The Vac-Scene Newsletter (Volume 8, No. 2

News from the Public Health Vaccines for Children Program

VACCINE SUPPLIES AND USAGE GUIDELINES

Varicella vaccine: Merck, maker of Varivax, is 60 days behind on filling orders. By the end of March, Merck expects half of back orders will be filled nationally; by mid April, all orders will be filled.

While the shortage persists, providers should delay vaccination of children 12 - 18 months until 18 months or the two-year visit. Use a call-back system when supply improves. See www.cdc.gov/nip/news/shortages/varicella_02-20-02.htm for details.

MMR: Merck also manufactures MMR vaccine. There have been reports of spot-shortages of MMR. As yet, this is not the case in King County. Expect a broadcast fax from Public Health - Seattle & King County Immunization Program in the event of a local MMR vaccine shortage.

DTaP: Delays continue at the manufacturer level. A back-order file is maintained; please do not place additional orders until the back-order is filled.

1.	Give all infants the 2-, 4-, and 6-month doses.
2.	For infants 15-18 months of age who have not been exposed to pertussis, defer the 4th dose of DTaP. Providers may choose to defer the 5th DTaP dose if necessary to maintain enough DTaP at their clinic for the three initial doses.
3.	Public Health is currently reviewing provider DTaP usage patterns and inventory. If necessary, we may recommend all providers defer the 5th dose until further notice.
4.	School status: WA Department of Health Immunization Program has notified schools and school nurses that the use of conditional status for children who miss doses due to supply shortages is allowed. When vaccine supply returns to normal, clinics should recall children whose vaccinations had been deferred.

For children who have been exposed to pertussis:

1.	Ensure that close contacts (<7 years of age) of exposed persons initiate or complete the primary DTaP series, including the 4th dose and subsequent booster doses according to the recommended schedule.
2.	Children who received a 3rd dose 6 months or more before exposure should be given a 4th dose.
3.	Children who have had 4 doses of DTaP should receive a booster dose of DTaP unless a dose has been given within the last 3 years, or they are >7 years of age.

Pneumococcal conjugate (Prevnar): Nationwide shortage continues. Focus on first three doses for all children at 2, 4 and 6 months, and the 4th dose for high-risk children. Defer #4 for healthy children until supply improves. Keep careful records of children who should be recalled for these doses when normal supply resumes. For more information, visit: www.cdc.gov/mmwr/preview/mmwrhtml/mm5050a4.htm

Other Vaccines: Orders for Td and DT are limited to 10 doses per provider per order. We have a good supply of all other vaccines, and they are readily available.

AMENDMENT:
In the November/December 2001 Vac-Scene, information under the heading "Breathe!" stated that providers should not store refrigerated vaccine on solid plastic or glass shelving. We wish to amend that statement. We were a bit over-expressive in our enthusiasm for barred or grid shelving because of the concern for air circulation. Most new refrigerators are equipped with solid glass shelving, and it was decided that asking providers to replace this shelving was unnecessary. To summarize, glass shelving is OK! Clinics that organize refrigerated vaccines in "containers" within the refrigerator, however, should use vented, rather than enclosed trays for optimum temperature circulation.

VFC VACCINE DISTRIBUTION IN KING COUNTY

Public Health - Seattle & King County has established procedures in order to distribute vaccine as equitably as possible to all VFC providers during vaccine shortages. The procedures are as follows:

1.	For all vaccines, we attempt to distribute a 30-45 day supply of vaccine to each VFC provider/site. In order to meet this target, vaccine orders are scrutinized in relation to provider inventory and average monthly usage. This supply target is reduced from the previous target of a 30-60 day supply. In severe shortages we may need to further ration available quantities of vaccine.
2.	Distribution of vaccines that are in short supply or with delayed delivery is prioritized according to provider/site inventory. Orders from providers who have the lowest or no supply, are filled first. This replaces the routine procedure of filling orders on a first-come, first-served basis.
3.	Providers are informed as soon as possible of modifications in the vaccine distribution process and changes in the recommended immunization schedule during vaccine shortages. We communicate with VFC providers through The VacScene newsletter, the VFC Provider e-mail List, broadcast faxes, and the posting of weekly updates on the Public Health website www.metrokc.gov/health/immunization/vfc.htm. Public Health-Seattle & King County follows CDC and Washington Department of Health recommendations when applicable to our local situation, and any additional recommendations for local use will be well publicized.

There may be concern among some health care providers and parents related to perceived "inconsistent" availability of childhood vaccines among different providers in the community. We are available to consult with health care providers to address specific questions about vaccine availability, to provide or clarify recommendations for managing vaccine supplies during shortages (e.g. DTaP doses 4 and 5), and to provide information about when we anticipate vaccine orders can be filled.

Public Health remains dedicated to distributing vaccine to providers as rapidly and as equitably as possible when supplies are available. Please call us at 206-296-4774 if you have questions.

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National Immunization Survey 2001

The latest immunization rates from the National Immunization Survey (NIS) have been released by the CDC for the period July 2000-June 2001. The rates are for children 19-35 months of age, born between August 1997 and November 1999.

There were no statistically significant changes in King County when comparing NIS data collected from July 2000-June 2001 with data collected for the calendar year 2000; however, immunization rates in King County continue to be below the rest of the state.

Here are some comparisons between the July 2000-June 2001 survey data and year 2000 data for King County:

Three doses of DTaP decreased from 93.2% to 92.1%; coverage for four doses of DTaP decreased from 81.3% to 79.2%. Rates for both vaccines have continued to decline since 1998.
Rates for three doses of IPV increased from 87.8% to 89.4%.
MMR remained essentially unchanged 87.2% vs. 87.9%
Three doses of Hib vaccine increased slightly from 91.8% to 92.4%.
Three doses of Hep B vaccine increased slightly from 82.9% to 83.5%.
Varicella vaccine increased from 50.2% to 56.0%. Use of varicella vaccine has increased steadily since it was introduced, but is still low compared to the U.S.

Coverage rates for combined vaccination series 4:3:1* and 4:3:1:3** have decreased slightly in King County since 1997***, (79% vs.74.8% and 78.5% vs. 73.3% respectively) however, the decrease is not statistically significant. King County rates have been slightly below the national rates since 1997. The combined rate for the 3:3:1 series has remained around 81%, however, there are only two and a half years of survey data available for this series. Urban areas in other states are reporting coverage rates similar to rates in King County.

There may be several explanations for the possibly declining combined vaccination series rates in King County:

Missed opportunities or incomplete immunization documentation: Implementing a reminder/recall system would help identify children who are missing or behind in vaccinations. For information and suggestions on implementing reminder/recall systems, visit the American Academy of Pediatrics-sponsored website: www.cispimmunize.org/resour/catch_main.html and click on the provider section.
Selective vaccination: The fear that multiple immunizations may overwhelm their child's immune system may lead some parents to limit the number of vaccines they want their child to receive. The decision to selectively vaccinate may also be fueled by the "anti-vaccine" literature.
Belief that diseases no longer pose a substantial threat: The dramatic reduction and near elimination of several vaccine-preventable diseases have led many parents to believe that there is no longer a need to protect against them. At the same time, the perceived risks of vaccination have taken on greater significance.

Although the purpose of the NIS is to establish a consistent data set for analyzing childhood vaccination rates, it is important to consider at least three limitations of the NIS data: 1) Because NIS is a telephone survey, statistical adjustments have been made to compensate for households without telephones and for those who choose not to respond; 2) Samples are relatively small, especially at the state and city levels, thus larger confidence intervals are necessary, and 3) NIS tries to obtain provider verification of immunization histories, but when that is not possible, statistical adjustments are made based on previous studies.

* DTP, Polio, Measles-containing vaccine
** DTP, Polio, Measles-containing vaccine, Hib
*** The increase in 1998 is most likely due to a change in methodology and variation in the sample.

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Summary of ACIP 2002 General Recommendations on Immunization

The recently revised ACIP statement, General Recommendations on Immunization was published in the February 8,2002 edition of the MMWR (Vol.51/No. RR-2).

The following is a summary of the key changes:

4-day grace period for timing and spacing of vaccines: Vaccine doses administered up to four days before the minimum interval or age can be counted as valid. The "grace period" should NOT be used when scheduling future vaccination visits. Rather, it should be used primarily when reviewing vaccination records.
Non-simultaneous administration of live vaccines: If two live parenteral vaccines are given less than 28-days apart, the vaccine given second should NOT be counted as valid and should be repeated at least 4 weeks later. One exception is that yellow fever vaccine may be given at any time after measles vaccine.
Non-standard route or site of administration: ACIP continues to strongly discourage variation from the recommended route or site of any vaccine. However, repeating doses is only necessary in the case of rabies or
hepatitis vaccines administered in the gluteus, and hepatitis B vaccine administered by ANY route other than intramuscular (i.e., intradermal or subcutaneous).
Vaccination of internationally adopted children: Detailed guidance on determining whether vaccines received outside the US can be accepted as valid are contained within the full ACIP statement.
Aspiration before injection: No data exist to document the necessity of aspiration. The new Recommendation statement does not recommend aspiration before injection.
Hepatitis B vaccination for preterm infants: All infants whose mothers are HBsAg positive OR whose HBsAg status is unknown should be given both hepatitis B vaccine and HBIG within 12 hours of birth. If the infant is preterm, weighing <2000 grams, three additional doses of vaccine should be given at 1, 2 and 6 months of age. A premature infant weighing <2000 grams born to a HBsAg-negative mothers can receive the first dose of hepatitis B vaccine at chronological age one month, or sooner if the infant is medically stable and has gained weight consistently prior to hospital discharge.

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2002 Immunization Card

We are pleased to enclose the revised 2002 Immunization Card Health Advisories & Resources. This pocket-sized card contains the current Recommended Childhood Immunization Schedule and footnotes, a minimum interval table, General Rules of Childhood Vaccination, and a list of useful immunization-related resources.

The Immunization Card is a collaborative project of the Immunization Action Coalition of Washington; Healthy Mothers, Healthy Babies Coalition of Washington; Public Health - Seattle & King County, Snohomish Health District and the Washington State Department of Health. Funding for printing has been graciously provided by: Aventis Pasteur and Wyeth-Lederle Vaccines.

To order additional cards, health care providers in King County may call Ricky Robles at 206-205-1054. Providers outside of King County, please call Healthy Mothers, Healthy Babies at 1-800-322-2588.

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CDC Satellite Course June 27th: The Immunization Encounter: Critical Issues

Mark your calendars: On Thursday, June 27th, 9:00 am- 11:00am the CDC's National Immunization Program will be providing a course for immunization clinic managers and staff who administer vaccines (RNs, MAs, NPs, PAs, etc.)

The broadcast, "The Immunization Encounter: Critical Issues" will address topics related to a routine immunization clinic day, exemplifying best practice standards. The program will be held at the Region X Public Health Service office in Seattle. Registration forms will be mailed within the next few weeks. For more information, contact Tiffany Acayan at 206-205-5812.

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