P Letter

Background

Postural tachycardia syndrome (POTS) is a syndrome where individuals experience a cluster of symptoms including an inappropriate level of tachycardia (rapid heartbeat) upon standing. The condition is more common in females, especially adolescents and young adults. There can be a number of associated symptoms, including dizziness, weakness, vision changes, difficulty concentrating, sleep disturbances or nausea.

Although the pathophysiology of POTS is yet to be fully understood, it is thought to be due to an abnormal autonomic nervous system response. When changing positions from sitting to standing, gravity sends blood to the legs and pelvis activating the sympathetic (fight or flight) nervous system, releasing noradrenaline. This tightens bloods vessels in the lower body so that blood is moved back to the heart, slightly increasing the heart rate, usually all in under a second, keeping blood pressure and bloody supply to the brain stable. In individuals with POTS, this process does not work as well as it should and the brain compensates by increasing the heart rate.

POTS can have an impact on quality of life, with many people experiencing both physical symptoms as well as other effects on mood, cognition and sleep. However, most cases can be successfully managed with lifestyle modifications. Medications are only required in rare circumstances.

POTS and vaccines

A diagnosis of POTS is not a contraindication to receiving vaccinations. In fact, some cases of POTS are thought to occur following an acute infection, some of which are vaccine-preventable. Therefore it is important that any individual who has a diagnosis of, or is concerned about, POTS should receive all recommended vaccinations.

Human papillomavirus (HPV)

There have been concerns previously after a small number of case reports described POTS being diagnosed following human papillomavirus (HPV) vaccination. However, this has been thoroughly assessed by the Centers for Disease Control and Prevention (CDC) and after examining the data from more than 80 million doses of vaccines, no causal link has been established between HPV vaccines and POTS.

COVID-19

There has not been an established link between COVID-19 vaccines and an increased risk of developing POTS. In fact, there have been reports of POTS developing after COVID-19 infection and POTS has been recognised as a post-covid condition (colloquially known as long COVID). Therefore being vaccinated against COVID-19 is recommended for individuals concerned about developing this condition.

Summary 

For individuals with a previous diagnosis of POTS who are concerned for a worsening of their condition after vaccination, it is important to consider that most vaccine side effects are mild and transient. Overall the benefits of vaccination are likely to far outweigh the risks. However, any concerns should be discussed with an individual’s treating healthcare practitioner.

Resources

• Baker Heart and Diabetes Institute: Orthostatic intolerance
• CDC: Questions about HPV Vaccine Safety
• CDC: Evaluating and Caring for Patients with Post-COVID Conditions: Interim Guidance
• Immunologic Research: Postural orthostatic tachycardia syndrome (POTS) and other autonomic disorders after COVID-19 infection: a case series of 20 patients

What is it?

Polio (poliomyelitis) is caused by a gastrointestinal (gut) infection with one of 3 types of polioviruses (serotypes 1, 2 or 3). Polioviruses are RNA enteroviruses from the Picornaviridae family.

Once an individual is infected, the poliovirus replicates in the gut and enters the bloodstream via lymphoid tissue where it can then cause symptoms in the central nervous system.

What to look for

Approximately 70% of polio infections are asymptomatic or present as a non-specific febrile illness. In symptomatic cases an individual may experience fever, headache, gastrointestinal disturbance (nausea and vomiting) or malaise. In severe infections muscle pain and stiffness of the neck and back can occur.

Paralysis typically presents asymmetrically and can be life threatening when the respiratory and swallowing muscles are affected. The extent of paralysis is usually seen within 3-4 days of symptom onset and any existing paralysis present after 60 days is likely to be permanent. It is estimated that flaccid paralysis occurs in less than 1 percent of all polio cases.

A recurrence of muscle weakness in the years after an initial polio infection is known as post-polio syndrome. It is attributed to a progressive loss or dysfunction of motor neurons as opposed to a persistent or reactivated infection.

How is it transmitted?

Wild polio is transmitted through contact with the faeces or saliva of an infected person and is most often associated with conditions of poor sanitation.

The incubation period of polio is 3-35 days, with a person infectious during the 7-10 days prior to the onset of symptoms. Following acute infection, a person can continue to excrete the polio virus for up to 6 weeks in their faeces, or 2 weeks in saliva.

Epidemiology

Polio infection predominantly occurs in children with the greatest burden of disease affecting those less than 5 years of age (80-90% of cases).

Global vaccination programs and high rates of immunisation have shown great success with the near eradication of wild polio worldwide. A total of 350,000 infections were reported in 1988 across 125 countries and in 2021 this was reduced down to 6 reported cases across countries including Pakistan and Afghanistan. The COVID-19 pandemic has greatly impacted these vaccination programs and since 2022 a resurgence of case across many countries (including the United States and the UK) have been reported, largely in pockets of unimmunised communities.

Prevention

Vaccination remains the most effective measure in disease prevention with protection available in Australia through the administration of a course of inactivated vaccines. Polio vaccination is funded on the National Immunisation Program (NIP) as a combination vaccine for children at:

• 6 weeks, 4 months and 6 months – Infanrix® hexa/Vaxelis®
• 4 years – Infanrix® IPV/Quadracel®

Individuals who missed a dose or who have an incomplete vaccine history should be offered immunisation to ensure that they are protected. Catch up vaccines are funded for some individuals.

Completing a primary course of vaccination generally provides life-long protection and booster doses are not routinely indicated for the broader population. However, they may be indicated for travellers visiting countries with known cases of polio.

Precautions

The oral live-attenuated polio vaccine is no longer available in Australia due to the potential low risk (1 case per 2.4 million doses) of Vaccine Associated Paralytic Poliomyelitis (VAPP), also known as Vaccine Derived Poliovirus (VDPV). Following receipt of the oral polio vaccine some of the vaccine virus may be shed in a person’s faeces for up to 6 weeks. In areas of low vaccine coverage this has the potential to cause disease in an unvaccinated individual.

Resources

• Australian Immunisation Handbook: Poliomyelitis
• CDC: Vaccines and Preventable Diseases – Vaccine Derived Poliovirus
• The Blue Book: Guidelines for the control of infectious diseases
• Australian Government Department of Health and Aged Care: Changes to the National Immunisation Program schedule from July 1 2023

Background

Pneumococcal disease is caused by Streptococcus Pneumoniae (pneumococcus), a bacteria that can live in the nose and throat (nasopharynx) of healthy people and in most cases does not cause illness or disease. However, in some cases the bacteria may grow and spread to other parts of the body.  Invasive pneumococcal disease (IPD) can manifest as meningitis, pneumonia, sinusitis, otitis media (ear infections), osteomyelitis (bone infection), joint infections and septicaemia (blood infection). The severity of illness can vary, with severe disease requiring hospitalisation, causing significant morbidity and even death. Certain individuals with specific medical conditions (advancing age, identifying as Aboriginal and Torres Strait Islander, Asplenia etc) may be considered at increased risk of IPD and therefore require additional protection.

Pneumococcal vaccines

There are currently two multivalent pneumococcal vaccines available for free on the National Immunisation Program (NIP).

1. Prevenar 13® (13vPCV) – a conjugate vaccine, providing protection against 13 different serotypes of pneumococcal (1, 3, 4, 5, 6A, 7F, 9V, 14, 18C, 19A, 19F, 23F). It is available on the NIP for individuals >6 weeks of age.
2. Pneumovax 23® (23vPPV) – a polysaccharide vaccine, providing protection against 23 serotypes of pneumococcal (1, 2, 3, 4, 5, 6B, 7F, 8, 9N, 9V, 10A, 11A, 12F, 14, 15B, 17F, 18C, 19F, 19A, 20, 22F, 23F and 33F). It is available on the NIP as an additional recommendation for individuals >4-years of age who are at increased risk of IPD (it is not recommended for those <2 years of age due to poor immunogenicity in this population).

Co-administration with other vaccines

13vPCV and 23vPPV may be co-administered with other vaccines on the NIP, including the quadrivalent influenza vaccine (QIV), live attenuated vaccines (MMR/Varicella/Zostavax®) and COVID-19 vaccines.

Consider where possible, different injection sites when co-administering pneumococcal and QIV in adults due to the increased risk of injection site reactions.

Common side effects of pneumococcal vaccines

• fever
• irritability
• lethargy
• pain at the injection site
• injection site reactions (redness, heat, swelling and tenderness)
• body aches

Note – In children, injection site reactions are more commonly reported as occurring within 24-48 hours following immunisation. In adults, injection site reactions may occur >3 days following the 13vPCV dose given at >70years, particularly in those who have previously received 23vPPV [see resources]. In both age groups a history of large local injection site reactions following previous pneumococcal vaccines is not a contraindication to further doses.

Current pneumococcal recommendations as of July 2020

Specific population groups are at an increased risk of IPD. Updated ATAGI advice relating to these population groups include:

• Children and adults with conditions that increase their risk from pneumococcal disease
• All Aboriginal and Torres Strait Islander older adults (age ≥50 years)
• All non-Indigenous older adults (age ≥70 years)

It is important for immunisation providers to familiarise themselves with the pneumococcal vaccine recommendations specific to each patient, recognising the variations to recommendations for different age groups, at-risk medical conditions, and Aboriginal and Torres Strait Islander status.

Table 1: Summary of pneumococcal vaccine recommendations for all age groups and risk-categories

*Maximum amount of 23vPPV in a lifetime is 2 doses
^ Refer to specific pneumococcal catch up advice if commencing immunisations late/delayed including Table. Catch-up schedule for 13vPCV for Aboriginal and Torres Strait Islander children living in NSW, Vic, Tas or ACT, and all children who do not have risk condition(s) for pneumococcal disease, aged <5 years and Table. Catch-up schedule for 13vPCV for Aboriginal and Torres Strait Islander children living in NT, Qld, SA or WA ONLY, and all children with risk condition(s) for pneumococcal disease, aged <5 years
§ For those individuals who have already received a dose 23vPPV, 13vPCV must be given ≥12-months after the 23vPPV
# In July 2020, 13vPCV replaced the 23vPPV that was previously funded at > 65-years. 13vPCV should still be given even if 23vPPV has been administered previously. In scenarios where 23vPPV was administered first, there should be a minimum interval of 12-months before giving 13vPCV

Resources

• Australian Immunisation Handbook: Pneumococcal disease
• Australian Immunisation Handbook: List. Risk conditions for pneumococcal disease
• ATAGI clinical advice on changes to recommendations for the use and funding of pneumococcal vaccines from 1 July 2020 
• NCIRS: Pneumococcal vaccines- frequently asked questions
• Better Health Channel: Pneumococcal disease
• Human Vaccines and Immunotherapeutics: Coadministration of 13-valent pneumococcal conjugate and quadrivalent inactivated influenza vaccines in adults previously immunized with polysaccharide pneumococcal vaccine 23: a randomized clinical trial

Background

Pharmacist immunisers are registered pharmacists who have completed additional training that allows them to administer approved vaccines to specified patient groups. This improves vaccine accessibility for the community which is particularly important to limit the spread of vaccine preventable diseases.

Pharmacist immuniser requirements

In addition to completing an immunisation program recognised by the Chief Health Officer, pharmacist immunisers are required to display their certificate of completing said training, hold current First Aid and CPR certificates, and ensure that another suitably qualified staff member is on site when immunising in pharmacy settings. Completion of further training modules are required prior to administering some vaccines (COVID-19, monkeypox and Japanese encephalitis)

Pharmacist immunisers are bound by the policies and procedures of their local jurisdiction. For more information on requirements of pharmacists in Victoria, refer to the Victorian Pharmacist-Administered Vaccination Program Guidelines.

Which vaccines can pharmacist immunisers administer in Victoria?

In Victoria, pharmacist immunisers are authorised to administer the following vaccines:

• influenza vaccines to those aged ≥ 5 years
• diphtheria– tetanus–pertussis vaccines to those aged ≥ 12 years
• measles-mumps-rubella vaccines to those aged ≥ 15 years
• meningococcal ACWY vaccines to those aged ≥ 15 years
• COVID-19 vaccines under a time limited approval
• human papillomavirus vaccines to those aged ≥ 12 years
• pneumococcal vaccines to those ≥ 50 years
• herpes zoster vaccines to those ≥ 50 years
• mpox vaccines to eligible individuals aged ≥ 5 years
• Japanese encephalitis vaccines to eligible individuals aged ≥ 5 years.

Resources

Pharmacist Immuniser Training Programs

• Pharmaceutical Society of Australia: Manage the delivery and administration of injections and immunisations- Victoria
• Pharmacy Guild of Australia, Victoria: Delivering immunisation in a community pharmacy setting

Other resources

• DHHS: Pharmacist immunisers
• DHHS: Pharmacist-administered vaccination services
• Victorian COVID-19 Vaccination Guidelines
• Victorian Pharmacist-Administered Vaccination Program Guidelines

A number of families and health care providers may wonder if immunisations are permitted based on religious beliefs, given the presence of gelatin derived from pork in some vaccines.

Leaders of the Jewish faith have declared that pork derived additives in medicines are permitted for those observant of the Jewish faith. Rabbi Abraham Adler, from the Kashrus and Medicines Information Service in the United Kingdom has advised:
“It should be noted that according to Jewish laws, there is no problem with porcine or other animal derived ingredients in non-oral products. This includes vaccines, injections, suppositories, creams and ointments”

Scholars of the Islamic Organization for Medical Sciences have also determined that the process by which the original pork product is transformed into gluten, alters it enough whereby it is permitted for observers of Muslim faith to receive vaccines. A 2001 letter from the World Health Organization Regional Office for the Eastern Mediterranean reported:
“the gelatin formed as a result of the transformation of the bones, skin, and tendons of a judicially impure animal is pure, and it is judicially permissible to eat”
Grand Mufti of Australia has also released supportive statements noting that the use of vaccines containing gelatin derived from pork is permitted for observant Muslims.

Seventh-Day Adventists are not forbidden to use pork derivatives in medical products.

If there are any queries regarding porcine products in vaccines please contact [email protected]

Resources

• Australian Government Department of Health: Questions about vaccination
• Institute for Vaccine Safety: Religious leaders approval of use of vaccines containing porcine gelatin
• NCIRS: Vaccine components fact sheet

Prematurity, particularly extreme prematurity (< 28-weeks gestation) and low birth weight infants often have associated chronic (special risk) medical conditions. This can be associated with prolonged hospitalisation and frequent clinic visits. These are some of the reasons premature infants are at a greater risk of vaccine preventable diseases (VPDs) and their complications. Preterm infants may also not respond as well to some vaccines (e.g. Hepatitis B).

Immunisation recommendations

Infants should be immunised according to the recommended immunisation schedule based on their chronological age as opposed to their corrected age. This is because it is important to minimise the window preterm infants are not protected from VPDs. Specific special risk medical conditions, as well as birth weight need to be taken into account as extra vaccines may be required .

It should be noted that the Rotavirus immunisation must be given within a strict time frame, with the first dose required before turning 15-weeks (chronological age) and the second dose before 25-weeks of age.

Additional vaccines recommended:

< 28-weeks gestation

Pneumococcal vaccines

• Infants born at < 28-weeks gestation are recommended to receive 4 doses of 13vPCV and 2 doses of 23vPPV
  • 13vPCV in a 4-dose schedule at 2, 4, 6 and 12-months of age (the first dose may be given as early as 6-weeks of age)
  • 2 doses of 23vPPV; 1 dose at 4-years of age and another dose at least 5 years later

< 32-weeks gestation and/or < 2000g birth weight

Hepatitis B

• Hepatitis B vaccine should be given at 12-months of age

Additional risk condition vaccine recommendations

• Influenza vaccine should be given annually from 6 months of age
• Meningococcal vaccines (MenB and MenACWY) are now funded under the NIP for people of all ages with medical conditions associated with the highest risk of invasive meningococcal disease

Resources:

• ATAGI Clinical advice on changes to recommendations for pneumococcal vaccines from 1 July 2020
• ATAGI Clinical advice on vaccination recommendations for people with risk conditions from 1 July 2020

Household contacts

It is recommended that family members of premature infants be fully up to date with their immunisations including influenza and pertussis boosters. This concept of ‘cocooning’ will help protect vulnerable preterm infants from VPDs.

The whooping cough (pertussis) vaccine is free and recommended for pregnant women and can be given anytime between 20-32 weeks of each pregnancy. It should be given as early as possible (from 20 weeks) to women who have been identified as being at high risk of early delivery to protect baby in the first months of life when they are too young to be vaccinated.

Influenza vaccination in pregnancy is safe and strongly recommended in avoiding complications of influenza disease. It can be administered at any stage of pregnancy and not only aims to protect the expectant mother from disease, but also to provide protection to the infant once born. Babies less than 6-months of age are at greatest risk of disease and death from influenza and maternal vaccination will provide protection to babies for the first few months of life until they can be immunised against influenza from 6-months of age.

Resources

• MVEC: Influenza vaccine recommendations
• MVEC: Rotavirus
• MVEC: Maternal vaccination during pregnancy
• Ordering Preterm infant stickers for child healthcare books 
• MVEC: Special risk chapter of the Australian Immunisation Handbook

The Paediatric Integrated Cancer Service (PICS) is a statewide initiative supported by Cancer Australia, with guidelines endorsed by the Australian and New Zealand Childrens Haemotology/Oncology Group (ANZHOG).

The PICS immunisation resources detail vaccines to consider during cancer therapy [e.g. influenza (flu)], as well as highlighting the vaccines that are required after completion of chemotherapy. These resources cross-link with the MVEC Cancer immunisation guidelines (see Resources below).

The PICS Immunisation information sheets have been translated into a number of different languages.

Resources

• Paediatric Integrated Cancer Service (PICS): Immunisation Resources
• MVEC: Cancer immunisation guideline- chemotherapy and post haematopoietic stem cell transplant

What is it?

Pertussis (whooping cough) is a serious, highly contagious, respiratory infection caused by the bacterium Bordetella pertussis.

What to look for

Pertussis can be very serious in young children, especially those under 6 months of age. It usually begins just like a cold, with a runny nose and sometimes a mild fever.  Coughing then develops, which may occur in bouts, sometimes followed by a deep gasp (or “whoop”). Hospital admission may be required.

Complications can include pneumonia, encephalitis/encephalopathy and brain damage. There are reported cases of death from Pertussis infection.

How is it transmitted?

The Bordetella pertussis bacterium is highly infectious and is spread by coughing and sneezing.

Prevention

Previous infection with Pertussis does not provide lifelong immunity.

Immunisation is the most effective form of prevention. Booster doses of the vaccine are required throughout life to ensure protection is maintained.

Pertussis immunisation is available for free for the following individuals:

• Infants – doses at 6 weeks, 4 months and 6 months
• Children – booster doses at 18 months and 4 years
• Adolescents – 12 – 13 years of age
• Pregnant women – 20 – 32 weeks gestation
• Partners of pregnant women who are at least 28 weeks pregnant (if they have not received a dose in the last 10 years)
• Parents/guardians of a baby under 6 months of age (if they have not received a dose in the last 10 years)

Resources

• Better Health Channel Whooping cough
• Australian Immunisation Handbook: Pertussis chapter
• MVEC: Maternal Vaccination During Pregnancy
• The RCH kids health info fact sheet