Mary Koslap Petraco DNP, PNP BC, CPNP, FAANP Nurse Consultant Immunization Action Coalition Stony Brook University School of Nursing The Nurse Practitioner Association New York State 33 rd Annual Conference Modernizing Health Care Saratoga Springs, NY October 21, 2017 Declarations Dr. Mary Koslap Petraco has nothing to declare Objectives At the end of this presentation participants will be able to cite the updates to the ACIP Adult Immunization schedule At the end of this presentation participants will be able to preform an evaluation on adults immunization records At the end of this presentation attendees will be able to advocate for current immunization practice At the end of this presentation attendees will be able to recognize indications for updated immunization schedules 1
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Influenza Vaccine LAIV should not be used during the 2016 2017 influenza season Data indicate little to no protection from vaccine produced for 2016 17 season All LAIV produced for U.S. contained 4 strains Canada continued to use 3 strain vaccine 3 strain vaccine provided reasonable coverage 3
Influenza Vaccine Adults with a history of egg allergy who have only hives after exposure to egg Should receive age appropriate inactivated influenza vaccine (IIV) or recombinant influenza vaccine (RIV). Influenza Vaccine Adults with a history of egg allergy With symptoms other than hives (e.g., angioedema, respiratory distress, lightheadedness, or recurrent emesis Or who required epinephrine or another emergency medical intervention) may receive age appropriate IIV or RIV The selected vaccine should be administered in an inpatient or outpatient medical setting and supervised by a health care provider who is able to recognize and manage severe allergic conditions 4
Fluzone High Dose TIV Approved only for persons 65 years of age and older Each dose contains 4 times as much hemagglutinin as the standard formulation of IIV for adults High dose IIV was introduced to offer better protection to a group that is at very high risk for morbidity and mortality from influenza Expect to see more robust immune response in those aged 65 years and over Standard dose IIV while offering degree of protection does not stimulate robust immune response in this age group Hepatitis b Vaccine Adults with the following conditions should receive Hep b vaccine chronic liver disease hepatitis C virus infection cirrhosis fatty liver disease alcoholic liver disease autoimmune hepatitis alanine aminotransferase (ALT) or aspartate aminotransferase (AST) level greater than twice the upper limit of normal 5
Numbers of Cancers and Genital Warts Attributed to HPV Infections, U.S. CDC. Human papillomavirus (HPV) associated cancers. Atlanta, GA: US Department of Health and Human Services, CDC; 2013. Available at http://www.cdc.gov/cancer/hpv/statistics/cases.htm HPV Associated Cervical Cancer Incidence Rates by State, United States, 2006 2010 www.cdc.gov/cancer/npcr 6
HPV Vaccine Adult females through age 26 years and adult males through age 21 years who have not received any HPV vaccine Should receive a 3 dose series of HPV vaccine at 0, 1 2, and 6 months Males aged 22 through 26 years May be vaccinated with a 3 dose series of HPV vaccine at 0, 1 2, and 6 months HPV Case Study You are seeing a 26 year old woman in your office and she only received one dose of HPV vaccine. What do you do? 7
HPV Vaccine Adult females through age 26 years and adult males through age 21 years Males aged 22 through 26 years Who initiated HPV vaccination series before age 15 years AND received 2 doses at least 5 months apart are considered adequately vaccinated and do not need an additional dose of HPV vaccine HPV Vaccine Adult females through age 26 years and adult males through age 21 years (and males aged 22 through 26 years who may receive HPV vaccine) Who initiated HPV vaccination series before age 15 years AND received only 1 dose, or 2 doses less than 5 months apart, are not considered adequately vaccinated Should receive 1 additional dose of HPV vaccine 8
Meningitis Case Study Your patient has sickle cell disease. Is meningitis vaccine necessary and what is the schedule? Meningitis Vaccine Adults with anatomical or functional asplenia or persistent complement component deficiencies Need 2 dose primary series of MenACWY Administer doses at least 2 months apart Revaccinate every 5 years Should also receive a series of MenB Use either MenB 4C (2 doses administered at least 1 month apart) OR MenB FHbp (3 doses administered at 0, 1 2, and 6 months) 9
Meningitis Vaccine for HIV Positive Adults Adults with HIV infection who have not been previously vaccinated Give 2 dose primary MenACWY vaccination series Administer doses at least 2 months apart Revaccinated every 5 years Those who previously received 1 dose of MenACWY should receive a second dose at least 2 months after the first dose MenB is not routinely recommended for adults with HIV infection Meningococcal disease in this population is caused primarily by serogroups C, W, and Y. 10
Meningitis Vaccine Microbiologists who are routinely exposed to isolates of Neisseria meningitidis Administer 1 dose of MenACWY Revaccinate every 5 years if the risk for infection remains Also give either MenB 4C (2 doses administered at least 1 month apart) or MenB FHbp (3 doses administered at 0, 1 2, and 6 months) Meningococcal Vaccine Adults at risk because of a meningococcal disease outbreak Administer 1 dose of MenACWY if the outbreak is attributable to serogroup A, C, W, or Y If the outbreak is attributable to serogroup B Administer MenB 4C (2 doses administered at least 1 month apart) OR MenB FHbp (3 doses administered at 0, 1 2, and 6 months). 11
Meningococcal Disease Young adults aged 16 through 23 years (preferred age range is 16 through 18 years) Who are healthy and not at increased risk for serogroup B meningococcal disease May receive either a 2 dose series of MenB 4C at least 1 month apart OR a 2 dose series of MenB FHbp at 0 and 6 months for short term protection against most strains of serogroup B meningococcal disease 12
Question? Can a pregnant woman receive the Tdap vaccine or the DTaP vaccine? A 60 year old is due for a tetanus vaccine. What do you give and why? A 68 year old with young grandchildren had a Td vaccine 6 months ago. What is your course of action and why? Use of Tdap Among Adults 19 Years of Age and Older One time dose of Tdap to replace the next 10 year Td booster Should be administered as soon as feasible to: All previously pregnant women Postpartum women if not vaccinated during pregnancy Close contacts of infants younger than 12 months of age Healthcare personnel with direct patient contact Interval Between Td and Tdap Tdap can be administered regardless of interval since the last tetanus toxoid containing vaccine Longer intervals between Td and Tdap vaccination could decrease the occurrence of local reactions The benefit of protection against pertussis outweighs the potential risk for an adverse event 13
Use of Tdap Among Adults 65 Years of Age or Older Adults 65 years of age and older who previously have not received Tdap, should receive a single dose of Tdap When feasible, Boostrix should be used for adults 65 years of age and older Administer Adacel if Boostrix is not available Tdap and Pregnancy Updated recommendation: Tdap should be given during EACH pregnancy Preferred during 27 36 week of pregnancy Vaccinate during third trimester or late in second trimester (after 20 weeks gestation) Vaccinating at this time maximizes transfer of antibodies to baby to protect baby before baby is able to begin DTaP series Use Tdap for routine tetanus and diphtheria booster or wound management if no prior Tdap dose MMR Case Study You have an adult who denies receiving MMR vaccine and is traveling to Europe. What do you do? 14
Measles Mumps Rubella Recommendations Adults 1 dose Adults 2 doses 4 weeks apart college students international travelers all healthcare personnel CDC now recommends 2 doses of Measles, Mumps, & Rubella components for those who need second dose Varicella Case Study You have a 55 year old who does not remember any history of varicella disease. What do you do? Varicella Vaccine For persons aged 13 years and older, the minimum interval between doses is 4 weeks If adult has no history of varicella disease administer 2 doses of VAR separated by 4 weeks Health care personnel should be immunized if they do no demonstrate immunity 15
Zoster Questions An adult inadvertently received VAR rather than zoster vaccine. What is your course of action? An adult who is a candidate for zoster vaccine but does not have a history of chickenpox. What do you do? Herpes Zoster (Shingles) Estimated lifetime risk of 32% in the United States Estimated 1 million cases of zoster occur annually in the United States About 50% occur in persons 60 years of age and older Zoster Vaccine Contraindications Severe allergic reaction to a vaccine component or following a prior dose Pregnancy or planned pregnancy within 4 weeks Immunosuppression 16
Screening for Zoster Vaccine Eligibility Screening for a history of varicella disease is not necessary or recommended to administer zoster vaccine Birth in the U.S. before 1980 is acceptable evidence of varicella immunity Screening for Zoster Vaccine Eligibility Do NOT test for varicella antibody Negative test is more likely to indicate waning antibody level rather than true susceptibility Seronegative persons should receive 2 doses of standard varicella vaccine Zoster Vaccine Precautions Moderate or severe acute illness Current treatment with an antiviral drug active against herpes viruses discontinue at least 24 hours before administration of zoster vaccine should not be taken for at least 14 days after vaccination Recent receipt of a blood product is NOT a precaution 17
Pneumococcal Polysaccharide Vaccine (PPSV23) Recommendations Unvaccinated adults 65 years of age and older Adults 19 through 64 years of age with chronic conditions cardiovascular disease pulmonary disease (including asthma) diabetes mellitus alcoholism chronic liver disease Cigarette smokers PPSV23 Recommendations for Adults at Highest Risk of Invasive Pneumococcal Disease (IPD) Adults should receive two doses of PPSV23 separated by at least 5 years functional or anatomic asplenia cerebrospinal fluid (CSF) leak cochlear implant immunocompromised for any reason, including disease and immunosuppressive drugs or therapy PPSV23 Revaccination Persons who received one or two doses of PPSV23 before age 65 years for any indication should receive another dose at age 65 or older if at least 5 years have passed since previous dose Those who receive their first dose of PPSV23 at or after age 65 do not need any additional doses 18
Pneumococcal Vaccine Naïve Immunocompromised Adults A third and final dose of PPSV23 is recommended at 65 years of age or older as long as 5 years have elapsed since the second dose of PPSV23 Zoster and Pneumococcal Polysaccharide (PPSV23) Vaccines Zoster product information advises that clinicians consider administration of the two vaccines separated by at least 4 weeks Recent study found no evidence of increased risk of zoster in persons who received both zoster vaccine and PPSV23 on the same day Zoster and Pneumococcal Polysaccharide (PPSV23) Vaccines CDC has not changed its recommendation for either vaccine Zoster vaccine and PPSV23 should be administered at the same visit if both vaccines are indicated 19
Pneumococcal Vaccine Case Study 40 year old male with asplenia received PPSV23 three years ago. Does he need any more doses of any pneumococcal vaccine? Pneumococcal Conjugate Vaccine (PCV13) for Adults On December 30, 2011, PCV13 (Prevnar13, Pfizer) was approved for use among adults 50 years of age and older FDA approved expanded age indication through the Accelerated Approval Pathway Pneumococcal Conjugate Vaccine (PCV13) for Adults Immunogenicity of PCV13 was found to be noninferior to PPSV23 Indication prevention of pneumococcal disease, including pneumonia and invasive disease caused by the 13 Streptococcus pneumoniae serotypes in PCV13 20
Incidence of IPD in adults aged 18 64 years with selected underlying conditions, United States, 2009 200 186 180 20 fold increased risk 173 160 Cases per 100,000 persons 140 120 100 80 60 40 3 7 fold increased risk 41 26 28 32 52 59 20 8 0 HEALTHY CVD DIABETES PULMONARY KIDNEY LIVER ALCOHOL HIV/AIDS HEMATOLGICAL CANCER ACIP Recommendations for PCV13 for Immunocompromised Adults Benefits outweigh any risks Indirect effects of PCV13 use in children not likely to eliminate IPD due to PCV13 serotypes in adults PCV13 use alone may not provide adequate coverage Combined use of PCV13 and PPSV23 more effective than either vaccine alone Pneumococcal Vaccine Naïve Immunocompromised Adults Adults 19 through 64 years of age with immunocompromising conditions functional or anatomic asplenia CSF leak, or a cochlear implant who are vaccine naïve Should receive a single dose of PCV13 followed by a dose of PPSV23 at least 8 weeks later A second dose of PPSV23 is recommended 5 years after the first dose of PPSV23 21
Pneumococcal Vaccine Naïve Immunocompromised Adults PCV13 + PPSV23 + PPSV23 + PPSV23 At least 8 weeks apart At least 5 years apart At 65 years or later if 5 years have elapsed since the last dose PCV13 for Adults Previously Vaccinated with PPSV23 Adults with immunocompromising conditions, functional or anatomic asplenia, CSF leak, or a cochlear implant previously vaccinated with PPSV23 should receive PCV13 one or more years after the last PPSV23 dose Shorter interval will blunt immune response to PCV13 For those who require additional doses of PPSV23, the first dose should be administered 1 year after PCV13 and at least 5 years after the most recent dose of PPSV23 Hepatitis B Case Study You are treating a 37 year old with diabetes. What are your recommendations for Hepatitis b vaccine for this patient? What about a 70 year old with diabetes who lives in an assisted facility? 22
Hepatitis B Vaccine for Individuals With Diabetes Unvaccinated adult diabetics 19 through 59 years of age should receive a 3 dose series of Hepatitis B vaccine Hepatitis B vaccine may be administered to diabetics 60 years of age and older at the clinician s discretion Hepatitis A Hepatitis A vaccine (Hep A). (Minimum age: 12 months) Administer 2 doses at least 6 months apart For whomever immunity against Hepatitis A is desired So What Do We Have to Look Forward to? It the PATCH! A press on patch that delivers flu vaccine painlessly worked as well as an old fashioned flu shot with no serious side effects Vaccine will be cheaper, easier to give and more acceptable than a regular flu vaccine Your flu shot could arrive in the mail! Rouphael, N.G. Paine, M., Mosley, R., Henry, S., McAllister, D.V., Kalluri, H., Pewin, W., Frew, P.M., Yu, T., Thornburg, N.J., Kabbani, S., Lai, L., Vassilieva, E.V., Skountzou, J., Compans, R.W., Mulligan, M.J., & Prausnitz, M.R. The safety, immunogenicity, and acceptability of inactivated influenza vaccine delivered by microneedle patch (TIV MNP 2015): a randomised, partly blinded, placebo controlled, phase 1 trial The Lancet. DOI: http://dx.doi.org/10.1016/s0140 6736(17)30575 5 23
Social Media Channels Facebook Over 200,000 followers Blog Over 69,000 unique monthly visitors Over 11 Million Reached Annually With Social Media Messages 71 2017 24
The Vaccine Handbook App A comprehensive update of The Vaccine Handbook App is now available from the Immunization Action Coalition This free App, which is available for Apple iphones and ipads only, contains the new 2017 (6 th ) edition of The Vaccine Handbook ( The Purple Book ), by Dr. Gary Marshall, professor of pediatrics and chief of the Division of Pediatric Infectious Diseases at the University of Louisville The App is fully searchable, with functionality that includes bookmarking, highlighting, user annotation and links to important vaccination resources. The Vaccine Handbook App The Purple Book is a comprehensive source of vaccine information, drawing together vaccine science, guidance, and practice into a user friendly resource for the private office, public health clinic, academic medical center, classroom, and hospital The first section provides extensive background on vaccine immunology, development, infrastructure, policy, standards, implementation, special circumstances, and perhaps most important addressing concerns The second section contains details about every vaccine currently licensed in the U.S., including the burden and epidemiology of the respective disease, history of the immunization program, vaccine constituents, efficacy, safety, and recommendations The Vaccine Handbook App The Purple Book is a comprehensive source of vaccine information, drawing together vaccine science, guidance, and practice into a user friendly resource for the private office, public health clinic, academic medical center, classroom, and hospital The first section provides extensive background on vaccine immunology, development, infrastructure, policy, standards, implementation, special circumstances, and perhaps most important addressing concerns The second section contains details about every vaccine currently licensed in the U.S., including the burden and epidemiology of the respective disease, history of the immunization program, vaccine constituents, efficacy, safety, and recommendations 25
Accessing the App The free App may be found by searching the itunes App Store for The Vaccine Handbook App or clicking on the following link: https://itunes.apple.com/us/app/the vaccinehandbook app/id1043246009?ls=1&mt=8 Print copies of the book ($34.95 each; bulk discounts are available from the publisher) can be ordered from the Immunization Action Coalition website: http://www.immunize.org/vaccinehandbook Screening Questions Immunization Action Coalition web site www.immunize.org Has wealth of information in easy to access format http://www.immunize.org/catg.d/p4060.pdf Evidence Based Strategies Examples: standing orders reminder and recall AFIX: assessment, feedback, incentive, and exchange 26
Sources for Immunization Schedules, Changes, & Information Center for Disease Control www.cdc.gov/vaccines http://www.cdc.gov/vaccines/schedules/hcp/childadolescent.html Contains all schedules for child, adolescent, and adult immunization schedules American Academy of Pediatrics www.aap.org ACIP Advisory Committee on Immunization Practices http://www.cdc.gov/vaccines/recs/acip The Red Book CDC vaccine storage and handling took kit http://www.cdc.gov/vaccines/recs/storage/toolkit/storagehandling toolkit.pdf References Centers for Disease Control and Prevention. Epidemiology and Prevention of Vaccine Preventable Diseases. Hamborsky J, Kroger A, Wolfe S, eds. 13th ed. Washington D.C. Public Health Foundation, 2015. Kubo A, Shlager L, Marks AR, et al. Prevention of vertical transmission of hepatitis B: an observational study. Ann Intern Med 2014;160:828 35. Kim DK, Riley LE, Harriman KH, Hunter P, Bridges CB. Advisory Committee on Immunization Practices Recommended Immunization Schedule for Adults Aged 19 Years or Older United States, 2017. MMWR Morb Mortal Wkly Rep 2017;66:136 138. DOI: http://dx.doi.org/10.15585/mmwr.mm6605e2. McNeil LK, Zagursky RJ, Lin SL, et al. Role of factor H binding protein in Neisseria meningitidis virulence and its potential as a vaccine candidate to broadly protect against meningococcal disease. Microbiol Mol Biol Rev. 2013;77(2):234 252 The safety, immunogenicity, and acceptability of inactivated influenza vaccine delivered by microneedle patch (TIV MNP 2015): a randomised, partly blinded, placebo controlled, phase 1 trial Rouphael, Nadine GBeck, Allison et al. The Lancet, Volume 0, Issue 0, DOI: http://dx.doi.org/10.1016/s0140 6736(17)30575 5 27