Avoiding Administration Errors: Scheduling Errors

Dear Immunization Provider,

The Immunization Program thanks you for your critical role of ensuring children in Philadelphia receive up-to-date immunizations prior to the school year!

To help you in your immunization efforts we have assembled some tips for avoiding one of the most common vaccine administration errors: scheduling errors!

What are Administration Errors?

Administration errors due to scheduling occur when vaccines are given too early – either before the appropriate minimum age or before the recommended interval for a particular vaccine.

Unfortunately, early doses are not valid. Minimum ages and dosing intervals have been studied for efficacy and safety. Administering vaccines out of this range may not generate an adequate immune response, leading to vulnerability to disease, side effects, or harm to the provider’s relationship with the patient/parent. It is in everyone’s best interest to avoid administration errors!

Exception: There is a 4-day grace period before the minimum interval or age, although this should not be used when scheduling visits. This does not apply to the 28-day interval between two live injectable vaccines (e.g. MMR, Varicella) or Flumist if not administered simultaneously, or intervals between the rabies vaccine.

Common Scheduling Errors

Here are some of the most common scheduling errors found when reviewing immunization histories and scheduling immunization appointments:

• Administering the 1st dose of MMR, varicella, or hepatitis A vaccine before 12 months of age
• Giving the 4th dose of DTap before age 12 months (or less than 6 months after the 3rd dose)
• Not administering a dose of IPV after 4 years of age (at least 6 months after previous dose)
• Finishing the hepatitis B series before 24 weeks of age
• Administering any vaccine (except hepatitis B) before age 6 weeks
• Giving the 2nd dose of MenACWY vaccine before age 16 years for a healthy adolescent
• Inadequate spacing for the hepatitis A, hepatitis B, IPV and HPV series
• Using the incorrect needle size
• Injecting vaccine at the incorrect injection site
• Confusing Tdap (Tetanus, Diphtheria, Pertussis) and DTap (Diphtheria, Tetanus, Pertussis) vaccines

Tips from the Immunization Program

Here is a list of tips to find past administration errors and avoid them going forward:

• Keep an immunization schedule handy for clinical and office staff!
• When scheduling well-child visits, ensure a child will have reached the appropriate age (e.g., will be at least 12 months on the date of their 1-year well-child visit).
• Review the patient’s immunization record, by searching the PhilaVax IIS or by obtaining the patient’s vaccination records by contacting their previous healthcare provider.
• Use the tools in PhilaVax to understand what is indicated for the patient.
  • A red exclamation mark means that a dose is not valid.
  • Click “Recommend” below a patient’s record to see when vaccines are recommended.

Did you know? You can update your PhilaVax settings so recommended vaccines display at the top of your screen when reviewing patient records. Follow the steps below and reference the screenshots to do it yourself!

1. Click your username in the upper right-hand corner (see screenshot 1)
2. Under “User Defaults,” click “Display Today’s Recommendations” (see screenshot 2)
3. Click “Update” to save the change (see screenshot 2)

What do I do if an Administration Error Happens?

• Check for guidance from the Advisory Committee for Immunization Practices (ACIP) and Centers for Disease Control and Prevention (CDC)
• Make a report to the Vaccine Adverse Events Reporting System (VAERS)
  • Recommended if a dose administration error occurs (required for a COVID-19 vaccine under Emergency Use Authorization)
  • Required if an adverse event occurs

Have questions about vaccine scheduling or the PhilaVax software? The Philadelphia Immunization Program is here to help! You can email us at vaccines@phila.gov for assistance.

Resources & References

• Immunization Action Coalition (IAC):
  • The Importance of Minimum Ages and Intervals in the Vaccine Schedule
  • Clinic Tools: Vaccine Recommendations
  • Summary of Recommendations for Child/Teen Immunization
  • Ask the Experts
• Centers for Disease Control and Prevention (CDC):
  • Birth-18 Years Immunization Schedule
  • You can email CDC’s experts at nipinfo@cdc.gov
• CDC Pink Book:
  • Recommended and Minimum Ages and Intervals Between Doses of Routinely Recommended Vaccines
  • Epidemiology and Prevention of Vaccine-Preventable Diseases
• Advisory Committee on Immunization Practices (ACIP):
  • General Best Practice Guidelines for Immunization
• Institute for Safe Mediation Practices:
  • Recommendations for Practitioners to Prevent Vaccine Errors

MenQuadfi (MenACYW-TT), a New Meningococcal Vaccine, is Now Available for VFC

To download a PDF version of this PDF, click here!

In 2020, the Food and Drug Administration licensed an additional meningococcal serogroups A, C, W, and Y (MenACWY) – MenQuadfi
(MenACYW-TT), from Sanofi Pasteur Inc.

MenQuadfi is now available for providers enrolled in the Vaccines for Children (VFC) program. This advisory includes an overview
of important information about MenQuadfi.

MenQuadfi is licensed for use in individuals 2 years and older in the United States.

Recommendations For Use

Eligible Groups for Receipt of VFC Supplies of MenQuadfi

VFC supplies of MenQuadfi may be given to VFC-eligible children aged 2 years through 18 years.

Licensed Dosing Schedule

MenQuadfi is for intramuscular use only.

MenQuadfi is approved for routine vaccination of children and teens, age 11 through 18 years: a single dose at age 11 or 12 years with a booster dose at age 16 years.

MenQuadfi may also be used for children at increased risk who are age 2 years and older (the primary dosing schedule and booster dose interval varies by age and indication):

• People with functional or anatomic asplenia
• People who have persistent complement component deficiency (an immune system disorder) or who take a complement inhibitor (eculizumab [Soliris] or ravulizumab [Ultomiris])
• People who have HIV infection
• People who are at risk during an outbreak caused by a vaccine serogroup
• People age 2 months and older who reside in or travel to certain countries in sub-Saharan Africa as well as to other countries for which meningococcal vaccine is recommended (e.g., travel to Mecca, Saudi Arabia, for the annual Hajj)
• Microbiologists who work with meningococcus bacterial isolates in a laboratory
• First-year college students living in residence halls who are unvaccinated or undervaccinated; these students should receive a dose if they have not had a dose since turning 16 or if it has been more than 5 years since their previous dose

These recommendations are summarized in Table 3 of the recommendations published by ACIP in MMWR in 2020: www.cdc.gov/mmwr/volumes/69/rr/pdfs/rr6909a1-H.pdf.

The Advisory Committee on Immunization Practices (ACIP) recommends that whenever feasible, the same manufacturer’s brand should be used to complete the series. However, if the previous brand is unavailable or unknown, any brand may be used to complete the series. Do not defer immunization solely to wait for a specific meningococcal vaccine brand to be available. From age 2 years and up the MenACWY vaccines are interchangeable.

Storage

• MenQuadfi should be stored at 2º to 8ºC (36º to 46ºF). Do not freeze. Product which has been exposed to freezing should not be used. Do not use after the expiration date shown on the label.

How MenQuadfi is supplied

• MenQuadfi is supplied in a single-dose vial in packages of 5 vials (NDC No. 49281-0590-05). The dosage for MenQuadfi is 0.5 mL. MenQuadfi does not contain a preservative. The vial stopper for this product is not made with natural latex rubber.

Ordering and Billing

MenQuadfi is available for ordering through the PhilaVax IIS as of today, June 8, 2021. Please contact Christine Wilson (Christine.Wilson@phila.gov) or Charma Miller (Charma.Miller@phila.gov) to add MenQuadfi to your next order. Please note, your practice must choose a single product to order for each antigen. We recommend that sites that are part of a system, or are affiliated, use the same vaccine presentations across sites to ensure continuity of care and help prevent administration errors.

• CVX code: 203
• CPT code: 90619

Resources

• Meningococcal ACYW Vaccine Information Statement (VIS): https://www.cdc.gov/vaccines/hcp/vis/vis-statements/mening.pdf
• CDC Morbidity and Mortality Weekly Report (MMWR): https://www.cdc.gov/mmwr/volumes/69/rr/pdfs/rr6909a1-H.pdf
• Product insert for MenQuadfi includes additional vaccine information, found at: https://www.fda.gov/media/137306/download
• Additional information on vaccines and vaccine preventable diseases can be found at: http://www.cdc.gov/vaccines/

Vaxelis (DTaP-IPV-Hib-HepB), a Hexavalent Vaccine, is Now Available for VFC

To download a PDF version of this notice, click here!

Vaxelis is now available for providers enrolled in the Vaccines for Children (VFC) program. This advisory includes an overview of important information about Vaxelis.

Vaxelis is a hexavalent combined diphtheria and tetanus toxoids and acellular pertussis (DTaP) adsorbed, inactivated poliovirus (IPV), Haemophilus influenzae type b (Hib, PRP-OMP), and hepatitis B (HepB) (recombinant) vaccine. In 2018, FDA licensed Vaxelis for use in children age 6 weeks through 4 years: it is indicated as a 3-dose series for infants at ages 2, 4, and 6 months. ACIP voted to add Vaxelis to the Vaccines for Children (VFC) Program in 2019. Vaxelis became commercially available in the United States in 2021.

Recommendations For Use

Eligible Groups for Receipt of VFC Supplies of Vaxelis

VFC supplies of Vaxelis may be given to VFC-eligible children from 6 weeks through 4 years of age (prior to the 5th birthday).

Licensed Dosing Schedule

Vaxelis is indicated for active immunization to prevent diphtheria, tetanus, pertussis, poliomyelitis, hepatitis B, and invasive disease due to Haemophilus influenzae type b. Vaxelis is approved for use as a 3-dose series in children from 6 weeks through 4 years of age (prior to the 5th birthday). Vaxelis is indicated for use in infants at ages 2, 4, and 6 months.

Recommended minimum ages for administration of Vaxelis (DTaP-IPV-Hib-HepB) vaccine and intervals between doses — United States, 2020*

† If the third dose of DTaP-IPV-Hib-HepB is given before age 24 weeks, an additional dose of hepatitis B vaccine should be given at
age ≥24 weeks to complete the hepatitis B series.

*DTaP-IPV-Hib-HepB can be used for children aged <5 years requiring a catch-up schedule. However, vaccine doses should not be
administered at intervals less than the minimum intervals indicated in this table.

For guidance on transitioning to Vaxelis and how it fits into the immunization schedule, visit: https://www.vaxelistransition.com.

The Advisory Committee on Immunization Practices (ACIP) recommends that whenever feasible, the same manufacturer’s brand should be used to complete the series. However, if the previous brand is unavailable or unknown, any brand may be used to complete the series. Do not defer immunization solely to wait for a specific brand to be available.

Storage

Vaxelis should be stored at 2º to 8ºC (36º to 46ºF). Do not freeze. Product which has been exposed to freezing should not be used. Do not use after the expiration date shown on the label.

How Vaxelis is supplied

Vaxelis is supplied in a single-dose vial in packages of 10 vials (NDC no. 49281-0590-05). The dosage for Vaxelis is 0.5 mL. Vaxelis does not contain a preservative. The vial stopper, syringe plunger stopper, and syringe tip cap are not made with natural rubber latex.

Administration

Just before use, shake the vial or syringe until a uniform, white, cloudy suspension results.

Inspect the vial or syringe for particulate matter and discoloration prior to administration. If either of these conditions exist, the product should not be administered.

Administer a single 0.5 mL dose of Vaxelis intramuscularly. In infants younger than 1 year, the anterolateral aspect of the thigh is the preferred site of injection. The vaccine should not be injected into the gluteal area.

Vaxelis should not be combined through reconstitution or mixed with any other vaccine. Discard unused portion. Vaxelis is for intramuscular use only.

Precautions and Contraindications

Do not administer Vaxelis to anyone with a history of severe allergic reaction to a previous dose of Vaxelis, any ingredient of Vaxelis, or any other diphtheria toxoid, tetanus toxoid, pertussis containing vaccine, inactivated poliovirus vaccine, hepatitis B vaccine, or Hib vaccine.

Do not administer Vaxelis to anyone with a history of encephalopathy within 7 days of a pertussis containing vaccine with no other identifiable cause.

Do not administer Vaxelis to anyone with a history of progressive neurologic disorder until a treatment regimen has been established and the condition has stabilized.

Ordering and Billing

Vaxelis is available for ordering through the PhilaVax IIS as of today, June 8, 2021. Please contact Jillian Brown (Jillian.Brown@phila.gov) to begin the process of transitioning to Vaxelis at your site. Please note, your practice must choose a single type of combination vaccine to use as part of the primary series. We recommend that sites that are part of a system or are affiliated use the same vaccine presentations across sites to ensure continuity of care and help prevent administration errors.

• CVX code: 146
• CPT code: 90697

Resources

Vaccine Information Statements (VIS):

• Multi-Vaccine: https://www.immunize.org/vis/multi_vaccine_infants.pdf
• DTaP: https://www.immunize.org/vis/dtap.pdf
• Hib: https://www.immunize.org/vis/hib.pdf
• IPV: https://www.immunize.org/vis/polio_ipv.pdf
• Hep B: https://www.immunize.org/vis/hepatitis_b.pdf

CDC Morbidity and Mortality Weekly Report (MMWR): https://www.cdc.gov/mmwr/volumes/69/wr/pdfs/mm6905a5-H.pdf.

For guidance on transitioning to Vaxelis and how it fits into the immunization schedule, visit: https://www.vaxelistransition.com.

Product insert for Vaxelis includes additional vaccine information, found at: https://www.merck.com/product/usa/pi_circulars/v/vaxelis/vaxelis_pi.pdf.

Additional information on vaccines and vaccine preventable diseases can be found at: http://www.cdc.gov/vaccines/