Hello,

Please find the attached Immunization Program Newsletter Fall Winter 2016-2017.

If you have any questions about the contents of the newsletter, please contact the following numbers:

Vaccine availability, ordering or storage and handling: Vaccine Management Unit - 617-983-6828

MIIS enrollment or troubleshooting: MIIS Help Desk - 617-983-4335

Immunization schedules and recommendations, VPD disease morbidity, or other immunization related information:Immunization Program Main Number- 617-983-6800

Hello-

In honor of Cervical Health Awareness Month, the Immunization Program would like to remind providers that the HPV vaccine is cancer prevention! The HPV vaccine is recommended for all 11-12 year old boys and girls to protect against HPV and HPV-related cancers. Please take some time to familiarize yourself with some recent articles and resources about the HPV vaccine.

  • DPH Blog Article targeting a general audience focusing on how HPV vaccine is cancer prevention. The blog article features a video from the newly released American Cancer Society's Survivor Stories video bank. Feel free to share this blog within your practice, send it to parents/patients, and/or put in any other communication to your staff and patients. You can also follow DPH on Twitter to see immunization related tweets.
  • MDPH is running a digital billboard in 63 locations across 20 cities in Massachusetts to highlight the message "HPV vaccine is cancer prevention!" The billboard points people to the newly created general audience HPV vaccine page on our Immunization Program website. The friendly url is http://www.mass.gov/dph/hpvvax and you can find it by visiting the "HPV Vaccine is Cancer Prevention!" in the "Vaccine Preventable Disease" section of the Immunization Program website. The HPV billboard is below for your reference.
  • The MCAAP Immunization Initiative hosted a webinar on January 12th entitled 2017 HPV Vaccination Update. Please visit the MCAAP Immunization Initiative page for more information about that webinar. The direct link to the recorded webinar is here. (Please note that CME/CEU credit is not available for listening to the webinar recording.)

Topics included:

  • Review of ACIP Recommendation Regarding 2-Dose HPV Schedule and MA HPV Vaccination Uptake
  • Susan Lett, MD, MPH, Medical Director, MDPH Immunization Program
  • HPV Resource Review
  • Rebecca Vanucci, Immunization Outreach Coordinator, MDPH Immunization Program

CDC recently released updated and new resources on HPV vaccine:

HPV Talking Tips for Parents – CDC updated their "Addressing Parents' Questions" resource and this new version highlights the same day, same way message and the effective statement "Now that your son is 11, he is due for vaccinations today to help protect him from meningitis, HPV cancers, and pertussis." This strategy is similar to the messages we promote on the MDPH HPV Information sheet. If you used the older version of "Addressing Parents' Questions" for any reason, please update your files to use this resource.
Top Ten List for HPV Success – This new resource highlights the top 10 list to achieve and maintain high HPV vaccination rates.
o HPV Vaccine Information for Clinicians – a new resource geared towards clinicians to summarize the background of HPV infection, HPV vaccines, recommendations, safety, effectiveness, duration of vaccine protection, and dosing schedules. Please note: while the factsheet discusses the 3 FDA approved HPV vaccines, the 9vHPV vaccine (Gardasil 9) is the only vaccine available in the United States effective October 2016. The section on paying for vaccines is geared towards a national audience so please remember that Massachusetts is a universal pediatric state (all routinely recommended vaccines are provided for children 18 years and younger).

Would you like to get more involved in activities to increase HPV vaccination? Become a part of the Massachusetts HPV Initiative! Please email me (Rebecca Vanucci) at rebecca.vanucci@state.ma.us if you would like more information.

Let me know if you have any questions about the HPV campaign and/or resources.

Please share this new information with all pertinent colleagues within your institution.

Dear Providers,

Perinatal hepatitis B virus (HBV) transmission from mother to child has been dramatically reduced in Massachusetts, as a result of your efforts. However, despite timely post-exposure prophylaxis, mother-to-child HBV transmission still occurs in approximately 1% of infants born to hepatitis B surface antigen (HBsAg)-positive mothers.

Emerging evidence suggests that HBV treatment of pregnant women in the 3rd trimester is safe and reduces rates of transmission. In partnership with the American College of Obstetricians and Gynecologists (ACOG), CDC developed a Screening and Referral Algorithm for Hepatitis B Virus Infection among Pregnant Women (attachment). It is now recommended that all women who are found to be HBsAg-positive during pregnancy should have the following additional testing performed:
· HBeAg (hepatitis B e antigen)
· HBV DNA (viral load)
· ALT (alanine aminotransferase)

If any of the following results are obtained, pregnant women should be referred to a specialist immediately for further evaluation and consideration for possibleantiviral treatment:
HBeAg postive; or
HBV DNA >20,000 IU/mL (approximately 112,000 viral copies per mL); or
ALT > 19 IU/L

Providers of prenatal care should ensure that certain positive laboratory reports of hepatitis B infection (HBsAg, HBeAg, IgM anti-HBc and HBV DNA testing) in pregnant women are reported to the local board of health and the Massachusetts Department of Public Health (MDPH). In addition, providers should work with their laboratories to ensure that these postive results indicating hepatitis B infection in this group are also reported to the Massachusetts Department of Health within 24 hours.

In an effort to aid in the early identification of pregnant women with hepatitis B virus infection, four major commercial laboratories (ARUP Laboratories, LabCorp, Mayo Medical Laboratories and Quest Diagnostics) are now reporting pregnancy status as part of electronic laboratory reporting. Additional commercial and clinical laboratories are encouraged to participate in this initiative. To support this effort, it is recommended that providers order prenatal testing panels or prenatal HBsAg testing when available. Providers should also consult with their laboratory to determine the best method to indicate pregnancy status when ordering hepatitis B testing (e.g., "OB", "PRENATAL", ICD-10 code, etc.).

Thank you for your continued efforts to reduce the spread of HBV infection. We will be incorporating these new considerations into our MDPH perinatal hepatitis B prevention program. If you have any questions, please call the MDPH Immunization Program at 617-983-6800 and ask to speak to an immunization nurse or epidemiologist.

Resources for managing HBV infection in pregnant women can be found on the ACOG and CDC websites. For the latest recommendations for treatment of chronic HBV infection in pregnant women, see pages 276 and 277 in the American Association for the Study of Liver Diseases Guidelines for Treatment of Chronic Hepatitis (attachment).

References
Terrault, NA, et.al. AASLD guidelines for treatment of chronic hepatitis B. Hepatology 2016.
http://onlinelibrary.wiley.com/doi/10.1002/hep.28156/epdf
Brown, RS et.al. Antiviral therapy in chronic HBV infection: a systematic review and meta-analysis. Hepatology 2016.
http://onlinelibrary.wiley.com/doi/10.1002/hep.28302/epdf
Fan L., et al. Antiviral treatment among pregnant women with chronic hepatitis B. Infect Dis Obstet Gynecol 2014.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4274824/
Kubo A., et al. Prevention of vertical transmission of hepatitis B: an observational study. Ann Intern Med 2014.
http://annals.org/article.aspx?articleid=1876817&resultClick=1
Schille S., et al. Outcomes of infants born to women infected with hepatitis B. Pediatrics 2015.
http://pediatrics.aappublications.org/content/pediatrics/135/5/e1141.full.pdf
Wang L., et al. Safety of tenofovir during pregnancy for the mother and fetus: a systematic review. Clin Infect Dis 2013
http://cid.oxfordjournals.org/content/57/12/1773.full.pdf+html
Zhang H., et al. Telbivudine or lamivudine use in late pregnancy safely reduces perinatal transmission of hepatitis B virus in real-life practice. Hepatology 2014.
http://onlinelibrary.wiley.com/doi/10.1002/hep.27034/pdf

Susan

Susan M. Lett, MD, MPH
Medical Director, Immunization Program
Division of Epidemiology and Immunization
Massachusetts Department of Public Health

CDC created a helpful factsheet for parents to explain that only flu shots will be available this season. The double sided pdf of the factsheet is attached for your reference or print.

You can get a variety of great resources on flu from the CDC by visiting: https://www.cdc.gov/flu/freeresources/index.htm. You can find print materials for many audience types, CDC animated images, and syndicated material. Syndicated material (http://www.cdc.gov/flu/freeresources/mobile.htm) means putting CDC content directly on your website and it will automatically update whenever CDC updates their information.

You can also visit www.mass.gov/flu and click on "Information for Healthcare and Public Health Professionals" to find many provider resources and helpful links, such as:

  • MDPH Recommendations and Resources for the Control of Influenza and Pneumococcal Disease
  • Model Standing Order for IIV (under Vaccine Guidelines and Tools)
  • Sample Flu Consent forms (under Vaccine Guidelines and Tools)

This message is from Dr. Susan M. Lett, Medical Director, MDPH Immunization Program.

Please share these recommendations with all pertinent colleagues and staff within your practice or institution.

Dear Colleagues,

Please see the attached MDPH Recommendations and Resources for the Control of Influenza and Pneumococcal Disease in Long-Term Care Facilities, 2016-2017. Like last year, the advisory has a section which includes the latest recommendations for use of PCV13 followed by PPSV23 in those >65 years of age.

The advisory will be posted on www.mass.gov/flu shortly.

A. Influenza Vaccines

The 2016-2017 Recommendations of Prevention and Control of Influenza with Vaccines from the ACIP were published in the MMWR on August 26, 2016. Highlights include:

1) Live attenuated influenza vaccine (LAIV) for the 2016-2017 Season
The ACIP has made an interim recommendation that LAIV should not be used for the 2016-2017 influenza season. This decision was made in light of concerns about poor vaccine effectiveness against influenza A (H1N1) in the U.S. during recent seasons. The ACIP continues to recommend inactivated influenza vaccine (IIV) and recombinant influenza vaccine (RIV) for everyone one 6 months of age and older. There is no preferential recommendation for any one of these licensed, recommended age-appropriate formulations of IIV or RIV. See page 3 of MDPH guidance.

2) Changes to Guidelines Related to Management of Persons with Egg Allergy
Studies that have examined the use of both IIV and LAIV in egg-allergic and non-allergic patients indicate that severe allergic reactions in those with egg allergy are unlikely. Beginning this year, ACIP states that persons with egg allergy of any severity may receive any licensed and recommended influenza vaccine formulation that is otherwise appropriate for the recipient's age and health status. See page 4 of MDPH guidance.

3) Influenza VIS Information

The influenza VIS is no longer updated each year, unless needed. The current flu VIS posted on the CDC website is the one you can use for this upcoming flu season. If you need VISs in other languages, please visit the http://www.immunize.org/vis/vis_flu_inactive.asp.

B. Influenza Reporting and Control

1) Report cases or clusters if influenza-like illness in long-term care facilities, group homes, shelters, prisons or other high risk settings via faxed teleform. See page 5 of guidance.

2) Recommendations for people with neurological and neuromuscular conditions living in congregate housing have not changed. Staff and residents should be vaccinated, and healthcare providers should be notified immediately if influenza-like illness occurs, to consider rapid treatment of ill individuals and antiviral prophylaxis of those exposed. See page 5 of guidance.

C. Pneumococcal Vaccine Recommendations

PCV13 and PPSV23 are recommended to be administered routinely in a series to all immunocompetent adults aged ≥65 years. PCV13 should be administered only once for all adults. Specific recommendations are based on a person's previous pneumococcal vaccine history. See page 8 of guidance.

  • Persons who are pneumococcal vaccine-naïve. Adults aged ≥65 years who have not previously received pneumococcal vaccine or whose previous vaccination history is unknown should receive a single dose of PCV13 first, followed by a dose of PPSV23. The dose of PPSV23 should be given >1 year after a dose of PCV13. If PPSV23 cannot be given during this time window, the dose of PPSV23 should be given during the next visit.
  • Persons previously vaccinated with PPSV23. Adults aged ≥65 years who have previously received ≥1 doses of PPSV23 also should receive a single dose of PCV13 if they have not yet received it. A dose of PCV13 should be given ≥1 year after receipt of the most recent PPSV23 dose. For those for whom an additional dose of PPSV23 is indicated, this subsequent PPSV23 dose should be given >1 year after PCV13 and >5 years after the most recent dose of PPSV23.

The two vaccines should not be co-administered. If a dose of PPSV23 or PCV13 is inadvertently given on the same day or at an earlier than recommended interval, those doses need not be repeated.

For additional guidance about PCV13 and PPSV23 for those >65 years see the ACIP recommendations which were updated last year. In addition, CDC's job aid Pneumococcal Vaccine Timing for Adults contains a number of algorithms and a summary table. It was developed to help providers understand the complex pneumococcal recommendation across both age and risk groups -- and is an outstanding resource.

MDPH Resources
The MDPH Flu website at www.mass.gov/flu has information for providers and the general public. Click on 'Information for Healthcare Professionals' for such provider resources as clinical advisories and control guidance, model standing orders, screening forms and planning clinics and campaigns. Pneumococcal vaccine resources are also located here.

MDPH has also created an LAIV resource page: http://www.mass.gov/eohhs/provider/guidelines-resources/services-planning/diseases-conditions/influenza/aciprecomlaivnot-b-used-during-2016-2017-flu-season.html

Questions
For questions about state supplied vaccine availability and ordering, please contact the Vaccine Management Unit at 617-983-6828.

For questions about flu and pneumococcal vaccine recommendations, please call the Immunization Program at 617-983-6800 and ask to speak to an epidemiologist.

Thanks for all your efforts to protect our most vulnerable citizens against influenza during this challenging year.

Long term care control 2016

Susan

Susan M. Lett, MD, MPH
Medical Director, Immunization Program
Division of Epidemiology and Immunization
Massachusetts Department of Public Health

This message is from Dr. Susan M. Lett, Medical Director, MDPH Immunization Program

Please share this advisory with all pertinent colleagues and staff within your practice or institution.

Dear Colleagues
Attached are Model Standing Orders for Inactivated Influenza vaccines (IIV) and Recombinant Influenza Vaccine (RIV), as well as a sample Consent and Screening Form for IIV. They have been revised to reflect the recently published 2016-2017 Recommendations of Prevention and Control of Influenza with Vaccines from the ACIP.

Highlights of the updated recommendations are summarized below:

1) Live attenuated influenza vaccine (LAIV) Is Not Recommended for the 2016-2017 Season
The ACIP has made an interim recommendation that LAIV should not be used for the 2016-2017 influenza season. This decision was made in light of concerns about poor vaccine effectiveness against influenza A (H1N1) in the U.S. during recent seasons. The ACIP continues to recommend inactivated influenza vaccine (IIV) and recombinant influenza vaccine (RIV) for everyone one 6 months of age and older. Therefore, this year MDPH has only developed Model Standing Orders for IIV and RIV and a Consent and Screening form for IIV, also known as the 'Flu Shot'.

2) Changes to Guidelines Related to Management of Persons with Egg Allergy
Studies that have examined the use of both IIV and LAIV in egg-allergic and non-egg allergic patients indicate that severe allergic reactions in people with egg allergy are unlikely. Beginning this year, ACIP states that persons with egg allergy of any severity may receive any licensed and recommended influenza vaccine formulation that is otherwise appropriate for the recipient's age and health status.

Persons who experience hives only after eating eggs can receive any licensed, recommended age-appropriate influenza vaccine in any usual immunization setting. Persons with a history of severe allergic reaction to egg (involving any symptom other than hives, such as angioedema, respiratory distress, lightheadedness, or recurrent emesis; or who required epinephrine or another emergency medical intervention), may similarly receive any licensed and recommended influenza vaccine that is otherwise appropriate for a patients age and health status. The selected vaccine should be administered in an inpatient or outpatient medical setting (including but not necessarily limited to hospitals, clinics, and physician offices). Vaccine administration should be supervised by a healthcare provider who is able to recognize and manage severe allergic conditions. Clinics and practices will need to determine if they have the trained staff, protocols and equipment in place to safely vaccinate those with severe egg allergy or refer them to their medical home or another provider.

To ensure safety, providers should follow the guidance related to the evaluation and management of egg allergy outlined in the Standing Orders under the section 'Screen for contraindications and precautions' on pages 1 and 2.

Waiting Period
Persons with a history of egg allergy no longer need to be observed for an allergic reaction for 30 minutes after receiving flu vaccine. However, providers should continue with the general recommendation to observe all patients for 15 minutes after vaccination to decrease the risk for injury should they experience syncope.

For further guidance related to management of persons with egg allergy on pages 29-30 and 33 in the ACIP recommendations.

The influenza VIS is no longer updated each year, unless needed. The current flu VIS posted on the CDC website is the one you can use for this upcoming flu season. If you need VISs in other languages, please visit the http://www.immunize.org/vis/vis_flu_inactive.asp.

Attachments include:
1. Standing order for IIV
2. Sample screening and consent form for IIV
3. Influenza Vaccine Recommendations from the ACIP

These documents will also be posted on www.mass.gov/flu shortly.

We hope you find these resources helpful.

For questions about the standing order or flu vaccine recommendations, please call the Immunization Program at 617-983-6800 and ask to speak to an immunization nurse or epidemiologist.

Thanks for all your efforts to protect children and adults against influenza during this challenging year.

Susan

Susan M. Lett, MD, MPH
Medical Director, Immunization Program
Division of Epidemiology and Immunization
Massachusetts Department of Public Health