Vaccine Update for Healthcare Providers

 Technically Speaking - Archive

Deborah L. Wexler, MD, Executive Director, Immunization Action Coalition

Catching-up" kids – and don’t forget the supplemental dose of PCV13

Healthcare providers often encounter children who are behind schedule for recommended vaccines. These children need to be "caught up." Children who are more than one month or one dose behind schedule should be put on an accelerated immunization schedule, which means the intervals between doses should be reduced to the minimum allowable until the child is up to date. Each year, the U.S. recommended child immunization schedule comes with a catch-up schedule that spells out the minimum spacing interval recommended between various vaccine doses.

When children fall behind on their vaccinations, it's best to get them caught up by administering all indicated vaccines at the same appointment. For more information on how to accomplish this, please refer to the December 2010 issue of "Technically Speaking."

Once you have the child back on schedule, counsel the parents about the importance of bringing the child in on time for future vaccinations.

Many children up to age 5 need a supplemental dose of PCV13

 In December 2010, ACIP recommended:

Unfortunately, CDC data from five Immunization Information System Sentinel Sites showed that only about half of children ages 12-23 months, and only a quarter of children ages 24-59 months, had received a supplemental dose of PCV13. Moreover, CDC surveillance indicated that the majority of children younger than age 5 years who were reported with invasive pneumococcal disease had not received a supplemental dose of PCV13. Please see the article in the November issue of AAP News, by Larry Pickering, MD, AAP Red® Book editor, on this subject.

So remember, when patients younger than age 5 years come to the office, check their immunization status to make sure that those who are recommended for a supplemental dose of PCV13 receive it. In addition, consider checking charts and recalling children who are behind, so they don't miss this important opportunity for protection against invasive pneumococcal disease.

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Which children need two doses of influenza vaccine for the 2011-2012 season?

The Centers for Disease Control and Prevention (CDC) has simplified its guidance about which children age 6 months through 8 years need two doses of influenza vaccine during the current (2011–12) influenza vaccination season:

The following information may be helpful:

Guidance on number of doses for children

Influenza information for healthcare professionals

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Screening patients for contraindications to vaccination

Before giving a dose of any vaccine, healthcare providers should carefully question patients or parents about contraindications and precautions to vaccination.

A table in ACIP's "General Recommendations on Immunization" lists contraindications and precautions to commonly used vaccines. This information is also available as an online chart on CDC’s website.

The Immunization Action Coalition (IAC) offers this same information in a formatted page and also offers a version covering only vaccines recommended for adults.

IAC also has ready-to-copy screening questionnaires that can help healthcare providers identify contraindications and precautions prior to administering vaccines. Parents or patients fill out the questionnaire while waiting to be seen by their healthcare provider. Having patients do this ahead of time saves time and ensures that all necessary questions are reviewed.

To access all of IAC’s screening questionnaires and their translations, visit IAC’s web page of screening questionnaires.

Sometimes healthcare providers misperceive certain health conditions (e.g., antibiotic use, mild upper respiratory or ear infections) as contraindications when they are not. This can result in missed opportunities to vaccinate. To make sure healthcare providers know the health conditions that are not contraindications to vaccination, CDC offers an online chart titled "Conditions Commonly Misperceived as Contraindications to Vaccination."

With appropriate screening for true contraindications and precautions to vaccination, clinicians will ensure they provide all recommended vaccines while minimizing risk to their patients and keeping them on schedule.

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Guidance for busy clinics on prefilling your own syringes

The Immunization Action Coalition (IAC) frequently receives email inquiries from immunization staff asking if they can draw up vaccine into syringes ahead of time, especially before busy influenza or back-to-school vaccination clinics. The Centers for Disease Control and Prevention (CDC) discourages the practice of prefilling syringes because it can result in these undesirable outcomes:

Prefilling syringes might also violate basic medication administration guidelines, which state that an individual should administer only those medications he or she has prepared and drawn up him or herself.

Although pre-drawing vaccine is discouraged, immunization staff may pre-draw a limited amount of vaccine in a mass-immunization clinic setting if the following conditions apply:

At the end of the clinic day, discard any remaining syringes prefilled by staff. Never save these syringes for another day, and never attempt to put the vaccine dose back into a vial.

As an alternative to personally prefilling syringes, CDC recommends using manufacturer-supplied prefilled syringes, which are designed both for storage and administration. However, keep in mind that once you remove the syringe cap or attach a needle, the sterile seal is broken. You should either use the syringe or discard it at the end of the clinic day.

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Are your new patients missing their immunization records?

Vaccination providers often see patients who think their or their children's vaccinations are up to date but who do not have documentation of these vaccinations. According to the CDC, healthcare providers should only accept written records as evidence of vaccination – with two exceptions: Self-reports of receipt of influenza vaccine (given to any age person) and pneumococcal polysaccharide vaccine (PPSV; given to adults) can be accepted. Self-reports for any other vaccines without written and dated documentation should not be accepted. You should attempt to locate missing records whenever possible by:

If records cannot be located or will never be available because of the patient's situation (e.g., immigrant with no access to immunization records), revaccinate the patient using the age-appropriate vaccination schedule. Receiving extra doses of a vaccine does not pose a significant medical risk; instead it provides a boost to immunity if the patient was previously vaccinated.

Serologic testing for immunity is an alternative to vaccination for certain antigens (e.g., measles, rubella, hepatitis A, and tetanus). However, commercially available testing may not always be sufficiently sensitive or standardized to detect vaccine-induced immunity. Further, if the test does not indicate seroconversion, you will need to administer the needed vaccines anyway, likely requiring an additional appointment and, for the patient, possible increased out-of-pocket expenses.

ACIP's General Recommendations on Immunization (pages 27-29) includes detailed guidance on the use of questionable vaccination records for people vaccinated outside of the U.S. When you need to catch up an inadequately vaccinated person quickly, you can administer doses of all routine vaccines simultaneously (at the same visit, not in the same syringe). For children, use CDC's catch-up schedule to determine the necessary minimal intervals for additional doses.

Finally, remember to always give patients a record of any vaccines you administer to avoid confusion and receipt of unnecessary doses in the future. Print-outs from registries will serve this purpose. Also, some state health departments and medical practices make record cards available free of charge. If such cards are not available to you, and you would like to consider purchasing them, you can order them from the Immunization Action Coalition’s shopping page. You can choose from three styles of cards—for children, for adults, and for people of any age. If you would like to receive samples, send a request to IAC at admininfo@immunize.org.

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CDC’s "General Recommendations on Immunization" – make sure you have a copy!

In January 2011, CDC published "General Recommendations on Immunization: Recommendations of the Advisory Committee on Immunization Practices (ACIP)." This 61-page publication is a "must-have-at-your-fingertips" resource for healthcare professionals who administer vaccines.

Some of the topics covered in the general recommendations include:
 

Toward the end of the publication, you'll find 15 tables and six figures of practical information. Some of the tables you will likely refer to most often include:
 

Five of the six figures cover information about intramuscular and subcutaneous needle insertion; the final figure is a sample temperature log for monitoring refrigerators and freezers.

Make sure to circulate copies of these materials to all staff involved in vaccine administration (including providers) and post copies of the ones you find most useful in convenient locations to use as handy references.

Print your copy of the General Recommendations on Immunization»

You'll find yourself referring to this immunization "treasure" frequently.

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Administering multiple vaccines to a child during a single office visit

When infants and children need to be vaccinated, they often need to receive three or more injections, particularly if they are behind schedule. To make sure a child is fully protected as early as possible, the CDC and AAP recommend that at the next office visit, the child receive all the vaccines needed, no matter what the number (as long as there are no contraindications or precautions).

When a child needs several doses, it's sometimes necessary to give more than one intramuscular (IM) injection in a single muscle. The CDC recommends separating these IM injections by one inch or more. When administering subcutaneous (SC) injections, separate the doses in the fatty tissue by one inch or more, as well.

When giving a child two injections in the same anatomic area, it is important to document in the medical record the anatomic site where each vaccine was given. For example, when you give two vaccines in the same muscle, you might simply record which vaccine you gave in the "upper" portion of the injection area, and which in the “lower.” In this instance, your note in the patient chart might state, “DTaP: right thigh, upper; and Hib: right thigh, lower.”

For uniformity in providing vaccinations, it may be helpful if a medical practice chooses to consistently use a particular anatomic site for administering a specific vaccine. This can be done by using standardized charts called site maps. Site maps for administering vaccines to children of all ages are available for your review and use on the CDC website(PDF).

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Using Vaccine Information Statements (VISs) Correctly

CDC’s Vaccine Information Statements (VISs) provide a standardized way to present basic information about vaccine benefits and possible adverse events to patients. Before a healthcare provider vaccinates a child or an adult with a dose of any vaccine containing diphtheria, tetanus, pertussis, measles, mumps, rubella, polio, hepatitis A, hepatitis B, Hib, influenza, pneumococcal conjugate, meningococcal, rotavirus, human papillomavirus, or varicella vaccine, the provider is required by the National Childhood Vaccine Injury Act to provide a copy of the VIS to the parent/legal representative of the child who is receiving the vaccine or to the adult vaccine recipient.

The VIS must be provided before the vaccine is administered and must be offered before every dose of the vaccine. It is acceptable to have the patient read the VIS on an office computer or in a more permanent (e.g., laminated) format during the office visit, but the patient must also be offered a paper copy of the VIS to take home.

Federal law requires not only that the clinician provide a VIS to the patient, but also that the date the VIS is given to the patient and the VIS publication date are recorded in the patient's chart. It is important to use the most recent version of a VIS.

The website of the Immunization Action Coalition (IAC) has the following resources related to VISs, all of which are available at http://www.immunize.org/vis:

The release of new and revised VISs, as well as the availability of new VIS translations, is announced in IAC’s free weekly e-mail news service, IAC Express. To subscribe, visit www.immunize.org/subscribe.

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Use of vaccines with diluents

Most vaccines come ready to administer in vials or prefilled syringes. However, 11 vaccines need to be reconstituted before being administered: ActHib®, Hiberix®, Menveo®, Menomune®, M-M-R II®, Pentacel®, ProQuad®, Rotarix®, TriHIBit®, Varivax®, and Zostavax®.

To reconstitute a vaccine, a lyophilized (freeze-dried) vaccine in one vial must be mixed with a diluent (liquid) in another. Diluents are not just for dissolving vaccines---they are designed to meet an individual vaccine's specific requirements in terms of volume, sterility, pH, and chemical balance. In addition, certain vaccine diluents include some of the antigens that are components of the vaccines. For example, the diluent for Pentacel includes DTaP and IPV antigens, and Menveo's diluent contains the MenCYW serogroup antigens. See Vaccines with Diluents: How to Use Them for details.

In most cases, diluents are not interchangeable (except for the sterile water used in Merck's M-M-R II, ProQuad, Varivax, and Zostavax). If the wrong diluent is used, the vaccination will always need to be repeated. If an inactivated vaccine is reconstituted with the wrong diluent and is administered, the dose is invalid and should be repeated ASAP. If a live vaccine is reconstituted with the wrong diluent and is administered, the dose is invalid and if it can’t be repeated on the same clinic day, it needs to be repeated no earlier than four weeks after the invalid dose. This spacing is due to the effects of generating a partial immune response that could suppress the live replication of subsequent doses, even of the same live vaccine.

To minimize loss of vaccine potency, healthcare staff should reconstitute a vaccine just before administering it. Some vaccines must be discarded unless they are given immediately or within 30 minutes after they are reconstituted. Each vaccine’s package insert gives detailed instructions for reconstituting the product. It's important to read the instructions carefully BEFORE reconstituting the vaccine.

The Immunization Action Coalition (IAC) has developed a handout that lists all vaccines that require diluents, the substance(s) in each freeze-dried vaccine, the substance(s) in each diluent, and the time limit before the reconstituted vaccine product must be discarded. Check out "Vaccines with Diluents: How to Use Them" for more information»

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Proper vaccine administration

It’s essential that all clinic staff members are well trained in proper vaccine administration technique. Unfortunately, vaccine administration errors are not uncommon and may result in having to recall patients and repeat doses. Avoiding vaccine administration errors will save your clinic time, money and potential embarrassment.

The Immunization Action Coalition (IAC) receives frequent inquiries from healthcare professionals regarding vaccine administration errors and what to do about them (e.g., “do I repeat the dose, and if so, when?”) The most common vaccine administration errors include:

To prevent these errors from happening in your practice, make sure everyone is well trained and use a standardized system throughout the office. Resources are available to help train your staff and provide periodic refreshers during staff meetings:

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