Calling the Shots: Addressing vaccination concernsShelby Kelsh, PharmD, BCPS

Assistant Professor, Ferris State University

Conflicts of interest

Shelby Kelsh has no conflicts of interest to disclose.

Objectives

Recall the current state of measles and hepatitis A outbreaks in Michigan

Describe the recent changes to Advisory Committee for Immunization Practices (ACIP) recommendations for select vaccines.

Educate patients about the benefits of vaccines and address common concerns about vaccines.

Outbreak Status

Hepatitis A in Michigan

Michigan cases since August 2016

Total Cases 918

Hospitalizations 737 (80.3%)

Deaths 28 (3.1%)

MDHHS. Michigan Hepatitis A 2016-2019 Outbreak Summary. ww.michigan.gov/documents/mdhhs/HepA_Summ_County_SEMI2016_updated91517_601552_7.pdf

HepA Vaccination and Cases

Michigan Pharmacists Association. MDHHS pharmacy white paper. Oct 2018.

Measles cases in the USA

CDC. Measles Cases and Outbreaks. July 22, 2019. Website: https://www.cdc.gov/measles/cases-outbreaks.html. Accessed July 23, 2019.

Measles by State in 2019

CDC. Measles Cases and Outbreaks. July 22, 2019. Website: https://www.cdc.gov/measles/cases-outbreaks.html. Accessed July 23, 2019.

Childhood immunization 4313314 Series

MDHHS. Childhood immunization 4313314 series by zip code. Website: https://www.michigan.gov/documents/mdhhs/child_zip1_530331_7.pdf

4 DTaP, 3 Polio, 1 MMR, 3 Hib, 3 HepB, 1 Var, 4 PCV

Adolescent immunization 132321 Series

MDHHS. Adolescent immunization 132321 series by zip code. Website: https://www.michigan.gov/documents/mdhhs/adol_zip1_530333_7.pdf

1 Tdap, 3 Polio, 2 MMR, 3 HepB, 2 Var, 1 MenACWY

County Immunization Report Card

MDHHS. County Immunization Report Card: Kent. Website: https://www.michigan.gov/documents/mdch/Kent_447463_7.pdf

Updates to the Immunization Schedule

Influenza

Live, attenuated influenza vaccine AVAILABLE

oEligible patients are age 2 to 49

oContraindications Immunocompromised Anatomical/functional asplenia Pregnant Cerebrospinal fluid leak or cochlear implant 2-4yo diagnosed with asthma or wheezing within

the preceding 12 months Influenza antiviral in previous 48 hours

oPrecaution: Asthma age 5 years and older

Robinson CL, Bernstein H, Romero JR, Szilagyi P. Advisory Committee on Immunization Practices Recommended Immunization Schedule for Children and Adolescents Aged 18 Years or Younger — United States, 2019. MMWR Morb Mortal Wkly Rep 2019;68:112–114. Kim DK, Hunter P. Advisory Committee on Immunization Practices Recommended Immunization Schedule for Adults Aged 19 Years or Older — United States, 2019. MMWR Morb Mortal Wkly Rep 2019;68:115–118.

Hepatitis A

oNew indication: Homelessness

oClarification for International travel Age 6-11 months: 1 dose before departureRevaccinate with 2 doses between 12-23

months Unvaccinated age >12 months: 1st dose as soon as travel considered

oCombined HepA-HepB 3 dose series Adults only

Robinson CL, Bernstein H, Romero JR, Szilagyi P. Advisory Committee on Immunization Practices Recommended Immunization Schedule for Children and Adolescents Aged 18 Years or Younger — United States, 2019. MMWR Morb Mortal Wkly Rep 2019;68:112–114. Kim DK, Hunter P. Advisory Committee on Immunization Practices Recommended Immunization Schedule for Adults Aged 19 Years or Older — United States, 2019. MMWR Morb Mortal Wkly Rep 2019;68:115–118.

Hepatitis B

oNew product: CpG- adjuvanted HepB vaccine (Heplisav-B) 2 doses given at least 4 weeks apart Only in adults Do not use in pregnancy

oPrevious 3 dose product monovalent HepB vaccine (Engerix-B or Recombivax HB)

Kim DK, Hunter P. Advisory Committee on Immunization Practices Recommended Immunization Schedule for Adults Aged 19 Years or Older — United States, 2019. MMWR Morb Mortal Wkly Rep 2019;68:115–118.

Human Papillomavirus (HPV)

oNew 2 dose series 9-14yo at initial vaccination 0, 6-12months

oOriginal 3 dose series• 15-26yo at initial vaccination• 0, 1-2 month, 6 months

oExpanded age eligibility up to age 45 Will not become official until approved by CDC

director and published in MMWR

Immunization Action Coalition. Ask the experts about Human Papillomavirus (HPV). June 28, 2019. Website: http://www.immunize.org/askexperts/experts_hpv.asp. Accessed July 23, 2019.

Addressing Common Misconceptions

MYTH: I got sick from the flu vaccine

TRUTH: most vaccines are inactivated and cannot cause infection

Timing of vaccine efficacy vs onset of illness

Common cold vs influenza infection

Live attenuated vs inactivated vaccines

Ezeanolue E, Harriman K, Hunter P, Kroger A, Pellegrini C. General Best Practice Guidelines for Immunization. Best Practices Guidance of the Advisory Committee on Immunization Practices (ACIP) [www.cdc.gov/vaccines/hcp/acip-recs/general-recs/downloads/general-recs.pdf]. Accessed on 3/15/2019.

MYTH: You can’t vaccinate sick patients

TRUTH: OK to vaccinate if mild illness

Mild vs moderate illness

Inactivated vs Live attenuated

Risk with deferring vaccination

Centers for Disease Control and Prevention. Epidemiology and Prevention of Vaccine-Preven tab le Diseases. Ham borsky J, Kroger A, Wolfe S, eds. 13th ed . Washington D.C. Public Health Foundation , 2015.

MYTH: The flu vaccine doesn’t work

Truth: Flu vaccine reduces risk of flu illness 40-60% when well matched

Strain matching

Patient factors

CDC. Flu Vaccines Work. Website: https://www.cdc.gov/flu/vaccines-work/index.html Accessed July 23, 2019

MYTH: I’m not at risk for those diseases

Truth: Vaccination schedule developed with risks in mind

Local vs world prevalence

Comorbidities

Herd immunity

MYTH: Vaccines cause autism

TRUTH: no causation between MMR or thimerosal and autism

Falsified journal article

Timing association

Newer research MMR Before and after thimerosal in vaccine

Am Fam Physician. 2017;95(12):786-794 Human vaccines & immunotherapeutics 2018, VOL. 14, NO. 1, 218–224

MYTH: Spacing out vaccines is best

Truth: timing of schedule is best

Deferring delays immunity

Will not overwhelm immune system

Centers for Disease Control and Prevention. Epidemiology and Prevention of Vaccine-Preven tab le Diseases. Ham borsky J, Kroger A, Wolfe S, eds. 13th ed . Washington D.C. Public Health Foundation , 2015.

Helpful Resources

oCDC Vaccines website and app https://www.cdc.gov/vaccines/hcp/index.html

oMichigan Pharmacists Association (MPA) Immunization Page http://www.michiganpharmacists.org/PracticeResources/communitypr

actice

oI vaccinate https://ivaccinate.org/

oMichigan Care Improvement Registry (MCIR) https://www.mcir.org/

oMichigan Department of Health and Human Services (MDHHS) Vaccine resources https://www.michigan.gov/mdhhs/0,5885,7-339-

73971_4911_4914---,00.html Local health departments https://www.michigan.gov/mdhhs/0,5885,7-

339-73970_5461_74040---,00.html

Test your knowledge

Question 1

What is a contributing factor to the measles outbreak?

A. Ineffective vaccine

B. Resistant changes to virus

C. Increased travel of infected hosts

D. Vaccine shortage

Question 2

Who is eligible for the Live attenuated influenza vaccine?

A. 57yo health woman

B. 35yo hypertensive male

C. 3yo girl newly diagnosed with asthma

D. All of the above

Question 3

Which is the appropriate vaccination schedule for hepatitis B in an adult?

A. Heplisav-B 0, 1, 6 months

B. Engerix-B 0, 1 months

C. Engerix-B 0, Heplisav-B 1 month, Engerix-B 6 months

D. Heplisav-B 0, Engerix-B 1 month

Question 4

How can you address a patient’s concern about receiving multiple vaccines in one day?

A. Not delaying leads to faster immunity

B. Does not affect efficacy of most vaccine

C. Not a significant increase in antigen exposure

D. All of the above.

Question 5

Which patient should you defer vaccination for?

A. Observation unit for CHF exacerbation

B. Admitted to hospital for pneumonia

C. Complaining of runny nose and itchy eyes

D. Picking up antibiotic for UTI

Questions?Shelby Kelsh, PharmD, BCPS

Assistant Professor of Pharmacy, Ferris State University

shelbykelsh@ferris.edu