Ask the Experts: Needle Tips July 2009

The number of injections recommended to be given at a single office visit is increasing, and we are running out of injection sites. Should we defer certain vaccines?

We strongly recommend that you do not defer any recommended vaccines. This would be a missed opportunity. No upper limit has been established regarding the number of vaccines that can be administered in one visit. CDC�s Advisory Committee on Immunization Practices (ACIP) and the American Academy of Pediatrics (AAP) consistently recommend administering all vaccines indicated for the patient�s age. When giving several injections at a single visit, separate 2 intramuscular (IM) vaccines by at least 1 inch in the body of the muscle to reduce the likelihood of local reactions overlapping. Here is a link to a collection of illustrations (i.e., �site maps�) that show how one can administer all indicated doses to children: http://www.cdc.gov/vaccines/pubs/pinkbook/downloads/appendices/D/site-map.pdf.

When we are giving multiple injections in a limb, what is the best way to accurately document the injection site? It is not unusual for us to give 4�6 injections to each infant/child that we see, and I want to ensure that we are doing this safely and documenting it adequately.

One way to handle this is to indicate if the vaccination was given either in the �upper� or �lower� portion of the injection area selected (e.g., DTaP: right thigh, upper; Hib: right thigh, lower; or PCV7: left thigh, upper; HepB: left thigh, lower). It is helpful if everyone in your office or clinic uses the same sites for each vaccine. Use of standardized site maps can facilitate this. Site maps for administering vaccines to children are available at www.cdc.gov/vaccines/pubs/pinkbook/downloads/appendices/D/site-map.pdf. Site maps for administering vaccines to adults are at www.eziz.org/PDF/IMM-718adult.pdf.

If I have to give more than 1 injection in a muscle, are certain vaccines best given together?

Since DTaP and pneumococcal conjugate are the vaccines most likely to cause a local reaction, it�s practical to give DTaP and PCV in separate limbs (if possible), so there is no confusion about which vaccine caused the reaction.

When patients need multiple vaccines, can we just combine them in one syringe?

Absolutely not. Vaccines should never be mixed in a single syringe except when specifically approved by FDA and packaged for that specific purpose.

For which vaccines is an egg allergy a contraindication? What about MMR vaccine?

Influenza and yellow fever vaccines are the only vaccines that are contraindicated for people who have a history of a severe (anaphylactic) allergy to eggs. Allergy to eggs is no longer considered a contraindication for giving MMR vaccine. Though measles and mumps vaccines are grown in chick embryo tissue culture, several studies have documented the safety of these vaccines in children with severe egg allergy. In 1994, ACIP�s �General Recommendations on Immunization� listed egg allergy as a contraindication for administering MMR. That was changed, however, and by 1998 when ACIP�s most recent recommendations for MMR were published, egg allergy was no longer listed as a contraindication. That remains true today: Neither AAP's Committee on Infectious Diseases (�Red Book Committee�) nor ACIP consider egg allergy a contraindication to MMR vaccine. You can always check for contraindications for any vaccine in CDC�s Guide to Vaccine Contraindications and Precautions at www.cdc.gov/vaccines/recs/vac-admin/downloads/contraindications-guide-508.pdf.

We frequently see patients who are febrile or have an acute illness and are due for vaccinations. We�re never quite sure if we should withhold the vaccines or not. What do you advise?

A �moderate or severe acute illness� is a precaution for administering any vaccine. A mild acute illness (e.g., diarrhea or mild upper-respiratory tract infection) with or without fever is not. The concern in vaccinating someone with moderate or severe illness is that a fever following the vaccine could complicate management of the concurrent illness (that is, it could be difficult to determine if the fever was from the vaccine or due to the concurrent illness). In deciding whether to vaccinate a patient with moderate or severe illness, the clinician needs to determine if forgoing vaccination will increase the patient�s risk to vaccine-preventable diseases, as is the case if the patient is unlikely to return for vaccination or to seek vaccination elsewhere.

Some of our employees have a contact allergy to latex gloves. Can they receive vaccines that are supplied in vials or syringes that contains latex?

Yes. A contact allergy to latex is not a contraindication or precaution to vaccination. Consequently, a person with a contact allergy to latex can be safely vaccinated with a vaccine supplied in a vial or syringe that contains natural rubber or rubber latex. People who have an anaphylactic allergy to latex should not be vaccinated, however.

Which vaccines are supplied in vials or syringes containing latex?

You can find information on latex in vaccine packaging in Appendix B of CDC�s Guide to Vaccine Contraindications and Precautions at www.cdc.gov/vaccines/recs/vac-admin/downloads/contraindications-guide-508.pdf.

Our large pediatric practice is struggling with the requirement to provide VISs to the parents of every child we vaccinate. We think we have a solution and would like your opinion of it. We would like to create a re-usable packet of laminated VIS sheets (fastened together on a ring). We plan to place a packet in each exam room for parents to read prior to vaccine administration. On the bottom of each sheet would be a statement, "If you would like a copy of this sheet to take home, please ask our staff.� This will ensure that parents are given the VIS sheets to read prior to vaccine administration. It will also help save paper; our experience is that many parents throw out the VIS documents or leave them behind in the waiting room.

Many clinicians are looking for ways to reduce paper overload, so this is a common question. Your solution will meet the spirit of the federal law, as long as you make sure to encourage the patient (or parent) to take home a paper copy of the VIS and to refer to it if needed (e.g., if they need to know what to do if there is an adverse event or how to contact VAERS). Patients can also download VISs onto mobile devices. For more information about this technology, go to www.cdc.gov/vaccines/pubs/vis/vis-downloads.htm.

Where can I find names of vaccines used outside the U.S.?

Appendix B of the CDC publication Epidemiology and Prevention of Vaccine-Preventable Diseases (the Pink Book) contains a list of vaccines used outside the U.S. You�ll find Appendix B at www.cdc.gov/vaccines/pubs/pinkbook/downloads/appendices/B/foreign-products-tables.pdf.

Where can I find a list of vaccines currently licensed for use in the U.S.?

CDC maintains a sortable list of vaccine names at www.cdc.gov/vaccines/about/terms/USVaccines.html.

Many of my patients are reading The Vaccine Book, in which the author, Dr. Robert W. Sears, cites studies that he interprets as showing that the amount of aluminum found in certain vaccines might be unsafe. He thinks it is better to separate aluminum-containing vaccines, rather than give them according to the recommended U.S. immunization schedule. I would love any information you have about this.

Paul Offit, MD, and Charlotte Moser, BS, of the Vaccine Education Center (VEC) at the Children’s Hospital of Philadelphia, published an article, “The Problem with Dr. Bob’s Alternative Vaccine Schedule,” in the January 2009 issue of Pediatrics. It includes a section about aluminum. You can read it in its entirety at http://pediatrics.aappublications.org/cgi/content/full/123/1/e164. Here are two sources of related information:

•

“Aluminum in Vaccines: What you should know” is available from VEC here.

•

“Questions and Answers about Vaccine Ingredients” is available from AAP at: www.cispimmunize.org/pro/pdf/vaccineingredients.pdf.

Combination vaccines

Can Kinrix (DTaP-IPV; GSK) be used at kindergarten entry if the previous brand of DTaP is unknown?

Yes. Though it is preferable to use the same manufacturer�s DTaP vaccine for all of the doses in the series, you can give Kinrix as the fifth dose of DTaP and fourth dose of IPV at age 4 through 6 years if the previous brand is unknown or if Kinrix is the only product stocked.

We mistakenly gave Kinrix (DTaP-IPV) to a child age 3 years 10 months. We later realized that he had a prior history of receiving 4 doses of DTaP and IPV. Can the dose of Kinrix count as his 4 through 6 year booster?

Use of the vaccine in a child younger than age 4 is off-label and is not recommended. You should take measures to prevent this error in the future. The minimum age for the fifth dose of the DTaP series is 4 years, so this dose of DTaP is not valid. The current minimum age for the fourth dose of IPV is 18 weeks, so the IPV component may be counted as long as at least 4 weeks have elapsed since the third dose. Some states may require a dose of IPV on or after age 4 years regardless of the number of previous doses. For detailed information, see CDC�s useful table �Recommended and Minimum Ages and Intervals Between Doses of Routinely Recommended Vaccines� at www.cdc.gov/vaccines/pubs/pinkbook/downloads/appendices/A/age-interval-table.pdf.

If Kinrix is inadvertently given to a child age 15 through 18 months, as the fourth DTaP dose and the third IPV dose, does the Kinrix dose have to be repeated?

Since Kinrix is licensed and recommended only for children ages 4 through 6 years, you should take measures to prevent this error in the future. However, you can count this as a valid dose for DTaP and IPV as long as you met the minimum interval between administering dose #3 and dose #4 of DTaP (i.e., 6 months) and dose #2 and dose #3 of IPV (i.e., 4 weeks).

We inadvertently gave a child only the DTaP-IPV component of Pentacel (DTaP-IPV/Hib; sanofi pasteur), not realizing that this component was intended to reconstitute the Hib component. Does this count as a valid dose of DTaP and IPV? Can we mix the unused Hib component with sterile water and give it separately?

Use of DTaP-IPV solution as the diluent for the Hib component is specifically written both on the Pentacel box AND on the DTaP-IPV vial label. In answer to your first question, the DTaP-IPV component will count as valid doses of DTaP and IPV vaccines, but take measures to prevent this error in the future. In answer to your second question, NO, you cannot mix the Hib component with sterile water. ActHib must ONLY be reconstituted with either the DTaP-IPV solution supplied with Pentacel, or with a specific ActHib diluent. If you have ActHib but neither diluent, you must contact the manufacturer (sanofi pasteur) and obtain ActHib diluent.

I�ve lost a vial of MMR diluent, which is sterile water. Since it�s sterile water, is there any reason I can�t dilute the vaccine with sterile water from our clinic�s treatment room supply?

No, you cannot mix the MMR component with sterile water. A vaccine should only be mixed with the diluent formulated for it and supplied with it.

Our nurses have been routinely giving DTaP-HepB-IPV (Pediarix; GSK) to toddlers who were overdue for their third doses of DTaP, IPV, and HepB. Recently someone told me that Pediarix is only intended for use at 2, 4, and 6 months of age. Did we err?

No you did not err. Pediarix is licensed for use in children ages 6 weeks through 6 years for doses 1, 2, and 3 of the DTaP primary series. This would not constitute a vaccine error, as long as you observe the recommended minimum intervals for all the vaccine components (i.e., DTaP, IPV, and HepB).

We have been giving DTaP-HepB-IPV (Pediarix) to children who are overdue for DTaP #4, IPV #3, and HepB #3. Is this an acceptable practice?

No. Pediarix is intended to be used only for doses 1, 2, or 3 of the DTaP primary series; consequently using Pediarix for DTaP #4 is off-label and not recommended. You should take measures to prevent this error in the future. The DTaP, IPV, and HepB doses given in this scenario do not need to be repeated as long as you met the recommended minimum intervals for each vaccine component (DTaP, IPV, HepB). If you did meet the minimum intervals, the doses should be counted as valid.

Can we switch back and forth from monovalent vaccines at one visit to combination vaccines at another visit? For example, if a child is given monovalent DTaP, IPV, Hib, and Hep B during her 2-month visit, could we give her either DTaP-IPV/Hib (Pentacel) or DTaP-HepB-IPV (Pediarix) at her 4-month visit?

Switching between combination and single-antigen vaccines poses no problem as long as you maintain the recommended minimum intervals for all vaccines.

Tetanus, diphtheria, pertussis

If a dose of DTaP or Tdap is inadvertently given to a patient for whom the product is not indicated (e.g., wrong age group), how do we rectify the situation?

The first step is to inform the parent/patient that you administered the wrong vaccine. Next, follow these guidelines:

Tdap given to a child younger than age 7 years as either dose 1, 2, or 3, is NOT valid. Repeat with DTaP as soon as feasible.

Tdap given to a child younger than age 7 years as either dose 4 or 5, can be counted as valid for DTaP dose 4 or 5.

Tdap given to a child age 7 through 9 years can be counted as valid for the 1-time Tdap dose.

DTaP given to patients age 7 or older can be counted as valid for the 1-time Tdap dose.

Can an adult receive Tdap if they had a contraindication or precaution to DTP as a child?

Tdap has two contraindications and four precautions. The contraindications are (1) anaphylactic reaction to a prior dose of the vaccine or any of its components and (2) encephalopathy within 7 days of a previous dose of DTaP or DTP; in this case, give Td instead of Tdap. The precautions are (1) moderate or severe acute illness; (2) history of an Arthus reaction following a previous dose of a tetanus-containing and/or diphtheria toxoid-containing vaccine, including meningococcal conjugate vaccine; (3) Guillain-Barr� Syndrome (GBS) 6 weeks or sooner after a previous dose of tetanus-toxoid containing vaccine; and (4) progressive or unstable neurological disorder, uncontrolled seizures or progressive encephalopathy until a treatment regimen has been established and the condition has stabilized. CDC has recently issued an excellent publication, Guide to Vaccine Contraindications and Precautions. To access it, go to www.cdc.gov/vaccines/recs/vac-admin/downloads/contraindications-guide-508.pdf.

We recently saw a 30-year-old man who remembers that he received a �tetanus booster� in another state within the past 2 years. The problem is he cannot remember if he received Tdap or Td, and we can�t obtain an immunization record. His wife is pregnant, and we would like to immunize him against pertussis as a way to protect their soon-to-be-born child. Should we give him Tdap in this situation?

Yes. Whenever you lack vaccination documentation and vaccination is indicated, give the patient Tdap unless they are older than age 64.

Should we give Tdap to an adult who had pertussis as a child?

CDC recommends that adults who have a history of pertussis generally receive Tdap according to the routine recommendation. This practice is preferred because the duration of protection induced by pertussis is unknown (waning might begin as early as 7 years after infection) and because the diagnosis of pertussis can be difficult to confirm, particularly with tests other than culture for B. pertussis. Administering pertussis vaccine to persons with a history of pertussis presents no theoretical safety concern.

Human papillomavirus vaccine

We inadvertently gave HPV #1 to a woman who didn�t know she was pregnant at the time. How should we complete the schedule?

First, you should report the vaccination incident to the Merck registry at (800) 986-8999. Second, withhold further HPV vaccine until she is no longer pregnant. Shortly after the pregnancy is completed, administer HPV#2. Give HPV#3 at 16 weeks after HPV#2 and no sooner than 24 weeks after HPV#1.

Measles, mumps, rubella

What is the earliest age at which I can give MMR to an infant who will be traveling internationally? Also, which countries pose a high risk to children for contracting measles?

ACIP recommends that children who travel or live abroad be vaccinated at an earlier age than that recommended for children who reside in the United States. Before their departure from the United States, children age 6 through 11 months should receive 1 dose of monovalent measles vaccine (if available) or MMR. The risk for measles exposure can be high in both developed and developing countries. Consequently, CDC encourages all international travelers to be up to date on their immunizations regardless of their travel destination and to keep a copy of their immunization records with them as they travel. For continually updated information on the worldwide measles situation, and on CDC�s measles vaccination information for travelers, go to wwwn.cdc.gov/travel/content/in-the-news/measles.aspx.

Can I give the second dose of MMR earlier than age 4 through 6 years (i.e., the kindergarten entry dose) to young children traveling to areas of the world where there are measles cases?

Yes. The second dose of MMR can be given a minimum of 28 days after the first dose if necessary.

If I give MMR to an infant traveler younger than age 1 year, will that dose be considered valid for the U.S. immunization schedule?

No. A measles-containing vaccine administered before the first birthday should not be counted as part of the series. MMR should be repeated when the child is age 12 to 15 months (12 months if the child remains in an area where disease risk is high). The second dose should be administered at least 28 days after the first dose.

Why is the second dose of MMR routinely given at kindergarten entry (age 4 through 6 years) rather than at an earlier age?

The second dose of MMR vaccine is usually given at age 4 through 6 years as a scheduling convenience. The second dose of MMR may be given as early as 28 days after the first dose and can be counted as a valid dose if both doses were given after the first birthday. The second dose is not a booster; rather, it is intended to produce immunity in the small number of people who fail to respond to the first dose.

Varicella vaccine (chickenpox)

If a child had 1 varicella vaccination and developed a vesicular (chickenpox-like) rash at the vaccination site 7 to 10 days after vaccination, does the patient still need the second dose? What if the rash covered the entire body?

If you believe the child had varicella disease (that is, breakthrough varicella) after the first dose, the child does not need another dose. If you are uncertain whether the child had varicella, the second dose should be administered on schedule. If in doubt, plan to give the second dose. If this was a case of breakthrough varicella, a second dose will not be harmful.

Meningococcal vaccine

If a student received MCV (Menactra; sanofi pasteur) before their eleventh birthday, does the dose need to be repeated at age 11?

No. On October 17, 2007, FDA expanded the age indications for Menactra for use in children as young as age 2 years (i.e., it is now licensed for use in people ages 2 through 55 years). Right now only a 1-time dose of Menactra is recommended. ACIP will consider making recommendations for revaccination with Menactra as more data on duration of protection become available.

What do you do if an adult patient is in a high-risk situation for meningococcal disease (e.g., traveling to Sub-Saharan Africa) and doesn�t know whether they received MCV or MPSV (Menomune; sanofi pasteur) in the past. If they received MPSV 5 years ago or more, re-vaccination may be recommended, but if they received MCV it isn�t. Should we vaccinate them?

Yes. The ACIP recommendation is to vaccinate when vaccination is indicated and when you don�t have adequate documentation.

Pneumococcal vaccine

Some physicians in our area order PPSV every 5 years for their patients. Is this correct?

No. CDC recommends 1 dose of PPSV for most people in a lifetime and 2 doses for certain people. PPSV is a polysaccharide vaccine that does not boost well, and data do not indicate that more than 2 doses are beneficial. IAC has a handy summary piece about the use of PPSV vaccine titled �Pneumococcal polysaccharide vaccine: CDC answers your questions� at www.immunize.org/catg.d/p2015.pdf. For detailed information, see the 1997 ACIP recommendations on prevention of pneumococcal disease at ftp://ftp.cdc.gov/pub/Publications/mmwr/RR/RR4608.pdf. Also see the 2008 provisional recommendations at www.cdc.gov/vaccines/recs/provisional.

In its provisional pneumococcal recommendations ACIP recommends immunizing adult asthmatics with PPSV. Should I give PPSV to people with mild, intermittent asthma or exercise-induced asthma? Why isn’t PPSV recommended for asthmatic children?

PPSV is recommended for adults 19 years and older with all types of asthma. Available data do not indicate that asthma alone increases the risk of invasive pneumococcal disease among persons younger than 19 years, so PPSV is not currently recommended for persons younger than 19 years with asthma.

Zoster vaccine (shingles)

Can I give our long-term care residents zoster, injectable influenza, and pneumococcal vaccines on the same day?

Yes. Here are the general rules: (1) all vaccines used for routine vaccination in the United States can be given on the same day; (2) an inactivated vaccine can be administered either on the same day as or at any time before or after another inactivated or a live vaccine; and (3) any 2 LIVE vaccines that are not given on the same day must be spaced at least 4 weeks apart. Zostavax (Merck) is a live, attenuated vaccine; injectable trivalent influenza vaccine (TIV) and pneumococcal polysaccharide vaccine (PPSV) are inactivated vaccines. Therefore, these 3 vaccines can be given on the same day or at any time before or after each other. They cannot, however, be given in the same syringe.

When can a patient previously on immunosuppressive chemotherapy receive zoster vaccine?

If the patient was on anticancer therapy, wait 3 months. If they were on high-dose steroids, isoantibodies, immune-mediators, immunomodulators, wait 1 month. Lastly, if they were on low doses of methotrexate, azathioprine, or 6-mercaptopurine, waiting is not indicated as these are not considered immunosuppressive. See the ACIP recommendations for zoster at www.cdc.gov/mmwr/pdf/rr/rr5705.pdf for details.

How long should we wait before giving zoster vaccine to a patient who has had a blood transfusion?

There is no waiting period for administering zoster vaccine following transfusion. Studies have shown the efficacy of zoster vaccine in patients receiving blood products. The amount of antigen in zoster vaccine is so substantial that it overpowers any antibody to herpes zoster that may be in the blood product. This is not the case for varicella and MMR vaccines, however. Wait 3 or more months before administering these vaccines to a patient who has received an antibody-containing blood product.

Hepatitis A & B vaccines

I thought hepatitis A vaccine (HepA) was recommended for all children. Why does the bar on CDC�s childhood immunization schedule indicate that HepA should be routinely given to children ages 12 through 23 months, but not be given to children age 2 years and older unless they are in certain high-risk groups? In our practice in a historically �low-risk� state, we currently give hepA to any unvaccinated child. Is this incorrect?

No. Though the ACIP recommendation says children ages 12 through 23 months should routinely be vaccinated with 2 doses of HepA, it also says, �children who are not vaccinated by age 2 years can be vaccinated at subsequent visits.�

An infant was given monovalent hepatitis B vaccine (HepB) at birth. Later we gave her monovalent HepB at age 1 month and age 4 months. Did we give her the third dose too early?

Yes. Poorer immune response rates are seen in infants who complete the vaccination series prior to age 6 months. Do not count dose #3, which you gave at age 4 months. Repeat dose #3 when the infant is at least age 6 months (no earlier than age 24 weeks).

I understand there is a now a shortage of HepB vaccine for children and possibly for adults. Could you please tell me about it and what we should do to cut back on using it?

The supply of Merck�s hepatitis B vaccines (pediatric, adult, and dialysis formulations) is limited at this time, but recommendations for its use are unchanged. For detailed information about HepB shortages, go to CDC�s website at www.cdc.gov/vaccines/vac-gen/shortages.

We heard there is an alternative schedule for the adult HepA-HepB (Twinrix; GSK) vaccine that gives the patient protection sooner than the standard schedule does. Can you tell us more?

Yes. Licensed for use in people age 18 and older, the combined HepA-HepB vaccine is normally given as a 3-dose series at intervals of 0, 1, and 6 months. However, if someone needs protection sooner (e.g., imminent foreign travel), you can give it as a 4-dose series at intervals of 0, 7, and 21–30 days, followed by a dose at 12 months.

Click here for PDF version