10 Tips for Immunization in Practice Save

Dr. Jerome Greenberg from UCLA has published 10 tips and pearls (based on years of teaching and experience) on immunizations in an out-patient practice:

1. Consider reading the Immunization Action Coalition website (http://www.immunize.org)  that addresses common and not-so-common questions pertaining to a variety of immunizations. The questions and answers are categorized by type of vaccine. Examples include: 1) Should people who 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) 2) Can I give a tuberculin skin test (TST) on the 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 TST can reduce the reactivity of the skin test because of mild suppression of the immune system).
2. Pneumococcal vaccines present a challenge in terms of timing and use. Chronic conditions are often overlooked when it comes to Pneumovax (PPSV23). The 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 one dose of Prevnar (PCV13) followed by a PPSV23 dose eight weeks later and a second PPSV23 dose five years after the first. 
3. The CDC recommends giving hepatitis B vaccine to unvaccinated adults, especially those with diabetes mellitus ages 19-59 years. 
4. Zostavax has decreasing efficacy with increasing age, but appears to retain efficacy against post-herpetic neuralgia with age, so it should be offered to patients even at advanced ages. 
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 prescription drug plans (Part D) cover all preventive immunizations. 
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. The exact mechanism is not known. 
7. Only 31% of family physicians and 20% of general internists stock all vaccines routinely recommended for adults, Online tools, such as Vaccine Finder, can be useful for providers to identify vaccination service providers 
8. Only 29% of general internists and 32% of family physicians assess their patients vaccination status at every visit. Also, some adult patients rely on the specialists for primary care, including vaccinations. A recommendation by an adult patient’s health care provider for needed vaccines is a strong predictor of the patient receiving recommended vaccines.
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. (Editors note: hepatitis A and B vaccines are inactive vaccines that can safely be given to those receiving methotrexate, DMARDs, prednisone or biologics)
10. Use the acronym H-A-L-O (health condition, age, lifestyle and occupation or other risk factors) to sort patients and their vaccine needs. A checklist which organizes patients into these categories is useful to look at when considering immunizations, making it easier to remember what should be given to whom. Health conditions include certain chronic conditions, immunosuppressed , asplenic or organ transplants; 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.

All practitioners should refer to the clinical guidelines for immunization practices, put out by the Advisory Committee on Immunization Practices