Issue 1301:
April 25, 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).
Meningococcal ACWY Vaccines
- Q: The 2013 ACIP
meningococcal ACWY recommendations list household crowding and both active and passive smoking as risk factors for meningococcal disease. Should I recommend
MenACWY vaccine for a nonsmoker living in a crowded household of smokers?
- Q: We run immunization
clinics at the local jail, which has a living arrangement comparable to a college residential hall. In this setting, would you recommend vaccinating incarcerated individuals
who are younger than age 22, as is recommended for people living in a college dormitory?
- Q: If someone received
meningococcal polysaccharide (MPSV4, Menomune; Sanofi) or MenACWY at age 9 years, will two additional doses of Men-ACWY be needed?
- Q: If someone received
MPSV4 or MenACWY vaccine at age 10 years and a dose of MenACWY before the 16th birthday, will they still need a booster dose at age 16?
- Q: Sanofi is discontinuing
the production of Menomune (MPSV4) this year. I administer a lot of travel vaccine doses. Should I now give MenACWY (Menactra or Menveo) off-label to travelers age
56 years and older?
- Q: In its 2016
recommendations for use of meningococcal conjugate vaccines in HIV-infected persons, ACIP states not to use MenACWY-D (Menactra, Sanofi) in children younger
than age 2 years. However, in Table 3 of these recommendations (page 1192), MenACWY-D is listed as an option for children 9 through 23 months of age. This seems to
be a discrepancy. Please clarify.
Meningococcal B Vaccines
MMR Vaccine
Hepatitis B Vaccines
Meningococcal ACWY Vaccines
Q: The 2013 ACIP meningococcal ACWY
recommendations* list household crowding and both active and passive smoking as risk factors for meningococcal disease. Should I recommend MenACWY vaccine for
a nonsmoker living in a crowded household of smokers?
A: Although second-hand smoke and other environmental conditions have been identified as risk factors for meningococcal disease, ACIP does not
include them as indications for MenACWY vaccination. Providers are always free to use their clinical judgment in situations not addressed by ACIP.
* www.cdc.gov/mmwr/pdf/rr/rr6202.pdf
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Q: We run immunization clinics at the local jail,
which has a living arrangement comparable to a college residential hall. In this setting, would you recommend vaccinating incarcerated individuals who are younger than
age 22, as is recommended for people living in a college dormitory?
A: ACIP does not identify incarceration as an indication for meningococcal vaccination. Providers are always free to use their clinical judgment in
situations not addressed by ACIP.
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Q: If someone received meningococcal
polysaccharide (MPSV4, Menomune; Sanofi) or MenACWY at age 9 years, will two additional doses of Men-ACWY be needed?
A: Yes. Doses of quadrivalent meningococcal vaccine (either MPSV4 or MenACWY) given before 10 years of age should not be counted as part of the
series. If a child received a dose of either MPSV4 or MenACWY before age 10 years, they should receive a dose of MenACWY at 11 or 12 years and a booster dose at
age 16.
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Q: If someone received MPSV4 or MenACWY
vaccine at age 10 years and a dose of MenACWY before the 16th birthday, will they still need a booster dose at age 16?
A: Yes, they should receive a booster dose. A booster dose of MenACWY is recommended at 16 through 18 years even if 2 (or more) doses of
meningococcal vaccine were received before age 16 years. People age 19 through 21 years who are entering college or are first-year students living in a residence hall,
and who have not received a dose of MenACWY on or after age 16 years, should also be vaccinated.
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Q: Sanofi is discontinuing the production of
Menomune (MPSV4) this year. I administer a lot of travel vaccine doses. Should I now give MenACWY (Menactra or Menveo) off-label to travelers age 56 years and
older?
A: In its 2013 meningococcal recommendations, ACIP recommended off-label use of MenACWY vaccine (not MPSV4) for people age 56 years or
older who were vaccinated previously with MenACWY and are recommended for revaccination or for whom multiple doses are anticipated (for example, people with
asplenia and microbiologists). The situation of unavailability of MPSV4 is not addressed, but the use of MenACWY vaccine is appropriate when MPSV4 is not
available.
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Q: In its 2016 recommendations for use of
meningococcal conjugate vaccines in HIV-infected persons, ACIP states not to use MenACWY-D (Menactra, Sanofi) in children younger than age 2 years. However, in
Table 3 of these recommendations (page 1192), MenACWY-D is listed as an option for children 9 through 23 months of age. This seems to be a discrepancy. Please
clarify.
A: CDC meningococcal experts prefer MenACWY-D not be used before two years of age in children at increased risk of meningococcal disease (such
as those with HIV infection or asplenia) because of possible interference with the response to pneumococcal conjugate (PCV13) vaccine. However, they recognize that
vaccine supply or other constraints may require its use before age two years and provided permissive language with important guidance in the Table 3 footnote. These
recommendations are published in MMWR, November 4, 2016, at www.cdc.gov/mmwr/volumes/65/wr/pdfs/mm6543a3.pdf, pages 1189–94.
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Meningococcal B Vaccines
Q: I have a 9-year-old patient traveling to Kenya
for one week. In addition to MenACWY vaccine, should she be offered meningococcal serogroup B (MenB) vaccine?
A: ACIP does not recommend routine MenB vaccination for travel to countries in sub-Saharan Africa or to other countries for which MenACWY
vaccine is recommended. Meningococcal disease in these areas is generally not caused by serogroup B. pages 1189–94.
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MMR Vaccine
Q: Due to outbreaks of mumps in our state, I have
been asked about college students getting a third dose of the MMR vaccine, even if there was not a mumps outbreak on their campus. My understanding is that a third
dose of MMR is only recommended for students attending colleges that are experiencing an outbreak. Although I have advised families that this is the case, would there be
any issues with proceeding with the third dose preemptively?
A: You are correct that administration of a third dose of MMR vaccine has been used as a possible mumps outbreak control strategy. To date, the
evidence that this strategy is effective in mumps outbreak control is insufficient to recommend it as a routine measure for college students. However, some states
experiencing mumps outbreaks may recommend a third dose of MMR for students in certain situations. There is no problem giving a third dose of MMR to a person who
may already be immune to one or more of the vaccine components. Insurance is unlikely to pay for a third dose since this is not routinely recommended by CDC.
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Hepatitis B Vaccines
Q: We give hepatitis B vaccine to
newborns in the hospital followed by DTaP-IPV-HepB (Pediarix, GSK) at 2, 4, and 6 months of age, so our patients get 4 doses of hepatitis B vaccine. For some children,
the Pediarix dose #3 is delayed and given closer to 5 months of age, so the interval is less than 8 weeks between dose #3 and #4 of the hepatitis B component of
Pediarix. We are receiving conflicting information about whether their HepB dose #4 is a valid final dose because of the shortened interval between dose #3 and #4. Our
electronic health record says dose #4 is valid (regardless of the short interval from dose #3) but the health department says it is not. Which is correct?
A: According to subject matter experts at CDC, your electronic health record is correct. The CDC website states that hepatitis B vaccine dose
#4, if given, must be at 24 weeks of age or later, and at least 16 weeks from dose #1. There is no minimum interval requirement between dose #4 and the previous dose.
This information is not published in any current ACIP statement but it can be found under “Hepatitis B” at www.cdc.gov/vaccines/programs/cocasa/reports/algorithm-ref.html.
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Q: Some nephrologists give a high dose
(40 mcg) of hepatitis B vaccine (2 adult doses of Engerix-B, GSK, or Recombivax HB Dialysis Formulation, Merck) to all patients with renal failure with glomerular filtration
rates (GFRs) of less than 30 ml/min even if the patient is not on dialysis. Is this practice advisable?
A: A higher dose hepatitis B vaccine is recommended for hemodialysis and other immunocompromised persons, so to the extent these patients
are immunocompromised, this is within ACIP recommendations (note that “immunocompromised” is not defined in the recommendations). Regardless, this
practice is appropriate for several reasons, including that these patients may be starting hemodialysis soon, and because use of the higher dose is not harmful. This is
somewhat of a gray area but the clinician can use his/her clinical judgment.
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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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