|
1. |
Read "Ask the Experts" Q&As about vaccine errors
Many readers of Needle Tips, Vaccinate Adults,
and Vaccinate Women
consistently rank "Ask the Experts" as their favorite feature in
these publications. As a thank-you to our loyal IAC Express
readers, we have decided to periodically publish an Extra Edition
with new "Ask the Experts" Q&As answered by CDC experts.
IAC thanks William L. Atkinson, MD, MPH, Andrew T. Kroger, MD, MPH,
medical epidemiologists, and Donna L. Weaver, RN, MN, nurse
educator, at the National Center for Immunization and Respiratory
Diseases, CDC, for agreeing to answer the following questions.
All the Q&As in this edition of IAC Express deal with vaccine
errors. Unfortunately, vaccine errors occur all too frequently. The
result of making such errors can be serious, and can range from
possibly causing harm to the incorrectly vaccinated person from a
side effect or from increased vulnerability to a disease, to
causing inconvenience to the parent/patient, unreimbursed cost to
the provider, and possible negative publicity. Avoiding such errors
benefits everyone.
We encourage you to reprint any of these Q&As in your own
newsletters. Please credit the Immunization Action Coalition and
the Centers for Disease Control and Prevention. Information about
IAC's preferred citation style can be found at
http://www.immunize.org/citeiac
You can access more "Ask the Experts" Q&As in our online archive at
http://www.immunize.org/askexperts
Editor's note: Information about submitting a question to "Ask the
Experts" is provided at the end of this Extra Edition.
VACCINE DOSES GIVEN TOO CLOSE TOGETHER OR AT TOO YOUNG AN AGE
Q: We gave a dose of vaccine too soon after the previous dose. When
can we give another (valid) dose?
A: ACIP allows a grace period of 4 days (i.e., vaccine doses
administered up to 4 days before the recommended minimum interval
or age can be counted as valid). However, if a dose was
administered 5 or more days earlier than the recommended minimum
interval between doses, it is not valid and must be repeated. The
repeat dose should be spaced after the invalid dose by the
recommended minimum interval.
Likewise, doses administered 5 or more days before the minimum age
should be repeated on or after the patient reaches the minimum age
and 4 or more weeks after the invalid dose.
Avoid such errors by knowing the minimum intervals and ages for
routinely given vaccines. You can look up such information
here.
Other useful resources are
Summary of Recommendations for Adult Immunization
http://www.immunize.org/catg.d/p2011.pdf
Summary of Recommendations for Childhood and Adolescent
Immunization
http://www.immunize.org/catg.d/p2010.pdf
VACCINE GIVEN BY THE WRONG ROUTE
Q: One of our nurses accidentally gave Zostavax IM instead of SC.
What do we need to do?
A: You can count the dose as valid. ACIP recommends that vaccines
given by the wrong route be counted as valid with one exception:
hepatitis B administered by any route other than intramuscular
should not be counted as valid and should be repeated. Vaccines
should always be given by the route recommended by the
manufacturer, but errors do occur. Your practice should put
procedures in place to ensure that you give vaccines by the
recommended route.
Avoid such errors by using the following resources:
How to Administer Intramuscular (IM) and Subcutaneous (SC)
Injections
http://www.immunize.org/catg.d/p2020.pdf
How to Administer IM and SC Injections to Adults
http://www.immunize.org/catg.d/p2020a.pdf
Administering Vaccines to Adults: Dose, Route, Site, Needle Size,
and Preparation
http://www.immunize.org/catg.d/p3084.pdf
Administering Vaccines: Dose, Route, Site, and Needle Size
(includes all vaccines)
http://www.immunize.org/catg.d/p3085.pdf
DAMAGED OR EXPIRED VACCINE
Q: For an extended period, the temperature in the vaccine-storage
refrigerator in our practice was too cold. We assume all the
vaccines given during that period are considered invalid. How
should we schedule the revaccinations?
A: If administered vaccine is found to be stored at an
inappropriate temperature, the provider should contact the state
health department to determine if the vaccine dose is invalid. If
the vaccine dose is determined to be invalid, another dose should
be given. This applies to inactivated or live vaccines. If the
damaged vaccine was a live virus vaccine (e.g., MMR, VAR), you
should wait at least 4 weeks after the previous (damaged) dose was
given before repeating it. If the damaged vaccine was an
inactivated vaccine, you can give the repeat dose on the same day
you gave the damaged dose or at any other time. If you prefer, you
can perform serologic testing to check for immunity for certain
vaccinations (e.g., measles, rubella, hepatitis A, and tetanus).
Q: What should we do if a dose of expired vaccine is given to a
patient?
A: The dose should be repeated. If the expired dose is a live virus
vaccine, you should wait at least 4 weeks after the previous
(expired) dose was given before repeating it. If the expired dose
is not a live vaccine, the dose should be repeated as soon as
possible. If you prefer, you can perform serologic testing to check
for immunity for certain vaccinations (e.g., measles, rubella,
hepatitis A, and tetanus).
Avoid vaccine storage and handling errors by using the following
resources:
CDC's Vaccine Storage and Handling Toolkit
http://www2a.cdc.gov/vaccines/ed/shtoolkit
CDC's Vaccine Management booklet
http://www.cdc.gov/vaccines/pubs/downloads/bk-vac-mgt.pdf
Checklist for Safe Vaccine Handling and Storage
http://www.immunize.org/catg.d/p3035.pdf
Don't Be Guilty of These Errors in Vaccine Storage and Handling
http://www.immunize.org/catg.d/p3036.pdf
Vaccine Handling Tips
http://www.immunize.org/catg.d/p3048.pdf
Maintaining the Cold Chain during Transport
http://www.immunize.org/catg.d/p3049.pdf
Emergency Response Worksheet
http://www.immunize.org/catg.d/p3051.pdf
Temperature Log for Vaccines (Fahrenheit)
http://www.immunize.org/catg.d/p3039.pdf
Temperature Log for Vaccines (Celsius)
http://www.immunize.org/news.d/celsius.pdf
"Do Not Unplug" sign (color)
http://www.immunize.org/news.d/2090plugy.pdf
"Do Not Unplug" sign (black and white)
http://www.immunize.org/news.d/2090plug.pdf
WRONG DOSAGE GIVEN
Q: One of our staff gave a dose of pediatric hepatitis A vaccine to
an adult patient by mistake. How do we remedy this error?
A: In general, if you give less than a full age-appropriate dose of
any vaccine, the dose is invalid. You should revaccinate the person
with the appropriate dose as soon as feasible.
There are, however, two exceptions to the general rule: (1) If a
patient sneezes after receiving nasal-spray live attenuated
influenza vaccine, count the dose as valid. (2) If an infant
regurgitates, spits, or vomits during or after receiving oral
rotavirus vaccine, count the dose as valid.
If you give more than an age-appropriate dose, count the dose as
valid and notify the patient/parent about the error. Using larger
than recommended dosages can be hazardous because of excessive
local or systemic concentrations of antigens or other vaccine
constituents.
Avoid such errors by checking the vaccine vial label 3 TIMES! The
following print pieces are also helpful:
Administering Vaccines: Dose, Route, Site, and Needle Size
http://www.immunize.org/catg.d/p3085.pdf
Administering Vaccines to Adults: Dose, Route, Site, Needle Size,
and Preparation
http://www.immunize.org/catg.d/p3084.pdf
Hepatitis A & B Vaccines: Be sure your patient gets the correct
dose!
http://www.immunize.org/catg.d/p2081.pdf
WRONG VACCINE GIVEN
Q: We inadvertently gave a dose of Tdap to a 5-year-old instead of
pediatric DTaP. What is our next best step to take under this
circumstance?
A: First, inform the child's parent that you administered the wrong
vaccine. Here are some guidelines for what to do if you
inadvertently give Tdap to a child younger than age 10.
(1) Tdap given to child younger than age 7 years as either dose 1,
2, or 3 is NOT valid. Repeat with DTaP as soon as feasible.
(2) Tdap given to child younger than age 7 years as either dose 4
or 5 can be counted as valid for DTaP dose 4 or 5.
(3) Tdap given to a child age 7 through 9 years can be counted as
valid for the one-time Tdap dose.
Q: We mistakenly gave a teenage girl pediatric DTaP instead of
Tdap. Do we need to revaccinate her with Tdap?
A: No. DTaP given to patients age 7 or older can be counted as
valid for the one-time Tdap dose. Inform the girl and her parents
that though you administered the wrong vaccine, the DTaP vaccine
will provide the same protection against pertussis as Tdap.
Q: We accidentally gave a 47-year-old healthcare worker Zostavax
instead of Varivax for work. Does this count?
A: Yes, but this is a serious vaccine administration error because
Zostavax vaccine contains about 14 times as much varicella vaccine
virus as Varivax. You should document the event and establish
procedures to prevent this from happening again. The dose of zoster
vaccine can be counted as the first of two doses of varicella
vaccine for an adult who is not immune to varicella. The second
dose of varicella vaccine should be given 4 to 8 weeks after the
first dose.
Q: We mistakenly gave a 60-year-old patient varicella vaccine
instead of zoster vaccine. Should we still administer zoster
vaccine to the patient? If so, how long an interval should occur
between the 2 doses?
A: ACIP states the following: "If a provider mistakenly administers
varicella vaccine to a person for whom zoster vaccine is indicated,
no specific safety concerns exist, but the dose should not be
considered valid and the patient should be administered a dose of
zoster vaccine during that same visit. If the error is not
immediately detected, a dose of zoster vaccine should be
administered as soon as possible but not within 28 days of the
varicella vaccine dose to prevent potential interference of 2 doses
of live attenuated virus."
Avoid such errors by checking the vial label 3 TIMES to make sure
you're administering the product you intended!
Q: We mistakenly gave a 2-month-old PPSV instead of PCV. What
should we do?
A: PPSV is not effective or recommended for use in children younger
than age 24 months. PPSV given at this age should not be considered
to be part of the pneumococcal vaccination series. You should
administer PCV as soon as the error is discovered.
Anytime you give the wrong vaccine, you need to notify the
parent/patient.
MISSED OPPORTUNITIES
Q: There is more than one provider in our practice who will not
administer both MMR and varicella vaccines at the same visit. Their
belief is that the vaccines are more effective if given separately.
A: Not giving two or more recommended vaccines on the same visit is
a missed opportunity. A missed opportunity to vaccinate allows a
person to remain at risk of serious disease. Avoid such missed
opportunities by giving all indicated vaccines during the same
visit. There is no evidence that simultaneous administration of
vaccines either reduces vaccine effectiveness or increases the risk
of adverse events. 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.
If you miss giving recommended vaccines at the same visit, follow
these guidelines:
(1) Administer any missed inactivated vaccine (e.g., DTaP,
Tdap, HPV) at any time before or after a different inactivated or live vaccine (e.g., MMR, VAR, LAIV, RV).
(2) If you miss giving any 2 or more recommended live vaccines atthe same visit, you must wait at least 4 weeks before
administering any other routinely recommended live virus vaccine.
Q: I need both Tdap and MMR vaccines but my doctor won't give them
to me unless I stop breastfeeding. Is this really necessary?
A: No. Breastfeeding is not a contraindication to the
administration of any routinely recommended vaccine, either to the
mother or to the child.
Providers also often miss opportunities to vaccinate by assuming
contraindications when none exist. Only follow TRUE
contraindications and precautions to vaccinations.
Avoid missed opportunities by using the following resources:
Giving All the Doses (Immunization Site Map)
http://www.cdc.gov/vaccines/pubs/pinkbook/downloads/appendices/D/site-map.pdf
Guide to Vaccine Contraindications and Precautions
http://www.cdc.gov/vaccines/recs/vac-admin/downloads/contraindications-guide-508.pdf
Guide to Contraindications and Precautions to Commonly Used
Vaccines
http://www.immunize.org/catg.d/p3072a.pdf
Guide to Contraindications and Precautions to Commonly Used
Vaccines in Adults
http://www.immunize.org/catg.d/p3072.pdf
Suggestions to Improve Your Immunization Services
http://www.immunize.org/catg.d/p2045.pdf
INCORRECT ASSUMPTIONS
Q: I had my spleen removed as a teenager. I have been getting PPSV
vaccine every 5 years because my doctor recommends it, but this
doesn't agree with what the IAC website says. Which is right?
A: No more than 2 lifetime doses of PPSV vaccine are recommended
for anyone. Unfortunately, many healthcare providers seem to
believe that more is better when it comes to PPSV. For the facts,
read Pneumococcal Polysaccharide Vaccine (PPSV): CDC Answers Your
Questions at http://www.immunize.org/catg.d/p2015.pdf
Q: I work with university students and many of them miss coming in
on time for their next dose of HPV vaccine. What's the longest
interval allowed before we need to start the series over?
A: No vaccine series needs to be restarted because of an interval
that is longer than recommended (with the exception of oral typhoid
vaccine in certain circumstances). You should continue the series
where it was interrupted. If the HPV series is begun when the
university student is age 26 or younger, it can be completed after
she turns 27.
It's important to rely on the actual recommendations, not urban
legends or guesswork. All ACIP recommendations can be accessed at
www.immunize.org/acip ACIP's "General Recommendations on
Immunization" are especially useful:
http://www.cdc.gov/mmwr/PDF/rr/rr5515.pdf
Other useful resources:
CDC's "Pink Book"
http://www.cdc.gov/vaccines/pubs/pinkbook/pink-chapters.htm
IAC's "Ask the Experts" archive
http://www.immunize.org/askexperts
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 guarantee that we will print your specific question in
the "Ask the Experts" feature. However, you will get an answer. To
see if your question has already been answered, you can first check
the "Ask the Experts" online archive at
http://www.immunize.org/askexperts
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
admin@immunize.org
Please forward these "Ask the Experts" Q&As to your co-workers and
suggest they subscribe to IAC Express at
http://www.immunize.org/subscribe
Back to top |
