Pediatric & Adult Influenza Update 2009-10

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As in the past, MPCA will again present an immunization update on influenza vaccines. Both Seasonal Flu vaccine and H1N1 flu vaccine will be included in this presentation.

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  • Introduce yourself and any guests Thank the clinic for inviting you to present a Pediatric and Adult Influenza Update Review length of the presentation (approximately 1 hour). Encourage questions from the participants. All participants requesting certificates of credit must sign in. 1 contact hours are available for RNs/LPNs. 1 category 1 CME credits are available for physicians and physician’s assistants who complete the evaluation. Medical assistants and other attendees who complete the evaluation will be given a certificate of attendance. An outline of the course is available for MAs seeking certification or registration credentials.
  • Verbally review each bullet on the slide informing the participants of any financial interests you may have with the vaccine manufacturers. This must be done for professional credit purposes and is included on the program evaluation. ____________________________________________________________________ FYI ACIP recommendations are based on research findings, expert opinion and disease surveillance. They may be different from package insert/licensure information which are based on clinical trials .
  • Stress to clinics the importance of rotating stock, keeping only a 1-3 month supply (dependent on tiered ordering frequency or clinical need) and monitoring the expiration date. If publicly funded vaccines can’t be used by the expiration date---inform the LHD and request guidance _____________________________ FYI Why should we care?---Persons will not be protected unless vaccine is properly maintained. Vaccine is not potent and effective without proper storage/handling. FY 08 data: 401 losses due to expiration: 8,125 doses at a cost of $139,497.09 124 losses due to failure to store & handle properly: 24,000 doses at a cost of $620,679.08. Total losses for FY 08:  651 losses, 34,584 doses, total cost of $841,385.39 (Total losses for FY 07: 797 losses, 34,518 doses, total cost of $647,611.13) (Total losses for FY 06: 554 losses, 29,921 doses, total cost $436, 228.38) Vaccines should be stored in a standard household refrigerator/freezer with a separate, sealed freezer compartment and 2 separate temperature controls Vaccines should be received within 48 hours of the shipment date. Varicella, Zoster, and MMRV vaccine should be delivered and transported with dry ice. All other vaccines should be transported in an insulated cooler with cold packs. Place vaccines in refrigerator/freezer as soon as they are received. Do NOT store food in this refrigerator. A similar picture is available in the AIM Kit.
  • A vaccine management plan having these 8 components must be in place for all VFC providers and available for review by the LHD. _____________________________________________________________ FYI Vaccine Management: Storage and Handling module is available for offices that need more information
  • ______________________________________________________ FYI In the United States, annual epidemics of seasonal influenza occur typically during the late fall through early spring. Influenza viruses can cause disease among persons in any age group, but rates of infection are highest among children. Rates of serious illness and death are highest among persons aged > 65 years, children aged <2 years, and persons of any age who have medical conditions that place them at increased risk for complications from influenza. An annual average of approximately 36,000 deaths during 1990–1999 and 226,000 hospitalizations during 1979–2001 have been associated with influenza epidemics. Since 1977, influenza A (H1N1) viruses, influenza A (H3N2) viruses, and influenza B viruses have circulated globally. Influenza A (H1N2) viruses that probably emerged after genetic reassortment between human A (H3N2) and A (H1N1) viruses also have been identified in some influenza seasons. In April 2009, human infections with a novel influenza A (H1N1) virus were identified; as of June 2009, infections with the novel influenza A (H1N1) virus have been reported worldwide. This novel virus is derived partly from influenza A viruses that circulate in swine and is antigenically distinct from human influenza A (H1N1) viruses in circulation since 1977 Prevention and Control of Seasonal Influenza with Vaccines Recommendations of the Advisory Committee on Immunization Practices (ACIP), 2009 MMWR/Vol. 58 July 31, 2009
  • The incubation period for influenza is usually 2 days, with a range of 1 to 4 days. Infected persons can spread influenza starting the day before their symptoms appear and for about 4 or 5 days after symptoms begin. ____________________________________________________________ FYI The incubation period for influenza is usually 2 days, but can vary from 1 to 4 days. The severity of influenza illness depends on the prior immunologic experience with antigenically related virus variants. In general, only about 50% of infected persons will develop the classic clinical symptoms of influenza. “Classic” influenza disease is characterized by the abrupt onset of fever, myalgia, sore throat, nonproductive cough, and headache. The most frequent complication of influenza is pneumonia, most commonly secondary bacterial pneumonia (e.g., Streptococcus pneumoniae , Haemophilus influenzae , or Staphylococcus aureus ). Other complications include myocarditis (inflammation of the heart) and worsening of chronic bronchitis and other chronic pulmonary diseases. Death is reported in 0.5–1 per 1,000 cases. The majority of deaths occur among persons 65 years of age and older. Epidemiology and Prevention of Vaccine Preventable Diseases 11th Edition
  • This is true for both seasonal and H1N1 influenza 3 ° cases include working adults (parents), younger siblings, older family members (grandparents) and other contacts. The community at large includes persons at increased risk of complications, community-dwelling elderly, and social contacts of primary, secondary and tertiary cases. ___________________________________________________ FYI Evidence that influenza has substantial adverse impacts among school age children and their contacts (e.g., increased school absenteeism, antibiotic use, medical care visits, and parental work loss). Evidence that influenza vaccine is effective and safe for school-age children. The expectation that a simple age-based influenza vaccine recommendation will improve current low vaccine coverage levels among the approximately 50% of school-age children who already had a risk-or contact-based indication for annual influenza vaccination The potential for the indirect effect of reducing influenza among persons who have close contact with children, and reducing overall transmission within communities, if sufficient vaccination coverage among children can be achieved. Prevention and Control of Seasonal Influenza with Vaccines Recommendations of the Advisory Committee on Immunization Practices (ACIP), 2009 MMWR/Vol. 58 July 31, 2009
  • Vaccination is recommended for all children aged 6 months through 18 yrs. These are factors for which all patients should be screened during health care encounters. Also anyone wishing to avoid influenza disease may be immunized as vaccines as vaccine supply allows. __________________________________________________________________________ FYI Annual vaccination for all children aged 6 months–18 years is recommended. Annual vaccination of all children aged 6 months–4 years (59 months) and older children with conditions that place them at increased risk for complications from influenza should continue. Children and adolescents at high risk for influenza complications should continue to be a focus of vaccination efforts as providers and programs transition to routinely vaccinating all children. Case reports and limited studies also indicate that pregnancy can increase the risk for serious medical complications of influenza. One study of influenza vaccination of approximately 2,000 pregnant women demonstrated no adverse fetal effects associated with inactivated influenza vaccine; similar results were observed in a study of 252 pregnant women who received inactivated influenza vaccine within 6 months of delivery. No such data exist on the safety of LAIV when administered during pregnancy. Prevention and Control of Seasonal Influenza with Vaccines Recommendations of the Advisory Committee on Immunization Practices (ACIP), 2009 MMWR/Vol. 58 July 31, 2009
  • _____________________________________________________ FYI Vaccination to prevent influenza is particularly important for the following persons, who are at increased risk for severe complications from influenza, or at higher risk for influenza-related outpatient, ED, or hospital visits: all children aged 6 months–4 years (59 months); all persons aged > 50 years; children and adolescents (aged 6 months–18 years) who are receiving long-term aspirin therapy and who might be at risk for experiencing Reye syndrome after influenza virus infection; women who will be pregnant during the influenza season; adults and children who have chronic pulmonary (including asthma) or cardiovascular (except hypertension), renal, hepatic, neurological/neuromuscular, hematologic, or metabolic disorders (including diabetes mellitus); adults and children who have immunosuppression (including immunosuppression caused by medications or by HIV); and residents of nursing homes and other long-term–care facilities. Chronic neurologic and neuromuscular conditions include any condition (e.g., cognitive dysfunction, spinal cord injuries, seizure disorders, or other neuromuscular disorders) that can compromise respiratory function or the handling of respiratory secretions or that can increase the risk for aspiration. Prevention and Control of Seasonal Influenza with Vaccines Recommendations of the Advisory Committee on Immunization Practices (ACIP), 2009 MMWR/Vol. 58 July 31, 2009
  • Children aged less than 6 months cannot receive influenza vaccination. Household and other close contacts (e.g., daycare providers) of children aged less than 6 months, including older children and adolescents, should be vaccinated. Approximately 83% of the United States population is specifically recommended for annual vaccination against seasonal influenza ______________________________________________________________ FYI Children aged <6 months are not recommended for vaccination, and antivirals are not licensed for use among infants. Protection of young infants, who have hospitalization rates similar to those observed among the elderly, depends on vaccination of the infants’ close contacts. A recent study conducted in Bangladesh demonstrated that infants born to vaccinated women have significant protection from laboratory-confirmed influenza, either through transfer of influenza-specific maternal antibodies or by reducing the risk for exposure to influenza that might occur through vaccination of the mother. All household contacts, health-care and day care providers, and other close contacts of young infants should be vaccinated. Prevention and Control of Seasonal Influenza with Vaccines Recommendations of the Advisory Committee on Immunization Practices (ACIP), 2009 MMWR/Vol. 58 July 31, 2009
  • Health care personnel, including office staff should be one of the first groups vaccinated when the vaccine is received. _______________________________________________________ FYI Influenza virus infection and ILI are common among HCP. Influenza outbreaks have been attributed to low vaccination rates among HCP in hospitals and long-term–care facilities. One serosurvey demonstrated that 23% of HCP had serologic evidence of influenza virus infection during a single influenza season; the majority had mild illness or subclinical infection. Observational studies have demonstrated that vaccination of HCP is associated with decreased deaths among nursing home patients. Prevention and Control of Seasonal Influenza with Vaccines Recommendations of the Advisory Committee on Immunization Practices (ACIP), 2009 MMWR/Vol. 58 July 31, 2009
  • Because circulating influenza viruses have the ability to change, the composition of seasonal influenza vaccine usually changes each year. Because of this, it is important to receive influenza vaccine each year. Both inactivated (injectable) and live, attenuated (nasal) seasonal influenza vaccines prepared for the 2009-10 flu season will include these three strains. _____________________________________________________ FYI Antigenic shift is a major change in one or both surface antigens (H or N) that occurs at varying intervals. Antigenic shifts are probably due to genetic recombination (an exchange of a gene segment) between influenza A viruses, usually those that affect humans and birds. An antigenic shift may result in a worldwide pandemic if the virus is efficiently transmitted from person to person. Antigenic drift is a minor change in surface antigens that results from point mutations in a gene segment. Antigenic drift may result in an epidemic, since the protection that remains from past exposures to similar viruses is incomplete. Drift occurs in all three types of influenza virus (A,B,C). Epidemiology and Prevention of Vaccine Preventable Diseases 11th Edition
  • Handouts: “Quick Look at Influenza Vaccines”, and “Influenza Vaccination Pocket Guide” ___________________________________________________________ FYI Vaccination with TIV is recommended for the following persons who are at increased risk for severe complications from influenza, or at higher risk for influenza-associated clinic, emergency department, or hospital visits: • all children aged 6 through 23 months of age; • all persons aged >50 years; • children and adolescents (aged 6 months–18 years) who are receiving long-term aspirin therapy and who therefore might be at risk for experiencing Reye syndrome after influenza virus infection; • women who will be pregnant during the influenza season; • adults and children who have chronic pulmonary (including asthma), cardiovascular (except hypertension), renal, hepatic, hematological or metabolic disorders (including diabetes mellitus); • adults and children who have immunosuppression (including immunosuppression caused by medications or by HIV); • adults and children who have any condition (e.g., cognitive dysfunction, spinal cord injuries, seizure disorders, or other neuromuscular disorders) that can compromise respiratory function or the handling of respiratory secretions or that can increase the risk for aspiration; and • residents of nursing homes and other chronic-care facilities. Prevention and Control of Seasonal Influenza with Vaccines Recommendations of the Advisory Committee on Immunization Practices (ACIP), 2009 MMWR/Vol. 58 July 31, 2009
  • TIV products are licensed for specific age groups. Use the correct product for the patient. TIV formulations in multi-dose vials contain the vaccine preservative thimerosal; preservative-free single dose preparations also are available. Handout: “2009-10 Influenza Dosing Chart” ______________________________________________ FYI
  • _______________________________________________________ FYI No studies regarding the simultaneous administration of inactivated influenza vaccine and other childhood vaccines have been conducted. Inactivated vaccines usually do not interfere with the immune response to other vaccines. Children including those at high-risk and/or aged 6-23 months, can receive inactivated influenza vaccine at the same time they receive other routine vaccinations. Prevention and Control of Seasonal Influenza with Vaccines Recommendations of the Advisory Committee on Immunization Practices (ACIP), 2009 MMWR/Vol. 58 July 31, 2009
  • • For explanation and examples of 2-dose rule, see slide 42 “Who Needs 2 Doses of Flu Vaccine?” _____________________________________________________________ FYI
  • For children needing 2 doses, if possible, give the 2nd dose before December Handouts: “Quick Look at Influenza Vaccines”, “Influenza Pocket Guide” _________________________________________________________________________ FYI All children aged 6 months–8 years who have not received vaccination against influenza previously should receive 2 doses of vaccine the first influenza season that they are vaccinated. The second dose should be administered 4 or more weeks after the initial dose. When only 1 dose is administered to children aged 6 months–8 years during their first year of vaccination, 2 doses should be administered in the following season. However, 2 doses should only be administered in the first season of vaccination, or in the season that immediately follows if only 1 dose is administered in the first season. For example, children aged 6 months–8 years who were vaccinated for the first time with the 2008–09 influenza vaccine but received only 1 dose should receive 2 doses of the 2009–10 influenza vaccine. All other children aged 6 months–8 years who have previously received 1 or more doses of influenza vaccine at any time should receive 1 dose of the 2009–10 influenza vaccine. Children aged 6 months–8 years who received only a single vaccination during a season before 2007–08 should receive 1 dose of the 2009–10 influenza vaccine. If possible, both doses should be administered before onset of influenza season. However, vaccination, including the second dose, is recommended even after influenza virus begins to circulate in a community. Prevention and Control of Seasonal Influenza with Vaccines Recommendations of the Advisory Committee on Immunization Practices (ACIP), 2009 MMWR/Vol. 58 July 31, 2009
  • Review the case examples; determine the number of doses each child should receive with attendees . _______________________________________________________________ FYI 7 year old child who has never received flu vaccine 2 doses of LAIV or TIV . 3 year old child who received his first dose of flu vaccine at age 1 and no other doses 1 dose of TIV or LAIV . 5 year old child who received his first and only dose of flu vaccine at age 4 2 doses of LAIV or TIV. 12 year old getting flu vaccine for the first time 1 dose of TIV or LAIV. 4 year old who received 1 dose of flu vaccine at 1, 2 and 3 years of age 1 dose of TIV or LAIV. 82 year old with severe lung problems 1 dose of TIV
  • Handouts: “Influenza Vaccination Pocket Guide” and “A Quick Look at Influenza Vaccines” ______________________________________________________ FYI LAIV is an option for vaccination of healthy, nonpregnant persons aged 2–49 years, including HCP and other close contacts of high-risk persons (excepting severely immunocompromised persons who require care in a protected environment). No preference is indicated for LAIV or TIV when considering vaccination of healthy, nonpregnant persons aged 2–49 years. Prevention and Control of Seasonal Influenza with Vaccines Recommendations of the Advisory Committee on Immunization Practices (ACIP), 2009 MMWR/Vol. 58 July 31, 2009
  • This is a demonstration of LAIV and is a transition slide into intranasal vaccine administration. ________________________________________________________ FYI
  • Place sprayer tip just inside the nostril prior to depressing plunger for administering vaccine spray If the vaccine recipient sneezes after administration, the dose should not be repeated LAIV is a preservative-free vaccine ______________________________________________________ FYI Possible advantages of LAIV include its potential to induce a broad mucosal and systemic immune response in children, its ease of administration, and the possibly increased acceptability of an intranasal rather than intramuscular route of administration. If the vaccine recipient sneezes after administration, the dose should not be repeated. However, if nasal congestion is present that might impede delivery of the vaccine to the nasopharyngeal mucosa, deferral of administration should be considered until resolution of the illness, or TIV should be administered instead. No data exist about concomitant use of nasal corticosteroids or other intranasal medications. Prevention and Control of Seasonal Influenza with Vaccines Recommendations of the Advisory Committee on Immunization Practices (ACIP), 2009 MMWR/Vol. 58 July 31, 2009
  • ___________________________________ FYI Use of LAIV concurrently with measles, mumps, rubella (MMR) alone and MMR and varicella vaccine among children aged 12–15 months has been studied, and no interference with the immunogenicity to antigens in any of the vaccines was observed. In the absence of specific data indicating interference, following ACIP’s general recommendations for vaccination is prudent. Inactivated vaccines do not interfere with the immune response to other inactivated vaccines or to live vaccines. Inactivated or live vaccines can be administered simultaneously with LAIV. However, after administration of a live vaccine, at least 4 weeks should pass before another live vaccine is administered LAIV can be administered to persons with minor acute illnesses (e.g., diarrhea or mild upper respiratory tract infection with or without fever). However, if nasal congestion is present that might impede delivery of the vaccine to the nasopharyngeal mucosa, deferral of administration should be considered until resolution of the illness. Prevention and Control of Seasonal Influenza with Vaccines Recommendations of the Advisory Committee on Immunization Practices (ACIP), 2009 MMWR/Vol. 58 July 31, 2009
  • Handout: “Influenza Vaccine Dosing Chart” ________________________________________________________________________ FYI The intramuscular route is recommended for TIV. Adults and older children should be vaccinated in the deltoid muscle. A needle length of > 1 inch (>25 mm) should be considered for persons in these age groups because needles of <1 inch might be of insufficient length to penetrate muscle tissue in certain adults and older children . When injecting into the deltoid muscle among children with adequate deltoid muscle mass, a needle length of 7/8–1.25 inches is recommended . Infants and young children should be vaccinated in the anterolateral aspect of the thigh. A needle length of 7/8–1 inch should be used for children aged <12 months. Prevention and Control of Seasonal Influenza with Vaccines Recommendations of the Advisory Committee on Immunization Practices (ACIP), 2009 MMWR/Vol. 58 July 31, 2009 Handout: “Influenza Vaccine Dosing Chart” ___________________________________________________________ FYI
  • A contraindication is a condition in a vaccine recipient that greatly increases the chance of a serious adverse reaction. It is a condition in the person receiving the vaccine, not with the vaccine itself. If the vaccine is given in the presence of a contraindication, the resulting adverse reaction could seriously harm the recipient. _______________________________________________________________ FYI Precautions to flu vaccine include: TIV & LAIV Moderate or severe acute illness History of Guillain-Barre´ Syndrome within 6 wks of a previous influenza vaccination LAIV only Children 2-4 yrs of age with a history of wheezing Less than 2 yrs of age or 50 yrs of age & older Chronic medical conditions Children receiving long term aspirin therapy Pregnancy Immunosuppression from any cause Household/close contacts of severely immunosuppressed persons requiring a protective environment Prevention and Control of Seasonal Influenza with Vaccines Recommendations of the Advisory Committee on Immunization Practices (ACIP), 2009 MMWR/Vol. 58 July 31, 2009
  • HCPs who receive LAIV should refrain from contact with severely immunosuppressed patients in protective isolation for 7 days post vaccination. Persons with a high risk condition may administer LAIV. This includes pregnant women, persons with asthma or persons over 50 years of age. HCP who are severely immunosuppressed should not administer LAIV. _______________________________________________________ FYI Healthy persons who are infected with influenza virus, including those with sub clinical infection, can transmit influenza virus to persons at higher risk for complications from influenza. Healthy HCP and persons aged 2–49 years who are contacts of persons in these groups and who are not contacts of severely immunosuppressed persons (see Close Contacts of Immunocompromised Persons) should receive either LAIV or TIV when indicated or requested. All other persons, including pregnant women, should receive TIV. All HCP, as well as those in training for health-care professions, should be vaccinated annually against influenza. Close contacts of immunocompromised persons, including HCP, should be vaccinated to reduce the risk for influenza transmission. TIV is preferred for vaccinating household members, HCP, and others who have close contact with severely immunosuppressed persons (e.g., patients with hematopoietic stem cell transplants) during those periods in which the immunosuppressed person requires care in a protective environment (typically defined as a specialized patient-care area with a positive airflow relative to the corridor, high-efficiency particulate air filtration, and frequent air changes). Prevention and Control of Seasonal Influenza with Vaccines Recommendations of the Advisory Committee on Immunization Practices (ACIP), 2009 MMWR/Vol. 58 July 31, 2009
  • Review the case examples; determine which vaccine each should be administered for each case scenario with attendees _________________________________________________________ FYI A healthy, non-pregnant 42-year-old nurse who does not care for persons who are severely immunosuppressed- those requiring a protective environment LAIV or TIV LAIV may be given to eligible HCP who do not care for persons who are severely immunosuppressed- those requiring a protective environment A healthy 5 year old girl with a 3 month old brother TIV or LAIV A 55 year old woman who has not specifically asked to receive influenza vaccine TIV (LAIV cannot be given to persons 50 years of age and older) A 5 month old boy with asthma NONE He is too young to be vaccinated. Vaccinate his family members and close contacts. A 20 year old man who has severe cardiopulmonary disease and resides in a chronic-care facility TIV (LAIV may not be given to persons with high risk conditions)
  • ________________________________________________________ FYI In general, health-care providers should begin offering vaccination soon after vaccine becomes available and if possible by October. To avoid missed opportunities for vaccination, providers should offer vaccination during routine health-care visits or during hospitalizations whenever vaccine is available. The potential for addition of a novel influenza A (H1N1) vaccine program to the current burden on vaccination programs and providers underscores the need for careful planning of seasonal vaccination programs. Beginning use of seasonal vaccine as soon as available, including in September or earlier, might reduce the overlap of seasonal and novel influenza vaccination efforts. Vaccination efforts should continue throughout the season, because the duration of the influenza season varies, and influenza might not appear in certain communities until February or March. Providers should offer influenza vaccine routinely, and organized vaccination campaigns should continue throughout the influenza season, including after influenza activity has begun in the community. Vaccine administered in December or later, even if influenza activity has already begun, is likely to be beneficial in the majority of influenza seasons. The majority of adults have antibody protection against influenza virus infection within 2 weeks after vaccination. Prevention and Control of Seasonal Influenza with Vaccines Recommendations of the Advisory Committee on Immunization Practices (ACIP), 2009 MMWR/Vol. 58 July 31, 2009
  • _______________________________________________________________ FYI
  • ________________________________________________________ FYI Information current as of Aug 9, 2009 from the CDC website www.cdc.gov/h1n1flu- vaccine Q and A
  • ___________________________________________________________ FYI Information current as of Aug 9, 2009 from the CDC website www.cdc.gov/h1n1flu- vaccine Q and A
  • _________________________________________________________________ FYI CDC’s Advisory Committee on Immunization Practices (ACIP), a panel made up of medical and public health experts, met July 29, 2009, to make recommendations on who should receive the new H1N1 vaccine when it becomes available.  While some issues are still unknown, such as how severe the virus will be during the fall and winter months, the ACIP considered several factors, including current disease patterns, populations most at-risk for severe illness based on current trends in illness, hospitalizations and deaths, how much vaccine is expected to be available, and the timing of vaccine availability. The groups recommended to receive the novel H1N1 influenza vaccine include: Pregnant women because they are at higher risk of complications and can potentially provide protection to infants who cannot be vaccinated; Household contacts and caregivers for children younger than 6 months of age because younger infants are at higher risk of influenza-related complications and cannot be vaccinated. Vaccination of those in close contact with infants less than 6 months old might help protect infants by “cocooning” them from the virus; Healthcare and emergency medical services personnel because infections among healthcare workers have been reported and this can be a potential source of infection for vulnerable patients. Also, increased absenteeism in this population could reduce healthcare system capacity; All people from 6 months through 24 years of age Children from 6 months through 18 years of age because we have seen many cases of novel H1N1 influenza in children and they are in close contact with each other in school and day care settings, which increases the likelihood of disease spread, and Young adults 19 through 24 years of age because we have seen many cases of novel H1N1 influenza in these healthy young adults and they often live, work, and study in close proximity, and they are a frequently mobile population; and, Persons aged 25 through 64 years who have health conditions associated with higher risk of medical complications from influenza. www.cdc.gov/h1n1flu
  • __________________________________________________ FYI
  • The risks associated with influenza are greater than any hypothetical risks associated with vaccine ______________________________________________________ FYI No scientific evidence indicates that thimerosal in vaccines, including influenza vaccines, is a cause of adverse events in vaccine recipients or to children born to women who received vaccine during pregnancy. In fact, evidence is accumulating that supports the absence of any risk for neurodevelopment disorders or other harm resulting from exposure to thimerosal-containing vaccines. The benefits of influenza vaccination for all recommended groups, including pregnant women and young children, outweigh the unproven risk from thimerosal exposure through vaccination. The risks for severe illness from influenza virus infection are elevated among both young children and pregnant women, and vaccination has been demonstrated to reduce the risk for severe influenza illness and subsequent medical complications. In contrast, no scientifically conclusive evidence has demonstrated harm from exposure to vaccine containing thimerosal preservative. For these reasons, persons recommended to receive TIV may receive any age- and risk factor–appropriate vaccine preparation, depending on availability. ACIP and other federal agencies and professional medical organizations continue to support efforts to provide thimerosal preservative–free vaccine options. Prevention and Control of Influenza Recommendations of the ACIP MMWR August 8, 2008 .
  • Although influenza vaccination is the primary strategy for preventing complications of influenza, some antiviral medications (with activity against influenza viruses) can be effective for treatment. _________________________________________________ FYI Although annual vaccination is the primary strategy for preventing complications of influenza virus infections, antiviral medications with activity against influenza viruses can be effective for the chemoprophylaxis and treatment of influenza. Four licensed influenza antiviral agents are available in the United States: amantadine, rimantadine, zanamivir, and oseltamivir. Influenza A virus resistance to amantadine and rimantadine can emerge rapidly during treatment. Amantadine or rimantidine should not be used for the treatment or prevention of influenza in the United States until evidence of susceptibility to these antiviral medications has been reestablished among circulating influenza A viruses. Oseltamivir-resistant influenza A (H1N1) strains have been identified in the United States and some other countries. However, oseltamivir or zanamivir continue to be the recommended antivirals for treatment of influenza because other influenza virus strains remain sensitive to oseltamivir, and resistance levels to other antiviral medications remain high. Prevention and Control of Influenza Recommendations of the ACIP MMWR August 8, 2008
  • Zanamivir and oseltamivir are chemically related antivirals that have activity against both influenza A and B – resistance is rare Detailed guidelines for the use of these medications can be found in the Recommendations for the Prevention and Control of Influenza (ACIP) ___________________________________________________________________ FYI Oseltamivir or zanamivir can be prescribed if antiviral chemoprophylaxis or treatment of influenza is indicated. Oseltamivir is licensed for treatment of influenza in persons aged > 1 year, and zanamivir is licensed for treating influenza in persons aged > 7 years. Oseltamivir and zanamivir can be used for chemoprophylaxis of influenza; oseltamivir is licensed for use as chemoprophylaxis in persons aged > 1 year, and zanamivir is licensed for use in persons aged > 5 years. During the 2007–08 influenza season, influenza A (H1N1) viruses with a mutation that confers resistance to oseltamivir were identified in the United States and other countries. As of June 27, 2008, in the United States, 111 (7.6%) of 1,464 influenza A viruses tested, and none of 305 influenza B viruses tested have been found to be resistant to oseltamivir. All of the resistant viruses identified in the United States and elsewhere are influenza A (H1N1) viruses. Of 1020 influenza A (H1N1) viruses isolated from patients in the United States, 111 (10.9%) exhibited a specific genetic mutation that confers oseltamivir resistance. Influenza A (H1N1) virus strains that are resistant to oseltamivir remain sensitive to zanamivir. Neuraminidase inhibitor medications continue to be the recommended agents for treatment and chemoprophylaxis of influenza in the United States. However, clinicians should be alert to changes in antiviral recommendations that might occur as additional antiviral resistance data becomes available during the 2008–09 influenza season (http://www. cdc.gov/flu/professionals/antivirals/index.htm). However, because influenza antivirals reduce replication of influenza viruses, LAIV should not be administered until 48 hours after cessation of influenza antiviral therapy, and influenza antiviral medications should not be administered for 2 weeks after receipt of LAIV. Persons receiving antivirals within the period 2 days before to 14 days after vaccination with LAIV should be revaccinated at a later date. Prevention and Control of Influenza Recommendations of the ACIP MMWR August 8, 2008
  • Preparing for this flu season will be challenging. Discuss strategies for seasonal influenza vaccination as well as those for immunizing patients with H1N1 vaccines _______________________________________________________________ FYI
  • _____________________________________________________________ FYI
  • Let patients know they need vaccine. REMIND parents/patients when an immunization visit is coming up--Good reminder systems include: using the MCIR; having a tickler file - postcard or phone call reminders; having parents or patients completing a pre-addressed postcard, and using auto dialers for large practices RECALL parents/patients when immunization visit is missed- - Good recall systems include: MCIR and a return-appointment policy Handouts: “ Strategies to Enhance Influenza Vaccination for Practices that Care for Pediatric & Adolescent Influenza Immunization” and/or “Strategies to Enhance Influenza Vaccination for Practices that Care for Adults” _______________________________________________________________ FYI MDCH has an influenza brochures available free through the MDCH Clearinghouse. These can be ordered at www.hpclearinghouse.org Both the Standards for Child and Adolescent Immunization Practices and the Standards for Adult Immunization Practices call upon providers to develop and implement aggressive tracking systems that will both remind parents of upcoming immunizations and recall children who are overdue. ACIP supports the use of reminder/recall systems by all providers. CDC Epidemiology and Prevention of Vaccine Preventable Disease 11 th edition 2009
  • All providers who service VFC eligible children should be encouraged to become a VFC provider An administration fee maybe charged for VFC vaccine Additional information about the VFC program can be obtained from the local health department Handouts: “ MDCH 2008-2009 VFC Influenza Guidelines” “ Strategies to Enhance Influenza Vaccination for Practices that Care for Pediatric & Adolescent Influenza Immunization” and/or “Strategies to Enhance Influenza Vaccination for Practices that Care for Adults” ___________________________________________________________________________ FYI Using standing orders in hospitals increases vaccination rates among hospitalized persons. Prevention and Control of Influenza Recommendations of the ACIP MMWR August 8, 2008 Several studies have shown that eliminating missed opportunities could increase vaccination coverage by up to 20 percent. Strategies designed to prevent missed opportunities have taken many different forms, used alone or in combination. Examples include the following: • Standing orders . These are protocols whereby nonphysician immunization personnel may vaccinate clients without direct physician involvement at the time of the immunization. Standing orders are implemented in settings such as clinics, hospitals, and nursing homes. When used alone or in combination with other interventions, standing orders have had positive effects on immunization rates among adults. CDC Epidemiology and Prevention of Vaccine Preventable Disease 11 th edition 2009
  • For those who believe the flu shot gives them the flu: Systemic reactions to vaccines usually occur in <1% of recipients after the first time receiving the vaccine. These can include fever, chills, myalgia. These reactions occur within 6-12 hours of vaccination and may last 1-2 days. The "stomach flu" is a myth. Symptoms such as nausea, diarrhea, and vomiting are uncommon with the flu, except in very young children. Up to 50% of influenza infections are asymptomatic. And in addition only 50% of those who develop influenza, display the “classic symptoms”. ______________________________________________________ FYI As has been reported for older adults, a physician recommendation for vaccination and the perception that having a child be vaccinated “is a smart idea” were associated positively with likelihood of vaccination of children aged 6–23 months. Similarly, children with asthma were more likely to be vaccinated if their parents recalled a physician recommendation to be vaccinated or believed that the vaccine worked well. Implementation of a reminder/ recall system in a pediatric clinic increased the percentage of children with asthma or reactive airways disease receiving vaccination from 5% to 32%. Prevention and Control of Seasonal Influenza with Vaccines Recommendations of the Advisory Committee on Immunization Practices (ACIP), 2009 MMWR/Vol. 58 July 31, 2009 Influenza vaccine is included in the National Vaccine Injury Compensation Program.
  • Because there are 2 types of influenza vaccine (live and inactivated), and different vaccine –seasonal and H1N1- separate Vaccine Information Statements have been created. Be sure the VIS pertains to the vaccine you are administering. By law providers must inform parents/patients that vaccine doses will be documented in MCIR. The MDCH has received permission to add this information has been added to the VIS. It is important to use VIS obtained from the MDCH website or the local Health Department. . Suggested Handouts: “ 2009-10 Trivalent Inactivated Influenza VIS” “ 2009-10 Live Attenuated Influenza VIS” ______________________________________________________ FYI
  • Encourage offices to adopt one or more that would work for them. ______________________________________________________ FYI
  • VARs are easy to locate in charts when copied onto brightly colored paper. Adult immunizations can be documented in the immunization registry. MCIR can print out an immunization record for children and adults. Lifetime immunization record cards are available free of charge. ______________________________________________________ FYI
  • _____________________________________________________________ FYI Prevention and Control of Seasonal Influenza With Vaccines Recommendations of the ACIP MMWR July 31, 2009 are available on the CDC web site www.cdc.gov/vaccines
  • ______________________________________________________________ FYI Interim guidance for use of PPSV23 during novel influenza A (H1N1) outbreak  ACIP recommends a single dose of PPSV23 for all people 65 years and older and for persons 2 to 64 years of age with certain high-risk conditions. People in these groups are at increased risk of pneumococcal disease as well as serious complications from influenza. A single revaccination at least five years after initial vaccination is recommended for people 65 years and older who were first vaccinated before age 65 years as well as for people at highest risk, such as those who have no spleen, and those who have HIV infection, AIDS, or malignancy.   All people who have existing indications for PPSV23 should continue to be vaccinated according to current ACIP recommendations during the outbreak of novel influenza A (H1N1). Emphasis should be placed on vaccinating people aged less than 65 years who have established high-risk conditions because PPSV23 coverage among this group is low and because people in this group appear to be over represented among  severe cases of novel influenza A (H1N1) infection, based on currently available data.  http://www.cdc.gov/h1n1flu/guidance/ppsv_h1n1.htm
  • • A single dose of zoster vaccine is recommended for adults 60 years of age and older whether or not they report a prior episode of herpes zoster.* _____________________________________________________ FYI Persons with chronic medical conditions may be vaccinated unless a contraindication or precaution exists for their condition.* *ACIP Recommendations for the Use of Zoster Vaccine are posted at www.cdc.gov/vaccines Contraindication to vaccination includes pregnancy or the possibility of becoming pregnant in the next 3 months. (FDA licensing approval information) Herpes zoster (HZ), commonly know as shingles or zoster, is a manifestation of the reactivation of varicella zoster virus (VZV), which, as a primary infection, produces chickenpox (varicella). Following initial infection, the virus remains latent in the dorsal root or cranial sensory ganglia until it reactivates. The risk of developing zoster appears to be related to a decline in VZV-specific immunity. ZOSTAVAX was shown to boost VZV-specific immunity, which is thought to be the mechanism by which it protects against zoster and its complications. ZOSTAVAX ® (Zoster Vaccine Live, Oka/Merck) package insert information Efficacy was evaluated in the Shingles Prevention Study: For persons 60 years and above, reduced by 50% For persons 60-69 years, reduced by 64% Merck’s clinical study did not include persons who were immunocompromised or had a previous history of herpes zoster.
  • Sentinel sites are critical to monitoring influenza disease and viruses in this country. Information regarding sentinel surveillance-when, where, what type of influenza activity in occurring Michigan is available at www.michigan.gov/flu _________________________________________________ FYI
  • Information is regarding becoming a sentinel provider is also available on the MDCH flu website. (www.michigan.gov/flu) Handouts: MDCH PHYSICIAN–DISEASE REPORTING and Influenza Sentinel Physician Surveillance Brochure _________________________________________________ FYI
  • Information is regarding becoming a sentinel provider is also available on the MDCH flu website. (www.michigan.gov/flu) Handouts: MDCH PHYSICIAN–DISEASE REPORTING and Influenza Sentinel Physician Surveillance Brochure ________________________________________________________ FYI
  • Pediatric & Adult Influenza Update 2009-10

    1. 1. Pediatric and Adult Influenza Update 2009-2010
    2. 2. Disclosures <ul><li>The speaker will disclose any financial interest or conflict with the manufacturer of any product named in this presentation </li></ul><ul><li>The speaker will discuss the use of some vaccines in a manner not approved by the U.S. Food and Drug Administration (FDA) </li></ul><ul><li>The use of trade names and commercial sources during this presentation is for identification only, and does not imply endorsement </li></ul><ul><li>No commercial support has been received for this program </li></ul>
    3. 3. Objectives <ul><li>Discuss vaccine storage and handling principles of influenza vaccines </li></ul><ul><li>Identify adults and children who should receive influenza vaccine </li></ul><ul><li>Identify strategies to ensure that patients are protected </li></ul>
    4. 4. Safe Vaccine Storage <ul><li>Store seasonal LAIV & TIV in the </li></ul><ul><li>refrigerator at </li></ul><ul><ul><li>35˚F to 46˚F (2˚C- 8˚C ) </li></ul></ul><ul><li>LAIV & TIV should not be stored in the freezer </li></ul><ul><li>LAIV doses will expire in November or March - monitor expiration dates </li></ul><ul><li>closely to use vaccine before it expires </li></ul><ul><li>Place certified thermometers in both refrigerator and freezer </li></ul><ul><li>Check and record refrigerator and freezer temperatures 2 times a day </li></ul>≤ 5˚F (-15˚C) Var, *MMR, MMRV, Zoster 35˚F (2˚C) to 46˚F (8˚C) TIV & LAIV Td, Tdap, IPV, HepA, HepB, HPV4 PPV23, PCV7, MCV4, MPSV4, *MMR, HIB DTaP, Rota, IPV * MMR can be stored in the freezer or refrigerator
    5. 5. Be Prepared! <ul><li>A good vaccine management plan includes: </li></ul><ul><ul><li>A lead person responsible for the vaccines— and at least one back-up person </li></ul></ul><ul><ul><li>Written policies on: </li></ul></ul><ul><ul><ul><li>Proper storage and handling </li></ul></ul></ul><ul><ul><ul><li>Vaccine shipping--includes receiving and transporting vaccines </li></ul></ul></ul><ul><ul><ul><li>Procedures for vaccine relocation in the event of a power failure or mechanical difficulties </li></ul></ul></ul><ul><ul><ul><li>Review/update of Emergency Plan annually or when staff changes occur </li></ul></ul></ul><ul><ul><ul><li>Vaccine ordering procedure </li></ul></ul></ul><ul><ul><ul><li>Inventory control (such as rotating stock) </li></ul></ul></ul><ul><ul><ul><li>What to do in the event of a vaccine wastage </li></ul></ul></ul>
    6. 6. Influenza This Flu Season <ul><li>Influenza is a contagious respiratory illness caused by influenza viruses </li></ul><ul><li>Seasonal influenza outbreaks occur every year </li></ul><ul><li>Novel H1N1 is a new influenza virus causing respiratory illness in people. On June 11, 2009, the World Health Organization (WHO) declared a world wide pandemic of the novel H1N1 influenza </li></ul><ul><li>Both seasonal influenza and novel H1N1viruses are expected to cause illness this fall and winter </li></ul>
    7. 8. Seasonal & Novel H1N1 Influenza <ul><li>Both are highly contagious, respiratory, viral illness </li></ul><ul><li>Seasonal and novel H1N1 symptoms include an abrupt onset of: </li></ul><ul><ul><li>Fever, chills, muscle aches, headache, nonproductive cough, fatigue, and sore throat </li></ul></ul><ul><li>Vomiting and diarrhea has been reported more commonly with novel H1N1 flu infection than is typical for seasonal flu </li></ul><ul><li>Complications include: </li></ul><ul><ul><li>Pneumonia, myocarditis, encephalopathy, and Reye syndrome </li></ul></ul><ul><ul><li>Complications can occur in healthy as well as chronically ill persons </li></ul></ul>
    8. 9. Earliest Cases are in Schoolchildren Family Members of Schoolchildren More School-aged Children Infected Initial Case – Immunologically Naïve Schoolchild Elveback LR et al. Am J Epidemiol. 1976;103:152-65. 3° 2° 1° <ul><li>Community at Large </li></ul><ul><li>High-Risk populations </li></ul><ul><li>Elderly </li></ul><ul><li>Contacts of </li></ul><ul><li>1°, 2°, 3° cases </li></ul>
    9. 10. Seasonal Flu: Who Should Be Vaccinated? <ul><li>Annual seasonal influenza vaccination is recommended for: </li></ul><ul><ul><ul><li>All children 6 months through 18 years of age </li></ul></ul></ul><ul><ul><ul><li>Adults 50 years of age and older </li></ul></ul></ul><ul><ul><ul><li>Pregnant women </li></ul></ul></ul><ul><ul><ul><li>Children and teens (6 mo-18 yrs) receiving long term aspirin therapy </li></ul></ul></ul><ul><ul><ul><li>Residents of long term care facilities </li></ul></ul></ul><ul><ul><ul><li>Persons who wish to decrease the chances of getting flu </li></ul></ul></ul><ul><ul><ul><li>Persons with chronic medical conditions </li></ul></ul></ul>
    10. 11. Seasonal Flu: Who Should Be Vaccinated? <ul><li>Persons with chronic medical conditions including </li></ul><ul><ul><li>Chronic pulmonary disease (e.g. asthma) </li></ul></ul><ul><ul><li>Chronic cardiovascular disease </li></ul></ul><ul><ul><li>Metabolic disorders (e.g. diabetes) </li></ul></ul><ul><ul><li>Immunosuppression (e.g. HIV infection) </li></ul></ul><ul><ul><li>Hematological (e.g. sickle cell disease) </li></ul></ul><ul><ul><li>Chronic renal failure or nephrotic syndrome </li></ul></ul><ul><ul><li>Hepatic disorders </li></ul></ul><ul><ul><li>Neurologic/neuromuscular disorders that compromise respiratory function, handling of secretions or increase risk of aspiration (e.g. spinal cord injuries) </li></ul></ul>
    11. 12. Who Else Should Be Vaccinated for Seasonal Influenza? <ul><li>Household members and close contacts of those at increased risk including of: </li></ul><ul><ul><li>Children birth through 4 years of age including siblings, parents, day care workers </li></ul></ul><ul><ul><li>Persons who have a high risk condition </li></ul></ul><ul><ul><li>Persons 50 years of age and older </li></ul></ul><ul><ul><li>Health care personnel </li></ul></ul><ul><li>These people can transmit seasonal influenza to those at risk </li></ul>
    12. 13. Health Care Personnel (HCP) & Influenza Vaccination <ul><li>Only 44% of HCP in the U.S. received influenza vaccine in 2006-2007 </li></ul><ul><li>HCP often work while ill, exposing vulnerable patients and their coworkers to influenza </li></ul><ul><li>HCP can spread influenza if infected </li></ul><ul><ul><li>Virus can be shed before symptoms develop </li></ul></ul><ul><li>HCP have caused outbreaks among patients in health care settings </li></ul>
    13. 14. 2009-10 Seasonal Influenza Vaccine A/Brisbane/59/2007-like (H1N1) A/Brisbane/10/2007-like (H3N2) B/Brisbane/60/2008-like viruses <ul><li>All 3 influenza viral strains </li></ul><ul><li>are contained in both TIV </li></ul><ul><li>(shot) and LAIV (nasal) </li></ul><ul><li>The seasonal flu vaccine will </li></ul><ul><li>not protect against the novel </li></ul><ul><li>H1N1 flu </li></ul>Influenza Protection ACIP Influenza Recommendation available at www.cdc.gov/vaccines/recs
    14. 15. Trivalent Seasonal Influenza Vaccine (TIV) Recommendations <ul><li>TIV (flu shot) may be given to persons </li></ul><ul><li>6 months of age and older including: </li></ul><ul><ul><li>Persons with a high risk condition </li></ul></ul><ul><ul><ul><li>e.g. Pregnant women, children and adults with diabetes, asthma or sickle cell disease </li></ul></ul></ul><ul><ul><li>Health care personnel or close contacts of severely immunosuppressed persons </li></ul></ul><ul><ul><li>People who wish to decrease their risk of influenza disease </li></ul></ul>
    15. 16. <ul><li>Use the appropriate product based on age </li></ul>Trivalent Seasonal Influenza Vaccine (TIV) 18 yrs & older 18 yrs & older Single dose 0.5 mL syringe Multi dose vial Afluria ™ 18 yrs & older Multi dose vial FluLaval ® 18 yrs & older Single dose 0.5 mL syringe Fluarix ™ 4 yrs & older Multi dose vial Single dose 0.5 mL syringe Fluvirin ™ 6-35 mo 3 yrs & older 6 mo & older Pre-filled 0.25 mL syringe Single dose 0.5 mL syringe/vial Multi-dose vial Fluzone ® Ages Presentation Vaccine
    16. 17. Trivalent Seasonal Influenza Vaccine (TIV) <ul><li>Given IM annually prior to and during flu season </li></ul><ul><li>May be given at the same time as other vaccines </li></ul><ul><li>TIV is available through the Vaccines for Children (VFC) program for eligible children </li></ul><ul><li>Ensure the correct dose for the patient’s age </li></ul><ul><ul><li>Split virus is the type of vaccine; NOT a half dose </li></ul></ul><ul><ul><li>Do NOT administer partial/half doses of vaccine </li></ul></ul>
    17. 18. TIV “Flu Shot” Dosages <ul><li>0.25 mL is a full dose for a child 6 mo-35 mo. If the child needs 2 doses this season, give 2 doses of 0.25 mL </li></ul><ul><ul><li>Separate the doses by at least 4 weeks </li></ul></ul><ul><li>O.5 mL is a full dose for a child 3 years of age and older. </li></ul><ul><li>Children ages 3 thru 8 years may need 2 doses this season. If so, make sure both doses are 0.5 mL </li></ul><ul><ul><li>Separate the doses by at least 4 weeks </li></ul></ul>IM IM IM Route Age Dose No. of Doses 6-35 mos 0.25 mL 1 or 2 3-8 yrs 0.5 mL 1 or 2 9 yrs & older 0.5 mL 1
    18. 19. Who Needs 2 Doses of Seasonal Vaccine? <ul><li>Children, 6 mo thru 8 years of age, need 2 doses of seasonal flu vaccine, at least 4 weeks apart, if they are: </li></ul><ul><ul><li>receiving seasonal flu vaccine for the first time OR </li></ul></ul><ul><ul><li>received seasonal flu vaccine for the first time last flu season and only received 1 dose </li></ul></ul><ul><li>A healthy child needing 2 doses of flu vaccine may have 1 TIV and 1 LAIV 4 weeks apart </li></ul><ul><li>Children who were given flu vaccine during any other prior flu season should receive only 1 dose </li></ul><ul><li>There is NO recommendation for a 2 nd dose of vaccine in the same season for any person 9 years of age and older </li></ul>
    19. 20. How Many Doses of Seasonal Flu Vaccine Should Be Given? <ul><ul><li>7 year old child who has never received flu vaccine </li></ul></ul><ul><ul><li>3 year old child who received her first dose of flu vaccine at age 1 and no other doses </li></ul></ul><ul><ul><li>5 year old child who received his first and only dose of flu vaccine at age 4 </li></ul></ul><ul><ul><li>12 year old getting flu vaccine for the 1 st time </li></ul></ul><ul><ul><li>4 year old who received 1 dose of flu vaccine at 1, 2 and 3 years of age </li></ul></ul><ul><ul><li>82 year old with severe lung problems </li></ul></ul>
    20. 21. Live, Attenuated Seasonal Influenza Vaccine Recommendations <ul><li>LAIV can be given to persons 2-49 years of age, who are healthy and not pregnant </li></ul><ul><li>Do NOT administer LAIV to: </li></ul><ul><ul><li>Children 2-4 yrs of age with a history of wheezing </li></ul></ul><ul><ul><li>Persons within a chronic medical condition </li></ul></ul><ul><ul><ul><li>e.g. persons with asthma, or diabetes </li></ul></ul></ul><ul><ul><li>Persons in close contact with those who are severely immunosuppressed in protective isolation </li></ul></ul><ul><ul><li>Children or teens receiving long term aspirin therapy </li></ul></ul><ul><ul><li>Children less than 2 years of age </li></ul></ul><ul><ul><li>Adults 50 years of age and older </li></ul></ul>
    21. 22. Live attenuated influenza vaccine (LAIV)
    22. 23. Live, Attenuated Seasonal Influenza Vaccine (LAIV) <ul><li>Each pre-filled, single-use sprayer contains a 0.2 mL divided dose </li></ul><ul><li>Given intranasally; position recipient in an up-right position with head tilted back & breathing normally </li></ul><ul><ul><li>Spray ½ the dose in each nostril using the divider clip on the syringe </li></ul></ul><ul><li>Most common side effects are nasal congestion and runny nose </li></ul>
    23. 24. Special Considerations for LAIV <ul><li>May be administered with other vaccines </li></ul><ul><ul><li>If not given on the same day with other live vaccines, must be separated by 28 days </li></ul></ul><ul><li>May be administered to eligible patients in clinics that serve patients that should not be given LAIV e.g. OB/GYN offices </li></ul><ul><li>Protective masks and gloves are not required </li></ul><ul><li>Defer administration of LAIV for persons with severe nasal congestion </li></ul><ul><ul><li>Consider administering TIV </li></ul></ul><ul><li>LAIV is available through the VFC program for eligible children </li></ul>
    24. 25. Remember to Give Flu Vaccines Correctly! 1-1.5 in Deltoid or anterolat. thigh IM 0.5 mL 9 yrs & older LAIV (nasal) Route and Site Dosage Age 1in Deltoid or anterolat. thigh IM 0.5 mL 3-8 yrs Intranasal- Spray ½ the dose in each nostril as indicated on the syringe .2 mL sprayer 2 yrs & older TIV (Flu Shot) 1in Needle Length Anterolat. thigh Site IM 0.25 mL 6-35 mo Route Dosage Age
    25. 26. True Contraindications to Seasonal Flu Vaccine <ul><li>Permanent Contraindications </li></ul><ul><ul><li>Anaphylactic reaction to prior dose of flu vaccine </li></ul></ul><ul><ul><li>Anaphylactic reaction to a component of the flu vaccine including eggs </li></ul></ul><ul><li>Temporary Contraindications and Precautions </li></ul><ul><ul><li>Moderate-to-severe acute illness </li></ul></ul><ul><ul><li>History of Guillain Barré within 6 weeks of a previous influenza vaccination </li></ul></ul><ul><ul><li>LAIV only </li></ul></ul><ul><ul><ul><li>Pregnancy </li></ul></ul></ul><ul><ul><ul><li>Immunosuppression </li></ul></ul></ul><ul><ul><ul><li>Children 2-4 years with a history of wheezing </li></ul></ul></ul><ul><ul><ul><li>Children receiving long-term aspirin therapy </li></ul></ul></ul><ul><ul><ul><li>Chronic medical conditions </li></ul></ul></ul><ul><ul><ul><li>HCP, household/close contacts of severely immunosuppressed persons requiring a protective environment </li></ul></ul></ul>
    26. 27. Influenza Vaccines & Health Care Personnel FYI - HCP with a high risk condition, except severe immunosuppression, may administer LAIV TIV Caring for severely immunosuppressed person requiring a protective environment e.g. hematopoietic stem cell transplants LAIV or TIV Caring for persons within high risk groups e.g. diabetes, HIV, asthma taking corticosteroids, pregnant women Vaccine that can be received Health Care Personnel
    27. 28. TIV? LAIV? TIV or LAIV? Or Neither? <ul><li>Identify the appropriate seasonal flu vaccine for the patients listed below: </li></ul><ul><ul><li>A healthy, non-pregnant 42-year-old nurse who does not care for persons who are severely immunosuppressed- those requiring a protective environment </li></ul></ul><ul><ul><li>A healthy 5 year old girl with a 3 month old brother </li></ul></ul><ul><ul><li>A 55 year old woman who has not specifically asked to receive influenza vaccine </li></ul></ul><ul><ul><li>A 5 month old boy with asthma </li></ul></ul><ul><ul><li>A 20 year old man who has severe cardiopulmonary disease and resides in a chronic-care facility </li></ul></ul>
    28. 29. Timing of Seasonal Influenza Vaccination <ul><li>Offer vaccine soon after it becomes available </li></ul><ul><li>Providers should offer vaccine during ALL office visits including </li></ul><ul><ul><li>Both acute and chronic health care visits </li></ul></ul><ul><li>Continue to vaccinate throughout influenza season- through the end of March </li></ul><ul><ul><li>Obtain more flu vaccine for unvaccinated patients if your supply is depleted </li></ul></ul>
    29. 30. Influenza Vaccine Exchange Network <ul><li>Influenza Vaccine Exchange Network (IVEN) is a centralized location where providers can share information about their flu vaccine inventory to facilitate vaccine redistribution if necessary </li></ul><ul><ul><li>Do not use IVEN to redistribute VFC vaccine; call the local health department </li></ul></ul><ul><ul><li>Access IVEN through the Michigan Care Improvement Registry (MCIR) </li></ul></ul><ul><ul><ul><li>More information regarding IVEN and MCIR registration is available at www.michigan.gov/flu </li></ul></ul></ul>
    30. 31. Novel H1N1 Vaccine <ul><li>A novel H1N1 vaccine is in production </li></ul><ul><li>Candidate vaccines are currently being tested in clinical trials </li></ul><ul><li>The novel H1N1 vaccine is expected to be available in the fall </li></ul><ul><li>Novel H1N1 vaccine will ONLY protect against novel H1N1 influenza </li></ul><ul><ul><li>Will not protect against seasonal influenza viruses </li></ul></ul>
    31. 32. Novel H1N1 Vaccine <ul><li>Novel H1N1 vaccine is being purchased by the U.S. government and available to the public at no cost </li></ul><ul><li>Novel H1N1 vaccine is being procured by the U.S. government from five (5) vaccine manufacturers of currently U.S. licensed seasonal influenza vaccines </li></ul><ul><ul><li>Inactivated vaccine will be available in single-dose syringes, or multi-dose vials </li></ul></ul><ul><ul><li>Live attenuated vaccine will be available in nasal sprayers </li></ul></ul><ul><li>Single-dose syringes and nasal sprayers will be thimerosal-free </li></ul>
    32. 33. Novel H1N1 Vaccination Groups <ul><li>Groups recommended for initial vaccination include: </li></ul><ul><ul><li>Pregnant women </li></ul></ul><ul><ul><li>People who live with or care for children younger than 6 months of age </li></ul></ul><ul><ul><li>Healthcare and emergency services personnel </li></ul></ul><ul><ul><li>Persons between the ages of 6 months and 24 years of age </li></ul></ul><ul><ul><li>People 25 through 64 years of age with a chronic health disorders or compromised immune system </li></ul></ul>
    33. 34. Stay Tuned for More Information on H1N1 Influenza and Vaccines www.cdc.gov/flu www.michigan.gov/flu
    34. 35. Safety of Thimerosal-Containing Flu Vaccines <ul><li>Thimerosal is a preservative used in some vaccines </li></ul><ul><ul><li>Present in multi-dose flu vials to prevent bacterial growth </li></ul></ul><ul><li>TIV single-dose vials and syringes are either: </li></ul><ul><ul><li>Thimerosal-free or </li></ul></ul><ul><ul><li>Contain only a trace amount of thimerosal </li></ul></ul><ul><li>LAIV contains no thimerosal </li></ul><ul><li>Studies have NOT demonstrated evidence of harm to anyone, including pregnant women and children, caused by thimerosal-containing flu vaccine </li></ul><ul><li>Benefits of flu vaccine outweigh any hypothetical risks posed by thimerosal </li></ul>
    35. 36. Treating Influenza <ul><li>Currently 4 antiviral medications are licensed to treat influenza infections </li></ul><ul><li>Seasonal influenza viruses are resistant to some antiviral medications </li></ul><ul><ul><li>Amantadine and rimantadine should be not used for treatment of seasonal influenza infections </li></ul></ul><ul><li>Antiviral medications should only be used to treat novel H1N1 infections for persons at high risk </li></ul><ul><li>Further guidance regarding antiviral medication use for seasonal and novel H1N1 influenza may be found at www.cdc.gov/flu </li></ul>
    36. 37. Available Influenza Antiviral Medications <ul><li>Oseltamivir and zanamivir can be prescribed for treatment if antiviral drugs are needed </li></ul><ul><ul><li>Oseltamivir can be used for persons 1 yr of age & older </li></ul></ul><ul><ul><li>Zanamivir is used for persons aged 7 yrs of age & older </li></ul></ul><ul><li>These antivirals can also be used for prophylaxis </li></ul><ul><ul><li>Oseltamivir is approved for persons 1 yr of age & older </li></ul></ul><ul><ul><li>Zanamivir is approved for persons aged 5 yrs of age & older </li></ul></ul><ul><li>TIV & antiviral medications can be administered during the same visit </li></ul><ul><li>LAIV & antiviral medications should not be administered at the same time </li></ul><ul><ul><li>Persons receiving antivirals within a time period of 2 days before to 14 days after vaccination with LAIV should be revaccinated </li></ul></ul>
    37. 38. Prepare for Seasonal Influenza Prepare for H1N1 Influenza
    38. 39. 2009-10 Influenza Season <ul><li>Seasonal flu vaccine will be available in August or September before novel H1N1 vaccine </li></ul><ul><ul><li>Vaccinate with seasonal flu vaccine as soon as available </li></ul></ul><ul><li>Formal recommendations for the use of novel H1N1 vaccine will be made by the ACIP in August 2009 </li></ul><ul><li>The availability of the two vaccines during flu season is expected to overlap </li></ul>
    39. 40. Strategies to Prepare for Influenza Vaccination <ul><li>Raise staff awareness </li></ul><ul><ul><li>Staff education </li></ul></ul><ul><ul><li>Establish a plan to vaccinate staff </li></ul></ul><ul><ul><li>Use written materials- chart reminders, posters, or brochures </li></ul></ul><ul><ul><li>Watch your progress with chart reviews and tracking the number of flu vaccine doses given each year </li></ul></ul><ul><li>Raise patient awareness </li></ul><ul><ul><li>Use a reminder/recall systems </li></ul></ul><ul><ul><li>Be sure to include high risk groups </li></ul></ul><ul><ul><li>Family members and household contacts of those at risk </li></ul></ul><ul><ul><li>Michigan Care Improvement Registry (MCIR) can help with pediatric patients </li></ul></ul>
    40. 41. Increase Vaccine Availability <ul><li>Use standing orders </li></ul><ul><ul><li>The most consistently effective method for increasing adult vaccination rates </li></ul></ul><ul><ul><li>“ Vaccine only” visits to administer vaccines </li></ul></ul><ul><li>Use VFC seasonal flu vaccine for eligible patients </li></ul><ul><ul><li>Enables medical offices to provide publicly purchased vaccines to eligible children, birth through 18 years old, who are: </li></ul></ul><ul><ul><ul><li>Medicaid eligible, </li></ul></ul></ul><ul><ul><ul><li>Have no insurance (uninsured), </li></ul></ul></ul><ul><ul><ul><li>Have insurance with no coverage for immunization (underinsured), or </li></ul></ul></ul><ul><ul><ul><li>Native American or Alaskan Native </li></ul></ul></ul>
    41. 42. Patient Education <ul><li>Recommend flu vaccine to your patients </li></ul><ul><ul><li>63% of patients who were not vaccinated indicated that no one had spoken to them regarding influenza vaccination </li></ul></ul><ul><ul><li>Seasonal flu vaccine is recommended for 4 out of 5 people in the U.S. </li></ul></ul><ul><li>Dispel any preconceived myths </li></ul><ul><ul><li>“ The flu vaccine gave me the flu.” </li></ul></ul><ul><ul><li>“ Influenza is the stomach flu.” </li></ul></ul><ul><ul><li>“ I don’t need the vaccine. I never catch the flu.” </li></ul></ul><ul><li>Let your patients know you and the office staff received flu vaccine </li></ul>
    42. 43. Vaccine Information Statements <ul><li>Distribute the current influenza Vaccine Information Statements (VIS) to all patients during flu season </li></ul><ul><ul><li>The VIS includes information about the disease and potential complications, vaccine, side effects and aftercare instructions </li></ul></ul><ul><ul><li>Influenza VIS will be available for each vaccine type- </li></ul></ul><ul><ul><ul><li>Seasonal & H1N1 </li></ul></ul></ul><ul><ul><ul><li>TIV & LAIV </li></ul></ul></ul><ul><ul><li>Use “Michigan” VIS only </li></ul></ul><ul><ul><ul><li>Includes information about MCIR </li></ul></ul></ul><ul><ul><ul><li>Available free from your local health department or www.michigan.gov/immunize </li></ul></ul></ul><ul><ul><li>Available in many foreign languages </li></ul></ul>
    43. 44. Other Office Strategies <ul><li>Ensure convenience (and efficiency) of influenza vaccination </li></ul><ul><ul><li>Develop a plan and timeline for providing influenza vaccinations in your office </li></ul></ul><ul><ul><li>Plan special influenza vaccination clinic days or hours </li></ul></ul><ul><ul><li>Designate a clinic room for administering flu vaccine during regular clinic hours </li></ul></ul><ul><ul><li>Include measures to obtain additional vaccine, if needed, for late season vaccination </li></ul></ul><ul><li>Assess the immunization status of all your patients and administer all needed vaccines </li></ul><ul><ul><li>Offer other needed vaccines, e.g. PPV23, DTaP, Tdap </li></ul></ul><ul><ul><li>Remember influenza vaccine during regular office visits (e.g. well child checks) throughout flu season </li></ul></ul>
    44. 45. Document Both Vaccines Accurately <ul><li>Document vaccines administered to children and adults in MCIR- both seasonal and the novel H1N1 </li></ul><ul><li>Maintain a Vaccine Administration Record in each chart </li></ul><ul><li>Six required elements of documentation are: </li></ul><ul><li> 1. Date the vaccine dose is given </li></ul><ul><li> 2. Date the VIS is given </li></ul><ul><li> 3. Vaccine lot number </li></ul><ul><li> 4. Vaccine manufacturer </li></ul><ul><li> 5. VIS revision date </li></ul><ul><li> 6. Signature of person administering the vaccine </li></ul><ul><li>Strongly recommended: type, route, and anatomical site where the vaccine was administered </li></ul><ul><li>Provide/update immunization records for all vaccinees-both adults and children </li></ul>
    45. 46. Ensure YOUR Patients are Protected! <ul><li>Vaccinate yourself, & other clinic staff with both seasonal and novel H1N1 influenza vaccines </li></ul><ul><li>Recommend flu vaccines to your patients </li></ul><ul><li>Assess the immunization status of patients at every visit; give all needed vaccines </li></ul><ul><li>Vaccinate throughout flu season </li></ul><ul><li>Stay current and knowledgeable. Accurate information is available for both seasonal & novel H1N1 from: </li></ul><ul><ul><ul><li>Your local health department </li></ul></ul></ul><ul><ul><ul><li>CDC website www.cdc.gov/flu </li></ul></ul></ul><ul><ul><ul><li>MDCH website www.Michigan.gov/flu </li></ul></ul></ul>
    46. 47. Pneumococcal Polysaccharide Vaccine (PPSV23) and Influenza <ul><li>Influenza predisposes persons to bacterial community-acquired pneumonia </li></ul><ul><li>Ensure high risk patients have received PPSV 23 vaccine </li></ul><ul><ul><li>Any person age 65 years or older </li></ul></ul><ul><ul><li>Any person 2-64 years with a high-risk condition </li></ul></ul><ul><li>New recommended groups for vaccination are: </li></ul><ul><ul><li>Persons 19 years of age or older who have asthma or who smoke cigarettes </li></ul></ul><ul><li>No more than 2 lifetime doses are recommended, spaced at least 5 years apart </li></ul>
    47. 48. Herpes Zoster Vaccine (Zoster) <ul><li>Given SC, 1 dose, to persons 60 years and older </li></ul><ul><li>Indicated for prevention of shingles (herpes zoster) </li></ul><ul><ul><li>May be given to people with a previous history of shingles </li></ul></ul><ul><li>Live, attenuated vaccine stored & handled similar to varicella </li></ul><ul><ul><li>Stored in freezer at 5°F (-15°C); DO NOT refreeze </li></ul></ul><ul><ul><li>Must be used within 30 minutes of reconstitution or thaw </li></ul></ul><ul><li>Not intended for treatment of shingles or post herpetic neuralgia (PHN) </li></ul>
    48. 49. CDC U.S. Influenza Sentinel Provider Surveillance Network <ul><li>Designed to assess the impact of influenza on outpatient morbidity </li></ul><ul><li>Determine when, where, and what influenza activity is occurring in the general population </li></ul><ul><li>Detect large increases in the incidence of flu-like illness </li></ul><ul><li>May provide advance warning of influenza pandemics </li></ul>
    49. 50. Michigan’s Sentinel Provider Surveillance Network We Need You! <ul><li>Medical providers of any specialty who see patients with influenza-like illness can be sentinels </li></ul><ul><ul><li>Allied health care professionals can have a primary role when working under the direction of a licensed physician </li></ul></ul><ul><li>Sentinel physicians receive </li></ul><ul><ul><li>free laboratory testing (respiratory virus culture) for approximately 11 specimens per site per year </li></ul></ul><ul><ul><li>Weekly feedback on the data submitted </li></ul></ul><ul><ul><li>Summaries of regional, state, and national influenza data </li></ul></ul><ul><ul><li>Free subscriptions to Morbidity and Mortality Weekly Report (MMWR) and Emerging Infectious Diseases </li></ul></ul>
    50. 51. It Takes Less Than 30 Minutes per Week <ul><li>Submit weekly reports of: </li></ul><ul><ul><li># patients with influenza-like illness </li></ul></ul><ul><ul><li>(ILI) in four age groups </li></ul></ul><ul><ul><ul><li>Influenza-Like Illness (ILI) = </li></ul></ul></ul><ul><ul><ul><ul><li>Fever ( ≥100° F) AND cough and/or sore throat </li></ul></ul></ul></ul><ul><ul><li># patients seen for any reason </li></ul></ul><ul><li>Collect Respiratory Specimens from a subset of ILI patients for respiratory virus culture at MDCH Laboratory </li></ul>

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