Issue 1235: March 22, 2016
Ask the Experts: CDC Experts Answer Your Questions
The questions and answers in this edition of IAC Express first appeared in the March 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).
Pneumococcal Vaccine
Zoster Vaccine
Pneumococcal Vaccine
Q: If a provider does not yet stock pneumococcal conjugate vaccine (PCV13, Prevnar 13, Pfizer) for adults age 65 years and older but stocks pneumococcal polysaccharide vaccine (PPSV23, Pneumovax 23, Merck), should that provider refer patients to another provider to ensure they receive the PCV13 dose first? Or should the provider not miss an opportunity to give the PPSV23 and refer patients elsewhere for PCV13 in a year?
A: The Advisory Committee on Immunization Practices (ACIP) recommends that pneumococcal vaccine-naïve people age 65 years and older should receive PCV13 first, followed by PPSV23 one year later. If the provider is unwilling to stock PCV13, then patients should be referred elsewhere to get PCV13 first. The solution, of course, is to stock PCV13 and PPSV23, both of which are covered by Medicare Part B.
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Q: We have a healthy 66-year-old patient who received a dose of PPSV23 in January then received a dose of PCV13 five months later at a different facility. Should the PCV13 dose be repeated since it was given earlier than the 1-year interval recommended by ACIP?
A: ACIP recommends that healthy people age 65 years and older receive PCV13 first, then PPSV23 one year later. When PPSV23 has been given first, ACIP recommends an interval of one year before giving PCV13. What to do when doses of PPSV23 and PCV13 are given without the recommended minimum interval is not addressed in the ACIP recommendations. The CDC subject matter experts have advised that in such a case, the dose given second does not need to be repeated. This is an exception to the usual procedure for a minimum interval violation as described in ACIP’s General Recommendations on Immunization (see www.cdc.gov/mmwr/pdf/rr/rr6002.pdf, page 5). There is no evidence to support that there are benefits to repeating the dose of PCV13. Information about the recommended intervals between pneumococcal vaccines can be found at www.cdc.gov/mmwr/pdf/wk/mm6434.pdf, pages 944–7.
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Q: Diabetes is an indication for giving PPSV23 to patients younger than age 65 years. Does this include both insulin- and non-insulin-dependent diabetes?
A: Any diagnosis of diabetes, whether type 1 or type 2, is an indication for PPSV23. However, gestational diabetes does not qualify as an indication for PPSV23.
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Q: For adults without high-risk conditions, a 1-year interval is recommended between PCV13 and PPSV23 vaccines. What is the definition of a year? Does it need to be exactly one year? We have provided PCV13 to some individuals during flu season this year and told them to get the PPSV23 next year when they get their flu shot. What if they received their flu shot in November this year, but return for their flu shot in October next year?
A: What you describe is an excellent strategy for administration of PCV13 and PPSV23 to people age 65 years and older. ACIP does not define “one year” but this is assumed to be one calendar year. Receiving PPSV23 a few days or weeks earlier than one calendar year after PCV13 is not a medical problem. However, it could be a problem for reimbursement since Medicare will only pay for both vaccines if they are given at least 11 months apart. Private insurance may have similar rules. Here is the wording from the Centers for Medicare and Medicaid (CMS):
“An initial pneumococcal vaccine may be administered to all Medicare beneficiaries who have never received a pneumococcal vaccine under Medicare Part B. A different, second pneumococcal vaccine may be administered 1 year after the first vaccine was administered (i.e., 11 full months have passed following the month in which the last pneumococcal vaccine was administered).”
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Q: Why is there no recommendation for patients older than 65 years to get a booster dose of PPSV23 if they first received it at age 65 years or older? It seems to me that their protection against pneumococcal disease would benefit from a booster dose of PPSV23 five or ten years after the first dose.
A: People age 65 and older should be given a second dose of PPSV23 if they received the first dose 5 or more years previously and were younger than 65 years at the time of the first vaccination. Protection from a single dose of PPSV23 at age 65 years or older is believed to persist for 5–10 years. The benefit and safety of a second dose given after age 65 years is uncertain. Until such data are available, ACIP recommends only a single dose at age 65 years or older.
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Q: I have a patient who takes adalimumab (Humira) for rheumatoid arthritis. Does a person who takes adalimumab meet the definition of immunosuppression for the purposes of PCV13 vaccination?
A: Adalimumab is a potent anti-inflammatory drug that blocks the activity of tumor necrosis factor (TNF). Adalimumab is considered immunosuppressive because serious infections have been reported in people taking the drug, including tuberculosis and infections caused by viruses, fungi, or bacteria. Consequently, a person taking adalimumab or other drugs that affect TNF activity (such as infliximab [Remicade], certolizumab pegol [Cimzia], golimumab [Simponi], or etanercept [Enbrel]) should be considered to have immunosuppression and receive PCV13.
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Q: A healthy child received only one dose of PCV at age 10 months. She is now 6 years old. Our state requires one dose of PCV13 after the first birthday for school attendance. Her physician says because she is older than 59 months, she does not need another dose of PCV13. What should we do in this situation?
A: ACIP does not recommend routine PCV13 vaccination of healthy children 60 months of age or older. If there is a school requirement, the simplest solution is to give the child one dose of PCV13. However, health insurance may not pay for this dose. For more information on the ACIP recommendations for pneumococcal vaccination of children, go to www.cdc.gov/mmwr/pdf/rr/rr5911.pdf.
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Zoster Vaccine
Q: I know that ACIP only recommends zoster vaccine for adults age 60 years and older, although it is licensed for use in those 50 years and older. If I choose to vaccinate patients age 50–59 years, are there any criteria as to which patients in this age group might benefit most from zoster vaccination?
A: For vaccination providers who choose to use zoster vaccine among certain patients age 50 through 59 years despite the absence of an ACIP recommendation, factors that might be considered include particularly poor anticipated tolerance of herpes zoster or postherpetic neuralgia symptoms (e.g., attributable to preexisting chronic pain, severe depression, or other comorbid conditions; or inability to tolerate treatment medications because of hypersensitivity or interactions with other chronic medications). More information on this issue is available at www.cdc.gov/mmwr/pdf/wk/mm6044.pdf, page 1528.
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Q: We have an 18-year-old male patient with a history of chickenpox disease. He now has shingles. We are unsure what to advise for future vaccination. Should we administer zoster vaccine?
A: ACIP does not recommend zoster vaccination for people younger than age 60 years regardless of their history of shingles. Zoster vaccine is licensed by FDA for people age 50 years and older so a clinician may choose to vaccinate a person 50–59 years of age. Insurance may not pay for a dose of zoster vaccine given to a person younger than age 60 years.
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Q: My patient is a 66-year-old male with a condition that requires treatment with intravenous immune globulin (IVIG) once a month. Can he receive zoster vaccine?
A: Yes. The concern about interference by circulating antibody (from the IVIG) with varicella vaccine does not apply to zoster vaccine. The amount of antigen in zoster vaccine is high enough to offset any effect of circulating antibody. Also, studies of zoster vaccine were performed on patients who had circulating antibody (because they had varicella earlier in life) or who had received antibody-containing blood products and there was no appreciable effect on efficacy. Some patients who receive IVIG are immunosuppressed. Since immunosuppression is a contraindication to zoster vaccine, it is important to screen to ensure a patient is not immunosuppressed when administering zoster vaccine.
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Q: Before administering zoster vaccine is it necessary to ask if the person has ever had chickenpox or shingles?
A: No. All people age 60 years or older, whether they have a history of chickenpox or shingles or not, should be given zoster vaccine unless they have a medical contraindication to vaccination.
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Q: For patients age 60 or older who don’t remember having chickenpox in the past, should we test them for varicella immunity before giving zoster vaccine?
A: No. Simply vaccinate them with zoster vaccine according to the ACIP recommendations.
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Q: We weren’t familiar with the recommendation (not to test) and tested a 60-year-old for varicella antibody because she said she never had chickenpox. Her result was negative. Should this patient receive zoster vaccine or varicella vaccine?
A: In this situation, since you’ve tested the patient and the results were negative, the patient should receive varicella vaccine. A person age 60 years or older who has no medical contraindications is eligible for zoster vaccine, regardless of their memory of having had chickenpox. However, if an adult age 60 years or older is tested for varicella immunity for whatever reason, and the test is negative, he/she should be given 2 doses of varicella vaccine at least 4 weeks apart, not zoster vaccine. It is important to note that at the current time, zoster vaccine is not recommended for individuals whose varicella immunity is based on vaccination. See www.cdc.gov/vaccines/vpd-vac/shingles/hcp-vaccination.htm for more information.
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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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