VACCINATE ADULTS! March 17) from the Immunization Action Coalition

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Volume 20 – Number 1 March 2016 (Content current as of VACCINATE ADULTS! March 17) from the Immunization Action Coalition — www.immunize.org

Let’s Review! Healthy Patients Age 65 and Older Need Two Pneumococcal Vaccines Spaced One Year Apart

Despite the fact that more than a year has elapsed times that of any other ATE section, with more years and older, as long as recommended spacing since the Centers for Disease Control and Preven- than 20,000 visits in January alone. intervals are honored between vaccine doses. tion (CDC) first published its recommendations Let’s review the details of these recommenda- Please make sure your patients are vaccinated for use of two different pneumococcal vaccines tions. In 2014, followed by an update in 2015, according to CDC recommendations with pneu- (Prevnar [pneumococcal conjugate vaccine, PCV13, CDC published the following recommendations mococcal vaccines. And patients 65 and older may Pfizer] and Pneumovax [pneumococcal polysac- for the use of two pneumococcal vaccines in be behind on other routinely recommended vac- charide vaccine, PPSV23, Merck]) in healthy adults healthy adults age 65 years and older:1 cines. Remember to check your patient’s immuni- age 65 years and older, confusion abounds about • Administer 1 dose of Prevnar (PCV13) to zation status for zoster and Tdap, as well as annual the details of these recommendations. people age 65 years and older if they have influenza vaccine. The Immunization Action Coalition (IAC) not received a dose in the past. FOOTNOTES receives frequent inquiries about the use of pneu- − One year later, administer 1 dose of 1 The 2014 recommendations titled “Use of 13-Valent mococcal vaccines in older adults, including “Can Pneumovax (PPSV23). Pneumococcal Conjugate Vaccine and 23-Valent Pneu- I give the two vaccines at the same visit?” or “How • If your patient already received a dose of mococcal Polysaccharide Vaccine Among Adults Aged many months should I wait between doses of the Pneumovax at age 65 or older: >65 Years: Recommendations of ACIP” are available at www.cdc.gov/mmwr/preview/mmwrhtml/mm6337a4.htm. two vaccines?” IAC’s website for healthcare pro- − You don’t need to repeat Pneumovax. The 2015 recommendations titled “Intervals Between fessionals, www.immunize.org, continues to receive − However, make sure that all your patients PCV13 and PPSV23 Vaccines: Recommendations of ACIP” large numbers of visitors to its feature section age 65 and older who have not yet had are available at www.cdc.gov/mmwr/preview/mmwrhtml/ “Ask the Experts” (ATE) (www.immunize.org/ Prevnar receive one dose at least a year mm6434a4.htm. askexperts), where CDC experts answer ques- after the Pneumovax dose. 2 For patients vaccinated prior to age 65 due to high-risk conditions: tions about vaccines. The pneumococcal section (For patients who received any pneumococcal • If your patient received a dose of Prevnar at an age of ATE has been visited at a rate nearly three vaccine doses prior to age 65, see footnote 2.) younger than 65: In February, CDC published “Recommended − You do not need to repeat Prevnar. Adult Immunization Schedule, U.S., 2016 (see − Administer Pneumovax at age 65 years, allowing at least a 1-year interval between it and the earlier dose www.cdc.gov/vaccines/schedules/downloads/adult/ of Prevnar. What’s In This Issue adult-combined-schedule.pdf). The pneumococcal • If your patient received Pneumovax at an age younger vaccine recommendations are fully documented than 65: Healthy Patients >65 Need Two Pneumococcal in the schedule and its highly detailed footnotes. − You need to administer another dose of Pneumovax at age 65 or later (and at least 5 years after the last Vaccines Spaced One Year Apart...... 1 Medicare Part B fully covers pneumococcal dose), but first administer Prevnar if your patient vaccines. Both Prevnar and Pneumovax are cov- hasn’t had a dose, and then administer Pneumovax Ask the Experts: ered under Part B for Medicare recipients age 65 one year after the Prevnar dose. CDC Answers Your Questions...... 1 Vaccine Highlights: Recommendations, Schedules and More...... 5 to ensure they receive the PCV13 dose first? Screening Checklist for Vaccine Or should the provider not miss an oppor- Contraindications in Adults...... 6 Ask the tunity to give the PPSV23 and refer patients elsewhere for PCV13 in a year? Standing Orders Templates Experts The Advisory Committee on Immunization Prac- Available for Adults...... 7 tices (ACIP) recommends that pneumococcal The Immunization Action Coalition extends thanks vaccine-naïve people age 65 years and older should Take a Stand! Register for IAC’s to our experts, medical officer Andrew T. Kroger, MD, MPH, and nurse educator Donna L. Weaver, Standing Orders Workshops...... 8 Ask the Experts...continued on page 2 RN, MN, both with the National Center for Immu- • Vaccine Administration Guides: Copy nization and Respiratory Diseases at the Centers and Use Handy CDC-Reviewed Materials...... 9 for Disease Control and Prevention (CDC). MenB Vaccine Recommendations Immunization questions? and Standing Orders Template...... 10 Pneumococcal vaccines • Email [email protected]

Products You Can Purchase from IAC...... 11 If a provider does not yet stock pneumo- • Call your state health coccal conjugate vaccine (PCV13, Prevnar 13, department (phone numbers IAC’s Immunization Resources Order Form...... 12 Pfizer) for adults age 65 years and older but at www.immunize.org/ stocks pneumococcal polysaccharide vaccine coordinators) (PPSV23, Pneumovax 23, Merck), should that provider refer patients to another provider Vaccinate Adults! Ask the Experts...continued from page 1 IAC’s “Ask the Experts” team from the online at www.immunize.org/va Centers for Disease Control and Prevention Immunization Action Coalition receive PCV13 first, followed by PPSV23 one year 2550 University Ave. W., Suite 415 North later. If the provider is unwilling to stock PCV13, then Saint Paul, MN 55114 patients should be referred elsewhere to get PCV13 Phone: (651) 647-9009 Email: [email protected] first. The solution, of course, is to stock PCV13 and Websites: www.immunize.org PPSV23, both of which are covered by Medicare Part B. www.vaccineinformation.org www.immunizationcoalitions.org We have a healthy 66-year-old patient who received www.give2mcv4.org a dose of PPSV23 in January then received a dose Vaccinate Adults is a publication of the Immuni- of PCV13 five months later at a different facility. zation Action Coalition (IAC) for healthcare Should the PCV13 dose be repeated since it was professionals. Content is reviewed by the Centers for Disease Control and Prevention given earlier than the 1-year interval recommended (CDC) for technical accuracy. This publica- by ACIP? tion is supported in part by CDC Grant No. ACIP recommends that healthy people age 65 years Andrew T. Kroger, MD, MPH Donna L. Weaver, RN, MN U38IP000589. Content is solely the responsi- and older receive PCV13 first, then PPSV23 one year bility of IAC and does not necessarily represent the official views of CDC. ISSN 1526-1824. later. When PPSV23 has been given first, ACIP recommends an interval of one year before giving PCV13. Publication Staff assumed to be one calendar year. Receiving PPSV23 Editor: Deborah L. Wexler, MD What to do when doses of PPSV23 and PCV13 are Associate Editors: William L. Atkinson, given without the recommended minimum interval is a few days or weeks earlier than one calendar year after MD, MPH; Diane C. Peterson not addressed in the ACIP recommendations. The CDC PCV13 is not a medical problem. However, it could Consulting Editors: Teresa Anderson, DDS, subject matter experts have advised that in such a case, be a problem for reimbursement since Medicare will MPH; Marian Deegan, JD Editorial Assistant: Janelle T. Anderson, MA the dose given second does not need to be repeated. only pay for both vaccines if they are given at least 11 This is an exception to the usual procedure for a mini- months apart. Private insurance may have similar rules. IAC Staff Chief Strategy Officer: mum interval violation as described in ACIP’s General Here is the wording from the Centers for Medicare and L.J (Litjen) Tan, MS, PhD Recommendations on Immunization (see www.cdc.gov/ Medicaid (CMS): Associate Director for Research: mmwr/pdf/rr/rr6002.pdf, page 5). There is no evidence “An initial pneumococcal vaccine may be admin- Sharon G. Humiston, MD, MPH to support that there are benefits to repeating the dose of Coordinator for Public Health: istered to all Medicare beneficiaries who have Laurel Wood, MPA PCV13. Information about the recommended intervals never received a pneumococcal vaccine under Nurse Consultant: Pat Vranesich, RN, BSN between pneumococcal vaccines can be found at www. Medicare Part B. A different, second pneumococ- Coordinator for Hepatitis B Projects: cdc.gov/mmwr/pdf/wk/mm6434.pdf, pages 944–7. Lynn Pollock, RN, MSN cal vaccine may be administered 1 year after the first vaccine was administered (i.e., 11 full months Perinatal Hepatitis B Consultant: Diabetes is an indication for giving PPSV23 to Beth Rowe-West, BSN have passed following the month in which the last patients younger than age 65 years. Does this Policy Consultant: Sarah R. Landry, MA pneumococcal vaccine was administered).” Sr. Admin. for Grants and Leadership: include both insulin- and non-insulin-dependent Julie Murphy, MA diabetes? Senior Project Manager: Robin VanOss Why is there no recommendation for patients older Operations Manager: Casey Pauly Any diagnosis of diabetes, whether type 1 or type 2, is than 65 years to get a booster dose of PPSV23 Project Administrator: Chrystal Mann an indication for PPSV23. However, gestational dia- if they first received it at age 65 years or older? It IAC publishes a free email news service betes does not qualify as an indication for PPSV23. seems to me that their protection against pneumo- (IAC Express) and two free periodicals coccal disease would benefit from a booster dose For adults without high-risk conditions, a 1-year (Vaccinate Adults and Needle Tips). To sub- of PPSV23 five or ten years after the first dose. scribe, go to www.immunize.org/subscribe. interval is recommended between PCV13 and People age 65 and older should be given a second dose PPSV23 vaccines. What is the definition of a year? IAC, a 501(c)(3) charitable organization, of PPSV23 if they received the first dose 5 or more publishes practical immunization information Does it need to be exactly one year? We have years previously and were younger than 65 years at the for healthcare professionals to help increase provided PCV13 to some individuals during flu immunization rates and prevent disease. time of the first vaccination. Protection from a single season this year and told them to get the PPSV23 dose of PPSV23 at age 65 years or older is believed to The Immunization Action Coalition next year when they get their flu shot. What if is also supported by persist for 5–10 years. The benefit and safety of a they received their flu shot in November this year, Pfizer Inc., Merck Sharp & Dohme Corp., second dose given after age 65 years is uncertain. Until GlaxoSmithKline, Sanofi Pasteur, but return for their flu shot in October next year? such data are available, ACIP recommends only a single AstraZeneca, bioCSL Inc., Physicians’ What you describe is an excellent strategy for admin- dose at age 65 years or older. Alliance of America, Besse Medical, istration of PCV13 and PPSV23 to people age 65 years American Pharmacists Association, Mark and Muriel Wexler Foundation, and older. ACIP does not define “one year” but this is Ask the Experts...continued on page 3 • and many other generous donors. IAC maintains strict editorial independence in its publications. IAC Board of Directors Subscribe to IAC Express, the Immunization Action Coalition’s Stephanie L. Jakim, MD e-news and information service at www.immunize.org/subscribe Olmsted Medical Center Sheila M. Specker, MD University of Minnesota DISCLAIMER: Vaccinate Adults! is available to all readers free of charge. Some of the information in this issue is supplied to us by the Centers for Disease Control and Prevention in Atlanta, Georgia, and some information is supplied by third-party sources. The Immuniza- Debra A. Strodthoff, MD tion Action Coalition (IAC) has used its best efforts to accurately publish all of this information, but IAC cannot guarantee that the original Amery Regional Medical Center information as supplied by others is correct or complete, or that it has been accurately published. Some of the information in this issue is Deborah L. Wexler, MD created or compiled by IAC. All of the information in this issue is of a time-critical nature, and we cannot guarantee that some of the in- Immunization Action Coalition formation is not now outdated, inaccurate, or incomplete. IAC cannot guarantee that reliance on the information in this issue will cause no injury. Before you rely on the information in this issue, you should first independently verify its current accuracy and completeness. IAC is not licensed to practice medicine or pharmacology, and the providing of the information in this issue does not constitute such practice. Any claim against IAC must be submitted to binding arbitration under the auspices of the American Arbitration Association in St. Paul, Minnesota.

2 Vaccinate Adults! • March 2016 • Immunization Action Coalition • (651) 647-9009 • www.immunize.org • www.vaccineinformation.org Advisory Board Ask the Experts...continued from page 2 Sanofi Pasteur) in 2009, but no subsequent dose. She is now due for a booster. Should she receive Liaisons from Organizations 2 doses of MenACWY, 2 months apart, to catch Hepatitis B vaccine up, or just one dose? Bernadette A. Albanese, MD, MPH Council of State & Territorial Epidemiologists This situation is not addressed in the most recent ACIP A physician ordered a 40-mcg dose of hepatitis B Stephen L. Cochi, MD, MPH guidelines for meningococcal conjugate vaccine. It is Nat’l Ctr. for Immun. & Resp. Diseases, CDC vaccine for a hemodialysis patient. The clinic the CDC meningococcal subject matter expert’s opin- Bruce Gellin, MD, MPH does not stock the Recombivax HB 40-mcg/dose ion that this patient should receive 2 doses of Men- National Vaccine Program Office, DHHS dialysis formulation (Merck) and would like to ACWY separated by at least 8 weeks, followed by a Neal A. Halsey, MD Institute for Vaccine Safety, Johns Hopkins Univ. give 2 doses of Engerix-B 20-mcg/dose (GSK) for booster dose of MenACWY every 5 years thereafter. each dose in the series. Is this acceptable? Claire Hannan, MPH The concern is that having had only MPSV4 previ- Association of Immunization Managers Yes. If given on the same day as separate injections in ously, she may not have an adequate booster response Carol E. Hayes, CNM, MN, MPH separate sites, two Engerix-B 20-mcg doses can be to a single dose of MenACWY. American College of Nurse-Midwives counted as the equivalent of one Recombivax HB Gregory James, DO, MPH, FACOFP 40-mcg dose. According to the package insert, Engerix- American Osteopathic Association B is licensed for use in this manner. Vaccine package Samuel L. Katz, MD Meningococcal B vaccines Pediatric Infectious Diseases Society inserts for all vaccines are available at www.immunize. Elyse Olshen Kharbanda, MD, MPH org/packageinserts. I know the schedule for Trumenba (meningococ- Society for Adolescent Health and Medicine cal serogroup B vaccine, Pfizer) is 0, 2, and 6 Marie-Michele Leger, MPH, PA-C American Academy of Physician Assistants months. What are the MINIMUM intervals Lisa M. McKeown, MPH Meningococcal ACWY vaccines between doses of Trumenba and Bexsero (menin- Nat’l. Assn. of County & City Health Officials gococcal serogroup B vaccine, GSK)? Our immu- Kathleen M. Neuzil, MD, MPH I have an HIV-positive 64-year-old patient who nization information system needs to know the American College of Physicians received meningococcal conjugate vaccine last minimum intervals in order to assure that patients Paul A. Offit, MD week. Was this the correct vaccine for this Vaccine Education Ctr., Children’s Hosp. of Phila. are appropriately vaccinated. patient or should he have gotten MPSV4 due to Walter A. Orenstein, MD Neither ACIP nor the CDC meningococcal subject Emory Vaccine Center, Emory University his age? Also, should this patient get another matter experts have addressed this issue. Given the Mitchel C. Rothholz, RPh, MBA dose in 2 months? lack of guidance, we must assume that the routine American Pharmacists Association Quadrivalent meningococcal conjugate vaccine (Men- Thomas N. Saari, MD intervals are also the minimum intervals: for Trumenba, ACWY [MCV4]: Menactra, Sanofi Pasteur; Menveo, American Academy of Pediatrics 8 weeks between doses 1 and 2, 4 months between GSK) was the correct vaccine in this situation. The 2013 William Schaffner, MD doses 2 and 3, and 6 months between doses 1 and 3; Infectious Diseases Society of America ACIP recommendations on meningococcal vaccination for Bexsero, 4 weeks between doses 1 and 2. It is Anne Schuchat, MD recommend the use of meningococcal conjugate vac- Centers for Disease Control and Prevention important to use these intervals when scheduling doses. cine in adults age 56 years and older who (1) were Rhoda Sperling, MD However, if these intervals are violated, the doses still vaccinated previously with MenACWY and now need Amer. College of Obstetricians & Gynecologists count and do not need to be repeated. Thomas E. Stenvig, RN, PhD revaccination, or (2) are recommended to receive American Nurses Association multiple doses. ACIP does not consider HIV infection I have a patient who was given Trumenba in August. Kimberly Martin alone to be an indication for MenACWY vaccine. Two months later she was given a dose of Assn. of State & Territorial Health Officials However, if the decision is made to vaccinate a person Ann S. Taub, MA, CPNP Bexsero. How should I proceed with her MenB National Assn. of Pediatric Nurse Practitioners with HIV infection, the patient should receive 2 doses vaccination series? We stock both vaccines. John W. Ward, MD of MenACWY separated by 8–12 weeks. Both Men- The ACIP meningococcal serogroup B vaccine recom- Division of Viral Hepatitis, NCHHSTP, CDC ACWY vaccines are licensed for use in people through mendations (www.cdc.gov/mmwr/pdf/wk/mm6441.pdf, Patricia N. Whitley-Williams, MD, MPH age 55 years, which means that the use of these vac- pages 1171–6) state that the same vaccine must be used National Medical Association cines in people age 56 and older is off-label but recom- Walter W. Williams, MD, MPH for all doses in the MenB series. So the clinician needs Nat’l Ctr. for Immun. & Resp. Diseases, CDC mended by ACIP. to complete a series with one or the other vaccine. If a person has already received 1 dose of Bexsero and one Individuals We have a 68-year-old who has been asplenic of Trumenba, then pick a brand and finish a recom- Hie-Won L. Hann, MD since 2009. She had one dose of meningococcal mended schedule with that brand. Ignore the extra dose Jefferson Medical College, Philadelphia polysaccharide vaccine (MPSV4, Menomune, Mark A. Kane, MD, MPH of the other product. The next dose in the series (either Seattle, Washington Trumenba or Bexsero) should be separated from the Edgar K. Marcuse, MD, MPH previous dose of Bexsero by at least 1 month. University of Washington School of Medicine Harold S. Margolis, MD Stay current with FREE subscriptions Taos, New Mexico Brian J. McMahon, MD The Immunization Action Coalition’s Tdap vaccine Alaska Native Medical Center, Anchorage 2 periodicals, Vaccinate Adults and Stanley A. Plotkin, MD We would like to avoid stocking both Tdap and Td Vaxconsult.com Needle Tips, and our email news vaccines. Is CDC likely to recommend that Tdap Gregory A. Poland, MD Mayo Clinic service, IAC Express, are packed completely replace Td in the with up-to-date information. Sarah Jane Schwarzenberg, MD immunization schedule in the near future? University of Minnesota Subscribe to all 3 free publications in Currently, ACIP recommends giving only 1 dose of Coleman I. Smith, MD one place. It’s simple! Go to Tdap to adolescents and adults who have not previously Minnesota Gastroenterology, Minneapolis received the vaccine, with the exception of pregnant Richard K. Zimmerman, MD, MPH www.immunize.org/subscribe women, who should be vaccinated during each preg- University of Pittsburgh

Ask the Experts...continued on page 4 •

Vaccinate Adults! • March 2016 • Immunization Action Coalition • (651) 647-9009 • www.immunize.org • www.vaccineinformation.org Vaccinate Adults! • March 2016 • Immunization Action Coalition • (651) 647-9009 • www.immunize.org • www.vaccineinformation.org 3 Ask the Experts...continued from page 4 does not apply to zoster vaccine. The amount of children are covered by the program for all ages of antigen in zoster vaccine is high enough to offset patients). More information about the VICP is avail- any effect of circulating antibody. Also, studies of able on their website at www.hrsa.gov/vaccine nancy. ACIP is unlikely to recommend routine Tdap zoster vaccine were performed on patients who had compensation/index.html. revaccination for groups other than pregnant circulating antibody (because they had varicella women. Vaccine providers will need to continue to earlier in life) or who had received antibody-con- The protective cap on a single-dose vial was stock Td vaccine in order to administer it to patients taining blood products and there was no appreciable removed but the vaccine was not needed. who need to complete the full primary 3-dose teta- effect on efficacy. Some patients who receive IVIG No needle punctured the rubber seal. Accord- nus and diphtheria series and also to administer are immunosuppressed. Since immunosuppression ing to CDC’s Vaccine Storage & Handling 10-year booster doses of Td throughout the lifetime is a contraindication to zoster vaccine, it is impor- Toolkit, the vial without the cap should be of those who have completed the primary series. tant to screen to ensure a patient is not immuno- discarded at the end of workday. If no needle Note that if a person who previously received Tdap suppressed when administering zoster vaccine. punctured the seal, what is the reasoning needs a booster dose of Td (as a routine booster for discarding the vaccine? dose or for wound management), it is acceptable Before administering zoster vaccine is it Removing the protective cap increases the likeli- to administer Tdap if Td is not available. necessary to ask if the person has ever had hood the septum or stopper could be punctured. chickenpox or shingles? The puncture may not be visible. It is important to No. All people age 60 years or older, whether they ensure that the rubber seal on single-dose vials is Zoster vaccine have a history of chickenpox or shingles or not, not punctured because single-dose vials do not should be given zoster vaccine unless they have a contain a preservative. Once the protective cap has I know that ACIP only recommends zoster medical contraindication to vaccination. been removed, the vaccine should be discarded at vaccine for adults age 60 years and older, the end of the workday because it may not be pos- although it is licensed for use in those 50 years For patients age 60 or older who don’t sible to determine if the rubber seal has been and older. If I choose to vaccinate patients remember having chickenpox in the past, punctured. CDC’s Vaccine Storage & Handling age 50–59 years, are there any criteria as to should we test them for varicella immunity Toolkit is available at www.cdc.gov/vaccines/recs/ which patients in this age group might benefit before giving zoster vaccine? storage/toolkit. most from zoster vaccination? No. Simply vaccinate them with zoster vaccine For vaccination providers who choose to use zoster according to the ACIP recommendations. vaccine among certain patients age 50 through 59 years despite the absence of an ACIP recommendation, factors that might be considered include par- General vaccine questions Apply for IAC’s ticularly poor anticipated tolerance of herpes zoster or postherpetic neuralgia symptoms (e.g., attribut- What is the provider’s liability when Influenza Vaccination able to preexisting chronic pain, severe depression, using standing order protocols? Honor Roll or other comorbid conditions; or inability to tolerate While you did not say this explicitly, we assume treatment medications because of hypersensitivity the concern is about a vaccine injury in a person Join more than 500 health care or interactions with other chronic medications). who was vaccinated using a standing order. Of More information on this issue is available at www. course, as long as the person is properly screened settings already honored! cdc.gov/mmwr/pdf/wk/mm6044.pdf, page 1528. for contraindications and precautions, an injury from a vaccine is very unlikely. In the event that My patient is a 66-year-old male with a an injury does occur, the National Vaccine Injury condition that requires treatment with intra- Compensation Program (VICP) provides liability venous immune globulin (IVIG) once a month. protection for the vaccinator and the clinician who Can he receive zoster vaccine? signed the standing order for any vaccine that is Yes. The concern about interference by circulating covered by the vaccine injury compensation pro- antibody (from the IVIG) with varicella vaccine gram (all vaccines that are routinely administered to

This honor roll recognizes health- About IAC’s care settings that have implemented Question of the Week Ask the Experts mandatory vaccination policies for Each week, IAC Express health care personnel (HCP). highlights a new, topical, or important-to-reiterate Q&A. To find more than 1,000 To find the healthcare settings listed This feature is a cooperative Ask the Experts Q&As answered by state, visit www.immunize.org/ venture between IAC and honor-roll/influenza-mandates/ CDC. William L. Atkinson, by CDC experts, visit honorees.asp MD, MPH, IAC’s associate director for immunization www.immunize.org/ To read position statements sup- education, chooses a new askexperts porting mandatory HCP vaccination Q&A to feature every week from leading health care organizations from a set of Q&As prepared and professional medical societies by experts at CDC’s National Please encourage your healthcare professional or to apply, visit www.immunize.org/ Center for Immunization colleagues to sign up to receive IAC Express at honor-roll/influenza-mandates. and Respiratory Diseases. www.immunize.org/subscribe.

4 Vaccinate Adults! • March 2016 • Immunization Action Coalition • (651) 647-9009 • www.immunize.org • www.vaccineinformation.org IAC EXPRESS Get weekly updates Vaccine Highlights on vaccine information Recommendations, schedules, and more while it’s still news! All the news we publish in “Vaccine Editor’s note: The information in Vaccine High- Highlights” will be sent by email to lights is current as of March 17, 2016. More CDC news you every Wednesday. Free! To sign up for IAC Express – and any On Feb. 19, CDC published “Notes from the Field: of our other free publications – visit Next ACIP meetings Administration Error Involving a Meningococcal Conjugate Vaccine—U.S., Mar. 1, 2010–Sept. 22, www.immunize.org/subscribe 2015 in MMWR. In this report which examined The Advisory Committee on Immunization Prac- data from VAERS, the researchers found 407 tices (ACIP) is comprised of 15 national experts recipients in whom the meningococcal conjugate who advise CDC on the appropriate use of vac- vaccine Menveo (GSK) had been improperly cines. At its most recent meeting, held on Feb. 24, reconstituted and administered. See www.cdc.gov/ Vaccinate Adults correction policy the committee discussed HPV, influenza, cholera, mmwr/volumes/65/wr/mm6506a4.htm. If you find an error, please notify us immediately by meningococcal, and Japanese encephalitis vac- sending an email message to [email protected]. cines. The only vote taken during the meeting On Feb. 5, CDC published “Surveillance of Vacci- We publish notification of significant errors in our was to approve the 2016–17 influenza vaccination nation Coverage Among Adult Populations—U.S., email announcement service, IAC Express. Be sure recommendations. 2014,” in MMWR Surveillance Summary (www. you’re signed up for this service. To subscribe, visit www.immunize.org/subscribe. ACIP meets three times a year in Atlanta; meet- cdc.gov/mmwr/volumes/65/ss/pdfs/ss6501.pdf). ings are open to the public and viewable online via This report is based on data from CDC’s live webcast. The next meetings will be held on National Health Interview Survey (NHIS) and shows June 22–23 and Oct. 19–20. For more information, that vaccination coverage overall remained low for Human Services (HHS), released a National Adult visit www.cdc.gov/vaccines/acip. adults and that there continue to be missed oppor- Immunization Plan. It is available at www.hhs.gov/ ACIP periodically issues recommendations on tunities to vaccinate. nvpo/national-adult-immunization-plan/naip.pdf. the use of vaccines; they are published and readily On Dec. 18, 2015, CDC published “Notes from the available in the Morbidity and Mortality Weekly Field: Injection Safety and Vaccine Administra- Mandatory Influenza Vaccine Report (MMWR). Clinicians who vaccinate should tion Errors at an Employee Influenza Vaccination have a current set for reference. Here are sources:: Clinic—New Jersey, 2015,” in MMWR (www.cdc. The American Academy of Pediatrics published • Download from IAC’s website: www.immunize. gov/mmwr/pdf/wk/mm6449.pdf, pages 1363-4). the policy statement “Influenza Immunization for org/acip This article details the vaccine administration and All Health Care Personnel: Keep It Mandatory” in • Download from CDC’s website: www.cdc. vaccine storage and handling errors committed by a the October issue of Pediatrics and on its website gov/vaccines/hcp/acip-recs contracted health services company at an employee at http://pediatrics.aappublications.org/content/ influenza vaccination clinic and how the state pediatrics/136/4/809.full.pdf. CDC immunization schedules immunization program responded to the situation. CDC’s 47th National Immunization Conference Each year, CDC’s Advisory Committee on Immu- will be held Sept. 13–15, in Atlanta. For more Current VIS dates nization Practices publishes U.S. immunization information, visit www.cdc.gov/vaccines/events/ schedules for adults and children/teens to reflect nic/index.html. Check the dates on your supply of Vaccine current recommendations for the use of licensed Information Statements (VISs). If any are out- vaccines. dated, get current versions and VISs in more FDA vaccine news than 30 languages at www.immunize.org/vis. FOR ADULTS On Feb. 1, CDC published “Recommended Immu- Adenovirus...... 6/11/14 MMR...... 4/20/12 nization Schedule for Adults Aged 19 Years or On Dec. 22, 2015, FDA announced approval of Anthrax...... 3/10/10 MMRV...... 5/21/10 Older–U.S., 2016” online at www.cdc.gov/vac- Fluad (Novartis), a new injectable influenza vac- Chickenpox...... 3/13/08 Multi-vaccine...... 11/5/15 cines/schedules/downloads/adult/adult-combined- cine for use in people 65 years and older, the first DTaP...... 5/17/07 PCV13...... 11/5/15 schedule.pdf. The Feb. 5 issue of MMWR also seasonal influenza vaccine containing an adjuvant. Hib...... 4/2/15 PPSV...... 4/24/15 included an article summarizing the changes in See www.fda.gov/biologicsbloodvaccines/safety Hepatitis A...... 10/25/11 Polio...... 11/8/11 the 2016 adult schedule. It is available at www. availability/vaccinesafety/ucm473989.htm. Hepatitis B...... 2/2/12 Rabies...... 10/6/09 cdc.gov/mmwr/volumes/65/wr/pdfs/mm6504.pdf, On Dec. 14, 2015, FDA announced the expanded HPV-Cervarix...... 5/3/11 Rotavirus...... 4/15/15 pages 88–90. indication of Gardasil 9 (HPV9, Merck) to include HPV-Gardasil...... 5/17/13 Shingles...... 10/6/09 HPV-Gardasil 9.....4/15/15 Td...... 2/24/15 FOR CHILDREN AND TEENS males age 16–26 years. See detailed information Influenza...... 8/7/15 Tdap...... 2/24/15 On Feb. 1, CDC released the “Recommended Immu- at www.fda.gov/biologicsbloodvaccines/vaccines/ Japanese enceph...1/24/14 Typhoid...... 5/29/12 nization Schedules for Persons Aged 0 Through 18 approvedproducts/ucm426445.htm. MCV4/MPSV4....10/14/11 Yellow fever..... 3/30/11 Years, U.S., 2016” online at www.cdc.gov/vaccines/ MenB...... 8/14/15 schedules/downloads/child/0-18yrs-child-combined- schedule.pdf. The Feb. 5 issue of MMWR included HHS news  a summary article about the changes made for For a ready-to-print version of this table for 2016. See www.cdc.gov/mmwr/volumes/65/wr/ On Feb. 5, the National Vaccine Program Office posting in your practice, go to www.immunize. pdfs/mm6504.pdf, pages 86–87. (NVPO), part of the U.S. Department of Health and org/catg.d/p2029.pdf.

Vaccinate Adults! • March 2016 • Immunization Action Coalition • (651) 647-9009 • www.immunize.org • www.vaccineinformation.org 5 Use This Checklist to Screen for Contraindications and Precautions to Vaccines for Adults

Screening Checklist patient name • This checklist covers date of birth / / for Contraindications month day year precautions and contra- to Vaccines for Adults indications to vaccines For patients: The following questions will help us determine which vaccines you may be given today. If you answer “yes” to any question, it does not necessarily mean you should not be vaccinated. It just means for adults. additional questions must be asked. If a question is not clear, please ask your healthcare provider to explain it. don’t yes no know • Patients complete the 1. Are you sick today? □ □ □ checklist on page 1. 2. Do you have allergies to medications, food, a vaccine component, or latex? □ □ □ 3. Have you ever had a serious reaction after receiving a vaccination? □ □ □ • Page 2 provides detailed 4. Do you have a long-term health problem with heart disease, lung disease, asthma, kidney disease, metabolic disease (e.g., diabetes), anemia, or other blood disorder? □ □ □ information for healthcare

5. Do you have cancer, leukemia, HIV/AIDS, or any other immune system problem? □ □ □ professionals about why 6. In the past 3 months, have you taken medications that affect your immune system, each question is asked. such as prednisone, other steroids, or anticancer drugs; drugs for the treatment of □ □ □ rheumatoid arthritis, Crohn’s disease, or psoriasis; or have you had radiation treatments?

7. Have you had a seizure or a brain or other nervous system problem? □ □ □

8. During the past year, have you received a transfusion of blood or blood products, or been given immune (gamma) globulin or an antiviral drug? □ □ □

9. For women: Are you pregnant or is there a chance you could become pregnant during the next month? □ □ □

10. Have you received any vaccinations in the past 4 weeks? □ □ Information □ for Healthcare Professionals about the Screening Checklist for Contraindications to Vaccines for Adults Are you interested in knowing why we included a certain question on the screening checklist? If so, read the information below. If you want to find out even more, consult the references listed at the end. form completed by date 1. Are you sick today? [all vaccines] 7. Have you had a seizure or a brain or other nervous system problem? There is no evidence that acute illness reduces vaccine efficacy or increases vac- [influenza, Td/Tdap] cine adverse events (1). However, as a precaution with moderate or severe acute Tdap is contraindicated in people who have a history of encephalopathy within form reviewed by date illness, all vaccines should be delayed until the illness has improved. Mild illnesses 7 days following DTP/DTaP given before age 7 years. An unstable progressive (such as upper respiratory infections or diarrhea) are NOT contraindications to neurologic problem is a precaution to the use of Tdap. For people with stable vaccination. Do not withhold vaccination if a person is taking antibiotics. neurologic disorders (including seizures) unrelated to vaccination, or for people with a family history of seizure, vaccinate as usual. A history of Guillain-Barré 2. Do you have allergies to medications, food, a vaccine component, or latex? syndrome (GBS) is a consideration with the following: 1) Td/Tdap: if GBS has [all vaccines] occurred within 6 weeks of a tetanus-containing vaccine and decision is made to Did you bring your immunization record card with you? yes no continue vaccination, give Tdap instead of Td if no history of prior Tdap; 2) Influ- □ □ An anaphylactic reaction to latex is a contraindication to vaccines that contain enza vaccine (IIV/LAIV): if GBS has occurred within 6 weeks of a prior influenza latex as a component or as part of the packaging (e.g., vial stoppers, prefilled vaccine, vaccinate with IIV if at increased risk for severe influenza complications. It is important for you to have a personal record of your vaccinations. If you don’t have a personal record,syringe plungers, prefilled syringe caps). If a person has anaphylaxis after eating gelatin, do not administer vaccines containing gelatin. A local reaction to a prior ask your healthcare provider to give you one. Keep this record in a safe place and bring it with you every timevaccine dose or vaccine component, including latex, is not a contraindication 8. During the past year, have you received a transfusion of blood or blood to a subsequent dose or vaccine containing that component. For information on products, or been given immune (gamma) globulin or an antiviral drug? you seek medical care. Make sure your health care provider records all your vaccinations on it. vaccines supplied in vials or syringes containing latex, see reference 2; for an [LAIV, MMR, VAR, ZOS] extensive list of vaccine components, see reference 3. Certain live virus vaccines (e.g., LAIV, MMR, VAR, ZOS) may need to be deferred, An egg-free recombinant influenza vaccine (RIV3) may be used in people age 18 depending on several variables. Consult the most current ACIP recommenda- years and older with egg allergy of any severity who have no other contraindications for current information on intervals between antiviral drugs, immune globulin tions. People younger than age 18 years who have experienced a serious systemic or blood product administration and live virus vaccines. (1) or anaphylactic reaction (e.g., hives, swelling of the lips or tongue, acute respiratory distress, or collapse) after eating eggs can usually be vaccinated with inactivated influenza vaccine (IIV); consult ACIP recommendations (see reference 4). 9. For women: Are you pregnant or is there a chance you could become pregnant during the next month? [MMR, LAIV, VAR, ZOS]

3. Have you ever had a serious reaction after receiving a vaccination? Live virus vaccines (e.g., MMR, VAR, ZOS, LAIV) are contraindicated one month [all vaccines] before and during pregnancy because of the theoretical risk of virus transmis- sion to the fetus. Sexually active women in their childbearing years who receive History of anaphylactic reaction (see question 2) to a previous dose of vaccine live virus vaccines should be instructed to practice careful contraception for or vaccine component is a contraindication for subsequent doses (1). Under one month following receipt of the vaccine. On theoretical grounds, inactivated Technical content reviewed by the Centers for Disease Control and Preventionnormal circumstances, vaccines are deferred when a precaution is present. poliovirus vaccine should not be given during pregnancy; however, it may be However, situations may arise when the benefit outweighs the risk (e.g., during given if risk of exposure is imminent and immediate protection is needed (e.g., Saint Paul, Minnesota • 651-647-9009 • www.immunize.org • www.vaccineinformation.org a community pertussis outbreak). travel to endemic areas). Inactivated influenza vaccine and Tdap are both recommended during pregnancy. Both vaccines may be given at any time during preg- www.immunize.org/catg.d/p4065.pdf • Item #P4 0654. Do (2 you/1 have6) a long-term health problem with heart disease, lung disease, nancy but the preferred time for Tdap administration is at 27–36 weeks’ gestation. asthma, kidney disease, metabolic disease (e.g., diabetes), anemia, or (1, 4, 5, 6, 8, 9) other blood disorder? [LAIV] The safety of intranasal live attenuated influenza vaccine (LAIV) in people with 10. Have you received any vaccinations in the past 4 weeks? [LAIV, MMR, these conditions has not been established. These conditions, including asthma VAR, yellow fever] in adults, should be considered precautions for the use of LAIV. People who were given either LAIV or an injectable live virus vaccine (e.g., MMR, VAR, ZOS, yellow fever) should wait 28 days before receiving another vaccina- 5. Do you have cancer, leukemia, HIV/AIDS, or any other immune system tion of this type. Inactivated vaccines may be given at any spacing interval if they problem? [LAIV, MMR, VAR, ZOS] are not administered simultaneously. Live virus vaccines (e.g., LAIV, measles-mumps-rubella [MMR], varicella [VAR], zoster [ZOS]) are usually contraindicated in immunocompromised people. references However, there are exceptions. For example, MMR vaccine is recommended and 1. CDC. General recommendations on immu- 6. CDC. Prevention of varicella: Recommenda- varicella vaccine should be considered for adults with CD4+ T-lymphocyte counts nization, at www.cdc.gov/mmwr/pdf/rr/ tions of the Advisory Committee on Immu- of greater than or equal to 200 cells/µL. Immunosuppressed people should not rr6002.pdf. nization Practices. MMWR 2007; 56 (RR-4). receive LAIV. For details, consult the ACIP recommendations (4, 5, 6). 2. Latex in Vaccine Packaging: www.cdc.gov/ 7. Tomblyn M, Einsele H, et al. Guidelines vaccines/pubs/pinkbook/downloads/ for preventing infectious complications appendices/B/latex-table.pdf among hematopoietic stem cell transplant For a ready-to-copy 8½ x 11" of 6. In the past 3 months, have you taken medications that affect your immune recipients: a global perspective. Biol Blood 3. Table of Vaccine Components: www.cdc. system, such as cortisone, prednisone, other steroids, or anticancer drugs; Marrow Transplant 15:1143–1238; 2009 at drugs for the treatment of rheumatoid arthritis, Crohn’s disease, or gov/vaccines/pubs/pinkbook/downloads/ appendices/B/excipient-table-2.pdf. www.cdc.gov/vaccines/pubs/hemato-cell- psoriasis; or have you had radiation treatments? [LAIV, MMR, VAR, ZOS] transplts.htm. 4. CDC. Prevention and control of influenza this two-page screening checklist, 8. CDC. Notice to readers: Revised ACIP Live virus vaccines (e.g., LAIV, MMR, VAR, ZOS) should be postponed until after with vaccines: Recommendations of the recommendation for avoiding pregnancy chemotherapy or long-term high-dose steroid therapy has ended. For details Advisory Committee on Immunization Practices (ACIP), United States, 2015–16 after receiving a rubella-containing vaccine. and length of time to postpone, consult the ACIP statement (1, 5). Some immune MMWR 2001; 50 (49). mediator and immune modulator drugs (especially the antitumor-necrosis factor Influenza Season at www.cdc.gov/mmwr/ visit www.immunize.org/catg.d/ pdf/wk/mm6430.pdf, pages 818–825. 9. CDC. Updated recommendations for use agents adalimumab, infliximab, and etanercept) may be immunosuppressive. 5. CDC. Measles, mumps, and rubella – vac- of tetanus toxoid, reduced diphtheria tox- The use of live vaccines should be avoided in persons taking these drugs (MMWR cine use and strategies for elimination of oid, and acellular pertussis vaccine (Tdap) 2011;60 [RR2]:23). To find specific vaccination schedules for stem cell transplant measles, rubella, and congenital rubella in pregnant women: Recommendations of p4065.pdf (bone marrow transplant) patients, see reference 7. LAIV can be given only to syndrome and control of mumps. MMWR the ACIP. MMWR 2012; 62 (7):131–4. healthy non-pregnant people ages 2 through 49 years. 1998; 47 (RR-8).

Immunization Action Coalition • Saint Paul, Minnesota • 651-647-9009 • www.immunize.org • www.vaccineinformation.org www.immunize.org/catg.d/p4065.pdf • Item #P4065 – page 2 (2/16)

6 Vaccinate Adults! • March 2016 • Immunization Action Coalition • (651) 647-9009 • www.immunize.org • www.vaccineinformation.org Standing Orders Templates for Administering Standing Orders for Administering Pneumococcal Vaccine to Adults (continued) page 2 of 3

Vaccines3 Provide Vaccine Informationto Adults Statements Provide all patients with a copy of the most current federal Vaccine Information Statement (VIS). Provide non- English speaking patients with a copy of the VIS in their native language,Visit if one www.immunize.org/standing is available and desired; these can -orders for all sets. be found at www.immunize.org/vis. (For information about how to document that the VIS was given, see section Download6 titled “Document these Vaccination.”) standing orders and n Click blue text to view standing orders documents use them4 Prepare “as to Administer is” or V modifyaccine them to suit yourPCV13 work must be givensetting. intramuscularly (IM). PPSV23 may be administered either IM or subcutaneouslyvaccines (Subcut). standing order For vaccine that is to be administered IM, choose the needle gauge, needle length, and injection site according to (date of latest revision) the following chart: adult gender and weight of patient needle gauge needle length injection site HepA ( ) Female or male less than 130 lbs 22–25 ⅝"*–1" Deltoid muscle of arm JUNE 2013 Female or male 130–152 lbs 22–25 1" Deltoid muscle of arm Female 153–200 lbs 22–25 1–1½" Deltoid muscle of armHepB adult Male 153–260 lbs 22–25 1–1½” Deltoid muscle of arm (OCT 2015) Female 200+ lbs 22–25 1½” Deltoid muscle of arm Male 260+ lbs 22–25 1½” Deltoid muscle of arm adult * A ⅝" needle may be used in patients weighing less than 130 lbs (<60 kg) for IM injection in the deltoid muscle only if Hib ( ) the skin is stretched tight, the subcutaneous tissue is not bunched, and the injection is made at a 90° angle to the skin. JUNE 2015

Standing orders for other vaccines are available at www.immunize.org/standing-orders. If you prefer Subcut injection note:of ThisPPSV23, standing orders templatechoose may be adapted a 23–25 per a practice’s gauge, discretion without ⅝" needle for injection into the fatty tissue over- obtaining permission from IAC. As a courtesy, please acknowledge IAC as its source. adult standinglying ordersthe triceps for muscle. HPV Administering Pneumococcal Vaccines (PCV13 and PPSV23) to Adults (MAY 2015) 5 Administer PCV13 or PPSV23, 0.5 mL, according to the following dosing information and schedule: Purpose To• reduce PCV morbidity13 must and mortality be administered from pneumococcal disease by theby vaccinating IM route. all adults who meet the criteria established by the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices. adult • PPSV23 may be administered either IM or Subcut. Influenza Policy (AUG 2015) WhereRoutine allowed by vaccination state law, standing ordersfor all enable adults eligible nurses ages and 65 other years health care and professionals older (e.g., pharmacists) to assess the need for vaccination and to vaccinate adults who meet any of the criteria below. Procedure age of vaccine(s) indicated history of prior schedule for administration of PCV13 and PPSV23 adult 1 Assess patient Adults for(see Need table of Vaccination on page against 1) Streptococcusvaccination pneumoniae (pneumococcus) infection MMR according to the following criteria: (JUNE 2013) Routine pneumococcal vaccination – Assess adults age 65None years or olderor unknown for need of pneumococcal vaccination.Administer PCV13 followed in 1 year* by PPSV23. Pneumococcal conjugate vaccine (PCV13) should be administered routinely to all previously unvaccinated adults age 65 years and older. Pneumococcal polysaccharide vaccinePPSV23 (PPSV23) when is recommended younger for all adultsAdminister ages 65 PCV13 at least 1 year* after previous PPSV23. years or older. For complete details, see section 5 (page 2).than age 65 years; 0 or Administer another PPSV23 at least 5 years*MenACWY after previous adult Risk-based pneumococcal vaccination – Age 19 through 64 yearsunknown with an underlying PCV13 medical condition ordose other risk of PPSV23. factor as described in the following table: (MCV4), MPSV (JUNE 2013) 65category yrs of underlyingPPSV23 medical and condition 1-time recommended PPSV23 vaccines whenare marked younger “x” below Administer another PPSV23 at least 5 years after previous dose or otherolder risk factordose of PCV13 PCV13than age PPSV2365 years; PPSV23 booster*of PPSV23 and at least 1 year* after previous dose of PCV13. Chronic heart disease,1 chronic lung disease2 PCV13 x adult Diabetes mellitus x MenB Chronic liver disease, cirrhosis PPSV23 whenx age 65 Administer PCV13 at least 1 year* after PPSV23 (DEC 2015) Cigarette smoking years or older;x 0 or Alcoholism x Cochlear implant, cerebrospinal fluid leak x unknown PCV13x Sickle cell disease, other hemoglobinopathy x 0 or unknownx PPSV23; x Administer PPSV23 at least 1 year* after PCV13. Congenital or acquired asplenia x x x PCV Congenital or acquired immunodeficiency,3 HIV x PCV13 x x Chronic renal failure, nephrotic syndrome x x x adult * ForLeukemia, adults lymphoma age 65 years and older with ximmunocompromisingx conditions,x (NOV 2015) functionalGeneralized malignancy, or anatomic Hodgkin disease asplenia, cerebrospinalx fluidx leaks, or cochlearx implants, 4 theIatrogenic interval immunosuppression between PCV13 and PPSV23x should be shortenedx to 8 weeks.x Solid organ transplant, multiple myeloma x x x PPSV * a second dose 5 years after the first dose of PPSV23 1 Excluding hypertension 3 Including B- (humoral) or T-lymphocyte deficiency, 4 Diseases requiring treatment with immuno- continued on the next page ▶ Risk-based2 Including asthma vaccinationcomplement deficiencies for adults(particularly C1,ages C2, C3, 19–64suppressive years drugs, including (See long-term next systemic page.) and C4 deficiencies), and phagocytic disorders corticosteroids and radiation therapy (excluding chronic granulomatous disease) adult 2 Screen for Contraindications and Precautions Tdap/Td Contraindications – Do not give pneumococcal vaccine (PCV13 or PPSV23) to a person who has experienced a (OCT 2015) serious systemic or anaphylactic reaction to a prior dose of the vaccine or to any of its components. For a list of vaccine components, refer to the manufacturer’s package insert (www.immunize.org/packageinserts) or go to www.cdc.gov/vaccines/pubs/pinkbook/downloads/appendices/B/excipient-table-2.pdf. Precautions – Moderate or severe acute illness with or without fever continued on the next page ▶ pregnant woman Immunization Action Coalition • Saint Paul, MinnesotaTechnical • 651 content- reviewed647 by- the9009 Centers for •Disease www.immunize.org Control and Prevention • www.vaccineinformation.orgTdap (FEB 2014) Immunization Action Coalition Saint Paul, Minnesota • 651-647-9009 • www.immunize.org • www.vaccineinformation.org • www.immunize.org/catg.d/p3075.pdf • Item #P3075 (11/15) www.immunize.org/catg.d/p3075.pdf Item #P3075 (11/15) adult Varicella (FEB 2014) All sets of standing orders for routinely recommended vaccines are available at adult Zoster (NOV 2015) www.immunize.org/standing-orders

Vaccinate Adults! • March 2016 • Immunization Action Coalition • (651) 647-9009 • www.immunize.org • www.vaccineinformation.org 7 One-time, FREE workshop on raising your practice’s adult immunization rates while streamlining your practice

Coming soon to a city near you!

Seattle, Wash. March 15, 2016 Phoenix, Ariz. March 17, 2016 Tucson, Ariz. March 18, 2016 who should attend Clinicians, nurses, Orlando/Daytona Beach, Fla. and clinic managers April 12, 2016 Fort Lauderdale, Fla. April 13, 2016 Atlanta, Ga. no-cost April 15, 2016 Boston, Mass. Workshop on Using June 6, 2016 Standing Orders New York, N.Y. June 8, 2016 to Vaccinate Adults Philadelphia, Pa. why you should attend www.StandingOrders.org June 9, 2016 Baltimore, Md. ✔This workshop is a one-stop shop to help led by nationally recognized experts June 11, 2016 you easily implement standing orders in L.J Tan, MS, PhD, Chief Strategy Officer, your practice. Immunization Action Coalition Deborah L. Wexler Using standing orders for adult immuni - , MD, Executive Director, ✔ Immunization Action Coalition zations can help your practice be a leader William Atkinson, MD, MPH, Associate in quality adult care. Director for Immunization Education, Immunization Action Coalition ✔Our support for your practice does not Alexandra Stewart, JD, Associate Professor, end with the workshop. You receive full George Washington University access to direct phone and email support This free workshop is provided by the Immunization for one year after attending. Action Coalition (IAC), with sponsorship from Pfizer, Inc.

8 Use These Handy Guides to Help Your

Practice Administer Vaccines Properly • P ost these sheets in your vaccine preparation 1 area to help train staff in Administering Vaccines to Adults: Dose, Route, Site, and Needle Size proper administration vaccine dose route Intramuscular (IM) injection 2 ≤18 yrs: 0.5 mL Hepatitis A (HepA) IM ≥19 yrs: 1.0 mL technique. ≤19 yrs: 0.5 mL 90° angle Administering Vaccines: Hepatitis B (HepB) IM ≥20 yrs: 1.0 mL skin HepA-HepB (Twinrix) ≥18 yrs: 1.0 mL IM subcutaneous tissue Dose, Route, Site, and Needle Size Human papillomavirus (HPV) 0.5 mL IM muscle Vaccine Dose Route Injection Site and Needle Size • All technical content is 0.2 mL (0.1 mL into Diphtheria, Tetanus, Pertussis Influenza, live attenuated (LAIV) NAS (Intranasal spray) 0.5 mL. . IM .. Subcutaneous (Subcut) injection each nostril) (DTaP, DT, Tdap, Td) Use a 23–25 gauge needle. Choose the injection site that is appropriate to Subcutaneous (SubCut) injection the person’s age and body mass. Influenza, inactivated (IIV) and Haemophilus influenzae type b (Hib) 0.5 mL IM 0.5 mL IM recombinant (RIV) ≤18 yrs: 0.5 mL age Needle injection site reviewed by CDC. Hepatitis A (HepA) IM length 45° angle ≥19 yrs: 1.0 mL Influenza (IIV) Fluzone Intradermal, Fatty tissue over anterolateral Infants (1–12 mos) ⅝" 0.1 mL ID (Intradermal) skin Hepatitis B (HepB) ≤19 yrs: 0.5 mL thigh muscle for ages 18 through 64 years Persons 11–15 yrs may be given Recombivax HB (Merck) IM 1.0 mL adult formulation on a 2-dose schedule. ≥20 yrs: 1.0 mL Fatty tissue over anterolateral subcutaneous tissue Children 12 mos or older, Measles, Mumps, Rubella (MMR) 0.5 mL SubCut ⅝" thigh muscle or fatty tissue Human papillomavirus (HPV) 0.5 mL IM adolescents, and adults muscle over triceps Meningococcal conjugate (MenACWY) 0.5 mL IM 0.2 mL (0.1 mL in Intranasal Influenza, live attenuated (LAIV) each nostril) spray Intramuscular (IM) injection Meningococcal protein (MenB) 0.5 mL IM Use a 22–25 gauge needle. Choose the injection site and needle length that Influenza, inactivated (IIV); recombinant 6–35 mos: 0.25 mL IM is appropriate to the person’s age and body mass. Meningococcal serogroup B (MenB) 0.5 mL IM Intradermal (ID) administration(RIV), for ages 18 years and older ≥3 yrs: 0.5 mL of Fluzone ID vaccine needle Influenza (IIV) Fluzone Intradermal, age injection site 0.1 mL ID length Meningococcal polysaccharide (MPSV) 0.5 mL SubCut for ages 18 through 64 years 90° angle Newborns (1st 28 days) ⅝" Anterolateral thigh muscle Measles, Mumps, Rubella (MMR) 0.5 mL Subcut Pneumococcal conjugate (PCV13) 0.5 mL IM Infants (1–12 mos) 1" Anterolateral thigh muscle Administer Meningococcal conjugate 0.5 mL IM 1–1¼" Anterolateral thigh muscle or Pneumococcal polysaccharide (PPSV) 0.5 mL IM or SubCut in area (MCV4 [MenACWY]) Toddlers (1–2 years) ⅝–1" deltoid muscle of arm of deltoid Tetanus, Diphtheria (Td) with Pertussis Meningococcal serogroup B (MenB) 0.5 mL IM 3 0.5 mL IM Children and teens ⅝–1"* Deltoid mucle of arm or (Tdap) Meningococcal polysaccharide (MPSV) 0.5 mL Subcut (3–18 years) 1–1¼" anterolateral thigh muscle Pneumococcal conjugate (PCV) 0.5 mL IM Varicella (VAR) 0.5 mL SubCut Adults 19 years or older IM or Pneumococcal polysaccharide (PPSV) 0.5 mL Female or male <130 lbs ⅝–1"* Deltoid muscle of arm Zoster (HZV) 0.65 mL SubCut Subcut How to Administer Intramuscular, Intradermal, and Intranasal Influenza Vaccines Female or male 130–152 lbs 1" Deltoid muscle of arm IM or Intranasal (NAS) administraPolio,- inactivated (IPV) 0.5 mL Female 153–200 lbs Subcut 1–1½" Deltoid muscle of arm tion of Flumist (LAIV) vaccine Male 130–260 lbs Injection Site Subcutaneous (SubCut) injection – Use a 23–25 gauge, 5/8" needle. Rotarix: 1.0 mL Rotavirus (RV) Oral Female 200+ lbs Intramuscular injection (IM) Intradermal administration (ID) Intranasal administration (NAS) Inject in fatty tissue over triceps. 1½" Deltoid muscle of arm and Rotateq: 2.0 mL Male 260+ lbs Inactivated Influenza Vaccines (IIV), including Inactivated Influenza Vaccine (IIV) Live Attenuated Influenza Vaccine (LAIV) Needle Size Intramuscular (IM) injection – Use a 22–25 gauge needle. Inject in Varicella (Var) 0.5 mL Subcut recombinant hemagglutinin influenza vaccine (RIV3) deltoid muscle of arm. Choose the needle length as indicated below: Zoster (Zos) 0.65 mL Subcut * A 5/8" needle may be used for patients note: Always refer to the package insert included 1 Gently shake the microinjection system before 1 FluMist (LAIV) is for intranasal administration Gender/Weight Needle Length Combination Vaccines weighing less than 130 lbs (<60 kg) for with each biologic1 Use for complete a needle vaccine long administration enough to reach deep into administering the vaccine. only. Do not inject FluMist. IM injection in the deltoid muscle only information. CDC’s Advisory Committee on Immunization Female or male less than 130 lbs 5/8"*–1" * A 5/8" needle may be the muscle. Infants age 6 through 11 mos: 1"; DTaP-HepB-IPV (Pediarix) if the skin stretched tight, the subcuta- Practices (ACIP) recommendations for the particular used for patients weigh - neous tissue is not bunched, and the 2 Hold the system by placing the 2 Remove rubber tip protector. Do not remove DTaP-IPV/Hib (Pentacel) vaccine should be1 reviewed through as well. 2 Accessyrs: 1–1¼"; the ACIP children and adults Female or male 130–152 lbs 1" ing less than 130 lbs DTaP-IPV (Kinrix; Quadracel) 0.5 mL IM injection is made at a 90-degree angle. (<60 kg) for IM injection recommendations at www.immunize.org/acip. thumb and middle finger on dose-divider clip at the other end of the sprayer. Hib-HepB (Comvax) 3 yrs and older: 1–1½". Female 153–200 lbs in the deltoid muscle note: Always refer to the package insert included the finger pads; the index finger – 1/ Hib-MenCY (MenHibrix) 1 1 2" only if the subcutaneous with each biologic for complete vaccine administration 3 With the patient in an upright position, Male 153–260 lbs tissue is not bunched 2 With your left hand*, bunch up the muscle. should remain free. information. CDC’s Advisory Committee on ImmuniMMRV- (ProQuad) ≤12 yrs: 0.5 mL Subcut and the injection is made zation Practices (ACIP) recommendations for the place the tip just inside the nostril Female 200+ lbs at a 90-degree angle. 11/2" particular vaccine should be reviewed as well. AccessHepA-HepB (Twinrix) ≥18 yrs: 1.0 mL IM 3 With your right hand*, insert the needle at a 3 Insert the needle perpendicular to the skin, to ensure LAIV is delivered into Male 260+ lbs the ACIP recommendations at www.immunize.org/acip. How to Administer Intradermal, Intranasal,90° and angle to Oral the skin V withaccinations a quick thrust. in the region of the deltoid, in a short, quick the nose. The patient should movement. breathe normally. Intramuscular (IM) injectionWhileSubcutaneous most vaccines (Subcut) are administered injection Intradermal by either (intraID) administrationroute, andIntranasal the4 Push oral ( NASdownroute.) administrationon Here the plunger are some and simple inject the entire Technical content reviewed by the Centers for Disease Control and Prevention muscular or subcutaneous injection, thereof areFluzone several ID vaccine instructionsof to contentsFlumist use as (LAIV) ofa guide.the vaccine syringe. Complete There isinformation no need to 4 Once the needle has been 4 With a single motion, depress plunger as Saint Paul, Minnesota • 651-647-9009 • www.immunize.org • www.vaccineinformation.org inserted, maintain light pressure vaccines that are administered through other means. is available in aspirate.the package inserts and can also be rapidly as possible until the dose-divider clip www.immunize.org/catg.d/p3084.pdf • Item #P3084 (9/15) 90° angle on the surface of the skin and prevents you from going further. 90° angle These include45° angle the intradermal route, the intranasal obtained at5 www.immunize.org/packageinserts Remove the needle and simultaneously. apply inject using the index finger to Administer pressure to the injection site with a dry cotton ball skin skin push on the plunger. Do not 5 Pinch and remove the in area or gauze. Hold in place for several seconds. of deltoid aspirate. dose-divider clip from subcutaneous tissue Intradermalsubcutaneous (ID) tissue administration Intranasal (NAS) administration the plunger. Fluzone by Sanofi Pasteur, Intradermal Inactivated Influenza Vaccine FluMist by MedImmune,6 If there Liveis any Attenuated bleeding, Influenza cover theVaccine injection (LAIV) site 5 Remove the needle from the skin. muscle muscle with a bandage. With the needle directed away 6 Place the tip just inside 1 Gently shake the microinjection system before administering 1 FluMist (LAIV) is for intranasal administration only. Do not dose-divider clip from you and others, push very the other nostril, and with the vaccine. inject FluMist.7 Put the used syringe in a sharps container. Technical content reviewed by the Centers for Disease Control and Prevention firmly with the thumb on the a single motion, depress plunger as rapidly as Immunization Action2 HoldCoa ltheition system Saint by placing Paul, Minnesota the thumb • 651and- 647-9009 • www.immunize.org2 Remove • www.vaccineinformation.org the rubber tip protector. Do not remove the dose plunger to activate the needle shield. You will possible to deliver the remaining vaccine. middle finger on the finger pads; the index divider clip* Useat the the other opposite end hand of the sprayer. www.immunize.org/catg.d/p3085.pdf • Item #P3085 (11/15) hear a click when the shield extends to cover finger should remain free. if you are left-handed. 7 Dispose of the applicator in a sharps container. 3 With the patient in an upright position, place the tip just the needle. 90° angle 3 Insert the needle perpendicular to the skin, in the region of inside the nostril to ensure LAIV is deliv 6 Dispose of the applicator in a sharps container. the deltoid, in a short, quick movement. ered into the nose. The patient should skin breathe normally. For 8½ x 11" copies of these 4 Once the needle has been inserted, maintain subcutaneous tissue light pressure on the surface of the skin 4 With a single motion, depress the plunger and inject using the index finger to push on as rapidly as possible until the dosedivider muscle the plunger. Do not aspirate. clip prevents you from going further. pieces above, visit IAC’s website: 5 Remove the needle from the skin. With the needle directed 5 Pinch and remove the dosedivider clip away from you and others, push very firmly with the thumb from the plunger. on the plunger to activate the needle shield. 6 Place the tip just inside the other nostril, How to Administer Intramuscular and Subcutaneous Vaccine Injections 4 You will hear a click when the shield extends dosedivider clip and with a single motion, depress plunger Technical content reviewed by the Centers for Disease Control and Prevention to cover the needle. Saint Paul, Minnesota • 651-647-9009 • www.immunize.org • www.vaccineinformation.org www.immunize.org/handouts/ as rapidly as possible to deliver the remaining vaccine. Administration by thewww.immunize.org/catg.d/ Intramuscularp2024.pdf • Item #P 202(IM)4 (9/15) Route 6 Dispose of the applicator in a sharps container. 7 Dispose of the applicator in a sharps container.

Administer these vaccines patient age injection site needle size administering-vaccines.asp Oral administration: Rotavirus vaccines via IM route Newborn (0–28 days) Anterolateral thigh muscle ⅝"* (22–25 gauge) Rotateq by Merck Rotarix by GlaxoSmithKline • Diphtheria-tetanus-pertussis Transfer Infant (1–12 months) Anterolateral thigh muscle 1"* (22–25 gauge) adapter (DTaP, Tdap) 1 Tear open the pouch and remove the dosing 1 Remove the cap of the vial and push the transfer • Diphtheria-tetanus (DT, Td) Anterolateral thigh muscle 1–1¼" (22–25 gauge) 1 Administering Vaccines to Adults: Dose, tube. Clear the fluid from the dispensing adapter onto the vial (lyophilized vaccine). Vial • Haemophilus influenzae type b Toddler (1–2 years) Alternate site: Deltoid muscle of arm tip by holding the tube vertically and tapping ⅝–1"* (22–25 gauge) 2 Shake the diluent in the oral applicator Oral applicator (Hib) if muscle mass is adequate the cap. (white, turbid suspension). Connect the • Hepatitis A (HepA) Deltoid muscle (upper arm) ⅝–1"* (22–25 gauge) Route, Site, and Needle Size 2 Open the dosing tube in two easy motions: oral applicator to the transfer adapter. • Hepatitis B (HepB) Children (3–18 years) a) Puncture the dispensing tip by screwing cap clockwise Alternate site: Anterolateral thigh muscle 1–1¼" (22–25 gauge) 3 Push the plunger of the oral applicator to • Human papillomavirus (HPV) until it becomes tight. • Deltoid muscle (upper arm) 1–1½"*† (22–25 gauge) transfer the diluent into the vial. The Inactivated influenza (IIV) Adults 19 years and older b) Remove the cap by turning it counterclockwise. www.immunize.org/catg.d/p3084.pdf How to Administer Intramuscularsuspension will appear and white Subcutaneous and cloudy. • Meningococcal serogroup B Alternate site: Anterolateral thigh muscle 1–1½" (22–25 gauge) 3 Administer the dose by gently squeezing (MenB) 4 Withdraw the vaccine into the oral applicator. liquid into infant’sVaccine mouth toward Injections the inner to Adults • Quadrivalent meningococcal * A ⅝" needle usually is adequate for neonates (first cutaneous tissue is not bunched, and the injection is cheek until dosing tube is empty. (A residual 5 Twist and remove the oral applicator from conjugate (MenACWY [MCV4]) 28 days of life), preterm infants, and children ages made at a 90º angle; a 1" needle is sufficient in patients drop may remain in the tip of the tube.) the vial. • Pneumococcal conjugate (PCV13) 1 through 18 years if the skin is stretched flat between weighing 130–152 lbs (60–70 kg); a 1–1½" needle is Intramuscular (IM) Injections the thumb and forefinger and the needle is inserted recommended in women weighing 153–200 lbs (70– 2 Administering Vaccines: Dose, Route, Site, 4 Discard the empty tube and cap in an approved biological 6 Administer the dose by gently placing the applicator plunger Administer inactivated polio (IPV) at a 90° angle to the skin. 90 kg) and men weighing 153–260 lbs (70–118 kg); a waste containerAdminister according these to local vaccines regulations. via IM route into the infant’s mouth toward the inner cheek and gently and pneumococcal polysaccharide † A ⅝" needle may be used in patients weighing less 1½" needle is recommended in women weighing • Haemophilus influenzae type b (Hib) expelling the contents until the applicator is empty. (PPSV23) vaccines either IM or than 130 lbs (<60 kg) for IM injection in the deltoid more than 200 lbs (91 kg) or men weighing more than Note: If, for any reason,• Hepatitis an incomplete A (HepA) dose is administered (e.g., infant muscle only if the skin is stretched tight, the sub- 260 lbs (118 kg). and Needle Size 7 Discard the empty vial, cap, and oral applicator in an approved Subcut. spits or regurgitates• Hepatitisthe vaccine), B (HepB)a replacement dose is not recommended. • Human papillomavirus (HPV) biological waste container according toacromion local regulations. process (bony prominence above deltoid) • Influenza vaccine, injectable (IIV) • Note: If,level for ofany armpit reason, an incomplete dose is administered (e.g., the infant www.immunize.org/catg.d/p3085.pdf • Influenza vaccine, recombinant (RIV3) spits or regurgitates the vaccine), a replacement dose is not recommended. • Meningococcal conjugate (MCV4) IM injection site 6 • (shaded area = deltoid muscle) Intramuscular (IM) injection Intramuscular (IM) injection Meningococcal serogroup B (MenB) Technical content reviewed by the Centers for Disease Control and Prevention • Pneumococcal conjugate (PCV13) Saint Paul, Minnesota • 651-647-9009 • www.immunize.org • www.vaccineinformation.org 90° angle site for infants and toddlers site for children and adults • Pneumococcal polysaccharide (PPSV23) – elbow 3 How to Administer Intramuscular, Intra- may also be given Subcut www.immunize.org/catg.d/p2021.pdf • Item #P2021 (11/15) acromion skin • Polio (IPV) – may also be given Subcut process • Tetanus, diphtheria (Td), or with pertussis (Tdap) subcutaneous tissue (bony prominence above deltoid) dermal, and Intranasal Influenza Vaccines 90° angle Injection site muscle Give in the central and thickest portion of the deltoid skin • muscle – above the level of the armpit and approximately level of armpit www.immunize.org/catg.d/p2024.pdf 2–3 fingerbreadths (~2") below the acromion process. subcutaneous tissueNeedle insertion IM injection See the diagram. To avoid causing an injury, do not inject Use a needle long enough to reach site muscle too high (near the acromion process) or too low. deep into the muscle. (shaded area) Needle size Insert needle at a 90° angle to the IM injection site Note: A ⅝" needle is sufficient in adults weighing less than 130 lbs (shaded area) elbow 4 How to Administer Intradermal, Intranasal, 22–25 gauge, 1–1½" needle (see note at right) skin with a quick thrust. (<60 kg) for IM injection in the deltoid muscle only if the subcutane- (Before administering an injection of Needle insertion ous tissue is not bunched and the injection is made at a 90° angle; a 1" needle is sufficient in adults weighing 130–152 lbs vaccine,(60–70 kg); it is not necessary to aspi- • Use a needle long enough to reach deep into the muscle. and Oral Vaccinations a 1–1½" needle is recommended in women weighing 153–200rate, i.e.,lbs to pull back on the syringe • Insert the needle at a 90° angle to the skin with a quick ¶ (70–90 kg) and men weighing 153–260 lbs (70–118 kg); aplunger 1½" needle after needle insertion. ) Insert needle at a 90° angle into the Give in the central and thickest portion of the thrust. 5 is recommended in women weighing more than 200 lbs (91Multiple kg) or injections given in the anterolateral thigh muscle. deltoid muscle – above the level of the armpit www.immunize.org/catg.d/p2021.pdf • Separate two injections given in the same deltoid muscle men weighing more than 260 lbs (more than 118 kg). same extremity should be separated and approximately 2–3 fingerbreadths (~2") by a minimum of 1". by a minimum of 1", if possible. below the acromion process. See the diagram. To avoid causing an injury, do not inject too ¶ CDC. “ACIP General Recommendations on high (near the acromion process) or too low. Subcutaneous (Subcut) Injections Administer these vaccines via Subcut route Immunization” at www.immunize.org/acip 5 How to Administer Intramuscular and • Measles, mumps, rubella (MMR) continued on the next page � • Meningococcal polysaccharide (MPSV4) • Pneumococcal polysaccharide (PPSV23) – Technical content reviewed by the Centers for Disease Control and Prevention Subcutaneous Vaccine Injections to Adults acromion process may also be given IM Saint Paul, Minnesota • 651-647-9009 • www.immunize.org • www.vaccineinformation.org • Polio (IPV) – may also be given IM www.immunize.org/catg.d/p2020.pdf • Item #P2020 (12/15) • Varicella (Var; chickenpox) www.immunize.org/catg.d/p2020a.pdf Subcut injection site • Zoster (HZV; shingles) (shaded area) Injection site Give in fatty tissue over the triceps. See the diagram. elbow Needle size 6 How to Administer Intramuscular and 45° angle 23–25 gauge, 5/8" needle

skin Needle insertion • Pinch up on the tissue to prevent injection into the Subcutaneous Vaccine Injections subcutaneous tissue muscle. Insert the needle at a 45° angle to the skin. muscle • Separate two injections given in the same area of fatty www.immunize.org/catg.d/p2020.pdf tissue by a minimum of 1".

Technical content reviewed by the Centers for Disease Control and Prevention Saint Paul, Minnesota • 651-647-9009 • www.immunize.org • www.vaccineinformation.org www.immunize.org/catg.d/p2020a.pdf • Item #P2020a (11/15)

Vaccinate Adults! • March 2016 • Immunization Action Coalition • (651) 647-9009 • www.immunize.org • www.vaccineinformation.org 9 Make Sure Your Patients Are Protected from Meningococcal Disease Caused by Serogroup B Meningococcal Vaccine Recommendations This document covers MenB vaccine. For information on vaccine that provides protection against by Age and Risk Factor for meningococcal serogroup A, C, W, and Y disease, Serogroup B Protection see www.immunize.org/catg.d/p2018.pdf. Meningococcal serogroup type B vaccines: • Bexsero (MenB-4C, GlaxoSmithKline) • Trumenba (MenB-FHbp, Pfizer) Routine Recommendations for Meningococcal Serogroup B Vaccination This 1-page guide describes MenB For teens and young adults ages 16 through 23 years who wish to Give either 2 doses of Bexsero 4 weeks apart, or 3 doses of • vaccine recommendations by age be vaccinated. The preferred age is 16 through 18 years. Trumenba on a 0-, 2-, and 6-month schedule.

group, medical condition, Risk-based Recommendations for Persons with Underlying Medical Conditions or Other Risk Factors For people ages 10 years or older with Give either 2 doses of Bexsero 4 weeks apart, or 3 doses or other risk factors. • persistent complement component deficiencies1 of Trumenba on a 0-, 2-, and 6-month schedule. • anatomic or functional asplenia, including sickle cell disease, For people ages 10 years or older who • are present during outbreaks caused by serogroup B,2 or www.immunize.org/catg.d/p2035.pdf • have prolonged increased risk for exposure (e.g., microbiologists routinely working with Neisseria meningitidis) Note: The two brands of meningococcal B vaccine are not interchangeable. The series must be started and completed with the same brand of vaccine.

footnotes 1. Persistent complement component deficiencies (e.g., inherited or chronic deficiencies in C3, C5–C9, properdin, factor D, and factor H). 2. Seek advice of local public health authorities to determine if vaccination is recommended.

Standing orders for other vaccines are available at www.immunize.org/standing-orders. note: This standing orders template may be adapted per a practice’s discretion without obtaining permission from IAC. As a courtesy, please acknowledge IAC as its source. standing orders for Administering Meningococcal B Vaccine to Adolescents and Adults Standing Orders for Administering Meningococcal B Vaccine to Adolescents and Adults (continued) page 2 of 2 5 Administer MenB vaccine, 0.5 mL, via the intramuscular (IM) route, according to the following table: Purpose Schedule for vaccination Type of vaccine Age group Dose Schedule To reduce morbidity and mortality from serogroup B meningococcal disease by vaccinating all adolescents and Bexsero (MenB-4c, GlaxoSmithKline) 10 years and older 0.5 mL Two doses, 4 weeks apart adults who meet the criteria established by the Centers for Disease Control and Prevention’s Advisory Commit- Trumenba (MenB-FHbp, Pfizer) 10 years and older 0.5 mL Three doses at 0, 2, and 6 months Note: The two brands of MenB vaccine are not interchangeable. The series must be started and completed with the same tee on Immunization Practices (ACIP). brand of vaccine. 6 Document Vaccination Document each patient’s vaccine administration information and follow-up in the following places: Policy Medical chart: Record the date the vaccine was administered, the manufacturer and lot number, the vaccination site and route, and the name and title of the person administering the vaccine. You must also document, in the Where allowed by state law, standing orders enable eligible nurses and other healthcare professionals (e.g., patient’s medical record or office log, the publication date of the VIS and the date it was given to the patient. If vaccine was not administered, record the reason(s) for non-receipt of the vaccine (e.g., medical contraindication, pharmacists) to assess the need for and vaccinate adolescents and adults who meet any of the criteria below. patient refusal). Personal immunization record card: Record the date of vaccination and the name/location of the administering clinic. Procedure Immunization Information System (IIS) or “registry”: Report the vaccination to the appropriate state/local IIS, if available. 1 Assess adolescents and adults for need of vaccination against meningococcal serogroup B disease 7 Be Prepared to Manage Medical Emergencies Be prepared for management of a medical emergency related to the administration of vaccine by having a written according to the following criteria: emergency medical protocol available, as well as equipment and medications. For IAC’s “Medical Management of Vaccine Reactions in Children and Teens,” go to www.immunize.org/catg.d/p3082a.pdf. For “Medical Management • Age 16 through 23 years who desire to be vaccinated. The ACIP-preferred age is 16 through 18 years. of Vaccine Reactions in Adult Patients,” go to www.immunize.org/catg.d/p.3082.pdf. To prevent syncope, vaccinate patients while they are seated or lying down and consider observing them for 15 minutes after receipt of the • Age 10 years and older, including all adults, with vaccine. 8 Report Adverse Events to VAERS • Diagnosis of persistent complement component deficiency (e.g., inherited chronic deficiencies in C3, Report all adverse events following the administration of meningococcal vaccine to the federal Vaccine Adverse C5–C9, properdin, factor D and factor H) or taking eculizumab (Soliris) Event Reporting System (VAERS) at www.vaers.hhs.gov. Forms are available on the website or by calling (800) 822-7967. • Diagnosis of anatomic or functional asplenia (including sickle cell disease) Standing Orders Authorization • Risk of potential exposure due to an outbreak attributable to serogroup B

This policy and procedure shall remain in effect for all patients of the • Microbiologists routinely exposed to isolates of Neisseria meningitidis name of practice or clinic until rescinded or until . Technical content reviewed by the Centers for Disease Control and Prevention 2 Screen for contraindications and precautions date Immunization Action Coalition Saint Paul, MinnesotaMedical Director’s• 651- 6signature47-9009 • www.immunize.org Signature • www.vaccineinformation.org date Effective date Contraindication www.immunize.org/catg.d/p2035.pdf • Item #P2035 (12/15) Do not give meningococcal B vaccine to an adolescent or adult who has experienced a serious systemic or anaphylactic reaction to a prior dose of meningococcal B vaccine or to any of its components. For information on vaccine components, refer to the manufacturers’ package insert (www.immunize.org/packageinserts) or go to www.cdc. gov/vaccines/pubs/pinkbook/downloads/appendices/B/excipient-table-2.pdf. Precaution Moderate or severe acute illness with or without fever

Immunization Action Coalition • Saint Paul, Minnesota • 651-647-9009 • www.immunize.org • www.vaccineinformation.org 3 Provide Vaccine Information Statements www.immunize.org/catg.d/p3095.pdf • Item #P3095 (12/15) Provide all patients (or, in the case of minors, their parent, or legal representative) with a copy of the most current federal Vaccine Information Statement (VIS). Provide non-English speaking patients with a copy of the VIS in their

native language, if one is available and desired; these can be found at www.immunize.org/vis. (For information

about how to document that the VIS was given, see section 6 titled “Document Vaccination.”) 4 Prepare to Administer Vaccine • • Choose the needle gauge, needle length, and injection site according to the following chart: gender and weight of patient needle gauge needle length injection site Female or male less than 130 lbs 22–25 ⅝*–1" Deltoid muscle of arm Use this 2-page MenB standing Female or male 130–152 lbs 22–25 1" Deltoid muscle of arm Female 153–200 lbs 22–25 1–1½" Deltoid muscle of arm orders template for adolescents and Male 153–260 lbs 22–25 1–1½" Deltoid muscle of arm Female 200+ lbs 22–25 1½" Deltoid muscle of arm adults to streamline vaccination Male 260+ lbs 22–25 1½" Deltoid muscle of arm * A ⅝" needle may be used in patients weighing less than 130 lbs (<60 kg) for IM injection in the deltoid muscle in your practice setting. only if the skin is stretched tight, the subcutaneous tissue is not bunched, and the injection is made at a 90° angle to the skin. continued on the next page ▶ Technical content reviewed by the Centers for Disease Control and Prevention www.immunize.org/catg.d/p3095.pdf Immunization Action Coalition Saint Paul, Minnesota • 651-647-9009 • www.immunize.org • www.vaccineinformation.org www.immunize.org/catg.d/p3095.pdf • Item #P3095 (12/15)

10 Vaccinate Adults! • March 2016 • Immunization Action Coalition • (651) 647-9009 • www.immunize.org • www.vaccineinformation.org Recommended Adult Immunization Schedule – United States, 2015 Note: These recommendations must be read with the footnotes that follow containing number of doses, intervals between doses, and other important information. Figure 1. Recommended adult immunization schedule, by vaccine and age group1 Vaccine 19–21 years 22–26 years 27–49 years 50–59 years 60–64 years >65 years Influenza2,* 1 dose annually Tetanus, diphtheria, pertussis (Td/Tdap)3,* Substitute 1-time dose of Tdap for Td booster; then boost with Td every 10 yrs These products are available for purchase Varicella4,* 2 doses Human papillomavirus (HPV) Female5,* 3 doses Human papillomavirus (HPV) Male5,* 3 doses Zoster6 1 dose Measles, mumps, rubella (MMR)7,* 1 or 2 doses Pneumococcal 13-valent 1-time dose conjugate (PCV13)8,* Pneumococcal polysaccharide (PPSV23)8 1 or 2 doses 1 dose Meningococcal9,* Figure 1. Recommended1 or more doses Immunization Schedule for Persons Ages 0 through 18 Years, United States, 2016

Hepatitis A10,* 2 doses

from the Immunization Action Coalition 11,* These recommendations must be read with the footnotes that follow. For those who fall behind or start late, provide catch-up Hepatitis B 3 doses vaccination at the earliest opportunity as indicated by the green bars in Figure 1. To determine minimum intervals between Haemophilus influenzae type b (Hib)12,* doses, see the catch-up1 or 3 doses schedule (Figure 2). School entry and adolescent vaccine age groups are shaded.

Vaccine Birth 1 mo 2 mos 4 mos 6 mos 9 mos 12 mos 15 mos 18 mos 19–23 mos 2–3 yrs 4–6 yrs 7–10 yrs 11–12 yrs 13–15 yrs 16–18 yrs Figure 2. Vaccines that might be indicated for adults based on medical and other indications1 1 1st Hepatitis B (HepB) dose 2nd dose 3rd dose

Immuno- 2 Asplenia (includ- compromising HIV Infection Rotavirus (RV) ing elective 1st 2nd See conditions (ex- CD4+ T lymphocyte RV1 (2-dose series); RV5 (3-dose series) splenectomydose dose footnote 2 count4,6,7,8,13 cluding human Diphtheria, tetanus Kidney& acellular failure, pertussis Heart3 disease, and persistent immunode- Men who end-stage renal chronic lung complement1st 2nd 3rd 4th dose 5th dose (DTaP: <7 yrs) dose dose dose ficiency virus have sex with disease, receipt disease, chronic component Chronic liver Healthcare Pregnancy [HIV])4,6,7,8,13 <200 cells/μL >200 cells/μL men (MSM) of hemodialysis alcoholism deficiencies)8,12 disease Diabetes personnel Vaccine 4 1st 2nd See 3rd or 4th dose Haemophilus influenzae type b (Hib) dose dose footnote 4 (see footnote 4) 2,* I dose IIV or I dose IIV or Influenza 1 dose IIV annually LAIV annually I dose IIV annually LAIV annually 5 Pneumococcal conjugate (PCV13) 1st 2nd 3rd 4th dose 3,* 1 dose Tdap in dose dose dose Td/Tdap each pregnancy Substitute 1-time dose of Tdap for Td booster; then boost with Td every 10 yrs 4,* 6 Laminated adult and child/teen immunization schedules – Varicella Contraindicated Inactivated Poliovirus (IPV) (<18 yrs) 2 doses 1st 2nd 3rd dose 4th dose dose dose HPV Female5,* 3 doses through age 26 yrs 3 doses through age 26 yrs 7 Annual vaccination (LAIV or Annual vaccination ( LAIV or IIV) 5,* Influenza (IIV; LAIV) Annual vaccination (IIV only) 1 or 2 doses HPV Male 3 doses through age 26 yrs 3 doses through age 21 yrs IIV) 1 or 2 doses 1 dose only

6 Zoster Contraindicated 8 1 dose Measles, mumps, rubella (MMR) See footnote 8 1st dose 2nd dose MMR7,* Contraindicated 1 or 2 doses 9 PCV138,* Varicella (VAR) 1 dose 1st dose 2nd dose PPSV238 1 or 2 doses 10 Hepatitis A (HepA) 2-dose series, see footnote 10 Order one of each for every exam room Meningococcal9,* 1 or more doses Hepatitis A10,* Meningococcal11 (Hib-MenCY:2 doses >6 wks; See footnote 11 1st dose MenACWY-CRM: >2 mos; MenACWY-D >9 mos) Hepatitis B11,* 3 doses Booster Post-HSCT Tetanus, diphtheria & acellular pertus- 12,* 1 or 3 doses (Tdap) Hib recipients only sis12 (Tdap: >7 yrs)

Human Papillomavirus13 (HPV2: females Covered by the Vaccine Injury Compensation Program. (3-dose * only; HPV4, HPV9: males and females) series) For all persons in this category who meet the age requirements and who Recommended if some other risk factor is present (e.g., on the No recommendation lack documentation of vaccination or have no evidence of previous infection; basis of medical, occupational, lifestyle, or other indication) See footnote 11 11 zoster vaccine recommended regardless of prior episode of zoster Meningococcal B

These schedules indicate the recommended age groups and medical indications for which administration of currently5 licensed vaccines is commonly indicated for adults ages 19 years and older, as of NEW for 2016! The ACIP/AAFP/ACOG/ACNM- February 1, 2015. For all vaccines being recommended on the Adult Immunization Schedule:Pneumococcal a vaccine polysaccharide series does not(PPSV23) need to be restarted, regardless of the time that has elapsed between doses. Licensed See footnote 5 combination vaccines may be used whenever any components of the combination are indicated and when the vaccine’s other components are not contraindicated. For detailed recommendations on all vaccines, including those used primarily for travelers or that are issued during the year, consult the manufacturers’ package inserts and the complete statements from the Advisory Committee on Immunization Practices (www.cdc.gov/vaccines/hcp/acip-recs/index.html). Use of trade names and commercial sourcesRange is for of identification recommended only and does notRange imply ofendorsement recommended by agesthe U.S. DepartmentRange of Health of recommended and Human agesServices. Range of recommended ages for non-high- No recommendation ages for all children for catch-up immunization for certain high-risk groups risk groups that may receive vaccine, subject The recommendations in this schedule were approved by the Centers for Disease Control and Prevention's (CDC) Advisory Committee on Immunization Practices (ACIP), the American Academy to individual clinical decision making of Family Physicians (AAFP), the American College of Physicians (ACP), AmericanThis schedule College of Obstetriciansincludes recommendations and Gynecologists (ACOG), in effect and American as of January College of 1,Nurse-Midwives 2016. events (ACNM). that follow vaccination should be reported to the Vaccine Ad- Any dose not administered at the recommended age should be admin- verse Event Reporting System (VAERS) online (www.vaers.hhs.gov) or approved schedule for adults (8-sided) and the istered at a subsequent visit, when indicated and feasible. The use of a by telephone (800-822-7967). Suspected cases of vaccine-preventable R2009-Adult_Schedule_3.8.15.indd 2 combination vaccine generally is preferred over separate injections of diseases3/9/15 should 5:31 PM be reported to the state or local health department.

▼ To order, visit www.immunize.org/shop, its equivalent component vaccines. Vaccination providers should con- Additional information, including precautions and contraindica- sult the relevant Advisory Committee on Immunization Practices (ACIP) tions for vaccination, is available from CDC online (www.cdc.gov/ statement for detailed recommendations, available online at www.cdc. vaccines/recs/vac-admin/contraindications.htm) or by telephone or use the order form on page 12. ACIP/AAP/AAFP-approved immunization schedule gov/vaccines/hcp/acip-recs/index.html. Clinically significant adverse (800-CDC-INFO [800-232-4636]). Additional Vaccine Information • For contraindications and precautions to use of a vaccine and for additional information regarding that vaccine, vaccination providers should consult the relevant ACIP statement available online at www.cdc.gov/vaccines/hcp/acip-recs/index.html. • For the purposes of calculating intervals between doses, 4 weeks = 28 days. Intervals of 4 months or greater are determined by calendar months. • Vaccine doses administered 4 days or less before the minimum interval are considered valid. Doses of any vaccine administered >5 days earlier than the minimum interval or minimum age should not be counted as valid doses and should be repeated as age-appropriate. The repeat dose should be spaced after the invalid dose by the recommended minimum interval. For further details, see MMWR, General Recommendations on Immunization and Reports/Vol.60/No.2; Table 1. Recommended and minimum ages and for people ages 0 through 18 years (8-sided). Both intervals between vaccine doses available on-line at www.cdc.gov/mmwr/pdf/rr/rr6002.pdf. • Information on travel vaccine requirements and recommendations is available at wwwnc.cdc.gov/travel/destinations/list. • For vaccination of persons with primary and secondary immunodeficiencies, see Table 13, “Vaccination of persons with primary and secondary immunodeficiencies,” in General Recommendations on Immunization (ACIP), available at www.cdc.gov/mmwr/pdf/rr/rr6002.pdf; and American Academy of Pediatrics. Immunization in Special Clinical Circumstances, in Kimberlin DW, Brady MT, Jackson MA, Long SS, eds. Red Book: 2015 Report of the Committee on Infectious Disease. 30th ed. Elk Grove Village, IL: American Academy of Pediatrics. This schedule is approved by the Advisory Committee on Immunization Practices (www.cdc.gov/vaccines/acip), the American Academy of Pediatrics (www.aap.org), are laminated and washable for heavy-duty use, the American Academy of Family Physicians (www.aafp.org), and the American College of Obstetricians and Gynecologists (www.acog.org). complete with essential footnotes, and printed in color for easy reading. Schedules: $7.50 each Quantity discounts are available.

Wallet-sized immunization record cards for all ages: ▼ To order, visit www.immunize.org/shop, For adults, for children and teens, and for a lifetime! or use the order form on page 12. Record Cards: Now you can give any patient a permanent vaccination record card $45/box Quantity discounts are designed specifically for their age group: adult, child and teen, or available. To receive lifetime. These brightly colored cards are printed on durable rip-, sample cards, contact us: smudge-, and water-proof paper. Each box contains 250 cards. [email protected]

Training Video: “Immunization Techniques – ▼ To order, visit www.immunize.org/shop, Best Practices with Infants, Children, and Adults” or use the order form on page 12. The California Department of Public Health, Immunization For healthcare settings Branch, updated its award-winning training video, “Immunization in California, contact your Techniques: Best Practices with Infants, Children, and Adults.” The local health department 25-minute DVD can be used to train new employees and to refresh immunization program DVD: $17 each the skills of experienced staff on administering injectable, oral, for a free copy. Quantity discounts are available. and nasal-spray vaccines to children, teens, and adults.

The Vaccine Handbook: A Practical Guide for Clinicians (“The Purple Book” ) by Gary S. Marshall, MD

During my more than 25 years in NEW! Fifth edition extensively updated! the field of immunization education, I have not seen another book that is Purchase The Vaccine Handbook (560 pages) so brimming with state-of-the-science from IAC at www.immunize.org/vaccine-handbook. information. – Deborah L. Wexler, MD, Executive Director, IAC $29.95 + shipping • Discount pricing available!

Vaccinate Adults! • March 2016 • Immunization Action Coalition • (651) 647-9009 • www.immunize.org • www.vaccineinformation.org 11 Order Essential Immunization Resources from IAC 2016 Laminated U.S. Immunization Schedules – both adult and child/teen versions available!

IAC has two laminated immunization schedules for 2016 – one for includes a guide to vaccine contraindications and precautions, an ad- adults and one for children/teens. Based on CDC’s immunization ditional feature that will help you make on-the-spot determinations schedules, these laminated schedules are covered with a tough, wash- about the safety of vaccinating patients of any age. ❚ To order any of able coating. This allows them to stand up to a year’s worth of use as our essential immunization resources listed below, print out and mail at-your-fingertips guides to immunization and as teaching tools you or fax this page, or place your order online at www.immunize.org/ can use to give patients authoritative information. Plus, each schedule shop.

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■ The Vaccine Handbook: A Practical Guide for Clinicians How to Place an Order (“The Purple Book”) by Gary Marshall, MD Fifth edition • 2015 • 560 pages • $29.95 + shipping By Credit Card: Order easily online at our secure shopping cart at Order online at www.immunize.org/vaccine-handbook www.immunize.org/shop. By Check, Purchase Order, or Credit Card: Print out this page, fill out the necessary information, and Order Essential Immunization Resources Fax this page to: (651) 647-9131 or Mail this page to: Immunization Action Coalition ■ Laminated 2016 U.S. Immunization Schedules (details p. 11; call for discounts on bulk orders) 2550 University Avenue West, Suite 415 North Saint Paul, MN 55114 Qty. 1-4 copies–$7.50 each; 5-19 copies–$5.50 each Amt. �� R2008 Child/teen immunization schedules...... $______Our federal ID# is 41-1768237. �� R2009 Adult immunization schedules...... $______For Questions or International Orders: Contact us by phone at (651) 647-9009 or email [email protected] ■ DVD – Immunization Techniques: Best Practices with Infants, Thank you for your support of the Immunization Action Coalition. Children, and Adults (details p. 11; call for discounts on bulk orders) We depend on you! 1-9 copies–$17 each; 10-24 copies–$10.25 each; 25-49 copies–$7 each �� D2021 Immunization Techniques: Best Practices with Children/Teens/Adults.$______Method of payment: ❏ Check enclosed (payable to Immunization Action Coalition) ■ Patient Immunization Record Cards – for children and teens, ❏ Purchase order # ______for adults, and for a lifetime! (all are wallet-sized; details p. 11; call for discounts on bulk orders) ❏ Visa ❏ Mastercard ❏ Am. Express ❏ Discover 250 cards/box; 1 box–$45; 2 boxes–$40 each; 3 boxes–$37.50 each; 4-7 boxes–$34.50 each �� R2003 Child/teen immunization record cards ...... $______Card # �� R2005 Adult immunization record cards ...... $______�� R2004 Lifetime immunization record cards ...... $______Expiration Date mo/yr CV Code #* Total for Purchases $ ______*The CV Code is the Credit Verification Code, the additional 3- or 4-digit number on your credit card.

Name/Title ■ Make a Charitable Contribution. I am a ❏ new ❏ renewing contributor. Organization ❏ $250 ❏ $100 ❏ $50 ❏ $35 other: $______Shipping address (Check one: This is my ❏ organization address ❏ home address) IAC is a 501(c)(3) charitable organization and your contribution is tax deductible to the fullest extent of the law. Total for Purchases and Contribution $ ______City/State/Zip

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12 Vaccinate Adults! • March 2016 • Immunization Action Coalition • (651) 647-9009 • www.immunize.org • www.vaccineinformation.org