immunization update 2016 · • influenza activity was lower and peaked later compared to past 3...
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ImmunizationUpdate:2016
GoldenPeters,PharmD,BCPSAssociateProfessor,PharmacyPracticeDepartment
St.LouisCollegeofPharmacy
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FacultyDisclosure
• GoldenPetersdeclaresnoconflictsofinterest,realorapparent,andnofinancialinterestsinanycompany,product,orservicementionedinthisprogram,includinggrants,employment,gifts,andstockholdings
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PharmacistLearningObjectives
• Discussthenew2016AdvisoryCommitteeonImmunizationPractices(ACIP)recommendationsregardingadultandpediatricimmunizations• Reviewinfluenzavaccineconsiderationsinpreparationforthe2016-2017season• Applyimmunizationrecommendationstospecificpatientscenarios
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TechnicianLearningObjectives
• Discussthenew2016AdvisoryCommitteeonImmunizationPractices(ACIP)recommendationsregardingadultandpediatricimmunizations• Reviewinfluenzavaccineconsiderationsinpreparationforthe2016-2017season• Evaluatespecificpatientscenariostoscreenforvaccinecandidates
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Pre-testQuestion#1
Whatinfluenzavaccinecanbeusedinpatientswithaneggallergyofanyseverity?
A. IIVB. RIVC. LAIVD. ccIIV
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Pre-testQuestion#2
Whenadministeringaninfluenzavaccination,howlongshouldthepatientbeobserved?
A. 15minutesB. 30minutesC. 45minutesD. 60minutes
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Pre-testQuestion#3
Whichvaccinerecentlydisplayedpoorvaccineefficacy,leadingtheACIPtorecommenditnotbeusedatthistime?• FluMist• Prevnar• Gardasil• Menactra
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Pre-testQuestion#4
Whichofthefollowingisacholeravaccine?A. ACAM2000B. DengvaxiaC. TrumenbaD. Vaxchora
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Pre-testQuestion#5
Canbothmeningococcalvaccines(MenBandserogroupsA,C,W,&Y)begivenonthesameday?
A. Yes,attheexactsametimeB. Yes,butatdifferentinjectionsitesC. No,theyshouldbeseparatedby1monthD. No,theyshouldbeseparatedby6months
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Pre-testQuestion#6
Apatientreceived2dosesofTrumenba,forthethirdinjectionthereisonlyBexseroavailable.Whatisthebestcourseofaction?
A. GivethefinaldoseasBexseroB. Thedosingseriesiscompleteat2dosesC. ThesetwovaccinesarenotinterchangeableD. Provide2dosesofBexserotofinishtheseries
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Pre-testQuestion#7
A66yearoldpatientreceivedPPSV23atage63whatistheappropriatedpneumococcalvaccinationrecommendationforthispatient?
A. OnlyPCV13nowB. PCV13now,6monthslaterPPSV23C. PPSV23now,6monthslaterPCV12D. PCV13now,12monthslaterPPSV23
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Agenda
• SummarizeACIPrecommendationssinceSeptember2015toAugust2016• Discussadultimmunizationchanges• Discusschildhoodimmunizationchanges• Highlightinfluenzatreatmentchanges
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DearPharmacistLetter…
• AnneSchuchat,MD,AssistantSurgeonGeneralandPrincipalDeputyDirector,CDC• CDCapplaudedtheaccomplishmentofthepharmacyprofession• 20yearsofservice
• Improvedhealthinourcommunities• Reducedriskofvaccine-preventabledisease• Expandedimmunizationauthority• Improvedvaccinationsrates• Commitmentto“walkingthewalk”• Collaboratingwithotherproviders
• RecognizedAPhA’sPharmac-BasedImmunizationDeliveryCertificationTrainingProgram• Upcoming20th anniversary• Trainedmorethan260,000pharmacists
Pharmacist.comCDCLetter.2015.
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AdvisoryCommitteeonImmunizationPractices(ACIP)• Members• 15expertsinthefieldofimmunization• Ex-officioMembers(9)• LiaisonMembers(33)
• Mission• AdviceandguidancetotheCDC• Developrecommendations• Reducevaccine-preventabledeaths
• Meet3times/year• Subcommitteesmeetmoreoften• Opentothepublicandavailableonlivewebcast
Source:http://www.medscape.org/viewarticle/767661_transcript
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ChildhoodImmunizationUpdates
Source:http://www.keyshealthystart.org/general/newborn-and-toddler
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ImmunizationSchedule
• Reconfiguredscheduletolistvaccinationbyageofadministration• Earliesttolatestageoffirstrecommendedadministration• Goal:
• Improvereadability• Allowforgoldbarstoalignunderagewhenfirstrecommended
MMWR.February2,2016.65.
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CDC.gov.VaccineSchedules2015.
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CDC.gov.VaccineSchedules2016.
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HumanPapillomavirusVaccine
• HPVvaccinationrecommendations:• Routineadministrationat11or12yearsofage• Catch-upvaccinationcanoccurupto26yearsold• Administerbeginningat9yearsoldforanyhistoryofsexualassault• Noneedforrevaccinationoncecompletingafullseries
MMWR.February2,2016.65.Source:http://www.medicalnewstoday.com/articles/246670.php
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MeningococcalVaccine
• Meningococcalvaccinationrecommendations:• Routinevaccinationforpeople>10yearsathighriskforMenBdisease
• Asplenia• MicrobiologistroutinelyexposedtoNeisseriaMeningitidis
• Two-doseorthree-doseseriesofeitherMeningococcalB(MenB)vaccine• Bexsero(MenB-4c)(2doses)• Trumenba(MenB-FHbp)(3doses)
• Short-termprotectionagainstMenBstrainsforpersons16to23yearsold• ThereisnopreferenceforMenBvaccines
• TheyareNOTinterchangeable
MMWR.February2,2016.65.Source:http://www.multivu.com/Source:http://www.mainstreetvacs.com/partners/
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MeningococcalVaccine
• Meningococcalvaccinationrecommendations:• Routinevaccinationat11or12yearsoldwithaquadrivalentmeningococcalvaccineremainsunchanged• Boosterdoseatage16• (Menactra[MenACWY-D])
• Bothmeningococcalvaccinescanbeadministeredatthesameofficevisit• Differentinjectionsites
MMWR.February2,2016.65.
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Diphtheria,TetanusandPertussis(DTaP)Vaccine
• DTaPvaccinationrecommendations:• FourthdoseofDTaPusuallygivenat15monthsofage
• Canbegivenat12monthsoldIFseparatedfromthirddosebyatleastsixmonths
MMWR.February2,2016.65.
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AdultImmunizationUpdates
Source:http://tetonfamilymagazine.com/ourfrontporch/childhood-vaccines-whos-calling-the-shots
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HumanPapillomavirusVaccine
• HPVvaccinationrecommendations:• AddednonavalentHPVvaccine(Gardasil)asoneofthreeformulationsapprovedforroutinevaccination• Routinevaccinationforpersons11or12yearsold
• Women:administerthrough26yearsold• Men:administerthrough21yearsold
• Menathighrisk:administerthrough26yearsold
• Norevaccinationrecommendationforthosepreviouslycompletingafullseries
MMWR.February2,2016.65.
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MeningococcalVaccine
• Meningococcalvaccinationrecommendations:• Personsatincreasedriskshouldberoutinelyvaccinatedwithquadrivalentmeningococcalvaccine(Menactra[MenACWY-D])• HIVisNOTanindicationforroutinevaccinationwithMenACWY-DorMenBvaccine(MMWR.Feb.2,2016)• June2016,ACIPrecommendsMenACWY-DvaccinetoHIVinfectedpatientsages2monthsandolder• 2doseseries,2monthsapart
MMWR.February2,2016.65.MMWR.October23,2015.64(41).
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PneumococcalVaccine
• Pneumococcalvaccinationrecommendations:• 13-valentpneumococcalconjugatevaccine(PCV13[Prevnar13])• 23-valentpneumococcalpolysaccharidevaccine(PPSV23[Pneumovax])
• Immunocompetentadults65yearsandolder,separatePCV13andPPSV23vaccinesby1years• 2015recommendation:6– 12months
• Immunocompromisedadults> 19yearsold,separatePCV13andPPSV23byeightweeks
• Asplenia,CSFleak,cochlearimplant,HIV
• PCV13andPPSV23shouldNOTbeco-administered• PPSV23inadvertentlygivenearly,donotrepeat
MMWR.February2,2016.65.MMWR.September4,2015.64(34).
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PneumococcalVaccineinPatients> 65YearsOld
MMWR.September4,2015.64(34).
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Source:http://eziz.org/assets/docs/IMM-1152.pdf
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SmallpoxVaccine
• Smallpoxvaccinationrecommendation:• Livesmallpox(vaccinia)vaccine(ACAM2000)
• FDAapprovalin2007,replacingDryvax• RoutinevaccinationwithACAM2000for:
• Laboratorypersonneldirectlyhandling:• Culturesorcontaminated/infectedanimalswithvacciniavirus
• HealthCarepersonnel(e.g.physiciansandnurses)• Currentlytreatoranticipatetreatingpatientswithvacciniavirusinfection
• PersonsadministeringACAM2000smallpoxvaccine
MMWR.March18,2016.65(10).Source:http://www.historyofvaccines.org/content/acam2000-vaccine
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http://www.vaccinationinformationnetwork.com/revolts-and-opposition-against-compulsory-smallpox-vaccination/
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CholeraVaccine
• Choleravaccinationrecommendation:• Choleravaccine(Vaxchora)
• FDAapprovalJune10,2016• Onlyvaccineavailabletopreventcholeraatthistime
• Indicatedforcholerapreventionfortravelersages18– 64toareasofactivecholeratransmission
• Singledose,liveattenuatedoralvaccine• Administered10daysormorebeforetravel• Durationofcoverageisunknown
• (3– 6months)
AAFP.News.ACIPRecommendationJune2016.Source:http://www.vaxchora.com/
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Source:http://www.who.int/gho/epidemic_diseases/cholera/epidemics/en/
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InfluenzaVaccineSource:http://www.davegranlund.com/cartoons/2009/10/06/flu-vaccine-categories/
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InfluenzaSeason2015– 2016
• October4th,2015– May21st,2016intheUS• Influenzaactivitywaslowerandpeakedlatercomparedtopast3seasons• Peakedinmid-March2016• Overallinfluenzaactivitywasmoderate,comparedtolast3seasons:• Lowerpercentageofoutpatientvisits• Lowerhospitalizationsrates• Lowerpercentageofdeathsattributedtopneumoniaandinfluenza
MMWR.June10,2016.65(22).Source:https://blog.pkids.org/tag/flu/
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March
MMWR.June10,2016.65(22).
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March
MMWR.June10,2016.65(22).
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MMWR.June10,2016.65(22).
2015-2016Peak
2010-2011Peak
2014-2015Peak
2009-2010Peak
2013-2014Peak
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InfluenzaSeason2015– 2016
• Predominantstrains:• InfluenzaA:H1N1pdm09
• Vaccineeffectiveness(VE)• Overall:47%• Astrain:41%• Childrenage2– 17yearsold
• Inactivatedinfluenzavaccine(IIV):63%• Liveattenuatedinfluenzavaccine(LAIV):3%
CDC.ACIPJuneMeeting2016.
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InfluenzaSeason2015– 2016
• VaccineAdverseEventReportingSystem(VEARS)• Nofoundsafetyconcernsforanyinfluenzavaccine
CDC.ACIPJuneMeeting2016.Source:https://www.focusforhealth.org/ethics-and-finance-flu-shot-studies/
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InfluenzaVaccine
• LAIV(FluMist)offerednoprotectionagainstinfluenzainchildrenlastseason• PoororlowerthanexpectedVEforLAIVforthepast3seasons
• ACIPrecommendsagainst usingLAIVforthe2016– 2017influenzaseason• Approvedforuseinpeople2– 49yearold
• FDAhasnotactedagainstLAIV• Waitingformoreinformation
CDC.ACIPJuneMeeting2016.Source:https://www.flumistquadrivalent.com/
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InfluenzaVaccine
• PossiblecausesforLAIV’slackofeffectiveness:• PoorperformanceoftheAvaccinestainasanasalformulation• InterferencebytheadditionalBstraininthequadrivalentformulation
• AstraZenecamanufactureofFluMist:• Projectedtomake14milliondosesofFluMist• Unsureifpre-orderedsupplieswillberefundable
• Needlephobiasorvaccine-hesitantpatientsshouldNOTuseLAIV• ProposedlanguagetotheCDCDirectorforfinalapproval• “LAIVshouldnotbeusedinanysetting”
CDC.ACIPJuneMeeting2016.
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InfluenzaVaccine
• Clarificationforeggallergies:• Patientswithknownallergiestoeggs,regardlessofseveritycanreceiveanyinfluenzavaccine:• Inactivatedinfluenzavaccine(IIV)• Recombinantinfluenzavaccine(RIV)• Liveattenuatedinfluenzavaccine(LAIV)
• Post-vaccinationobservationshouldbe15minutesforallpatientsreceivingvaccines• Whythechange?
• Mostreactionstovaccinesareafterthe30minuteobservationperiod(oldrecommendation)• Reactionsareveryrare(1inamillion)
MMWR.February2,2016.65.Source:http://kidshealth.org/en/kids/egg-allergy.html
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InfluenzaSeason2016– 2017
• InfluenzaseasonisOctobertoMay• CommonlypeaksinJanuarytoFebruary• Annualinfluenzavaccinationisrecommendedforallpersons6monthsofageandolder
Source:http://www.pikecountyhealth.com/v3/
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InfluenzaSeason2016– 2017
• AnnuallytheWHOresearcheswhichinfluenzastrainswilllikelybethemostcommon• TheFDAthenconsidersthesesuggestions• Recommendedinfluenzavaccinescomposition(2016- 2017)
• Trivalentvaccine:• A/California/7/2009(H1N1)pdm09-likevirus• A/HongKong/4801/2014(H3N2)-likevirus• B/Brisbane/60/2008-likevirus
• Quadrivalentvaccine:• B/Phuket/3073/2013-likevirus
MMWR.June10,2016.65(22).
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InfluenzaSeason2016– 2017
• Totalamountofinfluenzavaccinespredictedtobeproduced:• 175milliondoses
• Rememberthiswillbereducedby14millionFluMistVaccines• Shortage???
• Similartolastyear,171– 179millionpredicted
MMWR.June10,2016.65(22).
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VaccinesinthePipeline
• Ebola• 100%efficacy(Guineatrial)• Singledose,storedat-80°C
• Dengue• Dengvaxia(Sanofi)• ApprovedinMexico
• 79%pooledefficacyagainstseveredengue• WHOrecommendsuseinendemicdengueareas
• Zika• ~21vaccinecandidates• NIHhasbeguntestinginhumans
Source:http://www.cdc.gov/travel/yellowbook/2016/infectious-diseases-related-to-travel/dengue
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Post-testQuestion#1
Whatinfluenzavaccinecanbeusedinpatientswithaneggallergyofanyseverity?
A. IIVB. RIVC. LAIVD. ccIIVE. Alloftheabove
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Post-testQuestion#2
Whenadministeringaninfluenzavaccination,howlongshouldthepatientbeobserved?
A. 15minutesB. 30minutesC. 45minutesD. 60minutes
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Post-testQuestion#3
Whichvaccinerecentlydisplayedpoorvaccineefficacy,leadingtheACIPtorecommenditnotbeusedatthistime?• FluMist• Prevnar• Gardasil• Menactra
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Post-testQuestion#4
Whichofthefollowingisacholeravaccine?A. ACAM2000B. DengvaxiaC. TrumenbaD. Vaxchora
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Post-testQuestion#5
Canbothmeningococcalvaccines(MenBandserogroupsA,C,W,&Y)begivenonthesameday?
A. Yes,attheexactsametimeB. Yes,butatdifferentinjectionsitesC. No,theyshouldbeseparatedby1monthD. No,theyshouldbeseparatedby6months
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Post-testQuestion#6
Apatientreceived2dosesofTrumenba,forthethirdinjectionthereisonlyBexseroavailable.Whatisthebestcourseofaction?
A. GivethefinaldoseasBexseroB. Thedosingseriesiscompleteat2dosesC. ThesetwovaccinesarenotinterchangeableD. Provide2dosesofBexserotofinishtheseries
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Post-testQuestion#7
A66yearoldpatientreceivedPPSV23atage63.Whatistheappropriatedpneumococcalvaccinationrecommendationforthispatient?
A. OnlyPCV13nowB. PCV13now,6monthslaterPPSV23C. PPSV23now,6monthslaterPCV12D. PCV13now,12monthslaterPPSV23
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Source:http://aboutdavidgeier.com/
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ImmunizationUpdate:2016
GoldenPeters,PharmD,BCPSAssociateProfessor,PharmacyPracticeDepartment
St.LouisCollegeofPharmacy