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Immunization Action Coalition
Ask the Experts
As appeared in the February 2013 issue of Needle Tips
Please note: A clarification has been published for an "Ask the Experts" answer for this issue. To view the clarification, please click here.
Click here for PDF version
Vaccine storage and handling
Q:
Is it still acceptable to use combination household units for storing vaccines?
A:  
CDC strongly recommends using stand-alone refrigerators and freezers for the following reasons:
 
Most combination household refrigerator/freezers have a combined temperature control unit that can create cold spots and temperature fluctuations in the refrigerator portion of the unit.
The risk of freeze damage to refrigerated vaccines is increased in combination units because air from the freezer is vented into the refrigerator to cool it. This can freeze temperature-sensitive vaccines.
The freezer portions of many combination units are not capable of maintaining the correct storage temperature for frozen vaccines. Purchasing new vaccine storage equipment requires planning, and you may need to use existing equipment for a while until you can purchase new equipment. In this situation, CDC recommends using a combination refrigerator/freezer unit for refrigerated vaccine only and using a separate stand-alone freezer to store frozen vaccines.
It is important to note that most combination refrigerator/freezers share a single condenser, and the very cold air from the freezer compartment is vented into the refrigerator compartment to cool the refrigerator. You should not turn off the freezer portion of the combination unit because it will not maintain the proper temperature for the refrigerated vaccines stored in the refrigerator portion of the unit. If you are using the refrigerator portion of the combination unit, it is important that you not store vaccines directly under the vent coming from the freezer and that you add water bottles to the refrigerator to absorb cold air blown in from the freezer. This will reduce the risk of vaccines becoming too cold.
 
Q:
What temperature is considered a temperature excursion on refrigerated vaccine? Frozen vaccine?
A:  
Any temperature readings outside the ranges noted below are considered temperature excursions.
 
For refrigerated vaccines, the minimum temperature is 35°F (2°C), and the maximum is 46°F (8°C).
For frozen vaccines, the minimum temperature is -58°F (-50°C), and the maximum is 5°F (-15°C).
If there is a question about whether a vaccine has been exposed to a temperature excursion, label the vaccines "DO NOT USE" and store them under appropriate conditions, separate from other vaccines. Then, contact the vaccine manufacturer for further guidance. If you are a VFC provider, contact either the vaccine manufacturer and/or your state or local immunization program as directed by the VFC Program in your area.
 
Q:
I keep hearing about changes to vaccine storage and handling recommendations. Why is CDC making these changes? And how can I make sure I am up to date with all the newest information?
A:  
Good questions! The why behind these changes has two parts. First, it had become increasingly apparent to CDC and state health departments that improper vaccine storage and handling is a big problem, leading to a huge waste of product, time, and money, and more importantly, to unprotected people. Second, improved technology (e.g., digital data loggers) provides tools that uncover and measure problems and also prevent them.
As far as how to keep up, on November 27, 2012, CDC released its updated Vaccine Storage and Handling Toolkit at www.cdc.gov/vaccines/recs/storage/toolkit/storage-handling-toolkit.pdf and posted it on CDC's Vaccine Storage and Handling Toolkit web section at www.cdc.gov/vaccines/recs/storage/toolkit. The Vaccine Storage and Handling Toolkit is based on the recommendations of ACIP, equipment manufacturers' product information, and studies from the National Institute for Scientific Technology. The toolkit outlines best practice strategies and recommendations on the following topics:
 
Equipment considerations for storage units and thermometers
Maintenance of the cold chain
Routine storage and handling practices
Inventory management
Emergency procedures for protecting vaccine inventories
Every vaccine provider should print out this document and read and reread it carefully. CDC has provided an overview of the new information as a separate item at www.cdc.gov/vaccines/recs/storage/interim-storage-handling.pdf, as well as a set of FAQs about the new recommendations at www.cdc.gov/vaccines/recs/storage/interim-faq-storage-handling.pdf.
DTaP/Tdap/Td vaccine
Q:
What are the new ACIP recommendations for vaccinating pregnant women with Tdap?
A:  
In October 2012, ACIP voted to recommend that a pregnant woman receive Tdap vaccine during each pregnancy, even if the woman had received Tdap previously. The optimal time to administer Tdap is between 27 and 36 weeks' gestation. Vaccination during this time maximizes maternal antibody response and passive antibody transfer to the infant. Women who have never received Tdap and who do not receive it during pregnancy should receive it immediately postpartum. When a woman gets Tdap during pregnancy, maternal pertussis antibodies transfer to the newborn, likely protecting the baby against pertussis in early life, before the baby is old enough to have received at least 3 doses of DTaP. Tdap also protects the mother, making it less likely that she will get infected with pertussis during or after pregnancy and thus less likely that she will transmit it to her infant.
The related provisional recommendations for the use of Tdap in pregnancy were published on December 6, 2012. CDC anticipates releasing the final updated recommendations in the Feb. 22 issue of MMWR. To access the new recommendations, visit www.cdc.gov/vaccines/pubs/ACIP-list.htm.
 
Q:
If a woman did not receive Tdap during pregnancy, and it is uncertain whether she received a dose of Tdap prior to her pregnancy, should she receive a dose of Tdap postpartum?
A:  
Yes. If there is no written documentation that she received a dose of Tdap prior to or during pregnancy, a dose of Tdap should be administered to her immediately postpartum.
 
Q:
A 7-year-old who needed a tetanus shot for wound management came into our emergency department. My question is, if a child has received the complete 5-dose series of DTaP but has never had Tdap, should the child receive Tdap or Td for wound management?
A:  
Neither. A child who has completed 5 doses of DTaP has by definition received the fifth dose on or after his/her 4th birthday. In this child's case, it has been less than four years since receipt of the complete series, so the child does not need either Tdap or Td. The child is fully vaccinated against tetanus according to CDC tetanus wound management guidelines.
 
Q:
I have an adult patient with controlled epilepsy who wishes to receive the Tdap vaccine. May I vaccinate him?
A:  
Controlled epilepsy is not a contraindication to receipt of Tdap. To access IAC's table of vaccine contraindications and precautions, go to www.immunize.org/catg.d/p3072a.pdf. CDC also makes this information available at www.cdc.gov/vaccines/recs/vac-admin/contraindications-vacc.htm.
Meningococcal vaccine
Q:
What are the new ACIP recommendations for use of MenHibrix, the new combination meningococcal Groups C and Y and Haemophilus influenzae type b vaccine?
A:  
Licensed in June 2012, MenHibrix (Hib-MenCY; GSK) is a vaccine indicated for active immunization to prevent invasive disease caused by Neisseria meningitidis serogroups C and Y and Haemophilus influenzae type b. This vaccine does not protect against meningococcal serogroups A, B, and W135.
In October 2012, ACIP voted to recommend that infants at increased risk for meningococcal disease be vaccinated with 4 doses of Hib-MenCY at age 2, 4, 6, and 12 through 15 months. This includes infants with recognized persistent complement pathway deficiencies and infants who have anatomic or functional asplenia, including sickle cell disease. Hib-MenCY can be used in infants age 2 through 18 months who live in communities with serogroup C and Y meningococcal disease outbreaks. On October 24, 2012, CDC published a media advisory on the use of Hib-MenCY vaccine. It's available at www.cdc.gov/media/releases/2012/a1024_HibMenCY.html.
IAC has developed a handy reference table that summarizes ACIP's recommendations for meningococcal vaccination of children and adults. It's available at www.immunize.org/catg.d/p2018.pdf.
HPV vaccine
Q:
Is fainting after the first or second dose of HPV vaccine a contraindication to administering subsequent doses?
A:  
No. Fainting is not a contraindication to administering a subsequent dose of any vaccine. Fainting after vaccination is fairly common in adolescence. Providers should prepare for the possibility by having patients sit or lie down when receiving the vaccine and observing patients for 15 minutes after vaccination. For more information on syncope and vaccination, visit the CDC website at www.cdc.gov/vaccinesafety/Concerns/syncope_faqs.html.
Influenza vaccine
Q:
How soon after taking prednisone for an asthma attack can a child receive a flu shot?
A:  
Steroid treatment is not a contraindication for vaccination with inactivated influenza vaccine. As this vaccine is not a live virus vaccine, you can (and should) give it to people who are immunosuppressed, although the patient's immune response may not be optimal. Immunosuppression (e.g., from certain steroid treatments) is a concern only when administering live virus vaccines.
 
Q:
We inadvertently administered an adult dose (0.5 mL) of influenza vaccine to an 8-month-old infant. Does this child need the second dose?
A:  
Yes. Giving a larger-than-recommended dose of any vaccine does not negate the need for indicated subsequent doses.
MMR vaccine
Q:
I understand that ACIP recently changed its definition of evidence of immunity to measles, rubella, and mumps. Please explain.
A:  
At its October 2012 meeting, ACIP voted to include "laboratory confirmation of disease" as evidence of immunity for measles, mumps, and rubella. ACIP voted to remove "physician diagnosis of disease" as evidence of immunity for measles and mumps. "Physician diagnosis of disease" had not previously been accepted as evidence of immunity for rubella. With the decrease in measles and mumps cases over the last 30 years, the validity of physician-diagnosed disease has become questionable. In addition, documenting history from physician records is not a practical option for most adults. The provisional MMR recommendations are currently available on the CDC website at www.cdc.gov/vaccines/recs/provisional/default.htm.
Please note that provisional ACIP recommendations become CDC recommendations once they are accepted by the director of CDC and the Secretary of Health and Human Services and are published in MMWR.
 
Q:
What are the new provisional ACIP recommendations for use of immune globulin (IG) for measles post-exposure prophylaxis?
A:  
At its October 2012 meeting, ACIP voted to expand the use of post-exposure IG prophylaxis for measles.
 
Infants younger than 12 months who have been exposed to measles should receive an IG dose of 0.5 mL/kg of body weight. Give IG intramuscularly (IGIM); the maximum dose is 15 mL. Alternatively, MMR vaccine can be given instead of IGIM, to infants age 6–11 months, if it can be given within 72 hours of exposure.
Pregnant women without evidence of measles immunity who are exposed to measles should receive an IG dose of 400 mg/kg of body weight. Give IG intravenously (IGIV).
Severely immunocompromised people, irrespective of evidence of measles immunity, who have been exposed to measles should receive an IG dose of 400 mg/kg of body weight. Give IG intravenously (IGIV).
Other people who do not have evidence of measles immunity can receive an IG dose of 0.5 mL/kg of body weight. Give priority to people who were exposed to measles in settings where they have intense, prolonged close contact (e.g., household, child care, classroom, etc.). Give IG intramuscularly; the maximum dose is 15 mL.
Full details about these provisional recommendations, including the definition of severely immunocompromised people, are available at www.cdc.gov/vaccines/recs/provisional/downloads/mmr-Oct-2012.pdf.
 
Q:
Please describe the new provisional ACIP recommendations for the use of MMR vaccine in people who are HIV-infected.
A:  
Provisional ACIP recommendations for vaccinating people with HIV infection are as follows:
 
Administer 2 doses of MMR vaccine to all HIV-infected people age 12 months and older who do not have evidence of current severe immunosuppression or current evidence of measles, rubella, and mumps immunity. To be regarded as not having evidence of current severe immunosuppression, a child age 5 years or younger must have CD4 percentages of 15% or more for 6 months or more; a person older than 5 years must have CD4 percentages of 15% or more and a CD4 lymphocyte count of 200 or more/mm3 for 6 months or more.
Administer the first dose to babies age 12 through 15 months and the second dose to children age 4 through 6 years, or as early as 28 days after the first dose.
Unless they have acceptable current evidence of measles, rubella, and mumps immunity, people with perinatal HIV infection who were vaccinated prior to establishment of effective antiretroviral therapy (ART) should receive 2 appropriately spaced doses of MMR vaccine after effective ART has been established. Children age 5 years or younger must have CD4 percentages of 15% or more for 6 months or more; people older than 5 years must have CD4 percentages of 15% or more and a CD4 lymphocyte count of 200 or more/mm3 for 6 months or more.
Vaccine administration
Q:
Some single-dose pre-loaded vaccines come with an air pocket in the syringe chamber. Do we need to expel the air pocket before vaccinating?
A:  
No. You do not need to get rid of the air pocket. The air will be absorbed. This is not true for syringes that you fill yourself; you should expel air bubbles from these syringes prior to vaccination to the extent that you can readily do so.
 
Q:
Is it recommended to use a new alcohol swab to cleanse the skin before administering a vaccine, or can we swab the skin with the same alcohol swab that we used to wipe off the stopper on the vial?
A:  
You should use separate alcohol wipes to clean the vial top and the patient's skin.
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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.