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Immunization Update: What Providers Need to Know

Immunization Update: What Providers Need to Know. Amelie Hollier, DNP, FNP-BC, FAANP Advanced Practice Education Associates Lafayette, LA. CDC.gov. Recommendations published every January or February 17 vaccine preventable diseases in infants, children, adolescents, and adults.

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Immunization Update: What Providers Need to Know

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  1. Immunization Update:What Providers Need to Know Amelie Hollier, DNP, FNP-BC, FAANP Advanced Practice Education Associates Lafayette, LA

  2. CDC.gov • Recommendations published every January or February • 17 vaccine preventable diseases in infants, children, adolescents, and adults

  3. 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

  4. 10 Adult Recommendations(> 19 years old) • Influenza • Tdap • Varicella • HPV • Zoster • MMR • PCV 13, PPSV23 • Meningococcal • Hepatitis A, B • Hib Impacting health of communities

  5. True or False Egg allergy is a contraindication to receiving the influenza vaccine.

  6. Influenza Immunization • Flublok: a trivalent seasonal flu vaccine made without eggs or influenza virus • Adults ages 18-49 • $30/dose

  7. 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!

  8. 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

  9. Influenza Immunization Trivalent vs. Quadrivalent? 3 influenza strains vs. 4 influenza strains

  10. True or False Quadrivalent flu immunization is more protective of influenza than trivalent immunization.

  11. Influenza Immunization Trivalent vs. Quadrivalent? • 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

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

  13. Influenza Immunization High dose IM flu vaccine • 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) Lowes R. Fluzone High-Dose foils flu better in seniors, says maker. October 24, 2013. http://www.medscape.com/viewarticle/813203?pa=92kly%2Bz1nWaeVh6vErodGqoM3ThPLDEGYJMeUNrocQFsmh0ZUQjnYgpNe4dbAp0DwrQkx7Oxp YMdU0y3IK88IA%3D%3D. (Accessed March 8, 2014).

  14. “Real Language” High dose IM flu vaccine • 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 Lowes R. Fluzone High-Dose foils flu better in seniors, says maker. October 24, 2013. http://www.medscape.com/viewarticle/813203?pa=92kly%2Bz1nWaeVh6vErodGqoM3ThPLDEGYJMeUNrocQFsmh0ZUQjnYgpNe4dbAp0DwrQkx7Oxp YMdU0y3IK88IA%3D%3D. (Accessed March 8, 2014).

  15. “Herd Immunity” Community 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

  16. 10 Adult Recommendations(> 19 years old) • Influenza • Tdap • Varicella • HPV • Zoster • MMR • PCV 13, PPSV23 • Meningococcal • Hepatitis A, B • Hib Follow CDC Schedules unless….

  17. Immunocompromised Patients 2014 Guidelines 2 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.

  18. 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

  19. True or False A patient uses inhaled fluticasone BID for asthma. Zostavax immunization is contraindicated.

  20. General Rules(These do NOT constitute immunocompromised states) • Use of topical or inhaled steroids • Oral steroids for < 14 days (any dose) • Steroid injection

  21. General Rules(Immunocompromised patient) Inactivated Vaccines • Flu, Tdap, others • Not harmful to administer! • Issue: Patient may not respond as well as an immunocompetent host

  22. 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

  23. General Rules Live Vaccines • Shingles, LAIV, MMR,varicella • Ask yourself the 2 questions: Is patient immunosuppressed? What level immunosuppression?

  24. Immunocompromised When 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)

  25. Immunization Fact Immunocompromised 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),

  26. Best Practice Immunosuppressed 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)

  27. 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? • Now • In 1 week • In 1 month • In 4-6 months

  28. 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

  29. 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)

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

  31. 10 Adult Recommendations(> 19 years old) • Influenza • Tdap • Varicella • HPV • Zoster • MMR • PCV 13, PPSV23 • Meningococcal • Hepatitis A, B • Hib Impacting health of communities

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

  33. Pneumococcal Disease • Pneumococcal disease is caused by Streptococcus pneumoniae • There are 90 different serotypes (PPSV23 immunizes against 23 serotypes)

  34. 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

  35. A 68 year old patient does not know whether he received a pneumococcal vaccine or not. How should this be handled? • Don’t administer. • Administer now.

  36. PPSV 23: Who? • Age 65 years or older with no or unknown history of prior receipt of PPSV

  37. 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

  38. PPSV23 and PCV13 Who 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 transplantation These patients need PCV13 also!!!!!!

  39. 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?

  40. 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?

  41. Vaccination Coverage Rates 2012 MMWR: February 7, 2014 / 63(05);95-102 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

  42. 12 Pediatric Recommendations • Influenza • Rotavirus • DTaP < 7 years • TdaP> 7 years • Varicella • IPV • MMR • PCV 13, PPSV23 • Meningococcal • Hepatitis A, B • Hib • HPV

  43. 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

  44. Pediatric Challenges Catch-up Vaccinations

  45. Rotavirus Vaccine CDC’s MMWR, March 18, 2014 • Oral immunization • Jan 2006-August, 2013 • 39 cases of oral vaccine administered by injection

  46. Worth Noting… Pertussis Rates: > 48,000 cases in 2012 (most since 1955)

  47. What’s Pertussis? Bordetella 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”

  48. What’s Pertussis? Bordetella pertussis • Highly contagious!!! • Vaccinating all age groups • Vaccination of pregnant women with EVERY pregnancy (to protect the infant)!

  49. Pertussis Bordetella pertussis

  50. Pertussis? Diagnosis • 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

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