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The Vac-Scene Newsletter
Volume 7, No. 4 - September-October 2001
News from the Public Health Vaccine Distribution Program
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Prioritizing Prevnar (PCV7) supply
As with other vaccines, manufacturing delays have led to a temporary nationwide shortage of PCV7 which may continue into early 2002. Until supplies are replenished, CDC recommends that all providers give highest priority to vaccinating all infants aged <12 months and children aged 1--5 years with the following high-risk conditions: sickle cell disease; congenital or acquired asplenia or splenic dysfunction; immunosuppressing conditions including HIV infection, malignancies, renal failure, nephrotic syndrome, organ transplant, high-dose steroid use; other chronic medical conditions including cardiac and pulmonary disease, cerebral spinal fluid leaks and diabetes. Catch-up vaccinations for healthy children aged
1 to 2 years and booster doses for healthy children who have completed the primary series may be deferred. Records should be kept so that the deferred vaccinations can be given when vaccine becomes available. (Visit the following website for full text of the CDC's recommendations: www.cdc.gov/mmwr/preview/mmwrhtml/mm5036a3.htm)
Provider orders will be carefully screened. State-supplied PCV7 should not be used for anyone older than age 59 months. Please call the WA Dept. of Health Materials Order Line at 360-664-8797 for updated Usage Report Forms that list both 'Pneumo' and 'PCV' (form #348-025). Updated Vaccine Request (Order) forms are available by calling: 206- 296-4782.
Pneumococcal Polysaccharid supply
The pneumococcal polysaccharide (23-valent) supply is extremely low, and the situation is unlikely to improve soon. Due to reduced manufacturing capacity and a recent cost increase for the vaccine, the federal VFC purchasing contract has expired. King County will receive only half its order for September. To make the best use of this remaining supply, Public Health's Vaccine Distribution Program staff will need to screen provider's pneumococcal polysaccharide orders to maximize distribution of available supplies.
As a reminder, the 23-valent pneumococcal vaccine is indicated only for children ages 2-18 years who are considered high risk for invasive pneumococcal disease. High-risk criteria include: asplenia; sickle cell disease; nephrotic syndrome; cerebral spinal fluid leaks; immunosuppression, including asymptomatic or symptomatic HIV infection; certain Native American populations (children living in special environments or social settings with an identified increased risk of pneumococcal disease or its complications).
In addition to screening orders for volume, distribution program staff will look at previous usage reports to determine if providers are administering the 23-valent vaccine within program guidelines. Before orders are filled, providers will receive a telephone call and faxed information confirming vaccine eligibility guidelines.
Hepatitis A vaccines, Havrix and VAQTA
Both brands of hepatitis A vaccine, Havrix (Glaxo- SmithKline) and Vaqta (Merck) can be used in children aged 2 through 18 years. Disregard the label that says "18 years only" on Havrix. Our vaccine distributor, General Injectables and Vaccines (GIV) had been labeling Havrix vials as "18 years only" during the time when Vaqta was only licensed through age 17 years. Those 19 years and older are not eligible to receive public-funded hepatitis A vaccine.
Usage report reminder
Usage Reports to the public funded vaccine program are to include only state-supplied vaccines, not vaccines acquired through other means. Inclusion of purchased vaccine on Usage Reports raises the question of inappropriate administration of public-funded vaccines and may delay the filling of provider orders.
Announcing our new Vaccine Distribution Coordinator!
On August 1, 2001, Darren Robertson joined Public Health's Vaccines For Children Program as the full-time Vaccine Distribution Coordinator. Darren can be reached at 206-205-5805, 8 am - 5 pm, M - F. Welcome, Darren!
This season, more influenza vaccine is expected to be available than in previous years. Some delays in distribution are projected, but they are not expected to be as great those in the 2000-01 season. In years without delays, most flu vaccine is distributed by the end of October. This year, however, manufacturers have told us to expect 60% of the vaccine to be delivered by the end of October, 30% by the end of November, and the final 10% in early December. The projected distribution of influenza vaccine for 2001, based on manufacturers' estimates as of August 6, 2001 is 79.1 million doses, which is greater than in 2000.
Prioritizing flu vaccine supply
Please allow those people who will benefit most from the vaccine - those over 65 years and older and all persons with chronic (long-term) health conditions and their families- to get their shots as soon as vaccine becomes available. Everyone else should wait until November and later to get protection when the supplies are more plentiful. Patients who receive the vaccine after November will still be protected as the flu season runs from November through April.
This information excerpted from CDC's National Immunization Program website at: http://www.cdc.gov/nip/flu. Refer to this site for the current status of this year's flu vaccine supply.
Febrile seizures after MMR and DTP vaccinations
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A study published in the August 30th issue of the New England Journal of Medicine (The Risk of Seizures after Receipt of Whole-cell Pertussis or Measles, Mumps and Rubella Vaccine, W. Barlow et al) found that children who experienced rare fever-related (febrile) seizures following MMR and whole cell DTP vaccinations did not have an increased risk for subsequent seizures or learning disabilities. The study also confirmed that DTP and MMR vaccination can temporarily increase the risk for febrile seizures. Febrile seizures occurred with the greatest frequency in the first 24 hours following following DTP vaccination (6-9 seizures per 100,000 children vaccinated); fever-related seizures following an MMR vaccination typically occur between days eight to fourteen (25-34 per 100,000 children vaccinated).
Since the period covered by this study, the use of acellular pertussis (DTaP) vaccine has replaced DTP vaccine in the United States. DTaP has been associated with fewer side effects than DTP, including febrile seizures.
Despite the small risk for febrile seizures linked to fever following vaccination, MMR and DTaP immunizations are strongly recommended. These vaccines prevent serious diseases that pose a much greater risk to most children's health than the seizures associated with vaccination. For example, encephalitis (inflammation of the brain that can lead to convulsions and cause deafness or mental retardation) will occur in one child in every 1,000 infected with measles. Encephalitis is a rare, potentially serious complication of pertussis, as well.
For more detailed information on the study, visit: www.cdc.gov/nip/issues/mmr-dtp/mmr-dtp.htm
Chickenpox in the Era of Varicella Vaccine, Part 2
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The varicella vaccine (Varivax) was approved for use in the United States in March 1995 and has been available through the public funded vaccine program in Washington State since May 1995. Despite the availability of free vaccine, only about half of all clinics in King County who participate in the Vaccines for Children (VFC) program provide Varivax to their patients.
Recently, Public Health-Seattle & King County conducted a mail survey of VFC clinics to determine the factors influencing the clinic's decision to not order varicella vaccine. All VFC clinics who do not order varicella vaccine (n=140) were surveyed; a 91% response rate was achieved. The two most frequently cited reasons for not providing the vaccine were: 1) inadequate storage unit, and 2) lack of parent demand for the vaccine. Further analysis revealed that sites who responded that inadequate refrigeration and lack of parent demand were most influential also considered the vaccine to be a low priority and/or questioned the efficacy of the vaccine.
The varicella vaccine must be kept frozen at an average temperature of -15° C (+5° F) or colder until it is reconstituted for use. The survey suggests there is a misperception about the type of freezer required for storage of varicella vaccine. Actually, most household freezers, including frost-free models manufactured within the last 5-10 years, will maintain an acceptable temperature range for storage of Varivax. Proper storage can also be accomplished with small, inexpensive chest freezers or refrigerators with ice compartments that are enclosed with sealed, insulated doors (with separate temperature controls for each compartment).
It is possible that providers who mistakenly believe that Varivax requires a unique storage unit also perceive that their current refrigerator/freezer is inadequate for proper storage of the vaccine. Hence, there may be some reluctance to devote additional resources and staff time toward investigating alternative storage units. This reluctance may be underscored if the clinic views the vaccine as a low priority or questions its efficacy. Additionally, clinic staff may be less likely to discuss or recommend the use of the vaccine with their client families. Thus, in certain settings, biases by immunization providers may be resulting in parents not being offered the varicella vaccine for their children.
Although some clinics may consider the varicella vaccine to be a low priority compared to other vaccines, there has been a steady increase in varicella immunization coverage rates among children aged 19-35 months in King County. Recent estimates from the 2000 National Immunization Survey indicate that coverage rates for varicella vaccine in children ages 19-35 months increased from 38.5% in 1999 to 50.2% in 2000.
With only 50% of children immunized against varicella in King County, there is some concern over how a partial uptake of the varicella vaccine in the community will affect the epidemiology of the disease in the future. As immunization coverage rates with varicella vaccine increase, the occurrence of natural disease decreases, as does the opportunity for susceptibles to acquire natural infection during childhood. Consequently, if these susceptibles are then exposed to wild varicella virus as adolescents or adults, they are more likely to experience more severe disease with an associated increase in complications. To prevent varicella among older children and adults, health care providers who do not routinely offer varicella vaccine to young children should be sure those children who have not had varicella infection by age 13 receive the vaccine.
Varicella vaccine supplied through the public-funded vaccine program is available for all children 12 months through 18 years of age. A single dose of varicella vaccine is routinely recommended for all children (without contraindications) at 12-18 months of age. Children who are first immunized at 13 years or older required 2 doses of vaccine separated by four weeks.
If you would like further information about the survey or how to order varicella vaccine for your clinic, please contact the Public Health-Seattle & King County Immunization Program at (206) 296-4774.
Vaccinating people in special circumstances
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People with certain medical conditions should receive additional vaccines not routinely recommended for all adults. Aside from HIV infection, conditions which cause severe immunosuppression may include congenital immunodeficiency, leukemia, lymphoma, or generalized malignancy, and current therapy with alkylating agents, antimetabolites, radiation, or high-dose corticosteroids. Systemic steroids create a contraindication to vaccination when administered for 2 or more weeks during the 3 months prior to vaccination, and in doses equivalent to >2 mg/kg of body weight/day or a total of >20 mg/day of prednisone.
No live vaccines should be given to people with severe immunosuppression. However, MMR and varicella vaccines may be administered to their household contacts. Persons with leukemia in remission who have not received chemotherapy for at least 3 months may receive live vaccines.
Vaccination should precede initiation of chemotherapy or immunosuppression by >2 weeks. Patients vaccinated while on immunosuppressive therapy or in the 2 weeks before starting therapy should be considered unimmunized and should be revaccinated at least 3 months after discontinuation of therapy. Passive immunoprophylaxis with immune globulins may be indicated instead of, or in addition to, vaccination. When exposed to a vaccine-preventable disease, severely immunocompromised children should be considered susceptible regardless of their vaccination history.
Medical conditions such as renal failure or chronic renal disease, diabetes, alcoholic cirrhosis, asplenia, chronic heart or pulmonary disease, and chronic hemoglobinopathies (such as sickle cell disease) may increase the patient's risk for certain diseases and their serious complications. Persons with renal failure should receive hepatitis B (with the higher dialysis dose), pneumococcal and influenza vaccines. Persons with diabetes or alcoholic cirrhosis should receive pneumococcal and influenza vaccines.
Asplenic patients (no spleen or a poorly functioning one) should receive pneumococcal vaccine (conjugate for children from age 2 months to 5 years and polysaccharide age 2 years and older), a single dose of Haemophilus influenzae b (Hib) vaccine, and a single dose of meningococcal vaccine (age 2 years and older). In elective splenectomy, these 3 vaccines should be administered >2 weeks prior to surgery if possible. In addition, these patients should receive influenza vaccine each fall.
Additional information about vaccinating patients with special medical conditions can be found in the ACIP Recommendations on "Use of Vaccines and Immune Globulins in Persons with Altered Immunocompetence", MMWR, No. 42/RR-4, April 9, 1993, available at: ftp://ftp.cdc.gov/pub/Publications/mmwr/rr/rr4204.pdf (Adobe PDF format.)
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key sites
Flu Season Update
 Learn about the latest case results affecting King County residents, fact sheets and where to get your flu shot.
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 Vaccines for Children
Vaccines for Children (VFC) was established in 1993 to remove the barriers of cost and access to attaining childhood immunizations.
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