Physicians Update 1 September 2015 From the Office of the Chief Medical Health Officer

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1 1 September 2015 Immunization Bulletin (Please share with your medical office assistants) 1. New publicly funded vaccines a. Expanded eligibility for free HPV vaccine for select males 9-26 years of age b. Fluzone a new inactivated quadrivalent influenza vaccine for children this fall 2. Reminders about recent changes a. Prevnar 13 publicly funded for HIV patients b. MMRV available for kindergarten age children 3. Frequently asked questions a. Should I recommend Gardasil 9 to my patients? b. Can public health provide cold chain support to physician offices? 4. Quick references to support you in your practice a. Routine Infant and Childhood Immunization Schedule (with injection site information) b. Adult Immunization Schedule 1a. New: Expanded eligibility for free HPV vaccine for select males 9-26 years of age Expanded eligibility: There is a new HPV vaccine program available for boys and young men who are gay, MSM, or who may be questioning their sexual identity. As heterosexual boys are likely to be protected through immunization of girls, this program aims to protect boys who remain otherwise unprotected. This program also includes other key populations: street involved youth, HIV positive males, youth in the care of the Ministry of Children and Family Development, and those in youth custody services. Orders and reporting: Effective immediately, you may order Gardasil from your local health unit in order to immunize eligible males. Males 9-14 years of age only need two doses six months apart, those 15 years and older require three doses at 0, 2 and 6 months. We appreciate your cooperation in reporting back on Gardasil doses administered so that we can update client immunization records and evaluate this important program. Private purchase recommendation for boys: The province is not funding a universal program for male youths as it is not considered cost-effective when vaccine coverage in females is over 50%. However, if parents wish to ensure their sons are protected, we recommend immunization. Vaccine can be purchased with a prescription or at VCH Travel Clinic. Many private drug plans cover vaccines. 1b. Fluzone : a new vaccine product in the influenza immunization campaign This fall, the campaign will have a new product for children. While the vaccines for adults provide protection against three strains of influenza virus (A/California/7/2009 (H1N1)pdm09-like virus, A/Switzerland/ /2013 (H3N2)-like virus, B/Phuket/3073/2013-like virus), the quadrivalent vaccines for children, Fluzone and Flumist, also provide protection against B/Brisbane/60/2008-like virus. Flumist is the preferred product for children but it cannot be administered to very young children, ages 6-23 months, or those with a contraindication to a live vaccine. Fluzone can be offered to children who cannot receive Flumist or choose not to receive Flumist. The other influenza vaccines available this fall include Fluad for seniors, and Fluviral or Agriflu for individuals years of age. More details on the influenza campaign will be coming in a few weeks time. You can reach a Medical Health Officer in Vancouver at For public health emergencies after hours, contact the Medical Health Officer on call at (604) Vancouver Medical Health Officers Dr. Patricia Daly (Chief Medical Health Officer) Dr. John Carsley Dr. Réka Gustafson Dr. Althea Hayden

2 1 September a. Reminder: Prevnar 13 now publicly funded for HIV patients HIV patients can now receive two types of pneumococcal vaccines: the conjugate (PCV13; Prevnar 13) should be offered in addition to polysaccharide vaccine (PPV23; Pneumo 23 or Pneumovax 23). Sequencing and interval between the two vaccines is important. Dose and schedule for adults with HIV: Pneumococcal Vaccine (Prevnar 13) - of 0.5mL, administered IM Client History Unimmunized Previously received PPV23 vaccine Schedule Dose 1: Prevnar 13; Dose 2: PPV23, 8 weeks later Wait 1 year interval from PPV23 and provide one dose Prevnar 13 2b. Reminder: MMRV now available for kindergarten age children Children now get their second dose MMR at kindergarten entry in a new formulation combined with varicella vaccine: MMRV (Priorix-Tetra ). Please order this product for your K children. We do not recommend children 12 months of age receive MMRV due to increased risk of febrile seizures. Please give the first dose of MMR and V as two different products at two different sites. 3a. Should I recommend Gardasil 9 to my patients? Gardasil 9 is the third HPV vaccine available in Canada (in addition to Cervarix and Gardasil ). It provides protection against HPV types 6, 11, 16 and 18 (included in Gardasil ) as well as HPV types 31, 33, 45, 52 and 58. HPV 6 and 11 cause genital warts while 16 and 18 are responsible for the majority of cervical (66-70%) cancers. The incremental benefit of Gardasil 9 is protection against additional 15-20% of cervical cancers in women and 5% of invasive cancers in men. At the moment, there are no Canadian recommendations for the use of Gardasil 9. The American Committee on Immunization Practices (ACIP) recommends that all three vaccines can be used to prevent cervical cancer in women and either of the two Gardasil vaccines can be offered to men. A HPV vaccine series started with Gardasil can be completed with Gardasil 9. For individuals who have already completed their HPV vaccine series, ACIP has not made a recommendation to provide additional doses of Gardasil 9. Should patients choose to buy additional protection against HPV infection, it is certainly safe to offer up to three doses of Gardasil 9 in this scenario. 3b. Can public health provide support to strengthen vaccine management in physician offices? Absolutely. Many of you have requested this support in the past and we have found one time funds to do exactly that. If you are interested in having a visit from one of our staff, please Arne.Faremo@vch.ca. We also recommend this half hour on-line vaccine storage and handling refresher course for your office staff: 4a. Routine Infant and Childhood Immunization Schedule (with injection site information) This tool was developed in partnership with family physicians and is intended to be posted on your vaccine fridge. Important note about injection site changes for children starting at 12 months of age: IM: Deltoid is the preferred site if children have adequate muscle mass (transition from vastus lateralis) Subcutaneous (for live vaccines): Upper outer aspect of triceps 4b. Adult Immunization Schedule This tool outlines publicly funded vaccines for ALL adults, free vaccines for adults with additional health or social criteria, and private pay vaccines that are recommended for adults. The latter category is based on recommendations by the National Advisory Committee of Immunization.

3 September 2015 Routine Infant and Childhood Immunization Schedule, current as of Sep Please discard all previous schedules. Age 1 Vaccines Admin. Site 2 months Rotavirus vaccine Oral Diphtheria/Tetanus/acellular Pertussis/HB/IPV/Hib (INFANRIX hexa [6]) Meningococcal C conjugate 4 months Rotavirus vaccine Oral Diphtheria/Tetanus/acellular Pertussis/HB/IPV/Hib (INFANRIX hexa [6]) Meningococcal C conjugate (at-risk infants only) 2 6 months Diphtheria/Tetanus/acellular Pertussis/HB/IPV/Hib (INFANRIX hexa [6]) (at-risk infants only) 3 Hepatitis A vaccine (Aboriginal children only) On or after 1 st birthday Meningococcal C conjugate Varicella (this dose will need to be repeated if given before 12 months) MMR (this dose will need to be repeated if given before 12 months) or 18 months Diphtheria/Tetanus/acellular Pertussis/IPV/Hib (INFANRIX IPV/Hib [5]) Hepatitis A vaccine (Aboriginal children only) Kindergarten Diphtheria/Tetanus/acellular Pertussis/IPV (INFANRIX IPV [4]) Entry starting Measles mumps, rubella, varicella (MMR-V) Age 4 years Grade 6 Meningococcal C conjugate booster HPV x 2 (0 and 6 months, girls) Grade 9 Tetanus/diphtheria/acellular pertussis Influenza Catch Up Vaccines Influenza vaccine is provided free to all infants 6-59 months of age and older children with risk factors; two doses one month apart are required if receiving influenza vaccine for the first time if 8 years of age and younger Catch up vaccines are vaccines that an eligible child may have missed previously. Public health nurses review histories and will offer these vaccines in kindergarten, grades 6 and 9. or intransal 1 Please follow the recommended schedule which includes minimum age and minimum interval criteria for vaccines. Vaccines given too early or too close together may need to be repeated (eg, MMR or Varicella given before 12 months of age). 2 Four-month meningococcal c conjugate vaccine dose is provided free for infants with the following conditions: functional or anatomic asplenia, immunodeficiency (congenital, acquired through disease or therapy), transplant recipients. 3 Six-month pneumococcal conjugate vaccine dose is provided free for infants with the following conditions: anatomic or functional asplenia, sickle cell disease, hemoglobinopathies, immunosuppression, transplant recipients, chronic conditions of the heart, lung, liver, or kidney, diabetes, cystic fibrosis, chronic CSF leak, chronic neurological conditions that impair clearance of oral secretions, and cochlear implant.

4 Vaccine administration and pain management information Physicians Update September 2015 Tips for managing pain: Breastfeeding is recommended during and after vaccine administration as it will decrease procedure related pain. In addition, oral rotarix vaccine should be given first to 2 and 4 month old infants as sucrose in the vaccine acts as an analgesic. To reduce pain, inject rapidly and remove the needle in one swift motion. When giving multiple injections at the same visit, give biological products that are known to cause more stinging and/or pain last (e.g., give MMR or Varicella last). Please do not administer injections into the gluteus due to increased risk of adverse reactions and lower immune response obtained at this site. Vaccines Needle & Technique Site for age <12 months Infants Intramuscular (IM) injection Diphtheria, Tetanus, Pertussis Haemophilus influenza b Hepatitis A, Hepatitis B Human papilloma virus (HPV) Influenza Meningococcal conjugate Pneumococcal conjugate Gauge: 22-25, depending on viscosity Length: Age 0-12 years: 7/8-1 Age 12 years: 1-1 1/2 Inject the vastus lateralis (anterolateral thigh): Subcutaneous (SC) injection Measles, Mumps, Rubella (MMR, MMR-V) Varicella Meningococcal polysaccharide Polio, inactivated (IPV) IM or SC: Pneumococcal polysaccharide Gauge: Length: Any age: 5/8-7/8 Pinching skin elevates SC tissue ensuring injection into SC tissue. Inject the fatty area of the antero-lateral thigh: Note: SC immunizations are provided by exception only to clients younger than 12 months of age. Site for age 12 months Vastus Lateralis can be used for older children with small deltoid muscle mass. Inject the deltoid muscle: Inject the upper outer triceps area:

5 Quick Reference: Adult Immunization Schedule 18 years as of September 2015 Further details of eligibility and scheduling found in BCCDC Immunization Manual at: Need help? VCH CDC on-call line at: Vaccine Adult Eligibility Schedule Publicly funded vaccines for ALL adults Hepatitis B Adults born on or after January 1, doses: 0, 1, 6 months HPV Females born 1994 or later. 3 doses: 0, 2, 6 months (Gardasil ) Meningococcal C Adults born on or after January 1, MMR* MMR 2 doses: 0, 1 month HCW Public Measles/ < Mumps/ Rubella Adults born prior to 1970 (1957 for HCW) are generally assumed to have acquired immunity to measles or mumps from natural infection. However, adults who are considered susceptible (no vaccine or disease) should be offered a series. Td Adults with no history of immunizations. Adults who have received a primary series are recommended to receive a one-time booster of Tdap (in lieu of Td for pertussis protection not provided free). Varicella* Adults with no history of varicella/shingles on or after one year of age AND negative varicella IgG serology. Publicly funded vaccines for adults based on additional criteria Hepatitis A Special populations anti-hav IgG negative: individuals with haemophilia A or B, chronic liver disease, HIV, HSCT recipients**, individuals receiving repeated blood transfusions, MSM, Illicit drug users, inmates; close contacts of a hepatitis A case. Recommended but not provided free for food handlers and travellers. Hepatitis B Post exposure and pre exposure for all students of health care professions; immunizing pharmacists; chronic liver and kidney disease, kidney transplant; HIV; HSCT recipients**; individuals receiving repeated blood transfusions and haemophilia; MSM; multiple sex partners; history of recent STI; Illicit drug users and sexual partners; inmates; staff and residents of homes for the developmentally disabled; teachers and classroom contacts of a known hepatitis B carrier who is developmentally challenged and poses a risk; staff in daycare setting with Hep B infected child; household contacts of internationally adopted children. Recommended but not provided free for travellers. Hib Unimmunized persons with specific medical conditions: functional or anatomic asplenia; sickle cell disease; immunosuppression related to disease or therapy; transplant candidates or recipients**, cochlear implants. HPV Provided free to males up to 26 years of age who meet the following criteria: MSM, HIV, street-involved youth, or in foster care. Influenza All adults > 65 years of age; adults < 65 who are at high risk of influenza complications; pregnant women in all stages of pregnancy; adults who are in close contact with those at high risk of influenza complications; essential community service providers. Recommended but not provided free for all others. Meningococcal B Provided free to contacts of a case up to 55 years of age. Recommended but not provided free: high risk individuals up to 55 years of age (asplenia, acquired or congenital immune deficiencies), researchers, military personnel, and travellers. Meningococcal Quadrivalent Pneumococcal Pneumococcal Polysaccharide Polio Rabies Medically high risk individuals: functional or anatomic asplenia, transplant recipient**, congenital immunodeficiency; close contacts of a case (A,C, Y, or W- 135). Recommended but not provided free: Some travellers, military recruits, research, industrial and clinical laboratory personnel who are at risk. HIV, HSCT transplant recipient** One dose recommended but not provided free asplenia and immune compromising conditions. All Adults > 65 years of age; individuals with high risk medical conditions; residents of care facilities; homelessness or illicit drug use. Booster - Individuals with asplenia, sickle cell disease, immunosuppression or immunodeficiency, chronic kidney or liver disease, or chronic hepatitis C. Persons at high risk of exposure to wild polioviruses: travellers, health care and refugee camp workers, lab workers, military personnel, transplant candidate/recipient**. BC students attending a vet college or animal health tech training centre. Recommended but not provided free to low high risk workers, hunters, and some travellers. 3 doses: 0 (Tdap), 1 (Td), 6 12 (Td) months Booster dose every 10 years 2 doses: 0, 6 weeks 2 doses: 0, 6 12 months HIV, 3 doses: 0, 1, 6 months 3 doses: 0, 1, 6 months For chronic kidney patients, use renal formulation: 1. Recomobivax HB : 0, 1,6 months 2. Engerix -B: 0, 1, 2, 6 months (12 months if under age 20) Note: All immunocompromised patients require a double dose 3 doses: 0, 2, 6 months (Gardasil ) Annual vaccination 2 doses 4 weeks apart VCH CDC Sept 2015 Medically high risk and other individuals, repeat every 5 years 3 doses (HSCT); (HIV) Interval as per provincial guidelines Once only booster, 5 years after initial dose for specific high risk 3 doses: 0, 1 2, 6 12 months Once only booster at 10 years 3 doses: 0, day 7, day 21 Booster doses required for mod-high risk individuals on a case-by-case basis Other recommended vaccines, REQUIRE PURCHASE ( recommended by the National Advisory Committee on Immunization) HPV Females born 1993 and earlier including older females at ongoing risk; males ages 9-26, 27 and older if at ongoing risk including MSM 3 doses: 0, 2, 6 months (Gardasil ) or 0, 1, 6 months (Cervarix, females only) Tdap A one-time adult booster with acellular pertussis (in lieu of Td) One time only when next 10 year Td booster required Varicella Zoster Adults > 60 years of age; can also be used in individuals years of age. Once only vaccination Travel Vaccines Adults travelling to high risk areas may be referred to the VCH Travel Clinic Notes * Immunocompromised individuals require special consideration prior to being given live attenuated vaccines such as MMR and Varicella. Please refer to the BCCDC immunization manual section VII biological products, p. 78. ** Transplant recipients (stem cell or solid organ) have tailored immunization schedules; please refer to section III of the BCCDC manual or call VCH CDC at