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Immunization Action Coalition
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What's New

Ask the Experts - What's New

Featured in Recent Publications

Administering Vaccines
Billing and Reimbursement
Combination Vaccines
Chickenpox (varicella)
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
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 - October 2014
I have a 2-month-old child with a cast for hip dysplasia that completely covers the entire anterolateral thigh on both legs. She is not due to have it removed for 10 weeks. What options do we have for her injectable vaccines?
Ideally, you can arrange to have the cast cut to administer vaccines in the anterolateral thighs. If that option is not available, the gluteal region can be used if not covered by the cast. There are no other sites we recommend for vaccination; however, the inactivated polio vaccine could be given subcutaneously in either arm, if the child is large enough. Rotavirus vaccine is given orally and should be administered. If vaccines cannot be given for the 10 weeks, please advise the family to keep people with any illness away from the child until she has been vaccinated. For more information, see ACIP's General Recommendations on Immunization at www.cdc.gov/mmwr/pdf/rr/rr6002.pdf, page 14–16.
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
Does ACIP recommend giving varicella vaccine to infants before age 1 year if they are traveling internationally?
No. ACIP recommends giving a dose of MMR to infants age 6 through 11 months before international travel, but not varicella vaccine. Varicella vaccine is neither approved nor recommended for children younger than age 12 months in any situation.
Needle Tips - July 2014, IAC Express Issue 1131
If a 5-year-old child has never received any doses of MMR or varicella vaccine and now the parents want him to catch up with the combination vaccine MMRV (ProQuad; Merck), what is the spacing requirement between the two doses?
Twelve weeks. The spacing between doses of a combination vaccine depends on the longest minimum interval of a component. The minimum interval between doses of MMR is 4 weeks; the minimum interval between doses of varicella vaccine is 12 weeks for a child this age. So you should wait 12 weeks between the doses of MMRV for the two doses to be valid.
Needle Tips - March 2014, IAC Express Issue 1115
MMRV was mistakenly given to a 31-year-old instead of MMR. Can this be considered a valid dose?
Yes, however, this issue is not addressed in the 2010 MMRV ACIP recommendations. Although this is off-label use, CDC recommends that when a dose of MMRV is inadvertently given to a patient age 13 years and older, it may be counted towards completion of the MMR and varicella vaccine series and does not need to be repeated.
Needle Tips, Vaccinate Adults - March 2014, IAC Express Issue 1115
>> view all chickenpox (varicella) Q&As
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Diphtheria Vaccine Back to top
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
We see many 10-year-olds for middle school entry immunization. Is one brand of Tdap preferred for this age group?
No. In March 2014, FDA lowered the age indication for Adacel brand Tdap vaccine (sanofi) from age 11 years to age 10 years. Both Tdap products, Adacel and Boostrix (GSK), now have the same lower age indication.
Needle Tips - July 2014, IAC Express Issue 1131
Is it acceptable to give breastfeeding mothers Tdap vaccine?
Yes. Women who have never received Tdap and who did not receive it during pregnancy should receive it immediately postpartum or as soon as possible thereafter. Breastfeeding does not decrease the immune response to routine childhood vaccines and is not a contraindication for any vaccine except smallpox. Breastfeeding is a precaution for yellow fever vaccine and the vaccine can be given for travel when indicated.
Needle Tips, Vaccinate Adults - July 2014
A 17-year-old received a dose of Tdap vaccine when she was 12 years old. She is now pregnant. Should she get another dose of Tdap vaccine?
Yes. ACIP recommends a dose of Tdap during each pregnancy irrespective of the patient's prior history of receiving Tdap. To maximize the maternal antibody response and passive antibody transfer to the infant, optimal timing for Tdap administration is between 27 and 36 weeks gestation. For more information, see www.cdc.gov/mmwr/pdf/wk/mm6207.pdf, page 131.
Needle Tips, Vaccinate Adults - March 2014, IAC Express Issue 1115
If Kinrix (DTaP-IPV; GSK) 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?
No, as long as minimum intervals between previous doses have been met. Kinrix is licensed and recommended only for children age 4 through 6 years. You should take measures to prevent this vaccine administration error in the future. However, you can count this as a valid dose for both 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).
Needle Tips - March 2014, IAC Express Issue 1115
>> view all diphtheria Q&As
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Documenting Vaccinations Back to top
What do we legally need to record when giving an immunization to a patient?
It is important to know the federal requirements for documenting the vaccines administered to your patients. The requirements are defined in the National Childhood Vaccine Injury Act enacted in 1986. The law applies to all routinely recommended childhood vaccines, regardless of the age of the patient receiving the vaccines. The only vaccines not included in this law are pneumococcal polysaccharide, zoster, and certain infrequently used vaccines, such as rabies and Japanese encephalitis.
The following information must be documented on the patient's paper or electronic medical record or on a permanent office log:
1. The vaccine manufacturer.
2. The lot number of the vaccine.
3. The date the vaccine is administered.
4. The name, office address, and title of the healthcare provider administering the vaccine. [Editor's Note: On July 31, 2104, IAC corrected an error in this statement of the "Ask the Experts" answer, which had previously stated that a "signature (electronic is acceptable) of the person administering the vaccine. Initials of the vaccine administrator ..." was required by federal law.]
5. The Vaccine Information Statement (VIS) edition date located in the lower right corner on the back of the VIS. When administering combination vaccines, all applicable VISs should be given and the individual VIS edition dates recorded.
6. The date the VIS is given to the patient, parent, or guardian.
The federally required information should be both permanent and accessible.
Federal law does not require a parent, patient, or guardian to sign a consent form in order to receive a vaccination; providing them with the appropriate VIS(s) and answering their questions is sufficient under federal law.
Needle Tips, Vaccinate Adults - July 2014, IAC Express Issue 1131
In updating immunizations for immigration ("green card") exams, I regularly come across intervals between catch-up vaccine doses that are shorter than ACIP recommendations—most often the last 2 doses of IPV are given less than 6 months apart, but also sometimes the 2 doses of varicella are given less than 3 months apart, and the next-to-last and last Td are given less than 6 months apart. How significant is this in terms of immunity?
The significance of non-standard intervals probably depends on the vaccine and the dose. This is a complex issue—studies have not been done to examine the effect of various intervals between doses on the immunogenicity of those doses. But ACIP has examined the available data and made recommendations about the minimum acceptable interval between doses for that dose to be considered valid (there is no maximum interval between doses). These minimum intervals are published as Table 1 in ACIP's General Recommendations on Immunization, available at www.cdc.gov/mmwr/pdf/rr/rr6002.pdf, pages 36–37. Doses with a minimum interval less than the recommended minimum, as described in Table 1, should not be counted as valid. More details on this topic can be found in the General Recommendations.
Needle Tips, Vaccinate Adults - July 2014
>> view all documenting vaccinations Q&As
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Hib Vaccine Back to top
Should adult patients who are not asplenic but who have hypogammaglobulinemia receive Haemophilus influenzae type b (Hib) conjugate vaccine? The February 2014 Hib ACIP statement includes immunoglobulin deficiency in its "high-risk groups" for Hib disease, but the recommendations seem to imply that Hib vaccine is not necessarily for adults with immunoglobulin deficiency whose spleens are intact. Am I interpreting ACIP correctly on this matter?
You are interpreting the recommendations correctly, and age is an important factor in this issue. The recommendation for Hib vaccination for asplenia applies to persons of all ages. The recommendation for Hib vaccination for immunoglobulin deficiency applies only to children 12 through 59 months of age.
Question of the Week - IAC Express Issue 1130
>> 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 - October 2014
Many travelers do not return for their second dose of hepatitis A vaccine and present years later, about to travel again. Is there a maximum interval between the first and second doses of hepatitis A vaccine? Should the series be restarted if it has been 5 or more years since the first dose?
No. There is no maximum interval between doses of hepatitis A vaccine. An interruption in the vaccination schedule does not require restarting the entire series of any other vaccine or toxoid or addition of extra doses, with the exception of oral typhoid vaccine. See the ACIP's "General Recommendations on Immunization" at www.cdc.gov/mmwr/pdf/rr/rr6002.pdf, page 10.
Question of the Week - IAC Express Issue 1129
>> view all hepatitis A Q&As
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Hepatitis B Vaccine Back to top
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
In December 2013, CDC released a new document titled CDC Guidance for Evaluating Health-Care Personnel for Hepatitis B Virus Protection and for Administering Postexposure Management (MMWR2013;62[RR-10]) available at www.cdc.gov/mmwr/pdf/rr/rr6210.pdf. Does the content of this document update ACIP recommendations on healthcare personnel vaccination and hepatitis B?
The new guidance published by CDC does not constitute new recommendations of ACIP. The CDC guidance was created based on the opinions of an expert panel convened by CDC. According to the document, the guidance from CDC "augments the 2011 recommendations" of the ACIP document titled Immunization of Health-Care Personnel published November 25, 2011 (www.cdc.gov/mmwr/pdf/rr/rr6007.pdf), for evaluating hepatitis B protection among healthcare personnel and administering postexposure prophylaxis.
Needle Tips, Vaccinate Adults - July 2014, IAC Express Issue 1134
Does CDC now recommend routine pre-exposure anti-HBs testing of all healthcare personnel who were previously vaccinated?
In general, no, but the type of testing (pre-exposure or postexposure) depends on the healthcare worker's profession and work setting. An expert panel convened by CDC acknowledged that the risk for hepatitis B virus (HBV) infection for vaccinated healthcare personnel (HCP) can vary widely by setting and profession. The risk might be low enough in certain settings that assessment of hepatitis B surface antibody (anti-HBs) status and appropriate follow-up can be done at the time of exposure to potentially infectious blood or body fluids. This approach relies on HCP recognizing and reporting blood and body fluid exposures and might be applied on the basis of documented low risk, implementation, and cost considerations. Trainees, some occupations (such as those with frequent exposure to sharp instruments and blood), and HCP practicing in certain populations are at greater risk of exposure to blood or body fluid exposure from an HBsAg-positive patient. Vaccinated HCP in these settings/occupations would benefit from a pre-exposure approach. Figure 6 on page 13 of the guidance document provides an algorithm for settings where the choice is to use a pre-exposure approach. Table 2, found on page 14 of the document, provides the algorithm when postexposure management is implemented. The document, tables, and figures are available at www.cdc.gov/mmwr/pdf/rr/rr6210.pdf.
Needle Tips, Vaccinate Adults - July 2014, IAC Express Issue 1134
If an employee receives both HBIG and hepatitis B vaccine after a needlestick from a patient who is HBsAg positive, how long should one wait to check the employee's response to the vaccine?
Anti-HBs testing for HCP who receive both hepatitis B immune globulin (HBIG) and hepatitis B vaccine can be conducted as soon as 4 months after receipt of the HBIG. However, a new recommendation in the 2013 document is to test for hepatitis B core antibody (anti-HBc) and hepatitis B surface antigen (HBsAg) among certain HCP (those previously unvaccinated, incompletely vaccinated, or revaccinated) with an exposure from an HBsAg-positive or unknown HBsAg-status patient at the time of the exposure and approximately 6 months after the exposure (that is, after the HBV incubation period). The CDC expert panel determined that it would be more efficient to do all the follow-up testing at one time, and recommended testing at 6 months after the exposure. Anti-HBs could be measured at a minimum of 4 months after the administration of HBIG, but testing for infection would then follow approximately 2 months later.
Needle Tips, Vaccinate Adults - July 2014, IAC Express Issue 1134
At our facility we do routine pre-employment anti-HBs testing regardless of whether the employee has documentation of a hepatitis B vaccination series and consider those who are anti-HBs positive to be immune. Is this the recommended strategy?
No. HCP with written documentation of receipt of a properly spaced 3-dose series of hepatitis B vaccine AND a positive anti-HBs can be considered immune to HBV and require no further testing or vaccination. Testing unvaccinated or incompletely vaccinated HCP (including those without written documentation of vaccination) is not necessary and is potentially misleading because anti-HBs of 10 mIU/mL or higher as a correlate of vaccine-induced protection has only been determined for persons who have completed a hepatitis B vaccination series. Persons who cannot provide written documentation of a complete hepatitis B vaccination series should complete the 3-dose series, then be tested for anti-HBs 1 to 2 months after the final dose.
Needle Tips, Vaccinate Adults - July 2014, IAC Express Issue 1134
Does CDC still recommend routine anti-HBs testing of HCP who are at risk for occupational blood or body fluid exposure following the hepatitis B vaccination series?
Yes. This recommendation has not changed.
Needle Tips, Vaccinate Adults - July 2014, IAC Express Issue 1134
Is there now a recommendation for a routine booster dose of hepatitis B vaccine?
No. HCP who have documentation of receiving a 3-dose series of hepatitis B vaccine and who tested positive for anti-HBs (defined as anti-HBs of 10 mIU/mL or higher) are considered to be immune to hepatitis B. Immunocompetent persons have long-term protection against HBV and do not need further testing or vaccine doses. Some immunodeficient persons (including those on hemodialysis) may need periodic booster doses of hepatitis B vaccine, as described in the 2006 adult hepatitis B vaccine ACIP recommendations (MMWR2006;55[RR-16]:26–9 www.cdc.gov/mmwr/pdf/rr/rr5516.pdf). These recommendations have not changed.
Needle Tips, Vaccinate Adults - July 2014, IAC Express Issue 1134
Does CDC now recommend restarting the hepatitis B vaccine series in the event the series is interrupted?
No. This recommendation has not changed. The series should not be restarted. Simply continue from where you left off.
Needle Tips, Vaccinate Adults - July 2014, IAC Express Issue 1134
On December 20, 2013, CDC published a new guidance document titled "CDC Guidance for Evaluating Health-Care Personnel for Hepatitis B Virus Protection and for Administering Postexposure Management" (MMWR 2013;62[RR-10]). What is new in this document?
The document provides a comprehensive review of the epidemiology of hepatitis B virus (HBV) infection among healthcare personnel (HCP), updated information about the persistence of anti-HBs antibody following vaccination and the duration of vaccine-induced protection, and new information about HCP serologic testing and postexposure prophylaxis. The document, available at www.cdc.gov/mmwr/pdf/rr/rr6210.pdf, updates recommendations made in the 2011 Immunization of Health-Care Personnel recommendations (MMWR 2011;60[RR-7] available at www.cdc.gov/mmwr/pdf/rr/rr6007.pdf ) and the 2006 adult hepatitis B vaccine ACIP recommendations (MMWR 2006;55[RR-16] available at www.cdc.gov/mmwr/PDF/rr/rr5516.pdf).
An important new recommendation is for the management of HCP who have written documentation of a complete series of hepatitis B vaccine doses in the past (including those vaccinated as infants, children, and adolescents) who were not tested for antibody response following the vaccination series and who now test negative for antibody to hepatitis B surface antigen (anti-HBs) defined as anti-HBs less than 10 mIU/mL. It is now recommended to administer 1 dose of hepatitis B vaccine to these individuals and then test for anti-HBs 1 to 2 months later. Those who test positive after the single "booster" dose are considered to be immune and no further testing or vaccination is needed. Those who test negative after the "booster" dose should receive 2 additional doses to complete a second 3-dose series. Anti-HBs testing should be repeated 1 to 2 months after completion of the second vaccination series. An algorithm is provided on page 13 of the new guidance document to assist clinicians with this process.
Another new recommendation in the guidance concerns the management of HCP who need post-exposure prophylaxis. In the section titled "Post Exposure Management" on page 12, the document provides detailed recommendations for more combinations of HCP vaccination/serologic status and source patient status than in previous recommendations. A revised postexposure management table is included in the document on page 14. One of the changes is a recommendation that when the hepatitis B surface antigen (HBsAg) status of the source patient is unknown (for example, as might occur from a puncture wound from a needle in the trash), the exposed unvaccinated or incompletely vaccinated HCP should be managed as if the source patient were HBsAg positive. In these situations, the new recommendation is to include a dose of hepatitis B immune globulin (HBIG) in addition to starting or completing the vaccination series for all exposures where the HBsAg status of the source is unknown.
Needle Tips, Vaccinate Adults - March 2014, IAC Express Issue 1115
>> view all hepatitis B Q&As
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HPV Back to top
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
 
Can human papillomavirus (HPV) be transmitted by non-sexual transmission routes, such as clothing, undergarments, sex toys, or surfaces?
Nonsexual HPV transmission is theoretically possible but has not been definitely demonstrated. This is mainly because HPV can't be cultured and DNA detection from the environment is difficult and likely prone to false negative results.
Needle Tips, Vaccinate Adults - July 2014, IAC Express Issue 1131
 
I read that HPV vaccination rates are still low. What can we do as providers to improve these rates?
Results from the Centers for Disease Control and Prevention's 2012 National Immunization Survey-Teen (NIS-Teen) indicate that HPV vaccination rates in girls age 13 through 17 years failed to increase between 2011 and 2012, and the 3-dose coverage rate actually declined slightly during this period. Just over half of the girls age 13 through 17 years had started the series that they should have completed by age 13 years. Only about one-third of girls this age had completed the series. In 2012, the first year HPV vaccine was routinely recommended for boys, 20.8% of boys age 13 through 17 years had received one dose and only 6.8% had received all three recommended doses. A summary of the 2012 NIS-Teen survey is available at www.cdc.gov/mmwr/pdf/wk/mm6234.pdf, page 685.
Providers can improve uptake of this life-saving vaccine in two main ways. First, studies have shown that missed opportunities are a big problem. Eighty-four percent 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 nearly 93% instead of 54%.
Second, the 2012 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 daughters.
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 - March 2014, IAC Express Issue 1115
>> view all HPV Q&As
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Influenza Back to top
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
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
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
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 – October 2014
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 – October 2014
I have a 24-year-old patient who received influenza vaccine in Colombia, South America, on June 19, 2014. Does he need to get another influenza vaccine during the current U.S. influenza season?
Yes. The person should be revaccinated with the 2014–15 U.S. vaccine, even though the strains in the U.S. vaccine are the same as the 2014 Southern hemisphere vaccine. Vaccination again with the current vaccine will help assure protection through the influenza season into next spring.
Question of the Week - IAC Express Issue 1146
May Fluzone High-Dose (sanofi) be administered to patients younger than age 65 years?
No. Fluzone High-Dose is licensed only for persons age 65 years and older and is not recommended for younger people. See MMWR, April 30, 2010, available at www.cdc.gov/mmwr/preview/mmwrhtml/mm5916a2.htm for details about the licensure of this vaccine.
Needle Tips, Vaccinate Adults - March 2014, IAC Express Issue 1115
>> view all influenza Q&As
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MMR Back to top
Many people age 60 years and older do not have records indicating what type of measles vaccine they received as children in the early 1960s. What measles vaccine was most frequently given in that time period? That guidance would assist many older people who would prefer not to be revaccinated.
Both killed and live attenuated measles vaccines became available in 1963. Live attenuated vaccine was used more often than killed vaccine. The killed vaccine was found to be not effective and people who received it should be revaccinated with live vaccine. Without a written record, it is not possible to know what type of vaccine an individual may have received. So persons born during or after 1957 who received killed measles vaccine or measles vaccine of unknown type, or who cannot document having been vaccinated or having laboratory-confirmed measles disease should receive at least 1 dose of MMR. Some people at increased risk of exposure to measles (such as healthcare professionals and international travelers) should receive 2 doses of MMR separated by at least 4 weeks.
Needle Tips, Vaccinate Adults - July 2014, IAC Express Issue 1131
Is there any harm in giving an extra dose of MMR to a child of age seven years whose record is lost and the mother is not sure about the last dose of MMR?
In general, although it is not ideal, receiving extra doses of vaccine poses no medical problem. Receiving excessive doses of tetanus toxoid (e.g., DTP, DTaP, DT, Tdap, or Td) can increase the risk of a local adverse reaction, however. For details, consult the ACIP's General Recommendations on Immunization at www.cdc.gov/mmwr/pdf/rr/rr6002.pdf, page 8.
Vaccination providers frequently encounter people who do not have adequate documentation of vaccinations. Providers should only accept written, dated records as evidence of vaccination. With the exception of influenza vaccine and pneumococcal polysaccharide vaccine, self-reported doses of vaccine without written documentation should not be accepted. An attempt to locate missing records should be made whenever possible by contacting previous healthcare providers, reviewing state or local immunization information systems, and searching for a personally held record.
If records cannot be located or will definitely not be available anywhere because of the patient's circumstances, children without adequate documentation should be considered susceptible and should receive age-appropriate vaccination. Serologic testing for immunity is an alternative to vaccination for certain antigens (e.g., measles, rubella, hepatitis A, diphtheria, and tetanus).
Question of the Week - IAC Express Issue 1127
If a woman's rubella test result shows she is "not immune" during a prenatal visit but she has 2 documented doses of MMR vaccine, does she need a third dose of MMR vaccine postpartum?
In 2013 ACIP changed its recommendation for this situation. It is now recommended that women of childbearing age who have received 1 or 2 doses of rubella-containing vaccine and have rubella serum IgG levels that are not clearly positive should be administered 1 additional dose of MMR vaccine (maximum of 3 doses) and do not need to be retested for serologic evidence of rubella immunity. This is the only situation where ACIP recommends a third dose of MMR vaccine. MMR should not be administered to a pregnant woman.
Question of the Week - IAC Express Issue 1122
Would you consider a healthcare provider with 2 documented doses of MMR vaccine (Merck) to be immune even if their serology for 1 or more of the antigens comes back negative?
Yes. Healthcare personnel (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. For more information, see ACIP's recommendations on the use of MMR at www.cdc.gov/mmwr/pdf/rr/rr6204.pdf, page 22.
Needle Tips, Vaccinate Adults - March 2014, IAC Express Issue 1115
I have patients who claim to 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 valid. You should only accept a written, dated record as evidence of vaccination.
Needle Tips, Vaccinate Adults - March 2014, IAC Express Issue 1115
We have adult patients in our practice at high risk for measles, including patients going back to college or preparing for international travel, who don't remember ever 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 one or more of the vaccine components, give your patient 2 doses of MMR at least 4 weeks apart. 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 2014, IAC Express Issue 1115
I have a 45-year-old patient who is traveling to Jordan to work with Syrian refugees. She doesn't recall ever getting a second dose of MMR (she didn't go to college and never worked in healthcare). She was rubella immune when pregnant 20 years ago. Her measles titer is negative. Would you recommend a second dose of MMR vaccine?
Yes. ACIP recommends 2 doses of MMR given at least 4 weeks apart for any adult born in 1957 or later who plans to travel internationally. There is no harm in giving MMR vaccine to a person who may already be immune to one or more of the vaccine viruses.
Needle Tips, Vaccinate Adults - March 2014, IAC Express Issue 1115
If a 5-year-old child has never received any doses of MMR or varicella vaccine and now the parents want him to catch up with the combination vaccine MMRV (ProQuad; Merck), what is the spacing requirement between the two doses?
Twelve weeks. The spacing between doses of a combination vaccine depends on the longest minimum interval of a component. The minimum interval between doses of MMR is 4 weeks; the minimum interval between doses of varicella vaccine is 12 weeks for a child this age. So you should wait 12 weeks between the doses of MMRV for the two doses to be valid.
Needle Tips - March 2014
MMRV was mistakenly given to a 31-year-old instead of MMR. Can this be considered a valid dose?
Yes, however, this issue is not addressed in the 2010 MMRV ACIP recommendations. Although this is off-label use, CDC recommends that when a dose of MMRV is inadvertently given to a patient age 13 years and older, it may be counted towards completion of the MMR and varicella vaccine series and does not need to be repeated.
Needle Tips, Vaccinate Adults - March 2014, IAC Express Issue 1115
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Meningococcal Back to top
We have a 10-year-old getting renal dialysis. The nephrologist will be starting her on a monoclonal antibody that interferes with C5 complement. If we administer a MCV4 and a PPSV23 now, and then give her a PCV13 in 8 weeks, will the PCV13 interfere with the efficacy of the PPSV23 or the MCV4?
Recommendations to separate MCV4 and PCV13 only apply to persons with functional or anatomic asplenia. So the best schedule is to give MCV4 (either MCV4-D or MCV4-CRM) simultaneously with PCV13, and then PPSV23 in eight weeks. ACIP recommends giving PCV13 before PPSV23 in order to maximize the immune response from PCV13. PPSV23 blunts the immune response to PCV13 if PCV13 is given after PPSV23, although in children there is a smaller effect than in adults.
Question of the Week - IAC Express Issue 1135
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Pertussis Back to top
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
We see many 10-year-olds for middle school entry immunization. Is one brand of Tdap preferred for this age group?
No. In March 2014, FDA lowered the age indication for Adacel brand Tdap vaccine (sanofi) from age 11 years to age 10 years. Both Tdap products, Adacel and Boostrix (GSK), now have the same lower age indication.
Needle Tips - July 2014
Is it acceptable to give breastfeeding mothers Tdap vaccine?
Yes. Women who have never received Tdap and who did not receive it during pregnancy should receive it immediately postpartum or as soon as possible thereafter. Breastfeeding does not decrease the immune response to routine childhood vaccines and is not a contraindication for any vaccine except smallpox. Breastfeeding is a precaution for yellow fever vaccine and the vaccine can be given for travel when indicated.
Needle Tips, Vaccinate Adults - July 2014, IAC Express Issue 1131
A 17-year-old received a dose of Tdap vaccine when she was 12 years old. She is now pregnant. Should she get another dose of Tdap vaccine?
Yes. ACIP recommends a dose of Tdap during each pregnancy irrespective of the patient's prior history of receiving Tdap. To maximize the maternal antibody response and passive antibody transfer to the infant, optimal timing for Tdap administration is between 27 and 36 weeks gestation. For more information, see www.cdc.gov/mmwr/pdf/wk/mm6207.pdf, page 131.
Needle Tips, Vaccinate Adults - March 2014, IAC Express Issue 1115
If Kinrix (DTaP-IPV; GSK) 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?
No, as long as minimum intervals between previous doses have been met. Kinrix is licensed and recommended only for children age 4 through 6 years. You should take measures to prevent this vaccine administration error in the future. However, you can count this as a valid dose for both 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).
Needle Tips - March 2014
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Pneumococcal Back to top
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 - October 2014
Would you include obstructive sleep apnea as chronic pulmonary disease which would require PPSV23 vaccination once for adults under the age of 65?
Obstructive sleep apnea alone is not an indication for vaccination with PPSV23 for persons 2 through 64 years of age. People with obstructive sleep apnea often have other pulmonary conditions (such as chronic obstructive pulmonary disease) that would put them at increased risk for invasive pneumococcal disease, for which they should be vaccinated. A table listing risk conditions and pneumococcal vaccine recommendations can be found at www.immunize.org/catg.d/p2019.pdf.
Question of the Week - IAC Express Issue 1138
We have a 10-year-old getting renal dialysis. The nephrologist will be starting her on a monoclonal antibody that interferes with C5 complement. If we administer a MCV4 and a PPSV23 now, and then give her a PCV13 in 8 weeks, will the PCV13 interfere with the efficacy of the PPSV23 or the MCV4?
Recommendations to separate MCV4 and PCV13 only apply to persons with functional or anatomic asplenia. So the best schedule is to give MCV4 (either MCV4-D or MCV4-CRM) simultaneously with PCV13, and then PPSV23 in eight weeks. ACIP recommends giving PCV13 before PPSV23 in order to maximize the immune response from PCV13. PPSV23 blunts the immune response to PCV13 if PCV13 is given after PPSV23, although in children there is a smaller effect than in adults.
Question of the Week - IAC Express Issue 1135
Is pneumococcal polysaccharide vaccine (PPSV23, Pneumovax, Merck) indicated for former smokers?
PPSV23 is currently recommended for people age 19 through 64 years who actively smoke cigarettes (see www.cdc.gov/mmwr/preview/mmwrhtml/mm5934a3.htm). However, chronic lung disease is an indication for PPSV23, which could be applicable for former smokers.
Question of the Week - IAC Express Issue 1124
Is pneumococcal polysaccharide vaccine (PPSV23) contraindicated in pregnancy? Our patient has asthma and is pregnant.
No. According to the 2014 adult immunization schedule, PPSV23 is recommended in pregnancy if some other risk factor is present (e.g., on the basis of medical, occupational, lifestyle, or other indications). See footnote 9 of the 2014 adult immunization schedule at www.cdc.gov/vaccines/schedules/downloads/adult/adult-combined-schedule.pdf.
Question of the Week - IAC Express Issue 1124
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Polio Back to top
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 - October 2014
Our 23-year-old patient has been accepted to a physician assistant program that requires polio vaccine for all students. She has 2 documented doses of oral polio vaccine (OPV) as a child, then recently had a dose of inactivated polio vaccine (IPV). How many more doses of IPV does she need to complete the series and on what schedule?
People who receive a mixed series of OPV and IPV should receive a total of 4 doses. The recent dose of IPV can be counted as the third dose in the primary series. The minimum interval between the third and last doses in the polio vaccination series is 6 months. So the final dose in the series should be given 6 months after the IPV dose.
Question of the Week - IAC Express Issue 1142
We have an adult who was diagnosed with polio as a child with some residual effects. This adult will be traveling overseas and the CDC travel website recommends a dose of polio vaccine. Should he be vaccinated with polio vaccine even though he had polio in the past?
Immunity to one of the serotypes of polio does not produce significant immunity to the other serotypes. A history of having recovered from polio disease should not be considered evidence of immunity to polio. It would be appropriate to vaccinate this adult if he will be traveling to an area for which polio vaccination is recommended.
Question of the Week - IAC Express Issue 1132
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Precautions and Contraindications Back to top
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 - October 2014
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 - October 2014
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 - October 2014
Can we give Tdap and RhoGam (anti-Rho[D] immune globulin) at the same prenatal visit?
Tdap is an inactivated vaccine and may be given at the same prenatal visit with RhoGam. For more information on this topic, including the timing for the use of other vaccines with regards to RhoGam, see ACIP's General Recommendations on Immunization at www.cdc.gov/mmwr/pdf/rr/rr6002.pdf, page 9.
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
 
We have a patient with a severe allergy to vancomycin who wants to receive zoster vaccine. According to the prescribing information, an allergy to neomycin would be a contraindication to vaccination but we are not sure about allergy to vancomycin.
Vancomycin and neomycin belong to different classes of antibiotics. An allergy to vancomycin is not a contraindication to zoster vaccine.
Question of the Week - IAC Express Issue 1139
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Scheduling Vaccines Back to top
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
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
Many travelers do not return for their second dose of hepatitis A vaccine and present years later, about to travel again. Is there a maximum interval between the first and second doses of hepatitis A vaccine? Should the series be restarted if it has been 5 or more years since the first dose?
No. There is no maximum interval between doses of hepatitis A vaccine. An interruption in the vaccination schedule does not require restarting the entire series of any other vaccine or toxoid or addition of extra doses, with the exception of oral typhoid vaccine. See the ACIP's "General Recommendations on Immunization" at www.cdc.gov/mmwr/pdf/rr/rr6002.pdf, page 10.
Question of the Week - IAC Express Issue 1129
Is it standard practice to revaccinate a child who is adopted from another country?
No. According to ACIP, vaccines administered outside the U.S. generally can be accepted as valid if the schedule (i.e., minimum ages and intervals) is similar to that recommended in the U.S. However, with the exception of the influenza vaccine and PPSV23, only written documentation should be accepted as evidence of previous vaccination. In general, if records cannot be located or will definitely not be available anywhere because of the patient's circumstances, children without adequate documentation should be considered susceptible and should be started on the age-appropriate vaccination schedule. Serologic testing for immunity is an alternative to vaccination for certain antigens. More information is available in the ACIP General Recommendations on Immunization, available at www.cdc.gov/mmwr/pdf/rr/rr6002.pdf, pages 27–29.
Needle Tips - July 2014, IAC Express Issue 1131
I have a five-month-old patient who received hepatitis B vaccine at birth, at 2 months, and at 5 months of age. I realize that the third dose was given too early and so the child should be given another dose after they turn 6 months old. However, I am unclear how long I have to wait to give the fourth (repeat) dose? Is it 4 or 8 weeks?
This is addressed in the ACIP’s General Recommendations on Immunization: "Doses of any vaccine administered 5 or more days earlier than the minimum interval or age should not be counted as valid doses and should be repeated as age appropriate. The repeat dose should be spaced after the invalid dose by the recommended minimum interval” (see www.cdc.gov/mmwr/pdf/rr/rr6002.pdf, page 5 and Table 1, page 36). So in this situation you would repeat the dose 8 weeks after the invalid dose.
Question of the Week - IAC Express Issue 1128
For the purpose of vaccine spacing, what constitutes a month: 28 days (4 weeks), 30 days, or 31 days?
For intervals of 3 months or less, you should use 28 days (4 weeks) as a "month." For intervals of 4 months or longer, you should consider a month a "calendar month": the interval from one calendar date to the next a month later. This is a convention that was introduced on the childhood schedule in 2002 and discussed in the paper "Evaluation of Invalid Vaccine Doses" (Stokley S, Maurice E, Smith PJ, et al. American Journal of Preventive Medicine, 2004: 26[1]: 34–40).
Question of the Week - IAC Express Issue 1126
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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 - October 2014
If the top of a single dose vial of diluent or vaccine is popped off and not used, is there a time limit as to when it must be used? We are just discussing whether the efficacy of the vaccine will be compromised with the passing of time.
Once the protective cap has been removed from a single-dose vial, it may not be possible to determine if the rubber seal has been punctured. Therefore, unused single-dose vials without a protective cap should be discarded at the end of the workday.
Question of the Week - IAC Express Issue 1143
Can you please guide me in finding storage containers and bins for vaccines?
CDC recommends the use of bins, baskets, or some other type of uncovered containers that allow for organization and air circulation for vaccines and diluents within the storage unit. Storage in any boxes or bins can help maintain temperature longer, especially if power is lost. Perforated bins may allow for better air circulation around the vaccine, thus helping to maintain correct temperature.
CDC does not have a specific recommendation for brands of containers or bins for storage of vaccine. We recommend that you contact your state immunization program, as they may find resources for purchasing this equipment. If you are a Vaccines for Children (VFC) program provider, you should contact your immunization program to ensure that you are in compliance with VFC policy.
Question of the Week - IAC Express Issue 1133
How long do we need to keep our refrigerator/freezer temperature tracking logs?
CDC recommends that refrigerator and freezer temperature logs be kept for at least 3 years. (See www.cdc.gov/vaccines/recs/storage/toolkit/storage-handling-toolkit.pdf, page 52.) The reasoning is that it is useful to be able to look back at the record to help determine if a unit is developing a problem.
Individual state Vaccines For Children (VFC) programs may have different requirements for retaining temperature logs. You should contact your state program for this information. Contact information for state immunization programs is available at www.immunize.org/coordinators.
Needle Tips, Vaccinate Adults - July 2014, IAC Express Issue 1131
How long should we monitor the temperature in a new refrigerator before storing vaccines in it?
CDC recommends you allow one week of twice daily refrigerator and freezer temperature recordings, including minimum/maximum temperatures daily (preferably in the morning) to make sure temperatures are within the appropriate ranges before using the units to store vaccines. See CDC's “Vaccine Storage & Handling Toolkit” for useful information on vaccine storage and handling at www.cdc.gov/vaccines/recs/storage/toolkit/storage-handling-toolkit.pdf.
IAC Express Special Edition - March 2014
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Tetanus Vaccine Back to top
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
We see many 10-year-olds for middle school entry immunization. Is one brand of Tdap preferred for this age group?
No. In March 2014, FDA lowered the age indication for Adacel brand Tdap vaccine (sanofi) from age 11 years to age 10 years. Both Tdap products, Adacel and Boostrix (GSK), now have the same lower age indication.
Needle Tips - July 2014
Is it acceptable to give breastfeeding mothers Tdap vaccine?
Yes. Women who have never received Tdap and who did not receive it during pregnancy should receive it immediately postpartum or as soon as possible thereafter. Breastfeeding does not decrease the immune response to routine childhood vaccines and is not a contraindication for any vaccine except smallpox. Breastfeeding is a precaution for yellow fever vaccine and the vaccine can be given for travel when indicated.
Needle Tips, Vaccinate Adults - July 2014, IAC Express Issue 1131
A 17-year-old received a dose of Tdap vaccine when she was 12 years old. She is now pregnant. Should she get another dose of Tdap vaccine?
Yes. ACIP recommends a dose of Tdap during each pregnancy irrespective of the patient's prior history of receiving Tdap. To maximize the maternal antibody response and passive antibody transfer to the infant, optimal timing for Tdap administration is between 27 and 36 weeks gestation. For more information, see www.cdc.gov/mmwr/pdf/wk/mm6207.pdf, page 131.
Needle Tips, Vaccinate Adults - March 2014, IAC Express Issue 1115
If Kinrix (DTaP-IPV; GSK) 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?
No, as long as minimum intervals between previous doses have been met. Kinrix is licensed and recommended only for children age 4 through 6 years. You should take measures to prevent this vaccine administration error in the future. However, you can count this as a valid dose for both 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).
Needle Tips- March 2014, IAC Express Issue 1115
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Zoster (shingles) Back to top
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 - October 2014
Can someone with hepatitis C receive zoster vaccine? The prescribing information indicates persons with immunosuppression should not get the vaccine, including people with HIV/AIDS, but hepatitis C is not specifically mentioned.
Hepatitis C infection is not a contraindication for zoster vaccine. However, if someone with hepatitis C is receiving a medication that can cause immunosuppression, they should consult with their healthcare provider and consider delaying vaccination until they have completed treatment.
Question of the Week - IAC Express Issue 1141
I know that ACIP only recommends zoster vaccine for adults age 60 years and older, although it is licensed for use in those 50 years and older. If I choose to vaccinate patients age 50–59 years, are there any criteria as to which patients in this age group might benefit most from zoster vaccination?
CDC had the following to say about your question in a November 11, 2011, issue of MMWR titled "Update on Herpes Zoster Vaccine: Licensure for Persons Aged 50 Through 59 Years" (www.cdc.gov/mmwr/preview/mmwrhtml/mm6044a5.htm): "For vaccination providers who choose to use Zostavax among certain patients aged 50 through 59 years despite the absence of an ACIP recommendation, factors that might be considered include particularly poor anticipated tolerance of herpes zoster or postherpetic neuralgia symptoms (e.g., attributable to preexisting chronic pain, severe depression, or other comorbid conditions; inability to tolerate treatment medications because of hypersensitivity or interactions with other chronic medications; and occupational considerations)."
Needle Tips, Vaccinate Adults - July 2014
If a person was exposed to shingles by a spouse within the last few days, is there a recommended waiting period before the exposed person can receive zoster vaccine?
There is no waiting period in such a situation. Zoster vaccine can be given right away or at any time to any person for whom the vaccine is recommended. Shingles is not caused by exposure to another person with shingles. People with shingles can only possibly cause a susceptible person to develop varicella (chickenpox), not zoster.
IAC Express Issue 1117
If zoster vaccine that has been damaged by a temperature excursion has been inadvertently administered to a patient, when should the dose be repeated?
According to the ACIP's General Recommendations on Immunization, an invalid dose of a live attenuated vaccine (such as zoster vaccine) should be repeated no less than 4 weeks after the invalid dose. This information is located at www.cdc.gov/mmwr/pdf/rr/rr6002.pdf, pages 18–19.
IAC Express Issue 1117
A long-term care resident age 80 years who received zoster vaccine (Zostavax; Merck) several years ago recently had a mild case of shingles. Is there any recommendation for administering a second dose of vaccine in such a circumstance? Are booster doses ever recommended?
The answer to both questions is no. Zoster vaccine is not 100% effective. In the key clinical trial, overall effectiveness among people age 60 years and older was 51% and decreased with increasing age. However, the vaccine was 67% effective in preventing post-herpetic neuralgia; this effectiveness did not decrease with increasing age. The duration of protection from shingles after a dose of zoster vaccine is not known at this time. However, ACIP has not recommended a second dose for anyone. ACIP recommendations for the use of zoster vaccine are available at www.cdc.gov/mmwr/PDF/rr/rr5705.pdf.
Needle Tips, Vaccinate Adults - March 2014, IAC Express Issue 1117
The Zostavax package insert says to inject the vaccine into the deltoid region of the upper arm. We always give subcutaneous vaccines in the triceps area of the arm. Are we wrong?
No. The subcutaneous tissue overlying the triceps muscle of the upper arm is the usual location for subcutaneous vaccine injection for an adult.
Needle Tips, Vaccinate Adults - March 2014, IAC Express Issue 1117
The Zostavax package insert says that the vaccine is contraindicated in a person with a history of primary or acquired immunodeficiency states, leukemia, lymphoma, or other malignant neoplasms affecting the bone marrow or lymphatic system. Does this mean that a person who was treated for lymphoma many years ago and is now healthy should not receive zoster vaccine?
No. A person who was treated for leukemia, lymphoma, or other malignant cancers in the past and is now healthy and not receiving immunosuppressive treatment may receive zoster vaccine. However, a person who is immunosuppressed for any reason (disease or treatment) should not receive the vaccine.
Needle Tips, Vaccinate Adults - March 2014, IAC Express Issue 1117
Can a person age 60 years or older with a diagnosis of an autoimmune disease, such as lupus or rheumatoid arthritis, receive zoster vaccine?
Yes, with one qualification. A diagnosis of an autoimmune condition such as lupus or rheumatoid arthritis is not a contraindication to zoster vaccination. However, the treatment of these conditions may involve the use of an immunosuppressive drug, which could be a contraindication.
Needle Tips, Vaccinate Adults - March 2014, IAC Express Issue 1117
A 65-year-old patient is having major back surgery next week. He is requesting zoster vaccine today. Can I give him the vaccine?
Yes, with one qualification. There is no contraindication to vaccinating against zoster before surgery, unless the patient is immunocompromised for some reason.
Needle Tips, Vaccinate Adults - March 2014, IAC Express Issue 1117
For patients age 60 or older who don't remember having chickenpox in the past, should we test them for varicella immunity before giving zoster vaccine?
No. Simply vaccinate them with zoster vaccine according to the ACIP recommendations.
Needle Tips, Vaccinate Adults - March 2014, IAC Express Issue 1117
We weren't familiar with the recommendations and tested a 60-year-old for varicella antibody because she said she never had chickenpox. Her result was negative. Should this patient receive zoster vaccine or varicella vaccine?
In this situation, since you've tested the patient and the results were negative, the patient should receive varicella vaccine.
A person age 60 years or older who has no medical contraindications is eligible for zoster vaccine regardless of their memory of having had chickenpox. However, if an adult age 60 years or older is tested for varicella immunity for whatever reason, and the test is negative, he/she should be given 2 doses of varicella vaccine at least 4 weeks apart, not zoster vaccine. See www.cdc.gov/vaccines/vpd-vac/shingles/hcp-vaccination.htm for more information.
Needle Tips, Vaccinate Adults - March 2014, IAC Express Issue 1117
How should zoster vaccine be transported to an off-site clinic location?
Neither CDC nor the vaccine manufacturer recommends transporting varicella-containing vaccines. If these vaccines must be transported (for example, during an emergency), CDC recommends transport in a portable freezer unit that maintains the temperature between -58°F and +5°F (-50°C and -15°C). Portable freezers may be available for rent in some places. If varicella-containing vaccines must be transported and a portable freezer unit is not available, do not use dry ice. Dry ice may subject varicella-containing vaccines to temperatures colder than -58°F (-50°C).
Varicella-containing vaccines may be transported at refrigerator temperature between 36°F and 46°F (2°C and 8°C) for up to 72 continuous hours prior to reconstitution. Vaccine stored between 36°F and 46°F (2°C and 8°C) that is not used within 72 hours of removal from a freezer should be discarded. Detailed instructions for the transport of varicella-containing vaccines at refrigerator temperature are available in the CDC "Vaccine Storage & Handling Toolkit" at www.cdc.gov/vaccines/recs/storage/toolkit/storage-handling-toolkit.pdf.
Needle Tips, Vaccinate Adults - March 2014, IAC Express Issue 1117
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