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Ask the Experts - What's New

Featured in Recent Publications

Administering Vaccines
Billing and Reimbursement
Combination Vaccines
Diphtheria
Documenting Vaccination
Hib
Hepatitis A
Hepatitis B
HPV
Influenza
MMR
Meningococcal
Pertussis
Pneumococcal
Polio
Precautions and Contraindications
Rabies
Rotavirus
Scheduling Vaccines
Storage and Handling
Tetanus
Vaccine Recommendations
Vaccine Safety
Varicella (chickenpox)
Zoster (shingles)
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Administering Vaccines Back to top
I gave a dose of ActHIB vaccine to a 15-month-old that was reconstituted with Menveo diluent. Can I count the dose? What are the possible side effects I should be concerned with?
Vaccines should be reconstituted according to manufacturer guidelines using only the diluent supplied by the manufacturer for that vaccine. Each diluent is specific to the corresponding vaccine in volume, pH, and chemical balance. If the wrong diluent is used, the vaccine dose is not valid and should be repeated using the correct diluent. Although there are no safety data for ActHib reconstituted with the wrong diluent, a significant adverse reaction, other than possibly a local reaction, seems unlikely.
Question of the Week: IAC Express - August 3, 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.
Question of the Week: IAC Express - February 17, 2016
Do you recommend staff who provide immunizations be certified in cardiopulmonary resuscitation (CPR) training or only have some CPR training?
ACIP's General Recommendations on Immunization states that all vaccination providers should be familiar with the office emergency plan and be currently certified in CPR. Epinephrine and equipment for maintaining an airway should be available for immediate use. Access the recommendations (see page 12) at www.cdc.gov/mmwr/pdf/rr/rr6002.pdf.
Question of the Week: IAC Express - October 8, 2015
I was taught that gloves should be worn when giving vaccines. Other nurses say that this is not necessary. Which is correct?
Occupational Safety and Health Administration (OSHA) regulations do not require gloves to be worn when administering vaccinations, unless persons administering vaccinations are likely to come into contact with potentially infectious body fluids or have open lesions on their hands. If gloves are worn, they should be changed between patients. For more information on vaccine administration, see ACIP's General Recommendations on Immunization.
Question of the Week: IAC Express - Issue 1203
Can teens receive Vaccines For Children (VFC) vaccines without a parent being present?
Each state has their own law as to the age limitations/requirements for a child to receive VFC services without parental consent.
Question of the Week: IAC Express - Issue 1199
The protective cap on a single-dose vial was removed but the vaccine was not needed. No needle punctured the rubber seal. According to CDC's Vaccine Storage & Handling Toolkit, the vial without the cap should be discarded at the end of workday. If no needle punctured the seal, what is the reasoning for discarding the vaccine?
Removing the protective cap increases the likelihood the septum or stopper could be punctured. The puncture may not be visible. Once the protective cap has been removed, the vaccine should be discarded at the end of the workday because it may not be possible to determine if the rubber seal has been punctured.
Question of the Week: IAC Express - Issue 1198
I recently had a patient ask if we could administer her baby's rotavirus vaccine in her pumped breast milk. Would this be acceptable?
No. Although ACIP does not specifically address this, it introduces a number of possible problems: possible loss of vaccine effectiveness when mixed with another liquid, possible contamination, possible temperature excursion, and potential loss of volume (e.g., if baby didn't drink the entire volume).
Needle Tips - March 2015, IAC Express - Issue 1176
One of our young patients made it impossible to administer the second part of the live attenuated influenza vaccine (LAIV; FluMist) dose. What should we do?
A half dose of LAIV (or any other vaccine) is a non-standard dose and should not be counted. If you weren't able to give the second half of the vaccine at that same appointment, you will have to provide another full dose of influenza vaccine at another time. If you want to try using a different route, you can give inactivated influenza vaccine any time after this partial dose. If you want to give LAIV again, you should wait four weeks, as it is a live vaccine.
Needle Tips - March 2015, IAC Express - Issue 1176
I need information about the administration of vaccines to 3-month-old conjoined twins (joined at the buttocks). The mother states that a hepatitis B vaccine was given at birth but there is no record of this. For their routine immunization, do we provide one set of vaccinations or two, given that they are conjoined at the buttock but share no major organs?
ACIP does not address this issue. However, CDC recommends that these children should each be vaccinated, notwithstanding they are conjoined. We believe even in conjoined twins who share organs and/or blood supply, vaccination of each child would also be indicated. The rationale is one cannot be sure, even in the latter case, that the common organs/blood supply would eliminate vaccine antigens less quickly, or the immune system(s) would respond adequately, to one dose of each vaccine for the two children. Therefore two doses seems appropriate, that is, one dose of each vaccine for each child.
Question of the Week: IAC Express - Issue 1173
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.
Question of the Week: IAC Express - Issue 1148
If a patient pulls away during administration of a vaccine and the needle comes out, is it okay to reintroduce the same needle and finish the injection?
No. The needle should be considered to be contaminated. The needle and syringe should be discarded. A new syringe, needle, and dose of vaccine should be used. A full repeat dose should be given.
Needle Tips, Vaccinate Adults - October 2014, IAC Express - Issue 1153
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.
Question of the Week: IAC Express - Issue 1147
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.
Question of the Week: IAC Express - Issue 1136
>> view all administering vaccines Q&As
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Combination Vaccines Back to top
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.
Question of the Week: IAC Express - Issue 1231, February 24, 2016
A dose of Kinrix (DTaP-IPV; GlaxoSmithKline) was inadvertently given to a 4-month-old in our practice who needed DTaP and IPV. Can this dose be considered valid?
Kinrix is only licensed for use as the fifth dose of the DTaP vaccine series and the fourth dose of the IPV series in children age 4 through 6 years. CDC has provided this guidance for when Kinrix is given off-label:
Kinrix given to a child younger than 4 years as DTaP and IPV doses 1, 2, or 3: Count as valid if all minimum intervals met.
Kinrix given to a child younger than 4 years as DTaP and IPV doses #4 and/or #5: Count as valid for DTaP #4; not valid for DTaP #5 or IPV #4, both of which must be administered at age 4 through 6 years.
However, you should check with your state immunization program to see what they will accept. Checking with your state is particularly important for validating a last dose of IPV vaccine administered before the fourth birthday. Their guidance may vary depending on the date of administration or your upcoming travel plans. Contact information can be found here: www.immunize.org/coordinators.
Needle Tips - March 2015, IAC Express - Issue 1176
If Kinrix (DTaP-IPV, GlaxoSmithKline) is inadvertently given to a child age 15 through 18 months, as the fourth DTaP dose and the third IPV dose, do the DTaP and IPV doses need 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 (6 months) and dose #2 and dose #3 of IPV (4 weeks).
Question of the Week: IAC Express - Issue 1163
>> view all combination vaccines Q&As
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Documenting Vaccination Back to top
I have patients who are in their 70s or 80s and remember getting a pneumococcal vaccine “a few years ago.” Should I assume that this was PPSV23? Should I assume that it was given before the 65th birthday?
You can accept a verbal report of PPSV23. Since the recommendation for routine vaccination with PCV13 is relatively recent (November 2014) it is reasonable to assume that PPSV23 was the pneumococcal vaccine that was administered earlier. Try to ascertain how long ago it was given. If you think the dose was given after the 65th birthday and it has been a year since the dose was administered, give a dose of PCV13 now. If the dose was administered before the 65th birthday, administer a dose of PCV13 now, and then administer a dose of PPSV23 one year later, assuming that it has been 5 years since the first dose of PPSV23 was administered.
Question of the Week: IAC Express - Issue 1255, July 13, 2016
Is it necessary for us to record the actual date that the Vaccine Information Statement (VIS) was provided or can it be assumed that the VIS was provided on the day the shot was given?
Federal law requires that the provider record in the medical record the date the VIS was provided and the date the vaccine was administered. In addition, providers are required to record the edition date of the VIS (found on the back at the right bottom corner), the name, office address, and title of the healthcare provider who administers the vaccine, and the vaccine manufacturer and lot number.
Question of the Week: IAC Express - Issue 1190
>> view all documenting vaccination Q&As
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Diphtheria Vaccine Back to top
If a six-year-old child is due for the fifth dose of DTaP and inadvertently receives Tdap, I know that this dose counts as the fifth dose of DTaP. But should this child receive another dose of Tdap at age 11–12 years?
Yes. In this situation, a second dose of Tdap should be administered at the recommended age of 11 or 12 years.
Question of the Week: IAC Express - Issue 1261, August 17, 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.
Question of the Week: IAC Express - Issue 1231, February 24, 2016
There is a debate within my clinical department about not allowing influenza vaccine to be given with DTaP and PCV13. Are there data that state these should not be given concomitantly?
A CDC study has shown a small increased risk for febrile seizures during the 24 hours after a child receives the inactivated influenza vaccine at the same time as the PCV13 vaccine or DTaP vaccine. However, the risk of febrile seizure with any combination of these vaccines is small and the Advisory Committee on Immunization Practices (ACIP) recommends giving these vaccines at the same visit if indicated. See www.cdc.gov/vaccinesafety/concerns/febrile-seizures.html for more information.
Question of the Week: IAC Express - December 9, 2015
An adult patient had a bone marrow transplant and had previously received a Tdap vaccine. The oncologist recommended another dose of Tdap. Is this acceptable in this situation?
Yes. A dose of Tdap 6 months after a bone marrow transplant is appropriate.
Question of the Week: IAC Express - Issue 1197
>> view all diphtheria Q&As
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Haemophilus influenzae type b (Hib) Vaccine Back to top
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.
Question of the Week: IAC Express - Issue 1231, February 24, 2016
>> view all Haemophilus influenzae type b (Hib) Q&As
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Hepatitis A Vaccine Back to top
It has just come to my attention that the plumbers working for our plumbing contractor receive hepatitis A vaccine because of their exposure to sewage. Is this a CDC recommendation?
Hepatitis A vaccine is not routinely recommended for workers exposed to sewage. More information on this topic can be found in the ACIP hepatitis A recommendations, available at www.cdc.gov/mmwr/PDF/rr/rr5507.pdf (page 8). However, it is important to ensure that people exposed to sewage in their work stay current on their tetanus vaccination with a routine booster dose every 10 years.
Question of the Week: IAC Express - November 25, 2015
For hepatitis A vaccination, the recommended interval between the 2-dose series is at least 6 months. Is this the same as 24 weeks?
No. The recommended interval between dose #1 and #2 of hepatitis A vaccine is 6 calendar months, not 24 weeks. See CDC's The Pink Book (Epidemiology and Prevention of Vaccine Preventable Diseases) available at www.cdc.gov/vaccines/pubs/pinkbook/downloads/appendices/A/age-interval-table.pdf, footnote 5.
Needle Tips, Vaccinate Adults - October 2014, IAC Express - Issue 1153
>> view all hepatitis A Q&As
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Hepatitis B Vaccine Back to top
We did a hepatitis B panel for a new hospital employee from Gambia. She had no documentation of having been vaccinated. Her results showed HBsAg nonreactive, anti-HBc reactive, IgM anti-HBc nonreactive, and anti-HBs borderline. We don’t know how to interpret these results. Should she be immunized?
Most likely this person has a resolved hepatitis B infection and is immune. However, it would be preferable to test her again for all these serologic markers, and also quantify the anti-HBs result. If the results are still positive for anti-HBc, and anti-HBs is less than the immune level of 10mIU/mL, you can give her one dose of hepatitis B vaccine and test again in 1–2 months. If the anti-HBs is positive (10 mIU/mL or higher), she is immune. No further action is needed other than to document the results. If the anti-HBs is still negative, complete the vaccine series and test again 1–2 months after the last dose of vaccine.
If she is still anti-HBs negative after 3 doses of vaccine, test again for HBsAg to be sure she is not chronically infected (unlikely) and counsel her as a nonresponder. See www.cdc.gov/mmwr/pdf/rr/rr6210.pdf for more information about hepatitis B vaccination of healthcare personnel. Information about persons with isolated positive anti-HBc is available at www.cdc.gov/hepatitis/hbv/hbvfaq.htm#general.
Question of the Week: IAC Express - Issue 1253, June 29, 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.
Question of the Week: IAC Express - Issue 1226, January 27, 2016
A physician ordered a 40-µg dose of hepatitis B vaccine for a hemodialysis patient. The clinic does not stock the Recombivax HB (40 µg/dose) formulation and would like to give 2 adult doses of Engerix B (20 µg/dose) for each dose in the series. Is this acceptable?
Yes. If given on the same day as separate injections in separate sites, the Energix B doses can be counted as the equivalent of one 40-µg dose. According to the package insert, Engerix B is licensed for use in this manner. Vaccine package inserts are available at www.immunize.org/packageinserts.
Question of the Week: IAC Express - Issue 1195
If an infant got a dose of the adult formulation of hepatitis B vaccine in error, should the dose be counted? When should the next dose be scheduled for this infant? Do we need to be concerned about a possible adverse event?
If an infant received an adult dose of hepatitis B vaccine (contains twice the antigen in a dose of the infant/child formulation), the dose can be counted as valid and does not need to be repeated. Hepatitis B vaccine is a very safe vaccine and no unusual adverse events would be expected because of this administration error. The next (age appropriate) dose should be given on the usual schedule.
Needle Tips - May 2015, Question of the Week: IAC Express - Issue 1177
>> view all hepatitis B Q&As
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HPV Vaccine Back to top
As I understand, the 4-day grace period for HPV vaccination can be applied to the minimum interval between dose #1 and #2 (4 weeks [28 days]) and dose #2 and #3 (12 weeks [84 days]) but you would still need to meet the 112 days between dose #1 and #3 for dose #3 to be valid. Is this right?
The 4-day grace period cannot be applied to both the interval between dose #1 and #2 and the interval between dose #2 and #3 because no grace period is allowed for the interval between dose #1 and #3. This interval must be 16 weeks (112 days). If the grace period is used for one of the first two intervals, then the other interval must be extended by at least that number of days to ensure that dose #1 and #3 meet the absolute minimum interval of 112 days.
Question of the Week: IAC Express - Issue 1263, August 31, 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 27, 2016
Are additional HPV9 doses recommended for a person who started a series with HPV2 or HPV4 and completed the series with one or two doses of HPV9?
There is no ACIP recommendation for additional doses of HPV9 for persons who started the series with HPV2 or HPV4 and completed the series with HPV9.
Needle Tips, Vaccinate Adults - November 2015
If a vaccination series was started with HPV2 or HPV4, can it be completed with HPV9? If the answer is yes, what are the spacing intervals that should be used for the remaining doses in the 3-dose series?
ACIP recommendations state that HPV9 may be used to continue or complete a series started with a different HPV vaccine product. The intervals between doses remain the same regardless of what vaccine is used to complete the series. The second dose is given 1 to 2 months after the first dose and the third dose 4 months after the second AND at least 6 months after the first dose.
Needle Tips, Vaccinate Adults - November 2015
Why is human papillomavirus (HPV) vaccine (Cervarix, GSK; Gardasil and Gardasil 9, Merck) not recommended for people who are known to have had an HPV infection—similar to shingles vaccine—to reduce chances of another outbreak?
Recommendations for use of HPV vaccine are based on age and not history of prior infection. Contrary to the assumption in your question, routine HPV vaccination is recommended for females through age 26 years and males through age 21 years (and certain males through age 26 years) regardless of their history of prior HPV infection. The chance of being infected with all nine vaccine-preventable strains of HPV included in the vaccine is very low, so there will most likely be benefit from the vaccine even in people with prior HPV infection.
Question of the Week: IAC Express - Issue 1211
Are healthcare personnel at risk of occupational infection with HPV?
Occupational infection with HPV is possible. Some HPV-associated conditions (including anogenital and oral warts, anogenital intraepithelial neoplasias, and recurrent respiratory papillomatosis) are treated with laser or electrosurgical procedures that could produce airborne particles. These procedures should be performed in an appropriately ventilated room using standard precautions and local exhaust ventilation. Workers in HPV research laboratories who handle wildtype virus or “quasi virions” might be at risk of acquiring HPV from occupational exposures. In the laboratory setting, proper infection control should be instituted including, at minimum, biosafety level 2. Whether HPV vaccination would be of benefit in these settings is unclear because no data exist on transmission risk or vaccine efficacy in this situation.
Needle Tips, Vaccinate Adults - May 2015, IAC Express - Issue 1189
Please summarize information about Merck’s 9-valent HPV vaccine (9vHPV, Gardasil 9).
9vHPV contains the four HPV types in 4vHPV (Gardasil; 16, 18, 6, and 11) and 5 additional "high risk" types (31, 33, 45, 52, and 58). It was licensed by the U.S. Food and Drug Administration (FDA) on December 10, 2014. 9vHPV is approved for use in females 9 through 26 years and males 9 through 15 years (Merck has subsequently submitted clinical trial data to the FDA for males 16 through 26 years of age). 9vHPV has the same schedule as 4vHPV (three intramuscular doses spaced 0, 1–2, and 6 months apart). In a clinical trial comparing 9vHPV to 4vHPV, 9vHPV reduced the risk of disease caused by the 5 additional strains by 97%.ACIP states that clinicians can administer either 4vHPV or 9vHPV to males through age 26 years to complete the HPV vaccine series.
Needle Tips, Vaccinate Adults - May 2015, IAC Express - Issue 1189
With the availability of 9vHPV, has the ACIP changed its recommendations for HPV vaccines?
The ACIP recommendations for HPV vaccination have not changed. ACIP recommends that routine HPV vaccination be initiated for females and males at age 11 or 12 years. The vaccination series can be started as early as age 9 years. Vaccination is also recommended for females aged 13 through 26 years and for males aged 13 through 21 years who have not been vaccinated previously or who have not completed the 3-dose series. In addition, vaccination is recommended for men age 22 through age 26 years who 1) have sex with men or 2) are immunocompromised as a result of infection (including HIV), disease, or medication. Other males 22 through 26 years of age may be vaccinated at the clinician’s discretion.
Vaccination of females is recommended with 2vHPV (Ceravix, GlaxoSmithKline), 4vHPV (as long as this formulation is available), or 9vHPV. Vaccination of males is recommended with 4vHPV (as long as this formulation is available) or 9vHPV. Ideally, HPV vaccine should be administered before potential exposure to HPV through sexual contact.
All 3 HPV vaccines should be given as a 3-dose schedule, with the second dose given 1 to 2 months after the first dose and the third dose 6 months after the first dose.
The 2014 ACIP recommendations are available at www.cdc.gov/mmwr/pdf/rr/rr6305.pdf (covers 2vHPV and 4vHPV), and the newly released 2015 ACIP recommendations (published March 27, 2015) are at www.cdc.gov/mmwr/pdf/wk/mm6411.pdf, pages 300–304 (covers 9vHPV).
Needle Tips, Vaccinate Adults - May 2015, IAC Express - Issue 1189
Does ACIP recommend revaccination with 9vHPV for patients who previously received a series of 2vHPV or 4vHPV?
ACIP has not recommended routine revaccination with 9vHPV for persons who have completed a series of another HPV vaccine. There are data that indicate revaccination with 9vHPV after a series of 4vHPV is safe. Clinicians should decide if the benefit of immunity against 5 additional oncogenic strains of HPV is justified for their patients.
Needle Tips, Vaccinate Adults - May 2015, IAC Express - Issue 1189
Is 9vHPV included in the Vaccines For Children (VFC) program?
Yes.
Needle Tips - May 2015, IAC Express - Issue 1189
Do women and men whose sexual orientation is same-sex need HPV vaccine?
Yes. HPV vaccine is recommended for females and males regardless of their sexual orientation.
Needle Tips, Vaccinate Adults - May 2015, IAC Express - Issue 1189
If a dose of HPV vaccine is significantly delayed, do I need to start the series over?
No, do not restart the series. You should continue where the patient left off and complete the series.
Needle Tips, Vaccinate Adults - May 2015, IAC Express - Issue 1189
What are the minimum intervals between doses of HPV vaccine?
Minimum intervals are used when patients have fallen behind on their immunization schedule or when they need their dosing schedule expedited (for example, if there is imminent travel). The minimum interval between the first and second doses of HPV vaccine is 4 weeks. The minimum interval between the second and third dose is 12 weeks. ACIP recommends an interval of 24 weeks between the first and third dose. However, the third dose can be considered to be valid if it was separated from the first dose by at least 16 weeks and from the second dose by at least 12 weeks.
Needle Tips, Vaccinate Adults - May 2015, IAC Express - Issue 1189
If HPV vaccine is given subcutaneously instead of intramuscularly, does the dose need to be repeated?
Yes. No data exist on the efficacy or safety of HPV vaccine given by the subcutaneous route. All data on efficacy and duration of protection are based on a 3-dose series given on the approved schedule and administered by the intramuscular route. In the absence of data on subcutaneous administration, the Centers for Disease Control and Prevention (CDC) and the manufacturers recommend that a dose of HPV vaccine given by any route other than intramuscular should be repeated. There is no minimum interval between the invalid (subcutaneous) dose and the repeat dose.
Needle Tips, Vaccinate Adults - May 2015, IAC Express - Issue 1189
If a patient has been sexually active for a number of years, is it still recommended to give HPV vaccine or to complete the HPV vaccine series?
Yes. HPV vaccine should be administered to people who are already sexually active. Ideally, patients should be vaccinated before onset of sexual activity; however, patients who have already been infected with one or more HPV types still get protection from other HPV types in the vaccine that have not been acquired.
Needle Tips, Vaccinate Adults - May 2015, IAC Express - Issue 1189
If a 30-year-old female patient insists that she wants to receive HPV vaccine, can I give it to her?
HPV vaccine is not FDA-licensed for use in women older than age 26 years. Studies have shown that the vaccine is safe in women age 27 years and older. ACIP does not recommend the use of this vaccine outside the FDA licensing guidelines unless the series was started but not completed by age 26 years. Clinicians may choose to administer HPV vaccine off-label to men and women age 27 years or older.
Needle Tips, Vaccinate Adults - May 2015, IAC Express - Issue 1189
What adverse events can be expected following HPV vaccine?
In clinical trials involving more than 35,000 subjects, the most common adverse event was injection site pain, which was reported in 58% to 90% of recipients (depending on vaccine and dose number). Other local reactions, such as redness and/or swelling, were reported in 30% to 40% of recipients. Local reactions were reported more frequently among 9vHPV recipients than among 4vHPV recipients, probably because of the larger amount of aluminum adjuvant present in 9vHPV. Systemic reaction, such as fever, headache, and fatigue, were reported by 2% to 50% of recipients (depending on vaccine and dose number). These symptoms generally occurred at about the same rate in vaccine and placebo recipients.
Needle Tips, Vaccinate Adults - May 2015, IAC Express - Issue 1189
Do HPV vaccines cause fainting?
Nearly all vaccines have been reported to be asso-ciated with fainting (syncope). Post-vaccination syncope has been most frequently reported after receipt of any of the three vaccines commonly given to adolescents (HPV, MCV4, and Tdap). However, it is not known whether the vaccines are responsible for post-vaccination syncope or if the association with these vaccines simply reflects the fact that adolescents are generally more likely to experience syncope.
Syncope can cause serious injury. Falls that occur due to syncope after vaccination can be prevented by having the vaccinated person seated or lying down. The person should be observed for 15 minutes following vaccination.
Needle Tips, Vaccinate Adults - May 2015, IAC Express - Issue 1189
>> view all HPV Q&As
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Influenza Vaccine Back to top
With the ACIP recommendation to not use live attenuated influenza vaccine (LAIV, FluMist, AstraZeneca) during the 2016–2017 season will there be enough inactivated influenza vaccine (IIV) to meet the demand for the upcoming season?
Influenza vaccine manufacturers project that as many as 171 to 176 million doses of influenza vaccine will be available for the 2016–2017 season. LAIV accounts for up to 14 million of those doses (about 8% of the total supply). Based on manufacturer projections, health officials expect that supply of IIV for the 2016–2017 season should be sufficient to meet any increase in demand resulting from the ACIP recommendation, though providers may need to check more than one supplier or purchase a vaccine brand other than the one they normally select.
Question of the Week: IAC Express - Issue 1266 - September 21, 2016
I know that live attenuated influenza vaccine (LAIV, FluMist) is not recommended to be used this season. If a dose of LAIV is administered this year, does it count or should we repeat it with inactivated influenza vaccine?
The dose can be counted. It does not need to be repeated with inactivated influenza vaccine.
Question of the Week: IAC Express - Issue 1265 - September 14, 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.
Question of the Week: IAC Express - Issue 1224 - January 13, 2016
A dose of live attenuated influenza vaccine (LAIV, Flumist) was inadvertently given to a 20-month-old. It was the first time the child had received influenza vaccine. Does the LAIV dose need to be repeated? We plan to give pediatric inactivated vaccine as dose #2 in one month.
The minimum approved age for LAIV is age 2 years. However, you can count the dose of LAIV because this vaccine has been demonstrated to be effective in children 1–2 years of age. You are correct that the second dose should be a pediatric dose of inactivated influenza vaccine. You should take steps to avoid this sort of vaccine administration error in the future. 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.
Question of the Week: IAC Express - December 23, 2015
There is a debate within my clinical department about not allowing influenza vaccine to be given with DTaP and PCV13. Are there data that state these should not be given concomitantly?
A CDC study has shown a small increased risk for febrile seizures during the 24 hours after a child receives the inactivated influenza vaccine at the same time as the PCV13 vaccine or DTaP vaccine. However, the risk of febrile seizure with any combination of these vaccines is small and the Advisory Committee on Immunization Practices (ACIP) recommends giving these vaccines at the same visit if indicated. See www.cdc.gov/vaccinesafety/concerns/febrile-seizures.html for more information.
Question of the Week: IAC Express - December 9, 2015
We see many patients with multiple co-morbidities (COPD, heart disease, diabetes, dialysis, etc.). Which influenza vaccine should we give to this patient population?
A person with chronic medical conditions should receive only inactive influenza vaccine. The vaccine should be given only to persons of the approved age range for that vaccine. For persons for whom more than one type of vaccine is appropriate and available, ACIP does not express a preference for use of any particular product over another.
Question of the Week: IAC Express - December 2, 2015
If a child only received a half dose of live attenuated influenza vaccine (LAIV, FluMist, MedImmune), I understand they are not considered immunized. Can the child receive inactivated influenza vaccine (IIV) on the same day?
You are correct that a half dose of LAIV (or any other vaccine) is a non-standard dose and should not be counted. If you weren't able to give the second half of the LAIV at that same appointment, you will need to provide another full dose of influenza vaccine at another visit. If you want to try using a different type of vaccine, you can give IIV any time after the partial dose of LAIV. If you want to give LAIV again, you should wait four weeks because it is a live vaccine.
Question of the Week: IAC Express - Issue 1209
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.
Question of the Week: IAC Express - Issue 1149
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MMR Vaccine Back to top
When not given on the same day, is the interval between yellow fever and MMR vaccines 4 weeks (28 days) or 30 days? I have seen the yellow fever and live virus vaccine recommendations published both ways.
The General Recommendations on Immunization makes the generic recommendation that live parenterally or nasally administered vaccines not given on the same day should be separated by at least 28 days. The CDC travel health website recommends that yellow fever vaccine and other parenteral or nasal live vaccines should be separated by at least 30 days if possible.
Question of the Week: IAC Express - Issue 1262, August 24, 2016
In a mumps outbreak, should we offer a third dose of MMR to persons who have two prior documented doses of MMR?
You should consult with the local health department about the necessity for a third dose of mumps-containing vaccine in this circumstance. Currently, data are insufficient to recommend for or against the routine use of a third dose of MMR vaccine for mumps outbreak control. CDC has issued guidance for considerations for use of a third dose in specifically identified target populations along with criteria for public health departments to consider in decision making. This information can be found at www.cdc.gov/vaccines/pubs/surv-manual/chpt09-mumps.html.
Question of the Week: IAC Express - Issue 1256, July 20, 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 18, 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 11, 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 20, 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, March 2, 2016
An infant is going to be traveling internationally before turning one year of age, but is not scheduled to travel for a few months. Do we need to wait to vaccinate with MMR vaccine until some point closer to departure?
Infants 6 through 11 months of age are recommended to receive MMR vaccine if they will be traveling internationally. There is no need to wait until travel is imminent. Optimally there should be one month between vaccine administration and travel, so vaccinate now if the infant is at least 6 months old and you know travel will occur before the child’s first birthday.
Question of the Week: IAC Express - Issue 1185
For an adult who experienced probable thrombocytopenic purpura after one dose of MMR as a child, it is my understanding that they should not receive MMR vaccine. Is this correct? This person has a positive serology for mumps and rubella but not measles.
A history of thrombocytopenia is considered a precaution, not a contraindication to MMR vaccine. What that means is that a provider should weigh the benefits of giving a dose of vaccine, even given the history, if circumstances indicate that the risk of disease is high (such as in an outbreak setting).
Question of the Week: IAC Express - Issue 1183
If MMR vaccine is given at 9 months of age, it will not count as the first dose. Is this because immunity at this age may not develop?
Studies indicate that about 86% of children vaccinated at 9 months of age respond to the vaccine while the estimate is about 97% for children vaccinated at 12 months or older. Maternal antibodies against measles virus may persist up to 11 months. For these reasons children vaccinated between 6 and 11 months of age should receive two more doses of MMR after their first birthday.
Question of the Week: IAC Express - Issue 1180
I have heard concerns from individuals who are undergoing chemotherapy about being exposed to a child who recently received MMR vaccine. Is there a risk for the vaccinated child to transmit vaccine virus to the chemotherapy patient?
MMR vaccine can be given to the healthy household contacts of immunosuppressed persons, such as those undergoing chemotherapy. Measles, mumps, and rubella vaccine viruses are not transmitted from the vaccinated person, so MMR vaccination of a household contact does not pose a risk to an immunocompromised person.
Question of the Week: IAC Express - Issue 1179
We have young adult patients in our practice at high risk for measles, including those going back to college or preparing for international travel, who don’t have a record of receiving MMR vaccine or having had measles disease. How should we manage these patients?
You have two options. You can test for immunity or you can just give 2 doses of MMR at least 4 weeks apart. There is no harm in giving MMR vaccine to a person who may already be immune to one or more of the vaccine viruses. If you or the patient opt for testing, and the tests indicate the patient is not immune to measles or mumps, give your patient 2 doses of MMR at least 4 weeks apart. If the test indicates the person is not immune to rubella only, give 1 dose of MMR. If any test results are indeterminate or equivocal, consider your patient nonimmune. ACIP does not recommend serologic testing after vaccination because commercial tests may not be sensitive enough to reliably detect vaccine-induced immunity.
Needle Tips, Vaccinate Adults - March 2015, IAC Express - Issue 1174
What are the contraindications and precautions for MMR vaccine?
Contraindications are the following:
History of a severe (anaphylactic) reaction to neomycin (or other vaccine component) or following previous dose of MMR
Pregnancy
Severe immunosuppression from either disease or therapy
Precautions are the following:
Receipt of an antibody-containing blood product in the previous 11 months
Moderate or severe acute illness with or without fever
History of thrombocytopenia or thrombocytopenic purpura
Important details about the contraindications and precautions for MMR vaccine are in the current MMR ACIP statement, available at www.cdc.gov/mmwr/pdf/rr/rr6204.pdf.
Needle Tips, Vaccinate Adults - March 2015, IAC Express - Issue 1174
I have patients who remember receiving MMR vaccine but have no written record, or whose parents report the patient has been vaccinated. Should I accept this as evidence of vaccination?
No. Self-reported doses and history of vaccination provided by a parent or other caregiver are not considered to be valid. You should only accept a written, dated record as evidence of MMR vaccination.
Needle Tips, Vaccinate Adults - March 2015, IAC Express - Issue 1174
Can I give MMR to a breastfeeding mother?
Yes. Breastfeeding does not interfere with the response to MMR vaccine. Vaccination of a woman who is breastfeeding poses no risk to the infant being breastfed. Although it is believed that rubella vaccine virus, in rare instances, may be transmitted via breast milk, the infection in the infant is asymptomatic.
Needle Tips, Vaccinate Adults - March 2015, IAC Express - Issue 1174
What is the recommended length of time a woman should wait after receiving MMR vaccine before becoming pregnant?
Although the MMR package insert recommends a 3-month deferral of pregnancy after MMR vaccination, ACIP recommends deferral of pregnancy for four weeks. For details on this issue see ACIP recommendations (MMWR 2013; 62[4]: 1–34) at www.cdc.gov/mmwr/pdf/rr/rr6204.pdf.
Needle Tips, Vaccinate Adults - March 2015, IAC Express - Issue 1174
Can we give an MMR to a 15-month-old whose mother is pregnant?
Yes. Measles, mumps, and rubella vaccine viruses are not transmitted from the vaccinated person, so MMR vaccination of a household contact does not pose a risk to a pregnant household member.
Needle Tips - March 2015, IAC Express Issue 1174
Would you consider HCP with 2 documented doses of MMR vaccine to be immune even if their serology for 1 or more of the antigens comes back negative?
Yes. HCP with 2 documented doses of MMR vaccine are considered to be immune regardless of the results of a subsequent serologic test for measles, mumps, or rubella. Documented age- appropriate vaccination supersedes the results of subsequent serologic testing. HCP who do not have documentation of MMR vaccination and whose serologic test is interpreted as “indeterminate” or “equivocal” should be considered not immune and should receive 2 doses of MMR. ACIP does not recommend serologic testing after vaccination.
Needle Tips, Vaccinate Adults - March 2015, IAC Express - Issue 1174
If a healthcare professional had a positive test for measles antibody more than 10 years ago, is it necessary to retest them now?
No. Once measles immunity is documented, there is no need for further vaccination or testing. “Once immune, always immune” is true for varicella, mumps, and rubella, as well as for measles, regardless of the results of subsequent testing. ACIP does not recommend repeat antibody testing once evidence of immunity (such as appropriate vaccination or IgG seropositivity) has been established.
Needle Tips, Vaccinate Adults - March 2015, IAC Express - Issue 1174
Can I give MMR to a child whose sibling is receiving chemotherapy for leukemia?
Yes. MMR vaccine should be given to the healthy household contacts of immunosuppressed people.
Needle Tips, Vaccinate Adults - March 2015, IAC Express - Issue 1174
Is there any evidence that MMR causes autism?
No. This issue has been studied extensively in recent years, including a thorough review by the Institute of Medicine (IOM), an impartial group of the world’s leading experts that advises Congress on science issues. After reviewing more than 200 studies in 2004 and more than 1,000 studies in 2011, the consensus report strongly stated that the evidence did not show a link between vaccines and autism. To access the IOM committee minutes, as well as the executive summaries and full reports, visit www.immunize.org/iom.
In 2014, researchers from the RAND Corporation published an update to the 2011 IOM report. In a systematic review of the evidence published on vaccine safety to date, they found the evidence was strong that MMR vaccine is not associated with autism. For more information, see “Evidence Shows Vaccines Unrelated to Autism” at www.immunize.org/catg.d/p4028.pdf and “MMR Vaccine Does Not Cause Autism” at www.immunize.org/catg.d/p4026.pdf.
Needle Tips, Vaccinate Adults - March 2015, IAC Express - Issue 1174
We received a call from a healthcare provider who inadvertently administered MMR vaccine to a woman who was 2 months pregnant. Please advise as to appropriate action steps. 
No specific action needs to be taken other than to reassure the woman that no adverse outcomes are expected as a result of this vaccination. MMR vaccination during pregnancy alone is not a reason to terminate the pregnancy. You should consult with the provider to determine if there is a way to avoid such vaccination errors in the future. Detailed information about MMR vaccination in pregnancy is included in the most recent MMR ACIP statement, available at www.cdc.gov/mmwr/pdf/rr/rr6204.pdf.
Needle Tips, Vaccinate Adults – May 2015, Question of the Week: IAC Express - Issue 1168
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Meningococcal Vaccine Back to top
The ACIP recommendations for meningococcal serogroup B (MenB) vaccine say the vaccine will provide “short term protection.” What does “short term protection” mean?The ACIP recommendations for meningococcal serogroup B (MenB) vaccine say the vaccine will provide “short term protection.” What does “short term protection” mean?
MenB vaccines were approved based on the serologic response to the vaccine. No data are available on vaccine effectiveness against clinical disease or duration of protection against clinical disease. Short term protection refers to the known duration of the antibody response. Available data indicate that a protective antibody level should persist in most recipients for 24 to 48 months after vaccination. This issue will continue to be monitored. For more information, see www.cdc.gov/mmwr/pdf/wk/mm6441.pdf, pages 1171–5.
Question of the Week: IAC Express - Issue 1260, August 10, 2016
The meningococcal conjugate vaccine recommendations state that a routine second dose of meningococcal conjugate (MenACWY) vaccine needs to be given at 16 years of age. Children with asplenia or other high-risk conditions should receive a booster dose every 5 years. If a child with a high-risk condition receives a dose of MenACWY at age 9 years (and a second primary dose 8 weeks later), should they receive a booster dose at age 14 years (5 years after the primary series), or should they receive a dose at age 16 years as recommended in the routine schedule?
The MenACWY booster dose should be given at 14 years (5 years after the primary series) and every 5 years thereafter. The every 5-year booster dose schedule for persons with high-risk conditions takes precedent over the routine second dose schedule.
Question of the Week: IAC Express - Issue 1254, July 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, April 6, 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 9, 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 - February 10, 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 - January 6, 2016
We are having difficulty getting meningococcal polysaccharide vaccine (MPSV4, Menomune, Sanofi). Does CDC have a recommendation for the use of meningococcal conjugate vaccine (MCV4) off label in vaccine-naïve older adults?
A meningococcal conjugate immunogenicity study in older adults indicated that this group did not have as high of an antibody response to serogroup Y compared to older adults who received polysaccharide vaccine. There is much more polysaccharide in MPSV4 (50 micrograms per serogroup) compared to MCV4 (5–10 micrograms per serogroup), which is thought to be the reason for the better response to polysaccharide vaccine in older adults. However, if there is an urgent need for travel, it is reasonable to administer MCV4 if MPSV4 is not available. If the need for vaccination is not urgent, awaiting availability of MPSV4 is preferred.
ACIP recommends that for meningococcal vaccine-naïve persons age 56 years or older who anticipate requiring a single dose of meningococcal vaccine (such as travelers and persons at risk as a result of a community outbreak), MPSV4 is preferred. For persons now age 56 years or older who were vaccinated previously with MCV4 and are recommended for revaccination or for whom multiple doses are anticipated (such as persons with asplenia and microbiologists), MCV4 is preferred. These recommendations are available at www.cdc.gov/mmwr/pdf/rr/rr6202.pdf, page 15.
IAC Express - December 16, 2015
Can MCV4 and MenB vaccines be given at the same visit?
Yes. MCV4 and MenB vaccines can be given at the same visit or at any time before or after the other.
Needle Tips, Vaccinate Adults - November 2015
By what route should meningococcal vaccines be administered?
MCV4 should be administered by the intramuscular route. MPSV4 should be given by the subcutaneous route. MenB is given by the intramuscular route.
Needle Tips, Vaccinate Adults - November 2015
Which groups should receive a booster dose of MenB vaccine?
ACIP does not currently recommend booster doses of MenB vaccine for any group.
Needle Tips, Vaccinate Adults - November 2015
Why does ACIP recommend a routine booster dose of MCV4 for adolescents age 16 years and older?
In 2005, ACIP recommended routine MCV4 vaccination for all adolescents at age 11 or 12 years to protect them from meningococcal disease as older teens. The peak age for meningococcal disease is 16 through 21 years. In 2005, ACIP reasoned that higher MCV4 vaccination rates could be achieved if, when administering the dose, it was coupled with giving the Td booster dose at the 11- or 12-year-old visit (the Td dose for 11- or 12-year olds was replaced by Tdap in 2006). Subsequent studies indicated that the protection provided by MCV4 wanes within 5 years following vaccination. For this reason, in 2010, ACIP recommended an MCV4 vaccine booster dose to provide continuing protection during the peak years of vulnerability (see www.cdc.gov/mmwr/pdf/wk/mm6003.pdf, pages 72-76).
Needle Tips, Vaccinate Adults - November 2015
Should all adolescents receive a routine booster dose of MCV4?
ACIP recommends people age 11 or 12 years be routinely vaccinated with quadrivalent MCV4 and receive a booster dose at age 16 years. Adolescents who receive the first dose at age 13 through 15 years should receive a one-time booster dose at age 16 through 18 years, which are the years before the peak in incidence of meningococcal disease among adolescents occurs. Teens who receive their first dose of meningococcal conjugate vaccine at or after age 16 years do not need a booster dose, as long as they have no risk factors.
Needle Tips, Vaccinate Adults - November 2015
I have a patient with paroxysmal nocturnal hemoglobinuria who is being treated with Soliris (eculizumab). Should he receive meningococcal vaccine?
Eculizumab binds to C5 and inhibits the terminal complement pathway. Persons with persistent complement component deficiency are at increased risk for meningococcal disease. This person should receive a series of both quadrivalent meningococcal conjugate (MCV4; 2 doses separated by at least 8 weeks) and a 2- or 3-dose series (depending on brand) of meningococcal serogroup B vaccine.
Needle Tips, Vaccinate Adults - November 2015
Can you provide a comprehensive overview of the MCV4 recommendations, including those for vaccinating younger children and older adults who have risk factors?
IAC has prepared a table that provides a summary of the ACIP recommendations for use of meningococcal vaccine for people of all ages, including recommendations published by ACIP in MMWR in March 2013. The table is available at www.immunize.org/catg.d/p2018.pdf.
Needle Tips, Vaccinate Adults - November 2015
Which previously vaccinated college students need a booster dose of MCV4?
A booster dose should be given to first-year college students age 21 years and younger who are or will be living in a residence hall if the previous dose was given before the age of 16 years.
Needle Tips, Vaccinate Adults - November 2015
What is the schedule for MenB vaccine?
Trumenba (Pfizer) is a 3-dose series with the second and third doses administered 2 and 6 months after the first dose. Bexsero (GSK) is a 2-dose series with doses given at least 1 month apart.
Needle Tips, Vaccinate Adults - November 2015
What is the schedule for MCV4 vaccine?
All adolescents should receive a dose of MCV4 at 11 or 12 years of age. A second (booster) dose is recommended at 16 years of age. Adolescents who receive their first dose at age 13 through 15 years should receive a booster dose at age 16 through 18 years. The minimum interval between MCV4 doses is 8 weeks. Adolescents who receive a first dose after their 16th birthday do not need a booster dose unless they become at increased risk for meningococcal disease. Colleges may not consider a second dose given even a few days before age 16 years as valid, so keep that in mind when scheduling patients.
Needle Tips, Vaccinate Adults - November 2015
Should college students be vaccinated against meningococcal disease?
MCV4 vaccine is recommended for previously unvaccinated first-year college students who are age 21 years and younger, who are or will be living in a residence hall. Some colleges and universities require incoming freshmen and others to be vaccinated with MCV4; some may also require that a dose of MCV4 have been given since the age of 16 years.
Although several small MenB outbreaks have occurred on college campuses since 2013, college students in general are not at higher risk of MenB then persons of the same age who are not college students. Consequently, ACIP does not routinely recommend MenB vaccination for college students. However, college students may choose to receive MenB vaccine to reduce their risk of serogroup B meningococcal disease.
Needle Tips, Vaccinate Adults - November 2015
ACIP now designates a vaccine recommendation as either Category “A” or “B.” My interpretation is that an A recommendation means the vaccine is routinely recommended for all people in an age or risk group, and a B recommendation is for use at the clinician’s discretion. Does the Affordable Care Act (ACA) require health plans (non-grandfathered) to provide benefit coverage on Category B recommended vaccines?
Your understanding of A and B recommendations is correct. ACA requires coverage of vaccines with both A and B recommendations. The Vaccines For Children program also covers vaccines with a Category B recommendation.
Needle Tips, Vaccinate Adults - November 2015
Who is recommended to be vaccinated against meningococcal disease?
Certain groups should receive both meningococcal conjugate vaccines (MCV4: Menactra, Sanofi Pasteur; Menveo, GSK) and MenB vaccines (Trumenba, Pfizer; Bexsero, GSK). Others are recommended to receive MCV4 only. MPSV4 (Menomune, Sanofi Pasteur) is recommended only for certain people older than 55 years.
MCV4 is recommended for these groups:
All children and teens, ages 11 through 18 years
  People younger than 22 years of age if they are or will be a first-year college student living in a residential hall
  People age 2 months and older with functional or anatomic asplenia (MenHibrix may be used for children age 6 weeks through 18 months in this group)
  People age 2 months and older who have persistent complement component deficiency (an immune system disorder) (MenHibrix may be used for children age 6 weeks through 18 months in this group)
  People age 2 months and older who are at risk during an outbreak caused by a vaccine serogroup (MenHibrix may be used for children age 6 weeks through 18 months in these groups)
  People age 2 months and older who reside in or travel to certain countries in sub-Saharan Africa as well as to other countries for which meningococcal vaccine is recommended (e.g., travel to Mecca, Saudi Arabia, for the annual Hajj)
  Microbiologists who work with meningococcus bacteria in a laboratory
MenB is routinely recommended for these groups:
People age 10 years and older who have functional or anatomic asplenia
  People age 10 years and older who have persistent complement component deficiency
  People age 10 years and older who are at risk during an outbreak caused by a vaccine serogroup, such as on college campuses
  Microbiologists who work with meningococcus bacteria in a laboratory
For adolescents and young adults, ACIP recommends that a MenB vaccine series may be administered to people 16 through 23 years of age with a preferred age of vaccination of 16 through 18 years. This Category B recommendation allows the clinician to make a MenB vaccine recommendation based on the risk and benefit for the individual patient.
Needle Tips, Vaccinate Adults - November 2015
Where can I find the most current meningococcal vaccine recommendations?
The most current recommendations for meningococcal polysaccharide and conjugate vaccines, which include serogroups A, C, W, and Y, were published in March 2013. This document is available on the MMWR website at www.cdc.gov/mmwr/pdf/rr/rr6202.pdf. Recommendations for use of MenB vaccine among persons at increased risk were published in June 2015 and are available at www.cdc.gov/mmwr/pdf/wk/mm6422.pdf, pages 608–12. MenB vaccine recommendations for adolescents and young adults were published in October 2015 and are available at www.cdc.gov/mmwr/pdf/wk/mm6441.pdf, pages 1171–6.
Needle Tips, Vaccinate Adults - November 2015
What meningococcal vaccines are currently available in the United States?
Since 2005, 2 types of meningococcal vaccines have been available in the United States that protect against meningococcal serogroups A, C, W, and Y: 1) meningococcal polysaccharide vaccine (MPSV4; Menomune, Sanofi Pasteur), which is made up of polysaccharide (sugar molecules) from the surface of the meningococcal bacteria; and 2) meningococcal conjugate vaccines (MCV4; Menactra, Sanofi Pasteur; Menveo, GSK) in which the polysaccharide is chemically bonded (“conjugated”) to a protein to produce better protection. MCV4 is more effective in young children than the original polysaccharide vaccine.
More recently, vaccines have become available that offer protection from meningococcal serogroup B. These vaccines are composed of proteins also found on the surface of the bacteria. Neither type of vaccine contains live meningococcal bacteria.
MPSV4 and MCV4 provide no protection against serogroup B disease, and meningococcal serogroup B vaccines (MenB) provide no protection against serogroup A, C, W, or Y disease. For protection against all 5 serogroups of meningococcus, it is necessary to receive MCV4 or MPSV4 and MenB.
Trade Name Type of Vaccine Serogroups Included Year Licensed Approved Ages
Menomune Polysaccharide A, C, W, Y 1981 2 years and older
Menactra Conjugate A, C, W, Y 2005 9 months–55 years*
Menveo Conjugate A, C, W, Y 2010 2 months–55 years*
MenHibrix Conjugate C, Y and Hib 2012 6 weeks–18 months
Trumenba Protein B 2014 10–25 years+
Bexsero Protein B 2015 10–25 years+
Needle Tips, Vaccinate Adults - November 2015
If someone received MPSV4 or MCV4 at age 9 years, will two additional doses of MCV4 be needed?
Yes. Doses of quadrivalent meningococcal vaccine (either MPSV4 or MCV4) given before 10 years of age do not count as part of the series. If a child received a dose of either MPSV4 or MCV4 before age 10 years, they should receive a dose of MCV4 at 11 or 12 years and a booster dose at age 16 years.
Needle Tips, Vaccinate Adults - November 2015
A 16-year-old female came to us prior to having an elective splenectomy for a congenital splenic cyst. Her primary doctor has given her PCV13, Menactra brand MCV4, and a dose of meningococcal B vaccine—all on the same day. Since PCV13 and Menactra were given on the same day, should I give her another dose of PCV13 and if so, when? She will also receive PPSV23 8 weeks after PCV13.
While it is ideal if all recommended doses are given prior to splenectomy, this schedule is acceptable, since PCV13 is being given before PPSV23 and splenectomy. The recommendation to separate PCV13 and Menactra applies only to asplenic persons. When she received the vaccines she was not asplenic.
Question of the Week: IAC Express - November 4, 2015
Should international travelers receive both meningococcal conjugate vaccine and meningococcal serogroup B vaccine?
Travelers are not considered to be a group at increased risk for serogroup B meningococcal disease and are not recommended to receive serogroup B vaccine. Meningococcal conjugate vaccine continues to be recommended for certain international travelers (residents of and travelers to sub-Saharan Africa and the Hajj in Saudi Arabia).
Question of the Week: IAC Express - Issue 1200
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Pertussis Vaccine Back to top
If a six-year-old child is due for the fifth dose of DTaP and inadvertently receives Tdap, I know that this dose counts as the fifth dose of DTaP. But should this child receive another dose of Tdap at age 11–12 years?
Yes. In this situation, a second dose of Tdap should be administered at the recommended age of 11 or 12 years.
Question of the Week: IAC Express - Issue 1261, August 17, 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.
Question of the Week: IAC Express - Issue 1231, February 24, 2016
There is a debate within my clinical department about not allowing influenza vaccine to be given with DTaP and PCV13. Are there data that state these should not be given concomitantly?
A CDC study has shown a small increased risk for febrile seizures during the 24 hours after a child receives the inactivated influenza vaccine at the same time as the PCV13 vaccine or DTaP vaccine. However, the risk of febrile seizure with any combination of these vaccines is small and the Advisory Committee on Immunization Practices (ACIP) recommends giving these vaccines at the same visit if indicated. See www.cdc.gov/vaccinesafety/concerns/febrile-seizures.html for more information.
Question of the Week: IAC Express - December 9, 2015
An adult patient had a bone marrow transplant and had previously received a Tdap vaccine. The oncologist recommended another dose of Tdap. Is this acceptable in this situation?
Yes. A dose of Tdap 6 months after a bone marrow transplant is appropriate.
Question of the Week: IAC Express - Issue 1197
How effective are the current pertussis vaccines and do they provide any protection against parapertussis?
DTaP vaccines are about 98% effective against pertussis within 1 year of receiving the fifth dose. However, 5 years later, protection declines to about 70%. Tdap vaccines are about 73% effective within 1 year of receiving a single dose. However, 2 to 4 years later protection declines to about 34%.
Parapertussis, like pertussis, can cause a whooping cough-like syndrome. Most studies agree that current pertussis vaccines provide limited to no immunity to parapertussis.
Question of the Week: IAC Express Issue - 1182
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Pneumococcal Vaccine Back to top
Why should we not give PCV13 vaccine to someone who has had a serious reaction to a diphtheria-containing vaccine in the past?
PCV13 vaccine is conjugated to a type of diphtheria-toxoid. So if someone has a past history of anaphylaxis following diphtheria-containing vaccine, it might be due to the diphtheria toxoid, and the cause of the anaphylactic allergy should be identified before the administration of PCV13 vaccine. This could be difficult since no single-antigen diphtheria toxoid is available in the U.S. Fortunately, true anaphylactic allergy to diphtheria-containing vaccine is rare.
Question of the Week: IAC Express - Issue 1264, September 7, 2016
I have patients who are in their 70s or 80s and remember getting a pneumococcal vaccine “a few years ago.” Should I assume that this was PPSV23? Should I assume that it was given before the 65th birthday?
You can accept a verbal report of PPSV23. Since the recommendation for routine vaccination with PCV13 is relatively recent (November 2014) it is reasonable to assume that PPSV23 was the pneumococcal vaccine that was administered earlier. Try to ascertain how long ago it was given. If you think the dose was given after the 65th birthday and it has been a year since the dose was administered, give a dose of PCV13 now. If the dose was administered before the 65th birthday, administer a dose of PCV13 now, and then administer a dose of PPSV23 one year later, assuming that it has been 5 years since the first dose of PPSV23 was administered.
Question of the Week: IAC Express - Issue 1255, July 13, 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, May 4, 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 23, 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 9, 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.
Question of the Week: IAC Express - Issue 1225, January 20, 2016
There is a debate within my clinical department about not allowing influenza vaccine to be given with DTaP and PCV13. Are there data that state these should not be given concomitantly?
A CDC study has shown a small increased risk for febrile seizures during the 24 hours after a child receives the inactivated influenza vaccine at the same time as the PCV13 vaccine or DTaP vaccine. However, the risk of febrile seizure with any combination of these vaccines is small and the Advisory Committee on Immunization Practices (ACIP) recommends giving these vaccines at the same visit if indicated. See www.cdc.gov/vaccinesafety/concerns/febrile-seizures.html for more information.
Question of the Week: IAC Express - December 9, 2015
A 16-year-old female came to us prior to having an elective splenectomy for a congenital splenic cyst. Her primary doctor has given her PCV13, Menactra brand MCV4, and a dose of meningococcal B vaccine—all on the same day. Since PCV13 and Menactra were given on the same day, should I give her another dose of PCV13 and if so, when? She will also receive PPSV23 8 weeks after PCV13.
While it is ideal if all recommended doses are given prior to splenectomy, this schedule is acceptable, since PCV13 is being given before PPSV23 and splenectomy. The recommendation to separate PCV13 and Menactra applies only to asplenic persons. When she received the vaccines she was not asplenic.
Question of the Week: IAC Express - November 4, 2015
A healthy child received only one dose of pneumococcal conjugate vaccine (PCV) at age 10 months. She is now 6 years old. Our state requires one dose of PCV13 after the first birthday for school attendance. Her physician says because she is older than 59 months, she does not need another dose of PCV. What should we do in this situation?
ACIP does not recommend routine PCV vaccination of healthy children 60 months of age or older. If there is a school requirement, the simplest solution is to give the child one dose of PCV13. However, health insurance may not pay for this dose. For more information on the ACIP recommendations for PCV13, go to www.cdc.gov/mmwr/pdf/rr/rr5911.pdf.
Question of the Week: IAC Express - Issue 1196
Why is it recommended to give PCV13 before PPSV23 to adults age 65 years and older? Wouldn’t PPSV23 protect them against ten additional strains of the pneumococcal virus?
Answer: PCV13 is recommended to be given first because of the immune response to the vaccine when given in this sequence. An evaluation of immune response after a second pneumococcal vaccination administered 1 year after an initial dose showed that subjects who received PPSV23 as the initial dose had lower antibody responses after subsequent administration of PCV13 than those who had received PCV13 as the initial dose followed by a dose of PPSV23.
Needle Tips, Vaccinate Adults - March 2015, IAC Express - Issue 1176
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.
Question of the Week: IAC Express - Issue 1150
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Polio Vaccine Back to top
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.
Question of the Week: IAC Express - Issue 1231, February 24, 2016
An 8-year-old child received three doses of oral polio vaccine before his first birthday. Should he receive an additional dose of inactivated poliovirus vaccine (IPV)?
Yes. This patient should receive a dose of IPV now. The final dose of the polio series should be received on or after the fourth birthday.
Question of the Week: IAC Express - Issue 1188
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.
Question of the Week: IAC Express Issue - 1142
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Precautions and Contraindications Back to top
Why should we not give PCV13 vaccine to someone who has had a serious reaction to a diphtheria-containing vaccine in the past?
PCV13 vaccine is conjugated to a type of diphtheria-toxoid. So if someone has a past history of anaphylaxis following diphtheria-containing vaccine, it might be due to the diphtheria toxoid, and the cause of the anaphylactic allergy should be identified before the administration of PCV13 vaccine. This could be difficult since no single-antigen diphtheria toxoid is available in the U.S. Fortunately, true anaphylactic allergy to diphtheria-containing vaccine is rare.
Question of the Week: IAC Express - Issue 1264, September 7, 2016
If my patient is taking Tamiflu (oseltamivir), can she receive zoster vaccine?
Yes. Although oseltamivir is an antiviral drug, it is only effective against influenza A and B viruses. Zoster vaccine contains varicella zoster virus which is not affected by oseltamivir.
Question of the Week: IAC Express - Issue 1257, July 27, 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 25, 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 11, 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 27, 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 13, 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 16, 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, March 2, 2016
Should a male postpone receiving the MMR vaccine if he and his spouse are trying to conceive?
No. If a man receives a dose of MMR vaccine, he does not need to avoid conception for any interval. There is no risk of transmission of MMR vaccine virus from a vaccinated man to a woman, regardless of the level of intimacy.
Question of the Week: IAC Express - Issue 1187
Can MMR, varicella, and hepatitis A vaccines be given to a child whose mother is hepatitis C positive?
Yes. These vaccines should be administered at the routinely recommended ages. A history of hepatitis C in the mother or other household contact is not a contraindication for any vaccine.
Question of the Week: IAC Express - Issue 1184
A 60-year-old patient will be starting corticosteroid therapy. He will start at 20 mg per day for 4 days, and then taper to 15 mg for 3 weeks. He will continue therapy for a year, but the dosing will change depending on his response. Should I administer zoster vaccine now or wait until he is taking a lower dose of corticosteroids? And if the patient should wait, what dose of corticosteroids would be safe for administration of the shingles vaccine?
Give the zoster vaccine now. Live vaccines should be deferred if a person is taking 20 mg or more of prednisone per day for 2 weeks or longer. An individual can receive a live virus vaccine (zoster in this case) one month after he is below 20 mg of prednisone (or equivalent) per day.
Question of the Week: IAC Express - Issue 1181
Does ACIP have any special recommendations regarding immunization in unimmunized children with celiac disease?
Celiac disease is neither an indication nor contraindication for any specific vaccines. Children with celiac disease should be vaccinated as indicated by their age.
Needle Tips - March 2015, IAC Express Issue 1176
I know that immunosuppressed patients can receive inactivated vaccines, but not live vaccines. Will these patients who receive inactivated vaccines develop a sufficient immune response to make vaccinating them worthwhile?
Inactivated vaccines can be administered to people who take immunosuppressive drugs or who have a condition that causes them to be immunocompromised. The vaccines might not be as effective as they would be when given to a person with an intact immune system. If possible, the immunosuppresive drug should be discontinued for a month prior to vaccination, then allow the vaccine 2–3 weeks to generate an immune response before restarting the immunosuppressive treatment, but obviously, this is not always possible.
Determination of altered immunocompetence is important because incidence or severity of some vaccine-preventable diseases is greater in people with altered immunocompetence. As a result, certain vaccines (e.g., inactivated influenza vaccine and pneumococcal vaccines) are recommended specifically for people with altered immunocompetence.
More information can be found in ACIP's General Recommendations on Immunization available at www.cdc.gov/mmwr/pdf/rr/rr6002.pdf, pages19–23.
Needle Tips, Vaccinate Adults - October 2014, IAC Express - Issue 1153
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Rotavirus Vaccine Back to top
We have a 20-week-old infant who was born prematurely. The infant has never received rotavirus vaccine and is technically past the maximum age for first dose. Should we give rotavirus vaccine to this infant?
ACIP recommends vaccination of preterm infants according to the same schedule and precautions as full-term infants. In preterm infants (as in full-term infants), the maximum chronological age for the first dose is 14 weeks 6 days. Vaccination should not be initiated for infants aged 15 weeks 0 days or older because of insufficient data on safety of dose 1 of rotavirus vaccine in older infants. For more information, see page 19 of ACIP's recommendations on rotavirus vaccination.
Question of the Week: IAC Express - Issue 1251, June 15, 2016
A child was inadvertently administered the first dose of rotavirus vaccine at five months of age. Since the rotavirus vaccine series was started after age 15 weeks, should the series be continued?
If a child inadvertently receives the first dose of rotavirus vaccine at 15 weeks or older, the remaining doses of the series can be given as long as they are administered by 8 months and 0 days of age. However, if the child is already 8 months and 1 day or older, ACIP does not recommend giving any further doses because 8 months and 0 days is the maximum age for administering any dose in the series. See page 17 of Prevention of Rotavirus Gastroenteritis Among Infants and Children Recommendations of the Advisory Committee on Immunization Practices (ACIP) for more information.
Question of the Week: IAC Express - Issue 1248, June 1, 2016
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Scheduling Vaccines Back to top
As I understand, the 4-day grace period for HPV vaccination can be applied to the minimum interval between dose #1 and #2 (4 weeks [28 days]) and dose #2 and #3 (12 weeks [84 days]) but you would still need to meet the 112 days between dose #1 and #3 for dose #3 to be valid. Is this right?
The 4-day grace period cannot be applied to both the interval between dose #1 and #2 and the interval between dose #2 and #3 because no grace period is allowed for the interval between dose #1 and #3. This interval must be 16 weeks (112 days). If the grace period is used for one of the first two intervals, then the other interval must be extended by at least that number of days to ensure that dose #1 and #3 meet the absolute minimum interval of 112 days.
Question of the Week: IAC Express - Issue 1263, August 31, 2016
When not given on the same day, is the interval between yellow fever and MMR vaccines 4 weeks (28 days) or 30 days? I have seen the yellow fever and live virus vaccine recommendations published both ways.
The General Recommendations on Immunization makes the generic recommendation that live parenterally or nasally administered vaccines not given on the same day should be separated by at least 28 days. The CDC travel health website recommends that yellow fever vaccine and other parenteral or nasal live vaccines should be separated by at least 30 days if possible.
Question of the Week: IAC Express - Issue 1262, August 24, 2016
We have a 20-week-old infant who was born prematurely. The infant has never received rotavirus vaccine and is technically past the maximum age for first dose. Should we give rotavirus vaccine to this infant?
ACIP recommends vaccination of preterm infants according to the same schedule and precautions as full-term infants. In preterm infants (as in full-term infants), the maximum chronological age for the first dose is 14 weeks 6 days. Vaccination should not be initiated for infants aged 15 weeks 0 days or older because of insufficient data on safety of dose 1 of rotavirus vaccine in older infants. For more information, see page 19 of ACIP's recommendations on rotavirus vaccination.
Question of the Week: IAC Express - Issue 1251, June 15, 2016
My 7-year-old patient has had only 1 dose of tetanus toxoid-containing vaccine at 11 months of age (a dose of DTaP). The catch-up schedule says he needs 3 additional doses of tetanus toxoid-containing vaccine (4 total). Why 4? If he were completely unvaccinated on the seventh birthday, he would only need a total of 3 doses.
If the first dose of a tetanus toxoid-containing vaccine is administered before the first birthday, 4 doses are necessary before beginning the 10-year cycle of booster doses. If the first dose is administered after the first birthday, 3 doses are necessary. The final dose should be spaced 6 months from the previous dose.
Question of the Week: IAC Express - Issue 1250, June 8, 2016
A child was inadvertently administered the first dose of rotavirus vaccine at five months of age. Since the rotavirus vaccine series was started after age 15 weeks, should the series be continued?
If a child inadvertently receives the first dose of rotavirus vaccine at 15 weeks or older, the remaining doses of the series can be given as long as they are administered by 8 months and 0 days of age. However, if the child is already 8 months and 1 day or older, ACIP does not recommend giving any further doses because 8 months and 0 days is the maximum age for administering any dose in the series. See page 17 of Prevention of Rotavirus Gastroenteritis Among Infants and Children Recommendations of the Advisory Committee on Immunization Practices (ACIP) for more information.
Question of the Week: IAC Express - Issue 1248, June 1, 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 18, 2016
There is a debate within my clinical department about not allowing influenza vaccine to be given with DTaP and PCV13. Are there data that state these should not be given concomitantly?
A CDC study has shown a small increased risk for febrile seizures during the 24 hours after a child receives the inactivated influenza vaccine at the same time as the PCV13 vaccine or DTaP vaccine. However, the risk of febrile seizure with any combination of these vaccines is small and the Advisory Committee on Immunization Practices (ACIP) recommends giving these vaccines at the same visit if indicated. See www.cdc.gov/vaccinesafety/concerns/febrile-seizures.html for more information.
Question of the Week: IAC Express - December 9, 2015
We have a child who received the second dose of hepatitis A vaccine 3 months after the first dose. A repeat dose (dose #3) was given 4 months after the (invalid) second dose. Both dose #2 and dose #3 appear to be invalid because the intervals were less than 6 months. Should this child receive a fourth dose of hepatitis A vaccine?
It is true that the recommended minimum interval between doses of hepatitis A vaccine is 6 calendar months. If the second dose is given too early, the repeat dose should be given 6 months after the invalid dose. However, in this situation CDC has recommended that dose #3 can be counted as valid if it was separated by at least 6 months from the first dose. So a fourth dose would not be recommended for this child.
Question of the Week: IAC Express - Issue 1193
Two live virus vaccines can be given on the same day. How do you define "day"?
The “same day” generally means at the same visit. This interval has not been precisely defined and probably will never be since it would be extremely difficult to study in order to develop an evidence- based recommendation. Immunization programs (and their computer systems) likely define this differently. It seems reasonable that if two vaccines were given on the same date then they would both be valid.
Needle Tips, Vaccinate Adults - March 2015, IAC Express - Issue 1176
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.
Question of the Week: IAC Express - Issue 1142
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Storage and Handling Back to top
Is it acceptable to write the expiration date (the “Beyond Use Date”) of an opened vaccine multi-dose vial on the box rather than the vial or must it be written on the vial?
It is acceptable to put the Beyond Use Date (BUD) on the packaging; this may help when reviewing inventory. But a provider should always read the label on the vial before administering a vaccine. It is possible for a vial to be placed in the wrong box. So the vial label is the safest place to put the BUD. Vial labels are small and it may require putting an extra sticky label on the vial.
Question of the Week: IAC Express - September 28, 2016
Is the top shelf of a pharmacy-grade storage unit acceptable for vaccine storage if there is a fan directly above it?
Generally speaking, CDC recommends avoiding the top shelf and the areas near vents due to temperature fluctuations. However, most pharmaceutical-grade units have more uniform temperatures than household units under normal operating conditions. During a power outage, the top shelf is an area of caution for all units as the temperatures increase most quickly there. In this instance, it would be best to check with the manufacturer to see if the top shelf is appropriate for storage in your unit.
Question of the Week: IAC Express - June 22, 2016
Multiple children were vaccinated with DTaP vaccine in the last month. We discovered after the fact that the vaccine was exposed to freezing temperatures on two occasions before the vaccines were administered. Should these children be revaccinated, and does revaccination depend on the dose number?
You need to repeat all the doses that were exposed to freezing temperatures regardless of dose number. There is no need for an interval with inactivated vaccines. Repeat the doses as soon as possible.
Question of the Week: IAC Express - November 11, 2015
Our office is small and we only store vaccine in the refrigerator of a two-compartment refrigerator/freezer. Can we use the freezer portion to store staff food?
CDC recommends using separate refrigerator and freezer units for vaccine storage, but still allows use of a combination refrigerator/freezer if you only use the refrigerator portion for storing vaccines (as you are doing). CDC also recommends that you store food and beverages in a separate storage unit from vaccines, which you are technically doing but there may still be an impact on the refrigerator temperature by the opening and closing of the freezer door by staff. (In most two-compartment units, cold air from the freezer is circulated for cooling the refrigerator.)
The ideal situation would be to get a stand-alone pharmaceutical/purpose-built refrigerator unit for your vaccines, and use your refrigerator/freezer combination unit for your food and drinks. Please refer to pages 30 and 50 of the "Vaccine Storage and Handling Toolkit" available at www.cdc.gov/vaccines/recs/storage/toolkit/storage-handling-toolkit.pdf, for more detailed information.
Needle Tips, Vaccinate Adults - October 2014, IAC Express - Issue 1153
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.
Question of the Week: IAC Express - Issue 1143
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Tetanus Vaccine Back to top
If a six-year-old child is due for the fifth dose of DTaP and inadvertently receives Tdap, I know that this dose counts as the fifth dose of DTaP. But should this child receive another dose of Tdap at age 11–12 years?
Yes. In this situation, a second dose of Tdap should be administered at the recommended age of 11 or 12 years.
Question of the Week: IAC Express - Issue 1261, August 17, 2016
My 7-year-old patient has had only 1 dose of tetanus toxoid-containing vaccine at 11 months of age (a dose of DTaP). The catch-up schedule says he needs 3 additional doses of tetanus toxoid-containing vaccine (4 total). Why 4? If he were completely unvaccinated on the seventh birthday, he would only need a total of 3 doses.
If the first dose of a tetanus toxoid-containing vaccine is administered before the first birthday, 4 doses are necessary before beginning the 10-year cycle of booster doses. If the first dose is administered after the first birthday, 3 doses are necessary. The final dose should be spaced 6 months from the previous dose.
Question of the Week: IAC Express - Issue 1250, June 8, 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.
Question of the Week: IAC Express - Issue 1231, February 24, 2016
There is a debate within my clinical department about not allowing influenza vaccine to be given with DTaP and PCV13. Are there data that state these should not be given concomitantly?
A CDC study has shown a small increased risk for febrile seizures during the 24 hours after a child receives the inactivated influenza vaccine at the same time as the PCV13 vaccine or DTaP vaccine. However, the risk of febrile seizure with any combination of these vaccines is small and the Advisory Committee on Immunization Practices (ACIP) recommends giving these vaccines at the same visit if indicated. See www.cdc.gov/vaccinesafety/concerns/febrile-seizures.html for more information.
Question of the Week: IAC Express - December 9, 2015
An adult patient had a bone marrow transplant and had previously received a Tdap vaccine. The oncologist recommended another dose of Tdap. Is this acceptable in this situation?
Yes. A dose of Tdap 6 months after a bone marrow transplant is appropriate.
Question of the Week: IAC Express - Issue 1197
We have a 63-year-old patient who states she had tetanus as a child. She does not know whether she ever had any tetanus-containing vaccines in her lifetime. Should Tdap be given to this patient, and is it safe?
A history of tetanus disease is not a reason to avoid tetanus-containing vaccines. Tetanus disease does not produce immunity because of the very small amount of toxin required to produce illness. As long as your patient has no other contraindications she should receive Tdap now. If she has no documentation of prior tetanus vaccination, she should receive a complete 3-dose primary series (dose #1 of Tdap, followed by dose #2 of Td 4 to 8 weeks later, and dose #3 of Td 6–12 months after dose #2).
Question of the Week: IAC Express - Issue 1170
>> view all tetanus Q&As
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Vaccine Recommendations Back to top
I know that live attenuated influenza vaccine (LAIV, FluMist) is not recommended to be used this season. If a dose of LAIV is administered this year, does it count or should we repeat it with inactivated influenza vaccine?
The dose can be counted. It does not need to be repeated with inactivated influenza vaccine.
Question of the Week: IAC Express - Issue 1265 - September 14, 2016
In a mumps outbreak, should we offer a third dose of MMR to persons who have two prior documented doses of MMR?
You should consult with the local health department about the necessity for a third dose of mumps-containing vaccine in this circumstance. Currently, data are insufficient to recommend for or against the routine use of a third dose of MMR vaccine for mumps outbreak control. CDC has issued guidance for considerations for use of a third dose in specifically identified target populations along with criteria for public health departments to consider in decision making. This information can be found at www.cdc.gov/vaccines/pubs/surv-manual/chpt09-mumps.html.
Question of the Week: IAC Express - Issue 1256, July 20, 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, May 4, 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 23, 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 9, 2016
It has just come to my attention that the plumbers working for our plumbing contractor receive hepatitis A vaccine because of their exposure to sewage. Is this a CDC recommendation?
Hepatitis A vaccine is not routinely recommended for workers exposed to sewage. More information on this topic can be found in the ACIP hepatitis A recommendations, available at www.cdc.gov/mmwr/PDF/rr/rr5507.pdf (page 8). However, it is important to ensure that people exposed to sewage in their work stay current on their tetanus vaccination with a routine booster dose every 10 years.
Question of the Week: IAC Express - November 25, 2015
A 16-year-old female came to us prior to having an elective splenectomy for a congenital splenic cyst. Her primary doctor has given her PCV13, Menactra brand MCV4, and a dose of meningococcal B vaccine—all on the same day. Since PCV13 and Menactra were given on the same day, should I give her another dose of PCV13 and if so, when? She will also receive PPSV23 8 weeks after PCV13.
While it is ideal if all recommended doses are given prior to splenectomy, this schedule is acceptable, since PCV13 is being given before PPSV23 and splenectomy. The recommendation to separate PCV13 and Menactra applies only to asplenic persons. When she received the vaccines she was not asplenic.
Question of the Week: IAC Express - November 4, 2015
My state has an immunization recommendation for school and child care employees, which states that prior to employment, all full- and part-time employees show proof of vaccination against measles, mumps, rubella, hepatitis B, tetanus, diphtheria, pertussis, influenza, varicella, and hepatitis A. It states that this recommendation is in accordance with the recommendations of CDC. I have not found anything from CDC that makes recommendations for employees in schools and child care centers. Is there any information that you can offer on vaccine recommendations for these populations other than the standard adult vaccine recommendations for the general population?
There is no specific ACIP document that addresses school and day care employees. High-risk persons are outlined in each vaccine’s published recommendations. You may access these at www.cdc.gov/vaccines/hcp/acip-recs.
Question of the Week: IAC Express - Issue 1210
The Advisory Committee on Immunization Practices now designates a vaccine recommendation as either "A" or "B." My interpretation is that an A recommendation means the vaccine is routinely recommended for all children in an age or risk group, and a B recommendation is for permissive use (at the clinician’s discretion). Does the Affordable Care Act (ACA) require health plans (non-grandfathered) to provide benefit coverage on permissive B recommended vaccines?
Your understanding of A and B recommendations is correct. ACA requires coverage of vaccines with both A and B recommendations. The Vaccines for Children program also includes vaccines with a B recommendation.
Question of the Week: IAC Express - Issue 1206
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”).
Needle Tips - March 2015, IAC Express Issue 1176
>> view all vaccine recommendations Q&As
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Vaccine Safety Back to top
Do you have any information on the use of aborted fetal cells in vaccine development?
Please see this article which summarizes the use of cells which produced the MRC5 and WI138 cell lines for certain vaccines used in humans: http://www.historyofvaccines.org/content/articles/human-cell-strains-vaccine-development.
The cells were taken from infants aborted for other reasons, and no new cells have been harvested since the 1960s. Rubella vaccine is one of those developed with such cells. Other commonly used vaccines from these cell lines include hepatitis A vaccines, varicella vaccine, and zoster (shingles) vaccine.
The National Council of Catholic Bishops has deemed use of such vaccines acceptable, if no other alternatives exist.
IAC Express Question of the Week - November 18, 2015
>> view all vaccine safety Q&As
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Varicella (chickenpox) Vaccine Back to top
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 18, 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 11, 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 30, 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.
Question of the Week: IAC Express - Issue 1228, February 3, 2016
A child in our practice received her first dose of varicella vaccine when she was 12 months old and her second dose when she was 14 months old, rather than at age 4–6 years. Is the second dose valid or does it need to be repeated?
The recommended minimum interval between two doses of varicella vaccine for children 12 months through 12 years of age is 12 weeks. However, the second dose of varicella vaccine does not need to be repeated if it was separated from the first dose by at least 28 days, which is the "minimum interval." For more information, access CDC's table: Recommended and Minimum Ages and Intervals Between Doses of Routinely Recommended Vaccines..
Question of the Week: IAC Express - Issue 1207
Can varicella vaccine be used as postexposure prophylaxis for a 9-month-old who was exposed to herpes zoster?
Varicella vaccine is neither approved nor recommended for children younger than age 12 months. Assuming that the child is not immunocompromised, varicella zoster immune globulin (VariZIG, Emergent BioSolutions Inc.) is also not recommended. If the child had a condition which was considered to place the child at greater risk for complications than the general population, then VariZIG could be considered (see www.cdc.gov/mmwr/pdf/wk/mm6228.pdf, page 574).
The Advisory Committee on Immunization Practices (ACIP) does not have a recommendation for acyclovir as varicella postexposure prophylaxis, although the American Academy of Pediatrics does provide some guidance on this issue in the 2015 edition of the Red Book.
Question of the Week: IAC Express - Issue 1171
A pediatric surgeon's 12-month-old child received the varicella vaccine and two days later developed a varicella-like rash. The surgeon had chickenpox as a child and had a positive varicella titer several years ago. Is it okay for the surgeon to continue to see patients? Also, is the varicella virus in the rash that develops following vaccination as virulent as the wild-type virus?
Because the surgeon is immune, the child's rash is not a problem and there is no need for the surgeon to restrict activity. In comparing a vaccine rash to wild-type chickenpox infection, transmission is less likely with a vaccine rash and, in general, there are fewer skin lesions.
Question of the Week: IAC Express - Issue 1164
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.
Question of the Week: IAC Express - Issue 1154
>> view all chickenpox (varicella) Q&As
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Zoster (shingles) Vaccine Back to top
If my patient is taking Tamiflu (oseltamivir), can she receive zoster vaccine?
Yes. Although oseltamivir is an antiviral drug, it is only effective against influenza A and B viruses. Zoster vaccine contains varicella zoster virus which is not affected by oseltamivir.
Question of the Week: IAC Express - Issue 1257, July 27, 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 25, 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 13, 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 16, 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.
Question of the Week: IAC Express - Issue 1228, February 3, 2016
My patient is a 66-year-old male with a condition that requires treatment with intravenous immune globulin (IVIG) once a month. Can he receive zoster vaccine?
Yes. The concern about interference by circulating antibody (from the IVIG), which we have for varicella vaccine, does not apply to zoster vaccine. The amount of antigen in zoster vaccine is high enough to offset any effect of circulating antibody. Also, studies of zoster vaccine were performed on patients receiving antibody-containing blood products with no appreciable effect on efficacy.
Vaccinate Adults - May 2015
My patient is a 66-year-old male with a condition that requires treatment with intravenous immune globulin (IVIG) once a month. Can he receive zoster vaccine
Yes. The concern about interference by circulating antibody (from the IVIG), which we have for varicella vaccine, does not apply to zoster vaccine. The amount of antigen in zoster vaccine is high enough to offset any effect of circulating antibody. Also, studies of zoster vaccine were performed on patients receiving antibody-containing blood products with no appreciable effect on efficacy.
Question of the Week: IAC Express - Issue 1162
>> view all zoster Q&As
This page was updated on September 28, 2016.
This page was reviewed on January 12, 2016.
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