# Presentation: 665938

## Immunization Update 2007
Satellite Broadcast/Webcast
August 9, 2007

Influenza Vaccine Segment

**Satellite Broadcast/Webcast**
**August 9, 2007**
**Influenza Vaccine Segment**

**Graphics subject to change.**
**This material in the public domain.**

## ACIP Statements Published Since August 2006

**Rotavirus (8/11/2006)**
***General Recommendations***** (12/1/2006)**
**Tdap (adult) (12/15/2006)**
**Hepatitis B (adult) (12/8/2006)**
**Human papillomavirus (3/23/2007)**
**Varicella (6/22/2007)**
**Influenza (7/13/2007)**

**All ACIP statements available at www.cdc.gov/vaccines/pubs/ACIP-list.htm**

## 2007-2008 InfluenzaVaccine Recommendations

**Children 6 months through 8 years of age who received only 1 dose in their first year of vaccination should receive 2 doses the SECOND YEAR they are vaccinated**

**Source:***** MMWR***** 2007;56 (RR-6)**

## 2007-2008 InfluenzaVaccine Recommendations

**Importance of 2 doses for children younger than 9 years of age being vaccinated for the first time**
**Immunization providers should offer influenza vaccine and schedule immunization clinics throughout the influenza season**

**Source:***** MMWR***** 2007;56 (RR-6)**

## 2007-2008 InfluenzaVaccine Recommendations

**Healthcare administrators implement policies to encourage vaccination of healthcare personnel (HCP)**
**Change in storage requirement for live attenuated influenza vaccine**

**Source:***** MMWR***** 2007;56 (RR-6)**

## Impact of Influenza, 1990-1999

**Approximately 36,000 influenza-associated deaths during each influenza season**
**Persons 65 years of age and older accounted for more than 90% of deaths**
**Average of 226,000 hospitalizations during each influenza season**

**Source:***** MMWR***** 2007;56 (RR-6)**

## Influenza Vaccination of Children

**ACIP recommends annual influenza vaccination of children 6 through 59 months of age (inactivated influenza vaccine only)**
**Vaccination of household contacts and out-of-home caregivers of all  children birth through 59 months of age**

**Source:***** MMWR***** 2007;56 (RR-6)**

## Timing of Influenza Vaccination

**Influenza activity can occur as early as October**
**In more than 80% of influenza seasons peak activity has not occurred until January or later**
**In more than 60% of seasons the peak was in February or later**

**Source:***** MMWR***** 2007;56 (RR-6)**

## Timing of Influenza Vaccination

**Immunization providers should begin offering vaccine soon after it becomes available and if possible by October**
**Providers should offer vaccine during routine healthcare visits or during hospitalizations whenever vaccine is available**

**Source:***** MMWR***** 2007;56 (RR-6)**

## Month of Peak Influenza Activity United States, 1976-2006

**13%**

**19%**

**45%**

**13%**

**3%**

**3%**

**3%**

**Source:***** MMWR***** 2007;56 (RR-6)**

## Timing of Influenza Vaccination

**Consider scheduling organized vaccination campaigns after at least mid-October**
**Scheduling campaigns after mid-October will minimize the need for cancellations because vaccine is unavailable **

**Source:***** MMWR***** 2007;56 (RR-6)**

## Continue to offer influenza vaccine in December, especially to healthcare personnel and those at high risk of complications
Continue to vaccinate throughout influenza season (December-March)

**Continue to vaccinate throughout influenza season (December-March)**

**Timing of Influenza Vaccination**

**Source:***** MMWR***** 2007;56 (RR-6)**

## Inactivated Influenza Vaccine Recommendations, 2007-2008

**Conditions that increase the risk of influenza complications:**
**Age**
**65 years and older**
**59 months and younger**
**Pulmonary (emphysema, asthma)**
**Cardiovascular**
**Metabolic (diabetes)**
**Renal dysfunction **
**Hemoglobinopathy**
**Immunosuppression, including HIV infection**
**Conditions that compromise respiratory function or increase the risk of aspiration**

## Inactivated Influenza Vaccine Recommendations, 2007-2008

**Persons at increased risk of influenza complications**
**Residents of long term care facilities**
**Persons 6 months to 18 years of age receiving chronic aspirin  therapy**
**Pregnant women**

## Pregnancy and Influenza Vaccine

**Risk of hospitalization more than 4 times higher than among nonpregnant women**
**Risk of complications comparable to nonpregnant women with high risk medical conditions**
**ACIP recommends vaccination with inactivated influenza vaccine for ALL women who will be pregnant during influenza season**

**Source:***** MMWR***** 2007;56 (RR-6)**

## Influenza Vaccine Recommendations, 2007-2008

**Immunization providers should administer influenza vaccine to  any person who wishes to reduce the likelihood of becoming ill with influenza or transmitting influenza to others**

**Source:***** MMWR***** 2007;56 (RR-6)**

## Household members of high-risk persons
Healthcare personnel, including home care
Employees of long-term care facilities

**Healthcare personnel, including home care**
**Employees of long-term care facilities**

**Source:***** MMWR***** 2007;56 (RR-6)**

**Influenza Vaccine ****Recommendations, 2007-2008**

## Benefits of Influenza Vaccination of Healthcare Personnel (HCP)

**Reduction in nosocomial influenza and influenza-related deaths**
**Reduction in staff illness and illness-related absenteeism**
**Reduction of direct medical costs and indirect costs from work absenteeism**

**Source:***** MMWR***** 2006;55 (RR-2)**

## Influenza Vaccination of Healthcare Personnel

**Only 42 percent of U.S. healthcare personnel  were vaccinated in 2004 **

**Source:***** MMWR***** 2006;55 (RR-2)**

## Reasons HCP Do Not Receive Influenza Vaccine

**Concern about vaccine adverse events**
**Perception of a low personal risk of **
**influenza virus infection**
**Insufficient time or inconvenience**
**Reliance on homeopathic medications**
**Avoidance of all medications**
**Fear of needles**

**Source:***** MMWR***** 2006;55 (RR-2)**

## Factors Facilitating HCP Influenza Vaccination

**Desire for self-protection**
**Previous receipt of influenza vaccine**
**Desire to protect patients**
**Perceived effectiveness of the vaccine**

**Source:***** MMWR***** 2006;55 (RR-2)**

## Strategies to Improve HCPInfluenza Vaccination Levels

**Education**
**Role models**
**Reduction of financial and time barriers**
**Monitor and report influenza vaccination levels in the facility**
**Signed vaccination declination* (?)**
**Legislation and regulation (?)**

***Examples of vaccination declination forms available in *****Infection Control and Hospital Epidemiology*****, November 2005, and from the Immunization Action Coalition at www.immunize.org**

## Trivalent Inactivated Influenza Vaccine (TIV) Schedule

**Age Group**
**6-35 mos**
**3-8 yrs**
**9 years or older**

**Dose**
**0.25 mL**
**0.50 mL**
**0.50 mL**

**# Doses**
**1 or 2**
**1 or 2**
**1**

**Source:***** MMWR***** 2007;56 (RR-6)**

## Influenza Vaccination of Children

**Children 6 months through 8 years of age who received only 1 dose in their first year of vaccination should receive 2 doses the second year they are vaccinated**
**Children who are in their third or more year of being vaccinated and who received only 1 dose in each of their first 2 years of being vaccinated should continue receiving a single annual dose**

**Source:***** MMWR***** 2007;56 (RR-6)**

## Inactivated Influenza Vaccines Available in 2007-2008

| Vaccine | Package | Dose | Age | Thimerosal |
| --- | --- | --- | --- | --- |
| Fluzone
(sanofi pasteur) | Multidose vial* | Age-dependent | >6 mos | Yes |
|    | Single dose syringe* | 0.25 mL | 6-35 mos | No |
|    | Single dose syringe | 0.5 mL | >36 mos | No |
|    | Single dose vial | 0.5 mL | >36 mos | No |
| Fluvirin
(Novartis) | Multidose vial | 0.5 mL | >4 yrs | Yes |
| Fluarix
(GSK)
Flulaval
(GSK) | Single dose syringe
Multidose vial | 0.5 mL

0.5 mL | >18 yrs

>18 yrs | Trace

Yes |

***vaccines approved for children younger than 4 years **

## Live Attenuated Influenza Vaccine (LAIV)

**Approved only for healthy persons 5 years through 49 years of age who are not pregnant**
**healthcare personnel**
**persons in close contact with high-risk groups**
**persons who want to reduce their risk of influenza **

**Source:***** MMWR***** 2007;56 (RR-6)**

##    LAIV Schedule

**   ****LAIV Schedule**

_**Age Group**_
**5 through 8 years**
**     ****-no previous**
**      ****influenza vaccine**
**     ****-previous influenza**
**      ****vaccine **
**9 through 49 years**

_**Number of Doses**_
**2 **
**(separated by 6-10 weeks)**
**1 or 2**
**1**

**Source:***** MMWR***** 2007;56 (RR-6)**

## Use of LAIV Among CloseContacts of High Risk Persons

**Inactivated influenza vaccine is preferred for close contacts of severely immunosuppressed persons who require care in a protective environment**
**Persons who receive LAIV should refrain from contact with severely immunosuppressed persons for 7 days after vaccination**
**Persons who receive LAIV do not need to be excluded from visitation of patients who are not severely immunosuppressed**

**Source:***** MMWR***** 2007;56 (RR-6)**

## Influenza VaccineStorage and Handling

**Both TIV and LAIV should be stored at refrigerator temperature (35****o****- 46****o**** F) at all times**
**Neither vaccine should be exposed to freezing temperature**

## Administration of LAIV

**Severely immunosuppressed persons should not administer LAIV**
**Other persons at increased risk for influenza complications* may administer LAIV**
**Gloves and masks are not required**

***e.g., pregnant women, persons with asthma and persons 50 years of age or older**

## Influenza Antiviral Use, 2007-2009

**Neither amantadine nor rimantadine should be used for treatment or chemoprophylaxis of influenza A infections during the 2007-2008 influenza season**
**Oseltamivir or zanamivir should be prescribed if an antiviral drug is indicated for the treatment of influenza**

**Source:***** MMWR***** 2007;56 (RR-6)**

## Immunization Update 2007
Satellite Broadcast/Webcast
August 9, 2007

Varicella Vaccine Segment

**Satellite Broadcast/Webcast**
**August 9, 2007**
**Varicella Vaccine Segment**

**Graphics subject to change.**
**This material in the public domain.**

## Varicella in the United States

**Coverage with one dose at highest level ever recorded (88%)**
**More than 70% decrease in cases, hospitalizations and death compared to prevaccine era**

## Varicella Outbreaks 2001-2005

**Occurred in elementary schools**
**Vaccine effectiveness 72%-85%**
**Highest attack rates occurred among the younger students **
**Outbreaks lasted about 2 months**
**Vaccinated children played a role in transmission although their disease was mild**
**Overall attack rates among vaccinated children 11%-17%**

## Varicella Vaccine Recommendations

**Routine vaccination at 12 to 15 months of age**
**Routine second dose at 4 to 6 years of age**
**Two doses recommended for all persons older than 4 to 6 years who do not have evidence of varicella immunity**
**Second dose recommended for persons of ANY age who have only received one dose**

**Source: *****MMWR***** 2007;56(RR-4)**

## Varicella Vaccine-MinimumInterval Between Doses

**Age**
**12 months through**
**12 years of age**
**13 years of age or **
** ****older**

**Interval**
**3 months**
**4 weeks**

**Source: *****MMWR***** 2007;56(RR-4)**

## Varicella Immunity

**Written documentation of age-appropriate vaccination**
**1 dose for preschool-aged children**
**2 doses for school-aged children, adolescents and adults**
**Born in the United States before 1980 EXCEPT healthcare personnel, immunocompromised persons and pregnant women**

**Source: *****MMWR***** 2007;56(RR-4)**

## Laboratory evidence of immunity or laboratory confirmation of varicella disease
Healthcare provider diagnosis or verification of a history of varicella disease
History of herpes zoster (shingles) based on healthcare provider diagnosis 

**Healthcare provider diagnosis or verification of a history of varicella disease**
**History of herpes zoster (shingles) based on healthcare provider diagnosis **

**Source: *****MMWR***** 2007;56(RR-4)**

**Varicella Immunity**

## Varicella Vaccination of Healthcare Workers

**Recommended for all healthcare personnel without evidence of immunity**
**Prevaccination serologic screening probably cost-effective**
**Postvaccination testing not necessary or recommended**

**Source: *****MMWR***** 1997;46(RR-18)**

## Varicella Immunity AmongHealthcare Personnel

**Laboratory evidence of immunity**
**History of clinician diagnosed or verified varicella or zoster**
**Documentation of age-appropriate vaccination **

**Source: *****MMWR***** 2007;56(RR-4)**

## MMRV (ProQuad)

**Approved for children 12 months through 12 years of age**
**Should NOT be administered to persons 13 years of age or older**
**Store frozen at 5°F (-15°C ) or lower at ALL times**

## Immunization Update 2007
Satellite Broadcast/Webcast
August 9, 2007

Rotavirus Vaccine Segment

**Satellite Broadcast/Webcast**
**August 9, 2007**
**Rotavirus Vaccine Segment**

**Graphics subject to change.**
**This material in the public domain.**

## Burden of Rotavirus Disease in the United States

**3 million infections every year**
**More than 400,000 physician visits**
**200,000 emergency dept visits**
**55,000-70,000 hospitalizations**
**20- 60 deaths**

**Source:***** MMWR***** 2006;55 (RR-12)**

## Rotavirus Vaccines

**Created by genetic reassortment**
**causes nonhuman rotavirus strains to express human rotavirus antigens on their surface**
**nonhuman rotaviruses have low pathogenicity for humans**
**replicate but do not cause disease**

## Rotashield and Intussusception

**Significantly increased risk of intussusception among infants who received Rotashield**
**Highest risk was observed 3-7 days after the first dose**
**Resulted in the vaccine being taken off the market in late 1999**

## Rotavirus Vaccine and Intussusception

**Within 42 days**
**of vaccination**
**Within 1 year**
**of vaccination**

**Vaccine**
_**Recipients**_
**6 cases**
**13 cases**

**Placebo**
_**Recipients**_
**5 cases**
**15 cases**

**Source: *****New Eng J Med***** 2006;354:23-33**

## RotaTeq Intussusception ReportsReceived by VAERS*

**117 confirmed reports**
**38 cases 1-21 days after vaccination**
**23 cases 1-7 days after vaccination**
**about one third of 38 cases occurred   following the first dose**
**6 million vaccine doses distributed**

***March 2006 through mid-June 2007**

## Expected and Reported Cases of

**Intussusception After RotaTeq**

| Age Group | Number Expected* | Number Reported |
| --- | --- | --- |
| 6-14 | 30 | 14 |
| 15-23 | 36 | 14 |
| 24-35 | 33 | 10 |
| Total | 99 | 38 |

***Among children 6-35 weeks of age, within 21 days **
** ****of a dose based on VSD data**

## Rotavirus Vaccine Recommendations

**3 oral doses at 2, 4, and 6 months of age**
**Series may be started as early as 6 weeks of age **
**First dose should be administered between 6 and 12 weeks of age**
**Vaccination should NOT be initiated for infants older than 12 weeks of age**
**Minimum interval between subsequent doses is 4 weeks**

**Source:***** MMWR***** 2006;55 (RR-12)**

## Rotavirus Vaccine Recommendations

**All 3 doses of vaccine should be administered by 32 weeks of age**
**Vaccine should NOT be administered after 32 weeks of age  **

**Source:***** MMWR***** 2006;55 (RR-12)**

## Immunization Update 2007
Satellite Broadcast/Webcast
August 9, 2007

Zoster Vaccine Segment

**Satellite Broadcast/Webcast**
**August 9, 2007**
**Zoster Vaccine Segment**

**Graphics subject to change.**
**This material in the public domain.**

## Herpes Zoster (Shingles)

**Caused by reactivation of varicella zoster virus**
**Can occur years or decades after illness with chickenpox**
**Generally associated with normal aging and with anything that causes reduced immunocompetence**
**Lifetime risk of up to 30% in the United States**
**Estimated 500,000 to 1 million cases of zoster diagnosed annually in the U.S   **

## Complications of Herpes Zoster

**Postherpetic neuralgia (can persist for weeks or months after rash resolves)**
**Ophthalmic zoster (involvement of the ophthalmic division of the trigeminal nerve and the eye)**
**Dissemination with generalized skin eruptions and involvement of the central nervous system, lung, liver, and pancreas **

## Herpes Zoster Vaccine (Zostavax)

**Contains live attenuated varicella virus in an amount that is approximately 14 times greater than that in regular varicella vaccine**
**Approved for persons 60 years and older**
**Administered by the subcutaneous route**

## Herpes Zoster Vaccine Trial

**Compared with the placebo group the vaccinated group had**
**51% fewer episodes of zoster**
**Less severe disease **
**66% less postherpetic neuralgia**
**No significant safety issues identified**

**Source:***** NEJM***** 2005;352(22):2271-84.**

## ACIP Recommendations* for Zoster Vaccine*

**Single dose of zoster vaccine for adults 60 years of age and older whether or not they report a prior episode of shingles**
**Persons with a chronic medical condition may be vaccinated unless a contraindication or precaution exists for their condition**

***Provisional recommendations, October 2006**

## Screening for Zoster Vaccine Eligibility

**Screening for a history of varicella disease is NOT necessary or recommended to administer zoster vaccine to a person 60 years of age or older**
**Persons born in the U.S. before 1980 can be assumed to be immune regardless of their recollection of chickenpox**

## Screening for Zoster Vaccine Eligibility

**Do NOT test the person for varicella antibody**
**A negative test is more likely to indicate waning antibody level rather  than true susceptibility**
**Seronegative persons should receive 2 doses of single antigen varicella vaccine**

## Zoster Vaccine Storage and Handing

**Must be stored at 5****o**** F (-15****o**** C) or colder AT ALL TIMES**
**Protect from light**
**Administer within 30 minutes of reconstitution**

## Immunization Update 2007
Satellite Broadcast/Webcast
August 9, 2007

Tdap Vaccine Segment

**Satellite Broadcast/Webcast**
**August 9, 2007**
**Tdap Vaccine Segment**

**Graphics subject to change.**
**This material in the public domain.**

## Tdap Vaccines

**Boostrix (GlaxoSmithKline)**
**Licensed May 2005**
**Single dose**
**Approved for persons 10 through 18 years of age**
**Adacel (sanofi pasteur)**
**Licensed June 2005**
**Single dose**
**Approved for persons 11 through 64 years of age**

## General Principles for Use of Tdap and Td

**No brand preference**
**Tdap preferred to Td to provide protection against pertussis**
**Approved only for a single booster dose in persons who have received a full series of pediatric DTaP or DTP**

## Use of Tdap Among Adults

**Single dose of Tdap to replace a single dose of Td**
**Special emphasis on adults with close contact with infants (*****e.g*****., childcare and healthcare personnel, and parents)**

**Source: *****MMWR***** 2006;55(RR-17) **

## Persons Without a History of Pertussis Vaccination

**All adolescents and adults should have documentation of having received a series of DTaP, DTP, DT, or Td**
**Persons without documentation should receive or complete a series of 3 doses**
**Preferred schedule:**
**single dose of Tdap**
**Td at least 4 weeks after the Tdap dose**
**second dose of Td at least 6 months after the prior Td dose**

**Source: *****MMWR***** 2006;55(RR-17) **

## Minimum Interval BetweenTd and Tdap

**ACIP did not define an absolute minimum interval between Td and Tdap**
**Provider will need to decide based on whether the benefit of pertussis immunity outweighs the risk of a local adverse reaction**

**Source: *****MMWR***** 2006;55(RR-17) **

## Tdap and Pregnancy

**Td is generally preferred during pregnancy**
**All women should receive a dose of Tdap in the immediate postpartum period**
**Any woman who might become pregnant is encouraged to receive a single dose of Tdap**

**Source: *****MMWR***** 2006;55(RR-17) **

## Tdap and Pregnancy

**A clinician may choose to administer Tdap to a pregnant woman in certain circumstances, such as during an outbreak of pertussis in the community**
**Pregnancy is not a contraindication to vaccination with Tdap**

**Source: *****MMWR***** 2006;55(RR-17) **

## Tdap and Healthcare Personnel (HCP)

**HCP who work in hospitals or ambulatory care settings and have direct patient contact should receive a single dose of Tdap (Adacel only) as soon as feasible***
**Priority should be given to vaccination of healthcare personnel who have direct contact with infants 12 months of age and younger**
**Other HCP should receive a single dose of Tdap to replace the next scheduled Td**

***if they have not previously received Tdap. **
** *****MMWR***** 2006;55(RR-17)**

## Resource to Help Reduce DTaP/Tdap Administration Errors

**“****Check Your Vials” poster showing images of DTaP/Tdap/Td vials and packaging**
**Developed by the California Immunization Branch**
**Free download from**
**www.dhs.ca.gov/ps/dcdc/izgroup/pdf/IMM-508.pdf**

## Immunization Update 2007
Satellite Broadcast/Webcast
August 9, 2007

Vaccine Briefs Segment

**Satellite Broadcast/Webcast**
**August 9, 2007**
**Vaccine Briefs Segment**

**Graphics subject to change.**
**This material in the public domain.**

## Human Papillomavirus (HPV) Vaccine Schedule

**Females 9 through 26 years of age**
**Routine schedule is 0, 2, and 6 months**
**Minimum intervals:**
**4 weeks between doses 1 and 2 **
**12 weeks between doses 2 and 3**

**Source:***** MMWR***** 2007;56(No. RR-2)**

## HPV Vaccination ACIP Recommendations 

**Routine vaccination of females 11-12 years of age with three doses of quadrivalent HPV vaccine **
**The vaccination series can be started as young as 9 years of age at the clinician’s discretion**

**Source:***** MMWR***** 2007;56(No. RR-2)**

## HPV Vaccination ACIP Recommendations 

**Vaccination is recommended for females 13 through 26 years of age not previously vaccinated**
**Vaccine should be administered before onset of sexual activity, if possible**
**Females who are sexually active should be vaccinated**

**Source:***** MMWR***** 2007;56(No. RR-2)**

## HPV VaccineSpecial Situations

**Females 26 years of age or younger with equivocal or abnormal Pap test, positive HPV DNA, or genital warts may be vaccinated**
**Vaccine will have no effect on existing disease or infection**

**Source:***** MMWR***** 2007;56(No. RR-2)**

## HPV VaccineSpecial Situations

**Females 26 years of age or younger who are lactating and breastfeeding, or are immuno-compromised may be vaccinated**
**NOT recommended for pregnant women**

**Source:***** MMWR***** 2007;56(No. RR-2)**

## HPV Vaccine 

**HPV vaccine is not approved for women older than 26 years or males**
**Efficacy data is not yet available for these groups**
**ACIP does NOT recommend off-label in either women older than 26 years or in males**

## General Recommendationson Immunization, 2006

**Vaccine administration**
**Vaccine storage and handling**
**Altered immunocompetence**
**Special situations**
**allergy to vaccine components**
**pregnancy**
**vaccines received outside the U.S.**
**persons with bleeding disorders**

## General Recommendationson Immunization, 2006

**New or expanded tables**
**minimum intervals and ages**
**contraindications and precautions**
**dose and route of administration**
**needle length and injection sites**
**vaccine storage temperatures**
**vaccine recommendations for     persons with immune deficiencies**

## Twinrix “Accelerated” Schedule

**Doses at 0, 7, 21-30 days and a booster dose at 12 months**
**Approved only for persons 18 years and older**
**The first THREE doses of the newly- licensed Twinrix schedule provide equivalent protection to**
**the first dose in the standard, single antigen adult hepatitis A vaccine series**
**the first two doses in the standard adult hepatitis B vaccine series **

## Vaccine Information Statements

**Every healthcare provider, public or private, who administers a vaccine covered by the National Childhood Vaccine Injury Act is required by law to provide a copy of the most current VIS with EACH DOSE of vaccine**

## Vaccine Information Statements

**Not required by Federal law to obtain a signature**
**Must note in each patient’s permanent medical record or permanent office file:**
**date printed on the VIS**
**date the VIS is given to the vaccine  recipient, or their legal representative **

## Vaccine Information StatementsNew or Revised Since August 2006

**New**
**Human papillomavirus**
**Zoster**
**Revised**
**DTaP**
**Hepatitis B**
**Varicella**
**Meningococcal**
**Influenza (TIV and LAIV)**

## CDC Vaccines and ImmunizationContact Information

**Hotline****	****(800) CDC-INFO**
**Email****	****	****nipinfo@cdc.gov**
**Website****	****www.cdc.gov/nip**
**Broadcast Updates and Resources **
**   ****Web Page**
**	****www.cdc.gov/vaccines/ed/broadcasts.htm**