In honor of Cervical Health Awareness Month in January, the Immunization Program would like to remind providers that the HPV vaccine is cancer prevention! Remember that HPV not only causes the majority of cervical cancers, but also cancers of the vagina, vulva, penis, anus, rectum, and oropharynx. Every year in the United States, HPV causes around 31,000 cancers in men and women. HPV vaccination can prevent most of the cancers (about 28,000) from occurring. You can find more information on HPV and cancer here.

While it is not January 2018 (yet!), we wanted to make sure you were aware of the following campaign and associated webinars occurring next month:

  • A blog article will be released on January 2nd on the DPH Public Health Blog targeting a general audience focused on how HPV vaccine is cancer prevention. The blog article will include a video from the Iowa Department of Public Health featuring HPV-related cancer survivors. Feel free to share this blog within your practice, send it to parents/patients, and/or put in any other communication to your staff and patients. You can also follow DPH on Twitter to see immunization related tweets throughout the month.
  • MDPH will be running a digital billboard in 63 locations across 20 cities in Massachusetts to highlight the message “HPV vaccine is cancer prevention!” The billboard points people to the newly updated general audience HPV vaccine page on our Immunization Program website. The friendly url is http://www.mass.gov/dph/hpvvax. The HPV billboard is at the bottom of this email for your reference.
  • Members of the Massachusetts Oral HPV Prevention taskforce will be presenting on the next CDC #PreTeenVax and VICNetwork webinar entitled “An Interprofessional Approach to HPV and Oropharyngeal Cancer Prevention Education” on Monday, January 8, 2018 at 12:00 - 1:00 pm EST. You can register here for the January 8th webinar.
    • Description of Webinar:  There are approximately 31,500 cancers attributed to HPV each year and that number continues to rise. Oropharyngeal cancer has surpassed cervical cancer as the most common HPV-related cancer. Rates of oropharyngeal cancer have increased more than 225% in the last few decades.  More than 70% of oropharyngeal cancers are related to HPV infection.  The Massachusetts Oral HPV Prevention Taskforce was created to build connections between medical and dental professionals to increase HPV vaccination rates, decrease HPV-related cancer, and educate both providers and patients on oropharyngeal cancers.  Most dental professionals are aware of the role of smoking and alcohol consumption as risk factors for oral cavity and oropharyngeal cancer; however, dedicated, trained dental professionals may be underutilized assets in the realm of HPV education and oropharyngeal cancer prevention. To this end, the Massachusetts Oral HPV Prevention Taskforce aims to educate and empower the dental community with relevant, medically sound cancer prevention information to educate patients to make well-informed oral health and cancer preventive decisions.
    • Learning Objectives:
      • Describe action steps to build a partnership with dental providers on HPV education and the importance of HPV vaccination
      • Identify the relationship between oral HPV infections and head and neck cancers
      • Discuss ways that dental professionals can include HPV education in patient visits, including an overview of helpful resources
      • Determine the effectiveness of an HPV prevention campaign via interprofessional education and consider strategies for sustainability
    • Speakers:
      • Rebecca Vanucci, MA, Immunization Outreach Coordinator, Massachusetts Department of Public Health
      • Alessandro Villa, DDS, Ph.D., MPH, Instructor in Oral Medicine, Infection, and Immunity, Harvard School of Dental Medicine and Associate Surgeon Brigham and Women’s Hospital and Dana Farmer Cancer Center
      • Rosie Wagner, DDS, Private Practice in Somerville, MA
      • Lisa Bennett Johnson, RDH, MS, MPH, Research Registered Dental Hygienist, Oral Medicine and Dentistry Division, Brigham and Women's Hospital
  • The MCAAP Immunization Initiative will be hosting a webinar entitled “Using Assessment, Feedback, Incentives and eXchange (AFIX) to Improve HPV Vaccination Rates in Your Practice” on Thursday, January 11, 2018, 12:00-1:00 p.m. EST. You can register here for the January 11th webinar.
    • Learning Objectives
      • Discuss the key components of the AFIX quality improvement process;
      • Review evidence-based strategies for addressing vaccine hesitancy and refusal and improving vaccine confidence in their practice;
      • Explain how they can utilize reports from the Massachusetts Immunization Information System (MIIS) to review their practice's HPV immunization rates compared to Massachusetts immunization rates from the National Immunization Survey (NIS-Teen);
      • Summarize the general findings to date of the use of AFIX for improving HPV vaccination rates in Massachusetts.
    • Speakers:
      • Katherine Hsu, MD, MPH, Medical Director, Division of STD Prevention & HIV/AIDS, Massachusetts Department of Public Health
      • Kathleen Shattuck, MPH, Assessment Coordinator, Immunization Program, Massachusetts Department of Public Health
  • CDC recently released their 12th HPV Quarterly Report and you can find it attached to this email.
  • Would you like to get more involved in activities to increase HPV vaccination? Become a part of the Massachusetts HPV Initiative! Please email me (Rebecca Vanucci) at rebecca.vanucci@state.ma.us if you would like more information.

The Immunization Program launched our new website this week! We hope that the website will be more user-friendly, searchable, and informative. You can find it here.
Please familiarize yourself with the new organization and update bookmarks accordingly. While things are redirected from the old website for now, those redirects will be taken away in the future.

Immunization Updates webinars
This is a reminder that the continuing education credits affiliated with the Immunization Updates recorded webinars will be removed on December 31, 2017. Please note that this only applies to people who have not watch the recorded webinars and were planning on doing so for continuing education credit(s).

There are currently four webinars available that you can find here.

  1. VFC Compliance/Storage and Handling
  2. Epidemiology of Vaccine Preventable Disease/Vaccine Confidence/School Immunization Data
  3. Massachusetts Immunization Information System (MIIS) Update
  4. Immunization Schedule Updates

VFC Compliance Training Certificates associated with the VFC Compliance/Storage and Handling webinar will continue to be awarded

On January 1, 2018 we will be removing all of the recorded webinars, except for the VFC Compliance/Storage and Handling webinar. The VFC Compliance/Storage and Handling webinar will be available through end of March 2018. At that point, registration for the 2018 Immunization Update in-person and webinar events will open.

You can find information on Immunization Program events and programs here.

If you have questions about the annual VFC Compliance Training, please contact the Assessment Unit at 617-983-4330 or immassessmentunit@state.ma.us.

A new shingles vaccine, Herpes Zoster Subunit (HZ/su) called Shingrix®, has been licensed by the U.S. Food and Drug Administration (FDA) and recommended by the Advisory Committee on Immunization Practices (ACIP).

New Shingles Vaccine Recommendations:

On Wednesday, October 25th, the ACIP voted on vaccination recommendations for shingles (herpes zoster) vaccines. For more information on the recent ACIP meeting, please visit the ACIP meetings page.

ACIP voted that the new herpes zoster subunit (HZ/su) vaccine is:
   · recommended for the prevention of herpes zoster and related complications for immunocompetent adults aged 50 years and older,
   · recommended for the prevention of herpes zoster and related complications for immunocompetent adults who previously received zoster vaccine live,
   · preferred over Zoster Vaccine Live (ZVL) for the prevention of herpes zoster and related complications.

Once approved by CDC, the shingles vaccination recommendations will be published in the MMWR, at which time the recommendations will become official CDC policy. Once published in the MMWR, CDC will add shingles vaccination information and educational materials to CDC’s website and in other communication channels.

General Information about the Herpes Zoster Subunit (HZ/su) Vaccine

Vaccine/Dosage
The HZ/su vaccine is a recombinant, adjuvanted vaccine for the prevention of herpes zoster (shingles). It was developed by GlaxoSmithKline (GSK). On October 20, 2017, the FDA licensed this new shingles vaccine, called Shingrix®, for adults 50 years and older in the United States. Two doses of the new shingles vaccine are given two to six months apart. The vaccine is administered intramuscularly.

Side Effects
Currently available data suggests that the new shingles vaccine is safe. In clinical trials, the most common side effect was mild to moderate pain where the shot was given. Other side effects included pain, redness or swelling where the shot was given, muscle pain, fatigue, fever, nausea, vomiting, diarrhea, headache, or shivering. The side effects lasted 1-2 days. Although no serious adverse events were observed, about 17% of people who received the vaccine did have a reaction that interfered with their activities.

As with all vaccines, CDC and FDA will continue to monitor the news shingles vaccine for potential safety concerns.

Clinical Trials
In clinical trials, the new shingles vaccine provided high levels of protection in all age groups against shingles and postherpetic neuralgia (PHN), the most common complication from shingles. The vaccine showed:
   · 97% protection against shingles in adults 50-69 years old
   · 1% protection against shingles in adults 70 years and older
   · 91% protection against PHN in adults 50 years and older
   · Protection of 85% or above was maintained for 4 years after vaccination.

For information about the clinical trials, see
   · Efficacy of the herpes zoster subunit vaccine in adults 70 years of age or olderNEJM, 2016
   · Efficacy of an Adjuvanted Herpes Zoster Subunit Vaccine in Older Adults,NEJM, 2015
   · A New Vaccine to Prevent Herpes ZosterNEJM, 2015

For information about shingles and vaccination, see:
   · CDC’s shingles website
   · CDC’s shingles vaccination website
   · Shingles Vaccine Information Statement (VIS)


A new vaccine information statement (VIS) for shingles vaccine will be available in 2018, after the recommendations are published in MMWR.

For more information about the shingles vaccines, visit the product websites:
   · Shingrix
   · Zostavax

There are two upcoming webinars to discuss the recent October ACIP meeting and the shingles vaccine recommendations:

Current Issues in Immunization Netconference
CDC will host a “Current Issues in Immunization Netconference” on Wednesday, November 8, at 12:00 – 1:00 p.m. EST. This Netconference, designed to provide health care providers with the most up-to-date information on immunization, will discuss the new recommendations.  The netconference will also provide information about Hepatitis A guidance and consideration in light of recent Hepatitis A outbreaks and current constraints related to the Hepatitis A vaccine supply. We encourage you to promote this Netconference to health care professionals in your jurisdiction who may be interested in learning more about these issues. Registration is available online at https://www2.cdc.gov/vaccines/ed/ciinc/. Registration is limited. However, an archived version will be posted to CDC’s website shortly after November 8.

NFID Webinar
The National Foundation for Infectious Diseases (NFID) will host a webinar on Thursday, November 9, 2017 at 12:00 PM EST about the October 2017 ACIP Meeting. William Schaffner, MD, NFID Medical Director and liaison to the Advisory Committee on Immunization Practices (ACIP), and Amanda C. Cohn, MD, MPH, ACIP Executive Secretary, will discuss updates from the October 2017 ACIP meeting, including current vaccination recommendations for adults, adolescents, and children. You can register for this webinar at https://cc.readytalk.com/registration/#/?meeting=pgpqytw5nveh&campaign=orme0xhijpsj

At the conclusion of this activity, participants will be able to:
   · Describe current ACIP recommendations for adult and childhood/adolescent immunization
   · Explain the impact of recent changes to vaccine recommendations on vaccination programs
   · Discuss information on new and/or future vaccines for potential use in practice

The 2017-2018 School Immunization Requirements Table included a small change in the requirements for polio vaccine.  Prior to this year, 4 doses of polio vaccine were required for school entry, and school nurses only needed to count the number of doses, without a need to take into consideration the minimum age or interval for each dose.  The School Immunization Requirements Table for this year now states that the final dose in the polio series must be given on or after 4 years of age and at least 6 months after the previous dose, consistent with the Advisory Committee on Immunization Practices (ACIP) recommendations.  This is the case even if the child has already received 4 or more doses of polio vaccine prior to 4 years of age. 

While the minimum age and interval for the final dose of the polio vaccine series is a new school requirement, it has been a routine recommendation for many years. The minimum age and spacing of the final dose in the polio vaccine series helps to ensure an optimum boosting response.  The latest guidance can be found in the Recommended Immunization Schedule for Children and Adolescents 18 Years or Younger, U.S., 2017, please see the footnote #6.  

School nurses have reported to the MDPH Immunization Program that a number of children are out of compliance with this requirement and that some pediatricians have been hesitant to provide an additional dose of polio vaccine.  Even if children have received 4 or more doses of polio vaccine prior to age 4, they should still receive a booster dose after age 4.  Providers should administer an additional dose of polio vaccine to children enrolled in school who are not in compliance, as long as it has been at least 6 months since their last dose of polio vaccine and the child is at least 4 years of age.

If you have any questions, please contact the Division of Epidemiology and Immunization at 617-983-6800.  

 

Please see the MDPH Recommendations and Resources for the Control of Influenza and Pneumococcal Disease, 2017-2018.  Like previous years, the advisory has a section added which includes the latest recommendations for use of PCV13 followed by PPSV23 in those >65 years of age. 

This year there are no major changes to the Advisory Committee on Immunization Practices (ACIP) Recommendations for Influenza Vaccine for the 2017-2018 season. You may find the Summary of the ACIP Influenza Recommendationshelpful as well.  Guidelines related to management of those with egg allergy are unchanged from last year.  In addition, live attenuated influenza vaccine (LAIV) is not recommended for the 2017-2018 season.

We have received a number of questions from providers concerning the correct dose volume of FluLaval Quadrivalent (IIV4), which is approved for use in children aged 6 months through 35 months as a 0.5 mL intramuscular dose.  This is the correct dose volume for this age group for this product.  See the table below for more information.

Take Care to Use Correct Volume for Dose in Children

·         For any dose needed, children aged 6 through 35 months may receive either:

o   0.5 mL FluLaval Quadrivalent (IIV4) intramuscularly, or

o   0.25 mL Fluzone Quadrivalent (IIV4) intramuscularly.

o   Note that dose volume differs for these two brands. Care should be taken to administer the correct dose.

·         Children aged 3 through 17 years may receive 0.5 mL intramuscularly of an age-appropriate IIV formulation.

Please note:  Children 6 months through 8 years who are receiving influenza vaccine for the 1st time or who have had a total of only 1 dose of influenza vaccine in any previous seasons will need 2 doses separated by >4 weeks.  For those children who need 2 doses this season, the 2 doses do not need to be the same product.

The MDPH Flu website at www.mass.gov/flu has information for providers and the general public. Click on 'Information for Healthcare Professionals' for provider resources such as clinical advisories and control guidance, model standing orders, screening forms and planning clinics and campaigns. Pneumococcal vaccine guidance is also located here.

We hope you find these resources helpful.

The influenza VIS is no longer updated each year, unless needed. The current flu VIS posted on the CDC website is the one you can use for this upcoming flu season. If you need VISs in other languages, please visit the http://www.immunize.org/vis/vis_flu_inactive.asp

For questions about state supplied flu vaccine availability and ordering, please contact the Vaccine Management Unit at 617-983-6828. For questions about flu vaccine recommendations, please call the Immunization Program at 617-983-6800 and ask to speak to an immunization epidemiologist.

This year the Advisory Committee on Immunization Practices (ACIP) is publishing its recommendations regarding influenza vaccine in 3 separate documents.  Below you will find the respective links:

·         2017-2018 ACIP influenza recommendations:  CDC. Prevention and Control of Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices (ACIP) - United States, 2017-18 Season. MMWR 2017; 66(RR-2):1-20. https://www.cdc.gov/mmwr/volumes/66/rr/pdfs/rr6602.pdf

  • See pages 5 and 6 for the primary changes and updates, which are not extensive this year.  Please note that live attenuated influenza vaccine (LAIV) should not be used during the 2017-2018 influenza season.

·         A summary of this year’s recommendations:  CDC. Prevention and Control of Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization (ACIP) – United States, 2017-2018, Summary of Recommendations.  Available at: https://www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/downloads/ACIP-recs-2017-18-summary.pdf

  • This 4 page ‘Job Aid’ is a new document that contains all the critical recommendations, tables and flow charts.

·         And a background document for this year’s recommendations: Background Document for “Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices—United States, 2017-18 Influenza Season.”  Available at https://www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/downloads/ACIP-recs-2017-18-bkgd.pdf

  • This is also a new document that contains all of the background information, data and studies which informed the ACIP deliberations when making their recommendations about the use of influenza vaccine.

We have received a number of questions from providers concerning the correct dose volume of FluLaval Quadrivalent (IIV4), which is approved for use in children aged 6 months through 35 months as a 0.5mL intramuscular dose.  This is the correct dose volume for this age group for this product.  See the table below for more information.
 

Take Care to Use Correct Volume for Dose in Children

·         For any dose needed, children aged 6 through 35 months may receive either:

  • 0.5mL FluLaval Quadrivalent (IIV4) intramuscularly, or
  • 0.25mL Fluzone Quadrivalent (IIV4) intramuscularly.
  • Note that dose volume differs for these two brands. Care should be taken to administer the correct dose.

·         Children aged 3 through 17 years may receive 0.5 mL intramuscularly of an age-appropriate IIV formulation.

Please note:  Children 6 months through 8 years who are receiving influenza vaccine for the 1st time or who have had a total of only 1 dose of influenza vaccine in any previous seasons will need 2 doses separated by >4 weeks.  For those children who need 2 doses this season, the 2 doses do not need to be the same product.

We will circulate our updated guidance for healthcare providers, guidance for long-term care, and model standing orders soon. 

The influenza VIS is no longer updated each year, unless needed.  The current flu VIS posted on the CDC website is the one you can use for this upcoming flu season.  If you need VISs in other languages, please visit the http://www.immunize.org/vis/vis_flu_inactive.asp.

 

For questions about state supplied flu vaccine availability and ordering, please contact the Vaccine Management Unit at 617-983-6828.

For questions about flu vaccine recommendations, please call the Immunization Program at 617-983-6800 and ask to speak to an immunization epidemiologist. 

 

The Centers for Disease Control and Prevention (CDC) and U.S. Food & Drug Administration (FDA) recently announced VAERS 2.0 (Vaccine Adverse Event Reporting System 2.0), the national adverse event reporting system for monitoring the safety of U.S.-licensed vaccines (https://vaers.hhs.gov/). VAERS 2.0 includes a new reporting form and a new website that allows users to:

  • Easily submit a VAERS report electronically
  • Access VAERS data
  • Learn more about how CDC and FDA monitor the safety of vaccines

Additionally, there are now two ways to report an adverse event following vaccination to VAERS:

  1. Use the online reporting tool
  2. Complete a writable VAERS PDF form and upload it onto the new VAERS website

By the end of 2017, CDC and FDA will phase out the old VAERS-1 paper form and fully transition to the new VAERS 2.0 electronic submission process. Accommodations will be made for persons unable to submit reports electronically. Additional assistance is available via email at info@vaers.org or by phone at 1-800-822-7967.

If you have any questions or concerns, please feel free to contact the Immunization Program at 617-983-6800.

CDC has released the General Best Practice Guidelines for Immunization as an online report, and it is available on the Advisory Committee on Immunization Practices (ACIP) web page (https://www.cdc.gov/vaccines/hcp/acip-recs/general-recs/index.html). The General Best Practice Guidelines for Immunization replace the General Recommendations on Immunization, last published in the Morbidity and Mortality Weekly Report (MMWR) in 2011.

The General Best Practice Guidelines for Immunization goes beyond vaccination recommendations to give providers guidelines on vaccination practice. The document will help vaccination providers to assess vaccine benefits and risks, use recommended administration practices, understand the most effective strategies for ensuring that vaccination coverage in the population remains high, and communicate the importance of vaccination to reduce the effects of vaccine-preventable disease.

By releasing the General Best Practice Guidelines for Immunization as an online report, ACIP will be able to update the document more quickly, giving vaccination providers the most up-to-date guidance on vaccination practice. 

We encourage you to share General Best Practice Guidelines for Immunization with your partners and health care professionals. Attached is a sample announcement you can modify to post online or share through a newsletter, as well as sample tweets.

The updated guidelines include:

1.       Confirmation that if a patient is not acutely, moderately, or severely ill, vaccination during hospitalization is a best practice;

2.       New information on simultaneous vaccination and febrile seizures;

3.       Enhancement of the definition of “precaution” to include any condition that might confuse diagnostic accuracy;

4.        More descriptive characterization of anaphylactic allergy;

5.       Incorporation of protocols for management of anaphylactic allergy;

6.        Allowances for alternate route (subcutaneous instead of intramuscular) for hepatitis A vaccination;

7.        An age cutoff of 12 years through 17 years for validating a dose of intradermal influenza vaccine;

8.       Deletion of much of the storage and handling content, including information on storage units, temperature monitoring, and expiration dates (this content is now contained and continually updated in CDC’s Vaccine Storage and Handling Toolkit, available at https://www.cdc.gov/vaccines/hcp/admin/storage/toolkit/index.html);

9.        Incorporation of the Infectious Diseases Society of America guidance on vaccination of persons with altered immunocompetence;

10.    Timing of intramuscular administration in patients with bleeding disorders;

11.   Updated data on vaccination record policy;

12.   Additional impacts of the Affordable Care Act on adult vaccination; and

13.    Updated programmatic contact information on source material for vaccine information.

Continuing education (CE) credit is available for the General Best Practice Guidelines for Immunization.

To receive updates on this and other ACIP recommendations and guidelines, sign up at https://www.cdc.gov/vaccines/hcp/acip-recs/index.html.


If you have questions regarding immunization practice, please send them to NIPinfo@cdc.gov. As always, if you have questions about immunizations please call the MDPH Immunization Program at 617-983-6800 and ask to speak to an immunization epidemiologist.