Category Archives: Education

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 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).


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.


  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)

Accessed 17 April 2018

  1. Immunization Action Coalition. Available at Slide 17, 19.  Accessed 17 April 2018


Comments Off on Minimum Ages & Intervals Clarified

Filed under All Posts, Education, Oregon Immunization, pharmacy

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



Comments Off on Raising HPV Vaccination Rates: What Works?

Filed under AFIX, Education, Oregon Immunization, Private Clinics, Public Clinics

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


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



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.



HPV-Associated Cancer Trends Among Men by Year. (2017, February 06). Retrieved July 31, 2017, from

HPV-Associated Cancer Trends Among Women by Year. (2017, February 06). Retrieved July 31, 2017, from

Division of Cancer Prevention and Control, Centers for Disease Control and Prevention. (2017, July 17) Retrieved August 24, 2017 from


Comments Off on The Challenge of Oral HPV: Little did I know…

Filed under Education, Oregon Immunization

Pharmacists Impact on Immunization

Quynh Tran, Pharm.D Candidate 2016

Pacific University School of Pharmacy

The role of pharmacists has come a long way from the classical “lick, stick, and pour” dispensary role (that is, “lick and stick the label, count and pour the pills”) and is experiencing significant growth and development. With the expansion in the scope of practice, community pharmacists are able to take on a stronger role in support of public health to improve vaccination rates and reduce the burden of vaccine preventable diseases. According to the American Pharmacist Association, three proposed roles that pharmacists can play in improving immunization rates include acting as immunization advocates, acting as facilitators and hosting other health care professionals to provide immunizations to the public, and lastly, taking on active roles as immunizers.

Pharmacists in all states are permitted to administer vaccinations, and the role of pharmacists in adult immunizations has increased significantly over the past few years. In 2011, Oregon pharmacy law allowed pharmacists to immunize adolescents down to age 11, and then in January of 2015, the law further lowered the age to 7. With less than half of adolescents receiving their yearly influenza vaccination, this change in pharmacy law can help more children get vaccinated and provide better access to immunizations.

The Oregon Immunization Program evaluated the impact of this change in the Oregon pharmacy law by using data from the Oregon ALERT Immunization Information System (IIS) limited to Clackamas, Marion, Multnomah, Polk, Washington and Yamhill Counties. The program compared influenza immunization rates before 2011 (2001 – 2010) and after the law was passed in 2011 (2011 -2014), between adolescents aged 11 -17 and those aged 7 – 10. Results revealed that between 2007 and 2014, adolescent influenza immunizations at community pharmacies increased from 36 to 6,372, with the largest increase happening after the law change, from 262 in 2010 to 2,083 in 2011. This evaluation demonstrated that expanding the scope of the pharmacist in immunizing adolescents can provide better accessibility to an adolescent population who may otherwise be unlikely to receive immunizations at clinics. This in turn can substantially help increase adolescent influenza immunization rates.


  1. Robison, Steve G. (2016). Impact of Immunizing Pharmacists on Adolescent Influenza Immunizations. Manuscript submitted for publication.
  2. Rothholz, Mitchel C. (2013). Role of community pharmacies/pharmacists in vaccine delivery in the United States [PowerPoint slides]. Retrieved from


Comments Off on Pharmacists Impact on Immunization

Filed under ALERT IIS, DataPokes, Education, Flu, Oregon Immunization, Research, School Law, VFC

Why We Care About HPV

By Isabel Stock, Colorado State University

Oregon Immunization Program Intern

The idea immunizing your child to prevent a sexually transmitted infection may seem foreign to many parents. People across the world have different views regarding vaccination, but all can agree on cancer prevention. It is our duty as public health advocators, medical professionals and community stakeholders to promote the importance of the HPV vaccination. Here are some astounding numbers to show the impact Human Papilloma Virus has compared to other diseases that we commonly vaccinate children for:

  • 1,904 polio deaths in the U.S. in 1950 (near the height of the epidemic)
  • 450 measles deaths every year in the U.S. before the vaccine
  • 500 tetanus deaths every year before widespread use of the vaccine in the U.S.
  • 100 chickenpox deaths every year in the U.S. before introduction of the vaccine
  • 4,000 HPV-related cervical cancer deaths in the U.S. every year

With 12,000 women being diagnosed every year with cervical cancer, it’s noteworthy that 1 in 3 of them do not survive for five years, especially when the HPV vaccination and screening can prevent up to 93% of these cancers. Other than the cervix, HPV is associated with cancer of the anus, vulva, vagina, oropharynx and cervix in women and HPV related cancers in men are found in the anus, oropharynx and penis.

With 79 million people in the U.S. currently infected with HPV, 14 million new infections every year, the National Cancer Institute has released a Call to Action. In the U.S. 40% of females and 21% of males are receiving all three doses of the HPV vaccine. In Oregon, 36.4% of females and 20.6% of males are receiving all three doses of the HPV vaccine. It is clear that the U.S. will fail to meet the Healthy People 2020 goal of 80% HPV vaccination rate for all three doses. We are faced with a significant public health threat if we don’t take immediate action to improving our vaccination rates.

Here are the best ways to begin improving HPV rates in your clinic today:

  • Know how to frame your conversation regarding HPV with parents and provide them with educational resources
  • Start the vaccine on time; schedule wellness visits at age 11 and 12
  • Schedule follow-up visits before they leave the office
  • Practice reminder/recall for 2nd and 3rd doses
  • Provide walk-in or immunization only visits
  • Immunize at sports physicals

For more information on how to implement these actions, go to:
HPV kids


Comments Off on Why We Care About HPV

Filed under Education, Nurses Notes, Oregon Immunization, Private Clinics, Public Clinics, Research, School Law, Social Media, VFC

Framing the HPV Conversation

By Isabel Stock, Colorado State University

Oregon Immunization Program Intern

Many parents who choose to vaccinate their children are faced with the worry, “Do I vaccinate my child for Human papillomavirus?” According to the 2012 National Teen Immunization Survey, one of the main reason parents that didn’t intend to vaccinate their children against HPV was a lack of healthcare provider recommendation. It’s time to frame the conversation between parents and providers on the importance of the HPV vaccination.

As a provider, it is important to recommend HPV vaccine as you would any other, especially on the same visit as other vaccinations. Here is a list of other important factors to highlight when discussing the HPV vaccine with parents:

  • It is one of the only vaccines available to prevent cancer.
  • HPV infection can be passed through any type of sexual activity, not just intercourse. Some types of HPV are spread by skin-to-skin contact.
  • Multiple research studies have shown that HPV vaccine does not make kids more likely to be sexually active.
  • HPV vaccine has a strong safety record. More than 62 million doses have been given in the United States, and there are no serious safety concerns.
  • Put HPV first when listing the vaccines that the child needs during the visit. For example, “Your child needs three shots today: HPV vaccine, meningococcal vaccine and Tdap vaccine.”
  • Vaccinate for HPV well before children might be exposed to it, just as you would for other diseases such as measles.
  • Emphasize your personal belief in the HPV vaccine, and let them know that you have given it to your son/daughter/family member/friend. This is a powerful tool to help parents feel more secure about their decision

All of these tips will help educate the parent to make a decision and avoid missed opportunities to increase HPV vaccination rates. There are many more resources available to frame the conversation between providers and parents on the CDC website. Below is a great resource for providers to start.

         HPV Tips FINAL

When talking with vaccine hesitant parents, it is helpful to use a communication approach that guides rather than directs and encourages the parent to ask questions. Engaging with good communication strategies allows parents to come to a decision on their own, using evidence based facts delivered by the provider. This technique has been shown to help families and providers address concerns in a way that allows the provider to convey respect and empathy while sharing medical information. For more information on effective communication strategies see,

To help parents understand just how safe, effective, and necessary this vaccine is for their children check out the National Cancer Institute’s recent Call to Action at, Now, more than ever, it is important we give parents all the necessary facts about HPV vaccination to give their child the best possible chance to live a cancer free life.



Comments Off on Framing the HPV Conversation

Filed under Education, Oregon Immunization, Private Clinics, Public Clinics, Research, School Law, Social Media, VFC

We Can Prevent Cervical Cancer

By Katherine McGuiness, MPH, MSW

ScreenWise Engagement and Eligibility Coordinator, Oregon Health Authority

January is Cervical Health Awareness month, which is a great time to reflect on the fact that most cases of cervical cancer are preventable.  The two main ways we have of preventing cervical cancer are through the HPV (human papillomavirus) vaccine and cervical cancer screenings like pap smears and HPV co-testing and subsequent treatment.


HPV Vaccine

The new Gardasil vaccine protects against the 9 of the most common HPV strains, many of which are found in a variety of cancers, including 90% of cervical cancers. The vaccine can be given between the ages of 9 and 26, with a preference of getting it earlier than later in age. Getting the HPV vaccine early is one of the best ways to prevent cervical cancer.

Cervical Cancer Screenings

Pap tests and HPV tests are screening tests that help prevent cervical cancer, or find it early. The HPV test looks for the virus that causes most cervical cancers. Currently, the HPV test is recommended for those over 30. The Pap test looks for precancers- like changes in cells on the cervix that can turn into cancer if they are not treated. National guidelines suggest that pap testing is recommended for people aged 21-65 with a cervix.

For people who have insurance, most insurance plans cover the cost of cervical cancer screenings. For those that do not have insurance, Oregon’s ScreenWise Program may be able to cover the cost. ScreenWise covers the cost of breast and cervical cancer screenings for people who live in Oregon, are uninsured, and meet certain income criteria. There are ScreenWise clinics all over the Oregon. To find out more about eligibility and clinic locations, call 1-877-255-7070.

Are you interested in having your clinic provide ScreenWise services?

Contact Katherine McGuiness at (971)673-0343 or


Comments Off on We Can Prevent Cervical Cancer

Filed under Education, Oregon Immunization, Private Clinics, Public Clinics