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What You Should Know about the
2019 Immunization Schedules
AAP Webinar
April 18, 2019
Susan M. Lett, M.D., MPH
Medical Director Immunization Program
Massachusetts Department of Public Health
susan.lett@state.ma.us
1MDPH 2019
Presenter Disclosure Information
• I, Susan Lett, have been asked to disclose any significant
relationships with commercial entities that are either providing
financial support for this program or whose products or services are
mentioned during our presentations.
• I have no relationships to disclose.
• I may/will discuss the use of vaccines in a manner not approved by
the U.S. Food and Drug Administration.
• But in accordance with ACIP recommendations.
2MDPH 2019
3
Outline• 2019 Childhood Schedule Changes
• 2019 Adult Immunization Schedule Changes
• Hepatitis A outbreak
• Homelessness as an indication
• Measles Outbreaks
• Continued Supply Shortage of Pediatric Hepatitis B Vaccine
MDPH 20189
MMWR 2019;68:12.
Pediatrics 2019;143:e20190065.
Available at:
https://www.cdc.gov/mmwr/volumes/68/wr/pdfs/mm6805a4-H.pdf
https://www.cdc.gov/vaccines/schedules/
https://pediatrics.aappublications.org/content/143/3/e20190065
MDPH 2019 4
2019 RECOMMENDED IMMUNIZATION SCHEDULES
FOR PERSONS 0-18 YEARS
• Influenza vaccination
• Use of LAIV
• Hepatitis A vaccination
• Homelessness as an indication
• Use of HepA for infants traveling internationally
• Hepatitis B vaccination
• Use of CpG-adjuvanted HepB vaccine (Heplisav-B)
• Tdap vaccination
• Vaccination of person who received Tdap at 7-10 years of age
Updates in ACIP Recommendations 2019 Child and Adolescent Immunization Schedule
MDPH 2019 5
MMWR 2019:68(5):112.
MDPH 2019 6
COVER PAGE
LAIV added
to table
Guidance
on how to
use the
schedule
Reporting
and Helpful
Info, with
links
MDPH 2019 7
MDPH 2019 8
REDESIGN OF CDC IMMUNIZATION WEBSITE
9MDPH 2019
Redesign of CDC’s ImmunizationSchedule Website
https://www.cdc.gov/vaccines/schedules/index.html
Routine Immunization Schedule
MDPH 201910
TABLE 1
Flu: Separate
row for LAIV
Hep A: purple
bar at 6-11 mos
for infant
travelers
Tdap: for those 13-18 yrs, row split
into green & purple bars to
separate pregnancy and catch-up
11MDPH 2019
Catch-Up Schedule
MDPH 201912
TABLE 2
13
Hib and PCV:
criteria for
‘no further
doses’ now
listed 1st
13MDPH 2019
Vaccination by Medical Indication
MDPH 201914
TABLE 3
Narrative text added to define
contraindication & precaution
Pregnancy cell in Men B changed to
orange precaution color (had been white)
MDPH 2019
New Pink Box:
Delay vaccination
until after
pregnancy if
vaccine indicated15
Added a row for LAIV
MDPH 201916
MDPH 2019 17
NOTES
• HepA • Combined HepA-Hep B vaccine (Twinrix) may be use in persons
>18 years
• HepA vaccine should be administered to infants aged 6–11 mos traveling outside the United States when protection against HAV is recommended* • The travel-related dose for infants aged 6–11 mos should not be counted
toward the routine 2-dose series. • The 2-dose HepA vaccination series should be initiated at age 12 months
according to the routine, age-appropriate vaccination schedule.
• Homelessness added as an indication
MDPH 201918
Notes Section Content Changes
*Off-label ACIP recommendationNelson et al. MMWR 2018;67(43):153.
Doshani et al. MMWR 2019;68(6):1216.
Notes Section Content Changes, cont.• Hep B
• CpG-adjuvanted HepB (Heplisav-B) vaccine and combination HepA-HepB (Twinrix) vaccine may be used in persons aged ≥18 years
• The word “ALL” has been added to the birth dose recommendation, for medically stable infants ≥ 2000 grams, to emphasize the importance of the universal birth dose
• IPV• A bullet has been added regarding the use of combination vaccines that
contain IPV
• LAIV• Can be used during the 2018–19 influenza season
• Information regarding persons with egg allergy and circumstances under which LAIV use is not recommended
MDPH 2019 19
Notes Section content Changes, cont.
• Tdap• Persons who received a dose of Tdap or DTaP at age 7–10 yrs
should still receive the routine dose of Tdap at age 11–12 yrs
• A link to information regarding use of Tdap/Td for wound prophylaxis has been added
• Mumps and meningococcal outbreaks• Specific language regarding the use of MMR, MenACWY, and MenB
vaccines in the setting of disease outbreaks has been removed from the MMR and meningococcal vaccine notes
• In the ‘Additional Info’ section (on page 5), providers are directed to their state or local health department for information regarding vaccination recommendations during an outbreak.
20MDPH 2019
Alphabetized Notes replace Footnotes
Definitions (e.g.
minimum intervals,
grace period, etc).
Links to important
resources like Best
Practices, and
vaccination for travel,
immunocompromised,
etc.
Contact local /state
health for vaccination
recs during outbreaks.
21MDPH 2019
MDPH 2019
HepA:
Recommended for infants 6-11 mos if travelling internationally.
Homelessness added.
Use of combined HepA-HepB vaccine (Twinrix) if >18 yrs.
23MDPH 2019
HepB:Use of CpG-adjuvanted HepB(Heplisav-B) if >18 years.
Use of combined HepA-HepB vaccine (Twinrix) if >18 years.
21
21Use of combination
vaccines that contain IPV
24MDPH 2019
Added LAIV
Vaccination of persons
with egg allergy
When use of LAIVnot recommended
25MDPH 2019
Removed language regarding use
of MMR in mumps outbreak and
MenACWY and MenB during
meningococcal outbreaks
26MDPH 2019
Added information regarding use of Tdap/Td for wound prophylaxis
MDPH 2019 27
HPV Vaccination Schedule• HPV vaccination routinely recommended at the 11-12 year old visit
• Only need two doses of HPV vaccine if the first dose is administered before age 15.
• Consider starting early at 9 or 10 years
• Many providers report that this facilitates completing the series by 11-12 years.
• For example, you could give the 1st dose at 9 years, the 2nd dose at 10 years – and be
finished!!
28
28
2018 ADULT IMMUNIZATION
SCHEDULE
MMWR 2019;68:117.
Annals of Internal Medicine 2019;170:182
29
Available at:
https://www.cdc.gov/mmwr/volumes/68/wr/pdfs/mm6805a5-H.pdf
https://www.cdc.gov/vaccines/schedules/
https://annals.org/aim/fullarticle/2723806/recommended-adult-immunization-schedule-
united-states-2019
MDPH 2019 29
• LAIV has been listed separately from inactivated influenza vaccine (IIV) on the immunization schedule
• Hep B vaccine, now 2 or 3 doses. Takes into account Heplisav-B two dose series
• Homelessness added as an indication for routine hepatitis A vaccination
• Cover page simplified, web links added
30
MMWR 2019:68(5):115.
MDPH 2019
Updates – 2019 Adult Immunization Schedule
Hepatitis A: National Outbreak
31MDPH 2019
Since the hepatitis A
outbreaks were first
identified in 2016, more
than 15,000 cases, 8,500
(57%) hospitalizations,
and 140 deaths as a
result of hepatitis A
virus infection have
been reported.
https://www.cdc.gov/hepatitis/index.htm
Outbreak in Massachusetts• Since April 2018, 344 cases reported to MDPH in
individuals experiencing homelessness and/or substance
use disorder
0
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Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
# c
ase
s re
po
rted
Month
Hepatitis A cases, by event date, Massachusetts, April 2018 - April 2019
Outbreak Non-outbreak
Cases occurring after Week 4 in March excluded. Data for more recent weeks may be incomplete due to diagnosis and reporting delays.
Data source: MDPH Bureau of Infectious Disease and Laboratory Sciences. Data as of 4/4/2019 and subject to change.
MDPH 2019 32
• In 2017, 1.4 million people used emergency shelter or transitional housing (not including unsheltered)
• Estimated 2mil–3.5mil persons experience homelessness each year, persons of color disproportionately affected
• Per night, estimated 500,000 persons experience homelessness, 35% in unsheltered locations
• Persons experiencing homelessness 1.5-11.5x increased risk of mortality compared to general population
• 2–3x increased risk of HAV infection, 2–3x increased severe outcomes
Homelessness in U.S.
U.S. Department of Housing and Urban Development. 2017 annual homeless assessment report
Koh HK. JAMA 2016
Gambatese M. Am J Public Health 2013
Doshani et al. MMWR 2019;68(6)
MDPH 201933
Homelessness in Massachusetts
• 20,068 people experienced homelessness in 2018
in Massachusetts (29 people per 10,000)
• 4.9% unsheltered
• Massachusetts has one of the largest increases in
homelessness in the country
• 32.7% increase from 2007 to 2018
US Department of Housing and Urban Development . The 2018 Annual Homeless Assessment Report (AHAR) to Congress.
Part 1: Point-In-Time Estimates of Homelessness. December 2018.
https://www.hudexchange.info/resources/documents/2018-AHAR-Part-1.pdf
34MDPH 2019
• Routine HepA series recommended for persons age ≥1 year who experience homelessness
• Might have difficulty implementing recommended non-vaccine strategies to protect themselves from exposure (e.g., access to clean toilet facilities, regular handwashing, and avoidance of crowded living conditions)
• Substantial benefit to vaccination• Cost/risk vaccinating much lower than not vaccinating
• Fewer hospitalizations, transplantations, deaths
• Provides individual protection
• Increases herd immunity over time
• Reduces risk for large outbreaks
ACIP Recommendations – Hepatitis A
MDPH 2019 35
Doshani et al. MMWR 2019;68(6):153.
MDPH 2019 36
MDPH 201937
RZV and HPV: Delay until after pregnancy
Pregnancy cell in Men B changed to
orange precaution color (had been white)
38
Added “homelessness” for HepA
Added use of Heplisav-B
Added “transgender persons”for HPV vaccination
Removed language on use of HepA and Hep B in outbreaks
MDPH 2019 39
LAIV added as an option. Vaccination of persons with eggs allergy reviewed. When not to use LAIV also outlined.
Removed language on use of MMR in mumps outbreak and MenACWY and MenB in meningococcal outbreak
Added “precaution” for MenB use in pregnancy
MDPH 2019 40
RZV: Consider delaying until after pregnancy. Its use in severely immunocompromised, currently under review by ACIP.
MDPH 2019 41
42MDPH 2019
Contraindications & PrecautionsImmunization Action Coalitionhttp://www.immunize.org/catg.d/p3072a.pdf
CDC’s General Best Practice Guidelines for
Immunization
https://www.cdc.gov/vaccines/hcp/acip-recs/general-
recs/contraindications.html
There’s an App for That!
• CDC Immunization
Schedule App
• https://www.cdc.gov/vaccines/s
chedules/hcp/schedule-
app.html
• PneumoRecs Advisor App
• https://www.cdc.gov/vaccines/v
pd/pneumo/hcp/pneumoapp.ht
ml
MDPH 2019 43
MEASLES
MDPH 2019 44
Measles Incidence Rate per Million(12M period as of March 2019)
Top 10**
Country Cases Rate
Ukraine 63948 1439.02
India 63364 47.85
Madagascar 59407 2386.35
Pakistan 30747 159.14
Philippines 19401 187.78
Yemen 11746 425.82
Brazil 10262 49.42
Nigeria 5847 31.44
Venezuela (Bolivarian Republic
of)5668 179.55
Thailand 5579 81.02
Notes: Based on data received 2019-03 and covering the period between
2018-02 and 2019-01 - Incidence: Number of cases / population* * 100,000
** Countries with the highest number of cases for the period
45MDPH 2019
Measles in the USA
Source: New York Times, 2/6/2019, and CDC https://www.cdc.gov/measles/cases-outbreaks.html
46
**Case count is preliminary and subject to change. Data are updated weekly.
MDPH Immunization Updates - VPD Epidemiology2019
Please
vaccinate!
Cases of measles
47MDPH 2019
Measles in MA• Three confirmed cases (two in 2018, one to date in 2019)
• All with recent travel
• Hundreds of people exposed in medical and other settings
• Enormous post-exposure efforts to identify susceptibles and vaccinate (or
refer for immune globulin)
• Dozens of people quarantined
We promise to return to our practices and immunize every last one of our patients with MMR vaccine (unless contraindicated or presumptive evidence of immunity).
MMR PLEDGE
Don’t miss vaccination opportunities!
48MDPH 2019
Measles Worldwide 2019
MDPH 201949
https://www.cdc.gov/measles/travelers.html
49
CONTINUED SUPPLY SHORTAGE OF PEDIATRIC HEPATITIS B VACCINE
MDPH 2019 50
Supply Shortage of Pediatric Monovalent Hepatitis B Vaccine
• Update: Merck’s supply of pediatric HepB vaccine (RecombivaxHB®) will continue to be limited through 2019.
• GSK will continue to make increased amounts of single-component HepB vaccine (Engerix-B®) and their combination DTaP-IPV-HepB vaccine (Pediarix®)
• Due to this shortage, MDPH is prioritizing single-component HepB doses to birthing hospitals
• Providers may receive either type of single-component HepB vaccine depending on supply
• Orders of single-component Hep B vaccine have been reduced by 25%
• Sites should use the MDPH guidance sent in October 2018 to choose which vaccine schedule options work best in their setting and adjust their orders accordingly
MDPH 201951
For Guidance See:
• MDPH: https://www.mass.gov/clinical-advisory/pediatric-hepatitis-b-vaccine-shortage-advisory-
october-1-2018
• CDC: : https://www.cdc.gov/vaccines/hcp/clinical-resources/downloads/Pediatric-hepB-vaccine-
supply-508.pdf
Hepatitis B Vaccine Shortage Guidance• MDPH recommendations during the shortage:
• Prioritize the birth dose• Prioritize vaccination of infants born to HBsAg-positive moms or
unknown status – recommendations unchanged
• If using Pentacel (DTaP-IPV/Hib) or single-component vaccines, choose the option that works best in your setting:• Defer the 3rd dose of single-component HepB vaccine until later
within the recommended range of 6-18 months of age for healthy infants born to HBsAg-negative mothers
• Transition to to an all Pediarix (DTaP-IPV-HepB) schedule for all 3 doses in the DTaP primary series at 2, 4, and 6 months
• Substitute 1 or 2 doses of Pediarix for Pentacel in the DTaP primary series, as a temporary measure during the shortage
• If using Pediarix can continue the infant schedule with no change
52MDPH 2019
Immunization Program Main NumberFor questions about immunization recommendations, disease reporting, etc.
• Phone: 617-983-6800• Fax: 617-983-6840• Website: www.mass.gov/dph/imm
MIIS Help Desk• Phone: 617-983-4335• Fax: 617-983-4301• Email: miishelpdesk@state.ma.us• Websites: www.contactmiis.info | www.mass.gov/dph/miis
MDPH Vaccine Unit• Phone: 617-983-6828• Fax: 617-983-6924• Email: dph-vaccine-management@state.ma.us• Website: www.mass.gov/dph/imm (click on Vaccine Management)
Contact Information
53MDPH 2019
MDPH Immunization Program
MDPH 2019
54
54
EXTRAS
56MDPH 2019
CDC’s Immunization Schedule Website
https://www.cdc.gov/vaccines/schedules/hcp/imz/child-adolescent.html
57MDPH 2019
CDC’s Immunization Schedule Website
https://www.cdc.gov/vaccines/schedules/hcp/imz/catchup.html#table-catchup
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