Education & Training:

Immunization Update 2011 Broadcast: Q&As
Questions submitted during broadcast - August 4, 2011

Influenza

1. Please give us more clarification on the new intradermal flu vaccine and how it is administered. 
   Only Fluzone Intradermal formulation provided in the manufacturer prefilled microinjection syringe should be administered by the intradermal route.  All other brands and formulations of inactivated influenza vaccine (TIV) should be administered by the intramuscular route. Fluzone Intradermal is FDA-approved for persons 18 through 64 years of age. It should not be given to children 17 years of age and younger or persons 65 years of age or older. For intradermal administration:

   1. Patient should be seated with the arm bent at the elbow and the hand resting on the hip.

   2. Remove the cap from the microinjection syringe.

   3. Holding the syringe between thumb and forefinger, insert the needle PERPENDICULAR to the skin over the deltoid area of the upper arm.

   4. Once the needle is inserted, push on the plunger with your index finger to inject the vaccine. Do not aspirate.

   5. Remove the syringe from the patient’s arm.  Once it is away from the patient’s arm, use your thumb to depress the plunger firmly to activate the needle shield. You will hear a click when the shield covers the needle.

   6. Discard the syringe in a biohazard container.

   Healthcare personnel should review the manufacturer’s product information for detailed instructions [PDF-167KB / 8 pages] prior to administering this vaccine.
   
   

2. If the Fluzone Intradermal vaccine is inadvertently administered to a 2-year-old, does the dose need to be repeated?
   Yes. The dose should be repeated as soon as possible. Children 8 years of age and younger are more likely to have skin that is too thin for proper intradermal administration.  For persons 9 through 17 years of age or 65 years of age and older, if the clinician is confident that the dose was administered intradermally, the dose can be counted.  Fluzone intradermal cannot be counted if it is administered into subcutaneous or muscle tissue. 

   Please note that a dose given outside the FDA approved age indications is a vaccine administration error. Fluzone Intradermal is approved only for persons 18 through 64 years of age, and providers should determine how the error occurred and put strategies in place to prevent it from occurring again.
   
   

3. What is the recommendation if the intradermal influenza vaccine is not given in the deltoid region?
   The deltoid region of the upper arm is the only recommended site for intradermal influenza vaccine. The vaccine may be counted if inadvertently administered in the upper back, waist, or anterolateral thigh region. If the dose is administered anywhere else, including the forearm (dorsal or volar), it is considered invalid and the dose should be repeated as soon as possible in the recommended deltoid region. The skin on the forearm is thin and the vaccine may enter subcutaneous tissue.
   
   

4. Has ACIP approved the use of high-dose and intradermal influenza vaccines?
   Yes, ACIP approves the use of high-dose and intradermal influenza vaccines along with all other FDA-approved inactivated influenza vaccines (TIV).  ACIP has not stated a preference for any TIV product over another.  The formulation or presentation a provider uses is their choice as long as an age-appropriate product is used and is administered correctly.  Providers need to choose the type of vaccine most appropriate for their patient population. All of the manufacturers’ influenza product information statements on the IAC web site.
   
   

5. What is the recommendation for timing of influenza and pneumococcal vaccines for hospitalized patients (on admission, after surgery or at discharge)?
   ACIP has not specifically addressed this issue but there is an ACIP general recommendation to delay vaccinating a person with moderate or severe acute illness until the illness has improved.  Therefore, we typically advise vaccination at the time of discharge, when the patient is assumed to be clinically stable, to avoid any potential adverse reaction from the vaccine being misconstrued as a complication of the patient’s illness/surgery. See page 11 of MMWR [PDF-966KB / 64 pages].  Standing orders for influenza and pneumococcal vaccination for hospitalized persons have shown to be an effective strategy for reaching high risk populations and should be considered, http://www.immunize.org/standing-orders/.
   
   

6. During the broadcast, it was stated that children 2 through 4 years of age with asthma or recurrent wheezing that might indicate asthma should not receive LAIV.  What about older children with asthma?
   LAIV is contraindicated for persons with certain chronic medical conditions, including asthma.  These persons should receive the age-appropriate inactivated influenza vaccine. See page 164 of Influenza chapter in Pink Book [PDF-990KB / 22 pages].
   
   

7. How many doses of influenza vaccine should be administered to a child who did not receive influenza vaccine in 2010-2011, but who did receive one or two doses of the monovalent H1N1 vaccine in 2009?
   According to the ACIP influenza recommendations for the 2011-2012 season, any child 6 months through 8 years of age who did not receive at least one dose of the 2010-2011 seasonal influenza vaccine should receive two doses of the age-appropriate 2011-2012 seasonal influenza vaccine at least 4 weeks apart. This is regardless of the child’s previous influenza vaccination history.  Anyone 9 years of age or older needs only one dose of influenza vaccine. An influenza vaccine dosing algorithm for children 6 months through 8 years of age can be found on the Immunization Update 2011 resources web page.
   
   

8. If a child 2 through 8 years of age needs two doses of influenza vaccine and the first dose given is TIV, does the second dose have to be TIV or can LAIV be used?
   As long as a child is eligible to receive nasal spray vaccine (i.e., is in the proper age range and health status), it is acceptable to give 1 dose of each type of influenza vaccine. The doses should be spaced at least 4 weeks apart.
   
   

9. In previous years there has been discussion that a single dose of influenza vaccine is not efficacious for influenza B strains and that a single dose of vaccine administered late in the spring does not provide adequate protection with only a single dose the next season for influenza vaccine naïve children less than 9 years of age.   Please provide some comments regarding the logic used this year.
   Children less than 9 years of age require 2 doses of influenza vaccine during their first season of vaccination in order to optimize immune response.  The importance of vaccine priming may depend more upon the similarity of the antigenic composition between the priming and second dose than the temporal interval between doses.
   
   Between the 2003-2004 and 2004-2005 seasons, the A (H1N1) virus antigen remained unchanged; however, the A(H3N2) virus antigen changed to a drifted strain while the B virus antigen changed more substantially to a different lineage. In a study conducted over these two seasons, 6-23 month old influenza-vaccine naïve children who received one dose of TIV in the spring of their first year of vaccination followed by a second dose in the fall were less likely to have protective antibody responses to the A (H3N2) and B virus antigens when compared with children who received two doses of identical vaccine in the fall. Response to the unchanged A (H1N1) virus antigen was comparable between the groups. 
   
   In another study conducted over the same two seasons, unprimed 10-24 months olds who received 1 dose of TIV during the fall of each season had similar responses to the unchanged A (H1N1) virus antigen, as well as the drifted A (H3N2) virus antigen when compared with 6-24 month olds who received two doses of the same TIV during the latter season, but significantly lower response to the B virus antigen. During two seasons in which all influenza vaccine virus antigens were identical, unprimed 6-23 month olds had similar responses when they received one dose in the spring followed by a second dose in the fall, as compared with two doses one month apart in the fall.
   
   

10. Would you please clarify when Afluria can be used for children?
    The age indication in the manufacturer’s product information is 5 years of age and older.  However, the ACIP recommends Afluria not be used in children 8 years of age and younger because of increased reports of febrile reactions noted in this age group. If no other age-appropriate, licensed inactivated seasonal influenza vaccine is available for a child aged 5 through 8 years who has a medical condition that increases the child's risk for influenza complications, Afluria can be used. However, providers should discuss with the parents or caregivers the benefits and risks of influenza vaccination with Afluria before administering this vaccine. Afluria may be used in persons 9 years of age and older. See MMWR for details.
    
    

11. A child received a 0.25 mL dose of inactivated influenza vaccine (TIV) at 34 months of age.  The child is scheduled to return for the second dose at 36 months of age.  Should the child receive a 0.25 mL dose or a 0.5 mL dose of TIV?
    The child should receive a 0.5 mL dose of TIV.  Always administer the volume of vaccine appropriate to the age of the patient when s/he presents at clinic for that dose.
    
    

12. Where can we locate the influenza vaccine dosing algorithms for children 6 months through 8 years of age and persons who report allergy to egg?
    Links to both of these algorithms are on the Immunization Update 2011 resources web page.
    
    

13. Can you offer more information about administering TIV and PCV13 at the same visit?
    Yes.  There is a statement on the 2011-2012 Influenza VIS which states that “young children who get inactivated flu vaccine and pneumococcal vaccine (PCV13) at the same time appear to be at increased risk for seizures caused by fever.”  We have seen increasing rates of febrile seizures in children, especially those 12 through 23 months of age when they have received simultaneous vaccination with TIV and PCV13, compared with children who received them separately.  Since we have some data that show this increased risk, we wanted to include the information on the VIS.  Febrile seizures are not uncommon, occurring in 2% to 5% of all children, and they are generally benign.  There are risks associated with delaying either of these vaccines.  We do not want providers to deviate from the recommended schedule, as ACIP has made no recommendation to administer these two vaccines at separate visits.  Healthcare providers should anticipate questions parents may have regarding caring for children after receiving vaccines.  Providers should be prepared to discuss after- care instructions with parents, including information about fever and febrile seizures. We will update this information on our website as more data becomes available.
    
    

14. Why do we vaccinate pregnant women against influenza when it is contraindicated to vaccinate infants younger than 6 months of age?
    ACIP has recommended immunization of pregnant women with inactivated influenza vaccine (TIV) for a number of years. Pregnant women are a high-risk group for complications, hospitalization and even death from influenza infections because of the increased physiologic strain of pregnancy on their heart, lungs, and immune system. Vaccination can occur in any trimester, including the first.
    
    Influenza vaccine is not approved for children younger than 6 months of age because it has not been found to be effective at this age. In addition, there are data that indicate that vaccinated pregnant women pass maternal antibodies to the fetus in the last few weeks of pregnancy, which helps protect the young infant against influenza. Vaccinating pregnant women will thus protect the women, their unborn babies, and the babies after birth. ACIP influenza vaccination recommendations are outlined on page 37 of the MMWR [PDF-1.16MB / 68 pages].
    
    

15. Should new mothers, including those who are breast feeding, be vaccinated with influenza vaccine? 
    Yes, all persons (e.g., mothers, fathers, siblings, grandparents, day care workers, nannies) who will be in close contact with infants, especially infants less than 6 months of age, should be vaccinated. Close contacts may be vaccinated with TIV or, if eligible, LAIV. Research shows that young children are at especially high risk for influenza and its complications. Flu vaccine is not approved for use in children younger than 6 months of age. Also, influenza antiviral drugs are not approved for use in children younger than 1 year. Because children younger than 6 months cannot get a vaccine or antiviral drugs, but are at high risk for serious flu-related complications, safeguarding them from influenza is especially important. See MMWR [PDF-1.16MB / 68 pages] for details.
    
    

16. Is it safe to administer LAIV to breastfeeding mothers?
    Yes. Women who are breastfeeding can receive either LAIV or TIV. Neither inactivated nor live, attenuated influenza vaccines administered to a lactating woman affect the safety of breastfeeding for women or their infants. See page 26 of MMWR [PDF-966KB / 64 pages] for details. However, LAIV should not be administered to pregnant women, TIV should be used.
    
    

17. Since we have started influenza vaccinations early for the 2011-2012 season, should the elderly and other high-risk patients receive a second dose of influenza vaccine later in the season to be sure they remain protected?
    No. There is no recommendation for anyone 9 years of age or older to receive two doses of influenza vaccine in the same season.
    
    

18. As Medical Director of programs that serve institutional and community cohorts of frail elderly, I am curious to know if you can provide the current data that supports the potential use of the high dose TIV manufactured by Sanofi.
    Fluzone High-Dose is FDA approved for use in persons 65 years of age and older.  ACIP approves the use of high-dose vaccines along with all other FDA-approved inactivated influenza vaccines (TIV), but has not stated a preference for the use of the high-dose influenza vaccine in person 65 years of age and older.  Use of the high dose formulation or any other TIV product is provider choice.  Providers should choose the type of vaccine most appropriate for their patient population. Consult the manufacturers’ influenza product information statements for details. ACIP and high dose influenza discussion and information can be found in the June 2011 Influenza Adverse Events meeting slides [PDF-218 / 21 pages] and the June 2011 Influenza High-Dose Vaccine meeting slides [PDF-403KB / 30 pages].
    
    

19. I was told that immunocompromised residents in long-term care facilities are often not given influenza vaccine. How do I respond to this as a new infection control nurse?
    We recommend that you keep on reinforcing to the institution that ACIP's influenza recommendations list immunocompromised persons and those in long-term care facilities among the highest risk groups. These patients should receive the inactivated influenza vaccine. See page 35 of MMWR [PDF-1.16MB / 68 pages].
    
    

20. What are the advantages of using intradermal flu vaccine compared with intramuscular or intranasal preparations?
    ACIP has not stated a preference or advantage for one form of influenza vaccine over another. Intradermal is another formulation that has been licensed by FDA, and our role is to be sure that providers who receive this product know how to use it properly. More information on this produce and results of clinical trials are available in the manufacturer's package insert [PDF-400KB / 34 pages].

Zoster

1. Can a person who has never had chickenpox disease, but did receive varicella vaccine, get herpes zoster (shingles)?
   Yes. Similar to wild-type varicella virus, vaccine virus can establish latent infection and subsequently reactivate, causing herpes zoster disease, or shingles, in vaccine recipients.  Cases of herpes zoster in healthy vaccine recipients have been confirmed to be caused by both vaccine virus and wild-type virus, suggesting that certain herpes zoster cases in vaccine recipients might result either from a previous natural varicella infection that might not have been detected by the patient, or from infection after vaccination. 
   
   There is no way to clinically distinguish herpes zoster due to vaccine strain from herpes zoster due to wild-type varicella virus.  Reports of cases following vaccination have been rare and generally milder than those known to occur following natural infection.  Studies suggest that the risk of herpes zoster following varicella vaccination is no higher than that following infection with wild virus. As varicella vaccine recipients get older we can further evaluate this. See page 21 of MMWR [PDF-697KB / 48 pages].
   
   

2. If a healthcare worker does not have a history of varicella vaccination or disease but has had a clinically diagnosed case of shingles, do they still need varicella vaccination?
   No.  Diagnosis or verification of a history of herpes zoster/shingles by a healthcare provider is acceptable evidence of immunity to varicella. See page 16 of MMWR [PDF-697KB / 48 pages].
   
   

3. If a person is vaccinated with the varicella vaccine as a young child, will zoster vaccination be recommended when the person is 60 years of age or older?
   Current ACIP recommendations state that “zoster vaccination is not recommended for persons of any age who have received varicella vaccine. However, health-care providers do not need to inquire about varicella vaccination history before administering zoster vaccine because virtually all persons currently or soon to be in the recommended age group have not received varicella vaccine. In the United States, varicella vaccination began in 1995. Since that time, few adults aged 40 years of age or older would have been susceptible to varicella and thus eligible to receive varicella vaccine. The number of persons eligible for zoster vaccination who have received varicella vaccine is extremely small and will remain so for at least a decade.” See page 19 of MMWR [PDF-758KB / 40 pages].
   
   

4. Did you say that a person over 60 years of age should receive zoster vaccine after receipt of 2 doses of the varicella vaccine if a blood test indicates that they are susceptible to varicella?
   No.  Persons who have received varicella vaccine are not eligible for zoster vaccine. Postvaccination serologic testing to verify an immune response to varicella vaccine is not routinely recommended because available commercial assays lack sensitivity to detect vaccine-induced immunity and might give false negative results. See page 17 of MMWR. http://www.cdc.gov/mmwr/pdf/rr/rr5604.pdf (page 17). [PDF-758KB / 40 pages].
   
   

5. If an individual was vaccinated with 2 doses of varicella vaccine and is later infected with the wild-type varicella virus, will the person still be at risk for zoster disease?
   Yes.  Regardless of whether the person is infected with wild-type varicella or vaccinated with the attenuated varicella virus, the virus can establish latent infection and subsequently reactivate, causing herpes zoster disease, or shingles.
   
   

6. If a person is older than 50 without proof of varicella immunity, could you give zoster vaccine instead of varicella vaccine?
   This question raises two issues. First, we do not recommend asking about varicella immunity in those eligible for zoster vaccine. ACIP recommends that a healthy person 60 years and older without contraindications receive zoster vaccine. And second, even though FDA has licensed zoster vaccine for persons 50 through 59 years of age, ACIP has not recommended use of zoster vaccine in this age group.
   
   

7. Can zoster vaccine be administered to a patient who has recently received a blood transfusion?  If so, is there an interval that should be waited before administering the vaccine?
   Zoster vaccine can be given to persons who have recently received blood products.  There is no waiting period for administering zoster vaccine following transfusion. Studies have shown the efficacy of zoster vaccine in patients receiving blood products. The amount of antigen in zoster vaccine is so substantial that it overpowers any antibody to herpes zoster that may be in the blood product. See page 20 of MMWR [PDF-758KB / 40 pages].
   
   

8. Please review the recommendations for use of zoster vaccine with immunocompromised patients.
   Zoster vaccine is contraindicated for persons with primary or acquired immunodeficiency.  For more detail please refer to the ACIP recommendations for zoster vaccine. See page 20 of MMWR [PDF-758KB / 40 pages].
   
   

Meningococcal (MCV4)

1. Would young adults (22-25) in a congregate setting such as jail or drug rehab who were immunized with meningococcal polysaccharide vaccine (MPSV4) at earlier age be considered an "at risk" group in need of revaccination with a meningococcal conjugate vaccine?
   No.  There are no routine recommendations for revaccination of this group.  They are outside of the age group considered to be at increased risk for meningococcal infection. However, persons who wish to decrease their risk for meningococcal disease may elect to be vaccinated. See MMWR for details.
   
   

2. Are college students considered high risk and in need of a booster dose of MCV4 if their first dose was received at 15 or 16 years of age?
   The current ACIP recommendations apply to students entering college, but it is permissible to administer a dose to persons already in college according to the following age recommendations.  A person who received the first dose of MCV4 at 15 years of age should receive a booster dose of MCV4 if it is administered before 22 years of age.  Routine vaccination with meningococcal conjugate vaccine is not are recommended for persons 22 years of age or older.  Persons who receive their first dose of MCV4 at or after age 16 years do not need a booster dose. See MMWR for details.
   
   

3. If an 18-year-old receives a booster dose of MCV4 less than 3 years from the initial dose, is it a valid booster or is another required?
   It is a valid dose. The minimum interval between doses of MCV4 is 8 weeks. See MMWR for details.
   
   

4. If a person between the ages of 18 and 21 years and already in college has not received a dose of MCV4, should a dose be administered?
   While a dose of MCV4 is not routinely recommended by ACIP because the person is already in college, a provider may choose to administer a dose if the person is not yet 22 years of age. See MMWR for details. MCV4 vaccine is not routinely recommended for persons 22 years of age and older.
   
   

5. If a 19-year-old is entering college and received the adolescent dose of MCV4 at 11 years of age, can a booster dose be administered now?
   Yes.  In this circumstance, a booster dose is recommended because the person is entering college. See MMWR for details.  If the person is already in college, the dose is not routinely recommended by ACIP, but the provider may administer it, and in fact it might be required by the college. MCV4 vaccine is not routinely recommended for persons 22 years of age and older, even if they are entering college.
   
   

6. If a patient younger than 56 years of age without a spleen needs a two-dose primary series of meningococcal vaccine and receives MPSV4 for the first dose, should it be repeated with MCV4?
   Yes.  Any meningococcal doses for high-risk persons younger than 56 years of age should be MCV4.  There is no minimum interval to wait for repeating the dose with MCV4.
   
   

7. Should an asplenic patient who is 56 years of age or older receive a 2-dose primary series of meningococcal polysaccharide vaccine (MPSV4)?
   No.  The 2-dose primary series applies only to meningococcal conjugate vaccines, MCV4.  An asplenic patient 56 years of age or older should receive one dose of MPSV4 with a booster dose every 5 years thereafter. See page 15 of MMWR [PDF-321KB / 21 pages].
   
   

8. If a 4-year-old asplenic child receives a two-dose primary series of MCV4, when is the first booster dose recommended?
   An asplenic child who received the two-dose primary series of MCV4 at 2 through 6 years of age should receive the first booster dose 3 years later and then a booster dose every 5 years thereafter. See MMWR on updated vaccine recommendations and MMWR on updated recommendations on revaccination.
   
   

9. If a 7-year-old asplenic child received a two-dose primary series of MCV4 at 4 years of age, is the child due for a booster dose now?
   Yes. An asplenic child who received the two-dose primary series of MCV4 at 2 through 6 years of age should receive the first booster dose 3 years later and then a booster dose every 5 years thereafter. See MMWR on updated vaccine recommendations and MMWR on updated recommendations on revaccination.
   
   

10. If a 7-year-old asplenic child receives a two-dose primary series of MCV4, when is the child due for a booster dose?
    An asplenic child who received the two-dose primary series of MCV4 at age 7 years or older should receive the first booster dose 5 years later and then a booster dose every 5 years thereafter. See MMWR on updated vaccine recommendations and MMWR on updated recommendations on revaccination.
    
    

11. If a two-year old child with no spleen is catching up on pneumococcal conjugate vaccination (PCV), can the child receive PCV and MCV4 at the same visit?
    Yes.  ACIP has not recommended administering these doses at separate visits.
    
    

12. Can Menveo be used for a child between the ages of 9 and 23 months if MCV4 is indicated and Menactra is not available?
    No.  Menveo is not FDA approved for used in anyone younger than 2 years of age and there is no ACIP off-label recommendation to use it in children 9 through 23 months of age.

Tdap

1. Our state law requires that all students entering 6th grade receive Tdap.  Some of these students are still 10 years old.  Does ACIP recommend we have these students return after their 11th birthday or should we go ahead and administer Tdap at this visit at 10 years of age?  Can MCV4 be administered at the same visit?
   The ACIP recommended age for both Tdap and MCV4 is 11 or 12 years of age. However, state laws must be adhered to and the age-appropriate vaccine should be used.  Boostrix is FDA approved for persons 10 years of age and older.  Adacel is FDA approved for persons 11 years of age and older.  Tdap and MCV4 can be administered at the same clinic visit.  However, if there is no school law requiring MCV4 vaccination at 10 years of age, we recommend vaccination at the recommended age of 11 or 12 years.  Because of the waning immunity seen after MCV4 vaccination, it is important to wait till age 11 years if possible.
   
   

2. If a child  between the ages of 7 and 10 years of age receives a Tdap dose, would this child still receive a Td booster at 11-12 years of age or should this child wait ten years from the Tdap dose for the next routine Td dose?
   Based on current ACIP recommendations, the child’s next routine tetanus toxoid and diphtheria toxoid booster would be a dose of Td 10 years after the Tdap dose.
   
   

3. If someone is 10 years old and previously received a complete series of DTaP, can we administer a dose of Tdap if it is required for school even if we only carry the Adacel brand?
   Adacel is FDA approved for use in persons 11 years of age through 64 years of age and Boostrix is licensed for persons 10 years of age and older.  There is no ACIP off-label recommendation for this situation so we would recommend using the Tdap vaccines according to their licensure.  The ACIP off-label use of Tdap vaccines is specific to children 7 through 10 years of age who are undervaccinated for pertussis and persons 65 years of age and older. See MMWR for details.
   
   

4. If a child was inadvertently given Tdap instead of DTaP at 5 years of age for the kindergarten dose, do we administer Td or Tdap at 11 or 12 years of age?
   The routine adolescent Tdap vaccination recommendation applies.  This child should receive a second dose of Tdap at 11–12 years of age. See page 27 of MMWR [PDF-473KB / 50 pages].
   
   

5. With the new Tdap guidelines for 7 through 10 year olds, should tetanus prophylaxis charts be revised to include the use of Tdap for children in this age range who have received an incomplete DTaP series and present with an injury that qualifies for a tetanus containing vaccine?
   The ACIP off-label recommendation for use of Tdap in children 7 through 10 years of age is specific to children who are not up-to-date for pertussis.  If a child 7 through 10 years of age who is not up-to-date for pertussis is seen for wound management and tetanus vaccination is indicated, Tdap could be used instead of Td.
   
   

6. Can the vaccine Adacel be used in adults older than 65?
   Yes.  Although, only Boostrix is FDA-approved for use in persons 65 years of age and older, ACIP’s off-label recommendation applies to either Tdap vaccine. See MMWR for details.
   
   

7. Should a person who receiving a Tdap booster as an adult receive Td or Tdap for their next booster?
   At this time Tdap is only FDA approved for a single dose so subsequent boosters would be with Td.  We may hear more about this in future years, but for now Tdap is only a one-time dose.
   
   

8. When is the Tdap guidance for pregnant adults going to come out?
   At time of this broadcast we did not have a date for publication of the final document in MMWR and so ACIP provisional recommendations were used.
   
   Oct. 21, 2011 UPDATE:
   Updated Recommendations for Use of Tetanus Toxoid, Reduced Diphtheria Toxoid and Acellular Pertussis Vaccine (Tdap) in Pregnant Women and Persons Who Have or Anticipate Having Close Contact with an Infant Aged <12 Months -- Advisory Committee on Immunization Practices (ACIP), 2011
   Source: MMWR; October 21, 2011 / 60(41);1424-1426

9. When administering Tdap vaccine to women in their 3rd trimester, should this be done and encouraged if they have not received the vaccine as their booster dose yet, or give during the third trimester as part of the primary series when they have not received a primary series of Td as of yet, and if they have received  the  primary series in the past, wait to give the Tdap after delivery? I understand Tdap would be preferred in the 3rd trimester due to injury if not received in the past and due for booster.
   If the Tdap dose is a booster dose or part of a primary series, it should preferably be administered during the third or late second trimester (after 20 weeks gestation). 
   
   As part of standard wound management care to prevent tetanus, a tetanus toxoid–containing vaccine might be recommended for a pregnant woman if 5 years or more have elapsed since the previous Td. If a Td booster is indicated for a pregnant woman who previously has not received Tdap, health care providers should administer Tdap. Consult the ACIP provisional recommendations.
   
   NOTE: Since this broadcast, the provisional recs have been published in the MMWR: Immunization of Health Care Personnel.

10. Is there a minimum interval between Td and Tdap vaccines?  Does this apply to pregnant women?
    Tdap can be administered regardless of the interval since the last Td dose.  This includes pregnant women.  The benefit of pertussis vaccination outweighs the risk of a local reaction from administering tetanus and diphtheria toxoid-containing vaccines close together.
    
    

11. Is high-pitched, inconsolable crying for a 3-hour period or longer that occurred within 48 hours of a dose of DTaP considered a precaution for Tdap?
    No.  Many of the precautions to DTaP (e.g., temperature of 105°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. See page 24 of MMWR [PDF-473KB / 50 pages] for details.
    
    

12. Do healthcare personnel need to provide a record of having received a primary series of tetanus and diphtheria toxoid-containing vaccines, even if the doses were received in childhood?
    Adults who have never been vaccinated against tetanus, diphtheria, or pertussis (DTP/DTaP/DT or Td) should receive a series of three vaccinations containing tetanus and diphtheria toxoids.  The preferred schedule is a single dose of Tdap, followed 4 weeks later by a dose of Td and another dose of Td 6 to 12 months after that.  However, Tdap can be used for any of the doses in the series.  Alternatively, in situations in which the adult probably received vaccination against tetanus and diphtheria but cannot produce a record, vaccine providers may consider serologic testing for antibodies to tetanus and diphtheria toxin to avoid unnecessary vaccination.  If tetanus and diphtheria antitoxin levels are each 0.1 IU/mL or greater, previous vaccination with tetanus and diphtheria toxoid vaccine is presumed, and a single dose of Tdap is indicated.  Adults who received other incomplete vaccination series against tetanus and diphtheria should be vaccinated with Tdap and/or Td to complete a 3-dose primary series.  A single dose of Tdap can be used in the series. See page 25 of MMWR [PDF-418KB / 44 pages].
    
    

13. Your webcast is saying Tdap is NOT approved by the FDA. Am I misunderstanding?
    On the webcast we stated that only Boostrix is FDA-approved for persons 65 years of age and older.  However, ACIP has made an off-label recommendation stating that either Boostrix or Adacel may be used to vaccinate persons 65 years of age and older. See MMWR for details.