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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
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
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
When should adolescents who received a dose of Tdap (tetanus-diphtheria, pertussis-containing vaccine; Adacel, sanofi; Boostrix, GSK) at age 11–12 years receive their next dose of Td or Tdap?
Currently, ACIP recommends only one lifetime dose of Tdap for everyone with the exception of pregnant women for whom a dose is recommended during each pregnancy. Someone who received a dose of Tdap at age 11 or 12 should receive a booster dose of Td vaccine ten years later, unless tetanus prophylaxis is required sooner due to an injury.
Needle Tips, Vaccinate Adults - November 2013, IAC Express Issue 1092
If a woman received Tdap in early pregnancy, should she get it again in the third trimester?
No, it is not recommended to give another dose of Tdap in such cases. Optimal timing for Tdap administration is between 27 and 36 weeks' gestation because of transplacental antibody kinetics.
According to ACIP recommendations published in MMWR on February 22, 2013, "Tdap may be administered any time during pregnancy, but vaccination during the third trimester would provide the highest concentration of maternal antibodies to be transferred closer to birth." More information is available at www.cdc.gov/mmwr/preview/mmwrhtml/mm6207a4.htm.
Needle Tips, Vaccinate Adults - September 2013, IAC Express Issue 1078
Each time there is a pregnancy in the family, should fathers and other family members receive a Tdap booster to ensure adequate protection and boost the cocoon effect to protect the newborn from pertussis?
At this time, ACIP does not recommend additional doses of Tdap for fathers or other family members/caregivers. The multiple Tdap recommendation to optimize immunity for the infant applies only to the pregnant woman.
Needle Tips, Vaccinate Adults - September 2013, IAC Express Issue 1078
A pertussis outbreak is occurring in our town, with many cases happening in the schools. Is there a recommendation for boosting middle- and high-school students with an additional dose of Tdap during an outbreak if students have already had 1 dose?
Currently, ACIP recommends only 1 lifetime dose of Tdap for everyone except pregnant women. In light of the ongoing pertussis outbreaks in the nation, ACIP is continuing to evaluate the need for additional pertussis protection. The Immunization Action Coalition always announces new ACIP recommendations in its free weekly electronic newsletter, IAC Express. If you're not already one of the newsletter's nearly 50,000 subscribers, you can sign up at www.immunize.org/subscribe.
Needle Tips - September 2013, IAC Express Issue 1078
>> 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
 
Why does CDC include 2D barcodes on VISs now?
As part of a modernization initiative, CDC began adding barcodes to VISs in April 2012. The addition of the barcode is intended primarily to help immunization providers save time by allowing them to scan certain required information about the VIS (e.g., the name and edition date of the VIS) into an electronic medical record, immunization information system, or other electronic database. Scanning the barcode instead of manually recording the information is optional.
Using barcodes requires a 2D barcode scanner and software that is programmed to accept and process data contained in the VIS barcodes. Providers may continue to use any VISs they printed before CDC started adding barcodes as long as the VIS content is otherwise the same. See the next question for more information about discarding old VISs. For more information about barcodes and scanning, visit www.cdc.gov/vaccines/hcp/vis/barcodes.html.
Needle Tips, Vaccinate Adults - September 2013, IAC Express Issue 1078
It seems CDC is changing the format of VISs. Do we have to throw our old supply away and use the new ones?
Not necessarily. CDC is in the process of re-releasing all VISs in a slightly modified format. The modified VISs have a consistent look and use consistent language in the sections common to all VISs. Modified VISs will not necessarily be new, but may simply be redesigned versions of existing VISs and have the same edition dates as existing VISs. Providers do not need to discard their existing VIS stocks when nothing but the VIS format has been changed. CDC posts information on its website to alert healthcare providers when the older version of a VIS should not be used. This information is available on CDC's web section titled What's New with VISs, available at www.cdc.gov/vaccines/hcp/vis/what-is-new.html.
Needle Tips, Vaccinate Adults - September 2013, IAC Express Issue 1078
>> 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
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 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
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
 
Why did Merck discontinue the registry for collecting reports of pregnant women who inadvertently received its HPV vaccine (Gardasil) during pregnancy?
Because HPV vaccine is not recommended for use during pregnancy, Merck facilitated a registry to document outcomes when its HPV vaccine (Gardasil) was inadvertently administered to pregnant women. This registry was ongoing for more than 6 years (June 2006–April 2013), and Merck has fulfilled its FDA obligation to facilitate it. But more importantly, the data from the registry are reassuring with respect to safety after pregnancy exposures. Review of the data collected during the first 5 years of the registry does not support a causal relationship between HPV vaccine and birth defects.
Needle Tips, Vaccinate Adults - September 2013, IAC Express Issue 1078
>> view all HPV Q&As
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Influenza Back to top
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
 
We inadvertently administered a 0.5 mL dose of FluLaval (GSK) to a 2-year-old child before realizing that the vaccine is only licensed for use in people age 3 years and older. Do we need to repeat the dose with an age-appropriate product?
No, the dose does not need to be repeated. However, two errors actually occurred here. In addition to the age discrepancy, the child also received a 0.5 mL dose of vaccine rather than the correct dose (0.25 mL) for the child's age. Clinicians should carefully select an influenza vaccine that is licensed for the
age group of the person being vaccinated. Fluzone 0.25 mL (sanofi) is the only inactivated influenza vaccine approved for use in children age 6 months through two years. The live attenuated nasal spray vaccine (LAIV, FluMist, MedImmune) is approved for use in most healthy children age 2 years and older (as well as for healthy nonpregnant adults through age 49 years).
If the child should need a second dose of influenza vaccine, an age-appropriate vaccine should be selected. The Immunization Action Coalition's educational piece "Influenza Vaccine Products for the 2013–2014 Influenza Season" (available at www.immunize.org/catg.d/p4072.pdf) provides helpful information on the wide variety of influenza vaccines in use this season.
Needle Tips - November 2013, IAC Express Issue 1092
 
We inadvertently administered intradermal influenza vaccine (Fluzone ID, sanofi) to a patient who is not in the recommended age range of 18 through 64 years. What should we do now?
Because people younger than age 9 years or older than 65 years are more likely to have skin that is too thin for proper intradermal administration, a dose given to a person in these age ranges should be considered invalid, and the patient should be revaccinated. For people age 9 through 17 years, the dose is considered valid and does not have to be repeated if the clinician is certain that the dose was administered intradermally rather than subcutaneously. If there is any doubt about whether the dose was injected intradermally, it should be repeated.
Needle Tips, Vaccinate Adults - November 2013, IAC Express Issue 1092
 
Is it acceptable to administer a dose of the quadrivalent influenza vaccine to a patient who has already received the trivalent vaccine? We've had a few patients request this.
No. ACIP does not recommend that anyone receive more than one dose of influenza vaccine in a season, except for certain children age 6 months through 8 years for whom two doses are recommended.
Needle Tips, Vaccinate Adults - November 2013, IAC Express Issue 1092
 
Sometimes patients age 65 years and older who have received the standard-dose influenza vaccine hear about the high-dose product (Fluzone High-Dose, sanofi) and want to receive that, too. Is this okay to administer?
No. ACIP does not recommend that anyone receive more than one dose of influenza vaccine in a season except for certain children age 6 months through 8 years for whom two doses are recommended.
Needle Tips, Vaccinate Adults - November 2013, IAC Express Issue 1092
 
Would giving an older patient 2 doses of standard-dose influenza vaccine be the same as administering the high-dose product?
No, and this is not recommended.
Needle Tips, Vaccinate Adults - November 2013, IAC Express Issue 1092
 
How soon after bone marrow transplant do we start to vaccinate our patients against influenza?
Inactivated influenza vaccine should be administered beginning at least 6 months after bone marrow transplant and annually thereafter for the life of the patient. A dose of inactivated influenza vaccine can be given as early as 4 months after transplant, but a second dose should be considered in this situation. A second dose is recommended routinely for all children receiving influenza vaccine for the first time. For more information about vaccination of people who receive hematopoietic stem cell transplantation, visit this CDC web page: www.cdc.gov/vaccines/pubs/hemato-cell-transplts.htm.
Needle Tips, Vaccinate Adults - November 2013, IAC Express Issue 1092
 
What influenza vaccine products will be available during the 2013–14 influenza season?
Seven manufacturers now produce influenza vaccine for the U.S. market through different technologies (e.g., egg-based, cell culture-based, and recombinant hemagglutinin vaccines). The seven manufacturers and the products they have available for the upcoming season are listed below.
A series of new abbreviations will help identify the different types of vaccines available. The current abbreviations include IIV for inactivated influenza vaccine, RIV for recombinant hemagglutinin influenza vaccine, LAIV for live, attenuated influenza vaccine, and ccIIV for cell culture-based IIV. The addition of either a 3 or a 4 at the end of an abbreviation indicates if the vaccine is trivalent or quadrivalent (e.g., IIV3, RIV3, IIV4, LAIV4). The available products are
Afluria (IIV3), CSL Limited
Fluarix (IIV3, IIV4), GlaxoSmithKline
FluLaval (IIV3), ID Biomedical Corporation of Quebec
FluMist (LAIV4), MedImmune
Fluvirin (IIV3), Novartis
Flucelvax (ccIIV3), Novartis
Flublok (RIV3), Protein Sciences Corporation
Fluzone (IIV3, IIV4), sanofi pasteur
Fluzone High-Dose (IIV3), sanofi pasteur
Fluzone Intradermal (IIV3), sanofi pasteur
IAC has developed a handout that provides information about these numerous products, their age indications, CPT and Q codes, and other details. Access it at www.immunize.org/catg.d/p4072.pdf.
Needle Tips, Vaccinate Adults - September 2013, IAC Express Issue 1078
 
What are the differences in trivalent and quadrivalent influenza vaccines?
Most of the influenza vaccine offered for the 2013–2014 season will be trivalent (three components), containing two A viruses and one of the B viruses. The 2013–2014 trivalent influenza vaccine is made from the following three viruses:
A/California/7/2009 (H1N1)pdm09-like virus
A(H3N2) virus antigenically like the cell-propagated prototype virus A/Victoria/361/2011
B/Massachusetts/2/2012-like virus
A limited quantity of seasonal influenza vaccine will be quadrivalent (four components), containing two A viruses and two B viruses. The quadrivalent vaccines will contain the three viruses listed above, plus a B/Brisbane/60/2008-like virus.
Needle Tips, Vaccinate Adults - September 2013, IAC Express Issue 1078
 
If quadrivalent vaccine includes one additional strain, why isn't it preferred for use over trivalent vaccines in ACIP's 2013–14 influenza recommendations?
Even though both influenza B viruses are likely to cause disease during an influenza season, for trivalent vaccine, experts had to choose between the two very different B viruses to pair with the two A viruses. The quadrivalent vaccine that will be available for the 2013–14 season includes both B viruses. However, while quadrivalent vaccines may eventually replace trivalent vaccines, it is anticipated that during the coming season only a limited quantity of quadrivalent vaccine will be available. Consequently, ACIP does not express a preference for use of one type of influenza vaccine over another type (i.e., live over inactivated, or quadrivalent over trivalent) for persons for whom more than one type of vaccine is indicated and available.
Needle Tips, Vaccinate Adults - September 2013, IAC Express Issue 1078
 
I heard there was a new influenza vaccine that can be given to people with severe egg allergies. Is that true?
If someone has a severe allergy to eggs with symptoms suggestive of anaphylaxis and the patient is age 18 through 49 years, then the provider can consider using Flublok, the recombinant influenza vaccine that is egg-free. Unlike current production methods for other available seasonal influenza vaccines, production of Flublok does not use the whole influenza virus or chicken eggs in its manufacturing process. If Flublok is not available or the patient is not age-eligible, then the patient should be referred to a provider experienced in managing allergy.
Flublok has a shorter shelf life than other currently available inactivated influenza vaccines. It expires 16 weeks from the production date. Other currently available inactivated influenza vaccines expire on June 30, 2014. You can find additional information about Flublok at www.cdc.gov/flu/protect/vaccine/qa_flublok-vaccine.htm.
Needle Tips, Vaccinate Adults - September 2013, IAC Express Issue 1078
 
How many doses of vaccine are recommended for children younger than 9 years who are receiving influenza vaccine for the first time?
In settings where adequate vaccination history from prior to the 2010–2011 season is unavailable, children 6 months through 8 years of age need only 1 dose of vaccine in 2013–2014 if they received a total of 2 or more doses of seasonal vaccine since July 1, 2010. Children who did not receive a total of 2 or more doses of seasonal vaccine since July 1, 2010, require 2 doses in 2013–2014. In settings where adequate vaccination history from prior to the 2010–2011 season is available, an alternate approach may be used. This is the alternate approach: If a child age 6 months through 8 years is known to have received at least 2 doses of seasonal influenza vaccine during any prior season, and at least 1 dose of a 2009 (H1N1)-containing vaccine—i.e., either 2010–2011, 2011–2012, or 2012–2013 seasonal vaccine or the monovalent (H1N1) 2009 vaccine—then the child needs only 1 dose for 2013–2014. Otherwise the child needs 2 doses for the 2013–2014 season.
Needle Tips- September 2013, IAC Express Issue 1078
 
Can a child who needs 2 doses of influenza receive 1 dose of quadrivalent vaccine and 1 dose of trivalent vaccine?
Yes. You can give these two vaccines, as long as the 2 doses are appropriately spaced.
Needle Tips- September 2013, IAC Express Issue 1078
 
Does ACIP recommend one influenza product over another for pregnant women?
Pregnant women can receive any of the inactivated vaccines. They should not be given the live quadrivalent attenuated influenza vaccine (FluMist, MedImmune, LAIV4).
Needle Tips, Vaccinate Adults - September 2013, IAC Express Issue 1078
 
Why is a higher dose influenza vaccine (Fluzone High-Dose) available for adults 65 and older?
Aging decreases the body's ability to develop a good immune response after getting influenza vaccine, which places older people at greater risk of severe illness from influenza. A higher dose of antigen in the vaccine should give older people a better immune response and therefore provide better protection against influenza. Data from clinical trials comparing Fluzone to Fluzone High-Dose among people age 65 and older indicate that a stronger immune response (i.e., higher antibody levels) occurs after vaccination with Fluzone High-Dose. Whether the improved immune response leads to greater protection against influenza disease after vaccination is not yet known. A study designed to determine how effective Fluzone High-Dose is in preventing illness from influenza, when compared with standard-dose Fluzone, is expected to be completed in 2014%#150;2015.
CDC has stated no preference for using high-dose influenza vaccine or standard-dose influenza vaccine when vaccinating people age 65 and older. CDC stresses that vaccination is the first and most important step in protecting against influenza.
Needle Tips, Vaccinate Adults - September 2013, IAC Express Issue 1078
 
If a patient is undergoing treatment for cancer, is it safe to vaccinate her or him against influenza?
People with cancer need to be protected from influenza, and they can and should receive inactivated influenza vaccine (not LAIV) even if they are immunosuppressed. Cancer patients and survivors are at higher risk for complications from flu, including hospitalization and death. Here is a helpful CDC web page on cancer and influenza for patients: www.cdc.gov/cancer/flu.
Needle Tips, Vaccinate Adults - September 2013, IAC Express Issue 1078
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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
 
Please describe the new Advisory Committee on Immunization Practices (ACIP) vote recommending the use of the meningococcal vaccine Menveo in high-risk children 2 through 23 months of age.
On October 23, the ACIP voted to recommend the use of Menveo (MCV4-CRM, Novartis) in high-risk children 2 through 23 months of age. Previously, the FDA had licensed the use of Menveo in children 2 years of age or older, but the agency expanded licensure to the 2 through 23 months age group on August 1. Three meningococcal conjugate vaccines are now approved and recommended for certain high-risk children: MenHibrix (Hib-MenCY, GSK) for children 6 weeks through 18 months of age, Menveo for children 2 months and older, and Menactra (MCV4-D, sanofi) for children 9 months and older.
Needle Tips, IAC Express Special Edition - November 2013
 
Why is it recommended to delay meningococcal vaccination for infants with functional or anatomic asplenia until after the PCV13 (pneumococcal conjugate vaccine, Prevnar, Pfizer) series is completed?
Although people with anatomic or functional asplenia also appear to be at increased risk for meningococcal disease, the data are less compelling than data that demonstrate the increased risk for pneumococcal disease in patients with asplenia (see page 6 of Prevention and Control of Meningococcal Disease: Recommendations of the Advisory Committee on Immunization Practices [ACIP], www.cdc.gov/mmwr/pdf/rr/rr6202.pdf). Data show that the MCV4-D vaccine (Menactra, sanofi) may interfere with the immunologic response to PCV13 if these two vaccines are given too close together. Therefore, ACIP recommends that MCV4-D not be administered until at least 4 weeks after completion of the age-appropriate PCV13 series. MCV4-CRM (Menveo, Novartis) and Hib-MenCY (MenHibrix, GSK) do not affect the immune response to PCV13, so these vaccines may be given at any time before or after PCV13 doses.
Needle Tips - November 2013, IAC Express Issue 1092
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Pertussis Back to top
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
When should adolescents who received a dose of Tdap (tetanus-diphtheria, pertussis-containing vaccine; Adacel, sanofi; Boostrix, GSK) at age 11–12 years receive their next dose of Td or Tdap?
Currently, ACIP recommends only one lifetime dose of Tdap for everyone with the exception of pregnant women for whom a dose is recommended during each pregnancy. Someone who received a dose of Tdap at age 11 or 12 should receive a booster dose of Td vaccine ten years later, unless tetanus prophylaxis is required sooner due to an injury.
Needle Tips, Vaccinate Adults - November 2013, IAC Express Issue 1092
If a woman received Tdap in early pregnancy, should she get it again in the third trimester?
No, it is not recommended to give another dose of Tdap in such cases. Optimal timing for Tdap administration is between 27 and 36 weeks' gestation because of transplacental antibody kinetics.
According to ACIP recommendations published in MMWR on February 22, 2013, "Tdap may be administered any time during pregnancy, but vaccination during the third trimester would provide the highest concentration of maternal antibodies to be transferred closer to birth." More information is available at www.cdc.gov/mmwr/preview/mmwrhtml/mm6207a4.htm.
Needle Tips, Vaccinate Adults - September 2013, IAC Express Issue 1078
Each time there is a pregnancy in the family, should fathers and other family members receive a Tdap booster to ensure adequate protection and boost the cocoon effect to protect the newborn from pertussis?
At this time, ACIP does not recommend additional doses of Tdap for fathers or other family members/caregivers. The multiple Tdap recommendation to optimize immunity for the infant applies only to the pregnant woman.
Needle Tips, Vaccinate Adults - September 2013, IAC Express Issue 1078
A pertussis outbreak is occurring in our town, with many cases happening in the schools. Is there a recommendation for boosting middle- and high-school students with an additional dose of Tdap during an outbreak if students have already had 1 dose?
Currently, ACIP recommends only 1 lifetime dose of Tdap for everyone except pregnant women. In light of the ongoing pertussis outbreaks in the nation, ACIP is continuing to evaluate the need for additional pertussis protection. The Immunization Action Coalition always announces new ACIP recommendations in its free weekly electronic newsletter, IAC Express. If you're not already one of the newsletter's nearly 50,000 subscribers, you can sign up at www.immunize.org/subscribe.
Needle Tips- September 2013, IAC Express Issue 1078
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Pneumococcal Back to top
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
 
Pneumococcal polysaccharide vaccine (PPSV, Pneumovax, Merck) is recommended for people with diabetes. Does this include gestational diabetes?
No.
Needle Tips, Vaccinate Adults - November 2013, IAC Express Issue 1092
 
Currently, ACIP recommends pneumococcal polysaccharide (PPSV23) for smokers age 19–64 years. Should we also vaccinate 16-year-olds who smoke?
No. Currently no data exist to indicate that people younger than 19 are at increased risk of pneumococcal disease.
Needle Tips - September 2013, IAC Express Issue 1078
 
Rather than giving pneumococcal conjugate vaccine (PCV13) first and waiting 8 weeks to give PPSV as recommended for an immunocompromised child (2 years+) or adult patient, we inadvertently gave both vaccines at the same visit. We are looking for guidance.
When these two vaccines are given simultaneously, each probably affects the other detrimentally. The risk of diminished responsiveness (which is "caused" by PPSV23, not PCV13) means that you should count the PPSV23 dose as valid for adults, and repeat the PCV13 dose 1 year after the PPSV23 dose was administered. You should count the PPSV23 dose as valid for children, and repeat the PCV13 dose 8 weeks after the PPSV23 dose was administered and complete the series as age appropriate.
Needle Tips, Vaccinate Adults - September 2013, IAC Express Issue 1078
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Polio Back to top
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
 
We frequently see children (mostly from certain foreign countries) who have received 6 or more doses of polio vaccine, all administered before age 4 years. How do we handle this when assessing the child's immunization history?
Because it is common practice in many developing countries to administer oral polio vaccine to children during both routine visits and periodic nationwide vaccination campaigns, a child's record may indicate more than 4 doses. Depending on the timing, some of these doses may be invalid according to the U.S. immunization schedule. To be counted as valid, the doses should all be given after age 6 weeks and be separated from each other by at least 4 weeks. If the history is of a complete series of inactivated polio vaccine (IPV) (unlikely given the context), at least one dose should be administered on or after age 4 years and at least 6 months after the previous dose. If a complete series cannot be identified that meet these criteria, then the child should receive as many doses of IPV as needed to complete the U.S. recommended schedule.
Needle Tips - November 2013, IAC Express Issue 1092
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Rotavirus Back to top
What is the latest on rotavirus vaccination and intussusception?
Some, but not all, studies suggest that RotaTeq and Rotarix vaccines may possibly cause a small increase in the risk of intussusception. It is possible that an estimated one to three U.S. infants out of 100,000 might develop intussusception within 7 days of getting their first dose of rotavirus vaccine. That means 40 to 120 vaccinated U.S. infants might develop intussusception each year.
The benefits of rotavirus vaccines in preventing hospitalizations and deaths from rotavirus illness far outweigh the small possible risk of intussusception. Rotavirus vaccines prevent more than 65,000 U.S. hospitalizations from rotavirus illness each year. CDC continues to recommend routine rotavirus vaccination of U.S. infants. More information can be found on this issue at www.cdc.gov/vaccinesafety/vaccines/rotavsb.html.
Needle Tips- September 2013, IAC Express Issue 1078
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Scheduling Vaccines Back to top
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
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
We plan to keep our influenza vaccine in coolers when we travel to off-site vaccination events. How can we ensure the vaccine remains within the proper temperature range?
CDC does not recommend keeping vaccines in transport containers unless they are portable refrigerator or freezer units. If vaccines must be kept in transport
containers during off-site clinics:
The containers should remain closed as much as possible.
Only the amount of vaccine needed at one time should be removed for preparation and administration.
A calibrated thermometer (preferably with a bio-safe glycol-encased thermometer probe) should be placed as close as possible to the vaccines within the container.
The temperature inside the container should be read and documented at least hourly.
If you have concerns that vaccines or diluents may have been compromised (exposed to inappropriate conditions/temperatures or handled improperly), label them "DO NOT USE" and store them under appropriate conditions separated from other vaccine supplies. Then contact your immunization program and/or vaccine manufacturer for guidance. Do not discard the vaccines or diluents unless directed to by your immunization program and/or the manufacturer. For more information, see the Transporting Vaccine in an Emergency or to Off-Site Facilities section on pages 91–96 of CDC's Vaccine Storage and Handling Toolkit at www.cdc.gov/vaccines/recs/storage/toolkit/storage-handling-toolkit.pdf. Additional information is available on IAC's Vaccine Storage and Handling website at www.immunize.org/handouts/vaccine-storage-handling.asp.
Needle Tips, Vaccinate Adults - November 2013, IAC Express Issue 1092
>> view all storage and handling Q&As
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Tetanus Vaccine Back to top
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
When should adolescents who received a dose of Tdap (tetanus-diphtheria, pertussis-containing vaccine; Adacel, sanofi; Boostrix, GSK) at age 11–12 years receive their next dose of Td or Tdap?
Currently, ACIP recommends only one lifetime dose of Tdap for everyone with the exception of pregnant women for whom a dose is recommended during each pregnancy. Someone who received a dose of Tdap at age 11 or 12 should receive a booster dose of Td vaccine ten years later, unless tetanus prophylaxis is required sooner due to an injury.
Needle Tips, Vaccinate Adults - November 2013, IAC Express Issue 1092
If a woman received Tdap in early pregnancy, should she get it again in the third trimester?
No, it is not recommended to give another dose of Tdap in such cases. Optimal timing for Tdap administration is between 27 and 36 weeks' gestation because of transplacental antibody kinetics.
According to ACIP recommendations published in MMWR on February 22, 2013, "Tdap may be administered any time during pregnancy, but vaccination during the third trimester would provide the highest concentration of maternal antibodies to be transferred closer to birth." More information is available at www.cdc.gov/mmwr/preview/mmwrhtml/mm6207a4.htm.
Needle Tips, Vaccinate Adults - September 2013, IAC Express Issue 1078
Each time there is a pregnancy in the family, should fathers and other family members receive a Tdap booster to ensure adequate protection and boost the cocoon effect to protect the newborn from pertussis?
At this time, ACIP does not recommend additional doses of Tdap for fathers or other family members/caregivers. The multiple Tdap recommendation to optimize immunity for the infant applies only to the pregnant woman.
Needle Tips, Vaccinate Adults - September 2013, IAC Express Issue 1078
A pertussis outbreak is occurring in our town, with many cases happening in the schools. Is there a recommendation for boosting middle- and high-school students with an additional dose of Tdap during an outbreak if students have already had 1 dose?
Currently, ACIP recommends only 1 lifetime dose of Tdap for everyone except pregnant women. In light of the ongoing pertussis outbreaks in the nation, ACIP is continuing to evaluate the need for additional pertussis protection. The Immunization Action Coalition always announces new ACIP recommendations in its free weekly electronic newsletter, IAC Express. If you're not already one of the newsletter's nearly 50,000 subscribers, you can sign up at www.immunize.org/subscribe.
Needle Tips- September 2013, IAC Express Issue 1078
>> view all tetanus Q&As
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Vaccine Recommendations Back to top
What are the ACIP recommendations for vaccination of preterm infants?
Preterm infants should be vaccinated at the same chronological age and according to the same schedule as full-term infants, regardless of birth weight, with the exception of the birth dose of hepatitis B vaccine. Infants weighing less than 2 kg (4.4 lb) whose mothers' HBsAg status is either positive or unknown should receive HBIG (hepatitis B immune globulin) and hepatitis B vaccine within 12 hours of birth. This dose of hepatitis B vaccine should not be counted as a valid first dose in the series, and it should be repeated at age 1–2 months. If the preterm infant's mother's HBsAg status is negative, the infant's first dose of hepatitis B vaccine should be withheld until the infant is chronologically 1 month of age or is ready to be discharged from the hospital, whichever occurs first. For complete details, see the Vaccination of Preterm Infants section (pages 25–26) of the ACIP General Recommendations on Immunization, available at www.cdc.gov/mmwr/pdf/rr/rr6002.pdf.
Needle Tips, Vaccinate Adults - November 2013, IAC Express Issue 1092
>> view all vaccine recommendations Q&As
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Zoster (shingles) Back to top
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
>> view all zoster Q&As
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This website is supported in part by a cooperative agreement from the National Center for Immunization and Respiratory Diseases (Grant No. 5U38IP000290) at the Centers for Disease Control and Prevention (CDC) in Atlanta, GA. The website content is the sole responsibility of IAC and does not necessarily represent the official views of CDC.