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Issue 1497
IAC Express: Weekly immunization news and information

Issue 1497: May 26, 2020

Ask the Experts: IAC Experts Answer Your Questions about Vaccination During the Pandemic and about Tdap Recommendations


As a thank-you to our loyal IAC Express readers, we periodically publish special editions such as this one, providing you with new and updated “Ask the Experts” questions that are answered by IAC experts. This issue’s Q&As include several about COVID-19 and routine vaccination as well as Q&As about Tdap (tetanus, diphtheria, acellular pertussis) vaccination based on recently updated ACIP recommendations.

You can find all of these questions and answers, plus more than a thousand others about vaccines and vaccine administration, on our Ask the Experts web page: www.immunize.org/askexperts/.
 
IAC wishes to recognize our team of experts: Kelly L. Moore, MD, MPH (team lead); Carolyn Bridges, MD, FACP; William Atkinson, MD, MPH; and Deborah Wexler, MD.

Routine Vaccination during the COVID-19 Era

Tdap Vaccine Recommendations


Routine Vaccination during the COVID-19 Era


Q: What is the status of the COVID-19 vaccine?

A: There is currently no licensed vaccine to prevent coronavirus disease 2019 (COVID-19). Research and development programs are underway in the U.S. and around the world to develop a vaccine that is safe and effective.

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Q: What does CDC advise about administering routine immunizations to children and teens when COVID-19 is circulating?

A: The COVID-19 pandemic is changing rapidly and continues to affect communities across the U.S. differently. Ensuring the delivery of newborn and well-child care, including childhood immunization, requires strategies to keep children safe. Healthcare providers in affected communities are using strategies to separate well visits from sick visits.

Examples include:

  • Scheduling well visits in the morning and sick visits in the afternoon.
  • Placing patients with sick visits in different areas of the clinic or another location from patients with well visits.
  • Collaborating with other immunization providers in the community to identify separate locations for holding well visits for children.
Because of personal, practice, or community circumstances related to COVID-19, some providers may not be able to carry out well-child visits, including provision of immunizations, for all patients in their practice. If a practice can provide only limited well-child visits, healthcare providers are encouraged to prioritize newborn care and vaccination of infants and young children (through age 24 months) when possible.

CDC will continue to provide guidance as the pandemic unfolds. Visit this link for the latest information: www.cdc.gov/coronavirus/2019-ncov/hcp/pediatric-hcp.html

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Q: Should infants born to women with hepatitis B virus infection (hepatitis B surface antigen-positive [HBsAg+]) be treated differently during the COVID-19 pandemic?

A: The prevention of mother-to-child transmission of hepatitis B virus infection requires timely vaccination and administration of hepatitis B immune globulin (HBIG) at birth, followed by completion of the hepatitis B vaccine series and post-vaccination serologic testing. Every effort should be made to complete the vaccination series on time. CDC has provided interim guidance for the prevention of mother-to-child transmission of hepatitis B available at www.cdc.gov/vaccines/schedules/hcp/schedule-changes.html.

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Q: What does CDC advise about administering routine immunizations to adults when COVID-19 is circulating?

A: In areas with community transmission of COVID-19, vaccination visits should be postponed except when:

  • An in-person visit must be scheduled for some other purpose and vaccination can be done during that visit without increasing the risk of COVID-19 exposure; or
  • An individual patient and their clinician believe that there is a compelling need for vaccination based on an assessment that the potential benefit outweighs the risk of exposure to the virus that causes COVID-19.

CDC recommendations about how to deliver immunizations to adults in areas with community transmission of COVID-19 may be updated regularly. Current guidance is available at this website:
www.cdc.gov/vaccines/schedules/hcp/schedule-changes.html 

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Q: When COVID-19 is circulating, if I have the opportunity to vaccinate a child, teen, or an adult, should I administer only high priority vaccines, or should I administer all routine vaccines that are due at that visit?

A: You should continue to follow CDC’s best practice guidelines and administer all recommended vaccines simultaneously when no specific contraindications exist at the time of the visit. By administering all vaccines due at the visit, you will reduce the total number of healthcare encounters necessary for the patient to be fully vaccinated.

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Q: Some patients develop flu-like symptoms or fever after vaccination with recombinant zoster vaccine (RZV, Shingrix; GSK). Should I defer Shingrix vaccination because such a reaction might be confused with COVID-19?

A: No. If you have an opportunity to vaccinate a patient age 50 years or older who is due for dose 1 or dose 2 of Shingrix, proceed with vaccination as usual. It is important to counsel the patient about the risk of self-limited side effects, including local reactions, such as redness, pain, or swelling at the injection site, and systemic reactions, which include fever, chills, headache, and body aches. If they occur, such side effects normally resolve within 72 hours after vaccination.  
 
Because of concerns about COVID-19, if a vaccine recipient develops fever after vaccination, they should stay home until it resolves. Shingrix vaccination does not cause respiratory symptoms common in COVID-19, such as cough or shortness of breath. If the vaccine recipient develops new symptoms of cough or shortness of breath, or if fever does not resolve within 72 hours of vaccination, the recipient should contact their healthcare provider. 

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Q: Due to COVID-19 circulation in my community, I am delivering more patient care via telemedicine. Does that mean I can do nothing about vaccinations?

A: No. You can consider conducting your immunization assessment and counseling during the telemedicine visit and scheduling the patient for a brief vaccination-only encounter at an appropriate time and location.

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Tdap Vaccine Recommendations


Q: Is it true that pertussis in children is increasing? Are more infants dying from the disease?

A: Since the 1980s, the number of reported pertussis cases has increased. In 2018 and 2019, CDC received reports of more than 15,600 cases of pertussis each year. Increases in pertussis have been noted in infants younger than age 1 year, adolescents age 11–18 years, and adults. Approximately 1 in 10 U.S. pertussis cases were among infants. An increase in the number of reported deaths from pertussis among very young infants has paralleled the increase in the number of reported cases. Reasons for the increases in pertussis are not completely clear; however, multiple factors have likely contributed to the increase, including waning immunity from the pediatric acellular vaccine (DTaP), increased recognition of pertussis, and improved diagnostic testing and reporting.

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Q: Where can I find the most recent recommendations for use of pediatric diphtheria-tetanus-acellular pertussis (DTaP) and adolescent/adult tetanus-diphtheria-acellular pertussis (Tdap) vaccine?

A: In April 2018, the Advisory Committee on Immunization Practices (ACIP) published a compilation of all previous recommendations for the prevention of pertussis, tetanus, and diphtheria (MMWR 2018;678 [RR-2]:1-31). The document can be accessed on the CDC website at www.cdc.gov/mmwr/volumes/67/rr/pdfs/rr6702a1-H.pdf.

In January 2020, ACIP published updated Tdap recommendations, stating that either Td or Tdap may be used in situations where Td only was previously recommended. The document can be accessed on the CDC website at www.cdc.gov/mmwr/volumes/69/wr/pdfs/mm6903a5-H.pdf.

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Q: What are the recommendations for use of Tdap in children and adults age 7 and older?

A: The most current ACIP recommendations for Tdap can be accessed here at www.cdc.gov/mmwr/volumes/69/wr/pdfs/mm6903a5-H.pdf

A listing of the recommendations follows:

  • Tdap can be given regardless of the interval since the last Td was given. There is NO need to wait 2–5 years to administer Tdap following a dose of Td.
  • Adolescents should receive a single dose of Tdap (instead of Td) at the 11–12-year-old visit.
  • Adolescents and adults who have not received a dose of Tdap, or for whom vaccine status is unknown, should receive a single dose of Tdap as soon as feasible. As stated above, Tdap can be administered regardless of interval since the previous Td dose.
  • Children age 7–10 years who are not fully immunized against pertussis (i.e., did not complete a series of pertussis-containing vaccine before their seventh birthday) should receive a single dose of Tdap. If needed, they should complete their series with Td or Tdap. If a Tdap dose is administered at age 10 years or older, the Tdap dose may count as the adolescent Tdap dose.
  • All healthcare personnel, regardless of age, should receive a single dose of Tdap as soon as feasible if they have not previously received Tdap and regardless of the time since the last dose of Td.
  • Pregnant teens and women should receive Tdap during each pregnancy, preferably between 27 and 36 weeks' gestation. Women who have never received Tdap and who do not receive it during pregnancy should receive it immediately postpartum.
  • Tdap may be administered in any situations where Td only was previously recommended.

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Q: My 11-year-old patient received a dose of Tdap when he was 7 years old. He also received a dose of Td 6 months later in order to finish a primary series of tetanus-toxoid. Can I give him a dose of Tdap now?

A: Yes. The January 2020 ACIP updated statement on the use of Tdap (available at www.cdc.gov/mmwr/volumes/69/wr/pdfs/mm6903a5-H.pdf) states that a child who receives a dose of Tdap from age 7–9 years as part of the catch-up series (as in this case), should receive another dose of Tdap at age 11 or 12 years.

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Q: When should adolescents who received a dose of Tdap (Adacel, Sanofi; Boostrix, GSK) at age 11–12 years receive their next dose of Td or Tdap?

A: As of January 2020, ACIP recommends that Td or Tdap may be administered in any situation when only Td vaccine was previously recommended. Someone who received a dose of Tdap at age 11 or 12 years should receive a booster dose of Td or Tdap vaccine ten years later, unless tetanus prophylaxis is required sooner due to an injury or if Tdap vaccination is needed during pregnancy.

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Q: We have a 63-year-old patient who states she had tetanus as a child. She does not know whether she ever had any tetanus-containing vaccines in her lifetime. Should Tdap be given to this patient, and is it safe?

A: A history of tetanus disease is not a reason to avoid tetanus-containing vaccines. Tetanus disease does not produce immunity because of the very small amount of toxin required to produce illness. As long as your patient has no other contraindications she should receive Tdap now. If she has no documentation of prior tetanus vaccination, she should receive a complete 3-dose primary series (dose #1 of Tdap, followed by dose #2 of Td or Tdap 4–8 weeks later, and dose #3 of Td or Tdap 6–12 months after dose #2).

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Q: We would like to avoid stocking both Tdap and Td vaccines. May we stock only Tdap vaccine under the updated Tdap CDC recommendations?

A: Yes. The updated ACIP recommendations for the use of Tdap vaccine state that Tdap or Td may be used in any situation where Td only was previously recommended. The updated guidelines are available at www.cdc.gov/mmwr/volumes/69/wr/pdfs/mm6903a5-H.pdf.  

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Q: If a dose of DTaP or Tdap is inadvertently given to a patient for whom the product is not indicated (e.g., wrong age group), how do we rectify the situation?

A: The first step is to inform the parent/patient that you administered the wrong vaccine. Next, follow these guidelines:

  • Tdap given to a child younger than age 7 years as either dose 1, 2, or 3, is not valid. Repeat with DTaP as soon as feasible.
  • Tdap given to a child younger than age 7 years as either dose 4 or 5 can be counted as valid for DTaP dose 4 or 5.
  • Tdap given to a fully vaccinated child age 7–10 years: If the child is age 7– 9 years, the child should receive the routine Tdap dose at age 11–12 years. If the child is age 10, the child does not need to receive the routine Tdap dose at age 11–12 years.
  • DTaP given to a fully vaccinated child age 7–10 years: count this dose as the routine adolescent Tdap dose. The child does not need to receive the routine Tdap dose at age 11–12 years. Note that DTaP is neither approved nor recommended for person older than 6 years (except hematopoietic stem cell transplant recipients in some situations; see www.cdc.gov/vaccines/hcp/acip-recs/general-recs/immunocompetence.html).
  • DTaP given to an undervaccinated child age 7–10 years: count this dose as a Tdap dose of the catch-up series. The child should receive the routine booster dose of Tdap at age 11–12 years.
  • DTaP given to a person age 11 years or older: count this dose as a routine Tdap dose.

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Q: ACIP states that children up to date on vaccines who receive a Tdap vaccine when 7–9 years old should receive another Tdap dose at age 11 or 12 years old. What about a child who is 10 years old?

A: Tdap vaccination for adolescents is recommended at age 11–12 years. A 10-year-old who is already up to date on diphtheria/tetanus/pertussis vaccines and gets a Tdap vaccine for any reason does not need to receive another Tdap at age 11–12 years.

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Q: Some children in my practice are not up to date on their immunizations, and pertussis is circulating in our community. Can you guide me in determining how to make the decision about which vaccine to choose?

A: You should use DTaP in children younger than age 7 years. In addition, ACIP recommends giving a dose of Tdap to children age 7–10 years who did not finish a minimum 3-dose series of pertussis-containing vaccines before their 7th birthday or for whom their pertussis vaccine status is unknown. Children age 7–10 who require more than one dose of tetanus-containing vaccine to be up to date may be given either Td or Tdap for doses needed after the initial Tdap dose. Although this is an off-label use of the vaccines, it's important that you vaccinate these vulnerable children with Tdap as well as any other adolescent or adult who hasn't received Tdap previously.

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Q: According to the ACIP recommendations, which healthcare personnel should be vaccinated against pertussis with tetanus-diphtheria-acellular pertussis (Tdap) vaccine?

A: ACIP recommends the following for the use of Tdap in healthcare personnel:

  • All healthcare personnel (HCP), regardless of age, should receive a single dose of Tdap as soon as feasible if they have not previously received Tdap and regardless of the time since last Td dose.
  • Tdap may be administered in any situations where Td only was previously recommended. After receipt of Tdap, HCP should receive routine booster immunization against tetanus and diphtheria with either Td or Tdap vaccine. Additionally, pregnant HCP should receive a dose of Tdap during each pregnancy.
  • Hospitals and ambulatory-care facilities should provide Tdap for HCP and use approaches that maximize vaccination rates (e.g., education about the benefits of vaccination, convenient access, and the provision of Tdap at no charge).

To view updated recommendations on the use of Td or Tdap in situations where only Td was previously recommended, go to www.cdc.gov/mmwr/volumes/69/wr/pdfs/mm6903a5-H.pdf. For details about Tdap and other recommendations for healthcare personnel, go to "Immunization of Health-Care Personnel" (MMWR 2011;60[SS-7]:4-46) at www.cdc.gov/mmwr/pdf/rr/rr6007.pdf.

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Q: Please review the current recommendations for the use of Tdap in adults.

A: ACIP recommends the following:

  • All adults age 19 years and older who have not yet received a dose of Tdap should receive a dose.
  • All pregnant women should receive a dose of Tdap during each pregnancy, preferable between 27 and 36 weeks' gestation. Women who have never received Tdap and who do not receive it during pregnancy should receive it immediately postpartum.
  • A person who has not yet received a dose of Tdap can be given a dose of Tdap regardless of the interval since the person last received a tetanus or diphtheria toxoid-containing vaccine.
  • Providers should not miss an opportunity to vaccinate adults age 65 years and older with Tdap. When feasible, give Boostrix to adults age 65 and older. However, either vaccine product (Adacel or Boostrix) provides protection and is considered valid for use in people in this age group.
  • For adults not previously vaccinated with Tdap who need wound management care to prevent tetanus, Tdap is preferred over Td.
  • For adults who have received an initial dose of Tdap, Tdap may be administered in any situations where Td only was previously recommended.

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Q: A pertussis outbreak is occurring in our town, with many cases happening in the schools. Is there a recommendation for boosting middle- and high-school students with an additional dose of Tdap during an outbreak if students have already had 1 dose?

A: Revaccination of individuals who are up to date on Tdap immunization with an additional dose of Tdap during a pertussis outbreak is currently not recommended.

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Q: How effective is giving Tdap during pregnancy at preventing pertussis in early infancy?

A: A CDC evaluation found Tdap vaccination during the third trimester of pregnancy prevents 78% of pertussis cases in infants younger than 2 months of age. These findings are similar to other studies from the United Kingdom and the United States that suggest that vaccinating the mother during pregnancy is highly effective at protecting infants against pertussis.

When infants do get pertussis, their infection is less severe if their mother received Tdap during pregnancy. A CDC evaluation found maternal vaccination is 90% effective at preventing infant hospitalization from pertussis. Another U.S. study showed that infants whose mothers got Tdap during pregnancy had a significantly lower risk of hospitalization and shorter hospital stays. That same study showed that no infants born to vaccinated mothers required intubation or died of pertussis.

Links to published research on Tdap vaccination during pregnancy are available here: www.cdc.gov/pertussis/pregnant/research.html.

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Q: Each time there is a pregnancy in the family, should fathers and other family members receive a Tdap booster to ensure adequate protection and boost the cocoon effect to protect the newborn from pertussis?

A: ACIP does not recommend additional doses of Tdap for fathers or other family members or caregivers. The recommendation for Tdap vaccination with each pregnancy to optimize immunity for the infant applies only to the pregnant woman.      

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Q: What schedule should I use to vaccinate adolescents or adults who never received the primary series of tetanus toxoid-containing vaccine?

A: Children, age 7 years and older, and adults who have never received tetanus-containing vaccines, or whose vaccination history is unknown, should receive the 3-dose series. In this situation, ACIP recommends Tdap for dose #1, followed 4 weeks later by Td or Tdap for dose #2, followed at least 6 months later by Td or Tdap for dose #3. The amount of protection provided by one or more doses of Tdap in a person who has not previously received pertussis vaccine is not known. Following the primary series, booster doses of Td or Tdap should be given every 10 years thereafter.

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Q: A 7-year-old has a history of 3 doses of DTaP, appropriately spaced, between 4 years and 6 years of age. Is her DTaP series complete?

A: Although the child would be considered complete for tetanus and diphtheria toxoids, she is not complete for pertussis vaccine. DTaP vaccines are FDA-approved only through age 6 years so no more DTaP doses are recommended.
 
However, ACIP recommends that children age 7–10 years who are not fully vaccinated against pertussis (defined as 5 doses of DTaP or 4 doses of DTaP if the fourth dose was administered on or after the fourth birthday) and who do not have a contraindication to pertussis vaccine should receive a single dose of Tdap to provide protection against pertussis. If the child in this case is age 7–9 years at the time of Tdap vaccination, the next dose due will be the routine adolescent dose of Tdap at age 11 or 12 years. If the child is age 10, the dose counts as the adolescent dose and no additional dose at age 11 or 12 years is recommended.

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Q: When a patient seen in the ER needs tetanus protection, which type of tetanus vaccine should be given?

A: Children age 7–10 years should receive Tdap if they are not fully vaccinated for prevention of pertussis. Otherwise they may receive Td or Tdap. If additional doses are necessary for full tetanus protection, they may be administered as Td or Tdap. Adolescents, and adults age 11 years and older should receive a single dose of Tdap, if they have not received a dose of Tdap after the 11th birthday, otherwise they may receive Td or Tdap. If additional doses are necessary for full tetanus protection, they may be administered as Td or Tdap.

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Suggest a question for "Ask the Experts"

If you have a question that you think may be of interest to our readers, please send it to us using our online form. We will consider it for inclusion in a future update of the “Ask the Experts” feature.

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About IAC Express 

We encourage you to reprint any of these Q&As in your own newsletters. 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.

 IAC Express is supported by Grant No.
6NH23IP922550 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.

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