Download - Immunization CE 1.2018 NHC Handout Version

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KristyBrittain,PharmD,BCPS,CDEAssociateProfessor,MUSCCollegeofPharmacy

ClinicalPharmacySpecialist,MedicalUniversityofSC

Diclosures� KristyBrittainhasnoconflictofinteresttoreport.

Objectives�  Describerecentchangesinadultandpediatricimmunizations

�  Discussspecificstoragerequirementsforvaccines�  Applyimmunizationrecommendationstospecificpatients

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ImmunizationPracticesinUS

Howarewedoing?

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TipsinImprovingVaccineRates� Communicatingwithotherhealthcareproviders

� Directreferralforservices

�  Stayingup-to-datewithrecommendations

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PattyWatkins

Age:65years Gender:Female

PMH Type2diabetesx4yearsHypertensionx10years

Medications Metformin850mgtwicedailyLantus15unitsSQQHSLisinopril40mgoncedaily

VaccineHistory Influenza(IIV3)Oct2016Influenza(IIV3)Nov2015Influenza(IIV3)Dec2014Zoster(Zostavax)1doseDec2014

Otherinformation NKDA

PattyWatkins� HowwillwedeterminewhatvaccinesPattyneeds?� Wherecanwefindthisinformation?

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VaccinationinDiabetesADAStandardsofCareGuidelines(2018)Recommendation:� Provideroutinevaccinationsforchildrenandadultswithdiabetesasforthegeneralpopulationaccordingtoage-relatedrecommendations.

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FluSeason2017-2018

http://www.cdc.gov/flu/weekly/

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FluSeason2017-2018

http://www.cdc.gov/flu/weekly/

FluSeason2017-2018

2017-2018InfluenzaFormulaTrivalentvaccineincludes:� A/Michigan/45/2015(H1N1)� A/HongKong/4801/2014(H3N2)� B/Brisbane/60/2008

Quadrivalentincludestheseplus:� B/Phuket/3073/2013

http://www.who.int/influenza/vaccines/virus/recommendations/2017_18_north/en/

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InfluenzaRecommendations� Annualvaccinationforallpersonsaged6monthsandolderwhodonothaveanycontraindications�  Shouldoccurbeforeonsetofinfluenzaactivityincommunity

�  BeginvaccinatingassoonasthevaccinebecomesavailableandbyOctoberifpossible

� Children6monthsto8yearsshouldreceive2dosesifthisisthefirstyearthevaccineisreceived�  Seconddoseshouldbegiven4weeksafterinitialdose

InfluenzaVaccineLiveattenuatedinfluenzavaccine(LAIV)� NOTCURRENTLYRECOMMENDED!Inactivatedinfluenzavaccine(IIV)� Contains“dead”virus� Unabletocauseinfluenza� Contains3(trivalent)or4(quadrivalent)strains

AppropriateVaccineSelection� Agerestriction�  IIV3vsIIV4� Eggallergy?�  Specificvaccineeligibility

�  Fluad�  FluzoneHD

� Patientpreference� Needlefear

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Brand(Manufacturer) Type RouteofAdmin Approvedforages

AfluriaAfluriaQuad(Seqirus)

IIV3IIV4

IM 9+years18+years

Fluad(Seqirus)

aIIV3 IM 65+years

FluarixQuad(GSK)

IIV4 IM 6+months(PFS)3+years(MDV)

FluBlokFluBlokQuad(ProteinSciences)

RIV3RIV4

IM

18+years

FlucelvaxQuad(Novartis)

ccIIV4 IM 4+years

FluLavalFluLavalQuad(IDBiomedCorp)

IIV3IIV4

IM 3+years

FluMistQuad(MedImmune)

LAIV4 Intranasal 2-49years

Fluvirin(Seqirus)

IIV3 IM 4+years

FluzoneQuadFluzoneIDFluzoneHD(SanofiPasteur)

IIV4IIV4

IIV3-HD

IMIntradermal

IM

6+months18-64years65+years

PattyWatkins






PattyWatkins� WhatarewegoingtorecommendtoPattyforherinfluenzavaccination?

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IIV3IIV4

IM 9+years18+years

Fluad(Seqirus)

aIIV3 IM 65+years

FluarixQuad(GSK)



RIV3RIV4

IM 18+years


ccIIV4 IM 4+years


IIV3IIV4

IM 3+years



Fluvirin(Seqirus)

IIV3 IM 4+years


IIV4IIV4

IIV3-HD

IMIntradermal

IM


PattyWatkins






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InfluenzaWhereshouldinfluenzavaccinesbestoredinthepharmacy?A. FridgeB. FreezerC. Shelf(room-temperature)

InfluenzaHowsoonshouldpatientsstartreceivingtheinfluenzavaccine?A. AssoonasitsavailableB. September1stC. October1stD. October15th

InfluenzaWhatisthemostappropriatestartingageforinfluenzavaccinationinchildren?A. 3monthsB. 6monthsC. 12monthsD. 18months

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InfluenzaHowcanwescreenpatientsforinfluenzavaccine?Whattechniquesareusedinyourpracticetoincreasevaccinationrates?

TypesofPneumococcalVaccinePneumococcalConjugateVaccine(PCV13)–targets13pneumococcalserotypesthatcausediseaseinchildren–PCVisdesignedtobeadministeredtochildrenage5andyounger

•  ReplacedPCV7

PneumococcalPolysaccharideVaccine(PPSV23)–contains23pneumococcalbacterialserotypesknowtocause85%-90%ofinfections

•  UsedinadultsonlyaschildrenwillnotmountaneffectiveimmuneresponsetoPPSV

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PneumococcalRecommendationsPCV13recommendedfor:• Children<5yearsold• Adults65+yearsold• Age6to64yearsoldwithcertainmedicalconditionsresultinginimmunosuppression

Immunocompromised=HIVinfectionChronicrenalfailureOrgantransplantLeukemiaLymphoma

Is Patty a candidate for PCV13?

PneumococcalRecommendationsPCV13recommendedfor:• Children<5yearsold• Adults65+yearsold• Age6to64yearsoldwithcertainmedicalconditionsresultinginimmunosuppression

PPSV23recommendedfor:• Adults65+yearsold• Age2+yearsoldwithhighriskforpneumococcaldiseasesuchassicklecelldiseaseandHIVinfection• Age19to64yearsoldwhosmokecigarettesorhaveasthma,includingdiabetes

Is Patty a candidate for PPSV23?

PneumococcalIntervals

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6434a4.htm

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PneumococcalIntervals

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6434a4.htm

PattyWatkins






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PneumococcalWhereshouldPCV13andPPSV23vaccinesbestoredinthepharmacy?A. FridgeB. FreezerC. Shelf(room-temperature)

PneumococcalIfapatient(over65years)needsbothPCV13andPPSV23(andhasneverreceivedeitherbefore),whatistheappropriatedosinginterval?A. PCV13first,wait6months,thenPPSV23B. PPSV23first,wait1yearthenPCV13C. PCV13first,wait1yearthenPPSV23D. PPSV23andPCV13givenonthesameday

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PneumococcalWhichofthefollowingconditionswarrantrevaccinationafter5yearsforPCV13orPPSV23?A.  AlcoholismB.  CigarettesmokingC.  SolidorgantransplantationD.  Diabetesmellitus

PneumococcalIdentifythebrandname:PCV13PPSV23

PneumococcalHowcanwescreenpatientsforpneumococcalvaccine?Whattechniquesareusedinyourpracticetoincreasevaccinationrates?

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HepatitisBVaccineIndicationsforhepatitisBvaccine� Patientswithdiabetes� Healthcareprofessionals� Patientsw/ESRDoronhemodialysis,chronicliverdisease� DiagnosedorseekingtreatmentforSTIsorMSM� InternationalTravelers

HepatitisBVaccineDosingschedule:� 0,1,4-6monthsProductsavailability:� EngerixB� RecombivaxHB� Twinrix(HepAandHepB)

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PattyWatkins� HowwillweschedulePatty’svaccinesforhepatitisB?

PattyWatkins� WhatarePatty’sTdapneeds?

� Whatfollowupwouldsherequire?

PattyWatkins






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PattyWatkins� WhatarePatty’szosterneeds?

� Whatfollowupwouldsherequire?

Shingrix(ZosterVaccineRecombinant,Adjuvanted)Whoshouldgetit?

�  Shingrix®isrecommendedforthepreventionofherpeszosterandrelatedcomplicationsforimmunocompetentadults50andolder,eveniftheyhavepreviouslyreceivedZostavax®

�  PreferredoverZostavax®forthepreventionofherpeszosterandrelatedcomplications

�  Thisvaccineisnottobeusedforthetreatmentofzoster,post-herpeticneuralgiaorforpreventionofprimaryvaricella

�  A2doseseriesofIMinjections(0.5mLeach),withtheseconddosegiven2to6monthsafterthefirst

Shingrix(ZosterVaccineRecombinant,Adjuvanted)WhatifIwaspreviouslyvaccinatedwithZostavax®?DoIstillneedShingrix?

�  Shingrix®isrecommendedforthepreventionofherpeszosterandrelatedcomplicationsforimmunocompetentadults50andolder,eveniftheyhavepreviouslyreceivedZostavax®

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Shingrix(ZosterVaccineRecombinant,Adjuvanted)Whatarethemostcommonsideeffects?

�  ThemostcommonsideeffectsseenwiththeShingrix®vaccinearepain,redness,orswellingattheinjectionsite.Systemicsideeffectsmayincludemyalgia,fatigue,headache,shivering,orfever.Thesereactionsaretransientandusuallylastfrom1to3days.

Shingrix(ZosterVaccineRecombinant,Adjuvanted)Howwellarepeoplecoveredafterthefirstdose?

� WhilenumbersofpatientswhoreceivedonlyonedosewereprovidedinthephaseIIIapprovalstudies,anevaluationontheefficacywasnotelucidated

�  ItwasdeterminedthatasuboptimalimmuneresponsewasnotedafteronlyoneinjectionoftheShingrix®vaccine

Shingrix(ZosterVaccineRecombinant,Adjuvanted)UpdateonavailabilityinUSMarket

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PattyWatkins-RecapTime Vaccines

Today FluPPSV13HZV(Shingrix)HepB1Tdap

1month HepB24months HepB3

HZV(Shingrix)1year PCV23Yearly FluEvery10years Tdbooster

SherieJohnsonAge:33years Gender:Female

PMH Pregnant(28weeks)Thyroiddisorder

Medications Levothyroxine100mcgoncedailyPrenatalvitaminoncedailywithdinnerEpi-penprnanaphylaxis

VaccineHistory Influenza(RIV3)Dec2016TdapJan2015TdFeb2014HepB3doseseries(2010)

Otherinformation Allergies:Eggs/Milk(hives/rash)Currentlypregnant(28weeks)Previousvaginalchildbirth(2.5yearsago)Returningtoschooltoearnherdoctorateinnursing.

SherieJohnson� HowwillwedeterminewhatvaccinesSherieneeds?� Wherecanwefindthisinformation?

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IIV3IIV4

IM 9+years18+years

Fluad(Seqirus)

aIIV3 IM 65+years

FluarixQuad(GSK)



RIV3RIV4

IM

18+years


ccIIV4 IM 4+years


IIV3IIV4

IM 3+years



Fluvirin(Seqirus)

IIV3 IM 4+years


IIV4IIV4

IIV3-HD

IMIntradermal

IM


EggAllergyandInfluenza

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IIV3IIV4

IM 9+years18+years

Fluad(Seqirus)

aIIV3 IM 65+years

FluarixQuad(GSK)



RIV3RIV4

IM

18+years


ccIIV4 IM 4+years


IIV3IIV4

IM 3+years



Fluvirin(Seqirus)

IIV3 IM 4+years


IIV4IIV4

IIV3-HD

IMIntradermal

IM


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SherieJohnsonAge:33years Gender:Female

PMH Pregnant(28weeks)Thyroiddisorder

Medications Levothyroxine100mcgoncedailyPrenatalvitaminoncedailywithdinnerEpi-penprnanaphylaxis

VaccineHistory Influenza(RIV3)Dec2016TdapJan2015TdFeb2014HepB3doseseries(2010)

Otherinformation Allergies:Eggs/Milk(hives/rash)Currentlypregnant(28weeks)Previousvaginalchildbirth(2.5yearsago)

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TdapRecommendations�  Foreveryone11yearsandolder,includingpregnantwomen

� DTaPisforchildren2monthsthrough6yearsofage

CDCrecommendsthatpregnantwomenreceivetheTdapvaccineduringthethirdtrimesterofeachpregnancy.

When should Sherie receive the Tdap?

TdapRecommendations� Tdapshouldbegivenbetween27and36weeksgestation,althoughitmaybegivenatanytimeduringpregnancy.

� Currentavailabledatasuggestsearlierinthe27-36weekwindowwillmaximizeantibodytransfertotheinfant.

� Antibodiesarehighest2weeksafterreceivingthevaccine.

TdapRecommendations� HowcanwescreenpatientsforneedingTdapvaccination?

� WhoelsecanwetargettoreceiveTdapvaccination?

� Howcanthisbeaccomplished?

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SherieJohnson-RecapTime Vaccines

Today FluTdap

Yearly Flu

WaltWhitmanAge:66years Gender:Male

PMH: COPDType2DiabetesProstateCancer(diagnosed7/1/17)

Medications Metformin1000mgBIDStioltotwoinhalationsdailyProairPRNLeuprolide7.5mgIMmonthly

VaccineHistory

FullchildhoodvaccinationsInfluenza(RIV3),October2016Nootherimmunizationsasanadult.

Otherinformation

ReceivingradiationtherapyforprostateCANKDA

VaccineRecommendationsGivenWW’smedicalhistory,whichvaccinesshouldheeventuallyreceive?A. Zostavax,PCV13,HepatitisB,TdapB. Zostavax,PPSV23,HepatitisA/B,TdapC. PCV13,HepatitisB,TdD. PPSV13,HepatitisA/B,Td

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During Chemotherapy/

Radiation

Post radiation

VaccineRecommendationsWhenshouldWWreceivethesevaccinations?A. AllshouldbegivennowB. Giveinactivatedvaccinesnow,givelivevaccines3monthspostradiationC. Giveallvaccinesat3monthspostradiationD. Giveinactivatedvaccinesat3monthspostradiationandlivevaccinesat6months

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VaccineRecommendations� Zoster� PCV13� HepatitisB� Tdap� MMR

*Given3monthsaftertheterminationofradiationtherapy*

PearlsforImmunizingImmunocompromisedPatients

�  IDSAandACSbothrecommendinactivatedandlivevaccinesbeadministered3monthsfollowingthecessationofchemotherapy/radiationinmostcases.IfB-cellsuppressivetherapywasused,bothsocietiesrecommendwaiting6months.

�  Inactivatedvaccinescanbeadministered,butshouldnotbecountedinthedoseseries,becausepatientsmaybeunabletomounttheimmuneresponsenecessaryforadequateantibodyproduction.

FluShotforWalt?Whatrecommendationscanyoumakeregardinginfluenzavaccination?A.  GiveFluadIM3monthspostradiationB.  GiveFluMistquadintranasaltodayC.  GiveFluBlockwithnextadministrationofradiationD.  GiveAfluriaQuadinbetweenradiationcycles

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Brand(Manufacturer) Type RouteofAdmin ApprovedforagesAfluriaAfluriaQuad(Seqirus)

IIV3IIV4

IM 9+years18+years

Fluad(Seqirus)

aIIV3 IM 65+years

FluarixQuad(GSK)



RIV3RIV4

IM

18+years


ccIIV4 IM 4+years


IIV3IIV4

IM 3+years



Fluvirin(Seqirus)

IIV3 IM 4+years


IIV4IIV4

IIV3-HD

IMIntradermal

IM


�  Influenzavaccinemaygiventocancerpatients>6monthsofageunlesstheyare:�  1.undergoingintensivechemotherapy,meaninginduction/

consolidation�  2.ReceivingB-cellantibodies

�  Livevaccinesshouldnotbeadministeredduring

radiation/chemotherapybecauseactiveandseriousinfectionshaveoccurredsecondarytolivevaccineuseinthesepatients.


�  AccordingtotheAmericanCancerSociety,influenzavaccinationisbestgiven2weeksbeforechemo/radiationorin-betweencycles.

�  Hematopoieticstemcelltransplantrecipientsneedtowaitatleast6monthsbeforereceivinginfluenzavaccine


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Recommendationsvarywiththetypeofimmunodeficiency.Thefollowingresourcesshouldbeconsultedinprovidingpatientspecificcare:� TheIDSA2013guidelinesVaccinationoftheImmunocompromisedHost.(CID2013;58;1-57)� TheAmericanCancerSociety’s“VaccinationDuringCancerTreatment.”(Cancer.org)� NCCNsupportivecareguidelines

ResourcesforImmunizingImmunocompromisedPatients

MollyFlandersAge:12years Gender:FemalePMH: Chickenpoxatage7

Medications DailyFlintstone'smultivitamin

VaccineHistory

Lastvaccinationsatage6UptodatebyCDCrecommendationsatthattime

Otherinformation

NKDA

VaccinationsforMolly:WhatvaccinationsdoesMollyneedbeforestartingschoolthisyear.Yourecommend:A.  Zostavax,PCV13,TdapboosterB.  Meningococcal,HPV,TdapboosterC.  MMR,HPV,TdapboosterD.  Meningococcal,PCV13,Tdapbooster

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FlushotforMollyCanMollygetherflushottoday?Yourecommend:A.  Afluriatri-valent,pursuant

toaprescriptionfromPCPB.  FluBlockQuad,pursuantto

aprescriptionfromPCPC.  FlucelvaxQuad,perstate

protocolD.  AfluriaQuad,persate

protocol

Age:12years

Gender:Female

PMH: Chickenpoxatage7

Medications

DailyFlintstone'smultivitamin

VaccineHistory

Lastvaccinationsatage6UptodatebyCDCrecommendationsatthattime

Otherinformation

NKDA


IIV3IIV4

IM 9+years18+years

Fluad(Seqirus)

aIIV3 IM 65+years

FluarixQuad(GSK)



RIV3RIV4

IM

18+years


ccIIV4 IM 4+years


IIV3IIV4

IM 3+years



Fluvirin(Seqirus)

IIV3 IM 4+years


IIV4IIV4

IIV3-HD

IMIntradermal

IM


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IIV3IIV4

IM 9+years18+years

Fluad(Seqirus)

aIIV3 IM 65+years

FluarixQuad(GSK)



RIV3RIV4

IM

18+years


ccIIV4 IM 4+years


IIV3IIV4

IM 3+years



Fluvirin(Seqirus)

IIV3 IM 4+years


IIV4IIV4

IIV3-HD

IMIntradermal

IM



IIV3IIV4

IM 9+years18+years

Fluad(Seqirus)

aIIV3 IM 65+years

FluarixQuad(GSK)



RIV3RIV4

IM

18+years


ccIIV4 IM 4+years


IIV3IIV4

IM 3+years



Fluvirin(Seqirus)

IIV3 IM 4+years


IIV4IIV4

IIV3-HD

IMIntradermal

IM


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KristyBrittain,PharmD,BCPS,CDEAssociateProfessor,MUSCCollegeofPharmacy

ClinicalPharmacySpecialist,MedicalUniversityofSC