Issue 1283: January 3, 2017
Ask the Experts: CDC Experts Answer Your Questions
The questions and answers in this edition of IAC Express first appeared in the December 2016 issue of Needle Tips.
IAC extends thanks to our experts, medical officer Andrew T. Kroger, MD, MPH, and nurse educator Donna L. Weaver, RN, MN, both from the National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention (CDC).
HPV Vaccine
MenACWY Vaccine
MenB Vaccine
Influenza Vaccine
HPV Vaccine
Q: What is the new HPV vaccine schedule recommendation?
A: In October 2016, the Advisory Committee on Immunization
Practices (ACIP) voted to recommend a routine 2-dose HPV
vaccine schedule for adolescents who start the vaccination
series before the 15th birthday. The two doses should be
separated by 6–12 months (the minimum interval between doses
is 5 months). A 3-dose schedule continues to be recommended
for people who start the series on or after the 15th birthday
and for people with certain immunocompromising
conditions (such as cancer, HIV infection, or taking
immunosuppressive drugs). A revised ACIP statement is being
prepared and is expected to be published in December 2016.
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Q: Has ACIP expressed a preference for the 2-dose over the 3-dose schedule for adolescents 9 through 14 years of age?
A: Yes. ACIP recommends the 2-dose schedule for people starting the HPV vaccination series before the 15th birthday, as long as they are immunocompetent.
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Q: Does the 2-dose HPV vaccine schedule need to be completed with the same vaccine, or can it include different vaccines (such as bivalent or quadrivalent vaccine)
A: The 2-dose schedule can be completed with any combination of
HPV vaccine brands as long as dose #1 was given before age 15
years. Dose #2 should be administered 6–12 months after dose
#1.
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Q: If dose #1 of HPV vaccine was given before the 15th birthday and it has been more than a year since that dose was given, would the series be complete with just one additional dose?
A: Yes. Adolescents and adults who started the HPV vaccine series prior to the 15th birthday and who are not immunocompromised are considered to be adequately vaccinated with just one additional dose of HPV vaccine.
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Q: We have adolescents in our practice who have received the first 2 doses of the HPV series 1 or 2 months apart according to the 3-dose schedule.
Can we consider their HPV vaccine series to be complete or do we need to give these patients a third dose?
A: People who have received 2 doses of HPV vaccine separated by
less than 5 months should receive a third dose 6–12 months
after dose #1 and at least 12 weeks after dose #2.
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Q: Will the 2-dose recommendation be retroactive for children and teens vaccinated prior to 2016?
A: Yes. Any person who ever received 2 doses of any combination of HPV vaccines can be considered fully vaccinated if dose #1 was given before the 15th birthday and the 2 doses were separated by at least 5 months.
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MenACWY Vaccine
Q: Please review the new recommendations for use of MenACWY vaccine in people with human immunodeficiency virus (HIV) infection.
A: A growing body of evidence supports an increased risk for
meningococcal disease in HIV-infected people. The Advisory
Committee on Immunization Practices (ACIP) recommends that all
HIV-infected people 2 months of age and older should routinely
receive an age-appropriate MenACWY vaccine (Menactra, Sanofi
Pasteur; Menveo, GSK). Children younger than age 2 years
should be vaccinated using a multidose schedule (see the IAC
educational piece “Meningococcal Vaccine Recommendations by
Age and Risk Factor for Serogroups A, C, W, or Y Protection”
available at www.immunize.org/catg.d/p2018.pdf
for details). People age 2 years and older with HIV infection
who have not been previously vaccinated should receive a
2-dose primary series of MenACWY vaccine (doses separated by
8–12 weeks). People with HIV infection who have previously
received one dose of MenACWY should receive a second dose at
the earliest opportunity (at least 8 weeks after the previous
dose) and then receive booster doses at the appropriate
intervals. If the most recent dose was received before age 7
years, a booster dose should be administered 3 years later. If
the most recent dose was received at age 7 years or older, a
booster should be administered 5 years later and every 5 years
thereafter throughout life.
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Q: I have an HIV-positive 64-year-old patient who received MenACWY vaccine last week. Was this the correct vaccine for this patient or should he have gotten meningococcal polysaccharide vaccine (MPSV4, Sanofi Pasteur) due to his age? Also, should this patient get another dose in 2 months?
A: MenACWY was the correct vaccine in this situation. The 2013
ACIP recommendations on MenACWY vaccination recommend the use
of meningococcal conjugate vaccine in adults age 56 years and
older who were vaccinated previously with MenACWY and now need
revaccination, or are recommended to receive multiple doses. A
person of this age with HIV infection should receive 2 doses
of MenACWY separated by 8–12 weeks. Both MenACWY vaccines are
licensed for use in people through age 55 years, which means
that the use of these vaccines in people age 56 and older is
off-label but recommended by ACIP.
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Q: I have a 24-month-old patient with HIV infection and I want to use Menactra (Sanofi Pasteur) because this is the only vaccine we have available in our clinic. However, this child received DTaP vaccine yesterday at another clinic. Can I administer Menactra today?
A: ACIP recommends that you wait 4 weeks from the dose of DTaP to administer the dose of Menactra. This is because data suggest a reduced response to the Menactra if given within a month after DTaP. If Menactra is to be administered to a child at increased risk for meningococcal disease, including children who have HIV infection, Menactra should be given either before or at the same visit as DTaP. Menveo brand MenACWY vaccine (GSK) can be given at any time before or after DTaP.
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Q: I have a 24-month-old patient with a complement component deficiency who received a dose of DTaP at 23 months of age and then received a dose of Menactra two weeks later. Do I need to repeat the dose of Menactra?
A: No. Even though ACIP recommends that Menactra should be given no less than 4 weeks after a dose of DTaP, there is no evidence to support repeating the dose of Menactra. A child with a complement component deficiency should still receive a second dose of MenACWY vaccine 8 weeks after the first dose.
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Q: Does the recommendation about separation of DTaP and Menactra also apply to children with functional or anatomic asplenia?
A: Yes. The recommendation about spacing of DTaP and Menactra (described above) applies to children of any age with a high-risk condition for meningococcal disease, including travelers.
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Q: The ACIP MenACWY vaccine recommendations state that a routine second dose needs to be given at 16 years of age. Children with asplenia or other high-risk conditions should receive a booster dose every 5 years. If a child with a high-risk condition receives a dose of MenACWY at age 9 years (and a second primary dose 8 weeks later), should they receive a booster dose at age 14 years (5 years after the primary series), or should they receive a dose at age 16 years as recommended in the routine schedule?
A: The MenACWY booster dose should be given at 14 years (5 years after the primary series) and every 5 years thereafter. The every 5-year booster dose schedule for persons with high-risk conditions takes precedence over the routine second dose schedule.
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MenB Vaccine
Q: Which individuals in risk groups are recommended to be vaccinated against meningococcal serogroup B disease?
A: CDC’s Advisory Committee on Immunization Practices (ACIP)
recommends routine MenB vaccination of the following
individuals in certain risk groups:
- People age 10 years and older who have functional or anatomic asplenia
- People age 10 years and older who have persistent complement component deficiency, including
- people taking eculizumab (Soliris)
- People age 10 years and older who are at risk during an outbreak caused by a vaccine serogroup, such as on a college campus
- Microbiologists who work with meningococcus bacteria in a laboratory
Both MenB vaccines are licensed for use in people through age 25 years, which means that the use of these vaccines in people age 26 and older is off-label but recommended by ACIP.
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Q: Which individuals are recommended to be vaccinated against meningococcal serogroup B disease who are not in risk groups?
A: ACIP recommends that a MenB vaccine series (Bexero, MenB-4C,
GSK; Trumenba, MenB-FHbp, Pfizer) may be administered to
people 16 through 23 years of age with a preferred age of
vaccination of 16 through 18 years. This Category B
recommendation gives clinicians an opportunity to discuss the
value of MenB vaccination with their patients and to make a
decision together about the individual’s need or desire for
the vaccine based on risks, benefits, and wish for protection
from the disease. Because it is a Category B recommendation,
MenB vaccination is covered by the Vaccines for Children
Program for anyone who is eligible. Under the Affordable Care
Act, private insurance must also cover the costs of both
Category A and B recommended vaccines.
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Q: What is the new schedule for Trumenba MenB vaccine?
A: The Food and Drug Administration approved a 2-dose schedule for Trumenba in April 2016. At its October 2016 meeting, ACIP voted to recommend a 2-dose schedule of Trumenba for people not at increased risk of MenB (for example, healthy adolescents). The two doses should be administered at least 6 months apart. ACIP recommends that people at increased risk of MenB disease (complement component deficiency, functional or anatomic asplenia, at risk during an outbreak of meningococcal B disease, and certain microbiologists) receive a 3-dose Trumenba series with dose #2 and dose #3 administered 2 and 6 months after dose #1.
The schedule for Bexsero has not changed. Bexsero is a 2-dose series with dose #2 given at least 1 month after dose #1.
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Q: Should college students be vaccinated against meningococcal B disease?
A: Although several small meningococcal serogroup B disease outbreaks have occurred on college campuses since 2013, college students in general are not at higher risk of meningococcal B disease then people of the same age who are not college students. Consequently, ACIP does not routinely recommend MenB vaccination for college students. However, college students may choose to receive MenB vaccine to reduce their risk of serogroup B meningococcal disease.
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Q: ACIP recommendations for MenB vaccine say the vaccine will
provide “short term protection.” What does “short term
protection” mean?
A: MenB vaccines were approved based on the serologic response
to the vaccine. No data are available on vaccine effectiveness
against clinical disease or duration of protection against
clinical disease. Short-term protection refers to the known
duration of the antibody response. Available data indicate
that a protective antibody level should persist in most
recipients for 24–48 months after vaccination. This issue will
continue to be monitored. For more information, see the ACIP
recommendations at www.cdc.gov/mmwr/pdf/wk/mm6441.pdf,
pages 1171–5.
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Q: Can the MenB series be completed with a different MenB brand from the one the series was begun with?
A: No. You may not switch MenB vaccines in order to complete a series. The series must be started and completed with the same MenB brand.
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Q: Can meningococcal conjugate (MenACWY) and MenB vaccines be given at the same visit?
A: Yes. Meningococcal conjugate and MenB vaccines can be given at the same visit or at any time before or after the other.
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Q: Which groups of patients should receive a booster dose of MenB vaccine after completion of the series?
A: ACIP does not currently recommend booster doses of MenB vaccine for any group.
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Influenza Vaccine
Q: Please provide details about the use of FluLaval influenza vaccine (GlaxoSmithKline) in children younger than 3 years.
A: On November 18, 2016, the Food and Drug Administration
approved an extension of the age range of quadrivalent
FluLaval (inactivated influenza vaccine, GSK) to include
children 6 through 35 months of age. FluLaval was previously
approved for people 3 years of age and older. The approval of
the extended age range for FluLaval was based on a study
showing an equivalent (“non-inferior”) response compared to
children who received Fluzone (Sanofi Pasteur) pediatric
formulation. The vaccine will be supplied for this indication
in manufacturer-filled syringes and multi-dose vials. The
dosage approved for children 6 through 35 months of age is 0.5
mL—the same dosage as for people 3 years of age and older.
ACIP has not yet issued a recommendation regarding the use of FluLaval in children 6 through 35 months of age. However, clinicians are free to use this and other vaccines in a manner consistent with their labeling.
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Q: Can a child 6 through 35 months of age who needs 2 doses of influenza vaccine this season receive one each of Fluzone Pediatric and FluLaval vaccine?
A: Yes. Both Fluzone Pediatric (0.25 mL dose) and FluLaval (0.5 mL dose) are approved by the Food and Drug Administration for use in children 6 through 35 months of age.
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Q: A 2-year-old was inadvertently given a 0.25 mL dose of FluLaval rather than the recommended 0.5 mL dose. What should we do?
A: If the error is discovered while the child is still in the
office you can administer the other “half” of the FluLaval
dose. If the error is discovered later, then the child should
be recalled to the office and given a full age-appropriate
repeat dose, either a 0.5 ml dose of FluLaval or a 0.25 mL
dose of Fluzone.
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Q: Can a clinic vaccinate children younger than age 3 years with influenza vaccine taken from a multidose vial of Fluzone or FluLaval? The multi-dose vials contain thimerosal as a preservative.
A: Yes. Multidose vials of Fluzone and FluLaval contain a small amount of thimerosal to prevent bacterial and fungal growth in the vial. Thimerosal-containing vaccines are safe to use in children. No scientific evidence indicates that thimerosal in vaccines causes adverse events unless the patient has a severe allergy to thimerosal. However, a few states have enacted legislation that restricts the use of thimerosal-containing vaccines in children. To find out if your state has such restrictions, check with your state immunization program (see www.immunize.org/coordinators for phone numbers).
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How to submit a question to Ask the Experts
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 promise that we will print your specific question in our 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.
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