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| As appeared in the July 2009 issue of Vaccinate Adults |
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| Click here for PDF version |
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We sometimes see patients who have an acute illness but are due for vaccination. We’re never quite sure if we should withhold the vaccine or not. What do you advise? |
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A “moderate or severe acute illness” is a precaution for administering any vaccine. A mild acute illness (e.g., mild upper-respiratory tract infection or diarrhea) with or without fever is not. |
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Some of our employees have a contact allergy to latex gloves. Can they receive vaccines that are supplied in vials or syringes that contain latex? |
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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. |
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When patients need multiple vaccines, can we just combine them in one syringe? |
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Absolutely not. Vaccines should never be mixed in a single syringe except when specifically approved by FDA and packaged for that specific purpose. |
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Our policy in our large internal medicine practice is to routinely review and administer all vaccinations that are indicated for our adult patients. We struggle with the requirement to provide VISs to each patient 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 patients 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 patients are given the VIS sheets to read prior to vaccine administration. It will also help save paper; our experience is that many patients throw out the VIS documents or leave them behind in the waiting room. |
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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 ask the patient if they would like 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). 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. |
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| Mumps, measles, rubella vaccine |
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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? |
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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. |
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| Tetanus, diphtheria, pertussis |
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Someone in our clinic gave the childhood DTaP to a 50-year-old instead of Tdap. How should this be handled? |
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The adult who received DTaP received the appropriate amount of tetanus toxoid and MORE diphtheria toxoid and pertussis antigen than is recommended for adults. Count the dose as valid, but take measures to prevent this error in the future. |
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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? |
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Yes. Whenever you lack vaccination documentation and vaccination is indicated, give the patient Tdap unless they are older than age 64. Tdap vaccine is not licensed by the FDA for people who are older than age 64. |
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Should we give Tdap to an adult who has a history of pertussis infection? |
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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. |
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Recently, one of our staff went to a conference where she heard that Boostrix [Tdap; GSK] can be administered to adults. Is this correct? We thought Boostrix could be used only for pre-teens and teens. |
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Yes, it’s correct. In December 2008, FDA expanded the age indication for Boostrix for use in people ages 10 through 64. Previously it was indicated for people ages 10 through 18. The other Tdap vaccine—Adacel [sanofi pasteur]—is indicated for people ages 11 through 64. To read a summary of indications for use of Boostrix, as published in the Morbidity and Mortality Weekly Report (MMWR), go to www.cdc.gov/mmwr/preview/mmwrhtml/mm5814a5.htm. |
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Can an adult receive Tdap if they had a contraindication or precaution to DTP as a child? |
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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-Barré 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. |
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| Human papillomavirus vaccine |
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We inadvertently gave HPV #1 to a woman who didn’t know she was pregnant at the time. How should we complete the schedule? |
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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. |
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Some physicians in our area order PPSV every 5 years for their patients. Is this correct? |
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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. |
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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? |
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PPSV is recommended for adults 19 years and older with all types of asthma. |
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We know that pneumococcal polysaccharide vaccine (PPSV) is now recommended for asthmatics, but we’re not sure exactly what the recommendation is. Can you spell it out for us? Also, is PPSV recommended for smokers as well? |
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In December 2008, ACIP issued provisional recommendations that call for administering 1 dose of PPSV to adults ages 19 through 64 years who have asthma or who smoke cigarettes. Also, 1-time revaccination with PPSV is recommended for these patients when they reach age 65 if 5 or more years have elapsed since they received a previous dose of PPSV. To access the provisional recommendations, go to www.cdc.gov/vaccines/recs/provisional. For a useful 1-page summary of the people for whom PPSV is indicated, go to www.immunize.org/catg.d/p2015.pdf. |
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Lately, some of our patients have been asking if they should receive PPSV during the current pandemic influenza situation. Has CDC changed the indications for use of PPSV during the pandemic? |
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No, but it has issued new guidance because people for whom PPSV is indicated—i.e., those age 65 years and older and those age 2 through 64 years with certain high-risk conditions—are at increased risk for serious complications from influenza, as well as for pneumococcal disease. The new guidance reminds healthcare professionals that at this time, it is particularly important to administer PPSV to ALL the groups for whom it is indicated. To access the new CDC guidance, go to www.cdc.gov/h1n1flu/guidance/ppsv_h1n1.htm. |
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| Zoster vaccine (shingles) |
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Can I give our long-term care residents zoster, injectable influenza, and pneumococcal vaccines on the same day? |
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| 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. |
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| 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. |
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When can a patient previously on immunosuppressive chemotherapy receive zoster vaccine? |
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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. |
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How long should we wait before giving zoster vaccine to a patient who has had a blood transfusion? |
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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. |
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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? |
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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. |
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| Click here for PDF version |
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