Scheduling Vaccines
Vaccine Safety
Dtap/Tdap/Td Vaccines
Q: Is there any contraindication to administering Tdap vaccine and Rhogam at the same time to a pregnant woman?
A: No. Tdap is an inactivated vaccine and may be administered at the same time as Rhogam (in a separate site with a separate syringe).
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Q: Mom comes in with her 19-month-old. She reports that her (the mother’s) sibling has a history of a severe reaction to pertussis vaccine in the mid-1990s. Now mom is reluctant to give her child pertussis vaccine although the child received Pediarix (DTaP-HepB-IPV, GlaxoSmithKline) 2 months ago without incident. Should we be concerned about the mother’s family history of a severe reaction to pertussis vaccine?
A: A family history of a neurologic disorder or reaction to a pertussis-containing vaccine is not a contraindication to vaccination of this child. The child should receive additional DTaP doses as indicated in the catch-up schedule.
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Q: A dose of Kinrix (DTaP-IPV; GSK) should have been administered to a 4-year-old, but Pentacel (DTaP-IPV/Hib; Sanofi Pasteur) was administered instead. Does the dose of DTaP count?
A: Yes. The DTaP in the Pentacel can be counted. Although Pentacel is licensed as a 4-dose series and this may represent a fifth dose of Pentacel (in which case it would be off-label use), the dose of DTaP counts as the fifth dose of DTaP.
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Q: Are there recommendations for administering Tdap when Td is not available?
A: If Td is indicated but unavailable, Tdap should be administered in place of Td, including persons who previously received Tdap.
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Q: If a person received a Tdap vaccine and then had a positive pertussis PCR two weeks later, could it be a false positive from the vaccine or should we consider this a case of pertussis? The patient had a cough, nausea, and vomiting for 2–3 days prior to PCR testing.
A: Recent Tdap vaccination does not affect PCR testing. PCR tests are used to detect DNA sequences of the Bordetella pertussis bacterium. PCR tests are very sensitive and could give a false positive result for other reasons. For more information on the interpretation of pertussis diagnostic tests, see www.cdc.gov/pertussis/clinical/diagnostic-testing/diagnosis-confirmation.html.
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Q: A 7-year-old has a history of 3 doses of DTaP, appropriately spaced, between 4 years and 6 years of age. Is her DTaP series complete?
A: Although the child would be considered complete for tetanus and diphtheria toxoids, she is not complete for pertussis vaccine. ACIP recommends that children age 7 through 10 years who are not fully vaccinated against pertussis (defined as 5 doses of DTaP or 4 doses of DTaP if the fourth dose was administered on or after the fourth birthday) and who do not have a contraindication to pertussis vaccine should receive a single dose of Tdap to provide protection against pertussis. The child may also receive an additional dose of Tdap at 11 or 12 years of age. See MMWR 2011;60(No.1):13–15 and footnote 12 of the 2017 child and adolescent immunization schedule, available at www.cdc.gov/vaccines/schedules/hcp/child-adolescent.html.
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Q: Tenivac Td (Sanofi Pasteur) for adults is expected to be unavailable until the second half of 2017. Another Td vaccine produced by MassBiologics is available at our wholesaler, but it looks like the components are slightly different from Tenivac. Are the two products interchangeable during the shortage?
A: Yes, the Td products are equivalent and interchangeable.
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Q: My 11-year-old patient received a dose of Tdap when he was 7 years old. He also received a dose of Td 6 months later in order to finish a primary series of tetanus-toxoid. Can I give him a dose of Tdap now?
A: Yes. Footnote 12 of the 2017 child and adolescent immunization schedule (available at www.cdc.gov/vaccines/schedules/hcp/child-adolescent.html) states that a child who receives a dose of Tdap between 7 through 10 years of age as part of the catch-up series (as in this case), may receive another dose of Tdap at age 11 or 12 years.
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Q: A 16-year-old refugee’s record indicates 2 doses of Td separated by 1 month and 1 dose of Tdap given 4 months after the second Td. The first Td was given at age 16 years. Is he up to date?
A: The first two doses of Td are valid because they are separated by at least 4 weeks. However, the minimum interval between the second and third doses of tetanus-containing vaccine is 6 calendar months. So, the Td component of the Tdap dose is not valid because it was given only 4 months after the second dose. The pertussis component can be counted as valid. The patient should receive another dose of Td 6 months after the invalid Tdap dose. If Td is not available, Tdap can be used for this dose.
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Pneumococcal B Vaccines
Q: Is systemic lupus erythematosus (SLE, lupus) a risk-based indication for pneumococcal vaccines?
A: Lupus per se is not an indication for either pneumococcal vaccine. However, immunosuppressive medication that may be used to treat lupus could create an indication for administering both pneumococcal vaccines. Also, if the patient has certain complications of lupus (such as nephrotic syndrome), the person would be a candidate for pneumococcal vaccines. Both immunosuppression and nephrotic syndrome are indications for administering both PCV13 (Prevnar, Pfizer) AND PPSV23 (Pneumovax, Merck). Administer PCV13 first, then PPSV23 8 weeks later. A handy document that summarizes indications for both pneumococcal vaccines is available at www.immunize.org/catg.d/p2019.pdf.
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Q: We have a 45-year-old patient taking Mesalamine for ulcerative colitis. Should he receive PCV13 and/or PPSV23?
A: Mesalamine (mesalazine) is a non-steroidal anti-inflammatory drug. It is not immunosuppressive, so its use would not be an indication for early pneumococcal vaccination with either of these vaccines (i.e., prior to the routine vaccination age of 65 years).
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Rabies Vaccines
Q: A patient recently exposed to a bat received the rabies vaccine series. One of the doses was given in the gluteus. Does this dose count?
A: No. Doses of rabies vaccine given in the gluteus should not be counted as valid and should be repeated. If repeating the invalid dose results in an interval between doses more than 3 days longer than the recommended interval, then you should perform a rabies serology 7–14 days after administration of the final dose in the series to ensure an adequate immune response to the series. For more information, see www.cdc.gov/mmwr/pdf/rr/rr5902.pdf.
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Varicella Vaccine
Q: I have a patient who is 62 years old and is immigrating to the U.S. She received a dose of zoster vaccine 2 months ago. The immigration requirements state she should receive 2 doses of varicella vaccine. Does she need additional varicella vaccine?
A: To meet the immigration requirements, the dose of zoster vaccine counts as the first dose of the varicella vaccine series. You should give a dose of varicella vaccine now since it has been more than 4 weeks since the dose of zoster vaccine. The varicella vaccine dose may not be needed, but it will not be harmful and will allow your patient to meet the regulatory requirement.
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Zoster Vaccine
Q: For our "Mother's Day Out" program, one of the teachers has shingles. The program serves moms of 2-month-olds to 4-year-olds. All children are up to date with their vaccinations, but some are too young to have received varicella vaccine. Is it safe for the teacher to work?
A: In a school setting, an immunocompetent person with zoster (staff or students) can remain at school as long as the lesions can be completely covered. People with zoster should be careful about personal hygiene, wash their hands after touching their lesions, and avoid close contact with others. If the lesions cannot be completely covered and close contact avoided, the person should be excluded from the school setting until the zoster lesions have crusted over. See www.cdc.gov/chickenpox/outbreaks/manual.html for more information. If your program is licensed by a state or county, you should check their regulations as well.
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Q: My healthy 29-year-old son recently had a mild episode of herpes zoster. He has no underlying medical problems. He was treated with famcyclovir. Should he now get zoster vaccine?
A: The Advisory Committee on Immunization Practices (ACIP) does not recommend zoster vaccine for persons younger than 60 years of age regardless of their history of zoster. The currently available vaccine is licensed for persons 50 years and older. A clinician may choose to give the vaccine to a person younger than 50 years, but such use would be off-label.
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Precautions and Contraindications
Q: I had an 18-year-old in the clinic today for varicella vaccination. He reports having antiphospholipid syndrome being treated with rituximab (a drug that affects the function of B lymphocytes). The next dose of rituximab will be in 2 weeks. He has also had 12 immune globulin (IG) injections in the last year. Should he get the varicella vaccine at all with this condition, and if so, what time frame do we need to be concerned with in relation to the rituximab treatment and/or IG?
A: The Infectious Diseases Society of America guidelines indicate that persons receiving rituximab should be considered to have high-level immunosuppression. Both inactivated and live vaccines should be withheld at least 6 months following treatment with anti-B cell medications such as rituximab. As for the IG, the interval to live vaccination depends on the dose. Please refer to the table on pages 37–39 of the "General Best Practices Guidelines for Immunization" at www.cdc.gov/vaccines/hcp/acip-recs/general-recs/downloads/general-recs.pdf for guidance. This interval could be as long as 11 months, depending on the dose he receives.
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Scheduling Vaccines
Q: If a child falls behind on immunizations, is it recommended to use only minimum intervals to get the child caught up? Or should we use a minimum interval for the same vaccine only once?
A: If a child is behind on immunizations, the Advisory Committee on Immunization Practices (ACIP) recommends using the minimum intervals between each dose until the child is caught up. The minimum interval for a vaccine can be used as many times as necessary, until the child is back on schedule.
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Vaccine Safety
Q: Why are zoster, pneumococcal polysaccharide (PPSV23) and meningococcal serogroup B (MenB) vaccines not covered by the National Vaccine Injury Compensation Program?
A: The National Vaccine Injury Compensation Program includes payment only for injuries determined to have occurred following vaccination with a vaccine routinely recommended for children in the United States. The recipient can be of any age, but the vaccine must be routinely recommended for children and teens through age 18 years. Zoster, PPSV23 and MenB vaccines are not routinely recommended for children. Zoster is only licensed and recommended for adults. PPSV23 and MenB vaccines are routinely recommended only for select high-risk groups of children and adults. More information about the program and the covered vaccines is at www.hrsa.gov/vaccinecompensation/coveredvaccines/index.html.
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