Issue 1042: February 28, 2013

Ask the Experts: CDC Experts Answer Your Questions

The questions and answers in this edition of IAC Express first appeared in the February 2013 issue of Needle Tips. All relate to new recommendations or frequently asked questions.

IAC extends thanks to our experts, medical epidemiologist Andrew T. Kroger, MD, MPH; nurse educator Donna L. Weaver, RN, MN; and medical officer Iyabode Akinsanya-Beysolow, MD, MPH. All are with the National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention (CDC).

• Q: I keep hearing about changes to vaccine storage and handling recommendations. Why is CDC making these changes? And how can I make sure I am up to date with all the newest information?
• Q: Is it still acceptable to use combination household units for storing vaccines?
• Q: What temperature is considered a temperature excursion on refrigerated vaccine? Frozen vaccine?
• Q: What are the new ACIP recommendations for vaccinating pregnant women with Tdap?
• Q: If a woman did not receive Tdap during pregnancy, and it is uncertain whether she received a dose of Tdap prior to her pregnancy, should she receive a dose of Tdap postpartum?
• Q: I have an adult patient with controlled epilepsy who wishes to receive the Tdap vaccine. May I vaccinate him?
• Q: A 7-year-old who needed a tetanus shot for wound management came into our emergency department. My question is, if a child has received the complete 5-dose series of DTaP but has never had Tdap, should the child receive Tdap or Td for wound management?
• Q: What are the new ACIP recommendations for use of MenHibrix, the new combination meningococcal Groups C and Y and Haemophilus influenzae type b vaccine?
• Q: Is fainting after the first or second dose of HPV vaccine a contraindication to administering subsequent doses?
• Q: How soon after taking prednisone for an asthma attack can a child receive a flu shot?
• Q: We inadvertently administered an adult dose (0.5 mL) of influenza vaccine to an 8-month-old infant.  Does this child need the second dose?

A: Good questions! The why behind these changes has two parts. First, it had become increasingly apparent to CDC and state health departments that improper vaccine storage and handling is a big problem, leading to a huge waste of product, time, and money, and more importantly, to unprotected people. Second, improved technology (e.g., digital data loggers) provides tools that uncover and measure problems and also prevent them.

As far as how to keep up, on November 27, 2012, CDC released its updated Vaccine Storage and Handling Toolkit and posted it on CDC’s Vaccine Storage and Handling Toolkit web section. The Vaccine Storage and Handling Toolkit is based on the recommendations of ACIP, equipment manufacturers’ product information, and studies from the National Institute for Scientific Technology. The toolkit outlines best practice strategies and recommendations on the following topics:

• Equipment considerations for storage units and thermometers
• Maintenance of the cold chain
• Routine storage and handling practices
• Inventory management
• Emergency procedures for protecting vaccine inventories

Every vaccine provider should print out this document and read and reread it carefully. CDC has provided an overview of the new information as a separate item, as well as a set of FAQs about the new recommendations.

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A: CDC strongly recommends using stand-alone refrigerators and freezers for the following reasons:

• Most combination household refrigerator/freezers have a combined temperature control unit that can create cold spots and temperature fluctuations in the refrigerator portion of the unit.
• The risk of freeze damage to refrigerated vaccines is increased in combination units because air from the freezer is vented into the refrigerator to cool it. This can freeze temperature-sensitive vaccines.
• The freezer portions of many combination units are not capable of maintaining the correct storage temperature for frozen vaccines.

Purchasing new vaccine storage equipment requires planning, and you may need to use existing equipment for a while until you can purchase new equipment. In this situation, CDC recommends using a combination refrigerator/freezer unit for refrigerated vaccine only and using a separate stand-alone freezer to store frozen vaccines.

It is important to note that most combination refrigerator/freezers share a single condenser, and the very cold air from the freezer compartment is vented into the refrigerator compartment to cool the refrigerator. You should not turn off the freezer portion of the combination unit because it will not maintain the proper temperature for the refrigerated vaccines stored in the refrigerator portion of the unit. If you are using the refrigerator portion of the combination unit, it is important that you not store vaccines directly under the vent coming from the freezer and that you add water bottles to the refrigerator to absorb cold air blown in from the freezer. This will reduce the risk of vaccines becoming too cold.

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A: Any temperature readings outside the ranges noted below are considered temperature excursions.

• For refrigerated vaccines, the minimum temperature is 35° F (2° C), and the maximum is 46° F (8° C).
• For frozen vaccines, the minimum temperature is -58° F (-50° C), and the maximum is 5° F (-15° C).

If there is a question about whether a vaccine has been exposed to a temperature excursion, label the vaccines “DO NOT USE” and store them under appropriate conditions, separate from other vaccines. Then, contact the vaccine manufacturer for further guidance. If you are a VFC provider, contact either the vaccine manufacturer and/or your state or local immunization program as directed by the VFC Program in your area.

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A: In October 2012, ACIP voted to recommend that a pregnant woman receive Tdap vaccine during each pregnancy, even if the woman had received Tdap previously. The optimal time to administer Tdap is between 27 and 36 weeks’ gestation. Vaccination during this time maximizes maternal antibody response and passive antibody transfer to the infant. Women who have never received Tdap and who do not receive it during pregnancy should receive it immediately postpartum.

When a woman gets Tdap during pregnancy, maternal pertussis antibodies transfer to the newborn, likely protecting the baby against pertussis in early life, before the baby is old enough to have received at least 3 doses of DTaP. Tdap also protects the mother, making it less likely that she will get infected with pertussis during or after pregnancy and thus less likely that she will transmit it to her infant.

The related provisional recommendations for the use of Tdap in pregnancy were published on December 6, 2012. CDC published the final updated recommendations in the February 22 issue of MMWR (pages 131-135).

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A: Yes. If there is no written documentation that she received a dose of Tdap prior to or during pregnancy, a dose of Tdap should be administered to her immediately postpartum.

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A: Controlled epilepsy is not a contraindication to receipt of Tdap. See IAC’s table of vaccine contraindications and precautions. CDC also makes this information available on its website.

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A: Neither. A child who has completed 5 doses of DTaP has by definition received the fifth dose on or after his/her fourth birthday. In this child’s case, it has been less than four years since receipt of the complete series, so the child does not need either Tdap or Td. The child is fully vaccinated against tetanus according to CDC tetanus wound management guidelines.

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A: Licensed in June 2012, MenHibrix (Hib-MenCY; GSK) is a vaccine indicated for active immunization to prevent invasive disease caused by Neisseria meningitidis serogroups C and Y and Haemophilus influenzae type b. This vaccine does not protect against meningococcal serogroups A, B, and W135.

In October 2012, ACIP voted to recommend that infants at increased risk for meningococcal disease be vaccinated with 4 doses of Hib-MenCY at age 2, 4, 6, and 12 through 15 months. This includes infants with recognized persistent complement pathway deficiencies and infants who have anatomic or functional asplenia, including sickle cell disease. Hib-MenCY can be used in infants age 2 through 18 months who live in communities with serogroup C and Y meningococcal disease outbreaks.

On October 24, 2012, CDC published a media advisory on the use of Hib-MenCY vaccine.

IAC has developed a handy reference table that summarizes ACIP’s recommendations for meningococcal vaccination of children and adults.

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A: No. Fainting is not a contraindication to administering a subsequent dose of any vaccine. Fainting after vaccination is fairly common in adolescence. Providers should prepare for the possibility by having patients sit or lie down when receiving the vaccine and observing patients for 15 minutes after vaccination. For more information on syncope and vaccination, visit the CDC website.

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A: Steroid treatment is not a contraindication for vaccination with inactivated influenza vaccine. As this vaccine is not a live virus vaccine, you can (and should) give it to people who are immunosuppressed, although the patient’s immune response may not be optimal. Immunosuppression (e.g., from certain steroid treatments) is a concern only when administering live virus vaccines.

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Q: We inadvertently administered an adult dose (0.5 mL) of influenza vaccine to an 8-month-old infant.  Does this child need the second dose?

A: Yes. Giving a larger-than-recommended dose of any vaccine does not negate the need for indicated subsequent doses.

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IAC works with CDC to compile new Ask the Experts Q&As for our publications based on commonly asked questions. We also consider the need to provide information about new vaccines and recommendations. Most of the questions are thus a composite of several inquiries.

You can email your question about vaccines or immunization to IAC at admin@immunize.org.

As we receive hundreds of emails each month, we cannot guarantee that we will print your specific question in the Ask the Experts feature. However, you will get an answer.

You can also email CDC's immunization experts directly at nipinfo@cdc.gov. There is no charge for this service.

If you have a question about IAC materials or services, email admininfo@immunize.org.

Please forward these Ask the Experts Q&As to your co-workers and suggest they subscribe to IAC Express.

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