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Issue 1153
IAC Express: Weekly immunization news and information

Issue 1153: November 19, 2014

Ask the Experts: CDC Experts Answer Your Questions


The questions and answers in this edition of IAC Express first appeared in the October 2014 issue of Needle Tips.

IAC extends thanks to our experts, medical officer Andrew T. Kroger, MD, MPH, and nurse educator Donna L. Weaver, RN, MN, both from the National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention (CDC).

Influenza Vaccine

Pneumococcal Vaccine Zoster Vaccine   Hepatitis B Vaccine Hepatitis A Vaccine Polio Vaccine General Vaccine Questions  
Influenza Vaccine
Q: Which influenza vaccines can we give to children?

A: Among the injectable inactivated influenza vaccines (IIV), only Fluzone (Sanofi) is approved by the FDA for use in children ages 6 through 35 months. However, there are several injectable influenza vaccines that can be given to children age 3 years or older.

The nasal spray live attenuated influenza vaccine (LAIV, FluMist, MedImmune) is approved for healthy children age 2 years and older. You can find information on all influenza vaccines available in the U.S. for the current season and the age groups approved by FDA by going to IAC's handout titled "Influenza Vaccine Products for the 2014–2015 Influenza Season" available at www.immunize.org/catg.d/p4072.pdf.

When immediately available, LAIV is preferred for use in healthy children ages 2 through 8 years who do not have a contraindication or precaution to LAIV. ACIP states this preference because two studies have shown LAIV to be more effective than IIV in preventing influenza in this age group. However, both LAIV and IIV are safe and effective in this age group. If LAIV is not immediately available, IIV should be used. Vaccination should not be delayed in order to procure LAIV.

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Q: Does the ACIP preference for use of LAIV in children ages 2 through 8 years include children with asthma?

A: No. Asthma or a wheezing episode noted in the medical record within the past 12 months is still considered a contraindication to the use of LAIV for children ages 2 through 4 years. For people age 5 years and older, asthma is considered to be a precaution (not a contraindication) for the use of LAIV.

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Q: Which children younger than age 9 years will need 2 doses of influenza vaccine in the current influenza season?

A: Children age 6 months through 8 years should receive a second dose 4 weeks or more after the first dose if they 1) are receiving influenza vaccine for the first time, or 2) did not get a total of at least two doses of seasonal influenza vaccine since July 1, 2010. Children in this age group who received at least one dose during the 2013–2014 season need only one dose during the 2014–2015 season.

CDC has developed an alternative approach that may be used with children who have well-documented histories of influenza vaccination (for example, vaccination records maintained in an electronic registry). By this approach, children age 6 months through 8 years need only one dose of vaccine in this season if they have received any of the following: 1) at least one dose of vaccine during the 2013–2014 influenza season; 2) two or more doses of seasonal influenza vaccine since July 1, 2010; 3) two or more doses of seasonal vaccine given before July 1, 2010, and one or more dose of monovalent 2009 H1N1 vaccine; or 4) at least one dose of seasonal vaccine given before July 1, 2010, and at least one dose of seasonal vaccine since July 1, 2010.

For more details about the ACIP recommendations for which children need two doses, see pages 691–7 of "Prevention and Control of Seasonal Influenza with Vaccines" available at www.cdc.gov/mmwr/pdf/wk/mm6332.pdf.

You can also find this information in IAC's "Guide for Determining the Number of Doses of Influenza Vaccine to Give to Children Ages 6 Months through 8 Years" available at www.immunize.org/catg.d/p3093.pdf.

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Q: I've heard there is a newer influenza vaccine that can be given to people with severe egg allergy. Is that true?

A: Yes. If someone age 18 through 49 years has a severe allergy to eggs with symptoms suggestive of anaphylaxis, then the provider can use a recombinant influenza vaccine (RIV3, Flublok, Protein Sciences) that is egg-free. Unlike current production methods for other available seasonal influenza vaccines, production of RIV3 does not use the whole influenza virus or chicken eggs in its manufacturing process. If RIV3 is not available or the person is not age-eligible, then inactivated influenza vaccine should be administered by a physician with experience in the recognition and management of severe allergic conditions.

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Q: A study has now been published that found that the injectable vaccine Fluzone High-Dose (Sanofi) protects people 65 years and older better than standard-dose Fluzone. Does ACIP preferentially recommend use of Fluzone High-Dose for all people age 65 years and older?

A: Despite published evidence of better protection from Fluzone High-Dose when compared to standard-dose Fluzone (N Engl J Med 2014; 371:635–45), ACIP has not stated a preference for this vaccine for people age 65 years and older.

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Pneumococcal Vaccine
Q: Please describe the new ACIP recommendations for the use of PCV13 vaccine along with PPSV23 vaccine in people age 65 years and older. Can we give both vaccines at the same visit?

A: According to the ACIP recommendations published in September 2014, both pneumococcal conjugate vaccine (PCV13, Prevnar 13, Pfizer) and pneumococcal polysaccharide vaccine (PPSV23, Pneumovax, Merck) should be administered routinely in a series to all adults age 65 years and older. The two vaccines should not be given at the same visit.

Pneumococcal vaccine-naïve persons: Adults age 65 years and older who have not previously received pneumococcal vaccine or whose previous vaccination history is unknown should receive a dose of PCV13 first, followed by a dose of PPSV23 6–12 months later. If PPSV23 cannot be administered during this time window, the PPSV23 dose should be given at the next visit. The two pneumococcal vaccines should not be co-administered.

If the doses of PCV13 and PPSV23 are administered at an interval less than 6–12 months apart (sooner than recommended), the minimum acceptable interval between the two doses is 8 weeks (which means that PPSV23 must be repeated if given earlier than this).

Previous vaccination with PPSV23: Adults age 65 years and older who have previously received one or more doses of PPSV23 also should receive a dose of PCV13 if they have not yet received it. A dose of PCV13 should be given at least 1 year after receipt of the most recent PPSV23 dose. For those in whom an additional dose of PPSV23 is indicated, this subsequent PPSV23 dose should be given 6–12 months after PCV13 and at least 5 years after the most recent dose of PPSV23.

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Zoster  Vaccine
Q: Is a history of genital herpes a contraindication or precaution to zoster vaccination?

A: No. There is no evidence that zoster vaccine has any effect on herpes simplex virus.

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Hepatitis B Vaccine
Q:  In our newborn nursery, we administer hepatitis B vaccine and HBIG to all infants born to HBsAg-positive mothers (including premature newborns) within 12 hours of birth, but now I've heard that we're also supposed to administer HBIG (along with hepatitis B vaccine) to infants weighing less than 2,000 grams and born to mothers whose HBsAg status is unknown. Is this true, and if so, what is the rationale?

A: Yes, what you have heard is correct. Please refer to the ACIP recommendations for hepatitis B vaccine in children published in December 2005 available at www.cdc.gov/mmwr/PDF/rr/rr5416.pdf. See page 9, Table 4. Women who have not been screened prenatally for HBV infection have a higher prevalence of HBsAg seropositivity than women who are screened prenatally. Preterm infants weighing less than 2,000 grams have a decreased response to hepatitis B vaccine administered before age 1 month, so the HBIG dose provides some additional protection.

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Hepatitis A Vaccine
Q: For hepatitis A vaccination, the recommended interval between the 2-dose series is at least 6 months. Is this the same as 24 weeks?

A: No. The recommended interval between dose #1 and #2 of hepatitis A vaccine is 6 calendar months, not 24 weeks. See CDC's The Pink Book (Epidemiology and Prevention of Vaccine Preventable Diseases) available at www.cdc.gov/vaccines/pubs/pinkbook/downloads/appendices/A/age-interval-table.pdf, footnote 5.

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Polio Vaccine 
Q: Please describe the new CDC interim recommendations for polio vaccination for infants, children, and adults traveling to and from countries affected by wild polio.

A: In the U.S., all infants and children should receive 4 doses of inactivated poliovirus vaccine (IPV, Sanofi) at ages 2, 4, and 6–18 months, and 4–6 years. The final dose should be administered at age 4 years or older, regardless of the number of previous doses, and should be given 6 months or more after the previous dose. A fourth dose in the routine IPV series is not necessary if the third dose was given at age 4 years or older and 6 months or more after the previous dose. Infants and children traveling to areas where there has been wild poliovirus circulation in the last 12 months should be vaccinated according to the routine schedule. If the routine series cannot be administered within the recommended intervals before protection is needed, an accelerated schedule can be used as follows: 1) the first dose should be given to infants age 6 weeks and older, 2) the second and third doses should be administered at 4 weeks or more after the previous doses, and 3) the minimum interval between the third and fourth doses is 6 months.

If the age-appropriate series is not completed before departure, the remaining IPV doses to complete a full series should be administered when feasible, at the intervals recommended for the accelerated schedule. If doses are needed while residing in the affected country, the polio vaccine that is available (IPV or oral polio vaccine [OPV]) may be administered. See the MMWR article titled "Interim CDC Guidance for Polio Vaccination for Travel to and from Countries Affected by Wild Poliovirus" available at www.cdc.gov/mmwr/pdf/wk/mm6327.pdf, pages 591–4.

For adults who were routinely vaccinated as children, CDC states those adults are considered to have lifelong immunity to poliovirus, but data are lacking. As a precaution, people age 18 years and older who are traveling to areas where there has been wild poliovirus circulation in the last 12 months and who have received a routine series with either IPV or OPV in childhood should receive another dose of IPV before departure. For these adults, available data do not indicate the need for more than a single lifetime booster dose with IPV.

For detailed information about how to protect adults who are unvaccinated, incompletely vaccinated, or whose vaccination status is unknown, refer to the CDC guidance document cited above.

Ten countries (Afghanistan, Cameroon, Equatorial Guinea, Ethiopia, Iraq, Israel, Nigeria, Pakistan, Somalia, and Syria) are currently considered polio-infected. For more information for clinicians, visit CDC's Travel website at wwwnc.cdc.gov/travel/news-announcements/polio-guidance-new-requirements.

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General Vaccine Questions
Q: Our office is small and we only store vaccine in the refrigerator of a two-compartment refrigerator/freezer. Can we use the freezer portion to store staff food?

A: CDC recommends using separate refrigerator and freezer units for vaccine storage, but still allows use of a combination refrigerator/freezer if you only use the refrigerator portion for storing vaccines (as you are doing). CDC also recommends that you store food and beverages in a separate storage unit from vaccines, which you are technically doing but there may still be an impact on the refrigerator temperature by the opening and closing of the freezer door by staff. (In most two-compartment units, cold air from the freezer is circulated for cooling the refrigerator.)

The ideal situation would be to get a stand-alone pharmaceutical/purpose-built refrigerator unit for your vaccines, and use your refrigerator/freezer combination unit for your food and drinks. Please refer to pages 30 and 50 of the "Vaccine Storage and Handling Toolkit" available at www.cdc.gov/vaccines/recs/storage/toolkit/storage-handling-toolkit.pdf, for more detailed information.

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Q: If a patient pulls away during administration of a vaccine and the needle comes out, is it okay to reintroduce the same needle and finish the injection?

A: No. The needle should be considered to be contaminated. The needle and syringe should be discarded. A new syringe, needle, and dose of vaccine should be used. A full repeat dose should be given.

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Q: I know that immunosuppressed patients can receive inactivated vaccines, but not live vaccines. Will these patients who receive inactivated vaccines develop a sufficient immune response to make vaccinating them worthwhile?

A: Inactivated vaccines can be administered to people who take immunosuppressive drugs or who have a condition that causes them to be immunocompromised. The vaccines might not be as effective as they would be when given to a person with an intact immune system. If possible, the immunosuppresive drug should be discontinued for a month prior to vaccination, then allow the vaccine 2–3 weeks to generate an immune response before restarting the immunosuppressive treatment, but obviously, this is not always possible.

Determination of altered immunocompetence is important because incidence or severity of some vaccine-preventable diseases is greater in people with altered immunocompetence. As a result, certain vaccines (e.g., inactivated influenza vaccine and pneumococcal vaccines) are recommended specifically for people with altered immunocompetence.

More information can be found in ACIP's General Recommendations on Immunization available at www.cdc.gov/mmwr/pdf/rr/rr6002.pdf, pages19–23.

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Q: Is protective eyewear needed for those who administer vaccines so they can avoid blood spatter?

A: ACIP does not specifically recommend eye protection when administering vaccines.

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Q: If a patient has had an anaphylactic reaction to a bee sting, is it safe for her to receive injected vaccines?

A: Yes. Allergy to bee venom is not a contraindication for any vaccine.

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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 promise that we will print your specific question in our 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 colleagues and ask them to 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: bioCSL Inc.; MedImmune, Inc.; Merck Sharp & Dohme Corp.; Novartis Vaccines; Ortho Clinical Diagnostics, Inc.; Pfizer, Inc.; and sanofi pasteur.
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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. 6NH23IP22550) 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.