Adolescent and Adult Immunization Update

1. Adolescent and Adult Immunization Update Presentation to: Presented by: Date:

2. Disclosure Statements • To obtain nursing contact hours for this session, you must be present for the entire presentation and complete an evaluation. • Neither the planners of this session nor I have any financial relationship with pharmaceutical companies, biomedical device manufacturers, or corporations whose products and services are related to the vaccines we discuss. • There is no commercial support being received for this event. • The mention of specific brands of vaccines in this presentation is for the purpose of providing education and does not constitute endorsement. • The GA Immunization Office utilizes ACIP recommendations as the basis for this presentation and for our guidelines, policies, and recommendations. • For certain vaccines this may represent a slight departure from or off-label use of the vaccine package insert guidelines.

3. Objectives • Define Herd Immunity and Cocooning Strategy; Current Morbidity for VPDs • Discuss Indications, Recommendations, and Requirements; Review Adult Immunization Schedule and Routinely Recommended vaccines for Adolescents and Adults • Vaccine Preventable Diseases and Vaccine Antigens Used to Prevent VPDs • Overview of GRITS • Challenges To Adult Vaccinations • Recommended Vaccines for HCW • VAERS/NVICP • Resources

4. Why Do We Immunize? We Immunize To Prevent These Diseases

5. Herd ImmunityImmunized individuals block infection from reaching those who are unimmunized UNIMMUNIZED INFECTED INFECTED INFECTED = immunized

6. Cocooning Strategy

7. 20th Century Peak & Current Morbidity for VPDs MMWR (Weekly), August 17, 2012, 61(32); 624-637

8. Indications Recommendations Requirements • Indication • Information about the appropriate use of the vaccine • Recommendation • ACIP statement that broadens and further delineates the Indication found in the package insert • Basis for standards for best practice • Requirement • Mandate by a state that a particular vaccine must be administered and documented before entrance to • child care and/or school

9. 2013 Adult Immunization Schedule Be sure to review the “Notes” section – many changes

10. 2013 Footnote Changes • Influenza vaccine –the abbreviation IIV for inactivated influenza vaccine and drops the abbreviation TIV for trivalent inactivated vaccine (TIV). • Tdap and Td vaccines - is updated to include the recommendation to vaccinate pregnant women with Tdap during each pregnancy, regardless of the interval since prior Td/Tdap vaccination. • MMR vaccine - Footnote was modified to reflect the new recommendation that a provider diagnosis of measles, is no longer considered acceptable evidence of immunity to measles.   • Pneumococcal vaccines: • Pneumococcal polysaccharide (PPSV23) vaccine and PPSV23 revaccination footnotes clarification. • Pneumococcal conjugate 13-valent (PCV13) vaccine - A new footnote was added for PCV13 vaccine. • Hepatitis A vaccine - Footnote was updated to clarify that vaccination is recommended for persons with a history of noninjection illicit drug use in addition to those with injection drug use.

11. 2013 Footnote Changes Contraindications Table Changes • The inactivated influenza vaccine precautions were updated to indicate that persons who experience only hives with exposure to eggs should receive IIV rather than LAIV. • Pregnancy was removed as a precaution for hepatitis A vaccine. This is an inactivated vaccine, and similar to hepatitis B vaccines, is recommended if another high risk condition or other indication is present. • Language was clarified regarding the precaution for use of antiviral medications and vaccination with varicella or zoster vaccines.

12. Recommended Adult Vaccines • Influenza • Td/Tdap • Varicella • HPV • Zoster • MMR • Pneumococcal • Meningococcal • Hepatitis A • Hepatitis B

13. Burden of Seasonal Influenza • 36,000 Flu related deaths each year in the US • ~90% of deaths among persons age 65 and older • October – November best time to receive flu vaccination • Takes about 2 weeks to develop antibodies • December to Spring not too late!

14. Seasonal Influenza Vaccine • Influenza Vaccine Strains for the 2012-13 • A/California/7/2009 (H1N1)-like antigens • A/Victoria/361/2011 (H3N2)-like virus • B/Wisconsin/1/2010-like(Yamagata lineage) • The H1N1 virus is the same, the H3N2 and B vaccine viruses are different from those in the 2011-2012 influenza vaccine used in the U.S. Recommended for all people age 6 months and older. http://www.cdc.gov/flu/about/qa/vaccine-selection.htm http://www.cdc.gov/flu/about/qa/vaccine-selection.htm

15. Inactivated Influenza Vaccines (TIV) Administer by Injection • Fluzone®sanofi-pasteur - 6 months of age and older • Agriflu ® Novartis - 18 yrs and older • Fluzone®Intradermal – 18 – 64 years • Fluzone®High-Dose- 65 years and older (4 times more antigen) • Fluarix™ GSK - 3 years of age and older • Fluvirin™ Novartis - 4 years of age and older • Afluria® CSL – 9 years of age and older • Flulaval™ GSK - 18 years of age and older Live, Attenuated Influenza Vaccine (LAIV) • Administer by Nasal spray: • MedImmune FluMist® • - for healthy persons 2 through 49 years of age • - not for pregnant women MMWR / August 17, 2012 / Vol. 61 / No. 32

16. How well does the flu shot work? • 70%-90% effective among healthy persons younger than 65 years of age • For persons older than 65 yrs • 50%-60% effective in preventing hospitalization • 80% effective in preventing death

17. Inactivated Influenza Vaccines and Egg Sensitivity • All influenza vaccine viruses for the 2012-2013 season are grown in hen’s eggs • Allergy to eggs must be distinguished from allergy to influenza vaccine

19. Frequently Asked Questions • Some of my patients refuse influenza vaccination because they insist they "got the flu" after receiving the injectable vaccine in the past. What can I tell them? • How long does immunity from influenza last? • In which month is it too late to receive influenza vaccine? • My patient came in last February and asked for a “flu” shot. Should I have given it to her?

20. Can you get the flu from the flu shot??? NO!!! NO!!! NO!!! • Flu vaccine in the shot is made from killed bits and pieces on influenza virus • Some people get a little soreness or redness where they get the shot • It goes away in a day or two • Serious problems from the flu shot are very rare

21. I got the flu shot and still got the flu… • For healthy persons takes about 2 weeks after the shot before your body makes enough antibodies to be protected • You are vulnerable to flu infection during this time • Flu vaccination does not protect you from colds, sinus infections, and other respiratory illnesses that also circulate during flu season

22. ‘Flu Season’ • Can begin as early as October and last through Spring • In GA, Flu usually peaks mid-February • Best to get vaccinated before flu season starts December– March is Not Too Late to get a Flu Vaccination

23. Pneumococcal Disease • Pneumococcal infection may cause pneumonia, bacteremia, meningitis and otitis media resulting in thousands of hospitalizations and deaths each year in the United States • As many as 175,000 hospitalizations from pneumococcal pneumonia are estimated to occur annually in the United States. • Common bacterial complication of influenza

24. Pneumococcal Polysaccharide Vaccine for Adults (PPSV23) – Part one Recommended for all persons with the following: Age 65 years and older without history of PPSV23 vaccine Adults who smoke cigarettes • Adults less than 65 years with: • Chronic lung disease (including asthma) • Chronic cardiovascular disease • Chronic liver disease • End stage renal disease, kidney failure, hemodialysis • Diabetes mellitus • Immunocompromising conditions • Anatomic/functional a-splenia • Alcoholism • Cochlear implants Ref: Recommended Adult Immunization Schedule – United States , 2012 MMWR Vol. 61/ No. 4/ February 3, 2012

25. Pneumococcal Polysaccharide Vaccine for Adults (PPSV23) – Part two • A one time revaccination 5 years after the first dose is recommended for those with: • chronic renal failure • functional/anatomic asplenia • immunocompromising conditions • Individuals who received PPSV23 before age 65 years should receive a second dose of vaccine at age 65 years or later if at least 5 years have passed since the previous dose. Ref: Recommended Adult Immunization Schedule – United States , 2012 MMWR Vol. 61/ No. 4/ February 3, 2012

26. Pneumococcal Polysaccharide Vaccine (PPSV23) • My patient doesn’t have a record of receiving PPSV23, but she believes she may have had it in the past. What should I do? • Persons with uncertain or unknown vaccination status should be vaccinated. • If I give PPSV23 to my patient now, must I wait a month before giving influenza vaccine or Td or Tdap vaccine? • Inactivated influenza vaccine and Td or Tdap may be given at the same time as or at any time before or after a dose of PPSV23. There are no minimum interval requirements between the doses of these or any other inactivated vaccines.

27. Pneumococcal Conjugate Vaccine (PCV13) Licensed for adults 50 years and olderfor: Prevention of pneumonia and invasive disease caused by Streptococcus pneumoniae serotypes 1, 3, 4, 5, 6A, 6B, 7F, 9V, 14, 18C, 19A, 19F and 23F. Indication is based on immune responses elicited by Prevnar 13. No controlled trials available in adults demonstrating a decrease in pneumococcal pneumonia or invasive disease after immunization. NEW ACIP has made a recommendation for use of PCV13 in adults 19 years and older with immunocompromising conditions, functional or anatomic asplenia, CSF leaks or cochlear implants. MMWR Vol. 61/No. 21 June 1, 2012

28. Advantages of Conjugate Vaccines PropertyPolysaccharideConjugate B-cell-dependent immune response Yes Yes T-cell-dependent immune responseNo Yes Immune memory No Yes Lack of hyporesponsiveness No Yes Booster effect No Yes Long-term protectionNo Yes Reduction of carriage No Yes Herd immunity No Yes Granoff DM, et al. In: Vaccines. 2004: 959.

29. Adult Recommendations for Tetanus, Diphtheria, and Pertussis vaccine (Tdap) • A single dose of Tdap is recommended for • All adults aged 19 years and older who have not yet received a dose of Tdap • Td should be administered: • As a booster dose every 10 years for persons who have already received 1 dose of Tdap

30. Updated Recommendations for Use of (Tdap) Vaccine • Use Tdap regardless of interval since the last tetanus- or diphtheria-toxoid containing vaccine • Use Tdap in under-vaccinated children aged 7 through 10 years.

31. Tdap and Pregnancy • June 2011 ACIP votes to recommend Tdap for women > 20 weeks pregnant

32. Tdap and Pregnancy On October 24, 2012, the ACIP voted to recommend tetanus toxoid, reduced diphtheria toxoid and acellularpertussis vaccine (Tdap) for pregnant women with every pregnancy irrespective of previous Tdap history.

33. Use of Tdap in Special Situations • Wound management---1 time dose Tdap • History of Pertussis---1 time dose • Adults ≥65 years of age---1 time dose

34. Hepatitis B

35. Hepatitis B Transmission: 1. Percutaneous or mucosal exposure to blood or body fluids including contaminated surfaces 2. Perinatal infection from HbSAg + mother. • Vaccine Recommendations • All adolescents less than 19 years of age should receive the hepatitis B vaccine series. • All adults at risk for hepatitis B infection, including those aged 19 through 59 years with diabetes mellitus. • All adults seeking protection from HBV infection should be vaccinated according to recommended adult schedule.

36. Every person being evaluated or treated for an STD, who is not already vaccinated, should receive hepatitis b vaccination

37. Hep B Vaccine Recommendations • All Adolescents • Adults with at risk conditions: • Household contacts and sexual partners of persons with acute and chronic infections • Users of street injectable drugs • More than one sex partner in 6 months • Hemodialysis patients • Health care and Public Safety workers • Certain international travelers • Inmates • Clients and staff of institutions for the developmentally disabled

38. New Hepatitis B Vaccine Recommendations 2011 • Hepatitis B vaccination should be administered to unvaccinated adults with diabetes mellitus who are aged 19 through 59 yrs • Hepatitis B vaccination may be administered at the discretion of the treating clinician to unvaccinated adults with diabetes mellitus who are aged >60 yrs

39. Management of Non-responders • Complete a second series of three doses • Make sure using appropriate needle length. ACIP recommends 1-1½ inches for IM injections • Should be given on the usual schedule of 0, 1 and 6 months • Retest 1 to 2 months after completing the second series • If test results are neg. for antibody after 2nd series, test for hepatitis B surface antigen

40. Currently Licensed SINGLE ANTIGEN Hepatitis B Vaccines Vaccine Age Group Number of Doses Dose/ Volume Engerix B Pediatric Formulation (GLAXO-SmithKline) 0 through 19 yrs 3 10 mcg/ 0.5 ml Engerix B Adult Formulation (GLAXO-SmithKline) 20 years & older 3 20 mcg/ 1.0 ml Recombivax HB Pediatric Formulation (Merck & Co) 0 through 19 yrs 3 5mcg/ 0.5 ml Recombivax HB Pediatric Formulation (Merck & Co) 20 years & older 3 10mcg/ 1.0 ml Recombivax HB Adult Formulation (Merck & Co) 11 through 15 years 2 10mcg/ 1.0 ml Recombivax HB Adult Formultion (Merck & Co) 20 years & older 3 10 mcg/ 1.0 ml

41. Measles, Mumps, & Rubella • Highly contagious viral diseases • Respiratory transmission • Most cases imported from outside the U.S. • Congenital Rubella Syndrome • Required for college entrance

42. Measles, Mumps, & Rubella Vaccine Recommendations • Measles, Mumps, & Rubella vaccines are usually given as the combination MMR vaccine • 0.5 mL given subcutaneously • First dose should be given after 1st birthday • If two doses are needed, doses should be administered at least 28 days apart Egg Allergy is NOT a contraindication!

43. Measles, Mumps, and Rubella Vaccine Recommendations • Adults born in 1957 or later, if not previously vaccinated, need one dose • All women of child bearing age who do not have evidence of rubella immunity need one dose -- Advise to avoid getting pregnant for 28 days after receiving MMR • High Risk groups needing 2 doses: exposed persons; those vaccinated with killed or unknown type of vaccine; health care workers; students; and international travelers

44. Evidence of Immunity

45. Recommendations for Public Health Employees • Document immune status of each employee for all vaccine preventable diseases • Strongly encourage employees born prior to 1957 who lack evidence of immunity to mumps to be vaccinated with two doses of MMR vaccine.

46. Spacing of Live Virus Vaccines and Other Products • PPD and live virus vaccine • Apply PPD at same visit as MMR • If MMR given first, delay PPD 4 weeks or longer • Apply PPD first, then give MMR when skin test read • Spacing with antibody-containing products such as immune globulin (IG)

47. Varicella • Virus is a member of the herpes group • Primary infection results in chickenpox • Recurrent infection results in shingles • Risk of death due to complications from chickenpox is 25 times greater for adults than children

48. The Recommended Schedule For Varicella Vaccine • Varicella vaccination is also recommended in these situations: • A 2nd dose catch-up is recommended for all children, adolescents and adults who have had 1 dose. • Some HIV-infected children should receive 2 doses of single antigen varicella vaccine spaced at least 3 months apart. Do not use MMRV. • Postpartum vaccination of 2 doses for women whose prenatal assessment indicated susceptibility • During outbreak, 2nd dose should be given to those who have received only 1 dose, provided the minimal interval has elapsed.

49. Evidence of Varicella Immunity • Documentation of age-appropriate vaccination: • Preschool-aged children > 12 months: 1 dose • School-aged children, adolescents and adults: 2 doses • Laboratory evidence of immunity or laboratory confirmation of disease • Born in US before 1980 • A healthcare provider diagnosis of varicella or healthcare provider verification of history of varicella disease. For mild or atypical case: • Assessment by physician is recommended to determine: • Epidemiological link to typical case • Laboratory evidence of immunity if titer done at time of disease • History of herpes zoster based on healthcare provider diagnosis

50. Herpes Zoster “Shingles” Shingles is caused by reactivation of varicella zoster