Preventing Disease with Adolescent Immunizations

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Preventing Disease with Adolescent Immunizations

• Nancy Rudner Lugo, DrPH, NP

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Even 2,500 Years Ago, People Knew Immunity
Worked.

• 500 BC Greece
• Observation people who survived smallpox never
  got the disease again.
• The insight Surviving smallpox infection
  protects against further infections---give
  immunity.

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• Until mid 20th century, infectious diseases were
  the leading cause of death
• Jenners small pox innoculations from cowpox
  (cowsvacas) and from smallpox patient scabs

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Life Expectancy
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Healthy People 2010 objectives
Reduction in Vaccine-Preventable Diseases 1998 Baseline 2010 Target
Reduction in Vaccine-Preventable Diseases Number of Cases Number of Cases
Congenital rubella syndrome (lt 1 year) 7 0
Diphtheria (persons under age 35 years) 1 0
Haemophilus influenzae type b ( lt 5 years) 163 0
Hepatitis B (2 to 18 years) 945 9
Measles (persons of all ages) 74 0
Mumps (persons of all ages) 666 0
Pertussis (children lt age 7 years) 3,417 2,000
Polio (wild-type virus) (persons of all ages) 0 0
Rubella (persons of all ages) 364 0
Tetanus (persons lt age 35 years) 14 0
Varicella (chicken pox) (persons lt 18 years) 4 million 400,000
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SUCCESS Reducing VPD
Disease Maximum Cases 2001
Change()
Diphtheria 206,939 2 -99.99
Measles 894,134 108 -99.99
Mumps 152,209 231 -99.60 Polio
21,269 0 -100.00 Rubella
57,686 19 -99.40 Congenital
rubella syndrome 20,000 2
-99.97 Tetanus 1,733 27
-98.04 HIB (lt5 years) 20,000 183
-99.25 Smallpox 58,000
0 -100.00 Hepatitis B 200,500
80,000
-60.00 Pertussis 265,269 5,396
-97.63 Varicella
83,500 14,980
-82.00 Pneumoccocal Disease
15,933 14, 008 ----------
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Quick review-How do vaccine work?

• Antigen causes antibody formation, without
  causing full disease
• Killed or Live attenuated (live and weakened)
  viruses stimulate body to make antibodies and
  develop immunologic memory. Body will recognize
  virus/bacteria and fight it off microbe cannot
  replicate in vaccinated body
• Community Immunity so many people immune that
  virus cannot spread. Usually needs 90 immunity

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Immunization schedules

• Determined by Advisory Committee on Immunization
  Practices (ACIP)
• Revised December each year
• Always be sure you are using the most current
  schedule (www.cdc.gov/vaccines)
• 3 schedules Child, 7-18 y.o (not called
  adolescent since could not agree to who is an
  adolescent), adult

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Assess IZ needs every adolescent, every adult,
every visit

1. Assess immunization needs for
2. Catch up missing childhood immunizations
3. Age specific immunization
4. Risk-based immunizations
5. Travel immunizations
6. Assess every patient, every time

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Lets get to the details

• Who gets what vaccine,
• why and when??

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First, what about you?Vaccines for health care
personnel

• Influenza, annually- to protect HCP, their
  families, and patients
• Rubella to protect HCP and babies
• Pertussis- protect HCP and babies
• Hepatitis B-to protect HCP from BBP

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11-12 year old visit-

• A great time to
• assess growth and development
• provide anticipatory guidance
• reaffirm provider-patient/family relationship
• assess need for catch up immunizations
• give age-specific immunizations
• New immunizations added to 11-12 y .o visit

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Adolescent Immunizations

• Catch up immunizations-
• check for completion of pediatric vaccinations-
• Hep B, MMR, varicella, IPV series
• Immunizations for adolescents
• HPV to prevent cervical cancer (series of 3)
• MCV4 to prevent meningoccocal infection
• Tdap as adol. tetanus, diphtheria, and pertussis
  booster
• Influenza each year
• Immunization for at risk pneumo, hep A, travel

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Catch Up-Hepatitis B

• Most teens have completed series
  prior to kindergarten
• Adolescence can be Hep B risky
• Hepatitis B infection can lead to hep CA
• Give IM,
• Engerix 3 doses over 6 months
• OR Recombivax , 2 doses 4-6 months apart
• If started but did not finish series, do NOT
  start series over.

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measles
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mumps
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Catch UP-MMR

• Needs 2 doses after age 1, at least 4 weeks apart
• Do not give if pregnant or will be pregnant in 3
  months
• Do not use MMRV after age 13
• Live vaccine, given SC

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Varicella
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Catch UP-varicella

• Varicella-
• Unimmunized, no history of disease-Adolescents
  need two doses SC
• 4-8 weeks apart
• Temperature sensitive- in freezer
• Do not use MMRV gt13 y.o.
• Outbreaks in immunized, reduced w booster

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Catch Up-IPV

• Series of 3, at 0,1, and 6-12 months
• Everyone lt18 y.o should finish series
• If started but did not finish series, give what
  is needed do not restart series
• Global goal to eradicate polio. Especially a
  challenge is areas of distrust and/or war

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Wild Poliovirus 2001
494 confirmed cases worldwide
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Adolescent Immunizations

• Catch up immunizations-
• check for completion of pediatric vaccinations-
• Hep B, MMR, varicella, IPV series
• Immunizations for adolescents
• HPV to prevent cervical cancer
• MCV4 to prevent meningoccocal infection
• Tdap as adol. tetanus, diphtheria, and pertussis
  booster
• Immunization for at risk pneumo, influenza, hep
  A
• Travel immunizations prn

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Human Papilloma Virus

• Major cause of cervical and anogenital cancer
• In U.S. 11,150 new cases of cervical cancer each
  year
• Globally, 500,000 (a half million) new cases each
  year
• 50 of women have HPV 4 years after first
  intercourse most infections are transient,
  asymptomatic healthy immune system clears the
  infection

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Human Papilloma Virus

• Persistant infection may
  lead to cancer
• HPV strains 16, 18 cause 80 of cervical cancer
• HPV strains 6,11 cause most venereal warts

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Human Papilloma Virus

• 1 in 3 women will have an abnormal Pap test in
  her lifetime
• Abnormal Paps may require further evaluation and
  treatment, such as culposcopy, cyrosurgery
• 4 billion spent on Pap management annually
• Screening has its challenges
• Over 50 of women with cervical cancer have never
  had a Pap test
• Follow up for abnormal Paps can be difficult

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HPV vaccines

• Guardasil HPV 6,11, 16,18
• Approved ages 9-26
• Cervarix (not yet approved), HPV 16,18
• 3 shots, 0,2,6 months, IM in deltoid
• 4 weeks between doses 1 and 2 12 weeks between
  doses 2 and 3
• Made w VLPs-viral like particles

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HPV vaccine

• Recommended for 11-12 y.o., prior to sexual debut
  and in sync with other 11-12 y.o IZ
• 26 females age 15, 49 age 17 have had
  intercourse
• Approved for ages 9-26
• OK for women who have had multiple partners and
  women with abnormal Paps. Protects against at
  least 2 strains, so may be infected w one and can
  benefit from vaccine
• Potential to reduce cervical cancer incidence by
  70
• Still need Pap tests

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Should I give HPV when.

• Abnormal Pap or positive HPV test- still give HPV
  vaccine. DK which strain of HPV caused abnormal
  Pap
• Pregnancy-avoid giving immunization no data
• Immunosuppression- ok to give HPV
• Breastfeeding- ok to give

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Meningococci

• Can cause devastating neurological damage,
  encephalitis, death. Rare but devastating
• Case fatality 10-14
• 11-19 cases have severe sequelae-
• e.g. loss of limbs, hearing, seizures
• Peak incidence and mortality age 15-24
• Current vaccines-strains A C Y W-135 which cause
  80 of meningitis but not B (which mostly infects
  younger children)

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Meningococci Transmission

• 5-10 of the population carries meningococci
• Adolescents and young adults most frequent
  carriers few carriers develop disease
• Transmission via air droplets, secretions from
  infected person

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Meningococcal Vaccine

• ACIP recommendation
• MCV4 (conjugate) at the 11-12 years old visit.
• Conjugate duration approx 10 years
• Unimmunized college freshmen should be immunized
• Prior to availability of conjugate meningococcal
  vaccine, polysacchride-shorter duration--given
  just before college
• Young adults (18-24 y.o.) living in aggregate
  housing such as dormitories or military barracks
  are at higher risk for meningococcal disease.

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tetanus
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Bordetella pertussis

• Spreads by droplet--through the air by infectious
  droplets
• AKA whooping cough (go to pertussis.com to hear
  it)
• Also known as 100 day cough
• Highly contagious
• Only VPD in US on the rise
• (gt25,000 cases of pertussis in US 2004-05)
• The incubation period is 5-10 days, upper limit
  21 days
• Most pertussis deaths in U.S. are in infants too
  young to complete series, most infected by family
  member
• Antibiotics if given early enough can shorten
  course and spread.

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Tdap-tetanus, diphtheria, pertussis

• Tdap has different amounts than DTaP
• (Beware look alikes!)
• Two Tdap products
• Adacel approved for 11-64 y.o.
• Boostrix approved for 10-18 y.o.
• ACIP recommendations
• all11-12 y.o.
• gt 12 y.o if have not had it
• Adults lt65 y.o. (Adacel only) in contact w
  infants lt12 months old
• Routine interval- 5 years after Td no minimum
  interval

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Tdap

• Pregnancy not contraindicated, but Td
  recommended by ACIP
• Breastfeeding- yes
• Immunosuppressed- yes

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Adolescent Immunizations

• Catch up immunizations-
• check for completion of pediatric vaccinations-
• Hep B, MMR, varicella, IPV series
• Immunizations for adolescents
• HPV to prevent cervical cancer
• MCV4 to prevent meningoccocal infection
• Tdap as adol. tetanus, diphtheria, and pertussis
  booster
• Immunization for at risk
• pneumo, influenza, hepatitis A
• Travel immunizations

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Pneumonia and influenza vaccines for those w
risks

• Chronic conditions made worse by infection
• Respiratory (e.g. asthma)
• Metabolic (eg diabetes)
• Cardiovascular
• Renal dysfunction
• Neurological disorder impairing ability to handle
  secretions

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Influenza

• Influenza is serious infection, causing
  hospitalizations and 135,000 deaths/yearMost
  morbidity and mortality is among young, old, ill
• Common infection
• Strain changes each year, need annual vaccination

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Influenza

• Recommended for
• ages 6 months to 18 years
• gt50 y.o.
• ANYONE who does not want to get influenza!
• 2 forms
• Injectible
• Intranasal -LAIV-For healthy 5-49 y.o. with no
  influenza risk factors

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Hepatitis A
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Hepatitis A Virus (HAV)

• Spread by fecal oral route
• Unwashed hands preparing food, contaminated water
• Unwashed fruit or other food
• close personal contact with an infected person
• Crack users share rocks with dirty hands
• Children can be asymptomatic and spread (think
  diapers)
• 100 deaths/year in US from fulminating liver
  destruction. Most have history of liver
  impairment
• HAV vaccine recommended for all 1-2 y.o., all at
  risk-
• MSM, travel to endemic areas, liver disease
• Series of 2, 6 months apart

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Vaccine-preventable adult diseases

• Diphtheria
• Haemophilus influenzae type b(Hib)
• Hepatitis A
• Hepatitis B
• Herpes Zoster (Shingles)
• Human Papillomavirus (HPV)
• Influenza(flu)

• Measles
• Meningococcal
• Mumps
• Pertussis (whooping cough)
• Pneumococcus
• Polio
• Rubella (German measles)
• Tetanus (lockjaw)
• Varicella (chickenpox)

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Contraindicated in Pregnancy

• MMR
• Varicella

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Hepatitis A and B risks

• Hepatitis A
• MSM
• drug users (not just IV)
• Male prison inmates
• Chronic liver disease
• Heavy drinkers
• Dialysis
• Travel to endemic areas

• Hepatitis B
• gt1 sex partner in 6 months
• MSM
• IV drug users
• Male prison inmates
• Chronic liver disease
• dialysis

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But how do you know who is at risk?

• Risk-based immunizations underutilized
• Screen questionnaires w option to select
  immunization without ID risk criteria

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Missed Opportunities for Immunizations

• Minor illness is NOT a contraindication
• If one in a series of immunizations is missed
  (not given on the schedule), do NOT restart
  series continue the series.

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Where to get immunizations

• Health care home
• Local health departments, often at much lower
  cost than private provider
• Nurse Practitioners in retail settings
• Health fairs
• Employers
• Pharmacies

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Payment for adolescent and adult IZ

• Adolescents
• Most health plans cover ACIP recommended or
  school required IZ (but some have high
  deductible)
• Vaccines for Children (VFC) ages 0-18 (to 19th
  birthday)
• Payment for adult immunizations spotty
• Health plans do not pay for work-related IZ

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Immunization Process

1. Assess immunization needs
2. Educate the patient/family on IZ, S/E
3. Screen for contraindications
4. Prepare vaccine, select needle size
5. Give immunization
6. Document
7. Schedule next immunization

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Educate patient/family VISVaccine Information
Sheets
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Immunization Process

• Screen for contraindications
• Egg allergy
• Neomycin allergy
• Previous reaction, such as temp gt 105 seizure or
  convulsion cried for 3 or more hours (child)
  needed medical care within 48 hours
• Immunocompromised
• Pregnancy- avoid live vaccines like MMR

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Immunization Process

• Prepare the vaccine
• Follow manufacturer directions
• If need to mix dilutent, use aseptic technique
• Have process to identify which vaccine in which
  syringe

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Immunization Process

• Determine route and needle size
• 5/8 length needle for SC,
• IM needle length by age, size, route

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Recommendations from Nurse Practitioner
Healthcare Foundation

• To be released 2009
• Raise awareness of the need for adolescent
  immunizations among 11-to 12-year-olds and their
  parents.
• Communicate with adolescents in their own venues
  put messages where adolescents are and make it
  fashionable to get immunized.
• Remove financial barriers.
• Leverage health plans to encourage adolescent
  immunizations.
•  

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Recommendations from Nurse Practitioner
Healthcare Foundation

• Encourage local, state, and national registries
  to include adolescent data.
• Support multiple venues for immunization
  education and for the immunizations themselves.
• Every healthcare practitioner needs to be current
  on immunizations.
• Eliminate practice barriers to immunizations.

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Vaccine Life Cycle

• Image and content adapted fromChen RT, Rastogi
  SC, Mullen JR, Hayes S, Cochi SL, Donlon JA,
  Wassilak SG. The Vaccine Adverse Event Reporting
  System (VAERS). Vaccine 199412542-50., accessed
  Sept 4, 2007 from www.cdc.gov/vaccine

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Great resources

• www.immunize.org (Immunization Action Coalition)
• www.cdc.gov/vaccines
• www2a.cdc.gov/TCEOnline
• Lots of great online and satellite training,
  including immunization updates, w CEU credits

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Standards for Immunization Practice

• Availability of vaccines
• Vaccines are readily available
• PCP, specialists, etc
• Vaccines are coordinated with other health
  services and medical home
• Barriers are identified and minimized
• --scheduling, requiring WCC and PE, long waits
• Patient costs are minimized

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Standards for Immunization Practice

• Assessment of vaccine status
• Review IZ status every child, every time
• Assess and follow only true contraindications

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Standards for Immunization Practice

• Effective communication about benefits and risks
• Educate families
• In easy to understand language
• In culturally appropriate manner
• Allow enough time
• Give VIS
• Address questions and concerns
• Encourage families to inform of adverse events

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Standards for Immunization Practice

• Proper storage, administration and documentation
• Follow storage and handling procedures
• Note expiration date
• Monitor and record temperature BID
• Up-to-date written vaccination protocols
• Current schedule, contraindications
• Administration techniques
• Storage and handling requirements
• Treatment and reporting of adverse events
• Benefit and risk communication
• Vaccine record maintenance

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Standards for Immunization Practice

• Proper storage, administration and documentation
• Ongoing education of staff
• Current schedule, contraindications
• Storage and handling requirements
• Treatment and reporting of adverse events
• Benefit and risk communication
• Give as many indicated doses as possible in the
  same visit
• Reduce need for more visits, risk of missed doses
• Avoid delayed protection

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Standards for Immunization Practice

• Proper storage, administration and documentation
• IZ records are accurate, complete, easily
  accessible
• On a standard form
• Document all vaccines received from you and other
  HCP
• Report to registry
• Give family hand-held record to bring to all hc
  encounters
• Report adverse events promptly to VAERS-Vaccine
  Adverse Event Reporting System
• All personnel who have contact with patients are
  appropriately vaccinated
• Have systems in place to review and maintain IZ
  status of all personnel and trainees

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Standards for Immunization Practice

• Implement strategies to improve vaccination
  coverage
• Systematic reminders and recall (SR)
• Mailed, phone reminders and recall to families
• Provider reminder/recall systems
• Annual office/clinic patient record reviews
• Practice community-based approaches
• Work with partners (SR)
• Develop strategies to meet community needs

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• An once of prevention is worth