2013 Immunization Update. Presented by Janna Pastir, MPH NDDoH Immunization Program

Transcription

1 2013 Immunization Update Presented by Janna Pastir, MPH NDDoH Immunization Program

2 Outline Vaccine Preventable Diseases Influenza Vaccines in Adolescent Vaccine Schedule Adult Vaccine Schedule Vaccine Storage and Handling North Dakota Immunization Information System (NDIIS) Vaccines for Children Program State-supplied Vaccine Program

3 Vaccine Preventable Diseases in ND

4 What is Pertussis? Coughing illness caused by bacteria Bordetella pertussis. Also called Whooping Cough after the characteristic whoop that results between coughing fits. Symptoms can include cold-like symptoms, coughing fits, posttussive vomiting, whoop, and apnea. Cough will persist for at least 14 days.

5 Big Year for Pertussis Highest number of pertussis cases in US since 1959(40,000). Highest number of pertussis cases in North Dakota since 2004 (757). North Dakota had more than triple the number of cases in 2011(70). North Dakota had more than triple the number of cases in 2012(215). Rates: United States: 12.97/100,000 people North Dakota: 31.14/100,000 people 27 counties in North Dakota had a least one case of pertussis Ward county: 88.96/100,000 people Burleigh County: 25.25/100,000 Cass County: 19.03/100,000 Grand Forks County: 19.5/100,000

6 Influenza An acute respiratory disease caused by influenza viruses. Symptoms typically include fever, body aches, dry cough, headache, and fatigue. Definitive diagnosis requires both symptoms and laboratory confirmation.

7 Influenza Vaccine 2013 Trivalent and Quadrivalent flu Vaccines

8 Live Attenuated Influenza Vaccine Manufactured by MedImmune as Flumist and is only available in quadrivalent. Not injectable Trivalent offered protection from 2 A strains and 1 B strain of influenza virus. Quadrivalent will protect against 2 A and 2 B strains. This should increase the coverage provided. Licensed for healthy people 2-49 years. Contraindicated for pregnant women, someone with weakened or compromised immune system or problems with the heart, kidney, and lungs.

9 Live Vaccine for Flu Quadrivalent Flumist Approved for ages Live attenuated influenza vaccine. Healthy people who are not pregnant may receive Flumist. People who have frequent contact with immuno-compromised individuals should not receive Flumist. Flumist for influenza vaccine covers two B strains and two A strains for the first time ever. The previous trivalent forms only offered protection for one B strain and two A strains.

10 Inactivated Vaccines for Flu Intramuscular Standard flu shot Some brands approved for people 6 months or older. Age indications vary by brand Intradermal Approved for people 18 to 64 years of age Lower dose but produces same immune response at IM High Dose Indicated for adults 65 years and older Quadrivalent Injectable from GlaxoSmithKline

11 VFC Program Influenza Vaccine Influenza vaccine is only available from NDDoH for use in children 18 years and younger that are VFC eligible. Fluzone (Sanofi Pasteur): IIV3 (0.25mL (p/f) prefilled syringes) is licensed for children 6-35 months IIV3 (0.5mL (p/f) PFS/SDV is licensed for 36 months + IIV3 (w/p) MDV is licensed for 6 months+ Fluarix (GlaxoSmithKline): IIV3 (0.5mL) PFS is licensed for 36 months + IIV4 (0.5mL) PFS is licensed for 36 months + Fluvirin (Novartis) IIV3 (0.5mL) PFS is licensed for 4 years + IIV 3 (w/p) MDV is licensed for 4 years +

12 VFC Program Influenza Vaccine (cont.) Influenza Vaccine types continued: Afluria (Merck) IIV3 (0.5mL) PFS is licensed for 9 years + IIV3 (w/p) MDV is licensed for 9 years + Flumist (MedImmune) LAIV4 Quadrivalent Single Dose Sprayers is licensed for 2-49 Influenza vaccine from the NDDoH is only available for persons 18 years and younger.

13 Adolescent Vaccines Schedule and recommendations

14 Adolescent Immunization Schedule

15 Tetanus, Diphtheria, and Acellular Pertussis (Tdap) Vaccine Provides protection from tetanus, diphtheria and pertussis. Different vaccine than DTaP! Routinely recommended for adolescents at years of age. Catch-up recommended for ages who were not previously vaccinated and any adult not previously vaccinated. No minimum interval between doses of tetanus- or diphtheria-containing vaccines.

16 Tdap (cont.) Children ages 7 and older who are unvaccinated or incompletely vaccinated with DTaP should receive a single dose of Tdap Td should be given 4 weeks later, followed by another booster dose of Td at 6 12 months If Tdap is not given as the first dose, it may be substituted for any Td dose in the series

17 Human Papilloma Virus (HPV) Vaccine HPV types 16 and 18 cause 70% of cervical cancers. HPV types 6 and 11 are associated with more than 90% of anogenital warts in males and females. HPV4 (Gardasil) types 6, 11, 16 and 18 Recommended for prevention of cervical, vulvar, vaginal and anal cancers and precancers and genital warts. HPV2 (Cervarix) types 16 and 18 Recommended for prevention of cervical cancers and precancers.

18 HPV (cont.) All adolescents are recommended for routine vaccination at years of age. Only Gardasil can be used to vaccinate males Series can be started as young as 9 years. Routine schedule is 0, 2, 6 months. Minimum intervals: 4 weeks between doses 1 and 2 12 weeks between doses 2 and 3 Third dose should follow the first dose by at least 24 weeks Accelerated schedule using minimum intervals is not recommended.

19 HPV (cont.) Vaccine brands are not interchangeable. Catch-up vaccination is recommended for females years and males years who have not been previously vaccinated or have not completed the full series. Catch-up vaccination is also recommended for MSM or immunocompromised males years. No maximum interval if the series is interrupted: After the first dose, administer the second dose as soon as possible, and the third dose should follow by an interval of at least 12 weeks. After the second dose, administer the third dose as soon as possible.

20 Meningococcal Conjugate Vaccine (MCV-4) MCV-4 is recommended for all children at years of age, with a booster dose at age 16. For adolescents who receive the first dose at age years, a one-time booster dose should be given, preferably at years. Patients who received their first dose of meningococcal conjugate vaccine at or after age 16 years do not need a booster dose.

21 MCV-4 (cont.) Single dose of MCV-4 recommended for: College freshmen living in dormitories Microbiologists working with N. meningitidis Military recruits People who travel to or live in places where meningococcal disease is hyperendemic or epidemic (the meningitis belt of sub-saharan Africa)

22 MCV-4 (cont.) All are protective against invasive meningococcal disease caused by Neisseria meningiditis types A, C, Y, and W-135. Conjugate vaccines Menactra, for ages 9 months 55 years Menveo, for ages 2-55 Polysaccharide vaccine Menomune, for ages 2 and up Not recommended for routine vaccination because of its relative ineffectiveness in infants and its relatively short duration of protection.

23 Catching up Adolescents There are some cases where a child may not have received all of their required vaccines in childhood and will need to be caught up for various reasons: For school attendance Living on college campuses Certain employment requirements The Centers for Disease Control and Prevention (CDC) has a catch-up dosing scheduled specifically for adolescents. Vaccines may have accelerated intervals when received as adolescents or adults versus children.

24 Catching up Schedule for Adolescents

25 Adult Vaccines Schedule and Recommendations

26 Adult Immunization Schedule

27 Pneumococcal Polysaccharide 23(PPSV23) Vaccine A single dose is recommended for all adults ages 65 and older. Also recommended for people of any age with: Chronic illness: cardiovascular disease, pulmonary disease, diabetes, alcoholism, cirrhosis, CSF leaks, cochlear implants Decreased immunologic function HIV infection Smokers People with asthma Routine revaccination is not recommended Adults 65 and older need to be revaccinated once if they received a dose prior to turning 65. Second dose should be given at least 5 years after first.

28 Adult PCV13 Recommendations Expanded in June 2012, to include adults 19 years or older with specific immunocompromising conditions To be used in conjunction with PPSV 23 to prevent severe or fatal pneumococcus infection These high risk patients can be more than 20 times more likely than healthy adults to be infected

29 Adult PCV13 Recommendations (cont.) The CDC recommends the use of PCV13 in adults 19 years of age or older with specific immunocompromising conditions Immunocompromised- Having the immune system impaired or weakened by illness and some treatments.

30 Tetanus, Diphtheria, Acellular Pertussis (Tdap) Vaccine Tdap should replace a single dose of Td for adults older than 19 who have not received a dose of Tdap previously. Adults who received last dose of Td 10 years earlier should receive a single dose of Tdap instead of Td. Tdap should be used instead of Td for wound management. Adults (parents, grandparents, caregivers, healthcare personnel) who will be in close contact with infants <12 months of age should be vaccinated. adults older than 65 should be vaccinated with Tdap No minimum interval between doses of tetanus- and diphtheria-containing vaccines.

31 Tdap (cont.) New recommendations from the ACIP for the use of Tdap in women during each pregnancy were released in October All pregnant women should receive a dose of Tdap during each pregnancy regardless of immunization history. If not during pregnancy then it should be administered immediately postpartum only after the first pregnancy. The expectation is that antibodies will be passed to the fetus and protect the baby for the first 6-8 weeks of life until able to be vaccinated with DTaP.

32 TD Vaccine Td should only be used for: Wound prophylaxis for patients who have documentation of a previous dose of Tdap. If unknown, give Tdap Individuals who are incompletely immunized against tetanus and diphtheria. Need three doses of tetanus- and diphtheria-containing vaccine, one dose should be Tdap Minimum interval between first two doses is 4 weeks Third dose should follow second dose by 6-12 months

33 Varicella Zoster Virus (Shingles) Vaccine Shingles Vaccine is not a state-supplied Vaccine. Transmission: Shingles is a reactivation of the varicella zoster virus and this condition is not spread through sneezing, coughing or casual contact. Anyone who has recovered from chickenpox may develop shingles. Shingles is more common in people 50 years old or older, people who have medical conditions that keep the immune system from working properly, or people who receive immunosuppressive drugs.

34 Shingles (cont.) A single dose of zoster vaccine is recommended for adults ages 60 and older regardless of whether they report a prior episode of herpes zoster. Zoster vaccine is now approved for use in adults 50 and older, but the ACIP has not yet changed their recommendation due to unknown length of immunity. Should be vaccinated, even if unknown history of chickenpox.

35 Measles, Mumps, and Rubella (MMR) Vaccine Adults may need to be caught up with MMR vaccine for college attendance, working in healthcare facilities, or traveling outside the U.S. Protection against measles, mumps and rubella. College students are required to have documentation of 2 doses in North Dakota Healthcare workers must have proof of immunity General public is considered immune if born prior to 1957 Minimum interval is 4 weeks

36 Vaccine Administration

37 Adolescent Vaccine Administration This age group experiences fainting (syncope) more often than any other group. All providers who administer vaccine to this age group should be aware of potential for syncope after vaccination and take measures to prevent it. 66.7% post-vaccination syncope reported since 2008 occurred in people 6-17 years. Have the patient seated or lying down while administering. Be aware of symptoms that precede fainting (weakness, dizziness, pallor, etc.). Provide supportive care and take appropriate measures to prevent injuries if such symptoms occur. The ACIP recommends observing the patient (seated or lying down) for 15 minutes after vaccination.

38 Health condition Age Lifestyle Occupational or Other Adult Vaccines- Think HALO Immunosuppression Chronic disease Pregnancy 26 and younger 60 and older 65 and older High-risk behaviors International travel Healthcare workers Parent or caregiver of young children College students Lab workers

39 Precautions Precaution: A condition in a recipient that might increase the chance or severity of a serious adverse reaction, or that might compromise the ability of the vaccine to produce immunity. Vaccines may be deferred but given at a later date. Temporary precautions (all vaccines) include moderate to severe acute illness and recent receipt of antibody-containing blood products (for live vaccines). Permanent precautions to further pertussis-containing vaccine are temperature of 105 F within 48 hours of a dose, collapse or shock-like state within 48 hours of a dose, persistent inconsolable crying lasting 3 or more hours occurring within 48 hours of a dose or a seizure occurring within 3 days of a dose.

40 Contraindications Contraindication: A condition in a recipient that greatly increases the chance of a serious adverse reaction. Vaccines will generally not be given if present. Few true contraindication conditions 2 permanent conditions Severe anaphylactic allergic reaction to a vaccine component or following a prior dose of vaccine Encephalopathy not due to another identifiable cause occurring within 7 days of pertussis vaccination 2 temporary conditions (live vaccines only) Pregnancy Immunosuppression

41 Vaccine Storage and Handling Vaccine quality is the shared responsibility of all parties, from the time it is manufactured until its administration.

42 Vaccine Storage All vaccines, except varicella, MMR, shingles, and MMRV must be stored in the refrigerator at F (2-8 C). Optimal refrigerator temperatures are F (4-6 C) MMRV, shingles, and varicella vaccine must be stored in the freezer at -58 F to 5 F (-50 C to -15 C). Optimal freezer temperatures are 3 F or colder ( -17 C) MMR can be stored in the refrigerator or freezer. Never store vaccines: In vegetable bins, on the refrigerator floor, next to the walls, in the door of the unit, or on the top shelf (underneath the cold air outlet from the freezer). Always store vaccines: In their original packaging, in such a way that air can circulate.

43 Storage and Handling Personnel Have a written plan and emergency relocation policy where are staff can access it. Record temperatures twice daily. Record the minimum and maximum temperature once a day. Keep the temperature logs for at least 3 years. In addition to a primary vaccine contact a backup person should be familiar with all aspects of vaccine storage and handling.

44 Vaccine Storage Units Check temperatures at the beginning and end of the day to determine if the unit is getting too warm. As storage units age, recurring problems can be tracked. If out-of-range temperatures have been documented, it is easy to determine how long it s been happening. Great way to lobby for new refrigerator!

45 Vaccine Storage Units (cont.)

46 Vaccine Refrigerators CDC recommends the use of stand alone refrigerators/freezers. Combination refrigerator- the refrigerator can be used for vaccine storage but it is not recommended to use the freezer part for vaccine storage. Pharmacy grade refrigerators are the best units to store vaccines. Automatic defrost refrigerators are preferred. The refrigerator should be large enough to hold one year s vaccine supply and should have enough space to hold water bottles.

47 Thermometers Providers are recommended to use a calibrated thermometer with certificate of traceability and calibration for all vaccine storing units. The calibration testing gives information on the level of accuracy of the thermometer. It is recommended to use a thermometer with accuracy levels of +/- 1oF/+/-.5oC Thermometers should be calibrated annually or according to the manufacturers recommendation.

48 CDC Thermometer Recommendations CDC recommends the use of digital thermometer with bio safe glycol-encased probe. A probe with detachable data logger A thermometer which can provide continuous data monitoring information with easily downloadable data A thermometer display which can be placed outside the refrigerator/ freezer to ease reading with easily downloadable data from the thermometer CDC recommends the use of thermometer with: Alarm system for out-of-range temperature Current, minimum and maximum temperature records Reset button Low battery indicator User programmable recording interval Memory of at least 4000 recordings

49 Thermometers That are Not Recommended Chart recorder Thermometer that is not calibrated Fluid-filled biosafe liquid thermometer Food thermometers Household mercury thermometer Infrared thermometer

50 North Dakota Immunization Information System

51 North Dakota Immunization Information System (NDIIS) NDIIS is an online immunization registry for the state of North Dakota. All immunizations administered to North Dakota children are required by law to be entered. All immunizations using state-supply or VFC vaccine are required by law to be entered by lot number. Can be used to look up immunization records, forecast immunizations needed, view comments and reactions to vaccine, assess immunization rates, order vaccine from NDDoH.

52 Access to NDIIS Access can be requested online. Once submitted, your user name and password will be mailed to you. You will need your immunization provider name and number.

53 Entering Doses in NDIIS Providers can search for patients already in NDIIS and in some cases may have to add the patient if they cannot be found. All vaccines administered to patients under 18 years is required by law to be entered into NDIIS. All vaccines from the VFC program or state-supply are required to be entered into NDIIS regardless of age. Entering all doses will assist in keeping accurate records for all ND residents and prevent administration errors/duplicate vaccines.

54 NDIIS Uses for Pharmacists Using the forecaster and being able to look at when a patient was last immunized will prevent missed opportunities and giving the same vaccine multiple times resulting in invalid doses. This will help bring down the cost of vaccine ordering and improve patient trust in providers.

55 NDIIS Uses for Pharmacists (cont.) Pharmacists that immunize can look up to see if a patient has previously received a dose to prevent administering unnecessary doses. This is more effective for all providers, if all providers that administer state or private vaccine to any age group, enter all doses into the registry. View any adverse reactions to vaccine in the past to prevent administering vaccines that may be dangerous to the patient.

56 State-supplied Vaccine and VFC Program Requirements

57 What is the VFC Program Vaccines for Children (VFC) is a federal program that provides vaccines to children 18 years and younger who meet one of the following criteria: Medicaid eligible (including those with Medicaid as a secondary insurance) American Indian or Alaska Native (considered VFC, even if the child has insurance) No Insurance Underinsured: has insurance, but insurance does not cover vaccinations (must be vaccinated at a Federally Qualified Health Center (FQHC) or Rural Health Center; also served by those providers who have signed memorandum of understanding (MOU). FQHCs deputize ND Local Public Health Units to immunize underinsured on their behalf

58 Enrolling in Prevention Provider Partnership Program Can be done by contacting the NDDoH Immunization Program and completing requested materials. Allows providers to order state-supplied vaccine for free to immunize VFC eligible adolescents and un/underinsured adults.

59 State-supplied Vaccine for Adults HPV for uninsured/underinsured adults ages Adults ages with Medicaid should be given privately purchased vaccine and Medicaid should be billed. Adults ages with Medicaid may be given statesupplied vaccine. Insured adults must be given privately purchased vaccine and insurance should be billed. Meningococcal Conjugate (MCV-4) for adults that are uninsured/underinsured MMR for 19 years and older that are uninsured/underinsured

60 State-supplied Vaccine for Adults (cont.) Pneumococcal Polysaccharide (PPSV23) for adults 19 years and older that are uninsured/underinsured Chronic illnesses such as cardiovascular disease, chronic pulmonary disease (including asthma), diabetes mellitus, alcoholism, chronic liver disease, or CSF leaks. Functional or anatomic asplenia (splenectomy) Conditions associated with immunosuppression including: HIV infection, leukemia, lymphoma, Hodgkin s disease, multiple myeloma, generalized malignancy, chronic renal failure, nephritic syndrome, or other conditions associated with immunosuppression (organ or bone marrow transplantation); and people receiving immunosuppressive chemotherapy, including long-term high-dose corticosteroids. Smokers

61 State-supplied Vaccine for Adults (cont.) Td/Tdap for adults 19 years and older that are uninsured or underinsured A single dose is recommended for all adults, including those 65 years and older. Medicare Part D does cover Tdap, therefore the adults who have Medicare Part D are considered insured and state-supplied vaccines cannot be used. If a patient does NOT have Medicare Part D and only has Medicare Part B (very rare) they would be considered underinsured and would qualify for state-supplied Tdap. Medicare Part B covers influenza and pneumococcal vaccines.

62 ND Rules for Pharmacies Injection of Drugs- Rules Any pharmacist who administers drugs by injection must have a certificate of authority from the board. The authority to administer a drug by injection my not be delegated. Educational requirements of a minimum of 20 hours, a portion of which must include basic immunology, administration schedules, educating patients, injection techniques, and record keeping established by law, rule, or regulation and successfully complete testing with a passing score.

63 ND Rules for Pharmacies (cont.) Orders for a pharmacist to administer injections must be written, received electronically, or if received orally be reduced to writing and contain: Identity of Physician of NP issuing the order Identity of patient to receive the injection Identity of vaccine and dose to be administered Date of the original order and dates/schedule of each subsequent administration.

64 Dr. Dwelle Standing Orders for Pharmacies that do not have a physician to sign An Immunization Protocol, Authority to Immunize and initiate immunization and standing prescription orders to administer immunizations must be completed and signed by the ND Health Officer and Physician Dr. Dwelle, MD by pharmacies that are unable to find a physician to sign for their standing orders. This grants permission to pharmacists to immunize eligible patients that are at least 11 years old. Influenza vaccine can be administered to eligible patients at that are at least 11 years old.

65 Transferring and Transporting Vaccines Patients may provide a prescription from their physician for an immunization to their authorized pharmacist. Patients cannot pickup Zostavax or any other vaccine from their pharmacist and bring it to the physician for administration in any case. Zostavax, MMRV, and Varicella must remain frozen until administration and all others are to remain at the refrigerated temperatures. A break in the cold chain can cause the vaccine to lose effectiveness.

66 Contact Information Molly Howell, MPH Program Manager Abbi Pierce, MPH VFC Manager Amy Schwartz, MPH Immunization Surveillance Coordinator Janna Pastir, MPH VFC/AFIX Coordinator Stacy Lovelace VFC/AFIX Coordinator Mary Woinarowicz, MA NDIIS Sentinel Site Coordinator Rahel Gemmeda, MPH Quality Assurance Coordinator

67

68 Credit This presentation is available for CEU s