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The Vac-Scene Newsletter
Volume 10, No. 3 - December 2004
Public Health has announced plans to distribute approximately 62,000 doses of adult flu vaccine in King County. Over 40,000 doses were allocated to King County from Washington state’s 162,000 dose allotment per the federal reallocation plan: 22,000 doses were acquired through independent orders and local redistribution. Sixty-five percent of the state’s allotment of vaccine is available in December, with the remaining 35 percent coming in January. Public Health also has facilitated redistribution of another 10,000 doses in the community.
Since the national flu vaccine shortage was announced in early October, Public Health has been assessing the supply and need of flu vaccine among those who vaccinate groups prioritized for influenza vaccine this season. Public Health has surveyed all 84 long term care facilities (nursing homes), all major hospitals, all 32 community and public health centers, and over 200 medical organizations and physician practices.
Public Health is distributing the adult flu vaccine as follows:
- Nursing homes and long term care facilities
11,000 doses
- Public flu clinics by health care organizations
15,000 doses
- Medical organizations and hospitals
24,000 doses
- Safety net providers: community and public health clinics
12,000 doses
Influenza Vaccine for Children
Through the federal Vaccines for Children (VFC) Program, Public Health has received 48,000 doses this year for high risk children. All orders for influenza vaccine supplied by VFC will be filled by mid-December. Last year 33,000 doses from VFC were distributed and used by over 300 health care providers and Public Health sites in King County.
Public Influenza Vaccination Clinics
Adult influenza vaccination clinics are being organized by three private health care organizations. Referrals may be directed to GetAFluShot.com (1-888-536-6900), PreventionMD.com (1-800-346-4915), and VNSNW.com for Visiting Nurse Services (1-800-449-2221).
Who Should Be Vaccinated?
Currently, influenza activity is low in King County. Because influenza activity typically peaks in January or February and lasts until spring, patients at high risk for severe influenza and prioritized for vaccination should be encouraged to continue to seek vaccination through February, as along as supplies are available. In October, Public Health issued a health order to assure that inactivated flu vaccine (Fluzone) in King County was allocated first to people at high risk of flu complications including:
Consider FluMist
People who are not in a priority group for injectable inactivated flu vaccine (Fluzone) this season may be able to receive the live attenuated intranasal vaccine (FluMist). FluMist is currently available in many hospitals and pharmacies in King County.
To reserve injectable inactivated vaccine for high risk patients who are not eligible for FluMist, the Washington State Vaccine Advisory Committee particularly encourages FluMist preferentially for the following persons:
* The CDC defines severely immune suppressed as "patients with hematopoietic stem cell transplants during those periods in which the immunosuppressed person requires care in a protective environment."
Can people vaccinated with FluMist pass the vaccine virus to others?
In clinical studies, transmission of vaccine viruses to close contacts has occurred only rarely. The current estimated risk of getting infected with vaccine virus is very low (0.6%-2.4%). Infection is unlikely to result in influenza illness since the vaccine viruses have not been shown to mutate into naturally occurring influenza viruses. A person vaccinated with FluMist is only excluded from contact with severely immune suppressed people (for seven days after vaccination). People who have contact with others with lesser degrees of immune suppression (for example, people with diabetes, people with asthma taking corticosteroids, or people infected with HIV) can get FluMist.
Vaccine Administration Considerations
A person with an acute febrile and/or respiratory illness should delay vaccination at least 72 hours. Because influenza antiviral medications reduce the replication of these viruses, FluMist should not be administered until 48 hours after cessation of antiviral therapy, and should not be resumed until two weeks after vaccination.
If another live vaccine (e.g. MMR, varicella) is indicated at the time of receiving FluMist, it should be given at the same time. If not done simultaneously, it is prudent to wait four weeks between doses of live vaccines.
FluMist Contraindications
- Age < 5 years or > 50 years
- Asthma, chronic lung or cardiovascular conditions
- Underlying medical conditions such as diabetes, renal dysfunction, hemoglobinopathies
- Weakened immune system from disease or therapy
- Age < 18 years and taking aspirin or other salicylates
- History of Guillain-Barre Syndrome
- Current pregnancy
- History of severe allergy to eggs
- Close contacts of severely immune suppressed people as defined by the CDC
For More Information
For updated information on the flu season and vaccine availability, visit Public Health’s flu season web site www.metrokc.gov/health/immunization/fluseason.htm or call the Public Health influenza hotline at 205-296-1100
The CDC website (cdc.gov/flu/professionals/flugallery/shortageflyers.htm) has resources for providers including a flu vaccine screening form, dosing chart, patient education flyers, and other information. For CDC information about FluMist visit www.cdc.gov/flu/about/qa/nasalspray.htm.
For providers in the Vaccines for Children program
The VFC Program has an adequate supply of flu vaccine in both pre-filled syringes (for children 6-35 months) and multi-dose vials (for high-risk children 3-18 years) to fill all orders by mid-December. If you anticipate needing either more or less flu vaccine than your original order, please contact the VFC Program immediately.
Supply and Demand
Due to the shortage this year, the CDC prioritization guidelines remain in effect. Some providers have actually reported a drop in demand in recent weeks, but keep in mind that it is still quite early in the flu season. The VFC Program recommends continuing flu vaccinations through February before returning unused vials to Public Health.
Vaccine Administration
Children through nine years old who have never received flu vaccine before should ideally receive two doses* separated by one month. However, doses should not be held in reserve to ensure that a second dose will be available. Rather, use available vaccine to immunize people in eligible priority groups on a first come, first serve basis.
* Dosing for Children < 9 Years Who Have Not Been Previously Vaccinated Number of Doses
6 - 23 months old
0.25 ml
2
3 - 9 years old
Please note: Flu vaccine from the VFC Program should not be given to adult patients or clinic staff.
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Birth Dose of Hepatitis B
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Unsafe to Assume Hepatitis B Given at Birth
Although a birth dose of hepatitis B vaccine is recommended by the American Academy of Pediatrics and U.S. Public Health Service, the proportion of newborns getting the birth dose in some King County hospitals is as low as 61 percent.
Birth Dose of Hepatitis B Vaccine by Hospital*
King County 2003
* Includes data from hospitals that receive VFC vaccine from
Public Health Seattle-King County.
The graph illustrates the error of assuming infants have received a dose of hepatitis B in the hospital. Public Health’s review of charts in outpatient clinics found numerous records in which hepatitis B vaccine was not given. Further, there was documentation of parents refusing the birth dose.
The chart review also revealed that some clinic staff were documenting that infants received a birth dose when, in fact, they hadn’t. Protection against hepatitis B requires completion of the three-dose series. In many clinics, the first dose of hepatitis B vaccine documentation was either missing or recorded as “in hospital” or “at birth.” Problems with documentation in clinical records and inaccurate assumptions about hepatitis vaccination procedures can lead to incomplete hepatitis B coverage. For example:
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Assuming hepatitis B was administered because there was an order for vaccine in the hospital record. An order for the vaccine does not mean it was given. |
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Assuming that all hospitals routinely administer the birth dose. The birth dose of hepatitis B vaccine is not routine at all hospitals.
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Relying on the parents’ report that hepatitis B vaccine was given. Parents may mistake other procedures (PKU testing or vitamin K injections) as receipt of the hepatitis B vaccine. |
To ensure all children receive the entire hepatitis B vaccine series and are protected, the CDC recommends restarting the series when solid documentation (mm/dd/yy) is absent. Practices may choose a system to obtain documentation of the birth dose from the hospital or to remind parents to bring their immunization record to the well child visit.
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The New VFC Provider Manual
The VFC Provider Manual has been given a thorough makeover. In fact, so much has changed that Public Health has sent each enrolled practice a complete, new manual in a handsome green binder. It should have arrived in a Priority US Mail cardboard box, along with a cover memo listing some of the most important changes. Please call 206-296-4774 if you did not receive a new manual.
New Vaccine Information Statements
Be sure that you have the 2004-2005 Influenza Vaccine Information Statements. There are two—one for inactivated flu vaccine and one for intranasal flu vaccine. The CDC has developed flu vaccine screening tools to use during this years’ flu vaccine shortage. In addition, there is a new VIS for the hepatitis A vaccine. Visit www.immunize.org to print camera-ready copies for your office, or call (206) 296-4774 to ask that a set be mailed to you.
Vaccine Shipment Delays
In late August and early September, many King County VFC providers did not receive vaccine orders in a timely manner. This occurred for several reasons, primarily due to manufacturer shipping delays. August and September are busy months for many practices, and it is unfortunate that shipping delays occurred during this time.
Because of occasional, unpredictable times such as these, the VFC Program Vaccine Request Form states, “Please allow 8 business days to receive your order.” It rarely takes eight days, as Public Health strives to ship orders for overnight delivery within 2-3 days of receipt.
Allowing for eight business days reduces frustration when incidental problems arise. The process works smoothly most of the time, but there are many ways the “vaccine train” can be held up. Public Health orders vaccine from the Washington State Department of Health (DOH), who then orders for the entire state through the Centers for Disease Control (CDC). The CDC must approve the order and transmit it to the vaccine producers. Then manufacturers fill the order and ship it to our warehouse.
King County alone distributes 50,000-75,000 doses of vaccine each month. Public Health and DOH are working together to improve communication and responsiveness among all the partners in vaccine purchase.
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Other Vaccine Considerations During Flu Season
PPV
People at high risk for influenza-related complications may also need pneumococcal polysaccharide vaccine (or PPV). This vaccine is given only once except for people with certain medical conditions who may need a booster.
Tetanus-Diphtheria
This is a good time to get patients caught up on tetanus-diphtheria (Td) boosters. Due to previous shortages many people may have missed their booster doses. Now that the Td supply has returned to normal, providers should recall those people and routinely assess whether patients are due for a booster dose.
Reinstatement of the 4th Dose Pneumococcal Conjugate Vaccine (PCV)
As reported in the September 17th broadcast fax, the Centers for Disease Control (CDC), along with the American Academy of Family Physicians and the American Academy of Pediatrics, has authorized a return to the full 4-dose schedule of pneumococcal conjugate vaccine (PCV).
It is recommended that patients who have missed doses of PCV in recent months be gradually recalled because large scale recalls of all deferred patients may create another spot shortage. The VFC Program is endeavoring to increase its supply of the vaccine to meet the anticipated need.
For more details on PCV and the catch-up schedule, contact the VFC Program at (206) 296-4774 or visit www.cdc.gov/nip and click on “Catch Up Schedule” under “Recommended Vaccination Schedules.” It is important to consult the catch-up schedule because the fourth dose is only necessary for children 12 months to five years old who received three doses before 12 months of age.
2005 Epidemiology and Vaccine Preventable Disease CDC Four-Part Series Satellite Course
Mark your calendars for CDC’s live four-part satellite course, Epidemiology and Prevention of Vaccine-Preventable Diseases, scheduled for February 17, 24, March 3 and 10, 2005. The course is co-sponsored by the Region X Public Health Service and will be held in Seattle at the Blanchard Plaza Building (6th and Blanchard). Each interactive broadcast will run from 9:00-12:30 p.m.
The primary focus of the sessions will be to provide the most current information available on vaccine-preventable diseases, vaccine management and safety, and recommended immunization practices.
Providers who either give immunizations or set policy for their offices or clinics, are encouraged to attend. CME/CEUs will be awarded to course participants who complete the training. Course fee is $20.00 (please contact us if payment is not possible). For more information, call (206) 296-5252.
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