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Question of the Week

May 2016 Back to top
May 25, 2016
A provider has a 54-year-old woman with rheumatoid arthritis who had been on etanercept (Embrel) at a dose of 50 mg per week. The etanercept was stopped two weeks ago. What is the interval between stopping etanercept and receiving zoster vaccine?
The safety and efficacy of zoster vaccine administered concurrently with recombinant human immune mediators and immune modulators (such as the anti-tumor necrosis factor agents adalimumab, infliximab, and etanercept) is not known. It is preferable to administer zoster vaccine before treatment with these drugs. Otherwise, administration of zoster vaccine (and other live vaccines) should be deferred for at least one month after discontinuation of treatment.
Question of the Week: IAC Express - Issue 1247
May 18, 2016
An expired dose of ProQuad (MMRV, Merck) was given to a patient. We assume that the repeat dose should be given in three months because the spacing between doses of a combination vaccine depends on the longest minimum interval of a component (in this case the varicella vaccine component). Is this correct?
In the case of an expired live vaccine, the issue is not necessarily the routine minimum interval (three months in the case of varicella and ProQuad vaccines), but the interval that would prevent viral interference if the expired vaccine happened to be still viable. This interval is considered to be four weeks (28 days). The repeat dose should be administered four weeks after the expired dose.
Question of the Week: IAC Express - Issue 1246
May 11, 2016
We have a 40 lb six-year-old patient who has been taking 15 mg of methotrexate weekly for arthritis for 12 months. Can we give the child MMR and varicella vaccine based on this methotrexate dosage?
Based on the weight and dosage provided (40 lbs and 15 mg/week), the child is currently receiving more than 0.4 mg/kg/week of methotrexate. This meets the Infectious Disease Society of America (IDSA) definition of high-level immunosuppression. Administration of both varicella and MMR vaccines are contraindicated until such time as the methotrexate dosage can be reduced.
The IDSA states that administration of varicella vaccine (but not MMR) can be considered for non-varicella-immune patients treated for chronic inflammatory disease who are receiving long-term low-dose immunosuppression. Low-dose immunosuppression for methotrexate is a dosage of less than 0.4 mg/kg/week. See Table 6 (and associated footnotes): cid.oxfordjournals.org/content/early/2013/11/26/cid.cit684.full.pdf.
Question of the Week: IAC Express - Issue 1245
May 4, 2016
If a patient has a history of cerebrospinal fluid (CSF) leak but no current leak, is this a risk factor and a reason to administer PCV13 and PPSV23 to an adult?
No. If there is no longer a CSF leak, neither vaccine is recommended, unless there is another risk factor for invasive pneumococcal disease or an age-based indication.
Question of the Week: IAC Express - Issue 1244
April 2016 Back to top
April 27, 2016
I have read that HPV vaccine should not be administered to pregnant women. Do we need to perform a pregnancy test prior to administering this vaccine to our patients? Currently, we ask about pregnancy prior to providing the vaccine.
HPV vaccines are not recommended for use in pregnant women. The vaccines have not been associated causally with adverse outcomes of pregnancy or adverse events in the developing fetus. However, if a woman is found to be pregnant after initiating the vaccination series, the remainder of the three-dose series should be delayed until completion of pregnancy. Pregnancy testing is not needed before vaccination. If a vaccine dose has been administered during pregnancy, no intervention is needed.
Question of the Week: IAC Express - Issue 1243
April 20, 2016
I have a female patient who has a non-immune rubella titer two months after her second MMR vaccination. Should she be revaccinated? If so, should the titer again be checked to determine seroconversion?
ACIP recommends that vaccinated women of childbearing age who have received one or two doses of rubella-containing vaccine and have a rubella serum IgG levels that is not clearly positive should be administered one additional dose of MMR vaccine (maximum of three doses). Repeat serologic testing for evidence of rubella immunity is not recommended. See http://www.cdc.gov/mmwr/pdf/rr/rr6204.pdf, pages 18–20, for more information on this issue.
MMR vaccines should not be administered to women known to be pregnant or attempting to become pregnant. Because of the theoretical risk to the fetus when the mother receives a live virus vaccine, women should be counseled to avoid becoming pregnant for 28 days after receipt of MMR vaccine.
Question of the Week: IAC Express - Issue 1242
April 13, 2016
Zoster vaccine was inadvertently given to a patient taking Humira (adalimumab) 40 mg per week for rheumatoid arthritis. Because of the high dose, should the patient be started on antivirals as prophylaxis or should the patient just be monitored?
Although herpes zoster vaccine is contraindicated for patients taking biologic agents including tumor necrosis factor (TNF) antagonists (adalimumab is a TNF antagonist), vaccinating patients that are immunocompromised is unlikely to result in serious adverse events.
It is prudent to monitor your patient with a low threshold for any signs of adverse events (such as rash or fever), within one month after vaccination, but prophylactic antivirals are not indicated. Acyclovir, valacyclovir, and famciclovir are active against the vaccine virus and can be used in the unlikely situation in which illness develops.
Question of the Week: IAC Express - Issue 1241
April 6, 2016
We have a two-month-old male with his second episode of meningococcemia (group B). He is still undergoing an evaluation for primary immunodeficiency, but we are planning to proceed with immunizations, including meningococcal ACWY-CRM vaccine, but wanted to provide meningococcal B as well. Given that in the U.S., meningococcal B vaccine is only approved in children age 10 years and older, can we use it in the infant age group?
Use of either meningococcal serogroup B vaccine in persons younger than age 10 years is off-label in the U.S. There is currently no ACIP recommendation for use of this vaccine for this age group. However, Bexsero brand meningococcal B vaccine has been studied among infants and is approved for infants by the European Medicines Agency (the European version of the U.S. Food and Drug Administration). It is routinely recommended for infants in the United Kingdom (see www.nhs.uk/conditions/vaccinations/pages/meningitis-b-vaccine.aspx for details). A clinician may choose to use a vaccine off-label if, in their opinion, the benefit of the vaccine exceeds the risk from the vaccine. Product information for Bexsero can be found on the European Medicines Agency website at www.ema.europa.eu/ema.
Question of the Week: IAC Express - Issue 1240
March 2016 Back to top
March 30, 2016
I have a patient who is a medical student about to start clinical rotations. She has written documentation of two doses of varicella vaccine (the first at age 12 years and the second at age 26 years). Her varicella IgG is negative. Is she a non-responder? Should I give her a booster dose?
Titers are not necessary or recommended if there are documented doses of varicella vaccine. Commercial serologic tests may not be sensitive enough to detect vaccine-induced antibody. In this situation, a negative titer should be disregarded. The student should be considered immune because of her documented vaccination history. See ACIP's Immunization of Health-Care Personnel, pages 23–24, for more information on this issue.
Question of the Week: IAC Express - Issue 1238
March 23, 2016
Does an adult younger than age 65 years with beta thalassemia minor meet the criteria for a recommendation for vaccination with PCV13?
No. Beta thalassemia minor is a hemoglobinopathy, but compared to sickle cell disease, these patients have less risk for functional asplenia, and by extension a reduced risk for invasive pneumococcal disease.
Question of the Week: IAC Express - Issue 1236
March 16, 2016
We have a 61-year-old patient who is taking 500 mg of valacyclovir (Valtrex) daily. Can she receive zoster vaccine?
Acyclovir, famciclovir, and valacyclovir are antiviral drugs that are active against herpesviruses. These drugs' agents might interfere with replication of live zoster vaccine. All three drugs have relatively short serum half-lives and are quickly eliminated from the body. Persons taking acyclovir, famciclovir, or valacyclovir should discontinue the drug at least 24 hours before administration of zoster vaccine, if possible. The drug should not be taken again for at least 14 days after vaccination, by which time the immunologic effect of the vaccine should be established.
Question of the Week: IAC Express - Issue 1234
March 9, 2016
An adult patient with asplenia received Menactra two weeks after a dose of PCV13. Should the PCV13 dose be repeated?
Yes. ACIP recommends that for persons 2 through 55 years of age with a high-risk condition (asplenia or complement component deficiency), Menactra be administered at least 4 weeks after completion of all PCV13 doses. See the footnote of the table on page 16 here for more information on this issue.
Question of the Week: IAC Express - Issue 1233
March 2, 2016
I have a patient who is traveling internationally and needs MMR vaccine. He recently received an injectable steroid. How long should he wait before receiving MMR vaccine?
There is no need to wait a specific interval before giving MMR. Injectable steroids are not considered immunosuppressive for the purpose of vaccination decisions, and so there is no concern about safety or efficacy of MMR.
Question of the Week: IAC Express - Issue 1232
February 2016 Back to top
February 24, 2016
Although licensed by the Food and Drug Administration for use through age 4 years, a dose of Pentacel was inadvertently given to a six-year-old. Do any components of the Pentacel dose need to be repeated?
Pentacel (DTaP-IPV/Hib) inadvertently administered to children six years of age and older is considered a vaccine administration error. However, none of the vaccine components need to be repeated.
IAC Express - Issue 1231
February 17, 2016
Do we need to wait for the vaccine to reach room temperature before we administer it to a patient?
There is no recommendation to wait until a vaccine reaches room temperature before administration. The vaccine should be administered as soon as it is prepared.
IAC Express - Issue 1230
February 10, 2016
If someone is older than 55 years and had their spleen removed, are they recommended for meningococcal polysaccharide vaccine or meningococcal conjugate vaccine?
Meningococcal conjugate vaccines (MCV4) are licensed for persons through age 55 years. For persons older than 55 years with a high-risk medical condition (such as asplenia), the Advisory Committee on Immunization Practices (ACIP) recommends off-label use of MCV4. Asplenic persons should receive a primary series of two doses of MCV4 separated by eight weeks, followed by a dose every five years thereafter. These recommendations are available at www.cdc.gov/mmwr/pdf/rr/rr6202.pdf, page 15.
IAC Express - Issue 1229
February 3, 2016
We have an 18-year-old male who had a history of chickenpox disease. He now has shingles. We are unsure what we are to advise for future treatment. Should we administer zoster vaccine?
The Advisory Committee on Immunization Practice does not recommend zoster vaccination for people younger than age 60 years regardless of their history of shingles. Zoster vaccine is licensed by the Food and Drug Administration for people age 50 years and older so a clinician may choose to vaccinate a person 50 through 59 years of age. Insurance may not pay for a dose of zoster vaccine given to a person younger than age 60 years.
IAC Express - Issue 1228
January 2016 Back to top
January 27, 2016
What is the schedule for hepatitis B vaccination for infants weighing less than 2000 grams? I read that the birth dose should still be given in the hospital, but what would be the schedule after that?
Decreased seroconversion rates might occur among preterm infants with low birth (less than 2,000 grams) after administration of hepatitis B vaccine at birth. However, by the chronological age of one month, all preterm infants, regardless of initial birth weight, are likely to respond as adequately as larger infants.
Preterm infants born to HBsAg-positive women and women with unknown HBsAg status must receive hepatitis B vaccine within 12 hours after birth. The initial vaccine dose should not be counted toward completion of the hepatitis B series, and three additional doses of hepatitis B vaccine should be administered, beginning when the infant is age one month. For mothers with unknown HBsAg status, attempts should be made to determine HBsAg status. The infant also must be given HBIG within 12 hours of birth unless the mother is found to be HBsAg negative. Infants weighing less than 2,000 grams born to HBsAg-negative mothers should receive the first dose of the hepatitis B series at chronological age one month or at hospital discharge.
IAC Express - Issue 1226
January 20, 2016
An 86-year-old patient came in today and stated he needed a pneumococcal vaccine booster. He reports receiving a dose of "pneumonia vaccine" when he was 77 years old. Which pneumococcal should he receive today, PCV13 or PPSV23?
It is unlikely that the previous dose of pneumococcal vaccine was PCV13, since this vaccine was not routinely recommended for any adult population nine years ago. The patient most likely received pneumococcal polysaccharide vaccine (PPSV23). A dose of PCV13 should be given now. People who receive PPSV23 after age 65 years are not recommended to receive additional doses of PPSV23.
IAC Express - Issue 1225
January 13, 2016
If an egg-free influenza vaccine (FluBlok, Protein Sciences) was given inadvertently to a person younger than 18 years, can it be counted? Would there be any adverse side effects from this error?
Flublok is not licensed for persons younger than 18 years of age, so there are no data regarding safety and efficacy in this age group. However, no serious side effects would be expected. The dose does not need to be repeated. Even if no adverse reaction occurs, we request that vaccine administration errors like this be reported to the Vaccine Adverse Events Reporting System at www.vaers.hhs.gov.
IAC Express - Issue 1224
January 6, 2016
If a patient received Trumenba (MenB; Pfizer) two months ago and Bexsero (MenB, GSK) yesterday, should they complete the series with two additional doses of Trumenba or one more of Bexsero since the two brands are not interchangeable? What would be the interval from the Bexsero to the next dose?
The patient can complete the series with either vaccine. If Bexsero is chosen, the next dose (Bexsero #2) should be administered at least one month after yesterday’s dose. The Bexsero #2 would be the final dose. If Trumenba is chosen, the next dose (Trumenba #2) should be administered at least one month after yesterday’s Bexsero dose. The one-month interval between doses of Trumenba and Bexsero is recommended because one component (FHbp) is contained in both of the vaccine products and there is concern about potential interference. The final dose (Trumenba #3) should be administered four months after Trumenba #2.
IAC Express - Issue 1222
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