Adult Pneumococcal Disease

Transcription

1 Adult Pneumococcal Disease Reviewed and updated July 2018

2 S. pneumoniae and pneumococcal disease The bacterium Streptococcus pneumoniae causes pneumococcal disease S. pneumoniae is commonly found in human nasopharynx (nose and throat) of many people without disease Generally, the presence of S. pneumoniae in the nasopharynx does not cause illness. However, vulnerable individuals (e.g: asplenic, HIV, malignancy) may develop pneumococcal disease Streptococcus pneumoniae S pneumoniae spreads from person to person through contaminated respiratory droplets (i.e. droplets containing the bacteria) Ref: Dowling JN, et al. J Infect Dis 1971; 124: Hendley JO, et al. J Infect Dis 1975; 132: Musher DM, in Mandell Principles and Practice of Infectious Diseases 2005

3 What is pneumococcal disease? Pneumococcal disease covers a wide spectrum of illnesses ranging from mild to life-threatening Sinusitis Sinusitis Otitis media Osteomyel itis Otitis media Bacteraemia Pneumonia Meningitis Septic arthritis Bacteraem ia Peritonitis Septic arthritis Osteomyelitis Peritonitis Meningitis Pneumoni a Ref: Musher DM, in Mandell Principles and Practice of Infectious Diseases 2005

4 Treating pneumococcal disease Pneumococcal disease is treated with antibiotics Antibiotic-resistance has become an increasing challenge Therefore, prevention of pneumococcal disease, especially in vulnerable individuals, is a priority Ref: Ward J. Rev Infect Dis 1981; 3: Schoemakers MCJ, et al Reviews in Med Microbiology 2002 Australian Technical Advisory Group on Immunisation (ATAGI). The Australian immunisation handbook 10th ed (2017 update). Canberra: Australian Government Department of Health, 2017.

5 What is invasive pneumococcal disease? Invasive pneumococcal disease (IPD) is defined as the isolation of a S. pneumoniae from a normally sterile site (generally blood, and also pleural, joint and cerebrospinal fluid) Major clinical presentations of IPD include: Pneumococcal pneumonia (most common in adults) Bacteraemia without focus (most common in children) Meningitis IPD is used as an overall indicator of pneumococcal disease burden In children + adults the morbidity associated with IPD can be substantial. IPD may be life-threatening resulting in hospitalisations and death Ref: Musher DM, in Mandell Principles and Practice of Infectious Diseases 2005 Australian Technical Advisory Group on Immunisation (ATAGI). The Australian immunisation handbook 10th ed (2017 update). Canberra: Australian Government Department of Health, McIntyre PB, et al. Medical Journal of Australia 2000; 173(Suppl):S22-6. Robinson KA, et al. JAMA 2001;285: WHO Position paper, WER Oct 2008, Vol. 83, 42 (pp ).

6 Invasive Pneumococcal Disease in Australia Highest incidence is seen at extremes of age: young children and elderly In 2017: 2,047 cases of IPD were reported to the National Notifiable Diseases Surveillance System (NNDSS) Notification rate of 8.3 cases per 100,000 population 295 cases of IPD in children under 5 and 792 cases in people 65 years of age Ref: Dept. of Health National Notifiable Diseases Surveillance System Accessed 8 th July 2018

7 Number of notifications of Invasive Pneumococcal Disease Number of IPD notifications Number of IPD notifications Ref: Dept. of Health National Notifiable Diseases Surveillance System Accessed 8 th July 2018

8 Poll 1 In 2016, in non-indigenous Australians 65 years which serotype caused the highest rate of IPD notifications? A. 7vPCV B. Serotype 3 C. Non-vaccine serotypes D. 13vPCV not 7vPCV not serotype 3 E. 23vPPV only serotypes Ref: Stein A et al Trends in serotype distribution of invasive pneumococcal disease in non-indigenous older Australians collected through National Notifiable Diseases Surveillance System from 2002 to 2016 Dept Health IPD Quarterly Report Invasive Pneumococcal Disease Surveillance 1 st April to 30 th June 2017

9 Invasive Pneumococcal Disease in Non Indigenous Australians 65 years Ref: Dept Health IPD Quarterly Report Invasive Pneumococcal Disease Surveillance 1 st April to 30 th June 2017

10 Who is at risk of IPD? Children < 2 years and the elderly Aboriginal and Torres Strait Islanders Individuals with risk factors or medical condition(s) placing them at risk of IPD including: Ref: Australian Technical Advisory Group on Immunisation (ATAGI). The Australian immunisation handbook 10th ed (2017 update). Canberra: Australian Government Department of Health,

11 Invasive pneumococcal disease risk in people with underlying chronic conditions Adults with diabetes, chronic heart disease, or chronic lung disease exhibit a 3 to 6-fold increased risk of IPD, compared with healthy adults Ref: Kyaw MH et al. J Infect Dis 2005; 192:377 86

12 Pneumococcal disease and chronic health conditions Diabetes: increased risk of lower respiratory tract infections is a risk factor for S. pneumoniae infections and bacteraemia in patients with pneumococcal pneumonia & is associated with increased mortality is often associated with cardiovascular or renal disease, which increases the risk for severe pneumococcal illness blood glucose control can be impaired by S. pneumoniae Chronic heart failure: Increased risk of infection respiratory tract infections which are a major cause of acute cardiac decompensation in heart failure patients, especially in the elderly Ref: Koziel H, et al. Infect Dis Clin North Am 1995, 9(1) Joshi N, et al. NEJM 1999, 341(25) MMWR. Prevention of pneumococcal disease recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 1997;46(RR-8):1-24. Therapeutic Guidelines Endocrinology, version 4, 2009.

13 Pneumococcal disease and diabetes Vaccination recommendations The following guidelines recommend vaccination against pneumococcal disease for people with diabetes: NHMRC The Australian Immunisation Handbook 10 th Edition online version The Diabetes Management in General Practice Guidelines for Type 2 Diabetes (Diabetes Australia and the RACGP) Guidelines for the prevention, detection and management of chronic heart failure in Australia Updated 2011 (National Heart Foundation of Australia and the Cardiac Society of Australia and New Zealand) Ref:. Australian Technical Advisory Group on Immunisation (ATAGI). The Australian immunisation handbook 10th ed (2017 update). Canberra: Australian Government Department of Health, Diabetes Management in General Practice 2016/18 18 th Ed Guidelines for Type 2 Diabetes.

14 Pneumococcal disease and chronic health conditions Chronic pulmonary disease Severe Asthma: is an independent risk factor for IPD increases risk of developing IPD two-fold Cigarette smoking: the strongest independent risk factor for IPD among immunocompetent, nonelderly adults damages the mucosal lining of the airways increases number inflammatory molecules hinders mucociliary clearance increases susceptibility to upper respiratory tract colonisation, infection and otitis media About half of otherwise healthy adults with IPD are tobacco smokers Ref: Talbot TR, et al. N Engl J Med 2005; 352: MMWR. Updated recommendations for prevention of invasive pneumococcal disease among adults using the 23-valent pneumococcal polysaccharide vaccine (PPSV23) 3 rd September mm5934a3.htm Australian Technical Advisory Group on Immunisation (ATAGI). The Australian immunisation handbook 10th ed (2017 update). Canberra: Australian Government Department of Health, 2017

15 Pneumococcal vaccines Background 2005 Universal Australian NIP for: 23vPPV for all adults 65 years 7vPCV for all infants, replaced by 13vPCV in vPPV - first recommended for high risk populations vPPV recommended for all adults > 65 years and Indigenous adults years vPPV funded for adults 65 years and Indigenous adults years in Victoria vPPV funded for all Indigenous adults >50 years and high risk Indigenous years vPPV NIP for all adults 65 years vPPV revaccination restricted to at-risk population vPCV - NIP for high risk infants vPCV - NIP for all infants vPCV - NIP for all infants Today Ref: Adapted from NCIRS publication Significant events in pneumococcal vaccination practice in Australia available at accessed 8 May 2018

16 23-valent pneumococcal polysaccharide vaccine (23vPPV) Contains capsular polysaccharides derived from 23 types of S. pneumoniae Not recommended for children less than 2 years of age 23-valent pneumococcal polysaccharide vaccine has been available in Australia since 1983 For adults 65 years: Funded in Victoria since 1998 Listing on the National Immunisation Program commenced in 2005 Duration of immunity: antibody levels decline after 5-10 years A more rapid decline may occur in some groups (e.g. the elderly) The minimum recommended interval between any 2 doses of 23vPPV is 5 years Immune hyporesponsiveness ( blunting of the antibody response) may occur after repeat doses Not known if this has any significant negative outcome on effectiveness Ref: Pneumovax 23 Approved Product Information Barry C, et al. Commun Dis Intell (2): E Australian Technical Advisory Group on Immunisation (ATAGI). The Australian immunisation handbook 10th ed (2017 update). Canberra: Australian Government Department of Health, 2017.

17 23-valent pneumococcal polysaccharide vaccine (23vPPV) NIP and PBS information National Immunisation Program 23vPPV is listed on the NIP for: People aged 65 years Aboriginal and Torres Strait Islanders 50 years of age years of age who have underlying condition(s) placing them at risk of IPD. Children aged 4 years with a condition(s) associated increased risk of IPD Pharmaceutical Benefits Scheme (PBS) 23vPPV is listed on the PBS (restricted benefit) for: Persons at high risk of pneumococcal infections Splenectomised persons over 2 years of age Persons with Hodgkin s disease Ref: Australian Technical Advisory Group on Immunisation (ATAGI). The Australian immunisation handbook 10th ed (2017 update). Canberra: Australian Government Department of Health, Schedule of Pharmaceutical Benefits (PBS) [Accessed July 2018]

18 13-valent pneumococcal conjugate vaccine (13vPCV) Contains capsular polysaccharides derived from 13 types of S. pneumoniae - linked to a protein (non-toxic CRM 197 protein) 13-valent pneumococcal conjugate vaccine has been available in Australia since 2010 Indicated in adults and children from 6 weeks of age for active immunisation for the prevention of pneumococcal disease due to pneumococcal types contained in the vaccine. Dosage in Adults >18 years of age with Category A Highest increased risk of IPD: One single dose, including those previously vaccinated with pneumococcal polysaccharide vaccine* If sequential administration of 13vPCV and 23vPPV is considered, 13vPCV should be given first for maximal efficacy and to avoid blunting of the immune response by 23vPPV Most commonly reported adverse events include fever and injection site reactions Ref: Prevenar13 Product Information *Hematopoietic stem cell transplant (HSCT) patients should receive 4 doses of 13vPCV, see full product information for details Ref: Prevenar13 Product Information Barry C, et al. Commun Dis Intell (2): E Australian Technical Advisory Group on Immunisation (ATAGI). The Australian immunisation handbook 10th ed (2017 update). Canberra: Australian Government Department of Health, 2017.

19 Pneumosmart Vaccination Tool (PVT) Created to assist GPs, medical specialists, and other immunisation providers to comply the Australian Immunisation Handbook recommendations Note: The tool does not accommodate catch-up pneumococcal immunisations for children less than 5 years of age. Refer either: Australian Immunisation Handbook or Immunisation Calculator If no written records are available to confirm pneumococcal vaccination status, or the type of vaccine (Conjugate or Polysaccharide) that may have been previously administered, the provider should proceed as if the patient has not received previous pneumococcal vaccinations.

20 Conclusions Pneumococcal disease can cause considerable morbidity and mortality in those most at risk of pneumococcal infection Those most at-risk include very young children, the elderly, Aboriginal and Torres Strait islander individuals, and those with certain risk factors or medical condition(s) placing them at risk of invasive pneumococcal disease For those at-risk, Australian guidelines recommended: Vaccination with pneumococcal vaccine* *Refer to NHMRC Australian Immunisation Handbook 10th edition for official recommendations New recommendations for infant pneumococcal vaccine to be given at 12 months rather than 6 months for those with no underlying medical conditions Potentially at-risk individuals should have their pneumococcal vaccination status checked Ref :Australian Technical Advisory Group on Immunisation (ATAGI). The Australian immunisation handbook 10th ed (2017 update). Canberra: Australian Government Department of Health, TGA. Pneumovax 23 - recommendation about revaccination 18 April Accessed 20 December 2012 from:

21 Please review full Product Information before prescribing. Pneumovax23 PBS Information: This product is listed on the National Immunisation Program (NIP) Schedule and the PBS. Refer to the NIP and PBS Schedule. Product Information is available from biocsl (Australia) Pty Limited ABN , 63 Poplar Road, Parkville, Pneumovax 23 is a registered trademark of Merck & Co. Inc. Whitehouse Station, NJ, USA Date of preparation: March Prevenar 13 PBS Information: This product is listed on the National Immunisation Program (NIP) for children only and is not listed on the PBS. Refer to the NIP Schedule. Prevenar 13 Product Information is available from Pfizer Australia on request on or at Registered trademark. Pfizer Australia Pty Limited Wharf Road, West Ryde, NSW 2114.

22 Changes to the National Immunisation Program 1 st July 2018 Thank you to Dr Paul Effler, Medical Director CDCB, Western Australia Health Department and NCIRS for sharing the slides that contributed to this presentation

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24 What are the changes trying to achieve? 1. Expand protection from just MenC to MenACWY 2. Reduce break-through Pneumococcal infections 3. Mitigate potential crowding at specific age points caused by the above changes

25 2 Months No change 4 Months No change 6 Months Change 12 Months Change 18 Months Change 4 Years No change

26 Meningococcal vaccination what s changed? Previously: Dose of MenC conjugate vaccine at 12 months introduced on NIP in 2003 Recently given as Menitorix combination Hib-MenC conjugate vaccine Now: From 1 July 18, MenC vaccine is replaced by MenACWY vaccine at 12 months 4 th dose of Hib to be given as monovalent vaccine at 18 months

27 What is the new meningococcal vaccine? Nimenrix a quadrivalent meningococcal vaccine Provides protection against MenC as well as 3 additional serogroups: A, W 135 and Y Conjugated to a tetanus-toxoid carrier protein >97% of 12 month olds given Nimenrix in clinical trials develop an immune response against all 4 serogroups Good safety profile when given alone and with other routine vaccines

28 Why has the meningococcal vaccine schedule changed? Meningococcal C disease has been well controlled since the meningococcal C vaccine was included in the NIP from Replacing meningococcal C vaccine with Nimenrix will broaden protection against meningococcal disease caused by serogroups A, W and Y in addition to serogroup C among young Australian children Since 2013, the occurrence of meningococcal W disease has been increasing rapidly in Australia. A smaller yet steady rise in the occurrence of meningococcal Y disease has also been seen since 2016 Together, these two serogroups cause close to half of all recently reported cases of meningococcal disease. Young children aged <2 years have the highest rates of new cases reported

29 IMD notification rate by serogroup and year,

30 Notifications and rates of IMD, Australia, 2002 to 2017, by serogroup

31 IMD notification rate by serogroup and age group,

32 The bottom line MenACWY doses Age at commencement Healthy children At risk children 6 weeks to 5 months months to 11 months >11 months weeks between doses +1 dose given at 12 months of age and 8 weeks after previous dose Only single dose MenACWY at 12 months is NIP funded Nimenrix only registered for >=12 months of age Children with specific medical conditions require extra doses of MenACWY vaccine: Functional or anatomical asplenia HIV infection Haematopoetic stem cell transplant Inherited defects or deficiency of complement components orproperdin Treatment with eculizumab

33 Considerations recommended regardless of whether the child has previously received one or more privately purchased doses of any brand of Men ACWY vaccine in infancy there is no catch-up program. Children who have already received their meningococcal C vaccine at 12 months of age are not eligible for a meningococcal ACWY vaccine if a child has not received their 12 month meningococcal C-Hib vaccination they will be offered a meningococcal ACWY vaccine and monovalent Hib vaccine at the appropriate time parents wishing to initiate meningococcal ACWY vaccinations prior to their child s first birthday can speak to their GP about private prescription and administration if a child has received a full course of any meningococcal ACWY vaccine after 12 months of age then they are considered protected against meningococcal ACWY and are not recommended to receive further doses under the NIP

34 Poll 2 Child presents to your clinic at 13 months of age. They have not yet received their 6 month old immunisations so is on a catch-up. The parent only wants 2 vaccines given at any one time. What is the preferred option if administering Infanrix hexa, Nimenrix, MMR and Prevenar 13 over 2 visits? A. Give MMR and Hexa and wait 4 weeks to give Prevenar 13 and Nimenrix B. Give Nimenrix and Prevenar 13 first, then bring them back about a week later for Infanrix hexa and MMR C. Give MMR and Prevenar 13 first, then bring them back in 3 days for Infanrix hexa and Nimenrix D. Give Nimenrix and MMR first, then bring them back in 4 weeks for Infanrix hexa and Prevenar 13.

35 13-valent pneumococcal conjugate vaccine (13vPCV) what s changed? Status Previous Schedule Schedule from 1 July 2018 Healthy Non-Aboriginal Prevenar 13 at 2, 4 and 6 months Schedule Prevenar 13 at 2, 4 and 12 months Schedule Medical at risk or Aboriginal Prevenar 13 at 2, 4 and 6 months Booster at 12 months Schedule Prevenar 13 at 2, 4 and 6 months Booster at 12 months Schedule Ref: Australian Technical Advisory Group on Immunisation (ATAGI). The Australian immunisation handbook 10th ed (2017 update). Canberra: Australian Government Department of Health, Update from April 2018

36 Healthy Non- Aboriginal children 2 months* Dose 1 4 months Dose 2 6 months 12 months Dose 3 Medical at Risk or Aboriginal children 2 months* 4 months 6 months 12 months Dose 1 Dose 2 Dose 3 Dose 4 *can be given as early as 6 weeks MAR recommend to receive 23vPPV at 4-5 years of age

37 Why has the Prevenar 13 vaccine schedule changed?

38 What should we gain by moving the third dose of 13vPCV from 6 months to 12 months? Rate of breakthrough IPD in kids 12 months of age AUS 3+0 schedule à 3.4 cases/10 6 in Australia UK schedule à 0.7 cases/10 6 in UK New schedule likely result in less breakthrough cases in toddlers (78 less cases with 2+1 vs 3+0) & greater herd benefit overall However: Potential small increase in 2 dose VFs between 6-12 months age may be transient Post schedule change essential to carefully monitor IPD incidence

39 Poll 3 Can 13v PCV be given concurrently with other childhood vaccines? A. No, must given 3 weeks apart from other childhood vaccines B. Yes including inactivated influenza vaccine but warn patient of increased fever if flu vaccine and 13vPCV given concurrently C. Yes but not with the inactivated influenza vaccine D. Yes but not with pertussis vaccine Ref: Australian Technical Advisory Group on Immunisation (ATAGI). The Australian immunisation handbook 10th ed (2017 update). Canberra: Australian Government Department of Health, Update from April 2018.

40 Considerations for children who have missed 13vPCV doses at the recommended schedule points and require catch-up doses, refer to the Catch-up section for pneumococcal vaccines in the online Australian Immunisation Handbook or use the online Immunisation Calculator children born between 1 July 2017 and 31 December 2017 without increased risk of IPD, may receive a total of 4 doses of 13vPCV during the transition in this instance, the vaccine is funded, but is not required to be considered fully immunised for the purposes of child care subsidies and family assistance payments KEY MESSAGE: All children born after 1 st July 2017 receive Prevenar 13 at 12 months

41 Resources are available ATAGI advice Posters Magnets New schedule advice for providers New schedule advice for consumers New schedule card NCIRS

42 Hib vaccination what s changed? 2 Months 4 Months 6 Months 12 Months 18 Months ACWY Hexa PCV13 Hexa PCV13 Hexa PCV13 Men C PCV13 Hib DTPa Rota Rota MMR MMR-V

43 Why has the Hib vaccine schedule changed? Due to the change to meningococcal ACWY vaccine, the fourth and final Hib vaccine dose will now be provided as a monovalent vaccine and moved to 18 months of age. Four doses of Hib vaccine will continue to be provided through the NIP, for infants at 2*, 4, and 6 months of age, with the final dose recommended for 18 months of age instead of 12 months of age All children who are 12 months of age at 1 July 2018 or later are recommended to receive a funded booster dose of Hib vaccine at 18 months of age What If a child already received a Hib vaccine at 12 months of age? o Children born between 1 January 2017 and 30 June 2017 may receive a total of 5 doses of Hib vaccine during the transition o Parents should be reassured that this is safe o For this small cohort, the 18 month vaccine is funded, but is not required to be considered fully immunised for the purposes of child care subsidies and family assistance payments * can be administered at six weeks

44 Changes in Hib disease trends over time Cases of Hib disease have declined due to vaccination; however a small number of Hib cases still occur continued vaccination with booster dose in second year of life essential

45 Putting it all together Track Nickname Old Schedule "Hib Transition" "PCV13 Transition " New Schedule Date of Birth Age at 1 July 2018 Schedule point On or before 31 Dec Jan 2017 to 30 June July 2017 to 31 Dec 2017 On or after 1 Jan 2018 >= 18 months of age > 12 to 18 months > 6 to 12 months =< 6 months 2 M Hexa+Rota+PCV13 Hexa+Rota+PCV13 Hexa+Rota+PCV13 Hexa+Rota+PCV13 4 M Hexa+Rota+PCV13 Hexa+Rota+PCV13 Hexa+Rota+PCV13 Hexa+Rota+PCV13 6 M Hexa+PCV13 Hexa+PCV13 Hexa+PCV13 Hexa 12 M MMR+[Hib/MenC] MMR+[Hib/MenC] MMR+ACWY+PCV13 MMR+ACWY+PCV13 18 M MMRV+DTP MMRV+DTP+Hib MMRV+DTP+Hib MMRV+DTP+Hib

46 Track Nickname Old Schedule "Hib Transition" "PCV13 Transition " New Schedule Date of Birth Age at 1 July 2018 Schedule point On or before 31 Dec Jan 2017 to 30 June July 2017 to 31 Dec 2017 On or after 1 Jan 2018 >= 18 months of age > 12 to 18 months > 6 to 12 months =< 6 months 2 M Hexa+Rota+PCV13 Hexa+Rota+PCV13 Hexa+Rota+PCV13 Hexa+Rota+PCV13 4 M Hexa+Rota+PCV13 Hexa+Rota+PCV13 Hexa+Rota+PCV13 Hexa+Rota+PCV13 6 M Hexa+PCV13 Hexa+PCV13 Hexa+PCV13 Hexa 12 M MMR+[Hib/MenC] MMR+[Hib/MenC] MMR+ACWY+PCV13 MMR+ACWY+PCV13 18 M MMRV+DTP MMRV+DTP+Hib MMRV+DTP+Hib MMRV+DTP+Hib Not funded for ACWY or additional doses of PCV13 or Hib

47 Track Nickname Old Schedule "Hib Transition" "PCV13 Transition " New Schedule Date of Birth Age at 1 July 2018 Schedule point On or before 31 Dec Jan 2017 to 30 June July 2017 to 31 Dec 2017 On or after 1 Jan 2018 >= 18 months of age > 12 to 18 months > 6 to 12 months =< 6 months 2 M Hexa+Rota+PCV13 Hexa+Rota+PCV13 Hexa+Rota+PCV13 Hexa+Rota+PCV13 4 M Hexa+Rota+PCV13 Hexa+Rota+PCV13 Hexa+Rota+PCV13 Hexa+Rota+PCV13 6 M Hexa+PCV13 Hexa+PCV13 Hexa+PCV13 Hexa 12 M MMR+[Hib/MenC] MMR+[Hib/MenC] MMR+ACWY+PCV13 MMR+ACWY+PCV13 18 M MMRV+DTP MMRV+DTP+Hib MMRV+DTP+Hib MMRV+DTP+Hib

48 Track Nickname Old Schedule "Hib Transition" "PCV13 Transition " New Schedule Date of Birth Age at 1 July 2018 Schedule point On or before 31 Dec Jan 2017 to 30 June July 2017 to 31 Dec 2017 On or after 1 Jan 2018 >= 18 months of age > 12 to 18 months > 6 to 12 months =< 6 months 2 M Hexa+Rota+PCV13 Hexa+Rota+PCV13 Hexa+Rota+PCV13 Hexa+Rota+PCV13 4 M Hexa+Rota+PCV13 Hexa+Rota+PCV13 Hexa+Rota+PCV13 Hexa+Rota+PCV13 6 M Hexa+PCV13 Hexa+PCV13 Hexa+PCV13 Hexa 12 M MMR+[Hib/MenC] MMR+[Hib/MenC] MMR+ACWY+PCV13 MMR+ACWY+PCV13 18 M MMRV+DTP MMRV+DTP+Hib MMRV+DTP+Hib MMRV+DTP+Hib

49 Track Nickname Old Schedule "Hib Transition" "PCV13 Transition " New Schedule Date of Birth Age at 1 July 2018 Schedule point On or before 31 Dec Jan 2017 to 30 June July 2017 to 31 Dec 2017 On or after 1 Jan 2018 >= 18 months of age > 12 to 18 months > 6 to 12 months =< 6 months 2 M Hexa+Rota+PCV13 Hexa+Rota+PCV13 Hexa+Rota+PCV13 Hexa+Rota+PCV13 4 M Hexa+Rota+PCV13 Hexa+Rota+PCV13 Hexa+Rota+PCV13 Hexa+Rota+PCV13 6 M Hexa+PCV13 Hexa+PCV13 Hexa+PCV13 Hexa 12 M MMR+[Hib/MenC] MMR+[Hib/MenC] MMR+ACWY+PCV13 MMR+ACWY+PCV13 18 M MMRV+DTP MMRV+DTP+Hib MMRV+DTP+Hib MMRV+DTP+Hib

50 Track Nickname Old Schedule "Hib Transition" "PCV13 Transition " New Schedule Date of Birth Age at 1 July 2018 Schedule point On or before 31 Dec Jan 2017 to 30 June July 2017 to 31 Dec 2017 On or after 1 Jan 2018 >= 18 months of age > 12 to 18 months > 6 to 12 months =< 6 months 2 M Hexa+Rota+PCV13 Hexa+Rota+PCV13 Hexa+Rota+PCV13 Hexa+Rota+PCV13 4 M Hexa+Rota+PCV13 Hexa+Rota+PCV13 Hexa+Rota+PCV13 Hexa+Rota+PCV13 6 M Hexa+PCV13 Hexa+PCV13 Hexa+PCV13 Hexa 12 M MMR+[Hib/MenC] MMR+[Hib/MenC] MMR+ACWY+PCV13 MMR+ACWY+PCV13 18 M MMRV+DTP MMRV+DTP+Hib MMRV+DTP+Hib MMRV+DTP+Hib All should get a 4 th dose of PCV13- funded but not required for No Jab No Pay

51 Track Nickname Old Schedule "Hib Transition" "PCV13 Transition " New Schedule Date of Birth Age at 1 July 2018 Schedule point On or before 31 Dec Jan 2017 to 30 June July 2017 to 31 Dec 2017 On or after 1 Jan 2018 >= 18 months of age > 12 to 18 months > 6 to 12 months =< 6 months 2 M Hexa+Rota+PCV13 Hexa+Rota+PCV13 Hexa+Rota+PCV13 Hexa+Rota+PCV13 4 M Hexa+Rota+PCV13 Hexa+Rota+PCV13 Hexa+Rota+PCV13 Hexa+Rota+PCV13 6 M Hexa+PCV13 Hexa+PCV13 Hexa+PCV13 Hexa 12 M MMR+[Hib/MenC] MMR+[Hib/MenC] MMR+ACWY+PCV13 MMR+ACWY+PCV13 18 M MMRV+DTP MMRV+DTP+Hib MMRV+DTP+Hib MMRV+DTP+Hib

52 Track Nickname Old Schedule "Hib Transition" "PCV13 Transition " New Schedule Date of Birth Age at 1 July 2018 Schedule point On or before 31 Dec Jan 2017 to 30 June July 2017 to 31 Dec 2017 On or after 1 Jan 2018 >= 18 months of age > 12 to 18 months > 6 to 12 months =< 6 months 2 M Hexa+Rota+PCV13 Hexa+Rota+PCV13 Hexa+Rota+PCV13 Hexa+Rota+PCV13 4 M Hexa+Rota+PCV13 Hexa+Rota+PCV13 Hexa+Rota+PCV13 Hexa+Rota+PCV13 6 M Hexa+PCV13 Hexa+PCV13 Hexa+PCV13 Hexa 12 M MMR+[Hib/MenC] MMR+[Hib/MenC] MMR+ACWY+PCV13 MMR+ACWY+PCV13 18 M MMRV+DTP MMRV+DTP+Hib MMRV+DTP+Hib MMRV+DTP+Hib Can get a 5 th dose of Hib but don t really need it. Not funded for PCV13 or ACWY

53 Track Nickname Old Schedule "Hib Transition" "PCV13 Transition " New Schedule Date of Birth Age at 1 July 2018 Schedule point On or before 31 Dec Jan 2017 to 30 June July 2017 to 31 Dec 2017 On or after 1 Jan 2018 >= 18 months of age > 12 to 18 months > 6 to 12 months =< 6 months 2 M Hexa+Rota+PCV13 Hexa+Rota+PCV13 Hexa+Rota+PCV13 Hexa+Rota+PCV13 4 M Hexa+Rota+PCV13 Hexa+Rota+PCV13 Hexa+Rota+PCV13 Hexa+Rota+PCV13 6 M Hexa+PCV13 Hexa+PCV13 Hexa+PCV13 Hexa 12 M MMR+[Hib/MenC] MMR+[Hib/MenC] MMR+ACWY+PCV13 MMR+ACWY+PCV13 18 M MMRV+DTP MMRV+DTP+Hib MMRV+DTP+Hib MMRV+DTP+Hib Over 12 months of age but did not get 12 month vaccinations yet.

54 Track Nickname Old Schedule "Hib Transition" "PCV13 Transition " New Schedule Date of Birth Age at 1 July 2018 Schedule point On or before 31 Dec Jan 2017 to 30 June July 2017 to 31 Dec 2017 On or after 1 Jan 2018 >= 18 months of age > 12 to 18 months > 6 to 12 months =< 6 months 2 M Hexa+Rota+PCV13 Hexa+Rota+PCV13 Hexa+Rota+PCV13 Hexa+Rota+PCV13 4 M Hexa+Rota+PCV13 Hexa+Rota+PCV13 Hexa+Rota+PCV13 Hexa+Rota+PCV13 6 M Hexa+PCV13 Hexa+PCV13 Hexa+PCV13 Hexa 12 M MMR+[Hib/MenC] MMR+ACWY MMR+ACWY+PCV13 MMR+ACWY+PCV13 18 M MMRV+DTP MMRV+DTP+Hib MMRV+DTP+Hib MMRV+DTP+Hib Over 12 months of age but did not get 12 month vaccinations yet. Give ACWY with MMR and then Hib at 18 months. Not NIP funded for PCV13.

55 Track Nickname Old Schedule "Hib Transition" "PCV13 Transition " New Schedule Date of Birth Age at 1 July 2018 Schedule point On or before 31 Dec Jan 2017 to 30 June July 2017 to 31 Dec 2017 On or after 1 Jan 2018 >= 18 months of age > 12 to 18 months > 6 to 12 months =< 6 months 2 M Hexa+Rota+PCV13 Hexa+Rota+PCV13 Hexa+Rota+PCV13 Hexa+Rota+PCV13 4 M Hexa+Rota+PCV13 Hexa+Rota+PCV13 Hexa+Rota+PCV13 Hexa+Rota+PCV13 6 M Hexa+PCV13 Hexa+PCV13 Hexa+PCV13 Hexa 12 M MMR+[Hib/MenC] MMR+[Hib/MenC] MMR+ACWY+PCV13 MMR+ACWY+PCV13 18 M MMRV+DTP MMRV+DTP+Hib MMRV+DTP+Hib MMRV+DTP+Hib All can get a 4 th dose of PCV13

56 New schedule Pregnant women Flu and dtpa vaccination of pregnant women provides dual benefits: reduces the risk of complications from influenza in pregnancy helps protect very young infants, who are at high risk of severe disease from both pertussis and influenza in the first few months of life vaccination of pregnant women provides protection to the newborn baby o by passive transfer of antibodies from mother to baby across the placenta during the pregnancy o vaccination during pregnancy is estimated to reduce the risk of influenza in infants aged <6 months by about half o high levels of maternal antibody give temporary protection up until the time that babies can be vaccinated themselves Vaccination of pregnant women with pertussis and influenza vaccines is safe. Pertussis and influenza vaccines can be given at the same visit during pregnancy, if needed.

57 Reviewed and updated July 2018 Thank you for your time