Adult Immunization: Its Your Best Shot A Clinician to Clinician Educational Program

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Adult ImmunizationIts Your Best Shot!A
Clinician to Clinician Educational Program

• California Adult Immunization Coalition

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Important Disclaimer
This slide set is presented to you on behalf of
the California Adult Immunization Coalition.
It is an educational tool that should be used
alongside ACIP and other published guidelines and
only by qualified healthcare professionals.
The information contained in the presentation is
accurate as of the date it was released Sept.
12, 2007.
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Vaccine Preventable Diseases in Adults

• VPD's kill hundreds of times more adults than
  children every year!
• Burden of Illness on Hospitals
• 114,000 Influenza admissions
• 15,000 Hepatitis admissions
• More than 40,000 deaths per year
• 20-40,000 from pneumonia and influenza
• 5,000 from hepatitis B
• Adult IZ Coverage levels generally low

Strengthening Adult Immunization A Call to
Action, Partnership for Prevention, 2005
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Healthy People 2010 Goals and Current Coverage
Healthy People 2010 Goal
www.healthypeople.gov National Health Interview
Survey (CDC, NCHS)
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Recommended Adult Immunization ScheduleOctober
2006September 2007
For everyone
Risk factors other than age
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Select Changes to the Adult Immunization Schedule

• Human papillomavirus (HPV) vaccine was added to
  the age-based schedule for women with all indications except pregnancy. A footnote
  was added to reflect these recommendations.
• Tdap vaccine has been added to the age-based
  schedule, for persons medical/other indications schedule for all
  indications except pregnancy. The tetanus and
  diphtheria footnote has been reworded to reflect
  ACIP recommendations.
• The measles, mumps, and rubella (MMR) footnote
  has been reworded to reflect ACIP recommendations
  to administer a second dose of mumps vaccine to
  adults in certain age groups and with certain
  risk factors.

Centers for Disease Control and Prevention
http//www.cdc.gov/vaccines/recs/schedules/adult-s
chedule.htm
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Select Changes to the Adult Immunization
Schedule (CONTINUED)

• The varicella schedule reflects new ACIP
  recommendations for administering a routine
  second dose for all adults without evidence of
  immunity and a new definition of evidence of
  immunity
• documentation of 2 doses of varicella vaccine 4
  weeks apart
• born before 1980 (for HCWs pregnant women,
  birth before 1980 should not be considered
  evidence of immunity)
• history of varicella based on diagnosis or
  verification by a HCP
• history of herpes zoster based on HCP diagnosis
  OR
• laboratory evidence of immunity or laboratory
  confirmation of disease.
• ACIP recommendations have also been updated to
  reflect a recommendation for prenatal assessment
  and postpartum vaccination expanding the use of
  the varicella vaccine for certain HIV-infected
  children, and establishing middle school, high
  school, and college entry vaccination
  requirements.

Centers for Disease Control and Prevention
http//www.cdc.gov/vaccines/recs/schedules/adult-s
chedule.htm
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Select Changes to the Adult Immunization
Schedule (CONTINUED)

• The influenza footnote has been revised to
  reflect ACIP recommendations to vaccinate close
  contacts of children aged 059 months rather than
  023 months.
• The hepatitis B footnote has been revised to
  reflect recommendations to vaccinate any adult
  seeking protection from hepatitis B virus
  infection and vaccinate adults in specific
  settings.

Centers for Disease Control and Prevention
http//www.cdc.gov/vaccines/recs/schedules/adult-s
chedule.htm
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If Your Patient ( 18 years old) HasThey Need

• DM
• CVD
• COPD
• Immunodeficiency
• Chronic Alcoholism
• Kidney Failure
• Asplenia

VACCINES
Pneumo23 and Flu (TIV)
Pneumo23 Meningococcal
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If Your Patient isThey Need
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Vaccine Essentials
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Tetanus Diphtheria- Acellular Pertussis Vaccine

• Composition of Tdap
• Inactivated
• Tetanus and diphtheria toxoids pertussis
  antigens
• Duration and Level of Protection
• 10 years (for Td) unknown for Tdap
• 99 protection
• Administration
• DECAVAC (Td), Boostrix (licensed for 10-18 year
  olds) or Adacel (Tdap)
• 0.5 ml IM only
• Comments
• Tdap is the recommended booster for adults, 19-64
  years, including pregnant women

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Diphtheria United States, 1980-2004Age
Distribution of Reported Cases
"Epidemiology and Prevention of
Vaccine-Preventable Diseases", National
Immunization Program, Centers for Disease
Control and Prevention, 2007.
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TetanusUnited States, 1980-2003Age Distribution
of Reported Cases
"Epidemiology and Prevention of
Vaccine-Preventable Diseases", National
Immunization Program, Centers for Disease
Control and Prevention, 2007.
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Pertussis Complications by AgeCases reported to
CDC 1997-2000
N28,187
"Epidemiology and Prevention of
Vaccine-Preventable Diseases", National
Immunization Program, Centers for Disease
Control and Prevention, 2007.
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Influenza
Spanish Influenza Pandemic, 1918 Influenza Ward,
U.S. Army Field Hospital No. 29, Hollerich,
Luxembourg
Influenza germs spread through the air through a
cough
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Influenza Vaccine Trivalent Inactivated

• Composition
• Inactivated
• Type A (H3N2 H1N1) and B strains included
• Duration and Level of Protection
• Revaccinate yearly
• Highly protective
• Protects individuals
• Limits the spread of influenza
• Administration
• Fluarix, Fluzone, Fluvirin, FluLaval
• 0.5 ml IM only
• Comments
• Do not use in people with egg allergy
• Start vaccinating in September-October and
  continue through March

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Live Attenuated Influenza Vaccine(LAIV)
Cold Adapted Influenza Vaccine , trivalent
(FluMist)
LAIV for Healthy HCWs, Children Adults
0.1 ml each nostril
Refrigerate ONLY
TIV for others
Healthy 5-49 year olds with NO chronic conditions
or pregnancy
MMWR. July 13, 2007 / 56(RR-06)1-54
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Influenza Vaccine Live Attenuated Influenza
(LAIV)

• Composition
• Cold adapted intranasal vaccine-trivalent
• Type A (H3N2 H1N1) and B strains included
• Duration and Level of Protection
• Revaccinate yearly
• Similar efficacy to TIV
• Administration
• Flumist
• 0.2 ml intranasal (0.1 ml per nostril)
• Comments
• Do not use in people with egg allergy
• Store at 35F-- 46F
• Start vaccinating in September-October and
  continue through March

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Hospitalization Rates for Influenza By Age and
Risk Group
Rate (not high-risk) 496-1038 186 86 41 23-25
13-23 125-228
Rate (high-risk) 1900 800 320 92 56-110 392-6
35 399-518
Age Group 0-11 mos 1-2 yrs 3-4 yrs 5-14
yrs 15-44 yrs 45-64 yrs 65 yrs
Data from several studies 1972 - 1995
Hospitalizations per 100,000 population
"Epidemiology and Prevention of
Vaccine-Preventable Diseases", National
Immunization Program, Centers for Disease
Control and Prevention, 2007.
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Shortage StrategyTIV Influenza Vaccine
ONLY if a shortage is declared!
http//www.cdc.gov/flu/professionals/vaccination/v
ax_priority.htm
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Pneumococcal Vaccine

• Composition
• Inactivated pure polysaccharide
• 23 strains of S. pneumoniae
• Duration and Level of Protection
• 3-5 years (maximum 2 doses)
• 60-70 effective against Invasive Pneumococcal
  Disease
• Administration
• Pneumovax 23
• 0.5 ml IM or SC
• Comments
• Not effective in children

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• Invasive Pneumococcal Disease
• Incidence by Age Group1998

Rate per 100,000 population Source Active
Bacterial Core Surveillance/EIP Network
"Epidemiology and Prevention of
Vaccine-Preventable Diseases", National
Immunization Program, Centers for Disease
Control and Prevention, 2007.
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Hepatitis B
Woman suffering from liver cancer caused by
hepatitis B
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Hepatitis B Vaccine

• Composition
• Inactivated
• Recombinant HBsAg (yeast)
• Duration and Level of Protection
• 15 years
• After 3 doses, 90 protection
• Administration
• Recombivax HB and Engerix-B
• 1 ml IM only of the adult formulation
• Comments
• Brands are interchangeable
• Can accelerate the series

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Hepatitis B IncidenceUnited States, 1978-2004
"Epidemiology and Prevention of
Vaccine-Preventable Diseases", National
Immunization Program, Centers for Disease
Control and Prevention, 2007.
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Hepatitis A
Man with jaundice caused by hepatitis A
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Hepatitis A Vaccine

• Composition
• Inactivated
• Duration and Level of Protection
• Predicted 20 years after 2 doses
• 99 protected after 1 month and 1 dose
• Administration
• Havrix and VAQTA
• 1 ml IM only of the adult formulation
• Comments
• VAQTA is preservative free
• Use IGIM if traveling in less than 2 weeks

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Hepatitis A Incidence by Age GroupUnited
States, 1997
rate per 100,000 population. 1997 data.
"Epidemiology and Prevention of
Vaccine-Preventable Diseases", National
Immunization Program, Centers for Disease
Control and Prevention, 2007.
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Hepatitis A Incidence by Age GroupUnited
States, 1990-2004
"Epidemiology and Prevention of
Vaccine-Preventable Diseases", National
Immunization Program, Centers for Disease
Control and Prevention, 2007.
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Measles, Mumps, Rubella

• Composition
• Live attenuated virus vaccine
• Duration and Level of Protection
• Lifelong protection
• 99 are protected after 2 doses
• Administration
• MMR II
• 0.5 ml SC (use for adults and pediatrics)
• Comments
• Immunity may be assumed by
• Antibody titers
• Born before 1957
• Immunization record with record of 1 dose
• Titers often required for healthcare workers
• Store frozen

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Measles
Koplik spots on the inside of the mouth that
occur 24-48 hours before the measles rash stage
Measles rash
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MeaslesUnited States, 1975-2002 Age Distribution
of Reported Cases
"Epidemiology and Prevention of
Vaccine-Preventable Diseases", National
Immunization Program, Centers for Disease
Control and Prevention, 2007.
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Measles Complications by Age Group
"Epidemiology and Prevention of
Vaccine-Preventable Diseases", National
Immunization Program, Centers for Disease
Control and Prevention, 2007.
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Mumps - United States, 1980-2003Age Distribution
of Reported Cases
40 yrs
"Epidemiology and Prevention of
Vaccine-Preventable Diseases", National
Immunization Program, Centers for Disease
Control and Prevention, 2007.
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Rubella - United States, 1980-2003Age
Distribution of Reported Cases
"Epidemiology and Prevention of
Vaccine-Preventable Diseases", National
Immunization Program, Centers for Disease
Control and Prevention, 2007.
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Varicella or Chickenpox
Woman with chickenpox
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Varicella or Chickenpox Vaccine

• Composition
• Live attenuated virus vaccine
• Keep frozen at 5?F (-15?C)
• Duration and Level of Protection
• Should have lifelong protection
• 99 after 2 doses
• Administration
• Varivax
• 0.5 ml SC (use for adults and pediatrics)
• Comments
• Serologic testing in adults is recommended
• Effect on epidemiology of shingles is unknown

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Varicella Antelope Valley, California,
1995-2004Cases by Month
"Epidemiology and Prevention of
Vaccine-Preventable Diseases", National
Immunization Program, Centers for Disease
Control and Prevention, 2007.
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Meningococcal Vaccine

• Composition
• Inactivated, tetravalent (A,C,Y,W-135)
• Pure polysaccharide (MPSP4) and conjugate (MCV4)
• Duration and Level of Protection
• 3-5 yrs for MPSP4 and 5 yrs for MCV4
• 85 against A and C strains
• Administration
• Menomune (MPSP4) and Menactra (MCV4)
• 0.5 ml SC (MPSP4) and 0.5 ml IM (MCV4)
• Comments
• MCV4 only indicated for 11-55 yrs
• Substitute MCV4 for MPSP4 whenever possible
• High diphtheria toxoid content of MCV4 does not
  change spacing recommendations with other vaccines

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Meningococcal Disease United States, 1972-2004
"Epidemiology and Prevention of
Vaccine-Preventable Diseases", National
Immunization Program, Centers for Disease
Control and Prevention, 2007.
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New Vaccines
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HPV Vaccine (Quadrivalent)

• Indication (Gardasil)
• Prevention of HPV related cancers due to HPV 16
  and 18
• Prevention of genital warts due to HPV 6 and 11
• Composition
• Derived from non - infectious HPV - like
  particles (VLP), composed of the L1 major capsid
  protein
• Duration and Level of Protection
• The length of vaccine protection unknown, but
  studies indicate protection for at least five
  years.
• Administration
• 0.5 mL, IM route
• 3 dose series (0, 2, 6 months)
• Comments
• Quadrivalent HPV is not recommended for use in
  pregnancy
• Vaccine is contraindicated for people with a
  history of immediate hypersensitivity to yeast or
  to any vaccine component
• At present, cervical cancer screening
  recommendations have not changed for females who
  receive quadrivalent HPV vaccine

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Prevalent Cancer- Causing HPV Types
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HPV Recommendations

• Routine vaccination with three doses of
  quadrivalent HPV vaccine is recommended for
  females 11-12 years of age
• Catch up vaccination is recommended for females
  13-26 yrs of age who have not been vaccinated
  previously or who have not completed the full
  vaccine series
• Special situations
• Can be given to females who have an equivocal or
  abnormal Pap test, positive Hybrid Capture II
  test, or genital warts
• Lactating women can receive the vaccine
• Females who are immunocompromised either from
  disease or medication can receive quadrivalent
  HPV vaccine

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Breaking Down Barriers to Immunization
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Barriers to Immunization of Adults

• System Barriers
• Provider Barriers
• Patient Barriers

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System Barriers

• Distribution
• Communication
• Redistribution
• Documentation in medical record

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Provider Barriers

• Uncertainty about who should be vaccinated
• Missed opportunities
• Written consent
• Cost and reimbursement issues

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Patient Barriers

• Lack of recommendation from health care provider
• Changing ACIP recommendations
• Myths about vaccines
• Access to vaccine
• Cost of vaccines
• Needle Phobia
• Negative media stories

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Comprehensive Program to Deliver Adult
Immunizations
Briss et al., The Guide to Community Preventive
Services, 2000.
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Strategies to Improve Adult Immunization Rates
Short Term

• Effective Evidence-Based Strategies
• Reminders
• Provider and Patient
• Education
• Staff, Provider and Patient
• Offer alternative sites for vaccine
  administration

NFID. A Call To Action Improving Influenza And
Pneumococcal Immunization Rates Among High-risk
Adults
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Strategies to Improve Adult Immunization Rates-
Long Term

• Effective Evidence-Based Strategies
• Organizational change
• Standing orders, standardized procedures,
  preprinted orders
• Expanded access to vaccinations
• Financial incentives
• Provider and Patient, including reducing
  out-of-pocket costs
• Assessment and feedback

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Simple Steps You Can Take to Improve Rates

• Dont underestimate the impact of a provider
  recommendation to get vaccinated!
• Educate staff in your office or facility enlist
  everyone from the front desk to the exam room to
  encourage patients to get vaccinated.
• Work toward a specific vaccination goal for your
  practice or facility.

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Simple Steps You Can Take to Improve Rates
(CONTINUED)

• Use every encounter with a patient as an
  opportunity to immunize or educate!
• Offer walk-ins and evening or weekend shot
  clinics.
• Use a simple reminder system.
• Make reminder calls or send reminder letters.
• Use a colorful poster (Ask us if you are due for
  any shots today!) to prompt patients.
• Record a reminder message on your hold message.
• Include a reminder message in materials mailed to
  your patients.
• Use chart stickers or preventive flow sheets to
  remind clinicians staff when shots are due.

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Key Messages The Problem

• Adult vaccination rates fall far below Healthy
  People 2010 leaving thousands of adults at risk
  for vaccine preventable diseases.
• Many barriers contribute to low immunization
  rates.
• Many adults are not aware of their need to
  receive immunizations as a preventive care
  measure.

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Key Messages Solutions

• The ACIP and CDC provide clear age and risk-based
  recommendations for adult vaccinations.
• Clinicians have a key role in communicating
  preventive care messages to their patients.
• A range of strategies including system changes
  have been found to be highly effective in
  increasing adult immunization rates.

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Questions?
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A Statewide Campaign to promote National Adult
Immunization Awareness Week September 23 29,
2007
Thank you for your efforts to improve adult
immunization systems and coverage levels.
For additional materials and information, please
visit our website at www.immunizecaadults.org!
This project is sponsored by the CAIC.