Vaccine Update for Healthcare Providers

Technically Speaking

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

Use this handy checklist to help improve your practice’s vaccination rates

We all know that vaccines are cost-effective, safe and life-saving. But sometimes, competing priorities in a busy medical practice can push vaccines off the radar during office visits. This can contribute to low vaccination rates, leaving our patients unprotected against preventable diseases.

Vaccination rates in teens and adults are appallingly low. According to recent statistics from the Centers for Disease Control and Prevention (CDC), completion rates for three doses of human papillomavirus (HPV) vaccine for 13- to 17-year-old females (recommended in 2007) have plateaued at 37.6 percent; for males in the same age range (recommended in 2010), the completion rate is a dismal 13.9 percent. Two doses of meningococcal conjugate vaccine (MCV4) have been recommended for teens ages 11 to 18 since 2011, yet only 29.6 percent have completed the two-dose series.

Adults fare even worse. Tdap (tetanus, diphtheria, pertussis) vaccine for adults age 19 to 64 (recommended in 2007) has a coverage rate of only 15.6 percent, and zoster (shingles) vaccine for those age 60 and older (recommended in 2008) has only reached 20.1 percent of that age group.

What can you do?

Be sure you are taking steps in your practice to help your staff administer recommended vaccines on time! Need help? The Immunization Action Coalition has developed a clear, step-by-step, three-page checklist, Suggestions to Improve Your Immunization Services, that contains more than 35 ideas that medical practices can use to improve their immunization delivery. As highlighted below, these ideas are conveniently grouped under eight different categories:

Download Suggestions to Improve Your Immunization Services today and use these practical ideas to help you determine where improvements might be made in your delivery of immunization services.

Here are more resources to help you.

Vaccine schedules, guidance, and clinic tools

Vaccine storage and handling

Tools for communicating with patients/parents

State and local health department contacts

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Know the “7 Rights” of vaccine administration

Unfortunately, it is all too easy to make a vaccine administration error. And even more unfortunately, the error is likely impossible to undo. Although some improperly administered doses may be considered valid, all such errors open the possibility of patients being unprotected against disease, losing faith in the provider, or even experiencing a serious adverse event following vaccination. You can’t simply hit the delete key to go back in time. So be careful to do the “right” thing the first time.

Make sure you know and adhere to the "7 Rights” of vaccine administration:

#1 The right patient

You don't want to administer the vaccine dose on your vaccine tray to the wrong patient! Make sure you're vaccinating the right person by verifying the patient’s name and date of birth before you administer vaccine to them. And while you're at it, make sure you've screened for contraindications and precautions for that vaccination.

#2 The right time

Sometimes vaccines are not administered according to the official U.S. immunization schedule. They are given to the wrong age patient or they're administered earlier than they should be. Be sure the patient is the appropriate age for the vaccine you plan to administer and that the appropriate interval has passed since a previous dose of the same vaccine or between two live vaccines.

#3 The right vaccine (and diluent)

Errors have occurred administering the wrong vaccine product to a patient. Check the vial label three times to be sure you have chosen the correct vaccine product (and diluent, when applicable). Check the expiration date of the vaccine (and diluent) before using to be sure they are not out of date.

#4 The right dosage

Errors have been made giving a wrong amount of vaccine to a person, such as giving a pediatric vaccine to an adult or vice versa. Vaccine dosages are usually guided by the patient’s age (and are not based on the patient's weight). Check the package insert or an appropriate guidance document (see resources below) to confirm the appropriate dose for your patient's age.

#5 The right route, needle, and technique

Errors are often made administering vaccines using the wrong route, needle, or technique. Be sure you know the appropriate route of administration (oral, intranasal, subcutaneous, intramuscular (IM), or intradermal) for the vaccine you are using. Needle selection should be based on the prescribed route, size of the individual, volume and viscosity of vaccine, and injection technique. Follow CDC guidance to confirm you are adhering to the correct route, needle, and technique.

Deviation from recommendations can reduce vaccine efficacy or increase local adverse reactions.

#6 The right injection site

Errors often happen administering vaccine into the wrong site, such as giving an IM injection subcutaneously or vice versa, or, for example, giving an IM injection below or lateral to the deltoid muscle, rather than into its thick central portion. Make sure you use the appropriate injection site for the specific vaccine you are administering.

#7 The right documentation

It's best to follow federal law and fully document each immunization in your patient’s chart. Be sure to include the vaccine manufacturer; vaccine lot number; date of vaccine administration; name, office address, and title of the healthcare provider administering the vaccine; the date printed on the VIS; and the date the VIS was given to the patient, parent or guardian. And while you're at it, make sure to give your patient an immunization record. Don't forget to submit vaccine information to the appropriate state or local immunization information system.

And finally, here are just a few of the many resources available to help you “do the right thing!”

From the Centers for Disease Control and Prevention (CDC)

From the Immunization Action Coalition (IAC)

“Site Maps” to help your practice standardize sites of injection

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CDC issues new pneumococcal vaccine recommendations for adults age 65 years and older

The Centers for Disease Control and Prevention (CDC) released new pneumococcal vaccine recommendations for adults age 65 years and older in the September 19 issue of Morbidity and Mortality Weekly Report. These recommendations involve administering in series BOTH pneumococcal conjugate vaccine (PCV13, Prevnar 13®, Pfizer) and pneumococcal polysaccharide vaccine (PPSV23, Pneumovax®23, Merck) to patients beginning at age 65 years. The two pneumococcal vaccines are not to be administered at the same office visit, and PCV13 should only be given to patients age 65 and older who have not received a previous dose of PCV13. Some details follow:

New pneumococcal vaccine recommendations for adults age ≥ 65 years

In addition to the new recommendations for adults age ≥ 65 years, PCV13 and/or PPSV23 continue to be recommended for high-risk adults age 19 years and older with certain health conditions (e.g., immunosuppression, asplenia, heart disease, lung disease, sickle cell disease, diabetes, alcoholism, and cirrhosis) and lifestyles (e.g., cigarette smoking). The prior vaccine history of these individuals increases the complexity of applying the new pneumococcal vaccine recommendations when they reach age 65 years. Detailed information covering the recommendations for these persons may be accessed through the links shown below.

Every year in the United States, thousands of adults die and many more are hospitalized from pneumococcal disease. Be sure your patients are appropriately immunized by assessing their immunization status for all recommended vaccines – including pneumococcal – during every healthcare visit. Of course, an especially opportune time for this assessment is when they receive influenza vaccine in the fall. According to CDC, either type of pneumococcal vaccine may be administered at the same time as influenza vaccine.

CDC pneumococcal vaccine recommendations

For adults ≥ 65 years of age
Use of 13-Valent Pneumococcal Conjugate Vaccine and 23-Valent Pneumococcal Polysaccharide Vaccine Among Adults Aged ≥65 Years: Recommendations of the Advisory Committee on Immunization Practices (ACIP) (pages 822–5)

For adults 19 through 64 years of age with certain health conditions or lifestyles

Use of 13-Valent Pneumococcal Conjugate Vaccine and 23-Valent Pneumococcal Polysaccharide Vaccine for Adults with Immunocompromising Conditions: Recommendations of the Advisory Committee on Immunization Practices (ACIP) (pages 816–9)

Additional pneumococcal vaccine information from CDC

Pneumococcal vaccine information from IAC

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What's new in the 2014–15 CDC influenza vaccine recommendations

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

The Centers for Disease Control and Prevention’s (CDC) annual update on the use of influenza vaccine, Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices (ACIP) — United States, 2014–15 Influenza Season, was published in the August 15 issue of MMWR on pages 691-697.

All people age 6 months and older who do not have contraindications should receive influenza vaccination annually — a core ACIP recommendation since the 2010-11 influenza season. Healthcare providers should begin recommending and providing influenza vaccination as soon as vaccine is available and continue vaccinating as long as influenza viruses are circulating.

Changes in the 2014-15 ACIP recommendations

Be sure to consult the ACIP recommendations (pages 691-697) for complete details about influenza vaccine use including all contraindications and precautions.

If you have additional questions, be sure to check the following helpful influenza vaccine resources.

From CDC

Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices (ACIP)—United States, 2014–15 Influenza Season on pages 691-697

CDC's Influenza web section
 
CDC's free resources related to influenza

From the Immunization Action Coalition

Influenza (IIV) Vaccine Information Statement (and available translations)

Influenza (LAIV) Vaccine Information Statement (and available translations)

Influenza Vaccine Products for the 2014–2015 Influenza Season

Screening Checklist for Contraindications to Inactivated Injectable Influenza Vaccination

Screening Checklist for Contraindications to Live Intranasal Attenuated Influenza Vaccination

Standing Orders for Administering Influenza Vaccine to Adults

Standing Orders for Administering Influenza Vaccines to Children and Adolescents

Guide for Determining the Number of Doses of Influenza Vaccine to give to children age 6 months through 8 years during the 2014–2015 influenza season

Influenza Vaccination of People with a History of Egg Allergy

Declination of Influenza Vaccination

Declination of Influenza Vaccination (Spanish)

From the Vaccine Education Center

Influenza: What you should know

Influenza: What you should know (Spanish)

Make sure you choose the proper needle length when vaccinating your patients 

To determine the proper needle length for your patients’ vaccinations, the first things you need to consider are the route of injection — whether it is intramuscular (IM) or subcutaneous (SC) — and the anatomic site of the injection. For infants and children, the patient's age must be considered, and for adults, the patient's weight may need to be taken into account.

Below is a summary of the guidance on choosing the proper needle length for IM and SC injections based on CDC’s General Recommendations on Immunization: Recommendations of the Advisory Committee on Immunization Practices (pages 13–16).

For infants and children

Intramuscular injections: Injection site and needle size

Subcutaneous injections: Injection site and needle size

For adults

Intramuscular injections

The deltoid muscle is most often used as the site for IM injections in adults: Needle length is usually 1–1½", 22–25 gauge, but a longer or shorter needle may be needed depending on the patient's weight.

According to CDC’s General Recommendations on Immunization (page 16), you should choose needle length based on the weight of your adult patients as follows:

An alternate site for IM injection in adults is the anterolateral thigh muscle (use 1–1 ½” needle, 22–25 gauge).

Subcutaneous injections

Fatty tissue overlying the triceps muscle: ⅝" needle, 23–25 gauge

Related resources

For more detailed information on IM and SC injections, including proper injection technique, please see the following resources:

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Protect your significant investment in vaccines so that they can protect your patients

$8,079 — That’s the total private sector cost for 10 doses of each of the 13 vaccines recommended by the Centers for Disease Control and Prevention (CDC) for routine use in children from birth through 17 years of age.*

Since most vaccines are available in 10-dose packages, this means that even small medical practices are storing approximately $8,000 of vaccine at any one time. Of course, the total value of vaccines available in a practice is usually much greater than that, and very large practices may be storing more than 10 times that value in inventory. How can you ensure that your sizeable vaccine investment is appropriately protected from potential loss (and subsequent replacement costs) and that your patients receive viable vaccines?

To assist with your efforts to properly store and protect your vaccine supply, CDC recently released a wide range of new tools, including:

The Immunization Action Coalition (IAC) also maintains a wide variety of helpful tools in its Clinic Resources: Storage & Handling Web section, such as temperature logs for refrigerators and freezers and the following two recently updated pieces:

All of these tools provide great information to assist your medical practice with appropriate vaccine storage and handling. Take a minute to have your staff review the tools, and institute recommended policies and systems in your healthcare setting. You will be rewarded with dollars saved from reduced vaccine wastage. But more importantly, you’ll have the satisfaction of knowing that your efforts have helped ensure that your patients receive effective protection against vaccine preventable diseases — and nothing is more valuable than that!

*Private sector cost1 (rounded to nearest dollar) for 10 doses each of DTaP ($235), influenza ($148), IPV ($274), Hepatitis A ($296), Hepatitis B ($223), Hib ($245), HPV ($1,351), meningococcal conjugate ($1,152), MMR ($561), pneumococcal conjugate ($1,351), rotavirus ($909), Tdap ($393), and varicella ($941) vaccines. (Note: When more than one brand of a vaccine type was available, the average cost was used. Due to the wide variety of formulations/costs, combination vaccines were not included in this assessment.)

1Cost per CDC Pediatric/VFC Vaccine Price List (accessed July 7, 2014)

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Immunization Action Coalition launches “Question of the Week” in its free weekly newsletter

Question of the Week: For the purpose of vaccine spacing, what constitutes a month: 28 days (4 weeks), 30 days, or 31 days? (Find the answer at end of this article.*)

Looking for answers to difficult, real-life immunization questions like the one above? The Immunization Action Coalition's (IAC's) free weekly electronic immunization newsletter, IAC Express, recently launched “Question of the Week,” a new feature that highlights a topical or important-to-reiterate question that is answered by experts from the Centers for Disease Control and Prevention (CDC).

This new feature is a cooperative venture between IAC and CDC. IAC's associate director for immunization education, William L. Atkinson, MD, MPH, selects a new Q&A every week based on common or especially intriguing questions forwarded to IAC by CDC experts.

In addition to being featured in IAC Express, the “Question of the Week” is posted online in the following places:

We hope you enjoy this new feature in IAC Express and find it helpful when dealing with real-life scenarios that arise in your vaccination practice. To receive these weekly questions, be sure to subscribe to IAC Express and please encourage your healthcare professional colleagues to sign up as well, so they too will benefit from this practical and invaluable resource.

And if you have a question for CDC’s immunization experts, you may email them directly at nipinfo@cdc.gov. There is no charge for this service.

*Answer to Question of the Week: For intervals of three months or less, you should use 28 days (4 weeks) as a "month." For intervals of four months or longer, you should consider a month to be a "calendar month": the interval from one calendar date to the next a month later. This is a convention that was introduced on the childhood schedule in 2002 and discussed in the paper "Evaluation of Invalid Vaccine Doses" (Stokely S, Maurice E, Smith PJ, et al. Am J. Prev Med. 2004 Jan; 26(1):34–40).

Use these resources to help you avoid vaccine administration errors in your practice

Unfortunately, vaccine administration errors happen all too often. To avoid this situation, it is essential that all clinic staff members be well trained in proper vaccine administration technique. Avoiding vaccine administration errors will save your clinic time and money, as well as potential embarrassment. Most importantly, it can prevent your practice from having unprotected patients who must be recalled to have doses repeated.

The Immunization Action Coalition (IAC) receives frequent inquiries from healthcare professionals regarding vaccine administration errors and what to do about them. Some of the most common errors are:

To prevent these errors from happening, make sure that everyone who administers vaccines is properly trained and that you use standardized protocols for vaccine administration. The following resources can help with training for new staff, as well as for providing periodic refreshers for all staff members.

Video

Immunization Techniques: Best Practices with Infants, Children and Adults. This 25-minute DVD was developed by the Immunization Branch, California Department of Public Health, and is available for a nominal charge from the Immunization Action Coalition (IAC). It provides excellent training for new staff members and is a first-rate refresher for experienced staff.

Print resources for administering vaccines from IAC

Several free print materials are available for downloading from IAC’s Administering Vaccines Web section. Some of the most utilized materials are:

Related resources from IAC and other organizations

Do you have a question about vaccine administration errors? Check out IAC's "Ask the Experts" archive for Q&As answered by CDC experts. If you are unable to find answers to your specific vaccine administration questions, e-mail CDC at nipinfo@cdc.gov or IAC at admin@immunize.org for answers.

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Resources to help assure competency of clinic staff administering vaccines

Protecting the health of your patients depends on following the recommendations of the U.S. Centers for Disease Control and Prevention (CDC) for preparing and administering vaccines to patients. Are you and your staff fully versed in the technical aspects of administering vaccines? Can the staff who provide vaccines in your setting answer “yes” to the following questions?

Do you know how to:

The Immunization Action Coalition (IAC) is here to help with a multitude of both practical and technical vaccination resources for healthcare professionals, including free print materials covering important topics in vaccine administration. Also available for a nominal charge is an excellent training DVD, Immunization Techniques: Best Practices with Infants, Children and Adults.

Handy print materials and forms

IAC’s immunize.org website features helpful print materials on vaccine administration in its Handouts for Patients and Staff web section. Its Administering Vaccines Web section  includes the following up-to-date tools and forms for clinic staff:

Immunization techniques DVD

Developed by the Immunization Branch of the California Department of Public Health, in collaboration with a team of national experts, the 35-minute DVD "Immunization Techniques: Best Practices with Infants, Children, and Adults" focuses on the skills and techniques needed for vaccine administration. Every organization that administers vaccines should have a copy of this comprehensive educational program, which includes “how to” information about providing vaccinations in a clinic or non-traditional setting. It is appropriate for training and orientation, as well as a refresher for more experienced staff. To purchase this great DVD, visit www.immunize.org/dvd.

Vaccine information statements

Finally, please remember that it’s a federal requirement to provide a copy of the relevant Vaccine Information Statement (VIS) to your patient or their legal guardian before administering almost all vaccines to infants, children and adults. Check the IAC website to find a wealth of VIS information, including translations of the forms into a wide variety of languages.

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Simple tips to expedite vaccination in your practice

Missed opportunities to vaccinate contribute to lower immunization rates in medical practices and healthcare systems across the nation. Here are some simple tips to help your practice facilitate vaccination during all patient visits.

Tip #1: Remember that vaccines can be given at any clinic visit — not just during well-child or adult physical exam visits.
All medical visits (including acute care and follow-up visits) offer the opportunity to assess your patients’ immunization status and provide them with needed vaccinations. In particular, patients with chronic illnesses, many of whom visit a provider only during an acute episode, may be the individuals who are most at risk for complications from vaccine-preventable illnesses. Don’t miss any opportunity to provide protection for your patients. Consider facilitating patient access to vaccines by establishing systems that allow them to walk in during regular office hours or to call ahead for a “nurse only” visit.

Tip #2: You don't need to routinely check temperatures on all patients before vaccinating them.
Routinely measuring temperatures is not a prerequisite for vaccinating patients who appear to be healthy. As part of your routine pre-vaccination screening for contraindications and precautions, simply ask the parent or patient about the patient's current state of health. Here are two handy checklists to help you screen:

Mild acute illness (e.g., diarrhea or mild upper-respiratory tract infection) with or without fever is not a reason to postpone vaccination. If an illness is reported that is moderate or severe, vaccination is considered to be a precaution, not a contraindication; but, in general, it probably should be postponed.

Tip #3: You don't need to routinely test for pregnancy in girls and women of childbearing age before administering a live virus vaccine.
Routine pregnancy testing of girls and women of childbearing age before administering a live virus vaccine is not recommended, according to CDC's General Recommendations on Immunization (see page 27). However, females of childbearing age should be asked about the possibility of their being pregnant or their intention to become pregnant during the next four weeks prior to being given any vaccine for which pregnancy is a contraindication or precaution. (See CDC’s Guidelines for Vaccinating Pregnant Women, page 8). The patient's answer should be documented in the medical record. If the patient is uncertain if she is pregnant, a pregnancy test should be performed before administering live virus vaccines.

Tip #4: Implementing standing orders for vaccination allows appropriate medical personnel to administer vaccines even if a physician is not on site.
Vaccines can be administered only with an order from a physician or a healthcare provider who is authorized by the state to prescribe them. However, a physician may not necessarily need to be present to administer vaccines if standing orders are used. Several studies have shown that the use of standing orders can improve vaccination rates, and the Task Force on Community Preventive Services strongly recommends the use of standing orders programs among children, adolescent and adult vaccination programs (see Table 15 on page 50). A comprehensive set of Sample Standing Orders for Child and Teen Vaccination and Adult Vaccination is available from IAC. These sample orders may be modified to suit your work setting.

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Newly updated! CDC’s 2014 Immunization schedules and IAC’s easy-to-use summaries

At the beginning of each year, the Centers for Disease Control and Prevention (CDC), in collaboration with professional societies, releases updated versions of the recommended U.S. immunization schedules for children and teens as well as for adults. These updated schedules reflect changes that were made in vaccination recommendations during the previous year.

Immunization Schedules for People Age 0–18 Years

Recommended Immunization Schedules for Persons Aged 0 Through 18 Years, U.S., 2014. This six-page schedule, which was published on the CDC website on January 31, 2014 includes the age-based routine vaccination schedule for children and teens and the approved catch-up immunization schedule for people age 4 months through 18 years who start vaccination late or who are more than one month behind. The schedule also includes three pages of essential explanatory footnotes. An article in the February 7 MMWR provides a summary of these changes.

Immunization Schedules for Adults 19 Years and Older

Recommended Immunization Schedule for Adults Aged 19 Years and Older, U.S., 2014. Released by CDC on February 3, this five-page schedule for adult vaccination provides recommendations by age group as well as by medical condition, two pages of essential footnotes, and a final page summarizing the contraindications and precautions for adult vaccine use. An article in the February 7 MMWR summarizes the changes to the adult guidance.

Several additional formats of the schedules, including patient-friendly versions, are available on the CDC website.

IAC’s easy-to-use summaries

To make your job easier, the Immunization Action Coalition (IAC) has designed two user-friendly documents that summarize the guidance contained in the current CDC/ACIP recommendations.

These summaries distill the ACIP recommendations for child, teen and adult immunization into two easy-to-use documents. Each summary includes the routine schedule, spacing between doses, schedules for catch-up vaccination, routes of administration, and contraindications and precautions for all routinely recommended vaccines in the United States.

These summaries of the recommendations have long proved their value — for almost two decades, they have been top downloads from IAC's website for busy healthcare professionals. They have been reprinted in textbooks and state health department newsletters and distributed at countless medical, nursing and public health conferences. Print the summaries on card stock and place them in every exam room for easy reference — you'll be glad you did!

In addition, IAC has developed the following specialized recommendation summaries for situations that providers often find confusing:

You can access these and more than 250 other ready-to-copy IAC materials
for healthcare professionals and patients on the IAC website.

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A strong provider recommendation matters. Don’t just “offer” HPV vaccine to parents for preteens. Recommend it!

Let’s start with the good news. Since human papillomavirus (HPV) vaccine was licensed for use in the U.S. in 2006, vaccine-type HPV prevalence has declined 56 percent among females 14 through 19 years of age.

Now for the bad news. According to the United States Centers for Disease Control and Prevention’s (CDC) most recent National Immunization Survey for teens, HPV vaccination rates did not increase at all from 2011 to 2012 in 13- to 17-year-old girls. Only half of these teens received the first dose of this anticancer vaccine, and only one-third received the full three-dose series.

Tdap and meningococcal vaccines were added to the vaccination schedule for preteens at about the same time, yet their coverage rates are much higher, 85 percent and 74 percent, respectively.

These survey results demonstrate that we are missing opportunities to vaccinate preteens against HPV. We need to do better.

Provider recommendations matter

Research consistently shows that a provider’s recommendation to vaccinate is the single most influential factor in convincing parents to vaccinate their children. Here are some important points to remember and statements you can make to parents when recommending HPV vaccine:

How you approach the HPV vaccine discussion matters

Your approach to discussing HPV vaccination with a parent strongly influences whether they have their child vaccinated. When you only ask parents if they’d like to vaccinate their child, rather than recommending it, vaccine acceptance drops significantly. Your strong recommendation is what is needed to protect our nation’s children from HPV.

Useful HPV resources for your practice

From the CDC

From the Immunization Action Coalition (IAC)

From the Vaccine Education Center at the Children's Hospital of Philadelphia (VEC)

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