Objectives Adult Immunization: Identify the recommended vaccines for adults Identify three functions of the Michigan Care Improvement Registry (MCIR) Discuss vaccine procurement options for adults Barbara K. Wolicki RN, BSN Michigan Department of Community Health Division of Immunization wolickib@michigan.gov 313-410-9634 Reasons Why Adults Are Under Immunized Adults are not aware of immunization needs Adults are influenced by myths about vaccines Recommended Adult Schedule 2010 I got the flu from the flu vaccine Getting natural immunity to chickenpox is best Adults rely on providers to keep them up to date on immunizations Providers fail to assess immunization status at every encounter Recommended Adult Schedule 2010 Assessing Immunization Record Assess for needed vaccines at all visits using HALO H = Health factors A = Age factors L = Lifestyle factors 0 = Occupational factors Has your client received all recommended vaccines? Check the chart, immunization record card and MCIR 1
Michigan Care Improvement Registry (MCIR) Michigan Care Improvement Registry A repository for all vaccine doses administered in MI Can enter as historical data vaccine doses: Given in other provider offices Given in other countries Persons of all ages should have all vaccine doses entered into MCIR within 72 hours of administration Use required by state law for persons under age 20 years Use highly recommended for persons 20 years and older MCIR data for adults 20 years and older (June 2010): 3,149,869 individuals have a MICR Record There are 16,503,812 individual vaccine ( shot ) records Can generate a number of reports through MICR including how many vaccine doses you administered Capability to assess for routine vaccination doses due Capability to forecast when next dose is due Types of Vaccine Live, attenuated vaccines Produced by weakened disease-producing viruses that, when administered into the body, replicate and produce immunity without causing illness Include: Var, MMR, LAIV ( nasal flu ), RV, Zoster Inactivated vaccines Cannot replicate or cause disease from infection even in immunocompromised persons Inactivated vaccines generally require 3-5 doses for immunity Include: DTaP, Tdap, Td, Hib, hep A, hep B, PCV, PPSV23, MCV4, MPSV4, IPV, HPV, TIV ( flu shot ) 2
Human Papillomavirus HPV is the most common sexually transmitted infection in the United States Approximately 6.2 million people are infected each year Over half of sexually active men and women become infected at some time in their lives First infection is usually acquired soon after sexual debut; infection with multiple types is common Infection is usually transient and not associated with symptoms 90% of infections clear within 2 years Persistent HPV infection causes cervical cancer as well as other anogenital cancers Points About Human Papillomavirus Vaccine It is important to vaccinate persons before they become sexually active for the full benefit of either vaccine Sexually active females should/males may also be vaccinated Few will have been infected with all HPV vaccine types Those already infected with 1or more of the HPV vaccine types, can still be protect against disease from the other HPV vaccine types HPV is not indicated during pregnancy Report women who are inadvertently vaccinated to: Merck at (800) 986-8999 (for HPV4) GSK at (888) 452-9622 (for HPV2) 14 Human Papillomavirus Vaccines (HPV) Vaccine Type, Brand and Manufacturer HPV4 (Gardisil, Merck) HPV2 (Cervarix, GSK) Serotypes contained in the vaccine: 6, 11, 16, 18 16, 18 Protects against: Cervical, vaginal, vulvar cancers; Cervical cancer Genital warts Approved for use in: Females and Males Females Recommended schedule: 0, 1-2 and 6 months Routine age to begin series: 11-12 years Minimum age to begin series: 9 years Maximum age to begin series: 26 years Minimum interval between doses: Dose 1 to 2: 4 wks; Dose 2 to 3: 12 weeks; Dose 1 to 3: 24 wks Tetanus/Diphtheria/Pertussis (Tdap/Td) Tetanus: Clostridium tetani exotoxin Organism found in soil, intestinal tract; causes skeletal muscle spasms 11% mortality rate overall; 22% in unvaccinated persons Diphtheria: Corynebacterium diphtheriae toxin Respiratory tract entry resulting in local inflammatory membrane and distal neuritis and myocarditis 10% mortality rate Pertussis: Bordetella pertussis Highly contagious respiratory infection, causing inflammation of respiratory tract and local tissue damage Pertussis Disease Challenges The number of reported pertussis cases continues to increase in Michigan 2003-07: average of 340 cases per year 2008: 315 cases 2009: 902 cases As of August 15, 2010: 560 cases Adults with pertussis can transmit the infection to infants who are at highest risk of pertussis-related complications and death There has been one verified infant death in 2010 Tetanus/Diphtheria/Pertussis (Tdap) All adults who will have close contact with an infant less than 12 months of age should receive one Tdap dose At least 2 weeks before beginning close contact is optimal This includes father, grandparents, friends, infant s caregivers Health care personnel who have direct patient contact should receive a dose of Tdap as soon as feasible Includes, but not limited to, physicians, nurses, aides, therapists, technicians, students, social workers, volunteers, dietary, clerical Tdap is for persons ages 11-64 years Given as a one-time single dose in place of one Td May use an interval of 2 years or less since last Td **All persons need a tetanus-containing vaccine at least every 10 years 3
Use of Tdap/Td During Pregnancy Td/Tdap guidelines indicate: During pregnancy, use Td for booster vaccination if 10 yrs has elapsed since last Td If Td or Tdap are not given during pregnancy, give Tdap immediately post partum Interval of 2 years or less since last Td booster may be used to best protect the newborn However, Tdap is not contraindicated in pregnancy and can be considered by the provider if: Td booster is needed during pregnancy There is an outbreak of pertussis in the community Measles Cases in U.S. Average 63 reported measles cases per year (2000-2007) From January-July 2008, 131 reported cases 24% in persons 20 years and older 91% were in persons unvaccinated or unknown status 89% were imported from or associated to importations from other countries, particularly countries in Europe where several outbreaks are on-going Findings demonstrate: Measles outbreaks can occur in communities with high number of unvaccinated persons Maintaining high overall MMR vaccination rates is needed to continue to limit the spread of measles MMWR, Update: Measles U.S. Jan-Jul 2008, Aug. 22, 2008 Measles, Mumps, Rubella (MMR) Vaccine: Adults born after 1956 and without proof of immunity or previous vaccination should receive 1 dose of MMR vaccine High risk adults need 2 doses - Includes: healthcare personnel, college students, international travelers - Minimum interval between 2 doses is 4 weeks Varicella Disease and Vaccine Highly contagious childhood illness resulting in chickenpox and shingles 5%-10% of adults are susceptible Fetal risks for congenital varicella syndrome (CVS) and increased neonatal mortality Assure vaccination of any women born in 1980 or later without evidence of immunity to chickenpox Prenatal assessment of women for evidence of varicella immunity is recommended. Vaccine: 2 doses SC; minimum interval between doses is 4 weeks Herpes Zoster Vaccine (Zoster) Live attenuated vaccine indicated for prevention of herpes zoster (shingles) May be given to persons with a previous history of shingles Efficacy was evaluated in the Shingles Prevention Study: For persons 60 years and above, reduced by 51% Not intended for treatment of shingles or post herpetic neuralgia (PHN) Contraindicated 1 month prior to and during pregnancy Vaccine: 1 dose, SC, to persons 60 years and older wishing to reduce their risk of shingles Hepatitis B DNA virus infecting the liver, leading to acute, chronic, fulminant, and non-infectious sequelae Acquired through blood, sexual contact and perinatal transmission If mom is positive for HBsAg and HBeAg, 70-90% of infants will become infected in the absence of postexposure prophylaxis Vaccine: 3 doses, IM, for all newborns; assure vaccination of all adolescents and high risk adults Assure minimum intervals between all doses are met 4
MDCH Perinatal Program Michigan law requires testing every pregnant woman during each pregnancy for HBsAg status Physicians must report a positive HBsAg test result in a pregnant woman to the local health department within 24 hrs Dual reporting by the healthcare provider and lab is required Assure that HBsAg test results for all patients are sent to L&D All HBsAg(+) moms and their newborns are monitored through this program to assure: Infants born to HBsAg (+) moms should receive Hep B vaccine and HBIG within 12 hours of birth Hep B series and post-series testing is completed Other Risk Factors for Acquiring Hepatitis B Include: More than one sexual partner in last 6 months Health care personnel Injection drug use History of sexually transmitted disease Hepatitis B carrier in household Require hemodialysis or clotting factor Influenza RNA virus with frequent genetic reassortment, causing seasonal recurrent epidemics New influenza virus variants result from frequent antigenic change (i.e., antigenic drift) Leads to 36,000 deaths in U.S. per year Induced immunity is relatively short-lived (less than 1yr) Prompts need for annual influenza immunization Influenza Vaccine: Every One, Every Year All persons 6 months and older should receive an annual flu vaccine Especially important to vaccinate persons at increased risk for complications including persons: With a chronic medical condition i.e., diabetes, asthma, sickle cell With immunosuppresion (including that caused by medication or HIV) Who are pregnant Who are obese (BMI of 40% or higher) American Indians/Alaskan Natives Who will be living with or caring for persons at increased risk This includes all Health Care Personnel Two Types of Influenza Vaccine TIV: Trivalent (inactivated) Influenza Vaccine Given IM May be given to any person at high risk for acquiring the flu, including pregnant women LAIV: Live, Attenuated Influenza Vaccine Given Intranasal An option for vaccinating healthy persons 2-49 years Do not administer to pregnant women The 2009 H1N1 virus strain will be included in both types of 2010-11 seasonal flu vaccine Pneumococcus Streptococcus pneumoniae (90 different serotypes) Pneumococcal Polysaccharide Vaccine contains 23 Significantly higher mortality in persons 65 years and in those with certain health conditions Associated with increase morbidity and mortality with influenza disease No specific risks associated with pregnancy Vaccine: 1 dose > 65 years or those 2-64 with risk condition; Those at highest risk may need one an additional dose NO more than 2 life-time doses, spaced at least 5 years apart 5
Risk Factors/Target Groups for PPSV23 Vaccination Persons 65 years Smokers, 19 years and older Persons with: Chronic pulmonary disease, including asthma Diabetes mellitus Chronic cardiovascular disease Alcoholism Immunosuppression including: nephrotic syndrome, chronic renal failure, HIV, functional or anatomical asplenia, sickle cell disease, general malignancy Meningococcal Conjugate Vaccine (MCV4) Persons recommended for vaccination: Are adolescents (routinely given at age 11-12 years) Are college freshmen living in dorms Have terminal complement component deficiency Have HIV infection; functional or anatomic asplenia Are certain international travelers or military recruits Are lab personnel working with these organisms MCV4 vaccine: 1 dose for persons ages 2 through 55 years* Revaccinate, every 5 years, persons who remain at high risk (see bolded groups above) *Meningococcal Polysaccharide (MPSV4) for persons age 56 & older Why are Adolescents at Risk for Vaccine- Preventable Disease? Adolescents may have: Received incomplete immunization series Received vaccines without meeting minimum intervals Escaped natural infection (i.e., varicella) Not been immunized with all recommended vaccines New vaccines may have been added Adolescent schedule may not have been followed 10 Publicly Funded Programs for Adolescents Vaccine for Children Program (VFC) is for children under age 19 years Public and private providers may participate Eligibility categories: Medicaid Uninsured Alaskan Native or American Indian Underinsured Have insurance that does not cover any of the cost of vaccines Public Funded Programs for Adult Vaccines Two current programs allow for free* vaccines for persons 19 years and older who are uninsured or underinsured MI Vaccine Replacement Program (ongoing) MMR, Hep A, Hep B, Td/Tdap Available at Local Health Departments and Federally Qualified Health Centers ARRA Funded Adult Vaccine Program (limited time) Zoster, HPV, Var, PPSV23 Available at Local Health Departments only *Administration fee may be charge but may be waived if client is unable to pay 6
Some State Programs that Cover Vaccine Costs Other Programs to Assist in Adult Vaccination For these programs, use privately purchased vaccine and bill for the cost of vaccine and an administration fee MI-Child State-funded insurance program for low income families Covers all routine vaccines on the schedules for children under age 19 years Adult Medicaid Allows for administration of any vaccine on the routine schedule (following CDC recommendations) for persons 19 years and older Check with the vaccine manufacturers Example: Merck Vaccine Patient Assistance Program provides vaccines free of charge to eligible ibl adults, primarily the uninsured who, without our assistance, could not afford needed Merck vaccine http://www.merck.com/merckhelps/vaccines/home.html Strategies to Keeping your Clients Protected Check immunization status at every visit Client s chart, immunization record card and MCIR Be prepared to either vaccinate or refer your clients to another clinic If you have vaccines, utilize a reminder/recall system Keep up-to-date on current vaccine information MDCH provides free in-services with CNE and CME credits for your office staff Contact us at lockwoodc@michigan.gov or 517-335-9070 Utilize Your Resources Your Local Health Department Michigan Department of Community Health, Immunization Division at 517/335-8159; www.michigan.gov/immunize Centers for Disease Control and Prevention National Immunization Program: www.cdc.gov/vaccines Alliance for Immunizations in Michigan, Provider Toolkit: www.aimtoolkit.org REMEMBER... They are counting on You! Ensure that all your patients t are protected t against vaccine preventable diseases. 7