Read "Ask the Experts" Q&As about influenza and pneumococcal polysaccharide
vaccination from CDC experts
Many readers of Needle Tips, Vaccinate Adults,
and Vaccinate Women
consistently rank "Ask the Experts" as their favorite feature in
these publications. As a thank-you to our loyal IAC Express
readers, we have decided to periodically publish an Extra Edition
with new "Ask the Experts" Q&As answered by CDC experts.
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IAC thanks William L. Atkinson, MD, MPH, and Andrew T. Kroger, MD,
MPH, medical epidemiologists at the National Center for
Immunization and Respiratory Diseases, CDC, for agreeing to answer
the following questions.
Editor's note: Information about submitting a question to "Ask the
Experts" is provided at the end of this IAC Express article.
For which age groups of children is influenza vaccination now
Starting in fall 2008, all children ages 6 months through 18 years
are recommended to receive annual vaccination against influenza.
CDC issued this expanded recommendation with the intent to begin in
the 2008–09 influenza vaccination season and be fully in place by
the 2009–10 season.
Which adults should receive influenza vaccine this year?
Influenza vaccination is recommended for the following adults:
those age 50 years and older; women who will be pregnant during the
influenza season; those with any of the following medical
conditions that increase the risk of complications of influenza: a
chronic disorder of the pulmonary or cardiovascular system, a
chronic disease of the blood, liver, or kidneys, immunosuppression,
or diabetes; residents of nursing homes or other chronic-care
facilities; all healthcare personnel; and household contacts and
caregivers of children ages 0 through 59 months and of other
persons at increased risk of complications of influenza. Influenza
vaccine is also recommended for persons who want to reduce the risk
of becoming ill with influenza or of transmitting it to others.
What percentage of the U.S. population is recommended to receive
With the new recommendation to vaccinate all children ages 6 months
through 18 years, 85% of the U.S. population should be vaccinated
Who can receive the nasal spray influenza vaccine (FluMist) and who
can receive injectable influenza vaccine?
FluMist can be given to all healthy, non-pregnant people ages 2
through 49 years. However, FluMist should not be given to healthy
children younger than age 5 years who have recurrent wheezing or
have had a wheezing episode within the past 12 months. Injectable
influenza vaccine can be given to all people age 6 months and older
who have no contraindications or precautions to receiving the
Which children need 2 doses of influenza vaccine?
Children ages 6 months through 8 years who are receiving influenza
vaccine for the first time should be given 2 doses at least 4 weeks
apart. If they fail to get 2 doses during the current vaccination
season, they should get 2 doses during the next season.
When a child needs 2 doses of influenza vaccine, can I give 1 dose
of each type (injectable and nasal spray)?
Yes. As long as a child is eligible to receive nasal spray vaccine
(i.e., is in the proper age range and health status), it is
acceptable to give 1 dose of each type of influenza vaccine. The
doses should be spaced at least 4 weeks apart.
If patients need other vaccines, which ones can they get at the
same time as influenza vaccine?
All vaccines used for routine vaccination in the United States may
be given simultaneously.
If you miss giving recommended vaccines at the same visit, any
inactivated vaccine (e.g., DTaP, Tdap, HPV) can be administered any
time before or after a different inactivated or live vaccine (e.g.,
MMR, Var, LAIV). Any 2 live vaccines not given at the same time
must be given at least 4 weeks apart.
We have some adults who are in need of multiple vaccines (e.g.,
influenza, pneumococcal, and a tetanus-containing vaccine). When
only 2 vaccines are needed, we inject 1 in each arm, but when 3 or
more are recommended, we're not sure whether we should give all of
them or defer 1 or more until a later date.
ACIP recommends giving all indicated vaccines simultaneously
(i.e., at the same visit, NOT in the same syringe). Giving vaccines
together produces seroconversion rates and occurrences of adverse
reactions similar to those observed when the vaccines are
administered separately. Simultaneous administration also eliminates
the possibility that the patient will not return in a timely manner
for the deferred vaccine(s).
When giving 2 IM injections in the same limb, the vaccines should
be separated by 1 inch or more if possible in the muscle so that
any local reactions are unlikely to overlap.
Is it true that I can vaccinate pregnant women with influenza
vaccine during their first trimester?
Yes. All women who are pregnant or will be pregnant during the
influenza season should be vaccinated, including those who are in
their first trimester. Only inactivated (injectable) influenza
vaccine should be given to pregnant women.
Can thimerosal-containing vaccine be given to pregnant women?
Yes, unless you live in a state that has enacted legislation
restricting use in pregnant women. There is no scientific evidence
that thimerosal in vaccines, including influenza vaccines, is a
cause of adverse events, unless the patient has a systemic allergy
What is the Joint Commission's recommendation on vaccinating
healthcare workers against influenza?
In January 2007, a new infection control standard of the Joint
Commission became effective that requires accredited organizations
to offer annual influenza vaccination to staff, volunteers, and
licensed independent practitioners who have close patient contact.
If half of a dose of influenza vaccine leaked out of a prefilled
syringe while it was injected into a patient, does the dose need to
be repeated and if so, when?
When this happens, it is difficult to judge how much vaccine the
person received. This would be a nonstandard dose and should not be
counted. You should go ahead and re-immunize the individual at that
During which month is it no longer worthwhile to give influenza
vaccine to my patients?
If you have influenza vaccine in your refrigerator and unvaccinated
patients in your office, you should vaccinate them. Vaccinating in
June is likely unnecessary.
We mistakenly gave an infant pneumococcal polysaccharide vaccine
(PPSV) instead of pneumococcal conjugate vaccine (PCV). What should
PPSV is not effective in children younger than age 24 months. PPSV
given at this age should not be considered to be part of the
pneumococcal vaccination series. PCV should be administered as soon
as the error is discovered.
I have heard that there have been changes in the pneumococcal
polysaccharide vaccination recommendations for adults with asthma
and for smokers. Is this true?
Yes. The 1997 CDC recommendations for the use of pneumococcal
polysaccharide vaccine (PPSV) exclude asthma in the chronic
pulmonary disease category because no data on increased risk of
pneumococcal disease among persons with asthma were available when
the recommendation was issued. At its June 2008 meeting, the
Advisory Committee on Immunization Practices (ACIP) reviewed new
information that suggests that asthma is an independent risk factor
for pneumococcal disease among adults. At its October 2008 meeting,
ACIP reviewed new information that demonstrates an increased risk
of pneumococcal disease among adult cigarette smokers.
Consequently, ACIP voted to include both asthma and cigarette
smoking as risk factors for pneumococcal disease among adults ages
19 through 64 years and as indications for PPSV.
The new provisional ACIP recommendations for use of pneumococcal
vaccines can be accessed at
The new recommendations will be included in the 2009 Recommended
Adult Immunization Schedule, due to be published in January 2009.
My patient doesn't remember if he ever was vaccinated with PPSV and
we can't locate a record of vaccination. What should we do?
Providers should not withhold pneumococcal polysaccharide
vaccination in the absence of an immunization record or complete
record. Persons with uncertain or unknown vaccination status should
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