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Question of the Week

December 2014 Back to top
December 16, 2014
My patient is a 14-year-old girl who has received one dose of bivalent HPV vaccine (HPV2, Cervarix, GlaxoSmithKline) and now wants to change over to quadrivalent HPV vaccine (HPV4, Gardasil, Merck). What is the recommendation to be followed?
You can complete the series with HPV4 (two more doses), which will assure protection against HPV types 16 and 18 (those types most likely to cause cervical and other cancers and that are in both HPV2 and HPV4). However, receiving only two doses of HPV4 may provide less protection against genital warts than the usual 3 doses. More information is available at www.cdc.gov/mmwr/pdf/rr/rr6305.pdf.
December 9, 2014
What is the acceptable volume for a single dose of immune globulin (IG) to inject into the deltoid muscle of a normal-weight adult? What is the acceptable volume for a single dose of IG to inject into the vastus lateralis of a normal-weight adult?
Here are the suggested volumes:
Average 0.5 mL
Range 0.5–2 mL
Vastus Lateralis:
Average 1–4 mL
Range 1–5 mL
Infants and toddlers would fall at the lower end of the range, whereas adolescents and adults would generally fall on the higher end of the range.
December 2, 2014
I was told that it is not recommended to give vaccines using the Z-track method. Is this correct?
The Z-track method is not contraindicated for IM vaccinations, but is not deemed necessary for vaccine administration. The Z-track technique is most beneficial for administering irritating medications, such as iron preparations.
November 2014 Back to top
November 25, 2014
A one-month-old infant was exposed for the last 6 days to chickenpox. What should be done to protect the exposed infant, who is too young to vaccinate and past the time for varicella zoster immune globulin (VZIG) administration (96 hours)?
There is no evidence that healthy full-term infants born to women in whom varicella occurs more than 48 hours after delivery are at increased risk for serious complications such as pneumonia or death. VZIG (VariZIG, Emergent) can be given up to 10 days after exposure but is only recommended for newborn infants whose mothers have signs and symptoms of varicella around the time of delivery (5 days before to 2 days after), hospitalized premature infants born at 28 or more weeks of gestation whose mothers do not have evidence of immunity to varicella, or hospitalized premature infants born at less than 28 weeks of gestation or who weigh 1,000 grams or less at birth regardless of their mothers' evidence of immunity to varicella. Assuming this is an infant discharged from the hospital at home, VZIG would not be recommended. Varicella, if it develops, would be managed as for any child.
November 18, 2014
What is the maximum number of hepatitis B vaccine doses a dialysis patient can receive?
There is no maximum number of booster doses a dialysis patient can receive. Serology should be performed once a year and a booster dose given if serology is negative (less than 10 mIU/mL). Serology is not recommended more frequently than once a year, so boosters wouldn't be given more than once a year. See www.cdc.gov/mmwr/PDF/rr/rr5516.pdf, pages 2729.
November 11, 2014
A 4-year-old patient came in with a rash and a low-grade fever. The first MMR dose was given 10 days ago. Her measles IgM was positive. Can the child have the disease or are the IgM results from the vaccination? After the rash resolves, how long is the patient contagious?
If there is no one else known to have measles in the community, or to have had contact with the child, the rash and positive IgM test are most likely related to the vaccination and the child is not contagious. We also recommend a viral specimen (nasopharyngeal swab) for PCR, to determine the genotype, which would be the only way to distinguish between wild-type virus and vaccine virus. If there is ANY possibility the child has been in contact with someone with measles, he/she should be isolated at home, and deemed possibly contagious until 4 days after the onset of the rash.
If you suspect measles disease for any reason, please also contact your local health department for assistance with contact tracing and disease control.
November 4, 2014
The pneumococcal conjugate vaccine (PCV13) package insert says that in adults, antibody responses to Prevnar 13 (Pfizer) were diminished when given with inactivated influenza vaccine. Does this mean we should not give PCV13 and influenza vaccine at the same visit?
No. The available data have been interpreted that any changes in antibody response to either vaccines' components were clinically insignificant. If PCV13 and influenza vaccine are both indicated and recommended they should be administered at the same visit. See ACIP recommendations, page 824.
October 2014 Back to top
October 28, 2014
The Vaccine Information Statement for inactivated influenza vaccine states that you should not get the vaccine if you are severely allergic to antibiotics. Which antibiotics are they referring to?
The antibiotics, of which there are trace amounts in some influenza vaccines, are neomycin, gentamicin, and polymyxin B. You should check each product's package insert information to see which, if any, antibiotics are listed. For a list of the package insert information for vaccines, visit FDA's website  or IAC's website.
October 21, 2014
A nurse had a leftover drawn-up syringe of influenza vaccine taken from a multi-dose vial. Can we use the vaccine the next day?
Once a provider draws up a dose of vaccine into a syringe, the dose should be administered that day or discarded at the end of the clinic day.
October 14, 2014
I have a 2-month-old child with a cast for hip dysplasia that completely covers the entire anterolateral thigh on both legs. She is not due to have it removed for 10 weeks. What options do we have for her injectable vaccines?
Ideally, you can arrange to have the cast cut to administer vaccines in the anterolateral thighs. If that option is not available, the gluteal region can be used if not covered by the cast. There are no other sites we recommend for vaccination; however, the inactivated polio vaccine could be given subcutaneously in either arm, if the child is large enough. Rotavirus vaccine is given orally and should be administered. If vaccines cannot be given for the 10 weeks, please advise the family to keep people with any illness away from the child until she has been vaccinated. For more information, see ACIP's General Recommendations on Immunization at www.cdc.gov/mmwr/pdf/rr/rr6002.pdf, page 14–16.
October 7, 2014
I have a 24-year-old patient who received influenza vaccine in Colombia, South America, on June 19, 2014. Does he need to get another influenza vaccine during the current U.S. influenza season?
Yes. The person should be revaccinated with the 2014–15 U.S. vaccine, even though the strains in the U.S. vaccine are the same as the 2014 Southern hemisphere vaccine. Vaccination again with the current vaccine will help assure protection through the influenza season into next spring.
September 2014 Back to top
September 30, 2014
Can we give Tdap and RhoGam (anti-Rho[D] immune globulin) at the same prenatal visit?
Tdap is an inactivated vaccine and may be given at the same prenatal visit with RhoGam. For more information on this topic, including the timing for the use of other vaccines with regards to RhoGam, see ACIP's General Recommendations on Immunization at www.cdc.gov/mmwr/pdf/rr/rr6002.pdf, page 9.
September 23, 2014
If the top of a single dose vial of diluent or vaccine is popped off and not used, is there a time limit as to when it must be used? We are just discussing whether the efficacy of the vaccine will be compromised with the passing of time.
Once the protective cap has been removed from a single-dose vial, it may not be possible to determine if the rubber seal has been punctured. Therefore, unused single-dose vials without a protective cap should be discarded at the end of the workday.
September 16, 2014
Our 23-year-old patient has been accepted to a physician assistant program that requires polio vaccine for all students. She has 2 documented doses of oral polio vaccine (OPV) as a child, then recently had a dose of inactivated polio vaccine (IPV). How many more doses of IPV does she need to complete the series and on what schedule?
People who receive a mixed series of OPV and IPV should receive a total of 4 doses. The recent dose of IPV can be counted as the third dose in the primary series. The minimum interval between the third and last doses in the polio vaccination series is 6 months. So the final dose in the series should be given 6 months after the IPV dose.
September 9, 2014
Can someone with hepatitis C receive zoster vaccine? The prescribing information indicates persons with immunosuppression should not get the vaccine, including people with HIV/AIDS, but hepatitis C is not specifically mentioned.
Hepatitis C infection is not a contraindication for zoster vaccine. However, if someone with hepatitis C is receiving a medication that can cause immunosuppression, they should consult with their healthcare provider and consider delaying vaccination until they have completed treatment.
September 2, 2014
My office recently changed HPV vaccine brands from Gardasil to Cervarix. We have several males who received doses of Cervarix instead of Gardasil. Do the males who received Cervarix need to be revaccinated?
Yes. Cervarix (HPV2, GlaxoSmithKline) is not approved or recommended for use in males. Doses of HPV2 administered to males should not be counted and need to be repeated using Gardasil (HPV4, Merck).
August 2014 Back to top
August 26, 2014
We have a patient with a severe allergy to vancomycin who wants to receive zoster vaccine. According to the prescribing information, an allergy to neomycin would be a contraindication to vaccination but we are not sure about allergy to vancomycin.
Vancomycin and neomycin belong to different classes of antibiotics. An allergy to vancomycin is not a contraindication to zoster vaccine.
August 19, 2014
Would you include obstructive sleep apnea as chronic pulmonary disease which would require PPSV23 vaccination once for adults under the age of 65?
Obstructive sleep apnea alone is not an indication for vaccination with PPSV23 for persons 2 through 64 years of age. People with obstructive sleep apnea often have other pulmonary conditions (such as chronic obstructive pulmonary disease) that would put them at increased risk for invasive pneumococcal disease, for which they should be vaccinated. A table listing risk conditions and pneumococcal vaccine recommendations can be found at www.immunize.org/catg.d/p2019.pdf.
August 12, 2014
A 16-year-old has a written record of receiving two doses of DTaP at 2 and 5 months of age and one dose of Tdap at 15 years of age. Since she has had three doses of pertussis-containing vaccine, would she still need two additional doses of Td?
Since the first DTaP was received before 12 months of age and one Tdap dose has been given, this person needs one dose of Td 6 calendar months after the Tdap dose. A routine Td booster should be administered every 10 years. See IAC's new handout: DTaP, Tdap, and Td Catch-up Vaccination Recommendations by Prior Vaccine History and Age.
August 5, 2014
What are the CDC guidelines regarding use of multiple dose vaccine vials?
Vaccines in multidose vials can be used through the expiration date on the vial unless indicated otherwise by the manufacturer. For example, inactivated polio vaccine in a multidose vial can be used through the expiration date on the vial. For some vaccines, the manufacturer specifies that once the multidose vial has been entered or the rubber stopper punctured, the vaccine must be used within a certain number of days. This is commonly referred to as the "beyond-use date" (BUD). Any vaccine not used within the BUD should be discarded. Specific information regarding the BUD can be found in the product information. For example, the package insert for some inactivated influenza vaccine indicates once the stopper of the multidose vial has been pierced, the vial must be discarded within 28 days. Package inserts for vaccines can be found at www.immunize.org/packageinserts.
July 2014 Back to top
JULY 29, 2014
We have a 10-year-old getting renal dialysis. The nephrologist will be starting her on a monoclonal antibody that interferes with C5 complement. If we administer a MCV4 and a PPSV23 now, and then give her a PCV13 in 8 weeks, will the PCV13 interfere with the efficacy of the PPSV23 or the MCV4?
Recommendations to separate MCV4 and PCV13 only apply to persons with functional or anatomic asplenia. So the best schedule is to give MCV4 (either MCV4-D or MCV4-CRM) simultaneously with PCV13, and then PPSV23 in eight weeks. ACIP recommends giving PCV13 before PPSV23 in order to maximize the immune response from PCV13. PPSV23 blunts the immune response to PCV13 if PCV13 is given after PPSV23, although in children there is a smaller effect than in adults.
JULY 22, 2014
Can you please guide me in finding storage containers and bins for vaccines?
CDC recommends the use of bins, baskets, or some other type of uncovered containers that allow for organization and air circulation for vaccines and diluents within the storage unit. Storage in any boxes or bins can help maintain temperature longer, especially if power is lost. Perforated bins may allow for better air circulation around the vaccine, thus helping to maintain correct temperature.
CDC does not have a specific recommendation for brands of containers or bins for storage of vaccine. We recommend that you contact your state immunization program, as they may find resources for purchasing this equipment. If you are a Vaccines for Children (VFC) program provider, you should contact your immunization program to ensure that you are in compliance with VFC policy.
JULY 15, 2014
We have an adult who was diagnosed with polio as a child with some residual effects. This adult will be traveling overseas and the CDC travel website recommends a dose of polio vaccine. Should he be vaccinated with polio vaccine even though he had polio in the past?
Immunity to one of the serotypes of polio does not produce significant immunity to the other serotypes. A history of having recovered from polio disease should not be considered evidence of immunity to polio. It would be appropriate to vaccinate this adult if he will be traveling to an area for which polio vaccination is recommended.
JULY 8, 2014
Should adult patients who are not asplenic but who have hypogammaglobulinemia receive Haemophilus influenzae type b (Hib) conjugate vaccine? The February 2014 Hib ACIP statement includes immunoglobulin deficiency in its "high-risk groups" for Hib disease, but the recommendations seem to imply that Hib vaccine is not necessarily for adults with immunoglobulin deficiency whose spleens are intact. Am I interpreting ACIP correctly on this matter?
You are interpreting the recommendations correctly, and age is an important factor in this issue. The recommendation for Hib vaccination for asplenia applies to persons of all ages. The recommendation for Hib vaccination for immunoglobulin deficiency applies only to children 12 through 59 months of age.
JULY 1, 2014
Many travelers do not return for their second dose of hepatitis A vaccine and present years later, about to travel again. Is there a maximum interval between the first and second doses of hepatitis A vaccine? Should the series be restarted if it has been 5 or more years since the first dose?
No. There is no maximum interval between doses of hepatitis A vaccine. An interruption in the vaccination schedule does not require restarting the entire series of any other vaccine or toxoid or addition of extra doses, with the exception of oral typhoid vaccine. See the ACIP's "General Recommendations on Immunization" at www.cdc.gov/mmwr/pdf/rr/rr6002.pdf, page 10.
June 2014 Back to top
JUNE 24, 2014
I have a five-month-old patient who received hepatitis B vaccine at birth, at 2 months, and at 5 months of age. I realize that the third dose was given too early and so the child should be given another dose after they turn 6 months old. However, I am unclear how long I have to wait to give the fourth (repeat) dose? Is it 4 or 8 weeks?
This is addressed in the ACIP’s General Recommendations on Immunization: "Doses of any vaccine administered 5 or more days earlier than the minimum interval or age should not be counted as valid doses and should be repeated as age appropriate. The repeat dose should be spaced after the invalid dose by the recommended minimum interval” (see www.cdc.gov/mmwr/pdf/rr/rr6002.pdf, page 5 and Table 1, page 36). So in this situation you would repeat the dose 8 weeks after the invalid dose.
JUNE 17, 2014
Is there any harm in giving an extra dose of MMR to a child of age seven years whose record is lost and the mother is not sure about the last dose of MMR?
In general, although it is not ideal, receiving extra doses of vaccine poses no medical problem. Receiving excessive doses of tetanus toxoid (e.g., DTP, DTaP, DT, Tdap, or Td) can increase the risk of a local adverse reaction, however. For details, consult the ACIP's General Recommendations on Immunization at www.cdc.gov/mmwr/pdf/rr/rr6002.pdf, page 8.
Vaccination providers frequently encounter people who do not have adequate documentation of vaccinations. Providers should only accept written, dated records as evidence of vaccination. With the exception of influenza vaccine and pneumococcal polysaccharide vaccine, self-reported doses of vaccine without written documentation should not be accepted. An attempt to locate missing records should be made whenever possible by contacting previous healthcare providers, reviewing state or local immunization information systems, and searching for a personally held record.
If records cannot be located or will definitely not be available anywhere because of the patient's circumstances, children without adequate documentation should be considered susceptible and should receive age-appropriate vaccination. Serologic testing for immunity is an alternative to vaccination for certain antigens (e.g., measles, rubella, hepatitis A, diphtheria, and tetanus).
JUNE 10, 2014
For the purpose of vaccine spacing, what constitutes a month: 28 days (4 weeks), 30 days, or 31 days?
For intervals of 3 months or less, you should use 28 days (4 weeks) as a "month." For intervals of 4 months or longer, you should consider a month a "calendar month": the interval from one calendar date to the next a month later. This is a convention that was introduced on the childhood schedule in 2002 and discussed in the paper "Evaluation of Invalid Vaccine Doses" (Stokley S, Maurice E, Smith PJ, et al. American Journal of Preventive Medicine, 2004: 26[1]: 3440).
JUNE 3, 2014
Is pneumococcal polysaccharide vaccine (PPSV23) contraindicated in pregnancy? Our patient has asthma and is pregnant.
No. According to the 2014 adult immunization schedule, PPSV23 is recommended in pregnancy if some other risk factor is present (e.g., on the basis of medical, occupational, lifestyle, or other indications). See footnote 9 of the 2014 adult immunization schedule at www.cdc.gov/vaccines/schedules/downloads/adult/adult-combined-schedule.pdf.
May 2014 Back to top
MAY 27, 2014
If a woman's rubella test result shows she is "not immune" during a prenatal visit but she has 2 documented doses of MMR vaccine, does she need a third dose of MMR vaccine postpartum?
In 2013 ACIP changed its recommendation for this situation. It is now recommended that women of childbearing age who have received 1 or 2 doses of rubella-containing vaccine and have rubella serum IgG levels that are not clearly positive should be administered 1 additional dose of MMR vaccine (maximum of 3 doses) and do not need to be retested for serologic evidence of rubella immunity. This is the only situation where ACIP recommends a third dose of MMR vaccine. MMR should not be administered to a pregnant woman.
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