W h at ' s I nsi d e ImmunGiezoergia A publication of the Georgia Department of Public Health 2012 issue 2 Kay Davis Receives 6th Annual Clay Coleman Excellence in Customer Service Award Did You Know? Truth & Consequences: Hepatitis Perinatal Hepatitis G.R.I.T.S. Congratulations to the recipients of the 2011 Walt Orenstein Champions for Immunization Awards Advisory Committee on Immunization Practices (ACIP) Update: New Recommendations for Tdap Vaccine To help prevent pertussis in both mother and newborn, the ACIP now recommends that women's health care providers implement a Tdap vaccination program for pregnant women who previously have not received Tdap. Health care providers should administer Tdap during pregnancy, preferably during the third trimester or late second trimester (after 20 weeks' gestation). If not administered during pregnancy,Tdap should be administered immediately postpartum. Adolescents and adults who have, or who anticipate having close contact with an infant younger than 12 months (e.g., parents, siblings, grandparents, child care providers and health care providers) and who previously have not received Tdap should receive a single dose of Tdap to protect themselves and the infant against pertussis. As part of standard preventive care, if a tetanus and diphtheria booster vaccine is indicated, or a tetanus toxoid-containing vaccine is recommended for wound management in a pregnant woman,Tdap should always replace the tetanus toxoid-containing vaccine if the woman has not previously received Tdap. Pregnant women who have never been vaccinated against tetanus should receive three vaccinations containing tetanus and reduced diphtheria toxoids. The recommended schedule is zero, 1 month, and 6 months to 12 months. Tdap should replace one dose of Td, preferably during the third or late second trimester of pregnancy, if the woman has not previously received Tdap. Reference: CDC. Updated recommendations for use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine (Tdap) in pregnant women and persons who have or anticipate having close contact with an infant aged <12 months Advisory Committee on Immunization Practices (ACIP), 2011. MMWR 2011;60(No.40). ImmunGiezoergia 1 (L-R) Kay Davis and Clay Coleman Kay Davis Receives 6th Annual Clay Coleman Excellence in Customer Service Award A role model for providing excellent customer service in the Southeast Health District, the 2011 recipient of the Clay Coleman Excellence in Customer Service Award was Kay Davis. The Clay Coleman Excellence in Customer Service Award is named for Clay Coleman, who received the Service Excellence Award from the Georgia Immunization Program for his commitment to provide exceptional customer service for the program from 1993 to 2006. The Award is presented to a Georgia Immunization Program employee who exhibits excellent customer service. Davis' knowledge of the Immunization Program and her desire to advocate for the benefits of vaccination against disease make her an enormous resource, not only to staff in the 16-county health departments, but to district staff, other agencies and the public. As the Immunization Program manager, Davis worked tirelessly to coordinate the school flu vaccination project sites and provide student packets. She collaborated with 16 county nurse managers and school districts in the Southeast Health District 9-2 to accomplish a highly successful school flu project, which ran for four months and resulted in nearly 13,000 doses of flu vaccine to students in 142 schools. Did you know? Viral Hepatitis Facts HEPATITIS A is transmitted through fecal-oral contact via: Contaminated food or water International travel Household or sexual contact Men who have sex with men Injection drug use There is a vaccine available to prevent hepatitis A. HEPATITIS B is transmitted through exposure to blood or body fluids via: Sexual contact Sharing needles or syringes or other drug equipment Perinatal exposure Close household contact Occupational exposure There is a vaccine available to prevent hepatitis B. HEPATITIS C is transmitted through exposure to blood via: Sharing needles or syringes or other drug equipment Getting tattoos or piercings from an unlicensed, non-professional parlor Blood transfusions prior to 1992 Clotting factors prior to 1987 Long-term hemodialysis Perinatal exposure Occupational exposure Sexual contact There is NO vaccine to prevent hepatitis C. 2 Immunize Georgia Truth & Consequences A publication of the Georgia Department of Publlic Health Guide to Viral Hepatitis What is hepatitis? The term "hepatitis" means inflammation of the liver. This inflammation can be caused by multiple factors, such as toxins, certain medications, specific medical conditions, and alcohol use. However, most often it is caused by a virus. What are the common types of viral hepatitis? The most common types of viral hepatitis in the United States are hepatitis A, B and C. Although symptoms for each type of viral hepatitis are similar, each has different transmission risks and levels of severity. Hepatitis A virus (HAV) is spread through fecal-oral contact, typically through contaminated food or water; international travel to countries with a high prevalence of HAV; or being a household or sexual contact of someone infected with HAV. Men who have sex with men (MSM) and injection drug users (IDUs) are also at high risk for HAV. HAV is an acute (short-term) infection and, once resolved, provides lifelong immunity. Hepatitis B virus (HBV) is spread through exposure to blood or body fluids. Transmission most commonly occurs through sexual contact, illegal and/or injection drug use, having a close household contact, and perinatal exposure (from an infected mother to baby at birth). Most people that become infected with HBV will recover within six months; however, many will develop a chronic (lifelong) infection. Babies infected at birth by an infected mother have a 90 percent chance of developing chronic hepatitis B infection. Those infected as adults have a 10 percent chance of developing chronic infection. Hepatitis C virus (HCV) is spread through exposure to blood. Transmission occurs primarily among injection drug users. However, HCV also affects anyone who had a blood transfusion before 1992 or received clotting factors before 1987. Transmission through perinatal exposure (from an infected mother to baby at birth) is rare less than 5 percent risk. Transmission through a sexual contact is also rare; however, having multiple sex partners increases your risk. Approximately 15 percent to 20 percent of those infected will recover from HCV infection; however, the remaining 80 percent to 85 percent of those infected with HCV will develop a chronic (lifelong) infection. Symptoms of viral hepatitis can include: Fever Fatigue Loss of appetite Nausea with or without vomiting Abdominal pain Dark urine Clay-colored bowel movements Joint pain Jaundice (yellowing of the skin or eyes) Many people do not experience symptoms with hepatitis B or hepatitis C. However, chronic hepatitis B and hepatitis C infections can lead to complications such as cirrhosis, liver disease, liver cancer or liver failure. If you participate in any behaviors that put you at risk for viral hepatitis A, B or C, you should be tested and/or vaccinated. ImmunGiezoergia 3 How can I protect myself and my family against viral hepatitis? Hepatitis A is vaccine preventable. The vaccine is a two-dose series and is recommended for all children 12 months to 18 years of age; men who have sex with men; HIV-infected individuals; American-Indians and Alaska natives; refugees older than 19 years of age; illegal drug users; and individuals with chronic hepatitis B or chronic hepatitis C infection. Hepatitis B is vaccine preventable. The vaccine is a three-dose series and is recommended for all children from birth to 18 years of age; men who have sex with men; illegal drug users; those with multiple sex partners; those with a recent STD diagnosis; homeless adults; household contacts and sexual partners of HBV-positive individuals; individuals with chronic hepatitis C infection; and healthcare workers. Approximately 5 percent of people do not develop immunity after completing the vaccine series. Blood tests are available to test for immunity to ensure individuals are protected; however, this is not a routinely recommended practice except for specific risk groups such as infants born to hepatitis B infected women, HIVpositive individuals and healthcare workers. There is NO vaccine currently available to protect against hepatitis C. However, those that are infected with hepatitis C should be vaccinated against hepatitis A and hepatitis B to prevent additional damage and complications to the liver. What should I do if my child or I am exposed to someone with a hepatitis infection? If you are exposed to hepatitis A, B or C, you should talk to your primary care provider as quickly as possible. Blood tests are available to test for viral hepatitis to determine if you have been infected. For hepatitis A and hepatitis B, there are medications that can be given to protect you from developing the disease. If you have been exposed to hepatitis A and not previously vaccinated against hepatitis A, it is recommended that you receive the hepatitis A vaccine within two weeks of the exposure. This recommendation is for those between 12 months and 40 years of age. Immune globulin (IG) is available for those who have been exposed to HAV, but are too young to get hepatitis A vaccine or are over 40 years of age. If you have been exposed to hepatitis B and not previously vaccinated against hepatitis B, tell your 4 Immunize Georgia healthcare provider right away. You can receive an injection of hepatitis B immune globulin (HBIG) within 7 days or 14 days, depending on the type of exposure. Hepatitis B vaccine should also be given. Women who are infected with hepatitis B can transmit the infection to their infants during birth. It is important that all pregnant women get tested for hepatitis B during every pregnancy so that their infants can be given HBIG and hepatitis B vaccine within 12 hours of birth. This is highly effective in protecting the newborn from becoming infected. The infant should receive additional doses of hepatitis B vaccine at 1 month and 6 months of age. Follow-up blood tests should be ordered between 9 months and 18 months of age to confirm immunity to HBV. If you have been exposed to the hepatitis C virus, it is important to see a health care provider for a blood test right away and again in three months to six months after the exposure to determine if you are infected. There is no vaccine or IG currently available to prevent hepatitis C. Can hepatitis infections be treated? If infected with any type of hepatitis, the first step is to consult a physician. Hepatitis A infection will typically clear up on its own within six months with no treatment required; however, supportive care such as adequate rest, a healthy diet, plenty of fluids, and eliminating or reducing alcohol intake will be necessary. Treatment for acute hepatitis B infection is the same as that of hepatitis A. For chronic hepatitis B, there are antiviral medications available to slow the progression of the disease and to minimize the long-term effects and damage to the liver; however, treatment does not work for everyone. It is important that individuals with chronic hepatitis B regularly see a physician to monitor their liver health and progression of the disease. About 15 percent to 20 percent of individuals with hepatitis C will clear the virus on their own with no treatment. However, 80 percent to 85 percent will develop chronic infection. It is important for those with chronic infection to be monitored by a physician for liver health and progression of the disease. Treatments are available for hepatitis C infections; however, it is important to note that treatment does not work for everyone stressing the importance of being monitored by a physician. For additional information on viral hepatitis, visit http://health.state.ga.us/epi/disease/ hepatitis/ or http://cdc.gov/hepatitis Perinatal Hepatitis B The hepatitis B virus (HBV) is transmitted through contact with blood or body fluids of an infected person. HBV can be transmitted from mother to child during childbirth. Infants born to hepatitis B surface antigenpositive mothers are at risk of infection and have a 90 percent chance of becoming chronically infected with HBV, if appropriate precautions are not taken immediately following birth. When not treated, chronic hepatitis B is a serious health condition which can lead to cirrhosis, liver cancer, and death. The Centers for Disease Control and Prevention (CDC) recommends that all pregnant women be tested each pregnancy for the presence of hepatitis B surface antigen (HBsAg). A reactive HBsAg result indicates that the pregnant woman is infectious and could expose her newborn to HBV during delivery. Screening during every pregnancy is necessary to verify that the mother's HBsAg status has not changed and to ensure public health is alerted so that follow-up can occur. Prenatal providers should notify the delivery hospital prior to delivery when a pregnant patient is HBsAgpositive. An original copy of the woman's HBsAg lab result should be sent to the delivery hospital to reduce the risk of medical transcription errors. This will alert hospital delivery staff that the infant is high-risk for HBV and will need postexposure prophylaxis at birth. Pregnant women with unknown HBsAg status should be tested prior to delivery. Postexposure prophylaxis for newborns includes administration of hepatitis B immune globulin (HBIG) and the first dose of hepatitis B vaccine within 12 hours of birth. Administering HBIG and hepatitis B vaccine within 24 hours of birth is 85 percent to 95 percent effective in preventing acute and chronic HBV infection. The Advisory Committee on Immunization Practices (ACIP) recommends all infants receive hepatitis B vaccine at birth. The hepatitis B birth dose serves as a safety net for any high-risk infant who did not receive HBIG. The hepatitis B vaccine alone is 70 percent to 95 percent effective in preventing perinatal HBV infection. According to the American Academy of Pediatrics Red Book*, high-risk infants should receive the second dose of hepatitis B vaccine at 1 month to 2 months of age. The third dose of hepatitis B vaccine should be given at 6 months of age. A fourth dose is recommended for infants with a birth weight less than 2,000 grams. The schedule for infants less than 2,000 grams at birth is HBIG and hepatitis B birth dose; dose 2 at 1 month of age; dose 3 at 2 months; and dose 4 at 6 months of age. Recommended Hepatitis B Immunization Schedule for Persons Aged 0 Through 6 Years Age Hepatitis B Immune Globulin (HBIG) Hepatitis B Vaccine Post Vaccination Serologic Testing Birth X X 1-2 Months X 4 Months 6 Months X 9-18 Months X Low Birth Weight Infants (less than 4.4 lbs or 2,000 grams) should receive HBIG and 4 doses of vaccine at birth, 1, 2 and 6 months. Georgia Immunization Registry - GRITS GRITS is designed to collect and maintain accurate, complete and current vaccination records to promote effective and cost-efficient disease prevention and control. The Georgia Immunization Registry law, passed in 1996 and expanded by House Bill 1526, requires reporting by "any person who administers a vaccine or vaccines licensed for use by the United States Food and Drug Administration to a person." Several options are available for submitting immunization records to the Registry. Georgia's immunization providers also have quick and easy access to immunization records on individual children and are able to generate a variety of reports on their immunization status. For more information, visit http://health.state.ga.us/ programs/immunization/grits/. ImmunGiezoergia 5 Infants born to HBsAg-positive mothers should be tested for immunity after completing the hepatitis B vaccine series. Post vaccination testing (PVT) should include HBsAg and anti-HBs. These tests confirm whether the child developed immunity or has become infected with HBV. Infants that do not develop immunity are recommended to repeat the hepatitis B vaccine series and serologic testing. The parents of infants that do not develop immunity after the second series should be counseled about risk reduction strategies. Interpretation of Post Vaccination Testing (PVT) Hepatitis B Surface Antigen (HBsAg) Hepatitis B Surface Antibody (Anti-HBs) Positive Infected; Notify Public Health (no additional vaccine needed) Negative Not Infected Positive Immune to hepatitis B Negative No immunity; Revaccinate with another hepatitis B vaccine series. The Georgia Department of Public Health Perinatal Hepatitis B Prevention Program strives to protect infants born to HBsAg-positive mothers from being infected with the hepatitis B virus. Georgia is divided into 18 public health districts, each with a perinatal hepatitis B case manager. Case managers are responsible for tracking HBsAg-positive pregnant mothers throughout their pregnancies, ensuring their newborns receive HBIG & hepatitis B vaccine at birth, complete the hepatitis B vaccine series, and complete post-vaccination serologic testing. Perinatal hepatitis B cases are tracked for an average of 15 months from pregnancy to post-vaccination testing completion. For more information about Georgia's Perinatal Hepatitis B Prevention Program or to locate your local perinatal hepatitis B case manager, please call 404-651-5196 or visit our website at www.health.state.ga.us/ programs/perinatalhepatitisb. *Reference: American Academy of Pediatrics. Hepatitis B. In: Pickering LK, Baker CJ, Kimberlin DW, Long SS, eds. Red Book: 2009 Report of the Committee on Infectious Diseases. 28th ed. Elk Grove, IL: American Academy of Pediatrics; 2009; 347-350 Centers for Disease Control and Prevention: Recommended Childhood Hepatitis A and Hepatitis B Immunization Schedule Hepatitis A1 Hepatitis B Birth Dose 1 1 Month 2 Months 3 Months 4 Months 5 Months 6 Months 12 Months 15 18 Months Months (2 Doses)1 19-23 Months Dose 2 Dose 3 1Hepatitis A vaccine (HepA). (Minimum age: 12 months) Two doses of HepA vaccine are needed for lasting protection.The first dose of HepA vaccine should be given between 12 months and 23 months of age.The second dose should be given 6 months to 18 months later. HepA vaccination may be given to any child 12 months and older to protect against HepA. Children and adolescents who did not receive the HepA vaccine and are at high-risk should be vaccinated against HepA. Centers for Disease Control and Prevention: Recommended Adult Hepatitis A and Hepatitis B Immunization Schedule* Hepatitis A1 Hepatitis B 19-49 Years 50-64 Years 65 Year & Older 2 Doses (6-12 or 6-18 months apart)1 3 Doses (0, 1-2, 4-6 months) 1 Hepatitis A vaccine (HepA) Single-antigen vaccine formulations should be administered in a 2-dose schedule: initial dose and then 6 months to 12 months later for second dose (Havrix); or initial dose and 6 months to 18 months later for second dose (Vaqta). 6 ImmunGiezoergia Congratulations to the recipients of the 2011 Walt Orenstein Champions for Immunization Awards The Georgia Department of Public Health announced the winners of the 2011 Walt Orenstein Champions for Immunization on Sept. 15, 2011 at the 18th Annual Immunize Georgia Conference held in Macon, Georgia. The Walt Orenstein Champions for Immunization Award, named after Walt Orenstein, M.D., honors those who exemplify a standard in immunization care set forth in the Standards for Child Adolescent and Adult Immunization Practices. These standards are a national strategy to protect America's children against vaccine-preventable diseases and provide guidelines and resources to follow when providing immunizations. Dr. Orenstein achieved the highest immunization levels ever in the United States during his tenure of 26 years with the Centers for Disease Control and Prevention focusing on infectious disease and immunizations. He later worked as the deputy director for vaccine-preventable diseases at the Bill and Melinda Gates Foundation, but returned to Atlanta to renew his appointment as professor of medicine in the Department of Medicine at Emory University and serve as associate director of the Emory Vaccine. The 2011 recipients of the Walt Orenstein Champions for Immunization Award The Atlanta Women's Health Group One of the first OB/GYN practices to implement an immunization program for their patients, the Atlanta Women's Health Group realized it was not only good medicine but also made perfect business sense as a primary care provider. It was logical to also screen and immunize patients. The Atlanta Women's Health Group filled a gap for preventive medicine services for their patients. In addition to being one of the first OB/GYN practices to implement a full adult vaccination service for their clients, this group has greatly influenced other OB/GYN practices interested in adopting this model. They presented their information to the Georgia OB/GYN Society's board meeting and are now assisting other practices to understand how to incorporate an immunization program into their own practices. To learn more about their work, visit http://www.awhg.org/atlanta-womens-health-group--about-us. Upson County Health Department Nurses The nurses of Upson County Health Department (UCHD) are committed to providing quality nursing care. Demonstrated through their Immunization Program, UCHD provides not only childhood and adult vaccines but also travel vaccines to the community and surrounding areas. They go above and beyond what is necessary to ensure clients are fully immunized. Through a "tag team" approach, UCHD nurses review CDC recommendations with all clients, educating them on the benefits of receiving all recommended vaccinations. (L-R) Debra Crummie, LPN, Patsy Duke, RN, Lakeitha Lee, LPN, and Tina Kent, RN,WHNP Suzette Profit Suzette Profit (pictured left) works consistently and exceptionally to increase vaccination rates in Dougherty County. A leader in creative thinking, Profit is a leader in the Dougherty County Health Department Immunization Clinic. Last flu season, Profit created an influenza vaccination program working with the Albany Mall. She, along with others from the health department, worked early mornings, late nights and weekends educating shoppers and providing influenza,Tdap and other vaccines then available under American Recovery and Reinvestment Act (ARRA) funds. The Georgia Department of Public Health's Immunization Program congratulates the Atlanta Women's Health Group, Upson County Nurses and Suzette Profit for their extraordinary efforts to provide immunizations services in 2011. ImmunGiezoergia 7 Immunize Georgia c/o GolinHarris 1545 Peachtree Street NE, Suite 260 Atlanta, Georgia 30309 save the date 09.13.12 Georgia Department of Public Health presents the 19th Annual Immunize Macon Marriott City Center Geor gia 240 Coliseum Drive Macon, Georgia conference For information, call 404.367.2766 or e-mail immunizegeorgia@golinharris.com rev. 2.29.12