question and answer with the on-call nurse. objectives discuss the most common questions posed from...

Question and Answer Question and Answer

With the On-Call NurseWith the On-Call Nurse

ObjectivesObjectives

•Discuss the most common Discuss the most common questions posed from the field.questions posed from the field.

• Identify where to find answers to Identify where to find answers to these questions.these questions.

•Resources to have on handResources to have on hand..

Where do calls come from?Where do calls come from?

• Private Physicians Private Physicians OfficesOffices

• HospitalsHospitals• Local Health Local Health

DepartmentsDepartments• Other State Health Other State Health

DepartmentsDepartments• CDCCDC• Schools/UniversitiesSchools/Universities• General PublicGeneral Public

What type of questions?What type of questions?

• VaccineVaccine Immunization SchedulesImmunization Schedules Minimum IntervalsMinimum Intervals Catch-up scheduleCatch-up schedule AdministrationAdministration The LawThe Law

• Memos from the Immunization BranchMemos from the Immunization Branch• Coverage CriteriaCoverage Criteria• Vaccine Preventable Diseases (VPD)Vaccine Preventable Diseases (VPD)• NCIRNCIR

And even ?????And even ?????

MOST COMMONLY MOST COMMONLY ASKED QUESTIONS: ASKED QUESTIONS: VACCINE RELATEDVACCINE RELATED

VACCINES-GENERALVACCINES-GENERAL

Q: Why do ACIP recommendations Q: Why do ACIP recommendations not not

always agree with package always agree with package inserts?inserts?


A: There is usually very close agreement A: There is usually very close agreement between vaccine package inserts and the ACIP between vaccine package inserts and the ACIP statements. The FDA must approve the statements. The FDA must approve the package insert, and requires documentation for package insert, and requires documentation for all claims and recommendations made in the all claims and recommendations made in the insert. ACIP sometimes makes insert. ACIP sometimes makes recommendations based on expert opinion and recommendations based on expert opinion and public health considerations. Published public health considerations. Published recommendations of national advisory groups recommendations of national advisory groups (such as ACIP or AAP’s Committee on Infectious (such as ACIP or AAP’s Committee on Infectious Diseases) should be considered equally as Diseases) should be considered equally as authoritative as those on the package insert.authoritative as those on the package insert.


Q: Is it necessary to start a vaccine series over if a Q: Is it necessary to start a vaccine series over if a patient doesn’t come back for a dose at the patient doesn’t come back for a dose at the recommended time, even if there has been a year recommended time, even if there has been a year or more delay?or more delay?

A: For routinely administered vaccines, there is no A: For routinely administered vaccines, there is no vaccine series that needs to be restarted because vaccine series that needs to be restarted because of an interval that is longer than recommended. In of an interval that is longer than recommended. In certain circumstances, oral typhoid vaccine (which certain circumstances, oral typhoid vaccine (which is sometimes given for international travel) needs is sometimes given for international travel) needs to be restarted if the vaccine series isn’t to be restarted if the vaccine series isn’t completed within the recommended time frame.completed within the recommended time frame.


Q: Are vaccine diluents Q: Are vaccine diluents interchangeable?interchangeable?


A: As a general rule vaccine diluents are not A: As a general rule vaccine diluents are not interchangeable. One exception is that the interchangeable. One exception is that the diluent for MMR can be used to reconstitute diluent for MMR can be used to reconstitute varicella vaccine, and vice versa. The diluent varicella vaccine, and vice versa. The diluent for both vaccines is sterile water for the for both vaccines is sterile water for the injection, and is produced by the same injection, and is produced by the same company. No other diluent can be used for company. No other diluent can be used for MMR and varicella vaccines, and these MMR and varicella vaccines, and these diluents must not be used to reconstitute any diluents must not be used to reconstitute any other lyophilized vaccineother lyophilized vaccine

VACCINES-GENERAL VACCINES-GENERAL

Q:If some portion of a vaccine (e.g., Q:If some portion of a vaccine (e.g., influenza) leaks out of the syringe while it influenza) leaks out of the syringe while it is injected into a patient, does the dose is injected into a patient, does the dose need to be repeated and if so, when?need to be repeated and if so, when?

A: When this happens, it is difficult to judge A: When this happens, it is difficult to judge how much the person received. This would how much the person received. This would be a nonstandard dose and should not be be a nonstandard dose and should not be counted. You should go ahead and re-counted. You should go ahead and re-immunize the individual at that time. immunize the individual at that time.


Q: What should we do if a dose of expired vaccine is Q: What should we do if a dose of expired vaccine is given to a patient?given to a patient?

A: The dose should be repeated. If the dose is a live A: The dose should be repeated. If the dose is a live virus vaccine, you should wait at least 4 weeks virus vaccine, you should wait at least 4 weeks after the previous (expired) dose was given after the previous (expired) dose was given before repeating it. If the expired dose is not a before repeating it. If the expired dose is not a live virus vaccine, the dose should be repeated as live virus vaccine, the dose should be repeated as soon as possible. If you prefer, you can perform soon as possible. If you prefer, you can perform serologic testing to check for immunity for certain serologic testing to check for immunity for certain vaccinations (e.g. measles, rubella, mumps, and vaccinations (e.g. measles, rubella, mumps, and varicella)varicella)


Q: How long should a woman Q: How long should a woman of child-bearing age avoid of child-bearing age avoid pregnancy after receiving pregnancy after receiving a live attenuated vaccine?a live attenuated vaccine?

A: Due to theoretical risks to A: Due to theoretical risks to the developing fetus, ACIP the developing fetus, ACIP recommends that a women recommends that a women avoid pregnancy for four avoid pregnancy for four weeks after receiving a live weeks after receiving a live attenuated vaccine (e.g., attenuated vaccine (e.g., MMR, varicella, LAIV). This MMR, varicella, LAIV). This interval may be shorter interval may be shorter than that recommended by than that recommended by the manufacturer.the manufacturer.

COMBINATION VACCINESCOMBINATION VACCINES

Q: Can we switch back and forth from Q: Can we switch back and forth from monovalent vaccines at one visit to monovalent vaccines at one visit to combination vaccines at another?combination vaccines at another?

A: Switching between combination and A: Switching between combination and single-antigen vaccines poses no single-antigen vaccines poses no problem as long as you maintain the problem as long as you maintain the recommended minimum intervals for recommended minimum intervals for all vaccines.all vaccines.


Q: Is Pediarix (DTaP-HepB-IPV) only intended Q: Is Pediarix (DTaP-HepB-IPV) only intended for use at 2, 4, and 6 months of age?for use at 2, 4, and 6 months of age?

A: No, Pediarix is licensed for use in children A: No, Pediarix is licensed for use in children ages 6 weeks through 6 years for doses 1, ages 6 weeks through 6 years for doses 1, 2, and 3 of the DTaP primary series, as 2, and 3 of the DTaP primary series, as long as the minimum intervals are met for long as the minimum intervals are met for all components of the vaccine.all components of the vaccine.


Q: If Kinrix (DTap-IPV) is inadvertently given to a Q: If Kinrix (DTap-IPV) is inadvertently given to a child 12 to 18 months, as the fourth DTaP dose child 12 to 18 months, as the fourth DTaP dose and the third IPV dose, does the DTap and IPV and the third IPV dose, does the DTap and IPV dose have to be repeated?dose have to be repeated?

A: Since Kinrix is licensed and recommended only A: Since Kinrix is licensed and recommended only for children ages 4 through 6 years, you should for children ages 4 through 6 years, you should take measures to prevent this error in the future. take measures to prevent this error in the future. However, you can count this as a valid dose for However, you can count this as a valid dose for DTaP and IPV as long as the minimum interval DTaP and IPV as long as the minimum interval has been met beween the individual components.has been met beween the individual components.


Q: I have seen adults who have Q: I have seen adults who have had 1 or 2 doses of Twinrix, but had 1 or 2 doses of Twinrix, but we carry only single–antigen we carry only single–antigen vaccine in our practice. How vaccine in our practice. How should we complete their should we complete their vaccination series with single-vaccination series with single-antigen vaccines?antigen vaccines?


A: Twinrix is licensed as a 3-dose series for people age 18 A: Twinrix is licensed as a 3-dose series for people age 18 years and older. A dose of Twinrix contains a standard adult years and older. A dose of Twinrix contains a standard adult dose of hepatitis B vaccine and a pediatric dose of hepatitis dose of hepatitis B vaccine and a pediatric dose of hepatitis A vaccine. Thus, a dose of Twinrix can be substituted for A vaccine. Thus, a dose of Twinrix can be substituted for any dose of the hepatitis B series but not for any dose of any dose of the hepatitis B series but not for any dose of the hepatitis A series. If the Twinrix is not available or if you the hepatitis A series. If the Twinrix is not available or if you choose not to use Twinrix to complete the Twinrix series, choose not to use Twinrix to complete the Twinrix series, you should do the following:you should do the following:

• Any combination of 3 doses of adult hepatitis B or 3 doses Any combination of 3 doses of adult hepatitis B or 3 doses of Twinrix = a complete series of hepatitis B vaccineof Twinrix = a complete series of hepatitis B vaccine

• One dose of Twinrix + 2 doses of adult hepatitis A = a One dose of Twinrix + 2 doses of adult hepatitis A = a complete series of hepatitis A vaccinecomplete series of hepatitis A vaccine

• Two doses of Twinrix + 1 dose of adult hepatitis A = a Two doses of Twinrix + 1 dose of adult hepatitis A = a complete series of hepatitis A vaccinecomplete series of hepatitis A vaccine

VACCINES: LAW RELATEDVACCINES: LAW RELATED


Q: The ACIP recommendations for Q: The ACIP recommendations for IPVIPV

changed in 2009, but the NC changed in 2009, but the NC LawLaw

has not, how do we handle has not, how do we handle thisthis??

VACCINES: LAW RELATEDVACCINES: LAW RELATEDA: The new recommendations are:A: The new recommendations are:

IPV at 2mos; 4mos; 6-18mos; and at 4-6 yrs of ageIPV at 2mos; 4mos; 6-18mos; and at 4-6 yrs of age Final dose should be on or after the 4Final dose should be on or after the 4thth birthday birthday

(whether this is dose 3 or dose 4)(whether this is dose 3 or dose 4) Minimum interval between dose 3 and 4 is Minimum interval between dose 3 and 4 is

recommended now to be 6 monthsrecommended now to be 6 months

NC law still states children must have 4 doses: two byNC law still states children must have 4 doses: two by

5mos; a third before age 19mos; and a booster before5mos; a third before age 19mos; and a booster before

enrolling in school. We cannot enforce ACIPenrolling in school. We cannot enforce ACIP

recommendations that are not reflected in the NC Law.recommendations that are not reflected in the NC Law.


Q: Are there any exemptions or exceptionsQ: Are there any exemptions or exceptions to the immunization requirements? to the immunization requirements?

A: Yes. There are two exemptions: one for A: Yes. There are two exemptions: one for children with medical contraindications, children with medical contraindications, and one for children whose parents or and one for children whose parents or guardians have bona fide religious guardians have bona fide religious objections to immunizations. NC law does objections to immunizations. NC law does not recognize a nonreligious not recognize a nonreligious “philosophical” or “personal” exemption to “philosophical” or “personal” exemption to immunizations. immunizations.


Q: Must a child be immunized before Q: Must a child be immunized before attending school or day careattending school or day care??


A: NC’s childhood immunization requirements A: NC’s childhood immunization requirements apply to all children, not just those enrolling in apply to all children, not just those enrolling in school or daycare. “Every child present in this school or daycare. “Every child present in this state” must be immunized according to the state” must be immunized according to the schedule in the state immunization rules.schedule in the state immunization rules.

Thus NC’s childhood immunization requirementsThus NC’s childhood immunization requirementsare not triggered by school or daycare enrollmentare not triggered by school or daycare enrollment– – but they are reinforced by it. but they are reinforced by it.


Q: May adolescents consent to their Q: May adolescents consent to their own immunizations?own immunizations?


A: Under NC’s minor’s consent law, some A: Under NC’s minor’s consent law, some adolescents may consent to receive adolescents may consent to receive immunizations on their own. The law allows immunizations on their own. The law allows physicians to accept an unemancipated physicians to accept an unemancipated minor’s consent for the prevention of venereal minor’s consent for the prevention of venereal diseases and reportable communicable diseases and reportable communicable diseases. Most of the immunizations that are diseases. Most of the immunizations that are required or recommended for children prevent required or recommended for children prevent either venereal diseases or communicable either venereal diseases or communicable diseases that are reportable under NC law. diseases that are reportable under NC law. Cont’d………Cont’d………


The law actually says that “any” minor mayThe law actually says that “any” minor maygive effective consent, but “any” should notgive effective consent, but “any” should notbe taken literally. The minor’s consent law givesbe taken literally. The minor’s consent law givesunemancipated minors legal capacity to consent tounemancipated minors legal capacity to consent toimmunizations for venereal disease or reportableimmunizations for venereal disease or reportablecommunicable diseases, but a health care provider still must communicable diseases, but a health care provider still must determine that a particular minor who presents himself or determine that a particular minor who presents himself or

herselfherselffor immunization has the capacity to make a decision on his or for immunization has the capacity to make a decision on his or

herherown.own.

Varicella is the only required vaccine thatVaricella is the only required vaccine thatprevents a disease that is neither venerealprevents a disease that is neither venerealnor reportable under NC lawnor reportable under NC law..


Q: The Hib shortage has now been resolved; Q: The Hib shortage has now been resolved; how does that effect the NC law how does that effect the NC law requirements?requirements?

A: A memo was sent out from the A: A memo was sent out from the Immunization Branch on January 11, 2011 Immunization Branch on January 11, 2011 announcing the removal of the temporary announcing the removal of the temporary suspension of the Hib booster dose, suspension of the Hib booster dose, effective August 1, 2011.effective August 1, 2011.

NCIR NCIR

Q: Will you look at a Q: Will you look at a client and tell me client and tell me why the vaccine is why the vaccine is invalid?invalid?

NCIRNCIR

Q: Why is NCIR recommending another Q: Why is NCIR recommending another meningococcal vaccine?meningococcal vaccine?

A: In October 2010, the ACIP came out A: In October 2010, the ACIP came out with new recommendations for a with new recommendations for a booster dose of meningococcal booster dose of meningococcal vaccine.vaccine.

VACCINE PREVENTABLE VACCINE PREVENTABLE DISEASESDISEASES

Q: What is the gold standard and only tests Q: What is the gold standard and only tests we should we be doing for pertussis?we should we be doing for pertussis?

A: All suspected cases of pertussis should A: All suspected cases of pertussis should have a nasopharyngeal swab obtained for have a nasopharyngeal swab obtained for PCR and culture from the posterior PCR and culture from the posterior nasopharynx.nasopharynx.

PCRs should always be backed up with a PCRs should always be backed up with a culture and serology can not be used to culture and serology can not be used to confirm disease.confirm disease.


Q: Do close contacts to a pertussis case Q: Do close contacts to a pertussis case still need postexposure prophylaxis still need postexposure prophylaxis even if they are up to date on all of even if they are up to date on all of their pertussis vaccines?? What if they their pertussis vaccines?? What if they just had a Tdap in the past year or so. just had a Tdap in the past year or so.

A:YES---vaccine status has NO bearing A:YES---vaccine status has NO bearing on prophylaxis treatment of contacts!!on prophylaxis treatment of contacts!!


Q: I am a private provider when should I call Q: I am a private provider when should I call the LHD regarding a patient whom I the LHD regarding a patient whom I SUSPECT has pertussis???SUSPECT has pertussis???

A: As soon as you “SUSPECT”; the Local Health A: As soon as you “SUSPECT”; the Local Health Department is a great resource to help you: Department is a great resource to help you: Determine if patient meets the clinical case Determine if patient meets the clinical case

definition for testingdefinition for testing What labs to do? What labs to do? Initiate contact investigationInitiate contact investigation


Q: If I am the LHD and get such a call when Q: If I am the LHD and get such a call when do I call the Immunization Branch??do I call the Immunization Branch??

A: A: Grab a paper copy of NC EDSS pertussis Grab a paper copy of NC EDSS pertussis reportreportComplete as much of Part 2 Wizard questions Complete as much of Part 2 Wizard questions

(pg 1) as possible(pg 1) as possible If you are certain they meet case definition & If you are certain they meet case definition &

test ---then calltest ---then callNever had a pertussis case and don’t know Never had a pertussis case and don’t know

where to start ---- Call us where to start ---- Call us IMMEDIATELY!!!!!!!!IMMEDIATELY!!!!!!!!

RESOURCES: WEBSITESRESOURCES: WEBSITES

www.immunize.nc.govwww.immunize.nc.govwww.immunize.orgwww.immunize.orghttp://www.cdc.gov/gov/vaccines/http://www.cdc.gov/gov/vaccines/

http://www.immunize.nc.gov/

http://www.immunize.org/

http://www.cdc.gov/gov/vaccines/

RESOURCES: RESOURCES: PUBLICATIONS/MANUALSPUBLICATIONS/MANUALS

• ““The Pink Book”The Pink Book”

• Manual for the Surveillance of Manual for the Surveillance of Vaccine-Preventable DiseasesVaccine-Preventable Diseases

• Guidelines for the Control of Guidelines for the Control of PertussisPertussis

• Guidelines for Vaccinating Pregnant Guidelines for Vaccinating Pregnant WomenWomen

MANUALS/PUBLICATIONS MANUALS/PUBLICATIONS Cont’dCont’d

• Vaccine Management: Vaccine Management: Recommendations for Handling & Recommendations for Handling & StorageStorage

• Vaccine Storage and Handling ToolkitVaccine Storage and Handling Toolkit

• ACIP General Recommendations on ACIP General Recommendations on Immunization - MMWRImmunization - MMWR

And at the end of the And at the end of the day………..day………..

THANK YOU!THANK YOU!

Mary Stanley, RNMary Stanley, RNClinical Nurse ConsultantClinical Nurse ConsultantNorth Carolina Immunization BranchNorth Carolina Immunization [email protected]@dhhs.nc.gov

Elizabeth Draper, RNElizabeth Draper, RNClinical Nurse Consultant Clinical Nurse Consultant North Carolina Immunization BranchNorth Carolina Immunization [email protected]@dhhs.nc.gov

mailto:[email protected]

mailto:[email protected]

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