Office of the Chief Medical Health Officer West Broadway V5Z 4C2 Telephone:

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1 Office of the Chief Medical Health Officer West Broadway V5Z 4C2 Telephone: Seasons greetings from the public health team at Vancouver Coastal Health. We hope 2011 brings you and your family good health, happiness, and prosperity. SUPPORTING PREVENTION IN CLINICAL PRACTICE This edition of Physicians Update marks the beginning of efforts to increase support for your prevention activities more comprehensively. We will publish a Physicians Update five times a year (roughly every two months, except during the summer). You may choose to receive it by mail or electronically. If urgent public health problems arise, you will still receive alerts by FAX. We will limit them to one page. We need your feedback as well. Please let us know how we can support your preventive practice better. Eventually, we hope to create a public health advisory group of family physicians, under the auspices of your Division of Family Practice, to help guide this work. Our goal is simple: make sure primary care practitioners have the information they need to deliver the best preventive care possible. IMMUNIZATION NEWS 1. HPV vaccine (Gardasil ) schedule change for girls aged years of age: two doses, six months apart. HPV vaccine (Gardasil ) is currently routinely offered in grades 6 and 9 in British Columbia. Based on results of a recent Canadian trial, the HPV schedule for girls years of age has changed. This trial showed that girls aged 9-13 years have a robust immune response to HPV vaccine, and two doses produce a response equivalent to three doses in young adult women. Therefore, starting in the school year, girls aged years have received two doses of HPV vaccine at 0 and 6 months in the routine school immunization program. The need for an eventual booster dose at 60 months is under assessment. The schedule for Gardasil remains three doses at 0, 2 and 6 months for girls 14 years of age and older. All girls who have an immune deficiency associated with a solid organ transplant, stem cell transplant, or HIV infection should also receive three doses. 2. HPV vaccine (Gardasil ) for eligible girls years of age is now available to family physicians from their Community Health Centre. You may now order up to five doses of HPV vaccine at a time from your local health office for unvaccinated eligible girls in your practice who did not receive HPV vaccine through the routine school

2 program in grade 6 or 9. All girls born after 1994 who are 10 years of age or older are eligible for publicly funded HPV vaccine. The vaccine will come with an administration form. Please return it to your local community health office by FAX so we can bring the child's vaccine record in our registry up to date. 3. Cervarix For patients who are not eligible for publicly funded HPV vaccine, but wish to buy it for cervical cancer prevention only, two choices are available. Gardasil protects against the oncogenic HPV genotypes 16 and 18 as well as genotypes 6 and 11 which cause most genital warts. Cervarix protects against the two oncogenic genotypes 16 and 18 only. Although Gardasil provides protection against genital warts as well, it costs $150/dose, compared to Cervarix at $90/dose. 3. Updating immunizations when a child falls behind the normal schedule. Immunization schedules are designed to stimulate the best and most long lasting immune response in the shortest possible time. When a child falls behind the routine schedule, plan to catch them up as quickly as possible, using the minimum interval acceptable between doses. We have included several quick references to help your patient get back on track: A table with the youngest age at which a vaccine can be given and the minimum time interval between doses. The HIB schedule when the normal schedule is delayed. The pneumococcal conjugate vaccine schedule depending on the age at first presentation. A quick reference for adults updated to December The only change is a year of birth (1957) added to the rubella vaccine section. For unique situations, please don t hesitate to call us at or refer to the BCCDC immunization manual found at: 4. Multiple vaccines at the same visit Parents may balk at multiple vaccines (and injections) at the same time. We recommend providers administer all vaccines for which the child is eligible at the time of each visit. There are many reasons for this: protecting children as early as possible, reducing the number of visits for families who may not return on time (or at all). Probably most important for you and your patient is reducing the number of visits associated with needles. Side effects are no greater with multiple vaccines. Vaccine effectiveness is not reduced and children tolerate the practice well. When a visit calls for more than one injection, give products known to cause more stinging (like MMR) last. If more than one injection in the same limb is required, leave a space of 2.5cm between injection sites so local reactions are unlikely to overlap. For intramuscular injections, a rapid injection technique without aspirating is less painful.

3 5. New recommendations for the maximum volume of vaccine injected in each limb: Vastus lateralis: o 1.0 ml in infants o 2 ml in children 12 months to 5 years o 3 ml in children 5 years to 18 years o 5.0 ml in adults Deltoid: o 1.0 ml in children 12 months to 18 years o 2.0 ml in adults 6. Potential cold chain problems If your office has a power failure, a fridge failure, or if vaccines were inadvertently left out of the fridge for too long, please call us before you throw out any vaccine. Some may be salvageable. OTHER NEWS IN THE PREVENTIVE CARE OF INFANTS AND CHILDREN Three important tools for the preventive care of infants and children appeared in 2010: 1. The Rourke Baby Record has been entirely updated 2. The Grieg Health Record (for children 6-18) was published: ents/cp/preventivecare.htm 3. BC adopted the new WHO growth standards and references for infants and children: ry-pages/public/who-growth- Charts.aspx Both the Rourke and the Canadian Dieticians web sites have good PDF versions of all the charts. The Canadian Pediatric Society web reference is an excellent guide to their use: DC_HealhProGrowthGuide.pdf The Rourke and Grieg tools are the best preventive recommendations, endorsed by the College of Family Physicians of Canada and the Canadian Pediatric Society, and based on the most recent evidence. We encourage you to use them with all your young patients. LAST WORD Also enclosed is the annual flu vaccine report form, due by Feb. 28 th VANCOUVER MHO S An MHO is always available at the numbers below or through Dr. John Carsley ( ) Dr. Meena Dawar ( ) Dr. Réka Gustafson ( ) The Chief MHO for Vancouver Coastal Health is Dr. Patty Daly Please send your feedback about the Physicians Update to John Carsley: john.carsley@vch.ca If you would like to receive the Update electronically, please Ryan Krell: ryan.krell@vch.ca

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5 Age at presentation for immunization Completing a Pneumococcal Conjugate Vaccine Series History of prior Completion of series requires doses of PCV7, PCV10 or PCV13 given Healthy Infant High Risk Infant 1, 2 Booster dose Healthy and High Risk 2 3 to 11 months 0 doses 2 doses 3 doses One dose at 12 months 2 doses of age 3 2 doses 0 doses 3 12 to 23 months 0 doses 2 doses 4 2 doses 4 No booster dose < 12 months 2 doses 4 2 doses 4 No booster dose 12 months 4 4 No booster dose 2 doses < 12 months 3 2 doses 4 No booster dose < 12 months 4 4 No booster dose & 12 months 24 to 59 months 0 doses No booster dose Any age-appropriate series incomplete by 24 months 4 4 No booster dose Complete PCV series 5 0 doses 4 No booster dose 1 If an infant is diagnosed with a high risk medical condition after starting their PCV primary series, use the table to complete the primary series as high risk. 2 High risk children should also receive one dose of pneumococcal polysaccharide vaccine at 2 years of age, and at least 8 weeks after their final pneumococcal conjugate vaccine dose. 3 At least 8 weeks after the previous dose 4 8 weeks between doses 5 A complete series is: Two PCV (or three for high risk children) primary doses given at appropriate intervals and a 3 rd or 4 th dose given on or after 12 months of age, and at least 8 weeks after previous dose or A delayed or interrupted schedule that has been completed at a later age according to the information in this table. HIB Schedule when the Basic Schedule Has Been Delayed Age at Presentation 1 Primary Series 2 Booster 2-6 months 3 3 doses, 2 months apart 4 18 months 7-11 months 2 doses, 2 months apart 18 months months 18 months months None 6 1 If series is interrupted, complete series according to age at which child re-presents 2 It is preferable to use the same Hib product for all doses of the primary series. Using different Hib products during the primary series is acceptable only when is not possible to continue with the initial product. 3 Initial dose can be given as early as 6 weeks of age. 4 The minimum interval between doses is 4 weeks. 5 The booster recommended at 18 months may be given as early as 15 months provided there is an 8 week interval following the previous dose. 6 At 15 months of age and older, a single dose of any Hib product is all that is required to complete the schedule, even for a previously unimmunized child.

6 Quick Reference: Adult Immunization Schedule For Unimmunized Adults 18 Years as of December 2010 Need help? VCH CDC on call line at: Vaccine Adult Eligibility Schedule to Complete Series in an Unimmunized Adult Publicly funded vaccines for ALL Healthy adults Td MMR* Adults Tdap: a one time booster with acellular pertussis (in lieu of Td) is recommended but not provided free Adults with no history of disease; number of vaccine doses determined by birth date (BD). 3 doses: 0 (Tdap), 1 (Td), 6 12 (Td) months Booster dose every 10 years Rubella, if BD January Mumps 2 doses: 0, 1 month if BD January (, BD ) Measles 2 doses: 0, 1 month if BD January (0 doses if BD pre 1957) 2 doses: 0, 1 month Varicella* Adults with no history of varicella/shingles after one year of age AND negative varicella IgG serology Hepatitis B Adults born on or after January 1, doses: 0, 1, 6 months Meningococcal C Adults born on or after January 1, 1988 Conjugate Publicly funded vaccines for HIGH RISK adults Influenza All adults > 65 years of age; adults < 65 who are at high risk of influenza complications; pregnancy in third trimester during Nov April; adults who are in close contact with those at high risk of influenza complications; essential community service providers Recommended but not provided free for all others Pneumococcal All Adults > 65 years of age; individuals with high risk medical conditions; polysaccharide residents of care facilities; homelessness or illicit drug use Booster Individuals with asplenia, sickle cell disease, immunosuppression or immunodeficiency, chronic kidney or liver disease, or chronic hepatitis C Hepatitis B Post exposure and pre exposure for all students of health care professions; immunizing pharmacists; chronic liver and kidney disease, kidney transplant; HIV; HSCT recipients**; individuals receiving repeated blood transfusions and haemophilia; MSM; multiple sex partners; history of recent STI; Illicit drug users and sexual partners; inmates; staff and residents of homes for the developmentally disabled; teachers and classroom contacts of a known hepatitis B carrier who is developmentally challenged and poses a risk; staff in daycare setting with Hep B infected child; household contacts of internationally adopted children. Recommended but not provided free for travellers Hepatitis A Special populations anti HAV IgG negative: individuals with haemophilia A or B, chronic liver disease, HIV, HSCT recipients**, individuals receiving repeated blood transfusions, MSM, Illicit drug users, inmates; close contacts of a hepatitis A case. Recommended but not provided free for travellers/others at higher risk Meningococcal Quadrivalent Conjugate Hib IPV Rabies Medically high risk individuals: functional or anatomic asplenia, transplant recipient**, congenital immunodeficiency; close contacts of a case (A,C, Y, or W 135). Recommended but not provided free: Some travellers, military recruits, post secondary students Unimmunized persons with specific medical conditions: functional or anatomic asplenia; sickle cell disease; immunosuppression related to disease or therapy; transplant candidates or recipients**, cochlear implants Persons at high risk of exposure to wild polioviruses: travellers, health care and refugee camp workers, lab workers, military personnel, transplant candidate/recipient** BC students attending a vet college or animal health tech training centre. Recommended but not provided free to low high risk workers, hunters, and some travellers Annual vaccination Once only booster, 5 years after initial dose for specific high risk 3 doses: 0, 1, 6 months For chronic kidney patients, use renal formulation: 1. Recomobivax HB : 0, 1,6 months 2. Engerix B: 0, 1, 2, 6 months (12 months if under age 20) Note: All immunocompromised patients require a double dose 2 doses: 0, 6 12 months HIV, 3 doses: 0, 1, 6 months Medically high risk individuals, repeat every 5 years 3 doses: 0, 1 2, 6 12 months Once only booster at 10 years 3 doses: 0, day 7, day 21 Booster doses required for mod high risk individuals on a case by case basis Other recommended vaccines, require purchase HPV Recommended but not provided free for females and males up to age 26 3 doses: 0, 2, 6 months Varicella Zoster Recommended but not provided free for adults > 60 years of age; can also be Once only vaccination used in individuals years of age Travel Vaccines Adults travelling to high risk areas may be referred to the Vancouver travel clinic [ ] Notes: *Immunocompromised individuals require special consideration prior to being given live attenuated vaccines such as MMR and Varicella. Please refer to the BCCDC immunization manual section VII biological products p. 78. **Transplant recipients (stem cell or solid organ) have tailored immunization schedules; please refer to section III of the BCCDC manual or call VCH CDC at For complete details of eligibility and scheduling refer to the BCCDC Immunization Manual at: cond/comm manual/cdmanualchap2.htm August 2010

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