Meningococcal B Update for Oregon Providers

This message comes to you as an update on the meningococcal disease outbreak at the University of Oregon, including some recommendations for you for the upcoming spring break when we expect many UofO students to head home to other areas of the state.

Outbreak Update:

There is an outbreak of serogroup B meningococcal disease at the University of Oregon. There have been 5 confirmed cases among University of Oregon undergraduates since January of this year, one of which was fatal. Ongoing vaccination efforts have vaccinated about 9,000 undergraduates to date, but the goal is to vaccinate all (22,000) undergraduates, and all University of Oregon graduate students and staff with immune deficiencies.

What you need to know:

  • Both Trumenba (Pfizer) and Bexsero (Novartis) vaccines are available on the private market for providers to purchase.
  • Spring break is Friday, March 20th through Sunday, March 29th. Students may be  returning home and seeking vaccination or may present to care.
  • Current standing orders exist for pharmacies to vaccinate all University of Oregon undergraduates due to the outbreak.
  • Undergraduate students of any age from other colleges/universities who live at the 13th & Olive apartments (Capstone buildings) in Eugene are also covered by the standing orders.
  • Others who should be vaccinated are staff or graduate students at the University of Oregon who live in campus residence halls, fraternities or sororities, or who are high risk (those with asplenia, sickle cell disease, or terminal complement component deficiency).
  • Serogroup B vaccine is available at Walgreens, Safeway and Albertsons stores near the University of Oregon. Individuals seeking vaccination outside the Eugene area should call ahead to their local pharmacy, and if the vaccine is not in stock it can be ordered within a day or so.
  • Most insurance companies, including Oregon’s Medicaid CCO Plans, have been paying for the vaccine as given by local pharmacies.
  • Some students may be seeking the first dose, or the second dose. Individuals should stick with one vaccine brand for the series whenever possible.
  • All students who have had the disease to date did not present with classic meningeal signs, but with disseminated meningococcal disease found on blood culture. Other presenting symptoms include fever and rash.

Please be aware of this situation and let returning students and concerned parents know where they can get vaccinated, and who the vaccine is currently recommended for.

Will the newly licensed mening B vaccines be available through the Vaccines For Children (VFC) program?

Yes, probably in late April.  We will keep you posted.  The vaccines will be available for any VFC-eligible child (through age 18) with one of the high-risk conditions listed in our current model standing order.  Those are:

RECOMMENDATIONS FOR USE

  1. Approved for the following high‐risk individuals ≥10 years of age. Those with:

 functional or anatomic asplenia

 sickle cell disease

 terminal complement component deficiency (e.g., C5–C9, properidin, factor H, factor D,

and patients taking Eculizumab [Soliris®]) AND

 microbiologists who work routinely with isolates of Neisseria meningitidis

  1. B. University of Oregon outbreak control (expires 6/30/2015):

Approved for the following individuals ≥11 years of age:

  • University of Oregon undergraduate students.
  • University of Oregon graduate students, faculty and staff who:
  1. live in campus residence halls, fraternities, or sororities
  2. who are at high risk (see above)

3.) Undergraduate students of any college living in the 13th & Olive apartments

(Capstone Buildings), including but not limited to undergraduates from the University

of Oregon, Lane Community College, and Northwest Christian University

  1. Others may be vaccinated only with a specific physician prescription.

Where can I find the current recommendations for the new vaccines?

You can find all of our model standing orders here:  https://public.health.oregon.gov/preventionwellness/vaccinesimmunization/immunizationproviderresources/pages/stdgordr.aspx

Should we have vaccine on hand now?

That is a decision for each clinic/health system/pharmacist.  Both vaccines are currently available for purchase on the private market.

I have questions; whom should I call?

Your local health department! You can find contact information here: https://public.health.oregon.gov/ProviderPartnerResources/LocalHealthDepartmentResources/Pages/lhd.aspx

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Having Difficult Conversations- Working through Conflict and Uncertainty with Motivational Interviewing

With the minefield of subjects growing ever larger, talking to patients and community members can become a difficult process when it comes to scientifically sophisticated and divisive topics. We know that having tactics, training, and reinforcements makes talking about difficult subjects a lot easier and ultimately more successful. In the public health and medical communities, we know that these instances are not only inevitable but sometimes a weekly occurrence, and the health of our communities depends on these conversations.

This is exactly what Immunize Oregon and Oregon AWARE had in mind when they created the “Having Difficult Conversations” seminar. The seminar focuses on the basic techniques of motivational interviewing and its applications in patient education settings, specifically around the topics of immunizations and antibiotic use. Motivational interviewing (MI) is a method that works on facilitating and engaging intrinsic motivation within the client in order to change behavior. Typically used for more traditional behavior change counseling such as smoking cessation, motivational interviewing is a goal-oriented, client-centered counseling and conversation style that can helping clients explore and resolve ambivalence. These methods are easily applied to the charged and emotionally driven conversations that surround for other health topics, like immunizations. Combining MI techniques, local statistics, case studies, and plenty of group and individual practice, this seminar strives to provide participants with alternatives to stonewalling and conflict through empathy and empowerment.

The seminar has gleaned positive reviews on practical applications and confidence building with regards to these tricky patient/community member interactions. After the initial presentation, Immunize Oregon and Oregon AWARE saw the potential for this to be a tool for partners and providers throughout the state. The scope of the seminar was expanded so that it could be tailored to varying group sizes and provider types. Immunize Oregon and Oregon AWARE hope to be able to provide this seminar to as many groups as possible and are offering a series of free presentations at the Portland State Office Building. If you are interested in attending, please click on the date you want to register for, as we do require an RSVP to attend.

Thursday April 23, 2015 from 9:00am-11:00am

Tuesday May 19, 2015 from 2:00pm-4:00pm

Friday June 26, 2015 from 8:00am-10:00am

We hope to add more workshops later in the year in different locations, so stay tuned for future dates!

For more information about the seminar or scheduling a presentation please email katherine.h.mcguiness@state.or.us or tessa.r.jaqua@state.or.us .

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University of Oregon Meningococcal Update and Immunization Efforts

As of March 1st, 2015, 4 students at the University of Oregon have contracted type B meningococcal disease, and one of these students has died. The Oregon Immunization Program is working Lane County health officials, the University of Oregon, and other Oregon Health Authority programs to prevent the spread of this disease. To find the most up to date information on this emergency, please visit our 2015 Meningococcal Update website.

There are vaccine options available for students U of O students in the form of mass vaccination clinics at Matthew Knight arena from March 2-5, and over 15 pharmacies in Lane County, including Safeways, Walgreens and Albertsons, are offering the vaccine to students. You can find out more details about those events and participating pharmacies by visiting https://healthcenter.uoregon.edu/getthevax.aspx

 

Meningitis: What It Is, How it Spreads and Symptoms to Look For

Meningitis is a disease caused by the inflammation of the protective membranes covering the brain and spinal cord.  Meningitis is usually caused by bacteria or viruses, but can also be caused by physical injury, cancer or certain drugs.  Neisseria meningitidis is a bacterium that causes meningitis and other serious infections. The 6 subtypes of these bacteria are responsible for most meningococcal disease worldwide. Type B causes approximately 50% of the cases in Oregon and is suspected to be the cause of the most recent outbreak in Eugene (2015). 

Meningitis is generally transmitted through direct exchange of respiratory and throat secretions by close personal contact, such as sharing drinks or kissing. Fortunately, none of the bacteria that cause meningitis are as contagious as the common cold or the flu. In order for the illness to spread, a person would need to have close contact with the patient for several hours in a seven day period. 

Meningococcal disease can progress rapidly, and early symptoms are not easily recognized and are difficult to distinguish from other more common infections like the flu. These include:

• Fever
• Headache
• Stiff Neck
• Confusion
• Drowsiness
• Rash

Students who notice these symptoms (in themselves, friends, or others), should contact the University Health Center at 541-346-2770. 

If the symptoms are unusually sudden or severe, they should consider going directly to a local emergency room.

Some people are carriers of the bacteria and show no symptoms. The disease is unpredictable, and no one really knows all the reasons why some carriers become sick while others do not.

 

How You Can Prevent the Spread of Meningitis

Get vaccinated. In an emergency, such as the one we are in now, people over the age of 10 can be vaccinated.

Do Not Share:

• drinking glasses/cups
• water bottles
• utensils
• toothbrushes
• cosmetics
• cigarettes/e-cigarettes/hookah

 

Don’t drink out of a common source such as a punchbowl

Cough into a sleeve or tissue

Know that kissing poses a risk

Wash and sanitize your hands often

Resources

Oregon Health Authority Meningococcal Disease Fact Sheet

University of Oregon Health Center

Lane County Vaccine Clinics

CDC Website on Meningococcal Disease

CDC Website on Meningococcal B Vaccines


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Celebrating School-Based Health Centers in February!

February is School-Based Health Center Awareness month, so we are excited to highlight some of the great work they are doing in communities in Oregon.

School-based health centers (SBHCs) are medical clinics that offer primary care services either within or on the grounds of a school. SBHCs provide physical, mental, dental, and preventative health services to children and youth, regardless of their ability to pay. Currently, there are 68 SBHCs located in 20 counties in Oregon. Nine additional communities are planning for new SBHCs, with 8 new centers anticipated to open during the 2014-2015 school year.

Nearly 52,500 school aged children (5-21 years old) currently have access to a SBHC in Oregon. During the 2013-2014 school year, Oregon SBHCs served 23,797 clients in 70,666 visits.  Of these visits:

  • 26% related to a mental health or substance use concern
  • 13% an immunization was administered
  • 13% related to a reproductive health service

SBHCs help get students back to the classroom faster and ready to learn. According to surveyed students who used their SBHC in the 2013-2014 school year, 63% reported they didn’t miss a class while using SBHC services; 77% estimated they would miss one class or more if they had to go to a clinic located elsewhere.

SBHCs also provide quality care and developmentally appropriate services. In the 2013-2014 student survey, 65% of surveyed students reported their overall health was better because of their use of the SBHC; 84% were “very satisfied” with their center.

Want to learn more about SBHCs in Oregon? Visit the SBHC State Program Office website: www.healthoregon.org/sbhc or check out our 2015 SBHC Status Report.

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New Vaccines for Children Program Requirements for 2015

With the New Year come new CDC requirements for the Vaccines for Children (VFC) program. These requirements went into effect January 1, 2015 and will now be assessed during VFC Site Visits or as requested by the Oregon Immunization Program (OIP). The new requirements are as follows:

1.Required training on VFC Program Requirements
All key staff (i.e. Vaccine Coordinator and Back-up Coordinator) must undergo annual training on VFC Program Requirements and training must be documented. This training is currently being developed by OIP. When the training is available, staff will be notified via the VFC list serv. If you would like to be added to the VFC list serv, please email Mimi Luther at lydia.m.luther@state.or.us.

2.Additions to your Vaccine Management Plan
All vaccine plans for routine and emergency vaccine management must include the signature, name, and title of the preparer of the documents. Clinics will be notified when an updated OIP Vaccine Management Guide is available with this change. See example below. In the meantime, please include the required documentation on your current vaccine management plan.

3. Maintain a calibrated back-up thermometer
VFC providers are required to have at least one backup thermometer with a current certificate of calibration on hand (not stored in unit alongside current thermometer). It should be available in case a thermometer in use is no longer working appropriately or calibration testing of the current equipment is required. OIP strongly recommends clinics have a thermometer with a probe in glycol as their primary thermometer; ambient air thermometers are acceptable as a backup. OIP encourages clinics to research options for thermometers that have the option for two year calibration to reduce cost and frequency of calibration. CDC says the backup thermometer should have a different calibration retesting date.

4. Place thermometers in a central location
Thermometers must be placed in a central area of the storage unit with the vaccines. Thermometers should not be placed in the doors, near or against the walls, close to vents, or on the floor of the unit. If you have a thermometer that is currently mounted on the wall of your vaccine storage unit it will need to be relocated to the center to meet this new CDC requirement.

5.Record name/initials and exact time twice-daily
The time and name or initials of the person recording twice daily temperature recordings must be documented with temperature readings. Temperate log templates can be found here: http://www.immunize.org/clinic/storage-handling.asp
CDC recommends that providers using a data logger record the minimum and maximum temperatures once each work day (preferably in the morning).

If you have questions regarding any of the above requirements, or VFC in general, please call
971-673-0300. Thank you for all you do to keep Oregonians well immunized!

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The 2015 Childhood Immunization Schedule is Now Available

from the Centers for Disease Control and Prevention

The 2015 Childhood Immunization Schedule is now available online.  Every year, the Advisory Committee on Immunization Practices (ACIP) develops recommendations for routine use of vaccines in children, adolescents, and adults. When adopted by the CDC Director, they become official CDC/HHS policy.

The Morbidity and Mortality Weekly Report will publish a summary of childhood schedule changes in early February.  However, all of the 2015 figures, footnotes, and tables for the childhood schedule are currently available on the CDC website.

CDC has also updated the following parent-friendly schedules to reflect the new 2015 recommended immunization schedule:

CDC encourages organizations to syndicate content rather than copy a PDF version of the schedule onto their websites to share with visitors. Content syndication allows other organizations’ websites to mirror CDC web content, with automatic updates whenever changes are made on the CDC site. This helps ensure that all schedules are current across the Internet. See how to display the schedules on your site.

The 2015 adult schedule also on the available.

We encourage you to share this information with your colleagues and other interested parties to spread the message about the new schedules.

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Adult Pneumococcal Recommendations in Practice

by Kerry Nolan, Oregon Immunization Program Pharmacy Intern

This is part one of our two part pneumococcal vaccination series. 

Update: This post was edited on 2/5/2015 for clarification.

Situation: A 65 year-old patient has come to our clinic today for a pneumococcal vaccination following her first dose of Pneumovax at age 62.

What vaccination should she receive today? If and when will she need another one? Will it be covered? Since the Advisory Committee on Immunization Practices (ACIP) introduced their latest pneumococcal recommendations for patients 65 and older, both providers and patients have been asking the right questions.

What are the new recommendations?

Adults aged 65 and older should now receive one dose each of Prevnar 13 and Pneumovax 23. Previously, a single dose of Pneumovax 23 alone was recommended for this age group. Although Prevnar 13 has been FDA approved for adults 50 years and over since 2011, it just earned the ACIP recommendation for adults age 65 and up last September. ACIP recommends that adults 19–64 years receive PCV13 if they have an identified health risk.  Healthy individuals age 50–64 may have a dose of Prevnar 13 per FDA approval, however, this dose may not be covered by insurance.  Sounds simple enough, but determining when and who should receive which vaccine gets a bit more complicated. The recommended pneumococcal vaccination schedule separates patients ≥65 years into those who have:
1. Never received any pneumococcal vaccine, and should receive Prevnar 13 first then Pneumovax 23 between 6 to 12 months later
2. Received one (or more) doses of Pneumovax 23, and should receive Prevnar 13 at least one year after their last Pneumovax 23 vaccination
3. Received Pneumovax 23 before turning 65, and should still wait at least one year since their last Pneumovax 23 vaccination to receive Prevnar 13, but must also wait at least 5 years between Pneumovax 23 doses to receive one final dose at ≥65.

In this diagram provided by the ACIP, the latest adult pneumococcal vaccination schedules are summarized:
Pneumococcal vaccine
Image: Sequential administration and recommended intervals for PCV13 and PPSV23 for adults aged ≥65 years — Advisory Committee on Immunization Practices, MMWR 2014

So- which should our patient receive and when? She received a dose of Pneumovax 23 prior to turning 65, which places her in the third category. It has been 3 years since Pneumovax was given, so she should receive Prevnar 13 today. However, when considering the best time for her to return for the final Pneumovax dose, we find that even in 12 months, only a total of four years (not the recommended five) will have passed since her last dose. What should we do? In this situation, the patient should wait the full five years since her Pneumovax dose before receiving the final one. In other words, she will receive Prevnar 13 today and a final Pneumovax 23 dose in about two years.

Will the new vaccine be covered?
On December 31st the Center for Medicaid and Medicare Services (CMS) released a statement announcing that an update to pneumococcal vaccine coverage requirements would be in effect as of September 19, 2014 to align with ACIP recommendations. Effective February 2nd, two pneumococcal vaccines and their administration will be covered under Medicare part B: the first for patients who have never received any pneumococcal vaccine and a second (different) vaccine one year after the first was administered. This coverage is not perfectly aligned with ACIP’s recommendations, but captures where vaccination schedules overlap at the one-year mark. Additionally, Medicare will adjust previously denied claims for qualifying pneumococcal vaccinations administered September 19th or later if the claim is resubmitted. Our patient is more likely to have her second vaccination covered if she is insured privately. As part of the Affordable Care Act, health plans are now required to cover ACIP-recommended vaccines without co-pays or cost-sharing.

As we become comfortable with the nuances of these recommendations, we are better able to provide vaccine protection and education. Tricky timing, different vaccines and varying coverage are each good reasons for giving pneumococcal vaccines in older adults your careful consideration.

References:

1. CDC. Use of 13-Valent Pneumococcal Conjugate Vaccine and 23-Valent Pneumococcal Polysaccharide Vaccine among Adults Aged ≥65 Years: Recommendations of the Advisory Committee on Immunization Practices (ACIP) MMWR 2014; 63 (37); 822-825. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6337a4.htm. Accessed 26 Jul 2015.
2. Centers for Medicare & Medicaid Services (CMS). Modifications to Medicare Part B Coverage of Pneumococcal Vaccinations. MLN Matters 2014; p1-3. Available at: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9051.pdf. Accessed 26 Jan 2015.

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