Read "Ask the Experts" Q&As on topics from February and
June 2009 ACIP meetings
Many readers of Needle Tips, Vaccinate Adults,
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
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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.
All the Q&As in this edition of IAC Express deal with issues
discussed at the February and June 2009 ACIP meetings.
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.
Information about IAC's preferred citation style can be
found at http://www.immunize.org/citeiac
You can access more "Ask the Experts" Q&As in our online
archive at http://www.immunize.org/askexperts
Editor's note: Information about submitting a question to
"Ask the Experts" is provided at the end of this Extra
Q: I understand a second dose of meningococcal conjugate
vaccine (MCV4) is now recommended for certain people. Please
tell me more about this.
A: When meningococcal conjugate vaccine (Menactra; sanofi
pasteur) was licensed in January 2005, data were lacking on
long-term efficacy and the need for additional vaccination.
Since that time, studies indicate that antibody level
declines over time. ACIP voted on June 24, 2009, to
recommend a routine second dose of MCV4 for people at
highest risk for meningococcal infection. This group
includes people (1) with persistent complement component
deficiencies, (2) with anatomic or functional asplenia, (3)
who are infected with HIV, or (4) who frequently travel to
or live in areas with high rates of meningococcal disease
(African meningitis belt). Children at continued high risk
who received the first dose of MCV4 at ages 2 through 6
years should receive the second dose no sooner than 3 years
after the first dose. People at continued high risk who
received the first dose of meningococcal vaccine at age 7
years or older should receive the second dose no sooner than
5 years after the first dose. Because MCV4 is licensed only
for people through age 55, adults 56 and older should
instead receive meningococcal polysaccharide vaccine (MPSV;
Menomune; sanofi), as should people ages 2 through 55 years
who have a precaution or contraindication to MCV4. Students
living in on-campus housing are not included in the at-risk
group to receive second doses of MCV4 vaccine.
Q: I understand that the recommendation to give routine Hib
boosters at 12-15 months has been reinstated. When did this
happen, and how do we catch children up on their doses?
A: The Hib booster dose was reinstated on June 26, 2009.
Here's some background: As you probably know, a shortage of
Hib vaccine began in late 2007 when Merck voluntarily
recalled certain lots of its PedvaxHIB (Hib) and Comvax
(Hib-HepB) vaccines and temporarily suspended production.
Healthcare providers were advised to conserve the limited
supply of the other Hib-containing products (sanofi's ActHIB
[Hib] and Pentacel [DTaP-Hib/IPV] vaccines) by temporarily
deferring the routine Hib booster dose in healthy children.
The booster is typically given to children ages 12-15
months. In July 2009, sanofi increased its production of
these 2 Hib-containing vaccines such that the supply will be
sufficient to reinstate the Hib vaccine booster dose for all
children. CDC published "Updated Recommendations for Use of
Haemophilus influenza Type b (Hib) Vaccine: Reinstatement of
the Booster Dose at Ages 12-15 Months" in the June 26 MMWR
About catching children up: CDC does not recommend a mass
recall of all children who missed their booster dose.
Rather, healthcare providers should administer Hib boosters
to all children age 12-15 months who have completed the 3-dose primary series of Hib vaccine (typically given at ages
2, 4, and 6 months). Children who have not yet reached their
fifth birthday, and for whom the booster dose was deferred,
should be vaccinated at their next routinely scheduled
appointment or medical encounter. CDC has posted online
guidance, "Hib Vaccine--Q&A for Providers about the Return
to the Hib 'Booster' Dose," on its website at
Q: When we vaccinate children age 12-15 months or 4-6 years,
should we use a separate MMR vaccine and a separate
varicella vaccine, or should we use the combination MMRV
vaccine? Does ACIP state a preference?
A: At its June 2009 meeting, ACIP voted to recommend (1) no
preference for use of either the combination MMRV vaccine or
the separate MMR and varicella vaccines when giving the
first dose to a child age 12-15 months; (2) a general
preference for MMRV vaccine (over separate MMR and varicella
vaccines) when giving the first dose to a child age 4 years
or older; and (3) a general preference for MMRV vaccine
(over separate MMR and varicella vaccines) when giving the
second dose to a child up through age 12 years. ACIP also
voted to include a personal or family history of seizures as
a precaution for administering MMRV vaccine. Data from post-licensure studies of administration of the combination MMRV
vaccine and the individual MMR plus varicella vaccines have
suggested an increased risk for febrile seizures in the 1-2
week period after the first dose of MMRV when it is given to
children at age 12-15 months.
Q: When we give the combination DTaP-IPV/Hib vaccine
(Pentacel by sanofi) for the primary series to a child at
ages 2, 4, 6, and 15-18 months, the child receives a total
of 4 doses of IPV. Does the child still need a booster dose
of IPV before entering kindergarten?
A: Yes. In summer 2009, ACIP updated its recommendations for
use of inactivated poliovirus vaccines (IPV), partly in
response to the availability of newer combination vaccines
(e.g., Pentacel) that include an IPV component. ACIP now
recommends that children receive at least 1 dose of IPV at
age 4 through 6 years, even if they have previously received
4 doses. The interval between the next-to-last and last dose
should be at least 6 months. This means that some children
may receive a total of 5 doses, a practice ACIP considers
acceptable. This is similar to the recommendation for the
last dose in the DTaP series. To view the updated polio
vaccine recommendations, go to:
Q: This summer we saw a 4-year-old child who had a record of
only 1 dose of polio vaccine (IPV). I understand that
because of his age, he needs only 2 more doses of IPV. Can
we give him those doses at 4-week intervals so he can be all
caught up by the time he starts school in the fall?
A: No. In summer 2009, ACIP updated its recommendations for
use of IPV to clarify that the interval between the last 2
doses must be at least 6 months. To view the
recommendations, go to:
Q: I understand that ACIP now recommends fewer doses of
rabies vaccine be given in certain post-exposure situations.
Can you tell me more?
A: In June 2009, ACIP voted to eliminate the fifth dose of
vaccine given as post-exposure prophylaxis to previously
unvaccinated persons who are not immunosuppressed. This
decision was based on evidence that the elimination of the
fifth dose will not compromise immunity. The implications of
this change are that it will conserve the supply of rabies
vaccine, protect the patient, and reduce the number of
office visits. To view the provisional recommendations, go
Q: We provide vaccinations and health advice for
international travelers. I understand that the
recommendations for Japanese encephalitis virus (JEV)
vaccines have recently changed. Can you explain?
A: You are probably aware that there had been a shortage of
JEV vaccine because JE-Vax (Biken) is no longer being
produced. The shortage of vaccine for adults has been
alleviated somewhat since the licensure of a second vaccine
(Ixiaro, Intercell Biomedical) in March 2009. Ixiaro is
given as a 2-dose series to adults age 17 and older. JE-Vax
is given as a 3-dose series to people ages 1 year and older.
The remaining inventory of JE-Vax is now restricted for use
in children ages 1 through 16 years. The revised JEV
recommendations will include Ixiaro; the targeted
populations (e.g., travelers who plan to spend a month or
longer in endemic areas during the JEV transmission season)
are the same for both JEV vaccines. CDC is revising the JEV
Vaccine Information Statement to reflect the dosing
information and age indications for both vaccines; in the
meantime, providers can refer patients to the Ixiaro package
for more detailed information on the product.
To view ACIP's provisional recommendations for JEV vaccine,
Q: We have begun a more aggressive approach to vaccinating
our high-risk patients against pneumococcal disease,
especially in light of the pending 2009 H1N1 influenza virus
pandemic. Do you have any suggestions on how we can improve
A: Congratulations on your efforts to increase your clinic's
vaccination rates against this serious and deadly disease.
Health experts have found that influenza predisposes
individuals to bacterial community-acquired pneumonia, and
studies have shown that this is heightened during influenza
pandemics. In June 2009, CDC issued interim guidance for use
of 23-valent pneumococcal polysaccharide vaccine (PPSV) in
preparation for the upcoming influenza season. Though the
interim guidance does not change the groups indicated for
PPSV vaccination, it does remind providers that many at-risk
people younger than age 65 years and many people who are age
65 and older have not yet been vaccinated--and they need to
be. You can find the interim guidance statement at
For more information on PPSV vaccination, including a
listing of the high-risk people recommended to be
vaccinated, read IAC's professional education sheet
"Pneumococcal polysaccharide vaccine (PPSV): CDC answers
your questions" (http://www.immunize.org/catg.d/p2015.pdf).
Q: We've heard there is a new recommendation for giving
hepatitis A vaccine to people who will be in contact with
recently adopted children. Would you give us the details?
A: Yes. ACIP voted in February 2009 to recommend vaccination
against hepatitis A for all previously unvaccinated people
who anticipate having close personal contact with an
international adoptee from a country of high or intermediate
endemicity during the first 60 days following the adoptee's
arrival in the U.S. In addition to the adoptee's new parents
and siblings, this group could include grandparents and
other members of the extended family, caregivers, and
healthcare providers. Ideally, the first dose of HepA
vaccine should be given to close contacts as soon as
adoption is planned but no later than 2 weeks prior to the
arrival of the adoptee. A second dose should be given no
sooner than 6 months after the first dose.
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