has been refreshed! Take a tour.
IAC Express 2009
Issue number 789: April 6, 2009
Please click here to subscribe to IAC Express as well as other FREE IAC periodicals.
Contents of this Issue
Select a title to jump to the article.
  1. Read "Ask the Experts" Q&As about changes in vaccine recommendations, vaccine shortages, recently approved vaccines, and more
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 789: April 6, 2009
1.  Read "Ask the Experts" Q&As about changes in vaccine recommendations, vaccine shortages, recently approved vaccines, and more

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.

Many of these Q&As were published previously in the December 2008 issue of Needle Tips. If you did not receive this issue as a print publication or did not read it online, these questions will be new to you. If you have read "Ask the Experts" in the last issue of Needle Tips, look for new, previously unpublished questions at the beginning of this Extra Edition.

We encourage you to reprint any of these Q&As in your own newsletters. Please credit the Immunization Action Coalition and the Centers for Disease Control and Prevention. Information about proper citations can be found at You can access more "Ask the Experts" Q&As in our online archive at

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


Q: Where can I find more information to educate parents when they ask about alternative vaccination schedules?

A: Paul Offit, MD, and Charlotte Moser, BS, Vaccine Education Center, Children's Hospital of Philadelphia, published an article in the January 2009 issue of the AAP journal "Pediatrics" titled "The Problem with Dr Bob's Alternative Vaccine Schedule." "Pediatrics" has made the entire article available online at

The Vaccine Education Center has also recently released a tear sheet for parents titled "Too Many Vaccines? What you should know." To access this resource, go to: (English) or (Spanish)

Health professionals can order two 50-sheet pads in each language at no charge. Additional pads are available for $3, plus shipping. For additional ordering information, go to:

The American Academy of Pediatrics published a helpful commentary in the January 2009 "AAP News" titled "Adhering to vaccine schedule is best way to protect children from disease." To access the contents of this article, go to:

AAP posted a Q&A piece for parents on its website that explains why it's important to vaccinate children on time. Titled "The Childhood Immunization Schedule: Why Is It Like That?" the piece is located at

CDC maintains a web page titled "Frequently Asked Questions about Multiple Vaccinations and the Immune System." To access it, go to:

Q: The new recommendations for rotavirus vaccine scheduling state that the series should be completed by 8 months 0 days. Can vaccine be given on the 8-month birthday?

A: Yes. Doses of rotavirus vaccine should be administered on or before age 8 months 0 days; i.e., the infant is no older than 8 months 0 days from date of birth.

For example, if the child was born on February 4, the last dose should be given on or before October 4 (and no later).

Q: I heard there was a change in the recommendations as to who can receive Boostrix brand Tdap vaccine. What are the specifics?

A: On December 4, 2008, FDA approved GlaxoSmithKline's request to supplement their license for Boostrix. The vaccine is now approved for use as a one-time booster for people ages 10-64 years. Previously, it was approved for use in people ages 10-18 years.

Adacel, sanofi pasteur's brand of Tdap vaccine, is licensed for people ages 11-64 years.

Q: I'm wondering whether we should re-vaccinate adult patients and employees with a second dose of influenza vaccine in the spring if they got their first dose early in the fall.

A: CDC does not recommend a second dose of influenza vaccine for anyone during the course of a single influenza season with the following exception. Give 2 doses (separated by at least 4 weeks) to children who are younger than age 9 years who are receiving influenza vaccine for the first time or who were vaccinated for the first time during the previous influenza season but received only 1 dose.

Q: I understand there is a now a shortage of hepatitis B vaccine for children and possibly for adults. Could you please tell me about it?

A: Hepatitis B vaccine for pediatric use is in short supply at this time but recommendations for its use are unchanged. The information below about the hepatitis B vaccine shortages is available on CDC's website at
In February 2009, both Merck and GSK experienced an inability to fill orders for pediatric hepatitis B vaccine, resulting in backorders. CDC has released doses from its monovalent pediatric hepatitis B vaccine stockpiles to each manufacturer to support private and public sector vaccine usage through March. Merck expects supplies of pediatric Recombivax HB to be limited during the remainder of 2009 and does not expect to return to a full supply until some time in 2010. GSK expects to be able to meet the U.S. market demand for monovalent hepatitis B vaccine through the end of May with its pediatric hepatitis B vaccine (Pediatric Engerix-B), and is working closely with CDC to determine how much additional monovalent hepatitis B product can be supplied to the U.S. market during the second half of 2009.

In December 2008, Merck communicated with CDC that it expected to deplete available adult and dialysis formulations of their hepatitis B vaccine, Recombivax HB, in the first quarter of 2009. Once depleted, these formulations will be unavailable for the remainder of 2009. Supply of GSK's adult hepatitis B vaccine (Adult Engerix-B) and adult hepatitis A/hepatitis B combination vaccine (Twinrix) is sufficient to meet demand for routine adult usage of this vaccine as well as for CDC's ongoing High Risk Adult Hepatitis B Initiative.

Q: Are there other vaccine shortages or delays I should know about?

A: ProQuad (MMRV) will not be available in 2009. There is adequate supply of Varivax (varicella vaccine) to fully implement the recommended 2-dose immunization schedule for all age groups. Zostavax (zoster vaccine) is available for ordering; however, the manufacturer is experiencing shipping delays. Merck anticipates a return to normal shipping times for Zostavax in mid-2009.

Find up-to-date information on vaccine shortages and delays on CDC's website at

Q: I've heard that some people are "brown-bagging" zoster vaccine, i.e., picking up a dose in a local pharmacy and carrying it to their provider's office for administration. What is CDC's opinion on this practice?

A: CDC strongly discourages the practice of patients' transporting vaccine from a pharmacy to a doctor's office, as does the American Pharmacists Association. Zoster vaccine must be transported on dry ice, with strict adherence to stringent vaccine transport guidelines.

Q: Should a healthy person age 60+ years receive zoster vaccine if they are going to be in contact with an unvaccinated infant or an immunocompromised person?

A: Neither situation is a contraindication to zoster vaccination. A person who gets vaccinated with zoster vaccine who has close household or occupational contact with people who are at risk for developing severe varicella or zoster infection need not take any precautions after receiving zoster vaccine. The only exception is in the rare instance when a person develops a varicella-like rash after receiving zoster vaccine. A vaccine rash is expected to occur less frequently after zoster vaccine is given than after varicella vaccine is given. If a rash develops, the vaccinated person should restrict contact with an immunocompromised person if the immunocompromised person is susceptible to varicella.


Q: If the vaccine expiration date is written as month/year, how do we know the exact date of expiration?

A: Vaccine may be used through the last day of the month indicated on the expiration date. After that, do not use it. Monitor your vaccine supply carefully so that vaccines do not expire.

Q: If we gave a dose of expired vaccine in error, what is the proper timing for repeating the dose?

A: The dose should be repeated. If the expired dose is a live virus vaccine, you should wait at least 4 weeks after the expired dose was given before repeating it. If the expired dose is not a live vaccine, the dose should be repeated as soon as possible.

Q: Where can I find Vaccine Information Statement (VIS) translations in Spanish and other languages? We have many patients from outside the U.S. in our practice.

A: You're in luck. The Immunization Action Coalition (IAC) has dozens of translations of most VISs at

Q: I'm unclear about when to use the multi-vaccine VIS versus the individual VISs.

A: The multi-vaccine VIS is a 4-page alternative VIS that you can use in place of the individual VISs for any or all of the 6 vaccines routinely given to infants (i.e., DTaP, IPV, Hib, PCV, HepB, and rotavirus). It is not designed to be used with adolescents or adults (risk factors that apply only to older persons are not included on this VIS). Use of this VIS saves paper and staff time. When giving the multi-vaccine VIS to a parent, check the boxes on the first page that correspond to the vaccines you plan to administer at the current visit. The multi-vaccine VIS, as well as all other VISs in English and more than 30 languages, are available on IAC's website at English-language VISs are available on CDC's website at

Q: We sometimes have differences of opinion among our staff in determining the minimum interval or age for administering vaccines. Recommendations are sometimes written in months, weeks, or days. Can you help clarify?

A: This is a common source of frustration. Customarily, if the dosing interval is 4 months or more, it is common to use calendar months (e.g., 6 months from October 1 is April 1). If the interval is less than 4 months, it is common to convert months into days or weeks (e.g., 1 month = 4 weeks = 28 days).

Q: Is it okay to store blood products in the same unit as vaccines?

A: CDC's vaccine storage and handling toolkit states "If possible, other medications and other biologic products should not be stored inside the vaccine storage unit. If there is no other choice, these products must be stored below the vaccines on a different shelf. This prevents contamination of the vaccines should the other products spill."

Q: Does CDC still have a vaccine handling and storage toolkit?

A: Yes. You can access it from CDC's website at The toolkit contains 2 videos on CD-ROM (How to Protect Your Vaccine Supply and Top 10 Storage and Handling Errors); an interactive game; and resources including forms, checklists, posters, and contact information. Single copies of the CD-ROM can be ordered from CDC at

Q: What is the maximum number of IM or SC doses of vaccines that a child can receive at a single visit? Is it okay for a child to receive 3 live vaccines at one visit (e.g., MMR, VAR, and LAIV)?

A: All vaccines can be administered at the same visit. There is no limit to the number of IM or SC injections that can be given at a single visit. So, an age-appropriate child can get MMR, VAR, and LAIV vaccines during a single visit. If live parenteral (injected) vaccines (MMR, VAR, MMRV, zoster, and/or yellow fever) and LAIV are not administered during the same visit, they should be separated by 4 weeks or more. For details, consult CDC's "General Recommendations on Immunization" at

Q: Do Occupational Safety and Health Administration (OSHA) guidelines require the use of gloves when administering vaccines?

A: OSHA regulations do not require gloves during vaccine administration, unless the administering person is likely to come into contact with potentially infectious body fluids or has an open lesion on their hand.

Q: When a parent is unable to produce documentation but insists that their child received the vaccine doses, what should we do?

A: Vaccination providers frequently encounter persons who do not have adequate documentation of vaccinations. Providers should only accept written, dated records as evidence of vaccination. With the exception of influenza vaccine and pneumococcal polysaccharide vaccine (PPSV), self-reported doses of vaccine without written documentation should not be accepted. An attempt to locate missing records should be made whenever possible--by contacting previous healthcare providers, reviewing state or local immunization information systems, and searching for a personally held record. However, if records cannot be located or will definitely not be available anywhere because of the patient's circumstances, children without adequate documentation should be considered susceptible and should be started on the age-appropriate vaccination schedule. Serologic testing for immunity is an alternative to vaccination for certain antigens (e.g., measles, rubella, hepatitis A, and tetanus).

In general, although it is not ideal, receiving extra doses of vaccine poses no medical problem. Receiving excessive doses of tetanus toxoid (e.g., DTP, DTaP, DT, Tdap, or Td) can increase the risk of a local adverse reaction, however. For details, consult CDC's "General Recommendations on Immunization" at

Q: Some parents are requesting that we space out their infant's vaccinations because they are concerned that receiving multiple vaccinations at a single office visit might overwhelm the infant's immune system. What do you think about using alternative schedules?

A: Vaccine recommendations are determined after extensive studies in large clinical trials. They include studies on how vaccine recipients respond to multiple vaccines given simultaneously. The overall aim is to provide early protection for infants and children against vaccine-preventable diseases that could endanger their health and life. No scientific evidence exists to support that delaying vaccinations or separating them into individual antigens is beneficial for children. Rather, this practice prolongs susceptibility to disease, which could result in a greater likelihood of the child becoming sick with a serious or life-threatening disease. There could also be added expense (e.g., multiple office visits), additional time off from work for parents, and increased likelihood that the child will fail to get all necessary vaccinations.

Q: If a patient or parent refuses recommended vaccinations, is it necessary for them to sign a refusal form, or is the provider's documentation sufficient?

A: The American Academy of Pediatrics states that healthcare providers may decide it is in their best interest to formally document a parent's refusal to accept vaccination for their (minor) child. To read a discussion on this topic and to access a prototype refusal form, go to

Q: Is it necessary to routinely obtain a pregnancy test before administering any vaccines to young women?

A: No. Pregnancy tests are not routinely recommended. However, females of childbearing age should be asked about the possibility of their being pregnant prior to being given any vaccine for which pregnancy is a contraindication or precaution. The patient's answer should be documented in the medical record. If the patient is uncertain if she is pregnant, a test should be performed before administering live virus vaccines (e.g., measles-mumps-rubella [MMR], varicella [VAR], LAIV [live attenuated influenza vaccine, i.e., FluMist]).

Q: What guidance is there for preventing patients from fainting after vaccination?

A: All providers who administer vaccinations should be aware of the potential for syncope (fainting) after vaccination and take appropriate measures to prevent it. Thus, clinicians should (1) make sure that people who are being vaccinated are always seated; (2) be aware of symptoms that precede fainting (weakness, dizziness, pallor, etc.); and (3) take appropriate measures to prevent injuries if such symptoms occur. [Note: IAC has two pertinent educational pieces for healthcare professionals: "Medical Management of Vaccine Reactions in Children and Teens" at and "Medical Management of Vaccine Reactions in Adult Patients" at]

Since 2005, VAERS has received an increased number of reports of syncope. Fainting among girls and young women ages 11-18 accounted for most of the increase. Serious injuries have occurred, including one fatality from intracranial hemorrhage caused by head trauma. The May 2, 2008, MMWR included a summary of findings on the increase in fainting after vaccination (see In people for whom vaccination time and fainting time were reported, it was discovered that 52% of fainting episodes occurred within 5 minutes of vaccination and 70% occurred within 15 minutes. Vaccine providers should strongly consider observing vaccinated people for 15 minutes after vaccination, in accordance with ACIP General Recommendations (see This is particularly important when vaccinating adolescents and young adults.

Q: Please describe the newly licensed rotavirus vaccine, Rotarix.

A: FDA licensed Rotarix (GSK) on April 3, 2008. It is approved for oral administration as a 2-dose series to infants at ages 2 and 4 months. The lyophilized (freeze-dried) vaccine is reconstituted with a 1-mL liquid diluent and administered from a prefilled oral applicator.

Q: How do the two rotavirus vaccines differ?

A: The rotavirus vaccination series consists of either two 1-mL doses of Rotarix (GSK) given at ages 2 and 4 months or three 2-mL doses of RotaTeq (Merck) given at ages 2, 4, and 6 months. CDC has revised its recommendations to make the schedule less confusing: the maximum age for the first dose of both vaccines is 15 weeks 0 days and the series should be completed on or before the time the infant turns 8 months 0 days. CDC's recommendations for rotavirus vaccine are available at

Q: Now that there are two licensed vaccines for rotavirus that have different schedules, how can we keep track of which vaccine an infant might have previously received?

A: That may be difficult at first. The generic abbreviation for the rotavirus vaccine was recently changed to "RV" (it used to be "Rota"). CDC has also developed abbreviations to distinguish the two RV vaccines. Rotarix is now abbreviated as RV1 (a monovalent vaccine containing a live, attenuated human G1P[8] virus), and RotaTeq as RV5 (a pentavalent vaccine comprising 5 live reassortant rotaviruses). Immunization providers should use these new abbreviations when recording the vaccine they administered.

Q: If we don't know which rotavirus vaccine an infant previously received, how should we complete the schedule?

A: If you have any doubt about which vaccine the infant previously received and the infant is at an age when the vaccine can still be given, give a total of 3 doses of rotavirus vaccine.

Q: Please describe the new combination vaccine Pentacel and how it should be used.

A: On June 20, 2008, FDA licensed Pentacel (sanofi pasteur), a DTaP-IPV/Hib combination vaccine. It is approved for use as a 4-dose series in infants and children at ages 2, 4, 6, and 15–18 months. It should not be used for any dose in the primary series for children age 5 years or older or as the booster dose for children ages 4-6 years. The DTaP-IPV component is supplied as a sterile liquid, which is used to reconstitute lyophilized (freeze-dried) ActHIB vaccine. The two components of the vaccine should be stored together in the carton to reduce vaccine administration errors. The DTaP-IPV component should never be administered alone.

Q: Can we give Pentacel to a child who has previously received separate injections of one or more of these antigens?

A: Yes, as long as minimum intervals are maintained.

Q: Can I use Pentacel to give the 12-15 month booster dose of Hib vaccine to children not at high risk of Hib complications, even though there is a Hib vaccine shortage?

A: No. During the Hib vaccine shortage, you should not give Pentacel as dose #4 of the series to children at low risk Administer a single dose of DTaP for dose #4.

Q: Can we give Pentacel if we don't know the type of DTaP vaccine the child previously received?

A: Yes. CDC recommends that whenever feasible, only one manufacturer's DTaP product be used for the entire pertussis series, but that vaccinations should not be deferred if the DTaP product previously given is unavailable or unknown.

Q: Please tell us about the new combination vaccine Kinrix and the recommendations for its use.

A: On June 24, 2008, FDA licensed Kinrix (GSK), a combination DTaP and IPV vaccine. It is approved for use as the fifth dose of DTaP and the fourth dose of IPV in children ages 4 through 6 years who received DTaP (Infanrix) and/or DTaP-HepB-IPV (Pediarix) as the first three doses and DTaP (Infanrix) as the fourth dose. It should not be given to children younger than age 4 years.

Q: When administering combination vaccines like Kinrix and Pentacel, which VISs should be used?

A: You can use either the individual VISs that exist for the separate antigens or you can use the multi-vaccine VIS. Remember to check the appropriate boxes on the front page of the multi-vaccine VIS.

Q: We have a 13-year-old patient who was given DT (pediatric) as a preschooler after she had experienced excessive crying following a dose of DTP. Now, we are wondering if we can give her Tdap since we know she may not be protected against pertussis.

A: Yes, you can. Many of the precautions to DTaP (e.g., temperature of 105 degrees F or higher, collapse or shock-like state, persistent crying lasting 3 hours or longer, seizure with or without fever) do not apply to Tdap. This issue is discussed in CDC's Tdap recommendations, available at

Q: We gave Tdap to a child who was just short of their 10th birthday. What should we do?

A: Use of Tdap in children ages 7-9 years is considered off-label and is not recommended; however, the dose can be counted and does not need to be repeated with Td.

Q: When a patient seen in the ER needs tetanus protection, which vaccine should be given, Td or Tdap?

A: Adolescents and adults ages 11-64 years who require a tetanus toxoid-containing vaccine as part of wound management should receive a single dose of Tdap instead of Td, if they have not previously received Tdap. If Tdap is not available, or was previously administered, these persons should receive Td.

Q: When will the Hib vaccine shortage be over?

A: It is anticipated that the Hib vaccine supply will improve in the last quarter of 2009.

Q: Can a woman complete the HPV series after age 26 years?

A: The series should be completed, even if this means that the series is completed after a woman turns 27.

Q: We've heard stories in the media lately about severe reactions to the HPV vaccine. Is there any substance to these stories?

A: No. In summer 2008 some concerns were raised over two issues--reports of deaths and reports of Guillain-Barre syndrome (GBS) following vaccination with Gardasil. As of August 2008, Merck reported it had distributed more than 20 million doses of Gardasil in the United States. The Vaccine Adverse Events Reporting System (VAERS) had received reports of 27 deaths. CDC reported that there was not a common pattern to the deaths; if there had been a common pattern, it would suggest the deaths might be caused by the vaccine. Occurrences of GBS, a rare neurological disorder, have been reported through VAERS. FDA and CDC reviewed the reports and found no evidence that Gardasil increased the rate of GBS above what is expected in the population. CDC, working with the FDA and other immunization partners, will continue to monitor the safety of Gardasil. You can find complete information on this and other vaccine safety issues at

Q: Who is recommended to be vaccinated against meningococcal disease?

A: CDC recommends routine vaccination against meningococcal disease for the following groups:
  • All previously unvaccinated adolescents ages 11 through 18 years
  • All previously unvaccinated college freshmen who will be living in dormitories
  • All persons ages 2 years and older with anatomic or functional asplenia, or terminal complement component deficiencies
  • All persons ages 2 years and older who travel to or reside in countries in which N. meningitidis is hyperendemic or epidemic, particularly if contact with the local population will be prolonged; this includes anticipated travel to Mecca, Saudi Arabia, for the annual Hajj
  • Any person working as a microbiologist with routine exposure to isolates of N. meningitidis
  • Military recruits, and
  • Any other person wishing to decrease their risk for meningococcal disease

Q: Why isn't hepatitis A vaccine recommended for sewage and solid waste disposal workers?

A: Existing data do not support the use of hepatitis A vaccine routinely in this setting. In published reports of three serologic surveys conducted among U.S. wastewater workers and appropriate comparison populations, no substantial or consistent increase in the prevalence of anti-HAV was identified among wastewater workers. No work-related instances of HAV transmission have been reported among wastewater workers in the United States.

Q: Who is recommended to receive 2 doses of varicella vaccine?

A: All persons without evidence of varicella immunity age 12 months and older should receive 2 doses of varicella vaccine. For children ages 12 months through 12 years, the minimum interval between doses is 3 months; for persons age 13 years and older, the minimum interval is 4 weeks.

Q: I understand that Varivax, ProQuad, and Zostavax each have different concentrations of antigen. Would you tell me how they are different?

A dose of Varivax has 1,530 plaque forming units (PFUs), ProQuad contains 9,800 PFUs (7 times higher than Varivax), and Zostavax contains 19,400 PFUs (13 times higher than Varivax).

Q: Can we give zoster vaccine to elderly patients who have cancer or an immunosuppressed condition?

A: No. Zoster vaccine is contraindicated in persons with primary or acquired immunodeficiency.

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

Back to top

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.

IZ Express Disclaimer
ISSN 2771-8085

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

This page was updated on .