(content current as of May ??)

Volume 23 – Number 4 November 2013

NEEDLE TIPS (content current

as of November 15)

from the Immunization Action Coalition — www.immunize.org

What’s In This Issue

Ask the ExpertsIAC extends thanks to our experts, medical officer Andrew T. Kroger, MD, MPH; nurse educator Donna L. Weaver, RN, MN; and medical officer Iyabode Akinsanya-Beysolow, MD, MPH. All are with the National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention (CDC).

Immunization questions?• CalltheCDC-INFOContactCenterat

(800)232-4636or(800)CDC-INFO• Emailnipinfo@cdc.gov• Callyourstatehealthdept.(phonenumbers

atwww.immunize.org/coordinators)

Don’t Just “Offer” HPV Vaccine to Parents for Preteens. Recommend It .............................. 1Ask the Experts: CDC answers questions ......... 1IAC Connects with the Public ............................ 2Vaccine Highlights: Recommendations, schedules, and more ........................................ 4Tips for talking with parents about HPV ............ 6Parent’s guide to preteen and teen HPV vaccination ......................................................... 7Checklist for safe vaccine storage & handling ... 8Do You Qualify for the Hepatitis B Birth Dose Honor Roll? If so, apply today ............................ 9First do no harm: HCP flu vaccination policies ... 10Screening for flu vaccine contraindications ....... 12Standing orders for administering flu vaccine .... 13How many doses of flu vaccine for kids? .......... 14Influenza vaccination and egg allergy… ............ 15Seek emergency medical care if ....................... 16Don’t take chances with your family’s health ..... 17Influenza Vaccine Products for 2013–2014 ...... 18Influenza educational materials ........................ 19Patient-friendly adult immunization schedules ... 20IAC’s Immunization Resources Order Form ...... 22

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General vaccine questionsWhat are the ACIP recommendations for vaccination of preterm infants? Preterminfantsshouldbevaccinatedatthesamechronological age and according to the samescheduleasfull-terminfants,regardlessofbirthweight, with the exception of the birth dose ofhepatitis B vaccine. Infants weighing less than2 kg (4.4 lb) whose mothers’ HBsAg status iseitherpositiveorunknownshouldreceiveHBIG(hepatitis B immune globulin) and hepatitis Bvaccine within 12 hours of birth. This dose ofhepatitis B vaccine should not be counted as avalidfirstdoseintheseries,anditshouldbere-peatedatage1–2months.Ifthepreterminfant’smother’sHBsAg status is negative, the infant’sfirstdoseofhepatitisBvaccineshouldbewith-helduntiltheinfantischronologically1monthofageorisreadytobedischargedfromthehospital,whicheveroccursfirst.Forcompletedetails,seetheVaccinationofPretermInfantssection(pages25–26)oftheACIPGeneral Recommendations on

Ask the Experts . . . continued on p. 5

Don’t Just “Offer” HPV Vaccine to Parents for Preteens. Recommend It!

FEDERAL and

MILITARY

EMPLOYEES

Makethe

Immunization Action CoalitionyourcharityofchoicefortheCombinedFederalCampaign.

Useagencycode

TheImmunizationActionCoalitionisa501(c)(3)charitableorganization

andyourcontributionistax-deductibletothefullestextentofthelaw.

#10612

Let’sstartwiththegoodnews.Sincehumanpap-illomavirus(HPV)vaccinewaslicensedforuseintheU.S.in2006,vaccine-typeHPVprevalencehasdeclined56%amongfemales14–19yearsofage.Nowforthebadnews.AccordingtoCDC’smost recent National Immunization Survey forteens,HPVvaccinationratesdidnotincreaseatallfrom2011to2012in13-to17-year-oldgirls.Only half of these teens received the first doseof this anticancer vaccine, and only one-thirdreceivedthefull3-doseseries.Tdapandmenin-gococcalvaccineswereaddedtothevaccinationschedule for preteens at about the same time;theircoverageratesarequitehigh,85%and74%,respectively. These survey results demonstratethat we are missing opportunities to vaccinatepreteensforHPV.Weneedtodobetter.

Research consistently shows that a provider’srecommendation tovaccinate is the singlemostinfluential factor in convincing parents to vac-cinate their children. Here are some importantpointstorememberandstatementsyoucanmaketoparentswhenrecommendingHPVvaccine:

•Ratherthanaskingaparent if they’reinterest-edingettingHPVvaccinefortheirchild,say:“HPVvaccineisveryimportantbecauseitpre-vents cancer. That’s why I’m recommending

thatyourdaughter/sonreceivethefirstdoseofHPVvaccinetoday.”

•You can say: “HPV can cause cancers of thecervix,vagina,andvulvainwomen,cancerofthepenis inmen,andcancersof theanusandthemouthorthroatinbothmenandwomen.”

•Youcansay:“We’revaccinatingtodaysoyourchildwillhavethebestprotectionpossible,wellbeforetheygetexposedtoHPV.”

•Youcansay:“Istronglybelieveintheimpor-tance of this cancer-preventing vaccine, and Ihave given HPV vaccine to my son/daughter/grandchild/niece/nephew/friend’schildren.Ex-perts(liketheAAP,AAFP,ACOG,cancerdoc-tors, andCDC) also agree that this vaccine isveryimportantforyourchild.”

Your approach to discussing HPV vaccinationwith a parent strongly influences whether theyhave their childvaccinated.Whenyouaskpar-ents if they’d like to vaccinate their child, vac-cineacceptancedropssignificantly.Your strong recommendation is what is needed to protect our nation’s children from HPV.

See page 6 for more sample scripts from CDCabout how to recommend HPV vaccine, andpage7forIAC’snewHPVhandoutforparents.

NEEDLE TIPS •November2013•ImmunizationActionCoalition•(651)647-9009•www.immunize.org•www.vaccineinformation.org 5

Check the dates on your supply of VaccineInformation Statements (VISs). If any areoutdated,getcurrentversionsandVISsinmorethan30languagesatwww.immunize.org/vis.

New and updated VISs

Multi-vaccine VIS (for 6 vaccines given to infants/children: DTaP, IPV, Hib, HepB, PCV, RV)

11/16/12 ...

DTaP/DT/DTP .... 5/17/07Hepatitis A ..... 10/25/11Hepatitis B ........ 2/2/12Hib ................ 12/16/98HPV (Cervarix) ..... 5/3/11HPV (Gardasil) ....5/17/13Influenza (LAIV) ...7/26/13Influenza (TIV) ....7/26/13Japan. enceph. .12/7/11Meningococcal .10/14/11MMR ................4/20/12

MMRV ..............5/21/10PCV13 ...............2/27/13PPSV ............... 10/6/09Polio ................ 11/8/11Rabies ............. 10/6/09Rotavirus .......... 8/26/13Shingles ........... 10/6/09Td/Tdap ........... 1/24/12Tdap .................. 5/9/13Typhoid ............ 5/29/12Varicella .......... 3/13/08Yellow fever .... 3/30/11

For a ready-to-print version of this table for posting in your practice, go to www.immunize.org/catg.d/p2029.pdf.

Ask the Experts . . . continued from page 1Immunization,availableatwww.cdc.gov/mmwr/pdf/rr/rr6002.pdf.

We plan to keep our influenza vaccine in coolers when we travel to off-site vaccina-tion events. How can we ensure the vaccine remains within the proper temperature range? CDC does not recommend keeping vaccinesin transport containers unless they are portablerefrigeratororfreezerunits. Ifvaccinesmustbekeptintransportcontainersduringoff-siteclinics:•Thecontainersshouldremainclosedasmuchas

possible.•Onlytheamountofvaccineneededatonetime

shouldberemovedforpreparationandadminis-tration.

•Acalibratedthermometer(preferablywithabio-safeglycol-encasedthermometerprobe)shouldbe placed as close as possible to the vaccineswithinthecontainer.

•Thetemperatureinsidethecontainershouldbereadanddocumentedatleasthourly.

Ifyouhaveconcernsthatvaccinesordiluentsmayhavebeencompromised(exposedtoinappropriateconditions/temperatures or handled improperly),labelthem“DONOTUSE”andstorethemunderappropriate conditions separated from other

vaccinesupplies.Thencontactyourimmunizationprogramand/orvaccinemanufacturerforguidance.Do not discard the vaccines or diluents unlessdirectedtobyyourimmunizationprogramand/orthemanufacturer.Formoreinformation,see theTransportingVaccineinanEmergencyortoOff-SiteFacilitiessectiononpages91–96ofCDC’sVaccine Storage and Handling Toolkit atwww.cdc.gov/vaccines/recs/storage/toolkit/storage-handling-toolkit.pdf. Additional information isavailableonIAC’sVaccineStorageandHandlingwebsiteatwww.immunize.org/handouts/vaccine-storage-handling.asp.

Influenza vaccineWe inadvertently administered a 0.5 mL dose of FluLaval (GSK) to a 2-year-old child before realizing that the vaccine is only licensed for use in people age 3 years and older. Do we need to repeat the dose with an age-appropri-ate product?No,thedosedoesnotneedtoberepeated.How-ever,twoerrorsactuallyoccurredhere.Inadditiontotheagediscrepancy,thechildalsoreceiveda0.5mLdoseofvaccinerather than thecorrectdose(0.25mL) for thechild’sage.Cliniciansshouldcarefullyselectaninfluenzavaccinethatislicensedfortheagegroupofthepersonbeingvaccinated.Fluzone0.25mL(sanofi)istheonlyinactivatedinfluenzavaccineapprovedforuseinchildrenage6monthsthroughtwoyears.Theliveattenuatednasalsprayvaccine(LAIV,FluMist,MedImmune)isapprovedforuseinmosthealthychildrenage2yearsandolder(aswellasforhealthynonpregnantadultsthroughage49years).

Ifthechildshouldneedaseconddoseofinflu-enzavaccine,anage-appropriatevaccineshouldbeselected.

The Immunization Action Coalition’s educa-tionalpiece“InfluenzaVaccineProductsforthe2013–2014InfluenzaSeason”(availableatwww.immunize.org/catg.d/p4072.pdf)provideshelpfulinformationonthewidevarietyofinfluenzavac-cinesinusethisseason.

We inadvertently administered intradermal influenza vaccine (Fluzone ID, sanofi) to a patient who is not in the recommended age range of 18 through 64 years. What should we do now? Becausepeopleyoungerthanage9yearsorolderthan65yearsaremorelikelytohaveskinthatistoothinforproperintradermaladministration,adosegiventoapersonintheseagerangesshouldbeconsideredinvalid,andthepatientshouldberevaccinated.Forpeopleage9through17years,thedoseisconsideredvalidanddoesnothavetoberepeatediftheclinicianiscertainthatthedosewasadministeredintradermallyratherthansubcutane-ously.Ifthereisanydoubtaboutwhetherthedosewasinjectedintradermally,itshouldberepeated.

Is it acceptable to administer a dose of the quadrivalent influenza vaccine to a patient

Vaccine Highlights . . . continued from page 4

Visit IAC’s newly designed website for parents, adults, and teens,

“Vaccine Information You Need” www.vaccineinformation.org

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Ask the Experts . . . continued on p. 21

for certain high-risk children: MenHibrix (Hib-MenCY,GSK)forchildren6weeks through18months of age, Menveo for children 2 monthsand older, and Menactra (MCV4-D, sanofi) forchildren9monthsandolder.

IntheNovemberissueofthejournalPediatrics, the American Academy of Pediatrics (AAP)endorsed ACIP’s recommendations formeningococcal vaccination of children andadults. See http://pediatrics.aappublications.org/content/132/5/e1463.full. The publicationPrevention and Control of Meningococcal Disease: Recommendations of ACIPisavailableatwww.cdc.gov/mmwr/pdf/rr/rr6202.pdf.

Measles newsIntheSeptember13issueofMMWR,CDCpub-lished three reportsonmeaslesoutbreaks in theUnitedStates:•“Measles—U.S., January1–August24,2013,”

available at www.cdc.gov/mmwr/preview/mmwrhtml/mm6236a2.htm;

Needle Tips correction policyIfyoufindanerror,pleasenotifyusimmediatelybysendinganemailmessagetoadmin@immunize.org.Wepublishnotificationof significanterrors inouremailannouncementservice,IAC Express.Besureyou’resignedupforthisservice.Tosubscribe,visitwww.immunize.org/subscribe.

•“Notes from the Field: Measles OutbreakAmongMembersofaReligiousCommunity—Brooklyn, New York, March–June 2013” atwww.cdc.gov/mmwr/preview/mmwrhtml/mm6236a5.htm;and

•“Notes from the Field: Measles Outbreak As-sociatedwithaTravelerReturningfromIndia—NorthCarolina,April–May2013”atwww.cdc.gov/mmwr/preview/mmwrhtml/mm6236a6.htm.

J. encephalitis vaccine newsOnNovember15,CDCpublished“UseofJapa-nese Encephalitis Vaccine in Children: Recom-mendations of the Advisory Committee on Im-munization Practices, 2013.” In May 2013, theFoodandDrugAdministrationapprovedIntercellBiomedical’s license application to extend theagerangeofitsinactivatedJapaneseencephalitisvaccine (IXIARO) fromage17yearsandoldertoage2monthsandolder.ThisACIPstatementcanbeaccessedatwww.cdc.gov/mmwr/pdf/wk/mm6245.pdf,pages898–900.

NEEDLE TIPS •November2013•ImmunizationActionCoalition•(651)647-9009•www.immunize.org•www.vaccineinformation.org 21

Andrew T. Kroger, MD, MPH Donna L. Weaver, RN, MN Iyabode Akinsanya-Beysolow, MD, MPH

IAC’s“Ask theExperts”

teamfromCDC

who has already received the trivalent vac-cine? We’ve had a few patients request this.No.ACIPdoesnotrecommendthatanyonereceivemorethanonedoseofinfluenzavaccineinaseason,exceptforcertainchildrenage6monthsthrough8yearsforwhomtwodosesarerecommended.

Sometimes patients age 65 years and older who have received the standard-dose influ-enza vaccine hear about the high-dose prod-uct (Fluzone High-Dose, sanofi) and want to receive that, too. Is this okay to administer?No.ACIPdoesnotrecommendthatanyonereceivemorethanonedoseofinfluenzavaccineinaseasonexceptforcertainchildrenage6monthsthrough8yearsforwhomtwodosesarerecommended.

Would giving an older patient 2 doses of standard-dose influenza vaccine be the same as administering the high-dose product?No,andthisisnotrecommended.

How soon after bone marrow transplant do we start to vaccinate our patients against influenza?Inactivated influenza vaccine should be admin-istered beginning at least 6 months after bonemarrowtransplantandannuallythereafterforthelifeofthepatient.Adoseofinactivatedinfluenzavaccinecanbegivenasearlyas4monthsaftertransplant,butaseconddoseshouldbeconsideredinthissituation.Aseconddoseisrecommendedroutinelyforallchildrenreceivinginfluenzavac-cineforthefirsttime.

Formoreinformationaboutvaccinationofpeo-plewhoreceivehematopoieticstemcelltransplan-tation, visit this CDC web page: www.cdc.gov/vaccines/pubs/hemato-cell-transplts.htm.

Tdap and Td vaccinesWhen should adolescents who received a dose of Tdap (tetanus-diphtheria, pertussis-containing vaccine; Adacel, sanofi; Boostrix, GSK) at age 11–12 years receive their next dose of Td or Tdap?Currently, ACIP recommends only one lifetimedoseofTdapforeveryonewiththeexceptionofpregnantwomenforwhomadoseisrecommendedduring each pregnancy. Someone who received

Ask the Experts . . . continued from page 5

adoseofTdapatage11or12shouldreceiveaboosterdoseofTdvaccinetenyearslater,unlesstetanusprophylaxis isrequiredsoonerduetoaninjury.

Meningococcal vaccinePlease describe the new Advisory Committee on Immunization Practices (ACIP) vote recom-mending the use of the meningococcal vac-cine Menveo in high-risk children 2 through 23 months of age.OnOctober23,theACIPvotedtorecommendtheuseofMenveo(MCV4-CRM,Novartis)inhigh-riskchildren2through23monthsofage.Previ-ously, theFDAhadlicensedtheuseofMenveoinchildren2yearsofageorolder,buttheagencyexpanded licensure to the 2 through 23 monthsage group on August 1. Three meningococcalconjugatevaccinesarenowapprovedandrecom-mendedforcertainhigh-riskchildren:MenHibrix(Hib-MenCY,GSK)forchildren6weeksthrough18monthsofage,Menveoforchildren2monthsand older, and Menactra (MCV4-D, sanofi) forchildren9monthsandolder.

Why is it recommended to delay meningococ-cal vaccination for infants with functional or anatomic asplenia until after the PCV13 (pneu-mococcal conjugate vaccine, Prevnar, Pfizer) series is completed? Although people with anatomic or functionalasplenia also appear to be at increased risk formeningococcaldisease,thedataarelesscompel-lingthandatathatdemonstratetheincreasedrisk

forpneumococcaldiseaseinpatientswithasplenia(seepage6ofPrevention and Control of Meningo-coccal Disease: Recommendations of the Advisory Committee on Immunization Practices [ACIP],www.cdc.gov/mmwr/pdf/rr/rr6202.pdf). DatashowthattheMCV4-Dvaccine(Menactra,sanofi)may interfere with the immunologic response toPCV13 if these twovaccinesaregiven tooclosetogether.Therefore,ACIPrecommendsthatMCV4-Dnotbeadministereduntilatleast4weeksaftercompletion of the age-appropriate PCV13 series.MCV4-CRM(Menveo,Novartis)andHib-MenCY(MenHibrix,GSK)donot affect the immune re-sponsetoPCV13,sothesevaccinesmaybegivenatanytimebeforeorafterPCV13doses.

Polio vaccineWe frequently see children (mostly from certain foreign countries) who have received 6 or more doses of polio vaccine, all admin-istered before age 4 years. How do we handle this when assessing the child’s immunization history? Becauseitiscommonpracticeinmanydevelop-ingcountries toadministeroralpoliovaccinetochildren during both routine visits and periodicnationwidevaccinationcampaigns,achild’srecordmayindicatemorethan4doses.Dependingonthetiming, someof thesedosesmay be invalid ac-cordingtotheU.S.immunizationschedule.Tobecountedasvalid,thedosesshouldallbegivenafterage6weeksandbeseparatedfromeachotherbyatleast4weeks.Ifthehistoryisofacompleteseriesofinactivatedpoliovaccine(IPV)(unlikelygiventhecontext),atleastonedoseshouldbeadminis-teredonorafterage4yearsandatleast6monthsafterthepreviousdose.Ifacompleteseriescannotbeidentifiedthatmeetthesecriteria,thenthechildshouldreceiveasmanydosesofIPVasneededtocompletetheU.S.recommendedschedule.

Pneumococcal poly. vaccinePneumococcal polysaccharide vaccine (PPSV, Pneumovax, Merck) is recommended for people with diabetes. Does this include gestational diabetes?No.

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