P Letter

背景

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.

人乳头瘤病毒 (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.

新冠肺炎

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.

资源

• 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

什么是结核病？

脊髓灰质炎（脊髓灰质炎）是由 3 种脊髓灰质炎病毒（血清型 1、2 或 3）之一的胃肠道（肠道）感染引起的。脊髓灰质炎病毒是 RNA 肠道病毒，来自 小核糖核酸病毒科 家庭。

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.

需要特别留意的情况

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.

结核病是如何传播的？

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.

流行病学

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.

预防措施

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.

防范措施

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.

资源

• Australian Immunisation Handbook: Poliomyelitis
• CDC: Vaccines and Preventable Diseases – Vaccine Derived Poliovirus
• The Blue Book: Guidelines for the control of infectious diseases
• 澳大利亚政府卫生和老年护理部：2023 年 7 月 1 日起国家免疫计划时间表发生变化

背景

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 原住民和托雷斯海峡岛民, Asplenia etc) may be considered at increased risk of IPD and therefore require additional protection.

肺炎球菌疫苗

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/水痘/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

• 发烧
• irritability
• lethargy
• pain at the injection site
• 注射部位反应 (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 和 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

资源

• 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

背景

药剂师免疫接种员是已完成免疫接种的注册药剂师 附加训练 这使他们能够向特定的患者群体注射批准的疫苗。这提高了社区疫苗的可及性，这对于限制疫苗可预防疾病的传播尤为重要。

药剂师免疫接种者要求

除了完成首席卫生官认可的免疫计划外，药剂师免疫员还必须出示完成上述培训的证书，持有有效的急救和心肺复苏证书，并确保在药房免疫时有另一名合格的工作人员在场设置。在接种某些疫苗（COVID-19、猴痘和日本脑炎）之前，需要完成进一步的培训模块

药剂师免疫接种者受当地司法管辖区的政策和程序的约束。有关维多利亚州药剂师要求的更多信息，请参阅 维多利亚州药剂师管理的疫苗接种计划指南.

维多利亚州药剂师免疫员可以注射哪些疫苗？

在维多利亚州，药剂师免疫接种员有权接种以下疫苗：

• 流感 年龄≥5岁的人接种疫苗
• 白喉– 破伤风–百日咳 年龄≥12岁的人接种疫苗
• 麻疹- 年龄≥15岁的人接种腮腺炎-风疹疫苗
• 脑膜炎球菌 ACWY 疫苗适用于 15 岁以上的人群
• 新冠肺炎 疫苗有时间限制的批准
• 人乳头状瘤病毒 年龄≥12岁的人接种疫苗
• 肺炎球菌 ≥ 50 岁的人接种疫苗
• 带状疱疹 ≥ 50 岁的人接种疫苗
• mpox 为年龄 ≥ 5 岁的符合资格的个人接种疫苗
• 日本脑炎 为年龄 ≥ 5 岁的符合资格的个人接种疫苗。

资源

药剂师免疫员培训计划

• 澳大利亚药学会： 管理注射和免疫接种的交付和管理 - 维多利亚
• 澳大利亚维多利亚州药房协会： 在社区药房环境中提供免疫接种

其他资源

• DHHS：药剂师免疫接种者
• DHHS：药剂师管理的疫苗接种服务
• 维多利亚州 COVID-19 疫苗接种指南
• 维多利亚州药剂师管理的疫苗接种计划指南

鉴于某些疫苗中含有从猪肉中提取的明胶，许多家庭和医疗保健提供者可能想知道是否允许基于宗教信仰进行免疫接种。

犹太信仰的领袖们已经宣布，对于遵守犹太信仰的人来说，药物中使用猪肉衍生的添加剂是允许的。来自英国 Kashrus 和药物信息服务的拉比亚伯拉罕阿德勒建议：
“应该注意的是，根据犹太法律，非口服产品中的猪或其他动物来源成分没有问题。这包括疫苗、注射剂、栓剂、乳膏和软膏”

伊斯兰医学组织的学者还确定，原始猪肉产品转化为面筋的过程对其进行了充分的改变，从而允许穆斯林信仰的观察者接种疫苗。世界卫生组织东地中海区域办事处 2001 年的一封信报告说：
“由司法不纯动物的骨骼、皮肤和肌腱转化而成的明胶是纯净的，在司法上是允许食用的”
澳大利亚的大穆夫提也发表了支持性声明，指出允许虔诚的穆斯林使用含有从猪肉中提取的明胶的疫苗。

基督复临安息日会并未禁止在医疗产品中使用猪肉衍生物。

如果对疫苗中的猪产品有任何疑问，请联系 [email protected]

资源

• 澳洲政府卫生部：关于疫苗接种的问题
• 疫苗安全研究所：宗教领袖批准使用含有猪明胶的疫苗
• NCIRS：疫苗成分情况说明书

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).

免疫建议

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

肺炎球菌疫苗

• 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

乙型肝炎

• 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

资源：

• 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

家庭联系人

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.

资源

• MVEC：流感疫苗建议
• MVEC: Rotavirus
• MVEC：怀孕期孕妇疫苗接种
• Ordering Preterm infant stickers for child healthcare books 
• MVEC: Special risk chapter of the Australian Immunisation Handbook

这 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.

资源

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

什么是结核病？

Pertussis (whooping cough) is a highly contagious, respiratory disease caused by an infection with the bacterium Bordetella pertussis. The bacteria attach to the cilia (tiny, hair-like structures) that line the upper respiratory system. The bacteria release toxins, which damage the cilia and cause airways to swell. Pertussis infection is usually more serious in infants under 6个月, but it can affect people of any age.

需要特别留意的情况

Symptoms begin 6 to 20 days after exposure and initially include rhinorrhoea (runny nose), malaise and a non-specific cough (the catarrhal phase). Approximately one week later, periods of coughing increase with intensity (the paroxysmal phase). A characteristic deep gasp (or “whoop”) may be heard on inspiration, but this is not present in all infections.

During or just following an episode of paroxysmal coughing, babies may have a period of apnoea where they stop breathing for a short period. This may be associated with some colour changes where their skin may appear blue or dusky, especially around the mouth.

Complications of pertussis in infants can include vomiting and difficulty feeding due to prolonged paroxysmal coughing episodes. Rare complications of pertussis in infants include pneumonia and encephalitis, which can be fatal. Complications in older children and adults can include fainting episodes, sleeplessness and rib fractures due to paroxysmal coughing episodes.

结核病是如何传播的？

Transmission of pertussis is through the inhalation of infected respiratory secretions that have been made airborne by coughing, sneezing and speaking. Pertussis is highly contagious, with one infected individual likely to transmit infection to 70–100% of their household members. Some people with mild symptoms of pertussis may be unaware they are infected, but can still spread the bacteria to others. Humans are the only known reservoir for pertussis.

The incubation period is 1 to 3 weeks. Without treatment, people with pertussis are considered infectious just prior to symptom onset and for 21 days thereafter. The infectious period is reduced to 5 days if a course of targeted antibiotics is completed.

流行病学

Australia has historically experienced pertussis epidemics every 3 to 4 years. There is a seasonal pattern to pertussis infections with most cases reported in the spring and summer months.

Infants under 6 months of age have the highest rates of hospitalisation and death from pertussis infection. Aboriginal and Torres Strait Islander children under 5 years have higher rates of pertussis infection and hospitalisation compared with non-Indigenous children of the same age.

With the introduction of the maternal pertussis vaccination program in 2015, there has been a significant reduction in young infants infected with pertussis and a substantial reduction in both morbidity and mortality associated with infection. In Australia, the incidence of pertussis infections in all age groups has continued to decline. Between 2016 and 2018, infants under 2 months of age had the lowest incidence of disease, and children aged 9 to 11 years had the highest incidence of disease.

预防措施

Vaccination against Bordetella pertussis is the most effective public health measure for the prevention of pertussis for both vaccine recipients (direct effect), and among unimmunised populations (indirect ‘herd’ effect).  Vaccination of 孕 people Also provide秒 short-term, passive protection to infants through the transplacental transfer of antibodies.

Pertussis vaccination is only available in Australia in combination with diphtheria and tetanus. Vaccines may also include protection against poliomyelitis, hepatitis B and haemophilus influenzae type B.

The pertussis vaccines available in Australia are acellular, meaning they are made using pertussis toxin and/or components of pertussis bacterium. In contrast, whole-cell pertussis vaccines are first generation pertussis vaccines that are made using an entire bacterium that has been inactivated. While whole cell pertussis vaccines are still available internationally, they were phased out in Australia in 1997, in favour of acellular pertussis vaccines.

初级课程

As per the National Immunisation Program (NIP), a primary course of pertussis vaccination is given at 6 weeks, 4 months, and 6 months of age (Infanrix Hexa/瓦克斯利斯).

Boosters

Booster doses are scheduled to be administered at:

• 18 months (Infanrix/Tripacel)
• 4 years (Infanrix-IPV/Quadracel)
• 12 to 13 years of age/Year 7 high school program (Boostrix)
• Pregnant people at 20–32 weeks gestation (every pregnancy, regardless of how closely spaced).

In addition, pertussis vaccination is recommended (but not funded) for:

• Parents/guardians of a baby under 6 months of age (if they have not received a dose in the last 10 years)
• Adults aged 65 years and older who have not received a pertussis-containing vaccine in the last 10 years
• Any adult who wishes to be protected against pertussis infection who has not received a dose in the last 10 years (including healthcare workers, travellers, and early childhood educators and carers).

Grey shaded boxes – Not routinely recommended for use in this age group.
* ATAGI recommends the use of Infanrix Hexa 和 瓦克斯利斯 in children aged < 10 years. However, the Royal Children’s Hospital (RCH) preferentially uses them up to < 18 years in instances where multiple vaccines are required (e.g. catch up, post chemotherapy/post HSCT). 

疫苗副作用

Common side effects from pertussis vaccination include 注射部位反应, fever, lethargy, headache and irritability in infants and young children. Rare side effects include allergic reaction and hypotonic-hyporesponsive episode (HHE) in infants. There has been a decrease in the incidence of HHE following the change from whole-cell pertussis to acellular pertussis vaccines on the 掐.

资源

• Better Health Channel: Whooping cough
• Australian Immunisation Handbook: Pertussis chapter
• MVEC: Maternal Vaccination During Pregnancy
• RCH: Kids health info fact sheet
• The Immunisation Foundation of Australia
• The Raising Children Net Whooping Cough Guide
• National Notifiable Diseases Surveillance System (NNDSS)
• Australian vaccine preventable disease epidemiological review series: Pertussis, 2013-2018
• RCH: Clinical Practice Guideline Whooping cough