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IAC Express 2008
Issue number 771: December 16, 2008
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Contents of this Issue
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  1. Read "Ask the Experts" Q&As about influenza and pneumococcal polysaccharide vaccination from CDC experts
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 771: December 16, 2008
1.  Read "Ask the Experts" Q&As about influenza and pneumococcal polysaccharide vaccination from CDC experts

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.

Editor's note: Information about submitting a question to "Ask the Experts" is provided at the end of this IAC Express article.

For which age groups of children is influenza vaccination now recommended?

Starting in fall 2008, all children ages 6 months through 18 years are recommended to receive annual vaccination against influenza. CDC issued this expanded recommendation with the intent to begin in the 2008–09 influenza vaccination season and be fully in place by the 2009–10 season.

Which adults should receive influenza vaccine this year?

Influenza vaccination is recommended for the following adults: those age 50 years and older; women who will be pregnant during the influenza season; those with any of the following medical conditions that increase the risk of complications of influenza: a chronic disorder of the pulmonary or cardiovascular system, a chronic disease of the blood, liver, or kidneys, immunosuppression, or diabetes; residents of nursing homes or other chronic-care facilities; all healthcare personnel; and household contacts and caregivers of children ages 0 through 59 months and of other persons at increased risk of complications of influenza. Influenza vaccine is also recommended for persons who want to reduce the risk of becoming ill with influenza or of transmitting it to others.

What percentage of the U.S. population is recommended to receive influenza vaccination?

With the new recommendation to vaccinate all children ages 6 months through 18 years, 85% of the U.S. population should be vaccinated every year.

Who can receive the nasal spray influenza vaccine (FluMist) and who can receive injectable influenza vaccine?

FluMist can be given to all healthy, non-pregnant people ages 2 through 49 years. However, FluMist should not be given to healthy children younger than age 5 years who have recurrent wheezing or have had a wheezing episode within the past 12 months. Injectable influenza vaccine can be given to all people age 6 months and older who have no contraindications or precautions to receiving the vaccine.

Which children need 2 doses of influenza vaccine?

Children ages 6 months through 8 years who are receiving influenza vaccine for the first time should be given 2 doses at least 4 weeks apart. If they fail to get 2 doses during the current vaccination season, they should get 2 doses during the next season.

When a child needs 2 doses of influenza vaccine, can I give 1 dose of each type (injectable and nasal spray)?

Yes. As long as a child is eligible to receive nasal spray vaccine (i.e., is in the proper age range and health status), it is acceptable to give 1 dose of each type of influenza vaccine. The doses should be spaced at least 4 weeks apart.

If patients need other vaccines, which ones can they get at the same time as influenza vaccine?

All vaccines used for routine vaccination in the United States may be given simultaneously.

If you miss giving recommended vaccines at the same visit, any inactivated vaccine (e.g., DTaP, Tdap, HPV) can be administered any time before or after a different inactivated or live vaccine (e.g., MMR, Var, LAIV). Any 2 live vaccines not given at the same time must be given at least 4 weeks apart.

We have some adults who are in need of multiple vaccines (e.g., influenza, pneumococcal, and a tetanus-containing vaccine). When only 2 vaccines are needed, we inject 1 in each arm, but when 3 or more are recommended, we're not sure whether we should give all of them or defer 1 or more until a later date.

ACIP recommends giving all indicated vaccines simultaneously (i.e., at the same visit, NOT in the same syringe). Giving vaccines together produces seroconversion rates and occurrences of adverse reactions similar to those observed when the vaccines are administered separately. Simultaneous administration also eliminates the possibility that the patient will not return in a timely manner for the deferred vaccine(s).

When giving 2 IM injections in the same limb, the vaccines should be separated by 1 inch or more if possible in the muscle so that any local reactions are unlikely to overlap.

Is it true that I can vaccinate pregnant women with influenza vaccine during their first trimester?

Yes. All women who are pregnant or will be pregnant during the influenza season should be vaccinated, including those who are in their first trimester. Only inactivated (injectable) influenza vaccine should be given to pregnant women.

Can thimerosal-containing vaccine be given to pregnant women?

Yes, unless you live in a state that has enacted legislation restricting use in pregnant women. There is no scientific evidence that thimerosal in vaccines, including influenza vaccines, is a cause of adverse events, unless the patient has a systemic allergy to thimerosal.

What is the Joint Commission's recommendation on vaccinating healthcare workers against influenza?

In January 2007, a new infection control standard of the Joint Commission became effective that requires accredited organizations to offer annual influenza vaccination to staff, volunteers, and licensed independent practitioners who have close patient contact.

If half of a dose of influenza vaccine leaked out of a prefilled syringe while it was injected into a patient, does the dose need to be repeated and if so, when?

When this happens, it is difficult to judge how much vaccine the person received. This would be a nonstandard dose and should not be counted. You should go ahead and re-immunize the individual at that time.

During which month is it no longer worthwhile to give influenza vaccine to my patients?

If you have influenza vaccine in your refrigerator and unvaccinated patients in your office, you should vaccinate them. Vaccinating in June is likely unnecessary.

We mistakenly gave an infant pneumococcal polysaccharide vaccine (PPSV) instead of pneumococcal conjugate vaccine (PCV). What should we do?

PPSV is not effective in children younger than age 24 months. PPSV given at this age should not be considered to be part of the pneumococcal vaccination series. PCV should be administered as soon as the error is discovered.

I have heard that there have been changes in the pneumococcal polysaccharide vaccination recommendations for adults with asthma and for smokers. Is this true?

Yes. The 1997 CDC recommendations for the use of pneumococcal polysaccharide vaccine (PPSV) exclude asthma in the chronic pulmonary disease category because no data on increased risk of pneumococcal disease among persons with asthma were available when the recommendation was issued. At its June 2008 meeting, the Advisory Committee on Immunization Practices (ACIP) reviewed new information that suggests that asthma is an independent risk factor for pneumococcal disease among adults. At its October 2008 meeting, ACIP reviewed new information that demonstrates an increased risk of pneumococcal disease among adult cigarette smokers. Consequently, ACIP voted to include both asthma and cigarette smoking as risk factors for pneumococcal disease among adults ages 19 through 64 years and as indications for PPSV.

The new provisional ACIP recommendations for use of pneumococcal vaccines can be accessed at

The new recommendations will be included in the 2009 Recommended Adult Immunization Schedule, due to be published in January 2009.

My patient doesn't remember if he ever was vaccinated with PPSV and we can't locate a record of vaccination. What should we do?

Providers should not withhold pneumococcal polysaccharide vaccination in the absence of an immunization record or complete record. Persons with uncertain or unknown vaccination status should be vaccinated.

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 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

You can also email CDC's immunization experts directly at There is no charge for this service.

If you have a question about IAC materials or services, email

Please forward these "Ask the Experts" Q&As to your co-workers and suggest they subscribe to IAC Express at

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About IZ Express

IZ Express is supported in part by Grant No. 1NH23IP922654 from CDC’s National Center for Immunization and Respiratory Diseases. Its contents are solely the responsibility of and do not necessarily represent the official views of CDC.

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Editorial Information

  • Editor-in-Chief
    Kelly L. Moore, MD, MPH
  • Managing Editor
    John D. Grabenstein, RPh, PhD
  • Associate Editor
    Sharon G. Humiston, MD, MPH
  • Writer/Publication Coordinator
    Taryn Chapman, MS
    Courtnay Londo, MA
  • Style and Copy Editor
    Marian Deegan, JD
  • Web Edition Managers
    Arkady Shakhnovich
    Jermaine Royes
  • Contributing Writer
    Laurel H. Wood, MPA
  • Technical Reviewer
    Kayla Ohlde

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