Transcript Immunizations and Vaccinations

Themen Danielson, MD, MPH
Indiana State Department of Health
800-701-0704
Themen Danielson, MD, MPH has no relevant
financial relationships to disclose.






CHIRP Legislation
2014 Pediatric Immunization Schedules
2014-2015 Indiana School Immunization
Requirements
Rotavirus vaccine: Update
Adult immunizations: Recent Updates
Parental hesitancy
Top Three….(unchanged from 2013)
1.
2.
3.
Infant Mortality
Adult Obesity
Adult Smoking
IC 16-38-5 (SEA 0415)
◦ All providers must enter immunization records into
CHIRP for individuals under the age of 19 years
◦ Includes a complete record for the immunization,
but does not include historical records
◦ Effective July 1, 2015
5
All Providers of immunizations must submit the
following data to the registry:
◦
◦
◦
◦
◦
◦
◦
◦
◦
◦
Patient first and last name
Patient date of birth
Patient address
Patient race
Patient gender
Vaccine for Children (VFC) program eligibility, if the patient
is eligible for the VFC program
Dose at the administration level under the Vaccine for
Children Program, if the patient is eligible for the Vaccine
for Children program.
Vaccination presentation or vaccination code using
approved IIS code type
Vaccinate date
Vaccine lot number
CHIRP Homepage can be accessed at: https://chirp.in.gov
2014-2015
Note: Read recommendations with the
footnotes for each schedule
New School Requirements

Kindergarten
◦
2 doses Hepatitis A
Grade 12

◦
◦
2 MCV4
Students who receive dose 1 on or after the 16th
birthday need only 1 dose of MCV4



Hep B #3 given
before 24 weeks of
age*
MMR or Varicella #1
given prior to 1st
birthday*
Polio final dose prior
to 4th birthday
(grades K-3 this
year)*

Live virus vaccines
spaced < 28 days
apart
* 4 Day Grace Period
applies
Addressing Parental Hesitancy
http://www.iom.edu/Reports/2013/The-Childhood-Immunization-Schedule-and-Safety.aspx
15
Key Findings:
▶
Parents are concerned about number, frequency,
and timing of immunizations in the overall
immunization schedule
▶
No significant evidence to imply that the
recommended immunization schedule is not safe
▶
Suggested further work to assess opportunities to
study the safety of the immunization schedule
using large-linked databases like the Vaccine
Safety Datalink (VSD)
16
10% of parents choose selective or delayed
vaccination schedules


Increased number office visits
Susceptibility to disease
1-2% refuse vaccination
http://www.cdc.gov/vaccines/hcp/patient-ed/conversations/provider-resourcessafetysheets.html


We know vaccines are our best defense
Children are given vaccines at a young age
◦ When most vulnerable to diseases


Vaccines protect against 14 diseases by age 2
Due to recombinant technology there is a
decrease in number of antigens although more
vaccines
◦ 1960: over 3,200 antigens
◦ 1980: over 3,000 antigens
◦ 2000: 123-126 antigens
▶ Thimerosal
= ethyl mercury (CH2-Hg)
◦ Broken down differently and cleared quickly
◦ Not the highly toxic methyl mercury (CH3-Hg)
▶ Since
July 1999, thimerosal has been virtually
eliminated from vaccines
◦ Vaccines perceived as safer
◦ Still a steady increase in autism rates
Case-control study comparing cumulative antigen
exposure and maximum number of antigens
each child received in a single day of vaccination


Total antigens from vaccines received by age 2
and the maximum number of antigens received
on a single day was the same between cases and
controls
No relationship was found between antigen
numbers and the development of autistic
disorder and ASD using regression analyses
DeStefano, F, Price, C, Weintraub, E. Increasing exposure to antibody-stimulating proteins and polysaccharides in
vaccines is not associated with risk of autism. Journal of Pediatrics . 2013 Mar 29.



Provider recommendation is one of the
strongest predictors of whether parents will
choose to vaccinate
Take advantage of early opportunities such as
prenatal, newborn, 1-week and 1-month
visits to discuss immunizations
Be sure to document any discussions held
with parents as this will serve as a reference
at future visits
Resource: http://www.cdc.gov/vaccines/hcp/patient-ed/conversations/conv-materials.html

Use a mix of anecdotal and scientific
information when talking with parents
◦ Consider health literacy. Too much science may be
a deterrent for some parents
◦ Personal stories can be an effective way to
communicate with parents.
 “I vaccinated my children and I recommend you do the
same”
 “I had a patient who was hospitalized from
complications of chickenpox; now I always recommend
the vaccine”


Consider designating a staff member or
yourself as someone who can address
parental concerns
Connect parents with online resources
Immunization Action Coalition (IAC)
CDC
Every Child by Two (ECBT)
Vaccine Education Center with the Children’s
Hospital of Philadelphia (CHOP)
◦ Indiana Immunization Coalition (IIC)
◦
◦
◦
◦
Vaccine resources: http://www.vaccineinformation.org/trusted-sources/

The AAP does not recommend excluding
patients from your practice when parents
decline immunizations
◦ Places the child at risk for other serious health
effects
◦ Inform families of symptoms of VPD’s
◦ Ask families call ahead if suspect VPD to protect
others

Share the facts
◦ If you choose not to vaccinate, understand the risks
and responsibilities
ACIP Update
There are two vaccines licensed in the US to prevent rotavirus
gastroenteritis in infants
RotaTeq® (RV5) licensed in 2006, is
a 3 dose series recommended at 2
months, 4 months, and 6 months of
age.
 Rotarix® (RV1) licensed in 2008, is a
2-dose series, with doses
administered at ages 2 and 4
months.


Rotavirus causes diarrhea, vomiting and fever
mostly in babies and young children leading
to severe dehydration
◦ Leading cause of severe diarrhea and dehydration
worldwide
◦ Before rotavirus vaccination program in US




400,000 cases/year
200,000 emergency visits
70,000 hospitalizations
60 deaths




One portion of the bowel “slides” into the
next
Medical emergency treated with
hospitalization
Most patients recover fully with quick
detection and treatment
2,000 cases occur in the U.S. each year that
are unrelated to vaccination.

Review of vaccine safety data from 3 sources
◦ Vaccine Adverse Event Reporting System (VAERS)
◦ Post-licensure Rapid Immunization Safety
Monitoring Program (PRISM )
◦ Vaccine Safety Data Link (VSD)

Estimated risk to be about 1 in every 20,000
to 1 in every 100,000 infants within 7 days of
the first dose of vaccine.
◦ Roughly 40 to 120 vaccinated infants might develop
intussusception

VAERS reports Feb 2006 – April 2012
◦ 584 reports after RV5 (Rotateq)
◦ 52 after RV1 (Rotarix)

Poisson Regression model evaluating daily
reporting ratios of intussusception for 3 - 6
vs 0 - 2 days post-vaccination
◦ Small clustering reports 3-6 days post-vaccination
dose #1
 Excess risk estimated to be 0.79 events per 100,000
for all 3 doses after RV5
 Sample too small to estimate risk following RV1
Haber, P, Patel, M, Pan, Y, Baggs, J et al. Intussusception after rotavirus vaccine report to us
vaers, 2006-2012. Pediatrics 2013 Jun.
Following rotavirus vaccination, parents or
caregivers should watch their infants for
signs and symptoms of intussusception
including episodes of stomach pain with
severe crying (which may be brief), vomiting,
blood in the stool, or acting weak or very
irritable, especially within the first 7 days
after rotavirus vaccination.
In 1999, CDC initiated a multistate
investigation to determine whether an
association existed between administration of
Rotashield (RRV-TV) and intussusception in
infants. The study confirmed an association
and the risk was estimated to be about 1 case
of intussusception in every 10,000 infants
vaccinated with the first dose of rotavirus
vaccine.
Updates and Questions
▶

▶
All regardless of age or
risk
─ Tetanus/Pertussis
─ Influenza
Age based criteria
—Zoster
—Pneumococcal
Risk-based (health,
occupational, travel,
etc…)
─ Hepatits B
─ Hepatitis A
─ Pneumococcal
─ Meningococcal
─ Hib

Catch up any missing
immunizations,
including:
◦ Varicella
◦ MMR
◦ Polio
Population
Vaccination Rate
Adults > 65 Years
All adults > 18 Years
61.8%
39%
Healthcare Personnel
62.9%
88.8% (mandated vaccination)
Pregnant Women
40.7%
National Early Season Flu Vaccination Coverage, United States, November 2013. Available at:
http://www.cdc.gov/flu/fluvaxview/1314season.htm
▶
ACIP recommends administering Tdap during each
pregnancy, regardless of the number of
pregnancies or the spacing of the pregnancies
∘ Optimal timing for Tdap administration is
Between 27 and 36 weeks gestation to maximize
the maternal antibody response and passive
antibody transfer to the infant
∘ Administer post-partum if not administered
during pregnancy
▶
▶
ACIP recommends a single dose of zoster (shingles)
vaccine for adults 60 years and older, whether or not
the patient reported a prior episode of shingles.
o Persons with chronic medical conditions may be
vaccinated unless a contraindication or precaution
exists for their condition.
o Not necessary to screen for history of chickenpox
disease
FDA approval for use in individuals ages 50 -59
(March 2011). Consider offering vaccine to adults who
report:
o Preexisting chronic pain, severe depression, or
other co-morbidities
o Intolerance to treatment medications for shingles
o Extenuating employment-related factors
▶
▶
Licensed in 2006
Overall Vaccine Efficacy:
• Reduces risk of shingles 51% (44.2-57.6%)
• VE Ages 50-59 Years: 69.8% (54.1-80.6%)
• VE Ages 60-69 Years: 64%
• VE Ages 70 Years & Older: 38%
• Reduces risk of PHN 67% (95% CI: 47.5-79.2%)
▶
2012 Vaccination Rate in adults > 60 = 20.1%
1Schmader
KE, Levin M, Gnan J, McNeil A, Vesikari T, et al. Efficacy, safety, and tolerability of herpes
zoster vaccine in persons aged 50-59 years. Clin Infect Dis 2012; 54:922-8.
2CDC. Herpes Zoster Vaccination Information for Health Care Professionals. Accessed 5.29.13 at:
http://www.cdc.gov/vaccines/vpd-vac/shingles/hcp-vaccination.htm
3CDC. Non-influenza vaccination coverage among adults – united states, 2012. MMWR 63(05): 95102
Adults 56 and older should receive MCV4 and not
MPSV4 if:



Previously vaccinated with MCV4 and are now in
need of revaccination
Will be in need of additional booster doses (ie
asplenic persons, microbiologists)
This is an off-label recommendation.
CDC. Prevention and control of meningococcal disease: recommendations of the advisory
committee on immunization practices. MMWR 62(RR02): 1-22.
Administer 1 dose of Hib vaccine to:
Asplenic persons 5 years and older (including
adults) if they have no history of receiving the
vaccine.
◦ Administer 14 days before surgery if possible or as
soon as the patient is stable post surgery.
◦ If patient has previously had a splenectomy,
administer Hib vaccine at next clinic visit.
CDC. Prevention and control of haemophilus influenzae type b disease: recommendations of
the advisory committee on immunization practices. MMWR 63(RR01): 1-14.
▶
▶
▶
Removed documentation of physician diagnosed disease as an
acceptable criterion for evidence of immunity for measles and mumps
Expanded recommendations for persons >12 months with HIV infection
who do not have evidence of current severe immunosuppression and
gave recommendation to revaccinate persons with perinatal HIV infection
if vaccinated prior to establishment of effective ART
Expanded recommendations for use of immune globulin for measles
prophylaxis
o Administer IGIM to include infants < 6 months
o Increased dosing IGIM for immunocompetent persons
o Use of IGIV for severely immunocompromised persons and pregnant
women without evidence of immunity to measles if exposed to
measles.
CDC. Prevention and control of measles, rubella, congenital rubella syndrome, and mumps, 2013:
recommendations of the advisory committee on immunization practices. MMWR 62(RR04): 1-34.
Thank you!