Panel Physician Medical & Health 1

VAC C I N AT I O N P RO C ES S BY: VIVIANA MÉLINCHON, MD LIMA – PERU MARCH 2013

Agenda 2

Purpose Vaccination Process Contraindications / Precautions Management of Relevant Cases

Lessons learned and opportunities for improvement

Purpose 3

 Of the presentation 

Create awareness about the main activities, tools and techniques employed in the vaccination process to be performed on applicants for American Visa as a Panel Physician.

 Of the vaccination process 

Ensure that the applicants who enter the United States do so free from vaccine preventable diseases in compliance with the Technical Instructions.

Purpose of the Presentation 4

 Describe the Technical Instructions regarding the Panel

Physician’s vaccination process.  Show how we have been doing it in Peru for 1.5 years.  Continuously improve the process in order to reach the

best vaccination practice.

Purpose of Vaccination Process in the Medical Exam for Immigrants 5

 Protect against diseases that could produce outbreaks.

 The vaccines should protect against diseases that have

been or are being eradicated in the United States.  Apply the vaccines recommended by ACIP calendar,

according to the applicants age, considering the exemptions of the New Criteria 2009

Medical & Health Strategic 6Direction  Mission 

Comply with the Technical Instructions efficiently during the medical evaluation process for immigrants to ensure a process consistent with the levels of service agreed with the Consular Office and CDC (DGMQ).

 Vision 

Become an expert Panel Physician and be acknowledged by the Consular Office and CDC (DGMQ) as a loyal executor of the Technical Instructions capable of providing experience, resources and information.

Medical & Health 7

Current Organization 8

Panel Physician Dra. Viviana Mélinchon

Manager

Assistant

Ana María Camero

Magaly García

TB Nurse

Vaccination Nurse

Triage Nurse

Fidela García

Rocío Meza

Patricia Tacza

Agenda 9

Purposes Vaccination Process Contraindications / Precautions Management of Relevant Cases

Lessons learned and opportunities for improvement

Vaccination Process Process Map 10

PP: Check applicants’ vaccination record

PP: Prescribe vaccines according to age and ACIP calendar

PP: Inquire about contraindications and precautions

VN: Fill in DS 3025 Form

PP: Sign DS 3025 Form

TBN: Fill in DS 2053 Form

VN: Give a copy of the DS 3025 Form to applicant

VN: Explain adverse effects and Provide brochure

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PP: Panel Physician VN: Vaccination Nurse TBN: TB Nurse

VN: Administer vaccines

VN: Control of applied vaccines

Vaccination Process Vaccine Administration –“Wheel of Rights” 11

Right #6 - The right site • Partially dependent on the correct route • Related to the age of the patient.

Right #1 – The right patient Right #2 - The right • Check photo identification • Ensure screening has identified vaccines vaccine that are needed and vaccines that should • Check your vials 3 be avoided. times to make sure you have the correct vaccine in hand.

Right #5 - The right route • Vaccine administration may be oral, intranasal, subcutaneous, or intramuscular. • Correct needle length is essential.

Right #3 - The right time • Check age to see if vaccine is appropriate. • Check interval from other doses of the same or different vaccines. • Vaccines and their diluents might expire as well, so check those dates.

Right #4 - The right dosage • Vaccine dosage is based on the age of the patient, not the weight.

Vaccination Process DS-3025 Vaccination Form 12

Vaccination Process Vaccination Form 13

DS-3025 Form  If any of the boxes under “Not Medically Appropriate” are

checked, the first box below must be checked 

The “blanket waiver” line is also usually checked  exception is if applicant refuses all vaccines due to religious or moral convictions.

Vaccination Process Vaccination Report 14

DS-2053 Form

 Page 2 of DS-2053 

Immunizations: Boxes checked must match those on DS-3025

Vaccination Process Vaccines: Practical Issues 15

 How to assess the applicants’ vaccination history?  

  

! Verify identity! of applicant Applicant to submit written available information  Personal vaccination records  Entries in medical charts Dates of receipt of vaccine – Month/Day/Year Reasonable vaccination dates Document must not appear to have been altered

 Self-reported vaccines are NOT valid

New vaccination criteria for immigration purposes: 2009 16

 December 14, 2009: New Vaccination Technical

Instructions (TI)  Criteria:

Age-appropriate vaccine recommended by ACIP for the general U.S. population  But

ALSO

2009 New Vaccination Criteria 17

The vaccine must protect against a disease with a potential to cause an outbreak

AND/OR The vaccine must protect against a disease that has been eliminated in the US or is in the process of elimination in the US

Main Changes from prior instructions 18

 Human Papillomavirus – removed  Zoster vaccine - removed  Tetravalent conjugate meningococcal vaccine (MCV4)  

For applicants 11 through 18 years of age MPSV and monovalent MCV not acceptable in this age group

 Influenza vaccine 



For everyone 6 months of age and older unless there is a specific contraindication Revision in 2009 TI and further changes in subsequent vaccine schedules

Vaccination Process Vaccine Storage and Handling 19

Vaccine Reception

• • • •

Verification of vaccine requested Control of the Production Lot Verification of Expiration Date Shelf life

Vaccine Storage and Handling

• • • • • •

Label Vaccine Trays Implement Cold Chain Vaccine Classification (children / adults) Register of Temperature control (datalogger) Weekly inventory of vaccines FEFO Control (first to expire , first out)

Vaccine Rotation

• Invoicing control of vaccines • Vaccines applied per applicant

Vaccination Process Importance of the ACIP Calendar 20

 The Advisory Committee on Immunization Practices (ACIP) is a group

of medical and public health experts that develops recommendations on how to use vaccines to control diseases in the United States.  The recommendations stand as public health advice that will lead to a

reduction in the incidence of vaccine preventable diseases and an increase in the safe use of vaccines and related biological products  However, the vaccinations advised by ACIP for U.S. residents are

REQUIRED for immigrants, currently with the exception of the human papillomavirus and zoster vaccines

Vaccination Process ACIP Calendar 21

1 of 2 footnote pages for 0-18 schedule

Vaccination Process ACIP Calendar 23

1 of 2 footnote pages for adult schedule

Adapted from ACIP recommendations 25

Agenda 26

Purposes Vaccination Process Contraindications / Precautions Management of Relevant Cases

Lessons learned and opportunities for improvement

Vaccine Contraindications 27

Any vaccine

Severe allergic reaction

Pregnancy* and severely immunocompromised conditions  Oral poliovirus Live attenuated  MMR** vaccines  Varicella  Intranasal influenza

Pertussis

Encephalopathy within 7 days of pertussis vaccination

*See www.cdc.gov/vaccines/pubs/preg-guide.htm **Should advise applicants that they should avoid becoming pregnant for 4 weeks after vaccination

Not Contraindications to Vaccine Administration 28

 Mild to moderate local reactions to previous dose of vaccine  Mild acute illness (e.g., low-grade fever, upper respiratory

infection, diarrhea)  Recovering from illness  Antimicrobial therapy  Tuberculin skin test*

*All vaccines can be given on the same day as a TST or any time after TST is applied. If MMR, varicella or live attenuated (intranasal) influenza vaccine is given before TST, delaying at least 4 weeks is recommended before giving TST.

Not Contraindications to Vaccine Administration (cont.) 29

 Pregnant or immunosuppressed persons in the household*  Breastfeeding  Preterm birth

 Family history of adverse events *Exception:

Live attenuated influenza vaccine (LAIV) should not be administered to persons who have contact with severely immunosupressed persons who are isolated because of immunosuppression. LAIV may be administered to contacts of persons with lesser degrees of immunosuppression.

Vaccine Precautions 30

 Any vaccine 

Moderate or severe acute illness (e.g., high-grade fever)

 Td/Tdap, meningococcal and influenza vaccines 

Prior Guillain-Barré syndrome

 Rotavirus vaccine 

Prior intussusception



Rhesus-based vaccine associated with intussusception in 1999 no longer on market

Vaccine Precautions (cont.) 31

 DTP/DTap vaccine

Any of the following after a previous dose of DTP/DTap vaccine 

Fever of 40.5oC (105oF) or higher within 48 hours



Persistent crying for >3 hours within 48 hours



Convulsions w/ or w/o fever within 3 days

 If a vaccine is not administered due to a precaution, mark

“contraindicated” on DS-3025 form

2013 acip adult vaccination schedule, p. 4

Use with document at www.cdc.gov/vaccines/pubs/preg-guide.htm

http://www.immunize.org/vis/polio-ipv.pdf

http://www.immunize.org/vis/meningococcal.pdf

Vaccine Information Statements 33

Vaccine Adverse Reactions 34

Local  Pain, swelling, redness at injection site  Common with inactivated vaccines  Usually mild and self-limited

Systemic  Fever, malaise, headache  Nonspecific  May be unrelated to vaccine

Vaccine Adverse Reactions (cont.) 35

 Allergic  Due

to vaccine or vaccine component  Rare  Risk minimized by screening

Agenda 36

Purposes Vaccination Process Contraindications / Precautions Management of Relevant Cases

Lessons learned and opportunities for improvement

Management of Relevant Cases: Pregnancy 37

 Case Description 

Vaccines to be applied to an 18- year-old , 5-week pregnant woman

 Inquiry for this condition 

Which vaccines can be safely administered during pregnancy?  Hepatitis B: Administer in some circumstances (consider risk of disease)

 Actions to be taken    

Apply: Tdap, Influenza (Inactivated). Do not administer Varicella (Chicken pox) Do not administer MMR Do not administer Intranasal Influenza (LAIV)

Management of Relevant Cases Fiancé 38

 Case Description 

A 22 -year-old is a fiancé of US citizen to be married in US

 Inquiry for this condition 

Are vaccines necessary?

 Action to be taken 

She can get vaccines at the time of the immigration examination in her own country or in the US when she applies to change from a non-immigrant to an immigrant visa status (obtain green card).

Management of Relevant cases Refugees 39

 Case Description 

A refugee applies to enter the United States

 Inquiry Applicable for this condition 

Are vaccines necessary?

 Action to be taken 

Refugees don’t require vaccinations at the time of the overseas medical examination. Vaccination will be required in the United States when the refugee applies to change status from refugee to immigrant (obtain a green card).

Management of Relevant Cases Adoption 40

 Case description 

A 2-year old- child comes with his adoptive parents who state that the child will have a consultation with a US physician for vaccination.

 Inquiry applicable for this condition 

Can parents sign an affidavit?

 Action to be taken 

Do not administer vaccines if affidavit signed  An adopted child 10 years of age or younger does not require vaccination at the time of the overseas immigration examination and can instead be vaccinated in United States

http://adoption.state.gov/hague/overview/countries.html

Management of Relevant Cases DUI 41

 Case Description 

A non-immigrant visa applicant is sent to our office for a medical exam after being charged with a DUI infraction

 Inquiry applicable for this condition 

Are vaccines neccessary?

 Actions to be taken 

Do not administer vaccines 

Non-immigrant visa applicants do not require vaccinations

Agenda 42

Purposes

Vaccination Process Contraindications / Precautions Management of Relevant Cases

Lessons learned and opportunities for improvement

Lessons learned 43

Always contract with highly trained staff (Cold Chain, Updated on vaccines, storage, datalogger, etc) Need to employ protocol to store vaccines Contract with a supplier to collect biohazardous material (syringes) Ensure vaccine cold chain (electric generator, refrigerator (ICELINE), datalogger) Periodic inventory control (quantity, expiration date, shelf life, vaccine movement)

Program the purchase of vaccines according to seasons Establish more control points during the process to recognize and avoid fraud Inform about vaccine contraindications and precautions as well as adverse events In case of severe adverse effects, document applicant acceptance by signing the Informed Consent Form before vaccination

Opportunities for Improvement (To Be Implemented) 44

Opportunities

Purpose

Expand and improve establishment (New office)

Improve service

The web page shall include the contraindications and precautions per type of vaccine (http://medicalvisaperu.com/)

Share information with applicants that log onto the website

Implement an annual training plan for the team responsible for vaccination

Improve capabilities of the vaccination staff

Develop a distribution map which shall be placed on the ICE LINED refrigerator

Make storage and release of vaccines easier

Develop an integrated software program Automate the process of registration and for process control by the Panel Physician control followed by the applicant during (appointments, general exam, vaccine his medical exam prescriptions, stock control, invoicing, vaccines applied per applicant)

References 45

2009 Technical Instructions for Panel Physicians for Vaccinations

•http://www.cdc.gov/immigrantrefug eehealth/exams/ti/panel/vaccination -panel-technical-instructions.html OR • http://www.cdc.gov/panelphysicians

• http://www.cdc.gov/vaccines/sc hedules/index.html ACIP: Develops vaccination recommendations for • http://www.cdc.gov/vaccines/ac the United States. ip/index.html

ACIP Immunization Schedules

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The Immunization Action Coalition (IAC) - Creates and distributies

educational materials on safe and effective delivery of immunizations

• http://www.immunize.org/vis

References 46

Guidelines for Vaccinating Pregnant Women - Updated December 2012

• http://www.cdc.gov/va ccines/pubs/pregguide.htm

- 13 pages in PDF version - CDC publication

Vaccine Storage and Handling Toolkit (Nov 2012) - Comprehensive resource for providers - Equipment, proper storage and handling practices, inventory management and emergency procedures for protecting vaccine inventories

•http://www.cdc.gov/va ccines/recs/storage/tool kit/

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Thank you