vaccinology Course Mar 2017 What Usually Happens When a Patient is Hesitant? The provider might ask why the patient does not want the vaccine Often patients will state all the reasons they do not want to be vaccinated In the process, the patient strengthen their resolve against the vaccination The provider is vulnerable to falling into conversation traps

14 Communication Traps Persuasion trap Data dump trap Q and A trap O Leary, S. Strategies for Talking to Vaccine-Hesitant Parents. NFID Clinical Vaccinology Course Mar 2017 Persuasion Trap When the provider becomes the champion for the vaccine and tries to convince the hesitant or resistant patient of the benefits This usually ends up in an argumentative type of yes, but cycle The Lecture (Data Dump) Trap The tendency here is to provide the full story about some aspect of the vaccine This often ends up putting people off and raising resistance because it implies that they don t know the full story and you re going to give it to them Also, it can be counterproductive because you end up raising concerns that the patient had not previously considered

15 The Question and Answer Trap When the provider begins asking a series of closed questions that require a yes or no answer and does not invite any additional information or thoughts What Does This Mean? Becoming increasingly clear that simply correcting knowledge gaps whether through informational brochures, community campaigns, or direct provider conversations s often not enough to address parents concerns about vaccines Investigators are now focusing on developing interventions to improve vaccination uptake focused on how people actually think rather than how they ought to think Remember correcting misconceptions, can successfully reduce misperceptions but does not always result in vaccination O Leary, S. Strategies for Talking to Vaccine-Hesitant Parents. NFID Clinical Vaccinology Course Mar 2017 How You Start the Conversation Matters, Too The best predictor of vaccination was how the provider started the conversation For both vaccine hesitant and non-hesitant patients Opel DJ, Smith R, et al. The Influence of Provider Communication Behaviors on Parental Vaccine Acceptance and Visit Experience. American Journal of Public Health Oct 2015

16 Participatory versus Presumptive Approach Participatory: provides more decision-making latitude Example: Have you thought about what shots you d like today? Presumptive: presupposes that vaccines will be given today Example: You have some vaccines due today. Opel DJ, et al. The Architecture of Provider-Parent Vaccine Discussion at Health Supervision Visits. Pediatrics 2013;132:1037 Participatory versus Presumptive Among all parents, a larger proportion resisted vaccine recommendations when providers used a participatory rather than presumptive initiation format (83% vs 26%; P <.001) This finding remained true among vaccine-hesitant parents (89% vs 30%; P <.001) Opel DJ, et al. The Architecture of Provider-Parent Vaccine Discussion at Health Supervision Visits. Pediatrics 2013;132:1037 Why Presumptive Style Might Be Better Most patients perceive decisions about vaccination to be complicated As humans, when we make decisions we perceive to be complicated, we tend to have a status quo bias (also called a default bias), meaning we go with what is expected or normal Using a presumptive approach, patients are made to feel that vaccination is what most people do, and it is the socially acceptable norm O Leary, S. Strategies for Talking to Vaccine-Hesitant Parents. NFID Clinical Vaccinology Course Mar 2017

17 Towel Reuse Rates as a Function of Sign in Room Goldstein NJ, et al. J Consum Res 2008;35: by JOURNAL OF CONSUMER RESEARCH, Inc Could Social Norms Influence a Decision to Vaccinate? Increasing attention to this as a strategy Fits with the presumptive recommendation Study from 1990s suggested university students were more likely to receive influenza vaccine if they were told most students got it O Leary, S. Strategies for Talking to Vaccine-Hesitant Parents. NFID Clinical Vaccinology Course Mar 2017 What You Say Matters Health care personnel are a patient s most trusted source of information on vaccines Research shows a patient who receives a strong recommendation from a provider is 4 5 times more likely to be vaccinated * Good recommendation = simple, strong and personalized Bundle all needed vaccines into the same recommendation Same day Same way *2007 National Survey of Children s Health. Factors associated with human papillomavirus vaccine-series initiation and health care provider recommendation in U.S. adolescent females. Vaccine2012;30(20):

18 In Summary Directive patient/provider recommendations followed by a closed question work fine for the patient who is ready to be vaccinated or for the patient who expects the doctor to tell him or her what to do For patients who are unsure or resistant, a closed-ended question following a recommendation can lead to less productive conversations Motivational Interviewing Motivational interviewing (MI) is a patient-centered, guiding communication style for enhancing a person s own motivation for change or behavioral activation Engages the patient respectfully and fully in the discussion The 4 elements include: Empathy Collaboration Evocation Support for autonomy O Leary, S. Strategies for talking to Vaccine-Hesitant Parents. Mar 2017 Motivational Interviewing Motivational interviewing has not been tested and proven effective for convincing those who are hesitant about vaccination HOWEVER, it has been shown to be effective in other health interventions, including: Diabetes self care Smoking cessation Cognitive behavioral therapy O Leary, S. Strategies for Talking to Vaccine-Hesitant Parents. NFID Clinical Vaccinology Course Mar 2017

19 Using Motivational Interviewing for Vaccine Discussions Motivational interviewing includes: Open-ended questions Affirmations Reflection Summary Remember to: Include simple, strong, and personalized recommendation Highlight social norms O Leary, S. Strategies for Talking to Vaccine-Hesitant Parents. NFID Clinical Vaccinology Course Mar 2017 Motivational Interviewing and Vaccine Conversations Ask in a non-threatening way to share the patient s concerns Example: HCP to patient: You seem to be concerned about HPV vaccine. We are asked a lot of questions about this vaccine. Would you mind sharing what your particular concerns are? Parent's response: She certainly is NOT having sex! She is 11! I don t think she needs this vaccine. Motivational Interview and Vaccine Conversations HCP reflects back what the patient is saying to be sure he/she understands (empathy) and summarizes what has been heard before proceeding, again with permission, to make a recommendation Example: HCP to patient: So I can hear you are concerned the vaccine. I ve had this question a lot so I did some research on it. Is it okay if I share with you what I learned? O Leary, S. Strategies for Talking to Vaccine-Hesitant Parents. NFID Clinical Vaccinology Course Mar 2017

20 Motivational Interviewing and Vaccine Conversations Address the specific concern and, if possible, put the concern into a perspective the family can relate to: HPV vaccine is about protecting her from cancer in the future. Its like a seat belt you put on the seat belt every time you drive, not just on the days you think you may have an accident. Most of our parents decide to vaccinate their children. O Leary, S. Strategies for Talking to Vaccine-Hesitant Parents. NFID Clinical Vaccinology Course Mar 2017 Motivational Interview and Vaccine Conversations Now, its time for a simple, strong, and personalized recommendation End the conversation with an open-ended question Example I gave my daughter HPV vaccine to protect her from cancer. And I recommend my friends and family vaccinate their children. However, this is a decision only you can make. What do you think? O Leary, S. Strategies for Talking to Vaccine-Hesitant Parents. NFID Clinical Vaccinology Course Mar 2017 Additional Resources

21 CDC Resources for Staff Education Multiple education products available free through the CDC website: Immunization courses (webcasts and online self-study) Netconferences You Call the Shots self-study modules Continuing education available Immunization Education and Training: Current Issues in Immunization Netconferences (CIINC) Provides clinicians with the most up-todate information on immunizations Live, 1-hour webinars Conducted 4 to 5 times a year Topics announced prior to each one Webinars are archived CE available Sign up for alerts at html You Call the Shots Web-Based Training YCTS is a series of modules on each vaccine-preventable disease and ACIP recommendations for the use Each module provides learning opportunities self-test practice questions, reference and resource materials, and an extensive glossary CE available New and updated modules Influenza Human Papillomavirus Vaccines For Children (VFC) Vaccine Storage and Handling You Call the Shots:

22 Immunization Questions? Questions? CDC or Vaccines and Immunizations website HCP education Twitter Influenza Vaccine safety CDC Immunization Apps for Health Care Personnel Childhood and adult immunization schedules app.html Influenza information Morbidity and Mortality Weekly Report (MMWR) Travel well Questions?? JoEllen Wolicki For more information, contact CDC CDC-INFO ( ) TTY: The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. Photographs and images included in this presentation are licensed solely for CDC/NCIRD online and presentation use. No rightsare implied or extended for use in printing or any use by other CDC CIOs or any external audiences.