Issue 1044: March 6, 2013
Questions and Answers
Q: I understand that ACIP recently changed its definition of evidence of immunity to measles, rubella, and mumps. Please explain.
A: At its October 2012 meeting, ACIP voted to include “laboratory confirmation of disease” as evidence of immunity for measles, mumps, and rubella. ACIP voted to remove “physician diagnosis of disease” as evidence of immunity for measles and mumps. “Physician diagnosis of disease” had not previously been accepted as evidence of immunity for rubella. With the decrease in measles and mumps cases over the last 30 years, the validity of physician-diagnosed disease has become questionable. In addition, documenting history from physician records is not a practical option for most adults. The provisional MMR recommendations are currently available on the CDC website.
Q: What are the new provisional ACIP recommendations for use of immune globulin (IG) for measles post-exposure prophylaxis?
A: At its October 2012 meeting, ACIP voted to expand the use of post-exposure IG prophylaxis for measles.
Q: Please describe the new provisional ACIP recommendations for the use of MMR vaccine in people who are HIV-infected.
A: Provisional ACIP recommendations for vaccinating people with HIV infection are as follows:
Q: Some single-dose pre-loaded vaccines come with an air pocket in the syringe chamber. Do we need to expel the air pocket before vaccinating?
A: No. You do not need to get rid of the air pocket. The air will be absorbed. This is not true for syringes that you fill yourself; you should expel air bubbles from these syringes prior to vaccination to the extent that you can readily do so.
Q: Is it recommended to use a new alcohol swab to cleanse the skin before administering a vaccine, or can we swab the skin with the same alcohol swab that we used to wipe off the stopper on the vial?
A: You should use separate alcohol wipes to clean the vial top and the patient’s skin.
Q: I have a 45-year-old patient who is traveling to Haiti for a mission trip. She doesn’t recall ever getting an MMR booster (she didn’t go to college and never worked in health care). She was rubella immune when pregnant 20 years ago. Her measles titer is negative. Would you recommend an MMR booster?
A: ACIP recommends 2 doses of MMR given at least 4 weeks apart for any adult born in 1957 or later who plans to travel internationally. There is no harm in giving MMR vaccine to a person who may already be immune to one or more of the vaccine viruses.
Q: A nursing student received 2 valid, documented doses of varicella vaccine. For whatever reason, she subsequently had a titer drawn. The titer was negative. Do you recommend revaccination with 2 doses of varicella vaccine?
A: No. Documented receipt of 2 doses of varicella vaccine supersedes results of subsequent serologic testing. Most commercially available tests for varicella antibody are not sensitive enough to detect vaccine-induced antibody, which is why CDC does not recommend post-vaccination testing. For more information, see page 24 of ACIP’s Immunization of Health-Care Personnel.
Q: If a patient is not able to receive rotavirus vaccine orally, can we give it through a G-tube?
A: You can give rotavirus vaccine through a tube as long as the child is otherwise eligible.
Q: What vaccines can we safely give to an infant or older child who has a sibling undergoing treatment for leukemia?
A: Household contacts and other close contacts of people with altered immunocompetence can receive all age-appropriate vaccines, with the exception of smallpox vaccine. MMR, varicella, and rotavirus vaccines should be administered to susceptible household contacts and other close contacts of immunocompromised patients when indicated. MMR vaccine viruses are not transmitted to contacts, and transmission of varicella vaccine virus is rare. No specific precautions are needed unless the varicella vaccine recipient develops a rash after vaccination. In this case, the varicella vaccine recipient should avoid direct contact with susceptible household contacts until the rash resolves. Anyone who changes an infant’s diaper should always wash their hands afterward. This will help prevent rotavirus vaccine virus transmission from a vaccinated infant. Household and other close contacts of people with altered immunocompetence should receive annual influenza vaccination and all other age appropriate vaccines. LAIV may be administered to healthy household and other close contacts of people with altered immunocompetence. For more information about vaccinating people in contact with immunosuppressed people, see page 20 of ACIP’s General Recommendations on Immunization.
Q: If the lymph nodes under a patient’s arm were surgically removed, should we avoid giving vaccines in that arm?
A: We have heard that some surgeons advise against vaccination in an arm where lymph nodes were dissected. ACIP does not address this, so feel free to use your professional judgment in determining whether to use the arm that was operated on, the other arm (if not affected), or the anterolateral aspect of the thigh, which is an acceptable secondary route for adult immunization.
Q: An employee is currently taking prophylactic acyclovir daily to prevent herpes type 2 recurrent infection. Can she receive zoster vaccine?
A: ACIP’s zoster recommendations include the following:
Q: Is it safe for a pregnant healthcare worker to administer zoster (shingles) vaccine?
A: Yes. A pregnant woman may administer any vaccine, including live virus vaccines, except smallpox vaccine.
Q: We inadvertently reconstituted a vaccine with the wrong diluent and administered the vaccine. By the time we realized our error, the patient had already left the clinic. Do we need to revaccinate the patient? If so, when should we do it?
A: Yes, you need to revaccinate the patient. If an inactivated vaccine is reconstituted with the wrong diluent and is administered, the dose should be repeated ASAP. If a live virus vaccine is reconstituted with the wrong diluent and is administered, it can be repeated on the same clinic day. However, if you can’t get the patient back to the office that day, you need to wait at least 4 weeks to repeat the dose.
Q: An adult came to our office for hepatitis A, hepatitis B, Tdap, and influenza vaccination. Afterward, it appeared that we did not record influenza vaccination on her chart. When questioned, the patient said she thought she got all four shots. Should we give her another dose of influenza vaccine or assume we gave it as intended?
A: If there is ever any doubt that you gave a vaccine, repeat it.
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