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Adult Immunizations 2012 Update

Adult Immunizations 2012 Update. Kenneth McCall, BSPharm , PharmD Associate Professor & Dept. Chair. Disclosure. I, Kenneth McCall, do not have an interest in selling a technology, program, product, and/or service to CME/CE professionals. I am a speaker for Merck Vaccines. Objectives.

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Adult Immunizations 2012 Update

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  1. Adult Immunizations2012 Update Kenneth McCall, BSPharm, PharmD Associate Professor & Dept. Chair

  2. Disclosure • I, Kenneth McCall, do not have an interest in selling a technology, program, product, and/or service to CME/CE professionals. • I am a speaker for Merck Vaccines.

  3. Objectives • Discuss the gap between current rates and Healthy People 2020 goals for vaccinations. • Categorize each of the CDC recommended vaccines based upon live/inactivated, route, prep., and storage. • Recognize vaccine-preventable pathogens by common name, classification, and transmission. • Discuss the influenza vaccines for 2012 including the new High-Dose and Intradermal vaccines. • Identify vaccine contraindications and recommend vaccines based upon age and medical history. • Apply ACIP recommendations and FDA approved indications for the CDC recommended vaccines.

  4. Outline • Background & Principles of Vaccination • Influenza • Pneumonia • Herpes zoster

  5. Background &Principles of Vaccination

  6. Immunization Resources • The Pink Book http://www.cdc.gov/vaccines/pubs/pinkbook/index.html • Adolescent and Adult Vaccine Quiz http://www2a.cdc.gov/nip/adultImmSched/ • Screening Questionnaire http://www.immunize.org/catg.d/p4065.pdf • The Yellow Book http://wwwnc.cdc.gov/travel/ • 1-800-CDC-INFO • Apps • ACP Immunization Advisor • CDC Vaccine Schedule for Adults

  7. Second Regular Session – 125th Maine Legislature • LD 1608 “An Act to Clarify the Laws Governing Pharmacy Interns” • Sponsored by Speaker Bob Nutting • “…authorized to engage in the practice of pharmacy while under the direct supervision of a licensed pharmacist.” • LD 1715 “An Act for Timely Access to Enhanced Administration of All Vaccines” • Sponsored by Representative Meredith Strang Burgess • “‘Practice of pharmacy’ means…the administration of vaccines licensed by the US FDA that are recommended by the US CDC ACIP for administration to adults…” • “A pharmacy may operate a vaccine administration clinic inside, outside, or off the pharmacy’s premises…with one-time board approval”

  8. Pharmacist Administered VaccinesTypes of Vaccines Authorized to Administer Based upon APhA / NASPA Survey of State IZ Laws/ Rules (updated March 2012) * Via Rx for some; ** broad list of vaccines

  9. Pharmacist Administered VaccinesMay student interns administer vaccines? Based upon APhA / NASPA Survey of State IZ Laws/ Rules (updated March 2012)

  10. Principles of Vaccination* • Passive immunity • Transplacental • Breast milk • Blood products • Active immunity • Infection • Vaccination *Epidemiology and Prevention of Vaccine-Preventable Diseases, 12th Edition

  11. Classification of Vaccines • Live attenuated • Weakened form of the “wild” virus or bacteria • Inactivated • Whole viruses or bacteria • Fractions of viruses or bacteria *Epidemiology and Prevention of Vaccine-Preventable Diseases, 12th Edition

  12. Classification of Vaccines • Live attenuated: • Measles, mumps, rubella, varicella, zoster, intranasal influenza • Inactivated: • hepatitis A, hepatitis B, influenza, pneumonia, diphtheria, tetanus, pertussis, HPV, meningicoccal *Epidemiology and Prevention of Vaccine-Preventable Diseases, 12th Edition

  13. Timing & Spacing of Vaccines • All vaccines can be administered at the same visit as all other vaccines. • Individual vaccines should not be mixed in the same syringe. • When live vaccines (MMR, Varicella, Zoster, and Flumist) are not administered at the same visit, they should be separated by at least 4 weeks. • All other combinations of two inactivated vaccines, or live and inactivated vaccines may be given at any time before or after each other. • Increasing the interval between doses of a multidose vaccine does not diminish the effectiveness of the vaccine. • Decreasing the interval between doses of a multidose vaccine may interfere with antibody response and protection. *Epidemiology and Prevention of Vaccine-Preventable Diseases, 12th Edition

  14. A healthcare provider requests a flu shot, MMR, and varicella vaccine. Which of the following statement about the timing of the vaccines is true? • All three , separate syringes, same day • All three, mix in 1 syringe, same day • Must separate MMR and varicella by 4 wks • Must separate MMR and varicella by 7 days

  15. An 12-year-old girl received the first dose of the HPV vaccine six months ago. The recommend HPV series is a second dose 1-2 mos after first and third dose at least 3 mos after second. What would you recommend to the parent? • The vaccine is no longer indicated • Start the series over and repeat first dose • Give 2nd dose today; 3rd dose in 1 month • Give 2nd dose today; 3rd dose in 3 mos.

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  18. Recommended Adult Immunization Schedule, by vaccine and age group < -------------TIV or LAIV--------- > TIV or TIV HD < -----------------------------TIV or TIV ID-------------------------------- > FDA approved age 50+ yrs

  19. Vaccines that might be indicated for adults based on medical and other indications Smoker College Dorm / Military Recruit

  20. Influenza Vaccination

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  22. Influenza Virus Strains • Influenza A virus • Moderate to severe illness • All age groups • Humans and other animals • Influenza B virus • Milder disease • Primarily affects children • Humans only • Influenza C virus • Rarely reported in humans • No epidemics Seasonal influenza vaccine contains 2 type-A and 1 type-B

  23. Estimated Influenza Vaccination Coverage: 2010-11. †Persons with asthma, diabetes, or heart disease MMWR / June 10, 2011 / Vol. 60 / No. 22

  24. 2012-13 ACIP/CDC Recommendations • Routine influenza vaccination continues to be recommended for all persons aged ≥6 months. • While the H1N1 virus is the same as the 2011-2012 recommendation, the recommended influenza H3N2 and B vaccine viruses are different from those recommended for the Northern Hemisphere for the 2011-2012 influenza vaccine. • Persons aged ≥65 years can be administered any of the standard-dose inactivated vaccine or Fluzone High-Dose. • A new intradermally administered TIV preparation, Fluzone Intradermal, was licensed in May 2011 for adults 18 to 65. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6132a3.htm?s_cid=mm6132a3_e

  25. US Influenza Vaccines: 2012-13 http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6132a3.htm?s_cid=mm6132a3_e#tab

  26. Recommendations regarding influenza vaccination for persons who report allergy to eggs

  27. Live Attenuated Influenza Vaccine (LAIV)Flumist ®

  28. Live Attenuated Influenza Vaccine • Indication • Healthy people 2 through 49 years of age • Contraindications • Pregnant women • People who have long-term health problems with: • heart disease • kidney or liver disease • lung disease • metabolic disease, such as diabetes • asthma • anemia, and other blood disorders • Anyone with a weakened immune system • Severe egg allergy I pick my nose!

  29. Live Attenuated Influenza VaccineAdverse Reactions • Runny nose or nasal congestion • Fever > 100°F in children 2-6 years of age • Sore throat in adults • Wheezing and hospitalization in children < 2 years old

  30. Administration • Flumist®: 0.1-mL dose in each nostril • Intranasal

  31. FlumistQuadrivalent ® • In February 2012, FDA approved a new seasonal quadrivalent LAIV, FluMistQuadrivalent (MedImmune). This vaccine currently is not anticipated to be available until the 2013–14 influenza season. • All currently available influenza vaccines are trivalent and contain A(H1N1), A(H3N2), and B viral antigens. There are two antigenically distinct lineages of influenza B viruses referred to as Victoria and Yamagata lineages.

  32. High-Dose Trivalent Inactivated Vaccine (HD TIV)Fluzone HD ®

  33. Methods: • Multicenter, randomized, double-blind controlled study • HD vaccine (60 mcg of hemagglutinin per strain): N=2,575 • SD vaccine (15 mcg of hemagglutinin per strain): N=1,262 • in adults 65 years of age and older. J Infect Dis. 2009;200(2):172-80

  34. Comparison of responses to high-dose (HD) and standard-dose (SD) influenza vaccine antibody titer level J Infect Dis. 2009;200(2):172-80

  35. Comparison of systemic side effects to HD and SD influenza vaccine Percent J Infect Dis. 2009;200(2):172-80

  36. Administration • Fluzone HD®: 0.5-mL dose • IM - deltoid • 1 inch, 25 gauge needle

  37. A 30-year-old healthy male requests an annual flu shot. He has no allergies. His wife is currently pregnant. Which flu vaccine(s) is/are appropriate? • Influenza intradermal vaccine 0.1 ml • Influenza SD shot 0.5 ml IM • Influenza HD shot 0.5 ml IM • Flumist nasal spray 0.1 ml in each nostril • Either 1 or 2 • Either 3 or 4 • Either 1, 2 or 4

  38. Intradermal Influenza VaccineFluzone Intradermal®

  39. Intradermal Influenza Vaccine • Indication • Persons 18 through 64 years of age • Contraindications • Severe egg allergy

  40. Intradermal vs Traditional IM needle Length

  41. 30 Gauge Needle and Less Volume

  42. Methods: • Multicenter, randomized, double-blind controlled study • ID vaccine (9 mcg of hemagglutinin per strain) N=1,803 • IM vaccine (15 mcg of hemagglutinin per strain): N=452 • in adults 18 to 60 years of age. Human Vaccines. 2010;6:346-54.

  43. Comparison of responses to Intradermal (ID) and Intramuscular (IM) influenza vaccine Seroprotection Rate Human Vaccines. 2010;6:346-54.

  44. Comparison of systemic side effects to ID and IM influenza vaccine Percent Human Vaccines. 2010;6:346-54.

  45. Comparison of local side effects to ID and IM influenza vaccine Percent Human Vaccines. 2010;6:346-54.

  46. Which side effect is more common with the intradermal influenza vaccine than the IM influenza vaccine? • Injection site pain • Headache • Fever • Injection site swelling • Malaise

  47. A 35-year-old woman requests an annual flu shot. She has ulcerative colitis and is taking Prednisone 40 mg QD. Which flu vaccine(s) is/are appropriate? • Influenza intradermal shot 0.1 ml • Influenza SD shot 0.5 ml IM • Influenza HD shot 0.5 ml IM • Flumist nasal spray 0.2 ml nasal • Either 1 or 2 • Either 2 or 3 • Either 2 or 4

  48. Pneumococcal VaccinePPSV23 / Pneumovax® PCV13 / Pnevnar®

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