REFERENCE GUIDE to IMMUNIZATION PRACTICES AND SCHEDULES. Developed by: The Vaccine Preventable Diseases Program Fifth Edition, November 2006

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1 REFERENCE GUIDE to IMMUNIZATION PRACTICES AND SCHEDULES Developed by: The Vaccine Preventable Diseases Program Fifth Edition, November 2006 Updated TABLE January OF CONTENTS 2008

2 Table of Contents Introduction to The Reference Guide for Immunization Practices and Schedules... 3 Expansion of Ontario s Publicly Funded Vaccination Program for Children... 4 Immunization Standards of Practice... 5 Routine Schedule For Healthy Children Starting Immunizations In Early Infancy... 7 Footnotes for Table # Recommended Schedule for Healthy Children One to Six Years of Age Not Previously Immunized in Infancy and Still Not Imune...11 Recommended Schedule for Children Seven Years of Age and Older Not Previously Immunized in Infancy and Still Not Immune Recommended Schedule for Pneumococcal Conjugate Vaccine (Prevnar) For Healthy Unvaccinated Children Recommendations for Pneumococcal Immunization with Prevnar (PCV7) and 23-Valent Pneumococcal Polysaccharide Vaccine (Pneumo 23) for Children at High Risk for Pneumococcal Disease Recommended Schedule for Children Whose Pneumococcal Conjugate Vaccination Schedule has been Interrupted Recommended Schedule for Varicella Vaccines (Varilrix or Varivax) Recommended Schedule for Meningococcal C Conjugate Vaccines for Healthy Infants/Children Ministry of Health and Long Term Care Guidelines for Recommended Use of Adacel NACI Guidelines for Recommended Use of Adacel Vaccine Recommended Schedule for Haemophilus Influenza Type B (Hib) Vaccine Recommended Schedule for Hepatitis B Vaccine Recommended Schedule for Hepatitis A Vaccine Recommended Schedule for Twinrix (Hepatitis A and Hepatitis B Vaccine Combined) Recommended Use of Influenza Vaccine Recommended Use of Pneumococcal Polysaccharide Vaccines(Pneumovax and Pneumo 23) Recommended Schedule for Meningococcal (Groups A, C,Y, W-135) Polysaccharide Diptheria Toxoid Conjugate Vaccine (Menactra) Recommended Schedule for Quadrivalent Human Pappillomavirus Types 6, 11, 16 & 18 (Gardasil) References Immunization Websites

3 The Reference Guide for Immunization Practices and Schedules What s New for the January 2008 Update of the Reference Guide? Dear Doctor /Office Staff: Children who receive the Meningococcal C Conjugate vaccine (Menjugate, NeisVacC) prior to one year of age (not publicly funded), should still be given the 0.5ml publicly funded single dose after their 1 st birthday during 2 nd year of life. The manufacturer of Pentacel (DPTP+Hib) vaccine has replaced this vaccine with a new fully liquid version called PEDIACEL. No reconstitution is necessary for Pediacel. What is considered a completed series for polio immunizations? Although with our use of Pentacel / Pediacel and Quadracel vaccines, infants and younger children receive 5 doses of IPV, Public Health accepts 3 doses as a completed series. The additional doses are considered doses of convenience as they are part of the Pentacel / Pediacel or Quadracel vaccinations. If children have come from other places where their other immunizations i.e. diphtheria, tetanus, pertussis, Hib appear to be up to date for age, use the following guideline to determine whether a single antigen of polio is required. For infants and children, two doses of IPV should have been received 4 to 8 weeks apart, followed by a booster dose 6 to 12 months later. A combination of IPV/OPV is acceptable. Interruption of a series does not require the practitioner to restart the series. Recommended schedule for Meningococcal (Group A,C, Y & W-135) Polysaccharide Diphtheria Toxoid Conjugate Vaccine (Menactra). Recommended schedule for Quadravalent Human Papillomavirus Types 6,11,16 & 18 (Gardasil). A reminder that Adacel vaccine (dtap) is licensed up to 64 years of age now but is not publicly funded for adults Please call us if you have any questions. 3

4 Update for Ontario s Publicly Funded Vaccination Programs for Pneumococcal Conjugate, Meningococcal Conjugate and Varicella Vaccines Vaccine Varicella Vaccine Who Qualifies All children born on or after September 1, 2003 who are at least 12 months old Catch-up program for children who are 5 years of age on or after January 1, 2005 who have not yet been vaccinated and have not had chickenpox High risk people of all ages *See pg. 14 Pneumococcal Conjugate Vaccine All children born on or after January 1, 2004 Children under 5 years of age who meet the high risk criteria * See pg. 8. Meningococcal C Conjugate Vaccine All children born on or after on September 1, 2003 who are at least 1 year of age Catch up programs for youth who are 12 years of age or 15 to 19 years of age during or after the 2004/2005 school year Certain high risk people of all ages and people in close contact with a person who has vaccine preventable meningococcal disease *See pg. 15 4

5 Immunization Standards of Practice The following are standards of practice for immunizations that are important to follow. 1. Offer more than one vaccination per clinic visit when child is age eligible. Administration of multiple vaccines during one clinic visit can improve immunization coverage rates significantly and increase the probability that a child will be fully immunized at the appropriate age. It is also critical to administer multiple vaccinations if uncertainty exists that a child will return for further doses of a vaccine. The more visits a family needs to make for immunizations, the greater the chance the child will be delayed in immunization or miss doses of vaccine. Simultaneous administration of multiple vaccines can be done safely and does not interfere with the immune response. If a parent does not want their child to receive more than one vaccination at a time, the health provider should discuss with the parent the importance of providing optimal protection to all vaccine preventable diseases as soon as possible. Reassure the parent that the child s immune system is capable of handling all antigens in required vaccines. Also reassure the parent that the practice of giving multiple injections is safe and does not increase the frequency or severity of clinically significant side effects. 2. Give full dosage recommended by the manufacturer. Immunizing children with less than the full dose recommended by the manufacturer e.g. half doses is a practice that has been done with the belief that adverse reactions to a vaccine can be minimized. The serologic response, clinical efficacy and frequency and severity of adverse reactions with half dose schedules have not been adequately studied. Attempts at reducing reactions by altering vaccine dosages can result in inadequate protection. Scientific research shows that the practices of administering multiple reduced doses that together equal a full immunizing dose or the use of smaller divided doses cannot be endorsed or recommended. Current Canadian immunization standards in accordance to the National Advisory Committee for Immunization (NACI) do not accept the administration of half doses of vaccines as being valid. 3. Give immunizations at recommended time intervals. Giving immunizations at less than the recommended interval may result in a reduced antibody response with sub-optimal immunity occurring. Timing of vaccine administration for children can be a complex and detailed domain. Refer to Tables and Footnotes provided for scheduling details and for some basic principles that must be adhered to. Public Health Department Immunization Records Reviews do not accept vaccines administered at less than the minimum recommended intervals/age as valid doses. If unsure, consult with the Vaccine Preventable Diseases Program at the Public Health Department. 5

6 4. Give age-appropriate vaccines. Giving immunizations that are appropriate for the child s age helps to ensure that they receive adequate protection against diseases that they are vulnerable to due to their age. Also helps to ensure that the appropriate concentration of specific antigens is received thereby reducing the possibility of adverse reactions. e.g. children under 7 years of age require a higher concentration of diphtheria in order for them to gain the required immunity. After 7 years of age, they should receive the lower concentration of diphtheria in order to reduce incidence of increased localized reactions. Another example would be for the use of Hib vaccine. Immunization with Hib vaccine is required up to 59 months of age. It is not given after 59 months of age, even if the child missed receiving Hib immunizations in early childhood. Another example is using Adacel for the teen booster not Td or TdP. 5. Give immunizations following procedures recommended by the manufacturer e.g. recommended sites, routes etc. There is the potential for sub-optimal immunity if vaccines are not administered according to recommended procedures. Mixing vaccines in the same syringe is strictly prohibited. Product Monograph information clearly recommends no mixing and also specifies if a specific diluent must be used. Consultation with the manufacturer is required when recommended procedures are not followed as re-immunization may be required in order to ensure adequate immunity has been achieved. Because of decreased immunogenicity reported with several vaccines, the buttock is not recommended as an immunization site, except when large volumes must be given e.g. administration of immunoglobulin. Unless otherwise specified by the manufacturer, the recommended intramuscular site for infants is the anterolateral thigh muscle. For children >1year of age, adolescents and adults the recommended intramuscular site is the deltoid muscle. Following the route recommended by the manufacturer e.g. subcutaneous, intramuscular, ensures that the vaccine is deposited into the proper tissue layer. 6. Give MMR on or after the first birthday. Need for consistent decision-making rules have led authorities to decide that the MMR must be given on or after the 1 st birthday. Consultation with the Ministry of Health and the Centre for Disease Control and Prevention in the United States has confirmed that a dose of MMR prior to the 1 st birthday cannot be counted as valid and re-immunization is recommended in such cases. In general, this rule is strictly enforced across Canada and the United States. Effective January 2005, the MOHLTC recommends routine administration of the 2 nd MMR at 18 months of age. 7. Store all vaccines according to required Cold Chain Standards. In order to maintain vaccine potency, vaccines must be stored at +2 to +8 C at all times unless otherwise recommended by the manufacturer. Notify the Public Health Department immediately if temperatures fall outside the range of +2 to +8 C. Vaccine fridge must be monitored with a digital thermometer. Current/max/min temperatures are to be recorded in logbook 2/day. 6

7 Routine Schedule For Healthy Children Starting Immunizations In Early Infancy Table #1 Age cpdt 1 IPV Hib 2 MMR Td or dtap 3 Var Pneumo Conjugate 2 months 7 4 months Meningo C Conjugate Hepatitis B Influenza 9 6 months 12 months months 6 18 months 5 Recommended Annually for all persons 6 months of age and older (healthy and high risk) 4 to 6 years years Grade years 3 15 to 19 years 8 Adult 3 cpdt= diphtheria, tetanus, acellular pertussis vaccine IPV = inactivated poliovirus vaccine Hib = haemophilus influenza type b conjugate vaccine MMR = measles, mumps, rubella vaccine dtap,td = tetanus, diphtheria toxoid, acellular pertussis adolescent/adult type; tetanus, diphtheria toxoid adult formulation Hepatitis B = Hepatitis B vaccine Var = varicella (chickenpox) vaccine PneumoConjugate = pneumococcal conjugate vaccine Meningo Conjugate = meningococcal C conjugate vaccine Influenza = influenza vaccine* 7

8 Footnotes for Table #1 1. Diphtheria, tetanus, acellular or component pertussis (cpdt) Diphtheria, tetanus, acellular pertussis, IPV and Hib are combined in the Pentacel / Pediacel vaccine. Pentacel / Pediacel vaccine is given at 2, 4, 6 and 18 months of age. 1 st dose of Pentacel / Pediacel must be given no earlier than 42 days of age. Note: New minimum age for 1 st dose effective Sept. 1 st, 2005 Must have at least 28 days between the first 3 doses of Pentacel / Pediacel. Must have at least 6 months between the 3 rd and 4 th dose of Pentacel / Pediacel. If the 4 th dose of Pentacel / Pediacel given after the 4 th birthday, 4 to 6 year old booster needle is NOT required. At 4-6 years of age, cpdt and IPV vaccines are combined into the Quadracel vaccine. If a child misses their 4-6 year old school entry Quadracel and is now between the ages of 7 and 11, a TdP or Td should be administered depending on the child s polio requirements. If child has reached their 11 th birthday and missed their school entry needles, Adacel should be administered along with a separate IPV only if their polio requirements have not been met. Refer to Tables #2 and #3 for children who do not start immunizations for diphtheria, pertussis, tetanus and polio in infancy. 2. Haemophilus Influenza Type B (Hib) Hib is given at 2, 4, 6 and 18 months of age as a component of the Pentacel vaccine. 1 st dose of Hib must be given no earlier than 42 days of age. Note: New minimum age for 1 st dose effective Sept. 1 st, 2005 It is not required after 59 months of age as incidence of Hib disease after age of 5 is minimal. Refer to Table #10 for children who do not start their immunization against Hib in the first 3 to 6 months of life. 3. Tetanus Diphtheria (Td); Tetanus, Diphtheria, acellular component Pertussis (dtap), and Polio Td (tetanus and diphtheria toxoid), a combined adsorbed "adult type" preparation for use in people > 7 years of age, contains less diphtheria toxoid than preparations given to younger children and is less likely to cause reactions in older people. dtap adult formulation with reduced diphtheria toxoid and acellular pertussis component (Adacel vaccine) has replaced the Td booster in adolescence. NACI and the MOHLTC guidelines differ with regards to recommendations for use of Adacel. For a complete explanation of these differences, refer to Tables # 3, 9a and 9b. Generally the adolescent booster is due 10 years after the school entry needle (Quadracel) is given. However the minimum interval between the school entry booster of Quadracel and the adolescent booster of Adacel can be 5 years. In addition, child should be 11 years of age to receive the adolescent booster of Adacel. The teen booster for polio is not necessary as long as the child has a completed polio vaccine series. See next page for information on what is considered to be a completed series for polio immunizations. Effective September 1 st, 2005, minimum age for 1 st dose of polio is 42 days of age. 8

9 For infants and children, two doses of IPV are recommended 4 to 8 weeks apart, followed by a booster dose 6 to 12 months later. When given as part of the Pentacel /Pediacel and Qudaracel vaccines, it is acceptable to give the additional doses for convenience of administration. However, two doses of IPV plus a booster dose is considered a complete primary series. A primary series of polio immunizations may be considered to be complete even when combinations of IPV/OPV have been used. Children 7 years of age or greater and adults who have never been immunized against polio require 3 doses. The 2 nd dose is given 2 months after the 1 st dose and the 3 rd dose is recommended to be given 12 months after the 2 nd dose. 4. Hepatitis B At birth, infants of hepatitis b surface antigen positive mothers or suspected maternal infection should receive Hep B vaccine along with an injection of Hep B immunoglobulin followed by the 2 nd and 3 rd dose of Hep B vaccine at 1 and 6 months of age. Refer to Table #11 for complete details on how to administer a 3-dose series. The 2- dose Grade 7 Hepatitis B Program uses Recombivax HB adult formulation. Recombivax HB 1cc is given at the time of the 1 st dose. At least 4 full months must pass before the 2 nd dose can be given. Hepatitis B vaccines produced by different manufacturers can be used interchangeably even though their antigen content is not the same, provided that the dosage used is the one recommended by the manufacturer for the appropriate age group and schedule. 5. Measles, Mumps, Rubella (MMR) In Ontario the first dose of MMR must always be given on or after the first birthday. A second dose of MMR is recommended and can be given at least 1 month after the first dose. Effective January 2005, the 2 nd MMR is recommended to be given at 18 months of age. Note: the MMR and Varicella vaccines are live virus vaccines. They must either be given on the same day at different injection sites or be separated by at least 28 days. 6. Varicella (chickenpox) Children aged 12 months to 12 years should receive one dose of varicella vaccine (Varivax/Varilrix). Individuals > 13 years of age should receive two doses 4 to 8 weeks apart (Varivax); at least 6 weeks apart (Varilrix).. Note: the MMR and Varicella vaccines are live virus vaccines. They must either be given on the same day at different injection sites or be separated by at least 28 days. Refer to Table #7 for varicella immunization dosage and schedules. 7. Pneumococcal Conjugate Recommended schedule, # of doses for pneumococcal conjugate vaccine (Prevnar) and subsequent use of 23-valent polysaccharide pneumococcal vaccine, (Pneumo 23 vaccine) depends on age of the child when vaccination is begun and whether considered healthy or at risk. Pneumococcal conjugate vaccine is publicly funded for high risk children < 5 years of age with medical conditions: sickle cell disease or other sickle cell pathologies; congenital or acquired asplenia or splenic dysfunction; chronic cardiac and respiratory 9

10 conditions (excluding asthma unless on high dose oral steroids); CSF leaks; chronic renal failure or nephrotic syndrome; poorly controlled diabetes; immunocomprimising conditions including HIV infection, congenital immunodeficiencies, malignancies, leukemias, lymphomas, Hodgkin s Disease, radiation therapy, immunosuppressive therapy, solid organ transplant recipients; cochlear implant recipients (pre/post implant). Minimum age to receive 1 st dose is 6 weeks of age. Refer to Tables # 4, 5, 6 for scheduling details for Prevnar. 8. Meningococcal C Conjugate Recommended schedule and # of doses of meningococcal conjugate vaccine (Menjugate, Meningitec, NeisVac -C) depends on the age of the child and product used. Children receiving meningococcal C conjugate vaccine during infancy, should receive a booster dose of the vaccine after the 1 st birthday during the 2 nd year of like. This booster dose is publicly funded Minimum age to receive 1 st dose is 2 months of age. See page 15 for high risk criteria Refer to Table #8 for meningococcal conjugate vaccine schedules for Menjugate, Meningitec, and NeisVac-C. 9. Influenza The type of influenza vaccine used each year may vary. Influenza vaccine is usually administered between October-April of each year. Minimum age to receive the vaccine is 6 months. Individuals 6 months to end of their 35 th month of age should be given 0.25 ml. From age 3 years and up, give 0.5ml.. Children <9 years require 2 doses with an interval of 4 weeks if they have received one or no doses in the previous influenza season and have never received 2 doses within a single season. Refer to Table #14 for influenza schedule. 10

11 Recommended Schedule for Healthy Children One to Six Years of Age Not Previously Immunized in Infancy and Still Not Immune Table #2 Timing cpdt IPV HIB MMR Var Pneumo Conjugate Meningo C Conjugate 1 st visit - 1 year old 1 st visit - 2 to 6 years old 2 months after 1 st visit - 1 year old 2 months after 1 st visit - 2 to 6 years old 2 months after 2 nd visit 12 months after 3 rd visit (up to 59 mos.) 4 to 6 years old (5 yr. olds) Grade 7 students (12 year olds) dtap Td Hep B Influenza Immunize each year in fall/winter * Children <9 years require 2 doses with an interval of 4 weeks if they have received one or no doses in the previous influenza season and have never received 2 doses within a single season. 14 to 16 years old Adult years Every 10 yrs 11

12 Recommended Schedule for Children Seven Years of Age and Older Not Previously Immunized in Infancy and Still Not Immune Table #3 Timing TdP dtap Td MMR Hep B Varicella Meningococcal C Conjugate Influenza 1 st Visit 2 months after 1 st visit 6 to 12 months after 2 nd visit Every 10 years thereafter If between ages of 11 and 18 years of age, replace one of the series of three TdP with an Adacel and a separate IPV (would not be publicly funded unless high risk ) * If 13 years or older will need another dose at least 6 weeks apart from 1 st dose Immunize each year in fall/winter * Children<9years require 2 doses with an interval of 4 weeks if they have received one or no doses in the previous influenza season and have never received 2 doses within a single season. Grade 7 15 to 19 years old MOHLTC recommendations state that adolescents between the ages of 11 and 18 years, who have not been immunized should receive a single dose of Adacel plus a separate dose of IPV for one of their series of three TdP. NACI Recommendations differ from the MOHLTC recommendations. NACI recommends that children 7 years of age or older and adolescents who have never been immunized or whose immunization status is unknown should receive 3 doses of Adacel plus 3 separate IPVs following the same intervals recommended in the chart above. 12

13 Recommended Schedule for Pneumococcal Conjugate Vaccine (Prevnar) For Healthy Unvaccinated Children Table #4 Age at 1 st dose 2-6 months Primary Series 3 doses of 0.5 ml IM 6 to 8 weeks between doses (Minimum age for 1 st dose is 6 weeks of age) (For children < 1 year of age, minimum interval between doses is 4 weeks) Additional Doses 1 dose of 0.5ml IM at age months; at least 6-8 weeks after 3 rd dose of primary series 7-11 months 2 doses of 0.5ml IM 6 to 8 weeks between doses 1 dose of 0.5ml IM at age months; at least 6-8 weeks after 2 nd dose of primary series months 2 doses of 0.5ml IM 6 to 8 weeks between doses None 24 to 59 months 1 dose None 13

14 Recommendations for Pneumococcal Immunization with Prevnar (PCV7) and 23-Valent Pneumococcal Polysaccharide Vaccine (Pneumo 23) for Children at High Risk for Pneumococcal Disease Table #5 Age Previous Doses Received Recommendations < 23 months None Prevnar as per recommendations for healthy previously unvaccinated children (See Table #4) 24 to 59 months of age 24 to 59 months of age 24 to 59 months of age 24 to 59 months of age 4 doses of Prevnar (PCV7) 1 to 3 doses of Prevnar (PCV7) 1 dose of Pneumo 23 (PPV23) None 1 dose of Pneumo 23 at 24 months of age; at least 6 to 8 weeks after the last dose of Prevnar 1 dose of Pneumo 23, 3 to 5 years after the 1 st dose of Pneumo 23 1 dose of Prevnar at least 6 to 8 weeks after last dose 1 dose of Pneumo 23, 6 to 8 weeks after the last dose of Prevnar 1 dose of Pneumo 23, 3 to 5 years after the 1 st dose of the Pneumo 23 2 doses of Prevnar, 6 to 8 weeks apart, starting at least 6 to 8 weeks after the last dose of Pneumo 23 1 dose of Pneumo 23, 3 to 5 years after the 1 st dose of Pneumo 23 2 doses of Prevnar 6 to 8 weeks apart 1 dose of Pneumo 23, 6 to 8 weeks after the last dose of Prevnar 1 dose of the Pneumo 23, 3 to 5 years after 1st dose of Pneumo 23 14

15 Recommended Schedule for Children Whose Pneumococcal Conjugate Vaccination Schedule Has Been Interrupted Table #6 Age at Re- Presentation for Immunization Completion of Primary Series Booster Dose Children who are < 6 months of age e.g. Got 1 st Prenvar at 2 months of age, missed 2 nd dose and is representing at 5-6 months of age. 7 to 11 months of age 1 previous dose given 2 previous doses given Should complete their immunization schedule as if no interruption has occurred 2 doses, 6-8 weeks apart 1 dose (For children < 1 year of age, minimum interval between vaccine doses is 4 weeks) 1 dose at 12 to 15 months of age 1 dose at 12 to 15 months of age ( Booster doses to be given at least 6 to 8 weeks after the final dose of the primary series 12 to 23 months of age e.g. Missed dose #2 and/or dose #3 and representing between months. >= 24 months of age e.g. Missed dose #2 and/or dose #3 and/or and are representing at over 2 years of age. 2 doses, 6-8 weeks apart None 1 dose None 15

16 Recommended Schedule for Varicella Vaccines (Varilrix or Varivax) Table #7 Age at First Dose Dosage 12 months to 12 years of age Give single dose of 0.5ml S/C 13 years and older Initial dose of 0.5 ml S/C followed by a second dose of 0.5ml S/C at least 6 weeks later (Varilrix) or 4 weeks later (Varivax) High risk criteria for varicella vaccine include: Children and adolescents given chronic salicylic acid therapy Persons with cystic fibrosis Immunocompromised persons * special considerations are recommended. See table below. There is no additional or undue risk in immunizing the following persons: Persons with nephritic syndrome or those undergoing dialysis if they are not taking any immunosuppressive medications Persons taking low dose steroid therapy of < 2mg prednisone/kg daily and to a maximum of 20 mg/day for more than 2 weeks Persons taking inhaled or topical steroids DO NOT GIVE TO PERSONS WITH blood dyscrasias, leukemia except for acute lymphoblastic leukemia,lymphomas of any type malignant neoplasms affecting the bone marrow or lymphatic system other defects in cell-mediated immunity treatments associated with T-cell abnormalities such as intensive chemotherapy, high dose of steroids, cyclosporine, azathioprine, methotrexate, tacrolimus. RECOMMEND CONSULTATION WITH EPERT BEFORE IMMUNIZATION OF PERSONS WITH congential transient hypogammaglobulinemia HIV with normal immune status *Some HIV infected children should be considered for immunization if they are asymptomatic or mildly symptomatic, in CDC class N1 or A1 with age-specific CD4 + T- lymphocyte percentages greater or equal to 25%. Such eligible children should receive 2 doses of varicella vaccine with a 3-month interval between doses. They should be encouraged to return for assessment if they experience a post-vaccination varicella-like rash. solid organ transplant recipients. Vaccine should be given a minimum of 4 to 6 weeks before transplant surgery. 16

17 Recommended Schedule for Meningococcal C Conjugate Vaccines for Healthy Infants/Children Table #8 NeisVac-C (ID Biomedical) Age at 1 st Dose # Doses and Scheduling 2 to 12 months ( * minimum age to receive first dose is 2 months of age) 2 doses; at least 8 weeks apart ;each dose is 0.5 ml *Then administer booster dose after first birthday during 2 nd year of life * Booster dose is funded Over 1 year of age 1 dose is required; dose is 0.5 ml Menjugate (Merck Frosst) and Meningitic ( Wyeth) Age at 1 st Dose # Doses and Scheduling < 4 months of age (*minimum age to receive first dose is 2 months of age) 3 doses; at least 4 weeks apart; each dose is 0.5 ml *Then administer booster dose after first birthday during 2 nd year of life. * Booster dose is funded 4 to 12 months of age 2 doses; at least 4 weeks apart; each dose is 0.5 ml *Then administer booster dose after first birthday during 2 nd year of life. * Booster dose is funded Over 1 year of age 1 dose required; Dose is 0.5 ml High risk criteria for the meningococcal C conjugate vaccine include: Persons with functional or anatomic asplenia. Give vaccine 10 to 14 days before splenectomy. Persons with complement, properdin or factor D deficiency and persons who are HIV positive. These high risk groups may receive more durable protection against serogroup C meningococcal disease by giving both the conjugate vaccine and the quadrivalent vaccine. If giving both types of meningococcal vaccines, the following guidelines need to be followed. If giving conjugate vaccine first, wait a period of at least 2 weeks before giving quadrivalent polysaccharide vaccine. If giving quadrivalent polysaccharide vaccine first, wait at least 6 months before giving conjugate vaccine to avoid interference with generation of immune response. Note: Children < 2 years of age with any of the above immunodeficiencies should be immunized with conjugate vaccine according to their age and then receive meningococcal quadrivalent polysaccharide vaccine at 2 years of age. 17

18 Ministry of Health and Long Term Care Guidelines for Recommended Use of Adacel Table #9a Age Group Dosage Comments Adolescents between ages of 14 to 16 years of age who are due for their teen booster (10 years after their 4-6 year old booster) Adolescents ages 11 to 18 years of age who have never been immunized Pre-adolescent children 11 to 14 years who missed their school age boosters and are now 11 years of age Adults up to 64 years of age Give single dose of 0.5ml IM Give Adacel 0.5ml IM and a separate IPV for one of the 3 doses of their TdP series Give Adacel 0.5ml IM Administer a single dose of Adacel, regardless of whether has received a diphtheria toxoid-containing vaccine (Td/TdP) < 5 years ago. If does not want, give Td every ten years Replaces the teen booster of Td Note: Polio not required at teen booster if has met polio requirements as outlined on pg. 6/7. If polio requirements have not been met, give a separate IPV along with Adacel. *Publicly funded for this group See Table #3 *Publicly funded for this group * They are eligible for Adacel as it is licensed for use from age 11 to 64 years of age. * If Polio requirements have not been met give a separate IPV along with an Adacel *Publicly funded for this group * It is not publicly funded for persons 20 years of age and over. 18

19 NACI Guidelines for Recommended Use of Adacel Vaccine Group year olds due for adolescent booster Any younger adolescent who is otherwise up to date with their immunizations and who has not ever received a dose of the acellular pertussis vaccine Children 7 years of age and older, who have missed their preschool booster of Quadracel Children 7 years of age and older and adolescents, who are unimmunized or whose immunization status is unknown Children 7 years of age or older and adolescents, who are partially immunized against the diseases, prevented by the childhood vaccines i.e. less than three doses Adults up to 64 years of age Table #9b Given instead of booster for Td. Comments Administer a single dose of Adacel, regardless of whether has received a diphtheria toxoidcontaining vaccine (Td/TdP) < 5 years ago, since monovalent acellular pertussis is not available in Canada; acellular pertussis was first used in Pentacel in Ontario in July This recommendation is made to provide protection against pertussis for those adolescents who received only the previous, less effective whole cell pertussis vaccine; the additional doses of tetanus and diphtheria toxoid in Adacel are unlikely to cause any serious side effects. Administer a single dose of Adacel to bring them up to date. According to NACI recommendations for polio, an IPV would not be necessary in this situation if the child has received three doses of polio vaccine previously. Note: The MOHLTC recommendations for polio differ from NACI s. According to MOHLTC polio recommendations, a child who has missed their school booster of Quadracel would still be considered overdue for polio. Refer to pages 6 and 7 of Reference Guide. Administer two doses of Adacel at four weeks intervals and a third dose 6 to 12 months later. Note: The Ministry of Health and Long Term Care guidelines for use of Adacel. MOHLTC recommends that only one of the three doses for the series be Adacel. Provide the best protection by using Adacel to complete the series. Since recommendations will depend on age and previous doses, however, we ask that you call for specific recommendations that will be determined by the specific situation. One dose of Adacel may be given in lieu of usual Td booster. Administer a single dose of Adacel, regardless of whether has received a diphtheria toxoid-containing vaccine (Td/TdP) < 5 years ago. Not publicly funded once 20 years of age and older. 19

20 Recommended Schedule for Haemophilus Influenza Type B (Hib) Vaccine for Healthy Children Not Previously Immunized in the First 3 to 6 months of life Table #10 Hib Vaccine This schedule applies to the use of Act-Hib vaccine Timing Age at 1 st Visit At 1 st visit 2 months later At months 7-11 months ( must be at least 2 months after 2 nd dose) months ( must be at least 2 months after 1 s dose) 15 months to 59 months of age 20

21 Recommended Schedule for Hepatitis B Vaccine Table #11 Recommended Doses of Currently Licensed Hepatitis B Vaccines Recipients Recombivax HB Engerix-B ug ml Schedule (months) µg ml Schedule (months) Infants of HBV-carrier mothers , 1, , 1, 6 Infants of HBV-negative mothers and children <10 years (Thimerosol-free) , 1, > , 1, 6 Or 0, 1, 2, 12 Children 11 to 19 years (3 dose schedule , 1, > , 1, 6 Or 0, 1, 2, 12 Children 11 to 15 years (2-dose schedule Grade 7 Hep B Program) , 4 to ,6 Adults , 1, > , 1, 6 or 0, 1, 2, 12 or 0, 7, 21, 365 days Hemodialysis and Immunocompromised patients 40 1 or 2 ml 0, 1, , 1, 6 21

22 Recommended Schedule for Hepatitis A Vaccine Those eligible for publicly funded Hepatitis A vaccine are the following: Persons with chronic liver disease including those with hepatitis B and C, intravenous drug users, men who have sex with men and contacts of infected HAV persons within 1 week of exposure. Table #12 Type of Hep A Vaccine Age Dose Booster Dose Additional Comments Havrix 720 Junior 1 to 18 years 0.5 ml IM deltoid 0.5 ml to be given 6 to 12 months after the primary dose given; If late do not repeat primary dose Havrix 1440 Avaxim Pediatric Avaxim Adult 19 years and over 12 months to 15 years of age inclusive 12 years of age and older Vaqta Pediatric 2 years to 17 years inclusive Vaqta Adult 18 years of age and older 1.0 ml IM deltoid 0.5 ml IM deltoid 0.5 ml IM deltoid 0.5 ml IM deltoid 1.0 ml IM deltoid 1.0 ml to be given 6 to 12 months after primary immunization; If late do not repeat primary dose 0.5 ml to be given 6 to 12 months after the primary dose given; If late do not repeat primary dose 0.5 ml to be given 6 to 12 months after the primary dose given; If late do not repeat primary dose 0.5 ml to be given 6 to 18 months after primary dose; If late do not repeat primary dose; Can be used as a booster 6 months after 1 st dose of Havrix Jr. 1.0 ml to be given 6 to 18 months after primary dose; If late do not repeat primary dose; Can be used as a booster 6 months after 1 st dose of Havrix adult. Consult with the Public Health Department and/or specific product monographs for recommendations regarding the need for further boosters. 22

23 Recommended Schedule for Twinrix (Hepatitis A and Hepatitis B Vaccine Combined) Table #13 Product Age Dose Standard Recommended Vaccination Schedule Rapid Accelerated Schedule for Traveler Alternative Schedule Only for Pediatric 1-15 years Booster Dose Twinrix Adult (contains 720 Elisa Units of Hep A and 20 mcg of Hep B in a 1.0 ml dose Use for clients 19 years of age and older 1.0 ml IM 3 doses: #1 given on elected date #2 1 month after 1 st dose #3 6 months after 1 st injection If leaving in < 2 months Give 4 dose schedule 0, 7, 21 days and 12 months Give 2 dose schedule 0, 6 or 12 months ***Twinrix Adult (720/20) is given in this schedule. It is not recommended, unless completion of series can be assured. Use same product to complete Consult with Public Health Department and/or Product Monographs for the specific details. Twinrix Junior (contains 360 Elisa Units of Hep A and 10 mcg of Hep B in a 0.5 ml dose Use for clients 1 to 18 years of age 0.5ml IM 3 doses: #1 given on elected date #2 1 month after 1 st dose Not applicable Not applicable Consult with Public Health Department and/or Product Monographs for the specific details. #3 6 months after 1 st injection 23

24 Recommended Use of Influenza Vaccine Table #14 Recommended Dosage By Age Age Group Vaccine Type Dose # 0f Doses 6 months of age to end of 35 months of age Split virus 0.25 ml IM 1 or 2 * 3-8 years of age Split virus 0.5 ml IM 1 or 2 * 9 years of age and older Split virus 0.5 ml IM 1 * Children less than 9 years of age require 2 doses with an interval of 4 weeks if they have received one or no doses in the previous influenza season and have never received 2 doses within a single season. 24

25 Recommended Use of Pneumococcal Polysaccharide Vaccines (Pneumovax and Pneumo 23) Table #15 Indications for Use Dosage/ Route Booster Requirements Indicated for all persons 65 years of age or older Persons with unknown pneumococcal immunization histories should receive the vaccine Indicated for all persons > 5 years of age with asplenia, splenic dysfunction or sickle cell disease if not previously immunized Indicated for individuals > 5 years of age with the following conditions: chronic cardio-respiratory disease (except asthma), cirrhosis, alcoholism, chronic renal disease, nephrotic syndrome, diabetes mellitus, chronic cerebrospinal fluid leak, HIV infection and other conditions associated with immunosuppression (Hodgkin's disease, lymphoma, multimyeloma, immunosuppression for organ transplantations). For children when circumstances permit, the conjugate vaccine may be given as the initial dose followed by the Pneumo 23 to provide additional serotype coverage and as a booster. (See Table #5) Indicated for individuals who smoke. 0.5 ml Can be given IM or SC Routine re-vaccination with pneumococcal polysaccharide vaccine is NOT recommended except for those at highest risk of invasive disease. These include persons with: functional or anatomic asplenia or sickle cell disease hepatic cirrhosis chronic renal failure or nephrotic syndrome HIV infection Immunosuppression related to disease or treatment It is presently recommended that a single reimmunization be carried out 5 years after the initial immunization for those greater than 10 years of age, or after 3 years in those less than or equal to 10 years of age. The vaccine used to booster at this time is Pneumo 23 or Pneumovax. Important Note: Pneumo 23/Pneumovax can be administered at any time during the year. Historically, there has been a problem of offices/facilities over-ordering this vaccine, resulting in increased wastage when it expires before able to be used up. Please as with all vaccines only order a 1-month supply at a time. 25

26 Recommended Schedule for Meningococcal (Group A, C, Y, W-135) Polysaccharide Diphtheria Toxoid Conjugate Vaccine Age 2 55 Years * Not publicly funded Table # 16 Menactra (Sanofi Pasteur) Dosage Give Single Dose of 0.5 ml IM NOTE: As vial stoppers contain dry natural rubber latex, caution should be exercised when the vaccine is administered to subjects with known hypersensitivity to latex. The syringe presentation of this vaccine contains no latex. Pregnant and nursing women should be given Menactra only if there is a defined risk and only following an assessment of the risks & benefits by the Doctor. Persons previously diagnosed with Guillain-Barré syndrome (GBS) SHOULD NOT receive Menactra. 26

27 Recommended Schedule for Quadrivalent Human Papillomavirus Types 6, 11, 16 & 18 (Gardasil) Age Girls and Women 9 26 years of age * Not Publicly Funded except for Grade 8 females who must complete all 3 doses prior to starting Grade 9 for all doses to be funded Table # 17 Dosage and Scheduling 3 Doses of 0.5 ml IM 1 st Dose At elected date 2 nd Dose 2 months after the 1 st dose (must be at least 1 month after 1 st dose) 3 rd Dose - 6 months after the 1 st dose (must be at least 3 months after 2 nd dose) All 3 doses should be given within a one year period Note: This vaccine is not intended to be used for treatment of active genital warts, cervical, vulvar or vaginal cancers; CIN, VIN or VALN. 27

28 References Canadian Immunization Guide, 7 th Edition, 2006 Ministry of Health and Long Term Care, Immunization Schedules for Ontario, February 2005 National Advisory Committee on Immunization Guidelines for: NACI Guidelines: Recommended Use of Meningococcal Vaccines, October 15, 2001, Volume 27 NACI Guidelines: Recommended Use of Pneumococcal Conjugate Vaccine, January 15, 2002, Volume 28 NACI Guidelines: Update to Statement on Varicella Vaccine, February 15, 2002, Volume 28 NACI Guidelines: Supplementary Statement on Influenza Vaccination for , August 15, 2003, Volume 29 ( note: updated yearly) NACI Guidelines: Addendum Statement on Recommended Use of Pneumoccocal Conjugate Vaccine, September 15, 2003, Volume 28 NACI Guidelines: Prevention of Pertussis in Adolescents and Adults, September 1, 2003, Volume 29 NACI Guidelines: Supplementary Statement on Conjugate Meningococcal Vaccines, September 1, 2003, Volume 29 NACI Guidelines: Update on Meningococcal C Conjugate Vaccines, April 15, 2005 Volume 31 NACI Guidelines: Interval between Administration of Vaccines against Diphtheria, Tetanus and Pertussis, October 15, 2005, Volume 31 NACI Guidelines: Statement on Human Papillomavirus Vaccine February 15, 2007 Volume 33 NACI Guidelines: Statement on Conjugate Meningococcal Vaccine for sero-groups A,C,Y & W-135 NACI Guidelines: Statement on Meningococcal C Conjugate Vaccination Recommendations for Infants, November 2007, Volume 33 Product Monographs for: Act-Hib Conjugate, Sanofie Pasteur, July 1998 Adacel, Sanofie Pasteur, April 1999 Avaxim, Sanofie Pasteur, June 2003 DT Polio, Sanofie Pasteur, August 2000 Engerix B, GlaxoSmithKline, 2001 Gardasil, Merck Frosst, July 2006 Havrix, GlaxoSmithKline, 2001 Influenza Vaccines, Fluviral/Vaxigrip * new product monographs printed yearly Menactra, Sanofi Pasteur, August 2006 Menjugate, Merck Frosst, August 10, 2001 MMRII, Merck Frosst, March 2002 NeisVac-C, ID Biomedical, April 24, 2003; Update on Change to NeisVac-C Recommended Schedule, ID Biomedical, April 2004 Pentacel, Sanofie Pasteur, August 2000 Pneumo 23, Sanofie Pasteur, January 1998 Prevnar, Wyeth, 2002 Quadracel, Sanofie Pasteur, August 2000 Recombivax HB, Merck Frosst, March 16, 2001 Td, Sanofie Pasteur, June 2000 TdP, Sanofie Pasteur, June 2000 Twinrix, GlaxoSmithKline, 2004 Vaqta, Merck Frosst, September 2002 Varilrix, GlaxoSmith Kline, September 2002 Varivax III, Merck Frosst, October

29 Immunization Websites Canadian Coalition for Immunization Awareness and Promotion The Canadian Health Network.click on the letter l then search under immunization. The Canadian Paediatric Society Immunization Site Ontario Ministry of Health.. Quick Search immunize Canadian Paediatric Society National Advisory Committee on Immunization (NACI) Centre of Disease Control, National Immunization Program, Advisory Committee on Immunization Practice Centre of Disease Control Regional Niagara Public Health Department 29