Vaccination Decision Making: What Providers Need to Know

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1 Objectives Vaccination Decision Making: What Providers Need to Know Kelli Smith, RN, BSN Iowa Department of Public Health Immunization Program Catch-up Schedule: how to most efficiently bring persons up-to-date on vaccinations when behind Available Vaccines: what are your choices and how are they licensed Combination versus Single-antigen Vaccines: deciding which to use Recommended Schedules: childhood/adolescent, and adult School Entry Requirements: Iowa State law When the way is clear Case Study 1 Ethan, 7 month old, male Vaccine History includes: DTaP, IPV, HepB, Hib, PCV13, RV at ages 2 months and 4 months Look to the Recommended schedule for his age child-adolescent.html 1

2 Case Study 1 He is due to receive: IPV, HepB : At some point between 6 and 18 months of age RV, Hib : Needed if 3-dose brand was used for primary series DTaP, PCV13 Influenza : At some time between age 6 months and the end of the Influenza season Diphtheria/Tetanus/Pertussis DT: generic (Sanofi Pasteur) Ages: 6 wks-6 years DTaP Daptacel (Sanofi Pasteur) Ages: 6 wks-6 years Infanrix (GlaxoSmithKline) Ages: 6 wks-6 years DTaP Combination Vaccines Pediarix: DTaP-HepB-IPV (GlaxoSmithKline) Ages: 6 wks-6 years 1 Pentacel: DTaP-IPV/Hib (Sanofi Pasteur) Ages: 6 wks-4 years 2 Kinrix: DTaP-IPV (GlaxoSmithKline) Ages: 4-6 years 3 1 Used for primary 3-dose series (2, 4, 6 months of age) 2 Used for primary 4-dose series (2, 4, 6, months of age) 3 Used for 5 th dose of DTaP and 4 th dose of IPV (Kindergarten age) Hepatitis B Engerix-B (GlaxoSmithKline) Pediatric Formulation Ages: birth-19 years Adult Formulation Ages: 20+ years Recombivax HB (Merck) Pediatric Formulation Ages: birth-19 years Adult Formulation Ages: 20+ years 1 Hepatitis B Combination Vaccines Comvax: Hib-HepB (Merck) Ages: 6 wks-4 years Pediarix: DTaP-HepB-IPV (GlaxoSmithKline) Ages: 6 wks-6 years Twinrix: HepA-HepB (GlaxoSmithKline) Ages: 18+ years 1 Alternatively licensed for adolescents 11 through 15 years of age as a two-dose regimen (10 mcg at 0 and 4-6 month interval) Haemophilus influenzae b ActHIB (Sanofi Pasteur) Ages: 6 wks-18 mos 1 Hiberix (GSK) Ages: 15 months- 4 yrs 2 PedvaxHIB (Merck) Ages: 6 wks-5 years dose primary series (age 2, 4, 6 months), booster (age months) 2 Booster (age months) 3 2-dose primary series (age 2, 4 months), booster (age mo) Haemophilus influenzae b Combination Vaccines Comvax: Hib-HepB (Merck) Ages: 6 wks- 4 years 1 Menhibrix : HibMenCY (GSK) Ages: 6 wks- 18 months 2 Pentacel: DTaP-IPV/Hib (Sanofi Pasteur) Ages: 6 wks-4 years dose schedule given at ages 2, 4, and months 2 4-dose schedule given at ages 2, 4, 6, and months 3 4-dose schedule given at ages 2, 4, 6, and months Pneumococcal Polysaccharide Pneumovax 23 (Merck) Ages: 2+ years (0, 5 year interval in high risk populations) 1 dose 65 years of age Conjugate Prevnar13 (Wyeth) Ages: 6 wks-5 years, 50+ years 3-dose primary series (age 2, 4, 6), booster dose (age months) 2

3 Rotavirus Rotarix (GSK) Ages: 6 wks-24 weeks 2-dose series (2 mo., 4 mo. of age) Rotateq (Merck) Ages: 6 wks-32 weeks 3-dose series (2, 4, 6, mo. of age) For ease of use, Advisory Committee on Immunization Practices recommends beginning either brand no later than age 14 weeks, 6 days; and completing either series by age 8 mo., 0 days Options to get Ethan caught up: Pediarix (DTaP-HepB-IPV) + Hib (Pedvax or Act) + Prevnar 13 + RV (Rotateq or Rotarix) 3 IM, 1 PO Pentacel (DTaP-IPV/Hib) + HepB (Engerix or Recombivax HB) + Prevnar 13 + RV 3 IM, 1 PO Comvax (Hib-HepB) + DTaP (Infanrix or Daptacel) + IPV + Prevnar 13 + RV 4 IM, 1 PO DTaP + IPV + HepB + Hib + Prevnar 13 + RV 5 IM, 1 PO Case Study 2 Alex, 3-year old male, born 5/1/2010 Vaccine history: Birth 2 mo 5 mo 2 yr, 4 mo DTaP: 7/1/2010, 10/1/2010, 9/1/2012 HepB: 5/1/2010, 7/1/2010, 9/1/2012 IPV: 7/1/2010, 10/1/2010, 9/1/2010 Hib: 7/1/2010, 10/1/2010, 9/1/2012 MMR: 9/1/2012 PCV: 7/1/2010, 10/1/2010, 9/1/2012 Varicella: 9/1/2012 Case Study 2: What is He Missing? According to the Recommended Schedule: Rotavirus #1-3 DTaP #4 Hib #4 PCV# 4 Hepatitis A #1-2 Now let s look closer at the Catch-Up Schedule Case 2: What is He Missing? 3

4 Hepatitis A Havrix (GSK) 2-dose series (0, 6 month interval) Pediatric Formulation Ages: 12 months 18 years Adult Formulation Ages: 19+ years Vaqta (Merck) 2-dose series (0, 6 month interval) Pediatric Formulation Ages: 12 months 18 years Adult Formulation Ages: 19+ years Twinrix: HepA-HepB (GSK) Ages: 18+ years 3 dose series (0, 1, 6 month interval); OR accelerated 4- dose schedule (0, 7 days, days, 12 month interval) Everything Else Measles, Mumps, Rubella M-M-R II (Merck) Ages: 12+ months Varicella Varivax (Merck) Ages: 12+ months Herpes Zoster Zostavax (Merck) Ages: 50+ years MMRV ProQuad (Merck) 1 Ages: 12 months 12 years Polio Ipol (Sanofi Pasteur) age 6 weeks + Also found in Kinrix, Pediarix, and Pentacel combination vaccines 1 Recommended as second dose only until age 4 years at which time recommended as 1 st and/or second dose d/t risk of febrile seizures Plan for vaccination: Today: DTaP and HepA 1 In 6 months: HepA 2 In 1-3 years: Kindergarten vaccines (DTaP, IPV, MMR, Var) When things get complicated Where do we start 1. Identify the current age of the patient 2. What is recommended per the CDC 3. What is required for school entry (Iowa law) 4. Look at the patient s vaccine history 5. Which vaccines do you have in stock Case Study 3 Johanna, female, age 13 years Recent refugee, no vaccine documentation available Go to the Catch-up immunization schedule for persons aged 4 mo-18 yr. who start late catchup.html 4

5 Dose 1 Dose 2 Dose 3 Dose 4 Iowa Administrative Code, Chapter 7, (139A) iowa.gov/docs/a CO/IAC/LINC/Chap ter pdf 7. A fourth dose (IPV) is not necessary if the third dose was administered at age 4 years or older and at least 6 months after the previous dose. Case Study 3, continued If our case is 13, she was born between 5/18/99 and 5/17/00 She is RECOMMENDED to receive: Tdap/Td (3) IPV (3) Varicella (2) HepB (3) MMR (2) HepA (2) Mening (1) HPV (3) She is REQUIRED by Iowa law to receive: Tdap/Td (3) IPV (3) Varicella (1) HepB (3) MMR (2) Diphtheria/Tetanus/Pertussis (cont d) Td Ages: 7+ years generic (Massachusetts Biological Labs) Tenivac (Sanofi Pasteur) TT: generic (Sanofi Pasteur) Ages: 7+ years Tdap Boostrix (GlaxoSmithKline) Ages: 10+ years 1 Adacel (Sanofi Pasteur) Ages: 11+ years 1 1 Off-label use: approved by ACIP down to age 7 years for those who were incompletely immunized prior to 7 th birthday (MMWR January 14, 2011 /60(01);13-15) Everything Else Continued HPV 3-dose series (0, 1-2, 6 months interval) Cervarix (GSK) Ages: 9 years-25 years 1 females only Guardasil (Merck) Ages: 9 years-26 years 2 males and females Influenza - 1 or 2 doses/season in children aged 6 months-8 years, 1 dose/season in people 9+ years old 1 For ease of use, ACIP recommends using either brand through age 26 years 2 Recommended for all males through age 21 years, high-risk males through age 26 years 5

6 Meningococcal Conjugate Menveo (Novartis) Everything Else Continued Menactra (Sanofi Pasteur) Menhibrix (GSK) Ages: 2 yrs-55 yrs Ages: 9 mos-55 yrs Ages: 6 wks-18 mos Polysaccharide Menomune (Sanofi Pasteur) Ages: 2+ years 1 1 ACIP recommends reserving MCV for those aged 6 wks-55 years and using MPSV in adults aged 56+ years Options to get Johanna caught up: For 13 year olds, no combination vaccines are licensed Today she is due to receive: Tdap, HepB, IPV, Mening, MMR, Varicella, HPV, HepA (8 vaccines) ACIP states, Simultaneously administering all vaccines for which a person is eligible at the time of a visit increases the probability that a child, adolescent or adult will be vaccinated fully by the appropriate age Although there is no exact limit on the number of injections, with a little flexibility, a provider can ensure that [the primary series] doses are given without administering too many injections at each visit. In 4 weeks: Td, HepB, IPV, MMR, Varicella, HPV (6 vaccines) 16 weeks from 1 st dose: HepB (1 vaccine) 24 weeks from 1 st dose: HPV (1 vaccine) 6 months from previous dose: Td, HepA, IPV (3 vaccines) Vaccines Per Visit (Option 1) Vaccines Per Visit (Option 2) Visit 5 Visit 3 Visit 2 Visit 3 Visit 4 Visit 5 Visit Visit 4 Visit 2 Visit 3 Visit 4 Visit 5 Certificates of Exemption 6

7 Adult Immunization Schedule, 2013 References: 2013 CDC Childhood/Adolescent Vaccine Schedule, CDC Vaccine Catch-up Schedule, CDC Adult Vaccine Schedule, Vaccine Package Inserts, Iowa Immunization Law Chart, Certificate of Immunization Exemption, (Forms Immuniza on Record Exemp on) Iowa Immunization Program, &pg=immhome Kelli Smith, RN, BSN Immunization Nurse Consultant Perinatal Hepatitis B Prevention Program Coordinator Bureau of Immunization and TB Iowa Department of Public Health (800) x2 7

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