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Immunization Action Coalition
IAC Express 2009
Issue number 818: August 19, 2009
Please click here to subscribe to IAC Express as well as other FREE IAC periodicals.
Contents of this Issue
Select a title to jump to the article.
  1. Read "Ask the Experts" Q&As on topics from February and June 2009 ACIP meetings
 
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.
  
Issue 818: August 19, 2009
1.  Read "Ask the Experts" Q&As on topics from February and June 2009 ACIP meetings

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.

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 Edition.


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 (http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5824a5.htm).

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
http://www.cdc.gov/vaccines/vpd-vac/hib/faqs-return-to-booster-hcp.htm


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:
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5830a3.htm


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:
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5830a3.htm


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 to:
http://www.cdc.gov/vaccines/recs/provisional/downloads/rabies-July2009-508.pdf


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 insert (http://www.fda.gov/downloads/BiologicsBloodVaccines/Vaccines/ApprovedProducts/UCM142570.pdf) for more detailed information on the product.

To view ACIP's provisional recommendations for JEV vaccine, go to:
http://www.cdc.gov/vaccines/recs/provisional/downloads/je-july2009-508.pdf


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 our system?

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 http://www.cdc.gov/h1n1flu/guidance/ppsv_h1n1.htm

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.


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. To see if your question has already been answered, you can first check the "Ask the Experts" online archive at
http://www.immunize.org/askexperts

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 admin@immunize.org

Please forward these "Ask the Experts" Q&As to your co-workers and suggest they subscribe to IAC Express at http://www.immunize.org/subscribe

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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. 5U38IP000290) 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.