Childhood Immunization Update Presented by: Date: Disclosure Statements

Childhood Immunization Update Presented by: Date: Disclosure Statements

Childhood Immunization Update Presented by: Date: Disclosure Statements

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 Program 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. Disclosure Statement To obtain nursing contact hours for this session, you must

be present for the entire session and complete an evaluation. Continuing education will be provided through the Georgia Department of Public Health Georgia Department of Public Health is an approved provider of continuing nursing education by the Alabama State Nurses Association, an accredited approver by the American Nurses Credentialing Centers Commission of Accreditation Objectives At the end of this presentation,

participants will be able to: Recall the role vaccines play in preventing vaccinepreventable diseases Discuss the role of a vaccine champion Discuss GA Immunization law and DPH rules and regulations for schools and child care attendance List two reliable resources for immunization information Topics for discussion 2018 Immunization Schedule Changes

ACIP Recommendations/Updates New and future vaccines for potential use in practice The Impact of Vaccines Disease Average Annual Reported Cases Pre-vaccine* Cases

in U.S. 2015** Provisional Cases in U.S. 2016** Provisional % Reduction In U.S. 2016 Smallpox

Diphtheria Measles 48,164 175,885 503,282 Mumps Pertussis Polio (paralytic) Rubella Congenital Rubella

Syndrome Tetanus 152,209 147,271 16,316 47,745 823 1,329 20,762 0

5 1 5,311 15,737 0 5 1 96.5% 89.3% 100%

>99.9% >99.9% 1,314 20,000 29 29 33 22

98.1% 99.9% H. Influenzae Type b Age<5 years *MMWR 48(12);243-248 April 2, 1999 Eradicated worldwide in 1980 0 0 100%

188 69 >99.9% **MMWR 64(52), ND-924-ND-941, January 6, 2017 VPD Vaccination Rate Needed for Herd Immunity

Measles 92-94% Pertussis 92-94% Diphtheria 83-85%

Rubella 83-85% Mumps 75-86% Influenza 30-75%

Immunization Schedule Updates All staff must use the same immunization schedule Schedules: Children & Adolescents 0 through 18 years Catch-up schedule for ages 4 months -18 years Children and Adolescents 18 years or younger based on medical indications Adult 19 years and older

Adult based on medical and other indications READ THE FOOTNOTES http://www.cdc.gov/vaccines/schedules/hcp/child-adolescent.html http://www.cdc.gov/vaccines/schedules/hcp/adult.html What Does It All Mean? 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 General Best Practice Guidelines

Timing and Spacing of Immunobiologics Contraindications and Precautions

Preventing and Managing Adverse Reactions Vaccine Administration Storage and Handling of Immunobiologics Altered Immunocompetence Special Situations Vaccination Records Vaccination Programs Vaccine Information Sources General Best Practice Updates The 4-day grace period should not be applied to the 4-week interval between 2 different live

vaccines Allowances for alternate administration route (subcutaneous instead of intramuscular) for hepatitis A vaccine An age cutoff of 12 years through 17 years of age for validating a dose of intradermal influenza vaccine if given in error Diphtheria, Tetanus, and Pertussis Vaccines Routine Recommendations DTaP: 5 dose series administered at 2, 4, 6,

15-18 months and 4-6 years Tdap: 1 dose administered at 11-12 years of age; administer 1 dose to pregnant adolescent (preferably during the early part of gestational weeks 27-36) Hepatitis B Vaccine Routine Recommendations Dose 1 @ birth* Dose 2 @ 4 months of age at least 1 month after first dose Dose 3 @ 6-18 months of age:

Minimum of 4 months after the first dose Minimum of 2 months after the second dose but not before an infant is 24 weeks of age Hepatitis A Vaccine Routine Recommendations Administer 2 doses of hepatitis A separated by 6-18 months between the 1st and 2nd birthdays Catch-up vaccination Administer 2 doses to children 2 years of age or

older separated by 6 months Special Populations Administer 2 doses to persons who anticipate close, personal contact with an international adoptee during the first 60 days after arrival in the U.S. MMWR, May 19, 2006, Vol 55, #RR-07 Hepatitis A ACIP voted unanimously to pass the

following recommendations to Hepatitis A: Hep A vaccine should be administered for postexposure for all persons age 12 months or older Hep A vaccine or IG may be administered to persons age 40 years or older, depending on the providers risk assessment Hep A vaccine should be administered to infants age 6-11 months traveling outside the U.S. when protection against hepatitis A is recommended Haemophilus influenzae type b (Hib)

Routine Recommendation 4-dose series at 2, 4, 6, and 12-15 months (ActHIB, Hiberix, or Pentacel) 3-dose series at 2, 4, and 12-15 months (PedvaxHIB) Refer to Catch-up Immunization Schedule for children who start their vaccination series at 7 months and older Polio Routine Recommendation 4- dose series at 2, 4, 6 through 18 months, and 4 through 6 years

Final dose after the fourth birthday and at least 6 months after the previous dose Catch-up A 4th dose is not necessary if the 3rd dose was given on or after the 4th birthday and at least 6 months after the previous dose IPV is not routinely recommended for U.S. residents 18 years and older Evaluate travelers for the need of polio vaccine if traveling to endemic countries.

Measles, Mumps, Rubella Routine Recommendation 2- dose series at ages 12 through 15 months and 4 through 6 years (dose 2 may be given as early as 4 weeks after the 1st dose) 1-dose of mumps-containing vaccine to persons 12 months of age or older during a mumps outbreak* Varicella Routine Recommendation 2-dose series at 12 through 15 months and 4 through 6 years

The 2nd dose may be given as early as 3 months after the 1st dose (a dose given after a 4-week interval may be counted Catch-up Administer 2 doses to persons 7-18 years without evidence of immunity Ages 7-12 years routine interval between doses 3 months (minimum interval: 4 weeks) Ages 13 years and older minimum interval 4 weeks between doses Varicella Immunity

ACIP considers evidence of immunity to varicella to be: Documentation of 2 doses of vaccine given no earlier than age 12 months, with at least 3 months between doses for children younger than age 13 years, or at least 4 weeks between doses for people age 13 years and older U.S.-born before 1980* A healthcare provider's diagnosis of varicella or verification of history of varicella disease History of herpes zoster, based on healthcare provider diagnosis Laboratory evidence of immunity or laboratory confirmation of disease *Note: year of birth is not considered as evidence of immunity for healthcare personnel, immunosuppressed people, and pregnant women.

MMWR 2007;56(RR-4); 16-17 MMRV (ProQuad) Routine Recommendation May be administered to children 12 months through 12 years of age MMRV is not licensed for people 13 years of age or older A third dose of MMRV might be recommended in certain mumps outbreaks situations*

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 if not given during the same visit If PPD given first, administer MMR when client returns for skin test reading Spacing with antibody-containing products such as immune globulin (IG)

Pneumococcal Vaccines (PCV13) (PPSV23) Routine Recommendation for PCV13 4-dose series at 2, 4, 6, and 12-15 months Catch-up vaccination with PCV13 1-dose for healthy children 24-59 months with any incomplete* PCV13 schedule Pneumococcal Vaccines (PCV13) (PPSV23)

Special situations: High-risk conditions: Administer PCV13 doses before PPSV23 if possible. Chronic heart disease (particularly cyanotic congenital heart disease and cardiac failure); chronic lung disease (including asthma treated with high-dose, oral, corticosteroids); diabetes mellitus) Cerebrospinal fluid leak; cochlear implant Sickle cell disease and other hemoglobinopathies; anatomic or functional asplenia; congenital or acquired immunodeficiency; HIV infection; chronic renal failure; nephrotic syndrome; malignant neoplasms, leukemias, lymphomas, Hodgkin disease, and other diseases associated with treatment with immunosuppressive drugs or radiation therapy; solid organ transplantation; multiple myeloma

Chronic liver disease, alcoholism Serogroup A, C, W, Y Meningococcal Vaccines Routine Recommendation 2-dose series at 11-12 years and 16 years Age 13-15 years administer 1-dose and booster at age 16-18 years (minimal interval 8 weeks) 1-dose at age 16-18 years Meningococcal Vaccines for Special Populations and

Situations Anatomic or functional asplenia, sickle cell disease, HIV infection, persistent complement component deficiency (including eculizumab use) Children who travel to or live in countries where meningococcal disease is hyperendemic or epidemic, including countries in the African meningitis belt or during the Hajj, or exposure to an outbreak attributable to a vaccine serogroup Serogroup B Meningococcal Vaccines

ACIP Recommendation May be given at clinical discretion to adolescents 16-23 years (preferred age 16-18 years) who are not at increased risk Bexsero: 2 doses at least 1 month apart Trumenba: 2 doses at least 6 months apart. If 2nd dose given earlier than 6 months, give 3rd dose at least 4 months after the 2nd dose Serogroup B for Special Populations and Situations Anatomic or functional asplenia, sickle cell

disease, persistent complement component deficiency (including eculizumab use), serogroup B meningococcal disease outbreak Bexsero: 2-doses at least 1 month apart Trumenba: 3-dose series at 0, 1-2, and 6 months Bexsero and Trumenba are not interchangeable Influenza Vaccines for 2017-2018 Season in the U.S. Trivalent Vaccines (IIV3): A/Michigan/45/2015 (H1N1) (NEW)

A/Hong Kong/4801/2014 (H3N2)-like virus B/Brisbane/60/2008-like virus Quadrivalent Vaccines (IIIV4) will also include: B/Phuket/3073/2013-like virus ACIP recommends annual influenza vaccine for all persons 6 months of age and older who do not have contraindications. Recommendations and Reports Vol. 66 / No. 2 MMWR / August 25, 2017 Product Updates FDA licensure and labeling changes: Approval of Afluria Quadrivalent (Seqirus) and

Flublok Quadrivalent (Protein Sciences) Expansion of the age indication for FluLaval Quadrivalent (GSK) and Fluarix Quadrivalent (GSK) to age 6 months and older (previously licensed for people 3 years and older) Expansion of the age indication for Afluria (Seqirus) to include persons 5 years and older (previously recommended for persons 9 years and older) Dosing Algorithm for Children ACIP VOTE

On February 21, 2018 ACIP voted to include the nasal spray flu vaccine among the recommended influenza vaccines for the 2018-2019 season. CDC does not currently have a contract for LAIV LAIV will likely be available for private purchase before it is available on public contracts Contact the VFC Program for additional information 1-800-848-3868 HPV Vaccine

Routine recommendation for adolescents 11-12 years (can start at age 9) Number of doses dependent on age at initial vaccination >Age 9-14 years: 2-dose series at 0 and 6-12 months >Age 15 years or older: 3-dose series at 0, 1-2 months, and 6 months Persons who completed a valid series with any HPV vaccine do not need any additional doses Special Situations >History of sexual abuse or assault: begin series at age 9 years >Immunocompromised: aged 9-26 years administer 3-dose series >Pregnancy: vaccination not recommended, but if administered

inadvertently while pregnant delay remaining doses until after pregnancy. HPV Vaccine At the February 2018 ACIP Meeting they presented a session about harmonizing of HPV vaccination age recommendations for females and males Considerations for harmonization of upper age recommendations for males and females - would simplify immunization schedule -facilitate reaching males, including high risk

Rotavirus Vaccine Routine Recommendation Rotarix: 2-dose series at 2 and 4 months RotaTeq: 3-dose series at 2, 4, and 6 months If any dose in the series is either RotaTeq or unknown, default to 3-dose series BE ON THE LOOK OUT!!! NEW AND FUTURE VACCINES

SHINGRIX (RZV) Administer 2 doses of recombinant zoster vaccine (RZV) 2-6 months apart to adults aged 50 years or older regardless of past episode of herpes zoster or receipt of zoster live (ZVL) Administer 2 doses of RZV 2-6 months apart to adults who previously received ZVL at least 2 months after ZVL For Adults aged 60 years or older, administer either RZV or ZVL (RZV is preferred) SHINGRIX (RZV)

SHINGRIX delivered 90% efficacy against shingles Recombinant vaccine; do not freeze For intramuscular administration only Reconstitute and use immediately; reconstituted vaccine is stable for 6 hours refrigerated between 36-46F and should be discarded after 6 hours Contraindicated for a history of severe allergic

reaction (e.g., anaphylaxis) to any component of the vaccine or after a previous dose of SHINGRIX HEPLISAV-B FDA licensed November 9, 2017 Indicated for active immunization against infection caused by all known subtypes of HBV in persons 18 years or older Series of 2 doses, separated by 1 month Uses 1018 adjuvant Just as a reminder

Regardless of: the availability of vaccine the funding of the vaccine (VFC, statesupplied, or private stock) whether the vaccine is required for school or child care or not. FOLLOW ACIP Recommendations!!! Test Your Knowledge! We have adolescents in our practice who have received the first 2 doses of the HPV series 1 or 2 months apart

according to the 3-dose schedule. Can we consider their HPV vaccine series to be complete or do we need to give these patients a third dose? Test Your Knowledge! We have adolescents in our practice who have received the first 2 doses of the HPV series 1 or 2 months apart according to the 3-dose schedule. Can we consider their HPV vaccine series to be complete or do we need to give these patients a third dose? People who have received 2 doses of HPV vaccine separated by less

than 5 months should receive a third dose 612 months after dose #1 and at least 12 weeks after dose #2. Test Your Knowledge! Which patients should receive a 2-dose schedule of Trumenba (MenB, Pfizer)? Ref: Recommended Immunization Schedule for Children and Adolescents Aged 18 years or younger, United States, 2017 Test Your Knowledge! Which patients should receive a 2-dose schedule of

Trumenba (MenB, Pfizer)? Healthy adolescents who are not at increased risk for meningococcal disease should receive 2 doses of Trumenba administered at 0 and 6 months. If the second dose is given at an interval of less than 6 months, a third dose should be given at least 4 months after the 2nd dose. Ref: Recommended Immunization Schedule for Children and Adolescents Aged 18 years or younger, United States, 2017 Test Your Knowledge! If someone received MPSV4 or MenACWY at age

9 years, will two additional doses of MenACWY be needed? Ref: Recommended Immunization Schedule for Children and Adolescents Aged 18 years or younger, United States, 2017 Test Your Knowledge! If someone received MPSV4 or MenACWY at age 9 years, will two additional doses of MenACWY be needed? Yes. Doses of quadrivalent meningococcal vaccine (either MPSV4 or MenACWY) given before 10 years of

age should not be counted as part of the routine 2-dose series. If a child received a dose of either MPSV4 or MenACWY before age 10 years, they should receive a dose of MenACWY at 11 or 12 years and a booster dose at age 16 years. Ref: Recommended Immunization Schedule for Children and Adolescents Aged 18 years or younger, United States, 2017 Requirements for School and Childcare Attendance School Requirement Updates

3231 INS updated December 2017 Goal Vaccines work Goal 100 % compliance rate Immunization Laws work Partnerships work Job Aids

3231 REQ 3231 INS Certificate of Immunization (Form 3231) Certificate on file at each facility or school Photocopies acceptable A licensed Georgia physician, APRN, PA or public health official is responsible for completing the

certificate Only physician offices and health clinics can obtain blank certificates Valid Certificates All certificates must be marked with : Childs name Birth date Name and Address of Physician, APRN, PA, Qualified Board of Health official or State Immunization Office Official Certified Signature

Date of Issue Expiration Date Expires on the date entered as Expiration Date Must be replaced with a current certificate within 30 days Required for all children less than age four years Required for all children ages four through ten years who have not completed K through 6th grade requirements or children 10 years and older who have not completed 7 th grade or higher requirements Required if a medical exemption for a vaccine(s) is marked

Complete for School Attendance Issued only to children who: Are four years of age or older; and Have met all the requirements for school attendance as outlined in the Policy Guide 3231REQ; and Have all the required vaccine administration

dates or natural immunity dates filled in; and Do not have a Date of Expiration Exemptions Medical: Physical disability or condition Documented in the medical exemption box indicated for each vaccine Reviewed annually

Exemptions Religious: Documented on form 2208 Form kept on file by the school or facility in lieu of a Certificate of Immunization (form 3231) Do not expire School Requirement Updates

DPH Rules and Regulations 511-22-.07 Child Care Requirements Number of vaccine doses Always need more doses Must have a current expiration date School Requirements Any new entrant enrolling in a Georgia school at any grade or level, must be age appropriately immunized with required vaccines Number of doses depends on the childs age

Complete for 7th Grade or higher is marked; certificate is complete 3: Completing both boxes: When all requirements have not been met 10: Complete for School checked for child under age 4 9: No dose DTaP after 4th birthday 2: Doses Hep B spaced incorrectly 11. No dose of Tdap or MCV4 for students born on or after 1-1-2002 entering 7th grade or new entrants 7: 1st dose MMR given before age 1 yr.

6: 1st dose varicella given before age 1 yr. 8: No 2nd dose varicella documented 5: Varicella Immunity not documented by vaccine or hx/dx/serology date 4: Address and/or contact information not completed 1: No physician, APRN or PA signature Filing of Certificates

Available for inspection by health officials Photocopy acceptable Sent copy to the new school/facility In the case of religious exemption, form 2208 must be on file in lieu of form 3231 Tickler Filing System Instructions located in the

Immunization Guidelines for Child Care Facility Operators & School Personnel (Form 3258) Set up by month and year Parent reminders Summary of GA Immunization requirements Document follow-up Enforce requirements GRITS

Responsibilities Physicians and Public Health Clinics Child Care and School Parent/Caregiver Become a Vaccine Champion!! Critical Elements

Appropriate storage and handling of all vaccines. Correct administration of vaccines Education of patients and parents about vaccines Every office and clinic needs a vaccine champion. Vaccine Champion Key Characteristics

Lead your immunization team. Educate all staff about new vaccines and recommendations. Educate new staff about vaccine storage, handling, & administration. Initiate processes to improve immunization rates in your practice/facility. Assure immunizations of all staff are up-todate.

Improve Access To Immunizations Immunization only visits Walk-ins for immunizations Implement standing orders Early, extended, or weekend hours Mass vaccination clinics

VAERS Public Health Reports should be faxed or mailed to the State Immunization Program. Fax number (404)657-1463 Vaccine Injury Compensation Program (VICP) National Vaccine Injury Compensation Program provides compensation to individuals found to be injured by or have died from certain childhood vaccines. Established in 1988 by NCVIA

Federal no fault system to compensate those injured Claim must be filed by individual, parent or guardian Must show that injury is on Vaccine Injury Table Resources for Factual & Responsible Vaccine Information www.immunize.org

Internet Resources Georgia Department of Public Health http://dph.georgia.gov/immunization-section https://dph.georgia.gov/train-trainer CDC Immunization information http://www.cdc.gov/vaccines/ CDC Flu information http://www.cdc.gov/flu/ Immunization Action Coalition www.immunize.org

State Resources GA Immunization Program Office On call Help line: 404-657-3158 GRITS Help Line:1-866-483-2958 VFC Help Line:1-800-848-3868 Website http://dph.georgia.gov/immunizationsection Your local Immunization Regional Program Consultant (IRC) Epidemiology: 1-866-782-4584 GA Chapter of the AAP GA Academy of Family Physicians

Its a Team Effort! High Immunization rates begin with a team designed plan! What can your team do to improve rates?

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