Immunization

What are the clinical pearls for intranasal administration of LAIV?

-Provide patient with a tissue prior to administration -Instruct patient not to sniff or inhale spray -Insert tip of the sprayer just inside the nose and depress the plunger to spray half the dose into the first nostril -Remove the dose-diver clip; administer second dose in the other nostril -No need to repeat if sneezing or coughing occur

Shingrix

-Recombinant, adjuvanted zoster vaccine -Two 0.5ml mL doses administered IM at months 0 and 2-6 · If second dose is given less than 4 weeks after first, then must be repeated · If patient is late on receiving second dose, do not restart series -For adults >50 and older

What are the steps to prepare vaccine doses from vials?

-Remove the protective cap -Swap the top of the vial with alcohol -Pull back the plunger to draw air into the syringe equal to the designated volume for injection -Insert the syringe into the vial and inject the air to displace the volume to be withdrawn -Turn the vial and syringe upside down and withdraw the dose -Ensure that large air bubbles do not exist

Vaccine schedules

-Separate childhood/adolescent and adult: 2 adult schedules many footnotes -Catch-up schedule available: lists minimal intervals -Approved by ACIP in fall; released in Jan or Feb each yr; new editions on CDC website earlier if changed

How to safeguard against needlesticks?

-Sharps container should be placed where the risk of needlestick is minimized- pharmacist should not cross their body to deposit the syringe in the sharps container after injection -Never recap a needle after the needle has been removed from the patient -Never throw trash in the sharps' container "Following injection, activate the safety device and deposit it in the sharps container. Do not take your eye off the needle"

What is the highest shoulder injury related to vaccine administration?

-Shoulder Injury Related to Vaccine Administration (SIRVA) is often associated with vaccine given too high on the arm

Tetanus, Diphtheria, and Pertussis

-Tetanus: Found in spores in soil, dust, feces (natural disasters) Transmitted through puncture wounds, abrasions, chronic wounds -Pertussis (whooping cough) DTaP and Tdap vaccines -0.5mL IM Tdap has lower diphtheria and acellular pertussis dose to avoid reactions in adults DTap for those younger than 7 Tdap (Boostrix) for 10 years or older, (Adacel) for 11-64 years

Steps to give IM injection

-The patient should be seated -Uncover area -Wipe with alcohol and let alcohol dry -Tell patient to relax -Insert needle at 90 degree to skin in a smooth controlled motion while bracing against the arm -Depress the plunger -Withdraw the needle swiftly -Activate safety device immediately -Dispose of syringe in sharps container -Press cotton or gauze and tape to patient -Wash hands

Steps to give SC injection

-The patient should be seated -Uncover the area -Wipe with alcohol and let alcohol dry -Tell patient to relax -Pinch fold of skin -Insert needle at 45 degree angle to skin while bracing against the arm -Depress the plunger -Withdraw needle swiftly -Activate safety device immediately -Dispose of syringe in sharps container -Press cotton or gauze and tape to patient -Wash hands

Minimum intervals between vaccines and other products if not given at the same time

-Two inactivated vaccines: no minimum -Inactivated and live vaccines: no minimum -Two live vaccines if not given same day: 28 days -Inactivated and antibodies: no minimum -Live vaccines followed by blood products: 2 weeks -Blood product given before live vaccine: varies -Live vaccine followed by PPD skin test: 28 days -PPD skin test followed by live vaccine: administer vaccine after PPD skin test has been read

Hep A

-Virus: Picornavirus fecal-oral transmission -target groups: all infants at least 1 year old, HIV, chronic liver disease, men who have sex with men, illicit drug users, travelers, occupational exposure, pregnant women at risk, homeless -Routine vaccination for all children 1-2 years old Catch-up by age 18 0.5mL IM -Unvaccinated persons through 18 years should complete a 2 dose series (6 months apart) -19 years and older: 1 mL IM

How to prevent SIRVA?

-know the anatomy of the upper arm -Injector should be at same level as the patient -Injector should target the lower 2/3rds of the deltoid muscle -Assess history of previous injuries -Pay attention to proper technique

Immunization grace period

-minimum interval on catch up schedule: most is 28 days -Administration slightly earlier unlikely to interfere with antibody production ACIP grace period is 4 days Does not apply to different live vaccines Oral vaccines do not have this restriction Different live vaccines may have interference if interval less than 28 days

- Pneumococcal Poly saccharide vaccine (PPSV23)

0.5mL IM (or SC) o SINGLE DOSE FOR - >65 - 19-64 who smoke - 19-64 who have asthma -at least 2 years old with chronic illness o 2 doses 5 years apart for anyone younger than 65yrs with - Immune suppression - Asplenia/ sickle cell disease o 1 dose for <65yrs - Cochlear implants -CSF leaks Recommend one dose for patients 65 years and older who received 1 or 2 doses at least 5 years ago and when younger than 65 years

Flu vaccine administration

0.5mL IM, except FluMist (intranasal)

Steps to administer intranasal vaccine

1. Check expiration date 2. Remove rubber tip protector. Do not remove dose-divider clip at the other end of the sprayer 3. With the patient in an upright position, place the tip just inside the nostril to ensure the vaccine is delivered into the nose 4. With a single motion, depress plunger until the dose divider clip prevents you from going further 5. Pinch and remove the dose-divider clip from plunger 6. Place the tip just inside the other nostril and with a single motion, depress plunger as rapidly as possible to deliver remaining vaccine

Hep B

Blood-borne pathogen Target groups: all infants, those not previously vaccinated, high risk adults Recombivax HB and Engerix-B -Infants: 3 doses at birth, 1-2 months, 6 months -Teens and adults: 3 doses at 0, 1, 6 months

What is the difference between polysaccharide vaccines and conjugate vaccines?

Polysaccharide -Stimulate T cell independent immunity Stimulate B cells without assistance of helper T cells -Short lived immunity -No booster effect -Not consistently immunogenic in children younger than 2 years: only use in adults, because they can process whole vaccine Conjugate polysaccharide -Stimulate T cell dependent immunity -Produce immunologic memory -Result in booster effect upon subsequent exposure -Increased immunogenicity in children younger than 2 years. OK for children, especially infants

MMR dosing

· 2 dose series for children 12-15 months of age and 4-6 years of age o 2nd dose is not a booster o For all children o All susceptible patients at high risk for disease o Health care personnel born before 1957 o ProQuad: patients age 12 months-12 years · At least 1 dose; recommend a 2nd dose is a risk factor present (4 weeks apart) o Adults born in 1957 or later who have not been vaccinated with MMR · 0.5 mL SC

Who is considered immune to MMR?

· Adults born before 1957 · For adults born after 1957 need lab evidence of immunity or documentation of vaccination · Provider diagnosis not adequate

Target groups for MMR

· All children—routine vaccination · All susceptible people at high risk: o health care personnel o college students o international travelers o nonpregnant women of childbearing age without evidence of immunity o patients with HIV if CD4 count adequate · Adults born in 1957 or later who have not been vaccinated with MMR

MMR contraindications

· Allergy to gelatin or neomycin, pregnancy, immunosuppression, receipt of blood products

Vaccines for 50-64 years old

· Flu (inactivated) · 1 dose Tdap · MMR (if born in 1957 or later) · Shingrix

Vaccines for >65 years old

· Flu (inactivated) · 1 dose Tdap · Shingrix · PPSV23

Vaccines for 27-49 years old

· Flu (live or inactivated) · 1 dose Tdap · MMR · Varicella · 27-45: HPV

o Immunocompromised individual

- Flu - Tdap, then Td or Tdap booster every 10 years - HPV- 3 doses through ages 26 - PCV13 - PPSV23

o Patient has asthma or is a smoker?

- Flu vaccine - 1 dose Tdap - PPSV23 - HPV - MMR

o What if the patient has diabetes?

- Flu vaccine - 1 dose Tdap, then Td or Tdap booster every 10 years - 1 or 2 doses MMR - PPSV23 - HepB - HPV

o Health care personnel?

- Flu vaccine - Tdap - MMR - Varicella - HPV - HepB

What are the general guidelines for vaccine administration?

- Wash hands -Check expiration dates -Confirm right vaccine -Verify preparation instructions- some vaccines need to be shaken -Maintain sterility while preparing the dose -Draw up dose using appropriate technique -Position sharps container within reach -Never take your eyes off the needle -Activate safety device immediately -Dispose of needle properly -Remove gloves and wash hands

o If you have a patient who is, e.g., pregnant, then which vaccine(s) is/are indicated?

-1 dose Tdap for each pregnancy - Flu vaccine- 1 dose - All other vaccines are contraindicated, especially live vaccines

What needle size and gauge is needed to give intramuscular injection?

-22-25 gauge -Insert at 90 degree angle -Men and women less than 60kg: 1 inch -Men and women 60 kg and over: 1 1/2 inch -Children: 5/8 to 1 1/4 inch

What needle size and gauge is needed to give SC injection?

-5/8 inch needle -23-25 gauge -Insert at 45 degree angle

General rules on contraindications

-A condition that greatly increases the risk of an adverse reaction -Do not vaccinate if vaccine likely to injure patient -Universal CI for all vaccines: Severe allergy (immediate and life-threatening anaphylaxis) to a vaccine following a previous dose

Pneumococcal conjugate Vaccine 13-valent (PCV13)

-Indicated for ages 6 weeks through 5 years -Routine schedule: 2, 4, 6, 12 to 15 months -Recommended in all adults >19 years with cochlear implants, CSF leaks, immunosuppression, asplenia -Shared clinical decision making for immunocompetent adults >65 years

False contraindications

-Minor illness (mild fever, upper respiratory infection, mild diarrhea) -Allergies to products not in the vaccine -Allergies that are not immediate or life-threatening -Pregnancy in the household -Breastfeeding -Premature birth

What is the Jet Injector Technology?

-Needle-free: eliminates needlesticks, for patients with fears of needles -Approved in 2014

What are the clinical pearls for injection administration? ex what position should the patient be in? What kind of skin surface to avoid?

-Patient should be sitting- may want to use a chair with arms and want to have adequate space to lay person down if necessary -Expect bleeding- patient can hold cotton swab until bandage is places -Hitting bone does not hurt patient -Avoid (when possible) scars, tattoos, moles- this skin won't heal properly -Do not aspirate syringe while needed is in patient Our safety is always more important

Age ranges for flu vaccine

>6 months: Fluzone, Fluarix, FluLaval > 3 years: Fluarix > 4 years: Flucelvax QUAD >5 years: Afluria > 18 years: Flublok QUAD 65 years and older: Fluzone High-Dose, Fluad 2-49 years: FluMist (live attenuated)

What site are subcutaneous injections given?

Children 3 years and older and adults: outer aspect of upper arm (posterolateral)

Vaccines and immunosuppression

Complicated Use references. Decisions should be made with medical provider -Live vaccines pose a risk for increased risk of adverse effects -Inactivated vaccines concerned with decreased effectiveness -Vaccines should be given before immunosuppression if possible Live vaccines 4 weeks prior Inactivated preferable 4 weeks prior, but def no sooner than 2 weeks before -Household contacts can receive inactivated and most live, but caution handling diapers following oral rotavirus and avoid contact with skin lesions following varicella or zoster

Meningococcal

Conjugate vaccines: (MCV4) -Menactra: Two dose series age 9-23 months Single dose age 2-55 years -Menveo Four dose series age 2-23 months Single dose 2-55 years -MenQuadfi Single dose 2 years and older A, C, W, Y vaccines All teens: give 1 dose at age 11-12 years, give 1 booster at age 16 years, give only 1 dose if first dose after age 16 years Adults with certain medical conditions: give 2 doses at least 8 weeks apart Meningococcal B Trumenba: 3 dose series (0, 1-2, 6 months). 2 dose series (0, 6 months) Bexsero: 2 dose series (0, 1-6 months) Important for during outbreaks

o How long should you provide influenza vaccine?

Continue vaccinating until supply is gone, even after influenza activity begins

What happens if the interval between vaccine doses in a series is decreased?

Decreasing the interval between doses may interfere with antibody response and protection

What happens if the interval between vaccine doses in a series is increased?

Does not reduce vaccine effectiveness but it does delay protection for the patient

Vaccines and pregnancy

Encourage vaccination prior to pregnancy -Inactivated seasonal influenza vaccine if pregnant during influenza season -Tdap for every pregnancy after 20 wks gestation (27-36 wks ideal) -avoid giving other vaccines to women who are or might become pregnant (especially live vaccines); risks theoretical; -pregnant providers may administer live vaccines -discuss w/ pt's physician or refer to physician for vaccine decisions; -after pregnancy, admin any deferred vaccines

IIV3-HD

IIV3-HD: High-Dose Trivalent Inactivated Influenza Vaccine

IIV4

IIV4: Quadrivalent Inactivated Influenza Vaccine

Where is the deltoid muscle located in adults?

In adults, the midpoint of the deltoid is about 2 inches (or 2 to 3 fingers) below the acromion process (bony prominence) and above the armpit in the middle of the upper arm -DO NOT inject too high on the arm

What site are intramuscular injections given?

Infants: anterolateral thigh Children 3 years and older and adults: deltoid muscle

LAIV4

LAIV4: Quadrivalent Live Attenuated Influenza Vaccine

Vaccine types: live vs inactivated

Live attenuated vaccines: -Made from viruses or bacteria -Must replicate to work Inactivated: -Made from portions of viruses or bacteria -Various fractions: suvirons, subunits. polysaccharides. toxoids, recombinant antigens -May contain adjuvants to enhance immune response

Name all the live vaccines

MrHCIVOrY Mr: MMR H: herpes zoster C: cholera I: influenza LAIV V: varicella Or: oral rotavirus Y: yellow fever

Flu vaccines and allergies

Person with history of egg allergy who have experienced only hives after egg exposure should receive vaccine Person who have other reactions other than hives after egg exposure, may receive recommended vaccine A previous severe allergic reaction to flu vaccine is contraindication to future vaccine—must be sent to provider to receive vaccine

RIV4

RIV4: Recombinant Quadrivalent Influenza Vaccine

o When should you begin to offer influenza vaccine?

Soon after vaccine becomes available: no earlier than September and no later than October

Varicella vaccination

Varivax: -Live attenuated virus -2 doses: 1 at 12 months and again at 4-6 years -Dose 0.5ml SC -Adults without evidence of immunity should receive 2 doses at least 4 weeks apart -Verbal history of chickenpox is not considered sufficient evidence of immunity. Need documentation of vaccine, lab confirmation, birth in US before 1980, diagnosis of varicella or herpes zoster by MD

Can you get multiple vaccines in one day?

Yes! Data shows this does not cause any adverse effects Immune system can handle it Delaying vaccines increases risks of infection and outbreaks, number of appointments, likelihood that vaccine schedule will not be completed

aIIV3

aIIV3: Adjuvanted Trivalent Inactivated Influenza Vaccine (>65)

ccIIV4

ccIIV4: Cell Culture-based Quadrivalent Inactivated Influenza Vaccine

Flu vaccine recommendations..starting at age_____ All children aged __to___ who received the vaccination for the first time should receive ____doses spaced at ______apart

o Annual vaccination recommended for those aged 6 months or younger Children aged 6 months-8 years who need 2 doses, should receive the first dose as soon as vaccine becomes available and second dose >4 weeks later

HPV

o Human Papillomavirus Infection Types: · High-risk types 16 and 18—cervical cancers and anal cancers · Low-risk types 6 and 11—low grade pap smear abnormalities, warts -Most common STD o 9vHPV Vaccine: 9 valent - For ages 9-45 years in both genders, but preferred age to vaccinate is 11-12 years · Can start at 9 years old for patients with any history of sexual abuse - 3 dose series ONLY option for anyone 15-26 years of age: 0, 1-2 months, and 6 months · Immunocompromised patients need 3 doses regardless of age - 2 dose series for 9-14 years given at 0 and 6-12 months · If second dose given prior to 6 months after 1st dose, 3rd dose is needed -Individuals 27-45 years who are not properly vaccinated may be vaccinated with shared clinical decision making -Covers 90% of cervical cancers and genital warts -More effective if given more sexual activity begins

MMR

o Measles, Mumps, and Rubella -Respiratory transmission -Adults born before 1957 considered immune -Those born in 1957 or later need documentation of 1 or more doses of MMR o MMR Vaccine (MMR II and ProQuad- MMR + Varicella) -Live- attenuated

Who gets a third dose of MMR?

o Previously vaccinated with 2 doses of mumps-containing vaccine who are identified by public health as at increased risk for mumps because of an outbreak should receive a 3rd dose to improve protection