Vaccine Update and
Refresher for Immunizations:
2012
Krista D. Capehart, PharmD, MSPharm, AE-C
David G. Bowyer, R. Ph.
Assistant Professors of Pharmacy Practice
University of Charleston School of Pharmacy
Objectives
• Determine the appropriate vaccine recommendations for a patient
based on current immunization schedules.
• Apply individual vaccine characteristics to identify anticipated
vaccine adverse events.
• Explain the Advisory Committee on Immunization Practices (ACIP)
recommendations for vaccines pharmacists can administer in West
Virginia.
• Summarize critical information needed for the administration of
influenza and pneumococcal.
• Investigate information about the vaccines added to Title 15 Series
12 of the West Virginia Code for immunization rules.
Pharmacist Administered
Immunizations in WV
• HB 3056 passed in 2008 authorizing specially trained
pharmacists in WV to administer influenza and
pneumococcal polysaccharide
• Additional vaccines could be added following joint rulemaking with WV Board of Medicine, WV Board of
Osteopathy, and WV Board of Medicine
• Summer 2011 joint rule-making occurred and was
approved by the 2012 Legislature
• Pharmacists can now administer Hepatitis A, Hepatitis B,
Tetanus, and Herpes Zoster in addition to influenza and
pneumococcal vaccines
Current Title 15 – Series12
• Qualifications for pharmacists to
administer immunizations:
– Any person ≥ 18 years old
– Registered with the Board of Pharmacy (BOP) to
administer immunizations
– Successfully complete immunization training course
approved by the BOP
– Maintain current certification to basic life-support
– Complete 2 hours annually of continuing education
related to immunizations
Current Title 15 – Series12
• Must have immunization questionnaire and consent form, notify
patient’s primary care provider (PCP) within 30 days of
administration
• Report the administration to the WV Statewide Immunization
Information (WVSII) database within 30 days of administration
• Must have consent & questionnaire readily retrievable and
maintained on file for not less than 5 years
• Pharmacists can administer epinephrine and diphenhydramine to
manage acute allergic reaction following CDC guidelines
• Pharmacists must have readily retrievable emergency response plan
as outlined by the CDC and a readily retrievable emergency kit to
manage an acute allergic reaction to an immunization administered
Pharmacists as Immunizers in
WV
• As of June 2012, 1663 pharmacists have
completed the mandated training course and
are registered with the West Virginia Board of
Pharmacy as Immunizing Pharmacists.
• This represents approximately 50% of the
pharmacists practicing in WV.
• This addition to the immunizing workforce
increases the access to immunizations for the
public.
Updates to Title 15 – Series 12
• Adds:
–
–
–
–
Hepatitis A
Hepatitis B
Herpes Zoster
Tetanus (follows CDC recommendations and permits tetanusdiphtheria (Td) or tetanus-diphtheria-pertussis (Tdap)
• Pharmacists must report all adverse
events to the Vaccine Adverse Events
Reporting System (VAERS) and provide a
copy to the BOP (available at
http://vaers.hhs.gov/index)
Case Study 1
• A family comes in to the pharmacy. The mother
is a 40yo WF with a 15yo WM and 19 WF
children requests immunizations for herself and
her family. After discussing with her what she
needs, you determine that they all need TIV and
her daughter needs Hep B.
• What immunizations could the pharmacist
currently provide for the family?
Advisory Committee on Immunization
Practices (ACIP)Recommendations for Adult
Influenza Immunizations
• Vaccination recommended for all adults (including
healthy adults 19-49 years without risk factors)
• Live attenuated influenza vaccine – only approved for
healthy non-pregnant people age 2-49 years
• 65 years and older can get standard-dose Trivalent
inactivated influenza vaccine (TIV) or the high does TIV
• Give 1 dose every year in the fall or winter
• Begin vaccination as soon as vaccine is available and
continue until supply is depleted
• If 2 or more live virus vaccine are given – give same day
or they must be separated by at least 28 days
Needle Tips from the Immunization Action Coalition Volume 21 Number 3 July 2011 available at www.immunize.org
Advisory Committee on Immunization
Practices (ACIP)Recommendations for Adult
Influenza Immunizations
• Mild illness is not a contraindication
• Contraindications:
– Previous anaphylactic reaction to vaccine, components, or eggs
– LAIV only: pregnancy, chronic pulmonary problems, cardiovascular
(except hypertension), renal, hepatic, neurological/neuromuscular,
hematologic, or metabolic disorders, immunosuppression
• Precautions:
– Moderate or severe acute illness
– History of Guillain-Barre syndrome within 6 weeks of previous influenza
– LAIV only: taking antivirals 48 hours before vaccination and avoid using
antivirals for 14 days after vaccination
Needle Tips from the Immunization Action Coalition Volume 21 Number 3 July
2011 available at www.immunize.org
Estimates of Cumulative Influenza
Vaccination Coverage for 2010-2011
Season
•
•
•
•
West Virginia 48%
United States 43%
Among those ≥ 18 years in US vaccination rate 40.4%
High risk group remains: elderly, young children,
pregnant women, and people with chronic conditions
• Healthy People 2020 target is:
– 80% for persons 6 months – 64 years
– 90% for those ≥ 65 years
Final state-level influenza vaccination coverage estimates for the 2010–11 season–United
States, National Immunization Survey and Behavioral Risk Factor Surveillance System, August
2010 through May 2011 available at
http://www.cdc.gov/flu/professionals/vaccination/coverage_1011estimates.htm
Influenza Activity
U.S. 2010-2011
• Higher rates of hospitalization in ≥ 65
years than in 2011-2012
• 22% of specimens tested were positive
with the virus peaking in February 2011
• 74% of positive specimens were Type A
and 26% were Type B
• Proportion of specimens testing positive
was <10% during the week ending April
16, 2011
MMWR 2011;60(21):705-712
Resistance in 2010 to Antivirals
• 5,758 influenza viral specimens tested for resistance
• All 723 influenza B were sensitive to oseltamivir and
zanamivir
• 2 of 806 Influenza A (H3H2) were resistant to oseltamivir
• All 784 influenza A (H3H2) were sensitive to zanamivir
• Of the 4,229 influenza A (H1N1) 39 were resistant to
oseltamivir; of the 771 testes with zanamivir, all were
sensitive
• High resistance to adamantanes (amantadine and
rimantadine)
MMWR 2011;60(21):705-712
2010-2011 Pneumonia and
Influenza Related Mortality
• Percentage of deaths attributable to
pneumonia and influenza exceeded the
epidemic threshold from January 29, 2011
to April 23, 2011
• Peaked at 8.9% week ending February 12,
2011
• From October 3, 2010 to May 21, 2011
had 311 lab confirmed influenzaassociated deaths were reported to CDC
MMWR 2011;60(21):705-712
Place of Influenza Vaccination
Among Adults US 2010-11 Season
• Overall: doctor’s office was the most common
place (39.8%), followed by “store” (supermarket
or drug store) at 18.4%, and workplace 17.4%
• Those 65 and older were most likely (51.5%) to
be vaccinated at a doctor’s office than a store
(24.3%)
• High risk individuals were more likely to get their
vaccination in a doctor’s office than those
without (49.1% vs 35.7%)
MMWR; 60(23): 781-785
.
Early Estimates of Cumulative
Influenza Vaccination Coverage for
2011-2012 Season
• Among adults ≥ 18 years, estimated vaccination coverage was
45.5%, an increase from 41.1% the previous season
• Estimated 2011-12 coverage among adults 18-49 years
increased by 7 percentage points compared to the 2010-11
season.
• Estimated coverage among adults increased with each increase
in adult age group. Estimated coverage among adults was
highest in adults ≥ 65 years (70.8%) and lowest among adults
18-49 years (35.8%).
• Estimated coverage among adults 50 to 64 years or ≥ 65 years
did not differ when compared to the same time the previous
season.
March 2012 National Immunization Survey and National Flu Survey - United States, 2011-12 Influenza Season
http://www.cdc.gov/flu/professionals/vaccination/nfs-survey-march2012.htm accessed 6/6/12
Place of Vaccination 2011-12
• The most common place of vaccination among
adults (32.5%) was a doctor’s office These results
are similar to results from the 2010-11 season
when 31.6% of adults were vaccinated in doctor’s
offices.
• Other common places of influenza vaccination
reported for adults during the 2011-12 season
included medically related places besides doctor’s
offices (24.7%), pharmacies or stores (19.7%),
and workplaces (13.8%).
•
March 2012 National Immunization Survey and National Flu Survey - United States, 2011-12 Influenza Season
http://www.cdc.gov/flu/professionals/vaccination/nfs-survey-march2012.htm accessed 6/6/12
Pneumococcal disease
• Pneumococcal disease most often occurs in older people as
well as in people with a predisposing condition (e.g.,
pulmonary disease, asplenia).
• Pneumococcal disease most commonly presents as a serious
infection in the lungs (pneumonia), blood (bacteremia), or
brain (meningitis). The annual U.S. case estimate for invasive
pneumococcal disease (bacteremia and/or meningitis) is
40,000.
• PPSV is 60–70% effective in preventing serious
pneumococcal disease; it does not provide substantial
protection against all types of pneumonia (viral and bacterial).
It is not a “pneumonia” vaccine.
Pneumococcal Polysaccharide Vaccination Pocket Guide :
http://www.immunize.org/ppvguide/pocketguide.pdf; accessed 6/6/12
Pneumococcal Polysaccharide
(PPSV)
• Recommended for people 65 years and older; younger
than 65 years with chronic illnesses or other risk factors
(cardiac, pulmonary, liver disease, alcoholism, diabetes,
cigarette smoking); Those at highest risk including
asplenia, immunocompromising condition,
chemotherapy, or has received organ or bone marrow
transplant
• Give 1 dose if history is unknown or unvaccinated
• Give a 1 time revaccination to:
– Age 65 years and older if 1st dose was before age 65 years and
more than 5 years ago
– Age 19-64 years at high risk of fatal pneumococcal infection and
5 years have elapsed since the 1st dose
Needle Tips from the Immunization Action Coalition Volume 21 Number 3 July 2011 available at
www.immunize.org
Estimated proportion of adults who
received Pneumococcal vaccination
2010
• 19–64 yrs, high risk
18.5
• ≥65 yrs
59.7
• Healthy People 2020 goals call for 90 % of the
non-institutionalized adults aged 65 years and
older and 60% of non-institutionalized high-risk
adults aged 18 to 64 years to be immunized.
• Neither overall coverage nor coverage for any
specific age or racial/ethnic group differed
significantly from 2009 coverage.
National Health Interview Survey, United States, 2010-MMWR February 3, 2012 / 61(04);66-72 accessed 6/6/12
Case Study 2
• A 70 yo male comes into the pharmacy to be
immunized for influenza and pneumococcal. He
had his last flu shot last year and pneumococcal
when he was 60yo.
• He asks about the nasal flu vaccine. Is he a
candidate? Why or why not?
• He asks about the “high dose” flu vaccine. Is he
a candidate? Why or why not?
• Should he get his PPSV today? Why or why
not?
Herpes Zoster (Shingles) – Give
Subcutaneous Injection
•
•
•
•
•
For people age 60 years and older
Give 1 time dose if unvaccinated, regardless of history of shingles or
chickenpox
If giving 2 or more live vaccines at same time (MMR, Zoster, Yellow fever),
should be given on the same day or must be separate by 28 days
Contraindications
– Previous anaphylactic reaction to any component of vaccine
– Primary cellular or acquired immunodeficiency
– Pregnancy
Precautions
– Moderate or severe acute illness
– Receipt of antivirals 24 hours before vaccination; if possible, delay
resuming antivirals for 14 days after vaccination
Needle Tips from the Immunization Action Coalition Volume 21 Number 3 July 2011
available at www.immunize.org
Tetanus
• Comes as tetanus-diphtheria (Td), tetanus-diphtheria-pertussis
(Tdap), or tetanus (TT)
• Give intramuscular
• All who do not have written documentation of a primary series of at
least 3 doses of tetanus and diphtheria
• Booster of Td or Tdap may be needed for wound management
• In pregnancy, give Td or Tdap if indicated in 2nd or 3rd trimester. If
not given during pregnancy, give Tdap immediate postpartum period
• Tdap ONLY:
– Adults <65 years who have not already had Tdap
– Adults of any agent in close contact with infants < 12 months who have not had a
dose of Tdap
– Healthcare personnel of all ages
– Adults ≥ 65 years without a risk factor may also be vaccinated with Tdap
Needle Tips from the Immunization Action Coalition Volume 21 Number 3 July 2011
available at www.immunize.org
Tetanus (cont.)
• Schedule
– Those unvaccinated or behind, complete the primary Td series (spaced at 0, 12months, 6-12 month intervals); substitute a one-time dose of Tdap for one of
the doses in the series, preferably the first
– Give Td booster every 10 years after primary series has been completed
– Tdap can be given regardless of interval since previous Td
• Contraindications
– Previous anaphylactic reaction to vaccine or components
– For Tdap only, history of encephalopathy, not attributable to an
identifiable cause, within 7 days following DTP/DTaP
• Precautions
– Moderate and severe acute illness
– Guillian-Barre syndrome within 6 weeks following previous dose of
tetanus toxoid containing vaccine
– Progressive or unstable neurologic disorder, uncontrolled seizures, or
progressive neuropathy
Needle Tips from the Immunization Action Coalition Volume 21 Number 3 July 2011
available at www.immunize.org
Hepatitis A (Hep A)
• Give Intramuscularly
• All who want protection from Hep A and those who work or travel
anywhere EXCEPT U.S., Western Europe, New Zealand, Australia,
Canada, and Japan
• Those with chronic liver disease; injecting & non-injecting drug
users; men having sex with men; those getting clotting concentrates;
those who work in labs with Hep A; some food handlers
• People with close contact with an international adoptee from a
country of high or intermediate endemicity during the first 60 days
following the adoptee’s arrival in the US
• Adults age 40 years or younger with recent (within 2 weeks)
exposure to Hep A. For older people (<40years), with recent (within
2 weeks) exposure to Hep A immune globulin is preferred over the
Hep A Vaccine
Needle Tips from the Immunization Action Coalition Volume 21 Number 3 July 2011 available at
www.immunize.org
Hepatitis A (Hep A) cont.
• Give 2 doses; minimum interval between doses
1 and 2 is six months
• If 2nd dose is delayed, don’t repeat the first dose,
just give the second dose.
• Contraindications:
– Previous anaphylactic reaction to this vaccine or to
any of its components.
• Precautions:
– Moderate or severe acute illness
– Weigh risk versus benefit in pregnancy
Needle Tips from the Immunization Action Coalition Volume 21 Number 3 July 2011
available at www.immunize.org
Hep A and Hep B Combination
(Twinrix®)
• For 18 years and older
• 3 doses on 0,1, and 6 month schedule
• At least 4 weeks between dose 1 and 2 and 5 months
between dose 2 and 3
• OR
• Alternative schedule: 0, 7day, 21-30 day, and a booster
at 12 months
Needle Tips from the Immunization Action Coalition Volume 21 Number 3 July 2011
available at www.immunize.org
Hep B
• Give intramuscularly
• All who want to be protected against Hep B
• High risk: household contacts, sex partners,
injecting drug users, those not in long term mutually
monogamous relationships, men having sex with
men, people with HIV, persons seeking STD
evaluation or treatment, hemodialysis patients,
healthcare personnel and public safety workers,
inmates at long term correction facilities, chronic
liver disease and certain international travel
Needle Tips from the Immunization Action Coalition Volume 21 Number 3 July 2011 available
at www.immunize.org
Hep B (cont.)
• 3 doses on a 0, 1, 6 month schedule
• At least 4 weeks between dose 1 and 2, at least
eight weeks between doses 2 and 3, at least
sixteen weeks between doses 1 and 3
• If patients fall behind in schedule, do not start
over just pick up where left off
• Contraindications: previous anaphylactic
reaction to this vaccine or any components
• Precautions: Moderate or severe acute illness
Needle Tips from the Immunization Action Coalition Volume 21 Number 3 July
2011 available at www.immunize.org
Case study 3
• A 70yo patient comes into the pharmacy. She is
interested in getting her flu shot, pneumococcal
vaccine, and anything else she “needs” before
she goes to Arizona to help take care of her new
twin granddaughters who are 6 weeks old.
• What other information do you need to know?
• What vaccinations does she need?
• What could the pharmacist give her today?
References
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Needle Tips from the Immunization Action Coalition Volume 21 Number 3 July 2011
available at www.immunize.org
Final state-level influenza vaccination coverage estimates for the 2010–11
season–United States, National Immunization Survey and Behavioral Risk
Factor Surveillance System, August 2010 through May 2011 available at
http://www.cdc.gov/flu/professionals/vaccination/coverage_1011estimates.htm
MMWR 2011;60(21):705-712
MMWR 2011; 60(23): 781-785.
MMWR 2011:60(33):1128-1132.
Questions & Answers Fluzone High–Dose Seasonal Influenza Vaccine available
at http://www.cdc.gov/flu/protect/vaccine/qa_fluzone.htm
Intradermal Influenza (Flu) Vaccination available at
http://www.cdc.gov/flu/protect/vaccine/qa_intradermal-vaccine.htm
Vaccines, Blood and Biologics FDA Updated Communication on Use of Jet Injectors
with Influenza Vaccines. Available at
http://www.fda.gov/BiologicsBloodVaccines/Vaccines/QuestionsaboutVaccines/ucm2
76773.htm
accessed on October 26, 2011.