8/8/2015. Calling the Shots for Patients with Diabetes. Objectives. Patient Case #1

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1 Calling the Shots for Patients with Diabetes An Immunization Update Debra J. Reid Pharm.D., BC-ADM, CDE, BCACP Assistant Clinical Professor Northeastern University Boston, MA Objectives Describe the importance of vaccination in adults with diabetes List the vaccines recommended for adults with diabetes Discuss the role of the diabetes educator in improving vaccination rates in adults with diabetes Disclosure to Participants Notice of Requirements For Successful Completion Please refer to learning goals and objectives Learners must attend the full activity and complete the evaluation in order to claim continuing education credit/hours Conflict of Interest (COI) and Financial Relationship Disclosures: Presenter: Debra J. Reid, Pharm.D., BC-ADM, CDE, BCACP No COI/Financial Relationship to disclose Non-Endorsement of Products: Accredited status does not imply endorsement by AADE, ANCC, ACPE or CDR of any commercial products displayed in conjunction with this educational activity Off-Label Use: Participants will be notified by speakers to any product used for a purpose other than for which it was approved by the Food and Drug Administration. Patient Case #1 Ms. Santos is a 56 year old female who presents to your clinic to establish care. She has type 2 diabetes and has been treated with insulin for the past 8 years. She recalls receiving a tetanus booster in the ED about 5 years ago when she was bit by a dog, but no other recent vaccines. She states she got all her routine childhood vaccines. Which vaccines would you recommend today? Influenza IIV, LAIV or RIV Pneumococcal PCV13 or PPSV23 Hepatitis B Td or Tdap Zoster 1

2 Disease Burden Influenza Millions of cases and average of 226,000 hospitalizations annually with >75% among adults 3,000 to 49,000 deaths annually ~90% among adults 65 years and older Invasive pneumococcal disease (IPD) 39,750 total cases and 4,000 deaths in % of IPD cases and nearly all IPD death among adults Disease Burden Hepatitis B 2,895 acute cases reported 2012 Zoster About 1 million cases annually Approximately 1-4% hospitalized for complications Pertussis ~28,000 cases per year for 2013 and 2014 ~9,000 among adults Risk in Adults with Diabetes Risk of Developing Diseases Compared to Healthy Adults Influenza Pneumococcal disease Herpes Zoster 9.9 ( ) 3.4 ( ) Age 50-64: 1.5 ( ) Age 65: 3.1 ( ) Healthy People 2020 Immunization Goals Vaccine and Target Group Goal (%) Influenza Adults aged 18 years and older 70 Pneumococcal High risk adults aged years 60 Adults aged 65 years and older 90 Institutionalized adults 90 Zoster Adults aged 60 years and older 30 Vaccination Rates (2013) Pneumococcal vaccine High risk aged years % Aged 65 years 59.7% Hepatitis B vaccine With diabetes aged19-59 years % With diabetes aged 60 years 13.9% Zoster vaccine Aged 60 years 24.2% Influenza Vaccination Rates 2

3 8/8/2015 Advisory Committee on Immunization Practices Vaccines for Adults with Diabetes Vaccine Recommendation Administration Influenza All adults 1 dose annually Pneumococcal All adults aged years Adults aged 65 years Vaccines for Adults with Diabetes Vaccine Recommendation Hepatitis B All adults aged < 60 years 3-dose series given at 0, 1, 6 months Consider in those aged 60 years Start series at diagnosis Td/Tdap All adults 1 dose PPSV23 at diagnosis 1 dose PCV13 followed by PPSV23 at least 1 year later Administration Td every 10 years with Tdap in place of one Td Zoster (shingles) All adults aged 60 years 1 dose Influenza Vaccine INFLUENZA Schedule 1 dose annually to all adults Contraindications/ precautions Previous severe allergic reaction Moderate to severe illness Egg allergy (hives) give IIV History of Guillain-Barré syndrome within 6 weeks of receipt of influenza vaccine Adverse reactions Pain at injection site Mild systemic complaints 3

4 8/8/2015 Influenza Vaccine Formulations Inactivated influenza vaccine (IIV) Trivalent inactivated influenza vaccine (IIV3) Quadrivalent inactivated influenza vaccine (IIV4) Trivalent cell culture-based inactivated influenza vaccine (cciiv3) Trivalent recombinant influenza vaccine (RIV3) Use in egg allergy Live attenuated influenza vaccine, quadrivalent (LAIV4) Indicated in ages 2-49; precaution in those with diabetes Pneumococcal Disease Caused by Streptococcus pneumoniae Transmitted through respiratory droplets Clinical manifestations are bacteremia, meningitis, and pneumonia PNEUMOCOCCAL DISEASE Pneumococcal Vaccine Vaccine formulation Polysaccaride 23-valent Pneumovax23 (PPSV23) Schedule 1 dose given at diagnosis; 1 dose given at age 2nd dose given at least 1 65 years (at least 1 year* after dose of year after PPSV23) PCV13 Conjugate13-valent Prevnar 13 (PCV13) Contraindications/ Previous severe allergic reaction precautions Moderate to severe illness Adverse reactions Pain at injection site Fatigue Headache Recommended Vaccination Schedule HEPATITIS B 1 year 4

5 Hepatitis B Acute or chronic infection of liver Significant morbidity/mortality Higher rates in DM DM may increased HBV-associated mortality Hepatitis B HBV stable and highly transmissible for long periods of time Modes of transmission: Assisted glucose monitoring Use of same syringe or insulin pen Improper sterilization of podiatry equipment Case reports of HBV infection in hospitals and long-term care facilities HBV Vaccine Vaccine formulation Schedule Contraindications/precautions Adverse reactions Recombivax HB (Merck) 10 mcg/1 ml Engerix-B (GSK) 20 mcg/1 ml 3-dose series given at 0, 1, 6 months Previous severe allergic reaction Yeast allergy Moderate to severe illness Pain at injection site Mild systemic complaints HBV Vaccine Protective antibody response in healthy adults 90% after 3 rd dose Duration of response 20 years Similar responses in those with diabetes Reduced response in older adults Longer interval between final 2 doses associated with increased seroprotection Barriers to Vaccination ROLE OF DIABETES EDUCATOR Lack of provider and patient knowledge Management of acute and chronic illness receive priority over preventive measures Insurance coverage / reimbursement / out-ofpocket cost Challenges in determining vaccination status 5

6 NVAC Standards Call to action for all providers of adult health care Recognize importance of health care provider s recommendation Highlight current low vaccination rates of U.S. adults Reflect changed environment in which adults receive vaccines NVAC Standards: 4 Steps ASSESS immunization status Strongly RECOMMEND vaccines ADMINISTER needed vaccines or REFER DOCUMENT vaccines administered or received NVAC Standards: Step 1 ASSESS immunization status Stay informed with latest recommendations Implement protocols and policies Electronic health system reminders Patient intake questionnaires Standing orders Immunization registries NVAC Standards: Step 2 Strongly RECOMMEND vaccines Engage entire team in advocating for vaccination Describe the benefits of vaccine and the costs of getting sick Address patient questions and concerns Recommendation from health care provider is one of the most important strategies! Patient Case #2 Mr. Hill, 55 years old, has been a patient at your practice for over 20 years. His diabetes is well controlled and he is up to date with lab tests, eye and podiatry exams. He has received the hepatitis B series, Tdap, and PPSV23. You recommend the influenza vaccine at his visit in October, but he replies that he is very healthy, has never had the flu, and does not need the vaccine. Which of the following is the best response? A. Tell Mr. Hill that he is at increased risk for influenza but that it is up to him whether he should be vaccinated B. Tell Mr. Hill that he really should get the vaccine because it is an important measure of your healthcare quality C. Tell Mr. Hill that you strongly recommend influenza vaccination today to reduce his risk of infection and hospitalization as well as reduce the risk of transmitting influenza to his family members NVAC Standards: Step 3 ADMINISTER needed vaccines or REFER Offer vaccines you stock Refer patient to provider that offers vaccines you don t stock or can t administer 6

7 NVAC Standards: Step 4 DOCUMENT vaccines received Participate in state immunization registry Record in EHR Provide record to patient Communicate with PCP Follow up on referrals Components of Successful Vaccination Programs Electronic health records Standing order programs Vaccination status assessed at every encounter Referral to vaccinating provider Improved vaccination rates Physician champion for vaccination program Vaccination quality assurance team Strong commitment by administrators What could your practice do to increase vaccination rates among your patients? Patient Case #1 Ms. Santos is a 56 year old female who presents to your clinic to establish care. She has type 2 diabetes and has been treated with insulin for the past 8 years. She recalls receiving a tetanus booster in the ED about 5 years ago when she was bit by a dog, but no other recent vaccines. She states she got all her routine childhood vaccines. Which vaccines would you recommend today? A. Influenza IIV, LAIV or RIV B. Pneumococcal PCV13 or PPSV23 C. Hepatitis B D. Td/Tdap E. Zoster Patient Case #1 Ms. Santos is a 56 year old female who presents to your clinic to establish care. She has type 2 diabetes and has been treated with insulin for the past 8 years. She recalls receiving a tetanus booster in the ED about 5 years ago when she was bit by a dog, but no other recent vaccines. She states she got all her routine childhood vaccines. Which vaccines would you recommend today? A. Influenza IIV, LAIV or RIV B. Pneumococcal PCV13 or PPSV23 C. Hepatitis B D. Td/Tdap E. Zoster Resources Immunization Action Coalition Educational materials Clinic resources Centers for Disease Control and Prevention Recommendations and schedules Vaccine information Immunization Information Systems (IIS) 7

8 Fact Sheets for Healthcare Providers Conclusions Adult vaccination rates in the U.S. are low Adults with diabetes are more susceptible to certain infectious diseases Every health care provider has a responsibility to recommend immunizations References 1. Centers for Disease Control and Prevention. Summary of Notifiable Diseases, MMWR 2014;61(53): Shea KM, Edelsberg J, Weycker D, et al. Rates of pneumococcal disease in adults with chronic medical conditions. Open Forum Infec Dis. 2014;1: Williams WW, Lu PJ, O Halloran A, et al. Vaccination coverage among adults, excluding influenza vaccination United States, 2013 MMWR. 2015;64(04); Centers for Disease Control and Prevention. Seasonal influenza vaccination coverage by high-risk conditions, adults Years, United States, Behavioral Risk Factor Surveillance System (BRFSS), through influenza seasons. Available at: Accessed May 1, Kim DK, Bridges CB, Harriman HK. Advisory Committee on Immunization Practices. Advisory Committee on Immunization Practices recommended immunization schedule for adults aged 19 years or older: United States, Ann Intern Med. 2015:162: Healthy People Immunization and infectious diseases. Available at: Accessed May 1, Smith SA, Poland GA. Use of influenza and pneumococcal vaccines in people with diabetes. Diabetes Care 2000;23: Centers for Disease Control and Prevention. Use of hepatitis B vaccination for adults with diabetes mellitus: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep 2011;60: Lau D, Eurich DT, Majumdar SR, Katz A, Johnson JA. Working-age adults with diabetes experience greater susceptibility to seasonal influenza: a population-based cohort study. Diabetologia. 014;57: Grohskopf LA, Olsen SJ, Sokolow LZ, et al. Prevention and control of seasonal influenza with vaccines: recommendations of the Advisory Committee on Immunization Practices (ACIP) -- United States, influenza season. MMWR Morb Mortal Wkly Rep. 2014;63: Centers for Disease Control and Prevention. Use of 13-valent pneumococcal conjugate vaccine and 23-valent pneumococcal polysaccharide vaccine for adults with immunocompromising conditions: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep. 2012;61: References 12. Tomczyk S, Bennett NM, Stoecker C, et al. Use of 13-valent pneumococcal conjugate vaccine and 23-valent pneumococcal polysaccharide vaccine among adults aged 65 years: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep. 2014;63: Schillie SF, Spradling PR, Murphy TV. Immune response of hepatitis B vaccine among persons with diabetes. Diabetes Care. 2012;35: National Vaccine Advisory Committee. Recommendations from the National Vaccine Advisory Committee: standards for adult immunization practice. Public Health Rep. 2014;129: Mertz D, Kim TH, Johnstone J, et al. Populations at risk for severe or complicated influenza illness: systematic review and meta-analysis. BMJ. 2013;347:f Kyaw MH, Rose CE, Fry AM, et al. The influence of chronic illnesses on the incidence of invasive pneumococcal disease in adults. J Infect Dis. 2005;192: Guignard AP, Greenberg M, Lu C, et al. Risk of herpes zoster among diabetics: a matched cohort study in a US insurance claim database before introduction of vaccination, Infection. 2014;42: Robke JT, Woods M. A decade of experience with an inpatient pneumococcal vaccination program. Am J Health-Syst Pharm. 2010;67: Coyle CM, Currie BP. Improving the rates of inpatient pneumococcal vaccination: impact of standing orders versus computerized reminders to physicians. Infect Control Hosp Epidemiol. 2004;25: Middleton DB, Fox DE, Nowalk MP, et al. Overcoming barriers to establishing an inpatient vaccination program for pneumococcus using standing orders. InfectControl Hosp Epidemiol. 2005;26: Centers for Disease Control and Prevention. Standards for adult immunization practice: Vaccine needs assessment. Available at: cdc.gov/vaccines/hcp/patient-ed/adults/forpractice/standards/indeex.html. Accessed Jul 29, Hurley LP, Bridges CB, Harpaz R, et al. U.S. physicians' perspective of adult vaccine delivery. Ann Intern Med. 2014;160: Centers for Disease Control and Prevention. Standards for adult immunization practice: Vaccine referral. Available at: Accessed July 29, QUESTIONS? 8