Minimum Ages & Intervals Clarified

The Oregon Immunization Program responded to a request to clarify the terms recommended and minimum in the standing orders and pharmacy protocols. The issue of spacing also came up for clarification.

Do you know the difference between the preferred (recommended) age and the (minimum) acceptable age, the preferred (recommended) spacing and the (minimum) acceptable spacing as noted in the Oregon Model Standing Orders for Immunization, the Oregon Pharmacy Protocols and the Centers for Disease Control and Prevention (CDC) Recommended Immunization Catch-up Schedules?

Look at this section from the HPV vaccine schedule:Capture.JPG- Dose and route 1

 

The Preferred Age and spacing are established by the manufacturer through vaccine safety trials and approved by the Advisory Committee on Immunization Practices (ACIP); a group of medical and public health experts from across the US. The ACIP determines preferred age, minimum acceptable age, preferred spacing and minimum acceptable spacing intervals based many factors, including the safety and effectiveness of a vaccine(s) and situational identifiers. The ACIP recommendations do not become policy until they are published in the Morbidity and Mortality Weekly Report (MMWR). The MMWR is the CDC’s primary vehicle for scientific publication of timely, reliable, authoritative, accurate, objective and useful public health information and recommendations.

For HPV the recommended age is 11-12 years, as this coincides with the adolescent well visit which allows plenty of time for clients to complete the 2-dose series before age 15.

The Minimum Acceptable Age and spacing are based on the expert opinion of the Advisory Committee on Immunization Practices (ACIP); which are used under exceptional circumstances whereas the preferred age and spacing are for the general population identified for a specific vaccine.

Once the MMWR is published these same recommendations are available in the Oregon Model Standing Orders for Immunization and Pharmacy Protocols.

The standing orders and pharmacy protocols are updated as soon as new recommendations are made by the ACIP. The full ACIP meets three times a year to review, discuss and vote on vaccine issues and recommendations. Subcommittees of the ACIP work throughout the year.

The CDC publishes childhood and adult guidelines and vaccine schedules annually.

Vaccinators should ensure that they are following the most current schedules from CDC.

When to use a shorter interval than Recommended Spacing1

Minimum Acceptable Spacing: Administration of a multidose vaccine series using intervals that are shorter than preferred might be necessary in certain circumstances, such as impending international travel or when a person is behind schedule on vaccinations but needs rapid protection. In these situations, an accelerated schedule can be implemented using intervals between doses that are shorter than intervals preferred for routine vaccination. The minimum acceptable spacing and ages for scheduling catch-up vaccinations are available at www.cdc.gov/vaccines/schedules/hcp/index.html. Vaccine doses should not be administered at intervals less than these minimum acceptable intervals or at an age that is younger than the minimum acceptable age.

There is one more exception to the minimum acceptable spacing and age and that is the 4-day rule or grace period.1

Vaccine doses administered ≤4 days before the minimum acceptable interval or age are considered valid; however, local or state mandates might supersede this 4-day guideline. Day 1 is the day before the day that marks the minimum acceptable age or minimum acceptable interval for a vaccine. Because of the unique schedule for rabies vaccine, the 4-day guideline does not apply to this vaccine. Doses of any vaccine administered ≥5 days earlier than the minimum acceptable interval or age should not be counted as valid doses and should be repeated as age appropriate. The repeat dose should be spaced after the invalid dose by the minimum acceptable interval.

If the first dose in a series is given ≥5 days before the minimum acceptable age, the dose should be repeated on or after the date when the child reaches at least the minimum acceptable age. If the vaccine is a live vaccine, ensuring that a minimum interval of 28 days has elapsed from the invalid dose is preferred.

What is Time? 2

The ACIP introduced guidelines in 2002:  If the interval is less than 4 months, it is common to covert months into days or weeks. (e.g., 1 month = 4 weeks = 28 days).

For intervals of 4 months or longer, you should consider a month a “calendar month” – the interval from one calendar date to the next a month later. (e.g., 6 months from October 1 is April 1).

Make sure you check the exact wording on the CDC’s immunization schedules.

The 4-day “grace period” should not be used when scheduling future vaccination visits, and should not be applied to the 28-day interval between live parenteral vaccines not administered at the same visit. It should be used primarily when reviewing vaccination records (for example, when evaluating a vaccination record prior to entry to daycare or school).

Outbreaks

Sometimes outbreaks of certain vaccine preventable diseases take place. This may create exceptions to the standing orders and pharmacy protocols. Meningococcal B vaccine is one of these exceptions.

Here is a section of the vaccine schedule for an outbreak situation:Schedule for Outbreaks

And, here is the general recommendation for Meningococcal B vaccine:Schedule for Mening B JPG*The same edition of the MMWR covers both contingencies.

 

When you choose the age and timing of a vaccine you need to consider the optimal response.  The optimal response to a vaccine depends on multiple factors, including the type of vaccine, age of the recipient, and immune status of the recipient. Recommendations for the age at which vaccines are administered are influenced by age-specific risks for disease, age-specific risks for complications, age-specific responses to vaccination, and potential interference with the immune response by passively transferred maternal antibodies. “Vaccines are generally preferred for members of the youngest age group at risk for experiencing the disease for which vaccine efficacy and safety have been demonstrated.” This minimum age is not just for those persons aged from birth through 18 years.

Look at the new Shingrix vaccine: 

Shingrix® vaccine (RZV) by GlaxoSmithKline for immunocompetent adults at 50 years of age and older.

Schedule for Shingrix JPG

The preferred spacing interval of the first dose of Shingrix after Zostavax® (ZVL) is ≥5 years. This is the time period studied by the manufacturer and identified in the package insert. The minimum acceptable spacing between the most recent Zostavax® and the first dose of Shingrix® is 8 weeks. This has been determined by ACIP expert opinion. The MMWR states that: “Studies examined the safety and immunogenicity of RZV vaccination administered ≥5 years after ZVL; shorter intervals have not been studied… Clinical trials indicated lower efficacy of ZVL in adults aged ≥70 years; therefore, a shorter interval may be considered based on the recipient’s age when ZVL was administered. Based on expert opinion, RZV should not be given <2 months after receipt of ZVL”. The 4-day rule does not apply to the minimum spacing of Shingrix®.

What do you hope to avoid by paying close attention to age and spacing intervals?2

  • Avoid harm to the vaccinee from a side effect or vulnerability to disease;
  • Avoid the inconvenience to the parent/patient and perhaps ill will;
  • Avoid the unreimbursed cost to the provider; and
  • Avoid the loss of trust in the provider, with possible negative publicity or even legal action.

Helpful Hints:

  1. Schedule clients using the preferred age and preferred spacing to provide optimal protection.1
  2. Do not schedule your routine vaccine appointments by the minimum acceptable age, spacing or the 4-day rule. The Minimum Acceptable Age and spacing are used under exceptional circumstances, not general scheduling.
  3. Check the Oregon Model Standing Orders and the Oregon Pharmacy Protocols for the most current recommendations.

References

  1. Vaccine Recommendations and Guidelines of the ACIP. General Best Practice Guidelines for Immunization: Best Practice Guidance of the Advisory Committee on Immunization Practices (ACIP) https://www.cdc.gov/vaccines/hcp/acip-recs/general-recs/timing.html

Accessed 17 April 2018

  1. Immunization Action Coalition. Available at http://www.immunize.org/catg.d/s8025.pdf Slide 17, 19.  Accessed 17 April 2018

 

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Filed under All Posts, Education, Oregon Immunization, pharmacy

Fight the Flu #NIVW

Melita Lynch, Portland State University

Oregon Immunization Program Intern

December 3-9, 2017, is National Influenza Vaccination Week (or NIVW). NIVW highlights the importance of continuing flu vaccination through the holiday season and beyond. Getting vaccinated yourself protects people around you, including those who are more vulnerable to serious flu illness, like babies and young children, older people, and people with chronic health conditions. This week serves as a reminder that it’s not too late to get vaccinated for the flu!

 

NIVW

 

Protect yourself and your family this season with an annual flu vaccine for everyone in your family who is 6 months of age and older. While the timing of flu season is unpredictable, seasonal flu activity can begin as early as October and last as late as May. As long as flu viruses are circulating, vaccination should continue throughout the flu season in order to protect as many people as possible against the flu. Once you get the vaccine, it takes about two weeks for antibodies to develop in the body to protect against influenza virus infection. Now is a great time to get a flu vaccine if you have not gotten vaccinated yet—it’s not too late!

The Oregon Immunization Program encourages flu vaccination for everyone six months and older. People everywhere including people in good health, are at risk of contracting the flu. Even if you’ve already became ill from the flu, the vaccine still can provide protection. The 2017/2018 flu vaccine provides protection from three to four of the most common circulating flu viruses. Getting the flu vaccine is the best way to protect against this serious disease. You have the power to protect yourself and your loved ones against the flu this season!

 

Visit our social media platforms for daily #NIVW posts.

https://www.facebook.com/OregonImmunize

https://twitter.com/fluoregon?lang=en

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A Small Thank You to Peggy Lou Hillman

Mallory Metzger, Immunization Law Health Educator II, Oregon Immunization Program 

It is hard to imagine the school immunization process without Peggy Lou Hillman. That’s because she has been there from the beginning. Soon Peggy will be retiring from the Oregon Immunization Program after nearly 50 years of working in public health. Peggy is an immunization school law and forecasting expert, resident historian, seasonal decorator, and number one advocate for our partners.

Whether or not you know Peggy, you know her work. Go outside and take a deep breath and thank Peggy for the clean air.  After college, Peggy began working at the Tuberculosis and Respiratory Disease Association where she helped institute clean air requirements and car emission testing. These policies have led to the Department of Environmental Quality car emission testing that we see today.

 

Peggy

Peggy Hillman, Immunization Law Health Educator II, Oregon Immunization Program

 

After you take that deep breath, walk over to a school yard and watch kids running and playing outside. These healthy kids can thank Peggy for helping create the first immunization laws for school attendance in Oregon back in 1981. As the Immunization Program Coordinator for Multnomah County, Peggy hand-wrote thousands of exclusion letters in the early years of the law.

Once you have gone for that walk, get in a car and drive with a sense of safety because all the babies being driven around are in car seats. Yep, that’s her too. While at Multnomah County, Peggy started the car seat loan program, which ensured all families regardless of income could protect their babies.

When asking Peggy about her career in public health she responded, “I fell into a career that I didn’t even know existed and it has given to me as much I have given to it.”  You have given to us more than we can fathom. On behalf of the Oregon Immunization Program and all those living and breathing in Oregon, thank you Peggy!

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Filed under Oregon Immunization, Private Clinics, Public Clinics, Public Health Heroes, School Law

Raising HPV Vaccination Rates: What Works?

Mikaela Kramer, Oregon State University

Oregon Immunization Program HPV Intern

Figuring out how to increase human papilloma virus (HPV) vaccination rates doesn’t have to be different for every clinic. The barriers to vaccination typically fall into one of three categories: 1) misinformation (e.g. my child isn’t at risk for HPV, vaccination promotes sex, etc.); 2) communication (e.g. staff and/or parents discomfort discussing sex); or 3) timing (e.g. getting patients to initiate and complete the series). We spoke with a couple of local clinics that are succeeding in getting teens vaccinated with HPV vaccine. We wanted to know what works and what strategies other clinics could adopt.

Yellowhawk Tribal Health Clinic

Debbie Barry, the VFC Immunization Coordinator at Yellowhawk Tribal Health Clinic in Pendleton, credits their high HPV immunization rates with teamwork.  Instead of having one HPV vaccination champion in the clinic, Debbie makes sure each staff member is proactive and confident when communicating about HPV prevention. She educates staff about the human papilloma virus, HPV vaccine and about strategies for communication with patients and their parents.

Being straightforward with patients and their parents about HPV and the vaccine promotes open communication. When parents raise concerns that vaccination will promote sexual activity, Debbie keeps her answer simple – HPV provides protection from cancers and warts that the patient may be exposed to in the future by their partners. She encourages patients and their parents to educate themselves about the disease. To encourage completion of the series, Yellowhawk sends reminder letters to patient’s monthly showing which vaccines are due and providing contact information for making appointments or finding out more information.

Debbie Berry

Debbie Berry, VFC  Immunization Coordinator and her team (left to right) Shana Alexander, RN-Supervisor; Heather Brown-Lowry, CMA;  Debbie Berry, CMA; Sharman Sams, CMA; Molly Jim, RN; the two in front with their heads together are Rena Cochran, CMA and Bobi Tallman, RN BSN.

Yakima Valley Farm Worker (YVFW) Clinics

Not every strategy works perfectly without some refinement. Regional Nursing Supervisor for Western Oregon, Christine Wysock, emphasizes that trial and error is necessary for finding out what works. In her clinics, Christine has found that highlighting the new two-dose schedule and that the vaccine prevents cancer is persuasive, as well as reminding parents that the vaccine can prevent infections years from now. She also recommends talking with patients and their parents about getting the HPV vaccine done that day. Christine was also able to take advantage of educational materials and tracking tools provided by the vaccine’s manufacturer, saving the time and cost of developing her own materials. Christine also stresses that teamwork is essential. Her staff all receive continuing education about vaccination strategies, ensuring that everyone is giving the same messages.

Christine Wysock

Christine Wysock, Regional Nursing Supervisor -Western Oregon , Yakima Valley Farm Workers Clinic

Several of these strategies could be replicated in any size practice in a short time frame. Educating your staff and encouraging them to promote HPV at every patient encounter can make a measurable difference in your HPV immunization rates. If you want to institute reminder letters in your practice, ALERT Immunization Information System (IIS) can easily generate a custom letter. Educational materials are available from a variety of sources, including the Centers for Disease Control and Prevention and the Children’s Hospital of Philadelphia. If you need help implementing these strategies, please contact the Oregon Immunization Program. Let’s educate and vaccinate against HPV.

If you have any questions about your clinic’s immunization rates, please feel free to reach out to the Oregon Immunization Program’s Vaccines For Children Help Desk at 971-673-4832 or VFC.help@state.or.us

 

 

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The Challenge of Oral HPV: Little did I know…

Mikaela Kramer, Oregon State University 

Oregon Immunization Program HPV Intern

Little did I know there was more to the human papillomavirus (HPV) than I had thought. As the HPV intern at the Oregon Health Authority’s Immunization Program, I expected the internship to be challenging, given all the information I’d be acquiring. However, I did not completely understand the complexity of HPV, in particular, HPV oropharyngeal (mouth) cancer. I had the basic knowledge that HPV is a sexually transmitted infection (STI), it revolves around the genital area and if not prevented or treated HPV can lead to warts and sometimes cervical cancer. I, like many others, was unfamiliar with oral HPV. Oral HPV is a growing threat to all of us. Oral HPV can lead to cancer of the mouth and throat.

While we know HPV is one of the most common STIs, oral HPV is likely just as common. Human papillomavirus can infect the mouth and throat, it can lead to warts in the mouth and in some cases oropharyngeal cancers. In 2012, HPV related oropharyngeal cancer became the most common HPV associated cancer surpassing HPV related cervical cancer rates.  According the Centers for Disease Control and Prevention (CDC) HPV-Associated Cancer Trends, men are four times more likely to get oropharyngeal cancer than woman.

 

Number of HPV-Associated Cancers Among Men by Year and Cancer Site, United States, 2003 -2013

men_sex_year_cases

Number of HPV-Associated Cancers Among Women by Year and Cancer Site, United States, 2003 – 2013 

women_sex_year_cases

 

Exactly how oral HPV is spread and the impact the HPV vaccine to prevent oral HPV associate cancers is not entirely known. More research is needed to refine diagnosis of oropharyngeal cancers, identify what populations are most likely to develop oral HPV infections, and vaccine efficacy.

The best form of prevention we have from any HPV associated cancers is the 2-dose HPV vaccination series recommended for all 11 and 12 year olds. I’ve had my HPV vaccination series and hope all Oregon children have the opportunity to be protected with this vaccine. According to the Centers for Disease Control Prevention, the HPV vaccine could prevent oropharyngeal cancers because of the HPV strains the vaccine contains but studies have not yet been completed to show the HPV vaccine prevents oropharyngeal cancers.

 

References:

HPV-Associated Cancer Trends Among Men by Year. (2017, February 06). Retrieved July 31, 2017, from https://www.cdc.gov/cancer/hpv/statistics/trends/men.htm

HPV-Associated Cancer Trends Among Women by Year. (2017, February 06). Retrieved July 31, 2017, from https://www.cdc.gov/cancer/hpv/statistics/trends/women.htm

Division of Cancer Prevention and Control, Centers for Disease Control and Prevention. (2017, July 17) Retrieved August 24, 2017 from https://www.cdc.gov/cancer/hpv/basic_info/hpv_oropharyngeal.htm

 

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Jacie Zahler: A Champion for Children

Jacie Zahler has a vision.

In this vision, her community is healthy, empowered and – of utmost importance –fully vaccinated.

“I believe immunizations are a very important component of community health,” said Zahler, a quality care specialist from Klamath Health Partnership/Open Door. “There is so much to know and understand about vaccines. I’m intrigued to learn as much as I can, and share that information with as many people as possible.”

Zahler, a 35-year-old mother of four, is a champion for immunizations, and the CDC has confirmed just that. She was named the Oregon recipient of a CDC Childhood Immunization Champion Award, an annual award presented by both the CDC Foundation and CDC to honor people who improve public health through their work in childhood immunization.  Just one CDC Immunization Champion can be named from each of the 50 states, eight U.S. Territories and Freely Associated States, and the District of Columbia, each year. The award recipients were announced during National Infant Immunization Week, April 22-29, 2017.

Zahler believes vaccine hesitancy can be greatly reduced with knowledge, and has found that educating providers about recommendations and schedules helps them to feel more prepared to have those discussions with patients and guardians.

Listening to patients’ and guardians’ concerns is also of paramount importance, and being able to provide the answers to their questions can put them more at ease. She also believes in engaging vaccinating staff, “so that they aren’t just providing the vaccines, but truly understand why they are given, and have that ownership in protecting our patients,” she said.

“I am just a small link in the chain, but if enough links join together to do this work, it can make a huge impact.”

Jacie Photo

A closer look

You’ve said that time is one of your greatest challenges. Why is that?

I am constantly making “to do” lists with projects that I want to tackle. I want to do more community outreach, mobile vaccine clinics, school vaccine clinics, tons of reminder/recall projects, etc., however, I am only one person, and there is only so much time in the day. I have to focus on the current projects, and give them 100 percent, so they are successful, before I can say yes to another one. I just want to say yes to everything, and do it all, but I obviously cannot do that.

Why do you believe immunizations are such an important cause to champion?

Immunizations can be such a controversial topic. Social media, the internet, the news, technology, can definitely make it worse. So many of us see those “vaccines killed my child,” “vaccines caused this or that” – type articles or testimonies. No, vaccines are not perfect, but we are still not that far away from a time where vaccine-preventable diseases were all over the place. I think it is important for our immunization champions to spread the knowledge that they have, to encourage informed communities that can then make educated decisions about vaccination.

What do you like to do when you are not working? Any travel plans?

I love spending time with my children and husband. We are waiting for warmer weather. We enjoy camping, fishing and hunting. I also recently started working as an Independent Beauty Consultant for Mary Kay, so I can earn extra money to go back to school. As if my life is not busy and full enough already. I’m hoping to enroll in OIT for Population Health Management.

Is there anything else you can tell us about your work, or your life in general?

I am just thankful to God for all the blessings in my life. This award wouldn’t even be possible without all the great people I work with. The schedulers who get everyone in. The providers that educate about vaccines. The vaccinating staff that give so many vaccines. The panel managers that scrub the schedules. The administration of Klamath Health Partnership who see my vision, and truly believe in it, and support it. Everyone at Oregon Immunization Program, Erin has helped me learn how to run so many reports, and work in the most efficient way. Rex and Mimi for allowing us to be a delegate of our health department. I have a great team.

 

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Nurses Essential in Easing Parental Concerns about Vaccination

Parents consider health care professionals one of the most trusted sources in answering questions and addressing concerns about their child’s health. A recent survey on parents’ attitudes, knowledge, and behaviors regarding vaccines for young children — including vaccine safety and trust — found that 82% of parents cited their child’s health care professional as one of their top 3 trusted sources of vaccine information. With so many parents relying on the advice of health care professionals about vaccines, a nurse’s recommendation plays a key role in guiding parents’ vaccination decisions.

My daughter isn't afraid to pay a visit here

“A nurse’s expertise, knowledge, and advice are vital in creating a safe and trusted environment for discussing childhood immunizations,” said Dr. Nancy Messonnier, CDC’s Director of the National Center for Immunization and Respiratory Diseases. “How you communicate with parents during routine pediatric visits is critical for fostering parental confidence in the decision to vaccinate their children.”

The survey also found that 71 percent of parents were confident or very confident in the safety of routine childhood immunizations, although parents’ most common question is what side effects they should look for after vaccination. Twenty-five percent are concerned that children get too many vaccines in one doctor’s visit and 16 percent of survey participants are concerned that vaccines may cause autism.

“Reinforcing vaccine safety messages can go a long way towards assuring parents that they are doing the best thing for their children,” says Patsy Stinchfield, a Pediatric Nurse Practitioner who represents the National Association of Pediatric Nurse Practitioners. “One of the best ways you can establish trust with parents is by asking open-ended questions to help identify and address concerns they may have about vaccines. Also, restate their questions and acknowledge concerns with empathy.”

Make sure to address questions or concerns by tailoring responses to the level of detail the parent is looking for. Some parents may be prepared for a fairly high level of detail about vaccines how they work and the diseases they prevent while others may be overwhelmed by too much science and may respond better to a personal example of a patient you’ve seen with a vaccine-preventable disease. A strong recommendation from you as a nurse can also make parents feel comfortable with their decision to vaccinate.

For all parents, it’s important to address the risks of the diseases that vaccines prevent. It’s also imperative to acknowledge the risks associated with vaccines. Parents are seeking balanced information. Never state that vaccines are risk-free and always discuss the known side effects caused by vaccines.

If a parent chooses not to vaccinate, keep the lines of communication open and revisit their decision at a future visit. Make sure parents are aware of the risks and responsibilities they need to take on, such as informing schools and child care facilities that their child is not immunized, and being careful to stay aware of any disease outbreaks that occur in their communities. If you build a trusting relationship over time with parents, they may reconsider their vaccination decision.

To help communicate about vaccine-preventable diseases, vaccines, and vaccine safety, the Centers for Disease Control and Prevention (CDC), the American Academy of Family Physicians (AAFP), and the American Academy of Pediatrics (AAP) have partnered to develop Provider Resources for Vaccine Conversations with Parents. These materials include vaccine safety information, fact sheets on vaccines and vaccine-preventable diseases, and strategies for successful vaccine conversations with parents. They are free and available online.

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