Issue 1044: March 6, 2013

Please note: A clarification has been published for an "Ask the Experts" answer for this issue. To view the clarification, please click here.

Ask the Experts: CDC Experts Answer Your Questions

The first five questions and answers in this edition of IAC Express first appeared in the February 2013 issue of Needle Tips. We have also included nine new Q&As.

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 understand that ACIP recently changed its definition of evidence of immunity to measles, rubella, and mumps. Please explain.
• Q: What are the new provisional ACIP recommendations for use of immune globulin (IG) for measles post-exposure prophylaxis?
• Q: Please describe the new provisional ACIP recommendations for the use of MMR vaccine in people who are HIV-infected.
• Q: Some single-dose pre-loaded vaccines come with an air pocket in the syringe chamber. Do we need to expel the air pocket before vaccinating?
• Q: Is it recommended to use a new alcohol swab to cleanse the skin before administering a vaccine, or can we swab the skin with the same alcohol swab that we used to wipe off the stopper on the vial?
• Q: I have a 45-year-old patient who is traveling to Haiti for a mission trip. She doesn’t recall ever getting an MMR booster (she didn’t go to college and never worked in health care).  She was rubella immune when pregnant 20 years ago.  Her measles titer is negative.  Would you recommend an MMR booster?
• Q: A nursing student received 2 valid, documented doses of varicella vaccine.  For whatever reason, she subsequently had a titer drawn. The titer was negative. Do you recommend revaccination with 2 doses of varicella vaccine?
• Q: If a patient is not able to receive rotavirus vaccine orally, can we give it through a G-tube? 
• Q: What vaccines can we safely give to an infant or older child who has a sibling undergoing treatment for leukemia?
• Q: If the lymph nodes under a patient’s arm were surgically removed, should we avoid giving vaccines in that arm?
• Q: An employee is currently taking prophylactic acyclovir daily to prevent herpes type 2 recurrent infection. Can she receive zoster vaccine?
• Q: Is it safe for a pregnant healthcare worker to administer zoster (shingles) vaccine?
• Q: We inadvertently reconstituted a vaccine with the wrong diluent and administered the vaccine. By the time we realized our error, the patient had already left the clinic. Do we need to revaccinate the patient? If so, when should we do it? 
• Q: An adult came to our office for hepatitis A, hepatitis B, Tdap, and influenza vaccination. Afterward, it appeared that we did not record influenza vaccination on her chart. When questioned, the patient said she thought she got all four shots. Should we give her another dose of influenza vaccine or assume we gave it as intended?

A: At its October 2012 meeting, ACIP voted to include “laboratory confirmation of disease” as evidence of immunity for measles, mumps, and rubella. ACIP voted to remove “physician diagnosis of disease” as evidence of immunity for measles and mumps. “Physician diagnosis of disease” had not previously been accepted as evidence of immunity for rubella. With the decrease in measles and mumps cases over the last 30 years, the validity of physician-diagnosed disease has become questionable. In addition, documenting history from physician records is not a practical option for most adults. The provisional MMR recommendations are currently available on the CDC website.

Please note that provisional ACIP recommendations become CDC recommendations once they are accepted by the director of CDC and the Secretary of Health and Human Services and are published in MMWR.

Back to top

A: At its October 2012 meeting, ACIP voted to expand the use of post-exposure IG prophylaxis for measles.

• Infants younger than 12 months who have been exposed to measles should receive an IG dose of 0.5 mL/kg of body weight. Give IG intramuscularly (IGIM); the maximum dose is 15 mL. Alternatively, MMR vaccine can be given instead of IGIM, to infants age 6–11 months, if it can be given within 72 hours of exposure.
• Pregnant women without evidence of measles immunity who are exposed to measles should receive an IG dose of 400 mg/kg of body weight. Give IG intravenously (IGIV).
• Severely immunocompromised people, irrespective of evidence of measles immunity, who have been exposed to measles should receive an IG dose of 400 mg/kg of body weight. Give IG intravenously (IGIV).
• Other people who do not have evidence of measles immunity can receive an IG dose of 0.5 mL/kg of body weight. Give priority to people who were exposed to measles in settings where they have intense, prolonged close contact (e.g., household, child care, classroom, etc.). Give IG intramuscularly; the maximum dose is 15 mL.

Full details about these provisional recommendations, including the definition of severely immunocompromised people, are available on CDC's website.

Back to top

A: Provisional ACIP recommendations for vaccinating people with HIV infection are as follows:

• Administer 2 doses of MMR vaccine to all HIV-infected people age 12 months and older who do not have evidence of current severe immunosuppression or current evidence of measles, rubella, and mumps immunity. To be regarded as not having evidence of current severe immunosuppression, a child age 5 years or younger must have CD4 percentages of 15% or more for 6 months or more; a person older than 5 years must have CD4 percentages of 15% or more and a CD4 lymphocyte count of 200 or more/mm3 for 6 months or more.
• Administer the first dose to babies age 12 through 15 months and the second dose to children age 4 through 6 years, or as early as 28 days after the first dose.
• Unless they have acceptable current evidence of measles, rubella, and mumps immunity, people with perinatal HIV infection who were vaccinated prior to establishment of effective antiretroviral therapy (ART) should receive 2 appropriately spaced doses of MMR vaccine after effective ART has been established. Children age 5 years or younger must have CD4 percentages of 15% or more for 6 months or more; people older than 5 years must have CD4 percentages of 15% or more and a CD4 lymphocyte count of 200 or more/mm3 for 6 months or more.

Back to top

A: No. You do not need to get rid of the air pocket. The air will be absorbed. This is not true for syringes that you fill yourself; you should expel air bubbles from these syringes prior to vaccination to the extent that you can readily do so.

Back to top

A: You should use separate alcohol wipes to clean the vial top and the patient’s skin.

Back to top

A: ACIP recommends 2 doses of MMR given at least 4 weeks apart for any adult born in 1957 or later who plans to travel internationally. There is no harm in giving MMR vaccine to a person who may already be immune to one or more of the vaccine viruses.

Back to top

A: No. Documented receipt of 2 doses of varicella vaccine supersedes results of subsequent serologic testing. Most commercially available tests for varicella antibody are not sensitive enough to detect vaccine-induced antibody, which is why CDC does not recommend post-vaccination testing. For more information, see page 24 of ACIP’s Immunization of Health-Care Personnel.

Back to top

A: You can give rotavirus vaccine through a tube as long as the child is otherwise eligible.

Back to top

A: Household contacts and other close contacts of people with altered immunocompetence can receive all age-appropriate vaccines, with the exception of smallpox vaccine. MMR, varicella, and rotavirus vaccines should be administered to susceptible household contacts and other close contacts of immunocompromised patients when indicated. MMR vaccine viruses are not transmitted to contacts, and transmission of varicella vaccine virus is rare. No specific precautions are needed unless the varicella vaccine recipient develops a rash after vaccination. In this case, the varicella vaccine recipient should avoid direct contact with susceptible household contacts until the rash resolves. Anyone who changes an infant’s diaper should always wash their hands afterward. This will help prevent rotavirus vaccine virus transmission from a vaccinated infant. Household and other close contacts of people with altered immunocompetence should receive annual influenza vaccination and all other age appropriate vaccines. LAIV may be administered to healthy household and other close contacts of people with altered immunocompetence. For more information about vaccinating people in contact with immunosuppressed people, see page 20 of ACIP’s General Recommendations on Immunization.

Back to top

A: We have heard that some surgeons advise against vaccination in an arm where lymph nodes were dissected. ACIP does not address this, so feel free to use your professional judgment in determining whether to use the arm that was operated on, the other arm (if not affected), or the anterolateral aspect of the thigh, which is an acceptable secondary route for adult immunization.

Back to top

A: ACIP’s zoster recommendations include the following:

“Licensed antiviral medications active against members of the herpesvirus family include acyclovir, famciclovir, and valacyclovir. These agents might interfere with replication of the live, VZV-based zoster vaccine. All three agents have relatively short serum half-lives and are quickly cleared from the body. Persons taking chronic acyclovir, famciclovir, or valacyclovir should discontinue these medications at least 24 hours before administration of zoster vaccine, if possible. These medications should not be used for at least 14 days after vaccination, by which time the immunologic effect should be established.”

This information is available on page 20 of ACIP's Prevention of Herpes Zoster.

Back to top

A: Yes. A pregnant woman may administer any vaccine, including live virus vaccines, except smallpox vaccine.

Back to top

A: Yes, you need to revaccinate the patient. If an inactivated vaccine is reconstituted with the wrong diluent and is administered, the dose should be repeated ASAP. If a live virus vaccine is reconstituted with the wrong diluent and is administered, it can be repeated on the same clinic day. However, if you can’t get the patient back to the office that day, you need to wait at least 4 weeks to repeat the dose. 

Back to top

A: If there is ever any doubt that you gave a vaccine, repeat it.

Back to top

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.

Back to top