Issue 1300: April 20, 2017
Ask the Experts: CDC Experts Answer Your Questions
The questions and answers in this edition of IAC Express first appeared in the April 2017 issue of Needle Tips.
IAC extends thanks to our experts: Andrew T. Kroger, MD, MPH; Candice L. Robinson, MD, MPH; Raymond A. Strikas, MD, MPH, FACP, FIDSA; Donna L. Weaver, RN, MN; and Jessie Wing, MD, MPH, all from the National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention (CDC).
Influenza Vaccines
Pneumococcal Vaccines
Varicella and Zoster Vaccines
Td Vaccines
Influenza Vaccines
Q: I have a patient who is now 12 weeks pregnant. In September 2016, she received quadrivalent inactivated influenza vaccination (before she was pregnant). Should we give her another dose of 2016–17 influenza vaccine since she was not pregnant at the time of her first dose?
A: The Advisory Committee on Immunization Practices (ACIP) does not recommend more than one dose of influenza vaccine per season, except for certain children being vaccinated for the first time. The 2017–18 influenza vaccine may be available near the end of her pregnancy so she can be given a dose of next year’s formulation at that time.
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Q: A nursing home resident was admitted to the hospital with influenza and treated with oseltamivir. The person is now returned to the nursing home. The residents in the facility are being treated prophylactically with oseltamivir. Should the person who was hospitalized also receive oseltamivir prophylactically?
A: This is a complicated issue and the exact situation you describe is not addressed in the most recent ACIP recommendations on the use of influenza antiviral drugs. Whether to continue the antiviral drug depends on why the rest of the people in the facility are being treated. Oseltamivir for treatment of influenza is usually a 5-day course. If there is continued risk of exposure in the facility, it seems reasonable to continue the prophylactic treatment accordingly. The ACIP influenza antiviral guidelines are available at www.cdc.gov/mmwr/pdf/rr/rr6001.pdf.
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Pneumococcal Vaccines
Q: A child with selective IgA deficiency was sent by her physician to the health department to receive a dose of pneumococcal polysaccharide vaccine (PPSV23, Pneumovax; Merck). Does her illness fall under the criteria for administering PPSV23?
A: Selective IgA deficiency is a B-cell immunodeficiency, so PPSV23 is indicated if the child is age 2 years or older.
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Q: We have a 19-year-old patient with a history of vasculitis, nephritis, and asthma. She is on azathioprine (Imuran) and is immunosuppressed. Her rheumatologist recommends she receive pneumococcal conjugate vaccine (PCV13, Prevnar 13, Pfizer) and meningococcal B vaccine. How often should these vaccines be given? Will she require a series of PCV13 doses or just a booster?
A: For people with iatrogenic immunosuppression, ACIP recommends 1 dose of PCV13 followed by a dose of PPSV23 at least 8 weeks later (see www.cdc.gov/mmwr/pdf/wk/mm6434.pdf, pages 944–7). Meningococcal serogroup B vaccine (MenB) is not specifically recommended for immunosuppressed people. However, people age 16 through 23 years who are not at increased risk may receive routine MenB vaccination (a category B recommendation) of either a 2-dose series of Bexsero (GSK) 4 weeks apart, or a 2-dose series of Trumenba (Pfizer) 6 months apart.
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Varicella and Zoster Vaccines
Q: Recently we had a one-year-old with congenital heart disease and who is on chronic aspirin therapy in for a well-child check and routine vaccination. Are there any recommendations regarding varicella vaccine being given to children who are on chronic aspirin therapy?
A: The ACIP’s varicella vaccine recommendations state that no adverse events associated with the use of salicylates after varicella vaccination have been reported, however, the vaccine manufacturer recommends that vaccine recipients avoid using salicylates for 6 weeks after receiving varicella vaccines because of the association between aspirin use and Reye syndrome after varicella disease (chickenpox). Vaccination with subsequent close monitoring should be considered for children who have rheumatoid arthritis or other conditions requiring therapeutic aspirin. The risk for serious complications associated with aspirin is likely to be greater in children in whom natural varicella develops than it is in children who receive the vaccine containing attenuated varicella zoster virus. In other words, the benefit of varicella vaccine likely outweighs the theoretical risk of Reye syndrome. See the ACIP varicella recommendations at www.cdc.gov/mmwr/PDF/rr/rr5604.pdf, page 29.
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Q: A healthcare worker with no history of chickenpox, and unknown serologic immunity, was exposed to a patient with zoster. She received varicella vaccine two days later. She developed a pruritic maculopapular rash 11 days after vaccination. Is the rash from the vaccine or from her zoster exposure?
A: The only way to determine whether the rash is caused by wild-type varicella or vaccine virus is to try to isolate virus from the rash and send it to a laboratory that is capable of differentiating wild and vaccine-type virus. This is generally not practical. Given the history, the conservative approach is to assume she has an active case of chickenpox and act according to your infection control guidelines.
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Q: I was told by a coworker that varicella vaccine can be stored at refrigerator temperature for up to three days and still be used. Is this true?
A: According to the manufacturer, unreconstituted varicella vaccine may be stored at refrigerator temperature (2°C to 8°C, 36°F to 46°F) for up to 72 continuous hours prior to reconstitution. Vaccine stored at 2°C to 8°C that is not used within 72 hours of removal from +5°F (−15°C) storage should be discarded. See www.merck.com/product/usa/pi_circulars/v/varivax/varivax_pi.pdf.
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Td Vaccines
Q: The tetanus and diphtheria toxoid Tenivac (Td, Sanofi) is not currently available from the manufacturer and may not be available until later in 2017. What are we to do when someone is in need of a Td booster dose?
A: Although there is a shortage of Tenivac, there is another Td product available. It is produced by MassBiologics and distributed by Grifols USA LLC. More information, including prescribing information for Grifols Td vaccine, can be found at www.GrifolsTdvaccine.com.
If Td is unavailable in the work setting, Tdap should be used in its place whenever Td is indicated (e.g., for 10-year booster dose or wound management). If a person has previously received a dose of Tdap, it is acceptable to give another Tdap dose in place of Td when Td is not available.
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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.
Please forward these Ask the Experts Q&As to your colleagues and ask them to subscribe to IAC Express.
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