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CDC Immunization Updates 2020 Webinar Transcript

- [Phil] Hello everybody. While people trickle in, I think we are going to get started right on time. So welcome to the CDC Immunization Updates 2020 webinar. I'm Phil Wiltzius, an Immunization Health Educator from the Washington State Department of Health. I'm co-organizing this webinar with my associate, Trang Kuss. Trang, would you like to introduce yourself and talk about our continuing education statement.

- [Trang] Sure, thank you so much, Phil. So this is Trang Kuss, and I'm the Immunization Nurse Consultant in our office here at the Department of Health, and we really appreciate you all joining us today, especially with everything else that's going on. So we really appreciate your time. So, Dr. Freedman, can you go ahead and go on to the next slide for me please?

- [Mark] Okay.

- [Phil] He is also board certified by the American College of Veterinary Preventive Medicine. Currently he provides guidance to state and local health departments and health systems regarding immunization programs and vaccine recommendation based on the Advisory Committee for Immunization Practices recommendations. Additionally, he develops and implements immunization education and training materials for vaccine providers. He's previously worked in the field of HIV surveillance and the childhood vaccine coverage assessments in US territories. Okay, Mark, I'll turn it over to you, and thank you for presenting today.

- [Mark] Thank you so much. Hi, everybody and welcome and thank you for having me here. I have another disclosure that I'm required to go through, just to let you know I have no conflicts of interest. The use of trade names is for identification purposes only and does not imply endorsement. Discussion on unlicensed products or off-label use are in the context of ACIP or Advisory Committee on Immunization Practices' recommendations. And I'm only expressing my opinions in this presentation, and they don't necessarily represent official positions at CDC or ACIP. So just a quick overview of the presentation for today. I'll give you a little bit of background on the immunization schedules, then I'll go through some ACIP policy updates, and then I'll show how those updates are reflected in both the 2020 child and adolescent as well as the adult immunization schedules. And then I'll cover a little bit about dealing with children with foreign records or foreign vaccinations and how to interpret those and figure out how they match to US recommendations. And then I'll end the presentation by talking about some guidelines for titer testing for immunity for some of the vaccine preventable diseases. So the child, adolescent and adult immunization schedules are updated annually, and represent current approved ACIP policy. They are designed to be a guide for healthcare professionals to make sure patients are getting all the vaccines they need when they need them. The Child and Adolescent and the Adult Schedule are both approved by the CDC Director and the partner agencies that are listed here. The schedules are also published each year in early February usually as a Notice to Reader in CDC's Morbidity or Mortality Weekly Report or MMWR. And the Adult Schedule is also published in its entirety each year in the Annals of Internal Medicine. So now I'll discuss some updated recommendations. These first few slides just briefly show which vaccines have had updated recommendations. And if there is a publication to reference, the updated recommendations, those are listed here in blue. This year's schedule was posted on February 3rd, 2020 for both the Adult and the Child and Adolescent Schedules. So just to briefly show you these, and then I'll go through each one in more detail. So first I'll start with influenza updates related to children and adolescents. The overall recommendation hasn't changed, routine annual influenza vaccination is still recommended for all persons aged six months and older who do not have contraindications. Any licensed, recommended and age-appropriate vaccine should be used. For children this year starting this where two doses are recommended for children aged six months through eight years who have received fewer than two influenza vaccine doses prior to July 1, 2019. So if in any previous flu season, they only got one flu vaccine, they are recommended to get two. And the dose two should be administered even if the child turns nine during the current influenza season. So if you gave a child the first flu vaccine say in October, say October 1st when you're eight, and then the recommendation is to give the second one four weeks later if they turn nine by then, you could still go ahead and give that second one because you started that when they were eight-years-old. As far as adults go, again, the recommendation has really not changed much where all persons aged six months and older should be vaccinated. Inactivated influenza vaccines, recombinant influenza vaccine and live attenuated influenza vaccine or LAIV are all available for the 2019-2020 season. There is no preferential recommendation for one influenza vaccine product over the other for persons for whom more than one licensed, recommended, and appropriate product is available. LAIV or the live attenuated influenza vaccine is an option for adults through age 49. It's actually for children two years of age and older, and then in adults through 49 years of age, except for those who have immunocompromising conditions, and this includes persons living with HIV, persons who have anatomical or functional asplenia, persons who are pregnant, persons who have close contact with or our caregivers have severely immunocompromised persons in a protected environment. Persons who have received influenza antiviral medication in the previous 48 hours or persons who have cerebrospinal fluid leak or a cochlear implant. Next, for hepatitis A updates in children and adolescents, ACIP recommends that all children and adolescents aged two through 18 years who have not previously received-hepatitis A vaccine be vaccinated routinely at any age. So it's children and adolescents are recommended for catch-up vaccination at any age, and then ACIP recommends all persons with HIV aged one year of age and older be routinely vaccinated with hepatitis A vaccine. For adults the same recommendation, all persons aged one year of age and older should be routinely vaccinated. And new this year, hepatitis A vaccination is recommended in settings of exposure. For example, healthcare settings for injection or non-injection drug users or group homes and nonresidential day care facilities, for developmentally disabled persons. So a little bit about settings providing services for these, for such persons. Settings in which a high proportion of persons who have risk for hepatitis A infection includes healthcare settings, targeting services to people who use injection or non-injection drugs or group homes and nonresidential day care facilities or persons with developmental disabilities. Healthcare, oops, sorry. Healthcare providers may assume that unvaccinated adults aged 19 years of age and older in these settings are at risk for hepatitis A virus infection and should offer hepatitis A vaccine if they had not previously completed vaccination. Hepatitis A vaccination may be offered in outreach and other settings, in which services are provided to persons at risk for hepatitis A infection. For example, homeless shelters, survey and service programs, etc. Healthcare providers should consider implementing standing orders to identify adults recommended for hepatitis A vaccination and administer vaccination as part of routine services. And lastly, hepatitis A vaccination of staff should be considered in facilities where hygiene is difficult to maintain. For example, as I mentioned group homes for persons with developmental disabilities and homeless shelters. And then one last change, sorry, again, clotting factors have been removed as an indication for hepatitis A vaccine. So next I'll talk about meningococcal B updates in children and adolescents. A booster dose of meningococcal B vaccine is recommended for high-risk individuals one year after completing the primary series and every two to three years thereafter. A booster dose is also recommended for anyone who may have previously received a primary series and are not currently exposed to serogroup B. The interval from primary series to booster is one year, meaning booster vaccination is not necessary, if it has been less than one year. Although providers may use a six-month window in communication with public health authorities during an outbreak. This is an off label use since it implies booster doses of the serogroup B meningococcal vaccine, which is not currently a labeled use. As far as recommendations for adults, it's essentially the same as for children. Persons 10 years of age and older who have complement deficiency, complement inhibitor use or asplenia or who are microbiologists should receive a meningococcal B booster dose one year following completion of the MenB primary series. And then they would get a booster every two to three years thereafter for as long as the increased risk remains. And so, some of this is pretty obvious, so some would use a microbiologist and can use their work, they would be at risk. If somebody has asplenia or has their spleen removed, they would be considered at risk for the rest of their lives, so they can get boosters. And then the same recommendation that I mentioned in children and adolescents for during an outbreak, you can give a booster dose, a one-time booster dose. If it has been one year or more since completion of the primary series, although that time interval can be shortened to six months or so or anytime in between six months and a year depending on the local outbreak and input from local public health authorities. And then another change for MenB for adults mainly was adults, adolescents and young adults 16 to 23 years of age, preferably at 16 to 18 years who are not at increased risk for meningococcal disease may be vaccinated based on shared clinical decision-making. So next I'll talk about Tdap updates in children and adolescents. New is that that Tdap vaccine maybe used any time Td is recommended. Also children 10 years of age who receive a Tdap dose do not need the routine 11 or 12-year-old dose as previously recommended. This is an off label recommendation as well, since it implies more than two doses of Adacel or Boostrix, which are not labeled to be given more than once. So just keep that in mind. For adults, again, either Td or Tdap can be used any time that Td was indicated in the past. For example, the decennial Td booster for tetanus prophylaxis for wound management and for additional required doses in catch-up immunization schedule if a person is behind and has still received at least one Tdap dose. Keep in mind that if you're catching up somebody, it is preferred that the first dose is Tdap, and then either Td or Tdap can be used for the remainder of the catch-up series. Next, I'll talk about some HPV updates in adults. In June 2019 ACIP recommended catch-up HPV vaccination for all adults through age 26 years of age who are not adequately vaccinated. Previously, catch-up vaccination was recommended through age 26 years for females and 21 years for males. The updated recommendation is harmonized across genders. In addition ACIP recommended shared clinical decision-making regarding HPV vaccination for adults aged 27 through 45 years of age who are not adequately vaccinated. Public health benefits of HPV vaccination for adults in this age range is minimal, yet some persons who are not adequately vaccinated might benefit. HPV vaccination does not need to be discussed with most adults older than 26 year of age, but clinicians can consider discussing HPV vaccination with persons who are most likely to benefit. HPV vaccines are not licensed for adults older than 45 years of age. Next, I'll discuss the pneumococcal updates. In June 2019, ACIP recommended PCV13 or Pneumococcal 13-valent conjugate vaccine based on shared clinical decision-making for adults 65 years of age or older who do not have an immunocompromising condition, cerebrospinal fluid leak or a cochlear implant, and who have not previously received PCV13. All adults 65 years of age and older should still receiver a dose of PPSV23 or the pneumococcal 23-valent polysaccharide vaccine. If a decision to administer PCV13 is made, PCV13 should be administered first followed by PPSV23 at least one year later. So we've been asked a lot about, why this recommendation is changed? In 2018, ACIP asked CDC to examine data on the PCV13 recommendation. The findings were presented to ACIP in 2019, and they updated the recommendations based on the findings. They found that the pediatric use of PCV13 has indirectly reduced the incidence of PCV13-type disease among adults aged 65 years and older. In addition, implementation of a PCV13 recommendation for all adults 65 years and older in 2014 has had minimal impact on PCV13-type disease at the population level in this age group. CDC now recommends that all adults 65 years or older should receive one dose of pneumococcal polysaccharide vaccine or PPSV23. And in addition healthcare professionals should talk to patients aged 65 years and older to decide if PCV13 or the pneumococcal conjugate vaccine is appropriate. So which adults 65 years of age and older are potentially at increased risk for exposure to the PCV13 serotypes? The following adults are at increased risk and those include persons residing in nursing homes, or other long-term care facilities, persons residing in settings with low pediatric PCV13 update, persons traveling to settings with no pediatric PCV13 program. If you are not sure if you have low PCV uptake either in your area or where a person maybe traveling to, you can check with the local health department, they should probably be able to provide you that information or if it's traveling abroad, probably the best place to go would be the Ministry of Health website for that country. The incidence of PCV13 type invasive pneumococcal disease and pneumonia increases with increasing age and is higher among persons with chronic heart, lung or liver disease, diabetes or alcoholism, and those who smoke cigarettes or those who have more than one chronic medical condition. So providers or practices caring for such patients may consider offering PCV13 to such patients who are age 65 years of age and older, who have not previously received PCV13. So since we have this new shared clinical decision-making recommendation, I wanted to just talk a little bit about what exactly this means because this has been something we've received a lot of questions about as well. So unlike routine catch-up and risk-based recommendations, shared clinical decision-making recommendations mean that vaccinations are not recommended for everyone in a particular age group or everyone in the identifiable risk group, rather share clinical decision-making recommendations are individually-based and informed by a decision process between the healthcare provider and the patient or parent/guardian. The key distinction between routine catch-up and risk-based recommendations and shared clinical decision-making recommendations is the default decision to vaccinate. For routine catch-up and risk-based recommendations, the default decision should be to vaccinate the patient based on age group or other indication unless there is a contraindication. For shared clinical decision-making recommendations, there is no default. The decision about whether or not to vaccinate maybe informed by the best available evidence of who may benefit from vaccination, the individual's characteristics, values and preferences, the healthcare provider's clinical discretion and the characteristics of the vaccine being considered. There is not a prescribed set of considerations or decision points in the decision-making process. Generally ACIP makes shared clinical decision-making recommendations when individuals may benefit from vaccination, but broad vaccination of people in that group is unlikely to have population level impacts. All right, here we have our first poll question. So if a person who is 30-years-old receive only one dose of quadrivalent HPV vaccine at age 18, should they complete the series now? And if so, how many doses would they need? I'll give you all a minute to think about the answer and you can enter your answers into the phone.

- [Phil] Okay, it looks like we've got about half the people who have voted. So, Mark, that's good for you, we can close that, and show the responses.

- [Mark] Okay.

- [Phil] Okay, it looks like we had about 60% respond, and there is the results. So 55% of people said, if clinical decision is made, give two doses three months apart.

- [Mark] And that is the correct answer. The answer is C. For persons aged 27 through 45 years of age, HPV vaccination can be considered after a shared decision between the provider and patient. The provider should determine what the risk of exposure is for the patient, including whether they have any sexual partner or are in a long-term monogamous relationship. If the decision is made to vaccinate, two additional doses of the 9-valent vaccine would be administered separated by at least three months. All right, great. So now I just wanted to go through and show you what all the changes look like in the Adult and Child and Adolescent Schedules. Just a quick note that we have been working to harmonize both the Child and Adolescent and Adult Schedules, so they have as much of the same language as possible. Some of the things that are harmonized are listed here, including trade names on a table, organizing the notes by heading, revisions are similar, if possible, for brevity, clarity and consistency. We use both text to highlight populations or indications for which vaccine is recommended and have minimized the use of specialized text. We've tried to remove articles, conjunctions and other words to keep things brief as long as we don't compromise the meaning, and we've tried our best to use consistent text structure and language throughout. So I'll start with the cover pages. The major change for the Child Schedule cover page is the American College of Nurse-Midwives or ACNM has been added as an approving organization for the Child and Adolescent Immunization Schedule. ACNM joins the American Academy of Pediatrics, the American Academy of Family Practitioners, and the American College of Obstetricians and Gynecologists among partner organizations to the ACIP. On the Child Schedule Table 1, which is the routine immunization schedule, this is what the Table 1 looks like. In the hepatitis A row, the bar representing vaccination for those two through 18 years has been changed from a split purple and green to solid green. This denotes the recommendation for routine hepatitis A catch-up vaccination for all children and adolescents through 18 years of age. And MenACWY row has been moved to appear just above the MenB row because this make more sense to have both meningococcal vaccines together rather than split up, it just makes harder to find the recommendations. Within the legend for the text for the blue box and gray boxes, there had been edits made to those. The blue box now reads that the vaccine is recommended based on share clinical decision-making and the phrase 'not applicable' has been added to the query box. The legend for these colors is harmonized with the Adult Immunization Schedule. Let's see. Moving on to the Adult Schedule Table 1, Table 1 lists immunizations recommended by age groups. Age groups 19 to 21 and 22 to 26 have been combined into one column because of the change in recommendations or catch-up HPV vaccinations for all adults aged 26 years, up to 26 years of age. The HPV row is now combined for males and females instead of having a separate row for each, reflecting the updated recommendation for catch-up for all adults through age 26 years. And finally a blue color has been added to vaccine rows that now have a shared clinical decision-making recommendation, and that would include HPV, PCV13 and meningococcal B. Also the blue footnote has been added, and as I mentioned for the Child Schedule, the gray footnote key has been modified, and now it indicates, no recommendations/not applicable. Moving on to Table 2 or The Catch-Up Table of the Child Schedule. This is different what the table looks like, and the only edit is that ACWY has been added next to meningococcal to clarify that these catch-up recommendations apply only to meningococcal ACWY and not meningococcal B. Table 2 of The Adult Schedule is the recommended schedule by medical conditions or other indications. Some of the changes include the text overlay for red boxes now reads recommended. I'm sorry, not recommended, instead of contraindicated. Additionally, the red footnote has been modified, it now reads, not recommended/contraindicated, vaccine should not be administered. This was done to clarify that some vaccines are not recommended in certain situations, but this does not represent an actual labeled contraindication. Again, the HPV row is now combined for males and females, reflecting the updated recommendation for catch-up for all adults through age 26. And hepatitis A vaccine is now recommended for all persons one year of age to older living with HIV of CD4 count if they had previously not been vaccinated or do not have immunity from natural infection. Table 3 in the Child/Adolescent Schedule is the vaccination by medical indication table. The columns within the hepatitis A row had been changed to Aug yellow to denote routine vaccinations recommended irrespective of medical condition. As in Table 1, the MenACWY row has been moved to appear just above the MenB row. Additionally, the pregnancy column of the MenACWY row has been changed from purple to yellow as pregnancy is not deemed a reason to withhold the recommended adolescent dose of this vaccine. The legend for the red box has been modified just like the Adult Schedule. It says, not recommended/contraindicated, vaccine should not be administered. And lastly the legend for the gray box has been modified to add, not applicable, to be consistent with the legends or Table 1. Next, I just wanna point out some changes made in the Notes section and I'll start with the Child Schedule. Within the DTaP note, language has been added to clarify the circumstances under which a fifth dose of DTaP is not necessary. The addition of the highlighted language is also harmonized with similar language that appears in the polio note. The first bullet states, dose five is not necessary, if dose four was administered at age four years of age and older and at least six months after dose three. Within the HIB note, a bullet has been added to clarify that catch-up vaccination is not needed for previously unvaccinated children aged 60 months and older who are not at high risk of HIB disease. Within the hepatitis A note, a bulleted list has been added to the catch-up vaccination section to reflect the recommendation for routine catch-up vaccination of all children and adolescents two through 18 years of age who have not previously received hepatitis A vaccine. Additionally, the Special Situations section has been removed as all persons recommended to receive vaccination through 18 years of age. I'm sorry, removed as all persons are recommended to receive vaccination through age 18 years of age irrespective of other indications. Within the hepatitis B vaccination note, a Special Situation section has been added. This section outlines the groups for whom revaccination may be recommended, including infants born to hepatitis B surface antigen positive mothers, hemodialysis patients and other immunocompromised persons, and refers to the hepatitis B ACIP recommendations for additional details, particularly involving serologic testing for hepatitis B surface antibody. The influenza note has been reformatted to more clearly present the recommendations, of which children are recommended to receive two doses of influenza vaccine, and which children are recommended to receive one dose of influenza vaccine. As I said earlier, two doses are recommended for children aged six months through eight years who have received fewer than two influenza vaccine doses before July 1st, 2019 for the current flu season. And dose two should be administered even if the child turns nine during the influenza season. Additionally, the section of the influenza note that outlines the situations under which LAIV should not be used has been reformatted to present this information in an easier to read bulleted list. I'll point out that of the 10 conditions on this list for are specifically contraindications meaning that this is a condition in a recipient that increases the risk of an adverse reaction. Those four are, one, history of severe allergic reaction to a previous dose of any influenza vaccine or to any vaccine component, excluding egg; two, receiving aspirin or a salicylate containing medications; three pregnancy; and four, having received influenza antiviral medications within the previous 48 hours. The others are not true contraindications, but are reasons where there is no recommendation. And these are mainly because there's not enough safety data to make a general recommendation. Within the Special Situations section of the MenACWY note, the term complement inhibitor use will be used where relevant to refer to all medications in this class, such as eculizumab. Pardon my pronunciation, and ravulizumab. These are drugs for which a patient is at increased risk of invasive meningococcal disease, and therefore is recommended to be vaccinated for MenACWY. Also information has been added to this section, which outlines the recommendations for adolescent vaccination of children who received MenACWY prior to age 10 years. The sub-bullet outline the recommendations for children in whom boosters are not recommended, and those in whom boosters are recommended. This is an off-label use because it implies multiple ongoing doses of MenACWY vaccine. Within the MenB notes, a link to detailed booster dose recommendations has been added. As you know, a booster dose of MenB is recommended for high-risk individuals one year after completing the primary series, and every two to three years thereafter as long as the risk remains. And as I also said, the booster dose is also recommended for anyone who may have previously received a complete primary series and are not currently exposed to serogroup B. The interval from primary series to booster is one year, but they may use a six-month window in communication with public health authorities. Again, this is an off-label use, so it implies booster doses. The inactivated poliovirus vaccination note has been renamed, poliovirus vaccination. As the note also contains information regarding OPV or the oral polio vaccine. In addition, detailed information regarding which doses of OPV can count as trivalent OPV has been added. Notes for tetanus now say Td or Tdap for boosters, which is a change since we previously recommended only one dose of Tdap vaccines for most persons older than 11 years. Now we provide flexibility in circumstances where providers may not have Td in their clinic. This is another off-label recommendations since it implies more than two doses of either Adacel or Boostrix. Finally, clinical guidance for children who receive Tdap or DTaP between seven to 10 years of age has been added to the notes. Children 10 years of age who receive a dose of Tdap do not need the routine 11 to 12-year-old dose of the Tdap. All right, so here's the next poll question. A healthy nine-year-old child with no underlying health conditions presents to your clinic for influenza vaccination. She had never been been vaccinated for influenza. How many doses of influenza vaccine will she need? I'll give you a minute to post your answers in the poll.

- [Phil] Okay, Mark, it looks like we've got about 70% of people have voted this time, which is pretty great. So I'm gonna close the poll here, and I'm gonna share people's responses. It looks like 63% of people said one dose.

- [Mark] Awesome, so that is the, well, let me get this to work again. A is the correct answer. For children who are nine or who turned nine and never received a first dose in the current season, they are recommended for one dose only. The background to this two dose recommendation is the need to give a priming dose and a boosting dose to persons who are naïve to influenza vaccine. CDC's influenza subject matter experts feel that at the age of nine or more precisely at some point while a child is nine, they've received an adequate prime from either previous vaccination or a previous disease. As we know influenza disease is pretty common, so when children are nine or older, they will only need one dose. All right, so now I'm gonna quickly go through the updates to the notes on the Adult Immunization Schedule. For hepatitis A, the notes reflect the recommendation to vaccinate all susceptible persons living with HIV who are at least one year of age regardless of CD4 count. And also that vaccine is recommended for persons who work in settings of exposure, including those working in healthcare settings for injection or non-injection drug users or those who work in group homes and nonresidential daycare facilities for developmentally disabled persons. For HPV, catch-up is recommended for all persons through 26 years of age, and shared clinical decision-making subsection was added to highlight this recommendation for persons 27 through 45 years of age. For influenza vaccination, just like the Child Schedule, a bulleted list of situations where LAIV should not be used is presented. In this situation for adults, there are eight conditions on the list and only three are specifically contraindications. Those are, one, history of severe allergic reaction to a previous dose of any influenza vaccine or to any vaccine component, excluding egg; two, pregnancy; and three, receiving influenza antiviral medications within the previous 48 hours. The remaining five conditions are situations where LAIV is not recommended. And like I said for the children, this is mostly due to a lack of safety data for use in these situations. For MenB, a shared clinical decision-making subsection was added to highlight this recommendation for adults 16 to 23 years of age. In addition, I'm sorry. Am I right? Here we go. Then for pneumococcal vaccination, a shared clinical decision-making subsection was added to highlight this new recommendation for immunocompetent adults 65 years of age and older. We also have a link that provides a link to the updated recommendations, which provides guidance on the definition of immunocompromised adults. And then finally, the Tdap note has been updated to indicate that Td or Tdap maybe in situations where only Td vaccine was indicated for the decennial tetanus booster for tetanus prophylaxis for wound management and for catch-up vaccination. So next I'll move on to some information on dealing with foreign immunization records. So generally vaccines administered outside the United States can be accepted as valid if the schedule, for example, minimum ages and intervals is similar to that recommended in the United States. With the exception of influenza vaccine, only written documentation should be accepted as evidence of previous vaccination. Written records are more likely to predict the protection if the vaccines, dates of administration, intervals between doses, and age at the time of vaccination are comparable to US recommendations. Repeating the vaccination is an acceptable option that is usually safe and prevents the need to obtain and interpret serologic results. Healthcare providers may use one of multiple approaches if the immunogenicity of vaccines or the completeness of series administered persons outside the United States is in question. As I just mentioned, repeating the vaccines is an acceptable option, it's usually safe, and it can make it easier than sometimes interpreting serologic tests. Serologic testing maybe performed, but keep in mind the availability and cost of antibody testing. In addition, some commercially available tests lack the sensitivity to detect vaccine-induced immunity and might yield false negative results. And I will get into serologic testing a bit more on some upcoming slides. So checking for laboratory evidence of immunity, for example, antibody levels is an acceptable alternative to vaccination, when previous vaccinations or disease exposures are likely. However, the clinician should be familiar with the efficacy and interpretation of available serologic test when relying on testing is proof of immunity. Also keep in mind that many refugees are offered some pre-departure vaccines before they enter the United States through the Vaccination Program for US-bound Refugees. And there's a link here on the bottom that you can click on to find out more about this program and which vaccines are offered. So when you're assessing vaccine records, we get a lot of questions about polio vaccine because in other countries they are still using the oral polio vaccine, and there have been some relatively recent updates and what can be counted as valid regarding the oral polio vaccine that I'll review. So doses of oral polio vaccine before April 2016, that minimum age intervals can count towards completion of a series regardless of how the dose is documented, unless it says "campaign." Doses from April 1st, 2016 through April 30th of 2016 should be documented as trivalent oral polio vaccine for it to count towards completion of the series unless, again, it says "campaign." And then doses on or after May 2016, OPV doses should not be counted, and that's because of the switch to the bivalent oral polio vaccine. If the dose includes the phrase "campaign," as I said on the earlier two bullets, those doses do not count because a campaign would have only used the bivalent oral polio vaccine. So some resources for foreign immunization records. On the CDC website on one of the Pink Book chapters, there is an appendix that has a pretty comprehensive list of foreign vaccine products, and you can follow the link here. Also our partner over at the Immunization Action Coalition or IAC have a great resource for foreign records as well. And that's at , and then we have a service here at CDC, it is nipinfo, it is an email service, and you can email copies of foreign vaccine records, especially if they need to be translated. We have a whole host of foreign language speaking folks here at CDC that can help us translate some of these and a lot of resources, so you can always send records to us through nipinfo@. Right, now I'll move on to titer testing for immunity. Serologic testing for immunity is an alternative when the provider believes the patient is likely to have had a previous infection that conveyed immunity or if they received a full series of vaccines that was not reported. Multiple factors influence the clinician's decisions to check for serologic evidence of immunity before vaccination, and some examples include the cost of the vaccine versus the cost of serologic testing, the likelihood of previous infection, the availability of antibody testing and acceptance that antibody presents confers immunity. The number of nurses needed to complete a series, the level or titer or the antibody known to confer immunity and the likelihood that the patient will return for results and further management. Vaccination in a person who might be immune from natural infection does not increase risk for adverse events, and so sometimes weighing all the factors I ran through, it may just be most effective to go ahead and revaccinate. So I'll go through some tests, some vaccines and vaccine preventable diseases that we do get a lot of questions about as far as titer testing. So for hepatitis A, testing of children is not indicated because of the expected low prevalence of infection. For adults, however, the decision to test should be based on on the following. One, the expected prevalence of immunity; two, the cost of vaccination compared with the cost of serologic testing, including the cost of the additional visit or visits; and three, the likelihood of the testing will not interfere with the initiation of vaccination. We wanna make sure that if you are doing serologic testing that the patient will be coming back to get the results, and then get vaccinated, if needed. So keep that in mind. Regarding hepatitis B, in populations that have high rates of previous hepatitis B infection, prevaccination testing might reduce costs by avoiding vaccination to persons who are already immune. In settings where testing is not feasible, vaccination of recommended persons should continue. Regarding measles, mumps and rubella, serologic screening for measles, rubella or mumps immunity is not necessary and not recommended if a person has other acceptable evidence of immunity. So what is acceptable evidence of immunity? That would be documented doses of previous vaccine or laboratory confirmed evidence of disease or provider confirmed documentation of previous disease. If you do run serology and you get some titers that show they are not protected, but you have documented age-appropriate vaccination, the documentation of the vaccine supersedes the results of subsequent serologic testing. Keep in mind that antibody response or antibody levels can wane over time, and the titers may not show protected levels, however, there still is humoral immunity or cell-mediated immunity or the quote unquote "immune memory," and that can be called upon if the person is exposed, but that's not something that's measured when we do serology testing. So if a person who has two documented doses of measles or mumps containing vaccines is determined to have negative or equivocal measles or mumps titers, it is not recommended that that person receive an additional dose of MMR vaccine. Again, the documented doses will supersede or trump the results of the serology testing. However, women of childbearing age who have one or two documented doses of rubella containing vaccine and have rubella specific IgG levels that are not clearly positive should be administered one additional dose of MMR vaccine for a maximum of three lifetime doses of MMR. Regarding varicella titer testing, persons aged 13 years of age and older without evidence of varicella immunity should receive two doses of single-antigen varicella vaccination administered sub-Q four to eight weeks apart. So if they don't have evidence, you can go ahead and vaccinate them, you do not need to titer to do the serologic testing. Evidence of immunity for varicella is: One, birthed before 1980, except in healthcare providers, pregnant women and immunocompromised persons; two, laboratory confirmation of immunity; three, healthcare provider confirmation of varicella or zoster disease. I'm sorry, varicella or zoster disease. Keep in mind that commercial assays can be used to assess immunity from natural infection, especially regarding varicella, but often will lack the sensitivity to always detect vaccine induced immunity. And that's why we often don't recommend doing the serology for varicella. That is everything that I have, I wouldn't have been able to get all this work done and these schedules would never be possible without all the contributions of both, the Child and Adolescent Immunization Work Group whose members are listed here as well as the Adult Immunization Work Group whose members are listed here. Thank you very much for your time and attention, and I will now turn his back over to discuss the continuing education requirements and things you need to do to get CE credit. Thank you.

- [Trang] Thank you so much, Dr. Freedman, for a very informative presentation. We really, really appreciate all of your time. So can you go ahead and go through the next slide. Before we take questions, I'll go ahead and talk about continuing education, and then the next slide please. So continuing education is available for nurses. Dr. Freedman, can you go ahead and advance to the next slide for me please.

- [Mark] Oh yeah, yep.

- [Trang] Thank you. Great, thank you. So continuing education is available for nurses, medical assistants, physicians and pharmacists. You can get continuing education for watching this live webinar or watching the webinar recording, and then making sure that you complete the evaluation that will show after this webinar is over. So please complete the evaluation, and then send me an email to my email address at trang.kuss@doh. to request the appropriate certificate. Now if you have any questions, you can definitely send me an email. And the expiration date is next year, April 16th, 2021. Is there a one more slide? Oh, no, okay. So we could go ahead and ask some questions at this time. So I'll hand it over to you, Phil.

- [Phil] Yes, so we have a couple of canned questions, but if people do have a couple of questions they wanna ask, you can type it into the questions panel, and we'll do our best to get to them. So the first question is on polio titer testing. Some providers have ordered polio type 1 and type 3 titer testing for their patients. If a patient tests positive for types 1 and 3, do they still need IPV or do they need to show a positive titers for type 2?

- [Mark] Thanks for the question. So the advisory committee on immunization practices recommends immunity to all three types of polio. For some vaccines, including polio vaccine, the most readily available serologic tests cannot document protection against infection. The general best practices guidelines document provides guidance to administer an additional dose of IPV to such persons. There is no reason to anticipate any increased risk of adverse events in persons receiving IPV, if needed. Inactivated polio vaccines provide protection against all three polio types. It is not a live virus vaccine and cannot cause polio or polio vaccine associated paralysis.

- [Phil] Okay, thank you. The second question is also on titer testing. Can you clarify if there are specific diseases, in which there isn't an appropriate titer test?

- [Mark] So as I said earlier, a lot of times titer testing can be difficult to interpret because it may do, you may be able to detect protection after natural infection, but not always after immunizations. And so interpreting these titer testing can sometimes be difficult, also especially in the case of hepatitis B, antibody levels can wane over time, and even though the titer test may show that they are not protected antibody levels, they're still immune memory and cell-mediated immunity can still protect against the disease. So the ones that are pretty clear that we don't really recommend testing and aren't appropriate tests are HIB, human papilloma virus, influenza, meningococcal ACWY and meningococcal B, pneumococcal and tetanus diphtheria and pertussis.

- [Phil] Okay. All right, we got another question here. Can you please discuss when an adult aged 40 years may need HPV vaccine?

- [Mark] All right, so for adults aged 27 through 45 years of age who are not adequately vaccinated, clinicians can consider discussing HPV vaccines with persons who are most likely to benefit. As I mentioned, HPV vaccine does not need to be discussed with most adults over 26 years of age, although new HPV infections are most commonly acquired in adolescence and young adulthood, some adults are at risk for acquiring new HPV infections. These include adults at any age having a new sex partner, persons who are a long-term mutually monogamous sexual partnerships are not likely to acquire new HPV infections, so probably are not as indicated. Most sexually active adults have been exposed to some HPV types, although not necessarily all the HPV types targeted by a vaccine. And so a vaccine may benefit for them, but keep in mind we can't really test to see, which HPV strains they may have been exposed to, and whether or not the others strains in the vaccine would help. So HPV vaccine efficacy is high among persons who have not been exposed to vaccine type HPV before vaccination. And lastly, HPV vaccine effectiveness might be low among persons with risk factors for HPV infection or disease. For example, adults with multiple lifetime sex partners and likely previous infection with vaccine type HPV as well as among persons with certain immunocompromising conditions.

- [Phil] Okay, thanks. I think we have a couple of more questions, we'll do our best to get to them. So, Mark, this question might be for both of us. Is there a short and easy to understand catch-up schedule for school aged kids?

- [Mark] So the best thing to do is at least for CDC, we have right now the Child and Adolescent Schedule, there is a catch-up table. The other thing is, you can look at each individual recommendation for the minimal intervals. So that way you can decrease time between doses, if need be just try and catch them up. Remember that the catch-up schedules to be used until the child is caught up. And then once they're caught up, you'd switch back to the regular recommended schedule. We don't really have the best tool that kind of covers all of the vaccines for catch-up. We do have some tools that can help catch-up with Tdap and pneumococcal. If you go to the IAC website, the Immunization Action Coalition website, they also have some additional tools that may help with catch-up, but I am not that familiar with one easy quick use catch-up schedule tool if there is one.

- [Phil] Thanks, Mark. And I know for us, for the Washington state Department of Health, we do have some family friendly school immunization charts. I'm not sure if we have specific catch-up charts, but we do have some parent-focused charts that are read on our website. Okay, let's see, there was a question I wanted to ask. Is there any risk if you receive more than three doses of MMR?

- [Mark] There is not really any additional risk, it's not recommended. Probably you would expect to see the same type of potential side effects that you can see with the regular dose of MMR unless there is a contraindication obviously, and you would not wanna give it, but it's just not recommendeded, it's probably, it's unnecessary, and it just isn't something that we recommend.

- [Phil] Okay, and then let's do one more question, and I think we'll wrap it up because we're kind of short on time here. Okay, so we have somebody asking about Tdap Boostrix for adults. They say that they're over 55, and they're due for a booster. Their doctor's office said that only a Td was needed, but they work in healthcare and they wanna know, wouldn't it be a good idea to get a pertussis booster as well. Isn't it recommended for new grandparents before seeing a baby?

- [Mark] So with the updated recommendations that were published in January of this year, now any time that Td is indicated, Tdap can be given to adults for their booster. So that would sort of do away with the previous recommendations for grandparents, healthcare workers, etc. So now any time that Td is indicated, Tdap can be used. And so we were getting a lot of feedback on one of the reasons for making that decision was, we were getting feedback that clinics were going ahead and using Tdap anyway because it didn't carry Tdap. And, Tdap can be harder to get sometimes than Tdap, I'm sorry, Td can be harder to get. So now basically anytime Td is indicated, you can give the Tdap vaccine.

- [Phil] Okay, well, thank you, Mark, very much. As a reminder to everybody, you can download the presentation off of the GoToWebinar panel. We will have the recording up on our website. If you go to doh., and search for immunization training, we have a immunization training page where we post all of our webinars. We will have the recording and the slides up, and then as Trang mentioned you'll be receiving a follow-up email if you wish to do your evaluation and get your CE credit. So with that, thank, oop, go ahead, Mark, if you had something else.

- [Mark] I just wanted to say, if there were more questions, feel free to send the questions to nipinfo@ and we'll try and get them answered if we didn't get a chance to answer your questions today, and anytime you may have immunization-related questions.

- [Phil] Great, thank you very much for presenting, and thank you everybody for your time. I hope you have a great day and thank you for your service providing the state and everywhere else with hopefully happy and healthy communities because of what you do. So thank you and have a good day.

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