Education & Training:

Adult Immunization Update 2006 Broadcast: Questions & Answers
Questions submitted during the broadcast of December 7, 2006

Hepatitis A

1. If a traveler received the first dose of hepatitis A vaccine 5 years ago and the second dose 3 years later, does this person need to be revaccinated if now traveling to an area where hepatitis A is endemic?
   
   No. Two documented valid doses of hepatitis A vaccine are a complete series and no further doses are indicated. As with most vaccines, there are minimum intervals between doses but no maximum intervals. Repeat doses are not necessary for extended intervals.

Hepatitis B

1. It has been my understanding that if a patient, healthcare worker, or nursing student has a documented history of hepatitis B vaccine, it is NOT necessary to get a titer to see where their level is. Is this true or false?
   
   After vaccination with a 3-dose series of hepatitis B vaccine, healthcare personnel who will have exposure to blood or blood-containing fluids should be tested for hepatitis B surface antibody (HBsAb or anti-HBs) 1-2 months after completion of the series. For healthcare personnel who were vaccinated before this recommendation was made in Dec. 1997 or for healthcare personnel/students who were vaccinated as children or adolescents without post-vaccination testing, catch-up testing is not recommended. These persons can be tested as indicated if an exposure occurs.

2. If the Hepatitis B vaccine series is not completed on time, is there any point at which the series needs to be restarted?
   
   No. There is no maximum interval between doses of most vaccine series, including hepatitis B vaccine. Just pick up where the person left off and complete the series.

Human Papillomavirus

1. Why is HPV vaccine not recommended for men?
   
   The vaccine manufacturer did not submit clinical trial data on men to the Food and Drug Administration (FDA) for licensure consideration. The vaccine is currently being tested in men, which may change approved indications in the future. However, for the present HPV vaccine is only FDA approved and ACIP recommended for use in females 9 through 26 years of age.

2. Can someone who has herpes, or is HIV positive, or has AIDS receive HPV vaccine?
   
   Yes. HPV is an inactivated vaccine. A person who is immunosuppressed may not have an optimal immune response to the vaccine, but the vaccine will not be harmful and may be helpful in protecting against HPV.

3. Should we repeat a dose of HPV vaccine given by the subcutaneous (subQ) route?
   
   No. In the absence of specific guidance for this vaccine, we default to the ACIP General Recommendations on Immunization, which recommends that only hepatitis B or Rabies vaccines need to be repeated when administered by a nonstandard route, www.cdc.gov/mmwr/PDF/rr/rr5515.pdf (pages 18-19).

4. If a woman is in the process of receiving the HPV series and turns 27 years old, can the series be completed.
   
   The vaccine is FDA approved through 26 years of age. We have no off-label ACIP recommendations that extend beyond the 27th birthday.

Influenza

1. If a patient comes in who recently received either influenza or pneumococcal vaccine, but is not sure which, should you vaccinate them? Is there a minimum interval between these two vaccines?
   
   We recommend that you make every effort to help the patient find out what vaccine(s) was received. If possible, contact the healthcare provider where the person thinks s/he was vaccinated and request a faxed copy of the record. However, if written documentation cannot be obtained, then you should vaccinate. There is no minimum interval between influenza vaccine (TIV or LAIV) and pneumococcal vaccine.

2. During the broadcast I learned that the rate of Guillain-Barré Syndrome (GBS) after receipt of influenza vaccine is in the neighborhood of 1 - 2 per million. The most frequently cited background rate in the general population for GBS is 1 - 2 per 100,000. Swine flu vaccine is the vaccine that appeared to raise the risk of GBS, but the incidence here too was only slightly elevated over the 1 - 2 per 100,000. Does receipt of influenza vaccine have a protective effect against GBS raising the rate to 1 - 2 per million? If so, is this because it is thought that GBS arises from viral/bacterial infections and flu vaccine by protecting against the flu virus would diminish its rate of occurrence?
   
   We have no data to indicate that influenza vaccine offers protection against GBS.

3. Last year, there appeared to be a "second wave" of influenza in this area and hospitals were revaccinating. Is that appropriate?
   
   ACIP has never recommended a second influenza vaccine in a single season except for children <9 years being vaccinated for the first time. To our knowledge, there is no plan to make such a recommendation and there are no data to support a second dose for adults.

4. If a young girl (age 14 now) had Guillain-Barré Syndrome (GBS) in December of the previous flu season and has had several medical problems throughout this year, how important is it for her to receive the influenza vaccine?
   
   This is an individual assessment of the patient that should be made by her healthcare provider. Her provider needs to determine her risk for complications of influenza in relationship to her other health issues and medical risks. The ACIP Recommendations for influenza include the following paragraph. “The incidence of GBS among the general population is low, but persons with a history of GBS have a substantially greater likelihood of subsequently experiencing GBS than persons without such a history. Thus, the likelihood of coincidentally experiencing GBS after influenza vaccination is expected to be greater among persons with a history of GBS than among persons with no history of this syndrome. Whether influenza vaccination specifically might increase the risk for recurrence of GBS is unknown. However, avoiding vaccinating persons who are not at high risk for severe influenza complications and who are known to have experienced GBS within 6 weeks after a previous influenza vaccination is prudent. As an alternative, physicians might consider using influenza antiviral chemoprophylaxis for these persons. Although data are limited, for the majority of persons who have a history of GBS and who are at high risk for severe complications from influenza, the established benefits of influenza vaccination justify yearly vaccination.”

5. Are there any contraindications to giving the influenza vaccine (TIV) to someone who has received other vaccines within the last 2 weeks?
   
   No. Inactivated influenza vaccine (TIV) can be administered at any interval before or after other vaccines.

6. If we have only pediatric influenza vaccine available, can we combine two doses to make one adult dose?
   
   We do not recommend combining two 0.25 mL doses of influenza vaccine to make one 0.5 mL dose. However, if this is the only alternative to missing an opportunity to provide influenza vaccine to an adult, then two separate 0.25 mL injections may be given at separate sites on the same clinic day. DO NOT try to combine two 0.25 mL doses into one syringe.

7. Why is there no recommendation to delay pregnancy for one month following vaccination with live attenuated influenza vaccine (LAIV)?
   
   Receipt of LAIV is not known to produce viremia, which is how a fetus could be infected. Other viral vaccines cause viremia, hence the waiting period.

8. Do instructions regarding the timing and spacing of live vaccines and blood products apply to LAIV?
   
   No. The immune response to LAIV is not believed to be affected by the administration of blood products or other antibody-containing products.

9. In our mass influenza immunization clinics, we prefill approximately 1,000 syringes with influenza vaccine. How long can these syringes be kept?
   
   We strongly discourage prefilling syringes with any vaccine. The syringes you routinely use for administration are not designed for vaccine storage. We also recommend that vaccine be drawn by the same person who will administer it. If it is not feasible to use manufacturer prefilled syringes for these situations, you will find guidance regarding prefilling syringes for mass influenza clinics in our “Vaccine Storage & Handling Toolkit,” www2a.cdc.gov/nip/isd/shtoolkit/012Chap11.pdf
   No more than one multidose vial (10 doses) should be prefilled by the person who will administer the vaccine. Any prefilled syringes (not filled by the manufacturer) should be discarded at the end of the clinic day.

Measles, Mumps & Rubella

1. If someone has two documented doses of MMR but tests negative for any of the antigens, should we revaccinate?
   
   We have no recommendation to administer more than two doses of MMR vaccine to anyone. We recommend that you accept two documented valid doses of MMR vaccine as evidence of immunity and STOP TESTING.

Meningococcal

1. Why is Menactra preferred over Menomune?
   
   Menomune (MPSV) is a pure polysaccharide vaccine. Because the immune response to a pure polysaccharide vaccine is T-cell independent, the antibody induced has less functional activity than that induced by other types of vaccines. This is because the predominant antibody produced in response to most polysaccharide vaccines is IgM, with little IgG antibody being produced. Also, repeat doses of polysaccharide vaccines do not stimulate a booster response. Conjugation (chemical combination of the polysaccharide with a protein molecule) changes the immune response from T-cell independent to T-cell dependent. This increases immunogenicity and the antibody booster response. Because the polysaccharides in Menactra (MCV) are conjugated to diphtheria toxoid, it is believed that this vaccine will have a longer duration of protection than MPSV. In addition, MCV is expected to reduce asymptomatic carriage of Neisseria meningitidis and produce “herd” immunity, as occurs with Streptococcus pneumoniae and Haemophilus influenzae type b following receipt of their respective vaccines. Pure polysaccharide vaccines have little or no effect on carriage of the vaccine organism.

2. When will Menactra vaccine be available to age groups other than person 11 – 55 years of age?
   
   We do not know if and when the age range for Menactra vaccination will be extended. The vaccine has been tested in persons 2 – 10 years of age and licensure for this age group is pending FDA review, http://aapredbook.aappublications.org/news/vaccstatus.shtml (exit)

Pneumococcal

1. Both influenza and pneumococcal vaccines are recommended for persons with chronic pulmonary disease. Asthma is listed as an example of chronic pulmonary disease in the influenza recommendations. Does this also apply to pneumococcal vaccination?
   
   No. Asthma alone is still NOT an indication for pneumococcal polysaccharide vaccine (PPV), because asthma has never been shown to be a risk factor for invasive pneumococcal disease. However if the person develops chronic obstructive pulmonary disease, then PPV would be indicated.

2. After a splenectomy should a patient receive pneumococcal vaccine every 5 years?
   
   No. Asplenic patients should receive a total of two pneumococcal polysaccharide vaccine doses (PPV) in a lifetime. These two doses should be separated by at least 5 years.

Polio

1. Do adults need polio vaccine?
   
   Adults 18 years of age and older do not need polio vaccine unless they are traveling to a country where polio is endemic or epidemic. If a traveling adult has never received a primary series of polio vaccine, then 3 doses of IPV should be administered, the first two doses separated by at least 4 weeks and the last dose given 4-8 weeks after the second. If a traveling adult has previously received a primary series, a once-in-a-lifetime IPV booster is recommended.

Tdap

1. A 62 year old male received Tdap vaccine on September 18, 2006. He was seen in a clinic on November 30, 2006 with pertussis symptoms and positive serologic tests for Bordetella pertussis IgG and IgA. Please explain how this is possible?
   
   The vaccine efficacy of Tdap is thought to be similar to that of DTaP, which is 80-85%. This means that 15%-20% of Tdap recipients will not be fully protected. The course of disease would be expected to be less severe than it might otherwise have been without the vaccine.

2. If Boostrix is given to an adult, rather than Adacel, should an adverse event report be submitted and does the patient need to be revaccinated?
   
   Boostrix is not approved for use in persons 19 years of age or older. Although no safety and efficacy data are available, there is no reason to think that the vaccine would not be effective. Therefore, we would not recommend revaccination if a dose is administered to someone older than 18. We do recommend that a Vaccine Adverse Event Report (VAERS) report be completed for any administration error (www.vaers.hhs.gov (exit)) and we recommend that office procedures be reviewed to avoid a repeat occurrence.

3. Is Tdap mandatory for pregnant women?
   
   As a point of clarification, CDC does not “mandate” vaccines, but rather makes recommendations for their use. If tetanus and diphtheria vaccination are indicated during pregnancy, the “preferred” vaccine is Td. However, Tdap may be given during pregnancy if indicated, e.g., during a pertussis outbreak. Tdap is recommended during the postpartum period not only to protect the mother against pertussis, but to add an additional layer of protection for the infant.

4. If an adult inadvertently receives a dose of DTaP instead of Tdap, should we revaccinate and when?
   
   No. You do not need to revaccinate. The patient received the correct amount of tetanus toxoid and more diphtheria toxoid and pertussis antigen than was recommended.

5. Why are the Tdap vaccines not recommended for persons younger than 10 years of age or older than 64 years of age?
   
   These vaccines were only studied in persons 11 – 64 years of age. No safety and efficacy data were available for FDA approval outside these age groups.

Varicella

1. I understand that ACIP now recommends accepting birth in the U.S. before 1980 as evidence of varicella immunity for everyone except healthcare personnel. What do we do if someone insists they are not immune?
   
   The assumption of immunity based on birth in the U.S. before 1980 is founded in data that showed that almost all persons in that age group were immune regardless of whether they knew their status. Serologic testing for varicella IgG antibody can be considered for a person with this history. However, if someone insists on getting the vaccine, you can go ahead and vaccinate them. The vaccine will not harm them if they are already immune.

2. If someone receives a dose of varicella vaccine and then develops a rash, does the person need the 2nd dose of vaccine?
   
   A post-vaccination rash could be either vaccine-associated or the result of a pre-vaccination exposure to wild varicella virus. (Or it could be something else entirely.) Unless you are absolutely positive the rash was wild-virus related (i.e., a case of chickenpox), we recommend that you give the second dose on schedule. When in doubt, vaccinate.

Miscellaneous

1. Are there any vaccines that should not be administered together?
   
   The general guideline is that inactivated vaccines can be administered either simultaneously or at any time before or after another inactivated vaccine or a live vaccine. Live vaccines administered by injection should be administered either on the same day or at least one month apart. More specific information is available in the ACIP General Recommendations on Immunization, www.cdc.gov/mmwr/PDF/rr/rr5515.pdf (page 6).

2. Can a woman who is breastfeeding receive MMR, varicella, or live attenuated influenza vaccine?
   
   Yes. Breastfeeding is NOT a contraindication for routine vaccination of either the woman or the infant. The only exception is smallpox vaccine.

3. Are there any laws that mandate that healthcare personnel must be vaccinated?
   
   You should consult your agency and state immunization program for any requirements that may apply.

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