NEW VACS FACTS A Clinician's Handbook for Childhood & Adult Immunizations in Georgia March 2012 2 TABLE OF CONTENTS Pediatric Immunization Standards 5 Adult Immunization Standards 6 General Recommendations 7 Immunization Resources 9 Screening Tools 11 Vaccine Administration 13 Anaphylaxis 15 VAERS 16 Georgia School Requirements 17 Certificate Bloopers 20 Vaccine Storage and Handling 23 DTaP 25 Td/Tdap 27 Catch-up Vaccination for Td/Tdap 29 Haemophilus Influenzae type B (Hib) 31 Hib Vaccination Schedule Tables 32 Hepatitis B (HepB) 33 Comvax 35 Comvax Administration Schedule 36 Polio (IPV) 37 PediarixTM 39 Pentacel 41 Measles, Mumps, Rubella (MMR) 43 Varicella 45 Measles, Mumps, Rubella, Varicella (MMRV) 47 MMR/VAR/IG Table 49 PCV13 (Prevnar 13TM) 51 PPSV 23 53 Influenza (TIV) 55 Influenza (LAIV, FluMistTM) 57 Hepatitis A (HepA) 59 Meningococcal polysaccharide (MPSV4) 61 Meningococcal conjugate (MCV4) 62 Rotavirus vaccine 63 Human Papilloma Virus (HPV) 65 Herpes zoster 67 3 FROM THE EDITOR VACS FACTS was developed and produced by the EPIC NEW (Educating Physicians In their Communities) program at the Georgia Chapter of the American Academy of Pediatrics and the Immunization Office, Georgia Department of Public Health. A special thanks to Penny Conner, BSN, RN, Ben Sloat, MPH and Janet McGruder, RN, MSN with the Immunization Office for their hard work and dedication which made this edition of VACS FACTS possible. The editors would also like to thank the Georgia Chapter American Academy of Pediatrics and other EPIC partners, the Georgia Academy of Family Physicians, Georgia OB- Gyn Society, Georgia Chapter-American College of Physicians (Internal Medicine) and the Immunization Office for their support & participation in the EPIC immunization program. The contents of this handbook were derived from the following publications & source documents: -Department of Health & Human Services - National Vaccine Advisory Committee -Immunization Action Coalition -2009 Report of the Committee on Infectious Disease, American Academy of Pediatrics, Red Book -CDC Advisory Committee on Immunization Practices recommendations The material published in this edition of VACS FACTS is current as of March 2012. For the most up-to-date immunization information readers are advised to visit the Center for Disease Control and Prevention (CDC) Advisory Committee on Immunization Practices (ACIP) website at: http://www.cdc.gov/vaccines/recs/acip/default.htm For more information on EPIC or to schedule an EPIC Immunization program in your office, contact the Georgia EPIC program by calling 404-881-5054 or email: smcclain@gaaap.org or visit our website at www.GAepic.org 4 STANDARDS FOR CHILD & ADOLESCENT IMMUNIZATION PRACTICES Availability of vaccines 1. Vaccination services are readily available. NEW 2. Vaccinations are coordinated with other health care services and provided in a medical home when possible. 3. Barriers to vaccination are identified and minimized. 4. Patient costs are minimized. Assessment of vaccination status 5. Health care professionals review the vaccination and health status of patients at every encounter to determine which vaccines are indicated. 6. Health care professionals assess for and follow only medically accepted contraindications. Effective communication about vaccine benefits and risks 7. Parents/guardians and patients are educated about the benefits and risks of vaccination in a culturally appropriate manner and in easy-to-understand language. Proper storage and administration of vaccines and documentation of vaccinations 8. Health care professionals follow appropriate procedures for vaccine storage and handling. 9. Up-to-date, written vaccination protocols are accessible at all locations where vaccines are administered. 10. People who administer vaccines and staff who manage or support vaccine administration are knowledgeable and receive ongoing education. 11. Health care professionals simultaneously administer as many indicated vaccine doses as possible. 12. Vaccination records for patients are accurate, complete, and easily accessible. 13. Health care professionals report adverse events after vaccination promptly and accurately to the Vaccine Adverse Events Reporting System (VAERS) and are aware of a separate program, the Vaccine Injury Compensation Program (VICP). 14. All personnel who have contact with patients are appropriately vaccinated. Implementation of strategies to improve vaccination coverage 15. Systems are used to remind parents/guardians, patients, and health care professionals when vaccinations are due and to recall those who are overdue. 16. Office- or clinic-based patient record reviews and vaccination coverage assessments are performed annually. 17. Health care professionals practice community-based approaches. From the National Vaccine Advisory Committee (NVAC), 2003 5 5 STANDARDS FOR ADULT IMMUNIZATION PRACTICES Make vaccinations available. 1. Adult vaccination services are readily available. 2. Barriers to receiving vaccines are identified and minimized. 3. Patient "out-of-pocket" vaccination costs are minimized. Assess patients' vaccination status. 4. Healthcare professionals routinely review the vaccination status of patients. 5. Healthcare professionals assess for valid contraindications. Communicate effectively with patients. 6. Patients are educated about risks and benefits of vaccination in easy-to-understand language. Administer and document vaccinations properly. 7. Written vaccination protocols are available at all locations where vaccines are administered. 8. Persons who administer vaccines are properly trained. 9. Healthcare professionals recommend simultaneous administration of indicated vaccine doses. 10. Vaccination records for patients are accurate and easily accessible. 11. All personnel who have contact with patients are appropriately vaccinated. Implement strategies to improve vaccination rates. 12. Systems are developed and used to remind patients and healthcare professionals when vaccinations are due and to recall patients who are overdue. 13. Standing orders for vaccinations are employed. 14. Regular assessments of vaccination coverage levels are conducted in a provider's practice. Partner with the community. 15. Patient-oriented and community-based approaches are used to reach target populations. From the National Vaccine Advisory Committee (NVAC), 2003 6 NEW 11 NEW 12 Policy Guide 3231REQ Vaccine Requirements for Attending Facilities and Schools in Georgia* Relative to the Certificate of Immunization (Form 3231) Side 1 Required Doses for Attendance in Facilities and Schools For Children Who Started Immunizations Before Age 7 Years* Required Vaccines** with footnote numbers in [ ] [1] DTP, DTaP, DT [2]Hepatitis B [3]Hib PRP-T or [3]Hib PRP-OMP [4]Polio [5]MMR [6] Varicella [7] PCV [8] Td/Tdap [9] Hepatitis A 2 Months of Age 1 1 1 1 1 1 4 Months of Age 2 2 2 2 2 2 6 Months of Age 3 3 3 12-15 Months of Age 4 3 4 3 3 1 1 4 1 18-24 Months of Age 2 4-6 Yrs.* (School Entry) 5 4 2 2 Total Doses Required*** For Checking Complete For School Attendance Box on Immunization Certificate 5 or 4 (See Footnote [1]) 3 (See Footnote [2]) N/A for school (See Footnote [3]) N/A for school (See Footnote [3]) 4 or 3 (See Footnote [4]) 2 (See Footnote [5]) 2 (See Footnote [6]) N/A for school (See Footnote [7]) (See Footnote [8]) (See Footnote [9]) *These requirements were established in accordance with the current Recommended Childhood and Catch-Up Immunization Schedules, United States. (See references on reverse side.) Georgia requirements for Kindergarten (5 years) include doses indicated for 4-6 years. Immunization Schedule that are recommended routinely but are not required in Georgia for child care or school attendance. ***Children who are behind schedule may attend while in the process of completing the requirements with minimum intervals as indicated below. Vaccine Minimum Age For For First Dose [1] DTP/DTaP (DT) 6 weeks [2] Hepatitis B birth [3] Hib (Primary Series) PRP-T 6 weeks PRP-OMP (Pedvax) 6 weeks [4] Polio 6 weeks [5] MMR 12 months [6] Varicella 12 months [7] PCV 6 weeks [8] Td/Tdap See Side 2, Footnote [5] [9] Hepatitis A 12 months Minimum interval from dose 1 to 2 1 month 1 month 1 month 1 month 1 month 1 month 3 months 1 month 6 months Minimum Ages For Initial Immunization And Minimum Intervals Between Doses Minimum interval Minimum interval from dose 2 to 3 from dose 3 to 4 1 month 6 months See Footnote [2] N/A 1 month See Footnote [3] 1 month N/A N/A 1 month See Footnote [3] N/A See Footnote [4] N/A N/A See Footnote [7] Minimum interval from dose 4 to 5 See Footnote [1] N/A N/A N/A N/A N/A N/A N/A With respect to these intervals, 1 month is a minimum of 4 weeks or 28 days. Don't restart any series, no matter how long since the previous dose. Doses given 4 days before tchoeunmteindimausmvaaligde. oTrwtohedimffeinriemnut mliveinvteirruvsalvmacacyinbees counted as valid. Two different live vaccines must be given on the same day or spaced at least 28 days apart. [1] One dose of DTP/DTaP/DT must be on or after the 4th birthday. If the 4th dose was on or after the 4th birthday, the 5th dose is not needed. The 4th dose should be administered a minimum of 6 months after the 3rd dose. However, the 4th dose does not need to be repeated if administered 4 months after dose 3. Total doses of diphtheria and tetanus toxoids should not exceed 6 before the 7th birthday. [2] The 3rd dose of Hepatitis B vaccine should be given a minimum of 4 months after the 1st dose and 2 months after the 2nd dose and not before 24 weeks of age. [3] The number of doses of Hib depends on age at 1st dose and brand of vaccine given. The last dose in the series, whether 3rd or 4th, should be given at least 2 months after the previous dose and not before 12 months of age. Hib is required for children younger than 5 years attending facilities. Hib is not required for admission to kindergarten (5 years) through grade 12 and is not indicated for children who have reached the 5th birthday. One dose is sufficient if it is given at age 15 months or later. Brand names for PRP-T are ActHIB and OmniHIB. The brand name for PRP-OMP is Pedvax Hib [4] Booster dose must be given on or after the 4th birthday and a 6 month interval is required between the last dose of the primary series and the booster dose. If the 3rd dose of all IPV or all OPV series is given on or after the 4th birthday, [5] The MMR requirement is 2 doses of measles vaccine, 2 doses of mumps vaccine and 1 dose of rubella vaccine . The vaccines may be given as MMR or MMRV (combined antigens) or as single antigens. [6] The varicella requirement is for 2 doses of varicella-containing vaccine for entry into any level, K-12. (See Side 2, Footnote [4]).These may be administered as single dose varicella or in combination as MMRV. [7] The number of doses in the PCV series depends on age at 1st dose. The last dose in the series should be given at least 2 months after the previous dose and not before 12 months of age. [8] The number of doses required depends on age at first dose and number of previous doses. See current ACIP Immunization Catch-Up Schedule. [9] Hepatitis A vaccine should be administered to all children born on or after 1-1-06. Rev. MFaerbc-h122007 NEW 17 18 Policy Guide 3231REQ Vaccine Requirements for Attending Facilities and Schools in Georgia* Relative to the Certificate of Immunization (Form 3231) Side 2 NEW 19 Required Doses for Attendance in Schools For Children Who Started Immunizations At Age 7 Years or Older* Required Vaccines** First 1 Month 1 Month 1 Month 4 Months 6 Months Total Doses Required*** For Checking with footnote Visit After After After After After Complete For School Attendance numbers in [ ] First Second Third First Previous Box on Immunization Certificate [1]Hepatitis B Engerix 10 mcg or Recombivax 5 mcg 1 2 3 3 (See Footnote [1]) Recombivax 10 mcg (11-15 years only) 1 2 2 (See Footnote [1]) [2]Polio 1 2 3 4 or 3 4 or 3 (See Footnote [2]) [3]MMR 1 2 2 (See Footnote [3]) [4]Varicella 1 2 2 (See Footnote [4]) [5]Td/Tdap 1 2 3 3 (See Footnote [5]) *These requirements were established in accordance with the current Recommended Childhood Immunization Schedule, United States. See References. **There are other vaccines included in the Childhood Immunization Schedule that are recommended routinely but are not required in GA for child care or school attendance. ***Children who are behind schedule may attend while in the process of completing requirements with minimum intervals indicated above. With respect to these intervals, 1 month is a minimum of 4 weeks or 28 days. Footnotes: [1] The 3rd dose of Hepatitis B Engerix-B 10 mcg or Recombivax-HB 5 mcg should be given a minimum of 4 months after the 1st dose and 2 months after the 2nd dose. A 3rd dose is not needed when 2 doses of Adult Recombivax-HB 10 mcg are given when a child is 11-15 years old and the 2 doses are at least 4 months apart. Documentation of the vaccine brand of this alternate schedule is very important, especially when issuing the 3231 certificate. [2] If the 3rd dose of all IPV or OPV series is given on or after the 4th birthday, a 4th dose of not required provided there is a 6 month interval since the previous dose. [3] The MMR requirement is 2 doses of measles vaccine, 2 doses of mumps vaccine and 1 dose of rubella vaccine . The vaccines may be given as MMR or MMRV (combined antigens) or as single antigens. [4] Two doses of varicella vaccine are required for children entering school at any level, K-12, for the first time. For children already enrolled, the second dose is required at 6th grade. If given before age 12, the doses should be separated by 3 months, however, the 2nd dose does not need to be repeated if administered 1 month after 1st dose. If given on or after the 13th birthday, the doses should be separated by 4 or more weeks. [5] One dose of Tdap is recommended in lieu of a dose of Td. If a primary series is indicated, one dose, preferably the first, should be Tdap. If Td has already been administered, 5 years is the preferred interval to a dose of Tdap, but shorter intervals may be used if risk warrants it. References: Official Code of Georgia Annotated, Section 20-2-771 Recommended Childhood & Catch-Up Immunization Schedules, U.S.: Rules of the Department of Human Resources Division of Public Health, Chapter 290-5-4 Centers for Disease Control and Prevention Georgia Immunization Program Manual American Academy of Pediatrics (AAP) Georgia VFC Program Manual Approved by ACIP, AAP and American Academy of Family Physicians Recommendations of the Advisory Committee on Immunization Practices (ACIP) (AAFP) The Red Book - Report of the Committee on Infectious Diseases Rev. February 2012 Top Ten Certificate "Bloopers" 3: Completing both boxes: Should be one or the other 10: "Complete for School" checked for child under age 4 9: No dose DTaP after 4th birthday 2: Doses Hep B spaced incorrectly NEW 20 7: 1st dose MMR given before age 1 yr. 6: 1st dose varicella given before age 1 yr. 8: No 2nd dose varicella documented 5: Varicella Immunity not documented by vaccine or hx/dx/serology date 4: Address and/or contact information not completed 1: No physician, APRN or PA signature Top 10 Immunization "Certificate Bloopers" 10. "Complete for School" checked for child under age 4. 9. No DTP/DTaP/DT given on or after the 4th birthday. 8. No 2nd dose of varicella documented. 7. 1st dose MMR given before age 1 yr. 6. 1st dose varicella given before age 1 yr. NEW 5. V aricella immunity not documented. A vaccine administration date, or a 4 year digit in the box for diagnosed/serology/history is required. 4. Address and/or contact information not completed. 3. W riting in an expiration date AND checking the "Complete for School Attendance" box. It should be one or the other. The most common mistake is that some providers fill in the date for the Tdap/Td booster here. Students in Georgia are encouraged but not routinely required to have this booster. 2. D oses of Hepatitis B spaced incorrectly. Frequently the 3rd dose is given before 24 wks. of age, the absolute minimum age. 1. N o physician signature. By law, the form must be signed by a physician, Advance Practice Registered Nurse, or Physician Assistant licensed in Georgia, public health official, or state immunization program personnel. A stamp of a physician, APRN or PA's written signature is permissible when cosigned by an office staff member. 21 22 Pathophysiology Td/Tdap Tetanus, Diphtheria & Tetanus. Diphtheria and Pertussis Diphtheria: Bacteria NEW Respiratory transmission Incubation 2-5 days Tetanus: Bacteria Enters the body through a wound Incubation 3-21 days Pertussis: Bacteria Respiratory transmission Incubation 5-10 days Vaccine Description Inactivated polysaccharide vaccine, containing diphtheria toxoid, tetanus toxoid & acellular pertussis Two diphtheria, tetanus and acellular pertussis vaccines (Tdap) are licensed: o BoostrixTM for administration to persons 10- 64 years of age o AdacelTM for administration to persons 11-64 years of age Dose & Route 0.5 mL given IM Administration Schedule Children 7 through 10 years Those never vaccinated against tetanus, diphtheria or Tdap can be administered regardless of interval pertussis or who have unknown vaccination status since the last tetanus-or diphtheria-toxoid containing should receive a series of three vaccinations containing vaccine. tetanus and diphtheria toxoids. The first dose of these three doses should be Tdap. Dose Minimal Dose Intervals 1...................0 2...................4 weeks after dose #1 3...................6 months after dose #2 *Fully vaccinated is defined as 5 doses of DTaP or 4 doses of DTaP if the fourth dose was administered on or after the fourth birthday. Administration Schedule for Td/ Tdap Booster Doses following a primary DTaP/Td series:* Adolescents 11-18 years For routine use, adolescents aged 11 through 18 years who have completed the recommended childhood DTP/DTaP vaccination series should receive a single dose of Tdap.* 27 Adults aged 19 and older NEW Contraindications for Td and Tdap Precautions Special considerations Administration Schedule for Td/ Tdap Booster Doses following a primary DTaP/Td series:* Td should be given every 10 years following a dose of Tdap. Adults 19-64 years of age, especially those who have close contact with infants < 1 year of age, should receive a single dose of Tdap to replace a single dose of Td as a booster immunization if they have not already received Tdap. Adults 65 years and older who have or anticipate having close contact with an infant aged less than 12 months should receive a single dose of Tdap. Other adults 65 years and older may be given a single dose of Tdap Td and Tdap: Anaphylactic reaction to any of the vaccine components. Life threatening allergic reaction after a previous dose of DTP, DTaP, DT, Td or Tdap Tdap: Encephalopathy not attributed to another identifiable cause within 7 days of a previous dose of a pertussis containing vaccine Td, Tdap: Acute, moderate or severe illness with or without fever Arthus-type hypersensitivity reactions Guillain-Barr syndrome (GBS) within 6 weeks after a previous dose of tetanus toxoid containing vaccine Tdap: Progressive neurological disorder, uncontrolled epilepsy, or progressive encephalopathy until treatment regimen has been established and condition stabilized Latex allergy Pregnancy/Postpartum: Pregnant women who have not been previously vaccinated with Tdap should get one dose of Tdap during the third trimester or late second trimester (after 20 weeks). Tdap is recommended in the immediate postpartum period before discharge from hospital or birthing center for new mothers who were not previously vaccinated or whose vaccination status is unknown. By getting Tdap during pregnancy, maternal pertussis antibodies transfer to the newborn and likely providing protection against pertussis in early life, before the baby starts getting DTaP vaccines. Tdap will also protect the mother at time of delivery, making her less likely to transmit pertussis to her infant. DTaP or Tdap (depending on age) is recommended for all family members and caregivers of the infant at least two weeks before coming into close contact with the infant. 27A Wound management: For detailed guidelines, refer to wound management guidelines in the ACIP Recommendation Statements for Td and Tdap located at: www.cdc.gov/vaccines/pubs/ACIP-list.htm Simultaneous Administration: Tdap and MCV4 should be administered to adolescents 11-18 during the same visit if both vaccines are indicated and available. 28 NEW 28 NEW 28A Pathophysiology Hep B Hepatitis B vaccine (HBV) Virus NEW Transmitted by parenteral or mucosal exposure to HBsAg-positive blood and body fluids Incubation 60-150 days Vaccine Description Recombinant hepatitis B vaccine Dose & Route: Intramuscular. Hepatitis B vaccine administered by any route or site other than IM in the anterolateral thigh or deltoid muscle should not be counted as valid. Recombivax HB Engerix-B Age Group Dose (mcg) Volume (mL) Dose (mcg) Volume (mL) Infants (< 1 yr) 5 0.5 10 0.5 Children (1-10yrs) 5 0.5 10 0.5 Adolescents 11-15 yrs 10 0.5 N/A N/A (2-dose Schedule) 11-19 yrs 5 0.5 10 0.5 Adults ( 20 yrs) 10 1.0 20 1.0 Hemodialysis pts & other immuno- compromised persons < 20 yrs 5 0.5 10 0.5 20 yrs 40 1.0 40 2.0 (3-dose schedule at (4 dose schedule at 0,1 & 6 months) 0,1,2 & 6 months) Combination Vaccine Comvax Pediarix Twinrix Age Groups Dose (mcg) Volume Dose (mcg) Volume Dose (mcg) Volume (mL) (mL) (mL) Infants (< 1 yr) 5 0.5 10 0.5 N/A N/A Children (1-10yrs) 5 0.5 10 0.5 N/A N/A Adults ( 20 yrs) N/A N/A N/A N/A 20 1.0 Administration Schedule Dose Recommended Age Minimum Interval 1............Birth..........................Birth 2............1-2 months..................4 weeks from dose 1 3............6-18 months.................At least 8 weeks after 2nd dose and at least 16 weeks after 1st dose and infants must be at least 24 weeks of age All children and adolescents < 19 years and not previously vaccinated with hepatitis B series should be vaccinated at the earliest opportunity It is permissible to administer 4 doses of hepatitis B vaccine (e.g., when combination vaccines are given after the birth dose). Adults aged 20 years at risk for hepatitis B infection should receive 1 mL x 3 doses typically given at 0, 2 & 6 months. 33 Contraindications Special Instructions NEW High Risk Populations Anaphylactic reaction following a prior dose of HepB Persons with hypersensitivity to yeast, yeast products or any vaccine component Defer vaccination in persons with moderate or severe acute illness until illness subsides. Infants born to hepatitis B positive (HBsAg) women must receive hepatitis B vaccine and hepatitis B immune globulin (HBIG) within 12 hours of birth. Intervention Recommended Age 1st dose............................Birth (within 12 hours) HBIG..............................Birth (within 12 hours) 2nd dose...........................1-2 months 3rd dose............................6 months PVT*..............................9-18 months *PVT: Post vaccination Test-includes Hepatitis B Surface Antigen/ HBsAg (infection) and Hepatitis B Surface Antibody/Anti-HBs (antibody protection) Protocol available on GIP website at http://health.state.ga.us/programs/immunization/ For infants weighing less than 2000 gms at birth: If the mother is HBsAg negative, the 1st dose should be given when the baby is chronologically 1 month of age. If the mother is HBsAg positive or her status is unknown, the infant should receive the 1st dose at birth, dose #2 at age 1 month, dose #3 at 2-4 months, and dose #4 at age 6 months. The infant should be tested at 9-18 months of age for infection and antibody. If the mother is HBsAg positive, the infant should also receive HBIG at birth or within 1 week. Clients seen at STD treatment centers Clients in institutions and nonresidential daycare facilities for developmentally disabled HIV testing and treatment centers Immigrants/refugees from areas of high endemic hepatitis B Patients of hemodialysis units IV drug users Homosexual males Household contacts of HepB virus carriers Recipients of certain blood products Alaska Natives, Asian/Pacific Islanders, African , Eastern European Diabetes (Type I or 2) for adults 19-60 years of age 34 NEW 49 Recommended intervals between administration of immune globulin preparations and measles- or varicella-containing vaccine Product / Indication Dose, including mg immunoglobulin G (IgG)/kg body weight Recommended interval before measles or varicella-containing1 vaccine administration Tetanus IG (TIG) 250 units (10 mg IgG/kg) IM 3 months Hepatitis A IG - Contact prophylaxis 0.02 mL/kg (3.3 mg IgG/kg) IM 3 months - International travel 0.06 mL/kg (10 mg IgG/kg) IM 3 months Hepatitis B IG (HBIG) 0.06 mL/kg (10 mg IgG/kg) IM 3 months Rabies IG (RIG) 20 IU/kg (22 mg IgG/kg) IM 4 months Varicella IG 125 units/10 kg (60-200 mg IgG/kg) IM, maximum 625 units 5 months Measles prophylaxis IG - Standard (i.e., nonimmunocompromised) contact 0.25 mL/kg (40 mg IgG/kg) IM 5 months - Immunocompromised contact 0.5 mL/kg (80 mg IgG/kg) IM 6 months Blood transfusion - Red blood cells (RBCs), washed 10 mL/kg (negligible IgG/kg) IV None - RBCs, adenine-saline added - Packed RBCs (hematocrit 65%)2 - Whole blood (hematocrit 35%-50%)2 10 mL/kg (10 mg IgG/kg) IV 10 mL/kg (60 mg IgG/kg) IV 10 mL/kg (80-100 mg IgG/kg) IV 3 months 6 months 6 months - Plasma/platelet products 10 mL/kg (160 mg IgG/kg) IV 7 months Cytomegalovirus IGIV 150 mg/kg maximum 6 months IGIV - Replacement therapy for immune deficiencies3 300-400 mg/kg IV 8 months - Immune thrombocytopenic purpura treatment 400 mg/kg IV 8 months - Immune thrombocytopenic purpura treatment 1,000 mg/kg IV 10 months - Kawasaki disease - Postexposure varicella prophylaxis4 2 g/kg IV 400 mg/kg IV 11 months 8 months Monoclonal antibody to respiratory syncytial virus F protein (SynagisTM)5 15 mg/kg (IM) None This table is not intended for determining the correct indications and dosages for using antibody-containing products. Unvaccinated persons might not be fully protected against measles during the entire recommended interval, and additional doses of IG or measles vaccine might be indicated after measles exposure. Concentrations of measles antibody in an IG preparation can vary by manufacturer's lot. Rates of antibody clearance after receipt of an IG preparation also might vary. Recommended intervals are extrapolated from an estimated half-life of 30 days for passively acquired antibody and an observed interference with the immune response to measles vaccine for 5 months after a dose of 80 mg IgG/kg. 1 Does not include zoster vaccine. Zoster vaccine may be given with antibody-containing blood products. 2 Assumes a serum IgG concentration of 16 mg/mL. 3 Measles and varicella vaccinations are recommended for children with asymptomatic or mildly symptomatic human immunodeficiency virus (HIV) infection, but are contraindicated for persons with severe immunosuppression from HIV or any other immunosuppressive disorder. 4 The investigational product VariZIG, similar to licensed VZIG, is a purified human IG preparation made from plasma containing high levels of anti-varicella antibodies (IgG). The interval between VariZIG and varicella vaccine (Var or MMRV) is 5 months. 5 Contains antibody only to respiratory syncytial virus Adapted from Table 5, ACIP General Recommendations on Immunization January 2011 50 Pathophysiology Vaccine Description Dose & Route Influenza (TIV) Inactivated Influenza Vaccine Virus Highly contagious Respiratory transmission Virus shed in respiratory secretions for 3-10 days Inactivated, split-virus vaccine composed of 3 virus strains - two type A and one type B Age 6-35 months of age 0.25 mL given IM Age 3 years 0.5 mL given IM Brand Information NEW Fluzone sanofi-pasteur Approved for persons 6 months of age and older Fluzone High Dose sanofi-pasteur Fluzone Intradermal sanofi-pasteur Afluria CSL Approved for persons 6 months of age and older FluarixTM GSK Approved for persons 3 years of age and older FluvirinTM Novartis Approved for persons 4 years of age and older Flulaval TM GSK Approved for persons 18 years of age and older Agriflu TM Novartis Approved for persons 18 years of age and older Administration Schedule & Minimum Intervals 1 dose annually to persons 6 months of age* *Children 2-8 years of age receiving influenza vaccine for the first time should receive 2 doses separated by at least 28 days. See algorithm below Recommendations Contraindications Annual influenza vaccination is recommended for all people ages 6 months and older. Anaphylactic reaction following a prior dose of influenza or to any of its components Do not give to persons who have had a serious 55 NEW Egg Protocol reaction to eggs.(see Egg Flu Protocol) Defer vaccination in persons with moderate or severe acute illness until illness subsides. History of Guillain-Barr Syndrome following a previous dose of influenza vaccine is considered a precaution. Delay vaccination in a person with an active or unstable neurologic condition. Special Considerations The best time to give influenza vaccine is October November; however, influenza vaccine can be administered through May. It takes approximately 2 weeks for influenza vaccine to be protective. Immunity from influenza vaccine rarely exceeds 1 year and the vaccine virus strains may vary each year. 56 Influenza (LAIV) Live Attenuated Influenza - FluMistTM Pathophysiology Virus Highly contagious Respiratory transmission Virus shed in respiratory secretions for 3-10 days Vaccine Description Live, attenuated, cold-adapted, 0.2ml intranasal vaccine composed of 3 virus strains - two type A and one type B Dose & Route 0.2 mL dose (0.1 mL per nostril),sprayed into each nostril If the vaccine recipient sneezes after administration, the dose should not be repeated. However, if nasal congestion is present that might impede delivery of the vaccine to the nasopharyngeal mucosa, deferral of administration should be considered until resolution of the illness, or TIV should be administered instead. Administration Schedule & Minimum Intervals Administer annually prior to influenza season to healthy persons 2-49 years of age* *Children 2-8 years of age receiving influenza vaccine for the first time should receive 2 doses separated by Recommendations Contraindications NEW Healthy persons 2-49 years of age who want to reduce the likelihood of becoming ill from influenza 1. Anaphylactic reaction following a prior dose of influenza or to any of its components 2. Do not give to persons who have had a serious reaction to eggs (Refer to Flu Egg Protocol below ) 3. Defer vaccination in persons with moderate or severe acute illness until illness subsides 4. Persons with chronic disease that constitutes an increased risk when exposed to wild influenza virus (such as asthma, heart or kidney disease, diabetes) 5. Pregnancy 6. Immunocompromised persons and their close contacts 55 57 Special Considerations The best time to give influenza vaccine is October - November, however, influenza vaccine can be administered through May Immunity from influenza vaccine rarely exceeds 1 year and the vaccine virus strains may vary each year NEW 55 58 Meningococcal Polysaccharide Vaccine (MPSV4) Pathophysiology Vaccine Description Dose & Route Administration Schedule Indications ** Persons 11-55 years of age, who meet any of these criteria, should be immunized with Meningococcal Conjugate Vaccine (MCV4) instead of MPSV4. MCV4 was licensed in January 2005. However, if MCV4 is not available, vaccination with MPSV4 is acceptable. See MCV4 guidelines on next page. Contraindications Special Instructions NEW Bacteria Inactivated polysaccharide vaccine, containing N. meningitidis serogroups A, C, Y, and W-135 0.5 mL given subcutaneously Dose 1 dose for persons aged 2 years and older* + *Re-vaccination at 3-5 years may be indicated for persons who remain at high risk for infection (e.g., those with asplenia, HIV infection, or travelers to endemic areas). +In certain high- risk situations, children as young as 3 months of age may have indication for this vaccine. Consult ACIP meningococcal statement at www.cdc.gov/nip/acip **Consider vaccination for: Persons with terminal complement component deficiency or asplenia Persons with HIV infection College freshmen living in dormitories not previously vaccinated Research or laboratory personnel routinely exposed to N. meningitidis Military recruits Persons traveling to countries where meningitis is hyperendemic or epidemic Persons who might have been exposed to meningococcal disease during an outbreak Anaphylactic reaction following a prior dose of vaccine or any vaccine component Defer vaccination in persons with moderate or severe acute illness until illness subsides. Not effective in children under 2 years of age Effective January 2004, persons attending college or universities in Georgia and living on campus must a) be provided information about meningococcal disease and vaccine, and b) sign documentation of receipt of meningococcal vaccine or that they have reviewed the information provided. 61 61 NEW 61A Pathophysiology Vaccine Description Meningococcal Conjugate Vaccine (MCV4) Bacteria Inactivated conjugate vaccine, containing N. meningitidis serogroups A, C, Y, and W-135 Menactra Approved for use in ages 2 through 55years Menveo Approved for use in ages 2 through 55 years Dose & Route Administration Schedule 0.5 mL given IM Dose- See Table on second sheet 1 dose for persons 2-55 years of age Indications Contraindications Adolescents 11-18 years of age Persons with asplenia, terminal complement deficiency, HIV infection Persons traveling to countries where meningitis is hyperendemic or epidemic Military recruits Research or laboratory personnel routinely exposed to N. meningitidis Severe allergic reaction (e.g. anaphylaxis) after a previous dose or to a vaccine component. Precautions Special Instructions NEW Acute, moderate, or severe illness with or without fever Use of MCV4 has not been studied sufficiently in pregnant women. For pregnant women in need of protection against N. meningitidis, MPSV4 may be considered. Because vaccinees may develop syncope, sometimes resulting in falling with injury, observation for 15 minutes after administration is recommended. If syncope develops, patients should be observed until the symptoms resolve. 62 NEW 62A Pathophysiology Vaccine Description Dose & Route Human Papillomavirus Vaccine Certain types of human papillomavirus can cause squamous cell cervical cancer, cervical adenocarcinoma, and genital warts. HPV4 (GardasilTM),Licensed in December 2010 for females and males 9 through 26. Indicated for the prevention of certain diseases caused by HPV types 6,11,16, and 18 HPV2 (Cervarix) Licensed in October 2009 for females ages 10 through 26 years; Indicated for the prevention HPV types 16 and 18 0.5 mL given intramuscularly Administration Schedule & Minimum Intervals If the HPV vaccine schedule is interrupted, the vaccine series does not need to be restarted. Dose Dose 1 Dose 2 Dose 3 Recommended Minimum Ages Intervals 11-12 years of age (see Minimum Age below) 2 months after Dose 1.....4 weeks from Dose 1 6 months after Dose 1....12 weeks from Dose 2 and 24 weeks from Dose 1 Minimum Age Contraindications Precautions Special Considerations NEW Also recommended for males and females ages 13 through 26 who did not receive the vaccine previously May be given at the same visit with other vaccines Should be given to persons with a previous history of HPV infection Vaccine is licensed for use in males and females ages 9-26 years. Anaphylactic reaction to any vaccine component or to previous dose of vaccine Not recommended for use in pregnant women Not intended for treatment of active genital warts or cervical cancer Moderate or severe acute illness with fever Vaccination in no way should replace: routine, periodic cervical cancer screening protective sexual behaviors 65 65 66