Vaccine Updates

Vaccine recommendations approved by ACIP on 02/24/2016

1. Regardless of a recipient's allergic history, all vaccines should be administered in settings in which personnel and equipment for rapid recognition and treatment of anaphylaxis are available. 2. A previous severe allergic reaction to influenza vaccine, regardless of the component suspected of being responsible for the reaction, is a contraindication to future receipt of the vaccine. 3. Persons with a history of egg allergy who have experienced only hives after exposure to egg should receive influenza vaccine [Any licensed vaccine - i.e., any form of IIV, LAIV, or RIV - that is otherwise appropriate for the recipient's age and health status may be used]. 4. Persons who report having had reactions to egg involving symptoms other than hives may receive influenza vaccine in a medical setting.

6 Rights of Vax Admin

1. Right patient: VFC eligibility screening 2. Right medication: Check your vials 3. Right time: Check the schedules 4. Right dose: Pediatric vs. adult vaccine 5. Right route: IM, subcutaneous, intranasal, oral 6. Right site: Based on age, muscle development; NO GLUTEAL

Pneumonia vaccine licensure

1977: 14-valent Pneumococcal Polysaccharide Vaccine (PPSV14) 1983: 23-valent Pneumococcal Polysaccharide Vaccine (PPSV23) [not immunocgentic in children <5] 2000: 7-valent Pneumococcal Conjugate Vaccine (PCV7) [greatly reduced ds in children<5] 2010: 13-valent Pneumococcal Conjugate Vaccine (PCV13)

2016-17 Influenza Vaccine Composition

A/California/7/2009 (H1N1)pdm09-like virus A/Hong Kong/4801/2014 (H3N2)-like virus [new for 2016-17] B/Brisbane/60/2008-like virus (Victoria lineage) [new for 2016-17 -was in quadravalent last year] Quadrivalent influenza also includes: B/Phuket/3073/2013-like virus (Yamagata lineage) [was in trivalent last year]

Vaccination with Meningococcal Vaccine A, C, Y, W-135

All adolescents: Give 1 dose of MCV4 at age 11-12 years; Give 1 booster dose of MCV4 at age 16 years; Give only 1 dose if first dose after age 16 years; Not routinely recommended after age 19 years; Adults with certain medical conditions i.e., persistent complement component deficiency, anatomical or functional asplenia, HIV: Give 2 doses of MCV4 at least 8 weeks apart

Wrong route scenario

CDC says vaccines given by the wrong route can be counted as valid with two exceptions -- HepB or rabies vaccine -- if not given IM should be repeated.

Vaccine administration errors

Can be serious and should be avoided; Should be documented and root-cause analysis conducted; Do not always result in adverse outcome; Do not always require re-administration of correct vaccine and dose

ACIP Recommendations for Tetanus, Diphtheria, and Pertussis Vaccines

Current ACIP Recommendations 6 weeks through 6 years old Use DTaP to complete the primary series. Schedule is 2, 4, 6, 15-18 months, and 4-6 years. Use DT only if patient has a specific contraindication to the pertussis component of DTaP. 7 years through 10 years old who are not fully vaccinated against pertussis Give a single dose of Tdap. If additional doses of tetanus- and diphtheria-containing vaccines are needed, refer to the catch-up schedule to complete the primary series. 11 years and older If there is no record of a Tdap dose, give a single dose of Tdap followed by one dose of Td every 10 years. Health Care Providers All health care providers should receive one dose of Tdap. Pregnancy ACIP recommendation for Tdap for every pregnancy to pass pertussis antibodies to newborn infant.

Herpes Zoster

Establishes latency in cells of dorsal root ganglia; Reactivates and travels along neuronal cell axons; Often associated with advancing age or a weakened immune system including immunosuppression; Appears as localized rash in dermatomes Complications: Postherpetic neuralgia [PHN]; Scarring; Bacterial infection; Ocular abnormalities

PPSV23 indications

Everyone 65 years and older; People 19 to 64 years who have asthma; People 19 to 64 years who are smokers; People 2 to 64 years who have chronic illness; 2 doses for adults 19 to 64 years with immunocompromising conditions and asplenia; [Meningicoccal, S. pneumoniae, Haemophillus all have capsids that spleen fights well]

ACIP Recommendation for HPV9

FDA Approved for Males and Females 9-26 years: Given 0,1-2, 6 months, 3rd dose important for duration of protection; Will replace HPV4* in 2016, May finish series started with HPV4; If HPV4 series is completed, not recommended to revaccinate with HPV9.; Even though there is limited data on the use of HVP9 in males, the ACIP workgroup proposed to follow similar recommendations as HPV4. It should be noted that the use of HPV9 in males over the age of 15 years is off-label or non-FDA approved. There was no recommendation to revaccinate those who already received HPV4 vaccine.

Vaccine scheduling errors

Giving 2nd dose of hepatitis A vaccine less than 6 months after the first dose; Giving the hepatitis B vaccine without at least 4 weeks between dose 1 and 2; 8 weeks between dose 2 and 3; and 16 weeks between doses 1 and 3; Giving HPV vaccine series without at least 4 weeks between dose 1 and 2; 12 weeks between dose 2 and 3; and 24 weeks between doses 1 and 3; *There is a 4 day grace period, except for the 28 day rule applied to live vaccines

What to do About DTaP and Tdap Errors

If DTaP is given to a person 7 years old or greater, count the dose as valid. If Tdap is given to a child less than 7 years of age as a DTaP 1, 2, or 3, do not count the dose and give DTaP now. If Tdap is given to children less than seven years as a DTaP #4 or 5, count the dose as valid. If Tdap is given to a child age 7 years to 9 years old, count the dose as valid.

Pneumococcal Vaccination for Adults over 65 years

If vaccine-naïve: Give PCV13 followed by PPSV23 one year later; If vaccinated with PPSV23 at age 65 years or older: Give PCV13 one year after the PPSV23; PCV13 recommendation to be re-evaluated by ACIP in 2018: Herd immunity may make vaccine unnecessary; No additional PCV13 is needed if a dose was given before age of 65

CDC Recommendation for LAIV 2016-17

LAIV4 should not be used; Based on low effectiveness of vaccine against H1N1 during the 2013-14 and 2015-16 influenza seasons

ACIP MenB Recommendations

Routine use of MenB vaccines in persons at increased risk for serogroup B meningococcal disease, including: During outbreaks of serogroup B meningococcal disease. College campuses that have recently experienced an outbreak of serogroup B meningococcal "A serogroup B meningococcal (MenB) vaccine series may be administered to adolescents and young adults 16 through 23 years of age to provide short-term protection against most strains of serogroup B meningococcal disease. The preferred age for MenB vaccination is 16 through 18 years of age (Category B)"

PCV13 indications

Routine vaccination for all children younger than 2 years; 1 dose for adults 65 years and older; 1 dose for adults 19 to 64 years with asplenia, cochlear implant, CSF leaks and immunosuppression

Common vaccines that are mixed up

Tetanus-containing vaccines; Varicella and Zoster; Wrong pneumococcal vaccine; Wrong influenza vaccine; Giving rotavirus by injection If vax given in error was stronger than the one that should have been given [eg. Zoster v Varicella] do not repeat with correct vax. Based on antigen exposure; Document. No clear rules for meningococcal vax.

Adult 19 to 64 Years Who Only Need PPSV23

Those with chronic conditions: Asthma, DM, Heart disease, Alcoholism, Liver disease; Cigarette smokers; Residents of nursing homes or other long-term care facilities; When they turn 65 this group should receive a dose of PCV13

Meningococcal B Vaccines

Two New Meningococcal B vaccines both licensed by FDA for ages 10-25 years: Accelerated pathway; Trumenba (Pfizer) 3-dose series (0, 1-2, 6 months), 2-dose series (0, 6 months), Choice depends upon risk of exposure and patient's susceptibility to Men B disease, Licensed Oct 29, 2014; Bexsero (Novartis) 2-dose series (0, 1-6 months), Licensed Jan 23, 2015, Licensed in over 30 countries for persons >2 months of age ACIP recommends serogroup B meningococcal vaccination - in addition to the current meningococcal vaccines which covers serogroups A, C, Y and W-135- to high risk population aged ≥10 yr; High risk populations: People with persistent complement component deficiencies, Persons receiving the drug eculizumab (Soliris) also are at increased risk because the drug binds to C5 and inhibits the terminal complement pathway, Patients with anatomic or functional asplenia, Microbiologists who are regularly exposed to Neisseria meningitides isolates, People at increased risk owing to an outbreak of serogroup B meningococcal disease; NOTE: The vaccine is not currently recommended for routine use in first-year college students living in residence halls, military recruits, or all adolescents. Physicians should determine vaccination needs for 16-23 year-olds on an individual basis; Recommendations for broader use of Men B vaccines in adolescents and college students will be considered separately by the ACIP; A change to the Trumenba (Men B - Pfizer) label was approved by the FDA on April 14, 2016. A two-dose schedule (0 through 6 months) was approved along with the 3-dose schedule (0, 1-2, 6 months). The choice depends upon the risk of exposure and patient's susceptibility to Men B disease

Tdap and pregnancy

Vaccination of mother transfers antibodies to fetus; Provides protection until administration of first few doses of DTaP; One dose every pregnancy, Preferably 27-36 weeks gestation; If not given in pregnancy, administer as soon as possible postpartum; Review vaccination of all family members and caregivers of the infant, Administer Tdap if indicated [cocooning]

Vaccine Administration Errors Examples

Wrong vaccine; Wrong route; Wrong diluent; Wrong schedule; Out of date; There are also storage/handling and documentation errors

If children receive PCV (Prevnar—Wyeth) in infancy, will they need PPSV later in life if they develop diabetes or another high-risk condition or after they turn 65 years old?

Yes; one vaccine's recommendations do not negate the other's recommendations—they are independent. Children who have completed the PCV vaccination series before age 2 years and who are among risk groups for which PPSV is already recommended should receive one dose of PPSV at age 2 years (at least 2 months after the last dose of PCV). These groups at high risk include children with sickle cell disease, children with functional or anatomic asplenia, children who are HIV-infected, and children who have immunocompromising or chronic diseases. Although data regarding safety of PPSV administered after PCV are limited, the opportunity to provide additional serotype coverage among these children at very high risk justifies use of the vaccines sequentially.

Zoster Vaccine

Zostavax (Merck) is 14x stronger than varicella [contains a much higher amount of antigen than the varicella vaccine - 19,400 plaque-forming units [PFU] vs 1,380 PFU for Varivax- or 14 times more antigen; This higher amount of antigen is necessary for older patients to mount an efficient immune response to the vaccine]; Live attenuated virus vaccine; The vaccine is about 50% effective, but it is less effective with advancing age. In those who actually develop zoster, the vaccine reduced the incidence of PHN by 39%. Most of the effectiveness in prevention of PHN is due to preventing zoster; ACIP target group for vaccination: Adults at least 60 years old; FDA approved for prevention (not treatment) in: Adults at least 50 years old; Note: ACIP recommendations still apply to adults 60 years and older; Dose and route 0.65 mL [entire contents of vial] SC

Zoster

Zoster can occur in any patient who was infected with chickenpox in the past or, more rarely, in a patient who received the live varicella vaccine. The photo shows a child with a history of leukemia who presented with a maculopapular rash, which was diagnosed as a herpes zoster outbreak due to the varicella zoster virus pathogen.