& Prevention of Vaccine-Preventable Diseases Broadcast
Questions & Answers
Questions submitted during the
Epidemiology & Prevention of Vaccine-Preventable Diseases broadcasts
January & February, 2007
are the products respiratory syncytial virus IGIV and VZIG no
longer on Table 4 of the ACIP General Recommendations?
These products are no longer listed because they are no longer
made. Fortunately the monoclonal antibody product RSV IG is
available and is still on Table 4, and VariZIG, an investigational
product used for post-exposure prophylaxis for varicella, is
included in a footnote to Table 4.
a person receiving Synagis delay receipt of live virus vaccines?
No. Synagis is a monoclonal immune globulin product to protect
against respiratory syncytial virus (RSV). It does not contain
any antibodies other than RSV, so there is no reason to delay
receipt of live virus vaccines.
Tdap and MCV4 need to be spaced one month apart if not given
experts recommend spacing these vaccines by a month if not given
simultaneously. This is out of a theoretical safety concern
of giving two vaccines containing diphtheria antigen (MCV4 contains
diphtheria antigen) in close temporal proximity. However, ACIP
feels that this theoretical safety concern does not warrant
spacing, and recommends that these two inactivated vaccines
can be administered simultaneously or non-simultaneously without
a need for an interval between them.
you recommend documenting the amount of vaccine on the provider’s
Vaccine Administration Record?
is not required by law; the National Childhood Vaccine Injury
Act, and laws establishing publicly purchased vaccine, require
chart documentation only of the date of administration of the
vaccine, the date of the VIS, the vaccine manufacturer, the
lot number, and the name/address/title of the person administering
new ACIP recommendations are published, do we need to keep the
most vaccine-specific ACIP recommendations this should be self-explanatory
or explained in the summary statement. For example, the 2006
General Recommendations build upon the 2002 recommendations,
so the 2002 recommendations are no longer needed. Updates that
supplement, but do not replace, prior ACIP recommendations are
sometimes published as a "Notice to Readers" in the
a child with sickle cell disease who receive blood transfusions
every month received the first transfusion less than two weeks
after their vaccines, when can the vaccinations be repeated?
is a challenge with the live vaccines. Measles and varicella
containing vaccines are not valid when given at a short interval.
A replacement dose of these vaccines would need to be spaced
at an interval which can range from zero to seven months following
the product, depending on the amount of antibody in the product.
Table 4 in the ACIP General Recommendations on Immunization
lists these specific intervals.
a child with sickle cell is taking hydroxyurea, do they need
to defer live vaccines?
is an antineoplastic agent that is used for some cancers as
well as sickle cell disease. It inhibits DNA synthesis and therefore
should be considered in the same category as antimetabolites.
Defer live vaccines for 3 months following therapy.
there a table of commercially licensed vaccine brand names and
what vaccines they contain?
Pink Book, available online at http://www.cdc.gov/nip/publications/pink/default.htm,
contains this information. See Appendix B.
we administer a vaccine dose with a minimum interval of 28 days,
and we observe the grace period, this results in an interval
of 24 days. Is this acceptable?
if your state recognizes the grace period. Also, if you use
the grace period, be sure it is for a good reason. For example,
if a child is in your office for some other reason, and you
are concerned that he or she will not come back for an immunization
visit, don't miss the opportunity to vaccinate. But do not schedule
patients routinely using the grace period.
Also, do NOT apply the grace period to the 28 day interval between
two different live vaccines not administered on the same day,
e.g., MMR and varicella. It should be applied only to intervals
between doses of the same vaccine.
a patient faints following vaccination, should we submit a VAERS
after medical attention has been given to the vaccine recipient.
Any occurrence of medical significance that is not an accepted
adverse reaction warrants a VAERS report.
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Storage and Handling
it okay to store vaccines in a cooler with ice packs for several
hours and then return the vaccines to the refrigerator at the
end of the day?
don’t encourage this practice but sometimes it is necessary
if you need to move vaccines to an off-site clinic. You must
make sure the vaccine is properly packed and place a certified
calibrated thermometer within. The temperature should be monitored
and recorded hourly. Be conservative and try to get this vaccine
into a refrigerator at the destination site if at all possible.
A frozen vaccine like varicella can be stored at refrigeration
temperature for seventy-two hours but must be discarded if not
used within that time. You cannot put varicella vaccine back
in the freezer after it has been at refrigerator temperature.
The Vaccine Storage & Handling Toolkit offers guidance on
“Transporting Vaccine to Off-Site Clinics,” http://www2a.cdc.gov/nip/isd/shtoolkit/011Chap10.pdf
a dose of expired vaccine is administered, does it need to be
repeated? How soon can the dose be repeated?
of expired vaccines are invalid and should be repeated. For
an inactivated vaccine you can give the repeat
dose ASAP. With a live vaccine there could
be some vaccine viral replication that would interfere with
a subsequent dose, so you should wait 28 days before giving
the repeat dose.
define "frozen" and "freezing" regarding
vaccines. Vaccine Providers are often under the impression that
"frozen" means only solid state or the formation of
ice crystals. I perform AFIX visits routinely and would like
to be able to inform the providers correctly as to what is meant
specifically by "freezing temperatures."
recently published temperature ranges in the General Recommendations
on Immunization Table 9 http://www.cdc.gov/mmwr/PDF/wk/mm5548.pdf,
page 12. (This link goes to an MMWR weekly that published a
corrected version of Table 9.) For inactivated vaccines the
appropriate temperature range is 35-46° F. Refrigerator
temperatures below 35° should prompt concern. Often one
cannot see the effects of vaccine stored too cold or too hot.
MMR and varicella vaccines effective if stored in the refrigerator
for 72 hours after reconstitution?
No. MMR vaccine must be used within 8 hours of reconstitution
and varicella vaccine must be used within 30 minutes of reconstitution.
opened, how long may a multidose vial of vaccine be used?
A multidose vial can be used until the expiration date as long
as it is stored and handled properly and is normal in appearance,
unless otherwise stated by the vaccine manufacturer. Always
consult the manufacturer’s package information that accompanies
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there evidence for the use of alcohol to clean the administration
site prior to injecting a vaccine?
has not directly addressed this issue. If alcohol is used, wait
a few seconds to let the alcohol dry before you inject vaccine.
a vaccine is inadvertently administered by the wrong route,
should the dose be repeated, and if so, when?
vaccines given by the intramuscular route need not be repeated.
Intramuscular vaccines given by the subcutaneous route usually
do not need to be repeated (exceptions: Hepatitis B vaccine
given by any route other than intramuscular, rabies vaccine
given in the gluteus). Incorrect routes other than intramuscular
subcutaneous generally should be repeated. An invalid vaccine
dose of a live vaccine should be repeated after
four weeks. An invalid dose of an inactivated
vaccine may be repeated immediately.
you use one site for more than one vaccine if there were other
sites available? For example, using two vaccines in the deltoid
of a child, as opposed to using one leg.
separate sites if possible. Which site(s) to use can depend
on the age of the vaccine recipient. The preferred site for
children two years old and younger is the anterolateral thigh.
The preferred site for children three years old and older is
the deltoid. The size of the muscle mass also is relevant for
intramuscular injections, as well as availability of certain
sites (e.g. a cast may make the anterolateral thigh inaccessible).
If you must use the same site for two vaccinations, you should
space them at least one inch apart.
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are so many vaccines recommended at the same time? If an allergic
reaction occurs, how would you know which vaccine caused it?
are recommended at the age for which there is a risk of disease.
For many vaccine-preventable diseases, the greatest risk is
in infancy and the early years of life. These diseases are still
out there, so the decision to vaccinate is one of risk versus
benefit; it is still very important to prevent these diseases.
It is difficult to pinpoint which vaccine may have caused an
anaphylactic reaction that occurred following multiple vaccinations;
but fortunately, anaphylaxis following vaccination is rare.
We are currently working on protocols for follow-up assessment
and vaccination of persons who have suffered an allergic reaction
following vaccination, protocols that involve giving one vaccine
at a time.
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someone has received Boostrix and then sustains a wound, what
vaccine would you give?
should follow the tetanus wound protocol and give Td if indicated.
Boostrix and Adacel are licensed for a one-time dose. If someone
has not received Boostrix or Adacel, sustains a wound,
and tetanus prophylaxis is indicated, then either Boostrix or
Adacel can be used, depending on the age of the recipient.
7-year-old received DT as an infant due to a seizure incident,
unrelated to vaccines or epilepsy. No further seizures occurred;
no medication was necessary. Can this child receive Tdap when
Yes, a history of infant seizures occurring within 72 hours
following vaccination is a precaution for further doses of infant
DTaP, but because seizures are not associated with Tdap, history
of infant seizures are neither a precaution nor a contraindication
to Tdap. The child should receive Tdap when age appropriate.
a 60-year-old patient presents for a Td booster without prior
vaccine history, can you offer Tdap?
Yes, you can and should offer Tdap. This is an off-label recommendation
by CDC (because the vaccine is licensed as a booster). Since
this person has no documented history of tetanus and diphtheria
vaccination, follow the Tdap one month later with a Td dose
and 6 months later with another Td dose.
the first case study, why did the 8-year-old girl not need a
Td? She had a DTaP combination at 2, 3, 4, and 18 months, but
no booster at 4-6 years. We give DTaP at 2, 4, 6, and 15 months
and then a booster at 4-6 years. Doesn’t she need a Td
Some experts recommend a dose of Td at this point (see Appendix
E of http://www.cdc.gov/mmwr/PDF/rr/rr5503.pdf,
Adolescent Tdap recommendations). The childhood/adolescent schedule
recommends a dose of Td now as well. However, others feel that
the fifth dose of tetanus-containing vaccine is driven by the
need for pertussis protection; this protection is not available
for children age seven years through nine years. Therefore,
our recommendation (if someone receives the first dose of tetanus-containing
vaccine at younger than 12 months and then receives four total
doses) is a dose of tetanus-containing vaccine is not needed
until the child is eleven years old. Of course,if the child
sustains a dirty wound in the interim, she would need a dose
of Td ASAP.
a child completes the primary DTaP series on schedule and then
receives a Td booster prior to age 11 years, when is a Tdap
dose due - 5 years from the Td they received, or 10 years?
An adolescent should receive a dose of Tdap five years from
the last dose of Td.
you please explain reported hyperimmune responses to tetanus
A reaction known as an Arthus reaction rarely
occurs following multiple doses of tetanus-toxoid or diphtheria-toxoid
containing vaccine given at short intervals. This reaction is
due to circulating antigen-antibody complexes. It is characterized
by pain and redness that can extend from shoulder to elbow.
Sometimes there is a necrotic center. The reaction is severe
but self-limited. For people who have experienced an Arthus
reaction we recommend giving all subsequent tetanus- or diphtheria-containing
vaccine doses at intervals no shorter than ten years.
an adult had pertussis as a child, does she need Tdap in adulthood?
Infection with pertussis does not confer lifelong immunity.
Adults with a history of pertussis generally should receive
Tdap according to the routine recommendations.
effective is Tdap when given to an adult who has not received
a primary series of DTP or DTaP?
There are no clinical data on this situation because this population
was not included in the Tdap clinical trials. Tdap is FDA approved
as a one-time booster dose. However, ACIP feels that one dose
is better than no doses and, thus, made the off-label recommendation.
Future data will provide evidence on the effectiveness of this
have an immunization record on a 6-year-old boy from Mexico.
The child has been given a total of 7 DTaP doses. His last dose
was given at the age of 3, two months before his 4th birthday.
Should the 5th dose be repeated since the child was not 4 years
of age when he received it?
The general guideline is to avoid administering more than 6
doses of DTaP before 7 years of age. This child likely has adequate
protection against all 3 antigens. However, if school law requires
a dose on or after the 4th birthday, then this dose can be repeated.
The child’s parents should be cautioned that the child
may experience an exaggerated local reaction, but this is transient.
a history of DTP or DTaP vaccination needed prior to administering
Tdap to all adults or only adults who need the vaccine for immigration,
to complete the primary series, or for school?
A history of DTP or DTaP is not a requirement for receiving
Tdap. The package insert indicates Tdap as a booster dose following
a primary series of pertussis-containing vaccine. However, CDC
makes the off-label recommendation that Tdap may be used as
one dose of the primary series (for anybody).
a 61-year-old received a Td booster one year ago, when should
he receive Tdap?
The recommended interval is 10 years after the last Td booster.
However, if there is a pertussis outbreak or this person has
contact with an infant younger than 12 months of age, there
is no minimum interval. The need for pertussis protection outweighs
the risk of a sore arm.
DTaP was given to an adult instead of Tdap, should the Tdap
dose still be given, and if so, at what interval?
Do not give the Tdap dose. This person has received the appropriate
amount of tetanus toxoid and MORE diphtheria toxoid and pertussis
antigen than is recommended. Count the dose, but take measures
to prevent this error in the future. A VAERS report should also
be submitted on any vaccine administration error.
a child completes the pediatric DT schedule at 15 months of
age, when would the next tetanus dose be due?
If pertussis is not contraindicated, the child should receive
a dose of Tdap at 11 years of age.
it the minimum interval between Td and Tdap for healthcare personnel
who work with children?
An interval as short as 2 years from the last dose of Td is
suggested to reduce the risk of local and systemic reactions;
but a shorter interval may be used. There is no absolute
it preferable to give Td or Tdap during pregnancy?
ACIP and AAP have different recommendations on the use of Tdap
ACIP voted to recommend Td (not Tdap) during
pregnancy if the woman is due for a routine tetanus booster.
If she is not due for the routine booster (i.e., the previous
Td booster was given within the preceding 10 years), the mother
should receive Tdap immediately postpartum. However there are
situations when a clinician can consider the use of Tdap for
a pregnant woman, such as if there is a risk of exposure because
of a pertussis outbreak. Tdap is not contraindicated for pregnant
women. The infant's other household contacts ages 10 through
64 years should also receive 1 dose of Tdap, if not already
AAP has endorsed preferential use of the Tdap
vaccine during pregnancy in adolescents who were not vaccinated
at the visit at age 11-12 years (Pediatrics 2006; 117:965-78).
Providers can follow either the AAP or ACIP recommendation.
a pregnant woman receives Td during pregnancy, how soon can
she receive a dose of Tdap?
She should receive a dose of Tdap during the postpartum period,
preferably before hospital discharge.
a public health nurse who is 66 years old and working with infants
No. There is no Tdap vaccine that is FDA-approved or ACIP-recommended
for use in anyone older than 64 years of age.
can’t Adacel be administered to persons older than 64
There are no safety and efficacy data for this age group and
FDA did not approve the vaccine for anyone older than 64 years
can’t we give a Tdap booster every 10 years?
The current Tdap vaccines are FDA-approved for only one dose.
it acceptable to administer Tdap to a 25-year-old healthcare
worker who had physician diagnosed pertussis (not lab diagnosed)
within the last 5 months?
Yes, especially if the healthcare provider works with children.
You should not consider withholding a dose of Tdap because of
disease history, unless you have culture-confirmed
disease within the last 5-10 years. Shorter intervals (shorter
than 2 years from last tetanus-toxoid-containing vaccine) can
be used with healthcare providers. You must use Adacel for anyone
19 through 64 years of age.
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Menactra is given to an infant instead of pneumococcal conjugate
vaccine, what do I do?
is not licensed for infants so of course this dose is invalid.
It does not provide any protection from Pneumococcus, so you
need to give a dose of Pneumococcal conjugate vaccine. This
can be given immediately, with no need for spacing, because
Menactra and pneumococcal conjugate vaccine are two separate
increasing pneumococcal conjugate vaccine coverage and increasing
non-vaccine serotypes present, are there concerns about increased
rates of antimicrobial resistance in these non-vaccine serotypes?
This is an issue that bears watching. Surveillance is ongoing
not only with the serotypes included the vaccine, but also others
that are prevalent. Vaccine manufacturers are working on development
of pneumococcal conjugate vaccines that will protect against additional
serotypes; and some vaccine serotypes offer cross-protection against
more than one disease serotype.
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a mother is nursing her child at 12 months, will a dose of MMR
still be effective?
Live vaccines like MMR are affected by circulating antibody
from blood products or maternally transferred antibody during
pregnancy. However, the antibody in breast milk is a different
type than maternally transferred antibody or blood products
(IgA versus IgG) so that breast feeding does not compromise
the efficacy of live vaccines.
there any indication that a person with idiopathic thrombocytopenia
purpura should not get a second MMR?
history of thrombocytopenia is a precaution for either dose
of MMR vaccine. The benefit of preventing the adverse reaction
thrombocytopenia by withholding the vaccine is potentially outweighed
by the fact that thrombocytopenia also can occur as a complication
of measles or rubella disease, and this could be worrisome in
someone with a previous history of thrombocytopenia. It is prudent
to withhold a dose of MMR from a patient with thrombocytopenia
that occurred within 6 weeks of a previous dose of MMR.
you have any suggestions on responding to a parent who requests
separate antigens (MMR) to avoid the vaccine made from an aborted
Helping these patients understand the origin and nature of fetal
tissue used in vaccine cultures might reduce their discomfort
about receiving MMR.
The rubella vaccine virus (used in MMR and single-antigen rubella
vaccine) is cultured in human cell-line cultures, and some of
these cell lines originated from aborted fetal tissue, obtained
from legal abortions in the 1960's. No new fetal tissue is needed
to produce cell lines to make these vaccines, now or in the
future. Fetal tissue is not used to produce vaccines; cell lines
generated from a single fetal tissue source are used; vaccine
manufacturers obtain human cell lines from FDA-certified cell
banks. After processing, very little, if any, of that tissue
remains in the vaccine. http://www.cdc.gov/nip/vacsafe/concerns/gen/humancell.htm
an international traveler born before 1957 who thinks s/he had
measles and mumps as a child be advised to get an MMR before
We recommend that you consider a dose of MMR for persons born
before 1957 if they are traveling to an area where measles is
common and the only evidence of immunity is their birthdate.
Seroprevalence studies in healthcare workers show that up to
5% of persons born before 1957 ARE susceptible. Five percent
susceptible is probably OK for adults at low risk of exposure,
but it is NOT OK for persons at high risk of exposure, such
as international travelers to areas with measles. You should
consult a travel medicine specialist to determine your specific
should be done for a pregnant woman whose serology shows that
she is not immune to Rubella (never had the disease or the vaccine)?
You cannot vaccinate her while she is pregnant. Just advise
her to be very careful about exposure during pregnancy. She
should receive a dose of MMR postpartum before discharge from
the hospital, http://www.cdc.gov/mmwr/PDF/rr/rr4708.pdf
did serology testing on a healthcare worker and the results
were negative. However, the healthcare worker brought in a vaccination
record with 2 MMRs documented. We did not vaccinate, but we
did ask the employee to sign a declination form. Was this the
correct action? Would the recommendation for Rubella be different
if the healthcare worker works in an OB-GYN outpatient clinic
or in a planned parenthood setting?
If a healthcare worker has a record of two age-appropriate doses
of MMR vaccine, no additional doses are needed in either situation.
The criteria for immunity have been met.
was stated at a CDC conference that MMR is light sensitive.
Does this sensitivity occur only before reconstitution or both
before and after? Would this light sensitivity also be true
for Varicella and MMRV?
HPV, MMR, MMRV, rotavirus, varicella, and zoster vaccines are
sensitive to light, which causes loss of potency. These vaccines
must be protected from light at all times. Therefore, store
these vaccines at the appropriate temperatures in their boxes
with the tops on until they are needed.
there ramifications if providers are vaccinating with the 2nd
MMR at the minimum interval instead of waiting until the child
is 4-6 years old?
The minimum interval between MMR-1 and MMR-2 is 28 days. As
long as the doses meet minimum age and minimum intervals, the
child is considered to be biologically protected. However, you
should make sure this is acceptable under your state's immunization
entry school law. If not, the state may invalidate MMR-2 and
require a dose on or after the 4th birthday.
we have a measles or mumps outbreak and have unvaccinated students
in school, how long after they receive their first MMR could
they be considered immune and allowed to return to school? How
about after their second MMR?
According to our surveillance manual, a person can be readmitted
as soon as the first dose is given.
healthcare personnel be required to have serologic evidence
of immunity for measles if they have documentation of receiving
two doses of vaccine?
Documentation of two valid doses of live-virus measles vaccine
is acceptable evidence of immunity and post-vaccination serologic
testing is not recommended,
(page 11, Table 1).
there fewer side effects with MMR-2 due to immunity?
Yes. The side effects are related to replication of vaccine
virus. Most persons (90%-95%) are immune after dose one, thus
fewer side effects are reported after dose two.
it preferable to freeze or refrigerate MMR? If it is stored
in the freezer, how long can the vaccine last outside the freezer?
Unreconstituted MMR vaccine can be stored either in the freezer
or the refrigerator. It can be stored in the refrigerator until
its expiration date as long as the refrigerator temperature
is 35° to 46° F, the vaccine is normal in appearance,
and it is protected from light. Once reconstituted, the vaccine
must be discarded if not used within 8 hours.
someone born before 1957 who works in a day care center need
Employees in a day care setting are not considered a high-risk
group for MMR vaccination. Someone born before 1957 meets the
birthdate critierion for immunity (except for rubella immunity
for child-bearing women).
an infant whose mother had an anaphylactic reaction to MMR be
A family history of an allergic reaction is not a contraindication
a person donate blood after receiving an MMR?
Yes. Red Cross guidelines advise waiting four weeks after receipt
of MMR before donating blood,
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VZIG is no longer produced, what are the current options for
an immunocompromised individual or a pregnant woman with no
known immunity who is exposed to varicella?
is an investigational new product known as VariZIG that can
be used for immunocompromised individuals or for pregnant women.
Remember, this is a concern if the individual is susceptible
to chickenpox. Instructions on the use of VariZIG are available
in MMWR 2006; 55:209-210. VariZIG must be given within the first
96 hours following exposure. For immunocompromised persons,
if this product cannot be obtained, IGIV can be administered
– also within 96 hours. If a pregnant woman cannot receive
VariZIG within 96 hours, she can be administered IGIV or can
be followed for signs of rash and treated with acyclovir if
a rash appears.
varicella vaccine be used for post-exposure prophylaxis with
children younger than 12 months of age? If not, would varicella
immune globulin or an anti-viral be indicated?
Varicella vaccine is neither recommended nor approved by FDA
for use in children younger than 12 months. Post-exposure prophylaxis
using varicella immune globulin (VariZIG) would only be indicated
in this situation if the child were immunocompromised. Please
for instructions on how to obtain and use VariZIG.
anti-virals are used for treatment, not post-exposure prophylaxis.
In this situation, if symptoms were to develop, anti-virals
could be used if the patient is immunocompromised, on long-term
salicylate therapy (including aspirin), or has a chronic skin
or pulmonary disorder.
state requires children born after January 1, 1997 to have a
dose of varicella vaccine before attending school. If the parent
verbally reports that the child has had chickenpox disease,
we do not administer the vaccine. What if the parent is not
reliable and what if it wasn't chickenpox that the child had?
Should we continue to accept the parents word, despite the number
of chickenpox disease outbreaks that we are seeing now.
We recommend that you apply the revised definitions of varicella
Note that we no longer recommend regarding parental reporting
alone as reliable evidence of immunity.
1. Documentation of age-appropriate vaccination: a. Preschool-aged
children >12 months of age: one dose b. School-aged
children, adolescents, and adults: two doses.
2. Laboratory evidence of immunity (reliable for disease-induced
immunity, but may yield false-negative results for vaccine-induced
immunity) or laboratory confirmation of disease.
3. Born in the US before 1980 (does not apply to pregnant women
or healthcare personnel).
4. A healthcare provider diagnosis of varicella or healthcare
provider verification of history of varicella disease (Verification
means that a healthcare provider may retrospectively diagnose
chickenpox based on the history provided by a patient or parent.
Verification of history or diagnosis of typical disease can
be done by any healthcare provider [e.g., school or occupational
clinic nurse, nurse practitioner, physician assistant, physician].
For people reporting a history of or presenting with atypical
and/or mild cases, assessment by a physician or their designee
is recommended and one of the following should be sought: a)
an epidemiologic link to a typical varicella case or b) evidence
of laboratory confirmation, if laboratory testing was performed
at the time of acute disease. When such documentation is lacking,
people should not be considered as having a valid history of
disease, because other diseases may mimic mild atypical varicella.)
5. History of herpes zoster based on healthcare provider diagnosis.
in doubt, vaccinate. The vaccine will not harm someone who is
an infant younger than one year of age who has lab-verified
chickenpox need varicella vaccine after the first birthday?
No. Laboratory confirmation of disease, regardless of age at
the time, is acceptable evidence of immunity.
a fever of 102° or greater 42 days after varicella vaccine
really be related to the vaccine? That seems like a very long
Obviously there are many things that could be related to a fever
of 102° or greater, but it is possible that it could be
related to vaccination.
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Mumps, Rubella, Varicella (MMRV)
is the interval between doses of MMRV vaccine three months instead
of one month? The interval between doses of MMR is one month.
of it has to do with data from clinical trials. MMRV was studied
at three month intervals. Licensure is based on the intervals
used in these prelicensure trials.
can we not give MMRV to people with HIV/AIDS if the monovalent
MMR and varicella vaccines can be given in some cases?
use of MMRV was not studied in patients with HIV/AIDS and the
titer of varicella virus in MMRV is more than seven times as
high as in monovalent varicella vaccine. So FDA did not license
MMRV for patients with HIV/AIDS.
a child who developes a mild rash, i.e. vesicles, following MMRV,
need to be isolated?
a child developes vesicles following MMRV, it could be a vaccine
associated rash, it could be breakthrough varicella, or it could
be something else entirely. You should use your clinical judgment
regarding the type and number of lesions to make this diagnosis.
Most vaccine-associated lesions are maculopapular. If the diagnosis
is breakthrough disease, treat this like wild-type varicella.
Vaccine recipients in this situation should restrict contact
with immunosuppressed persons who are susceptible to varicella.
MMRV is inadvertently administered to a healthcare professional
do either or both vaccines need to be repeated or should titers
We recommend that you count the dose. Do not draw titers, but
do assess your system to find out what measures can be taken
to prevent a recurrence of this medication administration error.
We also request that a VAERS report be submitted for all medication
errors even when there is no adverse event.
MMRV-2 is given one or two months after MMRV-1, is MMRV-2 invalid
and should it be repeated?
The minimum interval between MMRV-1 and MMRV-2 is 3 months.
However, if on record review you discover that MMRV-2 was given
less than 3 months after MMRV-1, it can be counted and does
not need to be repeated as long as there was an interval of
at least 4 weeks between the two doses. This 4-week interval
should NOT be used for forecasting or scheduling MMRV-2 doses.
It should ONLY be used for record review evaluation of doses
is MMRV not given to persons older than 12 years of age?
Because the manufacturer did not request licensure and did not
present safety and efficacy data on the use of MMRV in persons
13 years of age or older. The vaccine is not FDA approved for
use in anyone younger than 12 months of age or older than 12
years of age.
two doses of MMRV are given at 3-month intervals, but both doses
are given before 4 years of age, is a dose required at school
Another dose is not required unless your state will not accept
a 2nd dose administered before 4 years of age. As long as both
doses are administered after 12 months of age and are 3 months
apart, the person is considered to be biologically protected.
MMRV need to be delayed following receipt of Rhogam?
First, MMRV should not be administered to anyone 13 years of
age or older. If a post-partum woman is susceptible to measles,
mumps, rubella, or varicella, then MMR and/or varicella vaccines
should be administered before discharge from the hospital or
birthing center. The woman should be tested for antibodies 3
months later. If she has not responded, she should be revaccinated
does MMRV contain so much more varicella vaccine virus than
More varicella antigen was necessary to induce an immune response
when the varicella vaccine virus was combined with measles,
mumps, and rubella vaccine viruses, compared with the response
when monovalent Var is administered alone or simultaneously
varicella vaccine can be kept in the refrigerator for 72 hours
and MMR vaccine can be stored in the refrigerator, why can’t
MMRV be stored in the refrigerator?
There is a lot more varicella vaccine virus in MMRV than in
single-antigen varicella vaccine. The manufacturer storage data
does not demonstrate adequate viability of the vaccine viruses
in MMRV when stored at refrigerator temperatures.
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a booster required for Menactra?
We expect one dose of Menactra to provide life-long immunity.
As the vaccine has been in use for only two years, we are still
in the process of verifying this, but most conjugate vaccines
produce long-term immunity.
the incidence of Guillain Barré Syndrome (GBS) increase
when Menactra and influenza vaccines are administered at the
There are no data to indicate an increased risk of GBS when
Menactra and influenza vaccines are administered at the same
there a vaccine that is given in other countries that is effective
against meningococcal type B? If there is, why is it not available
in the US?
There are numerous sub-strains of Neisseria meningitidis
type B. Vaccines produced in other countries for their indigenous
strains would not necessarily be effective against the strains
found in the United States. Efforts are being made to produce
a U.S.-specific vaccine.
should I do if meningococcal conjugate vaccine was inadvertently
administered to a 55-year-old or older person?
Count the dose and do not revaccinate. Although the vaccine
is not FDA approved for use in anyone older than 54 years, we
have no reason to think that the person would not respond. However,
this is a medication error that should not be repeated.
MCV4 contains diphtheria toxoid, should we recommend that Td
or Tdap and MCV4 be given on separate days, or may they be given
at the same time?
ACIP recommends that Td or Tdap and MCV4 can be administered
in separate syringes at separate anatomical sites on the same
day or at any interval from each other, http://www.cdc.gov/mmwr/PDF/rr/rr5503.pdf.
an 18-year-old presents for meningococcal vaccine with a history
of a reaction to diphtheria toxoid, should we administer MPSV4
instead of MCV4?
It depends on the reaction. If it was an anaphylactic type reaction,
then give MPSV4. If it was an Arthus reaction and at least 10
years have elapsed, you can give MCV4.
zoster vaccine be administered with other vaccines? The package
insert says that administration with other vaccines has not
vaccine would be administered most often with inactivated influenza
vaccine and pneumococcal polysaccharide vaccines (also inactivated).
Applying guidelines from ACIP's General Recommendations, an
interval is not required between an inactivated vaccine and
a live vaccine.
sixty-one-year old male presents with an unknown history of
varicella illness. His wife is currently diagnosed with shingles.
He is asymptomatic. Does he need both the varicella vaccine
as well as the zoster vaccine?
The wife's current illness is irrelevant to the decision to
vaccinate the husband. Persons born in the U.S. before 1980
can be assumed to be immune to varicella and can receive zoster
vaccine if at least 60 years of age with no medical contraindications
to the vaccine.
you have a severe case of chickenpox, does this predispose you
to an increased risk of shingles?
There is no information indicating that the severity of chickenpox
has any effect on the chances of getting zoster (shingles) later
in life. If a person has had chickenpox, the virus is present
and logically the chances of it becoming reactivated and causing
zoster would be the same whether the disease was mild or severe.
Having had chickenpox at a very early age does seem to predispose
the person more to zoster. The reasons are not clear.
a dose of zoster vaccine need to be repeated if administered
by the intramuscular route instead of the subQ route?
No. Vaccines should always be given by the route recommended
by the manufacturer because data regarding safety and efficacy
of alternate routes are limited. If a dose of vaccine is inadvertently
given by the wrong route, ACIP recommends that it be counted
as valid. There are two exceptions to this recommendation: hepatitis
B or rabies vaccine given by any route other than IM should
not be counted as valid and should be repeated (http://www.cdc.gov/mmwr/PDF/rr/rr5515.pdf,
zoster vaccine indicated for persons with no history of varicella
In conducting routine zoster vaccination of persons 60 years
of age or older, there is no need to verbally screen for varicella
history (i.e., inquire about the person's history of varicella)
or to conduct laboratory testing for serologic evidence of prior
varicella. If the person is 60 years of age or older and has
no medical contraindications, s/he is eligible for zoster vaccine.
someone with shingles infect a susceptible person with varicella?
Yes. Shingles itself cannot be passed from one person to another.
However, the virus that causes shingles, VZV, can be spread
from a person with active shingles to a person who has never
had chickenpox through direct contact with the rash. The person
exposed would develop chickenpox, not shingles. The virus is
not spread through sneezing, coughing or casual contact. A person
with shingles can spread the disease when the rash is in the
blister-phase. Once the rash has developed crusts, the person
is no longer contagious. A person is not infectious before blisters
appear or during a period of post-herpetic neuralgia (pain after
the rash is gone).
is the interval between receiving zoster vaccine and donating
The general guideline is to wait at least 4 weeks after vaccination
with varicella vaccine to donate blood. However, you should
contact the Red Cross for specific guidance for zoster vaccine,
is known to occur in persons younger than 60 years of age. Can
zoster vaccine be given to them?
Not at this time. Zoster vaccine is only FDA approved for use
in persons 60 years of age and older, and there are no ACIP
off-label recommendations to use this vaccine in anyone younger
than 60 years old.
thinking about giving herpes zoster vaccine to a person 60 years
of age or older, how soon after a case of shingles can the vaccine
The general guideline for any vaccine is to wait until the acute
stage of the illness is over and symptoms abate.
if we violate the minimum 6 month interval between Hepatitis
A doses by more than four days?
second dose would be invalid, and should be repeated after an
interval of at least 6 months. A single dose of Hepatitis A
vaccine is 95-97 percent immunogenic, so it is protective in
the short term. The second dose is important to provide long-term
Hepatitis A vaccine be administered after a hematapoietic stem
should not be a problem, since Hepatitis A is an inactivated
vaccine. There are very little data on giving repeat doses of
this vaccine following HSCT, since it has only recently become
universally recommended. It makes sense to give this vaccine
with the other inactivated vaccines, 12 months post-transplant.
the two doses of hepatitis A vaccine need to be separated by
6 months, and one month equals four weeks, can we separate doses
by 24 weeks?
For periods of four months or longer, we recommend using calendar
months for spacing, rather than converting to weeks. The rationale:
because most months are longer than four weeks, using this conversion
introduces error that progressively shortens the interval. For
example, with 4 weeks equaling a month, 12 months would be only
336 days or almost a month short of a year. Therefore we prefer
you use calendar months for the Hepatitis A interval.
do you complete the hepatitis A and heptatis B series with single-antigen
vaccines if the patient started with Twinrix, and vice versa?
Because the hepatitis B component of Twinrix is equivalent to
a standard, adult, dose of hepatitis B vaccine, the schedule
is the same whether Twinrix or single-antigen hepatitis B vaccine
Single-antigen hepatitis A vaccine may be used to complete a
series begun with Twinrix and vice versa. A person 19 years
of age or older who receives one dose of Twinrix may complete
the hepatitis A series with two doses of adult formulation hepatitis
A vaccine separated by at least 5 months. A person who receives
two doses of Twinrix may complete the hepatitis A series with
one dose of adult formulation hepatitis A vaccine or Twinrix
5 months after the second dose. A person who begins the hepatitis
A series with single-antigen hepatitis A vaccine may complete
the series with two doses of Twinrix or one dose of adult formulation
hepatitis A vaccine.
second dose of hepatitis A vaccine was administered 4 months
after the first dose. A repeat dose was given 4 months after
the invalid second dose. What should we do now?
Nothing. We do not recommend a fourth dose of hepatitis A vaccine
in this situation. Response to one dose is 95% or better. There
is no reason to think this person does not have adequate protection.
hepatitis A vaccine be given to sewage workers?
No. Sewage workers are not at increased risk for hepatitis A
infection because of their occupation. Persons who are
at increased risk for HAV infection include:
• travelers to countries that have high or intermediate
endemicity of HAV infection (for map of endemic areas, see www.cdc.gov/travel/diseases.htm#hepa)
• men who have sex with men (MSM)
• users of injection and noninjection illegal drugs
• persons with clotting-factor disorders
• persons working with nonhuman primates
a health care worker received three doses of hepatitis B vaccine
in childhood and recently received two additional doses, should
we do a titer now or should we just give the third dose before
performing the titer?
can do a titer now. If the childhood series produced immunity,
the first of the two recent doses should have generated a detectable
antibody level. If the test is positive, you do not need to
give more doses; if the test is negative, you should give another
dose and then test for antibody at least one month but no later
than 2 months later.
we vaccinate someone with hepatitis B vaccine if they have a
diagnosis of hepatitis B disease?
diagnosed with hepatitis B does not need to be vaccinated, as
they are already infected and therefore immune. But they should
be counseled about the risks of transmission, and will require
follow up therapy to monitor for progression of disease.
a child receives a birth dose of Hepatitis B vaccine, and then
Pediarix at 2 months and 8 months, does there need to be an eight
week interval between the 2 and 3 dose of Pediarix?
need to make sure that the minimum spacing intervals are observed
for every antigen in the vaccine (except for those for which
the series is already complete). In this specific case, the
child is already complete for Hepatitis B and is late for the
3rd dose of DTaP and Hib. Since the minimum interval for dose
2 and dose 3 of Pediarix (per the package insert) is six weeks,
six weeks would seem to be an acceptable interval in this situation.
we are using a routine schedule for Hepatitis B vaccine for adults
– 0, 1 month and 6 months – what happens if someone
falls behind? Let’s say they receive the second dose 3 months
after the first. When should they return for dose three?
an adult is receiving Hepatitis B vaccine it means that he or
she might be at risk, and one could argue that minimum intervals
should be used to expedite vaccine doses if someone falls behind
in the schedule (presumably because of a missed clinic visit).
So give the third dose eight weeks after dose number two in
is the interval between the first two doses of Hepatitis B vaccine?
recommended interval is variable by age and allows for several
different schedules; it is important to remember that the minimum
interval between dose 1 and dose 2 is four weeks.
using the catch-up schedule for HBV for a 15-year-old. I gave
dose one on January 8th and scheduled dose 2 for February 5th
(28 days later). Mom called wanting him to get dose 2 on February
1st. Would this be considered 4 or 5 days before February 5th?
We would consider February 1st four days before February 5th.
February 4th would be one day before February 5th, February
3rd two days, etc. So by that logic February 1st would be four
days. Be sure your state accepts the Grace Period.
a police officer was previously vaccinated for Hepatitis B and
while patting down a suspect he is stuck with a needle, should
he have his antibody level checked? Should he start immune globulin?
Should he be tested 6 months later?
If the police officer is a known vaccine responder or if the
source of the exposure is known to be HBsAg-negative, no treatment
for Hepatitis B is necessary. However, if the police officer
was a known vaccine nonresponder or if his immune response is
unknown, then the treatment depends on the HBsAg status of the
source. If a program is in place to implement testing and follow-up
algorithms, the hepatitis B post-exposure prophylaxis protocol
should be followed, http://www.cdc.gov/nip/publications/pink/hepb.pdf.
5 years have elapsed since hepatitis B dose-2, should the series
No. There are no maximum intervals between doses; just pick
up where the person left off and complete the series.
hepatitis B vaccine and HBIG are administered to a newborn,
should the doses be given in separate extremities?
It is preferable to use separate extremities. If this is not
possible, the two IM injections should be separated by at least
one inch. This may be challenging in a newborn thigh.
have a new healthcare employee who needs hepatitis B protection.
She has 3 documented doses of hepatitis B vaccine from several
years ago, but she cannot remember if she had serologic testing
after the series. How should we proceed?
If the third dose of vaccine was administered prior to 1997,
you should consider someone with three documented age-appropriate
doses of vaccine as immune. In 1997 we began to recommend post-vaccination
testing. If the third dose was administered in 1997 or later,
first, check with the former employer to find out if there is
a record of post-vaccination serologic testing. Is the following
true? I thought we test, if negative give three doses, and then
test. If there is not, there are two options: 1) One is to repeat
the 3-dose series, testing for anti-HBs after the third dose.
2) A probably less expensive option is to administer a single
dose of vaccine and test in 4-6 weeks. If the person is anti-HBs
antibody positive, this most likely indicates a booster response
in a previous responder, and no further vaccination (or serologic
testing) is needed. If the person is anti-HBs antibody negative
after this “booster” dose, a second series should
be completed (i.e., two more doses). If the person is still
seronegative after six total doses, he or she should be managed
as a nonresponder. (10th Edition Pink Book http://www.cdc.gov/nip/publications/pink/hepb.pdf
are the minimum intervals for the Human Papillomavirus vaccine?
minimum intervals for HPV vaccine are: 4 weeks between dose
1 and dose 2, and twelve weeks between dose 2 and dose 3. You
can finish the entire series in sixteen weeks, and no faster.
The only place this is currently written is in the Vaccines
for Children HPV vaccine web page which reflects the ACIP recommendations
for this vaccine.
review of the literature indicates that the vaccine is 95% effective
after a single injection. Is the CDC reviewing the possibility
of changing to a single injection and is there discussion of
The data that led to licensure of HPV vaccine was based on three
doses. ACIP will only recommend the vaccine to be used in the
manner in which it was approved by FDA (3 doses). There are
no data on which to base a recommendation for fewer than 3 doses.
Duration of immunity studies are in progress.
the HPV vaccine be given to those with HIV?
Because quadrivalent HPV vaccine is a noninfectious vaccine,
it can be administered to females who are immunosuppressed as
a result of disease or medications. However, the immune response
and vaccine efficacy might be less than that in persons who
are immunocompetent, http://www.cdc.gov/mmwr/PDF/rr/rr56e312.pdf
there an indication for women older than 26 who are high risk?
HPV vaccine is not approved or recommended for women older than
HPV vaccine being tested for use in males?
Efficacy studies among males are in progress. At this time HPV
vaccine is not approved or recommended for males of any age.
the age range for HPV vaccine 9 years to 26 years or
9 years through 26 years?
The approved age range for HPV vaccine is 9 years THROUGH 26
years (i.e., to the 27th birthday). We do not recommend use
of this vaccine outside the age range approved by the Food and
long does protection from the Human Papillomavirus (HPV) vaccine
last? Is a booster required?
The vaccine is too new to know how long protection will last.
There are no booster doses recommended at this time. Studies
will continue to assess the duration of effectiveness.
it appropriate to administer HPV vaccine to a female who states
she is gay?
HPV vaccine is approved for all females 9 years through 26 years
of age. Sexual orientation is not a factor.
physician has written a standing order to give HPV vaccine to
all adolescent males and females in our practice. Is this appropriate?
HPV vaccine is only approved for use in females 9 years through
26 years of age. The vaccine is not approved for use in males.
we do pregnancy testing before administering HPV vaccine?
Routine pregnancy testing of women of childbearing age before
administering a vaccine is not recommended. Ask if the female
could be pregnant or is planning to become pregnant while receiving
the vaccine series. If the response is no, vaccinate and explain
in terms the patient can understand why it is important to avoid
pregnancy until 4 weeks after the series is complete. We do
suggest that you consider asking what form of birth control
is being used. Some sexually active females will say they could
not be pregnant, yet are not using birth control.
PPV recommended for persons with diabetes?
diabetes increases the risk for invasive disease from pneumococcus.
One dose of PPV vaccine should be administered to persons 2
years and older with diabetes.
is the recommendation regarding a second dose of PPV in a situation
where the risk is continuing (e.g., sickle cell disease)? Should
the patient receive the second dose 5 years after the first?
That would mean that, if the patient is a child, a considerable
amount of time may elapse after the second dose without another
booster. Would you suggest a longer interval in this situation?
The recommended interval between doses of PPV is 3 years if
the child is seven years old or younger at the time of the first
dose. Otherwise, the interval is 5 years. No more than two lifetime
doses of PPV are recommended, regardless of the age the doses
are received. Children 59 months and younger should also receive
pneumococcal conjugate vaccine as age-appropriate.
a person younger than 65 years of age has already received 2
doses of PPV, should a 3rd dose be given after age 65 if 5 years
have passed since the last dose?
No. There are no recommendations to administer more than 2 doses
of PPV in a lifetime.
you wait a specified time after a splenectomy to vaccinate with
Ideally, PPV should be administered at least two weeks before
a scheduled splenectomy. If this is not possible, then the patient
can be vaccinated when stable at hospital discharge.
physicians in our area order PPV every 5 years for their patients.
Is this correct?
ACIP does not recommend more than one or two doses of PPV vaccine
in a lifetime. PPV is a polysaccharide vaccine that does not
boost well and data do not indicate that multiple doses are
persons with chronic disease who receive PPV vaccine be revaccinated?
Persons with chronic disease (heart, lung, metabolic, etc.)
should receive one dose of PPV vaccine. If that dose is administered
before 65 years of age, then a second dose should be given after
65 years of age as long as 5 years have elapsed since the first
a person received a dose of PPV at 65 years of age and then
is treated for cancer at 75 years of age, would a second dose
of PPV be indicated?
Yes. This person would be immunocompromised and a second dose
would be indicated, http://www.immunize.org/catg.d/2015pne.pdf.
someone who has received a cochlear implant receive one or two
doses of PPV?
One dose of PPV is indicated for someone who has had a cochlear
implant. This is not an indication for revaccination.
someone receives live attenuated influenza vaccine, do they
need to wait 4 weeks before becoming pregnant?
attenuated influenza vaccine is contraindicated in pregnancy.
Neither the manufacturer nor ACIP has recommended a minimum
interval between vaccination and pregnancy, but because the
duration of replication is similar to that of MMR and varicella
viruses, it seems reasonable to follow the general rule for
live vaccines and avoid pregnancy for four weeks.
we run out of the thimerosal-free Flu vaccine for children younger
than 3 years of age, can the thimerosal-containing vaccine be
Yes, if this is all you have available and as long as the age-appropriate
dose is administered (0.25 mL for children 6 months through
35 months of age). The known risks to young children from complications
of influenza infection outweigh any theoretical risk from the
very small amount of thimerosal in the vaccine. NOTE: If using
prefilled syringes with 0.5 mL, the unused portion of the vaccine
should be discarded.
have told patients they cannot get an allergy shot on the same
day as a vaccine and must wait 24 hours between them. I was
told if there were a reaction you would not be able to tell
if it was from the vaccine or the allergy shot. The problem
comes during flu season when we have a large number of patients
coming in for allergy shots and influenza vaccination. What
do you advise?
The probability of a serious allergic reaction following any
vaccine is extremely low if the person is properly screened.
The ACIP has no recommendation for this situation, but has never
recommended that desensitization injections and vaccines be
separated by any specific time period.
year did inactivated influenza vaccine (TIV) become available?
Trivalent inactivated influenza vaccine has been available since
LAIV be used to treat influenza?
There are no recommendations to use influenza vaccine for treatment.
a child receives influenza vaccine at 34 or 35 months of age
for the first time (dose 0.25mL) and the child returns for the
second dose at 37 months (3 years) of age, should the child
receive 0.25 mL or 0.5 mL?
The child should receive the dose appropriate for his or her
age at the time of the clinic visit; for a 37-month-old child
that would be 0.5 mL.
the case of an influenza outbreak and a vaccine shortage, is
it an effective strategy to vaccinate previously unvaccinated
children with only one dose so there are more doses to go around?
If a child presents at the clinic for dose 2, the child should
be vaccinated. There are no recommendations to withhold adequate
vaccination from some to offer inadequate vaccination to many.
For influenza naïve children younger than 9 years of age,
one dose of vaccine primes the immune system, but offers little
or no protection. It is the second dose to which these children
will respond with an adequate immune response.
LAIV be given as early as 12 months of age in light of the new
No. There are no new recommendations regarding age indications
for LAIV. LAIV can only be used for healthy, nonpregnant persons
5 years through 49 years of age.
someone has had influenza, should they receive influenza vaccine?
Yes. There are two commonly circulating serotypes of influenza
A and one circulating serotype of influenza B. Someone with
a history of influenza disease is still vulnerable to the other
two serotypes. The vaccine is matched and protects against all
influenza activity increases in February or March, should second
doses of influenza vaccine be considered for high-risk groups?
No. Only one dose of influenza vaccine is recommended annually
except for children 6 months through 8 years of age who are
receiving influenza vaccine for the first time.
is the minimum interval between the two doses of influenza vaccine
for children who require two doses?
If the child receives two doses of TIV, the minimum interval
between the two doses is 4 weeks.
If the child receives two doses of LAIV (only healthy children
5 years through 8 years of age), the minimum interval is 6 weeks.
If the child receives one dose of TIV and one dose of LAIV,
it depends on which dose is administered first. If the child
receives TIV first, wait 4 weeks to administer LAIV. If LAIV
is given first, wait 6 weeks to administer TIV.
a flu shot be given at anytime during pregnancy or should we
wait until the second trimester?
Pregnant women can receive inactivated influenza vaccine (TIV)
regardless of the stage of pregnancy.
influenzae type b
Hib vaccine would you recommend for an adult who has had a splenectomy?
ACIP does not specify any brand of Hib vaccine for this purpose.
These persons can receive one pediatric dose of any single-antigen
28-year-old female with asplenia received Hib vaccine 5 years
ago. Should she now receive a booster dose?
There are no recommendations to give Hib booster doses in this
a baby eligible for RotaTeq #1 at 12 weeks and 1-6 days or is
the cut off 12 weeks and 0 days? Also the same question for
32 weeks, please.
An infant should not receive the first dose of rotavirus vaccine
once s/he is 13 weeks of age. An infant should not receive any
rotavirus vaccine once s/he is 33 weeks of age.
rotavirus vaccine contraindicated for a child who had surgery
for intestinal blockage when younger than 12 weeks of age?
This is a risk/benefit situation that should be evaluated on
an individual basis by the healthcare provider. For further
information, please review the contraindication/precaution section
of the ACIP recommendations, at http://www.cdc.gov/mmwr/PDF/rr/rr5512.pdf
it OK to give rotavirus vaccine to a child who is 13 weeks +
4 days of age?
No. This vaccine is not approved or recommended for use in children
13 weeks of age or older.
an infant received rotavirus vaccine at 16 weeks of age and
is not yet 24 weeks of age, do you count the first dose and
continue with the vaccine series?
Infants for whom the first dose of rotavirus vaccine was inadvertently
administered off label at 13 weeks of age or older may receive
the remaining two doses of the series at the routine intervals.
Timing of the first dose should not affect the safety and efficacy
of the second and third dose. The third dose should not be given
after 32 weeks, however.
rotavirus vaccine be given to a child who has had surgery for
This is an individual risk/benefit decision that must be made
by the child’s healthcare provider.
is the recommendation for adults who have had polio vaccine
but have no record of it and now need to show proof for college?
Polio vaccine is not recommended for adults unless they are
traveling to a polio endemic or epidemic country. If the college
insists, then the adult needs to follow the rules of the college
and show evidence of immunity or documentation of vaccination.
one adult dose of polio is recommended for travel, how does
this apply to older travelers who were already adults when they
got their primary series in the 1950's or 1960's? Is the recommendation
always for only one adult dose or is there ever a
time limit for people who have had an adult dose of polio but
it was many years ago?
Adult travelers who have already completed a primary series
need one additional dose for travel, regardless of their age
when they got their prior doses. If the primary series is unfinished
they should finish the primary series.
see exclusively refugees in our clinic who come from Africa,
eastern European countries, Middle Eastern countries. They frequently
come with no documentation of any vaccinations. Is a complete
IPV series recommended for adults from these countries?
If they plan to travel back to a country with endemic polio
or epidemic polio, they should receive a primary series.
see many children from other countries. Many have been given
the first polio at birth to one week of age.
1. What is the minimum acceptable age for the first polio dose?
2. Does a child who received four doses of OPV need a dose of
The minimum acceptable age for a dose of OPV or IPV is 6 weeks,
(Table 1 - page 3).
Four doses of OPV or IPV in any combination by age 4–6
years is considered a complete series, http://www.cdc.gov/mmwr/PDF/rr/rr4905.pdf.
IF your state law requires a dose on or after the 4th birthday
and the child's documented polio immunization history does not
meet that requirement, then you can give a dose of IPV to meet
the school requirement.
a person who has had polio disease travels to a polio endemic
country, does s/he need polio vaccine?
Yes. Polio infection only offers immunity to the serotype with
which the person was infected. Polio vaccine protects against
3 serotypes of polio virus. The person should receive age-appropriate
vaccination is traveling to a polio endemic area of the world.
serologic testing is so unreliable, why is there so much reference
to doing it in the latest ACIP recommendations?
If you are referring to the General Recommendations on Immunization,
we have added limited guidance on the use of serology in situations
where the results of false-negatives (common with serology)
do not impact negatively, and the cost of giving additional
doses may be high. Examples include:
1) the decision to perform serology instead of vaccinating someone
with unknown records (e.g. measles, rubella, hepatitis A, tetanus)
2) performing serology when thousands of people have received
improperly stored vaccine (wrong temperature) (i.e. MMR, Var,
MMRV). Notice that if the serology is negative, you give a dose
It all comes down to the cost-benefit of performing the test
instead of giving the vaccine. Because the tests do have high
false-negative rates, we do not recommend their use routinely
for persons who have documented evidence of vaccine doses. This
comes into play often with persons entering the medical profession.
One important exception is Hepatitis B (for health-care providers),
because the disease is quite prevalent still and the risk is
so high for clinicians and other health-care providers. The
false-negative rate for this test is high as well, unless performed
1-2 months after the 3rd dose, hence the complicated revaccination
four viruses have been eliminated from the U.S. by vaccine?
Smallpox (1949); Polio (1979); Measles (1994); Rubella (2004)
the diluents for MMR, MMRV, Varivax, and Zostavax interchangeable?
Yes. This diluent is produced by Merck and can be used for any
of these four Merck vaccines.
Pediarix insert says the interval between doses is 6-8 weeks (preferably
8 weeks). I thought I heard you say on the broadcast that the
interval between dose 1 and dose 2 could be as short as 4 weeks.
An interval of 6-8 weeks is recommended. It is acceptable to use
minimum intervals as long as you do not violate the minimum
intervals for any component in a combination vaccine. Pediarix
consists of DTaP, IPV, and hepatitis B vaccine. The minimum interval
between the first and second doses of each of these components
is 4 weeks.