Adult Immunization: Its Your Best Shot!

A Clinician to Clinician Educational Program

California Adult Immunization Coalition

CAIC 9/2007

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.
CAIC 9/2007

Vaccine Preventable Diseases in Adults

VPD's kill hundreds of times more adults than children every year! Burden of Illness on Hospitals
114,000 15,000 Influenza admissions 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

CAIC 9/2007

Healthy People 2010 Goals and Current Coverage

Healthy People 2010 Goal
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%
PPV23 65+ PPV23 18-49 High Risk Flu 65+ Flu 18-49 High Risk Hep B MSM Hep B HCW

90%

90%

98%

60%

60%

60%

75%

70% 56%

24% 13% 9%

www.healthypeople.gov National Health Interview Survey (CDC, NCHS)

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Recommended Adult Immunization Schedule October 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 agebased schedule for women <26 years of age 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 <65 years and to the 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.
CAIC 9/2007

Centers for Disease Control and Prevention: http://www.cdc.gov/vaccines/recs/schedules/adult-schedule.htm

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-schedule.htm

CAIC 9/2007

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.
CAIC 9/2007

Centers for Disease Control and Prevention: http://www.cdc.gov/vaccines/recs/schedules/adult-schedule.htm

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:

65 years A Health Care Worker

An IVDA/MSM Pregnant A College Freshman

Flu Pneumo23 Flu MMR Hepatitis B Td/Tdap Varicella (if there is no confirmed evidence of immunity) Hepatitis A Hepatitis B Flu (TIV) Td/Tdap Meningococcal MMR

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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
CAIC 9/2007

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

CAIC 9/2007

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 TIV for others Refrigerate ONLY

Healthy 5-49 year olds with NO chronic conditions or pregnancy

MMWR. July 13, 2007 / 56(RR-06):1-54

CAIC 9/2007

Live Attenuated Influenza (LAIV)

Composition
Cold adapted intranasal vaccine-trivalent Type A (H3N2 & H1N1) and B strains included

Influenza Vaccine:

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
CAIC 9/2007

Shortage Strategy TIV Influenza Vaccine

During periods of inactivated flu vaccine shortages, vaccination is prioritized based on the risk of serious flu-related complications. In the event of a shortage, the California and local public health departments will provide guidance regarding distribution using these tiers.

Tier
1A 1B

Priority Group
Persons aged >65 years with comorbid conditions Residents of long-term care facilities Persons aged 2-64 years with comorbid conditions Persons aged >65 years without comorbid conditions Children aged 6-23 months Pregnant women Children aged 24-59 months Health-care personnel Household contacts and out-of-home caregivers of children <6 months Household contacts of children and adults at increased for influenza-related complications Healthy persons aged 50-64 years Persons aged 5-49 years without high-risk conditions

1C

ONLY if a shortage is declared!

http://www.cdc.gov/flu/professionals/vaccination/vax_priority.htm

CAIC 9/2007

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

Hepatitis B

Woman suffering from liver cancer caused by hepatitis B

CAIC 9/2007

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

Comments

Hepatitis A
Man with jaundice caused by hepatitis A

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Hepatitis A Vaccine
Composition Duration and Level of Protection
Inactivated
Predicted 20+ years after 2 doses 99%+ protected after 1 month and 1 dose Havrix and VAQTA 1 ml IM only of the adult formulation

Administration
Comments

VAQTA is preservative free Use IGIM if traveling in less than 2 weeks

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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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Varicella or Chickenpox
Woman with chickenpox

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Varicella or Chickenpox Vaccine

Composition
Live attenuated virus vaccine Keep frozen at +5F (-15C)

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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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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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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Breaking Down Barriers to Immunization

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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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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

CAIC 9/2007

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.

CAIC 9/2007

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.

CAIC 9/2007

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.

CAIC 9/2007