Transcript Adult Immunizations: 2011 Interactive Update

Adult Immunization:
2013 Update
Robert H. Hopkins, Jr., MD, FACP, FAAP
Professor of Internal Medicine and Pediatrics
Director, Division of General Internal Medicine
Director, Internal Medicine-Pediatrics Residency
UAMS College of Medicine
Opportunity and Reward
 Immunization rates are far below goal levels
 Commonly identified measure of quality preventive care
 Many elements in process which can be ‘attacked’ to
make improvements
 Front desk
 Nursing/MA
 Physician
 Checkout
 Improvement can result in better health for your patients!
Adult Vaccination Rates= POOR!
Data: , NFS 2012, NHIS 2011
Population
Vaccine
Influenza [2011-12 season=NFS 2012]
45.5% (All adults)
(Hisp 38.8%, White 49.1%, Black 35.6%, Other 40.3%)
[All] 18-49 years
35.8%
[All] 50-64 years
51.0%
> 65 years
70.8%
HCW [19-64 years]
52.9 %
PPS-23
High risk 19-49 years
20.1 %
> 65 years
62.3 %
Tetanus/Tdap [19-49 years Td, 19-64 years Tdap]
64.5 %, 12.5%
Shingles [Zoster] age 60+
15.8 %
Hepatitis B Vaccine [19-49 years, 19-59 years+DM]
35.9 %, 26.9%
HPV Vaccine [women, men (19-26 years)]
29.5 %, 2.1%
http://www.cdc.gov/flu/professionals/vaccination/nfs-survey-march2012.htm
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6204a2.htm?s_cid=mm6204a2_e
Goals: 2013 AI Update
 Review current ACIP Adult Immunization recommendations
 Office/Clinic Practice
 Hospital Practice
 Healthcare Workers
 Quality improvement re: VPD
 No discussion of therapeutic and other vaccines
2013 Adult Schedule [Age-Based]
2013 Adult Schedule [Disease/Indication Based]
Patients: Office and Hospital
“Selectives”
“Universals”

Influenza

Pneumococcal [PCV13]

Pneumococcal [PPS23]

Meningococcal

Tdap

Hepatitis A

Zoster

Hepatitis B

HPV [HPV4, HPV2]

Women

Men

MMR

Varicella
Influenza
 Influenza: Orthomyxoviridae family [enveloped RNA virus]
 3 types based on surface Ag [HA, NA] + internal structure

A: Multiple hosts- Birds, Mammals [Man]. Many HA , NA types



‘Highly Pathogenic’ and ‘Mild’ strains
B: Human host.
C: Human host.
1 HA and 1 NA
Mild illness ‘URI’
 30-50K deaths annually in US from Influenza
 200K+ assoc. hospitalizations, chronic illnesses exacerbations
 > 90% seasonal influenza morbidity/mortality in persons > 65 years
 Vaccination is most effective intervention to reduce illness and death..
 Multiple vaccines avail. in US
 Effectiveness variable from year/year, different patient groups
http://www.cdc.gov/flu/avian/gen-info/flu-viruses.htm
US Influenza Vaccines
 IIV: =‘Inactivated’ and replaces ‘TIV’, IM admin. “All comers” 6 mo.+

Multiple vaccines varied indications [age, etc.]. 2013-14 most Trivalent-Limited supply of quadrivalent inactivated vaccine expected to be available
 Intradermal IIV [Approved May 2011 for 18-64 years--smaller needle]
 High-Dose IIV for 65+ population# [first avail 2010-11]



Same production as TIV, higher Ag content ~~ More local reactions
Phase 3 trials: Seroconversion, seroprotection rates > TIV for A,B strains
‘Real world’ efficacy data not yet published
 New Cell culture vaccine approved 2013- option in egg-allergic [2013-14]
 New Recombinant HA Vaccine approved 2013- higher HA content, no NA
 LAIV: Live-attenuated, cold-adapted nasal. Quadrivalent [2A2B] 2013-14
Indicated only for healthy people 2-49 yrs.
# Falsey, et.al. J ID 2009, June9 [Epub]; C. Bridges CDC Personal Comm. 3/2013
Influenza
Vaccine changes annually, recommend yearly vaccination!
 Vaccine production: ~9 months

Egg-based [all but new recombinant HA, cell-culture vaccines]
 Strain choice (Feb) reflects antigenic drift [Prior season + S. Hemisphere]
 US Vaccination season: Vaccine avail. to ‘disease passed’…[Sept-April?]
 Predominant strain types [Dz and Vax] since 1977: A H1N1, A H3N2, B
 2012-13 Vaccine strains:

Influenza A/California/7/09 (H1N1)-like virus [Since 2009 Pandemic]

Influenza A/Victoria/361/2011 (H3N2)-like virus

Influenza B/Wisconsin/1/2010-like virus (B/Yamagata lineage).

2/3 strains changed from 2011-12, likely at least B will change for 2013-14
http://www.cdc.gov/vaccines/recs/acip/downloads/mtg-slides-feb09/04-1-flu.pdf
Influenza Vaccine Priorities
 ALL 6 MONTHS AND OLDER + DON’T WANT THE FLU
 HEALTHCARE WORKERS
 High risk for
 High risk for
 If sick
disease (symptomatic and asymptomatic)
transmission
not available to provide healthcare…
 PATIENTS @ Highest Risk severe illness/spread






Pregnant women
Newborns and Children < 2 years
Elderly
“Medical Comorbidities” (including Obesity)
Household contacts of high-risk
Long-term care/institutionalized, Crowded living conditions
http://www.cdc.gov/vaccines/pubs/vis/downloads/vis-flu.pdf
Influenza ‘Nuts and
1
Bolts’
 IIV: 1 dose for adults
 Incl: QIV, TIV, sqTIV, hdTIV, LAIV, ccTIV, rHA (Flublock)
 Kids < 9 years, first vaccine season: 2 doses 4+ weeks apart
 LAIV can be safely used in MOST HC settings as alt. to TIV2
 Egg allergy: ACIP, AAAI: NO contraindication.
 Anaphalaxis EXCEEDINGLY rare [~1 in 4 million doses]
 History is key: Hives= higher risk, consider allergy referral
 Risk/benefit of disease vs. vaccine usually favors vaccine…
 When vaccinating egg-alergic, observe in office ~ 30 minutes
1.
2.
3.
http://www.cdc.gov/vaccines/pubs/vis/downloads/vis-flu.pdf
http://www.premierinc.com/all/safety/safety-share/12-05-downloads/03-shea-hcw-flu-position-paper.pdf
http://www.uptodate.com/contents/influenza-vaccination-in-individuals-with-egg-allergy
Influenza
 Vaccine effectiveness is multifactorial
 Match with ‘disease’ strains
 Vaccine availability and timing
 Patient ‘substrate’:
 ‘Healthy young < 65’ @ ~60-80% v. ‘Sick older > 65’ @ 30-40%
 Ongoing vaccine research
 Adjuvants
 Newer production methods
 Higher Ag content
http://www.cdc.gov/flu/professionals/antivirals/index.htm
http://www.cdc.gov/flu/professionals/diagnosis/
Pneumococcal
 > 2000 Adults 65+ die from invasive Pneumococcal Disease yearly
 Primary adult vaccine is purified capsular polysaccharide [PPS23]
 23 types- cause of 88 % bacteremic PNC dz
 60-70% efficacy vs. invasive disease [IPD]
 IPD= Pneumococcal meningitis, bacteremia
 Does not ‘prevent pneumonia’
 Immunity lasts at least 5 yr. following 1 dose
 ROUTINE REVACCINATION ONCE @ 5+ yr. + age 65 ACCEPTED
 RECOMMEND SELECTED Revaccination:

Vax > 5 yrs before, AND Asplenia, Immunosupressed, CKD or
Nephrotic Syndrome
 Local reactions- only common AE
http://www.cdc.gov/vaccines/recs/schedules/downloads/adult/2009/adult-schedule-bw.pdf
PPS 23 Vaccine Effectiveness
 7 Meta-Analyses of RCT [Most recent Cochrane 1/2013]

Conclusions inconsistent re: cause specific outcomes

Agreement: REDUCTION in IPD; NO reduction ALL CAUSE mortality, pneumonia
 3 Meta-Analyses of OBS studies

Consistent results: vaccine is effective for prevention of IPD
 Recent RCT Results

IPD:
Odds ratio [consistent]
0.26 (CI 0.25-0.46)

Pneumonia:
Odds ratio [signif. heterogeneity]
0.71 (CI 0.52-0.97)

Mortality:
Odds ratio
0.87 (CI 0.69-1.10)
 Summary

Data supports PPS to prevent IPD, not compelling for Pneumonia, Mortality
Fine, et.al. ArchivesIM 1994(154): 2666. Hutchinson et.al. CanJFP 1999(45): 2381. Watson, et.al. Vaccine 2002(20): 2166.
Conaty, et.al. Vaccine 2004(22): 3214. Dear, et.al. Cochrane DB Syst Rev 2004, Issue 3. Moberley , et.al. Cochrane DB Syst Rev
2008, Issue 1. Moberly, et.al. Cochrane DB Syst Rev 2013, Issue 1.
Pneumococcal Recommendations
PPS23 is recommended1 for:
 Adults 65+
[Since 2009]
 Cigarette Smokers
 Chronic conditions:


Diabetes
Heart, Lung, Liver, Kidney disease




Including Asthma
Immunocompromise
[Since 2009]
[PCV13+PPS Since 2012]

Disease-based: Solid tumor, Hematologic malig, Myeloma, HIV,…

Iatrogenic: Steroids, Organ transplants, BMT, …
Anatomic/functional asplenia [Sickle Cell, etc.][PCV13+PPS Since 2012]
CSF Leak, Cochlear Implant
[PCV13+PPS Since 2012]
2.
1. MMWR 2008;57(53).
Scott, et.al. Vaccine 25 (2007) 6164-6.
PCV13 Vaccine in Adults NEW 2012
 Routine PCV-13 in US infants since 2010
 2010 FDA approved + ACIP recommended

All children 6 weeks – 71 months [Series- another talk…]
 Dec 30, 2011 FDA approves for adults:

Prevention of pneumonia and IPD ≥ 50 years

Based on immunogenicity studies [not clinical efficacy]

Safety in ~6000 adults similar to PPSV23
 June 20, 2012 [Pub Oct 12, 2012] ACIP recommends PCV13 in adults:

Immune compromised adults ≥ 19 years + CSF leak/cochlear implant

Best practice PCV 13 should be administered before PPS23

1 Booster in children 6-18 years with immune compromise
ACIP. MMWR. 2012:61:394-395.
PCV 13 Recommended in Adults With:
 Solid Organ Transplants
 Multiple myeloma
 Hematologic malignancy [Leukemia, Lymphoma, Hodgkins]
 General Malignancy
 ESKD, Nephrotic Syndrome
 Sickle Cell, hemoglobinopathy
 HIV
 Immunosuppression/Immunodeficiency
 Not-immune-compromised

CSF leak, Cochlear implant
PCV13 Vaccine in Adults NEW 2012
 Pneumococcal (PPS23) vaccine-naïve patients:
 Adults ≥ 19 yrs with immunocompromise, CSF leak/Cochlear implant
 PCV13 FIRST followed by PPS23 at least 8 weeks later
 Booster PPS23 in 5 years
 AND boost PPS 23 after 5 years PLUS 65+ years old
 Previously PPS23-vaccinated subjects:
 Adults ≥ 19 yrs with immunocompromise, CSF leak/cochlear implant
 PCV13 should be given 1+ years AFTER PPSV23
 Booster PPS23 in 5 years
 AND boost PPS 23 after 5 years PLUS 65+ years old
ACIP. MMWR. 2012:61:394-395; ACIP June 20, 2012.
Td >> Tdap
 All patients should have primary Tetanus, diphtheria series


3 doses: 0, 1 m., 6 m. [Yields protective Ab ~ all for 10 yrs+]
Many adults > 60 y. never received primary T, d series
 Over 50% adults do not have protective T, d Ab’s

Booster Td every 10 years [Many adults do not receive routine boosters]

Most boosters given are ‘episodic trauma-related’
 Replace 1 dose Td with Tdap [In primary series or as ‘booster’]

Tdap need not wait on 10 year interval from last Td
 Td/Tdap Contraindications



Severe allergy to vaccine comp., Arthus reaction after prior Tetanus vax.
[Tdap] Encephalopathy < 7 days after pertussis containing vaccine
[Tdap] Unstable neurologic disease, Moderate-severe acute illness
http://www.cdc.gov/vaccines/vpd-vac/combo-vaccines/DTaP-Td-DT/Tdap.htm
Td >> Tdap
 Pertussis incidence increasing since 1970’s
 2012: CDC Passive Surveillance US >42,000 cases, likely 10+x higher
 Community outbreaks: Most in fall, winter and in persons of all ages
 Nosocomial Disease: Academic, Community

[Med/Surg, OR, L&D, NICU, Oncology]

Residential Care
 Adults/Adolescents do not have ‘classic’ triphasic disease
 Most have persistent Cough: Median 4 months [6 studies]
 20-40 % ‘Whoop’, 40-55 % Posttussive emesis
 12-32 % Lymphocytosis
 ~10% develop complications [Pneumonia most common]
http://www.cdc.gov/vaccines/vpd-vac/pertussis/
http://www.cdc.gov/vaccines/vpd-vac/combo-vaccines/DTaP-Td-DT/Tdap.htm
Td >> Tdap
 Tdap Recommendation: All Adults
 Single dose to replace one dose Td [Booster or primary]
 Current recommendation: subsequent Td q10yr

Research on repeated dosing ongoing
 May give any time (< 10 years) following last Td
 2011: Tdap recommendation extended to adults > 65 years
 No data to suggest harm
 Research in process re: effectiveness
 Special emphasis: adults with close infant contact:
 HEALTHCARE, Parents, Child Care, etc.
 NEW 2013: Tdap intrapartum all women, each pregnancy

Regardless of interval/prior Tdap [ideal @ 27-35 weeks]
http://www.cdc.gov/vaccines/vpd-vac/combo-vaccines/DTaP-Td-DT/Tdap.htm
Zoster
 Most who have varicella have measureable Ab for life
 Zoster occurs when CMI surveillance declines [theoretical]
 Reactivation or Varicella exposure re-stimulates CMI [Cycle repeats]

Lifetime risk of Zoster ~33% [99.5% adults serology + prior Varicella]
 At 85- lifetime risk ~ 50%
 PHN= most common AE


To 1/3 patients with Zoster

More common

Zoster occurs @ 70+

Immunocompromised
Vaccination stimulates CMI
Arvin A. NEJM 2005;352:2266-77.
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5705a1.htm
Zoster



Vaccinate 60+ adults [ACIP: Not immunocompromised]

FDA approved from age 50 [Coverage? Cost/Bene?]

Regardless of prior Zoster [opinion: wait 1 yr]

No need to test for/vaccinate against Varicella first
Contraindications

Pregnancy

Anaphylactic Hypersensitivity to Neomycin, Gelatin

No need to defer for ‘at risk contacts’- transmission risk low

No need to defer if recent transfusion, Ab containing products
Adverse events

Occasional mild varicella-like rash @ vaccine site

Frozen powdered vaccine: Give within 60 minutes, 0.65 ml SQ Deltoid

Duration of protection: At least 4 years. No booster.
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5705a1.htm
Zoster
Vaccine Efficacy Trial:
 38,546 Veterans:
Median age: 69 years

60-69: 20,747
[Efficacy greatest in this group]

≥ 70: 17,799 (46%)

≥ 80: ~2,500 (6.5%)

Excluded: Immunocompromised, prior zoster, < 60 yrs.
 Vaccine group had [v. placebo]:

51% fewer episodes of zoster

Less severe disease

66% less postherpetic neuralgia
 No significant safety issues were identified
Oxman MN et al. NEJM. 2005;352:2271-2284.
Varicella
 Varicella, Zoster vaccines from OKA-strain attenuated virus

Varicella
1,350 PFU virus/dose

Zoster
20,000-60,000 PFU virus/dose
 Varicella recommendations similar to MMR: 2 doses, live virus

Difference: Non-immune born after 1980

Risk of vaccination in pregnancy lower than MMR; but neither is
recommended: Vaccinate non-immune women postpartum
 Risk groups

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HEALTHCARE WORKERS (need 2 doses unless immune)
Education, Daycare, Institutional Employees
Women of childbearing age [Vaccinate pre-preg., post-partum]
International travel
MMR, Varicella
 Contraindications:

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
Severe immune compromise

Organ transplant

HIV: CD4 < 200
Allergy to vaccine component [MMR=Egg, Varicella=Neomycin, gelatin]
Acute/severe illness
Recent transfusion [Any immunoglobulin-containing product]
Active untreated TB
Pregnancy

MMR: not pregnant x 3 months after vaccine- prevent NRS

Varicella: Not major risk but avoiding all live vaccines recommended
 Live virus vaccines [Var., MMR, Zoster] and Tb skin test

OK same day, otherwise delay skin test > 3 months
http://www.cdc.gov/mmwr/preview/mmwrhtml/00053391.htm
MMR
 Disease reports increased since 2005….
 Live-attenuated vaccine, routine childhood in most ‘developed world’
 MMR for Adults: 2 doses in non-immune adults born after 1957
 High Risk

HEALTHCARE WORKERS [Born after 1957- Immune or 2 doses]

College Students, [Prison, military barracks, etc.]

International Travelers


Outbreaks assoc. with international travel, adoptions
Immigrants
CDC Health Advisory Network: June 22, 2011, 16 :00 EST (04:00 PM EST) CDCHAN-00323-11-06-22-ADV-N
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5733a1.htm
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5542a3.htm
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5753a6.htm
Hepatitis A, B
 Vaccination currently recommended in all US children
 Hepatitis A [2007]
 Hepatitis B [1995]
 Both have selective recommendations for adults
 Do NOT need to start over if completion of series is delayed
 Can be given individually or together [Combination vaccine]

HAV: 2 doses @ 6+ month interval

HBV: 3 doses @ 0, 1 m, 6 m.

Dose and alternate regimens are different for Hemodialysis patients

Combination: 3 doses @ 0, 1 m, 6 m.

Accelerated Combo.: 4 doses @ 0, 7 d., 21-30 d., booster @ 1 yr.
http://www.cdc.gov/vaccines/recs/schedules/downloads/adult/2009/adult-schedule-bw.pdf
Adult Hepatitis A,B Indications

Hepatitis A

Chronic Liver Disease


Including chronic HBV, HCV

Hepatitis B

Diabetes mellitus [12/2011]

Chronic Liver Disease incl. chronic HCV

MSM

MSM

Injection Drug Users

Injection Drug Users

Travel to endemic area

Travel to endemic area/intl. adoption

Recipients of Clotting factors

Recipients of Clotting factors

Lab workers

>1 sexual partner/6 mo, STD clinics

HEALTHCARE WORKERS

HIV

Household and sexual contacts of HBV patients

Male prison inmates, correctional staff

Developmental disability facility patients, staff

AK natives and pacific island natives

Any others that want to prevent HBV
Dialysis HBV

High dose vaccine: all ESRD pt.
http://www.cdc.gov/vaccines/recs/schedules/downloads/adult/2009/adult-schedule-bw.pdf
HPV
 Cervical Cancer is consequence of a STD [HPV]
 Second most common cause CA death in women


500,000 cases and 250,000 deaths per year
US: ~10 women die every day of cervical cancer
 Cause of anal CA and penile CA in men
 20 million current HPV infections
 By age 50, 80% SA women will have acquired genital HPV

Many clear spontaneously
 6.2 million new genital HPV infections/year in US

74% in women 15-24 years of age
 70% Cervical CA worldwide d/t serotypes 16 [54%], 18 [13%]
 >90% Genital Warts due to serotypes 6, 11
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5602a1.htm
HPV

Vaccines:

Gardasil [MSD]: Types 6,11,16,18
3 dose series @ 0, 2 m., 6 m.

Cervarix [GSK]: Types 16,18

Ideally should finish series with same vaccine begun, but mix is OK…

Effective protection at least 5 years based on published data [ongoing]

Effective only for types patient has NOT previously acquired
3 dose series @ 0, 1-2 m, 6 m.

HPV 2 or 4 Women 11-12 [9-26]: prevent Cervical CA [Pre-CA], Genital Warts

HPV4 Men 9-26 to prevent anal/penile preCA and CA

Contraindications/Cautions:




Local reaction, bronchospasm reported
Not recommended in pregnancy- no proven AE [administer after delivery]
Immunosupression can reduce efficacy
VACCINE DOES NOT CHANGE CERVICAL CANCER SCREENING RECs!
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5602a1.htm
Meningococcal
 Highly-contagious gram-negative bacterial infection
 Highest mortality in children < 1 year
 Recommended for children @ 11-12, pre-college ‘catch up’
 selective adult recommendation based on risk
 4 Current vaccines: A, C, Y, W-135 [no type B vaccine]
 MPS4: Polysaccharide vaccine
[SQ, 1 dose +?booster]
 Available since 1978, fair efficacy, OK if conjugate not available
 MCV4 [3 products]: Conjugate vaccines
[IM, 1 dose]
 Approved 2005, 2010, 2012
 Preferred for primary vaccination
 Selective booster dosing after 5 yrs [e.g. if high risk persists/recurs]
MMWR 2005;54(RR-7)
Meningococcal Indications
 All Children 11-12 years
 College freshmen who will live in dormitory/commune

Not previously vaccinated or vaccinated >5 years previously
 Asplenia [anatomic or functional]: Best to vaccinate pre-splenectomy
 Terminal complement deficiencies
 HIV: Best response if CD4 > 200
 Travelers to ‘at risk areas’: Sub-Saharan Africa, Dec-June

Required for entry into Saudi Arabia/Mecca during Hajj
 Microbiologists with potential occupational Meningococcus exposure
MMWR 2005;54(RR-7)
Healthcare Workers
Healthcare Workers
 Key in implementation of Adult Immunization
 Education

Multiple studies: MD recommendation  increases patient Vax uptake
 Need preventive benefits ‘for themselves’
 Potential source for disease transmission




Patients
Other staff
Communities
Families
 Potential for VPD to impair patient care


Adversely affect efficiency
Prevent HCW from working with [their] patients
http://www.cdc.gov/mmwr/preview/mmwrhtml/00050577.htm
HCW Vaccination
 Annual influenza vaccination
 Tdap: All should receive 1 dose
 MMR, Varicella: Proof of immunity or 2 doses [each vaccine]
 HBV: 3 dose series
 Titer 1 month after series; repeat series x 1 if titer < 10 IU
 No recommendation for screening titer otherwise
HCW Recommendations
Vaccine
HCW Recommendation
Other Consideration
Influenza
Annual
HCW vax. decr. risk to Pt +
Pneumococcal
[PPS, PCV]
No HCW Specific Rec.
All smokers, 65+, med.ind.
MMR*
2 doses
Unless immune, born before ‘57
Varicella*
2 doses
Unless immune
HPV
No HCW Specific Rec.
Rec. all women 9-26 yr.
Td/Tdap
Tdap 1 dose, Td Q10yr.
Tdap esp. infant contact
HAV
Only sel. lab workers
All kids [2007 forward]
HBV
3 dose series
HBsAb @ 1 mo; If -, rpt series
Meningococcal [MCV]
Only sel. lab workers
All 11+ kids [2006 forward]
Zoster*
No HCW Specific Rec.
Healthy 60+ adults
Adapted from data located at http://www.cdc.gov/vaccines/recs/schedules/adult-schedule.htm
* Live Virus Vaccines
Special Populations
 Hospitalized [Medical] Patients
 Influenza [in season], Pneumococcal year-round
 Consider ‘family ring’ Tdap, Influenza prior to L&D discharge
 Immune Compromise: Maximal ‘non-live’ vaccination
 Steroids: Prednisone 20 mg/d equivalent
 HIV: CD4 < 200
 Biologic Immunomodulators
 Preop Consult
 MeningCV, PCV13 then 8+ week PPS23
 PCV13 then 8+ week PPS 23
Pre-Splenectomy
Pre-Cochlear implant
 Travel
 CDC ‘Yellow Book’, Travel Clinics esp. for ‘specials’
Immunization
Improvement Strategies
 Reminder-Recall
 Telephone, E-mail, Text, Post card,..
 Partnering
 Local Pharmacy, Health Unit
 Team-based Care [Standing Orders]
 Front desk—MA--Nurse—MD
 Standing orders for vaccination are approved and
endorsed by CMS since 2002
 Regular P-D-S-A Cycling
 Internal and External reporting
Tools
 ACP Adult Immunization Guide


FREE!! I-phone/I-pad App [Available in App store]
Download complete guide [or sections] from ACP website
 CDC Adult Immunization Scheduler

http://www.cdc.gov/vaccines/recs/Scheduler/AdultScheduler.htm
 CDC/ACIP Recommendations


http://www.cdc.gov/immunizations
http://www.cdc.gov/vaccines/pubs/ACIP-list.htm
 IAC Summary of Adult Immuniztion Recs

http://www.immunize.org/catg.d/p2011.pdf
 STFM SHOTS Tools for ‘Smart’ Phones

http://www.immunizationed.org/
Thank you for your
attention! Questions???