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Issue 978
IAC Express: Weekly immunization news and information

Issue 978: February 15, 2012

Ask the Experts: CDC Experts Answer Your Questions

All the questions and answers in this edition of IAC Express pertain to new ACIP recommendations for the use of HPV and hepatitis B vaccines. These Q&As first appeared in the February 2012 issue of Needle Tips.

IAC extends thanks to our experts, medical epidemiologist Andrew T. Kroger, MD, MPH; nurse educator Donna L. Weaver, RN, MN; medical officer Iyabode Akinsanya-Beysolow, MD, MPH; and medical epidemiologist William L. Atkinson, MD, MPH. All are with the National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention (CDC).

Questions and Answers
Q: Please describe the new recommendations for the use of HPV4 vaccine in males and explain how these new recommendations differ from the previous ones.

A: ACIP recommends routine vaccination of males age 11–12 years with HPV4 (Gardasil, Merck) administered as a 3-dose series. The vaccination series can be started beginning at age 9 years. Vaccination with HPV4 is recommended for males age 13 through 21 years who have not been vaccinated previously or who have not completed the 3-dose series. Males age 22 through 26 years may be vaccinated with HPV4.

ACIP recommends that immunocompromised males who have not been vaccinated previously or who have not completed the 3-dose series receive routine vaccination with HPV4 through age 26 years.

Men who have sex with men (MSM) are at higher risk for infection with HPV types 6, 11, 16, and 18 and associated conditions, including genital warts and anal cancer. ACIP recommends that MSM who have not been vaccinated previously or who have not completed the 3-dose series receive routine vaccination with HPV4 through age 26 years.

Previously, ACIP had issued permissive recommendations for HPV4 use in males age 9-26 years for the prevention of genital warts.

To obtain a copy of the new recommendations, see Recommendations on the Use of Quadrivalent Human Papillomavirus Vaccine in Males — Advisory Committee on Immunization Practices (ACIP), 2011.

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Q: Is it recommended that patients age 26 years start the HPV vaccination series even though they will be older than 26 when they complete it?

A: Yes. HPV vaccine is recommended for all women through age 26 years and also may be given to men through that age. So, the 3-dose series can be started at age 26 even if it will not be completed at age 26. The series should be completed regardless of the age of the patient (i.e., even if the patient is older than 26). In certain situations, some clinicians choose to start the 3-dose HPV series in patients who are older than 26 years. This, however, is an off-label use.

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Q: Will patients who have already had genital warts benefit from receiving Gardasil?

A: A history of genital warts or clinically evident genital warts indicates infection with HPV, most often type 6 or 11. However, people with this history might not have been infected with both HPV 6 and 11 or with HPV 16 or 18. Vaccination will provide protection against infection with HPV vaccine types the patient has not already acquired. Gardasil (HPV4) protects against HPV vaccine types 6, 11, 16, and 18; Cervarix (HPV2; GlaxoSmithKline) protects against HPV 16 and 18. Providers should advise their patients/clients that results from clinical trials do not indicate the vaccine will have any therapeutic effect on existing HPV infection or genital warts.

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Q: If a patient has been sexually active for a number of years, is it still recommended to give HPV vaccine or to complete the HPV vaccine series?

A: Yes. You should not withhold HPV vaccine from people who are already sexually active. Ideally, patients should be vaccinated before onset of sexual activity; however, patients who have already been infected with one or more HPV types still get protection from other HPV types in the vaccine that have not been acquired.

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Q: If a patient’s vaccination history indicates she received the third dose of HPV vaccine earlier than the recommended minimum interval of 24 weeks, should she be given a fourth dose?

A: Maybe. If the 3-dose series was given with minimum intervals of at least 4 weeks between dose #1 and dose #2 AND at least 12 weeks between dose #2 and dose #3, do not repeat any doses. If the third dose was given at less than 12 weeks from dose #2, repeat dose #3 at least 12 weeks after the invalid dose.

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Q: Will the Vaccines for Children (VFC) program cover HPV vaccination for males?

A: Yes. VFC funding will cover HPV4 (Gardasil) vaccination for VFC-eligible males age 9 through 18 years.

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Q: If HPV vaccine is given subcutaneously instead of intramuscularly, does the dose need to be repeated?

A: No, the dose does not need to be repeated. Vaccines should always be administered by the route recommended by the manufacturer; however if a vaccine is inadvertently administered SC instead of IM, or IM instead of SC, ACIP recommends that the dose be counted as valid with two exceptions: Hepatitis B or rabies vaccine administered by a route other than IM should be repeated.

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Q: Would you please provide details about the new ACIP recommendations for the use of hepatitis B vaccine in adult diabetic patients?

A: In December 2011, CDC published new ACIP recommendations that hepatitis B vaccine be given to adults with diabetes. The vaccine series is recommended for unvaccinated adults with diabetes age 59 years and younger. At the discretion of the treating clinician, the vaccine may also be administered to unvaccinated adults with diabetes age 60 years and older.

The recommendations were prompted by a number of outbreaks of hepatitis B virus infection in settings that provide assisted blood glucose monitoring for people with diabetes.

Administration of the hepatitis B vaccine series should be completed as soon as feasible after diabetes is diagnosed. No serologic testing or additional hepatitis B vaccination is recommended for adults who received a complete series of hepatitis B vaccinations at any time in the past.

Hepatitis B vaccine may be administered during healthcare visits scheduled for other purposes, as long as minimum intervals between doses are observed. No maximum interval between doses exists that would make the hepatitis B vaccination series ineffective or that would require restarting the series.

You can read the details of this recommendation and the rationale behind it in the December 23, 2011 issue of MMWR.

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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 guarantee that we will print your specific question in the 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 co-workers and suggest they subscribe to IAC Express.

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About IAC Express 
The Immunization Action Coalition welcomes redistribution of this issue of IAC Express or selected articles. When you do so, please add a note that the Immunization Action Coalition is the source of the material and provide a link to this issue.
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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: Baxter Healthcare Corp.; CSL Biotherapies; GlaxoSmithKline; MedImmune, Inc.; Merck Sharp & Dohme Corp.; Novartis Vaccines; Ortho Clinical Diagnostics, Inc.; Pfizer, Inc.; and sanofi pasteur.
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Issue 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.
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Editor: Deborah L. Wexler, MD
Managing Editor: Dale Thompson, MA
Associate Editor: Teresa Anderson, DDS, MPH
Editorial Assistant: Janelle Tangonan Anderson
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