Immunization Update: What Providers Need to Know

Immunization Update:What Providers Need to Know

Amelie Hollier, DNP, FNP-BC, FAANPAdvanced Practice Education Associates

Lafayette, LA

CDC.gov• Recommendations published every January

or February• 17 vaccine preventable diseases in infants,

children, adolescents, and adults

Biggest Change in a Decade!• 2013 changed to a Single schedule (no

longer has 0-6 yrs., 7-18 yrs., catch-up)• More complex, so footnotes clarify all

recommendations

10 Adult Recommendations(> 19 years old)

• Influenza• Tdap• Varicella• HPV• Zoster• MMR• PCV 13, PPSV23• Meningococcal• Hepatitis A, B• Hib

Impacting health of communities

True or False

Egg allergy is a contraindication to receiving the influenza vaccine.

Influenza Immunization• Flublok: a trivalent seasonal flu

vaccine made without eggs or influenza virus• Adults ages 18-49• $30/dose

Influenza Immunization• Flublok: a recombinant vaccine;

replication of the viral protein that triggers immunity; not the flu virus• You CANNOT get the flu from this flu

shot!

CC Influenza Immunization• Some trivalent immunizations grown

in Cell Cultures (Flucelvax)

• Contain little or no egg protein• Not egg free but…..safe for most

patients with egg allergies• Can be made rapidly!• $18.25 per dose

Influenza Immunization

3 influenza strains vs.

4 influenza strains

Trivalent vs. Quadrivalent?

True or False

Quadrivalent flu immunization is more protective of influenza than trivalent immunization.

Influenza Immunization

• Not for adults; maybe for kids! (B strains seem to infect kids more than adults) (Quad contains a 2nd B strain)• No receommendation by CDC for one

vaccine vs another for any specific population• 20 % of vaccines this year are quadrivalent• $6 more expensive

Trivalent vs. Quadrivalent?

True or False

High dose flu vaccine (Fluzone) is more effective than standard dose vaccine in elderly patients.

Influenza Immunization

• Risk of getting the flu is reduced about 25% when the high dose is used. (Relative risk, not absolute risk)• Cost: $11 vs $28 (HD)

High dose IM flu vaccine

Lowes R. Fluzone High-Dose foils flu better in seniors, says maker. October 24, 2013. http://www.medscape.com/viewarticle/813203?pa=92kly%2Bz1nWaeVh6vErodGqoM3ThPLDEGYJMeUNrocQFsmh0ZUQjnYgpNe4dbAp0DwrQkx7OxpYMdU0y3IK88IA%3D%3D. (Accessed March 8, 2014).

“Real Language”

• To prevent one extra case of flu, 218 seniors have to be vaccinated with high dose vaccine vs standard• CDC does not recommend it over

the traditional flu vaccine

High dose IM flu vaccine

Lowes R. Fluzone High-Dose foils flu better in seniors, says maker. October 24, 2013. http://www.medscape.com/viewarticle/813203?pa=92kly%2Bz1nWaeVh6vErodGqoM3ThPLDEGYJMeUNrocQFsmh0ZUQjnYgpNe4dbAp0DwrQkx7OxpYMdU0y3IK88IA%3D%3D. (Accessed March 8, 2014).

“Herd Immunity”

• When a large enough part of the population is immunized, most members are protected even if not immunized. • Reason: There is little opportunity for an

outbreak.• This is important with contagious

diseases like flu, measles, rotavirus, pneumococcal disease, pertussis

Community Immunity

10 Adult Recommendations(> 19 years old)

• Influenza• Tdap• Varicella• HPV• Zoster• MMR• PCV 13, PPSV23• Meningococcal• Hepatitis A, B• Hib

Follow CDC Schedules unless….

Immunocompromised Patients

2014 Guidelines2 Questions: • Is patient

immunocompromised?• To what degree? (low or high)

Rubin LG, Levin MJ, Ljungman P, et al. 2013 IDSA clinical practice guideline for vaccination of the immunocompromised host. Clin Infect Dis 2014;58:e44-100.

Immunizations Facts• Immunocompromised patients

benefit from immunization• Weaker response than

immunocompetent patient• Possible greater (potential) risk of

infection from live vaccines

http://www.cdc.gov/vaccines/spec-grps/hcw.htm

True or False

A patient uses inhaled fluticasone BID for asthma. Zostavax immunization is contraindicated.

General Rules(These do NOT constitute immunocompromised states)

• Use of topical or inhaled steroids• Oral steroids for < 14 days (any

dose)• Steroid injection

General Rules(Immunocompromised patient)

Inactivated Vaccines• Flu, Tdap, others• Not harmful to administer!• Issue: Patient may not respond

as well as an immunocompetent host

Best Practice

Inactivated Vaccines and an Immunosuppressed Host• Give at least 2 weeks PRIOR to

immunosuppressive meds when possible

• If not possible, then re-immunize at least 3 months after therapy is discontinued, if immunocompetence is restored

General Rules

Live Vaccines• Shingles, LAIV, MMR,varicella• Ask yourself the 2 questions:

Is patient immunosuppressed?What level

immunosuppression?

ImmunocompromisedWhen is someone Immunocompromised?• Primary: cellular or humoral immunity (or

both) issues• Secondary: HIV, cancer chemo, radiation

treatment, immunosuppressive meds (methotrexate, corticosteroids, TNF-alpha inhibitors, rituximab, azathioprine)

Immunization FactImmunocompromised Individuals• Do not administer live vaccines• Some exceptions (low level

immunosuppression for varicella or zoster vaccines CAN be an exception if benefits outweight risks)

http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6002a1.htm),

Best PracticeImmunosuppressed Host/Live Vaccine• Give at least 4 weeks PRIOR to

immunosuppression (drug therapy, radiation, splenectomy)• Give at least 3 months AFTER

chemotherapy is stopped (if immunocompetence is restored)

An individual was treated with 20 mg prednisone daily for 30 days for a systemic inflammatory condition. Tapering occurred for 10 days. How soon may she safely receive the shingles immunization?

1. Now2. In 1 week3. In 1 month4. In 4-6 months

Best Practice

Immunosuppressed Host• Defer live vaccines for at least 1

month after discontinuation of high dose steroid therapy • High dose = >20 mg prednisone

daily for > 14 days

Low vs. High Levels• Low level immunosuppression:

prednisone < 20 mg/d or alternate steroid therapy; methotrexate < 0.4 mg/kg/week, azathioprine < 3 mg/kg/d• High level immunosuppression:

adalimumab, infliximab, etanercept, rituximab (anti-B-cell antibodies)

Special Considerations

See vaccine specific info for:• HIV, cancer• Solid organ transplant• Stem cell transplant• Asplenia, sickle cell disease• Antibody deficiencies

10 Adult Recommendations(> 19 years old)

• Influenza• Tdap• Varicella• HPV• Zoster• MMR• PCV 13, PPSV23• Meningococcal• Hepatitis A, B• Hib

Impacting health of communities

Pneumococcal DiseaseSimple Fact

Pneumococcal disease kills more people in the US than ALL other vaccine preventable diseases combined.

Pneumococcal Disease• Pneumococcal disease is caused by

Streptococcus pneumoniae• There are 90 different serotypes (PPSV23

immunizes against 23 serotypes)

Pneumococcal Disease• Very common!!!!• Pneumococcal disease spread by respiratory

droplet• Pneumococcal disease causes pneumococcal

pneumonia, bacteremia, meningitis• Pneumococcal pneumonia fatality rate is 7% but

higher in elderly, co-morbids• 25-30% of pneumococcal pneumonia patients

get bacteremia

A 68 year old patient does not know whether he received a pneumococcal vaccine or not. How should this be handled?

1. Don’t administer.2. Administer now.

PPSV 23: Who?• Age 65 years or older with no or

unknown history of prior receipt of PPSV

Who else needs PPSV 23?Age 19-64 years with no or unknown history of prior receipt of PPSV and any of the following:• Cigarette smoker age 19 and older• CV disease ( HF, cardiomyopathies, etc.)• Chronic pulmonary disease (COPD, asthma)• DM, alcoholism, chronic liver disease• Candidate for a cochlear implant, CSF leak• Functional or anatomic asplenia (SCA, splenectomy)• HIV, congenital immunodeficiency, hematologic and solid

tumors (immunocompromising conditions)• Immunosuppressive therapy (alkylating agents, antimetabolites,

long term systemic steroids, radiation therapy)• Chronic renal failure or nephrotic syndrome; Solid organ or

bone marrow transplantation

PPSV23 and PCV13Who gets a second PPSV 23?

• Functional or anatomic asplenia (SCA, splenectomy)• HIV, congenital immunodeficiency, hematologic or

solid tumors (immunocompromising conditions)• Immunosuppressive therapy (alkylating agents,

antimetabolites, long term systemic steroids, radiation therapy)

• Chronic renal failure or nephrotic syndrome; Solid organ or bone marrow transplantationThese patients need PCV13 also!!!!!!

A 59 year old female (who is a nurse) was diagnosed with sarcoidosis about 20 years ago. She remembers being on prednisone for about a year. Since then she has had no issues. However, for the past 12 months she has had leg and hip pain and has been diagnosed with sarcoidosis involving the muscles.

She has no recollection of pneumococcal vaccine. Should she receive one today?

A 59 year old female (who is a nurse) was diagnosed with sarcoidosis about 20 years ago. She remembers being on prednisone for about a year. Since then she has had no issues. However, for the past 12 months she has had leg and hip pain and has been diagnosed with sarcoidosis involving the muscles.

Which one?After the first one, what is given next?When?

Vaccination Coverage Rates 2012

Pneumococcal Vaccine • Highest risk: 20% fully vaccinated• Adults 19-64: 21%• Adults > 65 years: 59.9%

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6305a4.htm

MMWR: February 7, 2014 / 63(05);95-102

12 Pediatric Recommendations

• Influenza• Rotavirus• DTaP < 7 years• TdaP > 7 years• Varicella• IPV• MMR• PCV 13, PPSV23• Meningococcal• Hepatitis A, B• Hib• HPV

What’s new since 2013?Remarkably Little has

Changed• Meningococcal maybe given as early as 2 months for high risk infants

• Footnotes have been combined for routine, catch up and high risk patients

• Clarified some footnotes for influenza, pneumococcal, hepatitis A, and Hib

Pediatric ChallengesCatch-up Vaccinations

Rotavirus Vaccine• Oral immunization• Jan 2006-August, 2013• 39 cases of oral vaccine administered by

injection

CDC’s MMWR, March 18, 2014

Worth Noting…

Pertussis Rates: > 48,000 cases in 2012 (most since 1955)

What’s Pertussis?

• Major cause of mortality in the 20th century• Serious illness in all ages and can be

life threatening• Whooping cough: sound made when

patient gasps for breath after cough• “100 days of cough”

Bordetella pertussis

What’s Pertussis?

• Highly contagious!!!• Vaccinating all age groups• Vaccination of pregnant women with

EVERY pregnancy (to protect the infant)!

Bordetella pertussis

PertussisBordetella pertussis

Stage Length Clinical FeaturesStage 1:

CatarrhalUsually 7-10 days; range = 4-21 days

Runny nose, fever, occasional cough

Stage 2: Paroxysmal

1-6 weeks; maybe up to 10 weeks

Paroxysms of rapid cough (thick mucus in resp tree)Whoop at end of cough

15 attacks/24 hours

Stage 3: Convalescent

7-10 days; range = 4-21

Cough severity lessens

Pertussis?

• Diagnosis is made by collecting a nasopharyngeal swab• Specimen is used for both culture and PCR

(polymerase chain reaction): rapid test• Collect within first 3 weeks of illness• Culture has better specificity but takes 7

days for results

Diagnosis

Pertussis?

• Macrolides used for treatment• Azithromycin for 5 days,

clarithromycin for 7 days• TMP-SMX if not able to use

macrolide (14 days of treatment)• No therapy for cough

Treatment

Pertussis?

• Antibiotic warranted for symptoms up to 4 weeks (general public)• Antibiotics warranted for symptoms

up to 8 weeks if healthcare workers, pregnant women, individuals working with infants

Treatment

Worth Noting…When administering live and/or attenuated vaccines….both must be given on the same day OR you must wait 4 weeks to give the one you didn’t administer.

Worth Noting…At 12 months: MMR, varicella

Worth Noting…Unknown Vaccination Status• Provider should only accept written,

dated records as evidence• If no evidence, they are considered

susceptible and should be immunized

What are the two exceptions to this rule?

ExceptionsUnknown Vaccination Status• Influenza• PPSV

Alternative to Immunization

Serology• Measles• Rubella• Hepatitis A• Tetanus• Hepatitis B

Pediatric ChallengesHow do we Improve Immunization Rates?

What strategy results in the most consistently effective means for increasing immunization rates?

1. Chart reminders2. Computerized record reminders3. Mail and telephone reminders4. Standing orders

http://www2a.cdc.gov/vaccines/ed/whatworks/strategies.asp

Standing Orders

http://www.immunize.org/standing-orders/

Most consistently effective means to increase immunization rates. Examples found at:

Strategies to Improve Rates

Only identifies people who are scheduled for an appointment

Strategies to Improve Rates

Colorful stickers in the charts resulted in highest ratesHealth maintenance reminders

Strategies to Improve Rates

Mail and telephone reminders

Addresses patients without an office visit

Worth Noting…National Childhood Vaccine Injury Act of 1986 requires that Vaccine information statements (VIS) be provided each time a vaccine is administered.

Thank you!For questions or to contact me:

Amelie Hollieramelie@apea.com

Advanced Practice Education Associates

Lafayette, LA