Immunization Update 2012 Broadcast: Q&As
Questions submitted during broadcast - August 16, 2012
Should the frequency of Pap tests be different for girls and women who have received HPV vaccine compared with those who have not been vaccinated?
No. Receipt of HPV vaccine does not replace the need for cervical cancer screening. Women should consult with their healthcare provider for recommendations regarding the frequency of cervical cancer screening, which includes a Pap test and HPV testing.
We know CDC recommendations state that the minimum intervals for HPV vaccination are at least 4 weeks between doses 1 and 2 and at least 12 weeks between doses 2 and 3. This adds up to a total of 16 weeks between doses 1 and 3. But someone in our clinic said the interval is 24-weeks. Would you please clarify this?
When administering HPV vaccine, you must meet ALL the minimum intervals. Twenty-four weeks is ALWAYS the minimum interval between the first and last doses. So if you use the minimum interval of four weeks between dose 1 and dose 2, you must wait 20 weeks to administer dose 3 in order to meet the 24-week minimum interval between doses 1 and 3. On the other hand, if you separate doses 1 and 2 by at least 12 weeks, you can use the minimum 12-week interval between doses 2 and 3. Determination of these minimum intervals was based on extensive discussion with the manufacturers and on data from the HPV vaccine clinical trials. Note that there is one caveat to this recommendation: If a 3-dose HPV series has inadvertently been given with an interval of less than 24, but at least 16, weeks between doses 1 and 3, the series may be counted as complete as long as the minimum intervals between doses 1 and 2 and doses 2 and 3 were maintained.
What if the interval between the first 2 doses was long, say 20 weeks. Can the third dose be given 4 weeks later and satisfy the minimum interval rules?
No. The minimum interval between the second and third doses must be at least 12 weeks regardless of the interval between the first and second doses. So have the person come back in 12 weeks for the third and final dose.
A 2-year-old needs a second dose of influenza vaccine. Is it OK to administer LAIV if the first dose was TIV?
Yes. As long as a child is eligible to receive live attenuated influenza vaccine — i.e., is at least 2 years old and healthy, with no contraindications — it is acceptable to administer 1 dose of each type of influenza vaccine. This is an ACIP off-label recommendation. The doses should be spaced at least 4 weeks apart.
A family practice does not have many pediatric patients younger than 3 years of age. Consequently they do not order any influenza vaccine in the 0.25 milliliter preparation. But they do stock Fluzone in multidose vials. They want to know if it is acceptable to draw up the dose from a multidose vial since it contains thimerosal.
Yes, Fluzone is the only inactivated influenza vaccine that is approved for use in children younger than 3 years of age. The multidose vials do contain a small amount of thimerosal to prevent bacterial growth in the vials. No scientific evidence exists that thimerosal in vaccines, including influenza vaccines, is a cause of adverse events, unless the patient has a severe allergy to thimerosal. However, some states have enacted legislation that restricts the use of thimerosal-containing vaccines. So it would be important to check with the state immunization program first.
What would you recommend that healthcare providers say to patients who are reluctant to get influenza vaccine because they believe the vaccine gave them the flu?
There are several reasons why this misconception persists.
First – people confuse side effects from the vaccine, like mild fever and muscle aches, with symptoms of influenza.
Second - protective immunity does not develop until 1 to 2 weeks after vaccination. Some people may be exposed to influenza shortly before or after being vaccinated and become ill before they develop immunity.
Third - many people think "the flu" is any illness with fever and cold symptoms. If they get any viral illness, they may blame it on the vaccine, or think they got "the flu" despite being vaccinated. Influenza vaccine only protects against certain influenza viruses, not all viruses.
Fourth - influenza vaccine is not 100 percent effective, especially in older persons. There are always some people who do not respond to the vaccine.
But one thing is certain - you cannot get flu from flu vaccine. The viruses in TIV are inactivated and cannot cause disease. And the viruses in LAIV are attenuated and cold-adapted, meaning they are weakened to a form that does not cause disease and they can only survive in the nose and back of the throat. They cannot survive in the warmer environment of the lungs.
We have heard there is a flu vaccine that protects against 4 strains of influenza. We thought all influenza vaccines protected against 3 strains. What can you tell us about this?
All of the influenza vaccines currently distributed are trivalent. There are two A-strains and one B-strain in all TIV and LAIV vaccines. But quadrivalent vaccine is on the horizon. FDA approved FluMist Quadrivalent vaccine in February, 2012 and we anticipate that it will be distributed during the 2013-2014 influenza season. The quadrivalent vaccine will contain two A-strains and two B-strains.
What are the recommendations for asthmatic children age 5 years and older for LAIV?
LAIV is contraindicated for all asthmatics.
Why is influenza vaccination important for healthcare personnel? We already encourage employees to stay home from work when they are sick.
Unfortunately, by the time a healthcare provider has symptoms of influenza they will have already exposed many patients since the virus is shed for 1 to 2 days before symptoms begin. Do the right thing. Plan early to make sure all employees in your work setting receive annual influenza vaccination before the influenza season begins.
Should zoster vaccine be given to patients in a long-term care facility? If so, should the provider be tested for varicella immunity before taking care of someone who has received zoster vaccine?
ACIP recommends zoster vaccine for everyone 60 years of age and older regardless of where they reside, unless they have a contraindication to the vaccine. All healthcare personnel should ensure they are immune to varicella regardless of the setting in which they work and regardless of their patients' receipt of zoster vaccine.
I still am not clear about the need for testing if hepatitis B vaccine series was completed many years ago—can you advise?
All healthcare personnel with risk of exposure should be tested 1-2 months after the 3rd dose. There is no recommendation at this time for mass testing of persons who were not tested postvaccination. If there is an exposure, the person can be tested as part of postexposure management if indicated.
Does the hepatitis B vaccination recommendation for diabetics include pregnant women with gestational diabetes?
No. The 2011 ACIP recommendation for hepatitis B vaccination of persons with diabetes pertains to those with type-1 and type-2 diabetes. It does NOT apply to women with gestational diabetes. It is worth noting that pregnancy is not a contraindication to hepatitis B vaccination, and that women with gestational diabetes are more likely to develop type-1 or type 2 diabetes later in life. Diabetic women who become pregnant can be vaccinated, if indicated.
Our office uses photocopies of the VISs. Will that cause problems scanning the barcode?It shouldn't. Barcodes were successfully tested using 2nd and 3rd generation photocopies of VISs. However, we recommend creating master copy for each VIS, and making copies from that master. The quality of the barcode may decline after several generations of copies.
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