Spring, Measles and Mumps

Medical Director Notes

Dr. Kristen Feemster

Dr. Kristen Feemster is the Medical Director of the Philadelphia Department of Public Health’s Immunization Program.

Spring, Measles and Mumps

2019 is on track to have the highest number of measles cases since the disease was declared eliminated from the U.S. in the year 2000. Why are we seeing these outbreaks and what can we do to protect our community?

This has been a busy spring for vaccine-preventable diseases! Temple University is experiencing a mumps outbreak among students and reported almost 150 cases as of mid-April. While, across the nation, the Centers for Disease Control and Prevention (CDC) reports more than 600 cases of measles so far this year. While we have not yet had any measles cases in Philadelphia, some of the largest outbreaks are right next door. The MMR vaccine prevents both measles and mumps, and most schools require it for entry. Despite that, 2019 is on track to have the highest number of measles cases since the disease was declared eliminated from the U.S. in the year 2000. Why are we seeing these outbreaks and what can we do to protect our community? 

Mumps

Between January 2016 and July 2017, there were 150 mumps outbreaks (9,200 cases) across the country. Half of these outbreaks took place on college campuses despite the majority of students being vaccinated. Why? The effectiveness of two doses of MMR vaccine is 88% for mumps, meaning that out of 100 people, 12 may still get sick if exposed. Additionally, it appears that protection against mumps may decrease over time. How easy is it to be exposed to mumps? Mumps spreads through contact with saliva or respiratory droplets from an infected person. In a community like a college campus, where young students live in dormitories and socialize frequently, there are many opportunities for the mumps virus to spread. And, unfortunately, people with mumps can start spreading the virus before they know for sure that they are sick. The virus can be spread up to two days before developing the most common symptom, a swollen, painful jaw. The ability to spread the mumps virus before one knows that they are sick along with close personal contact inherit to dorm style living and college life, and a decreased protection from the MMR vaccine creates the ideal conditions for an outbreak. 

Measles

Unlike mumps, measles outbreaks are primarily occurring among unvaccinated individuals. The majority of our current measles cases are in New York City and state where returning travelers brought measles to some Orthodox Jewish communities where vaccination rates are low.  Large outbreaks have also occurred in Oregon where there are high rates of vaccine refusal among parents. The measles virus is so highly contagious, it is easy for it to spread quickly through a community if there are any unprotected people. How well does MMR vaccine work for measles? The effectiveness of 2 doses of MMR is 97% against measles AND immunity is lifelong. If we can maintain 95% or higher MMR vaccination rates we can prevent the spread of measles. 

Vaccine Hesitancy

While there is no explicit content barring vaccination in major religious texts and no evidence of any association between vaccines and autism, some parents still seek exemption on these grounds.

If MMR vaccine has been a part of the routine immunization schedule for decades, why do some communities have low MMR vaccination rates? In every state, MMR is one of the vaccines required for school attendance. And, nationally, MMR rates are greater than 90%. Yet, despite requirements, almost every state allows exemptions based upon personal or religious beliefs. And there are a wide range of reasons some parents refuse vaccination or choose to pursue an exemption. For example, some religious communities refuse vaccines based upon interpretation of religious teachings. And some parents refuse MMR vaccine because of vaccine safety concerns related to autism. While there is no explicit content barring vaccination in major religious texts and no evidence of any association between vaccines and autism, some parents still seek exemption on these grounds. 

Preventing Outbreaks

Simply, the best prevention tool that we have for both is the MMR vaccine.

What can we do to prevent or stop mumps and measles outbreaks? Simply, the best prevention tool that we have for both is the MMR vaccine. Be sure that your patients, whether children or adults, are up to date as per current recommendations. Early identification of cases of mumps and measles is also important. When we suspect cases, we can use appropriate isolation practices to prevent further spread. We can also identify contacts to make sure they are protected. 

For mumps specifically, it is time to implement requirements that all university and college students are up to date on their MMR vaccine and provide documentation of vaccine receipt. It is also important to consider a third MMR booster dose for people who are at risk of being exposed to mumps cases when there is an outbreak. At Temple, this has meant setting up vaccination clinics to provide MMR vaccine to students. 

For measles, we are encouraging providers to remain vigilant and consider measles when seeing patients with fever and a rash, especially if they have traveled domestically or internationally. Talk to your patients and their families about any vaccine-related concerns, especially if they have a history of vaccine refusal. Know about resources to help address specific questions, such as concerns about vaccine safety. And consider partnering with community leaders to communicate the importance of vaccination. 

Healthcare providers should also use our immunization registry, Philavax, to check your patients’ immunization histories and keep patients, especially students, up to date on their MMR. The Vaccines for Children (VFC) program can help you provide vaccines for publicly, under – or uninsured kids up to the age of 19. 

Working together we can keep measles and mumps from spreading any further this spring and keep everyone healthy to enjoy this wonderful weather. 

Staying Resilient: Controlling Hepatitis A Outbreak

Medical Director Notes

Dr. Kristen Feemster

Dr. Kristen Feemster is the Medical Director of the Philadelphia Department of Public Health’s Immunization Program.

Staying Resilient: Controlling Hepatitis A Outbreak

City personnel evacuated Kensington’s last homeless encampment during January’s polar vortex. Forty-five people left the Emerald City encampment and were referred for a combination of housing, medical or social services as a part of Mayor Kenney’s Philadelphia Resilience Project.

Launched in October 2018, the Philadelphia Resilience Project aims to bolster affected Philadelphia neighborhoods by uniting partners to address homelessness, drug addiction, violence, metal health challenges, and neighborhood clean-up. While these are all crucial needs, it is also important to remember that persons and communities affected by the opioid crisis are at higher risk for certain infectious diseases. Indeed, Philadelphia has seen increases in Hepatitis A, B and C, HIV and syphilis within neighborhoods most affected by the crisis. Hepatitis A has been particularly concerning.

Now is the time to immunize everyone who should get a Hepatitis A vaccine and the Immunization Program is here to support your efforts

Many states are experiencing outbreaks of Hepatitis A, especially among homeless persons. Hepatitis A spreads when stool from infected persons contaminates food, water or other surfaces. It is much easier for the virus to spread when it is difficult to wash hands or have regular access to a bathroom. Hepatitis A can also be spread through sexual activity or sharing needles. That is one of the reasons why there have been a rising number of outbreaks in communities affected by homelessness and injection drug use. Since March 2017, several states have declared Hepatitis A outbreaks for a total of more than 4,000 cases, the majority of whom have been hospitalized and over fifty have died. Pennsylvania joined the list of affected states in November 2018. Fortunately, there are things we can do to prevent the outbreak from escalating here…vaccinate!

Hepatitis A vaccines were first introduced in the U.S. in 1996. Since then they have been routinely recommended for all infants 12-23 months old and for anyone at increased risk for Hepatitis A exposure. Why vaccinate 12 month olds? When Hepatitis A was more common, it was often spread by young children who would be more likely to have asymptomatic infection and could spread virus without knowing it. This strategy helps reduce the amount of hepatitis A in the community – but it won’t stop all transmission. Only about 70% of infants get the vaccines. And there are many adolescent and adults who didn’t have a chance to get vaccinated as kids. Now is the time to immunize everyone who should get a Hepatitis A vaccine and the Immunization Program is here to support your efforts

  • If you see children and adolescents in your practice, check whether your patients have received Hepatitis A vaccine and catch them up if they haven’t. If you see adults, offer Hepatitis A vaccine to everyone but make sure you give it to your patients with a history of drug use or homelessness. Use our immunization registry, Philavax, to check your patients’ immunization histories.
  • The Vaccines for Children (VFC) and Vaccines for Adults at Risk (VFAAR) programs can help you provide vaccines for publicly, under- or uninsured kids and uninsured adults.
  • If any of your patients have signs of acute hepatitis (fever, jaundice, nausea, light colored stools), test for Hepatitis A and report any positive results. We can help make sure that the virus won’t spread to others.
  • Check the Health Information Portal for more information about Hepatitis A and other infections affecting persons who are homeless or use drugs.

In October and November, our team provided 222 Hepatitis A and over 200 influenza vaccines to people living in and around encampments in Kensington through street outreach. We have also collaborated with Prevention Point, Philadelphia’s needle exchange program, to provide vaccines to their clients. While we have been able to target a high risk community, let’s do what we can to increase Hepatitis A vaccination rates across the city.

Through partnership, we can contribute to resilient communities.

Update your Digital Data Logger software today

Update your Digital Data Logger (DDL) software today

 Please update to the latest version of the LogTag software, which makes small but important changes to how the digital data loggers  (DDL) work and prevent future compatibility issues.

This update will not affect downloading processes or your daily responsibilities and will take about 1 minute to do. Please do this update by Friday, 1/25.

 

How to update your software

To update your software:

If you need administrative or IT permission to download software, please contact your IT department as soon as possible.

 

If you have any questions about this update please contact:

Alexis Bridges and Adam Howsare

Storage & Handling Coordinators

TempCheck@phila.gov

Phone: 215-685-6777

Holiday DDL Download Reminder

Digital Data Logger Download Reminder During the Holiday Season

To make sure that your vaccines stay properly monitored over the busy holiday season, please be aware of the date indicator on your digital data loggers (DDLs). To prevent any gaps in temperature monitoring, please download your DDL files if the date indicator is approaching the 30 day capacity. With many offices having adjusted  holiday hours or staff members taking time off, the 30 day capacity on your DDL could be reached.

To prevent this, we suggest that you download your DDL files before they reach their 30 day memory capacity. This may mean downloading your DDL earlier than you normally would. This will ensure that they continue to        record temperature readings for your storage units over the holidays.

 

After you download your DDL files, remember to:

1) Email both your LTD (yellow and blue) and CSV (green) files to TempCheck@phila.gov

2) Upload your CSV files into the Clinic Tools module in PhilaVax

 

Contact the VFC or VFAAR program if you need assistance or have additional questions:

Storage and Handling Coordinators

Alexis Bridges       phone: 215-685-6777

Adam Howsare     phone: 215-685-6777

TempCheck@phila.gov

 

VFC & VFAAR Coordinator

Jillian Brown          phone: 215-685-6424

Jillian.Brown@phila.gov

 

HPV vaccine for adults?

Notes from the Medical Director

Dr. Kristen Feemster
Dr. Kristen Feemster is the Medical Director of the Philadelphia Department of Public Health’s Immunization Program.

HPV vaccine for adults?

On October 5, 2018, the Food and Drug Administration expanded the age range for HPV vaccines to include 27-45 years old men and women. The change has gotten a lot of coverage in the media and perhaps you have been getting questions about the expanded age range from patients, family or friends. Why was this change made and what does this change mean for you?

FDA approval does not mean that recommendations have changed.
While the FDA has approved the expanded age range, the Advisory Commission on Immunization Practices (ACIP), who makes our recommendations about when and to whom to give approved vaccines, has not yet changed their recommendations about who should get HPV vaccines. So, for now, HPV vaccines recommendations still focus on 9-26 year old males and females.

The committee has been reviewing information about not only how well HPV vaccines work, but also how much of an impact it is likely to have on preventing HPV infections, in this older age group. Adding a new recommendation takes resources to make sure there is enough vaccine supply, raise awareness and get providers ready to stock and recommend a vaccine. The ACIP considers all of this before making changes to the program.

Why wouldn’t HPV vaccines be recommended for adults, especially since HPV is a sexually-transmitted infection?
Current recommendations for HPV vaccines target 11-12 years old adolescents for routine vaccination with catch up through age 26. Our current recommendation target younger age groups for several reasons:

  1. The goal of vaccination is to get everyone protected BEFORE exposure: HPV vaccines work by providing immunity before exposure to the HPV types covered by the vaccine. Since HPV is a sexually transmitted infection, that means before onset of sexual activity. The best way to make sure this happens is to get kids vaccinated just as they are entering adolescence, well before likely exposure. HPV is very common- almost all of us are exposed at some point during adolescence and adulthood.
  2. HPV vaccine can be given as a part of the adolescent vaccine platform: This approach also works well because young adolescents are coming in to get other vaccines, Tdap and MCV4, when they are 11 or 12 years old. This an excellent time to make sure adolescents have everything they need to keep them healthy as they enter middle and high school.
  3. We have data that shows how well the vaccines work in this age group: The immune response in younger adolescents is so good, only 2 doses of the HPV vaccine are needed if you start the series before age 15 years, compared to 3 doses for older teens.

Recommendations have not included adults because as we get older, we are more likely to be exposed to HPV. Since the vaccine protects us BEFORE exposure- it won’t help if we have already been infected by the types covered by the vaccine. So, for now, recommendations focus on early protection to get as much impact as possible.

If adults are more likely to already be exposed to HPV, why did the FDA approve the expanded age range?
Even though adults are more likely to be already exposed to HPV, adults are not likely to have been exposed to ALL the HPV types covered by the vaccine. That means that there may still be some benefit to vaccination. Let’s say you have a patient who has been exposed to types 6 and 16. Your patient would still be protected against the 7 other types covered by the vaccine.
To make its decision, the FDA considered benefit by reviewing studies that show how well the vaccine works in women and men ages 27-45 years old. These studies looked at two things: the immune response (antibody levels) and vaccine effectiveness (ability to prevent HPV disease) in this age group. These studies showed that there is a good immune response but effectiveness is not quite as high since adults may have already been exposed to HPV before vaccination. No studies showed any safety issues.

Does this mean that I should or shouldn’t vaccinate adults >27 years old?
Remember that recommendations from the ACIP still have not changed. Keep emphasizing routine vaccination for 11-12 year olds. This is the best and most cost-effective way to ensure good protection before exposure to any HPV and reduce the overall prevalence of HPV in the community. For this reason, it is difficult to know whether HPV vaccines will be recommended universally for adults aged 27-45 years old. But, there still may be room for individual decision making. While adolescents and young adults are at highest risk of first exposure to HPV once they become sexually active, that does not mean the exposure risk goes away. HPV vaccination for 27-45 year old adults could still provide protection against some HPV types, especially for adults who remain at risk of exposure (i.e. have a new partner). While our HPV vaccination rates have been improving, we are still below Healthy People 2020 goals so there are unvaccinated adults out there.

More to come…

Holiday Vaccine Shipping Delays

Vaccine Shipment Delays During the Holiday Season

Submit orders by December 7th

To make sure that you receive vaccines when you need them, submit orders by 3:00 PM on Friday, December 7. These will be processed and shipped out as usual. Be sure to check the status of your order 2 business days after submitting.

Orders submitted between Monday, December 10 and Friday, December 28 may not be delivered until the week of January 8th. The distribution center will return to normal operations on January 2.

 

During the holiday season – from mid-December to early January – the distribution center that ships vaccine provided through the Vaccines for Children (VFC) and Vaccines for Adults At Risk (VFAAR) programs will have reduced shipping capacity. Orders submitted during this time may take longer than usual to ship.

 

Contact the VFC or VFAAR program if you need assistance.

Provider Education Coordinators

Joani Schmeling      phone: 215-685-6490

Mohan Nagaraja      phone: 215-685-6872

 DPHProviderhelp@phila.gov

 

VFC & VFAAR Coordinator

Jillian Brown          phone: 215-685-6424

Jillian.Brown@phila.gov

 

Vaccine Order Specialists

Christine Wilson      phone: 215-685-6728

Christine.Wilson@phila.gov   

Charma Miller         phone: 215-685-6667

Charma.Miller@phila.gov

 

How bad can the flu get?

Notes from the Medical Director

Dr. Kristen Feemster
Dr. Kristen Feemster is the Medical Director of the Philadelphia Department of Public Health’s Immunization Program.

How bad can the flu get?

Flu season is challenging. First, we need a new flu vaccine every year because the flu virus is always changing.  Before each flu season, a new flu vaccine is developed to match the flu strain that scientists expect will be dominant during the upcoming season. Then, vaccine producers start manufacturing the vaccine and distribute it all over the world. Finally, local public health professionals like us here in Philadelphia work hard to remind everybody to get a flu vaccine as early as September to make sure everyone is protected before flu arrives.

From vaccine development to vaccine delivery, it is a large amount of work. But it is important work because flu is serious, every year. During the height of a bad flu season, up to 8% of all emergency room visits in the USA – 1 out of every 12 – is somebody who’s sick with the flu and hundreds of thousands of people are hospitalized with illness caused by the flu. Last year’s flu season killed an estimated 80,000 people in the USA.

Despite flu’s severity every year, too few people get the flu vaccine – immunization rates hover around 40% in the USA. Why? Often, I think we underestimate how bad flu can be. We call lots of things ‘the flu,’ including milder infections like the common cold. That can lead us to think that the flu does not really make you very sick. But influenza can invade your lungs and make you feel horrible. In severe cases, your lungs can get so inflamed that they stop working.

The worst example of how bad the flu can get was the 1918 flu pandemic. It was so bad that “cities ran out of wood for coffins” as the virus killed 3 to 5 percent of the world’s population – an estimated 50 to 100 million people. The 1918 pandemic was caused by a new strain of influenza. We have had pandemics since that time and will probably have more the future. And we will continue to have flu epidemics every season. While we now have more tools to prevent and treat influenza, we need to keep being prepared and keep working to reduce the toll that the seasonal flu takes on our population.

To help, we’ve got a Flu Toolkit that health care providers can use to boost flu vaccination rates at their clinics this fall and winter – and, of course, resources for Philadelphia residents to Get Your Annual Flu Shot.

VFC and VFAAR Re-Enrollment is Coming

VFC/VFAAR Re-enrollment is right around the corner!

The Philadelphia VFC/VFAAR annual re-enrollment period is November 1-30, 2018. Re-enrollment is a requirement for the VFC/VFAAR programs. Failure to complete the re-enrollment form will result in un-enrollment from the program.

We’re very excited to announce that for the first time, enrollment will be done electronically through PhilaVax. This will save you time and allow us to process enrollment forms quicker.

To get you ready for re-enrollment, complete these three steps now (if you have done so already).

  1. Complete the Clinic Tools Training

The electronic enrollment form is part of the Clinic Tools module in PhilaVax. You will not be able to access the enrollment form until you complete this training.

If you have not completed the Clinic Tools training, sign up now:  https://vax.phila.gov/index.php/notices/register-for-a-required-clinic-tools-training/

If you have completed the Clinic Tools training, check to make sure the contact and staff information for your site is up-to-date. Submit any updates to our program through the module.

  1. Renew your PhilaVax User Confidentiality Agreement

You must log into the PhilaVax IIS to access and complete the electronic form. If you have not completed the 2018 user confidentiality agreement renewal process or do not have a PhilaVax user account, use the link below to complete it now.

  1. Make sure your site’s Medical Director has a PhilaVax Account

Your medical director needs an active PhilaVax account in order to sign the enrollment form. You will not be able to submit the enrollment form without the medical director’s signature.

 

Click here to complete a PhilaVax User Confidentiality Agreement:

https://docs.google.com/forms/d/1nQ6Kp4WrlVEsx0Ud1QrxCdYRiYP3Rpd70xE0E0RKKsc

If you have trouble accessing the above link or your PhilaVax account and need to update your password, you can email PhilaVax@phila.gov or call 215-685-6784.

 

Additional information and instructions will be communicated closer to the start of the re-enrollment period on November 1st.

 

The historical impact of vaccines

Notes from the Medical Director

Dr. Kristen Feemster
Dr. Kristen Feemster is the Medical Director of the Philadelphia Department of Public Health’s Immunization Program.

The historical impact of vaccines

It can be so easy to lose sight of the incredible impact that vaccines have had on our society. Mike Bostock, a data visualization specialist, reminds us of the history of the measles vaccine with the data visualization below.

Measles used to be incredibly common, but when the vaccine was introduced to the US in 1963, cases plummeted. Bostock’s visualization shows this clearly: moving from left to right, the darker colors begin to fade, just as the number of cases in each state decline immediately following the introduction of the vaccine.

If there are so few measles cases in the U.S., do we still need to maintain high immunization rates? Yes. The dramatic impact of measles vaccine introduction is testament to both the individual and community effects with immunizations.  Vaccinated children were no longer getting infected themselves, and they could no longer spread measles to others.  But to see the community effects of measles vaccines, we do need high vaccination rates.  Measles is one of the most contagious vaccine-preventable disease out there so almost everyone needs to be protected to stop transmission.  When we keep our measles vaccination rates above at least 92%, we eliminate measles outbreaks.

Measles still affects about 20 million people per year worldwide.  No other vaccine-preventable illness causes as many deaths.  Most cases occur in developing areas of Africa and Asia but there are also tens of thousands of cases in several European countries due to decreasing immunization rates. In fact, the Centers for Disease Control and Prevention has issued travel advisories for places from which many of us may receive visitors or visit ourselves.  So the likelihood of being exposed to measles is very real.  If communities do not maintain high immunization rates, outbreaks can happen here as well.

Here at the Philadelphia Department of Public Health, we’ve done similar work to highlight the history of vaccines and their important public health impact. The history of vaccine-preventable diseases in Philadelphia shows how these diseases used to kill nearly 3,000 Philadelphians per year. As more vaccines were licensed and distributed, this death toll fell steadily until the modern era, when vaccine-preventable diseases only kill 11 Philadelphians per year.  Let’s work together to make sure these trends don’t change.

 

Measles in the USA

Is it time for a Lyme vaccine?

Notes from the Medical Director

Dr. Kristen Feemster
Dr. Kristen Feemster is the Medical Director of the Philadelphia Department of Public Health’s Immunization Program.

Is it time for a Lyme vaccine?

The New York Times recently reported what we’ve seen for several years now: that Lyme disease and other tick-borne diseases are spreading.

The US Centers for Disease Control and Prevention (CDC) and the Environmental Protection Agency (EPA) have both observed that Lyme disease has been rising. In fact, since 1990, Lyme disease cases in the USA have tripled.

So what’s going on? Well, climate change is probably a factor. Lyme disease is spread by blacklegged ticks, which are commonly found on deer and white-footed mice. Because of changes in weather patterns, their habitat is expanding – and, milder winters mean that fewer ticks die off each winter.

Health officials are pretty sure that this is only going to get worse. Whether you spend time in city parks or live in wooded areas, it is possible to find blacklegged ticks – and there are things we can do to prevent getting bitten by ticks.

What about a Lyme vaccine?

In 1998, a vaccine for Lyme disease was released. Four years later, the company that made it took it off the market: it just didn’t sell very well. There were concerns that the vaccine could be linked to autoimmune diseases, even though all of the studies about the vaccine found that it was safe. Plus, a lot of health care providers were unclear about who should get the vaccine.

That was several years ago. Now, with Lyme disease on the rise – and expected to continue rising – there are initiatives to develop a new vaccine to prevent Lyme disease and to also potentially prevent other infections spread by ticks. If a vaccine comes to market, then the US Advisory Committee on Immunization Practices (ACIP) would review the evidence and make recommendations about who should get the vaccine, and when.

Lyme disease can be serious – people with the disease can have symptoms that range from a rash to joint swelling to neurologic symptoms. No matter how it presents, Lyme disease is treatable and responds well to antibiotics, but it can sometimes take time for symptoms to go away completely. And while the CDC counts about 30,000 people per year in the USA getting Lyme disease, they’re pretty sure that the actual figure is much higher – up to ten times higher – due to cases not getting properly diagnosed or reported.

This is the time to build up our prevention tool box for Lyme disease. Preventing its spread will take a lot of different strategies: teaching the public to prevent tick bites, developing better insect repellents, and reducing tick habitat around people’s homes. But adding a vaccine to our prevention options could be another powerful tool.

How to defrost your storage unit

Storage units, especially freezers, can sometimes build up too much ice. When you need to defrost your VFC/VFAAR storage unit, TempCheck – our storage and handling coordinators – can help. TempCheck will help you safely storage the vaccine while you defrost the unit.

Use this guide to plan your defrost. Review it when you plan a defrost, and consult it during the defrost process.

If you have any questions, or if your vaccine is exposed to out-of-range temperatures during the defrost or transport process, contact TempCheck as soon as possible.

TempCheck
Adam Howsare and Alexis Bridges
TempCheck@phila.gov
215-685-6777

Plan and prepare

  1. Contact TempCheck to tell them that you are planning to defrost your unit. TempCheck will need to know when you plan to defrost, and where your back-up unit is. TempCheck will send you a backup DDL to monitor the back-up unit. Keep the packing material so you can send the DDL back to PDPH.
  2. Prepare the back-up DDL. Once you get the back-up DDL, temper the probe by putting it in your primary freezer. After 30 minutes, start up the DDL. Monitor temperatures for at least 1 hour. Alternatively, place the probe in your unit overnight and start the DDL the next morning.
  3. Move the vaccine. It’s time to move the vaccine. Leave the primary DDL in your primary unit while you defrost the primary unit.
    1. If your back-up unit is on-site: Move the vaccine and back-up DDL to your secondary unit. Note the time.
    2. If your backup unit is off-site: using the emergency transport guide, set up a hard-sided cooler for transport. Move the back-up DDL to the cooler. Place the probe in the middle. Move the vaccine into the cooler. Note the time. Transport the vaccine directly to the back-up location. Note the time the vaccine and DDL are moved into the back-up unit.

Defrosting your unit

  1. Note the time when you start defrosting your primary unit. The DDL will warm up, which will probably trigger an alarm.
  2. Allow the ice in the unit to melt.
  3. Turn the freezer back on. Wait until the DDL shows that the temperature is back in the normal range.
  4. Transfer the vaccines back into the freezer, using the same transport protocol that you used to move them to the back-up unit.

Dealing with the data

  1. Download the data from both data loggers and email it to TempCheck@phila.gov.
  2. Include the following information in the email:
    1. When you took the vaccine out of the primary unit
    2. When you put the vaccine into the back-up unit
    3. When you started defrosting the primary unit
    4. When you took the vaccine out of the back-up unit
    5. When you put the vaccine back into the defrosted primary unit
  3. Reconnect the DDL and continue temperature monitoring as usual
  4. Repackage the back-up DDL and send it back to PDPH.

The return of the flu spray: what changed?

Notes from the Medical Director

Dr. Kristen Feemster
Dr. Kristen Feemster is the Medical Director of the Philadelphia Department of Public Health’s Immunization Program.

The return of the flu spray: what changed?

For the 2018-19 flu season, the Advisory Committee on Immunization Practices (ACIP) added the intranasal live-attenuated influenza vaccine (LAIV) back to the list of recommended flu vaccines for children and adults. The LAIV is a flu vaccine given as a nasal spray instead of as a shot – which a lot of patients liked.

LAIV, the flu spray, was fist introduced in 2003. It initially appeared to work really well in children, so in 2014, the ACIP made a recommendation to prefer it. But 2 years later, they changed their minds, recommending against it for the past few seasons because of LAIV’s poor effectiveness.

So what changed? Why is it being reintroduced now? Let’s take a deeper dive.

How is LAIV different from other flu vaccines?

Most flu vaccines are “inactived influenza vaccines,” or IIVs. These are made by growing the flu virus in eggs, purifying it, and then inactivating the virus – killing it. It’s then given as a shot that teaches our immune system how to respond to an actual live flu virus – even though the IIV can’t reproduce to cause a flu infection.

We’ve been using this method to make flu vaccines since the 1940s. Since the flu virus changes each year, we have to make a new vaccine each year so that the vaccine matches up with the flu strain that’s likely to emerge most strongly each year.


  • IIV: inactivated virus, given with a shot
  • LAIV: weakened virus, given with a nasal spray

Unlike the IIV, the LAIV (live attenuated influenza vaccine) is made by growing the flu virus in egg cells, and then just weakening it instead of inactivating the virus. It’s then given as a nasal spray instead of a shot – and the weakened virus can reproduce just enough to spark an immune response in a patient’s body. Though the virus is live, it’s too weak to cause infection; and since it’s administered in the nose – which is how a lot of people are exposed to the flu – it can be an especially effective way to provide protection: following the same path the disease would follow.

So why was the LAIV removed from the list of recommended vaccines in 2016?

When LAIV was first introduced, it did appear to work a little better, especially in children. So in 2014, the ACIP gave LAIV a preferential recommendation – preferring the spray over the shot.

Shortly after that – once the spray was used more widely – the ACIP’s research showed that the spray stopped working as well as it initially did. For 3 years in a row, the spray didn’t perform any better than the shot. In fact, it was less effective. So, while the CDC worked to understand what happened, the ACIP removed their recommendation for the spray (LAIV).

So what happened?

Every flu vaccine protects against 3 to 4 strains of the flu. And, the CDC found that one of the flu strains in the spray didn’t reproduce well enough to spark a good immune response in patients. Since the spray relies on weakened but live virus to reproduce in order to trigger protection in a patient, this was a problem.

This flu strain was H1N1. We had several seasons where a lot of the flu disease was due to H1N1 – so the spray just didn’t provide as much protection as originally hoped.

Okay – so now the spray is back?

Yes. Once the CDC figured out the problem with the spray, the vaccine manufacturer replaced the H1N1 strain – which wasn’t reproducing well – with another strain that works better. They also checked to make sure that there’s a good immune response to the new LAIV.

The ACIP reviewed all of the changes and felt that the problem was addressed – so the spray was added back to the list of recommended flu vaccines for anyone between age 2 and 49.

Even though the ACIP recommends the spray, the American Academy of Pediatrics recommends the shot. Why do they disagree?

When the ACIP reviewed information about the new version of the spray – including studies on the spray’s effectiveness from other countries that continued to use it – they felt that the strong immune response was a good sign that the spray should work at least as well as the shot.

The AAP was also reassured, but they wanted to see more information on protection against the actual disease before they strongly recommended it. So, they decided to recommend the inactivated vaccine (the shot) over LAIV (the spray) until we learn more about the spray’s effectiveness once it’s used more broadly.

So what should I do?

Offer both vaccines.

The effectiveness of the flu vaccine always varies from year to year as researchers try to match the vaccine to the flu virus that they expect to dominate the flu season. Despite varying effectiveness, vaccination is our best method of protection against this virus that kills tens of thousands of people in the USA each year. Since some people decline the flu vaccine because of a fear of injections, having the spray available may increase the likelihood that patients will accept the vaccine.

Patients look to us – health care providers – to listen to their concerns and make recommendations that will keep them healthy. So let’s offer them choices that can help protect them, and let’s remind them that we get our flu vaccines to protect ourselves, our children, our patients, and our community too.

ProQuad now available through VFC

ProQuad vaccine now available through the VFC program

ProQuad is now available through the Philadelphia Vaccines for Children (VFC) program. ProQuad is a combination MMR (measles, mumps, and rubella) and Varicella vaccine. This combined vaccine lets you administer more vaccines with fewer injections.

About ProQuad

The CDC’s Advisory Committee on Immunization Practices recommends ProQuad for a patient’s second dose of MMR and varicella vaccine. As a first dose, ProQuad is associated with a slightly higher risk of febrile seizure, so use separate MMR and varicella vaccines for the first dose unless a parent prefers ProQuad.

Ordering ProQuad

Order ProQuad through PhilaVax at https://vax.phila.gov the way you normally order other vaccines. Before you order ProQuad for your VFC-eligible patients, you should also stock enough privately-purchased ProQuad to treat patients who are not eligible for VFC.

Protect adults from shingles with the new Shingrix vaccine

Protect adults from shingles with the new Shingrix vaccine

Shingrix (recombinant zoster vaccine) is a vaccine to protect healthy adults age 50 and older from shingles. You can now order Shingrix through the Vaccines for Adults At Risk program (VFAAR) for adults 50+ and uninsured.

About Shingrix

Administer Shingrix to adults age 50 and older, with two doses separated by 2 to 6 months.

Ordering Shingrix

Order Shingrix through PhilaVax at https://vax.phila.gov the way you normally order other vaccines. We recommend ordering a small amount, initially, to gauge demand. We will work with you to help figure out how much to order: our VFAAR coordinator will review orders and make adjustments to avoid wastage. Before you order Shingrix for your VFAAR-eligible patients, you should also stock enough privately-purchased Shingrix to treat patients who are not eligible for VFAAR.

Storing and Handling

Shingrix must be stored in the refrigerator. Administer it immediately after reconstitution or store it in the refrigerator and use it within 6 hours. Do not freeze Shingrix. If Shingrix freezes, it is spoiled.

Important changes to kids.phila.gov

Over the next few weeks, you’ll notice some changes to kids.phila.gov. We hope these changes will make it easier to find resources that will be helpful for you in your job.

The website looks a little different

We re-organized the information on the website so that it will be easier for you to find resources that you need to vaccinate Philadelphia’s residents. Take a look. If there’s something you’d like to see on the site, feel free to email us at Vaccines@phila.gov.

And the URL will change—so update your bookmark!

On Tuesday, June 26th, the  web site’s URL will change. You’ll find the site at https://vax.phila.gov. So update your bookmarks: starting June 26th, you won’t be able to find us at the old URL.  Use the new URL to access PhilaVax, the Immunization Information System, the same way you do now. So make sure to update your bookmark.

 

Register for a required Clinic Tools training

Good news! PhilaVax is adding a new tool called Clinic Tools.

Clinic Tools makes it easier to communicate temperature and clinic information with the VFC/VFAAR programs. Through Clinic Tools, you’ll be able to:

  • Keep track of storage units and data loggers
  • Upload temperatures directly to PhilaVax (no more faxing in paper logs, though you still need to keep them filed for 3 years)
  • Maintain up-to-date clinic contact information
  • Access and complete your annual VFC/VFAAR enrollment form

Register for a required Clinic Tools training

We need to train you to use this tool. You can attend the training from your own computer. Click here to register. Unable to register? Give us a call at  215-685-6872 (Mohan) or 215-685-6490 (Joani), or email us at  DPHProviderHelp@phila.gov and we can help you out.

Training dates

Morning times: 10 AM – 10.30 AM

  • December 11

 

Reminder: we need your emergency management plan

The VFC/VFAAR Emergency Vaccine Management Plan has been updated for 2018. This document helps both you and us prepare for an emergency – like if the power goes out or if your refrigerator or freezer stops working.

If you haven’t already done this, we need you to update your information on the Emergency Management Plan and send it to us. To update your plan:

  • Download the Emergency Management Plan here
  • Print a copy of the plan
  • Complete the first page and fax it to us at 215-238-6948
  • Gather the supplies needed for emergency transport (listed on pages 6-7) and store them near your storage units
  • Post the Emergency Vaccine Management Plan near your storage units

Keep vaccines safe while defrosting – check out our guidance

Freezers can sometimes build up too much ice. When you need to defrost your VFC/VFAAR unit, we can help you move or store your vaccine while you defrost your primary unit. Contact us for defrosting guidance.

 

2018 Storage and Handling Update

The Philadelphia Department of Public Health has updated storage and handling guidelines for the Vaccines for Children (VFC) and Vaccines for Adults At Risk (VFAAR) programs. This update includes:

  1. New policies
  2. New forms
  3. New tools
  4. Contact us

These new guidelines help ensure that the cold chain is preserved and vaccines are protected.

New policies
These policies ensure that each dose of vaccine administered to patients is viable and effective. Please share this information with all staff who work with VFC and VFAAR vaccines.

Using Digital Data Loggers: Monitor all VFC/VFAAR vaccine with a certified, calibrated digital data logger (DDL) during:

  • Routine onsite vaccine storage
  • Vaccine transport
  • Mass vaccination clinics

PDPH will store back-up DDLs at our offices. You may need a back-up thermometer to:

  • Defrost units
  • Monitor new units
  • Identify issues with your primary DDL

If you need a back-up thermometer, contact TempCheck at 215-685-6777.

Recording vaccine temperature: Continue to use paper temperature logs to check and record vaccine storage unit temperatures twice a day. Record the min and max temperatures at the start of each clinic day.

We will review paper temperature logs at our yearly compliance visits, or during unannounced storage and handling visits. Keep copies of both paper and digital temperature logs on file for at least 3 years.

Storing vaccine: To protect the viability of vaccine, it’s important to store vaccines at acceptable temperatures in appropriate storage units.

Dormitory-style (or bar-style) units – refrigerators with one exterior door and an evaporator plate (cooling coil) for freezing – are not reliable enough to safely store VFC/VFAAR vaccine.

Freezers that are part of a household combination refrigerator/freezer unit are also not acceptable for storing VFC/VFAAR vaccine. For vaccines that must be stored in a freezer, you must use a standalone freezer unit.

Never use dorm-style units or household freezers – even to temporarily store vaccine while your’e defrosting your main units.

New forms

Updated forms are designed to help you maintain the cold-chain at your site. Please download and review the updated documents and fill out the necessary forms. Download them here.

  • Paper temperature logs: use the new log with your certified, calibrated DDLs. Please review the instructions to make sure you’re documenting temperatures correctly.
  • Vaccine management plan: this ensures that you can protect the viability of VFC/VFAAR vaccine. Keep this near the vaccine storage units.
  • Emergency vaccine management plan: Keep this near your vaccine storage units. Fax page 1 to VFC/VFAAR, and whenever you make updates.
  • Out-of-range Temperature Response Form: use this to document when vaccines are exposed to out-of-range temperatures, determine if you can still use the vaccines, and report your findings.

New tool: Clinic Tools, a new feature coming to PhilaVax

We have a new tool in PhilaVax: Clinic Tools, which makes it easier for you to meet program requirements.

Over the next few months, we will contact Vaccine Coordinators to conduct Clinic Tools trainings – after which your site can use Clinic Tools to:

  • Submit temperature logs online
  • Keep up-to-date clinic information like phone numbers, address, staff information, and delivery hours

Contact us if you need assistance

We know that changes can be confusing, so don’t hesitate to be in touch if you have questions about what to do.

Questions about storage and handling, out of range temperatures, or the DDLs? Contact Adam Howsare and Alexis Bridges at 215-685-6777 or TempCheck@phila.gov.

Recommendations for the Meningococcal Serogroup B Vaccine

The Philadelphia Department of Public Health is issuing recommendations on when healthcare providers should recommend and administer the meningococcal serogroup B (MenB) vaccine to patients. In October 2014 and January 2015, the FDA licensed two MenB vaccines for people age 10 to 25 years.

Guidelines on when to recommend the MenB vaccine, and answers to common questions, are below.

Recommend MenB vaccine to people over age 10 if they’re at increased risk

For patients at higher risk, the Advisory Committee on Immunization Practices (ACIP) recommendation for MenB is a Category A recommendation: routinely recommend this to people with conditions that increase the risk of meningococcal disease.

Certain conditions affect a person’s ability to mount an effective immune respose against meningococcal disease. Give MenB vaccine to patients who:

  • Have complement deficiency
  • Have functional or anatomic asplenia (including patients with a history of sickle cell disease)
  • Take eculizumab (Solaris), an immunosuppressive medication that supresses complement

Also give MenB vaccine to people who are part of a MenB outbreak – for example, to students at a high school or university with an active MenB outbreak. Make this determination in consultation with the Health Department.

Individual clinical decision: give MenB to people age 16 to 23

For most patients, the ACIP recommendation for the MenB vaccine is a Category B recommendation: the vaccine may be given to patients age 16 to 23 – preferably between 16 and 18 – to provide short-term protection from most strains of serogroup B meningococcal disease.

Meningococcal infections are fairly rare, with fewer than 500 reported cases per year in the United States and 50 to 60 cases due to serogroup B among adolescents and young adults. The highest rates of infection are among adolescents, especially older adolescents, even those who do not attend college or live in a dormitory. Giving the vaccine to people age 16 to 18 will protect them when they are at the highest risk of infection.

MenB questions and answers

How are MenB vaccines different from the other meningococcal vaccine that we give to adolescents?

There are now two types of meningococcal vaccine:

  • MCV4 (quadrivalent meningococcal conjugate vaccine) protects against 4 different meningococcal serogroups: A, C, W, and Y. It is routinely recommended for all 11-12 year olds with a booster dose at 16 years.
  • MenB vaccines only protect against serogroup B.

There is no single vaccine that protects against all of these types (A, B, C, W, and Y) at the same time.

Can MenB be given simultaneously with MCV4?

Yes, MenB and MCV4 can be administered at the same visit but if possible, in different arms. Since the MCV4 booster and Men B are recommended for the same age range, simultaneous administration may happen.

How many doses of the MeB vaccine do I need to give?

The 2 different MenB vaccines have different dosing schedules:

  • Bexsero: give in 2 doses (0 and >1 month after the first dose), regardless of risk status
  • Trumenba: give in 2 doses (0 and 6 months after the first dose) for healthy adolescents. Give in 3 doses (0, 1-2 months, and 6 months after the first dose) to adolescents with high risk conditions or during a MenB outbreak

Does it matter which MenB vaccine I offer?

You can use either one of the MenB vaccines – the CDC does not have a preference for either product. However, the two MenB vaccines are not interchangeable: you should use the same MenB vaccine for all doses in the series.

If your patient has HIV, the CDC recommends the 3-dose Trumenba series, though the 2-dose Bexsero may also be used.

Why is there a Category B recommendation for MenB vaccines?

The ACIP bases their recommendation on tow main factors:

  1. An overall low prevalence of meningococcal disease. The ACIP considered the number of potential cases prevented with different recommendation strategies. Targeting older adolescents, young adults, and individuals with high risk conditions would prevent the most cases for the number of individuals vaccinated.
  2. The ACIP is awaiting more data on duration of protection and vaccine effectiveness. Right now we know that vaccination increases antibodies against meningococcal B which is used as a measure of protection rather than reduction in clinical disease. The low prevalence of disease makes it difficult to measure the impact of actual infection. We also do not know how long protection will last. Based on current data, antibody levels are still elevated at about 3 years. This is why the vaccine is recommended for short term protection, targeting older adolescents.

Should I recommend it to teens going off to college?

MenB has been associated with recent outbreaks, many of which have been on college campuses. Therefore, some colleges may recommend or require both MCV4 and MenB vaccination.

Age 16 to 23 is the highest age-related risk period for any older adolescent and young adult, even if they are not attending college. The risk of exposure to meningococcus is associated with many behaviors that any adolescent and young adult may engage in, such as intimate kissing, tobacco exposure, large social gathering, and living in a dormitory. This is why MenB vaccine should be preferentially administered to people age 16 to 18.

Am I required to keep it on hand and offer it like the rest of the vaccines on the schedule?

No, there is no requirement to have MenB in stock because of the recommendation to offer vaccination for certain high risk conditions or at your discretion.

However, having MenB vaccine in stock will help ensure that you can provide MenB vaccination for your patients whom you do want to vaccinate and avoid missed opportunities. It is also important to have MenB available if you have patients with any high risk conditions for whom MenB vaccines should be given.

Am I in trouble if I don’t offer it?

Because MenB has a Category B recommendation, there are no penalties if you choose not to offer the vaccine. However, you may be asked about MenB during your regular VFC program audit visit so that we can help answer any questions that you may have.

Will private insurers pay for it?

Health plans are required to cover new vaccine recommendations without cost sharing within one year of the publication of the new recommendation. MenB recommendations were published in October 2015.

I’m just not sure how to proceed with this Category B recommendation.

This is a new vaccine that can help prevent meningococcal disease due to serogroup B for the age group at highest risk of infection. We do not see a lot of meningococcal disease but when we do, there can be significant morbidity and mortality that is difficult to predict. A higher proportion of the disease we do see is due to serogroup B which, until now, we have not been able to prevent through vaccination. When your patients come to clinic for their MCV4 booster, the MenB vaccine can be offered as an option to all 16-18 year old patients. Parents or teens may also request MenB.

The only way to see any of the potential benefits of vaccination is to provide the vaccine.