IAC Express 2010
Issue number 883: August 17, 2010
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Contents of this Issue
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  1. Read "Ask the Experts" Q&As on current immunization issues
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 883: August 17, 2010
1.  Read "Ask the Experts" Q&As on current immunization issues

Many readers of Needle Tips and Vaccinate Adults consistently rank "Ask the Experts" as their favorite feature in these publications. As a thank-you to our loyal IAC Express readers, we periodically publish Extra Editions 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.

The Q&As in this edition of IAC Express deal with a variety of current issues, with a special emphasis on Tdap vaccine use due to the outbreaks of pertussis in some locations.

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 IAC's preferred citation style can be found at http://www.immunize.org/citeiac

You can access more "Ask the Experts" Q&As in our online archive at http://www.immunize.org/askexperts

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

Q: When a vaccine vial is new and the cap has just been removed, is the rubber stopper sterile, or should it be cleansed with alcohol before inserting the needle?

A: The rubber stopper is not sterile. When you remove the protective cap from a vaccine or diluent vial, you should always clean the stopper with an alcohol wipe. This practice is covered in CDC's online vaccine storage and handling toolkit. To access the kit, go to http://www2a.cdc.gov/vaccines/ed/shtoolkit

Q: I understand that a prior history of Guillain-Barré‚ syndrome (GBS) is no longer a precaution for giving meningococcal conjugate vaccine (MCV4). Please tell me more about this.

A: A history of GBS had previously been a precaution for Menactra MCV4 vaccine (sanofi pasteur). Findings from two studies that examined more than 2 million doses of Menactra given since 2005 showed no evidence of an increased risk of GBS. Consequently, ACIP voted in June 2010 to remove the precaution for use of Menactra in people with a history of GBS. This precaution did not apply to Menveo (Norvartis) or Menomune (sanofi pasteur) vaccines.

Q: If a healthcare worker (HCW) receives tetanus-diphtheria-acellular pertussis (Tdap) vaccine and is then exposed to someone with pertussis, do you treat the vaccinated HCW with prophylactic antibiotics or consider them immune to pertussis?

A: You should follow the post-exposure prophylaxis protocol for pertussis exposure recommended by CDC (http://www.cdc.gov/vaccines/pubs/pertussis-guide/guide.htm) Research is needed to evaluate the effectiveness of Tdap to prevent pertussis in healthcare settings. Until studies define the optimal management of exposed vaccinated healthcare personnel, or experts arrive at consensus, healthcare facilities should continue post-exposure prophylaxis protocols for vaccinated HCWs who are exposed to pertussis.

Q: As a pediatrician, I am concerned about protecting my newborn patients from pertussis, especially given the recent outbreak in California where 7 infants have died. How many doses of pediatric diphtheria-tetanus-acellular pertussis (DTaP) vaccine does an infant need before she or he is protected from pertussis?

A: Vaccine efficacy is 80%-85% following 3 doses of DTaP vaccine. Efficacy data following just 1 or 2 doses are lacking but are likely lower. Therefore, it is especially important that you advise parents of infants that all people who live with the infant or who provide care to him or her be protected against pertussis. Recommend that all the infant's family members and visitors ages 10 through 64 years receive a one-time dose of adolescent/adult tetanus-diphtheria-acellular pertussis (Tdap) vaccine if they have not already done so.

Q: Tdap vaccine is licensed for use only in people ages 10-64 years. Are there exceptions for healthcare professionals or grandparents older than age 64 who are in contact with infants?

A: ACIP has not recommended off-label use of Tdap for adults age 65 years and older. However, there is no reason to believe that Tdap is any less safe for people age 65 years and older than it is for younger adults. Clinicians are always free to use their clinical judgment; they may decide that in this situation the benefit of administering Tdap off-label exceeds any hypothetical risk of giving the vaccine.

Q: We have a 16-year-old patient who received tetanus-diphtheria (Td) vaccine in the emergency room after a nail puncture a year ago. Can we give him Tdap vaccine now?

A: No minimum interval is required between giving doses of Td and Tdap to an adolescent who is or might be in contact with an infant. This includes adolescents who are older siblings of infants, babysitters, or hospital employees or volunteers, etc. In circumstances like this, give Tdap without delay. For adolescents who will not be in contact with infants, CDC/ACIP recommends a routine wait of 5 years between Td and Tdap administration unless a school vaccination mandate requires giving Tdap.

Q: How would I follow up with a new healthcare worker (HCW) who has 2 documented doses of measles-mumps-rubella (MMR) vaccine but whose serologic testing doesn't show immunity to one of these diseases?

A: Two documented doses of MMR vaccine is considered proof of immunity according to ACIP. However, what ACIP recommends is not always what schools and institutions accept. Here are some basics about MMR vaccination and healthcare personnel.
  • ACIP considers receipt of 2 documented doses of MMR vaccine, given on or after the first birthday and separated by at least 28 days, to be proof of immunity to measles, mumps, and rubella. No serologic testing is required or recommended to confirm immunity in this instance.
  • If a HCW does not have any documented doses of MMR, he or she can (1) be tested for immunity or (2) just be given 2 doses of MMR at least 4 weeks apart. If the testing option is used, and the test indicates that the HCW is not immune to one or more of the vaccine components, the HCW should receive 2 doses of MMR at least 4 weeks apart. Note that a test finding of an "indeterminate" or "equivocal" level of immunity indicates that a HCW who lacks 2 documented doses of MMR vaccine be considered nonimmune. Also note, that ACIP does not recommend serologic testing after vaccination.
  • ACIP does not routinely recommend more than 2 doses of MMR vaccine. A negative serology after 2 documented doses probably represents a false negative (i.e., antibody titer is too low to detect with commercial tests). If a healthcare setting relies on post-vaccination testing to determine immunity, a negative serology can erroneously indicate that a HCW needs additional doses. Remember, ACIP does not recommend routine serologic testing after MMR vaccination.

For more information, see ACIP's recommendations on the use of MMR at www.cdc.gov/mmwr/PDF/rr/rr4708.pdf

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. To see if your question has already been answered, you can first check the "Ask the Experts" online archive at http://www.immunize.org/askexperts

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 at http://www.immunize.org/subscribe

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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 Immunize.org 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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