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Vaccine Recommendations

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Vaccine Recommendations

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Vaccine Recommendations
Note: Recommendations for specific vaccines are included in the Ask the Expert set for that vaccine - see vaccine index.
Our practice has an 11-year-old patient who is having a splenectomy. The doctor requested meningococcal serogroup B vaccine (MenB) before the surgery and wants to know if the patient will need booster doses or a repeat MenB series at some point in the future (as in the meningococcal ACWY vaccine recommendations).
The current recommendations for MenB vaccine are to receive one series in a lifetime for high-risk people, such as your patient. There is no recommendation at present for booster doses. The recommendations for those at high-risk for meningococcal serogroup B disease are available at https://www.cdc.gov/mmwr/pdf/wk/mm6422.pdf#page=8.
Are there recommendations for meningococcal ACWY vaccination for people who reside in homeless shelters or halfway houses? In addition, can you comment on general vaccination recommendations for people who reside in homeless shelters or halfway houses?
Residence in a homeless shelter or halfway house is not in itself considered a high-risk condition for any vaccine. Recommendations for vaccinating adult residents would be the same as those for all adults on the ACIP adult immunization schedule. Residents with medical conditions identified on Table 2 of the schedule should be vaccinated according to that table.
Any residents 18 or younger should be vaccinated according to the catch-up recommendations on the ACIP child/teen immunization schedule. People age 19 through 21 years are not recommended routinely to receive MenACWY. MenACWY may be administered through age 21 years as a catch-up vaccination for those who have not received a dose after their 16th birthday.
My 36-year-old patient was diagnosed with idiopathic thrombocytopenic purpura and had a splenectomy three weeks ago. Prior to the splenectomy, the patient had one dose each of Hib, MenB, PCV13, MenACWY (Menactra), and PPSV23 (separated from the PCV13 by 9 weeks). What vaccines are recommended now?
Since the patient is asplenic, the second dose of the primary series of MenACWY should be given 8–12 weeks after the first dose. He/she will need a dose of MenACWY every 5 years for the rest of his/her life. The patient has already received the one dose of PCV13 recommended for adults, so another dose of this vaccine is not needed. A second dose of PPSV23 is recommended at least 8 weeks after the dose of PCV13 AND at least 5 years since the last dose of PPSV23. A third (and final) dose of PPSV should be given after the patient turns age 65. The series of MenB (whether Trumenba or Bexsero) should be completed. The same MenB vaccine should be used for all doses in the series. Based on the patient’s age, the previous dose of Hib vaccine was administered when the patient was old enough to require only one dose of Hib vaccine, so another dose is not needed. The patient should receive influenza vaccine annually.
Any of these vaccines can be given simultaneously (at the same appointment, not in the same syringe) except for PCV13 and PPSV23, and PCV13 and Menactra. If Menactra is used for an asplenic person it should be separated from the PCV13 by at least 4 weeks. Menveo has no spacing restriction.
Where can I find the most current vaccine recommendations?
Vaccine recommendations in the U.S. are issued primarily by two national bodies—the U.S. Public Health Service's Advisory Committee on Immunization Practices (ACIP) and the American Academy of Pediatrics (AAP) Committee on Infectious Diseases. To access the most current ACIP recommendations, go to www.cdc.gov/vaccines/hcp/acip-recs/index.html for statements in alphabetical order or www.immunize.org/acip for statements in chronological order (can also be sorted by vaccine or topic of interest from this web page). For the AAP policy statements on immunizations, go to www.immunize.org/aap.
How do I obtain copies of the newest U.S. recommended immunization schedules for children and for adults?
You can download electronic versions of the schedules from CDC's website at www.cdc.gov/vaccines/schedules/hcp/index.html. IAC has also created laminated versions of the child and adolescent schedule, as well as the adult schedule, which make an excellent resource for placement in each exam room. Each is based on the official schedules adopted by ACIP, AAP, AAFP, ACOG, and ACP. You can find them by going to www.immunize.org/shop.
The Catch-Up Immunization Scheduler on the CDC Vaccines and Immunization website is not working. Can you please fix it? We use it to make schedules for Head Start children who are behind schedule.
The child immunization scheduler tool is no longer available. Please use your state or local immunization information system (IIS) for this service. If you are not familiar with your state or local IIS, you can find your state or local immunization program online where you can access your IIS or contact the program for assistance.
What resources does IAC have to help parents and child caretakers evaluate the immunization needs of children and adolescents?
There are several very easy to read pieces that can be downloaded from the IAC website. This includes "Vaccinations for Infants and Children, Age 0-10 Years", "When do children and teens need vaccinations?", "Vaccinations for Preteens and Teens, Age 11-19 Years". These handouts can be found at www.immunize.org/handouts/discussing-vaccines-parents.asp
What resources are available to help adult patients evaluate their individual immunization needs?
IAC has developed several screening questionnaires for patient use. These include:
Do I need any vaccinations today? (adult vaccination assessment checklist)
Vaccinations for Adults—You're never too old to get immunized!
Vaccinations for Pregnant Women
Vaccinations for Adults with Diabetes
Vaccinations for Adults with Heart Disease
Vaccinations for Adults with Lung Disease
Vaccinations for Adults with HIV Infection
Vaccinations for Adults with Hepatitis C Infection
Vaccinations for Adults Without a Spleen
Vaccinations for Men Who Have Sex with Men
Should You Be Vaccinated Against Hepatitis B? A screening questionnaire for adults, and
Should You Be Vaccinated for Hepatitis A? A screening questionnaire for adults.
These handouts can be found at www.immunize.org/handouts/view-all.asp
In addition to these printed pieces, there are several interactive tools on CDC's website. For children, go to www2a.cdc.gov/nip/kidstuff/newscheduler_le, and for adults, go to www2.cdc.gov/nip/adultImmSched.
Why do ACIP recommendations not always agree with package inserts?
There is usually very close agreement between vaccine package inserts and ACIP statements. The Food and Drug Administration (FDA) must approve the package insert, and requires documentation for all data and recommendations made in the insert. Occasionally, ACIP may use different data to formulate its recommendations, or try to add flexibility to its recommendations, which results in wording different than in the package insert. ACIP sometimes makes recommendations based on expert opinion and public health considerations. Published recommendations of national advisory groups (such as ACIP or AAP's Committee on Infectious Diseases) should be considered equally as authoritative as those on the package insert.
Can vaccinations be given without a physician's order?
Vaccines must always be dispensed with a prescription or order from a physician or other healthcare provider authorized by the state to prescribe medications. However, there are situations where vaccines can be administered using a standing order or vaccine protocol that is not patient-specific. In these situations, a physician or other healthcare provider does not need to be physically present for the vaccine to be administered. Several studies have shown that the use of standing orders can improve vaccination rates, and ACIP recommends the use of standing orders programs in both outpatient and inpatient settings. A comprehensive set of standing orders for the routine vaccines given to children and adults can be found at www.immunize.org/standing-orders.
In updating immunizations for immigration ("green card") exams, I regularly come across intervals between catch-up vaccine doses that are shorter than ACIP recommendations—most often the last 2 doses of IPV are given less than 6 months apart, but also sometimes the 2 doses of varicella are given less than 3 months apart, and the next-to-last and last Td are given less than 6 months apart. How significant is this in terms of immunity?
The significance of non-standard intervals probably depends on the vaccine and the dose. This is a complex issue—studies have not been done to examine the effect of various intervals between doses on the immunogenicity of those doses. But ACIP has examined the available data and made recommendations about the minimum acceptable interval between doses for that dose to be considered valid (there is no maximum interval between doses). These minimum intervals are published as Table 1 in ACIP's General Recommendations on Immunization, available at www.cdc.gov/mmwr/pdf/rr/rr6002.pdf, pages 36–37. Doses with a minimum interval less than the recommended minimum, as described in Table 1, should not be counted as valid. More details on this topic can be found in the General Recommendations.
Is it standard practice to revaccinate a child who is adopted from another country?
No. According to ACIP, vaccines administered outside the U.S. generally can be accepted as valid if the schedule (i.e., minimum ages and intervals) is similar to that recommended in the U.S. However, with the exception of the influenza vaccine and PPSV23, only written documentation should be accepted as evidence of previous vaccination. In general, 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 be started on the age-appropriate vaccination schedule. Serologic testing for immunity is an alternative to vaccination for certain antigens. More information is available in the ACIP General Recommendations on Immunization, available at www.cdc.gov/mmwr/pdf/rr/rr6002.pdf, pages 27–29.
What vaccinations are recommended for new immigrants to the United States?
Effective December 14, 2009, the Centers for Disease Control and Prevention (CDC) revised the vaccination criteria for U.S. immigration. CDC will use these criteria for vaccines recommended by the Advisory Committee on Immunization Practices (ACIP) to decide which vaccines will be required for U.S. immigration. The criteria will be used at regular periods, as needed, by CDC. The new criteria are:
The vaccine must be age-appropriate* for the immigrant applicant, AND at least one of the following:
The vaccine must protect against a disease that has the potential to cause an outbreak, OR
The vaccine must protect against a disease that has been eliminated or is in the process of being eliminated in the United States.
*ACIP recommends vaccines for a certain age range in the general U.S. public. These ACIP recommendations will be used to decide which vaccines are age-appropriate for the general immigrant population.
Current immigration law requires that immigrants have proof of vaccination against mumps, measles, rubella, tetanus, diphtheria, pertussis, meningococcal disease, pneumococcal disease, Haemophilus influenzae type B, rotavirus, varicella, influenza, hepatitis A, hepatitis B, and polio. As of December 2009, human papillomavirus (HPV) and zoster vaccines are not required for immigrants. Additional information is available on the CDC website at www.cdc.gov/immigrantrefugeehealth/laws-regs/vaccination-immigration/revised-vaccination-criteria-immigration.html
Children adopted from outside the U.S. and political refugees are recommended to receive age-appropriate vaccination, with catch-up vaccination as appropriate, per the guidance in ACIP's General Recommendations on Immunization (see www.cdc.gov/mmwr/pdf/rr/rr6002.pdf, pages 27-28). People entering the U.S. as visitors are not required to provide proof of vaccination regardless of the length of stay.
Which vaccines are recommended for healthcare personnel (HCP)?
ACIP recommends that people working in healthcare settings be vaccinated against influenza, hepatitis B, measles, mumps, rubella, varicella, and pertussis. For measles, mumps, rubella, and varicella, serologic evidence of immunity is an acceptable substitute for documentation of vaccination. In addition, microbiologists working in a laboratory should receive meningococcal conjugate and meningococcal serogroup B vaccines. In rare cases, some laboratory personnel should also receive polio and typhoid vaccines. For more information, see www.cdc.gov/mmwr/pdf/rr/rr6007.pdf.
Where can I get the most up-to-date information on vaccination recommendations for people who travel outside the U.S.?
You can get this information from CDC's Travel Health website at http://wwwnc.cdc.gov/travel/page/yellowbook-home. CDC also publishes Health Information for International Travel (a.k.a. "Yellow Book") as a reference for those who advise international travelers of health risks. The Yellow Book is written primarily for healthcare providers, although others might find it useful. To order a copy of the Yellow Book from Oxford University Press, visit their website at https://global.oup.com/academic or call (800-451-7556) and ask for ISBN# 978-0-19-937915-6.
What vaccines should I administer to an infant who will be traveling internationally?
Infants who will travel outside the United States should be up to date for all routinely recommended vaccines. One dose of MMR is recommended for infants age 6 through 11 months before international travel. This dose does not count toward the two doses needed to complete the childhood schedule. Varicella vaccine is not recommended before age 12 months, even for travelers. An infant younger than age 12 months who is traveling to a hepatitis A endemic area should receive IG, not hepatitis A vaccine (for details, see ACIP recommendations: Update: Prevention of Hepatitis A After Exposure to Hepatitis A Virus and in International Travelers). For other vaccine recommendations for travelers, consult CDC Health Information for International Travel: 2014 (“Yellow Book”).
What vaccines are indicated for someone who has had a splenectomy?
People who do not have a functioning spleen or who have had a splenectomy are at increased risk for infection with encapsulated bacteria, especially Streptococcus pneumonia, Neisseria meningitidis, and Haemophilus influenzae type b (Hib).
In addition to receiving routine vaccinations, children and adults without a functioning spleen who are age 2 years and older should receive 1 dose of pneumococcal polysaccharide vaccine (PPSV) at least 8 weeks after the last dose of pneumococcal conjugate vaccine (PCV). Adults should receive 1 dose of PCV either 8 weeks before PPSV, or 1 year after PPSV. A second dose of PPSV should be administered 5 years after the first dose. All asplenic persons should receive at least 2 doses of meningococcal conjugate vaccine with a booster dose every 5 years. See the meningococcal conjugate vaccine recommendation table at www.immunize.org/catg.d/p2018.pdf for details. Asplenic persons age 10 years and older should also receive a series (either 2 or 3 doses depending on the vaccine brand) of meningococcal serogroup B vaccine. Two doses of Hib vaccine should be given to unimmunized persons 12-59 months of age (defined as persons who received zero or 1 dose before 12 months of age). A single dose of Hib vaccine should be administered to unimmunized persons age 5 years or older (defined as persons who have not received a primary Hib series and booster dose or at least 1 dose of Hib vaccine after 14 months of age).
Do any of the bacterial vaccines that are recommended for people with functional or anatomic asplenia need to be given before splenectomy? Do the doses count if they are given during the 2 weeks prior to surgery?
Ideally, both types of pneumococcal (PCV and PPSV), both types of meningococcal (conjugate and serogroup B), and Hib vaccines should be administered at least 2 weeks before a scheduled splenectomy, if possible. If vaccines are not administered before surgery, they should be administered as soon as the person's condition stabilizes post-operatively.
What are the ACIP recommendations for vaccination of preterm infants?
Preterm infants should be vaccinated at the same chronological age and according to the same schedule as full-term infants, regardless of birth weight, with the exception of the birth dose of hepatitis B vaccine. Infants weighing less than 2 kg (4.4 lb) whose mothers’ HBsAg status is either positive or unknown should receive HBIG (hepatitis B immune globulin) and hepatitis B vaccine within 12 hours of birth. This dose of hepatitis B vaccine should not be counted as a valid first dose in the series, and it should be repeated at age 1–2 months. If the preterm infant’s mother’s HBsAg status is negative, the infant’s first dose of hepatitis B vaccine should be withheld until the infant is chronologically 1 month of age or is ready to be discharged from the hospital, whichever occurs first. For complete details, see the Vaccination of Preterm Infants section (pages 25–26) of the ACIP General Recommendations on Immunization, available at www.cdc.gov/mmwr/pdf/rr/rr6002.pdf.
This page was updated on November 22, 2017.
This page was reviewed on December 9, 2016.
 
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