Download Immunization Update 2016

Kenneth McCall, BSPharm, PharmD
Associate Professor | UNE
Objectives
 Discuss the gap between current vaccination rates and Healthy People 2020 goals for
vaccinations.
 Categorize each of the CDC recommended flu vaccines based upon live/inactivated,
route, preparation, and storage.
 Discuss the influenza vaccines for 2016 including the new quadrivalent and
mammalian cell vaccines.
 Identify vaccine contraindications and recommend vaccines based upon patient age
and medical history.
 Apply ACIP recommendations and FDA approved indications for the CDC
recommended vaccines.
 Recognize Maine state laws that regulate vaccine administration.
2
Outline
 Background & Principles of Vaccination
 Influenza Vaccines
 Quadrivalent inactivated
 Quadrivalent live
 Mammalian
 High Dose
 Intradermal
Classification of Vaccines
 Live attenuated
 Weakened form of the “wild” virus or bacteria
 Inactivated
 Whole viruses or bacteria
 Fractions of viruses or bacteria
*Epidemiology and Prevention of Vaccine-Preventable Diseases, 12th Edition
Classification of Vaccines
 Live attenuated:
 Measles, mumps, rubella, varicella, zoster, intranasal
influenza
 Inactivated:
 hepatitis A, hepatitis B, influenza, pneumonia,
diphtheria, tetanus, pertussis, HPV, meningicoccal
*Epidemiology and Prevention of Vaccine-Preventable Diseases, 12th Edition
7
Immunization Schedules
 US Center for Disease and Prevention (CDC)
 Advisory Committee on Immunization Practices (ACIP)
 ACIP is a group of medical and public health experts who meet three
times per year to discuss vaccine recommendations
 Published annually
 Adult schedule approved by
 American Academy of Family Physicians (AAFP)
 American College of Obstetricians and Gynecologists
 American College of Physicians
 American College of Nurse-Midwives
8
CDC ACIP 2016 Recommended
Adult Immunization Schedule
11
12
Maine Pharmacist-Administered
Immunization Regulations
No Rx Required
Rx Requireda
Rx or Protocol
Not Permitted
Adult (≥18 years) with PCPb
Influenza
✓-RPh or Intern
✓-RPh or Intern
Other Vaccinesc
Adult (≥18 years) without PCP
Influenza
✓-RPh or Intern
✓-RPh or Intern
Other Vaccinesc
Child < 18 years
✗
Other Vaccinesc
Child 7-17 years
Influenza
✓-RPh only
Child <7 years
Influenza
Intern administration permitted as indicated under direct supervision of licensed pharmacist
a Verbal/phone authorization acceptable
b Primary care physician or existing relationship with a nurse practitioner or an authorized practitioner in Maine
c All vaccines licensed by the US FDA recommended by the CDC ACIP
✗
13
What is the Healthy People 2020 goal for annual flu
vaccination for adults 65 and older?
0%
100%
0%
0%
100%
2. 90%
3. 70%
4. 50%
1.
16
Influenza versus Common Cold
Signs &
Symptoms
Influenza
Common Cold
Onset
Sudden
Gradual
Fever
High (>101°F)
Less common (low grade)
Cough
Dry; can be severe
Hacking or congested
Headache
Common
Rare
Myalgias
Usual; severe
Slight
Can last 2-3 weeks
Very mild
Early and prominent
Rare or never
Common
Mild to moderate
Stuffy nose
Sometimes
Common
Sneezing
Sometimes
Usual
Sore throat
Sometimes
Common
Fatigue/malaise
Extreme
exhaustion
Chest discomfort
ACIP Recommendations
2015-2016 Influenza Season
 All persons aged 6 months and older should receive influenza
vaccine annually.
 Persons who care for severely immunosuppressed persons who
require a protective environment should not receive LAIV, or should
avoid contact with such persons for 7 days after receipt, given the
theoretical risk for transmission of the live attenuated vaccine virus.
 Persons who report having had reactions to egg involving such
symptoms as angioedema, respiratory distress, lightheadedness, or
recurrent emesis; or who required epinephrine or another
emergency medical intervention, may receive Flublok if they are
aged 18 years or older and there are no other contraindications.
LAIV: live attenuated influenza vaccine
18
2015-2016 Vaccine Coverage & Age Group
Distribution of Influenza Positive Specimens
Trivalent
 A/California/7/2009 (H1N1)-like
virus
 A/Switzerland/9715293/2013
(H3N2)-like virus
 B/Phuket/3073/2013-like virus
(Yamagata)
Quadrivalent
 A/California/7/2009 (H1N1)-like
virus
 A/Switzerland/9715293/2013
(H3N2)-like virus
 B/Phuket/3073/2013-like virus
(Yamagata)
 B/Brisbane/60/2008-like virus
(Victoria)
19
A (H1N1)
A (H3)
B (Yamagata)
B (Victoria)
http://www.cdc.gov/flu/weekly/FluViewInteractive.htm
Egg Allergy
Recommendation
Persons with egg allergy may
tolerate egg in baked products
(e.g., bread or cake). Tolerance
to egg-containing foods does not
exclude the possibility of egg
allergy.
Abbreviations: IIV = inactivated influenza vaccine,
trivalent or quadrivalent; RIV3 = recombinant
influenza vaccine, trivalent.
21
Influenza Vaccines – United States,
2015-2016 Influenza Season
Trade name Manufacturer
Presentation
Mercury
(from thimerosal)
µg/0.5 mL
Ovalbumin
µg/0.5 mL
Age
indications
Latex
Route
Inactivated influenza vaccine, quadrivalent (IIV4), standard dose
Contraindications*: Severe allergic reaction to any vaccine component, including egg protein, or after previous dose of any influenza
vaccine. Precautions*: Moderate to severe acute illness with or without fever; history of Guillain-Barré syndrome within 6 weeks of receipt
of influenza vaccine.
0.5 mL singleFluarix
GlaxoSmithKline dose prefilled
—
≤0.05
≥3 yrs
No
IM†
Quadrivalent
syringe
FluLaval
ID Biomedical
Quadrivalent Corp.
Fluzone
Sanofi Pasteur
Quadrivalent
Fluzone
Intradermal¶ Sanofi Pasteur
Quadrivalent
5.0 mL multi-dose
<25
vial
0.25 mL singledose prefilled
—
syringe
0.5 mL singledose prefilled
—
syringe
0.5 mL single—
dose vial
5.0 mL multi-dose
25
vial
0.1 mL single-dose
prefilled
—
microinjection
system
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6430a3.htm#Tab
≤0.3
≥3 yrs
No
IM†
§
6 through
35 mos
No
IM†
§
≥36 mos
No
IM†
§
≥36 mos
No
IM†
§
≥6 mos
No
IM†
§
18 through 64
yrs
No
ID**
Influenza Vaccines, 2015-2016 Influenza Season cont’d
Trade name
Manufacturer Presentation
Mercury
(from
thimerosal)
µg/0.5 mL
Ovalbumin
µg/0.5 mL
Age
indications
Latex
Route
Inactivated influenza vaccine, trivalent (IIV3), standard dose
Contraindications*: Severe allergic reaction to any vaccine component, including egg protein, or after previous dose of any influenza
vaccine. Precautions*: Moderate to severe acute illness with or without fever; history of Guillain-Barré syndrome within 6 weeks of receipt
of influenza vaccine.
0.5 mL singledose prefilled
syringe
Afluria
Fluvirin
Fluzone
—
<1
≥9 yrs††
No
IM†
No
IM†
bioCSL
Novartis
Vaccines and
Diagnostics
Sanofi Pasteur
5.0 mL multidose vial
24.5
<1
≥9 yrs†† via
needle;18
through 64 yrs
via jet injector
0.5 mL singledose prefilled
syringe
≤1
≤1
≥4 yrs
Yes§§
IM†
5.0 mL multidose vial
25
≤1
≥4 yrs
No
IM†
5.0 mL multidose vial
25
§
≥6 mos
No
IM†
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6430a3.htm#Tab
Influenza Vaccines, 2015-2016 Influenza Season cont’d
Trade name
Manufacturer Presentation
Mercury
(from
thimerosal)
µg/0.5 mL
Ovalbumin
µg/0.5 mL
Age
indications
Latex
Route
Inactivated influenza vaccine, cell-culture-based (ccIIV3), standard dose
Contraindications*: Severe allergic reaction to any vaccine component, including egg protein, or after previous dose of any influenza
vaccine. Precautions*: Moderate to severe acute illness with or without fever; history of Guillain-Barré syndrome within 6 weeks of receipt
of influenza vaccine.
Flucelvax
Novartis
Vaccines and
Diagnostics
0.5 mL singledose prefilled
syringe
—
¶¶
≥18 yrs
Yes§§
IM†
Inactivated influenza vaccine, trivalent (IIV3), high dose
Contraindications*: Severe allergic reaction to any vaccine component, including egg protein, or after previous dose of any influenza
vaccine. Precautions*: Moderate to severe acute illness with or without fever; history of Guillain-Barré syndrome within 6 weeks of receipt
of influenza vaccine.
Fluzone HighDose***
Sanofi Pasteur
0.5 mL singledose prefilled
syringe
—
§
≥65 yrs
No
IM†
Recombinant influenza vaccine, trivalent (RIV3), standard dose
Contraindications*: Severe allergic reaction to any vaccine component.
Precautions*: Moderate to severe acute illness with or without fever; history of Guillain-Barré syndrome within 6 weeks of receipt of
influenza vaccine.
Flublok
Protein
Sciences
0.5 mL singledose vial
—
0
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6430a3.htm#Tab
≥18 yrs
No
IM†
Influenza Vaccines, 2015-2016 Influenza Season cont’d
Trade name
Manufacturer Presentation
Mercury
(from
thimerosal)
µg/0.5 mL
Ovalbumin
µg/0.5 mL
Age
indications
Latex
Route
Live attenuated influenza vaccine, quadrivalent (LAIV4)
Contraindications*: Severe allergic reaction to any vaccine component, including egg protein, or after previous dose of
any influenza vaccine. Concomitant use of aspirin or aspirin-containing medications in children and adolescents.
In addition, ACIP recommends LAIV4 not be used for pregnant women, immunosuppressed persons, persons with egg
allergy, and children aged 2 through 4 years who have asthma or who have had a wheezing episode noted in the medical
record within the past 12 months, or for whom parents report that a health care provider stated that they had wheezing
or asthma within the last 12 months.
LAIV4 should not be administered to persons who have taken influenza antiviral medications within the previous 48
hours.
Persons who care for severely immunosuppressed persons who require a protective environment should not receive
LAIV4, or should avoid contact with such persons for 7 days after receipt.
Precautions*: Moderate to severe acute illness with or without fever; history of Guillain-Barré syndrome within 6 weeks
of receipt of influenza vaccine; asthma in persons aged 5 years and older; medical conditions which might predispose to
higher risk for complications attributable to influenza.
FluMist
Quadrivalent†
††
MedImmune
0.2 mL singledose prefilled
intranasal
sprayer
—
<0.24 (per 0.2
mL)
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6430a3.htm#Tab
2 through 49
yrs
No
IN
Which of the following is the
predominant flu strain of 2015-16?
0%
1. Type B strain in trivalent vaccine
0%
2. Type B strain not in trivalent vaccine
100%
3. Type A H1N1 strain
0%
4. Type A H3N2 strain
27
New Influenza Vaccines:
 Fluarix ® (GlaxoSmithKline) – inactivated, quadrivalent
vaccine which contains two type A and two type B strains
 FDA approved December 2012
 People ages 3 years and older
 Fluzone ® (Sanofi Pasteur) – inactivated, quadrivalent
vaccine which contains two type A and two type B strains
 FDA approved March 2013
 People ages 6 months and older
Quadrivalent Flu Vaccines Facts
 A quadrivalent (4-strain) flu vaccine helps to provide
protection against four flu virus strains (2 Type A and 2
Type B).
 4-strain flu vaccines are made in the same way 3-strain
flu vaccines are made.
 Quadrivalent flu vaccines are available as both shots
and intranasal spray.
Quadrivalent versus Trivalent
Influenza Vaccine
Excerpt from FDA Clinical Review: Fluarix Quadrivalent®
 Unmet Medical Need: “The B strain recommended for
use in the yearly [trivalent] vaccine has been matched
to the main circulating influenza B strain only in onehalf of the influenza season in the last eight years.
30
2015-2016 Vaccine Coverage: Trivalent versus
Quadrivalent
Trivalent
 A/California/7/2009 (H1N1)-like virus
 A/Switzerland/9715293/2013 (H3N2)like virus
 B/Phuket/3073/2013-like virus
(Yamagata)
Quadrivalent
 A/California/7/2009 (H1N1)-like virus
 A/Switzerland/9715293/2013 (H3N2)like virus
 B/Phuket/3073/2013-like virus
(Yamagata)
 B/Brisbane/60/2008-like virus (Victoria)
Conclusion: quadrivalent does not provide
significantly better coverage this flu season
31
Administration
 Fluarix®: 0.5-mL dose
 IM - deltoid
 1 inch, 25 gauge needle
32
Quadrivalent Influenza Vaccines
contain which of the following?
0%
1. Four type A strains
0%
2. Two type A strains, 1 type B, & 1 type C
100%
3. Two type A strains & 2 type B strains
0%
4. Four type B strains
34
New Influenza Vaccines:
 Flumist® Quadrivalent (MedImmune)– live attenuated
vaccine which contains two type A and two type B strains
 FDA approved March, 2012
 People ages 2 through 49 years
Live Attenuated Influenza Vaccine
 Indication
 Healthy people 2 through 49 years of age
 Contraindications
I pick my nose!
 Pregnant women
 People who have long-term health problems with:






heart disease
kidney or liver disease
lung disease
metabolic disease, such as diabetes
asthma
anemia, and other blood disorders
 Anyone with a weakened immune system
 Severe egg allergy
36
Administration
 Flumist®: 0.1-mL dose in each nostril
 Intranasal
37
Intranasal Administration
Active inhalation (sniffing) by the patient is not required
Which of the following patients is a candidate for the live
influenza vaccine?
2%
1. 45 yo man with severe egg allergy
95%
2. 27 yo healthy woman
0%
3. 38 yo man with diabetes
2%
4. 54 yo healthy man
2%
5. 19 yo pregnant woman
40
New Influenza Vaccines:
 Flucelvax® (Novartis)– trivalent inactivated vaccine grown
in mammalian cells rather than chicken embryo cells.
 FDA approved November, 2012
 Adults 18 years and older
 May contain a trace amount of egg protein.
Administration
 Flucelvax®: 0.5-mL dose
 IM - deltoid
 1 inch, 25 gauge needle
42
43
New Influenza Vaccines:
 Flublock® (Protein Sciences Corporation)– trivalent
inactivated vaccine grown in insect cells rather than
chicken embryo cells.
 FDA approved November, 2013
 Adults 18 years and older.
 Doesn’t list “severe allergic reaction to egg protein” in the
contraindications
Administration
 Flucelvax®: 0.5-mL dose
 IM - deltoid
 1 inch, 25 gauge needle
45
ACIP Recommendations for flu vaccination
of person who report egg allergy.
Select an influenza vaccine for a healthy 37year-old woman with severe egg allergy.
100%
1. Flublok
0%
2. Flumist
0%
3. Fluzone
0%
4. Fluarix
48
Why a high-dose influenza
vaccine?
•
Clinical Need
 31 studies from 1986 to 2002 found
that post-vaccination titers in older
adults were 2x to 4x less likely to
produce sufficient protection against
influenza
 Vaccine efficacy in a matched season:
 70% to 90% in younger adults
 17% to 53% in adults aged ≥65 years
•
HD Vaccine Efficacy
 RCTs and retrospective analyses
demonstrate superior efficacy
compared to IIV-SD
Wang J, Vardeny O, Zorek J. High-dose influenza vaccine in older adults. JAPhA. 2016; 56:95-97.
Methods:
Retrospective cohort study
HD vaccine (60 mcg of hemagglutinin per strain): N= 929,730
SD vaccine (15 mcg of hemagglutinin per strain): : N= 1,615,545
US Medicare beneficiaries 65 years and older who received influenza vaccine in a
community pharmacy
 Primary outcome: probable episode of influenza-related illness defined by a
community medical encounter with the provision of a rapid influenza test followed by
dispensing of oseltamivir within a 2-day period




50
Izurieta_2015_Lancet Infect Dis
 How well does the study design limit bias?
 Who was enrolled in the study/who does the study
apply to?
 What is the primary outcome, how was it measured
and is the result statistically significant?
 What can we infer from these findings? Is the result
clinically significant?
Efficacy of HD Vaccine versus SD Vaccine
Against Influenza-Related Illness
 Similar results to Diazgranados et al.
 Those who received IIV-HD 22% less likely to have influenzaassociated illness and 22% less likely to be admitted to the
hospital for influenza
Lancet Infect Dis 2015;15:293-300
52
Conclusions: IIV-HD versus -SD
•
Safety
 Injection site reactions have been reported at higher
rates for IIV-HD, though most cases were mild and
resolved within several days
 A 2015 study showed IIV-HD results in fewer serious
complications
•
Cost
 Cost to administer is $19.75 higher than IIV-SD per
individual
 A 2015 cost-utility analysis demonstrated a 587%
financial return for the health care system alone
(cost savings in the millions of dollars)
•
Implications for Pharmacists
 ACIP makes no recommendation for one influenza
vaccine formulation over another for older adults
 Regardless of which formulation is recommended,
be sure it is received in a timely manner so your
patients have the best possible flu protection
JAPhA. 2016; 56:95-97.
53
Administration
 Fluzone HD®: 0.5-mL dose
 IM - deltoid
 1 inch, 25 gauge needle
54
Intradermal Influenza Vaccine
 Indicated for persons 18
through 64 years of age
 Contraindications
 Severe egg allergy
 Associated with higher rates of
injection site reactions
(erythema, induration, swelling,
and pruritus, but not pain) than
the IM inactivated influenza
vaccines





Erythema (>75%)
Induration (>50%)
Swelling (>50%)
Pain (>50%)
Pruritus (>40%)
56
Intradermal vs Traditional IM needle Length
30 Gauge Needle and Less Volume
 Methods:
 Multicenter, randomized, double-blind controlled study
 ID vaccine (9 mcg of hemagglutinin per strain) N=1,803
 IM vaccine (15 mcg of hemagglutinin per strain): N=452
 in adults 18 to 60 years of age.
Human Vaccines. 2010;6:346-54.
Comparison of local side effects to ID
and IM influenza vaccine
90
80
70
Percent
60
50
IM 15 mcg
40
ID 9 mcg
30
20
10
0
Erythema
Swelling
Induration
Pain
Human Vaccines. 2010;6:346-54.
60
Intradermal Injection Technique
1. Remove needle cap
2. Hold microinjection system
between thumb and middle finger

Do not place fingers on the windows
3. Insert needle rapidly perpendicular
to the skin
4. Inject using the index finger
5. Remove needle from the skin and activate the needle
shield by
pushing firmly on the plunger
Which side effect is more common with the intradermal
influenza vaccine than the IM influenza vaccine?
17%
1. Injection site pain
0%
2. Headache
0%
3. Fever
67%
4. Injection site swelling
17%
5. Malaise
Age Indication for Influenza Vaccines:
United States, 2015-2016
0.5-2
years
2
years
3
years
4-8
years
9-17
years
18-49
years
50-64
years
65+
years
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
Fluarix Quad
✓
✓
✓
✓
✓
✓
FluLaval Quad
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
Flucelvax
✓
✓
✓
Flublok2
✓
✓
✓
Fluzone Intradermal Quad
✓
✓
Vaccine
Fluzone / Fluzone Quad
Flumist Quad
Fluvirin
Afluria1
Fluzone High-Dose
1.
2.
Age indication per package insert is >5 years; however the ACIP recommends >9 years.
FDA labeled age indication expanded in 2015 to 18 years and older (now including adults 65+).
✓
64
Characteristics of Influenza Vaccines:
United States, 2015-2016
Vaccine
Live
Fluzone / Fluzone Quad
Flumist Quad
Mercury
Egg
Protein
✓1
✓
✓
✓
✓
Fluarix Quad
FluLaval Quad
✓
✓
Fluvirin
✓1
✓
Afluria
✓1
✓
Flucelvax
Latex
✓2
✓3
✓3
Flublok
Fluzone Intradermal Quad
✓
Fluzone High-Dose
✓
1.
2.
3.
Multi-dose vials contain mercury. Single-dose prefilled syringes are mercury-free.
Estimated to contain <50 femtograms (5x10-8 mcg) of total egg protein per 0.5 ml dose.
Syringe tip may contain natural rubber latex.
65
Which of the following influenza vaccines is NOT
indicated for a 72-year old woman?
0%
1. Inactivated trivalent IM vaccine
0%
2. Inactivated quadrivalent vaccine
20%
3. Inactivated high dose vaccine
80%
4. Inactivated trivalent intradermal vaccine
A 35-year-old woman requests an annual flu shot. She
has ulcerative colitis and is taking Prednisone 40 mg QD.
Which flu vaccine(s) is/are appropriate?
0%
1. Influenza intradermal vaccine
33%
2. Influenza intramuscular vaccine
0%
3. Influenza high dose vaccine
0%
4. Flumist nasal spray 0.2 ml nasal
67%
5. Either 1 or 2
0%
6. Either 2 or 3
0%
7. Either 2 or 4
Pneumococcal Disease
 Pneumococcal disease is caused the bacterium Streptococcus
pneumoniae
 Clinical Features
 Pneumonia
 Otitis media
 Sinus infections
 Bacteremia
 Meningitis
 Risk Factors
 Asplenia
 Chronic heart, pulmonary, liver, or renal disease
 Cigarette smoking
 Cerebrospinal fluid leak
 Age less than 2 years, or 65 years and older
 Complex immunization recommendation for adults
69
Streptococcus Pneumoniae
 90 serotypes identified
 The 10 most common serotypes are
estimated to account for about 62% of
invasive disease worldwide
 Up to 36% of adult CAP
 Up to 50% of HAP
 13-19% of all cases of meningitis
CDC: Vaccines and Immunizations. Pneumococcal Disease. http://www.cdc.gov/. Accessed 30 July 2014.
70
Pneumococcal Vaccines
 Pneumovax 23®
(PPSV23,
pneumococcal
polysaccharide
vaccine)
• Prevnar 13® (PCV13,
pneumococcal conjugate
vaccine)
ACIP Recommendations on
Pneumococcal Vaccinations in Adults
PPSV23 (Pneumovax®)
Age
Who receives the vaccine?
≥65 years old
• Vaccination history unclear or never received vaccine before
• Revaccinate: If patient received vaccine before the age of 65
and it has been ≥ 5 years since administration
2-64 years old
•
•
•
•
•
•
Chronic cardiovascular disease (CHF, cardiomyopathies)
Chronic pulmonary disease (COPD)
Diabetes mellitus
Alcoholism
Chronic liver disease
Cerebrospinal fluid leaks
Re-vaccination after 5 years if:
• functional or anatomic asplenia
• Immunocompromising conditions
• Chronic kidney disease
19-64 years old
• Cigarette smokers
• Asthma
76
PCV13 (Prevnar®)
Age
Who receives the vaccine?
6 weeks through 5
years old
Routine series at 2, 4, 6, and 12 through 15 months. Minimum
intervals:
Dose 1 to Dose 2: 4 weeks
Dose 2 to Dose 3: 4 weeks
Dose 3 to Dose 4: 8 weeks
6-18 years old
Children 6 through 18 years who have not received PCV13
previously, and are at high risk for invasive pneumococcal
disease because of:
• Anatomic or functional asplenia (including sickle cell
disease)
• Immunocompromising conditions, including HIV infection
• Cochlear implant
• CSF leaks
should receive a single dose of PCV13 (regardless of any previous
history of PCV7 and/or PPSV23).
77
PCV13 (Prevnar®), cont’d
Age
Who receives the vaccine?
Adults 19
years old
and older
Adults 19 and older who have not received either PCV or PPSV
previously, and are at high risk for invasive pneumococcal disease
because of:
• Anatomic or functional asplenia (including sickle cell disease)
• Immunocompromising conditions, including HIV infection
• Cochlear implant
• CSF leaks
should receive a single dose of PCV13. (This should be followed with a
dose of PPSV at least 8 weeks later. Those who have indications for
revaccination with PPSV should receive a second dose at least 5 years after
the first.)
Adults 19 and older with any of these conditions who have received one
or more doses of PPSV previously should receive a single dose of PCV13
at least one year after the last dose of PPSV.
[Note that use of PCV13 for persons 18 through 49 years of age, while
recommended by ACIP in these circumstances, is off-label.] Appropriate
intervals between doses of PCV and PPSV can be found in PCV MMWR
(for children) and PSV MMWR (for adults).
http://www.cdc.gov/vaccines/hcp/vis/vis-statements/pcv13-hcp-info.html
78
ACIP Recommendations on Pneumococcal
Vaccinations in Adults
 Both PCV13 and PPSV23 should be administered routinely in series to
all adults aged ≥ 65 years.
 Pneumococcal vaccine-naïve persons. Adults aged ≥65 years who
have not previously received pneumococcal vaccine or whose previous
vaccination history is unknown should receive a dose of PCV13 first,
followed by a dose of PPSV23.
 The dose of PPSV23 should be given 6–12 months after a dose of
PCV13.
 If PPSV23 cannot be given during this time window, the dose of
PPSV23 should be given during the next visit.
 The two vaccines should not be coadministered, and the minimum
acceptable interval between PCV13 and PPSV23 is 8 weeks.
MMWR September 19, 2014 / 63 (37)
Pneumococcal vaccine-naïve persons aged > 65 years
*minimum interval between sequential administration of PCV13 and PPSV23 is 8 weeks;
PPSV23 can be given later than 6-12 months after PCV13 if this window is missed.
Persons who previously received PPSV23 at age > 65 years
*minimum interval between sequential administration of PCV13 and PPSV23 is 8 weeks;
PPSV23 can be given later than 6-12 months after PCV13 if this window is missed.
Persons who previously received PPSV23 before
age 65 years who are now aged > 65 years
Administration
 Pneumovax® & Prevnar®: 0.5 mL dose
 1 inch, 25 gauge needle
 Intramuscular (IM) - deltoid
CDC: Vaccines and Immunizations. Pneumococcal
Disease. http://www.cdc.gov/. Accessed 30 July
What is the Healthy People 2020 goal for pneumococcal
vaccination for adults 65 and older?
0%
100%
0%
0%
100%
2. 90%
3. 70%
4. 50%
1.
A 65-year-old man who is pneumonia vaccine naïve.
What pneumonia vaccine(s) is/are recommended?
2%
1. Pneumovax only
0%
2. Prevnar only
3%
3. Both; Pneumovax prior to Prevnar
95%
4. Both; Prevnar prior to Pneumovax
Which of the following statements about the administration of
influenza and pneumonia vaccines is true?
100%
1. Same day, opposite arm, separate syringe
0%
2. Same day, same arm, mixed in 1 syringe
0%
3. Must be separated by at least 7 days
0%
4. Must be separated by at least 4 weeks
Which of the following vaccines is a live vaccine?
0%
1. Pneumovax
100%
2. Flumist
0%
3. Prevnar
0%
4. Fluarix
0%
5. Fluzone HD
Pathogen (Common name) Table
Pathogen
Classification
Transmission
Complication
Influenza (flu)
virus
Respiratory
Pneumonia
Pneumococcus
Gram + Bacteria
Respiratory
Meningitis/Bacteremia
Varicella (chicken pox)
virus
Respiratory
Bacterial infection
Zoster (shingles)
virus
Latent varicella
Neuralgia
HPV (genital warts)
virus
Sexual contact
Cervical cancer
Meningococcus
Gram - Bacteria
Respiratory
Invasive disease
Tetanus (lockjaw)
Gram + Bacteria-toxin
wound
Respiratory failure
Diphtheria
Gram + Bacteria-toxin
Respiratory
Myocarditis/Neuritis
Pertussis (whooping cough)
Gram - Bacteria
Respiratory
Pneumonia
Measles
virus
Respiratory
Diarrhea, pneumonia
Mumps
virus
Respiratory
Meningitis
Rubella
virus
Respiratory
Arthritis
Hepatitis A
virus
Fecal-oral
Acute/chronic hepatitis
Hepatitis B
virus
Blood-serous fluids
Acute hepatitis
Adult Vaccine Table
Vaccine
Vaccine
Type
Route /
Reconstitute
Series
Storage
Influenza IIV
Inactivated
IM / No
1x annually
Fridge
Flumist
Live
Intranasal / No
1x annually
Fridge
Pneumovax
Inactivated
IM or SQ / No
1-2 doses
Fridge
Zostavax
Live
SQ / Yes
1 dose
Freezer
Gardasil (HPV9)
Cervarix (HPV2)
Inactivated
IM / No
3 doses
Fridge
Td
Inactivated
IM / No
1 q 10 years
Fridge
Tdap
Inactivated
IM / No
1x, then Td
Fridge
Varivax
Live
SQ / Yes
2 doses
Freezer
MMR
Live
SQ / Yes
1-2 doses
Fridge or Freezer
Menactra, Menveo
Menomune (MPSV4)
Inactivated
IM / No
1-2+ doses
Fridge
Havrix, Vaqta
Inactivated
IM / No
2 doses
Fridge
Recombivax-HB
Engerix-B
Inactivated
IM / No
3 doses
Fridge