W H AT ' S I N S I D E ImmunGiezoergia dph.georgia.gov A publication of the Georgia Department of Public Health SUMMER 2020 Maintaining Clinical Preventive Services, Including Immunizations, During the COVID-19 Pandemic Maintaining Clinical Preventive Services, Including Immunizations, During the COVID-19 Pandemic Vaccine Preventable Viral Hepatitis Preventing Perinatal Hepatitis B Transmission Provider Resources Flu Season 2020 Immunize Georgia Annual Conference The COVID-19 pandemic is rapidly changing and continues to affect communities across the United States differently. Clinicians must maintain access to clinical services in environments that are safe for all. Some of the strategies being used to slow the spread of disease in communities include postponing or cancelling non-urgent elective procedures and using telemedicine instead of face-to-face encounters for routine medical encounters. Clinics working with children: Healthcare providers in communities affected by COVID-19 are using strategies to separate well visits from sick visits. Examples include: Scheduling well visits in the morning and sick visits in the afternoon. Separating patients spatially, such as by placing patients with sick visits in different areas of the clinic or in another location from patients with well visits. Collaborating with providers in the community to identify separate locations for holding well visits for children. Healthcare providers should identify children who have missed well-child visits and/or recommended vaccinations and contact them to schedule in person appointments, starting with newborns, infants up to 24 months, young children and extending through adolescence. State-based immunization information systems and electronic health records may be able to support this work. All newborns should be seen by a pediatric healthcare provider shortly after hospital discharge (3 to 5 days of age). Ideally, newborn visits should be done in person during the COVID-19 pandemic in order to evaluate for dehydration and jaundice, ensure all components of newborn screening were completed and appropriate confirmatory testing and follow-up is arranged, and evaluate mothers for postpartum depression. Developmental surveillance and early childhood screenings, including developmental and autism screening, should continue along with referrals for early intervention services and further evaluation if concerns are identified. Clinics working with adults: Delivery of some clinical preventive services for adults, such as immunizations, requires face-to-face encounters. In areas with community transmission of SARS-CoV-2, these services should be postponed except when: An in-person visit must be scheduled for some other purpose and the clinical preventive service can be delivered during that visit with no additional risk; or An individual patient and their clinician believe that there is a compelling need to receive the service based on an assessment that the potential benefit outweighs the risk of exposure to the virus that causes COVID-19. CDC is monitoring the situation and will continue to provide guidance at cdc.gov/coronavirus/2019-ncov/hcp/ preparedness-checklists.html for adult recommendations and cdc.gov/coronavirus/2019-ncov/hcp/pediatric-hcp. html for pediatric recommendations. 4 ImmunGiezoergia 1 Vaccine Preventable Viral Hepatitis The term "hepatitis" refers to the inflammation of the liver, which can be caused by multiple factors, such as alcohol or substance abuse, toxins, medications, autoimmune disease, and both bacterial and viral infections. There are five types of viral hepatitis (A, B, C, D, and E); however, hepatitis A, B, and C are the most common. Hepatitis A and B are both vaccine preventable. There is no vaccine for hepatitis C. Symptoms of newly acquired viral hepatitis infection can include fever, fatigue, nausea, vomiting, diarrhea, abdominal pain, headache, loss of appetite, dark urine, clay-colored bowels, joint or muscle pain and/or jaundice (yellowing of the skin and eyes). Not everyone will experience symptoms (or all of these symptoms) when first infected with viral hepatitis. HAV and hepatitis B is vaccine preventable Hepatitis A Virus (HAV) HAV is spread through fecal-oral contact, typically through close contact with someone who is infected with HAV and contaminated food or water. HAV infection is an acute infection and most people will resolve the infection within 6 months of exposure. Once resolved, the person will develop lifelong immunity against HAV. HAV is vaccine preventable. The vaccine is a two-dose series and is recommended for: Children at 1 year of age People traveling to countries with a high incidence of HAV Men who have sex with men Illicit drug users (injection and non-injection) Homeless individuals; and Individuals with chronic liver disease, such as chronic hepatitis B or hepatitis C. The hepatitis A vaccine can provide pre- and postexposure protection. If someone has been exposed to HAV and has not been vaccinated against HAV, then it is recommended that anyone over 12 months of age receive the hepatitis A vaccine as post-exposure prophylaxis (PEP). Immune Globulin (IG) can be provided for contacts that are less than 12 months of age or anyone that is immunocompromised or has chronic liver disease. PEP must be provided within 14 days of the last exposure. (cdc.gov/mmwr/volumes/67/wr/mm6743a5.htm) Since 2016, 33 states, including Georgia, have reported experiencing HAV outbreaks, spread through close person-to-person contact. These outbreaks have been occurring primarily among those who use injection and non-injection drugs, homeless individuals and their close 2 ImmunGiezoergia contacts. Increases in HAV infection are also being seen among men who have sex with men. Since June 2018, Georgia has reported over 1,000 confirmed HAV infections. Similar to the trends being seen in other state outbreaks, HAV infections seen in Georgia have primarily been among injection and noninjection drug users, men who have sex with men and their close contacts. In response to the HAV outbreak, DPH has worked closely with local health department staff, healthcare providers and community organizations to not only increase awareness about HAV, but also increase administration of hepatitis A vaccinations among high-risk populations. Between June 2018 and March 2020, 112,798 adult doses of hepatitis A vaccine have been administered among both public health clinics and private providers. HAV infections are continuing to be reported in 2020; however, there have been decreases in the number of infections being reported. Count of Cases Figure 1: Confirmed HAV Infections, Georgia, June 1, 2018 to April 11, 2020 100 83 91 88 82 80 74 71 72 75 70 60 47 40 39 52 57 49 30 20 6 6 10 3 12 14 16 8 0 JUNE 20JU1L8AYU2G0S1UE8PSTTE2M01BO8ECRT2O0NB1O8ERVE2M01DB8EERCE2M01B8JEARN2U0A1F8REYBR2U01A9RYMA20R1C9H 2A0P1R9IL 20M19AY 20JU1N9 E 20J1U9LAYU2G0SU1E9SPTTE2M01BO9ERCT2O0N1B9OERVE2M01DB9EERCE2M01B9JEARN2U0A1F9REYBR2U02A0RYMA20R2C0H 2A0P2R0IL 2020 Month of Infection Source: GA DPH State Electronic Notifiable Disease Surveillance System (SendSS) Hepatitis B Virus (HBV) HBV is spread through exposure to blood or body fluids. Transmission most commonly occurs through sexual contact, injection drug use, having a close household contact, and perinatal exposure (from an infected mother to baby at birth). Pregnant women should be tested for Hepatitis B Surface Antigen (HBsAg) during each pregnancy. 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 an 80 to 90 percent chance of developing chronic hepatitis B infection. Those infected as adults have a 10 percent chance of developing chronic infection. Hepatitis B is vaccine preventable. Vaccination is recommended for: All children from birth to 18 years of age Men who have sex with men Illicit drug users Those with multiple sex partners Those with a recent STD diagnosis Homeless adults Household contacts and sexual partners of HBV- positive individuals; and Case Count Individuals with HIV and/or chronic hepatitis C infection. 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 or HIV-positive individuals. Acute (newly acquired) HBV infections continue to be reported in Georgia, primarily among those between 30 and 50 years of age. These trends highlight the need and importance of promoting hepB vaccination among adults. 4 Figure 2: Confirmed Acute HBV Infections, Georgia, 2015 to 2019 250 200 150 100 50 0 2015 2016 2017 2018 2019 Year of Symptom Onset Preventing Perinatal Hepatitis B Transmission Hepatitis B virus (HBV) can be transmitted vertically from an infected mother to her newborn at birth. Infants infected with HBV have an 80 to 90 percent risk of developing chronic infection, increasing their risk for cirrhosis of the liver, liver cancer and death. All medically stable infants weighing >2,000 grams should receive the hepatitis B vaccine (HepB) within 24 hours of birth. The birth dose of HepB vaccine serves as postexposure prophylaxis to prevent HBV infection and serves as a safety net for infants born to hepatitis B surface antigen (HBsAg)-positive mothers not identified prenatally. HepB vaccine given alone is 75 percent effective in preventing perinatal HBV transmission. Combining hepatitis B immune globulin (HBIG) with the HepB vaccine birth dose increases the efficacy to 94 percent. The Centers for Disease Control and Prevention estimate that 500700 HBV-exposed births occur annually in Georgia; however, in 2018, 297 HBV-exposed births were identified by the Georgia Department of Public Health (DPH). The discrepancy in estimated and identified births highlights the importance of Combining HBIG with the HepB vaccine birth dose increases the efficacy to 94 percent. Continued on page 4... ImmunGiezoergia 3 All medically stable infants weighing >2,000 grams should receive the hepatitis B vaccine (HepB) within 24 hours of birth. Preventing Perinatal Hepatitis B Transmission continued from page 3 ... administering the HepB birth dose and verifying the mother's HBsAg result during hospital newborn exams to protect unidentified exposed newborns. Infants born to HBsAg-positive women require additional interventions to help prevent transmission. The Advisory Committee on Immunization Practices (ACIP) recommends the following interventions: Management of Infants Born to HBsAg-Positive Women1 HepB vaccine and HBIG must be administered within 12 hours of birth. The HepB vaccine series should be completed according to the recommended schedule for infants born to HBsAg-positive mothers, which recommends completing the series at 6 months of age. - For infants weighing <2,000 grams, the birth dose should not be counted as part of the vaccine series because of the potentially reduced immunogenicity of HepB vaccine in these infants; 3 additional doses of vaccine (for a total of 4 doses) should be administered beginning when the infant reaches age 1 month. The final dose in the series should not be administered before age 24 weeks (164 days). Postvaccination serologic testing for anti-HBs and HBsAg should be performed after completion of the vaccine series at age 912 months. - Testing should not be performed before age nine months to avoid detection of passive anti-HBs from HBIG administered at birth and to maximize the likelihood of detecting late HBV infection. Anti-HBc testing of infants is not recommended because passively acquired maternal anti-HBc might be detected in infants born to HBsAg- positive mothers up to age 24 months. - HBsAg-negative infants with anti-HBs levels 10 mIU/mL are protected and need no further medical management. - HBsAg-negative infants with anti-HBs <10 mIU/mL should be revaccinated with a single dose of HepB vaccine and receive postvaccination serologic testing 12 months later (new recommendation). Infants whose anti-HBs remains <10 mIU/mL following single dose revaccination should receive two additional doses of HepB vaccine to complete the second series, followed by postvaccination serologic testing 12 months after the final dose. - Based on clinical circumstances or family preference, HBsAg-negative infants with anti-HBs <10 mIU/mL may instead be revaccinated with a second, complete 3-dose series, followed by postvaccination serologic testing performed 12 months after the final dose of vaccine. - HBsAg-positive infants should be referred for appropriate follow-up. The Georgia Perinatal Hepatitis B Prevention Program provides case management services to HBV-exposed infants and children to ensure they complete HepB vaccination and testing at the recommended time frames. Perinatal hepatitis B exposures are a reportable condition in Georgia and must be reported to DPH within seven days of identification. Your office may be contacted by public health to notify your practice of an exposure or to coordinate services. For additional information or to report HBV-exposed infants, please contact the Georgia Perinatal Hepatitis B Prevention Program by phone at (404) 651-5196 or visitdph.ga.gov/perinatal-hepatitis-b. 4 4 ImmunGiezoergia 1Schillie S,Vellozzi C, Reingold A, et al. Prevention of Hepatitis B Virus Infection in the United States: Recommendations of the Advisory Committee on Immunization Practices. MMWR Recomm Rep 2018;67(No. RR-1):131. DOI: cdc.gov/mmwr/volumes/67/rr/rr6701a1.htm Provider Resources CDC Vaccine Schedules App for Health Care Providers Healthcare providers who recommend or administer vaccines can immediately access all CDC recommended immunization schedules and footnotes using the CDC Vaccine Schedules app. Optimized for tablets and useful on smartphones, the app shows child, adolescent and adult vaccines recommended by the Advisory Committee on Immunization Practices (ACIP). The app visually mimics the printed schedules, which are reviewed and published annually. Users can identify correct vaccine, dosage, and timing with two or three clicks. Any changes in the schedules will be released through app updates. This app is one of an expanding collection of applications from CDC on a variety of topics, each optimized for your mobile device. This free tool provides the most current version of the: Child and adolescent schedule with immunization recommendations from birth through age 18 Catch-up schedule for children and adolescents 4 months through 18 years Adult schedule, including recommended vaccines for adults by age group and by medical conditions Adult Contraindications and precautions table Features of the app: Color coding coordinates with printed schedules Hyperlinked vaccine name opens as a pop-up with dose specifics Catch-up schedule for children and adolescents Related vaccine resources and websites are included Any changes in the schedules will be released through app updates For more information please visit: cdc.gov/vaccines/ schedules/hcp/schedule-app.html#download. 4 Flu Season The COVID-19 pandemic is affecting healthcare seeking behavior. The number of persons and their reasons for seeking care in the outpatient and ED settings is changing. Laboratory-confirmed flu activity as reported by clinical laboratories is now low. In the United States, flu season occurs in the fall and winter. While influenza viruses circulate year-round, most of the time flu activity peaks between December and February, but activity can last as late as May. Take everyday preventive actions to stop the spread of germs. Try to avoid close contact with sick people. While sick, limit contact with others as much as possible to keep from infecting them. If you are sick with a flu-like illness, CDC recommends that you stay home for at least 24 hours after your fever is gone except to get medical care or for other necessities. (Your fever should be gone for 24 hours without the use of a feverreducing medicine.) Cover your nose and mouth with a tissue when you cough or sneeze. After using a tissue, throw it in the trash and wash your hands. Wash your hands often with soap and water. If soap and water are not available, use an alcohol-based hand rub. Avoid touching your eyes, nose and mouth. Germs spread this way. Clean and disinfect surfaces and objects that may be contaminated with germs like flu. For more information please visit: cdc.gov/flu/prevent/ actions-prevent-flu.htm. 4 ImmunGiezoergia 5 VACCINATIONS: BREAKING THROUGH THE MYTHS CONFERENCE POSTPONED 2020 Immunize Georgia Annual Conference This year's annual Immunize Georgia Conference will be postponed, due to the current COVID-19 pandemic and the uncertainty it has placed on our public and private health care communities. The safety of our participants is our top priority, and this decision is in the best interest of all conference attendees, supporters and speakers. In lieu of the face-to-face conference, we want to continue to develop ways to promote immunizations throughout Georgia. To keep the health care community apprised of the latest immunization requirements, recommendations and best practices, we plan to develop creative, yet practical, ways of educating providers and equipping them with the tools and resources needed to keep our citizens protected. Despite current conditions, our cause remains the same: to improve Georgia's immunization rates and protect every adult and child from vaccine-preventable diseases. We will remain vigilant and continue to maintain immunization coverage rates and reduce the burden of vaccine preventable diseases in Georgia. We are actively monitoring all updates from the National Institutes of Health, as well as information and guidance from the U.S. Centers for Disease Control and Prevention to ensure we communicate the most accurate and relevant information. 6 ImmunGiezoergia As we continue to develop conference-related content, materials and resources, please ensure you are subscribed to conference updates via email at immunizegeorgia. com/subscribe. If you have any additional questions about the conference, please visit us online at immunizegeorgia.com, email us at ImmunizeGeorgia@golin.com or call us at (470) 419-8666. 4 SUBSCRIBE TO CONFERENCE UPDATES