Best Practices in Vaccine Administration

1. Donna L. Weaver, RN, MN Nurse Educator July 1, 2010 Current Issues in Immunization Netconference Education, Information and Partnership Branch, NCIRD/CDC Best Practices in Vaccine Administration Thank you Dr. Kroger. Thank you Dr. Kroger.

2. Dr. Beysolow mentioned the importance of advanced and ongoing training for new and existing staff. It is very concerning when we hear about a patient inadvertently receiving the wrong vaccine or that it was administered by the wrong route, using the wrong diluent, or given after the expiration date. But just as concerning is when we hear that AFTER such an error has occurred, the clinic has decided to institute orientation and continuing education practices. Remember the key message here is ADVANCED and ONGOING training. Orientation, training, and continuing education regarding vaccines and their administration is not a one shot event but a systematic ongoing program. It should be an integral part of quality assurance and risk management in your immunization practice. Clinical skill checks should be a standard part of your staff�s training and continuing education when new products are introduced into your practice. Dr. Beysolow mentioned the importance of advanced and ongoing training for new and existing staff. It is very concerning when we hear about a patient inadvertently receiving the wrong vaccine or that it was administered by the wrong route, using the wrong diluent, or given after the expiration date. But just as concerning is when we hear that AFTER such an error has occurred, the clinic has decided to institute orientation and continuing education practices. Remember the key message here is ADVANCED and ONGOING training. Orientation, training, and continuing education regarding vaccines and their administration is not a one shot event but a systematic ongoing program. It should be an integral part of quality assurance and risk management in your immunization practice. Clinical skill checks should be a standard part of your staff�s training and continuing education when new products are introduced into your practice.

3. Rights of Medication Administration Right patient Right medication Right time Right dosage Right manner/route Right documentation It is our duty and responsibility as healthcare providers to ensure quality and patient safety in the care we provide. I�m sure all of you nurses out there remember learning the �Rights of Medication Administration.� When I was in nursing school, there were 5 rights. Depending on the source, you can now find as many as 11 rights listed. Our time today is limited so I have listed 6 of these rights as the framework for this presentation. It is our duty and responsibility as healthcare providers to ensure quality and patient safety in the care we provide. I�m sure all of you nurses out there remember learning the �Rights of Medication Administration.� When I was in nursing school, there were 5 rights. Depending on the source, you can now find as many as 11 rights listed. Our time today is limited so I have listed 6 of these rights as the framework for this presentation.

4. Right Patient What is the patient�s name? Has the patient received any immunizations under another name? What is the patient�s date of birth? Has the patient received any vaccines or shots at another clinic or healthcare facility recently? Do you have a copy of the patient�s immunization record? The �Right Patient� Sometimes we hear that patients receive unnecessary vaccines because they have previously received care with different names at more than one clinic. Unfortunately this cannot always be prevented, but the incidence can be reduced if we remember to ask some critical questions from the start. What is the patient�s name? Has the patient received any immunizations under another name? What is the patient�s date of birth? Has the patient received any vaccines or shots at another clinic or healthcare facility recently? Do you have a copy of the patient�s immunization record? Certainly one of the best ways to prevent duplication of vaccines and to consolidate a patient�s immunization history is to participate in an immunization registry. Another best practice measure is to be sure that the patient or parent is provided with an immunization record and informed of how important it is to keep that record in a safe place and to bring that record anytime healthcare is sought.The �Right Patient� Sometimes we hear that patients receive unnecessary vaccines because they have previously received care with different names at more than one clinic. Unfortunately this cannot always be prevented, but the incidence can be reduced if we remember to ask some critical questions from the start. What is the patient�s name? Has the patient received any immunizations under another name? What is the patient�s date of birth? Has the patient received any vaccines or shots at another clinic or healthcare facility recently? Do you have a copy of the patient�s immunization record? Certainly one of the best ways to prevent duplication of vaccines and to consolidate a patient�s immunization history is to participate in an immunization registry. Another best practice measure is to be sure that the patient or parent is provided with an immunization record and informed of how important it is to keep that record in a safe place and to bring that record anytime healthcare is sought.

5. Right Medication Right vaccine � check the label at least 3 times DT, DTaP, Td, Tdap, TT DTaP/Hib, DTaP-HepB-IPV, DTaP-IPV, DTaP-IPV/Hib Hib, Hib-HepB HepA, HepB, HepA-HepB HPV2, HPV4 IPV LAIV, TIV MenACWYD , MenACWYCRM, MPSV4 MMR, MMRV PCV7, PCV13, PPSV23 RV1, RV5 VAR, ZOS The next right on the list is the �Right Medication.� As you can see on the slide, we now have quite a variety of vaccines available. We have several vaccines that contain the same components and some have very similar names and packaging. It is more important than ever that you read the label at least 3 times before administering the vaccine to be sure that you have the correct vaccine for your patient. Here are a few situations where we have heard about mix-ups.The next right on the list is the �Right Medication.� As you can see on the slide, we now have quite a variety of vaccines available. We have several vaccines that contain the same components and some have very similar names and packaging. It is more important than ever that you read the label at least 3 times before administering the vaccine to be sure that you have the correct vaccine for your patient. Here are a few situations where we have heard about mix-ups.

6. Right Medication � Check labels at least 3 times Be sure your staff are clear on the differences between DT, Td, and TST. DT is a routine vaccine for children 6 weeks through 6 years of age who cannot receive the pertussis component of DTaP. Td contains less diphtheria toxoid than DT and about the same amount of tetanus toxoid. It is used persons 7 years of age or older. You might be surprised to see that I have added TST, a tuberculin skin test or PPD, which is not even a vaccine. But unfortunately we sometimes hear about inadvertent administration of a diphtheria and toxoid-containing vaccine in place of a TST or vice versa. This can be a real problem since DT and Td are given intramuscular and a TST is administered by the intradermal route. Be sure your staff understands the differences in these medications AND that these medications are clearly labeled in your storage unit. Be sure your staff are clear on the differences between DT, Td, and TST. DT is a routine vaccine for children 6 weeks through 6 years of age who cannot receive the pertussis component of DTaP. Td contains less diphtheria toxoid than DT and about the same amount of tetanus toxoid. It is used persons 7 years of age or older. You might be surprised to see that I have added TST, a tuberculin skin test or PPD, which is not even a vaccine. But unfortunately we sometimes hear about inadvertent administration of a diphtheria and toxoid-containing vaccine in place of a TST or vice versa. This can be a real problem since DT and Td are given intramuscular and a TST is administered by the intradermal route. Be sure your staff understands the differences in these medications AND that these medications are clearly labeled in your storage unit.

7. Right Medication � Check labels at least 3 times Confusion between DTaP and Tdap is one of the most common mix-ups we are hearing about. DTaP is for active immunization of infants and children 6 weeks through 6 years of age. Tdap is indicated for active booster immunization for persons 10 years through 64 years of age. The component antigens in DTaP and Tdap vaccines are the same, but Tdap contains less diphtheria toxoid and pertussis antigens than DTaP. This is a perfect example of those sound-alike and look-alike vaccines that can present a challenge. ACIP was concerned enough about the potential for mix-ups that they included guidance in the Adolescent Tdap recommendations about what to do if the wrong vaccine is inadvertently administered. A link to the ACIP recommendations is included in the resources for this program.Confusion between DTaP and Tdap is one of the most common mix-ups we are hearing about. DTaP is for active immunization of infants and children 6 weeks through 6 years of age. Tdap is indicated for active booster immunization for persons 10 years through 64 years of age. The component antigens in DTaP and Tdap vaccines are the same, but Tdap contains less diphtheria toxoid and pertussis antigens than DTaP. This is a perfect example of those sound-alike and look-alike vaccines that can present a challenge. ACIP was concerned enough about the potential for mix-ups that they included guidance in the Adolescent Tdap recommendations about what to do if the wrong vaccine is inadvertently administered. A link to the ACIP recommendations is included in the resources for this program.

8. Right Medication � Check labels at least 3 times Hib booster vaccines ONLY Hib (Hiberix) DTaP/Hib (TriHIBit) Must be at least 12 months of age* and Must be at least 2 months (8 weeks) after last primary Hib dose A vaccine where we�ve noticed some confusion is the new Hib vaccine, Hiberix. There are several Hib vaccine formulations available, but Hiberix is unique in that it should only be used for the booster dose following an age-appropriate primary series, which is generally 2 0r 3 doses, depending on the brand used. But sometimes a child may be so delayed in starting the Hib series that only one dose total is indicated. If this is the situation, do not use Hiberix. In order to use Hiberix, it must be the final Hib dose for a child who is at least 12 months of age and who received at least one prior dose of Hib vaccine 8 weeks or more earlier. This would also apply to the combination DTaP/Hib vaccine, TriHIBit, which should only be used for the 4th dose of DTaP and the 4th (booster dose) of Hib. And administering the Hib booster at 12 months of age is an ACIP off-label recommendation for Hiberix and TriHIBit since both package inserts indicate 15 months for the booster. A vaccine where we�ve noticed some confusion is the new Hib vaccine, Hiberix. There are several Hib vaccine formulations available, but Hiberix is unique in that it should only be used for the booster dose following an age-appropriate primary series, which is generally 2 0r 3 doses, depending on the brand used. But sometimes a child may be so delayed in starting the Hib series that only one dose total is indicated. If this is the situation, do not use Hiberix. In order to use Hiberix, it must be the final Hib dose for a child who is at least 12 months of age and who received at least one prior dose of Hib vaccine 8 weeks or more earlier. This would also apply to the combination DTaP/Hib vaccine, TriHIBit, which should only be used for the 4th dose of DTaP and the 4th (booster dose) of Hib. And administering the Hib booster at 12 months of age is an ACIP off-label recommendation for Hiberix and TriHIBit since both package inserts indicate 15 months for the booster.

9. Right Medication � Check labels at least 3 times There are now two HPV vaccines. Both HPV2 (Cervarix) and HPV4 (Gardasil) are indicated for females 9 years through 26 years of age to protect against cervical cancer. HPV4 is different in that it can also be used to protect females against vaginal and vulvar cancers and to protect against genital warts in females AND males. And, just an FYI � the age indication for HPV2 is an off-label ACIP recommendation since the package insert indicates that HPV2 is for females 10 through 25 years of age.There are now two HPV vaccines. Both HPV2 (Cervarix) and HPV4 (Gardasil) are indicated for females 9 years through 26 years of age to protect against cervical cancer. HPV4 is different in that it can also be used to protect females against vaginal and vulvar cancers and to protect against genital warts in females AND males. And, just an FYI � the age indication for HPV2 is an off-label ACIP recommendation since the package insert indicates that HPV2 is for females 10 through 25 years of age.

10. Right Medication � Check labels at least 3 times There are now 3 varicella-containing vaccines. Varicella vaccine (Varivax) is indicated for anyone 12 mos of age and older who is susceptible to chickenpox. MMRV (ProQuad) is a combination vaccine of live attenuated measles, mumps, rubella, and varicella viruses. It is indicated for susceptible children 12 months through 12 years of age. There is approximately 7 times as much varicella vaccine virus in MMRV as there is in varicella vaccine. Unfortunately, we sometimes hear about teenagers and adults inadvertently receiving MMRV. Zoster vaccine (Zostavax) is indicated for persons 60 yrs of age and older to reduce the risk of shingles and post herpetic neuralgia. Zoster vaccine contains approximately 14 times as much varicella vaccine virus as does varicella vaccine. You can imagine why we are concerned when we hear that a child has inadvertently received zoster vaccine instead of varicella vaccine. If you stock these vaccines in your clinic, be sure they are clearly labeled and we recommend you include the age indications on the labeling.There are now 3 varicella-containing vaccines. Varicella vaccine (Varivax) is indicated for anyone 12 mos of age and older who is susceptible to chickenpox. MMRV (ProQuad) is a combination vaccine of live attenuated measles, mumps, rubella, and varicella viruses. It is indicated for susceptible children 12 months through 12 years of age. There is approximately 7 times as much varicella vaccine virus in MMRV as there is in varicella vaccine. Unfortunately, we sometimes hear about teenagers and adults inadvertently receiving MMRV. Zoster vaccine (Zostavax) is indicated for persons 60 yrs of age and older to reduce the risk of shingles and post herpetic neuralgia. Zoster vaccine contains approximately 14 times as much varicella vaccine virus as does varicella vaccine. You can imagine why we are concerned when we hear that a child has inadvertently received zoster vaccine instead of varicella vaccine. If you stock these vaccines in your clinic, be sure they are clearly labeled and we recommend you include the age indications on the labeling.

11. Right Medication = Right Vaccine + Right Diluent We have several vaccines now that are provided in powder form and must be reconstituted prior to administration. An important step in providing the right vaccine is ensuring that the correct diluent (or liquid) is used to reconstitute the powder. As you can see in this table and on the next slide, the manufacturer�s diluent is very specific to their vaccine and no other diluent should ever be used. The only vaccines that share the same diluent are Merck�s MMR, MMRV, Varicella, and zoster vaccines. For the combination Pentacel vaccine, the DTaP-IPV is provided by the manufacturer already combined in liquid form to be used to reconstitute the ActHIB powder. Do not administer the DTaP-IPV liquid separately even if you have a patient who only needs DTaP and IPV. We have several vaccines now that are provided in powder form and must be reconstituted prior to administration. An important step in providing the right vaccine is ensuring that the correct diluent (or liquid) is used to reconstitute the powder. As you can see in this table and on the next slide, the manufacturer�s diluent is very specific to their vaccine and no other diluent should ever be used. The only vaccines that share the same diluent are Merck�s MMR, MMRV, Varicella, and zoster vaccines. For the combination Pentacel vaccine, the DTaP-IPV is provided by the manufacturer already combined in liquid form to be used to reconstitute the ActHIB powder. Do not administer the DTaP-IPV liquid separately even if you have a patient who only needs DTaP and IPV.

12. Right Medication = Right Vaccine + Right Diluent The newest vaccine that requires reconstitution is the new meningococcal conjugate vaccine, Menveo. Like the other meningococcal vaccines, Menveo protects against four Neiserria meningitidis serogroups. But in order for the patient to benefit from all 4 serogroups, the vaccine must be reconstituted since the powder contains serogroup A and the diluent contains serogroups, C, W, and Y. If the wrong diluent is used, we generally recommend that the dose be repeated. We have no safety and efficacy data on vaccine doses administered using the wrong diluent. Whether diluents are stored in the refrigerator or on a shelf, they should be clearly labeled indicating the vaccine or vaccines for which they should be used One final note - You should also check the manufacturer�s package information regarding the time limit for using the vaccine once it is reconstituted. The clock is ticking once the vaccine is reconstituted and the timeframe varies by vaccine.The newest vaccine that requires reconstitution is the new meningococcal conjugate vaccine, Menveo. Like the other meningococcal vaccines, Menveo protects against four Neiserria meningitidis serogroups. But in order for the patient to benefit from all 4 serogroups, the vaccine must be reconstituted since the powder contains serogroup A and the diluent contains serogroups, C, W, and Y. If the wrong diluent is used, we generally recommend that the dose be repeated. We have no safety and efficacy data on vaccine doses administered using the wrong diluent. Whether diluents are stored in the refrigerator or on a shelf, they should be clearly labeled indicating the vaccine or vaccines for which they should be used One final note - You should also check the manufacturer�s package information regarding the time limit for using the vaccine once it is reconstituted. The clock is ticking once the vaccine is reconstituted and the timeframe varies by vaccine.

13. And Remember . . . NO Home Brews!!! Never attempt to make your own combination vaccines All vaccines will come to you already premixed with the exception of those listed on the previous two slides And Remember . . . NO Home Brews!!! Never attempt to make your own combination vaccines. All vaccines will come to you already premixed with the exception of those listed on the two previous slides. And Remember . . . NO Home Brews!!! Never attempt to make your own combination vaccines. All vaccines will come to you already premixed with the exception of those listed on the two previous slides.

14. Right Time Right age Right interval Before expiration date The next right of medication administration is the �Right Time.� There are several issues to discuss here, including the �Right age,� the �Right interval,� and administration �Before the expiration date.� The next right of medication administration is the �Right Time.� There are several issues to discuss here, including the �Right age,� the �Right interval,� and administration �Before the expiration date.�

15. Right Time � Right Age and Right Interval Vaccines are recommended for members of the youngest age group at risk for experiencing the disease for whom efficacy and safety have been demonstrated. Providers should adhere as closely as possible to recommended vaccination schedules in order to provide optimal protection and efficacy. In certain circumstances, administering doses of a multidose vaccine at shorter than the recommended intervals might be necessary, e.g., when a person is behind schedule or when international travel is impending. In these situations, an accelerated schedule can be implemented that uses intervals between doses shorter than those recommended for routine vaccination. ACIP believes that when accelerated intervals are used, the immune response is acceptable and will lead to adequate protection. Doses administered too close together or at too young an age can lead to a suboptimal immune response. ACIP recommends that vaccine doses administered 4 or fewer days before the minimum interval or age be counted as valid as long as your state immunization requirements allow for the 4-day grace period. Doses administered 5 or more days earlier than the minimum interval or age of any vaccine should not be counted as valid doses and should be repeated as age-appropriate. You will find more detail on minimum ages, minimum intervals, the 4-day grace period, and the timing for repeat doses given too early in the ACIP General Recommendations. We will include a link with the program resources.Vaccines are recommended for members of the youngest age group at risk for experiencing the disease for whom efficacy and safety have been demonstrated. Providers should adhere as closely as possible to recommended vaccination schedules in order to provide optimal protection and efficacy. In certain circumstances, administering doses of a multidose vaccine at shorter than the recommended intervals might be necessary, e.g., when a person is behind schedule or when international travel is impending. In these situations, an accelerated schedule can be implemented that uses intervals between doses shorter than those recommended for routine vaccination. ACIP believes that when accelerated intervals are used, the immune response is acceptable and will lead to adequate protection. Doses administered too close together or at too young an age can lead to a suboptimal immune response. ACIP recommends that vaccine doses administered 4 or fewer days before the minimum interval or age be counted as valid as long as your state immunization requirements allow for the 4-day grace period. Doses administered 5 or more days earlier than the minimum interval or age of any vaccine should not be counted as valid doses and should be repeated as age-appropriate. You will find more detail on minimum ages, minimum intervals, the 4-day grace period, and the timing for repeat doses given too early in the ACIP General Recommendations. We will include a link with the program resources.

16. Right Time � Right Age and Right Interval HepB Only vaccine that can be given before 6 wks of age Minimum of 4 wks between Dose 1 and Dose 2; 8 wks between Dose 2 and Dose 3; 16 wks between Dose 1 and Dose 3 Minimum age for Dose 3 is 24 wks Hib Administering Hib before 6 wks of age can lead to immune tolerance and reduced response to subsequent doses of Hib Hib-HepB (Comvax) Dose 3 should not be administered before 12 mos of age RV Maximum age for Dose 1 is 14 wks 6 days* Minimum interval between doses is 4 wks Maximum age for last dose is 8 mos 0 days* These next two slides list some of the most common age and interval errors that we hear about. As shown on the slide, there are several minimum intervals and a minimum age for the 3rd dose that must be honored for HepB doses to be valid. Like all routine infant vaccines except HepB, Hib vaccine should not be administered before 6 weeks of age because of the risk of immune tolerance and a reduced response to subsequent Hib doses. The Hib-HepB combination vaccine, Comvax which should be returning to the market later this year, completes the HepB and Hib series with 3 doses. Since the last dose is the Hib booster dose, it should not be given before 12 months of age. Since there are two Rotavirus vaccines with a different dosing schedules, ACIP made an off-label recommendation and reconciled the maximum ages for the 1st and last doses. The maximum age for the first dose of either rotavirus vaccine is 14 wks, 6 days. The maximum age for the final rotavirus dose of either vaccine is 8 calendar months, 0 days.These next two slides list some of the most common age and interval errors that we hear about. As shown on the slide, there are several minimum intervals and a minimum age for the 3rd dose that must be honored for HepB doses to be valid. Like all routine infant vaccines except HepB, Hib vaccine should not be administered before 6 weeks of age because of the risk of immune tolerance and a reduced response to subsequent Hib doses. The Hib-HepB combination vaccine, Comvax which should be returning to the market later this year, completes the HepB and Hib series with 3 doses. Since the last dose is the Hib booster dose, it should not be given before 12 months of age. Since there are two Rotavirus vaccines with a different dosing schedules, ACIP made an off-label recommendation and reconciled the maximum ages for the 1st and last doses. The maximum age for the first dose of either rotavirus vaccine is 14 wks, 6 days. The maximum age for the final rotavirus dose of either vaccine is 8 calendar months, 0 days.

17. Right Time � Right Age and Right Interval DTaP Minimum age for Dose 4 is 12 mos* Minimum interval between Dose 3 and Dose 4 is 6 calendar mos IPV Minimum age for Dose 4 is 4 yrs Minimum interval between next-to-last and last dose is 6 calendar mos DTaP-IPV (Kinrix) Only approved for Dose 5 of DTaP and Dose 4 of IPV Only approved for children 4 through 6 yrs of age DTaP-IPV/Hib (Pentacel) Only approved for first 4 doses of DTaP, IPV, and Hib Only approved for children 6 wks through 4 yrs of age MMR and VAR Minimum age for each of these vaccines is12 mos We receive many questions about the timing of the 4th DTaP dose. DTaP #4 should not be given before 12 months of age and there should be a minimum interval of 6 calendar months between the 3rd and 4th doses. The minimum age of 12 months for the 4th DTaP dose is an off-label ACIP recommendation. There was a recent change in the recommendation for the 4th dose of IPV. For optimum immune response and long-term protection, the 4th dose should be given on or after the 4th birthday and the minimum interval between the next-to-last and last doses should be 6 calendar months. As the name implies, the DTaP-IPV combination, Kinrix, is a kindergarten vaccine. It should only be used for the 5th DTaP and 4th IPV doses and the child should be between the ages of 4 and 6 years. The DTaP-IPV/Hib combination, Pentacel, is only approved for the first 4 doses of DTaP, IPV, and Hib and should only be used in children 6 wks through 4 yrs of age. Other DTaP and IPV vaccines should be used for the 5th DTaP and to provide a dose of IPV after 4 yrs of age. And, finally, the first MMR and varicella vaccine doses should not be given before the 1st birthday.We receive many questions about the timing of the 4th DTaP dose. DTaP #4 should not be given before 12 months of age and there should be a minimum interval of 6 calendar months between the 3rd and 4th doses. The minimum age of 12 months for the 4th DTaP dose is an off-label ACIP recommendation. There was a recent change in the recommendation for the 4th dose of IPV. For optimum immune response and long-term protection, the 4th dose should be given on or after the 4th birthday and the minimum interval between the next-to-last and last doses should be 6 calendar months. As the name implies, the DTaP-IPV combination, Kinrix, is a kindergarten vaccine. It should only be used for the 5th DTaP and 4th IPV doses and the child should be between the ages of 4 and 6 years. The DTaP-IPV/Hib combination, Pentacel, is only approved for the first 4 doses of DTaP, IPV, and Hib and should only be used in children 6 wks through 4 yrs of age. Other DTaP and IPV vaccines should be used for the 5th DTaP and to provide a dose of IPV after 4 yrs of age. And, finally, the first MMR and varicella vaccine doses should not be given before the 1st birthday.

18. Right Time - Check the Expiration Date Another important step in administering a vaccine at the right time is checking the expiration date on the product. All vaccines and diluents have expiration dates. When the expiration date is printed as month, day, and year, the product can be used until the end of the day indicated. When the expiration date is printed with only a month and year, the product may be used up to and including the last day of the month indicated on the vial. If an expired dose of a live virus vaccine is administered, wait at least 4 weeks to repeat the dose. If an expired dose is not a live vaccine, the dose should be repeated as soon as possible. But remember, when you check that label 3 times before administering the vaccine, include the expiration date in those checks.Another important step in administering a vaccine at the right time is checking the expiration date on the product. All vaccines and diluents have expiration dates. When the expiration date is printed as month, day, and year, the product can be used until the end of the day indicated. When the expiration date is printed with only a month and year, the product may be used up to and including the last day of the month indicated on the vial. If an expired dose of a live virus vaccine is administered, wait at least 4 weeks to repeat the dose. If an expired dose is not a live vaccine, the dose should be repeated as soon as possible. But remember, when you check that label 3 times before administering the vaccine, include the expiration date in those checks.

19. Right Medication � Check labels at least 3 times And now on to the �Right Dosage.� The first thing to remember about dosage is that vaccines dosages are age-based, not weight-based because it is the size or development of the immune system, not the body that influences the dosage. We�ve already talked about several vaccines where the components are essentially the same, but the amounts differ based on age, e.g., DTaP and Tdap and Varicella and Zoster vaccines. Deciding on the appropriate dose of hepatitis vaccines seems to also cause some confusion. You�ll notice that the start age for the adult dosage of HepA vaccine is different than it is for HepB. For HepA the adult dosage should be given to persons 19 years and older. The HepB adult dosage is not started until the person is 20 years of age. AND there is a HepA-HepB combination vaccine, Twinrix, that should only be used for persons 18 years and older. Just remember � you always give the dosage based on the age the person is on the day they arrive at your clinic for that dose. The Immunization Action Coalition has produced a handy hepatitis vaccine dosage job aid. The CDC Vaccine Administration webpage has a link to it, which you can reach from this program�s resource page. And now on to the �Right Dosage.� The first thing to remember about dosage is that vaccines dosages are age-based, not weight-based because it is the size or development of the immune system, not the body that influences the dosage. We�ve already talked about several vaccines where the components are essentially the same, but the amounts differ based on age, e.g., DTaP and Tdap and Varicella and Zoster vaccines. Deciding on the appropriate dose of hepatitis vaccines seems to also cause some confusion. You�ll notice that the start age for the adult dosage of HepA vaccine is different than it is for HepB. For HepA the adult dosage should be given to persons 19 years and older. The HepB adult dosage is not started until the person is 20 years of age. AND there is a HepA-HepB combination vaccine, Twinrix, that should only be used for persons 18 years and older. Just remember � you always give the dosage based on the age the person is on the day they arrive at your clinic for that dose. The Immunization Action Coalition has produced a handy hepatitis vaccine dosage job aid. The CDC Vaccine Administration webpage has a link to it, which you can reach from this program�s resource page.

20. The Right Dosage - Split or Partial Doses Split or partial (incomplete) doses are NOT valid doses Exceptions to partial doses LAIV if person sneezes RV if infant regurgitates, spits out, or vomits Administering volumes smaller than the recommended volumes, such as split doses, can result in inadequate protection. Using multiple reduced doses that together equal a full immunizing dose or using smaller divided doses are not endorsed or recommended. Any vaccination using less than the standard dose should not be counted, and the person should be revaccinated according to age, unless serologic testing indicates that an adequate response has been achieved. We often get the question �What do we do if a needle comes loose or a child moves and less than a full dose is administered. The best option is to prevent this situation. Always tighten the needle to make sure it is securely attached to the syringe before administering the vaccine. And use safe positioning techniques to ensure that the patient is secure and the limb is stabilized prior to administration. However, despite all efforts things do happen. We recommend that if, in your clinical judgment, a significant amount of vaccine was not administered, the full dose should immediately be repeated. As Dr. Beysolow mentioned, there are exceptions to this for the intranasal & oral vaccines, LAIV & rotavirus. Administering volumes smaller than the recommended volumes, such as split doses, can result in inadequate protection. Using multiple reduced doses that together equal a full immunizing dose or using smaller divided doses are not endorsed or recommended. Any vaccination using less than the standard dose should not be counted, and the person should be revaccinated according to age, unless serologic testing indicates that an adequate response has been achieved. We often get the question �What do we do if a needle comes loose or a child moves and less than a full dose is administered. The best option is to prevent this situation. Always tighten the needle to make sure it is securely attached to the syringe before administering the vaccine. And use safe positioning techniques to ensure that the patient is secure and the limb is stabilized prior to administration. However, despite all efforts things do happen. We recommend that if, in your clinical judgment, a significant amount of vaccine was not administered, the full dose should immediately be repeated. As Dr. Beysolow mentioned, there are exceptions to this for the intranasal & oral vaccines, LAIV & rotavirus.

21. Right Route � Meningococcal Vaccines Meningococcal conjugate vaccines should be administered by the intramuscular (IM) route MenACWYD (Menactra) MenACWYCRM (Menveo) Meningococcal polysaccharide vaccine should be administered by the subcutaneous (subcut) route MPSV4 � (Menomune) Since Dr. Beysolow already discussed route and site, I just want to mention one situation where we have seen some confusion. Meningococcal conjugate vaccines, and there are now two of them, Menactra and Menveo, should be administered by the intramuscular route. Meningococcal polysaccharide vaccine, Menomune, should be administered by the subcutaneous route.Since Dr. Beysolow already discussed route and site, I just want to mention one situation where we have seen some confusion. Meningococcal conjugate vaccines, and there are now two of them, Menactra and Menveo, should be administered by the intramuscular route. Meningococcal polysaccharide vaccine, Menomune, should be administered by the subcutaneous route.

22. Best Practices When Preparing for Vaccine Administration Hand hygiene Wash hands before preparing vaccines for administration Opening the vial Discard any single-dose vial at end of clinic day if rubber diaphragm is exposed Drawing up the vaccine Not always necessary to use air displacement when drawing up vaccine Never leave a needle in a multidose vial for drawing up multiple doses I would like to briefly review some other Best Practice issues related to the preparation phase of vaccine administration. Just a reminder, be sure to wash hands not only between patients, but also before preparing the vaccines for administration. Be careful not to open a single-dose vial and expose the rubber diaphragm until you are ready to use that vial. Single-dose vials do not contain a bacteriostatic. If the vaccine is not used by the end of the clinic day, it should be discarded because it is difficult to tell if someone pierced the rubber diaphragm even though they may not have actually drawn up any vaccine. Like many of you, I was taught to displace the air before drawing vaccine from a multidose vial. I have since learned that this is not always necessary and may caused a spritz of vaccine to spew from the vial as you remove the needle. Over time this has actually been known to cause the loss of a dose of vaccine, for example only getting 9 doses instead of 10 full doses from a multidose vial. Never leave a needle in a multidose vial for the purpose of drawing up several doses of vaccine into syringes and then placing needles on the syringes. This is not safe injection practice and is poor infection control. CDC�s safe injection practice motto is �One Needle, One Syringe, Only One Time.� I would like to briefly review some other Best Practice issues related to the preparation phase of vaccine administration. Just a reminder, be sure to wash hands not only between patients, but also before preparing the vaccines for administration. Be careful not to open a single-dose vial and expose the rubber diaphragm until you are ready to use that vial. Single-dose vials do not contain a bacteriostatic. If the vaccine is not used by the end of the clinic day, it should be discarded because it is difficult to tell if someone pierced the rubber diaphragm even though they may not have actually drawn up any vaccine. Like many of you, I was taught to displace the air before drawing vaccine from a multidose vial. I have since learned that this is not always necessary and may caused a spritz of vaccine to spew from the vial as you remove the needle. Over time this has actually been known to cause the loss of a dose of vaccine, for example only getting 9 doses instead of 10 full doses from a multidose vial. Never leave a needle in a multidose vial for the purpose of drawing up several doses of vaccine into syringes and then placing needles on the syringes. This is not safe injection practice and is poor infection control. CDC�s safe injection practice motto is �One Needle, One Syringe, Only One Time.�

23. Best Practices When Preparing for Vaccine Administration Filling syringes CDC strongly discourages prefilling syringes Unused syringes prefilled by provider should be discarded at end of clinic day Never transfer vaccine or diluent from one syringe to another Never draw a partial dose from two separate vials to make one dose Preparing manufacturer prefilled syringes Sterile seal is broken when needle is added to manufacturer prefilled syringes so discard at end of clinic day, even if unused CDC strongly discourages prefilling syringes. The syringes that you use for vaccine administration are meant just for that, administration, not storage. If you do have any unused syringes that you or other staff has prefilled on hand at the end of the clinic day, these syringes should be discarded. And we never recommend trying to transfer a dose of vaccine from one syringe to another. This is not an acceptable practice and certainly does not meet infection control standards. We also hear about providers combining the last drops in one vial with the last drops in another vial trying to squeeze out one more dose. Again, this is not an acceptable practice. On occasion you may receive manufacturer prefilled syringes that do not yet have the needle attached. Do not add the needle until you are ready to use that syringe because the sterile seal will then be broken and the syringe should be discarded at the end of the clinic day, even if the vaccine was not used. CDC strongly discourages prefilling syringes. The syringes that you use for vaccine administration are meant just for that, administration, not storage. If you do have any unused syringes that you or other staff has prefilled on hand at the end of the clinic day, these syringes should be discarded. And we never recommend trying to transfer a dose of vaccine from one syringe to another. This is not an acceptable practice and certainly does not meet infection control standards. We also hear about providers combining the last drops in one vial with the last drops in another vial trying to squeeze out one more dose. Again, this is not an acceptable practice. On occasion you may receive manufacturer prefilled syringes that do not yet have the needle attached. Do not add the needle until you are ready to use that syringe because the sterile seal will then be broken and the syringe should be discarded at the end of the clinic day, even if the vaccine was not used.

24. Administer Vaccines SAFELY! Have patients seated for vaccination Consider observing patients for 15 minutes after they are vaccinated If syncope develops, patients should be observed until symptoms resolve Dr. Beysolow talked about the importance of monitoring for adverse events and being prepared for the rare emergency, should it occur. There is one adverse event that we have been hearing about that can lead to very serious consequences if proper preventive measures are not taken. I�m talking about syncope or a vasovagal response, more commonly known to as fainting. Syncope (fainting) can occur after vaccination, most commonly among adolescents and young adults. To reduce the risk of syncope and injury, ACIP recommends that providers have adolescent and adult patients seated during vaccination and then have patients remain seated in the clinic for an observation period of approximately 15 minutes after vaccination. This applies to males and females. If syncope develops, patients should be observed until the symptoms resolve. Syncope is not a contraindication to further vaccine doses and is not the same as an allergic reaction.Dr. Beysolow talked about the importance of monitoring for adverse events and being prepared for the rare emergency, should it occur. There is one adverse event that we have been hearing about that can lead to very serious consequences if proper preventive measures are not taken. I�m talking about syncope or a vasovagal response, more commonly known to as fainting. Syncope (fainting) can occur after vaccination, most commonly among adolescents and young adults. To reduce the risk of syncope and injury, ACIP recommends that providers have adolescent and adult patients seated during vaccination and then have patients remain seated in the clinic for an observation period of approximately 15 minutes after vaccination. This applies to males and females. If syncope develops, patients should be observed until the symptoms resolve. Syncope is not a contraindication to further vaccine doses and is not the same as an allergic reaction.

25. Right Documentation Document date VIS provided & date printed on VIS Document Date vaccine administered Vaccine manufacturer Lot number Clinic name & address, title of person who administers vaccine Only accept written, dated records Use state immunization registry if available There is a federal requirement that the provider record certain information about the vaccines administered. The information can be recorded in the patient�s permanent medical record or in a permanent clinic log. The information required includes: the date the VIS was given to the patient, the publication date printed on the VIS, the date the vaccine was administered, the clinic name and address and the signature and title of the individual who administered the vaccine And the vaccine manufacturer and lot number. Please note � If there is more than one number on a vaccine vial, be sure you know which one is the lot number. For example, PPSV23 has two numbers. The number above the words �Lot & Exp� is a product identification number that is the same on all vials of Pneumovax 23. The top number within the black box is the actual lot number so be sure of the number you are documenting. If you are documenting immunizations received elsewhere to consolidate a patient�s history, be sure you have that history in writing. With the exception of influenza vaccine and PPSV23, self-reported doses of vaccine without written documentation should not be accepted. If you have a state immunization registry, we recommend using the registry. In the long run it will make things so much easier for you and your patients. There are some excellent examples of proper documentation that the Immunization Action Coalition has developed. We have links to them on the CDC Vaccine Administration webpage. And now I would like to thank you for your attention and turn things back over to Dr. Kroger.There is a federal requirement that the provider record certain information about the vaccines administered. The information can be recorded in the patient�s permanent medical record or in a permanent clinic log. The information required includes: the date the VIS was given to the patient, the publication date printed on the VIS, the date the vaccine was administered, the clinic name and address and the signature and title of the individual who administered the vaccine And the vaccine manufacturer and lot number. Please note � If there is more than one number on a vaccine vial, be sure you know which one is the lot number. For example, PPSV23 has two numbers. The number above the words �Lot & Exp� is a product identification number that is the same on all vials of Pneumovax 23. The top number within the black box is the actual lot number so be sure of the number you are documenting. If you are documenting immunizations received elsewhere to consolidate a patient�s history, be sure you have that history in writing. With the exception of influenza vaccine and PPSV23, self-reported doses of vaccine without written documentation should not be accepted. If you have a state immunization registry, we recommend using the registry. In the long run it will make things so much easier for you and your patients. There are some excellent examples of proper documentation that the Immunization Action Coalition has developed. We have links to them on the CDC Vaccine Administration webpage. And now I would like to thank you for your attention and turn things back over to Dr. Kroger.