Volume 18 – Number 1 March 2014

VACCINATE ADULTS!from the Immunization Action Coalition — www.immunize.org

(Content current as of March 25)

What’s in this issue?

Immunization questions?• CalltheCDC-INFOContactCenterat(800)232-4636or(800)CDC-INFO

• Emailnipinfo@cdc.gov•Callyourstatehealthdept.(phonenumbersatwww.immunize.org/coordinators)

Ask the ExpertsIAC extends thanks to our experts, medical officer Andrew T. Kroger, MD, MPH; nurse educator Donna L. Weaver, RN, MN; and medical officer Iyabode Akinsanya-Beysolow, MD, MPH. All are with the National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention (CDC).

Ask the Experts . . . continued on page 16

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Four leading national medical associations—the American Academy of Family Physicians(AAFP), the American Academy of Pediatrics(AAP), the American College of Physicians(ACP), and the American College of Obstetri-ciansandGynecologists(ACOG)—togetherwiththe Immunization Action Coalition (IAC) andtheCenters forDiseaseControl and Prevention(CDC),haveissuedacalltoaction,urgingphy-siciansacross theUnitedStates to educate theirpatientsabouthumanpapillomavirus(HPV)vac-cine,andtostronglyrecommendHPVvaccination.

In their "Dear Colleague" letter, these medicaland public health organizations emphasize tophysicians thatastronghealthcareproviderrec-ommendationiscritical to increasingtherateofHPVvaccinationandpreventingHPV-associatedcancers.Despitemorethansevenyearsofvaccinemonitoring showing overwhelming evidence ofHPVvaccinesafetyandeffectiveness,HPVvac-cination rates are not improvingwhile rates forotheradolescentvaccinesare.

IntheUnitedStatesalone,79millionpeoplearecurrentlyinfectedwithHPV.Everyyear,14mil-lion are newly infected and 26,000 cancers at-tributable to HPV are diagnosed. Studies show

Leading Medical and Public Health Organizations Join Efforts Urging Physicians to Strongly Recommend HPV Vaccination

thatwhenaproviderstronglyrecommendsHPVvaccination,patientsare4to5timesmorelikelytoreceiveHPVvaccine.Itistimeforphysiciansto strongly recommendHPVvaccine topreventcervicalandothercancers.

“Whatyousaymatters,andhowyousayitmat-ters even more,” says IAC Executive DirectorDeborahWexler,MD.“Alukewarmrecommen-dationmayleadpeopletoperceiveHPVvaccina-tionaslessimportantthanothervaccines.”

AAFPPresidentReidBlackwelder,MD, states,“It'sastonishingthatdespitearemarkableeffec-tivenessrecord,onlyaroundathirdofU.S.ado-lescent girls complete HPV vaccination. Coun-trieslikeRwandaareimmunizingmorethanfouroutoffiveadolescentgirls.We'vegottodobetterintheUnitedStates.”

“The AAP recognizes that parents have manyquestions about the HPV vaccine,” said AAPPresidentJamesM.Perrin,MD,FAAP.“It’sim-portantforproviderstobeabletoengageindia-logue,answerquestions,andstillprovideastrongrecommendationforthevaccine.Evenwithpar-ents who have questions, a healthcare provider

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Recommend HPV Vaccine. . . continued on p. 5

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HPV vaccineI read that human papillomavirus (HPV) vaccination rates are still low. What can we do as providers to improve these rates?ResultsfromtheCentersforDiseaseControlandPrevention’s2012NationalImmunizationSurvey-Teen (NIS-Teen) indicate thatHPVvaccinationrates in girls age 13 through 17 years failed toincreasebetween2011and2012,andthe3-dosecoveragerateactuallydeclinedslightlyduringthisperiod.Justoverhalfofthegirlsage13through17yearshadstartedtheseriesthattheyshouldhavecompletedbyage13years.Onlyaboutone-thirdofgirlsthisagehadcompletedtheseries.In2012,thefirstyearHPVvaccinewasroutinelyrecom-mendedforboys,20.8%ofboysage13through17yearshadreceivedonedoseandonly6.8%hadreceivedallthreerecommendeddoses.Asummaryofthe2012NIS-Teensurveyisavailableatwww.cdc.gov/mmwr/pdf/wk/mm6234.pdf,page685.Providerscan improveuptakeof this life-sav-

ingvaccineintwomainways.First,studieshaveshownthatmissedopportunitiesareabigproblem.

Eighty-fourpercentofgirlsunvaccinatedforHPVhadahealthcarevisitwheretheyreceivedanothervaccinesuchasTdap,butnotHPV.IfHPVvaccinehadbeenadministeredatthesamevisit,vaccina-tioncoverageforoneormoredosescouldbenearly93%insteadof54%.Second,the2012NIS-Teendatashowthatnot

receivingahealthcareprovider'srecommendationforHPVvaccinewasoneofthefivemainreasons

Leading Medical and Public Health Organizations Urge Physicians to Recommend HPV Vaccine ... 1Ask the Experts: CDC answers questions ......... 1HPV Vaccination Resources for Providers and Patients……………………………………… . 2Vaccine Highlights: Recommendations, schedules, and more………………………………. 4Give a Strong Recommendation for HPV Vaccine to Increase Uptake………………………. 6New! How to Administer Intradermal, Intranasal, and Oral Vaccinations ...................... 8Meningococcal Vaccination Recommendations by Age and/or Risk Factor…………………. ....... 9Recommended Adult Immunization Schedule, United States, 2014……………………….. ......... 10Guide to Contraindications and Precautions to Commonly Used Vaccines in Adults .................. 13 Before You Vaccinate Adults, Consider Their “HALO”…………………………………………. .... 14Patient Schedules for All Adults and for High-Risk Adults ................................................ 15 IAC’s Immunization Resources Order Form ..... 18

16 Vaccinate Adults! •March2014•ImmunizationActionCoalition•(651)647-9009•www.immunize.org•www.vaccineinformation.org

nonimmune.ACIPdoesnotrecommendserologictestingaftervaccinationbecausecommercialtestsmay not be sensitive enough to reliably detectvaccine-inducedimmunity.

I have a 45-year-old patient who is travel-ing to Jordan to work with Syrian refugees. She doesn’t recall ever getting a second dose of MMR (she didn’t go to college and never worked in healthcare). She was rubella immune when pregnant 20 years ago. Her measles titer is negative. Would you recom-mend a second dose of MMR vaccine? Yes.ACIPrecommends2dosesofMMRgivenatleast4weeksapartforanyadultbornin1957orlaterwhoplanstotravelinternationally.Thereis noharm ingivingMMRvaccine to apersonwhomayalreadybe immune tooneormoreofthevaccineviruses.

MMRV was mistakenly given to a 31-year-old instead of MMR. Can this be considered a valid dose?Yes,however, this issue isnot addressed in the2010MMRVACIPrecommendations.Althoughthisisoff-labeluse,CDCrecommendsthatwhenadoseofMMRVisinadvertentlygiventoapatientage13yearsandolder,itmaybecountedtowardscompletion of theMMR and varicella vaccineseriesanddoesnotneedtoberepeated.

Hepatitis B vaccineOn December 20, 2013, CDC published a new guidance document titled “CDC Guidance for Evaluating Health-Care Personnel for Hepatitis B Virus Protection and for Administering Post-exposure Management” (MMWR 2013;62[RR-10]). What is new in this document?Thedocumentprovidesacomprehensivereviewof theepidemiologyofhepatitisBvirus (HBV)infectionamonghealthcarepersonnel(HCP),up-datedinformationaboutthepersistenceofanti-HBsantibodyfollowingvaccinationandthedurationofvaccine-inducedprotection,andnewinformationaboutHCP serologic testing and postexposureprophylaxis. The document, available atwww.cdc.gov/mmwr/pdf/rr/rr6210.pdf,updatesrecom-mendationsmade in the 2011 Immunization ofHealth-CarePersonnelrecommendations(MMWR2011;60[RR-7]availableatwww.cdc.gov/mmwr/pdf/rr/rr6007.pdf) and the 2006 adult hepatitisB vaccine ACIP recommendations (MMWR2006;55[RR-16]availableatwww.cdc.gov/mmwr/PDF/rr/rr5516.pdf).An important new recommendation is for the

managementofHCPwhohavewrittendocumen-tationofacompleteseriesofhepatitisBvaccinedoses in thepast (including thosevaccinated asinfants,children,andadolescents)whowerenottestedforantibodyresponsefollowingthevaccina-tionseriesandwhonowtestnegativeforantibodytohepatitisBsurfaceantigen(anti-HBs)definedasanti-HBslessthan10mIU/mL.Itisnowrecom-

parentsreportedfornotvaccinatingdaughters.CDCurgeshealthcareproviderstoincreasethe

consistencyandstrengthofhowtheyrecommendHPVvaccine,especiallywhenpatientsareage11or12years.Thefollowingresourcescanhelppro-viderswiththeseconversations.•CDC's“TipsandTime-saversforTalkingwithParentsaboutHPVVaccine,”availableatwww.cdc.gov/vaccines/who/teens/for-hcp-tipsheet-hpv.pdf.

•IAC's “Human Papillomavirus HPV: A Parent’sGuidetoPreteenandTeenHPVVaccination,”avail-ableatwww.immunize.org/catg.d/p4250.pdf.

FormoredetailedinformationaboutHPVvaccina-tionstrategiesforproviders,visitwww.cdc.gov/vaccines/who/teens/for-hcp/hpv-resources.html.

TDTaP and Tdap vaccinesA 17-year-old received a dose of Tdap vaccine when she was 12 years old. She is now preg-nant. Should she get another dose of Tdap vaccine?Yes.ACIPrecommendsadoseofTdapduringeachpregnancyirrespectiveofthepatient’spriorhis-toryofreceivingTdap.Tomaximizethematernalantibodyresponseandpassiveantibodytransfertotheinfant,optimaltimingforTdapadministrationisbetween27and36weeksgestation.Formoreinformation, seewww.cdc.gov/mmwr/pdf/wk/mm6207.pdf,page131.

Influenza vaccineMay Fluzone High-Dose (sanofi) be adminis-tered to patients younger than age 65 years? No.FluzoneHigh-Doseislicensedonlyforpersonsage65yearsandolderandisnotrecommendedforyoungerpeople.SeeMMWR,April30,2010,avail-

Andrew T. Kroger, MD, MPH Donna L. Weaver, RN, MN Iyabode Akinsanya-Beysolow, MD, MPH

IAC’s“Ask theExperts”

teamfromCDC

Vaccinate Adults correction policyIfyoufindanerror,pleasenotifyusimmediatelybysendinganemailmessagetoadmin@immunize.org.Wepublishnotificationofsignificanterrors inouremailannouncementservice,IAC Express.Be sure you’re signed up for this service.Tosubscribe,visitwww.immunize.org/subscribe.

ableatwww.cdc.gov/mmwr/preview/mmwrhtml/mm5916a2.htmfordetailsaboutthelicensureofthisvaccine.

MMR and varicella vaccinesWould you consider a healthcare provider with 2 documented doses of MMR vaccine (Merck) to be immune even if their serology for 1 or more of the antigens comes back negative? Yes.Healthcare personnel (HCP)with 2 docu-menteddosesofMMRvaccineareconsideredtobeimmuneregardlessoftheresultsofasubsequentserologic test formeasles,mumps, or rubella.Documented age-appropriate vaccination super-sedestheresultsofsubsequentserologictesting.HCPwhodonot have documentation ofMMRvaccinationandwhoseserologictestisinterpretedas"indeterminate"or"equivocal"shouldbecon-siderednotimmuneandshouldreceive2dosesofMMR.ACIPdoesnotrecommendserologictestingaftervaccination.Formoreinformation,seeACIP'srecommendationsontheuseofMMRatwww.cdc.gov/mmwr/pdf/rr/rr6204.pdf,page22.

I have patients who claim to remember receiv-ing MMR vaccine but have no written record, or whose parents report the patient has been vaccinated. Should I accept this as evidence of vaccination?No.Self-reporteddosesandhistoryofvaccinationprovidedby a parent or other caregiver are notconsideredvalid.Youshouldonlyacceptawritten,datedrecordasevidenceofvaccination.

We have adult patients in our practice at high risk for measles, including patients going back to college or preparing for international travel, who don’t remember ever receiving MMR vaccine or having had measles disease. How should we manage these patients? Youhavetwooptions.Youcantestforimmunityoryoucan justgive2dosesofMMRat least4weeks apart.There is no harm in givingMMRvaccinetoapersonwhomayalreadybeimmunetooneormoreof thevaccineviruses. Ifyouorthepatientopt for testing,and the tests indicatethepatient isnot immunetooneormoreof thevaccinecomponents,giveyourpatient2dosesofMMRatleast4weeksapart.Ifanytestresultsareindeterminateorequivocal,consideryourpatient

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Ask the Experts . . . continued from page 16

mendedtoadminister1doseofhepatitisBvaccinetotheseindividualsandthentestforanti-HBs1to2monthslater.Thosewhotestpositiveafterthesingle“booster”doseareconsideredtobeimmuneand no further testing or vaccination is needed.Thosewhotestnegativeafterthe“booster”doseshould receive2 additional doses to complete asecond3-doseseries.Anti-HBstestingshouldberepeated1to2monthsaftercompletionofthesec-ondvaccinationseries.Analgorithmisprovidedonpage13ofthenewguidancedocumenttoassistclinicianswiththisprocess.Anothernewrecommendationintheguidance

concernsthemanagementofHCPwhoneedpost-exposureprophylaxis. In thesection titled“PostExposureManagement”onpage12,thedocumentprovidesdetailedrecommendationsformorecom-binationsofHCPvaccination/serologicstatusandsourcepatientstatusthaninpreviousrecommenda-tions.Arevisedpostexposuremanagementtableis includedin thedocumentonpage14.Oneofthe changes is a recommendation thatwhen thehepatitisBsurfaceantigen(HBsAg)statusofthesourcepatientisunknown(forexample,asmightoccurfromapuncturewoundfromaneedleinthetrash),theexposedunvaccinatedorincompletelyvaccinatedHCPshouldbemanagedasifthesourcepatientwereHBsAgpositive.Inthesesituations,thenewrecommendationistoincludeadoseofhepatitisBimmuneglobulin(HBIG)inadditiontostartingorcompletingthevaccinationseriesforallexposureswheretheHBsAgstatusofthesourceisunknown.

Zoster vaccineA long-term care resident age 80 years who received zoster vaccine (Zostavax; Merck) several years ago recently had a mild case of shingles. Is there any recommendation for administering a second dose of vaccine in such a circumstance? Are booster doses ever recommended? Theanswertobothquestionsisno.Zostervaccineis not 100% effective. In the key clinical trial,overalleffectivenessamongpeopleage60yearsandolderwas51%anddecreasedwithincreasingage.However,thevaccinewas67%effectiveinpreventingpost-herpeticneuralgia;thiseffective-ness did not decreasewith increasing age.Thedurationofprotectionfromshinglesafteradoseofzostervaccineisnotknownatthistime.How-ever,ACIPhasnotrecommendedaseconddosefor anyone.ACIP recommendations for the useofzostervaccineareavailableatwww.cdc.gov/mmwr/PDF/rr/rr5705.pdf.

The Zostavax package insert says to inject the vaccine into the deltoid region of the upper arm. We always give subcutaneous vaccines in the triceps area of the arm. Are we wrong?No.Thesubcutaneoustissueoverlyingthetricepsmuscleoftheupperarmistheusuallocationforsubcutaneousvaccineinjectionforanadult.

The Zostavax package insert says that the vaccine is contraindicated in a person with a history of primary or acquired immunodefi-ciency states, leukemia, lymphoma, or other malignant neoplasms affecting the bone marrow or lymphatic system. Does this mean that a person who was treated for lymphoma many years ago and is now healthy should not receive zoster vaccine?No.A personwhowas treated for leukemia,lymphoma,orothermalignantcancersinthepastandisnowhealthyandnotreceivingimmunosup-pressive treatmentmay receive zoster vaccine.However, a personwho is immunosuppressedforanyreason(diseaseor treatment)shouldnotreceivethevaccine.

Can a person age 60 years or older with a diagnosis of an autoimmune disease, such as lupus or rheumatoid arthritis, receive zoster vaccine?Yes,withonequalification.Adiagnosisofanau-toimmuneconditionsuchaslupusorrheumatoidarthritisisnotacontraindicationtozostervaccina-tion.However,thetreatmentoftheseconditionsmay involve the use of an immunosuppressivedrug,whichcouldbeacontraindication.

A 65-year-old patient is having major back surgery next week. He is requesting zoster vaccine today. Can I give him the vaccine?Yes,withonequalification.There is no contra-indication to vaccinating against zoster beforesurgery,unlessthepatientisimmunocompromisedforsomereason.

For patients age 60 or older who don't remem-ber having chickenpox in the past, should we test them for varicella immunity before giving zoster vaccine?No.Simply vaccinate themwith zoster vaccineaccordingtotheACIPrecommendations.

We weren't familiar with the recommendations and tested a 60-year-old for varicella antibody because she said she never had chickenpox. Her result was negative. Should this patient receive zoster vaccine or varicella vaccine?Inthissituation,sinceyou'vetestedthepatientandtheresultswerenegative,thepatientshouldreceivevaricellavaccine.

Apersonage60yearsorolderwhohasnomedi-calcontraindicationsiseligibleforzostervaccineregardlessoftheirmemoryofhavinghadchicken-pox.However,ifanadultage60yearsorolderistestedforvaricellaimmunityforwhateverreason,andthetestisnegative,he/sheshouldbegiven2dosesofvaricellavaccineatleast4weeksapart,not zoster vaccine. See www.cdc.gov/vaccines/vpd-vac/shingles/hcp-vaccination.htm for moreinformation.

How should zoster vaccine be transported to an off-site clinic location?NeitherCDCnorthevaccinemanufacturerrecom-mendstransportingvaricella-containingvaccines.Ifthesevaccinesmustbetransported(forexample,duringanemergency),CDCrecommends trans-port inaportablefreezerunit thatmaintains thetemperaturebetween-58°Fand+5°F(-50°Cand-15°C).Portablefreezersmaybeavailableforrentin someplaces. If varicella-containing vaccinesmustbetransportedandaportablefreezerunitisnotavailable,donotusedryice.Dryicemaysub-jectvaricella-containingvaccinestotemperaturescolderthan-58°F(-50°C).Varicella-containing vaccines may be trans-

ported at refrigerator temperature between36°Fand46°F(2°Cand8°C)forupto72continuoushoursprior toreconstitution.Vaccinestoredbe-tween36°Fand46°F(2°Cand8°C)thatisnotusedwithin72hoursofremovalfromafreezershouldbediscarded.Detailedinstructionsforthetransportofvaricella-containingvaccinesatrefrigeratortem-peratureareavailableintheCDC“VaccineStorage&Handling Toolkit” at www.cdc.gov/vaccines/recs/storage/toolkit/storage-handling-toolkit.pdf.

To submit an “Ask the Experts” question . . .You can email your questions about immunization to us at admin@immunize.org. IAC will respond to your inquiry. Because we receive hundreds of email messages each month, we cannot guarantee that we will use your question in “Ask the Experts.” IAC works with CDC to compile new Q&As for our publications based on commonly asked ques-tions. Most of the questions are thus a composite of several inquiries.

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