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Improving the Health of Children and Adults through Vaccines: Updates and Recommendations for Clinicians

Moderator:Leticia R. Davila

Presenter:Iyabode (Yabo) Akinsanya-Beysolow, MD, MPH

Date/Time:August 13, 2013 2:00 pm ET

NOTE:This transcript has not been reviewed by the presenter and is made available solely for your convenience. A final version of the transcript will be posted as soon as the presenter’s review is complete. If you have any questions concerning this transcript please send an email to coca@cdc.gov

Leticia Davila:
Thank you (Erin). Good afternoon. I am Leticia Davila. And I’m representing the Clinician Outreach and Communication Activity, COCA, with the Emergency Communication System at the Centers for Disease Control and Prevention.

I’m delighted to welcome you to today’s COCA Webinar, Improving the Health of Children and Adults through Vaccines: Updates and Recommendations for Clinicians. We are pleased to have with us today, Dr. Yabo Beysolow from the Centers for Disease Control and Prevention to discuss recent vaccine recommendations and available immunization resources. You may participate in today’s presentation by audio, only via Webinar, or you may download the slides if you are unable to access the Webinar.

The PowerPoint slide set and the Webinar link can be found on our COCA Web site at Emergency.CDC.gov/COCA. Click on COCA Calls. The Webinar link and slide set are located under the call in number and call passcode.

At the conclusion of today’s session the participant will be able to describe two recent vaccine recommendations made by the Advisory Committee on Immunization Practices, understand how and where to access immunization resources.

In compliance with continuing education requirements all presenters must disclose any financial or other association with the manufacturers of commercial products, suppliers of commercial services or commercial supporters as well as any use of an unlabeled product or products under investigational use.

CDC, our planners and the presenter for this presentation do not have financial or other associations with the manufacturers of commercial products, suppliers of commercial services or commercial supporters. This presentation does not involve the unlabeled use of a product or products under investigational use with the exception of HPV. There was no commercial support for this activity.

At the end of the presentation you will have the opportunity to ask the presenter questions. On the phone dialing Star 1 will put you in the queue for questions. You may submit questions through the Webinar system at any time during the presentation by selecting the Q&A tab at the top of the Webinar screen and typing in your question.

Today’s presenter Dr. Beysolow is a Medical Officer in the Education, Information and Partnership Branch of the National Center for Immunization and Respiratory Diseases at the CDC. Her responsibilities include the development and implementation of immunization education and training materials for vaccine providers, presentations at nationwide courses and lectures on vaccine preventable diseases, as well as, Web based and net conferences on immunizations for all ages. Dr. Beysolow is a graduate from the University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School with a joint MD/MPH Concentration and Family Health. She received her pediatrics residency training at Emory University Pediatrics Residency program in Atlanta. She is currently board-certified in pediatrics and a fellow of the American Academy of Pediatrics.

Again the PowerPoint slides set and Webinar links are available from our COCA Web page at Emergency.CDC.gov/COCA. At this time, please welcome Dr. Beysolow.

Dr. Yabo Beysolow:
Thank you so much Leticia and good afternoon to all of you out there. It is a pleasure to present to you today from Atlanta and thank you for this opportunity.

Leticia’s already done a great job going over the objectives for today as well as the disclosures so we’ll move forward with our presentation. Just to remind you that hopefully at the end of today’s session our knowledge will be increased regarding immunizations and the importance of promoting immunizations in the community.

Also the Web addresses that are listed are current as of the date of this presentation. To begin with, we really want to just find out a little bit about who you are, who’s in the audience and where you work and what age group you administer vaccines too. So in order to do this I’m going to turn back over to Leticia so she can ask you a few polling questions.

Leticia Davila:
Thank you Dr. Beysolow. We will now begin with the first polling question. To select a response please click the corresponding colored box or the Radio button. Please make your selection now.

Dr. Yabo Beysolow:
Thank you.

Leticia Davila:
We will now go on to poll question number two. Please make your selection now. The poll is now closed. Thank you. We will now go on to the third poll question. Please make your selection now. Thank you. That concludes this portion of the polling questions. Dr. Beysolow I will turn it back over to you.

Dr. Yabo Beysolow:
Thank you Leticia. And just from the preliminary findings that I saw there it seems that we have a wide mixture in the audience today.

We have a majority of nurses but also some physicians and pharmacists. The majority of you work in public health and a few in the hospital setting or private healthcare setting. And the majority administer vaccine to all ages. So hopefully this will help in your daily work.

As far as an outline for the talk today we’ll begin with an overview of the immunization schedules. Then we’ll touch on HPV disease and HPV vaccine, flu vaccine recommendations for the upcoming season, some issues regarding vaccine administration. I’ll share some resources with you and then leave time at the end for questions.

But beginning with the ACIP approved immunization schedules that are currently available at the CDC Web site, in 2013 both the child and adolescent and adult immunization schedules were published jointly in the MMWR. And it basically allowed one to view immunizations across the lifespan.

Beginning with the childhood and adolescent schedules there was a major format change to these schedules in 2013. Providers now have the opportunity to view a combined schedule showing vaccines recommended from birth through 18 years of age. Prior to 2013, there were two separate schedules, the zero to 6 and a 7 to 18 schedule.

As you can see on here, vaccines that begin during infancy are found more on the top end of the schedule whereas those for adolescents are more towards the bottom of the schedule with the exception of TDAP.

Also within the bars providers are reminded of the dose number in the series. Let’s look at the HPV row, for example, and you can see the pointer on there so there are three doses recommended to complete the series.

Please note also that vaccines recommended for high risk situations are shown in purple, for example meningococcal vaccines that I’m highlighting.

And then the white spaces denote where vaccines are not routinely recommended. The green bars indicate age ranges during which catch-up vaccination is recommended. In 2013 the catch- up table remained the same as in previous years.

Another new change for 2013 was to the footnote section. Please remember to always train all those in your office to look at the footnotes along with the schedule grids.

For each vaccine the footnotes now provide information on not only routine vaccination recommendations but also catch-up vaccination recommendations.

And then for some of the vaccines where appropriate, when the vaccine should be used in special or high risk circumstances.

Now turning to the adult schedule for 2013, the format did not change significantly. You can still view the recommended vaccines for adults in two ways.

The first is by age group as shown here. A provider can quickly determine which vaccines their patient needs by looking down the respective age column, say a 23-year-old or a 50-year-old and then going down to see which vaccines are recommended.

Routinely recommended vaccines are highlighted in yellow and then vaccines recommended when some other risk factor is present are shown in purple.

Another way a provider may view the adult schedule is by risk condition that the patient presents with such as pregnancy or immuno-compromising conditions, chronic diseases such as heart or lung disease.

A provider can quickly see which vaccines are recommended for patients with immuno- compromising positions for example, and which ones are contraindicated in red.

As with the child and adolescent schedules the adult schedules also come with footnotes. And again this is another reminder to look at the corresponding footnotes for the adult schedule in addition to the figures to find out some of the nuances. Lastly, the adult schedule also includes a table of contraindications and precautions to commonly used vaccines in adults.

And all these schedules are available on the CDC’s Web site. The URL is listed above. Even if you just went to www.cdc.gov/vaccines and on that tab you’ll be able to see the schedules tab and you will come to this page. On the left for healthcare professionals you’re able to download the schedule that I just showed you. On the right for parents and for patients or adults themselves, you can download easier to read schedules or sometimes we call them parent friendly schedules.

There are also easy to use schedule tools for your patient where they can answer a few questions about themselves, and the tool provides them with a personalized immunization schedule. Now we’ll turn our attention to a few of the vaccines and the recommendations. I’ll begin with a discussion of HPV disease and HPV vaccines.

Data from the 2012 National Immunization Survey which looked at immunization coverage rates for teens in the United States showed that no progress has been made in HPV vaccination coverage in girls since last year.

When we look at rates of HPV vaccination coverage compared to those of other recommended vaccines, rates for HPV vaccine did lag behind.

Between 2007 and 2011 vaccination coverage at that time had significantly increased each year for all three doses in the HPV vaccine series.

But then from 2011 to 2012 there really was no statistically significant change in coverage. The percentage of girls initiating the HPV vaccine series did not improve. And the number of girls receiving all three recommended doses of HPV vaccine failed to improve as well.

So let’s begin with just a brief overview of HPV disease. Many of you have seen this or perhaps a similar slide in the past.

There are over 100 HPV types. They’re the types that lead to infection in mucosal or genital sites and those that lead to infection in cutaneous sites such as common hand and foot warts.

For the purposes of today’s discussion, we’ll focus on those that infect mucosal or genital sites. They can be classified either as the low-risk types or non-oncogenic types which can lead to genital warts and low-grade cervical disease. They can also lead to mild Pap test abnormalities.

Then there are the high risk or oncogenic types which can lead to moderate to severe Pap test abnormalities, cervical dysplasia, and cervical cancer as well as other cancers.

Of note is that most genital HPV infections are transient, they’re asymptomatic and have no clinical consequences.

Statistics do show that HPV disease is very prevalent. Nearly all sexually active men and women acquire genital HPV at some time in their lives.

An estimated 79 million females between the ages of 14 through 59 are infected with HPV infection.

Each year over 30,000 new cases of cancer are found in parts of the body where HPV virus is often found. And HPV is found to cause about 26,000 of these cancers. Although about over 90% of cervical cancers are caused by HPV, cancer in some other areas of the body are often but also not always caused by HPV.

It’s found to be generally responsible for over 90% of anal cancers as well and over 50% of vaginal, vulva and penile cancers. Cancers of the head and neck are mostly caused by tobacco and alcohol but more recent studies have shown that about 60% to 70% of cancer of the oral pharynx may also be linked to HPV.

The two HPV vaccines that are currently available in the United States are shown here on the slide. There is the quadrivalent which is HPV4 and the bivalent HPV2 vaccines which protect against HPV types 16 and 18 which cause about 70% of cervical cancers and the majority of other HPV associated cancers.

HPV 4 also protects against types 6 and 11 which cause about 90% of the genital warts.

Both vaccines as you can see are routinely recommended at 11 to 12 years of age. Males are only recommended to receive HPV4 vaccine and not HPV2.

The ACIP recommended schedule for the three dose series is starting at zero, day zero and then one to two months later and six months later for either vaccine.

The minimum intervals for both vaccines are four weeks between the first and second doses, 12 weeks between the second and third doses -- we get this question often -- and then 24 weeks between the first and third doses.

However the minimum intervals between doses should not be used for routine HPV vaccination. They’re really almost no situations where a compressed or accelerated schedule is needed. Remember also that the series can be started as early as 9 years of age.

Another thing, another question we get often is that ACIP has not defined a maximum interval between HPV vaccine doses.

One of the common questions is what if a patient started a series at 13 years of age, never came back until they were 18 years old what do you do?

Well we recommend that you do not restart the series. We recommend that you continue where you left off.

So to repeat, if the interval between doses is longer than recommended you should just continue the series where it was interrupted. It is not necessary to add doses or restart the series because of an extended interval between doses.

So now I’ll turn it over to Leticia. This is just a little quiz to make sure everyone’s listening.

Leticia Davila:
Remember to select your response please click the corresponding colored box or the Radio button. Please make your selection now.

Dr. Yabo Beysolow:
Okay.

Leticia Davila:
Okay the poll is now closed.

Dr. Yabo Beysolow:
Thank you Leticia. So about 89% or so of you got this answer correct and the answer is the series should be completed. So even if this means that the series was completed after the person turns 27 as long it was begun before 26 years of age it may be completed after the person turns 27.

There are a variety of what ACIP calls special situations for use of HPV vaccines. One of them is that vaccine can be administered to females 26 years of age or younger with an equivocal or abnormal Pap test or a positive HPV DNA test meaning that they are currently infected or

perhaps they had genital warts already. So that’s a question we get often, and yes you may still administer the HPV vaccine in these situations.

However these women should be informed that a vaccine will have no effect on an existing disease or infection. But they can still definitely gain some benefit from vaccination as there are other strains contained in the vaccine.

Females 26 years of age or younger who are lactating and breast-feeding or who are immuno- compromised may be vaccinated.

Immuno-compromised males including those with HIV infection may also be vaccinated. HPV4 is recommended for immuno-compromised males 22 through 26 years of age who have not been vaccinated previously or who have not completed the three dose series.

We discussed the disease and its complications and the vaccine recommendations so far during this presentation but now let’s look at the coverage rates as I mentioned earlier.

This graph compares the vaccination rates of routinely recommended adolescent vaccines mainly TDAP and meningococcal vaccines and HPV vaccine.

It shows the immunization rates for teens 13 through 17 years of age over the last few years. And as you can see the years are across the bottom on the X axis. Vaccination rates are on the Y axis.

And we see that HPV vaccination coverage is stagnating as compared to the other vaccines. There’s a huge gap between HPV vaccination rates and other adolescent vaccines.

Barely half of all teen girls have begun HPV vaccinations and among those girls who have initiated HPV vaccinations almost one in three do not complete the series.

This is a similar graph to the previous one shown but includes HPV coverage levels among girls through 2012.

Although vaccination coverage with greater than one dose of any HPV vaccine increased from 12 point - I’m sorry from 25% in 2007 to 53% in 2011when you look at coverage in 2012 as compared to 2011 it was very similar. It really only went up very slightly to 53.8%.

And the national immunization survey on teen vaccine immunization coverage rates also called NIS Teen this is what we use. And it provides us basically with a report card to let us know how well we’re doing in protecting our nation’s teens against vaccine preventable diseases.

Another way to look at the coverage data is to try to find out if there were missed vaccination opportunities. There were and these need to be reduced.

Although providers cite infrequent preventive healthcare visits among the teen population as a vaccination barrier the data shows that health care access is not really the main issue.

This graph shows years along the X axis and percentage of coverage along the Y axis. Actual coverage for at least one dose of vaccine is shaded in white for each year and potential coverage if we eliminated missed opportunities shaded in red for that same year.

The way we define a missed opportunity is as a healthcare encounter that occurred on or after the girl’s 11th birthday and on or after March 23 of 2007 when the HPV4 recommendations were published and during that time if a girl received at least one vaccine but did not also receive HPV vaccine.

And let’s look at the latest year 2012. The 2012 NIS teen data showed that 84% of unvaccinated girls had a healthcare encounter where another vaccine was administered. Had the three dose HPV series been initiated at these visits, coverage for at least one dose of vaccine could be as high as 93%.

And when we look at reasons why this may not be happening despite the availability of safe and effective HPV vaccines approximately1/4 of surveyed parents did not intend to vaccinate their daughters in the next 12 months. And this chart outlines the top five reasons.

And parents felt like the vaccine was either not needed, was not recommended by the teen’s healthcare provider. Safety concerns were also expressed. And so how do we as providers address this? The first area truly is education of our parents. Three of those five reasons that you see there for not intending to vaccinate their daughters indicate gaps in understanding including why vaccination is recommended by age 13 years.

Parents also reported vaccine safety concerns as the main reason for not vaccinating. And there are tools that we can use. There are updated educational materials that address these issues and they’re available from CDC at the Web site that I’ll show you.

So we’ll now begin to look at some of this information and what we can use to help arm ourselves as clinicians.

First as clinicians we need to be aware of the disease prevalence, vaccine efficacy duration of immunity of the vaccine and vaccine safety.

And what we have here is the prevalence of HPV vaccine, this study just basically shows that within four years of vaccine introductions the vaccine type HPV prevalence decreased among females aged 14 through 19 years with about a 56% decrease despite low vaccine uptake. And the estimated vaccine effectiveness was high.

So the data suggests an early impact of HPV vaccination on vaccine type prevalence among females in the United States and a high vaccine effectiveness against vaccine type infection.

With regards to duration of immunity, studies suggest that vaccine protection is long-lasting. Current studies with up to about six years of follow-up data indicate that the vaccines are effective with no evidence of waning protection.

This information will be updated of course as additional data regarding duration of protection becomes available.

Safety concerns is one of the top five reasons that parents did not intend to vaccinate. However there are multiple studies that show that HPV vaccination is safe.

More than 170 million doses of HPV vaccine have been distributed worldwide and over 57 million doses have been distributed in the US.

And in the seven years of vaccine safety studies for HPV vaccine and monitoring in the US no serious safety concerns have been identified.

And this graph shows reports to VAERS (Vaccine Adverse Event Reporting System). Most of the reports as you can see on the top parts of the columns are non-serious reports.

Local reactions do occur and there have been some reports of serious adverse reactions but these events have mostly been coincidental to vaccinations.

Earlier on syncope was noted frequently, however what we know is that regardless of the vaccine given during these teen years syncope might occur.

And so syncope precautions should be observed when vaccinating adolescents and young adults with any vaccine.

Monitoring and evaluation of reports will continue. So armed with this information as clinicians we must really increase the consistency and strength of HPV vaccination recommendations.

Studies have documented that especially when counseling younger adolescents or their parents’ providers seem to give weaker recommendations for HPV vaccination compared with other vaccinations recommended for adolescents.

We do know that high HPV vaccinations coverage with the existing infrastructure and healthcare utilization is possible in the US.

And so taking advantage of every healthcare encounter including acute care visits to assess every teen’s vaccination status can help minimize some of these missed opportunities.

Some of the potential strategies would include using vaccination prompts available through electronic health records, checking local state immunization information systems to assess vaccination needs at every encounter.

And then series completion can also be promoted through scheduling appointments for second and third doses before patients leave provider’s offices after receiving their first HPV vaccine dose. Also using automated reminder recall systems.

Because provider counseling and recommendations greatly influence parental acceptance of vaccines CDC has recently developed a tip sheet to help parents - I’m sorry, to help providers respond to parent’s questions and communicate strong, clear HPV vaccination recommendations.

And I just wanted to share one or two of those tips on that tip sheet with you. They’re available at www.cdc.gov/vaccines/teens. I’ll share all of these resources with you again at the end.

This is what the tip sheet looks like. It’s a way as a provider you get some points across. Messages have been field tested amongst parents and providers across the country to really see what works.

Here is an example of one here. CDC research shows that if we as providers emphasize our personal belief in the importance of vaccine it helps parents feel secure in their decision.

For example you may try saying something to the effect I strongly believe in the importance of this cancer preventing vaccine. I’ve given it to my sons, my daughter. Other experts like the American Academy of Pediatrics, Oncologists, CDC also agree that this vaccine is very important for your child.

Just on a personal note what I usually say is I have two daughters, one is 21, one is 14. And what I always say to my patients is I really do not want my girls to come back to me in 20 years and say mommy I have cervical cancer. There was something you could have done to prevent this and you did not.

So that is my tool and one of the tips I use in encouraging my parents to get their children vaccinated.

Another tip is that many parents do not know that the full vaccine series requires three shots. And so your reminder would help them to complete the series.

And you could try saying something such as “I want to make sure that your son or daughter receives all three shots of HPV vaccine to give them the best possible protection from cancer.

So please make sure on your way out to make all those appointments, put them on your calendar.

We’ll even send you a reminder to make sure that you complete the three dose series.”

So at the bottom of the screen there again is the Web site for this tip sheet. And these slides will be available on the Website so you can get back to them and find out all these resources.

So now we’ll turn our attention to the flu vaccine recommendations for the upcoming season. In general there have been no major changes in the recommendation. Annual vaccination continues to be recommended for all persons age 6 months and older.

There were some minor changes related to vaccination in setting of egg allergy. Because of time I will not be able to discuss this but these recommendations will be published shortly. And currently there is a summary available for your review and I’ll share that Web site with you.

Today we’ll focus on five new vaccine products, new abbreviations, and the virus composition of the upcoming season’s vaccine.

Please note that the 2013 to 2014 ACIP influenza vaccination recommendations are not official until they’ve been adopted by the Director of CDC.

So the information I’ll be sharing was voted on in June of this year but are not yet official. We expect publication of the recommendations later this month. There is currently however a summary of those votes available on the Website.

So we’ll begin with the components of the influenza vaccine for the upcoming season. And the influenza strains for the vaccine are selected early each year by the Food & Drug Administration.

And this upcoming season’s vaccine, the Trivalent vaccine will contain two A strains -- H1N1 and H3N2 and then a B strain from the Yamagata lineage. This is a new B strain from the prior year’s vaccine.

There will also be a quadrivalent product available and will contain the same three strains above plus a second B strain from the Victoria lineage.

Not to scare you but rather to show you this is really the abundance of flu vaccine preparations that will be available this upcoming season.

They have different age indications, some are trivalent some are quadrivalent and also the variety of presentations.

Another change this year was that in order to account for the newer vaccine formulations on the market including the quadrivalent vaccine, we now need to account for how this is portrayed in our vaccine abbreviations.

So TIV, Trivalent Inactivated Influenza Vaccine is now going to be replaced with IIV to reflect the fact that that we now also have quadrivalent vaccines.

The IIV will refer to all the inactivated vaccines, egg and cell culture based, and include both trivalent and quadrivalent vaccines.

Where necessary cell culture based IIV is referred to as ccIIV. Another new abbreviation is RIV referring to the Recombinant Hemagglutinin Influenza vaccine. And that is a trivalent preparation.

And we will continue to use LAIV for the quadrivalent formulation. There will only be the quadrivalent formulation for this upcoming season. It is LAIV4.

And some of the influenza vaccines just to share with you that have been recently approved include the quadrivalent Flumist, the quadrivalent inactivated vaccines to include Fluarix quadrivalent and Fluzone quadrivalent.

There is also cell culture-based influenza vaccine, Flucelvax and a recombinant hemagglutinin vaccine, Flublok.

These newer technologies may permit more rapid scale up of a vaccine production. For example this might be needed during a pandemic. So just wanted to briefly tell you a little bit about one of the newer vaccines Flucelvax. This is a cell culture-based vaccine.

Vaccine virus is propagated in canine kidney cells. The vaccine viruses are not propagated in eggs. However the initial reference strains have been passed through eggs. Hence it cannot be considered egg-free though it is expected to contain less egg protein than the other available inactivated influenza vaccines.

It is an acceptable alternative to other licensed products when it’s used within the indications, age ranges and recommendations.

Flublok is a vaccine developed using recombinant technology approved for persons aged 18 to 49 years of age. The protein is produced in insect cell lines. There’s no egg or influenza virus used in production. So this is the egg-free formulation.

Fluzone intradermal, you may be familiar with this. It has been around since 2011, approved only for persons 18 through 64 years of age.

And the dose here is .1 mL and it’s administered in the deltoid area by a specifically designed micro-needle and injector system.

So again just to remind you that these are all the other options. These will still be available, the ones that you’ve been used to using over the last years. These are still around as well.

When choosing influenza vaccines the choice should primarily be driven by the age indication, contraindications and precautions.

There is no current preference for quadrivalent over trivalent. There is no current preference for high dose versus standard dose flu vaccine and no current preference for IIV versus LAIV in an age group for whom either is indicated.

And just to remind you again of the dosing schedule as you can see for children 6 through 35 months of age is one or two doses same as for children 3 through 8 years of age one or two doses, but .5 mL versus .25 mL.

And just to remind you the algorithm for children 6 months through 8 years will not change from the algorithm that was used during the 2012 to 2013 season.

So just to recap, influenza vaccination continues to be recommended for every person in the US 6 months of age and older.

Summary recommendations are available on the CDC Web site at this time for the upcoming season. And now we’ll pause just for another quick polling question as we get to the end of the presentation.

Leticia?

Leticia Davila:
Yes. Please make your selection now.

Dr. Yabo Beysolow:
Okay. And I’m seeing here the majority of you do have this correct, that only one dose of inactivated influenza is recommended for this 70-year-old man with asplenia.

So for adults or anyone 9 years and older only one dose of flu vaccine is recommended per season. Okay.

Leticia Davila:
For those on the call, we are on Slide 57. Dr. Beysolow?

Dr. Yabo Beysolow:
Yes I’m here. So now we’re going to turn our attention to a few issues regarding vaccine administration that are vital to practice before we end.

And this is just a reminder that all staff members in your facility permanent or temporary, anyone who will be administering vaccines should receive competency-based training and education on vaccine administration before providing vaccines to patients.

New staff needs to be oriented to vaccines used in their facility. Staff knowledge and skills should be validated with a skills checklist such as the one shown here.

And this checklist is available at the Web site shown at the bottom of the slide. And it’s a good idea to periodically review the skills checklist with all staff members.

Remember that training should occur not only during orientation but annually or when vaccine recommendations change or if the facility changes vaccine products that are in inventory.

Many common administration errors could be avoided by consistently using the rights of medication administration. And these rights should be applied to each encounter when vaccines are administered. Depending on your training you may have seen a variety or variation of these rights.

However, the take-home is that you make sure it’s the right patient of course especially when there’s siblings in the office for example.

Make sure it’s the right vaccine or diluent. Is it the right time to vaccinate this child or adult? Is it the correct age? Has there been an appropriate interval since the prior dose?

Is this the right route for administration of this vaccine? And of course making sure to appropriately document that the vaccine was given.

Also wanted you to be aware that the Vaccine Storage and Handling Toolkit is available on our Website. It’s based on recommendations of not only the ACIP but also the manufacturer’s product information and studies from the National Institute for Scientific Technology or NIST.

And the toolkit basically outlines best practice strategies and recommendations on equipment considerations, for storage units and thermometers, how do you maintain the cold chains, routine storage and handling practices, how do you manage your inventory and then also emergency procedures for protecting your vaccine inventory.

And this is our last polling question before we go on to resources. Clinical staff administering vaccines should receive skill-based training on vaccine administration and those are your choices there.

And that is great. The majority of you are saying all of the above. Yes so not only during orientation but annually when vaccine recommendations change or when the facility changes vaccine products in inventory.

Great. So now we’ll close with a few immunization resources that I wanted to share with you. And this is a screenshot of our Website if you went to www.cdc.gov/vaccines. This is what you will see. As you can see, you can scroll down to immunization schedules, basic and common questions regarding vaccines. Also the ACIP recommendations that we’ve talked about, this is where you can get those, more information on specific vaccines and preventable diseases.

If you click on this button, the Healthcare Professionals home page, it is very similar to this page but has definitely more information and tips for the busy healthcare professional and tools for your office.

The VIS’s are also in here. There’s also a button for parents to go to.

And here is where you’ll get the ACIP vaccine recommendations. So if you click on that link on the previous slide you will come to this page and you can quickly scroll down to either general recommendations of immunization, healthcare personnel recommendations. These are questions we get often.

For example, I have someone in my setting. I’m in an occupational health setting. This is a healthcare worker. And they do not show immunity to measles or Varicella. What do I do in this instance? And so there’s some guidance here for you.

One of the resources I did want to highlight was what we essentially call the pink book which is the Epidemiology and Prevention of Vaccine Preventable Diseases textbook.

And this pink book provides physicians, nurses nurse practitioners PAs pharmacists and others with the most comprehensive information on vaccine preventable diseases.

It may be ordered from the CDC vaccine’s Web page, downloaded onto your device or pages may be printed. It’s published annually. And the next edition is due to be published in November 2013.

And just to share a few highlights with you it’s broken down by chapters which are alphabetized by the actual disease. And then there are downloadable slides that you can use if you’re teaching or presenting information yourself.

The appendices as I’ll share with you now, some of the appendices are very valuable. For example, this is one of the appendices showing how long you should wait between receipt of an antibody containing product and giving that patient a live vaccine.

This is also another frequently used appendix which is contraindications and precautions of some of the commonly used vaccines. Screening questionnaires which are actually developed by one of our partners, Immunization Action Coalition is also included in the appendix. This should be used at every immunization encounter.

And there’s also an appendix which shows the contents or recipients of vaccines. And there’s also one on which vaccines contain latex.

So at this time I just want to thank you for your time. We’re going to be opening up for questions. I will leave up this slide and the subsequent slide that has resources during the question and answer period.

If we’re not able to answer all of your questions at the end of today please email them to NIPinfo@cdc.gov.

And actually Leticia is going to share with you another email address that all the COCA calls will be - COCA questions will be collected at. Thank you for your time.

Leticia Davila:
Thank you Dr. Beysolow for providing COCA - our COCA audience with such a wealth of information. We will now open up the lines for the question and answer session.

And also remember you can submit questions through the Webinar system.

Coordinator:
If you’d like to ask a question at this time please press Star then 1 and record your name slowly clearly when prompted. Your name is needed to introduce your question.

To withdraw the request it’s Star then 2. Once again Star 1 on your phone keypad at this time with your question. One moment please.

Leticia Davila:
And operator while we’re waiting for the questions to queue up in the system we do have one that has come through the Webinar system.

Dr. Beysolow, how many cases of cervical cancers or other cancer does the CDC know have been prevented directly due to the vaccine?

Dr. Yabo Beysolow:
The study - thank you for that question Leticia. The study that I highlighted on one of the slides shows an estimate of what we call the attributable risk. And I can go back to that slide here.

I don’t have the exact number to share with you but that’s a question that can be sent through to your email address that you’ll provide. And I’ll be happy to share that study with the questioner.

Just for a general reference (Amir Wolf) if you’re on the line you can please send that question to coca@cdc.gov. Operator?

Coordinator:
And we currently have no questions queued.

Leticia Davila:
We do have another one from the Webinar system. What does HA stand for in the previous slide referring to the ID fluzone containing more HA than traditional IN Fluzone. And I believe this came through when we were around Slide 55.

Dr. Yabo Beysolow:
Yes there was hemagglutinin, the hemaglutinin antigen HA.

Okay I’m going back to the slide but that was the answer to that. The HA stood for hemagglutinin.

Leticia Davila:
Perfect. Thank you. We do have another question from the Webinar system. It says some providers advise parents to wait until the child is 12 years old to receive HPV as they will develop better immunity. How do we counter that note from NPs, PAs and MDs?

Dr. Yabo Beysolow:
Thank you. Actually the - what we have found that it is better to go - that immune response is actually better in the long run when you do give the vaccine earlier. So the recommendation is to give that at 11 to 12 years of age, to give the HPV vaccine.

Coordinator:
We did have a couple queue up over the phone. Did you want to take one of those at this time?

Leticia Davila:
Yes please.

Coordinator:
(Deborah Killgo) your line is open for your question.

(Deborah Killgo):
Yes the slides will they be available on the COCA Website or the CDC Web site?

Leticia Davila:
Yes ma’am they are currently available to download on the COCA Web site.

(Deborah Killgo):
Okay thank you.

Leticia Davila:
And that’s emergency.cdc.gov/coca and just look for today’s COCA call.

(Deborah Killgo):
Okay. Can you say that one more time emergency.cdc...

Leticia Davila: Dot gov/coca.

(Deborah Killgo):
Thank you.

Leticia Davila:
Thank you.

Coordinator:
Our next question comes from Dr. (Norman Cashbo). Your line is open.

(Norman Cashbo):
Yes can you tell me home many days should elapse before a person who’s received live organisms vaccine can be exposed to a person who’s immuno-compromised?

Dr. Yabo Beysolow:
hat is a great question. Thank you Dr. (Norman) for that question. Actually with the live vaccines you may vaccinate even if there’s an immuno-compromised person in the household with one exception which I’ll describe.

But the general recommendations for immunization do note that it is better to provide protection for immunocompromised, immunhousehold members by having their contacts vaccinated and not bringing home the actual disease than to be concerned more with the possible risk of vaccine virus transmission to that immuno-compromised person.

So there is very low risk and we for the most part do not see documented cases of disease being transferred to the immuno-compromised person in the household.

The one exception is with LAIV. For those who receive LAIV, if they’re going to be in contact with someone who’s severely immunosuppressed and in a isolated environment such as a bone marrow transplant unit then we recommend that that contact not receive LAIV but instead receive TIV - I’m sorry IIV which is the inactivated vaccine.

(Norman Cashbo):
Okay thank you.

Dr. Yabo Beysolow:
Thank you.

Coordinator:
The last question in queue did not record their name. So if you press Star 1 your line is now open for your question. Please check the mute function on your phone. Again your line is open if you pressed Star 1 and have not asked your question yet.

And we have no further questions in queue at this time.

Leticia Davila:
Thank you. We do have a few more in the Webinar system. The first one is if the patient misses one dose of rabies vaccine how should we handle this scenario to consider a valid rabies PEP vaccination? Any additional booster shot is required?

Dr. Yabo Beysolow:
Thank you for that question and I’ll ask if that question could be sent through to the COCA email address and then we can answer that because it can really vary with rabies vaccine. And I want to be sure we’re answering that correctly.

Leticia Davila:
Thank you. The next question is is there research being conducted for new generation influenza vaccine not dependent on annual surface antigen changes?

Dr. Yabo Beysolow:
I’m not aware specifically of those vaccines not dependent on annual surface antigen changes. I know of course there’s always a lot of research going on to make sure that we can produce influenza vaccine faster, quicker. And I would advise the caller to perhaps look at the FDA Web site at fda.gov to see vaccines that are under licensure.

Leticia Davila:
Thank you. Operator?

Coordinator:
We have no questions.

Leticia Davila:
We have another from the Webinar system. You mentioned that the flu dosing algorithm for children 6 months to 8 years did not change from last year. Is that correct?

Dr. Yabo Beysolow:
Yes that is. And so that is available on the CDC Web site. So let me see if I can even show you here on one of the slides.

If you go to our Web site or you can go to http://www.cdc.gov/flu and you can see a summary of the 2013 to 2014 recommendations shown there.

And that also includes the algorithm for the upcoming season for children 6 months through 8 years of age.

Leticia Davila:
Thank you. Operator there any questions in the system?

Coordinator:
Not at this time. Okay. On behalf of COCA I would like to thank everyone for joining us today with a special thank you to our presenter, Dr. Beysolow. We invite you to communicate to our presenter after the Webinar. If you have additional questions for today’s presenter please email us at coca@cdc.gov. Put August 13 COCA Call in the subject line of your email and we will ensure that your question is forwarded to her for a response. Again that email address is coca@cdc.gov.

The recording of this call and transcript will be posted to the COCA Web site at emergency.cdc.gov/coca within the next few days. Free continuing education is available for this call. Those who participated in today’s COCA conference call and would like to receive continuing education, should complete the online evaluation by September 14, 2013 using course code EC1648 that is E as in Echo, C as in Charlie and the number’s 1648.

For those who completed the online evaluation between September 15, 2013 and August 12, 2014 use course code WD1648. All continuing education credits and contact hours for COCA conference calls are issued online through TCE online, the CDC training and continuing education online system at www the number 2, the letter A, .cdc.gov/tceonline.

To receive information on upcoming COCA calls subscribe to COCA by sending us an email to coca@cdc.gov and write subscribe in the subject line.

Also CDC launched a Facebook page for HealthPartners. Like our page at facebook.com/cdchealthpartnersoutreach to receive COCA updates. Thank you again for being a part of today’s COCA Webinar. Have a great day.

Coordinator:
Thank you for your participation on today’s call. You may disconnect your line at this time.

END

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