Updates to the Handbook

Pre-vaccination screening section updated to include guidance on appropriate spacing of inactivated and live parenteral vaccines.

Guidance on administration of rotavirus vaccine to infants exposed to bDMARDs in utero updated.

Guidance under Co-administration with other vaccines updated.

Guidance on concomitant and sequential administration of tetanus-containing vaccines with Menactra and Nimenrix has been added.

Editorial changes to 'Table. Recommended timing of live vaccine doses in adults and children taking corticosteroids' in the ‘Use of live vaccines in people who are immunocompromised' section, to correct prednisone-equivalent doses for children and adolescents aged <16 years who weigh >10 kg.

Guidance on assessing the level of immunocompromise in children and adults with HIV updated.

Guidance on vaccination of infants born to mothers who received bDMARDs during pregnancy updated.

Guidance on vaccination of infants exposed to bDMARDs (biological disease-modifying anti-rheumatic drugs) in utero has been updated. Infants born to mothers who received bDMARDs during pregnancy are not recommended to receive rotavirus vaccine. Drug levels may be measured to guide decision-making.

Guidance on international travel requirements updated.

Contraindications for people who are immunocompromised updated.

Editorial change in Adverse events section to correct placement of references for the rate of immediate hypersensitivity reactions after yellow fever vaccination.

Guidance on risk to travellers updated.

Guidance on vaccination of travellers against measles, mumps and rubella updated to reflect advice in the Measles chapter.

Changes to catch-up recommendations for infants receiving MMR vaccines. The recommended age at which infants can receive MMR vaccine in special circumstances has been lowered from 9 months to 6 months. For additional details refer to MMR and MMRV vaccines and Measles.

The recommended age at which infants can receive MMR vaccine in special circumstances has been lowered from 9 months to 6 months. Infants as young as 6 months of age can receive MMR vaccine for travel to highly endemic areas during outbreaks and as post-exposure prophylaxis.

For post-exposure prophylaxis, infants from 6 months can be offered MMR vaccine in place of normal human immunoglobulin.

Updates to influenza information in line with the ATAGI annual statement for seasonal influenza vaccines

ATAGI annual statement for seasonal influenza vaccines is available here: https://health.gov.au/resources/publications/atagi-advice-on-seasonal-influenza-vaccines-in-2019

• The  indicated ages for Fluarix Tetra and Afluria Quad have been extended. Fluarix Tetra can be used as a 0.5 mL dose in children aged 6 months and older, down from 3 years.
• The recommendation for administration during pregnancy has been updated. Pregnant women can receive influenza vaccine during any stage of pregnancy. The timing of vaccination should be considered in relation to the influenza season and vaccine availability. Please refer to the recommendation for further details.
• 'People who are travelling during the influenza season are strongly recommended to receive influenza vaccine, especially if influenza is circulating in the destination region or in settings with increased risk of influenza circulation during the trip. Please refer to the recommendations for travellers for further details.

Updates to the recommendation for pertussis vaccination during pregnancy.

The recommendation for pertussis vaccination during pregnancy has been updated. The optimal timing for vaccination has been updated to 20 (previously 28) to 32 weeks gestation (mid 2nd trimester to early 3rd trimester). Please refer recommendations for Women who are pregnant or breastfeeding.

Changes to dose schedule for Bexsero, and Variations from product information.

• The recommended dose schedule for Bexsero has been updated for healthy infants aged 6 weeks to 5 months. Two primary doses should be given with an 8 week interval between doses, followed by a 3rd dose at 12 months of age.
• Based on various changes to product information Nimenrix, Menactra, Bexsero and Trumenba, updates have been made, particularly in the Variations from product information.

Editorial changes to 'Table. Monovalent hepatitis B vaccines for adolescents and adults' in the 'Vaccines, dosage and administration' section to include paediatric formulations.

Corrected text in table describing monovalent hepatitis B vaccines for adolescents and adults.

No supporting evidence required. Editorial update due to error in table – paediatric formulations omitted.

Changes to existing Recommendations listed in Chapter 4.6 Human Papillomavirus.

Recommendations

The following replaces the existing Recommendations listed in Chapter 4.6 Human Papillomavirus:

1. All individuals (males and females) who commence vaccination at the age of 9 to 14 years, except immunocompromised individuals (refer to (b) below), should receive two doses of 9vHPV vaccine given 6–12 months apart (0, 6–12 months).
2. The following population groups should receive three doses of 9vHPV vaccine given at 0, 2 and 6 months:
   1. immunocompromised individuals (males and females) at any age;
   2. males and females who receive their first dose of 9vHPV after turning 15 years of age.

Table 1: Comparison of the ATAGI current and proposed recommendations for HPV vaccination

^*HPV vaccine may be administered from 9 years of age, however, the optimal time for vaccination is approximately 12–14 years, as provided under the school-based National Immunisation Program (NIP).

^†Both 2vHPV and 4vHPV vaccines have been registered in Australia. Only 4vHPV vaccine has been provided under the National Immunisation Program (NIP) since HPV vaccination was funded in 2007.

^‡Immunocompromised individuals include those with primary or secondary immunodeficiencies (B lymphocyte antibody and T lymphocyte complete or partial deficiencies), HIV infection, malignancy, organ transplantation, autoimmune disease, or significant immunosuppressive therapy (but does not include asplenia or hypopsplenia).

^§If an individual has received two doses of HPV vaccine with an interval of less than 5 months between dose 1 and dose 2, a third dose is required at least 12 weeks after the second dose, ensuring that the minimum intervals for 3 doses have been met. If the second dose is received at <6 months but ≥5 months after the first dose, a third dose is not required, as clinical trial data support this interval still being sufficiently immunogenic.

^¶Minimum intervals recommended for a 3-dose schedule are at least 4 weeks between dose 1 and dose 2 and at least 5 months between dose 1 and dose 3.

c.9vHPV vaccine can be used to complete an HPV vaccination schedule commenced with either the 4vHPV or 2vHPVvaccine.

No catch up is recommended for individuals who have completed a full schedule (either age and interval appropriate 2- or 3- dose schedules) with either 4vHPV or 2vHPV. Refer to evidence following.

The pneumococcal vaccination schedule has changed for:

• all children aged <5 years living in the Australian Capital Territory, New South Wales, Tasmania and Victoria
• all non-Indigenous children aged <5 years living in the Northern Territory, Queensland, South Australia and Western Australia without underlying medical conditions associated with an increased risk of invasive pneumococcal disease

These children now receive a 2+1 schedule:

• 2 primary doses of 13vPCV (13-valent pneumococcal conjugate vaccine) at 2 and 4 months of age
• a booster dose at 12 months of age

The previous schedule was 3 primary doses at 2, 4 and 6 months of age (3+0 schedule).

The pneumococcal vaccination schedule has changed for:

• all Aboriginal and Torres Strait Islander children living in the Northern Territory, Queensland, South Australia and Western Australia
• all children with underlying medical conditions associated with an increased risk of invasive pneumococcal disease

The booster dose previously recommended for these children at 12–18 months of age is now recommended at 12 months of age. This means that these children should continue to receive 4 doses of 13vPCV at 2, 4, 6 and 12 months of age (3+1 schedule).

These changes have also changed the catch-up schedules for pneumococcal vaccination. See Catch-up vaccination for more details.

Changes to recommendations.

• New recommendations have been added for the use of MenACWY vaccine for healthy people and people at higher risk of meningococcal disease, including Aboriginal and Torres Strait Islander people.
• Recommendations for the use of MenB vaccine for certain at-risk groups, particularly Aboriginal and Torres Strait Islander people and people living in close quarters, have been extended to people aged 15–24 years.
• Recommendations have been added for the dosing schedules for new vaccines and new age indications for existing vaccines

Advice regarding HRIG delay following high-risk situations of potential lyssavirus exposure has been updated. For bites to the head and neck, give post-exposure prophylaxis as soon as possible and no later than 48 hours after exposure, even if the animal has been sent for testing.

The Hib (Haemophilus influenzae type b) booster dose previously given in combination with Hib-MenC (combined Hib and meningococcal C vaccine) at 12 months of age has been replaced with a monovalent Hib dose at 18 months of age.

2018 Influenza seasonal updates. Updating the text to reflect the 2018 influenza season (Refer to Chapter 4.7 Influenza)

Recommendations

The following replaces the existing Recommendations for infant pneumococcal vaccination schedule listed in Chapter 4.6 Pneumococcal disease:

1. All children, except those specified in (b) below, should receive three doses of 13vPCV at 2, 4 and 12 months of age (called ‘2+1’ schedule) instead of the current schedule with doses at 2, 4 and 6 months of age (called ‘3+0’ schedule).
2. The following population groups at increased risk of pneumococcal infection should continue to receive four doses of 13vPCV at 2, 4, 6 and 12 months^ of age (called ‘3+1’ schedule):
   1. Aboriginal and Torres Strait Islander children living in the NT, QLD, SA and WA
   2. Children with underlying medical conditions associated with an increased risk of IPD.

^ Note the preferred schedule point for the fourth (last) 13vPCV dose is age 12 months rather than 18 months.

Table 1: Comparison of current and proposed ATAGI recommendations for 13vPCV schedules in children

^* Refer to The Australian Immunisation Handbook Chapter 4.13 Pneumococcal disease, section 4.13.7 ‘Recommendations’.

Schedules for catch-up doses of 13vPCV for children aged <5 years who have not received any pneumococcal conjugate vaccine (PCV) doses or who have only received incomplete courses of PCVs are covered in Tables 2 (for all children with medical condition(s) increasing IPD risk and Aboriginal and Torres Strait Islander children in NT, QLD, SA or WA) and 3 (for all other children).

Table 2: Catch-up schedule for 13vPCV for Aboriginal and Torres Strait Islander children living in NT, QLD, SA or WA ONLY, and all children with any medical condition(s)^* associated with an increased risk of invasive pneumococcal disease (IPD), aged <5 years

* Recommendations for vaccination of haematopoietic stem cell transplant (HSCT) recipients differ: a separate table for revaccination following HSCT in children and adults will be included in upcoming updates to The Australian Immunisation Handbook.

^† Prior PCV doses may have been given as 7vPCV (e.g. from overseas), 10vPCV or 13vPCV. Use 13vPCV as the vaccine formulation for catch-up doses, regardless of which formulation of PCV the child received previously.

^‡ Where possible, align doses with the standard schedule points at 2, 4 and 6 months of age for infants. The minimum interval between dose(s) is 1 month if aged <12 months, and 2 months if aged ≥12 months.

^§ The last dose should be given after the child reaches 12 months of age (as a booster dose) with a minimum interval of 2 months after the previous dose of PCV.

Table 3: Catch-up schedule for 13vPCV for all other children aged <5 years (not covered in Table 2a)

^* Prior PCV doses may have been given as 7vPCV (e.g. from overseas), 10vPCV or 13vPCV. Use 13vPCV as the vaccine formulation for catch-up doses, regardless of which formulation of PCV the child received previously.

^† Where possible, align doses with the standard schedule points at 2 months and 4 months of age for infants aged <5 months. The minimum interval between dose(s) is 1 month if aged <12 months, and 2 months if aged ≥12 months.

^‡ The last dose should be given after the child reaches 12 months of age (as a booster dose) with a minimum interval of 2 months after the previous dose of 13vPCV.