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Immunizations – What's New

Immunizations – What's New. Wendy Jensen Bender, PharmD, RPh SDSU College of Pharmacy and Allied Health Professions RH Rapid City Hospital. Disclosure. I have had no financial relationship over the past 12 months with any commercial sponsor with a vested interest in this presentation.

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Immunizations – What's New

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  1. Immunizations – What's New Wendy Jensen Bender, PharmD, RPh SDSU College of Pharmacy and Allied Health Professions RH Rapid City Hospital

  2. Disclosure • I have had no financial relationship over the past 12 months with any commercial sponsor with a vested interest in this presentation.

  3. Objectives • Identify recent updates to the immunization schedule • Define the term "vaccine hesitancy" and list strategies to improve vaccine rates among this patient target group • Summarize recent updates to the immunization schedule • Define the "vaccine hesitancy" and assist the pharmacist in working to improve vaccine rates among this patient target group

  4. Immunization Schedules • Updates and information for persons 0-18y • Influenza  • HPV • Tdap • Meningococcal serotype B • Hepatitis A • Pregnancy

  5. Influenza Immunization • Any licensed vaccine can be used for pediatric vaccination • No LAIV with: immunocompromise (or contact with), asplenia (anatomic or functional), pregnancy, antivirals in the last 48h, 2-4y with asthma diagnosis or wheezing within the last 12mo, salicylate medications, allergy to vaccine or components • Precaution with LAIV: asthma if 5yo or older, underlying medical conditions

  6. HPV Immunization • Age 9-14y  • 2 doses at 0 and 6-12mo • Series must start prior to 15th birthday • Immune response at least as good as persons 16-26y • Age 15y and older  • 3 doses at 0, 1-2mo, and 6mo  • Side effects: • Injection site pain, swelling, erythema • Fever, nausea, headache • Syncope more common in "older" females (11-18y) -- recommendation to monitor for 15min after vaccine administration

  7. HPV Immunization

  8. Tdap Immunization • Update: persons who receive a dose of Tdap inadvertently at age 7-10y or as part of the catch-up series should still receive the routine dose of Tdap at age 11-12y • Immunization schedule recommendation for persons age 13-18y has been clarified  • Adolescents with no documented DTaP series should receive a 3 dose primary series • Tdap, Td at least 4 weeks after Tdap, Td at least 6 mo after first Td (second dose in series) • Td booster every 10y • Adverse reactions: injection site pain, redness, swelling

  9. Group B Meningococcal Immunization • ACIP review reasoning for vaccine recommendations • Timing • Disease occurrence   • Trumenba (MenB-FHbp) • Bexsero (MenB-4C) • In brief: The benefit of a MenB booster outweighs any risk and may be given 1 year after the primary series if indicated.  Currently, there is no information regarding repeat booster doses.

  10. Hepatitis A Immunization • Homelessness an indication • Indicated for 6-11mos if traveling • Travelers over 1y who are unvaccinated • Expected: • Catch-up recommended for everyone 2-18y without documented immunization • Inclusion for children more than 12mo old with HIV infection

  11. Immunization Schedule, Pregnancy

  12. Immunization Schedule, Pregnancy • Tdap  • No minimum interval • Recommended at 27-36 weeks gestation • Influenza  • https://www.cdc.gov/flu/highrisk/pregnant.htm • Mom to be at increased risk • Antibodies pass to the infant • Vaccinate in any trimester

  13. Vaccine Hesitancy Defined The SAGE Working Group on Vaccine Hesitancy:  "Vaccine hesitancy refers to delay in acceptance or refusal of vaccination despite availability of vaccination services.  Vaccine hesitancy is complex and context specific, varying across time, place and vaccines.  It is influenced by factors such as complacency, convenience and confidence." Vaccine, 2015

  14. The "3 Cs" Model Confidence is trust Complacency occurs when the perceived risk of a vaccine is greater than the perceived risk of the VPD Convenience involves affordability, availability, health literacy Vaccine, 2015

  15. Vaccine Hesitancy Defined The SAGE Working Group on Vaccine Hesitancy:  "Vaccine hesitancy refers to delay in acceptance or refusal of vaccination despite availability of vaccination services.  Vaccine hesitancy is complex and context specific, varying across time, place and vaccines.  It is influenced by factors such as complacency, convenience and confidence." Accept some, delay some, refuse some Accept but unsure Refuse but unsure Refuse all Accept all Vaccine, 2015

  16. Vaccine Hesitancy • Review of reasons / types of objections • Safety • Too many vaccines, pain with injections, severe adverse reactions • Necessity  • Disease is "natural", VPD are gone/rare/not that severe • Distrust  • Vaccines aren't well tested, research inadequate • Societal "norm" • Other children unvaccinated • Religious / personal choice  • Right to choose, parent knows what is best, disallowed by religion

  17. Vaccine Hesitancy Tips  • Acknowledge concerns • Remain nonjudgmental  • Be knowledgeable • Provide science / evidence-based information • Discuss risk / benefit • Remind / educate: • Vaccines are extensively studied prior to licensure • Vaccine safety monitoring does not end at licensure

  18. Reliable Resources • https://www.cdc.gov/vaccines/schedules/parents-adults/index.html • https://www.cdc.gov/vaccines/schedules/easy-to-read/child-easyread.html • https://www.cdc.gov/vaccines/schedules/easy-to-read/adolescent-easyread.html • https://www.cdc.gov/vaccines/schedules/parents-adults/resources-parents.html • https://www.cdc.gov/vaccines/schedules/parents-adults/resources-adults.html • https://www.cdc.gov/vaccines/parents/index.html • https://www.immunize.org/reports • http://www.vaccineinformation.org

  19. Vaccine Hesitancy Tips  • Acknowledge concerns • Remain nonjudgmental  • Be knowledgeable • Provide science / evidence-based information • Discuss risk / benefit • Remind / inform: • Vaccines are extensively studied prior to licensure • Vaccine safety monitoring does not end at licensure

  20. Vaccine Hesitancy with HPV • AAP recommends emphasis on cancer prevention • Better immune response at a younger age • Fewer side effects seen at a younger age • Coadministration with other vaccines can boost response • Use of a "presumptive delivery strategy"  • Boost vaccine acceptance • Emphasize safety of the vaccine  • AAP has "HPV Talking Points" to help address safety

  21. Adolescent Vaccination • Lack of routine preventative care visits • Adolescent developmental changes • Risk perception • Questioning • Independence seeking  • Hesitancy versus lack of knowledge • Advocate for vaccine schedule

  22. https://www.npr.org/sections/health-shots/2019/02/09/692819105/defying-parents-a-teen-decides-to-get-vaccinatedhttps://www.npr.org/sections/health-shots/2019/02/09/692819105/defying-parents-a-teen-decides-to-get-vaccinated https://www.webmd.com/children/news/20190215/ohio-teen-gets-himself-vaccinated-inspires-others

  23. Other  • Herpes zoster in children • Immunization laws and personal exemptions • California law eliminating personal exemptions • Washington exemptions after mandated parent counseling • Other countries

  24. References Ames HMR, Glenton C, Lewin S.  Parents' and caregivers' views and experiences of communication about routine childhood vaccination: a synthesis of qualitative evidence.  Cochrane Database of Systematic Reviews, 2017, Issue 2. Art. No. CD011787.  doi: 10.1002/14651858.CD011787.pub.2 Bernstein HH, Bocchini JA, Committee on Infectious Diseases.  Practical approaches to optimize adolescent immunization. Pediatrics, 2017; 139(3): e1-13.  doi: 10.1542/peds.2016-4187  Centers for Disease Control at cdc.gov de St. Maurice A, Edwards KM, Hackell J.  Addressing vaccine hesitancy in clinical practice.  Pediatr Ann, 2018; 47(9): e366-e370.  doi: 10.3928/19382359-20180809-01 Delamater PL, Pingali SC, Buttenheim AM, et al.  Elimination of nonmedication immunization exemptions in California and school-entry vaccine status.  Pediatrics, 2019; 145(6): e20183301.  doi: 10.1542/peds.2018-3301 Edwards KM, Hackell JM, Committee on Infectious Diseases. Countering vaccine hesitancy.  Pediatrics, 2016; 138(3): e20162146. doi: 10.1542/peds/2016-2146  MacDonald NE, the SAGE Working Group on Vaccine Hesitancy.  Vaccine hesitancy: definition, scope and determinants.  Vaccine, 2015; 33: 4161-4164. doi: 10.1016/j.vaccine.2015.04.036  Mbaeyi, S.A. Serogroup B meningococcal vaccines booster doses: Work Group interpretation, considerations for policy options, and next steps.(Available at: https://www.cdc.gov/vaccines/acip/meetings/downloads/slides-2019-02/Meningococcal-5-Mbaeyi-508.pdf. Accessed August 15, 2019)Advisory Committee on Immunization Practices Meeting; February 28, Atlanta, GA; 2019 Nowak GJ, Cacciatore MA.  Parents' confidence in recommended childhood vaccinations: extending the assessment, expanding the context. Human Vaccines & Immunotherapeutics, 13(3): 687-700. doi: 10.10802/21645515.2016.1236881 Omar SB, Allen K, Chang DH, et al.  Exemptions from mandatory immunization after legally mandated parental counseling.  Pediatrics, 2018; 141(1): e20172364. doi: 10.1542/peds.2017-2364 

  25. Questions/Comments

  26. Which of the following influenza vaccines is not acceptable for an otherwise healthy 5-year old? A.  LAIV B.  Trivalent injectable vaccine C.  Quadrivalent injectable vaccine D.  High dose injectable vaccine

  27. Adverse reactions are the primary reasons behind vaccine hesitancy. A.  True B.  False

  28. Fear of needles is the primary reason behind vaccine hesitancy. A.  True B.  False

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