R Letter

What is it?

Respiratory syncytial virus (RSV) is one of the leading causes of respiratory tract infections in young children. While for some it can cause the common cold, for others, it may lead to more severe infection. Children < 1 year of age, individuals with underlying medical conditions (e.g., chronic cardiac and lung disease), the older population, and immunocompromised people are more likely to experience serious disease and hospitalisation.   

What to look for

Cold-like symptoms such as rhinorrhea (runny nose), fever, wheeze, headache and cough are common. Symptoms generally appear 1-5 days after exposure and can last 8-15 days. 

Whilst most infections are mild, bronchiolitis (inflammation of the small airways) and pneumonia (lung infection) can occur in severe presentations and may lead to hospitalisation for supportive measures such as oxygen therapy and rehydration.  

How can it be transmitted?

RSV is highly contagious and can be transmitted via the inhalation of droplets containing the virus. RSV can also be transmitted when a person touches a contaminated surface and then touches their face. 

People with RSV are generally considered infectious for 3-8 days. However, some people continue to spread the virus for up to 4 weeks. 

Epidemiology

RSV infections are commonly seasonal, with a peak in cases usually seen over autumn and winter. Almost all children will have experienced infection by the age of 2 years.  

Prevention

Practicing good hand hygiene is important in preventing infections. 

There are currently no vaccines registered for use within Australia. However, there are many RSV vaccines under development in clinical trials. Previous infection with RSV can provide some immunity but this protection is not long term. 

Synagis® (palivizumab) is an immunoglobulin (a blood product offering donated antibodies) currently available to some infants considered to be at higher risk of severe RSV disease (due to medical conditions such as prematurity, chronic lung disease, and specific cardiac conditions). It is not routinely available to all infants. Doses are calculated according to weight and given monthly over the winter period (usually May to October).  

Resources

• Health direct: Respiratory syncytial virus (RSV)
• RCH Kids Health Information: Respiratory syncytial virus (RSV)
• Sarah McNab and others, Changing Epidemiology of Respiratory Syncytial Virus in Australia—Delayed Re-Emergence in Victoria Compared to Western Australia/New South Wales (WA/NSW) After Prolonged Lock-Down for Coronavirus Disease 2019 (COVID-19), Clinical Infectious Diseases, Volume 73, Issue 12, 15 December 2021, Pages 2365–2366

Did you know there are additional vaccines recommended by vaccine experts that are available for private purchase? They are not free as they are not listed on the National Immunisation Program (NIP) or funded by the government. Most councils will offer some additional vaccines for purchase or alternatively all these vaccines are available for purchase with a prescription from your GP.

Influenza vaccine

Influenza vaccine is recommended annually for everyone from the age of 6-months.

Who is eligible for the free vaccine?

• Influenza vaccine is routinely funded for all children aged 6-months to less than 5-years of age, all Aboriginal & Torres Strait Islander people ≥ 6-months of age, pregnant women and for people with specific medical risk factors who are at risk of complications from influenza, regardless of age.

Recommended but not funded:

• For children (> 5-years), adolescents and adults. Influenza vaccines can be purchased and administered at most council community immunisation sessions or alternatively with a prescription from your GP or from pharmacist immunisers for people aged 10-years and over.
• Children less than 9-years of age require 2 doses, 1 month apart, in the first year they receive the vaccine.

Resources:

• MVEC influenza vaccine recommendations

Meningococcal vaccines

Meningococcal ACWY

Meningococcal ACWY (MenACWY) vaccine is recommended for any person who wants to protect themselves against invasive meningococcal disease (IMD) and can be administered from as early as 6-weeks of age. MenACWY provides protection against four strains of meningococcal disease, A, C, W and Y.

Who is eligible for the free vaccine?

• A single dose of Nimenrix® is currently provided at 12-months of age on the National Immunisation Program (NIP)
• Catch-up dose for any person aged under 20 years who did not receive a meningococcal C containing vaccine at 12-months of age
• Young people aged 15 to 16-years or in Year 10 of secondary school as a school based vaccine program
• All young people aged 15-19 years of age who have not received the vaccine at secondary school
• People of all ages with some specified medical conditions that increase the risk of IMD (complement deficiency, current or future treatment with eculizumab, asplenia) [see resources].

Recommended but not funded:

Some local councils offer Nimenrix^® (Meningococcal ACWY) as a fee for service if patients wish to be protected but do not meet the criteria on the NIP. Alternatively, this vaccine is available at the GP on private prescription.

Meningococcal B

Meningococcal B (MenB) vaccine provides protection against B strain meningococcal disease and can be administered from as early as 6-weeks of age.

Who is eligible for the free vaccine?

• People of all ages with some specified medical conditions that increase the risk of IMD (complement deficiency, current or future treatment with eculizumab, asplenia) [see resources]
• Aboriginal and Torres Strait Islander infants from 2-months of age [see resources]

There are currently 2 vaccines available on the private market for the protection of meningococcal B disease.

• Bexsero^® is for use from 6-weeks of age
• Trumenba^® is licensed for use in ≥ 10-years of age

Meningococcal B vaccines brands are not interchangeable.

Some local councils offer Bexsero^® as a fee for service if patients wish to be protected but do not meet the criteria on the NIP. Alternatively, this vaccine is available at the GP on private prescription.

Resources:

• MVEC Meningococcal disease and vaccines
• MVEC: Meningococcal vaccines in special risk and immunosuppressed patients
• ATAGI: Clinical advice on changes to recommendations for the use and funding of meningococcal vaccines from 1 July 2020

Chickenpox (varicella) vaccine

2 doses of varicella-containing vaccine provide 15-20% more protection against (mild) breakthrough varicella (chickenpox) in children <14 years of age, however a 2^nd dose is not included on the National Immunisation Program schedule.

Who is eligible for the free vaccine?

• A single dose of the live-attenuated varicella vaccine is currently funded on the NIP for children at age 18 months of age in a combined measles-mumps-rubella-chickenpox (MMRV) vaccine.
• For those ≥ 14 years of age, 2 doses (administered 4 weeks apart) are required for the protection of non-immune individuals.
• MMRV combination vaccine is not recommended for use in people from >14 years of age.

Recommended but not funded

• If parents or carers wish to minimise the risk of breakthrough varicella in children <14 years of age, a 2nd dose of varicella-containing vaccine is recommended and can be purchased at some council community immunisation sessions or purchased by prescription from the GP.
• Children can receive a chickenpox vaccine from as young as 12 months of age. This can provide earlier protection against varicella, which may be appropriate in the context of childcare, travel or a varicella outbreak. There is no safety concern if the child still receives the dose scheduled at 18 months of age.
• The minimum interval between doses of varicella-containing vaccine is 4 weeks.

Resources:

• MVEC: Varicella

Special risk groups

Individuals that are at higher risk of vaccine preventable diseases (VPD) are classified as ‘special risk’ groups in the Australian Immunisation Handbook.

This includes populations at special risk (e.g. Aboriginal and Torres Straight Islanders) and those with additional vaccine requirements (e.g. maternal vaccination; preterm infants). It also has detailed sections on those at special risk because of immune suppression (disease and/or therapy) e.g. Asplenia, cancer/chemotherapy.

Resources:

• Australian Immunisation Handbook: Vaccination for Special Risk Groups

Additional resources

Further information about childhood vaccination can be found at:

• The Better Health Channel: Healthy Living: Immunisation
• ATAGI: Clinical advice on changes to recommendations for the use and funding of meningococcal vaccines from 1 July 2020
• ATAGI: Clinical advice on changes to vaccine recommendations and funding for people with risk conditions from 1 July 2020
• National Immunisation Program Schedule
• MVEC: Victorian council immunisation sessions

Rituximab is becoming a frequently used treatment option for many patients with complex medical needs, including in oncology and rheumatology. It is an immune suppressive medication which greatly impacts the production and functionality of immune cells, including the near complete depletion of B-cells. Once treatment with rituximab has been completed, recovery of immune cell function can take 3-12 months, and even longer in some cases. It may be used as a once-only dose or as a long term therapy.

Due to the effects on lymphocytes, patients on rituximab therapy are considered immune suppressed and are at a greater risk of vaccine preventable diseases. However, recommendations for immunisation of these patients is complicated by the inability to produce an immune response to vaccines without functioning B- and T-cells.

Many patients on rituximab are also receiving concomitant immunoglobulin therapy. As this is a blood product, it further complicates the immunisation recommendations involving live-attenuated vaccines.

Prior to commencing treatment

Where possible please ensure patients are up to date for their age with the current immunisation schedule. Ideally inactivated vaccines should be completed at least 1 week prior, and any live-attenuated vaccines should be completed a minimum of 4 weeks prior to commencing treatment. The same principle also applies to COVID-19 vaccines.

During treatment

Due to lack of immune cell function, all future immunisations should be withheld whilst on rituximab. An immunisation medical exemption form should be completed where appropriate to ensure that the patient is not considered overdue [see resources].

The exception to this, may be for influenza and COVID-19 vaccines. Some studies have indicated that a partial immune response to the influenza vaccine in patients receiving rituximab therapy may occur. For this reason MVEC recommends that patients continue to be immunised against influenza whilst on therapy and receive 2 doses of the age-appropriate vaccine annually, minimum of 4 weeks apart (regardless of age or vaccine history).

Due to the potential risk for severe COVID-19 disease and its complications in this population, which may outweigh the lack of vaccine response, COVID-19 vaccination whilst on rituximab could be considered.

COVID-19 vaccination and rituximab

Studies are still ongoing to determine optimum timing and vaccine efficacy in patients on rituximab. However, based on evidence from other vaccines, the assumption is that there is a diminished response to COVID-19 vaccination.

Therefore, important principles to consider for this group of patients include:

• it is not recommended to delay initiation or disrupt optimum timing of rituximab if being used for cancer treatment
• due to its immunosuppressive effects, patients on rituximab are at higher risk of severe COVID-19 disease and poor COVID-19 disease outcomes.

As such, COVID-19 vaccination could be performed as close to the end of a rituximab cycle as possible, or prior to the initiation of therapy. There is no current data to inform optimum timing of two-dose COVID-19 vaccination regimes and intervals.

Refer to MVEC: immunosuppression and vaccines

Immunisation of household contacts

All close contacts should ensure that they are up to date with the routine immunisation schedule, including MMR, varicella and pertussis vaccines. Annual Influenza vaccination is strongly recommended. COVID-19 vaccination is encouraged.

Serology

There is no need to check serology pre- or post-rituximab therapy. There is currently no established immune correlate of protection for COVID-19.

Patients should be aware of their immune suppression and avoid potential exposures to vaccine preventable diseases. The need to continue preventative measures such as social distancing, mask wearing and hand hygiene should be discussed. Medical advice should be sought if exposure does occur [see resources for post-exposure immunoglobulin recommendations].

Post treatment

Post the completion of rituximab therapy, immunoglobulin and B-cell levels should be checked every 3 months. Once both levels have returned to normal AND ≥ 6 months post treatment has lapsed (whichever is later), immunisation with both inactivated and live-attenuated vaccines can recommence. For patients who have received immunoglobulin alongside their rituximab, specific intervals are recommended between the administration of live-attenuated vaccines and blood products/immunoglobulin [refer to MVEC: Live-attenuated vaccines and immunoglobulins or blood products]. Any previous vaccine history (routine vaccines) should be disregarded due to the loss of immune memory. There is currently no recommendation for additional booster doses of COVID-19 vaccines.

Please refer to MVEC: Post rituximab therapy immunisation guideline for re-immunisation recommendations.

Resources

• MVEC: Post Rituximab therapy immunisation guideline
• MVEC: Influenza vaccine recommendations
• DHHS: Medical exemption forms
• Australian Immunisation Handbook: Post-exposure prophylaxis for people non-immune to hepatitis B
• Australian Immunisation Handbook: Post exposure prophylaxis for people non-immune to measles
• Australian Immunisation Handbook: Post exposure prophylaxis for people non-immune to varicella
• Australian Immunisation Handbook: Post exposure prophylaxis for people non-immune to tetanus
• Cheng D, Barton R, Greenway A, Crawford N Rituximab and protection from vaccine preventable diseases; applying the evidence to pediatric patients. Expert Review of Vaccines 2016 Volume 15(12): 1567-1574

What is it?

Rotavirus gastroenteritis is caused by non-enveloped RNA viruses. It is a common cause of viral gastroenteritis in children. Globally, it is the most common cause of viral gastroenteritis related deaths in those less than 5 years of age.

What to look for

Rotavirus gastroenteritis classically occurs following a 1-3 day incubation period. Symptoms of disease include vomiting, diarrhoea, fever, dehydration and drowsiness. Symptoms can be particularly severe in children who are malnourished or immunocompromised.

How is it transmitted?

Rotaviruses can be transmitted via the faecal-oral route.

Prevention

Previous infection with rotavirus does not provide lifelong immunity. Hand hygiene and disinfecting contaminated surfaces are important measures for preventing transmission.

Prior to the introduction of rotavirus vaccination onto the National Immunisation Program (NIP) in 2007, approximately 10,000 children (< 5 years of age) were hospitalised each year with rotavirus gastroenteritis, with an average of one death per year. These rates have dropped dramatically since its introduction.

Vaccines

There are two live-attenuated rotavirus vaccines available for children in Australia:

• Rotarix- 2 dose course, available on the NIP at 6 weeks of age and 4 months of age
• RotaTeq- 3 dose course, previously given on the NIP, now available through private script.

There is limited data on the safety and efficacy of rotavirus vaccination when given outside of specific age groups. For this reason, it is recommended that rotavirus vaccines are administered within a set timeframe, with particular attention paid to the upper age limits. If adherence to the recommended timeframes for administration is not possible, vaccination should be withheld indefinitely. Pre-term infants are recommended to receive vaccines based on chronological age, not corrected age.

*whilst vaccines should be administered orally where possible, infants who have a feeding tube (eg nasogastric/PEG) can receive rotavirus vaccines via their tube. Rotavirus vaccines should never be injected.

Rotavirus vaccination is not required in order for a child to be considered up to date with their routine vaccines. It is not mandatory for the purposes of the no jab no pay or no jab no play legislations.

Please note, if an infant spits out a small amount of the dose of vaccine it is still considered a valid dose and doesn’t need repeating. If they spit out most of the dose of vaccine within minutes of receiving it, a repeat dose should be administered at the same visit.

Side effects and management

Side effects from rotavirus vaccination more commonly occur within the first 7 days following vaccination and can include vomiting, diarrhoea and irritability.

Supportive therapies such as paracetamol and additional fluids (breastmilk/formula) can help manage symptoms. Good hand hygiene practices are particularly important when handling soiled nappies during this period to minimise the risk of transmission as the virus can shed in stools for 7-10 post immunisation.

Very rare side effects can include anaphylaxis. It is recommended that infants are observed for 15 minutes following vaccination to monitor for symptoms.

There is some suggestion from Australian and international research that there is a small increase in intussusception cases in infants who receive the oral rotavirus vaccine. Intussusception is a rare condition where the bowel slides or telescopes inside itself causing a blockage. Infants may cry, pull up their legs and later have vomiting and sometimes blood in the stools. In most cases the cause of intussusception is not known. It has been estimated that the increased risk with rotavirus vaccines means an additional six cases per 100,000 infants vaccinated.

Precautions

Both rotavirus vaccines are live-attenuated oral vaccines. There is a theoretical risk of vaccine-associated gastroenteritis if vaccines are administered to infants with immunocompromise. However, for some infants with less severe immunocompromise the benefits of vaccine-induced protection may outweigh this risk. Further clarification on the degree of immunocompromise may be sought from specialist immunisation services.

Infants living in households with persons who have an immunodeficiency disorder or impaired immune status can still be vaccinated. Counselling on hand hygiene and disposing of soiled nappies to minimise the risk of vaccine-virus transmission is recommended.

For infants who are immunocompromised (other than severe combined immunodeficiency disorder) or living with HIV, the benefits of vaccination are thought to outweigh any potential risks of vaccine-associated gastroenteritis.

Contraindications

Rotavirus vaccine should not be given to any infant with a previous history of intussusception or a congenital bowel abnormality which pre-disposes them to intussusception.

Infants with severe combined immunodeficiency disorder (SCID) should not receive rotavirus vaccines due to the risks of vaccine-associated gastroenteritis, and lack of immune-system ability to generate a protective immune response.

The vaccine should not be administered to infants with anaphylaxis to a previous dose of rotavirus vaccine.

Infants whose mothers have received biological disease-modifying anti-rheumatic drugs (bDMARDS) during the third trimester of pregnancy should not receive vaccination without seeking specialist advice.

Resources

• MVEC: Preterm infant immunisation
• Australian Immunisation Handbook: Rotavirus
• RCH Kids Health Info: Gastroenteritis
• GSK Rotarix Dosing and Administration Wheel (Rotarix Wheel) ERRORS

What is it?

Rabies is a disease caused by exposure to saliva or nerve tissue of an animal infected with the rabies virus or other lyssavirus.

The majority of exposures occur in travellers visiting places where disease is endemic (e.g Asia, Africa)

What to look for

Initial symptoms are usually non-specific and can include cough, fever, headache, myalgia, tiredness and vomiting. Disorientation, anxiety, bizarre behaviour, agitation, hypersalivation (increase in saliva) and hyperactivity can then occur before sudden death.

How is it transmitted?

Disease can occur after a scratch or bite that has broken the skin, or via direct contact with a person’s mucosa (nose, eye or mouth)

Prevention

Rabies is a vaccine preventable disease. Pre-exposure prophylaxis is often recommended for those travelling to Rabies prone areas, as well as for those who work in an at-risk occupation such as bat-handlers and veterinarians.

Post-exposure treatment should be commenced as soon as possible. In cases of rabies exposure when prior immunisations have not been administered, treatment with Human Rabies Immunoglobulin (HRIG) and immunisation is recommended.

Resources

• Australian Immunisation Handbook: Rabies and other lyssaviruses
• Better Health Channel: Lyssavirus
• The RCH Clinical Practice Guideline: Rabies
• MVEC: Travel medicine

What is it?

The RCH Immunisation Service drop-in centre was established in March 2001.

The drop-in centre provides opportunistic vaccines for patients and parents at the hospital, and, where available, non-patients (appointments are required for catch-up immunisation plans). Led by a specialist nursing team (and run by Nurse Practitioner and Manager Sonja Elia), it also provides specialist immunisation advice. The team supports outpatient clinics such as the Immunisation Clinic (Tuesday am), Immigrant Health clinic (Monday pm) and dedicated BCG clinics (for infants aged less then 12 months). The drop-in centre provides seasonal vaccines, such as influenza; and delivers Palivizumab (RSV prophylaxis) for at risk infants. Additional vaccines such as varicella, meningococcal B and meningococcal ACWY are also available for purchase.

The staff at the drop-in centre employ a range of distraction techniques to reduce pain and anxiety and when these techniques are unsuccessful, an “immunisation under sedation” service can be offered. Please telephone the service for more information regarding this, bookings are essential.

Please note that the RCH has implemented additional precautions to ensure the safety of all patients, families and staff at this time. Access to medical care remains an essential service during the COVID-19 pandemic and staying up to date with scheduled immunisations is encouraged.

Referrals

Immunisation clinic – referrals can be sent directly to fax number (03) 9345 4163.

BCG clinic – referrals can be sent directly to fax number (03) 9345 5034.

Inpatients and Outpatients – can be seen by one of the Immunisation Nurse Specialists at RCH, no referral is required.

Contact

Telephone: Immunisation hotline 1300 882 924 (option 2) or direct (03) 9345 6599 / 9345 6399.

Pager: 4330 via hospital switchboard (03) 9345 5522.

Email: [email protected]

Facsimile: (03) 9345 4100.

Resources

• The Royal Children’s Hospital, Immunisation Service Drop-in Centre
• MVEC: BCG vaccine
• MVEC: Influenza vaccine recommendations
• MVEC: Needle phobia
• MVEC: Meningococcal vaccines
• MVEC: Catch up immunisations
• MVEC: Private vaccine prices at The Royal Children’s Hospital