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Issue 992
IAC Express: Weekly immunization news and information

Issue 992: May 2, 2012

Ask the Experts: CDC Experts Answer Your Questions

All the questions and answers in this edition of IAC Express pertain to new guidance for the use of Tdap, HPV, and pneumococcal vaccines.  

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 review the new recommendations for the use of Tdap in people 65 years and older.

A: At its February 2012 meeting, ACIP voted to recommend Tdap for adults age 65 years and older. CDC posted the provisional recommendations on its website on March 21 at www.cdc.gov/vaccines/recs/provisional/downloads/Tdap-feb2012.pdf

Two Tdap vaccines are currently licensed in the United States. They are Boostrix (GSK), approved for use in people age 10 years and older, and Adacel (sanofi pasteur) approved for use in people age 11 through 64 years.

The provisional recommendations state the following:

  • Give a single dose of Tdap to previously unvaccinated adults age 19 years and older. 
  • Give the Tdap dose regardless of the interval since the person last received a tetanus or diphtheria toxoid-containing vaccine.
  • Give the Tdap dose to adults for whom it is recommended if no record of previous administration exists.

Do not miss an opportunity to give Tdap to people age 65 years and older. Administer the vaccine you have available—either Boostrix or Adacel. When feasible, give Boostrix to adults age 65 and older. However, either vaccine product provides protection and is considered valid for use in people in this age group.

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Q: Is there an upper age limit for Tdap administration? For example, should I vaccinate an 85-year-old?

A: There is no upper age limit for Tdap vaccination. A one-time dose of Tdap is recommended for all adults.

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

A: Yes. No data exist on the efficacy or safety of HPV vaccine given by the subcutaneous route. All data on efficacy and duration of protection are based on a 3-dose series given on the approved schedule and administered by the intramuscular route. In the absence of data on subcutaneous administration, CDC and the manufacturers recommend that a dose of HPV vaccine given by any route other than intramuscular should be repeated. There is no minimum interval between the invalid (subcutaneous) dose and the repeat dose.

Editor's note: This question is identical to a question that appeared in Ask the Experts in the February 2012 issues of Needle Tips and Vaccinate Adults. The answer, however, is different. The answer given in February generated significant discussion, which led CDC experts to modify the answer.

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Q: Which children should receive PPSV vaccine (in addition to PCV7 and/or 13)? At what age should they receive it? What about older high-risk children who never received PCV13—should they get it now?

A: PPSV is recommended for children with an immunocompromising condition, or functional or anatomic asplenia, and also for immunocompetent children with chronic heart disease, chronic lung disease, diabetes mellitus, cerebrospinal fluid leak, or cochlear implant. Administer 1 dose of PPSV to children age 2 years and older; administer it at least 8 weeks after the child has received the final dose of PCV13. Children with an immunocompromising condition, or functional or anatomic asplenia should receive a second dose of PPSV 5 years after the first PPSV. Older high-risk children who have not yet received a dose of PCV13 should receive it now. To view a table describing these recommendations in more detail, see IAC's provider-education piece titled Recommendations for Pneumococcal Vaccine Use in Children.

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Q: Which adults need to receive PPSV prior to age 65 years?

A: PPSV is recommended for adults age 19 through 64 years who currently smoke cigarettes; reside in nursing homes or long-term care facilities; have chronic lung disease (including chronic obstructive pulmonary disease, emphysema, and asthma); chronic cardiovascular diseases; diabetes mellitus; chronic liver disease (including cirrhosis); alcoholism; cochlear implants; cerebrospinal fluid leaks; immunocompromising conditions; and functional or anatomic asplenia (e.g., sickle cell disease and other hemoglobinopathies, congenital or acquired asplenia, splenic dysfunction, or splenectomy [if elective splenectomy is planned, vaccinate at least 2 weeks before surgery]); asymptomatic or symptomatic HIV (vaccinate as soon as possible after diagnosis). Public health authorities may consider recommending PPSV for American Indians/Alaska Natives who live in areas where the risk for invasive pneumococcal disease is increased. Please see IAC's Pneumococcal Polysaccharide Vaccine: CDC answers your questions

The following Q&A explains which adults need a second dose of PPSV.

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Q: Which adults should receive a second dose of PPSV?

A: A one-time revaccination 5 years after the first dose is recommended for people age 19 through 64 years who have functional or anatomic asplenia (including persons with sickle cell disease or splenectomy patients); chronic renal failure (including dialysis patients) or nephrotic syndrome; are immunocompromised, including those with HIV infection, leukemia, lymphoma, Hodgkin’s disease, multiple myeloma, generalized malignancy; are receiving immunosuppressive therapy (including long-term systemic corticosteroids or radiation therapy); or who have received an organ or bone marrow transplant.

Adults who receive their first PPSV at or after age 65 years should receive only a single dose, regardless of their health status. Please see IAC's Pneumococcal Polysaccharide Vaccine: CDC answers your questions

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Q: PCV13 is now licensed for use in adults, but I don't see anything about it in the 2012 adult immunization schedule. How should it be used?

A: FDA licensed PCV13 (Prevnar13; Pfizer) for adults age 50 years and older in December 2011. At its February 2012 meeting, the Advisory Committee on Immunization Practices (ACIP) reviewed the evidence for the use of PCV13 in adults but did not vote on recommendations for its use in adults. As always, physicians can use their clinical judgment and use FDA-licensed vaccines if they would like to do so.

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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.
If you have trouble receiving or displaying IAC Express messages, visit our online help section.
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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