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What's New

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 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).
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.
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
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
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
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
>> 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.
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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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
>> 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
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
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, Vaccinate Adults - October 2014
>> view all hepatitis A Q&As
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Hepatitis B Vaccine Back to top
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.
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
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
>> view all hepatitis B Q&As
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HPV Back to top
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.
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
 
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
>> view all HPV Q&As
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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
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, Vaccinate Adults – 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, Vaccinate Adults – 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
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MMR Back to top
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.
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?
ealthcare 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
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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
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
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Meningococcal 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
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Pertussis Back to top
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
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
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Pneumococcal Back to top
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.
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.
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.
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
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
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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, Vaccinate Adults - 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
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Precautions and Contraindications Back to top
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
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
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
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.
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
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
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
>> 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
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
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
>> view all storage and handling Q&As
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Tetanus Vaccine Back to top
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
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
>> 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.
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”).
IAC Express Issue 1176
>> view all vaccine recommendations Q&As
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Zoster (shingles) 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
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
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
>> view all zoster Q&As
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