Hepatitis B Vaccine
Q: An adolescent received the first dose of hepatitis B vaccine at age 11 years but did not return for subsequent doses. If the patient comes back at age 16 years, is it necessary to repeat the first dose of the series?
A: It is not necessary to restart or add doses to the hepatitis B series (or any other routine vaccine series) because of a prolonged interval between doses. Just continue the series from the point where it was interrupted.
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Q: If a patient receives hepatitis B vaccine while undergoing hemodialysis, will the vaccine be effective? Will the dose need to be repeated?
A: Neither the Advisory Committee on Immunization Practices (ACIP) nor the manufacturers address the timing of vaccination and dialysis. Persons with end-stage renal disease including predialysis, hemodialysis, peritoneal dialysis, and home dialysis should be tested for hepatitis B surface antibody (anti-HBs) 1–2 months after vaccination, and annually. If the anti-HBs level is below 10mIU/mL, they should be revaccinated. See www.cdc.gov/mmwr/PDF/rr/rr5516.pdf, page 27, for more information.
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Human Papillomavirus (HPV) Vaccine
Q: I have a patient who was diagnosed with HPV types 16 and 18. The patient received a properly spaced Gardasil series in 2006 when she was 25 years old. Did the HPV vaccine she received in 2006 fail to protect her?
A: In clinical trials, HPV vaccines were shown to be highly effective (more than 95%) for prevention of HPV vaccine-type infection and disease among persons without prior infection. The most likely explanation for this situation is that the patient was sexually active prior to vaccination and was infected with HPV before she was vaccinated.
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Influenza Vaccine
Q: We have had three employees who have tested positive for influenza by nasal swab within 2 weeks of receiving Fluarix Quadrivalent (GlaxoSmithKline) vaccine. Is there a time period after receiving influenza vaccine that a nasal swab can give a false positive result?
A: Inactivated influenza vaccines, including Fluarix, are not known to cause false positive nasal swab tests. However, false positive test results are possible with rapid tests, and these are more likely to occur when influenza prevalence in the area is low. For more information regarding interpretation of rapid influenza tests see www.cdc.gov/flu/professionals/diagnosis/rapidlab.htm.
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Q: When I was 5 years old, I had Guillain-Barré syndrome (GBS) unrelated to vaccination. I am now 35 with no residual effects of the GBS. I am a nurse and my facility requires employees to receive influenza vaccine. Is it safe for me to be vaccinated?
A: Yes. A history of GBS unrelated to influenza vaccine is not a contraindication or precaution to influenza vaccination. GBS within 6 weeks following a previous dose of influenza vaccine is considered a precaution for use of influenza vaccines.
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Meningococcal ACWY and B Vaccines
Q: Several healthy adult college students from Asia (ages 24 years and older) presented to our clinic. They will be living in a residence hall. None have a record of having received meningococcal conjugate vaccine (MenACWY). Should they receive a dose of MenACWY now?
A: ACIP does not routinely recommend MenACWY for college students 22 years of age and older. It is recommended for previously unvaccinated first-year college students who are age 21 years and younger who are or will be living in a residence hall. However, some colleges and universities may require incoming freshmen and others to be vaccinated with MenACWY and some may also require that a dose have been given after 16 years of age.
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Q: A 32-year-old patient with ulcerative colitis is taking high-dose immunosuppressive medications (6-mercaptopurine). Should he receive meningococcal vaccine?
A: There is no specific indication for meningococcal vaccine in this patient. He is older than 21 years, and the risk–based recommendations are restricted to specific forms of altered immunocompetence (persistent complement component deficiency, functional or anatomic asplenia, use of eculizumab and HIV infection) and are not inclusive of other forms of altered immunocompetence.
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Q: Can the meningococcal serogroup B (MenB) vaccine and meningococcal conjugate (MenACWY) vaccine be given at the same visit?
A: MenB and MenACWY vaccines can be administered at the same visit or at any interval before or after each other. There is no need for spacing between these two vaccines.
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Q: I have a 3-month-old patient whose family will be doing mission work in sub-Saharan Africa. They are leaving as soon as the child is 6 months old. We gave her the first dose of Menveo brand MenACWY vaccine today. I know the usual Menveo schedule for an infant is 2, 4, 6, and 12 months. If we maintain usual spacing, she will only get 1 more dose before she leaves. Can we compress the schedule so she can get 2 more doses prior to travel?
A: The meningococcal ACIP recommendations don't clearly state a minimum interval for MenACWY in this situation. However, the minimum interval for a pediatric MenACWY schedule would presumably be 4 weeks like for other pediatric vaccines on a 2–4–6 schedule. You should try to give a third dose before travel begins.
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Q: If someone received MPSV4 or MenACWY at age 9 years, will two additional doses of MenACWY 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 routine 2-dose 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 years.
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Miscellaneous Vaccines
Q: What are the recommendations for use of the new oral cholera vaccine?
A: CVD 103-HgR (Vaxchora, PaxVax) cholera vaccine was approved by the Food and Drug Administration in June 2016. ACIP has not yet published recommendations for Vaxchora. However, at their June 2016 meeting, ACIP voted to recommend vaccination for adults 18 through 64 years old traveling to areas of active cholera transmission. An area of active cholera transmission is defined as a province, state, or other administrative subdivision within a country with endemic or epidemic cholera caused by toxigenic V. cholerae O1 and includes areas with cholera activity within the last 1 year that are prone to recurrence of cholera epidemics; it does not include areas where rare sporadic cases have been reported. No country or territory currently requires vaccination against cholera as a condition for entry.
In addition to vaccination, all travelers to cholera-affected areas should follow safe food and water precautions and proper sanitation and personal hygiene measures as primary prevention strategies against cholera infection. Travelers who develop severe diarrhea should promptly seek medical attention for rehydration therapy.
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MMR Vaccine
Q: I have an 8-month-old patient who is traveling internationally. The infant needs immune globulin (IG) for hepatitis A protection as well as MMR vaccine. The family is leaving in 11 days. Can I give the IG and the MMR vaccine simultaneously?
A: IG may contain antibodies to measles, mumps, and rubella that could reduce the effectiveness of MMR vaccine. The best course of action is to administer the MMR vaccine and defer the IG. Once the vaccine is given, an antibody-containing blood product like IG can be administered two weeks later. While it may be difficult to get this product administered before leaving, you are better off than if IG were administered first, as a 3-month interval is recommended between IG and MMR.
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Q: We have a patient who has selective IgA deficiency. We also have patients with selective IgM deficiency. Can MMR or varicella vaccine be administered to these patients?
A: There is no known risk associated with MMR or varicella vaccination in someone with selective IgA or IgM deficiency. It is possible that the immune response may be weaker, but the vaccines are likely effective.
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Administering Vaccines
Q: I've seen the recommendation stating air bubbles in manufacturer-filled syringes do not need to be expelled. Can you explain why those air bubbles can be injected but air bubbles in user-filled syringes must be expelled?
A: It is not wrong to expel the air from syringes filled by manufacturers, but typically it is such a small amount of air (0.2cc–0.3cc) that it is our opinion that it would not cause a problem. When the syringe is inverted during an injection, that small amount of air would typically just clear the medication from the needle. This is based on the recommendation that when the Z-track method is used for intramuscular injection of irritating medication (e.g., iron preparations), the guidance is to leave 0.2cc–0.3cc in the syringe to be sure that all of the medication leaves the needle and is not tracked back through subcutaneous tissue as the needle is withdrawn. While the Z-track injection technique is not recommended for vaccine administration, the Z-track method demonstrates the acceptability of leaving a very small amount of air in the syringe for intramuscular injections.
CDC does, however, recommend that when drawing vaccine from a vial into a regular syringe, the air be expelled because the amount of air drawn into the syringe may be larger than the amount in a manufacturer-filled syringe. Expelling the air is part of general medication guidelines for drawing medication into a syringe.
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Scheduling Vaccines
Q: A 5-year-old is in the office for vaccines and is due for MMR, polio, varicella, and DTaP. Is there a specific order I should be giving these vaccines?
A: The Advisory Committee on Immunization Practices (ACIP) does not address this issue. There is no recommended order in which the vaccines should be given. A best practice strategy to decrease injection or procedural pain is to administer the vaccine that causes the most pain (stinging, for example) last. For more information on vaccine administration, please see the "Vaccine Administration" chapter of Epidemiology and Prevention of Vaccine-Preventable Diseases at www.cdc.gov/vaccines/pubs/pinkbook/chapters.html.
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