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Ask the Experts - What's New

Featured in Recent Publications

Administering Vaccines
Billing and Reimbursement
Chickenpox (varicella)
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
Zoster (shingles)
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Administering Vaccines Back to top
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
What is the acceptable volume for a single dose of immune globulin (IG) to inject into the deltoid muscle of a normal-weight adult? What is the acceptable volume for a single dose of IG to inject into the vastus lateralis of a normal-weight adult?
Here are the suggested volumes:
Deltoid:
Average 0.5 mL
Range 0.5–2 mL
Vastus Lateralis:
Average 1–4 mL
Range 1–5 mL
Infants and toddlers would fall at the lower end of the range, whereas adolescents and adults would generally fall on the higher end of the range.
Question of the Week: IAC Express - Issue 1157
I was told that it is not recommended to give vaccines using the Z-track method. Is this correct?
The Z-track method is not contraindicated for IM vaccinations, but is not deemed necessary for vaccine administration. The Z-track technique is most beneficial for administering irritating medications, such as iron preparations.
Question of the Week: IAC Express Issue 1156
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
Is protective eyewear needed for those who administer vaccines so they can avoid blood spatter?
ACIP does not specifically recommend eye protection when administering vaccines.
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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Chickenpox (varicella) Back to top
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 2012 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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Combination Vaccines Back to top
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
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
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
Can we give Tdap and RhoGam (anti-Rho[D] immune globulin) at the same prenatal visit?
Tdap is an inactivated vaccine and may be given at the same prenatal visit with RhoGam. For more information on this topic, including the timing for the use of other vaccines with regards to RhoGam, see ACIP's General Recommendations on Immunization at www.cdc.gov/mmwr/pdf/rr/rr6002.pdf, page 9.
Question of the Week: IAC Express - Issue 1145
A 16-year-old has a written record of receiving two doses of DTaP at 2 and 5 months of age and one dose of Tdap at 15 years of age. Since she has had three doses of pertussis-containing vaccine, would she still need two additional doses of Td?
Since the first DTaP was received before 12 months of age and one Tdap dose has been given, this person needs one dose of Td 6 calendar months after the Tdap dose. A routine Td booster should be administered every 10 years. See IAC's new handout: DTaP, Tdap, and Td Catch-up Vaccination Recommendations by Prior Vaccine History and Age.
Question of the Week: IAC Express - Issue 1137
>> view all diphtheria Q&As
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Hib Vaccine Back to top
Do any of the bacterial vaccines that are recommended for people with functional or anatomic asplenia need to be given before splenectomy? Do the doses count if they are given during the 2 weeks prior to surgery?
Pneumococcal conjugate vaccine (PCV13), Haemophilus influenzae type b vaccine (Hib), and meningococcal conjugate vaccine (MCV4) should be given 14 days before splenectomy, if possible. Doses given during the 2 weeks (14 days) before surgery can be counted as valid. If the doses cannot be given prior to the splenectomy, they should be given as soon as the patient’s condition has stabilized after surgery. Pneumococcal polysaccharide vaccine (PPSV23) should be administered 8 weeks after the dose of PCV13 for people 2 years of age and older.
Question of the Week: IAC Express - Issue 1161
>> view all Hib Q&As
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Hepatitis A Vaccine Back to top
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
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
What is the maximum number of hepatitis B vaccine doses a dialysis patient can receive?
There is no maximum number of booster doses a dialysis patient can receive. Serology should be performed once a year and a booster dose given if serology is negative (less than 10 mIU/mL). Serology is not recommended more frequently than once a year, so boosters wouldn't be given more than once a year. See www.cdc.gov/mmwr/PDF/rr/rr5516.pdf, pages 27–29.
Question of the Week: IAC Express - Issue 1152
In our newborn nursery, we administer hepatitis B vaccine and HBIG to all infants born to HBsAg-positive mothers (including premature newborns) within 12 hours of birth, but now I've heard that we're also supposed to administer HBIG (along with hepatitis B vaccine) to infants weighing less than 2,000 grams and born to mothers whose HBsAg status is unknown. Is this true, and if so, what is the rationale?
Yes, what you have heard is correct. Please refer to the ACIP recommendations for hepatitis B vaccine in children published in December 2005 available at www.cdc.gov/mmwr/PDF/rr/rr5416.pdf. See page 9, Table 4. Women who have not been screened prenatally for HBV infection have a higher prevalence of HBsAg seropositivity than women who are screened prenatally. Preterm infants weighing less than 2,000 grams have a decreased response to hepatitis B vaccine administered before age 1 month, so the HBIG dose provides some additional protection.
Needle Tips - October 2014, IAC Express - Issue 1153
>> view all hepatitis B Q&As
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HPV Back to top
If a patient began the human papillomavirus (HPV) vaccine series with 4-valent HPV vaccine (4vHPV, Gardasil, Merck), can the series be completed with 9-valent HPV vaccine (9vHPV; Gardasil 9)? Should a booster dose of 9vHPV be given to persons who have already completed the 4vHPV series?
ACIP recommendations, published in March 2015 (www.cdc.gov/mmwr/pdf/wk/mm6411.pdf, page 300), state that 9vHPV may be used to complete a series begun with a different HPV vaccine. There is currently no recommendation for supplemental doses of 9vHPV following a completed series of 2vHPV or 4vHPV.
Question of the Week: IAC Express - Issue 1192
Which types of HPV are most likely to cause disease?
Of the annual average of 26,900 HPV-related cancers in the United States, approximately 64% are attributable to HPV 16 or 18 (65% for females; 63% for males; approximately 21,300 cases annually), which are included in all three HPV vaccines. Approximately 10% are attributable to HPV types 31, 33, 45, 52, and 58 (14% for females; 4% for males; approximately 3,400 cases annually), which are included in the 9-valent HPV vaccine. HPV type 16, 18, 31, 33, 45, 52, or 58 account for about 81% of cervical cancers in the United States. Approximately 50% of cervical precancers (CIN2 or greater) are caused by HPV 16 or 18 and 25% by HPV 31, 33, 45, 52, or 58. HPV 6 or 11 cause 90% of anogenital warts (condylomata) and most cases of recurrent respiratory papillomatosis. More information about HPV and HPV-related cancers is available in the 2014 HPV ACIP statement at www.cdc.gov/mmwr/pdf/rr/rr6305.pdf.
Needle Tips, Vaccinate Adults - May 2015, IAC Express - Issue 1189
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 new 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
Can an HPV vaccine series begun with 2vHPV or 4vHPV be completed with 9vHPV?
Yes. Any available HPV vaccine may be used to continue or complete the series for females. 9vHPV or 4vHPV may be used to continue or complete the series for males. However, receiving fewer than 3 doses of 4vHPV or 9vHPV may provide less protection against genital warts caused by HPV types 6 and 11 than the usual 3-dose series. There are no data on the efficacy of the 5 additional HPV types included in 9vHPV if the person receives fewer than 3 doses.
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
To accelerate completion of the HPV vaccine series, can doses be given at 0, 1, and 4 months?
No, there is no accelerated schedule for completing the HPV vaccine series. You should follow the recommended schedule of 0, 1–2, and 6 months.
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
I read that HPV vaccination rates are still low. What can we do as providers to improve these rates?
Coverage levels for HPV vaccine are improving but are still inadequate. Results from the CDC’s 2013 National Immunization Survey-Teen (NIS-Teen) indicate that HPV vaccination rates in girls age 13 through 17 years increased between 2012 and 2013. Just over 57% of girls age 13 through 17 years had started the series that they should have completed by age 13 years and 38% had completed the series. In 2013, 35% of boys age 13 through 17 years had received one dose but only 14% had received all three recommended doses. A summary of the 2013 NIS-Teen survey is available at www.cdc.gov/mmwr/pdf/wk/mm6329.pdf, page 625–633.
Providers can improve uptake of this life-saving vaccine in two main ways. First, studies have shown that missed opportunities are a big problem. Up to 88% (depending on year of birth) of girls unvaccinated for HPV had a healthcare visit where they received another vaccine such as Tdap, but not HPV. If HPV vaccine had been administered at the same visit, vaccination coverage for one or more doses could be 91% instead of 57%. Second, the 2013 NIS-Teen data show that not receiving a healthcare provider’s recommendation for HPV vaccine was one of the five main reasons parents reported for not vaccinating their daughters and the number one reason for not vaccinating their sons.
CDC urges healthcare providers to increase the consistency and strength of how they recommend HPV vaccine, especially when patients are age 11 or 12 years. The following resources can help providers with these conversations.
CDC’s “Tips and Time-savers for Talking with Parents about HPV Vaccine,” available at www.cdc.gov/vaccines/who/teens/for-hcp-tipsheet-hpv.pdf
IAC’s “Human Papillomavirus HPV: A Parent’s Guide to Preteen and Teen HPV Vaccination,” available at www.immunize.org/catg.d/p4250.pdf
For more detailed information about HPV vaccination strategies for providers, visit www.cdc.gov/vaccines/who/teens/for-hcp/hpv-resources.html.
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
My patient is a 14-year-old girl who has received one dose of bivalent HPV vaccine (HPV2, Cervarix, GlaxoSmithKline) and now wants to change over to quadrivalent HPV vaccine (HPV4, Gardasil, Merck). What is the recommendation to be followed?
You can complete the series with HPV4 (two more doses), which will assure protection against HPV types 16 and 18 (those types most likely to cause cervical and other cancers and that are in both HPV2 and HPV4). However, receiving only two doses of HPV4 may provide less protection against genital warts than the usual 3 doses. More information is available at www.cdc.gov/mmwr/pdf/rr/rr6305.pdf.
Question of the Week: IAC Express - Issue 1158
My office recently changed HPV vaccine brands from Gardasil to Cervarix. We have several males who received doses of Cervarix instead of Gardasil. Do the males who received Cervarix need to be revaccinated?
Yes. Cervarix (HPV2, GlaxoSmithKline) is not approved or recommended for use in males. Doses of HPV2 administered to males should not be counted and need to be repeated using Gardasil (HPV4, Merck).
Question of the Week: IAC Express - Issue 1140
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Influenza Back to top
We offer the quadrivalent inactivated influenza vaccine in our office. Will it protect our patients against the drifted H3N2 influenza virus?
The additional strain in the quadrivalent formulations of the inactivated influenza vaccine is an influenza-B strain. The drifted H3N2 viruses aren't precisely matched in influenza vaccines distributed in the United States. However, antibodies made in response to vaccination with one influenza virus may provide some protection against different but related viruses. A less than optimal match may result in reduced vaccine effectiveness but it can still provide some protection against influenza illness. In addition, even when there is a less than optimal match or lower effectiveness against one virus, it is important to remember that influenza vaccine contains three or four influenza virus strains, depending on the vaccine. There are presently B influenza viruses circulating, as well as the A/H3N2 viruses. For these reasons, even during seasons when there is a less than optimal match, CDC continues to recommend vaccination. This is particularly important for people at high risk for serious complications and their close contacts.
Question of the Week: IAC Express - Issue 1160
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
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
Which influenza vaccines can we give to children?
Among the injectable inactivated influenza vaccines (IIV), only Fluzone (Sanofi) is approved by the FDA for use in children ages 6 through 35 months. However, there are several injectable influenza vaccines that can be given to children age 3 years or older.
The nasal spray live attenuated influenza vaccine (LAIV, FluMist, MedImmune) is approved for healthy children age 2 years and older. You can find information on all influenza vaccines available in the U.S. for the current season and the age groups approved by FDA by going to IAC's handout titled "Influenza Vaccine Products for the 2014–2015 Influenza Season" available at www.immunize.org/catg.d/p4072.pdf.
When immediately available, LAIV is preferred for use in healthy children ages 2 through 8 years who do not have a contraindication or precaution to LAIV. ACIP states this preference because two studies have shown LAIV to be more effective than IIV in preventing influenza in this age group. However, both LAIV and IIV are safe and effective in this age group. If LAIV is not immediately available, IIV should be used. Vaccination should not be delayed in order to procure LAIV.
Needle Tips – October 2014, IAC Express - Issue 1153
Does the ACIP preference for use of LAIV in children ages 2 through 8 years include children with asthma?
No. Asthma or a wheezing episode noted in the medical record within the past 12 months is still considered a contraindication to the use of LAIV for children ages 2 through 4 years. For people age 5 years and older, asthma is considered to be a precaution (not a contraindication) for the use of LAIV.
Needle Tips – October 2014, IAC Express - Issue 1153
Which children younger than age 9 years will need 2 doses of influenza vaccine in the current influenza season?
Children age 6 months through 8 years should receive a second dose 4 weeks or more after the first dose if they 1) are receiving influenza vaccine for the first time, or 2) did not get a total of at least two doses of seasonal influenza vaccine since July 1, 2010. Children in this age group who received at least one dose during the 2013–2014 season need only one dose during the 2014–2015 season.
CDC has developed an alternative approach that may be used with children who have well-documented histories of influenza vaccination (for example, vaccination records maintained in an electronic registry). By this approach, children age 6 months through 8 years need only one dose of vaccine in this season if they have received any of the following: 1) at least one dose of vaccine during the 2013–2014 influenza season; 2) two or more doses of seasonal influenza vaccine since July 1, 2010; 3) two or more doses of seasonal vaccine given before July 1, 2010, and one or more dose of monovalent 2009 H1N1 vaccine; or 4) at least one dose of seasonal vaccine given before July 1, 2010, and at least one dose of seasonal vaccine since July 1, 2010.
For more details about the ACIP recommendations for which children need two doses, see pages 6917 of "Prevention and Control of Seasonal Influenza with Vaccines" available at www.cdc.gov/mmwr/pdf/wk/mm6332.pdf.
You can also find this information in IAC's "Guide for Determining the Number of Doses of Influenza Vaccine to Give to Children Ages 6 Months through 8 Years" available at www.immunize.org/catg.d/p3093.pdf.
Needle Tips – October 2014, IAC Express - Issue 1153
I've heard there is a newer influenza vaccine that can be given to people with severe egg allergy. Is that true?
Yes. If someone age 18 through 49 years has a severe allergy to eggs with symptoms suggestive of anaphylaxis, then the provider can use a recombinant influenza vaccine (RIV3, Flublok, Protein Sciences) that is egg-free. Unlike current production methods for other available seasonal influenza vaccines, production of RIV3 does not use the whole influenza virus or chicken eggs in its manufacturing process. If RIV3 is not available or the person is not age-eligible, then inactivated influenza vaccine should be administered by a physician with experience in the recognition and management of severe allergic conditions.
Needle Tips, Vaccinate Adults – October 2014, IAC Express - Issue 1153
A study has now been published (N Engl J Med 2014; 371:635–45) that found that the injectable vaccine Fluzone High-Dose (Sanofi) protects people 65 years and older better than standard-dose Fluzone. Does ACIP preferentially recommend use of Fluzone High-Dose for all people age 65 years and older?
Despite published evidence of better protection from Fluzone High-Dose when compared to standard-dose Fluzone, ACIP has not stated a preference for this vaccine for people age 65 years and older.
Needle Tips, Vaccinate Adults – October 2014, IAC Express - Issue 1153
I have a 24-year-old patient who received influenza vaccine in Colombia, South America, on June 19, 2014. Does he need to get another influenza vaccine during the current U.S. influenza season?
Yes. The person should be revaccinated with the 2014–15 U.S. vaccine, even though the strains in the U.S. vaccine are the same as the 2014 Southern hemisphere vaccine. Vaccination again with the current vaccine will help assure protection through the influenza season into next spring.
Question of the Week: IAC Express - Issue 1146
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MMR Back to top
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
In regard to the current measles outbreak, some people are saying that children who have not had the vaccine should pose no threat to vaccinated people. It is my understanding that during an outbreak, vaccinated people can still contract it. Am I correct?
You are correct that vaccinated people can still be infected with infections against which they are vaccinated. No vaccine is 100% effective. Vaccine effectiveness varies from greater than 95% (for diseases such as measles, rubella, hepatitis B) to much lower (influenza this year 23%, and 60% in years with a good match of wild and vaccine viruses, and the acellular pertussis vaccines after 5 years or so offer only about 70% protection). Therefore, we encourage as many people as possible to be vaccinated, to avoid outbreaks, while working towards the development of better vaccines (such as for influenza and pertussis). More information is available for each vaccine and disease at www.cdc.gov/vaccines/vpd-vac/default.htm and www.immunize.org/vaccines.
Needle Tips, Vaccinate Adults – May 2015, Question of the Week: IAC Express - Issue 1178
I have a female patient who has a history of immune thrombocytopenia and had a splenectomy as treatment. This patient responded to the treatment. She is not currently on medication for this condition. How long after a splenectomy should a person wait before they get an MMR vaccination?
A history of thrombocytopenia is a precaution for MMR vaccine. If there is a risk of disease, the benefit of vaccination would outweigh the risk of vaccination, particularly since the thrombocytopenia has been treated. For more information on vaccination of persons with asplenia, see the "Question of the Week" for January 6, 2015.
Question of the Week: IAC Express - Issue 1175
What are the signs and symptoms healthcare providers should look for in diagnosing measles?
Healthcare providers should suspect measles in patients with a febrile rash illness and the clinically compatible symptoms of cough, coryza (runny nose), and/or conjunctivitis (red, watery eyes). A clinical case of measles is defined as an illness characterized by
a generalized rash lasting 3 or more days, and
a temperature of 101°F or higher (38.3°C or higher), and
cough, coryza, and/or conjunctivitis.
Koplik spots, a rash present on mucous membranes, are considered pathognomonic for measles. Koplik spots occur from 1 to 2 days before the measles rash appears to 1 to 2 days afterward. They appear as punctate blue-white spots on the bright red background of the buccal mucosa (inside lining of cheek).
Providers should be especially aware of the possibility of measles in people with fever and rash who have recently traveled abroad, who have had contact with international travelers, or who have visited or had contact with someone who has visited an area affected by a measles outbreak.
Providers should immediately isolate and report suspected measles cases to their local health department and obtain specimens for measles testing, including viral specimens for confirmation and genotyping. Providers should also collect blood for serologic testing during the first clinical encounter with a person who has suspected or probable measles
Needle Tips, Vaccinate Adults - March 2015, IAC Express - Issue 1174
How long does it take to show signs of measles after being exposed?
There is an average of 10–12 days from exposure to a person infected with measles virus to the appearance of the first symptom, which is usually fever. The measles rash doesn’t usually appear until approximately 14 days after exposure, 2–4 days after the fever begins.
Needle Tips, Vaccinate Adults - March 2015, IAC Express - Issue 1174
Has ACIP made any new recommendations for use of MMR vaccine (Merck) because of the current multi-state outbreak of measles?
No. Existing recommendations for use of MMR are still applicable. The most current recommendations were published in June 2013 and are available at www.cdc.gov/mmwr/pdf/rr/rr6204.pdf.
Needle Tips, Vaccinate Adults - March 2015, IAC Express - Issue 1174
What is the earliest age at which I can give MMR to an infant who will be traveling internationally?
ACIP recommends that children who travel or live abroad should be vaccinated at an earlier age than that recommended for children who reside in the United States. Before their departure from the United States, children age 6 through 11 months should receive 1 dose of MMR. The risk for measles exposure can be high in both developed and developing countries. Consequently, CDC encourages all international travelers to be up to date on their immunizations regardless of their travel destination and to keep a copy of their immunization records with them as they travel. For additional information on the worldwide measles situation, and on CDC’s measles vaccination information for travelers, go to wwwnc.cdc.gov/travel.
Needle Tips - March 2015, IAC Express - Issue 1174
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
We have measles cases in our community. How can I best protect the young children in my practice?
First of all, make sure all your patients are fully vaccinated according to the U.S. immunization schedule.
In certain circumstances, such as for international travel, MMR is recommended for infants age 6 through 11 months. During a measles outbreak situation, consult your local or state health department to find out if measles vaccination of infants as young as age 6 months is recommended in your area as a control measure. Do not count any dose of MMR vaccine as part of the 2-dose series if it is administered before a child’s first birthday. Instead, repeat the dose when the child is age 12 months.
In the case of a local outbreak, you also might consider vaccinating children age 12 months and older at the minimum age (12 months, instead of 12–15 months) and giving the second dose 4 weeks later (at the minimum interval) instead of waiting until age 4 to 6 years.
Finally, remember that infants too young for routine vaccination and people with medical conditions that contraindicate measles immunization depend on high MMR vaccination coverage among those around them. Urge all your patients and their family members to get vaccinated if they are not immune.
Needle Tips - 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
If you can give the second dose of MMR as early as 28 days after the first dose, why do we routinely wait until kindergarten entry to give the second dose?
The second dose of MMR may be given as early as 4 weeks after the first dose, and be counted as a valid dose if both doses were given after the first birthday. The second dose is not a booster, but rather it is intended to produce immunity in the small number of people who fail to respond to the first dose. The risk of measles is higher in school-age children than those of preschool age, so it is important to receive the second dose by school entry. It is also convenient to give the second dose at this age, since the child will have an immunization visit for other school entry vaccines.
Needle Tips - 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
What is the recommendation for MMR vaccine for healthcare personnel (HCP)?
ACIP recommends that all HCP born during or after 1957 have adequate presumptive evidence of immunity to measles, mumps, and rubella, defined as documentation of two doses of measles and mumps vaccine and at least one dose of rubella vaccine, laboratory evidence of immunity, or laboratory confirmation of disease. ACIP also recommends consideration of MMR vaccination of all unvaccinated HCP who were born before 1957 and who lack laboratory evidence of measles, mumps, and/or rubella immunity or laboratory confirmation of disease.
During an outbreak of measles or mumps, 2 doses of MMR separated by at least 4 weeks should be recommended for unvaccinated HCP, regardless of birth year, who lack laboratory evidence of measles or mumps immunity or laboratory confirmation of disease. During an outbreak of rubella, 1 dose of MMR should be recommended for unvaccinated personnel, regardless of birth year, who lack laboratory evidence of rubella immunity or laboratory confirmation of infection or disease.
Needle Tips, Vaccinate Adults - 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
A patient born in 1970 has a history of measles disease and is also immunosuppressed due to multiple myeloma. The patient wants to travel to California, but is concerned about the measles outbreak. Should the patient receive the MMR vaccine?
A history of having had measles is not sufficient evidence of measles immunity. A positive serologic test for measles-specific IgG will confirm that the person is immune and is not at risk of infection regardless of the multiple myeloma. Multiple myeloma is a hematologic cancer and is considered immunosuppressive so MMR vaccine is contraindicated in this person.
Question of the Week: IAC Express - Issue 1169
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
How does being born before 1957 confer immunity to measles?
People born before 1957 lived through several years of epidemic measles before the first measles vaccine was licensed in 1963. As a result, these people are very likely to have had measles disease. Surveys suggest that 95% to 98% of those born before 1957 are immune to measles (see www.cdc.gov/vaccines/vpd-vac/measles/faqs-dis-vac-risks.htm). Persons born before 1957 can be presumed to be immune. However, if serologic testing indicates that the person is not immune, at least 1 dose of MMR should be administered. Additional information is available at www.cdc.gov/mmwr/pdf/rr/rr6204.pdf.
Question of the Week: IAC Express - Issue 1167
A 4-year-old patient came in with a rash and a low-grade fever. The first MMR dose was given 10 days ago. Her measles IgM was positive. Can the child have the disease or are the IgM results from the vaccination? After the rash resolves, how long is the patient contagious?
If there is no one else known to have measles in the community, or to have had contact with the child, the rash and positive IgM test are most likely related to the vaccination and the child is not contagious. We also recommend a viral specimen (nasopharyngeal swab) for PCR, to determine the genotype, which would be the only way to distinguish between wild-type virus and vaccine virus. If there is ANY possibility the child has been in contact with someone with measles, he/she should be isolated at home, and deemed possibly contagious until 4 days after the onset of the rash.
If you suspect measles disease for any reason, please also contact your local health department for assistance with contact tracing and disease control.
Question of the Week: IAC Express - Issue 1151
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Meningococcal Back to top
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
Does a patient living in the U.S. who has documentation of having had meningococcal vaccine at age 2 and 5 years in Saudi Arabia still need to have doses at ages 11–12 years and age 16 years or are the previous doses sufficient?
Even though Saudi Arabia uses a quadrivalent meningococcal vaccine routinely at those ages, doses given to a healthy child prior to the 10th birthday should not be counted as part of the U.S. series. The child should still receive meningococcal vaccine according to the routine U.S. schedule.
Question of the Week: IAC Express - Issue 1191
We have a 65-year-old male seeking vaccination due to international travel. Meningococcal polysaccharide vaccine (MPSV4, Menomune, Sanofi Pasteur) is unavailable, and we aren’t sure when we can get it. How should we proceed? Is this a circumstance in which a conjugate vaccine is appropriate at his age?
ACIP recommends off-label use of quadrivalent meningococcal conjugate vaccine (MCV4: Menactra, Sanofi Pasteur; Menveo, GlaxoSmithKline) in adults age 56 years and older who (1) were vaccinated previously with MCV4 and now need revaccination or (2) are recommended to receive multiple doses (e.g., adults with asplenia, microbiologists working with Neisseria meningitidis). Although MPSV4 is recommended in the situation you describe, it is acceptable to use MCV4 if MPSV4 is not available.
Needle Tips, Vaccinate Adults - May 2015
Do any of the bacterial vaccines that are recommended for people with functional or anatomic asplenia need to be given before splenectomy? Do the doses count if they are given during the 2 weeks prior to surgery?
Pneumococcal conjugate vaccine (PCV13), Haemophilus influenzae type b vaccine (Hib), and meningococcal conjugate vaccine (MCV4) should be given 14 days before splenectomy, if possible. Doses given during the 2 weeks (14 days) before surgery can be counted as valid. If the doses cannot be given prior to the splenectomy, they should be given as soon as the patient’s condition has stabilized after surgery. Pneumococcal polysaccharide vaccine (PPSV23) should be administered 8 weeks after the dose of PCV13 for people 2 years of age and older.
Needle Tips, Vaccinate Adults - May 2015, Question of the Week: IAC Express - Issue 1161
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Pertussis Back to top
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
Can we give Tdap and RhoGam (anti-Rho[D] immune globulin) at the same prenatal visit?
Tdap is an inactivated vaccine and may be given at the same prenatal visit with RhoGam. For more information on this topic, including the timing for the use of other vaccines with regards to RhoGam, see ACIP's General Recommendations on Immunization at www.cdc.gov/mmwr/pdf/rr/rr6002.pdf, page 9.
Question of the Week: IAC Express - Issue 1145
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Pneumococcal Back to top
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
We have a healthy 78-year-old female patient who received PCV13 (Prevnar13, Pfizer), then received PPSV23 (Pneumovax 23, Merck) approximately 5 weeks later. She had not received PPSV23 previously. Is the PPSV23 dose valid, or does it need to be repeated?
Answer: What to do when doses of PCV13 and PPSV23 are given without the recommended minimum interval between them isn’t spelled out in the new ACIP pneumococcal recommendations. The CDC subject matter experts have provided the following guidance: in such a case, the dose given second does not need to be repeated. This is an exception to the usual procedure for a minimum interval violation (as described in ACIP’s General Recommendations on Immunization). For your reference, the recommended interval between the dose of PCV13 and PPSV23 is 6 to 12 months and the recommended minimum interval between doses is 8 weeks.
Needle Tips, Vaccinate Adults - March 2015, IAC Express - Issue 1176
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
Rather than giving PCV13 first and waiting 8 weeks to give PPSV23 as recommended for an immunocompromised child (2 years or older) or adult patient, we inadvertently gave both vaccines at the same visit. We are looking for guidance.
Answer: Although PCV13 and PPSV23 should not be administered at the same visit, CDC does not recommend repeating either vaccine dose should this occur.
Needle Tips, Vaccinate Adults - March 2015, IAC Express - Issue 1176
Our patient is a 78-year-old female who received PCV13 (Prevnar13, Pfizer), then received PPSV23 (Pneumovax 23, Merck) approximately 10 weeks later. She had not received PPSV23 previously. Is the PPSV23 dose valid, or does it need to be repeated?
Answer: Even though the interval was shorter than the recommended 6–12 months, the dose of PPSV23 should be counted and does not need to be repeated. In the future, please note the ACIP recommendations for pneumococcal vaccine-naive patients age 65 and older are as follows: The dose of PPSV23 should be given 6–12 months after a dose of PCV13. If PPSV23 cannot be given during this time window, the dose of PPSV23 should be given during the next visit. The two vaccines should not be coadministered, and the minimum acceptable interval between PCV13 and PPSV23 is 8 weeks. For more information, see ACIP recommendations: Use of 13-Valent Pneumococcal Conjugate Vaccine and 23-Valent Pneumococcal Polysaccharide Vaccine Among Adults Aged ≥65 Years.
Question of the Week: IAC Express - Issue 1165
Do any of the bacterial vaccines that are recommended for people with functional or anatomic asplenia need to be given before splenectomy? Do the doses count if they are given during the 2 weeks prior to surgery?
Pneumococcal conjugate vaccine (PCV13), Haemophilus influenzae type b vaccine (Hib), and meningococcal conjugate vaccine (MCV4) should be given 14 days before splenectomy, if possible. Doses given during the 2 weeks (14 days) before surgery can be counted as valid. If the doses cannot be given prior to the splenectomy, they should be given as soon as the patient’s condition has stabilized after surgery. Pneumococcal polysaccharide vaccine (PPSV23) should be administered 8 weeks after the dose of PCV13 for people 2 years of age and older.
Question of the Week: IAC Express - Issue 1161
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
Please describe the new ACIP recommendations for the use of PCV13 vaccine along with PPSV23 vaccine in people age 65 years and older. Can we give both vaccines at the same visit?
According to the ACIP recommendations published in September 2014, both pneumococcal conjugate vaccine (PCV13, Prevnar 13, Pfizer) and pneumococcal polysaccharide vaccine (PPSV23, Pneumovax, Merck) should be administered routinely in a series to all adults age 65 years and older. The two vaccines should not be given at the same visit.
Pneumococcal vaccine-naïve persons: Adults age 65 years and older who have not previously received pneumococcal vaccine or whose previous vaccination history is unknown should receive a dose of PCV13 first, followed by a dose of PPSV23 6–12 months later. If PPSV23 cannot be administered during this time window, the PPSV23 dose should be given at the next visit. The two pneumococcal vaccines should not be co-administered.
If the doses of PCV13 and PPSV23 are administered at an interval less than 6–12 months apart (sooner than recommended), the minimum acceptable interval between the two doses is 8 weeks (which means that PPSV23 must be repeated if given earlier than this).
Previous vaccination with PPSV23: Adults age 65 years and older who have previously received one or more doses of PPSV23 also should receive a dose of PCV13 if they have not yet received it. A dose of PCV13 should be given at least 1 year after receipt of the most recent PPSV23 dose. For those in whom an additional dose of PPSV23 is indicated, this subsequent PPSV23 dose should be given 6–12 months after PCV13 and at least 5 years after the most recent dose of PPSV23.
Needle Tips, Vaccinate Adults - October 2014, IAC Express - Issue 1153
>> view all pneumococcal Q&As
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Polio Back to top
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
Please describe the new CDC interim recommendations for polio vaccination for infants, children, and adults traveling to and from countries affected by wild polio.
In the U.S., all infants and children should receive 4 doses of inactivated poliovirus vaccine (IPV, Sanofi) at ages 2, 4, and 6–18 months, and 4–6 years. The final dose should be administered at age 4 years or older, regardless of the number of previous doses, and should be given 6 months or more after the previous dose. A fourth dose in the routine IPV series is not necessary if the third dose was given at age 4 years or older and 6 months or more after the previous dose. Infants and children traveling to areas where there has been wild poliovirus circulation in the last 12 months should be vaccinated according to the routine schedule. If the routine series cannot be administered within the recommended intervals before protection is needed, an accelerated schedule can be used as follows: 1) the first dose should be given to infants age 6 weeks and older, 2) the second and third doses should be administered at 4 weeks or more after the previous doses, and 3) the minimum interval between the third and fourth doses is 6 months.
If the age-appropriate series is not completed before departure, the remaining IPV doses to complete a full series should be administered when feasible, at the intervals recommended for the accelerated schedule. If doses are needed while residing in the affected country, the polio vaccine that is available (IPV or oral polio vaccine [OPV]) may be administered. See the MMWR article titled "Interim CDC Guidance for Polio Vaccination for Travel to and from Countries Affected by Wild Poliovirus" available at www.cdc.gov/mmwr/pdf/wk/mm6327.pdf, pages 591–4.
For adults who were routinely vaccinated as children, CDC states those adults are considered to have lifelong immunity to poliovirus, but data are lacking. As a precaution, people age 18 years and older who are traveling to areas where there has been wild poliovirus circulation in the last 12 months and who have received a routine series with either IPV or OPV in childhood should receive another dose of IPV before departure. For these adults, available data do not indicate the need for more than a single lifetime booster dose with IPV.
For detailed information about how to protect adults who are unvaccinated, incompletely vaccinated, or whose vaccination status is unknown, refer to the CDC guidance document cited above.
Ten countries (Afghanistan, Cameroon, Equatorial Guinea, Ethiopia, Iraq, Israel, Nigeria, Pakistan, Somalia, and Syria) are currently considered polio-infected. For more information for clinicians, visit CDC's Travel website at wwwnc.cdc.gov/travel/news-announcements/polio-guidance-new-requirements.
Needle Tips, Vaccinate Adults - October 2014, IAC Express - Issue 1153
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
>> view all polio Q&As
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Precautions and Contraindications Back to top
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
A patient born in 1970 has a history of measles disease and is also immunosuppressed due to multiple myeloma. The patient wants to travel to California, but is concerned about the measles outbreak. Should the patient receive the MMR vaccine?
A history of having had measles is not sufficient evidence of measles immunity. A positive serologic test for measles-specific IgG will confirm that the person is immune and is not at risk of infection regardless of the multiple myeloma. Multiple myeloma is a hematologic cancer and is considered immunosuppressive so MMR vaccine is contraindicated in this person.
Question of the Week: IAC Express - Issue 1169
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
If a patient has had an anaphylactic reaction to a bee sting, is it safe for her to receive injected vaccines?
Yes. Allergy to bee venom is not a contraindication for any vaccine.
Needle Tips, Vaccinate Adults - October 2014, IAC Express - Issue 1153
Can we give Tdap and RhoGam (anti-Rho[D] immune globulin) at the same prenatal visit?
Tdap is an inactivated vaccine and may be given at the same prenatal visit with RhoGam. For more information on this topic, including the timing for the use of other vaccines with regards to RhoGam, see ACIP's General Recommendations on Immunization at www.cdc.gov/mmwr/pdf/rr/rr6002.pdf, page 9.
Question of the Week: IAC Express - Issue 1145
Can someone with hepatitis C receive zoster vaccine? The prescribing information indicates persons with immunosuppression should not get the vaccine, including people with HIV/AIDS, but hepatitis C is not specifically mentioned.
Hepatitis C infection is not a contraindication for zoster vaccine. However, if someone with hepatitis C is receiving a medication that can cause immunosuppression, they should consult with their healthcare provider and consider delaying vaccination until they have completed treatment.
Question of the Week: IAC Express - Issue 1141
>> view all precautions and contraindications Q&As
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Scheduling Vaccines Back to top
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
The Catch-Up Immunization Scheduler on the CDC Vaccines and Immunization website is not working. Can you please fix it? We use it to make schedules for Head Start children who are behind schedule.
The child immunization scheduler tool is no longer available. Please use your state or local immunization information system (IIS) for this service. If you are not familiar with your state or local IIS, you can find your state or local immunization program online where you can access your IIS or contact the program for assistance.
Question of the Week: IAC Express - Issue 1166
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
>> view all scheduling vaccines Q&As
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Storage and Handling Back to top
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
>> view all storage and handling Q&As
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Tetanus Vaccine Back to top
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
Can we give Tdap and RhoGam (anti-Rho[D] immune globulin) at the same prenatal visit?
Tdap is an inactivated vaccine and may be given at the same prenatal visit with RhoGam. For more information on this topic, including the timing for the use of other vaccines with regards to RhoGam, see ACIP's General Recommendations on Immunization at www.cdc.gov/mmwr/pdf/rr/rr6002.pdf, page 9.
Question of the Week: IAC Express - Issue 1145
>> view all tetanus Q&As
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Vaccine Recommendations Back to top
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
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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Zoster (shingles) Back to top
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
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 2012 edition of the Red Book.
Question of the Week: IAC Express - Issue 1171
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
Is a history of genital herpes a contraindication or precaution to zoster vaccination?
No. There is no evidence that zoster vaccine has any effect on herpes simplex virus.
Needle Tips, Vaccinate Adults - October 2014, IAC Express - Issue 1153
Can someone with hepatitis C receive zoster vaccine? The prescribing information indicates persons with immunosuppression should not get the vaccine, including people with HIV/AIDS, but hepatitis C is not specifically mentioned.
Hepatitis C infection is not a contraindication for zoster vaccine. However, if someone with hepatitis C is receiving a medication that can cause immunosuppression, they should consult with their healthcare provider and consider delaying vaccination until they have completed treatment.
Question of the Week - IAC Express Issue 1141
>> view all zoster Q&As
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