R Letter

इन्फ्लुएंजा क्या है?

Respiratory syncytial virus (RSV) is a virus that causes both upper and lower respiratory tract infections. Children under 1 year of age, individuals with underlying medical conditions (e.g. chronic cardiac and lung disease), the older population और immunocompromised people are more likely to experience serious disease requiring hospitalisation.

किन लक्षणों पर नज़र रखने की आवश्यकता है?

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

Symptoms may progress to shortness of breath, wheezing, bronchospasm (the sudden tightening of lung muscles) and feeding problems (in children). One third of children develop otitis media (ear infection).

Whilst most infections are mild, bronchiolitis (inflammation of the small airways) and pneumonia (lung infection) can occur, and may lead to hospitalisation for supportive measures such as oxygen therapy and rehydration. It is estimated that bacterial co-infections occur in around 30% of hospitalised patients. In older adults, RSV can exacerbate chronic obstructive pulmonary disease or lead to heart failure.

यह कैसे संचारित होता है?

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 to 8 days. However, some people continue to spread the virus for up to 4 weeks. 

एपिडेमियोलॉजी (महामारी विज्ञान)

Children and older adults have the highest rates of RSV infection. Almost all children will have experienced infection by the age of 2 years. Aboriginal and Torres Strait Islander adults are at greater risk of RSV-associated hospitalisation than non-Indigenous adults. Reinfection occurs throughout the lifetime since natural infection does not provide long-term immunity.

RSV infections are commonly seasonal, with a peak in cases usually seen over autumn and winter in temperate climates, and during the rainy season in tropical climates.  In recent years, RSV notification rates have increased significantly in Australia.

रोकथामं

Previous infection with RSV can provide some immunity but this protection is not long term.

Both monoclonal antibodies and vaccines are available in Australia for RSV prevention, and are recommended for specific populations.

Monoclonal antibodies

Monoclonal antibodies are a type of immunoglobulin (immune system protein) that can be administered to provide passive immunity (short-term protection gained from donated antibodies). In Australia, टीhere are two RSV monoclonal antibodies approved for use in बच्चे (from birth to under 2 years):

• Nirsevimab (Beyfortus)
• Palivizumab (Synagis).

Nirsevimab requires a single intramuscular injection which can provide protection for up to 6 months. In Australia, Nirsevimab is funded for some infants through state/territory infant immunisation programs (see Resources section below for information on jurisdictions’ programs). Palivizumab may be used as an alternative when Nirsevimab is unavailable.

Recommendations

Administrएtion of Nirsevimab is recommended for all infants: 

• whose mother did not receive RSV vaccination during pregnancy (maternal vaccination)
• born < 2 weeks after maternal RSV vaccination
• at increased risk of severe RSV, regardless of their mother’s vaccination status
• born to mothers with severe immunosuppression (due to the reduced immune response to maternal RSV vaccination).

Nirsevimab is also recommended for some children entering their second RSV season who are at risk or have medical conditions that place them at higher risk of severe RSV disease.

Table 1: RSV monoclonal antibody recommendations

*The 100 mg/mL preparation should never be halved and used for a patient weighing < 5 kg.

Co-administration with vaccines

Nirsevimab or Palivizumab can be given on the same day as all vaccines.

दुष्प्रभाव

Side effects from monoclonal antibodies are uncommon but can include injection site tenderness and swelling, mild respiratory symptoms, and rash.

टीके

There are two RSV vaccines available for use in adults within Australia:

• Arexvy
• Abrysvo.

Recommendations

RSV vaccination is recommended for: 

• all adults aged 75 years and over   
• Aboriginal and Torres Strait Islander adults aged 60–74 years  
• adults aged 60–74 years with specified medical conditions 
• pregnant people between 28 and 36 weeks’ gestation (to protect their newborn). 

Clinical trials demonstrate that when vaccines are administered during pregnancy the risks of hospitalisation due to severe RSV infection is reduced by 57% in infants less than 6 months of age.

Table 2: RSV vaccination recommendations for adults

*एफunded on the एनational Immunisation Program (NIP) for pregnant people from 28 को 36 weeks’ gestation. Abrysvo is registered for use in pregnancy from 24 को 36 weeks’ gestation.
^ Not funded on the NIP but available for private purchase.

Co-administration with अन्य vaccines

It is safe to administer RSV vaccines on the same day as other vaccines.

दुष्प्रभाव

Common side effects following administration of Arexvy या Abrysvo include इंजेक्शन साइट प्रतिक्रियाएं (pain, redness and swelling), malaise, सिर दर्द and fatigue. These side effects generally occur in the first 48 hours following vaccination and last 1 को 2 days.

Precautions and contraindications

RSV vaccines are not registered for use in children and should not be confused with monoclonal antibodies.   

Arexvy must नहीं be administered to pregnant women due to a lack of safety and efficacy data. Should inadvertent administration occur, it should be reported to the adverse event reporting service in your jurisdiction and the patient should be informed using the open disclosure process.

आमतौर पर पूछे जाने वाले प्रश्न

संसाधन

• Australian Immunisation Handbook: Respiratory syncytial virus (RSV)
• RCH Kids health Information: Respiratory syncytial virus
• Immunisation Foundation of Australia: Unite Against RSV
• Australian Government Department of Health and Aged Care: World-leading approach to protect babies from RSV
• Australian Government Department of Health and Aged Care: When to get vaccinated – Immunisation for pregnancy
• Jurisdiction-based immunisation programs:
  • New South Wales: RSV (respiratory syncytial virus) vulnerable babies program
  • Northern Territory: Respiratory Syncytial Virus (RSV)
  • Queensland: Paediatric Respiratory Syncytial Virus Prevention Program
  • South Australia: Program to protect SA newborns from RSV
  • Tasmania: Infant RSV immunisation program
  • Victoria: Respiratory syncytial virus (RSV) immunisation
  • Western Australia: Respiratory Syncytial Virus (RSV) immunisation
• McNab S, Ha Do LA, Clifford V, et al. Changing Epidemiology of Respiratory Syncytial Virus in Australia – Delayed Re-emergence in Victoria Compared to Western Australia/New South Wales (WA/NSW) After Prolonged Lockdown for Coronavirus Disease 2019 (COVID-19). Clin Infect Dis. 2021;73(12):2365-2366. doi:10.1093/cid/ciab240
• Crawford N, Alafaci A, Clark J, et al. Study of Children Aged Under 2 Years Admitted With RSV at Four Australian Hospitals [2021-2022], J Paediatr Child Health. 2025; 0:1-9. doi:10.1111/jpc.16796

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.

को देखें 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.

सीरम विज्ञान

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 एमवीईसी: लाइव-एटेन्यूएटेड टीके और इम्युनोग्लोबुलिन या रक्त उत्पाद]. 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.

कृपया देखें MVEC: Post rituximab therapy immunisation guideline for re-immunisation recommendations.

संसाधन

• MVEC: Post Rituximab therapy immunisation guideline
• एमवीईसी: इन्फ्लुएंजा वैक्सीन सिफारिशें
• 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

इन्फ्लुएंजा क्या है?

Rotaviruses belong to the genus रोटावायरस (in the family Reoviridae) which comprises eight species, referred to as A, B, C, D, E, F, G and H. Group A rotaviruses are responsible for most rotavirus infections in humans, although people have also been infected with groups B and C. Like in influenza viruses, the structure of rotaviruses enables them to mutate rapidly to produce new strains.

Rotavirus infections are the leading cause of dehydrating gastroenteritis in young children.

किन लक्षणों पर नज़र रखने की आवश्यकता है?

Rotavirus disease can present with a spectrum of symptoms, from asymptomatic or mild infection to severe disease. Clinical signs can include:

• बुखार
• vomiting
• abdominal pain
• watery diarrhoea.

Severe cases, if left untreated, can result in significant dehydration leading to electrolyte imbalance, hypotensive shock and death.

The incubation period for developing disease is usually between 24 and 72 hours. The diarrhoea usually lasts from 3 to 7 days.

यह कैसे संचारित होता है?

Rotaviruses are mainly transmitted through the faecal–oral route, through close person-to-person contact, contaminated food and water, and via fomites (e.g. toys and other surfaces contaminated by faeces). Rotaviruses are also transmitted through respiratory droplets (e.g. through coughing, sneezing, talking). Spread is common in families, hospitals and childcare settings.

Viral replication occurs in the villous epithelium of the small intestine.  The virus can be transmitted during the acute illness. Excretion for more than 30 days has been reported to occur.

Asymptomatic infected individuals can transmit the virus unknowingly.

एपिडेमियोलॉजी (महामारी विज्ञान)

Worldwide, rotaviruses are the most common cause of dehydrating diarrhoea among children under 5 years of age. Despite the availability of a vaccine, rotavirus continues to result in over 200,000 deaths per year. Deaths due to rotavirus are rare in Australia due to access to health care services.  

Rotavirus vaccines were added to the Australian National Immunisation Program (NIP) in 2007. Since then, there has been an estimated 64% decrease in hospitalisations for children aged under 3 years, and case numbers have fallen. In 2022, notification rates were lowest in Tasmania (at 11 per 100,000) and highest in the Northern Territory and Queensland (at 47 per 100,000). 

Compared with their non-Indigenous peers, Aboriginal and Torres Strait Islander infants and children are hospitalised with rotavirus gastroenteritis about 3 to 5 times more often, and are younger at age of hospitalisation. 

Without vaccination, most children will experience at least one rotavirus infection before the age of 3 years. Repeated infections can occur.  

In temperate areas of Australia infections are more common in the winter months. However, in the tropical/arid regions of Australia there is no seasonal pattern.  

रोकथामं

Rotavirus spread can be mitigated through: 

• effective hand hygiene measures 
• effective decontamination of fomites 
• vaccination.

टीके

Vaccination is approximately 88% effective in preventing rotavirus infection. There are 2 vaccines registered for use in Australia: 

• Rotarix  
• Rotateq. 

Both rotavirus vaccines are live-attenuated vaccines requiring oral administration (by mouth). A 2-dose course of Rotarix is currently provided on the NIP at 6 weeks and 4 months of age.  

There is limited data on the safety and efficacy of rotavirus vaccination when given outside of specific age groups. For this reason, rotavirus vaccines must be administered within the recommended 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.  

Infants who receive a first dose of either vaccine should complete the entire course of vaccination using the same oral rotavirus vaccine. However, if an infant inadvertently received one of each, give a 3rd dose of either rotavirus vaccine. The upper age limits and minimum intervals between doses must still be met.

* Preterm infants are recommended to receive vaccines based on chronological age, not corrected age.
^Dose 2 is ideally administered before turning 28 weeks to allow for dose 3 to be given 4 weeks later (before the infant turns 33 weeks). If dose 2 is administered later than 28 weeks, a 4 week interval is not possible, and dose 3 must not be administered.
shaded boxes indicate live-attenuated vaccines.
Rotateq is not routinely used in Australia.

Considerations

If an infant spits out a small amount of the dose of vaccine, it is still considered a valid dose and does not 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.

Infants who have an enteral feeding tube (e.g. orogastric, nasogastric, gastrostomy, or jejunal tube) can receive rotavirus vaccines via their tube. Rotavirus vaccines should never be injected.

Rotavirus vaccination is not required 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 legislation.

वैक्सीन के दुष्प्रभाव

Several large studies have showed that vaccinated infants had no increase in vomiting, diarrhoea or fever compared with unvaccinated infants. However, anecdotally, infants may be more fussy or gassy within the first 7 days following vaccination. 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 to 10 days following immunisation. 

Some Australian and international studies have shown a very small increase in risk of intussusception post rotavirus vaccine. The baseline risk of intussusception for Australian infants is around 80 cases per 100,000 infants. A 2013 study found 6 additional cases of intussusception for every 100,000 infants vaccinated. This equates to 14 more cases per year in Australia.

Intussusception is a rare condition where the bowel slides or telescopes inside itself causing a blockage. Infants with intussusception may show signs of lethargy, intermittent pain or distress, associated with episodes of pallor. They may pull up their legs, vomit and/or have diarrhoea. Jelly-like or bloody stools is a late sign. Immunisation providers should inform parents and carers to be alert for symptoms and the very rare risk of intussusception.

Precautions and contraindications

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 (including those with HIV who are asymptomatic and have adequate CD4+ count) 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.  

Infants with severe combined immunodeficiency (SCID) must not receive rotavirus vaccines due to the risk of vaccine-associated gastroenteritis.  

Infants born to mothers who received bDMARDs (biological disease-modifying anti-rheumatic drugs) during pregnancy can receive rotavirus vaccines. Refer to MVEC: Immunosuppression in pregnancy अधिक जानकारी के लिए।  

Rotavirus vaccines must not be given to any infant with a previous history of intussusception or a congenital bowel abnormality which predisposes them to intussusception.

अन्य टीकों के साथ सह-प्रशासन

Rotavirus vaccines can be safety administered with other vaccines including other live-attenuated vaccines, such as बीसीजी.

संसाधन

• Australian Immunisation Handbook: Rotavirus
• US Centers for Disease Control and Prevention (CDC), Pinkbook: Rotavirus
• RCH Kids Health Info: Gastroenteritis
• RCH Clinical Guidelines (Nursing): Enteral feeding and medication administration
• GSK Rotarix Dosing and Administration Wheel (Rotarix Wheel) ERRORS
• एमवीईसी: प्रीटरम शिशु टीकाकरण

इन्फ्लुएंजा क्या है?

आरabies है an acute viral encephalomyelitis (inflammatory disease of the brain and/or spinal cord) caused by infection with the rabies virus, a type of lyssavirus. Other lyssaviruses include Australian bat lyssavirus (ABLV) and the European bat lyssavirus (EBLV).

Rabies is transmitted to humans via bites or scratches from animals infected with the virus. Infection with the rabies virus, and other lyssaviruses, resultएस in ए progressive inflammation of the brain and spinal cord. Without vaccination और effective post-exposure management, rabies है almost always fatal. 

किन लक्षणों पर नज़र रखने की आवश्यकता है?

The incubation period of rabies is generally between 3 and 12 weeks, but the onset of symptoms has occurred as early as days after exposure or as long as 19 years later.   

Early signs of infection involve non-specific symptoms, such as loss of appetite, cough, fever, headache, discomfort and fatigue, nausea and vomiting, and sore throat. There also may be discomfort, paraesthesia (prickling or itching sensation) and fasciculations (muscle twitching) at the site of the scratch or bite.  A person may show signs of anxiety, confusion and agitation. These initial symptoms last 1 to 4 days. Following this, symptoms progress to: 

• delirium and bizarre behaviour 
• disorientation
• hallucinations 
• hypersalivation, hyperthermia and hyperventilation (signs of autonomic instability) 
• hydrophobia (fear of water) 
• paralysis 
• insomnia.

The disease progresses rapidly. Once clinical signs have developed, the person’s neurological status will deteriorate over a period of up to 12 days, resulting in death. There is no specific treatment for rabies.

यह कैसे संचारित होता है?

Rabies is a zoonotic disease (spread between animals and humans). Dog species (including wolves, coyotes, foxes and jackals) are the main source of infection for humans. Skunks, raccoons, monkeys and bats can also harbour infection.  

Human exposure occurs primarily through the scratch or deep bite of an infected animal. Transmission can also occur if saliva of an infected animal comes into direct contact with a person’s mucosal surface (nose, eyes or mouth).  

The virus travels from the site of the injury to the brain by moving along nerve pathways.

एपिडेमियोलॉजी (महामारी विज्ञान)

Rabies is found in animals on all continents of the globe except Antarctica. Australia is currently rabies free. However, ABLV has been known to occur in fruit bats and insectivorous bats.  It is difficult to determine the disease burden in animals, due to the impracticalities of testing wild and domestic animals. 

Each year, rabies infection causes approximately 59,000 human deaths worldwide, 95% of these occurring in Africa and Asia. The burden of disease in humans is higher in rural, low-income populations. Children are more likely to be infected due to their size and proximity to the ground, being less likely to appreciate an animal’s temperament, and their tendency to make sudden movements or loud noises which are intimidating to animals. 

रोकथामं

According to the World Health Organization, vaccinating dogs in rabies-prone regions is the most cost-effective strategy for preventing rabies in people.

People who will be travelling to, or living in, rabies-prone regions should take preventative measures. These include:

• avoiding close contact with wild and domestic animals (this is especially important for children)
• not feeding, patting or playing with animals
• getting vaccinated.

Vaccination

Vaccines can be administered either before potential exposure (pre-exposure prophylaxis), or after exposure has occurred (as part of post-exposure prophylaxis). 

Pre-exposure vaccination requires fewer vaccine doses and eliminates the need for immunoglobulin if exposed (except for those who are severely immunocompromised). Immunoglobulin may be expensive and difficult to source in developing countries.  

There are 2 rabies vaccines available in Australia: 

• Verorab 
• Rabipur 

Both Verorab and Rabipur are inactivated vaccines and can be administered via the intramuscular (IM) route or the intradermal (ID) route.  

It is preferable but not essential to use the same brand of vaccine for the entire course. If using the same brand is not possible, vaccination should not be delayed, and the alternate brand should be used. 

Boosters and serology 

Recommendations for vaccine boosters and serology (blood testing to check antibody levels) vary on a case-by-case basis. Individuals should seek personalised advice from their healthcare provider (e.g. immunisation provider, travel medicine adviser or other specialist consultant). 

It is especially important for individuals in the following groups to speak with their health provider for specific advice on boosters and serology: 

• immunocompromised individuals 
• laboratory workers who work with live lyssaviruses 
• people with ongoing exposure to bats or potentially rabid mammals. 

Table 2: Immunisation Handbook एसerology recommendations

* Or, receive a booster dose every 3 years without checking serology.

A single IM booster dose is recommended for people with significant ongoing exposure risk: 

• when serology is < 0.5 IU/mL   
• 12 months after dose 1 of primary course of vaccination (whether pre- or post-exposure) then every 3 years after first booster (may check serology first).

एहतियात

People with anaphylaxis to egg should receive Verorab instead of Rabipur. 

People with latex allergy should receive Rabipur instead of Verorab.  

अन्य टीकों के साथ सह-प्रशासन

Verorab and Rabipur can be co-administered with other vaccines, using separate injection sites.  

Tetanus vaccination status should also be considered after a bite or scratch from an animal, see MVEC: Tetanus. 

वैक्सीन के दुष्प्रभाव

Common side effects following rabies vaccination include nausea, headache, injection site pain and myalgia (muscle aches). 

Due to the seriousness of disease, post exposure vaccination should never be delayed, even in those who have experienced an unpleasant side effect or who have a history of allergic reactions. A specialist immunisation service should be contacted for specific advice. 

संसाधन

• Australian Immunisation Handbook guideline 
• RCH post-exposure Clinical Practice Guideline
• Overseas post-exposure prophylaxis guidelines
• Ordering vaccines online 
• DOH notification requirements