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.

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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

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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

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MMWR 2019:68(5):112.

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COVER PAGE

LAIV added

to table

Guidance

on how to

use the

schedule

Reporting

and Helpful

Info, with

links

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REDESIGN OF CDC IMMUNIZATION WEBSITE

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Redesign of CDC’s ImmunizationSchedule Website

https://www.cdc.gov/vaccines/schedules/index.html

Routine Immunization Schedule

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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

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Catch-Up Schedule

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TABLE 2

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Hib and PCV:

criteria for

‘no further

doses’ now

listed 1st

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Vaccination by Medical Indication

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TABLE 3

Narrative text added to define

contraindication & precaution

Pregnancy cell in Men B changed to

orange precaution color (had been white)

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New Pink Box:

Delay vaccination

until after

pregnancy if

vaccine indicated15

Added a row for LAIV

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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

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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

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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.

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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.

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MDPH 2019

HepA:

Recommended for infants 6-11 mos if travelling internationally.

Homelessness added.

Use of combined HepA-HepB vaccine (Twinrix) if >18 yrs.

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HepB:Use of CpG-adjuvanted HepB(Heplisav-B) if >18 years.

Use of combined HepA-HepB vaccine (Twinrix) if >18 years.

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21Use of combination

vaccines that contain IPV

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Added LAIV

Vaccination of persons

with egg allergy

When use of LAIVnot recommended

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Removed language regarding use

of MMR in mumps outbreak and

MenACWY and MenB during

meningococcal outbreaks

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Added information regarding use of Tdap/Td for wound prophylaxis

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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!!

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2018 ADULT IMMUNIZATION

SCHEDULE

MMWR 2019;68:117.

Annals of Internal Medicine 2019;170:182

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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

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• 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

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MMWR 2019:68(5):115.

MDPH 2019

Updates – 2019 Adult Immunization Schedule

Hepatitis A: National Outbreak

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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

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Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

# c

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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)

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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

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Doshani et al. MMWR 2019;68(6):153.

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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

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RZV: Consider delaying until after pregnancy. Its use in severely immunocompromised, currently under review by ACIP.

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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

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MEASLES

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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

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Measles in the USA

Source: New York Times, 2/6/2019, and CDC https://www.cdc.gov/measles/cases-outbreaks.html

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**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!

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Measles Worldwide 2019

MDPH 201949

https://www.cdc.gov/measles/travelers.html

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CONTINUED SUPPLY SHORTAGE OF PEDIATRIC HEPATITIS B VACCINE

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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

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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

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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