Influenza Vaccines

The flu shot is here (well the standard quadrivalent is here, the high dose trivalent is still coming), and ALL of your patients should get it! Why?

The flu is bad! Though most healthy people get through the flu without problems, the CDC estimates that influenza is responsible for 140K-710K hospitalizations and 12K-56K deaths each year. Elderly patients, very young children, pregnant women and patients with underlying health problems are at greatest risk.

The flu vaccine gives pretty good coverage! While it is impossible to know vaccine effectiveness until the flu season is over, vaccine effectiveness in recent years has ranged around 40-60% — though its not perfect, this protection significantly decreases the incidence of flu cases and complications.

…and has relatively few side effects! Pain at the injection site is noted in about 65% of people, but it usually does not interfere with activity. Though some patients will tell you that the vaccine has given them the flu, flu-like symptoms are similar after receiving the vaccine and placebo; perhaps some of them were actually exposed to a URI after getting the vaccine. Allergic reactions to vaccine components are rare and Guillain-Barre after the flu vaccine is very rare.

“But I am allergic to eggs.” You can still get the flu vaccine! Per the CDC, “persons with a history of egg allergy of any severity may receive any licensed, recommended and age appropriate flu vaccine.” Some of the vaccines do contain egg proteins (including the one we have in clinic), but the risk of an allergic reaction is minimal and the benefits of the vaccine are thought to outweigh this risk. However, in patients who have a history of angioedema, respiratory distress, lightheadedness or recurrent emesis from egg exposure should receive the vaccine in the presence of health care professional (i.e. in clinic rather than a pharmacy); those who have just had hives do not need special precautions. Only the RIV4 (Flublok Quadrivalent) vaccine is considered egg-free; th ccIIV4 (Flucelvax Quadrivalent) vaccine has minimal egg exposure.

“I’m afraid of needles.” Although the intranasal vaccine has not been available for the past two seasons, it is this year. The intranasal vaccine is a live attenuated virus so it is contraindicated for: immunocompromised patients, close contacts of immunocompromised persons, pregnant women, patients who have receive influenza antiviral meds within the past 48 hours, and parents or caregivers whose child has asthma or wheezing within the past 12 months. Also note that there are additional precautions for patients with egg-allergy who receive the intranasal vaccine.

Which one do I give – the standard dose quadrivalent or the high dose trivalent?

 For individuals ≥ 65 years of age, UpToDate suggests the high-dose trivalent IIV (Fluzone High-Dose) where available rather than a standard-dose quadrivalent inactivated vaccine, particularly in those taking a statin. It should be noted that the ACIP has not stated a preference for this vaccine over other influenza vaccines in older adults, although several studies have shown that the high-dose vaccine is more effective than the standard-dose trivalent vaccine in older adults (including a mortality benefit). Mild to moderate local reactions are more common with the high-dose vaccine than with standard-dose trivalent vaccine, but the incidence of serious adverse events is similar.

What about my transplant patients?

There is a preference for the HIGH-DOSE trivalent rather than the standard dose quadrivalent influenza vaccine for all pre-transplant patients >65 years old and all post-transplant patients (regardless of age). For pre-transplant patients <65 years old, and others for whom the high-dose trivalent vaccine is not feasible, standard dose quadrivalent inactivated vaccine is recommended. Pre transplant patients and potential living donors should be vaccinated as soon as possible. For post-transplant patients we recommend:

  • Defer vaccination until 1 month after either transplant or ATG administration
  • Routine vaccination with the injectable high-dose trivalent inactivated vaccine,  regardless of age 
  • Do NOT use the live attenuated nasal vaccine (“Flumist”)
  • For all close contacts transplant candidates or post-transplant patients, any of the
  • available flu vaccines (other than the live “FluMist” vaccine) should be given.

Also, please find here a recent study that may inform decision-making around optimal timing of flu vaccination given potential for waning immunity.

GIMC Measles Protocol

There are multiple ways patients with concern for measles may be scheduled at GIMC. If the measles concern is identified over the phone or otherwise in advance of the appointment, clinic staff will advise the patient and provider on the appropriate protocol to follow. If the concern for measles is identified at the point of arrival in clinic or during the visit, provider and staff should reference the protocol below.

 

  • Patients who screen positive for a high-risk of infection transmission on our general infection control protocol at the Front Desk will be roomed on an expedited basis and will follow our current rooming standard work for infection control

 

  • The rooming MA will ask patient the patient “Do you have RASH + Cough, Fever, Runny Nose, or Red Eyes?”
    1. If yes, patient will be preferentially roomed in the negative pressure rooms (Rooms 6, 7, or 8) and the MA will immediately have a face-to-face with the visit provider to determine what immediate assessment is needed.
    2. If no, the usual rooming standard work for infection control will be followed

 

  • If the provider identifies a concern for measles in the course of the visit, the provider should immediately pause the visit, step out of the exam room, and check-in with an MA to initiate appropriate general and measles infection control precautions (see below).

 

  • For measles infection control precautions, staff and provider should wear N95 or PAPR and gown when in the exam room with patient unless/until patient is cleared by the visit provider. Only non-pregnant staff with documented immunity should interact with patient.

 

  • An Airborne Contact Precautions sign will be placed on exam room door where patient is isolated.

 

  • Provider should notify King County Public Health (206-296-4774) or Snohomish County (425-339-5278) for public reporting purposes and for guidance on proceeding with testing.

 

  • Provider should notify UWMC Infection Control (206-598-6190) for institutional tracking purposes and for safe patient and infection control management.

 

  • MA should notify the Medical Director and/or Clinic Manager either in-person or by paging the Medical Director. Staff and provider can direct any immediate questions about how to proceed with the protocol to the Medical Director or Clinic Manager. If Medical Director or Clinic Manager are unavailable, questions can be directed to AWR/On-call.

 

  • Following the conclusion of the visit, all spaces used by the patients (waiting room seat, exam room, restroom if used) will be decontaminated per standard protocol, including any exam rooms or restrooms used being closed down for 2 hours following the time of the patient’s departure. The MA involved will contact Environmental Services to coordinate the cleaning with them.

Changes to Hemoccult Testing at GIMC

Given the low frequency with which Hemoccult testing is now done in our clinic, GI’s general recommendation against using Hemoccult cards for the evaluation of GI bleeding, and our transition to FIT as a CRC screening option, we have removed Hemoccult cards from the exam rooms. A few things of note:

–          Given the poor performance characteristics of Hemoccult in the setting of suspected lower acuity GI bleeds, with the possibility of a false negative if bleeding is intermittent or a false positives if dietary restrictions aren’t followed, GI generally advises against their use for GI bleed evaluation, recommending that patients with suspected GI bleeding or iron deficiency anemia should be referred for endoscopy/colonoscopy as appropriate.

–          Based on feedback from the group, given that some providers do occasionally find using a Hemoccult test helpful, Hemoccult testing will still be available for now by centralizing a small supply of Hemoccult cards in the treatment room. Our MA/RN staff will no longer complete regular Hemoccult development training, so providers who continue to do this testing at GIMC will need to develop the cards themselves and, in order to adhere to hospital point of care testing requirements, may be asked occasionally to complete an assessment of using the cards.

Measles Vaccination Q&A

Background
Since January 2019, approximately 700 cases of measles have been confirmed in 22 states, with large outbreaks in New York and Washington. This is the greatest number of cases reported in the U.S. since 1994. In the decade before the live measles vaccine was licensed in 1963, an average of 549,000 measles cases, 48,000 hospitalizations, 1000 cases of chronic disability from acute encephalitis and 495 deaths were reported annually in the U.S.

Why have there been more measles cases in the U.S. this year?
The increased number of cases has been attributed to:
  • measles outbreaks in countries to which Americans travel, and therefore more measles cases coming into the U.S., and/or
  • more spread of measles in U.S. communities with pockets of unvaccinated people.
Who Should Get the MMR Vaccine and How Many Doses Should They Get?Children
Children should get two doses of MMR vaccine, starting with the first dose at 12 to 15 months of age, and the second dose at 4 to 6 years of age.
Adults who do not have evidence of immunity should get at least one dose of MMR vaccine.
Some Adults who do not have evidence of immunity should get two doses of MMR vaccine (separated by at least 28 days):
  • College students and students at post-high school educational institutions.
  • Healthcare Workers.
  • People with HIV Infection who are >12 months of age and who do not have evidence of severe immunosuppression.
  • Household members and close contacts of immunocompromised persons.
International Travelers
Before any international travel:
  • Infants 6 to 11 months of age should receive one dose of MMR vaccine. Infants who get one dose of MMR vaccine before their first birthday should get two more doses (one dose at 12 through 15 months of age and another dose separated by at least 28 days).
  • Children > 12 months of age should receive two doses of MMR vaccine, separated by at least 28 days.
  • Teenagers and adults who do not have evidence of immunity against measlesshould get two doses of MMR vaccine separated by at least 28 days.
Women of Childbearing Age 
  • Women of childbearing age should make sure they are immune to measles before they get pregnant. Women of childbearing age who are not pregnant and do not have evidence of immunity should get at least one dose of MMR vaccine.
  • It is safe for breastfeeding women to receive MMR vaccination. The baby will not be affected by the vaccine through breast milk.
Who Does Not Need an MMR Vaccine?
A person is protected against measles and does not need an MMR vaccine if they meet any of these criteria for evidence of immunity:
  • Written documentation of adequate vaccination: o at least one dose of a MMR vaccine administered on or after the first birthday for preschool-age children and adults not at high risk for exposure and transmission o two doses of MMR vaccine for school-age children and adults at high risk for exposure and transmission, including college students, HCWs , international travelers, and groups at increased risk during outbreaks
  • Laboratory confirmation of measles at some point in their life. Laboratory confirmation of immunity to measles.
  • Born before 1957. (The majority of people born before 1957 are likely to have been infected naturally and therefore are presumed to be protected against measles. The exception is that HCWs born before 1957 should receive two doses of MMR vaccine).
If a person is unsure whether they’ve been vaccinated, they should first try to find their vaccination records. If they do not have written documentation of MMR vaccine, they should get vaccinated. The MMR vaccine is safe even if they are already immune tomeasles (or mumps or rubella).

Do people who got the killed measles vaccine in the 1960s need to be revaccinated with the current, live measles vaccine?
Yes, people who know they got the killed measles vaccine (an earlier formulation of measles vaccine that is no longer used) should get revaccinated with the current, live MMR vaccine. Not many people fall into this group; the killed vaccine was given to less than 1 million people between 1963 and 1968. If a person is unsure whether they fall into this group, they could ask their doctor to test their blood to determine whether they’re immune or they can just get a dose of MMR vaccine. There is no harm in getting another dose of MMR vaccine if they are already immune to measles (or mumps or rubella).
Who Should Not Receive the MMR Vaccine or Postpone Vaccination?
  • Persons who have any severe, life-threatening allergies to a previous dose or to a component of the vaccine.
  • Women who are pregnant. Pregnant women should wait to get MMR vaccine until after they are no longer pregnant. Women should avoid getting pregnant for at least one month after getting the MMR vaccine.
  • Persons who have a severely weakened immune system due to disease (such as cancer or HIV infection with evidence of severe immunosuppression) or medical treatments (such as radiation, immunotherapy, steroids, or chemotherapy).
  • Persons who have a parent, brother, or sister with a history of immune system problems should speak to their provider.
  • Persons who have a h/o thrombocytopenic purpura or thrombocytopenia.
  • Persons who have recently received a blood transfusion or other antibody containing blood products may be advised to postpone MMR vaccination for 3 months or more.
  • Persons who have gotten any other vaccines in the past 4 weeks. Live vaccines given too close together might not work as well.
  • Persons with moderate or severe acute illness.
Do people need a booster vaccine? No. People who received two doses of measlesvaccine as children according to the U.S. vaccination schedule are protected for life, and do not ever need a booster dose.
Do adults who only got one dose of measles vaccine as a child need a second dose? Most adults born after 1957 only need one dose of measles vaccine. Certain adults who are going to be in a setting that poses a high risk for measles transmission should get two doses separated by at least 28 days. These adults include:
  • students at college or other post-high school education institutions
  • HCWs
  • international travelers
  • people who public health authorities determine are at increased risk for getting measles during a measles outbreak
What should a person do if they are unsure whether they are immune to measles? The person should first try to find their vaccination records of measlesimmunity. If they do not have written documentation of measles immunity, they should either get vaccinated with MMR vaccine or have a doctor test their blood to determine whether they’re immune. There is no harm in getting another dose of MMR vaccine if they are already being immune to measles (or mumps or rubella).
How effective is the measles vaccine? The measles vaccine is very effective. Two doses of measles vaccine are about 97% effective at preventing measles if exposed to the virus. One dose is about 93% effective. About 3 out of 100 people who get two doses of MMR vaccine will get measles if exposed to the virus. However, they are more likely to have a milder illness, and are less likely to spread the disease to other people
How long does it take for the measles vaccine to work in your body? Detectable antibodies generally appear within just a few days after vaccination. People are usually fully protected after about 2 or 3 weeks. People traveling internationally should make sure to be fully vaccinated at least 2 weeks before you depart.
What should a person do if they’ve been exposed to someone who has measles?Promptly call their doctor and let them know that they have been exposed to someone who has measles. Their doctor can:
  • make special arrangements to evaluate them, if needed, without putting other patients and medical office staff at risk, and
  • determine if they are immune to measles based on their vaccination record, age, or laboratory evidence.
If a person is not immune to measles, MMR vaccine or a medicine called immune globulin may help reduce their risk developing measles. Their doctor can advise them, and monitor them for signs and symptoms of measles. If they are not immune and do not get MMR or immune globulin, they should stay away from settings where there are susceptible people (such as school, hospital, or childcare) until their doctor says it’s okay to return.

BHIP is back in business!

Kendra Koeplin, our founding BHIP social worker, is back from maternity leave, and BHIP is once again able to take new social work referrals (along with BHIP psychiatry referrals)! Thanks to everyone for your patience during this transitional period. We’re aware that (at least) a few referrals slipped through over the past couple months, and our BHIP team has been vigilant in seeking to triage/address them.

We wanted to take this opportunity to refresh everyone on the BHIP model – what’s in scope, what’s really beyond scope – and review the process for referring patients. The BHIP approach is essentially defined by goal directed, time limited intervention, focused on symptom reduction. Bottom line: the BHIP model is built around brief skills-based counseling interventions and brief psychiatry consultations. It’s not well-suited for patients in need of long-term mental healthcare, for patients in need of processing-based therapy (for example, grief counseling), or for urgent/crisis needs – Jan Eisenman should be consulted for patient with acute needs.