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Issue 1092
IAC Express: Weekly immunization news and information
Issue 1092: December 4, 2013

Ask the Experts: CDC Experts Answer Your Questions

The questions and answers in this edition of IAC Express first appeared in the November 2013 issue of Needle Tips.

IAC extends thanks to our experts, medical officers Andrew T. Kroger, MD, MPH, and Iyabode Akinsanya-Beysolow, MD, MPH, and nurse educator Donna L. Weaver, RN, MN. All are with the National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention (CDC).

Questions and Answers
Q: What are the ACIP recommendations for vaccination of preterm infants?

A: 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.

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Q: 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?

A: 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 biosafe 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. Additional information is available on IAC’s Vaccine Storage and Handling website.

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Q: 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?

A: 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 provides helpful information on the wide variety of influenza vaccines in use this season.

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Q: 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?

A: 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.

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Q: 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.

A: 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.

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Q: 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?

A: 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.

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Q: Would giving an older patient 2 doses of standard-dose influenza vaccine be the same as administering the high-dose product?

A: No, and this is not recommended.

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Q: How soon after bone marrow transplant do we start to vaccinate our patients against influenza?

A: 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.

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Q: 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?

A: 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.

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Q: 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.

A: 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.

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Q: 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?

A: 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]). 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.

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Q: 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?

A: 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.

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Q: Pneumococcal polysaccharide vaccine (PPSV, Pneumovax, Merck) is recommended for people with diabetes. Does this include gestational diabetes?

A: No.

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How to submit a question to Ask the Experts

IAC works with CDC to compile new Ask the Experts Q&As for our publications based on commonly asked questions. We also consider the need to provide information about new vaccines and recommendations. Most of the questions are thus a composite of several inquiries.

You can email your question about vaccines or immunization to IAC at admin@immunize.org.

As we receive hundreds of emails each month, we cannot guarantee that we will print your specific question in the Ask the Experts feature. However, you will get an answer.

You can also email CDC's immunization experts directly at nipinfo@cdc.gov. There is no charge for this service.

If you have a question about IAC materials or services, email admininfo@immunize.org.

Please forward these Ask the Experts Q&As to your co-workers and suggest they subscribe to IAC Express.

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About IAC Express 
We encourage you to reprint any of these Q&As in your own newsletters. Please credit the Immunization Action Coalition and the Centers for Disease Control and Prevention. Please refer to IAC's preferred citation style.
If you have trouble receiving or displaying IAC Express messages, visit our online help section.
IAC Express is supported in part by Grant No. U38IP000589 from the National Center for Immunization and Respiratory Diseases, CDC. Its contents are solely the responsibility of IAC and do not necessarily represent the official views of CDC. IAC Express is also supported by educational grants from the following companies: CSL Biotherapies; GlaxoSmithKline; MedImmune, Inc.; Merck Sharp & Dohme Corp.; Novartis Vaccines; Ortho Clinical Diagnostics, Inc.; Pfizer, Inc.; and sanofi pasteur.
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Issue Abbreviations
AAFP, American Academy of Family Physicians; AAP, American Academy of Pediatrics; ACIP, Advisory Committee on Immunization Practices; AMA, American Medical Association; CDC, Centers for Disease Control and Prevention; FDA, Food and Drug Administration; IAC, Immunization Action Coalition; MMWR, Morbidity and Mortality Weekly Report; NCIRD, National Center for Immunization and Respiratory Diseases; NIVS, National Influenza Vaccine Summit; VIS, Vaccine Information Statement; VPD, vaccine-preventable disease; WHO, World Health Organization.
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