The Vac-Scene Newsletter (Volume 6, No. 5

News From the Public Health Vaccine Distribution Program

Alert: Td shortage

The national shortage of tetanus/diphtheria (Td) vaccine that has been ongoing for several months is now impacting the availability of state-supplied Td. Please be prepared for delays or partial orders of state-supplied Td vaccine over the next few months. Earlier this year, one of the manufacturers of Td vaccine fell behind in production and the other major manufacturer has been unable to meet the increased demand.

Additionally, because of the shortage and increased cost of Td, the State Department of Health, Immunization Program, plans to restrict use of state-supplied Td to children 7-18 years of age. We do not yet know when the restriction will go into effect, but we expect notification in the near future. In the meantime, providers are strongly encouraged to purchase Td for patients who are >18 years of age to prepare for this expected change in eligibility status for the state-supplied vaccine.

Hepatitis A vaccine for 18-year olds

Merck has announced that indications for the pediatric formulation of VAQTA^® will soon include 18 year olds. Once this happens, providers will be able to use either pediatric VAQTA^® (Merck), or pediatric Havrix^® (SmithKline Beecham) to immunize children 2 through 18 years of age. We will send out notification as soon as this goes into effect. If you would like a copy of the new package insert for VAQTA^® after this licensing change, you may call Merck, Inc. at 800-637-2579.

Note: Boxes of state-supplied Havrix^® may continue to be labeled "for 18-year-olds-only," but once the new indications go into effect, you may disregard this and use the vaccine for any child 2 - 18 years of age.

Varivax Vaccine

VARIVAX orders will NOT be shipped during Thanksgiving week (November 20th-24th) or during the entire month of December. The last possible day to place an order for varicella vaccine this year will be November 28th. Normal shipping (two-week turnaround) for VARIVAX will resume in January 2001. Feel free to call the Vaccine Distribution Program at 206-296-4782 if you have any questions.

State-supplied influenza vaccine

The first shipment of state-supplied influenza vaccine (for high risk children only) is due to arrive in time to be shipped to clinics by early November. A memo to providers dated September 25th requested that flu vaccine orders be placed once for the entire season. Those who have submitted their influenza vaccine requests by October 15th will be shipped vaccine first. For providers who submit their one-time only order after this date, the flu vaccine order will be processed and shipped while supplies last.

Prevnar not yet a State-supplied vaccine

This past June, the ACIP voted to recommend the 7-valent pneumococcal conjugate vaccine (Prevnar, manufactured by Wyeth Lederle Vaccines) for all children 23 months of age and younger, and for children 24 to 59 months who are at high risk of serious pneumococcal disease, which includes children with sickle cell disease, HIV infection, chronic illness or weakened immune systems.

Due to the expense of Prevnar, it is challenging for the state to continue its overall policy of using state funds to assure access for all children to federally funded childhood vaccines. Currently the state is seeking budgetary appropriation for pneumococcal conjugate vaccine, with a potential start date of January 2001 or July 2001 depending on availability of funds and legislative concurrence. As more specific information is available, it will be passed along quickly to providers.

Reminder: Providers who order "pneumo" on the State-Supplied Vaccine Request Form will receive the 23-valent polysaccharide pneumococcal vaccine for high risk children (age 2-18 years). See the July/August issue of The VacScene for details.

To view or download the new pneumococcal resolution and all
other ACIP resolutions for VFC coverage, go to: http://www.cdc.gov/nip/vfc/acip.htm.

"Who, me? Couldn't be!"

ANY health care provider site that receives public-funded vaccines may be subject to audit from county, state, or federal offices. Therefore, clinics are responsible for retaining copies of temperature monitoring logs and vaccine usage reports for a single calendar year until the end of the following calendar year.

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Update: Flu Vaccine Supply

The Centers for Disease Control and Prevention recently confirmed that a substantial amount of influenza vaccine will reach providers later than usual. However, total flu vaccine supply should be approximately what was distributed last year. Some King County providers have received their full influenza vaccine order, while others have been informed that they will not receive any vaccine. Many have been notified that they will receive their vaccine in increments through the end of December.

Because our influenza season usually begins in January, receiving flu vaccine in December will still allow ample time to develop protective immunity against the flu. If your initial vaccine supply runs out, encourage your high-risk patients to seek vaccination through other resources in your community (e.g. pharmacies, grocery stores, senior centers). Beginning November 6th, a limited supply of vaccine for persons at high-risk for complications from the flu will be available at most public health clinic sites; call (206)296-4774 for more information. Additionally, information for providers regarding influenza vaccine suppliers and availability can be found at: http://www.cdc.gov/nip/flu-vac-supply.

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What's New In Hepatitis Reporting?

As of September 2000, changes to reporting requirements for notifiable conditions have made cases of chronic hepatitis B (HBV) and all cases of hepatitis C (HCV) legally notifiable conditions by health care providers (not laboratories) according to Washington Administrative Code (WAC 246-101).

The primary reason for adding hepatitis C and chronic hepatitis B to the list of legally notifiable conditions is to get a more accurate picture of the prevalence of these diseases in Washington. Having a better understanding of the burden of chronic hepatitis in our community will help us in obtaining resources for hepatitis prevention programs.

Cases of HCV and chronic HBV can be reported by health care providers to Public Health on a monthly basis. Cases are to be reported: a) at the time of initial diagnosis, or b) for previously-diagnosed unreported cases, when follow-up testing for chronic hepatitis is obtained after September 2000. Reporting of hepatitis C cases should include persons who have detectable antibody to HCV (anti-HCV positive) and/or persons who have detectable HCV RNA, either by a qualitative or a quantitative test. If you are uncertain if a case has already been reported, proceed with reporting when new hepatitis testing has been ordered. If the case has already been reported, the case report will be updated if there is new information.

The only exception to monthly reporting of chronic HBV is for pregnant women who are HBsAg-positive; these cases should be reported within 3 work days. Screening for HBsAg is recommended for all pregnant women during each pregnancy, and women who are HBsAg-positive should be reported to Public Health during each pregnancy. Women who are HBsAg-positive are enrolled in a confidential tracking and reminder system to assure that their infant receives timely and necessary post-exposure treatment.

Suspected or confirmed cases of acute HBV (and unspecified hepatitis suspected to be from an infectious source) are also reportable by health care providers within 3 work days.

Suspected or confirmed cases of hepatitis A are reportable to Public Health by health care providers immediately. This is particularly critical for persons working as food handlers, where a greater potential risk to the public exists.

Whenever possible, the following information should be included in your initial report of confirmed or suspected cases of viral hepatitis:

Case demographic information: name, birthdate, address, telephone number, race and gender.
Laboratory results: date blood drawn, results of all hepatitis markers and liver function tests, if done, not just abnormal results.
Clinical information: reason for testing, clinical symptoms and date of onset of hepatitis, whether the case is a known HBV or HCV "carrier".
Risk factor information: injection drug use, blood or blood product exposure, sexual exposure, close contact with a known case.
Health care provider's information: name, address, and telephone number.
Pregnancy status of females aged 12-52 years who are HBsAg-positive (or date of last menstrual period, if known).

To report hepatitis and other notifiable conditions to Communicable Disease Control and Epidemiology:

Call 206-296-4774 between 8 am - 5pm, or
Call our 24-hour report line at 206-296-4782, or
Fax a copy of the test results along with case report information to 206-296-4803, or
Mail a copy of the test results to our office (for chronic cases only).

For a list of current notifiable conditions, call 206-296-4774 . For the complete document of legally notifiable conditions, go to the following URL: http://www.doh.wa.gov/OS/Policy/246-101prp3.pdf (*see note at bottom about Adobe PDF files). For questions about reporting of suspected or confirmed hepatitis cases, contact Shelly McKeirnan, 206-296-4717. For questions about reporting of HBsAg-positive pregnant women, contact Linda Vrtis at 206-296-4777.

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Travel Services at Public Health - Seattle & King County Clinics

Three Public Health - Seattle & County Clinics offer travel immunizations and current information regarding health-related risks while traveling abroad: Downtown (206-296-4960), Northshore (206-296-9816), and Auburn (206-296-8414 or 253-833-8567).

Travel services are provided by appointment only. A travel assessment is required in order to receive travel immunizations at a Public Health clinic.

The travel assessment includes review of the itinerary, the traveler's medical history, discussion of travel-associated health risks and illness prevention tips, medical and emergency care while traveling, and vaccine requirements and recommendations. Recommendations for travel vaccines are based upon the traveler's itinerary and may include meningococcal, polio, rabies, typhoid, yellow fever and Japanese encephalitis vaccines. Downtown and Northshore Public Health sites also have a nurse practitioner available to evaluate and prescribe preventive medication for malaria (there is no vaccine for malaria), altitude sickness, travelers' diarrhea and other travel-related conditions.

All three sites also offer the following routinely recommended vaccines: Td (tetanus/diphtheria), MMR (measles, mumps and rubella), hepatitis A and B, varicella, influenza and pneumococcal vaccine.

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Limited Availability of HBIG at Public Health Clinics

Recently, vials of hepatitis B immune globulin (HBIG) delivered by the manufacturer have a short period of potential use before expiration. Unfortunately, supplies that are not used before their expiration date cannot be returned for a refund. HBIG is an expensive medication (about $500 per 5-ml vial) that is given based on a person's weight (0.06ml/kg). Thus, a 150 pound patient (68 kg) would need a dose of just over 4 ml, or almost all of a 5-ml vial. Thus, clinics maintaining a large supply of HBIG for "potential" use may end up wasting this medication.

For these reasons, Public Health's Central Pharmacy will maintain a small supply of HBIG for immediate use, which can be accessed by our Downtown Public Health site. Our other Public Health clinics can order HBIG if needed and receive shipment within 24 hours. Health care providers referring patients to Public Health for HBIG must call their local public health clinic (if not Downtown) to arrange for this medication to be delivered within 24 hours.

If you have questions about availability of HBIG or if your patient needs HBIG immediately, please call Shelly McKeirnan, Public Health Communicable Disease Control & Epidemiology, at (206) 296-4717.

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Lao Version of the Asian/Pacific Island Hepatitis B Poster Now Available

These free 11" x 17" hepatitis B prevention color posters target the importance of hepatitis B vaccine among Asian and Pacific Island children and are available in 7 languages: Laotian (new), Chinese, Vietnamese, Korean, Tagalog, Samoan, and Cambodian. Culturally appropriate graphics, photographs, and designs have been incorporated into these seven distinct posters. The message on each poster is: "Hepatitis B: Are Your Children Protected?"

To order posters: Providers in King County, call Shelly McKeirnan at (206) 296-4717; outside of King County, contact Jennifer Little, Immunization Action Coalition of Washington, at (206) 285-1461.

To view the poster graphics or to access mail-in forms online, go to the following URL address: http://www.metrokc.gov/health/prevcont/apiposters.htm

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