The Vac-Scene Newsletter (Volume 12, No. 3

Summary of Tdap Recommendations for Adolescents

Available at: www.cdc.gov/mmwr/PDF/rr/rr5503.pdf

Adolescents who completed a primary series of DTaP

11-12 yr olds should receive one dose of Tdap instead of Td
13-18 yr olds who missed the booster dose of Td should receive one dose of Tdap instead of Td
11-18 yr olds who received a Td booster are encouraged to receive one dose of Tdap

Adolescents without a history of DTP/DTaP or Td vaccination

Administer single Tdap dose, followed by a dose of Td > 4 weeks later, and a second Td 6-12 months after the 2nd Td. Tdap can be substituted for any one of the three doses in the series.

Adolescents with history of DT or Td vaccination only

Adolescents who were not vaccinated against pertussis, but completed the tetanus and diphtheria series (with DT or Td) generally should receive Tdap if they do not have a contraindication to the pertussis components.

Interval between Td and Tdap

A five year interval is encouraged, however the safety of a two-year interval between Td and Tdap is supported by a Canadian study among children and adolescents and is permitted by the ACIP.

Simultaneous Administration

Tdap (or Td) and meningococcal conjugate vaccine (MCV4) (which both contain diphtheria toxoid) can be given during the same visit if both vaccines are indicated.
If Tdap is not given at the same visit as MCV4, results of a pre-licensure trial suggest the safe sequential administration of Tdap first followed by MCV4 one month later: (www.cdc.gov/mmwr/PDF/rr/rr55e223.pdf)
Tdap should be administered with other vaccines that are indicated during the same visit when feasible.

History of Pertussis

Adolescents who have a history of pertussis should receive Tdap according to the routine recommendations.

Use of Td when Tdap is unavailable

Td can be deferred temporarily when the last pediatric DTP/DTaP/DT or Td was administered <10 years earlier and the adolescent is likely to return for follow-up. (Vaccine providers should maintain a system to recall adolescents when Tdap/Td vaccination is deferred.)
When Tdap is indicated but not available, vaccine providers should administer Td if the last pediatric DTP/DTaP/DT or Td dose was > 10 years earlier, to provide protection against tetanus and diphtheria.

Wound Management

Adolescents who require a tetanus toxoid-containing vaccine as part of wound management should receive a single dose of Tdap instead of Td (if they have not previously received Tdap).

Pregnancy

Pregnant women who received the last tetanus toxoid-containing vaccine < 10 years earlier should receive Tdap after delivery.

Pregnant women who received the last tetanus toxoid-containing vaccine > 10 years earlier should receive Td during pregnancy in preference to Tdap.

Pregnant women who have not received the primary 3-dose vaccination series for tetanus should begin the Td series during pregnancy, preferably during the second or third trimester when feasible.

New mothers who have never received a dose of Tdap should get a dose as soon as possible after delivery.

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New Thimerosal Information for Parents

The Vaccine Education Center – The Children’s Hospital of Philadelphia has developed educational materials for parents who have questions about the safety of thimerosal and vaccines (www.chop.edu/consumer/jsp/division/generic.jsp?id=75751).

The Vaccine Education Center was launched in October 2000, and has worked to dispel common misconceptions and misinformation surrounding childhood vaccines by providing accurate and up-to-date information to parents and healthcare professionals.

Summary of Hepatitis B Vaccination Recommendations for
Infants, Children and Adolescents

All pregnant women should be tested routinely for hepatitis B surface antigen (HBsAg).

Vaccination of Infants
At Birth:

Infants born to mothers who are HBsAg positive should receive hepatitis B vaccine and hepatitis B immune globulin (HBIG) < 12 hours of birth.
Infants born to mothers whose HBsAg status is unknown should receive hepatitis B vaccine < 12 hours of birth. The mother should have blood drawn as soon as possible to determine her HBsAg status; if she is HBsAg positive, the infant should receive HBIG as soon as possible (no later than age one week).
Full-term infants who are medically stable and weigh > 2000g born to HBsAg-negative mothers should receive hepatitis B vaccine before discharge.
Preterm infants weighing <2000 g born to HBsAg negative mothers should receive the first dose of vaccine at one month after birth or at hospital discharge.

After the Birth Dose:

All infants should complete the hepatitis B vaccine series with either single-antigen vaccine or combination vaccine, according to a recommended vaccination schedule
Infants born to HBsAg positive mothers should be tested for HBsAg and antibody to HBsAg after completion of the hepatitis B vaccine series at age nine to 18 months.

Vaccination of Children and Adolescents

All unvaccinated children and adolescents aged <19 years should receive the hepatitis B vaccine series.

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King County Vaccine for Children (VFC) News

New Prevnar Packaging
Wyeth Pharmaceuticals are now supplying VFC Programs in the US with pneumococcal conjugate (Prevnar) vaccine in boxes of 10 pre-filled syringes (only the packaging has changed). As more vaccine manufacturers switch to pre-filled syringes, the “dorm style” refrigerators may be too small to store vaccine supplies. Contact Public Health at 206-296-4774 for refrigerator purchase information.

New Vaccines, New Forms
All Seattle-King County health care providers enrolled in the VFC Program should have received a packet containing new report forms, order forms, and information on the new vaccines, meningococcal conjugate (MCV-4) and the tetanus-diphtheria-pertussis booster for teens (Tdap). Please discard old forms and use only the new ones. Forms are also available at: www.metrokc.gov/health/immunization/vfc.htm

Vaccine Supply
We have recently seen delays in receiving product from manufacturers. Please be assured that vaccines missing from recent shipments are noted as back-orders and will be shipped as soon as possible. As always, let us know if your office has run out of something completely, and we will prioritize your shipment.

Because we are still gauging the demand for the new vaccines, Tdap and MCV-4, orders may be initially reduced to assure that we can provide doses to all requesting health care providers. Be sure to follow the restricted guidelines for use of MCV-4 until further notice (use only for freshmen entering college, persons with high risk medical conditions, and travelers).

Merck is taking up to four weeks to ship varicella vaccine orders; plan accordingly when placing orders. Remember to visit the VFC Program’s Web page for updates on supply and usage guidelines: www.metrokc.gov/health/immunization/vfc.htm.

Varicella Vaccine
Varicella vaccine is stored in the freezer and has special ordering, handling, and storage instructions. Health care providers who wish to offer varicella vaccine can contact the VFC Program at (206) 296-4774 for more information, and should refer to the varicella handling instructions in the VFC Provider Manual. Please note: smaller, dorm-style units with freezers inside the refrigerator cannot be used for varicella vaccine storage.

Vaccine Storage Tip
A number of recent vaccine storage problems have resulted from clinic staff changing the temperature control in the refrigerator and failing to monitor the effect closely. PLEASE! Use extreme caution when changing temperature settings and check the temperature change frequently (about every half hour). Never make adjustments at closing time, but always early in the day, to leave plenty of time for monitoring.

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Highlights

Updates to ACIP Hepatitis B Prevention Strategies
A recently published ACIP report (available at: www.cdc.gov/mmwr/preview/mmwrhtml/rr5416a2.htm) includes recommendations to improve vaccine coverage of children and adolescents who were not previously vaccinated. One of many suggested strategies includes implementation of immunization record reviews for children and adolescents aged <19 years who were born in countries in which HBV endemicity is high or intermediate. (Refer to the list below of hepatitis B endemic countries.)

Geographic Areas with Intermediate and
High Hepatitis B Virus Endemicity

Africa : All countries

South Asia: All countries except Sri Lanka

Western Pacific: All countries and territories except Australia and New Zealand

Middle East: All countries except Cyprus

Eastern Europe: All countries except Hungary

Newly Independent States of the former Soviet Union :

All countries

Western Europe: Greece , Italy , Malta , Portugal and Spain

North America: Alaska Natives and indigenous populations of Northern Canada and Greenland

Central America: Belize , Guatemala , Honduras and Panama

South America: Argentina , Bolivia , Brazil , Ecuador , Guyana , Suriname , Venezuela , Amazonian areas of Colombia and Peru

Caribbean: Antigua and Barbuda, Dominica, Dominican Republic, Grenada, Haiti, Jamaica, Puerto Rico, St. Kitts and Nevis, St.Lucia, St, Vincent and Grenadines, Trinidad and Tobago, and Turks and Caicos

Serologic Testing Prior to Hepatitis B Vaccination
The decision to screen potential vaccine recipients for prior hepatitis B infection depends on the cost of vaccination, the cost of testing for susceptibility, and the expected prevalence of immune persons in the population being screened. Screening is usually not cost-effective for groups with a low expected prevalence of HBV serologic markers, such as health professional in their training years. Serologic testing is not recommended before routine vaccination of infants and children.

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