Questions
and Answers
NIP Answers Your
Questions
General Vaccination Topics
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General
Questions
-
How
are vaccines attenuated and inactivated?
Attenuation (weakening) is usually accomplished
through serial passage of the organism
through various tissue culture media. Inactivation
(killing) is done with formalin and/or
heat. "Understanding
Vaccines" (NIAID) (2/13/03)
-
Do
infants get passive immunity if the mother
is immunized or if the mother has the virus?
The infant will receive whatever antibodies
the mother has, whether they were acquired
from infection or vaccination. (2/13/03)
-
Passive
immunity interferes with live vaccines.
Therefore, if mothers are still nursing
their infants at one year of age, do live
virus vaccines for the infants need to
be delayed? If so, how long after mom stops
nursing do we wait?
There is no reason to delay vaccination
because of breastfeeding. Breastfeeding
is a good thing and it is not a contraindication
to administratin of any vaccine except
smallpox. ACIP
General Recommendations (see page 18)
(2/13/03) More Information
-
Can
ibuprofen be used safely following a live
vaccine (in children) instead of acetaminophen?
We have some patients who are allergic
to acetaminophen.
Acetaminophen or ibuprofen can be used
following vaccination unless medically
contraindicated for that patient. ACIP
General Recommendations (see page 13)
and "After
the Shots" (IAC) (2/13/03)
-
When
a child has an anaphylactic reaction after
multiple simultaneous injections, how do
we know which vaccine the child is allergic
to?
In this situation we would recommend an
allergy consult prior to administering
another dose of any vaccine administered
at the time of the anaphylactic reaction.
(2/13/03)
-
How
do I find out about vaccine components
in case my patient reports an allergy?
There
are several resources: The manufacturer’s
product information (package insert) that
accompanies the vaccine, The “Vaccine
Excipient and Media Summary”
table in Appendix A of Epidemiology
and Prevention of Vaccine-Preventable Diseases
(the Pink Book), and in the book ImmunoFacts,
http://www.immunofacts.com/.
(6/26/03)
-
Please
address the latex component in vaccine
stoppers in relation to patients with latex
allergies.
If a person reports a severe (anaphylactic)
allergy to latex, vaccines supplied in
vials or syringes that contain natural
rubber should not be administered, unless
the benefit of vaccination outweighs the
risk of an allergic reaction to the vaccine.
For latex allergies other than anaphylactic
allergies (e.g., a history of contact allergy
to latex gloves), vaccines supplied in
vials or syringes that contain dry natural
rubber or natural rubber latex can be administered.
ACIP
General Recommendations (see page 17)
(2/13/03) More
Information
-
What
is the danger of over-immunizing in cases
where you can’t find the immunization
records? Is it O.K. to revaccinate?
Every reasonable effort should be made
to locate a patient’s immunization
record. However, if it cannot be located,
then the recommendation is to revaccinate
according to their current age. The concern
is the risk of localized reaction with
the more immunogenic vaccines like tetanus-
and diphtheria-containing vaccines. In
some situations you may want to do serologic
testing for antibody. There is a good discussion
and helpful table in the General Recommendations
about which vaccines should be repeated
and when you may want to consider testing.
ACIP
General Recommendations (see pages
8, 20-21). (2/13/03)
-
If
someone has suffered a major blood loss,
should they be revaccinated after they
recover?
No, this is not necessary. Your immunologic
memory resides primarily in your bone marrow.
The only situation where a person should
be re-immunized is if their bone marrow
is ablated by drugs or radiation as with
a bone marrow transplant. (2/13/03)
-
Should
a nurse who is receiving chemotherapy be
administering live vaccines?
It really should not be a problem. The
vaccines are in a sealed vial, are drawn
into a syringe, and then injected under
the skin. Also, the health-care provider
administering the vaccines should be immune
to measles, mumps, rubella and varicella.
It should not be a problem with yellow
fever vaccine either. Smallpox
vaccine, however, is an exception.
Anyone who has not been recently vaccinated
against smallpox should not be administering
the vaccine. The vaccine is in an open
vial and is administered as a drop on the
bifurcated needle so there is risk of exposure
to the vaccine. (2/13/03)
- If
a patient is on antibiotics (e.g., tetracycline
for acne) for chronic problem , would this
have any effect on any live vaccine?
No.
Antibiotics do not have an effect on the
immune response to a vaccine. No commonly
used antibiotic or antiviral will inactivate
a live virus vaccine. (6/26/03)
Top
Intervals/Schedules/Spacing
-
Two
live virus vaccines, if not given on the
same day, must be separated by at least
28 days. If a second live vaccine is inadvertently
given before 28 days, how long should we
wait to give the repeat dose?
If injected live vaccines not given simultaneously
are separated by less than 4 weeks, the
vaccine administered second should not
be counted as a valid dose and should be
repeated. The repeat dose should be administered
at least 4 weeks after the last (invalid)
dose. (2/20/03) More
Information
-
Does
the four day grace period include the minimal
interval between live vaccine immunizations?
The 4-day grace period can be applied to
any value in Table 1 of the ACIP General
Recommendations. Therefore it can be applied
to the interval between two doses of the
same live vaccine (e.g.,
MMR doses 1 & 2 or varicella doses
1 & 2). However, it does not apply
to the interval between the doses of two
different live vaccines (e.g., MMR &
varicella), which should be separated by
28 days. ACIP
General Recommendations (see pages
4-5) (2/13/03) More
Information
-
Does
the 4-day grace period apply to the accelerated
schedule when giving a vaccine series?
Any accelerated or catch-up schedule should
not include doses administered
at ages or intervals less than those recommended
in Table 1 of the ACIP General Recommendations.
The 4-day grace period should not be considered
when scheduling doses of vaccine. But if
a dose of vaccine is inadvertently administered
4 days earlier than the appropriate age
or interval on Table 1, it needn't be repeated.
ACIP
General Recommendations (see page 3)
(2/13/03)
-
Why
can't inactivated vaccines be given to
infants under 6 weeks old?
Mainly because there are few safety or
efficacy data on doses given before 6 weeks
of age, and the vaccines aren’t licensed
for this use. What data exist suggest that
the response to doses given before 6 weeks
is poor, except for hepatitis B vaccine.
ACIP
General Recommendations (see page 2)
(2/13/03)
-
If
an expired dose of live vaccine is given,
when should it be repeated?
ACIP does not specifically address the
timing for repeating doses of expired vaccine.
However, it would be prudent to wait 4
weeks (at least one incubation period)
before repeating a dose of live vaccine
that has expired. Even though the vaccine
is expired, it might retain some viability
that could interfere with the repeat dose.
Therefore, it is best to wait 4 weeks to
be sure. However, if an expired inactivated
vaccine is inadvertently given, we do not
know of a biologic reason why the dose
could not be repeated immediately, although
there is still no official recommendation.
(4/16/04)
More Information
- If
a child has RSV disease, how soon can DTaP,
IPV, or other vaccines be given? The child
is not taking any medications.
Any moderate or severe acute illness with
or without fever is a temporary contraindication
to the administration of any vaccine. The
child can be vaccinated when symptoms abate.
ACIP
General Recommendations (see
page 11) (2/13/03)
-
We
have a baby that came to our clinic this
morning who gets RSV shots because she
was premature and the mom was wondering
if it was okay for her to receive PCV7
and Hib vaccines. She thought they were
all given to treat the same thing. What
do you recommend?
PCV7 and Hib vaccines are inactivated vaccines
so there is no concern about interference
from immune globulins. In fact, if the
child is receiving Synagis, then you could
even give live vaccines if they are indicated,
because Synagis is monoclonal (it contains
only antibodies to RSV) so it will not
interfere with vaccine antigens. You may
want to educate the mother about what the
vaccines and RSV protect against and explain
to the mother that the RSV provides temporary
immunity against RSV only, and is not a
vaccine. ACIP
General Recommendations (see page 7)
(2/13/03)
-
When
we speak of "simultaneous administration"
of vaccines, what does “simultaneous”
mean? Does it mean the same day, hour,
or what?
Simultaneous means the same day -- the
same clinic day. If someone receives a
vaccine in the morning and then another
that same afternoon, this would be considered
simultaneous. (2/13/03)
- What
are the recommendations regarding spacing
of vaccines and PPD testing?
All vaccines may be given on the
same day as a TB skin test, or any
time after a TB skin test
is applied. However, if MMR has been given,
and one or more days have elapsed, we recommend
waiting 4-6 weeks before giving a routine
TB skin test. No information on the effect
of varicella or other live injected vaccines
on a TB skin test is available. Until such
information is available, it is prudent to
apply rules for spacing measles vaccine and
TB skin testing to these vaccines. There
is no evidence that inactivated
vaccines interfere with PPD response. ACIP
General Recommendations (see page 16)
(2/13/03) More Information
-
Can
a PPD be administered to a patient has
had BCG vaccine?
Yes. As we understand the current recommendation,
you should interpret the PPD result without
consideration for the person’s BCG
status. Even if they have a history of
BCG vaccination, if there is a strong positive
PPD reading you should interpret it as
infection with Mycobacterium tuberculois.
(2/13/03) More Information
- A
person received 5 doses of pentevalent vaccine
in Mexico. If the spacing is right can we
consider this a complete series and are any
boosters needed?
There are at least two different pentevalent
vaccines available. But the bottom line is
that any vaccines received outside the United
States are considered valid doses if the
ages and intervals between doses are consistent
with Table 1 in the General Recommendations.
This is true even if it is a combination
vaccine that does not exist in the U.S.,
like DTaP-Hib.
Even if the child has received 5 doses of
DTaP, we would recommend an additional dose
at school entry if the last dose was given
before the 4th birthday. You may want to
give that dose at 5 or 6 years of age to
reduce the chance of a local reaction. ACIP
General Recommendations (see pages 19-21)
(2/13/03)
Top
Route/Site/Administration
-
In
the General Recommendations it states that
if you give a subcutaneous (SQ) vaccine
by the intramuscular (IM) route, you do
not have to repeat the dose. What if you
give an IM vaccine by the subcutaneous
route?
This recommendation was revised in the
2002 General Recommendations. Hepatitis
B and rabies
vaccines not given by the IM route should
be repeated. The Division of Viral Hepatitis
also recommends that Hepatitis
A vaccine should be repeated if
it is not given by the IM route. Otherwise,
IM vaccines needn't be repeated if inadvertently
given SQ. However, remember for optimal
immune response, the vaccine should be
administered by the recommended route.
If someone is routinely administering a
vaccine(s) by a route that is not recommended,
then some education is needed. ACIP
General Recommendations (see pages
13-14). (2/13/03)
-
As
the number of injections given at one encounter
increases, we are running out of injection
sites. If we defer an immunization for
this reason, how long before we can re-use
an injection site?
We strongly recommend that you do
not defer any recommended vaccines.
This is a missed opportunity. No upper
limit has been established regarding the
number of vaccines that can be administered
in one visit. ACIP and AAP consistently
recommend administration of all indicated
vaccines. There is no indication, or reason
to believe, that this practice is harmful
to the child.
You can administer 2 intramuscular (IM)
injections in each leg. They should be
separated by 1”-2” to avoid
overlap of any local reactions. You may
want to put DTaP in one leg and PCV7 in
the other leg, since they may be more reactive.
IPV, MMR, and varicella can all be administered
subcutaneously (SQ) in the posterior fatty
triceps area of the arm or the upper fatty
area of the thigh. ACIP
General Recommendations (see page 12),
Vaccine
Administration guidelines, Immunization
Techniques video (2/13/03)
-
What
do you recommend if a person receives Hepatitis
B or rabies vaccine in the gluteal area?
The immunogenicity of hepatitis B vaccine
and rabies vaccine is substantially lower
when the gluteal rather than the deltoid
site is used for administration. Doses
of rabies vaccine administered in the gluteal
site should not be counted as valid doses
and should be repeated. Hepatitis B vaccine
administered by any route or site other
than intramuscularly in the anterolateral
thigh or deltoid muscle should not be counted
as valid and should be repeated, unless
serologic testing indicates that an adequate
response has been achieved. ACIP
General Recommendations (see pages
13-14) (2/13/03)
- A
nurse was administering the first dose of
DTaP vaccine to a 2 month old child. Some
of the vaccine leaked out of the needle.
Should we revaccinate?
When this happens, it is difficult to judge
how much vaccine the child received. This
would be a nonstandard dose and should not
be counted. You should go ahead and reimmunize
the child at that time. ACIP
General Recommendations (see page 14)
(2/20/03)
Top
Records/VISs/HIPAA
-
Are
states required by law to have an immunization
registry?
No. However, most, if not all, states are
at some stage of registry development.
Use of immunization registries is strongly
recommended, and the National Immunization
Program is working closely with states
and territories to facilitate their development
and use. NIP
Registry Website (2/13/03)
-
Is
there any mechanism in place to screen
the immunization records of high school
foreign exchange students before they arrive
at their assigned schools in the U.S.?
By the time they arrive in this country
and report for school it can be quite difficult
to get them to obtain required vaccines.
It seems it would be much more effective
to make required vaccines for US school
children mandatory for foreign exchange
students before they arrive in this country.
Proof of vaccination requirements apply
to aliens who seek an immigrant visa or
adjustment of status for permanent residence,
but not for temporary admission to this
country. Also, school entry requirements
are mandated by individual states, not
the federal government. It would seem prudent
for the state immunization program and
schools to communicate with the folks managing
the foreign exchange student programs and
families who will be sending and sponsoring
these students about the immunization requirements.
Technical
Instructions for Civil Surgeons (2/20/03)
-
If
an individual does not have an immunization
record, what should we do?
Vaccination providers frequently encounter
persons who do not have adequate documentation
of vaccinations. Providers should only
accept written, dated records as evidence
of vaccination. With the exception of pneumococcal
polysaccharide vaccine, self-reported doses
of vaccine without written documentation
should not be accepted.
Although vaccinations should not be postponed
if records cannot be found, an attempt
to locate missing records should be made
by contacting previous health-care providers
and searching for a personally held record.
If records cannot be located, these persons
should be considered susceptible and should
be started on the age-appropriate vaccination
schedule. Serologic testing for immunity
is an alternative to vaccination for certain
antigens (e.g., measles, mumps, rubella,
varicella, tetanus, diphtheria, hepatitis
A, hepatitis B, and poliovirus). ACIP
General Recommendations (see pages
8, 19-21) (2/20/03)
-
If
someone is traveling to another country,
how do we know what vaccines are needed,
especially if they have no immunization
records? Should we draw blood to see if
they are already immune?
Vaccines recommended for travel to specific
areas can be found on CDC's Travelers
Health website. If there is no record
of immunizations, then we recommend that
you vaccinate.
S erologic testing for immunity is an alternative
to vaccination for certain antigens (e.g.,
measles, mumps, rubella, varicella, tetanus,
diphtheria, hepatitis A, hepatitis B, and
poliovirus). ACIP
General Recommendations (see pages
8, 19-21) (2/20/03)
-
Are
immunizations public information? Should
a nurse give a child’s vaccine record
to the day care where the child is registered
and vaccinations are a prerequisite for
admission?
The best course of action would be to provide
the record to the parent or legal guardian
who can then give the record to the day
care or school. We would recommend that
you consult your state immunization program
for guidance.
You will find information on HIPPA in the
Immunization Update 2003 broadcast script,
at http://www.cdc.gov/nip/ed/ImUpdate2003/update03briefs.pdf.
Additional HIPAA information is available
at, http://www.cdc.gov/nip/policies/hipaa/Default.htm.
(8/21/03)(2/13/03)
-
(For
HIPAA purposes) Are immunization records
public record?
I
don’t believe immunizations are a
public record. Immunization records are
part of the individual’s medical
record. You will find further guidance
about HIPAA uidelines and sharing immunization
information at, http://www.cdc.gov/nip/policies/hipaa/Default.htm.
(8/21/03)
-
When
patients are receiving vaccines, is it
necessary for the patient/parent to sign
each time a vaccine in a series is administered
or is the first in a series adequate? Also,
are the signatures really necessary? Would
documentation in the record that the Vaccine
Information Statement (VIS) was given and
parent gave consent (without actually having
the signature) suffice? Are there any reference
documents that address this topic?
There is no federal requirement for signed
consent to vaccinate. Please consult your
state immunization program and agency regarding
signed consent. The following website provides
federal guidelines regarding documentation
of immunizations in the medical record,
http://www.cdc.gov/nip/publications/vis/vis-instructions.pdf.
(8/21/03)
Top
Vaccine
Storage and Handling
-
When
a multi-dose vial is opened and a dose
has been used, how long can that vial be
retained for use?
We recommend that you ALWAYS review the
storage and handling guidelines in the
manufacturer’s package insert that
accompanies the vaccine. However, in almost
all cases, multi-dose vaccine vials can
be used until the expiration date on the
vial as long as the vaccine does not take
on an unusual appearance and the vial is
stored according to manufacturer guidelines.
One exception is Menomume. Unused vaccine
from a multi-dose vial of Menomune should
be refrigerated at 2°- 8° C (35°-
46° F) and discarded 35 days after
reconstitution if not used. [NOTE: Was
formerly 10 days after reconstitution.]
(2/20/03)
-
How
long can any inactivated vaccine remain
refrigerated while in the syringe?
NIP strongly discourages prefilling syringes. Commercial syringes
are not designed for vaccine storage. At the end of the clinic
day, any remaining vaccine in syringes (other than manufacturers'
prefilled syringes) should be discarded. Vaccine that has been
drawn up and not administered may not be used on subsequent
days. Additional information is available in the Vaccine Storage
and Handling Toolkit (http://www2a.cdc.gov/nip/isd/shtoolkit/splash.html),
Chapter 11, pages 6-8. (10/18/05)
Top
Additional
Information
Breastfeeding
and Passive Immunity
The
antibody in breast milk is secretory IgA antibody.
What is needed to protect against vaccine-preventable
diseases is IgG antibody in the blood. IgA
antibody is basically absorbed like protein,
not like antibody. There is some evidence that
breastfeeding will reduce the risk of Hib disease
and maybe pneumococcal disease. There is also
some evidence that breastfeeding actually improves
the immunogenicity of some inactivated vaccines.
Pre-exposure
smallpox vaccination is contraindicated for
women who are breastfeeding because of the
skin-to-skin contact between the mother and
infant. This contact increases the risk that
vaccinia virus from the mother’s vaccination
site could be transmitted to the infant. (02/13/03)
MMWR
"Recommendations for Using Smallpox Vaccine
in a Pre-Event Vaccination Program"
Back
Separating
Live Vaccines
It
is thought that a parenterally-administered
live vaccine can interfere with replication
of a second live vaccine administered after
it. Therefore, ACIP recommends waiting for
one replication cycle (i.e., one incubation
period, i.e., about 4 weeks), and then repeating
the second vaccine.
Yellow
fever vaccine can be administered at any time
after single-antigen measles vaccine. Ty21a
(live, oral) typhoid vaccine and parenteral
live vaccines (e.g., MMR, varicella, yellow
fever) can be administered simultaneously or
at any interval before or after eachother.
(02/20/03) ACIP
General Recommendations (see page 5)
Back
Intervals
Between Vaccine Doses
Remember,
it's better to put more rather than less space
between doses. Therefore, when scheduling appointments,
the recommended interval should be your first
choice, the minimum interval your second choice,
and the 4-day grace period your last option.
You will also need to check for compliance
with applicable day care/school laws in your
state. Some states do not accept the 4-day
grace period. (02/13/03) Back
Expired
Vaccine
Remember,
it is important to always recheck the vaccine
label before you administer the vaccine. If
it is expired, then remove it from the refrigerator
or freezer so there is no risk of using it.
Also, let’s be clear on the definition
of “expired”. Sometimes these vials
only contain a month and year. In that case,
you can use the vaccine right up through the
last day of the month printed on the vial or
box. For example, if the vial says June, 2003,
you can use the vaccine through the last day
of June. It does not expire on the first day
of the month, but definitely do not use it
if it is even one day out of date. (02/13/03)
Back
Vaccines
and PPD Testing
Measles
vaccine (and possibly mumps, rubella, and varicella
vaccines) may transiently suppress the response
to PPD in a person infected with Mycobacterium
tuberculosis. Simultaneously administering
PPD and measles-containing vaccine
does not interfere with reading the PPD result
after 48-72 hours. If a measles-containing
vaccine has already been given, delay PPD screening
until at least 4 weeks after vaccination. This
delay will remove any concern of suppressed
PPD reactivity from the vaccine.
PPD screening can also be performed and read
before administering a measles-containing
vaccine. But this option is the least favored
because it will delay receipt of the vaccine.
No data exist regarding PPD suppression with
other parenteral live virus vaccines
(e.g., varicella or yellow fever). In the absence
of data, following guidelines for measles-containing
vaccine when scheduling PPD screening and administering
these vaccines is prudent. If the opportunity
to vaccinate might be missed, vaccination should
not be delayed because of these theoretical
considerations.
Mucosally administered live vaccines
(e.g., OPV and intranasally administered influenza
vaccine) are unlikely to affect the response
to PPD.
No evidence has been reported that inactivated
vaccines, polysaccharide vaccines,
recombinant, or subunit vaccines, or toxoids
interfere with response to PPD.
The
biological basis for separating
a live vaccine and PPD if the vaccine is given
first was revealed in the 1960s. It was observed
that the early measles vaccine - the Edmonston
vaccine - could suppress the response to a
tuberculin skin test, the PPD. Cell mediated
immunity is slightly suppressed by viral infections,
including measles and measles vaccine. Cell
mediated immunity to TB antigens is exactly
what you're measuring with a PPD. If you give
measles vaccine first, then place a PPD during
the period of immune suppression, the response
to the skin test may be reduced- even if the
person DOES have TB. It's not known if the
current, more attenuated vaccine also has this
effect. But it’s safer to assume it does
and not risk interference with the accurate
reading of a PPD.
Back
PPD
and BCG Vaccine
There
are two problems with BCG vaccine. First, it
does not reduce the risk of being infected
with Mycobacterium tuberculosis. What
it probably does do is reduce the risk of disseminated
disease among very young children with Mycobacterium
tuberculosis. This is compounded by the
fact that BCG is used where there are high
rates of TB. If you have someone coming from
someplace where there is a lot of TB, they
should be tested with PPD. There is more information
available about TB on CDC's
Tuberculosis website. Back
Latex
Allergy
Latex
is liquid sap from the commercial rubber tree.
Latex contains naturally occurring impurities
(e.g., plant proteins and peptides), which
are believed to be responsible for allergic
reactions. Latex is processed to form natural
rubber latex and dry natural rubber. Dry natural
rubber and natural rubber latex might contain
the same plant impurities as latex but in lesser
amounts. Natural rubber latex is used to produce
medical gloves, catheters, and other products.
Dry natural rubber is used in syringe plungers,
vial stoppers, and injection ports on intravascular
tubing. Synthetic rubber and synthetic latex
also are used in medical gloves, syringe plungers,
and vial stoppers. Synthetic rubber and synthetic
latex do not contain natural rubber or natural
latex, and therefore, do not contain the impurities
linked to allergic reactions.
The most common type of latex sensitivity is
contact-type (type 4) allergy, usually as a
result of prolonged contact with latex-containing
gloves. However, injection-procedure--associated
latex allergies among patients with diabetes
have been described. Allergic reactions (including
anaphylaxis) after vaccination procedures are
rare. Only one report of an allergic reaction
after administering hepatitis B vaccine in
a patient with known severe allergy (anaphylaxis)
to latex has been published. Back
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