REACHING OUR GOALS: IMMUNIZATION PROVIDER EDUCATION

REACHING OUR GOALS: IMMUNIZATION PROVIDER EDUCATION 1 DISCLOSURES I have no relevant financial relationships with the manufacturers of any commercial products and/or providers of commercial services discussed in this presentation. I do not intend to discuss an unapproved/investigative use of a commercial product/device in the presentation. 2 1

GOVERNMENT FUNDERS Funding and support from the Illinois and Chicago Departments of Public Health through the Immunization Initiatives Project at the Illinois Chapter, American Academy of Pediatrics 3 PRESENTATION OUTLINE I. Updates on Immunization Schedule and where to locate on the CDC schedule II. Vaccines for 0-3 years III. Influenza IV. School entry vaccines V. Adolescent vaccines VI. HPV vaccine VII. Immunization FAQ s VIII. Your role to improve vaccination rates and reduce missed opportunities 4 2

2015 ACIP CHILDREN & ADOLESCENT VACCINE SCHEDULE UPDATES 5 6 3

2015 ACIP RECOMMENDATIONS Meningitis B complete two or three dose series depending on vaccine, no preference 9 valent HPV vaccine for ages 10 and up Age & gender recommendations the same as for quadrivalent vaccine Finish the series with whatever vaccine is available No change yet in 3-dose schedule No determination yet on what recommendations to make for those already fully vaccinated with the bivalent or quadrivalent vaccines Flu shot for all people 6 months and older annually No preference for children to receive LAIV/mist over IIV/shot MMR vaccine highlighted for children 6-11 months of age, and if they plan to travel or live abroad. 7 IMMUNIZE THEM. PROTECT OUR FUTURE. 8 4

0-3 YEARS Pertussis Measles Pneumococcal pneumonia CDC Get Vaccinated HiB periorbital cellulitis 9 Disease 20 TH CENTURY ANNUAL AND CURRENT MORBIDITY: VACCINE-PREVENTABLE DISEASES 20th Century 2011 Annual Morbidity Reported Cases Percent Decrease Smallpox 29,005 0 100% Diphtheria 21,053 0 100% Measles 530,217 212 > 99% Mumps 162,344 370 > 99% Pertussis 200,752 15,216 92% Polio (paralytic) 16,316 0 100% Rubella 47,745 4 > 99% Congenital Rubella Syndrome 152 0 100% Tetanus 580 9 98% Haemophilus influenzae 20,000 8* > 99% National Center for Immunization & Respiratory Diseases Source: JAMA. 2007;298(18):2155-2163 Source: CDC. MMWR January 6, 2012;60(51);1762-1775. (provisional 2011 data) * Haemophilus influenzae type b (Hib) < 5 years of age. An additional 14 cases of Hib are estimated to have occurred among the 237 reports of Hi (< 5 years of age) with unknown serotype. Historical Comparisons of Vaccine-Preventable Disease Morbidity in the U.S. 10 5

MEASLES, MUMPS AND RUBELLA - MMR VACCINE Routine RECOMMENDATIONS First dose of MMR vaccine at 12 to 15 months Second dose can be given 4 weeks later, but is usually given before the start of kindergarten at 4 to 6 years of age International travelers Infants 6 months through 11 months of age: 1 dose Children 12 months of age or older: 2 doses separated by at least 28 days. Non-immune adolescents measles: 2 doses separated by at least 28 days. Measles outbreak 11 VARICELLA (CHICKEN POX) Most often benign but can be deadly Routine 2-dose 1 st at 12-15 months 2 nd at 4-6 years Catch-up dose Give more than 3 months after 1 st dose if they are less than 13 years of age. 12 6

HEPATITIS A & B What is Hepatitis A? Liver disease caused by the virus Usually causes stomach flu-like symptoms, mainly in adults. Spread from children to adults, and adults can develop severe infections Routine vaccine at 1 year What is Hepatitis B? Contagious, silent infection Spread through bodily fluids, but many of those who get it have no known exposure. Complications from Hepatitis B are far more likely to develop in infants and young children then they are in adults (90% vs. 10%) Soreness, fever, irritability for a day or two. Rare allergic reaction Routine vaccine at birth, second dose at 1-2 months, third dose is at 6-18 months 13 DIPHTHERIA, TETANUS, AND PERTUSSIS DTAP RECOMMENDATIONS What are these? Diphtheria Tetanus Pertussis = Whooping cough = main reason for vaccine Who gets infected? Almost nobody gets diphtheria or tetanus, but around a million get pertussis in US every year, and it is especially serious in infants Who gets the vaccine? Given at 2,4,6, 15 months, booster at age 4 and 11. All adults should also get vaccinated. Women with each pregnancy. How effective is the vaccine? Example dramatic increase in pertussis cases and deaths when vaccine stopped in Japan in 1970 s What are the side effects? Side effects much lower with current vaccine Why is pertussis still so common? 14 7

POLIO IPV RECOMMENDATIONS Why do we still vaccinate against it? Only 3 countries that still see polio, but it could resurge if we don t vaccinate Routine vaccines 1 st dose at 2 months 2 nd dose at 4 months 3 rd dose at 6-18 months 4th dose for school entry 15 STREPTOCOCCUS PNEUMONIA PCV13 What is it? Now the most common cause of bacterial meningitis. Also causes pneumonia, blood infections, ear infections Who benefits from this vaccine? While the pneumococcal vaccine is very effective at preventing severe disease, it also reduces ear infections and need for ear tubes. Routine vaccination 4 dose series 2 months, 4 months, 6 months and 12-18 months Catch-up One dose at 24-59 months for children not completely vaccinated 16 8

ROTAVIRUS What is rotavirus? When is the vaccine given? How has the vaccine helped? Rotavirus vaccine could save millions of lives worldwide Initial concerns were of how the regulatory agencies react when there is a legitimate concern about a vaccine 17 HIB VACCINE SCHEDULE Administer a 2 or 3 dose Hib vaccine primary series ActHIB, MenHibrix or Pentacel administer 3 doses at 2, 4, and 6 months PedvaxHIB or Comvax administer 2 doses at 2 and 4 months of age; a dose at age 6 months is not indicated Administer a booster dose at age 12 through 15 months One booster dose of any Hib vaccine should be administered at age 12 through 15 months Exception: Hiberix should only be used for the booster (final) dose, in children aged 12 months through 4 years, who have received at least 1 prior dose of a Hib containing vaccine 18 9

INFLUENZA Who gets influenza? Almost everyone will, eventually Who should get vaccinated, and what type of vaccine should they get? There are 2 types of vaccines live (nasal), and injected (shot), each works against 3 or 4 strains of influenza. How effective is the vaccine? Depends on the season, but it is always more effective than not getting it! What are the side effects of the flu vaccine? You cannot get the flu from the flu shot!! 19 THE IMPACT OF INFLUENZA Yearly epidemics and sporadic pandemics Virus mutations create new strains 5 20% of US population infected annually 20 10

WHO IS AFFECTED BY INFLUENZA? Illnesses occur in all age groups High-risk populations Young children (highest illness rates) Elderly patients (highest death rates) Pregnant women People with asthma, diabetes, heart disease, neurologic conditions, chronic renal and liver disease, compromised immune systems Vaccination annually is the best way to prevent illness after 6 months of age 21 UNIVERSAL RECOMMENDATION FOR FLU Vaccinate everyone 6 months or older, unless contraindicated Very few contraindications exist IAC screening checklists for contraindications at immunize.org 22 11

ARE VACCINES SAFE? If safe = harmless, then no vaccine is 100% safe. But very few things are harmless If safe = preserving from a real danger, then vaccines are very safe For all vaccines, the benefits far outweigh the risks We have seen how quickly vaccines are pulled when true concerns arise (1st rotavirus) There is a system in place (VAERS - www.vaers.hhs.gov) where any patient or clinician can report concerns about vaccines 23 ARE INFANTS TOO YOUNG FOR IMMUNIZATIONS? Infants are immunized because infancy is when they are most vulnerable to many diseases. For example: Almost all of the deaths from pertussis in the US are in children under 6 months Children under 2 years old are 500x more likely to get Hib meningitis if someone with a Hib infection is living in the home 90% of newborns of mothers infected with Hep B will develop chronic liver disease Infants are born with fully responsive immune systems 24 12

VACCINE REQUIREMENTS FOR SCHOOL YEAR 2015-2016 25 WHICH VACCINES ARE REQUIRED FOR SCHOOL? For public and private schools in Illinois, DTaP, IPV, MMR, Chicken Pox, Hib, and Hep B. Pneumococcal, Rotavirus, flu, and Hep A are not required Illinois does not allow for philosophical exemptions - only Medical or Religious. Religious objections are validated by the local school board You can choose not to immunize if you have proof of immunity (blood test or doctor s note for Varicella, Mumps) 26 13

2015-2016 SCHOOL YEAR VACCINATION REQUIREMENT CHANGES Meningococcal Requirement (MCV4) for 6 th and 12 th graders 6 TH graders must show 1 dose of MCV4 at school entry 12 TH graders must show 2 doses of MCV4 at school entry; second dose must be administered on or after 16 th birthday If first dose of MCV4 administered > 16 th birthday; then only one dose required for entry to 12 TH grade. Child Health Examination Form revisions will occur to accommodate the Meningococcal Requirement CDC Immunization Schedule (2013): http://www.cdc.gov/vaccines/recs/schedules/default.htm, 27 ROLL-OUT FOR 2 VARICELLA REQUIREMENT 2014-15 Kindergarten,1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12 2015-16 Kindergarten,1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12 2016-17 Kindergarten,1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12 2017-18 Kindergarten,1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12 2018-19 Kindergarten,1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12 2019-20 Kindergarten,1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12 28 14

SCHOOL COMPLIANCE Mandated Intervals Between Shots 1 Month = 4 Weeks / 28 Days 2 Months = 8 Weeks / 56 Days 4 Months = 16 Weeks/112 Days One year of age = On or after the first birthday. For Preschool hepatitis B only: 6 months of age = 24 weeks = 168 days When interval is < 28 DAYS for live virus vaccines, the vaccine administered second should not be counted as valid and must be repeated. A 4 day grace period can only be allowed with a provider note; counts as a medical exemption. The 4 day grace period not accepted on 28 day interval between 2 live-virus vaccines (i.e. MMR, Varicella or FluMist). Laboratory Evidence of Immunity - + IgG or titers accepted for measles, rubella, mumps and varicella. - Hepatitis B infection: HBsAg, anti- HBc and/or anti-hbs. - Lab evidence of immunity is not allowed for Hib, pneumococcal, diphtheria, tetanus, pertussis and polio vaccines. Students Affected - Public AND Private Schools - Rules Target Students by Grade. - Students attending ungraded school programs (including special education), must comply in accordance with grade equivalent: - * Kindergarten =5 years of age * 6 th graders = 11 years of age * 9 th graders = 15 years of age 29 SCHOOL COMPLIANCE ONLY TWO TYPES OF EXEMPTIONS: MEDICAL AND RELIGIOUS MEDICAL OBJECTION Medical objection must indicate what the medical condition is that contraindicates the specific immunization Must be written by a M.D., D.O., APN or P.A. RELIGIOUS OBJECTION PERSONAL RELIGIOUS BELIEF, LOCAL SCHOOL AUTHORITY ACCEPTS OR DENIES Must detail specific religious belief which conflicts with the specific immunization and or exam. Local school authority is responsible for determining whether written statement constitutes a valid religious objection. 30 15

WHAT ABOUT ADOLESCENTS? 31 REASONS ADOLESCENT IMMUNIZATION IS CRUCIAL Prevent long-term sequelae cervical cancer (HPV), cirrhosis (Hepatitis B), meningitis complications Increase herd immunity -Tdap, Influenza, Varicella Take advantage of parental insurance coverage, VFC program and college health services New environments, new risks travel, summer programs, college Experimentation sexual activity, smoking, drinking Capitalize on physician trust developed through childhood 32 16

VACCINES RECOMMENDED FOR TEENS Tdap booster MCV4 (two doses) HPV (three doses) Influenza (annual) 33 PERTUSSIS VACCINE RECOMMENDATIONS - TDAP Tdap Booster Boostrix (GSK): 10 years of age and older Adacel (sanofipasteur): 11-64 years of age Recommended: 11 to 12 years Catch-up: 13 to 18 years if not received at 11-12 years Children 7 to 10 years of age not fully vaccinated with DTaP 34 17

MENINGOCOCCAL MCV4 Routine vaccination of adolescents, preferably at age 11 or 12 years A booster dose at age 16 years Potential decrease in immunity five years after initial dose 35 HPV VACCINE 36 18

HPV INFECTION Almost all females and males will be infected with HPV at some point in their lives 14 million new infections/year in the US HPV infection is most common in people in their teens and early 20s Most people will never know that they have been infected 37 Jemal A et al. J Natl Cancer Inst 2013;105:175-201 HPV TRANSMISSION HPV exposure can occur with any type of intimate sexual contact Intercourse is not necessary to become infected Nearly 50% of high school students have already engaged in sexual (vaginal-penile) intercourse 9th graders: 1/3 12th graders: 2/3; 1/4 have had 4 or more partners 38 Jemal A et al. J Natl Cancer Inst 2013;105:175-201 19

AVERAGE NUMBER OF NEW HPV-ASSOCIATED CANCERS BY SEX, IN THE UNITED STATES, 2005-2009 n=694 n=303 9 n=231 7 n=308 4 n=1687 n=1003 Oropharynx n=1127 9 n=9312 39 Jemal A et al. J Natl Cancer Inst 2013;105:175-201 HPV IS PREVENTABLE Doses distributed in US since 2006 Nearly 60 million Most common adverse events were mild For serious adverse events, no unusual patterns that would suggest the events were caused by the HPV vaccine Findings similar to the safety of MCV4 and Tdap 20

Percent 4/14/2015 VACCINE COVERAGE LEVELS AMONG 13-17 YEARS OLDS, US, NIS-TEEN, 2006-2012 100 80 60 40 20 0 2006 2007 2008 2009 2010 2011 2012 Year Tdap MCV4 >1 HPV (girls) 3 HPV (girls) >1 HPV (boys) 3 HPV (boys) 41 Source: MMWR. 2013;62;685-93 STRATEGIES TO APPROACH HPV Reminder/recall system Provider level (e.g., EMR prompts) Parent/patient level (e.g., postcards, telephone calls, text messaging) Standing orders Provider assessment and feedback Assessment of vaccination coverage levels within the practice and discussion of strategies to improve vaccine delivery Utilizing immunization information systems 42 21

YOUR ROLE IN IMPROVING VACCINE RATES 43 WHAT CAN YOU DO? Give a STRONG recommendation How often do you get a chance to prevent cancer? Start conversation early and focus on cancer prevention Vaccination given well before sexual experimentation begins Better antibody response in preteens Offer a personal story Own children/grandchildren/c lose friends children HPV-related cancer case Welcome questions from parents Remind parents that the HPV vaccine is safe and not associated with increased sexual activity Screen immunization status at every visit 44 22

VACCINE ADMINISTRATION FAQ S 45 CONTRAINDICATIONS Four True Contraindications: Anaphylactic reaction to vaccine or vaccine component Encephalopathy <7 days after previous dose of DTP, DTaP or Tdap Severely immunocompromised (live virus vaccines only) Pregnancy (live virus vaccines only) If a true contraindication exists, the vaccine should not be administered. There are contraindications other than those listed above that apply only to live attenuated influenza vaccine (FluMist ). 46 23

FALSE CONTRAINDICATIONS Mild acute illness Low-grade fever Antibiotics Premature birth (exception HepB and infants with birth weights <2000 g) Stable neurological condition Mild to moderate local reaction to previous dose Immunocompromised family member/close contact 47 ADVERSE REACTIONS 3 types Local (swelling at injection site) Systemic (fever) Allergic (anaphylaxis) Screening is most effective method of prevention. Will identify patients who have contraindications and precautions Screen at each immunization visit Sample screening form in Resource Binder 48 24

IMMUNIZATION PRIORITIES, 2015 Birth to 3 years Hepatitis B Hepatitis A Rotavirus Dtap Pneumococcal Polio MMR Hib *Flu School entry Adolescent Dtap MMR MMR/MMRV Meningitis (new) Tdap Hepatitis B HPV 3 dose series Pneumococcal *Flu *Flu *Flu recommended annually after 6 months of age 49 THANK YOU FOR LISTENING! 50 25