- Email: [email protected]
Ten Immunization-Related Tips in Outpatient Practice
Accepted Manuscript Ten Immunization-Related Tips in Outpatient Practice Jerome Greenberg, MD PII:
S0002-9343(16)31127-5
DOI:
10.1016/j.amjmed.2016.09.040
Reference:
AJM 13767
To appear in:
The American Journal of Medicine
Received Date: 29 September 2016 Accepted Date: 29 September 2016
Please cite this article as: Greenberg J, Ten Immunization-Related Tips in Outpatient Practice, The American Journal of Medicine (2016), doi: 10.1016/j.amjmed.2016.09.040. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
TITLE PAGE
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Title: Ten Immunization-Related Tips in Outpatient Practice Author: Jerome Greenberg, MD. David Geffen School of Medicine, UCLA
SC
Contact Information: [email protected]
Funding: none Running head: Immunization-Related Tips
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No conflict of interest
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Keywords: Immunization; tips; outpatient; practice
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Ten Immunization-Related Tips in Outpatient Practice
Keeping up with immunization recommendations and implementing them are ongoing challenges for clinicians. Following are ten pearls I have collected to help in my practice and in my teaching:
ACCEPTED MANUSCRIPT
1) One of the most useful (and interesting) websites related to common and not-so-common questions pertaining to a variety of immunizations is provided by the Immunization Action Coalition, which can be accessed by searching for: immunizations ask the experts.1 On this site,
RI PT
experts from the Centers for Disease Control answer questions (already posed and answered) about vaccines and their administration. The questions and answers are categorized by type of vaccine. Examples include: a) If a teen or adult mistakenly received a dose of tetanus-
SC
diphtheria (Td), when they should have received Tdap, what is the optimal time to give the missing Tdap dose? (As soon as possible, even if it is the same day) b) Should people who
M AN U
haven’t had chickenpox be vaccinated with zoster vaccine? (Serologic studies indicate that almost everyone born in the United States before 1980 has had chickenpox. As a result, there is no need to ask people age 60 and older for their varicella disease history or to conduct lab tests for serologic evidence of prior varicella disease) c) Can I give a tuberculin skin test (TST) on the
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same day as a dose of MMR vaccine? (A TST can be applied before or on the same day that MMR vaccine is given. However, if MMR vaccine is given on the previous day or earlier, the TST should be delayed for at least 28 days. Live measles vaccine given prior to the application of a
system).
EP
TST can reduce the reactivity of the skin test because of mild suppression of the immune
AC C
2) Pneumococcal vaccines present a challenge in terms of timing and remembering the appropriate target populations for each of the two approved vaccines. In my experience, many patients with conditions such as diabetes mellitus, chronic heart disease and smokers are often overlooked when it comes to Pneumovax (PPSV23). In addition, many patients who are considered immunocompromised, such as those with chronic renal failure, generalized malignancy or those on systemic corticosteroids equivalent to 20 mg of prednisone a day for at least 14 days, are overlooked when it comes to the recommended administration of one dose of
ACCEPTED MANUSCRIPT
Prevnar (PCV13) followed by a PPSV23 dose eight weeks later and a second PPSV23 dose five years after the first. An article that includes a table with an easy-to-understand approach to
Cleveland Clinic Journal of Medicine.2
RI PT
patients with specific conditions eligible for pneumococcal immunization was published in the
3) One vaccine recommendation I have seen not being adhered to often is that of giving hepatitis B vaccine to unvaccinated adults with diabetes mellitus ages 19-59 (a CDC “A” recommendation)
SC
with consideration given to those 60 and older with diabetes (a CDC “B” recommendation). These recommendations are based on an analysis that showed adults ages 23-59 with diabetes
M AN U
had a 2.1 times odds of developing acute hepatitis B as compared to those without diabetes, and the progression from acute to chronic infection is believed to be greater among older adults with diabetes. The risks come from many sources, including assisted monitoring of blood glucose and other procedures, and in many settings including long term facilities, surgery
TE D
centers, outpatient clinics and health fairs where lapses in infection control may take place.3 4) Zostavax has decreasing efficacy in the prevention of herpes zoster as people age but appears to retain efficacy against post-herpetic neuralgia with age, so it should be offered to patients even
EP
at advanced ages. Also, based on cellular immune response and the relatively low risk of recurrence, it is reasonable to delay giving Zostavax for three years following an episode of
AC C
zoster in an immunocompetent patient in whom the diagnosis of herpes zoster has been well documented.4
5) Medicare Part B only provides coverage for three vaccines: influenza, pneumococcal (both conjugate and polysaccharide) and hepatitis B for medium or high risk patients, such as those on hemodialysis, hemophiliacs and men who have sex with men. Medicare Part B does not cover tetanus vaccine unless one has a high risk injury. Generally, Medicare prescription drug plans (Part D) cover all preventive immunizations. As of 2015, 72% of Medicare beneficiaries had a
ACCEPTED MANUSCRIPT
Part D plan of some kind, but for those who don’t (and who do not have preventive immunization coverage through some other insurance plan), one must be aware that out-ofpocket costs may apply for vaccines other than the three mentioned above.5
RI PT
6) Some patients are reluctant to receive vaccines based on the injection itself hurting too much. There is accumulated experience that having patients cough immediately before the needle is inserted blunts pain. While the exact mechanism is not known, it is postulated that---based on
painful sensation traveling along slower nerve fibers.6
SC
the gate control theory of pain---stimuli traveling along fast nerve fibers partially override
M AN U
7) Because only 31% of family physicians and 20% of general internists reported stocking all vaccines routinely recommended for adults, many providers will need to refer some of their patients to other providers for vaccination.7 Online tools, such as Vaccine Finder, can be useful for providers to identify vaccination service providers in their area.8
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8) Although vaccination coverage estimates for adults with high-risk conditions are low, almost all general internists and family physicians feel responsible to ensure that patients receive recommended vaccines.7 But only 29% of general internists and 32% of family physicians assess
EP
their adult patients’ vaccination status at every visit.7 In addition, some adult patients may rely on the specialists they see for primary care, including vaccination. A recommendation by an
AC C
adult patient’s health care provider for needed vaccines is a strong predictor of the patient receiving recommended vaccines. 9 The reason it is important to assess immunization status at every visit, especially in the elderly, is that many patients may go years between visits, presenting only when they have a problem or presenting to urgent care centers at other times.
9) Hepatitis A and B immunizations are given to a very small percent of eligible patients. As of 2014, for example, for adults 19 and over with chronic liver disease, only 13.8% reported having received hepatitis A vaccination and 29.8% reported having had hepatitis B vaccination. It is
ACCEPTED MANUSCRIPT
important for primary care physicians taking care of such patients to inquire whether they have received these immunizations, and not to assume this vulnerable population with chronic liver disease has received them, even if they are co-managed by a specialist.10
RI PT
10) Remembering what vaccines to give our adult patients can be made easier by sorting patients into categories, using the acronym H-A-L-O, which stands for health condition, age, lifestyle and occupation or other risk factors. A checklist which organizes patients into these categories is
SC
useful to look at when considering immunizations, making it easier to remember what should be given to whom.11 Health conditions include certain chronic conditions, patients who are
M AN U
immunosuppressed , asplenic or who received organ transplants, among others; lifestyle factors include sexual practices and smoking, among others; occupational and other factors include college students, healthcare workers, laboratory workers and adults in institutional settings. And of course, the standard of clinical guidelines for immunization practices, put out by the Advisory Committee on Immunization Practices, can be relied upon for more detailed
AC C
References
EP
TE D
information, and is updated annually.12
1. Immunization Action Coalition: Ask the Experts. 2016. Available at http://www.immunize.org/askexperts/ Accessed September 27, 2016.
2. Pallotta A and Rehm SJ. Navigating pneumococcal vaccination in adults. Cleve Clin J Med. 2016; 83(6): 427-432
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3. Sawyer MH, Hoerger TJ, Murphy TV, et al. Use of hepatitis B vaccination for adults with diabetes mellitus: Recommendations of the advisory committee on immunization practices. MMWR
4. Cohen JI. Herpes Zoster. N Engl J Med. 2013; 369: 255-263
RI PT
Morb Mortal Wkly Rep. 2011; 60(50): 1709-1711
5. Hoadley J, Cubanski J, Neuman T. Medicare Part D at ten years: the 2015 marketplace and key trends, 2006-2015. 2015. Available at http://kff.org/report-section/medicare-part-d-at-ten-
SC
years-introduction/ Accessed September 27, 2016.
6. Dobson R. Coughing can reduce pain of injection, study shows. BMJ. 2004; 328 (7437): 424
Ann Intern Med. 2014; 160: 161
M AN U
7. Hurley LP, Bridges CB, Harpaz R, et al. U.S. physicians’ perspective of adult vaccine delivery.
8. Available at vaccine.healthmap.org. 2016. Accessed September 27, 2016. 9. Miller BL, Kretsinger K, Euler GL, et al. Barriers to early uptake of tetanus, diphtheria and
3850-3856
TE D
acellular pertussis vaccine (Tdap) among adults---United States, 2005-2007. Vaccine. 2011; 29:
10. Williams WW, Lu P, O’Halloran A, et al. Surveillance of vaccination coverage among adult
EP
populations---United States, 2014. MMWR Morb Mortal Wkly Rep. 2016; 65(1): 1-36 11. Immunization Action Coalition. Before you vaccinate adults, consider their “H-A-L-O”!
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Available at www.immunize.org/catg.d/p3070.pdf Accessed September 27, 2016. 12. Kim DK, Bridges CB, Harriman KH. Advisory Committee on Immunization Practices Recommended Immunization Schedule for Adults Aged 19 and Older: United States, 2016. Ann Intern Med. 2016; 164: 184-194
S0002-9343(16)31127-5
DOI:
10.1016/j.amjmed.2016.09.040
Reference:
AJM 13767
To appear in:
The American Journal of Medicine
Received Date: 29 September 2016 Accepted Date: 29 September 2016
Please cite this article as: Greenberg J, Ten Immunization-Related Tips in Outpatient Practice, The American Journal of Medicine (2016), doi: 10.1016/j.amjmed.2016.09.040. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
TITLE PAGE
RI PT
Title: Ten Immunization-Related Tips in Outpatient Practice Author: Jerome Greenberg, MD. David Geffen School of Medicine, UCLA
SC
Contact Information: [email protected]
Funding: none Running head: Immunization-Related Tips
M AN U
No conflict of interest
EP
TE D
Keywords: Immunization; tips; outpatient; practice
AC C
Ten Immunization-Related Tips in Outpatient Practice
Keeping up with immunization recommendations and implementing them are ongoing challenges for clinicians. Following are ten pearls I have collected to help in my practice and in my teaching:
ACCEPTED MANUSCRIPT
1) One of the most useful (and interesting) websites related to common and not-so-common questions pertaining to a variety of immunizations is provided by the Immunization Action Coalition, which can be accessed by searching for: immunizations ask the experts.1 On this site,
RI PT
experts from the Centers for Disease Control answer questions (already posed and answered) about vaccines and their administration. The questions and answers are categorized by type of vaccine. Examples include: a) If a teen or adult mistakenly received a dose of tetanus-
SC
diphtheria (Td), when they should have received Tdap, what is the optimal time to give the missing Tdap dose? (As soon as possible, even if it is the same day) b) Should people who
M AN U
haven’t had chickenpox be vaccinated with zoster vaccine? (Serologic studies indicate that almost everyone born in the United States before 1980 has had chickenpox. As a result, there is no need to ask people age 60 and older for their varicella disease history or to conduct lab tests for serologic evidence of prior varicella disease) c) Can I give a tuberculin skin test (TST) on the
TE D
same day as a dose of MMR vaccine? (A TST can be applied before or on the same day that MMR vaccine is given. However, if MMR vaccine is given on the previous day or earlier, the TST should be delayed for at least 28 days. Live measles vaccine given prior to the application of a
system).
EP
TST can reduce the reactivity of the skin test because of mild suppression of the immune
AC C
2) Pneumococcal vaccines present a challenge in terms of timing and remembering the appropriate target populations for each of the two approved vaccines. In my experience, many patients with conditions such as diabetes mellitus, chronic heart disease and smokers are often overlooked when it comes to Pneumovax (PPSV23). In addition, many patients who are considered immunocompromised, such as those with chronic renal failure, generalized malignancy or those on systemic corticosteroids equivalent to 20 mg of prednisone a day for at least 14 days, are overlooked when it comes to the recommended administration of one dose of
ACCEPTED MANUSCRIPT
Prevnar (PCV13) followed by a PPSV23 dose eight weeks later and a second PPSV23 dose five years after the first. An article that includes a table with an easy-to-understand approach to
Cleveland Clinic Journal of Medicine.2
RI PT
patients with specific conditions eligible for pneumococcal immunization was published in the
3) One vaccine recommendation I have seen not being adhered to often is that of giving hepatitis B vaccine to unvaccinated adults with diabetes mellitus ages 19-59 (a CDC “A” recommendation)
SC
with consideration given to those 60 and older with diabetes (a CDC “B” recommendation). These recommendations are based on an analysis that showed adults ages 23-59 with diabetes
M AN U
had a 2.1 times odds of developing acute hepatitis B as compared to those without diabetes, and the progression from acute to chronic infection is believed to be greater among older adults with diabetes. The risks come from many sources, including assisted monitoring of blood glucose and other procedures, and in many settings including long term facilities, surgery
TE D
centers, outpatient clinics and health fairs where lapses in infection control may take place.3 4) Zostavax has decreasing efficacy in the prevention of herpes zoster as people age but appears to retain efficacy against post-herpetic neuralgia with age, so it should be offered to patients even
EP
at advanced ages. Also, based on cellular immune response and the relatively low risk of recurrence, it is reasonable to delay giving Zostavax for three years following an episode of
AC C
zoster in an immunocompetent patient in whom the diagnosis of herpes zoster has been well documented.4
5) Medicare Part B only provides coverage for three vaccines: influenza, pneumococcal (both conjugate and polysaccharide) and hepatitis B for medium or high risk patients, such as those on hemodialysis, hemophiliacs and men who have sex with men. Medicare Part B does not cover tetanus vaccine unless one has a high risk injury. Generally, Medicare prescription drug plans (Part D) cover all preventive immunizations. As of 2015, 72% of Medicare beneficiaries had a
ACCEPTED MANUSCRIPT
Part D plan of some kind, but for those who don’t (and who do not have preventive immunization coverage through some other insurance plan), one must be aware that out-ofpocket costs may apply for vaccines other than the three mentioned above.5
RI PT
6) Some patients are reluctant to receive vaccines based on the injection itself hurting too much. There is accumulated experience that having patients cough immediately before the needle is inserted blunts pain. While the exact mechanism is not known, it is postulated that---based on
painful sensation traveling along slower nerve fibers.6
SC
the gate control theory of pain---stimuli traveling along fast nerve fibers partially override
M AN U
7) Because only 31% of family physicians and 20% of general internists reported stocking all vaccines routinely recommended for adults, many providers will need to refer some of their patients to other providers for vaccination.7 Online tools, such as Vaccine Finder, can be useful for providers to identify vaccination service providers in their area.8
TE D
8) Although vaccination coverage estimates for adults with high-risk conditions are low, almost all general internists and family physicians feel responsible to ensure that patients receive recommended vaccines.7 But only 29% of general internists and 32% of family physicians assess
EP
their adult patients’ vaccination status at every visit.7 In addition, some adult patients may rely on the specialists they see for primary care, including vaccination. A recommendation by an
AC C
adult patient’s health care provider for needed vaccines is a strong predictor of the patient receiving recommended vaccines. 9 The reason it is important to assess immunization status at every visit, especially in the elderly, is that many patients may go years between visits, presenting only when they have a problem or presenting to urgent care centers at other times.
9) Hepatitis A and B immunizations are given to a very small percent of eligible patients. As of 2014, for example, for adults 19 and over with chronic liver disease, only 13.8% reported having received hepatitis A vaccination and 29.8% reported having had hepatitis B vaccination. It is
ACCEPTED MANUSCRIPT
important for primary care physicians taking care of such patients to inquire whether they have received these immunizations, and not to assume this vulnerable population with chronic liver disease has received them, even if they are co-managed by a specialist.10
RI PT
10) Remembering what vaccines to give our adult patients can be made easier by sorting patients into categories, using the acronym H-A-L-O, which stands for health condition, age, lifestyle and occupation or other risk factors. A checklist which organizes patients into these categories is
SC
useful to look at when considering immunizations, making it easier to remember what should be given to whom.11 Health conditions include certain chronic conditions, patients who are
M AN U
immunosuppressed , asplenic or who received organ transplants, among others; lifestyle factors include sexual practices and smoking, among others; occupational and other factors include college students, healthcare workers, laboratory workers and adults in institutional settings. And of course, the standard of clinical guidelines for immunization practices, put out by the Advisory Committee on Immunization Practices, can be relied upon for more detailed
AC C
References
EP
TE D
information, and is updated annually.12
1. Immunization Action Coalition: Ask the Experts. 2016. Available at http://www.immunize.org/askexperts/ Accessed September 27, 2016.
2. Pallotta A and Rehm SJ. Navigating pneumococcal vaccination in adults. Cleve Clin J Med. 2016; 83(6): 427-432
ACCEPTED MANUSCRIPT
3. Sawyer MH, Hoerger TJ, Murphy TV, et al. Use of hepatitis B vaccination for adults with diabetes mellitus: Recommendations of the advisory committee on immunization practices. MMWR
4. Cohen JI. Herpes Zoster. N Engl J Med. 2013; 369: 255-263
RI PT
Morb Mortal Wkly Rep. 2011; 60(50): 1709-1711
5. Hoadley J, Cubanski J, Neuman T. Medicare Part D at ten years: the 2015 marketplace and key trends, 2006-2015. 2015. Available at http://kff.org/report-section/medicare-part-d-at-ten-
SC
years-introduction/ Accessed September 27, 2016.
6. Dobson R. Coughing can reduce pain of injection, study shows. BMJ. 2004; 328 (7437): 424
Ann Intern Med. 2014; 160: 161
M AN U
7. Hurley LP, Bridges CB, Harpaz R, et al. U.S. physicians’ perspective of adult vaccine delivery.
8. Available at vaccine.healthmap.org. 2016. Accessed September 27, 2016. 9. Miller BL, Kretsinger K, Euler GL, et al. Barriers to early uptake of tetanus, diphtheria and
3850-3856
TE D
acellular pertussis vaccine (Tdap) among adults---United States, 2005-2007. Vaccine. 2011; 29:
10. Williams WW, Lu P, O’Halloran A, et al. Surveillance of vaccination coverage among adult
EP
populations---United States, 2014. MMWR Morb Mortal Wkly Rep. 2016; 65(1): 1-36 11. Immunization Action Coalition. Before you vaccinate adults, consider their “H-A-L-O”!
AC C
Available at www.immunize.org/catg.d/p3070.pdf Accessed September 27, 2016. 12. Kim DK, Bridges CB, Harriman KH. Advisory Committee on Immunization Practices Recommended Immunization Schedule for Adults Aged 19 and Older: United States, 2016. Ann Intern Med. 2016; 164: 184-194