Issue 1239: April 4, 2016
Ask the Experts: CDC Experts Answer Your Questions
The questions and answers in this edition of IAC Express first appeared in the March 2016 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).
Hepatitis B Vaccine
Meningococcal ACWY Vaccines
Meningococcal B Vaccines
DTaP/Tdap Vaccines
General Vaccine Questions
Hepatitis B Vaccine
Q: An 18-year-old with a documented hepatitis B series as a child was seen for a school-required titer of antibody to hepatitis B surface antigen (anti-HBs). She has juvenile rheumatoid arthritis and receives immunoglobulin (IG) infusions every month. Her last treatment with an IG infusion was three weeks prior to her blood draw. The anti-HBs titer was positive. Could the IG infusion from three weeks ago cause her anti-HBs to be false positive? If so, how long should she wait to have another anti-HBs drawn?
A: ACIP does not address this issue but it is not likely that standard IG (as opposed to hepatitis B immune globulin [HBIG]) would cause a false positive anti-HBs. So if the anti-HBs was 10 mIU/mL or higher, the patient can be assumed to be immune to hepatitis B.
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Q: A physician ordered a 40-mcg dose of hepatitis B vaccine for a hemodialysis patient. The clinic does not stock the Recombivax HB 40-mcg/dose dialysis formulation (Merck) and would like to give 2 doses of Engerix-B 20-mcg/dose (GSK) for each dose in the series. Is this acceptable?
A: Yes. If given on the same day as separate injections in separate sites, two Engerix-B 20-mcg doses can be counted as the equivalent of one Recombivax HB 40-mcg dose. According to the package insert, Engerix-B is licensed for use in this manner. Vaccine package inserts for all vaccines are available at www.immunize.org/packageinserts.
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Meningococcal ACWY Vaccines
Q: I have an HIV-positive 64-year-old patient who received meningococcal conjugate vaccine last week. Was this the correct vaccine for this patient or should he have gotten MPSV4 due to his age? Also, should this patient get another dose in 2 months?
A: Quadrivalent meningococcal conjugate vaccine (MenACWY [MCV4]: Menactra, Sanofi Pasteur; Menveo, GSK) was the correct vaccine in this situation. The 2013 ACIP recommendations on meningococcal vaccination recommend the use of meningococcal conjugate vaccine in adults age 56 years and older who (1) were vaccinated previously with MenACWY and now need revaccination, or (2) are recommended to receive multiple doses. ACIP does not consider HIV infection alone to be an indication for MenACWY vaccine. However, if the decision is made to vaccinate a person with HIV infection, the patient should receive 2 doses of MenACWY separated by 8–12 weeks. Both MenACWY vaccines are licensed for use in people through age 55 years, which means that the use of these vaccines in people age 56 and older is off-label but recommended by ACIP.
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Q: We have a 68-year-old who has been asplenic since 2009. She had one dose of meningococcal polysaccharide vaccine (MPSV4, Menomune, Sanofi Pasteur) in 2009, but no subsequent dose. She is now due for a booster. Should she receive 2 doses of MenACWY, 2 months apart, to catch up, or just one dose?
A: This situation is not addressed in the most recent ACIP guidelines for meningococcal conjugate vaccine. It is the CDC meningococcal subject matter expert’s opinion that this patient should receive 2 doses of MenACWY separated by at least 8 weeks, followed by a booster dose of MenACWY every 5 years thereafter. The concern is that having had only MPSV4 previously, she may not have an adequate booster response to a single dose of MenACWY.
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Meningococcal B Vaccines
Q: I know the schedule for Trumenba (meningococcal serogroup B vaccine, Pfizer) is 0, 2, and 6 months. What are the MINIMUM intervals between doses of Trumenba and Bexsero (meningococcal serogroup B vaccine, GSK)? Our immunization information system needs to know the minimum intervals in order to assure that patients are appropriately vaccinated.
A: Neither ACIP nor the CDC meningococcal subject matter experts have addressed this issue. Given the lack of guidance, we must assume that the routine intervals are also the minimum intervals: for Trumenba, 8 weeks between doses 1 and 2, 4 months between doses 2 and 3, and 6 months between doses 1 and 3; for Bexsero, 4 weeks between doses 1 and 2. It is important to use these intervals when scheduling doses. However, if these intervals are violated, the doses still count and do not need to be repeated.
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Q: I have a patient who was given Trumenba in August. Two months later she was given a dose of Bexsero. How should I proceed with her MenB vaccination series? We stock both vaccines.
A: The ACIP meningococcal serogroup B vaccine recommendations (www.cdc.gov/mmwr/pdf/wk/mm6441.pdf, pages 1171–6) state that the same vaccine must be used for all doses in the MenB series. So the clinician needs to complete a series with one or the other vaccine. If a person has already received 1 dose of Bexsero and one of Trumenba, then pick a brand and finish a recommended schedule with that brand. Ignore the extra dose of the other product. The next dose in the series (either Trumenba or Bexsero) should be separated from the previous dose of Bexsero by at least 1 month.
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Q: My 8-year-old patient had a bone marrow transplant and has just finished the posttransplant re-vaccination process. Should I offer her vaccination with a MenB vaccine now or wait two years until she is 10 years old?
A: Neither brand of meningococcal B vaccine is approved by FDA or recommended by ACIP for people younger than age 10 years. You should defer meningococcal B vaccination until she is 10 years of age.
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DTaP/Tdap Vaccines
Q: Can Quadracel (DTaP-IPV, Sanofi Pasteur) be used to complete a series with vaccines other than Daptacel (DTaP, Sanofi Pasteur) or Pentacel (DTaP-IPV-Hib, Sanofi Pasteur)?
A: ACIP recommends the same brand of DTaP be used for all doses but that a different brand can be used if necessary. So Quadracel can be used in a series with another brand of DTaP if necessary. CDC published a short MMWR article about Quadracel on Sept. 4, 2015 (www.cdc.gov/mmwr/pdf/wk/mm6434.pdf, pages 948–9).
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Q: There is a debate within my clinical department about not allowing influenza vaccine to be given with DTaP and PCV13. Are there data that state these should not be given concomitantly?
A: A CDC study has shown a small increased risk for febrile seizures during the 24 hours after a child receives the inactivated influenza vaccine at the same time as the PCV13 vaccine or DTaP vaccine. However, the risk of febrile seizure with any combination of these vaccines is small and ACIP recommends giving these vaccines at the same visit if indicated. See www.cdc.gov/vaccinesafety/concerns/febrile-seizures.html for more information.
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Q: One of our staff inadvertently gave Tdap to an infant instead of DTaP. Now what should be done?
A: If Tdap was inadvertently administered to a child younger than 7 years of age, it should not be counted as either the first, second, or third dose of DTaP. The dose should be repeated with DTaP. Continue vaccinating on schedule. If the dose of Tdap was administered for the fourth or fifth DTaP dose, the Tdap dose can be counted as valid. Please remind your staff to always check the vaccine vial at least three times before administering any vaccine.
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Q: We would like to avoid stocking both Tdap and Td vaccines. Is CDC likely to recommend that Tdap completely replace Td in the immunization schedule in the near future?
A: Currently, ACIP recommends giving only 1 dose of Tdap to adolescents and adults who have not previously received the vaccine, with the exception of pregnant women, who should be vaccinated during each pregnancy. ACIP is unlikely to recommend routine Tdap revaccination for groups other than pregnant women. Vaccine providers will need to continue to stock Td vaccine in order to administer it to patients who need to complete the full primary 3-dose tetanus and diphtheria series and also to administer 10-year booster doses of Td throughout the lifetime of those who have completed the primary series. Note that if a person who previously received Tdap needs a booster dose of Td (as a routine booster dose or for wound management), it is acceptable to administer Tdap if Td is not available.
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General Vaccine Questions
Q: We have a question concerning delaying vaccinations for an infant born to a heroin-addicted mother. We had a foster parent come into our health department requesting only certain vaccines for a 3-month-old, stating that the private physician recommends delaying the schedule due to the possible residual effects of the heroin. The baby appeared to be healthy.
A: Heroin use or addiction of the mother is not a reason to delay vaccination of an otherwise healthy infant.
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Q: What is the provider’s liability when using standing order protocols?
A: While you did not say this explicitly, we assume the concern is about a vaccine injury in a person who was vaccinated using a standing order. Of course, as long as the person is properly screened for contraindications and precautions, an injury from a vaccine is very unlikely. In the event that an injury does occur, the National Vaccine Injury Compensation Program (VICP) provides liability protection for the vaccinator and the clinician who signed the standing order for any vaccine that is covered by the vaccine injury compensation program (all vaccines that are routinely administered to children are covered by the program for all ages of patients). More information about the VICP is available on their website at www.hrsa.gov/vaccinecompensation/index.html.
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Q: The protective cap on a single-dose vial was removed but the vaccine was not needed. No needle punctured the rubber seal. According to CDC’s Vaccine Storage & Handling Toolkit, the vial without the cap should be discarded at the end of workday. If no needle punctured the seal, what is the reasoning for discarding the vaccine?
A: Removing the protective cap increases the likelihood the septum or stopper could be punctured. The puncture may not be visible. It is important to ensure that the rubber seal on single-dose vials is not punctured because single-dose vials do not contain a preservative. Once the protective cap has been removed, the vaccine should be discarded at the end of the workday because it may not be possible to determine if the rubber seal has been punctured. CDC’s Vaccine Storage & Handling Toolkit is available at www.cdc.gov/vaccines/recs/storage/toolkit.
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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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