The rubber stopper is not sterile. When you remove the protective cap from a vaccine or diluent vial, you should always clean the stopper with an alcohol wipe. This practice is covered in CDC's online vaccine storage and handling toolkit. To access the kit, go to www2a.cdc.gov/vaccines/ed/shtoolkit.

Prior to the 2010–11 vaccination season, only children ages 6 months through 18 years and adults age 50 years and older were universally recommended for vaccination; recommendations for adults ages 19 through 49 years were targeted to people with specific risk factors, although other adults could be vaccinated if they wanted protection. Collectively, these targeted risk groups made up 85% of the U.S. population. During the 2009 H1N1 outbreak, additional risk groups were identified, such as obese individuals. The new universal vaccination recommendation simplifies previous recommendations, making it easier for healthcare providers to determine whom to vaccinate. The new recommendation also makes it easier for patients to remember to get vaccinated every year.

Supplies will be ample and there will likely be enough vaccine available to protect any person seeking vaccination. Vaccine manufacturers have projected supplies at around 165 million doses for the 2010–11 vaccination season. This is a significant increase in the number of doses of seasonal vaccine compared with any previous year. It should be noted that in the past, vaccine has consistently been left over at the end of each influenza season.

Yes, but you will have to observe a minimum interval of 4 weeks between the time the patient received 2009 H1N1 and the time you administer 2010–11 vaccine, regardless if the 2009 H1N1 dose was injectable or nasal-spray vaccine.

Whether you give injectable vaccine or nasal-spray vaccine or one of each, give 2 doses separated by at least 4 weeks to all children ages 6 months through 8 years who (1) are receiving influenza vaccine for the first time; (2) received their first dose of seasonal vaccine during the 2009–10 season but failed to get their second dose; or (3) failed to get at least 1 dose of 2009 H1N1 vaccine, regardless of their previous influenza vaccination history. If there is uncertainty about the previous season's vaccination history, give 2 doses this season to any child age 6 months through 8 years. CDC has developed a flow chart to aid in making the decision based on the child's previous vaccination history (see www.cdc.gov/vaccines/ed/imzupdate/downloads/doses-algorithm.pdf). The chart at the bottom of this page provides a different format of the information in the flow chart.

You can begin offering vaccine as soon as it becomes available, which is usually mid-to-late summer.

ACIP no longer advises this. It made this recommendation in the past, but removed it from the influenza recommendations in 2007 because of lack of evidence. Therefore, you should begin vaccinating everyone, including residents of long-term care facilities as soon as vaccine becomes available. A literature review of 14 studies that examined this issue is available at www.immunize.org/journalarticles/skowronski_21508.pdf.

LAIV can be administered to all HCWs for whom it is indicated based on age and health history—except to those who care for severely immunocompromised patients in a protective environment (typically defined as a specialized patient-care area with a positive airflow relative to the corridor, high-efficiency particulate air filtration, and frequent air changes). Despite the clarity of this strong recommendation, we have heard that some healthcare facilities erroneously take extreme measures to protect ALL patients from exposure to someone recently vaccinated with LAIV. Some even restrict visitors from seeing hospitalized patients, allowing only people vaccinated with injectable trivalent inactivated influenza vaccine (TIV) to visit. CDC addressed this issue in the recommendations for use of the 2010–11 influenza vaccine as follows: "Concerns about the theoretic risk posed by transmission of live attenuated vaccine viruses contained in LAIV to patients should not be used to justify preferential use of TIV in healthcare settings other than inpatient units that house severely immunocompromised patients requiring protective environments. Some healthcare facilities might choose to not restrict use of LAIV in close contacts of severely immunocompromised persons, based on the lack of evidence for transmission in healthcare settings since [LAIV's] licensure in 2004." To read more on this topic, see pages 35–37 of "Prevention and Control of Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices [ACIP], 2010" MMWR 2010; 59(No. RR-8):35–37 at www.cdc.gov/mmwr/PDF/rr/rr5908.pdf.

Many influenza vaccine products are available for vaccinating children during the 2010–11 influenza vaccination season: Afluria (CSL Laboratories, distributed by Merck); Fluarix (GlaxoSmithKline [GSK]); FluMist (MedImmune); Fluvirin (Novartis); and Fluzone (sanofi pasteur). You can use any of these vaccines in adults, as well as FluLaval (ID Biomedical Corp, distributed by GSK), Agriflu (Novartis), and Fluzone High-Dose (sanofi pasteur). On page 7 of this issue of Needle Tips you'll find a chart that lists all the available influenza vaccines for the 2010–11 vaccination season and simple instructions for administering them. You can also access the chart at www.immunize.org/catg.d/p4072.pdf.

Yes. You are referring to Afluria, which is manufactured in Australia by CSL Laboratories for the U.S. market. CSL's 2010 Southern Hemisphere influenza vaccine (Fluvax and Fluvax Junior) has been associated with increased post-marketing reports of fever and febrile seizures in children predominantly younger than age 5 years as compared with previous years. For this reason, on August 5, ACIP recommended that Afluria, 0.5 mL, licensed for use in people age 36 months and older, not be used in children younger than age 9 years. ACIP further recommended that Afluria could be administered to children ages 5 through 8 years who are at high risk for influenza complications if there is no other age-appropriate trivalent inactivated influenza vaccine (TIV; injectable) available, after risks and benefits of using this vaccine in this age group have been discussed with the parent or guardian. The vaccine should not be given to children younger than age 5 years. For detailed information, go to www.cdc.gov/mmwr/pdf/wk/mm5931.pdf, and see pages 989–92.

Several other products licensed for use in children are displayed on the chart on page 7 of this issue. If you don't have a regular supplier for influenza vaccine, you may want to check a listing of influenza vaccine distributors that have vaccine in stock or on order by going to www.preventinfluenza.org/ivats/ivats_10_11.pdf. The National Influenza Vaccine Summit maintains this list and updates it periodically; check back weekly if you don't find a vaccine on the list that you can use.

CDC discourages the practice of prefilling vaccine into syringes for several reasons, including

Yes.

A history of GBS had previously been a precaution for Menactra MCV4 vaccine (sanofi pasteur). Findings from two studies that examined more than 2 million doses of Menactra given since 2005 showed no evidence of an increased risk of GBS. Consequently, ACIP voted in June 2010 to remove the precaution for use of Menactra in people with a history of GBS. This precaution did not apply to Menveo (Novartis) or Menomune (sanofi pasteur) vaccines.

You should follow the post-exposure prophylaxis protocol for pertussis exposure recommended by CDC (www.cdc.gov/vaccines/pubs/pertussis-guide/guide.htm). Research is needed to evaluate the effectiveness of Tdap to prevent pertussis in healthcare settings. Until studies define the optimal management of exposed vaccinated healthcare personnel, or experts arrive at consensus, healthcare facilities should continue post-exposure prophylaxis protocol for vaccinated HCWs who are exposed to pertussis.

Vaccine efficacy is 80%–85% following 3 doses of DTaP vaccine. Efficacy data following just 1 or 2 doses are lacking but are likely lower. Therefore, it is especially important that you advise parents of infants that all people who live with the infant or who provide care to him or her be protected against pertussis. Recommend that all the infant's family members and visitors ages 10 through 64 years receive a one-time dose of adolescent/adult tetanus-diphtheria-acellular pertussis (Tdap) vaccine if they have not already done so.

ACIP has not recommended off-label use of Tdap for adults age 65 years and older. However, there is no reason to believe that Tdap is any less safe for people age 65 years and older than it is for younger adults. Clinicians are always free to use their clinical judgment; they may decide that in this situation the benefit of administering Tdap off-label exceeds any hypothetical risk of giving the vaccine.

No minimum interval is required between giving doses of Td and Tdap to an adolescent who is or might be in contact with an infant. This includes adolescents who are older siblings of infants, babysitters, hospital employees or volunteers, etc. In circumstances like this, give Tdap without delay. For adolescents who will not be in contact with infants, CDC/ACIP recommends a routine wait of 5 years between Td and Tdap administration unless a school vaccination mandate requires giving Tdap.

Two documented doses of MMR vaccine is considered proof of immunity according to ACIP. However, what ACIP recommends is not always what schools and institutions accept. Here are some basics about MMR vaccination and healthcare personnel.