Vax Qs

Answer: A. 1 dose

References:

• Individual Vaccine Requirements Summary
• Childhood Immunization Schedule Catch-Up Schedule (Table 2)

Unvaccinated children 7 months of age and older may not require a full series of 3 or 4 doses of Hib vaccines. The number of doses a child needs to complete the series depends on the child's current age. A 2 year old child who already received 2 doses, with dose 2 at 12 months of age, needs only 1 more dose to be complete for the series.

Answer: E. A and B

Reference: School and Child Care Rule Changes

As of August 1, 2020, the revised rule grants children conditional status entry into school or child care who are making progress towards completing their immunization requirements. Children may begin school or child care only if they received all of the required immunizations they are due to receive and submitted medically verified records on or before the first day of attendance.

If additional immunizations are needed after receiving all immunizations they are eligible to receive before starting school, children may start school or child care in conditional status and remain until the next dose becomes due. Children will then have 30 calendar days to turn in updated records showing they received the missing dose. If additional doses are due, conditional status continues until all required immunizations are complete. If the 30 days expire without updated records, the child must be excluded from further attendance.

Answer: F. A, B, C, and D

Reference: School and Child Care Rule Changes
As of August 1, 2020, the revised rule requires medically verified immunization records for school and child care entry. Medically verified record includes one or more of the following:

• A Certificate of Immunization Status (CIS) printed from the Immunization Information System (IIS)
• A physical copy of the CIS form with a healthcare provider signature
• A physical copy of the CIS with accompanying medical immunization records from a healthcare provider verified and signed by school staff
• A CIS printed from MyIR

Answer: E. A and C only

Patients who receive 4 total doses of PCV, with 3 doses before 12 months of age, and 1 dose on or after 12 months of age, are considered complete. Patients who receive 1 dose on or after 24 months of age are also considered complete with only 1 dose.

If a patient received only 2 doses before 12 months, they need at least 1 dose on or after 12 months of age (with 8 weeks separating the final doses) to be complete.

Resources:

• Individual Vaccine Requirements Summary (PDF) (page 17)
• CDC PCV Job Aid (PDF)
• CDC Childhood/Adolescent Immunization Schedule

Answer: F. A and B only

In the 2020-2021 school year, all students in 7th grade must have received their Tdap dose on or after age 10 years. Students in 8th through 12th grades must have received their Tdap dose on or after age 7 years.

For students in 7th grade:

• If Tdap (or DTaP given in error) is given at age 7 through 9 years of age, another Tdap should be given at age 11-12 years.
• If Tdap (or DTaP) given in error) is given at age 10, this dose counts for the age 11 recommended dose. A booster dose of Tdap or Td is recommended 10 years later.

Resources:

• Changes to School and Child Care Immunization Requirements starting August 1, 2020
• Individual Vaccine Requirements Summary School Year 2020-2021

Answer: E. B and C

In November 2019, CDC published updated PCV13 recommendations for adults. The incidence of PCV13-type disease has been reduced to historically low levels among adults age 65 and older through indirect effects from pediatric PCV13 use. Because of this, the Advisory Committee on Immunization Practices updated recommendations on PCV13 vaccination of adults 65 years of age and older:

• PCV13. PCV13 vaccination is no longer routinely recommended for all adults 65 years and older. Instead, shared clinical decision-making between the provider and patient is recommended for those who do not have an immunocompromising condition, CSF leak, or cochlear implant and who have not previously received PCV13.
• PPSV23. All adults age 65 years and older should continue to receive 1 dose of PPSV23. Adults age 65 years and older who received 1 or more dose of PPSV23 before age 65 years should receive 1 additional dose of PPSV23 at age 65 years and older, at least 5 years after the previous PPSV23 dose.
• If PCV13 is given, it should be administered before PPSV23. The recommended interval is at least 1 year between pneumococcal vaccines, regardless of the order in which they were received. PCV13 and PPSV23 should not be given at the same time.

References:

• ACIP PCV13 Recommendations
• Immunization Action Coalition Technically Speaking PCV13 Updates

Answer: F. A, B, and C only

The Advisory Committee on Immunization Practices updated recommendations on the Prevention of Pertussis, Tetanus, and Diphtheria on April 27, 2018. Here are the main changes:

• Tdap (or DTaP given in error) administered to patients between 7 through 9 years of age:
  • Tdap is forecast at 11 years of age
• Tdap (or DTaP given in error) administered to patients at age 10:
  • Counts as the adolescent Tdap dose
  • Tdap is NOT forecast at 11 years
  • Td is forecast 10 years later

The school immunization requirements are not yet following the updated recommendations to give an additional dose of Tdap if a patient receives a dose between 7-9 years of age. The school requirements will be updated next school year (2020-2021). If providers are following the updated Tdap recommendations, students will be complete when the requirements change next school year.

Send an email to immunenurses@doh.wa.gov for questions about the vaccine schedule or IIS forecast. Questions about the school immunization requirements can be emailed to oicpschools@doh.wa.gov.

Answer: E. All of the above

• The Food and Drug Administration approved Fluzone 0.5mL to be given to pediatric patients for the 2019-20 flu season. This helps providers to have consistent dosage volume for flu vaccine products for pediatric patients. Fluzone and FluLaval 0.5mL are available through the Childhood Vaccine Program and both can be used for the pediatric population (children 6-35 months of age).
• Fluzone 0.5mL pre-filled syringes can be given to pediatric patients 6-35 months, as well as 3 years through 18 years of age.
• Fluzone multi-dose vials should be used only for patients 3 years through 18 years of age due to the thimerosal laws in Washington state. Do NOT use multi-dose Fluzone for pregnant patients; give these patients pre-filled syringes only.
• FluLaval or Fluzone 0.5mL pre-filled syringes can be given to pediatric patients 6-35 months old or 6 months through 18 years of age. Pre-filled syringes should also be used for pregnant patients.

Answer: F. A and D only

The Advisory Committee on Immunization Practices recently updated the HPV vaccine recommendations.

Routine recommendations for HPV (human papilloma virus) vaccination of adolescents at 11-12 years of age have not changed, and vaccination can be started as early as 9 years of age. If HPV vaccine is started before 15 years of age, only 2 doses are recommended; if started after 15 years of age, 3 doses are needed.

Catch-up HPV vaccination is now recommended for females and males through age 26 years. Patients between 27 through 45 years of age should also discuss the benefits of vaccination with their health care provider according to the updated recommendations.

Answer: E. A, B, and D

Engrossed House Bill (EHB) 1638 specifies the documentation needed for staff and volunteers working at licensed child care centers. ECEAP and Head Start preschools are included because of a separate law that requires them to comply with the strictest requirements in the state.

EHB 1638 says the employee or volunteer must present the child care with:
(a) Immunization records indicating that he or she has received the measles, mumps, and rubella vaccine; or
(b) Proof of immunity from measles through documentation of laboratory evidence of antibody titer or a health care provider's attestation of the person's history of measles sufficient to provide immunity against measles.

There is no provision in the law that allows the person to demonstrate immunity to their employer by age alone. A health care provider must attest to the person's immunity. In our FAQs document we added for clarification that a health care provider may consider guidance from the CDC, including for those persons born before 1957, when determining immunity.

How does a child care staff person or volunteer comply with the requirement?
The new law requires that staff and volunteers at licensed child care facilities provide one of these options: • Immunization records showing they have received the MMR vaccine.

• Proof of immunity to measles through documented lab evidence of antibody titer.
• A healthcare provider's attestation of the person's history of measles sufficient to provide immunity against measles. (The provider may consider CDC guidance for evidence of immunity, including for those born before 1957.)

Written certification, signed by a Washington-licensed MD, ND, DO, ARNP, or PA, that the MMR vaccine is not advisable for that person.

Answer: D. Three doses of IPV to be complete

The main point of this question is to provide information about the change to the ACIP recommendations regarding OPV. This updated recommendation is reflected in the 2019-20 school year immunization requirements (page 2). Trivalent OPV was used throughout the world prior to April 2016. In April 2016, all countries using OPV switched to bivalent OPV (bOPV). In addition, some countries also use monovalent OPV (mOPV) during special vaccination campaigns. Doses recorded as bOPV or mOPV, or doses given during a vaccination campaign (which may be included on the record), do not count as valid doses for the U.S. polio vaccination schedule. If the record indicates OPV, and the dose was given prior to April 1, 2016, it can be counted as a valid tOPV dose. If the dose was administered on or after April 1, 2016, it should not be counted as a valid dose for the U.S. polio vaccination schedule because it was bivalent or monovalent vaccine rather than trivalent. Persons younger than 18 years of age with doses of OPV that do not count towards the U.S. vaccination requirements should receive IPV to complete the schedule according to the U.S. polio immunization schedule. This patient received 2 OPV doses after April 2016, so these doses don't count towards the required polio doses. Since the patient is 4 years old, this patient needs 3 IPV doses to be complete at this time.

References:

• Guidance for Assessment of Poliovirus Vaccination Status and Vaccination of Children Who Have Received Poliovirus Vaccine Outside the United States, January 13, 2017
• Individual Vaccine Requirements Summary (page 19)

Answer: B. False

On July 28, 2019, the new exemption law removes the option for a personal/philosophical exemption to the MMR (measles, mumps, and rubella) vaccine requirement for schools and child cares. Children in child care or school will be required to have 2 doses of MMR vaccine or they will need to obtain a religious, religious membership, or medical exemption instead of a personal/philosophical exemption. This law does not change religious and medical exemption laws and does not affect children who have one of these types of exemptions on file. It also does not change the availability of personal/philosophical exemptions for other vaccines.

References:

• MMR Vaccine Exemption Law Change 2019
• Exemption Law Frequently Asked Questions

Answer: D. Born in or after 1957 and has no documentation of MMR vaccine or history of immunity

Adults who are recommended to get MMR vaccine include:

• Those who are born in or after the year 1957
• Has not received any MMR vaccine
• No history of disease
• No evidence of immunity

Additional information about the number of MMR vaccine doses recommended for adults

No MMR vaccine recommended:

• adults born before 1957 except healthcare personnel*
• adults born 1957 or later who are at low risk (i.e., not an international traveler or healthcare worker) and who have received one or more documented doses of live measles vaccine
• adults with laboratory evidence of immunity or laboratory confirmation of measles

One dose of MMR vaccine:

• adults born 1957 or later who are at low risk (i.e., not an international traveler, healthcare worker, or person attending college or other post-high school educational institution) and have no documented vaccination with live measles vaccine and no laboratory evidence of immunity or prior measles infection

Two doses of MMR vaccine:

• high-risk adults without any prior documented live measles vaccination and no laboratory evidence of immunity or prior measles infection, including:
  • healthcare personnel*
  • international travelers born in 1957 or later
  • persons attending colleges and other post-high school educational institutions

Persons who previously received a dose of measles vaccine in 1963–1967 and are unsure which type of vaccine it was, or are sure it was inactivated measles vaccine, should be revaccinated with either one (if low-risk) or two (if high-risk) doses of MMR vaccine.

* Healthcare personnel born before 1957 should be considered for MMR vaccination in the absence of an outbreak, but are recommended for MMR vaccination during outbreaks.

References:

• Immunization Action Coalition Ask the Experts, MMR vaccine
• CDC Measles Web Page

Answer: F: A, B, C only

The Advisory Committee on Immunization Practices (ACIP) recommends routine hepatitis A vaccination for the following groups:

• All children at age 1 year (12-23 months). Children who have not received the 2nd dose by age 2 years should be vaccinated as possible
• People age 6 months or older who are traveling to or working in an area of the world except the United States, Canada, Japan, New Zealand, and Australia. Some (but not all) countries of Western Europe are also low risk. See the CDC Yellow Book for more information
• Men who have sex with men
• Users of illegal drugs
• Persons experiencing homelessness
• Previously unvaccinated people who anticipate having close personal contact with an international adoptee from a country of high or intermediate endemicity during the first 60 days following the adoptee's arrival in the U.S.
• Persons with blood clotting disorders
• Persons who work with HAV-infected nonhuman primates or with HAV in a research laboratory setting (no other groups have been shown to be at increased risk for HAV infection because of occupational exposure)
• Persons with chronic liver disease
• Any person who wishes to be immune to hepatitis A

Hepatitis A vaccine is not routinely recommended because of occupational exposure for healthcare personnel, sewage workers, or day care providers.

References:

• ACIP Hepatitis A Vaccine Recommendations
• Immunization Action Coalition Ask the Experts

Answer: B. False

For routinely administered vaccines, there is no vaccine series that needs to be restarted because of an interval that is longer than recommended. In certain circumstances, oral typhoid vaccine (which may be given for international travel) needs to be restarted if the vaccine series isn't completed within the recommended time frame.

References:

• Immunization Action Coalition Ask the Experts Scheduling Vaccines
• CDC Pink Book

Answer: F. A, B, E only

Any dose of measles-containing vaccine given before 12 months of age should not be counted as part of the series. Children who receive MMR vaccine before age 12 months, whether for international travel or post-exposure prophylaxis, should be considered potentially susceptible to all three diseases and should be revaccinated with 2 doses of MMR vaccine. The first dose should be administered when the child is at least 12 months of age and the second dose is routinely recommended at age 4 – 6 years, but may be administered as soon as 4 weeks (28 days) after the first dose.

Infants 6-11 months are NOT routinely recommended to get MMR vaccine to prevent measles infection during the outbreak. These infants are recommended to get MMR vaccine if they are traveling internationally or have been exposed to someone infected with measles.

A third dose of MMR vaccine may be recommended during a mumps outbreak, but is not recommended due to the measles outbreak.

Sources:

• MMWR, Prevention of Measles, Rubella, Congenital Rubella Syndrome, and Mumps, 2013: Summary Recommendations of the Advisory Committee on Immunization Practices (ACIP), June 14, 2013
• Immunization Action Coalition Ask the Experts, MMR section
• Washington Department of Health Measles Outbreak web page

Answer: G. C, D, E, F

Healthcare personnel, international travelers, college students, and people exposed to measles in an outbreak are recommended to get 2 doses of MMR vaccine.

Adults born before 1957 are considered immune because there were several measles epidemics in the past and these people are likely to be immune due to infection. A clinical decision can be made, however, to vaccinate these persons if appropriate.

Babies younger than 12 months of age are NOT recommended to get MMR vaccine, unless they are traveling internationally. National recommendations allow MMR vaccination for babies 6-11 months of age as a control measure during an outbreak; however, WA State has not made this recommendation based on the current outbreak.

Reference: Immunization Action Coalition MMR Ask the Experts

Answer: F. All of the above except E

Reference: CDC IM Flu Vaccination Infographic

Know the site. Get it right! When administering vaccine by an intramuscular (IM) injection to an adult:

Use the correct syringe and needle

• Vaccine may be administered using either a 1-mL or 3-mL syringe
• Use a 22 to 25 gauge needle
• Use the correct needle size based on your patient's size

Identify the injection site

• Locate the deltoid muscle of the upper arm
• Use anatomical landmarks to determine the injection site
• In adults, the midpoint of the deltoid is about 2 inches (or 2 to 3 fingers' breadth) below the acromion process (bony prominence) and above the armpit in the middle of the upper arm

Administer the vaccine correctly

• Inject the vaccine into the middle and thickest part of the deltoid muscle
• Insert the needle at a 90 degree angle and inject all of the vaccine into the muscle tissue

IM injection best practices

• Administering the injection too high on the upper arm may cause shoulder injury
• If administering additional vaccines into the same arm, separate the injection sites by 1 inch if possible

Answer: A. Recall the patient as soon as possible and administer Fluzone 0.5mL

The patient should be given Fluzone 0.5mL, which is the age-appropriate dose for this 3 year old. If the wrong dose of flu vaccine was incorrectly administered, the dose should be repeated as soon as possible. There is no need to wait 4 weeks to repeat an inactivated flu vaccine dose.

References:

• ACIP Recommendation: Prevention and Control of Seasonal Influenza with Vaccines, 2017-18 Influenza Season
• Immunization Action Coalition Ask the Experts about Influenza
• General Best Practices Guidelines Timing and Spacing of Biologics

Answer: E (A, C, and D)

FluLaval 0.5mL and Fluzone 0.25mL are recommended for children 6 months and older, and FluMist is recommended for 2 years and older. Fluzone multi-dose vials (MDV) available from the Childhood Vaccine Program are recommended for children 3 through 18 years of age. Although the Fluzone MDV is licensed for children >6 months of age, WA state has a law that limits thimerosal-containing vaccines for children under 3 years and for pregnant women. Thimerosal is a preservative used in multi-dose vials to prevent contamination of the vial. Pre-filled syringes don't contain thimerosal, so we recommend Fluzone and FluLaval pre-filled syringes, and FluMist for children under 3. Reference:

• ACIP Recommendation: Prevention and Control of Seasonal Influenza with Vaccines, 2017-18 Influenza Season (Table 1)
• Immunization Action Coalition List of Flu Vaccine Products

Answer: A. Yes

The patient only received one flu vaccine dose before July 1, 2018. This patient needs a second dose 4 weeks after the Fluzone dose given on 9/1/18. References: Immunization Action Coalition flowchart: which children 6 months through 8 years of age need two doses this flu season; MMWR Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices—United States, 2018-19 Influenza Season, August 24, 2018.

Answer: D. Tdap and 2 doses of Td

A patient who hasn't received any DTaP doses should receive a series of three doses of tetanus- and diphtheria-containing vaccine. One of these doses, preferably the first, should be Tdap. The remaining two doses should be adult formulation Td. References: www.cdc.gov/vaccines/pubs/pinkbook/pert.html; Catch-Up Guidance for Children 7 through 18 Years of Age: Tetanus, Diphtheria, and Pertussis-Containing Vaccines

Answer: B. Hep B, DTaP, IPV, MMR, and Varicella

• In Washington, kindergarteners are required to get Hep B, DTaP, IPV, MMR, and Varicella for school entry.
• Children attending child care or preschool are required to get Hep B, DTaP, IPV, Hib, PCV, MMR, and Varicella. Hib and PCV are required for child care, not kindergarten, because these two vaccines are recommended only for children through age 5. After a child turns 5, Hib and PCV vaccines are not recommended because older children are not considered high risk for Hib and pneumococcal infection.
• 6th graders are required to Hep B, DTaP, Tdap, IPV, MMR, and Varicella. Tdap is an additional vaccine requirement that applies to 6th graders based on the ACIP recommendation to routinely give Tdap at 11-12 years of age.

For more information, please visit the DOH School and Child Care Vaccine Requirements webpage.

Answer: A. True

• Live vaccines (MMR, MMRV, varicella) and live intranasal influenza vaccine (LAIV), if not administered during the same visit, should be separated by at least 28 days. This interval is intended to reduce or eliminate interference from the vaccine given first on the vaccine given later. If two live parenteral vaccines or LAIV are administered at an interval of less than 28 days, then the vaccine given second should be repeated in 4 weeks.

• In January 2016, the Food and Drug Administration approved the expanded use of Hiberix for a 3-dose infant primary vaccination series at ages 2, 4, and 6 months. All of the licensed Hib-containing vaccines may be used interchangeably.
• Menactra is only licensed for administration to children aged 9 months and older.
• Varicella vaccine is neither approved nor recommended for children younger than 12 months of age.
• Rotarix is administered in a 2-dose series, with doses administered at ages 2 and 4 months.

Sources:

• MMWR Use of Hiberix as a 3-Dose Primary Haemophilus influenza Type b (Hib) Vaccination Series, April 29, 2016, p. 418
• Immunization Action Coalition Ask the Experts: Haemophilus influenzae type b (Hib)
• Immunization Action Coalition Ask the Experts: Varicella
• MMWR Use of MenACWY-CRM Vaccine in Children Aged 2 Through 23 Months at Increased Risk for Meningococcal Disease: Recommendations of the Advisory Committee on Immunization Practices, 2013, page 528
• MMWR Prevention of Varicella: Recommendations of the Advisory committee on Immunization Practices (ACIP), June 22, 2007, p. 23
• MMWR Prevention of Rotavirus Gastroenteritis Among Infants and Children Recommendations of the Advisory Committee on Immunization Practices (ACIP), February 6, 2009, p. 17