The Vac-Scene Newsletter (Volume 7, No. 3

Update: Td Vaccine Storage

As you are aware, a nationwide shortage of Tetanus and diphtheria toxoids (Td) in the United States has occurred since one of two manufacturers discontinued production of tetanus toxoid-containing products in January 2001. The sole remaining commercial manufacturer, Aventis Pasteur, has increased production to attempt to meet national needs, however the shortage is expected to last for the remainder of this year. Until further notice, Aventis Pasteur is shipping Td vaccine only to public health clinics and urgent care facilities (i.e. hospital emergency rooms and burn units) so that adequate supplies are available for high priority indications, as defined by the U.S. Centers for Disease Control and Prevention (CDC).

To assure vaccine availability for high priority indications, the CDC recommends deferring all routine adult and adolescent tetanus booster vaccinations until 2002 or until the shortage has been resolved. Patients whose booster dose is delayed during the shortage should be recalled for vaccination when Td supplies are restored.

Public Health - Seattle & King County is restricting use of Td vaccine to the top two priority indications as recommended by the CDC: 1) wound management; and 2) travel to countries where the risk for diphtheria is high. As the vaccine supply improves, we will extend use of Td vaccine to the remaining CDC-designated high priority groups: 3) persons with an incomplete three-dose primary series of any vaccine containing Td; and 4) pregnant women who have not been vaccinated with Td within the preceding 10 years.

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Plan Now for Flu Season 2001-02!

As of June 15th, preliminary information from flu vaccine manufacturers suggests that more vaccine will be available this year as compared to last year, however, delays in the vaccine's distribution will occur. The CDC and FDA stress that these early projections could change as the season progresses.

On the basis of these projections, the Advisory Committee on Immunization Practices (ACIP) has agreed on supplemental recommendations to promote the administration of flu vaccine that is available early to persons at greatest risk of complications from influenza disease. The CDC's National Immunization Program has issued a request to all health care providers for assistance with implementing these updated influenza vaccine recommendations:

Identify your high risk patients!
1) Target your immunization efforts so that health care workers and those at highest risk of influenza complications are immunized first (September/October if possible) in the event of a delay or shortage. 2) Continue to vaccinate patients, especially those at high risk and in other target groups, through December and later, as long as vaccine is available.
Scheduling Mass Flu Vaccination Campaigns
1) Organized flu campaigns and events not in workplaces should be scheduled in late-October or November when vaccine supply is assured and make special efforts to vaccinate the elderly and those at high risk of complications. 2) Employee-based campaigns, especially those targeting healthy, younger populations, should be postponed until even later-especially if there is a shortage or delay. This will help high-risk people to get their immunizations first.

Refer to these websites for additional information on flu vaccine:
- www.cdc.gov/nip/issues/flu
  Definitive information about vaccine production and distribution usually will not be available until late summer or early fall. Be sure to check the CDC's website for updated information on influenza vaccine as the season progresses.
- www.cdc.gov/nip/Flu/Guidelines.htm
  Guidelines for Mass Influenza Vaccination Campaigns

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CDC's Immunization Update 2001

Mark your calendars for CDC's live satellite course, Immunization Update 2001, scheduled for September 20th.

The course is being co-sponsored by the Region X Public Health Service and will be held at the Blanchard Plaza Building in Seattle. The interactive broadcast will run from 9:00am - 11:30am. The course will help bring you up-to-date on the rapidly changing field of immunization.

Both private and public health care 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 $5.00.

Registration forms will be mailed in early August.

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Chickenpox in the Era of Varicella Vaccine (Part I)

In the pre-vaccine era, approximately 4 million cases of chickenpox occurred in the United States each year. These cases resulted in 11,000 hospitalizations and 105 deaths annually. "That is one child and one adult per week", said Jane Seward of CDC's National Immunization Program during a vaccine-preventable disease surveillance update session at the recent National Immunization Conference. She presented chickenpox data from three sites (Antelope Valley, CA; West Philadelphia; and Travis County, TX) where active surveillance has been done to monitor the effects of varicella vaccine on the incidence of herpes zoster disease. Chickenpox disease is not reportable nationally, but 12 varicella deaths are known to have occurred in the U.S. in each of the years 1998 and 1999. There have been three chickenpox-related deaths so far in 2001.

As of December 31, 2000, 26 million doses of varicella vaccine have been distributed in the USA. Overall coverage rate for 19-35 month old children in the USA was shown to be 64% in a July 2000 survey. This same survey revealed a 41% coverage rate in Washington's 19-35 month old children. The National Immunization Program has set a goal of 90% or greater coverage for children of this age group by 2010. Surveillance data from the three active surveillance sites seems to show 80% decline in chickenpox cases in the last half of 2000 when compared to the pre-vaccine rates of disease.

Because it is important to characterize the indigenously circulating strains of varicella virus before the disease becomes rare*, a national varicella virus laboratory has now been established. The CDC is requesting that providers who see chickenpox cases collect vesicular fluid or crust from lesions for viral isolation. This is especially important if an outbreak involves both vaccinated and unvaccinated individuals. If you are interested in collecting and submitting specimens for varicella virus isolation, please contact us at 206-296-4774. Public Health has the protocol for submission of specimens to the national varicella virus laboratory.

*For example, there is no longer an indigenous strain of measles virus circulating in the United States. All measles cases in recent years, where virus has been available for molecular typing, have proved to be imported strains.

(Part II of this article will appear in the next issue of the Vac Scene.)

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CHILD Profile Update

CHILD Profile, Washington State's Immunization Registry and Health Promotion system, continues to grow and improve under the new strategic direction of an expanded Governing Board. Recent developments include:

Planning for future sustainability - Through increased collaborative efforts of the Washington State Department of Health, DSHS Medical Assistance Administration, and Washington Health Foundation, strategic planning efforts continue, emphasizing sustained long-term funding and improved organizational structure.
Change in external relations - The working relationship between CHILD Profile and HEALTHradius has ended. As of April 30, 2001, the two parties are no longer exchanging patient demographic and immunization data.
New web interface in development - CHILD Profile staff is working on a new web-based interface to the Registry. Phase 1, due for release this Fall, will reproduce the immunization tracking module of the original text-based version (ability to look up, enter, and print out immunization histories and recommendations of vaccines due); Phase 2, a longer term project, will reproduce the full functionality of the text-based system, including recall and vaccine accountability reports, a CASA linkage, and other features.
Recognition for Health Promotion materials - The high quality of CHILD Profile's Health Promotion materials was recently recognized with the endorsements of the Washington Chapter of the American Academy of Pediatrics, the Washington Academy of Family Physicians, and the School of Public Health and Community Medicine at the University of Washington. These endorsements will soon appear on our envelopes and website.

Growing by Leaps and Bounds: CHILD Profile's new emphasis on populating the registry with claims data from Medicaid and health plans has resulted in a tremendous increase in the number of records in the system. Virtually all children under six years of age in Washington State now have demographic records in CHILD Profile. As of June 1, 2001, 72% of these children have one or more immunization events in the registry, a 130% increase in just one year. In King County, over 64% of children under six years (or 83,851 children) have some immunizations in CHILD Profile, up from 40% one year ago.

Although its emphasis remains on young children, CHILD Profile also includes records on many teens and adults. The system contains demographic records on 2.9 million individuals, with 8.7 million immunization events recorded. CHILD Profile's goal is to have all health care providers in Washington State participate in the Registry. For more information on the CHILD Profile Immunization Registry and how to participate, please call 800-325-5599 or 425-339-5242. For more information on the CHILD Profile Health Promotion system, please call 206-296-2784. You may also wish to refer to the CHILD Profile website: www.childprofile.org.

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Immunizations and Multiple Sclerosis: Studies Reveal No Relationship

Media attention has publicized claims that vaccination against hepatitis B virus may increase risk for developing multiple sclerosis (MS). These concerns have been raised by anecdotal reports from France of a possible increase in autoimmune disease, including MS, after hepatitis B vaccination. The anecdotal reports from France have NOT been confirmed by any scientific study in Europe or in the United States to-date. A study by the French National Drug Surveillance Committee among recipients of over 60 million doses of hepatitis B vaccine delivered between 1989 and 1997 found that the frequency of neurological disease, including MS, that might be linked to the vaccination was in fact LOWER than the frequency of MS in the general population. Visit www.nationalmssociety.org for more information.

More recently, the results of two large epidemiological studies that examined the risk of an association between vaccines and multiple sclerosis (MS) were published in the New England Journal of Medicine (Vol. 344, No.5). The first study* analyzed whether there is an association between exposure to any vaccination and short-term relapse of disease in persons with pre-existing MS. Subjects (n=643) were obtained from the European Database for Multiple Sclerosis and included women who had relapses of disease between 1993-1997. Researchers tracked whether women with MS had been vaccinated in the two months prior to a relapse, and compared this to whether they had been vaccinated in four previous two-month control periods. The data revealed that vaccination did not appear to increase the short-term risk of relapse of MS. Additionally, there was no association between receipt of particular vaccines, including hepatitis B, tetanus, or influenza and relapse among MS patients.

The second study** tracked participants from two large cohorts of nurses in the U.S.: the Nurses' Health Study (121,700 women since 1976) and the Nurses' Health Study II (116,671 women since 1989). The study evaluated the relative risk associated with exposure to hepatitis B vaccine ever and within 2 years of the onset of multiple sclerosis. One hundred ninety-two women with MS and 645 matched controls were included in the analysis.
No association was found between exposure to hepatitis B vaccine and development of multiple sclerosis, regardless of the timing of vaccination, or the number of doses received.

Additionally, the National MS Society's Medical Advisory Board finds no scientific data showing a connection between hepatitis B vaccination and MS: "The cause of MS remains unknown, but is believed to be due to the impact of an environmental or infectious trigger on the immune system of an individual who carries a genetic predisposition for the disease. After decades of searching, no environmental or infectious trigger for MS has been identified. There is no indication that infection with hepatitis B leads to MS, and there are no statistically significant data to support a link between hepatitis B vaccination and MS."

*Confavreux C, Suissa S, Saddier P, Bourdea V, Vukusic S. Vaccinations and the risk of relapse in multiple sclerosis, N Engl J Med 2001; 344:319026.

**Ascherio A, Szhang SM, et al. Hepatitis B vaccination and the risk of multiple sclerosis, N Engl J Med 2001; 344:327-332.

The studies cited above are also available online for subscribers at http://content.nejm.org

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