Deborah L. Wexler, MD, Executive Director, Immunization Action Coalition
Official immunization recommendations and vaccine product information are available online in several locations. The Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices (ACIP) publishes vaccination guidance for people of all ages, while the American Academy of Pediatrics (AAP) provides similar guidance for children and teens. The Food and Drug Administration (FDA) licenses new vaccines and approves additional indications for vaccines already in use, as well as requiring proper product labeling and the use of package inserts.
Quickly locating these important details can be challenging for busy healthcare professionals. But the Immunization Action Coalition (IAC) website makes accessing this information easy. With a visit to IAC's “Vaccine Policy and Licensing” Web section, you'll find links to ACIP and AAP vaccine recommendations, as well as FDA-approved package inserts. Here's what you'll find:
If you're not already a subscriber, be sure to sign up for IAC's free weekly vaccine news and information service, IAC Express for another way to stay current about what’s new in the world of vaccine recommendations. It's free of charge and provides information about newly released and updated ACIP and AAP recommendations, as well as details about newly licensed vaccines. Subscribing is easy!
For vaccinators, new and challenging questions typically surface every influenza season. And, this certainly is true for the 2013-2014 season, in which a number of new influenza vaccine products are available for use. Immunization experts from the Centers for Disease Control and Prevention (CDC) are here to help! Just in time for influenza season, you’ll find an up-to-date collection of more than 70 influenza-related Q&As on the Immunization Action Coalition’s (IAC) website.
“Ask the Experts,” one of the most popular destinations for healthcare professionals on IAC’s website, offers clear, easy to understand answers to commonly asked questions about vaccines and their use. The team of experts from CDC’s National Center for Immunization and Respiratory Diseases who provide these answers includes medical officers Dr. Andrew T. Kroger and Dr. Iyabode Akinsanya-Beysolow and nurse educator Ms. Donna L. Weaver.
“Ask the Experts” includes answers to common yet challenging questions about influenza vaccines and their administration such as:
While you’re visiting the “Ask the Experts” section on influenza, also be sure to visit the main “Ask the Experts” web page, which contains the table of contents for the entire range of questions about vaccine-preventable diseases, vaccines, and related vaccination topics.
The Immunization Action Coalition publishes new Ask the Experts Q&As at least five times a year in its weekly email news service IAC Express. Visit www.immunize.org/subscribe to subscribe to this free, informative service.
Twenty-five years ago, vaccines generally were not recommended for pregnant women. My, how things have changed! Although certain vaccines should not be given during pregnancy, two vaccines are specifically recommended during this time, and a few additional vaccines are recommended for pregnant women when indicated because of certain risk conditions.
So how do you keep these variations straight? This column provides an overview of the immunization recommendations for pregnant women and gives links to helpful resources, including a new handout, “Vaccinations for Pregnant Women,” created collaboratively by the American College of Obstetricians and Gynecologists (ACOG) and the Immunization Action Coalition (IAC). This great handout was designed to share with pregnant women to remind them about the vaccines they need.
Two vaccines — inactivated influenza vaccine and Tdap (tetanus-diphtheria-acellular pertussis) — are specifically recommended for pregnant women.
Several inactivated vaccines fall into a middle ground. Although they are not recommended for all pregnant women, they should be given if the woman has a particular risk condition — health, occupational, or other — indicating a need for a particular vaccine. These vaccines include hepatitis A, hepatitis B, meningococcal, and pneumococcal (PCV13 and PPSV23), all of which are safe to administer during pregnancy.
The vaccines that should not be given to pregnant women include
Healthcare professionals should try to ensure all women of childbearing age are up to date with their recommended vaccines before they try to conceive.
A patient's physical exam usually begins with checking vital signs of pulse, respiratory rate, blood pressure and temperature. But when checking your vaccine supply, only one “vital sign” — temperature — must be monitored to assure your vaccines remain viable. Regular monitoring of vaccine storage temperatures is critical to ensuring quality patient care.
The November 2012 issue of Technically Speaking highlighted the Centers for Disease Control and Prevention’s (CDC) Vaccine Storage & Handling Toolkit, which covers topics including routine storage and handling practices, proper storage and monitoring equipment, and inventory management. The toolkit also includes CDC's recommendation that only stand-alone units, i.e., self-contained units that only refrigerate or only freeze, be used for vaccine storage.
As a companion resource to the toolkit, CDC and the Immunization Action Coalition (IAC) have updated the popular vaccine temperature logs:
These logs provide a convenient tool for documenting storage unit temperatures a minimum of twice each workday, as recommended by CDC. They also have space to document daily minimum/maximum temperature readings. Twice-a-day monitoring is important even if temperatures are being assessed with a digital system. This proactive approach can prevent inadvertent loss of vaccine and the potential need for revaccination by assuring that temperature excursions are identified quickly so that immediate corrective action can be taken. This physical inspection also provides an opportunity to visually examine the storage unit, reorganize any vaccines that are inadvertently misplaced, and remove any expired vaccines.
In spite of appropriate monitoring, unacceptable vaccine storage events sometimes occur. For these instances, CDC and IAC have developed a new Vaccine Storage Troubleshooting Record. This one-page form leads clinic staff through a series of pertinent questions so they can document both the circumstances of the event and the subsequent actions taken. Most importantly, the form helps users identify ways to prevent similar problems from occurring in the future. The form is available both as a stand-alone document and as part of the vaccine temperature logs.
Be sure to use these updated resources to assist your clinic staff in monitoring storage unit temperatures, a “vital” aspect of ensuring vaccine viability.
For additional resources on vaccine storage and handling, visit the following:
Universal hepatitis B vaccination at birth is a major part of CDC’s Advisory Committee on Immunization Practices’ (ACIP) 2005 strategy to eliminate hepatitis B virus (HBV) transmission in the United States.
In 2011, the U.S. Department of Health & Human Services (HHS) echoed ACIP’s recommendations in its Action Plan for the Prevention, Care and Treatment of Viral Hepatitis. HHS further recommended birth dose coverage as a standard of care and a national quality measure.
In 2012, the National Quality Forum endorsed a new standard that calls for reporting “Hepatitis B Coverage Among All Live Newborn Infants Prior to Hospital or Birthing Facility Discharge.”
Yet, despite expert consensus on the importance of a hepatitis B vaccine birth dose, nearly 1 in 3 U.S. newborns leaves the hospital unprotected. As a result, approximately 800 U.S. newborns become chronically infected each year because of perinatal exposure. These newborns would be afforded a “safety net” if a birth dose was universally administered before hospital discharge.
That’s why this July the Immunization Action Coalition (IAC) launched a major campaign aimed at urging the nation’s birthing institutions to adopt or strengthen their hepatitis B vaccine birth dose policies. The centerpiece of the campaign is a new, comprehensive guidebook, “Hepatitis B: What Hospitals Need to Do to Protect Newborns.” Endorsed by the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Obstetricians and Gynecologists, and the Centers for Disease Control and Prevention, the guide contains a wide range of resources to help birthing institutions establish, implement and optimize their hepatitis B birth dose policies.
The guidebook explains that universal hepatitis B vaccination is needed at birth because it:
Medical errors in perinatal settings that can lead to newborn HBV transmission include the following:
Administering the hepatitis B vaccine birth dose can circumvent potentially tragic outcomes and save lives.
With the launch of its new guidebook and corresponding Hepatitis B Birth Dose Honor Roll, which recognizes birthing institutions that have attained high birth dose coverage rates, IAC urges hospitals and birthing centers to Give birth to the end of Hep B. What better time than now to join the cause?
For more information and to download the guidebook, visit immunize.org/protect-newborns.
The regular “Technically Speaking” column by Dr. Wexler will return in the July 2013 issue. In the meantime, please take a few moments to check out the latest issues of Needle Tips and Vaccinate Adults as both always contain a lot of helpful information and resources.
The Immunization Action Coalition (IAC) has recently released its May 2013 issue of Needle Tips, for healthcare professionals who administer vaccines. Also available is Vaccinate Adults, a shortened version of Needle Tips, modified for those who work only with adult patients. Both are now available for downloading, printing and reading.
These publications contain ready-to-print educational materials for healthcare professionals and their patients, vaccine news highlights, and IAC’s popular “Ask the Experts” column with answers by CDC experts Andrew Kroger, MD, MPH; Donna Weaver, RN, MN; and Iyabode Akinsanya-Beysolow, MD, MPH.
To receive direct notification when new issues are published, subscribe at www.immunize.org/subscribe. On this page, you can also subscribe to IAC’s free weekly email news service, IAC Express, which keeps you up to date on immunization news between issues of IAC’s periodicals.
The recommendations and available products for meningococcal vaccination of high-risk infants and children have evolved since 2007 when ACIP first recommended vaccination of children age 2 to 10 years who are at increased risk for meningococcal disease. Published on March 22, 2013, the current recommendations summarize and compile all previous meningococcal recommendations. The current recommendations are complex; for example, in the recommendations for vaccinating people in certain risk groups, the number of recommended vaccine doses and products varies, and includes some off-label use. This column offers an overview of the meningococcal recommendations for vaccinating high-risk infants and children, and provides links to some valuable resources that will help healthcare professionals make appropriate vaccination decisions.
It is important to understand the differences between vaccines available for meningococcal immunization. The nomenclature for meningococcal vaccines is based on both the number of serotypes included in the vaccine and whether the vaccine is conjugate or polysaccharide. Menomune® (Sanofi Pasteur), the only polysaccharide meningococcal vaccine, is known as MPSV4, with the 4 denoting the number of serotypes in the vaccine. Two different licensed quadrivalent meningococcal conjugate vaccines — Menactra® (MCV4-D, Sanofi Pasteur) and Menveo® (MCV4-CRM, Novartis) — are known as MCV4. All three vaccines (the polysaccharide and both conjugates) include the same 4 serotypes (A, C, W and Y). Licensed in June 2012, MenHibrix® (Hib-MenCY; GSK) is indicated to prevent invasive disease caused by Neisseria meningitidis serogroups C and Y and Haemophilus influenzae type b (Hib). MenHibrix® protects only against meningococcal serogroups C and Y; it does not protect against serogroups A and W. In general, ACIP recommends routine meningococcal vaccination of children age 2 months and older who are at increased risk for meningococcal disease, including:
The recommended product, dosing schedule and interval for booster dose(s) vary based on many factors. For example, a 12-month-old infant traveling to Saudi Arabia should get two doses of MCV4-D, three months apart, but an infant with asplenia should get Hib-MenCY at ages 2, 4, 6, and 12–15 months. Due to these complexities, providers who use these vaccines should consider printing the following resources for reference when needed. These resources also include information about routine meningococcal vaccination of adolescents and recommendations for vaccinating high-risk adults.
Sometimes healthcare personnel inadvertently administer the wrong dose of a vaccine to a child or adult patient. This often happens with vaccines that come in both pediatric and adult formulations, such as hepatitis A and hepatitis B vaccines, which are available in both 0.5 mL and 1.0 mL formulations. Routinely used injectable influenza vaccines come in two dosing amounts as well, with 0.25 mL for use in children younger than age 3 years and 0.5 mL for people age 3 years and older. Below is some guidance on what to do when such dosing errors occur, and how to avoid these errors in the future.
If you’ve administered too large a dose (e.g., you’ve given an “adult” dose to a child) instead of the correct dose of hepatitis A, hepatitis B, or influenza vaccine, inform the patient, parent or guardian of the administration error and document it in the medical record. This dose counts as valid. Although it is unlikely that your patient will suffer any untoward side effects from receiving a “double dose” of vaccine, using larger-than-recommended dosages can result in excessive local or systemic concentrations of antigens or other vaccine constituents. When errors of this nature occur, it is important to assess how the error happened and to implement strategies to ensure they will not be repeated. Administering larger-than-recommended doses of any vaccine does not negate the need for subsequent recommended doses.
If you’ve administered a pediatric dose or half dose of a vaccine in error, consider the dose invalid and repeat it. Giving less than a full dose might result in inadequate protection. Revaccinate the patient with the appropriate dose according to recommendations specific to inactivated and live-virus vaccines. You may give the additional dose during the same visit if the error is discovered while the patient is still in the office.
If you’ve administered an injectable influenza vaccine product that is not licensed for use in a child the age of the child you have vaccinated, this is an administration error. In such a case, if you administered the correct dosage to the child, even though it is the wrong product, consider the dose valid and do not repeat it. Inform the patient, parent or guardian of the error and document it in the medical record.
Here are examples of some strategies you can implement to prevent administering the wrong dose of vaccine:
Early each year, CDC publishes updated versions of the recommended U.S. immunization schedules to reflect changes that occurred throughout the previous year. This year, for the first time, schedules for children, teens and adults were all published simultaneously. If you have not seen them, consult the January 28, 2013 supplement issue of Morbidity and Mortality Weekly (MMWR). Although the updates for 2013 were not vast, it is important that your office staff, as immunization providers, is aware of the updates and implement appropriate procedural changes if necessary.
To make your job easier, the Immunization Action Coalition (IAC) has designed two user-friendly documents that summarize guidance in the current CDC recommendations: Summary of Recommendations for Child/Teen Immunization and Summary of Recommendations for Adult Immunization. Every year, IAC updates both summaries to reflect the new and updated recommendations made throughout the year by CDC’s Advisory Committee on Immunization Practices (ACIP). The summaries distill hundreds of pages of ACIP recommendations for child, teen and adult immunization into two handy, easy-to-use documents.
Formatted as a four-page reference table of essential immunization information for healthcare professionals, each summary incorporates information from the most current U.S. immunization schedules. This includes the spacing between doses, schedules for catch-up vaccination, routes of administration, and contraindications and precautions for all routinely recommended vaccines in the United States. The child/teen summary covers vaccines recommended for people from birth through age 18 years, and the adult schedule covers vaccines recommended for people 19 years and older.
With new vaccines being licensed and the recommended immunization schedules growing more complex, it is difficult to keep all the details in one’s mind. Supplying all vaccine providers in your healthcare setting with copies of the summaries will help them follow the ACIP recommendations and avoid such scheduling errors as giving vaccines too close together or administering them by the wrong route. In addition, the summaries include pithy general advice, such as "any vaccine can be given with another" and "mild illness is not a contraindication," which will help you avoid missing opportunities to vaccinate.
The summaries have long proved their value--for almost two decades, they have been the most popular downloads from IAC's busy website for healthcare professionals, www.immunize.org. They have been reprinted in textbooks and state health department newsletters and distributed at countless medical, nursing, and public health conferences. Take a look at the freshly updated 2013 Summary of Recommendations for Child/Teen Immunization and Summary of Recommendations for Adult Immunization. Print the summaries on card stock and place them in every exam room for easy reference--you'll be glad you did!
At its October 2012 meeting, CDC’s Advisory Committee on Immunization Practices (ACIP) voted to expand its recommendation for the use of Tdap vaccine during pregnancy to provide further protection to pregnant women and infants from pertussis (whooping cough). The new recommendations call for administering Tdap to every pregnant woman during each pregnancy, regardless of previous Tdap vaccination history. Optimal timing for administering the dose is at 27 through 36 weeks’ gestation to maximize the maternal antibody response and the passive antibody transfer to the infant.
If Tdap is not administered during pregnancy and has not been administered at any time before the current pregnancy, Tdap should be given to the mother immediately postpartum, before leaving the hospital or birthing center.
Providers of prenatal care should implement a Tdap immunization program for all pregnant women to assure that all pregnant women and their babies are protected from pertussis.
Prior to this new guidance, the ACIP recommendation for the use of Tdap vaccine in pregnant women was to administer the vaccine during the latter half of pregnancy, beginning as early as the 20th week, to those pregnant women who were previously unvaccinated. Tdap was to be given as a one-time dose.
The recommendations voted on in October 2012 were published in December 2012 on the CDC website in a document titled Provisional Updated Recommendations on Use of Tetanus Toxoid, Reduced Diphtheria toxoid and Acellular Pertussis Vaccine (Tdap) for Pregnant Women*
Of the 27,550 cases of pertussis reported in 2010, 3,350 were in infants younger than 6 months of age, and 25 of those infants died. According to studies of pertussis cases in infants, the source of infection can be traced to the mother in 30 percent to 40 percent of cases.
Administering the Tdap dose likely provides protection against pertussis in early life, before and during the time the baby is receiving his or her first three doses of DTaP vaccine. Tdap will also protect the mother at the time of delivery, making her less likely to transmit pertussis to her infant.
*ACIP provisional recommendations become official CDC recommendations once they are accepted by the director of CDC and the Secretary of Health and Human Services and are published in MMWR. In the interim, ACIP provisional recommendations are made available by CDC so that providers have guidance to follow when implementing new recommendations.
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