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Immunization Action Coalition
Ask the Experts
As appeared in the August 2012 issue of Needle Tips
Click here for PDF version
Immunization questions
Q:
Pneumococcal polysaccharide vaccine (PPSV23) is recommended for all adults who smoke. Are there recommendations for those who use smokeless tobacco products (e.g., chewing tobacco)?
A:  
No. ACIP does not identify people who use smokeless tobacco products as being at increased risk for pneumococcal disease or as being in a risk group for vaccination.
 
Q:
Now that FDA has licensed Prevnar 13 (PCV13; Pfizer) for adults, does ACIP have recommendations for its use?
A:  
To date, ACIP has not made recommendations for routine use of PCV13 for adults; however, at its June 2012 meeting, ACIP voted to recommend administering 1 dose of PCV13 to adults age 19 and older who are at highest risk for invasive pneumococcal disease. This includes adults who are immunosuppressed and those with functional or anatomic asplenia, renal disease, CSF leak, and cochlear implants. ACIP voted to recommend that when healthcare providers vaccinate highest-risk patients who have never received a pneumococcal vaccine, the provider administer PCV13 first, then follow with a dose of pneumococcal polysaccharide vaccine (PPSV23) 8 weeks later, and follow with a second dose of PPSV23 5 years later. For highest-risk patients who have already received PPSV23, ACIP voted to recommend that healthcare professionals wait 1 year since the previous dose of PPSV23 before giving PCV13 to avoid interference between the vaccines. More detail will be included when MMWR publishes the recommendations.
 
Q:
I am confused about which adults to vaccinate with Tdap vaccine and which product to use. Please help!
A:  
CDC published updated recommendations on Tdap vaccination for adults in MMWR on June 29, 2012, pages 468–470. ACIP recommends that ALL adults age 19 years and older who have not yet received a dose of Tdap receive a single dose. Tdap should be administered regardless of interval since the last tetanus- or diphtheria-toxoid-containing vaccine (e.g., Td). After receiving Tdap, people should receive Td every 10 years for routine booster immunization against tetanus and diphtheria, according to previously published guidelines.
Providers should not miss an opportunity to vaccinate adults age 65 and older with Tdap. Therefore, providers may administer any Tdap vaccine they have available. When feasible, providers should administer Boostrix (Tdap; GSK) to adults age 65 and older as it is licensed for this age group. Adacel (Tdap; sanofi) is licensed for use in people age 11 through 64. However, ACIP concluded that either vaccine administered to a person age 65 or older is immunogenic and will provide protection. A dose of either vaccine is considered valid.
When a tetanus-toxoid-containing vaccine is needed for wound management in a person who has not previously received Tdap, the use of Tdap is preferred over Td.
 
Q:
Is there guidance for pertussis protection for an adult who cannot receive the tetanus portion of the Tdap vaccine because of allergy?
A:  
Usually, an "allergy" to tetanus toxoid is anecdotal and not a true anaphylactic reaction to modern tetanus toxoid. Patients often claim to be allergic to tetanus toxoid because of (1) an exaggerated local reaction (which is not an allergy) or (2) a reaction to a tetanus vaccine received many years ago (probably serum sickness from equine tetanus antitoxin). A history of one of these events is not a contraindication to modern tetanus toxoid, Td, or Tdap.
Only an allergist-confirmed anaphylactic allergy to tetanus toxoid should be accepted as a valid contraindication to a modern tetanus-toxoid-containing product. A person who has an allergist-confirmed anaphylactic allergy to tetanus toxoid has no recourse for pertussis vaccination because no single-antigen pertussis vaccine is licensed for use in the United States.
 
Q:
Who should get a second dose of Tdap vaccine?
A:  
Currently, no one is recommended to receive more than 1 dose of Tdap. In the future, ACIP will discuss the need for administering additional doses of Tdap and the timing of revaccinating people who have received Tdap previously.
 
Q:
Why do we vaccinate pregnant women against influenza when it is not recommended to vaccinate infants younger than age 6 months?
A:  
ACIP has recommended vaccinating pregnant women with inactivated influenza vaccine (TIV) for a number of years. Pregnant women are a high-risk group for complications, hospitalization, and even death from influenza because of the increased physiologic strain of pregnancy on their heart, lungs, and immune system. Vaccination can occur in any trimester, including the first.
Influenza vaccine is not recommended for children younger than age 6 months because it is not approved for this age group. In addition, there are data that indicate that vaccinated pregnant women pass maternal antibodies to the fetus in the last few weeks of pregnancy; this helps protect the young infant against influenza. Vaccinating pregnant women thus protects women, their unborn babies, and their babies after birth.
 
Q:
A child received a 0.25 mL dose of inactivated influenza vaccine (TIV) at age 34 months. She is scheduled to return for the second dose at age 36 months. Should she receive a 0.25 mL dose or a 0.5 mL dose?
A:  
She should receive a 0.5 mL dose of TIV. Always administer the volume of vaccine appropriate to the age of the patient when the patient presents at the clinic for the dose.
 
Q:
If Cervarix (HPV2; GSK) is inadvertently administered to a male, does the dose need to be repeated with Gardasil (HPV4; Merck)?
A:  
Yes. Cervarix is recommended for use only in females. There is no minimum interval between the invalid dose of Cervarix and the dose of Gardasil.
ACIP recommends routine vaccination of males age 11–12 years with HPV4 administered as a 3-dose series. The vaccination series can be started at age 9 years. Vaccination with HPV4 is also recommended for males age 13 through 21 years who have not been vaccinated previously or who have not completed the 3-dose series. Males age 22 through 26 years may be vaccinated with HPV4; ACIP specifically recommends routine vaccination with HPV4 through age 26 years for immunocompromised males and men who have sex with men if they have not been vaccinated previously or have not completed the 3-dose series.
 
Q:
Is it safe to give the shingles vaccine (Zostavax; Merck) to patients age 60 years and older who have had a splenectomy? I am concerned because it's a live virus vaccine.
A:  
Yes, it is safe. Asplenic people can get all vaccines indicated. Immunosuppression is not a consideration unless the patient has other health issues or is undergoing treatments that suppress the immune system. A patient's response to shingles vaccination should not be affected by the lack of a functioning spleen.
 
Q:
If a healthcare worker does not have a history of varicella vaccination or disease but has had a clinically diagnosed case of shingles, does she or he still need varicella vaccination?
A:  
No. A healthcare provider's diagnosis or verification of a history of shingles is acceptable evidence of immunity to varicella. According to ACIP, acceptable evidence of varicella immunity in healthcare personnel includes (1) documentation of 2 doses of varicella vaccine given at least 28 days apart, (2) history of varicella or herpes zoster based on physician diagnosis, (3) laboratory evidence of immunity, or (4) laboratory confirmation of disease.
 
Q:
ACIP recommends that adolescents who receive the first dose of meningococcal conjugate vaccine (MCV4) at age 13–15 years receive a one-time booster dose at age 16–18 years. Given how hard it is to get teens into a medical office, is it okay to give the doses close together if the opportunity arises? For example, if a patient got the first dose at age 15, and then came back for a sports physical at age 16, could we give the second dose of MCV4 then or should we try to space it out as far as possible (age 18)?
A:  
If the first dose is given at age 13 through 15 years, you can give the booster dose as early as age 16 years, with a minimum interval of 8 weeks from the previous dose. So, even if the patient got vaccinated at age 15 years 11 months, you could wait at least 8 weeks and then give the booster at age 16 years 1 month (or later) if you chose to do so.
 
Q:
A 12-year-old patient new to our clinic brought immunization records from her previous clinic. Her records show that she received Menomune (meningococcal polysaccharide vaccine; MPSV4; sanofi) when she was age 11. Is this considered adequate coverage for the 11–12 year-old dose? Can we wait until she is 16 to give the meningococcal conjugate vaccine (MCV4) dose?
A:  
The answer to both of your questions is yes. You can count the MPSV4 dose as valid. Although MCV4 is preferred, MPSV4 is licensed for this age group, and a dose of either vaccine (i.e., MCV4 or MPSV4) at age 10 or older is considered valid. Just make sure the second dose is MCV4.
 
Q:
Can you switch brands of rabies vaccine to complete the 4-dose series?
A:  
Yes. The two rabies vaccines licensed for use in the United States are interchangeable.
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Immunization Action Coalition  •  Saint Paul, MN
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This website is supported in part by a cooperative agreement from the National Center for Immunization and Respiratory Diseases (Grant No. 5U38IP000290) at the Centers for Disease Control and Prevention (CDC) in Atlanta, GA. The website content is the sole responsibility of IAC and does not necessarily represent the official views of CDC.