Childhood Immunization Update (Final 2019 TTT).pptx

GEORGIA DEPARTMENT OF PUBLIC HEALTH
Childhood Immunization
Update
DPH
Audience / Presenter’s Name / Date
2019

Objectives
At the end of this presentation, participants will be able to:
• Recall the role vaccines have played in preventing diseases
• Discuss the importance of vaccines for children
• Recall two recent immunization updates
• Discuss the role of a vaccine champion
• Discuss GA Immunization law and DPH rules and regulations for schools
and child care attendance
• List at least two reliable sources for immunization information

Topics for Discussion
• 2019 Immunization Schedule Changes
• ACIP Recommendations/Updates
• New and future vaccines for potential use in practice

The Impact of Vaccines in the United States
CDC. National Notifiable Diseases Surveillance System, 2017 Annual Tables of Infectious Disease Data. Available at www.cdc.gov/nndss/infectious-
tables.html. NNDSS finalized annual data as of November 28, 2018.

VPD Vaccination Rate
Needed for
Herd Immunity
Measles 92-94%
Pertussis 92-94%
Diphtheria 83-85%
Rubella 83-85%
Mumps 75-86%
Influenza 30-75%
MMWR. 2017 Nov 3; 66(43): 1171–1177

Immunization Schedule Updates
• All staff must use the same
immunization schedule
• Schedules:
 Children & Adolescents 0 through
18 years
 Catch-up schedule for ages 4
months -18 years
 Children and Adolescents 18 years
or younger based on medical
indications
 Adults 19 years and older
 Adults based on medical and other
indications
http://www.cdc.gov/vaccines/schedules/hcp/child-adolescent.html
http://www.cdc.gov/vaccines/schedules/hcp/adult.html
READ THE NOTES

http://www.cdc.gov/vaccines/schedules/hcp/child-adolescent.html

What Does It All Mean?
Indication
-Information about the appropriate use of the vaccine
Recommendation
-ACIP statement that broadens and further delineates the Indication
found in the package insert
-Basis for standards for best practice
Requirement
-Mandate by a state that a particular vaccine must be administered and
documented before entrance to child care and/or school

General Best Practice Guidelines
• Altered
Immunocompetence
• Special Situations
• Vaccination Records
• Vaccination Programs
• Vaccine Information
Sources
• Timing and Spacing of
Immunobiologics
• Contraindications and
Precautions
• Preventing and Managing
Adverse Reactions
• Vaccine Administration
• Storage and Handling of
Immunobiologics

General Best Practice Updates
May 14, 2018
• Timing and Spacing, LAIV added, MPSV23 removed
July 18, 2018
• Hep A/ IG administration changed
• Three precautions removed from DTaP row
• Varicella updated for the use of aspirin or aspirin-containing products
• table 4-2 under contraindications and precautions, header changed to
conditions
• “Multiple vaccinations”, HepA and IG- this couplet added to the pairs
which should not be administered in the same limb
• Vaccine Administration, RZV Row/Dose Column state that only 0.5cc
should be withdrawn even if more vaccine remains in the vial
https://www.cdc.gov/vaccines/hcp/acip-recs/general-recs/general-recs-errata.html

Diphtheria, Tetanus, and Pertussis Vaccines
(DTaP & Tdap)
Routine Recommendation
• DTaP: 5 dose series administered at 2, 4, 6, 15-18 months and 4-6 years
• Tdap: 1 dose administered at 11-12 years of age; administer 1 dose to
pregnant adolescent (preferably during the early part of gestational weeks
27-36)
Catch-up vaccination
• A 5th dose of DTaP is not necessary if dose 4 was administer at age 4 years
or older
• Children ages 7 through 10 years who receive DTaP or Tdap inadvertently
or as part of a catch-up series should receive Tdap for the routinely
recommended adolescent dose at 11-12 years of age
• For other catch-up guidance, please refer to immunization schedule notes
Prevention of Pertussis, Tetanus, and Diphtheria with Vaccines in the United States: Recommendations of the Advisory Committee on
Immunization Practices (ACIP), MMWR/ April 27, 2018/ 67 (2); 1-44

Hepatitis A Vaccine
• Administer 2 dose series between the 1st and 2nd birthdays (Havrix 6-12
months apart or Vaqta 6-18 months apart)
• Administer 2 doses to children 2 years of age or older separated by 6
months
International Travel
• Infants age 6-11 months: 1 dose before departure; revaccinate with 2
doses (separated by 6-18 months), between 12 to 23 months of age.
• Unvaccinated children age 12 months and older: 1st dose as soon as travel
in considered
Prevention of Hepatitis A Through Active or Passive Immunization - Recommendations of the Advisory Committee on Immunization Practices
(ACIP) MMWR Vol. 55/No. RR-7 May 19, 2006

Hepatitis A Vaccine Special Situations
• Administer a 2 dose series to at risk population
 Chronic liver disease, clotting factor disorders, MSM, injection and non
injection drug users, homelessness, work with HepA virus (i.e. in
research labs or nonhuman primates with HepA infection)
 Persons who anticipate close, personal contact with an international
adoptee during the first 60 days after arrival in the U.S. from a country
with high or intermediate endemicity (administer the 1st dose as soon as
the adoption is planned, at least 2 weeks before the adoptee’s arrival)
• Administer for post-exposure for all persons age 12 months or older
 Hep A vaccine or IG may be administered to persons age 40 years or
older, depending on the provider’s risk assessment
MMWR/ February 15, 2019 / 68(6);153–156 MMWR November 2, 2018; 67(43); 1208–1210 MMWR 2018; 67(43); 1216-1220

Hepatitis B Vaccine
• Dose 1 @ birth
• Dose 2 @ 1-2 months of age
 at least 1 month after first dose
• Dose 3 @ 6-18 months of age
 minimum of 4 months after the first dose
 minimum of 2 months after the second dose but not before an infant
is 24 weeks of age
• Administration of 4 doses is permitted when a combination vaccine
containing HepB is used after the birth dose

HEPLISAV-B (HepB-CpG)
Administration
• 2-dose vaccine series administered at least 4 weeks apart (0, 1 month) via IM injection
• Licensed for use in persons ≥ 18 years
Dosing Schedule
• The 2-dose series ONLY applies when both doses are Heplisav
• A series consisting of 1 dose of Heplisav and a different Hep B vaccine, should consist of
3 total doses using the 3-dose schedule minimum intervals
• Doses administered at less than the recommended minimum interval should be repeated
Serologic Testing
• Post vaccination Serologic Testing is recommended 1-2 months after final dose for:
 hemodialysis patients; immunocompromised persons, including those with HIV;
healthcare personnel and/or partners of HBsAg-positive persons
MMWR Recommendations and Reports/ Vol. 67/ No. 15/ April 20, 2018
https://www.cdc.gov/vaccines/schedules/vacc-updates/heplisav-b.html

Haemophilus influenzae type b
(Hib)
• 4-dose series at 2, 4, 6, and 12-15 months (ActHIB, Hiberix, or Pentacel)
• 3-dose series at 2, 4, and 12-15 months (PedvaxHIB)
• Administer 1 dose for unvaccinated children ages 15-59 months
• Refer to catch-up immunization schedule for other catch-up guidance
Special situations
• Refer to immunization schedule notes for guidance when vaccinating high
risk children with medical indications (i.e. chemo, radiation, HSCT,
asplenia, elective splenectomy, HIV and immunoglobulin deficiency, early
complement deficiency)

HPV Vaccine
• All adolescents 11-12 years old (can start at age 9)
• Number of doses dependent on age at initial vaccination
 Age 9-14 years: 2-dose series at 0 and 6-12 months (minimum interval
of 5 months; repeat dose if administered too soon)
 Age 15 years or older: 3-dose series at 0, 1-2 months, and 6 months
• Persons who completed a valid series with any HPV vaccine do not need
any additional doses
• Through 26 years old, if not previously adequately vaccinated

HPV Vaccine for
Special Population and Situations
Special situations
• Immunocompromised: aged 9-26 years, administer 3-dose
series
• History of sexual abuse or assault: begin series at age 9
• Pregnancy: vaccine is not recommended during pregnancy
 If administered inadvertently while pregnant, no intervention
needed-delay further doses until after pregnancy
 Pregnancy testing not needed before vaccination

Influenza Vaccines
for 2018-2019 Season in the U.S.
• Trivalent Vaccines (IIV3):
 A/Michigan/45/2015 (H1N1)
 A/Singapore/INFIMH-16-0019/2016 (H3N2)-like virus (NEW)
 B/Colorado/06/2017-like virus (Victoria lineage)- like virus (NEW)
• Quadrivalent Vaccines (IIIV4) will also include:
 B/Phuket/3073/2013-like virus (Yamagata lineage)- like virus
• ACIP recommends annual influenza vaccine for all persons 6 months of
age and older who do not have contraindications
Recommendations and Reports Vol. 67 / No. 3 MMWR / August 24, 2018

FluMist Medimmune Nasal Spray
(LAIV4)
FluMist Medimmune nasal spray is licensed for healthy persons 2 through 49 years of age
Administration
• Pre-filled single-use sprayer contains 0.2mL of vaccine
• Ensure patient is in upright position
• 0.1mL to be sprayed into first nostril, then dose divider clip is removed from the sprayer
to administer second half of dose (remaining 0.1mL) into other nostril
Contraindications
• Children 2-4 yrs. of age with a diagnosis of asthma or who have had a history of
wheezing in the past 12 months; asthma in people 5 yrs. of age and older
• Persons who are immunocompromised, by medication or disease
• Close contacts and caregivers of severely immunosuppressed persons
• Pregnant women
• Persons who have received influenza antiviral medications within the previous 48 hrs
MMWR Recommendations & Reports/Vol. 67/No. 3, August 24, 2018
https://www.cdc.gov/flu/about/qa/nasalspray.htm

Product Updates
FDA licensure and labeling changes:
• January 23, 2019 FDA approved use of the 0.5mL dose of Sanofi’s Fluzone
Quadrivalent influenza vaccine to include children age 6 through 35
months
• Approval of Afluria Quadrivalent (Seqirus) and Flublok Quadrivalent
(Protein Sciences)
• Expansion of the age indication for FluLaval Quadrivalent (GSK) and
Fluarix Quadrivalent (GSK) to age 6 months and older (previously licensed
for persons 3 years and older)
• Expansion of the age indication for Afluria (Seqirus) to include persons 5
years and older (previously recommended for persons 18 years and older)
• CDC published ACIP’s recommendations for the use of quadrivalent live
attenuated influenza vaccine (LAIV4) in the 2018-19 influenza season

Dosing Algorithm for Children
Recommendations and Reports Vol. 67 / No. 3 MMWR / August 24, 2018

Measles, Mumps, Rubella
• 2- dose series at ages 12 through 15 months and 4 through 6 years (dose
2 may be given as early as 4 weeks after the 1st dose)
• Unvaccinated children and adolescents: 2 doses at least 4 weeks apart
Special situations
• International travel: 1 dose prior to departure for infants ages 6-11
months followed by routine 2 dose series at 12-15 months (12 months for
children in high-risk areas) and dose 2 as early as 4 weeks
• Administer a 2 dose series at least 4 weeks apart for unvaccinated children
12 months and older, prior to departure

Varicella
• 2-dose series at 12 through 15 months and 4 through 6 years
• The 2nd dose may be given as early as 3 months after the 1st dose (a dose
given after a 4-week interval may be counted)
• Administer 2 doses to persons 7-18 years without evidence of immunity
• Ages 7-12 years routine interval between doses 3 months (minimum
interval: 4 weeks)
• Ages 13 years and older minimum interval 4 weeks between doses
• The maximum age for use of MMRV is 12 years old

Varicella Immunity
ACIP considers evidence of immunity to varicella to be:
• Documentation of 2 doses of vaccine given no earlier than age 12 months,
with at least 3 months between doses for children younger than age 13
years, or at least 4 weeks between doses for people age 13 years and older
• U.S.-born before 1980*
• A healthcare provider's diagnosis of varicella or verification of history of
varicella disease
• History of herpes zoster, based on healthcare provider diagnosis
• Laboratory evidence of immunity or laboratory confirmation of disease
*Note: Year of birth is not considered as evidence of immunity for healthcare
personnel, immunosuppressed people, and pregnant women
MMWR 2007;56(RR-4); 16-17

MMRV (ProQuad®)
• May be administered to children 12 months through 12 years
of age
• Maximum age for MMRV use is 12 years old

Spacing of Live Virus Vaccines
and Other Products
• PPD and live virus vaccine
 Apply PPD at same visit as MMR
 If MMR given first, delay PPD 4 weeks or longer if not given during the
same visit
 If PPD given first, administer MMR when client returns for skin test
reading
• Spacing with antibody-containing products such as immune globulin (IG)
with live vaccines
MMWR 2007;56(RR-4); 16-17

Polio
• 4- dose series at 2, 4, 6 through 18 months, and 4 through 6 years
• Final dose after the fourth birthday and at least 6 months after the
previous dose
• 4 or more doses of IPV can be administered before the 4th birthday when
a combination vaccine containing IPV is used. However, a final dose after
the 4th birthday is still recommended
• Final dose to be given on or after the 4th birthday and at least 6 months
after the previous dose, regardless of the number of previous doses
• IPV is not routinely recommended for U.S. residents 18 years and older
In the first six months of life, use minimum ages and intervals only for travel to a polio-endemic region or during an outbreak

Pneumococcal Vaccines
(PCV13) (PPSV23)
Routine Recommendation for PCV13
• 4-dose series at 2, 4, 6, and 12-15 months
Catch-up vaccination for PCV13
• 1-dose for healthy children 24-59 months with any incomplete* PCV13
schedule
Special situations
• High risk conditions include: chronic heart disease, chronic lung disease,
diabetes, CSF leak, cochlear implants, asplenia, sickle cell, asplenia, HIV,
lymphomas, Hodgkin disease, chronic liver disease, alcoholism, etc.
• When both PCV13 and PPSV23 are indicated, administer PCV13 first.
PCV13 and PPSV23 should not be administered during the same visit

Serogroup A, C, W, Y Meningococcal Vaccines
• 2-dose series to be administered at 11-12 years old and 16 years old
• Age 13-15 years, administer 1-dose and booster at age 16-18 years
(minimal interval 8 weeks)
• 1-dose at age 16-18 years old
Special situations
• 1 dose for first year college students who live in residential housing (if not
previously vaccinated at age 16 years or older) or military recruits
• Refer to immunization schedule notes for additional guidance when
vaccinating clients with medical indications and/or traveling to
hyperendemic or epidemic countries

Serogroup B Meningococcal Vaccines
Clinical discretion
• May be given at clinical discretion to adolescents 16-23 years who are not
at increased risk (preferred age 16-18 years)
 Bexsero: 2 doses at least 1 month apart
 Trumenba: 2 doses at least 6 months apart. If 2nd dose given earlier than
6 months, give 3rd dose at least 4 months after the 2nd dose
Special situations
• Anatomic or functional asplenia, sickle cell disease, persistent
complement component deficiency (including eculizumab use)
 Bexsero: 2-doses at least 1 month apart
 Trumenba: 3-dose series at 0, 1-2, and 6 months
• Bexsero and Trumenba are not interchangeable

Rotavirus Vaccine
• Rotarix: 2-dose series at 2 and 4 months
• RotaTeq: 3-dose series at 2, 4, and 6 months
• If any dose in the series is either RotaTeq or unknown, default to 3-dose
series
• Do not start the series on or after age 15 weeks, 0 days
• Maximum age for final dose is 8 months, 0 days

Just as a reminder……
Regardless of:
• the availability of vaccine
• the funding of the vaccine (VFC, state-supplied, or private
stock)
• whether the vaccine is required for school or child care or
not……….
FOLLOW ACIP Recommendations!!!

Test Your Knowledge!
Q: We have adolescents in our practice who have received the
first 2 doses of the HPV series 1 or 2 months apart according to
the 3-dose schedule. Can we consider their HPV vaccine series to
be complete or do we need to give these patients a third dose?
A: People who have received 2 doses of HPV vaccine separated by
less than 5 months should receive a third dose 6–12 months after
dose #1 and at least 12 weeks after dose #2.

Q: Which patients should receive a 2-dose schedule of Trumenba
(MenB, Pfizer)?
A: Healthy adolescents who are not at increased risk for
meningococcal disease should receive 2 doses of Trumenba
administered at 0 and 6 months. If the second dose is given at an
interval of less than 6 months, a third dose should be given at
least 4 months after the 2nd dose.
Recommended Immunization Schedule for Children and Adolescents Aged 18 years or younger, United States, 2017

Q: If someone received MPSV4 or MenACWY at age 9 years, will
two additional doses of MenACWY be needed?
A: Yes. Doses of quadrivalent meningococcal vaccine (either
MPSV4 or MenACWY) given before 10 years of age should not be
counted as part of the routine 2-dose series. If a child received a
dose of either MPSV4 or MenACWY before age 10 years, they
should receive a dose of MenACWY at 11 or 12 years and a
booster dose at age 16 years.
Recommended Immunization Schedule for Children and Adolescents Aged 18 years or younger, United States, 2017

Requirements for School and Childcare
Attendance

Goal
• Vaccines work
Goal 100 % compliance rate
• Immunization Laws work
• Partnerships work

JOB AIDS

3231 REQ

3231 INS

School Requirement Updates
• 3231 INS updated December 2017

Certificate of Immunization
(Form 3231)
• Certificate on file at each facility or school
• Photocopies acceptable
• A licensed Georgia physician, APRN, PA or public health official
is responsible for completing the certificate
• Only physician offices and health clinics can obtain blank
certificates

Valid Certificates
All certificates must be marked with:
• Child’s name
• Birth date
• Name and Address of Physician, APRN, PA, Qualified Board of
Health official or State Immunization Office Official
• Certified Signature
• Date of Issue

Expiration Date
• Expires on the date entered as “Expiration Date”
• Must be replaced with a current certificate within 30 days
• Required for all children less than age four years
• Required for all children ages four through ten years who have
not completed K through 6th grade requirements or children
10 years and older who have not completed 7th grade or higher
requirements
• Required if a medical exemption for a vaccine(s) is marked

“Complete for School Attendance”
• Issued only to children who:
 Are four years of age or older;
and
 Have met all the requirements
for school attendance as
outlined in the Policy Guide
3231REQ; and
 Have all the required vaccine
administration dates or natural
immunity dates filled in; and
 Do not have a “Date of
Expiration”

Exemptions
Medical
• Physical disability or condition
• Documented in the medical exemption box indicated for each
vaccine
• Reviewed annually

Exemptions
Religious
• Documented on form 2208
• Form kept on file by the
school or facility in lieu of
a Certificate of
Immunization (form 3231)
• Do not expire

School Requirement Updates
• DPH Rules and Regulations 511-2-2-.07

Child Care Requirements
• Number of vaccine doses
• Always need more doses
• Must have a current “expiration date”

School Requirements
• Any “new entrant” enrolling in a Georgia school at any grade or
level, must be age appropriately immunized with required
vaccines
• Number of doses depends on the child’s age
• “Complete for 7th Grade or higher ” is marked; certificate is
complete

3: Completing both boxes: When all
requirements have not been met
10: “Complete for School” checked for child
under age 4
9: No dose DTaP after 4th birthday
2: Doses Hep B spaced incorrectly
7: 1st dose MMR given before age 1 yr.
6: 1st dose varicella given before age 1 yr.
8: No 2nd dose varicella documented
5: Varicella Immunity not
documented by vaccine or
hx/dx/serology date
4: Address and/or contact information not
completed
1: No physician, APRN or PA signature
11. No dose of Tdap or MCV4 for students born on or after 1-
1-2002 entering 7th grade or “new entrants”

Filing of Certificates
• Available for inspection by
health officials
• Photocopy acceptable
• Sent copy to the new
school/facility
• In the case of religious
exemption, form 2208 must be
on file in lieu of form 3231

Tickler Filing System
Instructions located in the
Immunization Guidelines for
Child Care Facility Operators &
School Personnel (Form 3258)
• Set up by month and year
• Parent reminders
• Summary of GA
Immunization requirements
• Document follow-up
• Enforce requirements

GRITS

Responsibilities
• Physicians and Public Health Clinics
• Child Care and School
• Parent/Caregiver

Become a Vaccine Champion!!
Critical Elements
• Appropriate storage and
handling of all vaccines
• Correct administration of
vaccines
• Education of patients and
parents about vaccines
• Every office and clinic needs a
vaccine champion

Vaccine Champion
Key Characteristics
• Lead your immunization team
• Educate all staff about new vaccines and recommendations
• Educate new staff about vaccine storage, handling, & administration
• Initiate processes to improve immunization rates in your practice/facility
• Assure immunizations of all staff are up-to-date

Improve Access To Immunizations
• Immunization only visits
• Walk-ins for immunizations
• Implement standing orders
• Early, extended, or weekend hours
• Mass vaccination clinics

VAERS
Public Health Reports should be faxed or mailed to the State Immunization Program. Fax number
(404)657-1463

Vaccine Injury Compensation Program (VICP)
The National Vaccine Injury Compensation Program provides
compensation to individuals found to be injured by or have died
from certain childhood vaccines
• Established in 1988 by NCVIA
• Federal “no fault” system to compensate those injured
• Claim must be filed by individual, parent or guardian
• Must show that injury is on “Vaccine Injury Table”

Should We Report Vaccine Errors to VAERS?
• The Vaccine Adverse Event Reporting System (VAERS) accepts all reports,
including reports of vaccination errors
• VAERS is primarily for monitoring adverse health events, and we
encourage reporting of clinically significant adverse health events
following vaccination
• Using clinical judgment, healthcare professionals can decide whether or
not to report a medical error. For example, a healthcare professional
might choose to report a vaccination error if the error might pose a safety
risk (e.g., administering a live vaccine to an immunocompromised patient)
or the error would be preventable with public health action or education

Resources for Factual & Responsible
Vaccine Information
www.immunize.org

Stay Current!
Sign up for listserv sites which provide timely information
pertinent to your practice
• www.immunize.org/resources/emailnews.asp
• AAP Newsletter
• CDC immunization websites (32 in all)
• CHOP Parents Pack Newsletter
• IAC Express
• Websites specific to particular vaccines

Internet Resources
Georgia Department of Public Health
 http://dph.georgia.gov/immunization-section
 https://dph.georgia.gov/train-trainer
CDC Immunization information
 https://www.cdc.gov/vaccines/index.html
 Send your clinical vaccine questions to NIPINFO@cdc.gov
CDC Flu information
 https://www.cdc.gov/flu/
Immunization Action Coalition
 www.immunize.org

State Resources
• GA Immunization Program Office
 On call Help line: 404-657-3158
 GRITS Help Line: 1-866-483-2958
 VFC Help Line: 1-800-848-3868
 Website http://dph.georgia.gov/immunization-section
 Your local Immunization Regional Program Consultant (IRC)
 Epidemiology: 1-866-782-4584
• GA Chapter of the AAP
• GA Academy of Family Physicians

It’s a Team Effort!
High Immunization rates begin with a team designed
plan!
What can your team do to improve rates?

Childhood Immunization Update (Final 2019 TTT).pptx

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