Vaccines: The Good, the Bad and the Ugly Olivia May, DNP, CRNP

Objectives Identify current recommended vaccines for persons of all ages. Identify current best practice related to the administration of vaccines, altering a vaccine schedule and readministration of vaccines. Identify current recommendations related to billing and coding of vaccines. Identify available resources for accessing the most up to date vaccine information for healthcare providers. Discuss ways to handle the anti-vaccine movement in regards to current practice.

Vaccine Safety Immunization is considered one of the ten most important public health developments of the twentieth century Most of the vaccines we use currently have been in wide use for at least ten years, allowing for extensive post-marketing surveillance to confirm their safety profile The culture in our practices should support a vigorous dialogue among all team members about safety and evidence-based medicine Remember: Vaccines are safer than the diseases they prevent!!

Current Recommendations Vaccine recommendations in the U.S. are issued primarily by two national bodies U.S. Public Health Service's Advisory Committee on Immunization Practices (ACIP) American Academy of Pediatrics (AAP) Committee on Infectious Diseases

Current Recommendations – Ages 0-18 Years DtaP/Tdap Polio MMR Varicella Hib Pneumococal Hep A Hep B Meningococcal HPV Flu

Current Recommendations – Ages 19+ Td/Tdap Flu HPV Zoster Pneumococcal (conjugate and polysaccharide) If no documentation of: MMR Varicella HAV HBV Hib Meningococcal (19-23 years)

Alabama Required School Vaccines DTaP/Tdap Polio MME Varicella (or disease) Hib Pneumococcal

Recommended Vaccines for College Students Meningococcal Meningococcal conjugate vaccines (Menactra®, MenHibrix® and Menveo®) Serogroup B meningococcal vaccines (Bexsero® and Trumenba®)

General Administration Issues NEVER aspirate before giving an IM or SQ injection Pain relief Rapid injection causes less pain (Z-track) Holding pressure for 10 seconds before injecting Topical anesthetics need 30-60 min Distraction (blowing the pain away) Nursing or sucrose on pacifier during injection Location Anterolateral upper thigh until at least 18 months Otherwise deltoid IM injections should go deeply into muscle mass; choose needle length wisely ALWAYS remember the VIS and blue card 5-point check: right product, right dose, right patient, right site, right lot number

Required Documentation Name of vaccine administered Date given Date VIS given Publication date of VIS Name of vaccine manufacturer Lot number Name and title of person giving vaccine Address of clinic

Storage and Handling Reminders NO dorm-style refrigerators Detailed temperature log Best practices: Recommended but not required Do NOT prepare vaccine until immediately prior to giving Leave in original packaging and place in middle of refrigerator, where the temperature is more stable NO FOOD IN UNIT Do NOT store vaccine in doors, floor, or vegetable bins Rotate vaccine every week and with new shipments, so that newest vaccine doses are in the back

What is VFC? Vaccines For Children program Federally-determined eligibility with administration at state level All Medicaid and some others, including underinsured and self-pay 0-19 years of age only; not available for adults

What is VFC? State program determines the office’s monthly or quarterly allotment of doses based on your practice’s recent history of usage; you can request specific products, but VFC ultimately decides this unilaterally Sets out requirements for tracking, storage, handling, documentation, and auditing Requires VIS on every vaccine with each dose Absolutely must keep stock physically separate from private; NO BORROWING

Why does VFC audit? Documentation (eligibility, administration) Storage and handling Billing practices Measure is the number of children between 24-36 months of age who have received the entire primary series and first boosters: basically the recommended doses for up until 18 months.

Billing and Coding ICD-10 guidelines instruct that the well child preventative visit codes (Z00.129 and Z00.121) include vaccines BUT Z23 may be used as a secondary code (encounter for immunizations) ICD010 requires only one code (Z23) per vaccination, regardless if single or combination Use modifier -25 if vaccine given during an E&M visit – ex. 99213-25 with a diagnosis code, vaccine code, administration code

Billing and Coding Administration Codes: 90460– Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first vaccine component +90461 (Pediatric)– Each additional vaccine/toxoid component (in addition to code for primary procedure) Report codes 90471-90474 for administration not accompanied by actual counseling or for patients over 18 years of age

Example A 45 year old patient presents for a visit to evaluate his/her diabetes control and also receives a flu vaccine How would you code this?

Example An 11-year old girl presents for a preventative visit. The child and mother are counseled by the NP on risks and benefits of HPV, and Tdap vaccines. Nurse administers and documents correctly. How would you code this?

Non Standard Schedules The recommended schedule is designed to protect children when they are most vulnerable to the diseases vaccines prevent. Non-standard schedules that spread out vaccines or start when a child is older do not provide protection against serious illnesses when infants and young children are most at risk for the diseases. If a parent maintains they do not want a vaccine, document the request for a nonstandard schedule and that the risks of not vaccinating were discussed​. Consider a tracking system to remind families to return for needed vaccines.

Answers to Common Questions All the recommended vaccines are safe to be given simultaneously Series doesn’t need to be restarted if vaccination has lapsed If records are unavailable or incomplete, it is safe to revaccinate based on age and usual recommendation Products from different companies are generally compatible It is acceptable and recommended to give shots during acute visits

Common Parental/Patient Questions Will giving an infant multiple vaccines overwhelm the immune system? Isn’t natural Infection better than receiving the vaccine? Does thimerosal/MMR cause autism? Why does my non-sexually active child need the HPV vaccine? Will the HPV vaccine cause an autoimmune disorder in my child? Why chickenpox when it’s not a deadly disease? Won’t the flu vaccine cause me to get the flu? What do YOU recommend?

Concerns About Ingredients Aluminum Aluminum salts have been used safely for more than 70 years. Aluminum is in our food, air, and water. Formula and breast milk include aluminum. The amount of aluminum in vaccines is similar to that found in 33-oz of infant formula.

Concerns About Ingredients Thimerosal Some parents worried that thimerosal used in vaccines may lead to autism. Rates of autism have actually increased since thimerosal was removed from vaccines in 2001. Today, most childhood vaccines do not contain thimerosal, with two exceptions: It is still often used during the manufacturing process but then removed, leaving only a very small (trace) amount. It is also used in vials that contain more than one dose of vaccine.

Social Media and the Anti-Vax Movement– The Good, the Bad and the Ugly

What is this Herd Immunity? Herd immunity is a form of immunity that occurs when the vaccination of a significant portion of a population (or herd) provides a measure of protection for individuals who have not developed immunity. Herd Immunity