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Issue 1435: July 16, 2019
Ask the Experts: CDC Experts Answer Your Questions
As a thank-you to our loyal IAC Express readers, we periodically publish extra editions such as this one, with new and updated "Ask the Experts" Q&As answered by CDC experts.
IAC extends thanks to our experts: Andrew T. Kroger, MD, MPH; Mark S. Freedman, DVM, MPH, DACVPM; Tina S. Objio, MSN, MHA, RN; Candice L. Robinson, MD, MPH; Raymond A. Strikas, MD, MPH, FACP, FIDSA; and JoEllen Wolicki, BSN, RN, all from the National Center for Immunization and Respiratory Diseases, CDC.
Administering Vaccines
Meningococcal ACWY Vaccine
MMR Vaccine
DTaP and Tdap Vaccines
Pneumococcal Vaccines
Precautions and Contraindications
Travel Vaccines
Vaccine Storage and Handling
Zoster Vaccine
Administering Vaccines
Q: How many vaccines can be given during an office visit?
A: All vaccines can be administered at the same visit*. There is no upper limit for the number of vaccines that can be administered during one visit. The Advisory Committee on Immunization Practices (ACIP) and the American Academy of Pediatrics consistently recommend that all needed vaccines be administered during an office visit. Vaccination should not be deferred because multiple vaccines are needed. All live vaccines (MMR, varicella, live zoster [Zostavax], live attenuated influenza [FluMist], yellow fever, and oral typhoid) can be given at the same visit if indicated. If live vaccines are not administered during the same visit, they should be separated by 4 weeks or more.
When giving several injections at a single visit, separate intramuscular (IM) vaccines by at least 1 inch in the body of the muscle if possible to reduce the likelihood of local reactions overlapping. For details see ACIP's General Best Practices Guidelines for Immunization, available at www.cdc.gov/vaccines/hcp/acip-recs/general-recs/administration.html.
*There are 2 exceptions to this general rule for routine vaccines: 1) if both pneumococcal conjugate vaccine (PCV13, Prevnar 13, Pfizer) and pneumococcal polysaccharide vaccine (PPSV23, Pneumovax 23, Merck) are indicated for a high-risk patient, these vaccines should not be given at the same visit. The PCV13 should be given first followed by PPSV23 at least 8 weeks later. If PPSV23 has already been given, wait 8 weeks (for a child) or 1 year (for an adult age 19 years or older) before giving PCV13 to avoid interference between the two vaccines. 2) A person with anatomic or functional asplenia or HIV should receive both PCV13 and meningococcal ACWY (MenACWY) vaccines. If Menactra brand (Sanofi) MenACWY is used, the person should first receive all recommended doses of PCV13 followed by Menactra at least 4 weeks later. Menveo brand (GSK) MenACWY can be given at the same time or at any time before or after PCV13.
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Q: Some single dose vials contain more than the recommended dosage of the vaccine. Should we administer the recommended dose of the vaccine, or the entire contents of the vial even if it contains more than the recommended dose?
A: In general, the entire volume should be used even if it is a little more than 0.5 mL. Discarding the excess vaccine is not required or recommended. An exception to this is recombinant zoster vaccine (RZV, Shingrix, GSK). The RZV adjuvant vial may contain up to 0.75 mL of liquid. The entire volume of the adjuvant solution should be withdrawn and used to reconstitute the lyophilized (powder) vaccine. After mixing, withdraw the recommended dose of 0.5 mL. Any reconstituted vaccine left in the vial should be discarded.
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Q: A child wiggled when we were injecting a dose of vaccine, and approximately half the dose was lost. Should we revaccinate the child? If so, when?
A: When injectable vaccine volume is lost (patient moves, syringe leaks), it may be difficult to judge how much vaccine the patient actually received. In general, you should treat this as a nonstandard injectable dose and should not count it. If it was an inactivated vaccine, you should re-immunize the person as soon as possible. In the case of Shingrix (RZV, GSK), if the person is still in the office the dose can be repeated immediately. If the repeat dose of RZV cannot be given on the same day, CDC recommends that it should be given 4 weeks after the invalid dose.
If it was a live vaccine, you can give another dose if you detect the error on the same clinic day; otherwise, you should wait 28 days to give the next dose. However, if part of a dose of an oral vaccine (rotavirus) was spit out, count the dose and do not administer a second dose. If a person sneezes after live attenuated influenza vaccine (FluMist, Medimmune), the dose can be counted as valid.
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Meningococcal ACWY Vaccine
Q: Who is recommended to be vaccinated against meningococcal ACWY disease?
A: MenACWY is recommended for these groups:
- All children and teens, ages 11 through 18 years
- People age 2 months and older with functional or anatomic asplenia
- People age 2 months and older who have persistent complement component deficiency (an immune system disorder) or who are being treated with a complement inhibiting drug (such as eculizumab [Soliris])
- People age 2 months and older with HIV infection
- First-year college students living in a residential hall who did not receive a dose of MenACWY on or after their 16th birthday
- People age 2 months and older who are at risk during an outbreak caused by a vaccine serogroup
- People age 2 months and older who reside in or travel to certain countries in sub-Saharan Africa as well as to other countries for which MenACWY vaccine is recommended (e.g., travel to Mecca, Saudi Arabia, for the annual Hajj)
- Microbiologists who work with meningococcus bacteria in a laboratory
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Q: Should college students be vaccinated against meningococcal ACWY disease?
A: MenACWY is recommended for previously unvaccinated first-year college students who are or will be living in a residence hall. Some colleges and universities require incoming freshmen and others to be vaccinated with MenACWY. Some may require that a dose of MenACWY have been given after age 16 years.
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Q: Several healthy adult college students from outside the U.S. (ages 24 years and older) presented to our clinic. They will be living in a residence hall. None have a record of having received MenACWY. Should they receive a dose of MenACWY now?
A: Yes. MenACWY is recommended for all first-year college students who are or will be living in a residence hall and have not received a dose of MenACWY on or after their 16th birthday.
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Q: MMR Vaccine
Q: What are the current recommendations for the use of MMR vaccine?
A: The most recent comprehensive ACIP recommendations for the use of MMR vaccine were published in 2013 and are available at www.cdc.gov/mmwr/pdf/rr/rr6204.pdf. MMR vaccine is recommended routinely for all children at age 12 through 15 months, with a second dose at age 4 through 6 years. The second dose of MMR can be given as early as 4 weeks (28 days) after the first dose and be counted as a valid dose if both doses were given after the child's first birthday. The second dose is not a booster, but rather is intended to produce immunity in the small number of people who fail to respond to the first dose.
Adults with no evidence of immunity (evidence of immunity is defined as documented receipt of 1 dose [2 doses 4 weeks apart if high risk] of live measles virus-containing vaccine, laboratory evidence of immunity or laboratory confirmation of disease, or birth before 1957) should get 1 dose of MMR vaccine. High-risk people need 2 total doses and include healthcare personnel, international travelers, and students attending post-high school educational institutions.
Live attenuated measles vaccine became available in the U.S. in 1963. An ineffective, inactivated measles vaccine was also available in the U.S. in 1963 through 1967. Combined MMR vaccine (MMRII, Merck) was licensed in 1971. For people who previously received a dose of measles vaccine in 1963 through 1967 and are unsure which type of vaccine it was, or are sure it was inactivated measles vaccine, that dose should be considered invalid and the patient revaccinated as age- and risk-appropriate with MMR vaccine. At the discretion of the state public health department, anyone exposed to measles in an outbreak setting can receive an additional dose of MMR vaccine even if they are considered completely vaccinated for their age or risk status.
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Q: For which adults are 0, 1, or 2 doses of MMR vaccine recommended to prevent measles?
A: Zero, 1, or 2 doses of MMR vaccine are needed for the adults described below.
Zero doses:
- adults born before 1957 except healthcare personnel*
- adults born 1957 or later who are at low risk (i.e., not an international traveler, post-high school educational student, or healthcare worker) and who have received one or more documented doses of live measles vaccine
- adults with laboratory evidence of immunity or laboratory confirmation of measles
One dose of MMR vaccine:
- adults born 1957 or later who are at low risk (i.e., not an international traveler, healthcare worker, or person attending college or other post-high school educational institution) and have no documented vaccination with live measles vaccine and no laboratory evidence of immunity or prior measles infection
Two doses of MMR vaccine:
- high-risk adults without any prior documented live measles vaccination and no laboratory evidence of immunity or prior measles infection, including:
- healthcare personnel*
- international travelers born in 1957 or later
- persons attending colleges and other post-high school educational institutions born in 1957 or later
Persons who previously received a dose of measles vaccine in 1963–1967 and are unsure which type of vaccine it was, or are sure it was inactivated measles vaccine, should be revaccinated with either one (if low risk) or two (if high risk) doses of MMR vaccine.
* Healthcare personnel born before 1957 should be considered for MMR vaccination in the absence of an outbreak, but are recommended for MMR vaccination during outbreaks.
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Q: Have recommendations for MMR vaccination of children or adults changed in light of the current measles outbreaks?
A: No. The most recent CDC recommendations for MMR vaccination were published in 2013 and can be found at www.cdc.gov/mmwr/pdf/rr/rr6204.pdf.
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Q: Do any adults need "booster" doses of MMR vaccine to prevent measles?
A: No. Adults with evidence of immunity do not need any further vaccines. No “booster” doses of MMR vaccine are recommended for either adults or children. They are considered to have life-long immunity once they have received the recommended number of MMR vaccine doses or have other evidence of immunity.
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DTaP and Tdap Vaccines
Q: If a dose of DTaP or Tdap is inadvertently given to a patient for whom the product is not indicated (e.g., wrong age group), how do we rectify the situation?
A: The first step is to inform the parent/patient that you administered the wrong vaccine. Next, follow these guidelines:
- Tdap given to a child younger than age 7 years as either dose 1, 2, or 3, is not valid. Repeat with DTaP as soon as feasible.
- Tdap given to a child younger than age 7 years as either dose 4 or 5 can be counted as valid for DTaP dose 4 or 5.
- DTaP given to an undervaccinated child 7 through 10 years of age: count this dose as the Tdap dose of the catch-up series. The child should receive an adolescent booster dose of Tdap at 11–12 years of age.
- DTaP given to a person 11 years of age or older: count this dose as the Tdap dose. The person should not receive an additional dose of Tdap.
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Pneumococcal Vaccines
Q: For whom is PPSV23 recommended?
A: Pneumococcal polysaccharide vaccine (PPSV23, Pneumovax 23, Merck) is recommended for all people who meet any of the criteria below:
- All adults age 65 years and older
- Age 2 through 64 years with any of the following conditions:
- cigarette smokers age 19 years and older
- chronic cardiovascular disease, excluding hypertension (e.g., congestive heart failure, cardiomyopathies)
- chronic pulmonary disease (including COPD and emphysema, and for adults ages 19 years and older, asthma)
- diabetes mellitus
- for people 6–64 years of age: alcoholism
- for people 6–64 years of age: chronic liver disease, cirrhosis
- candidate for or recipient of cochlear implant
- cerebrospinal fluid (CSF) leak
- functional or anatomic asplenia (e.g., sickle cell disease, splenectomy)
- immunocompromising conditions (e.g., HIV infection, leukemia, congenital immunodeficiency, Hodgkin's disease, lymphoma, multiple myeloma, generalized malignancy) or on immunosuppressive therapy
- solid organ transplantation; for bone marrow transplantation, see www.cdc.gov/vaccines/hcp/acip-recs/general-recs/immunocompetence.html
- chronic renal failure or nephrotic syndrome
Public health authorities may also consider recommending PPSV23 for Alaska Natives and American Indians ages 50 through 64 years who are living in areas in which the risk of invasive pneumococcal disease is increased.
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Q: Rather than giving PCV13 first and waiting 8 weeks to give PPSV23 as recommended for an immunocompromised child (2 years or older) or adult patient, we inadvertently gave both vaccines at the same visit. We are looking for guidance.
A: Pneumococcal conjugate vaccine (PCV13, Prevnar 13, Pfizer) and PPSV23 should not be administered at the same visit or at an interval less than 8 weeks. However, in adults, if PCV13 and PPSV23 are administered at the same visit or at an interval less than 8 weeks, neither dose needs to be repeated. In children, if PCV13 and PPSV23 are administered at the same visit, the PCV13 dose should be repeated, and should be administered no earlier than 8 weeks after doses that were administered on the same day.
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Precautions and Contraindications
Q: Do people who received chemotherapy need their vaccines repeated?
A: Vaccines received before starting chemotherapy generally do not need to be repeated after chemotherapy is completed. Chemotherapy does not negate vaccine-induced immunity. However, revaccination is recommended for people who are recipients of a hematopoietic cell transplant (HCT), such as a bone marrow transplant, because immunity present before the transplant is lost and may not be replaced by donor cells.
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Q: I have a healthy 5-year-old patient whose close household contact (her mother) is immunocompromised due to cancer chemotherapy. Can I administer live vaccines to the healthy child?
A: Yes. Household contacts and other close contacts of people who are immunocompromised (due to a disease, or treatment for a disease) should receive all routinely recommended vaccines, with the exception of smallpox vaccine. The live MMR, varicella, rotavirus and live zoster (Zostavax, Merck) vaccines should be administered to susceptible household contacts and other close contacts of immunocompromised patients when indicated. MMR vaccine viruses are not transmitted to contacts, and transmission of vaccine strain varicella-zoster virus is rare. No specific precautions are needed unless the varicella (or live zoster) vaccine recipient has a rash after vaccination, in which case direct contact with susceptible immunocompromised household contacts should be avoided until the rash resolves. All members of the household should wash their hands after changing the diaper of an infant who received rotavirus vaccine. This minimizes rotavirus transmission, as shedding may occur up to one month after the last dose.
Household and other close contacts of immunocompromised people should receive annual influenza vaccination. Introduction of low levels of vaccine viruses into the environment likely is unavoidable when administering live attenuated influenza vaccine (LAIV; FluMist, Medimmune). LAIV vaccine viruses are cold-adapted so they can replicate in the nose and generate an immune response without entering the lungs (that is, they are temperature sensitive and replicate poorly at core body temperatures). No instances have been reported of illness caused by attenuated vaccine virus infections among healthcare providers or immunocompromised patients. LAIV may be administered to healthy non-pregnant household members and other close contacts of immunocompromised people unless the immunocompromised person is hospitalized in a protective environment, typically defined as a specialized patient-care area with a positive airflow relative to the corridor, high-efficiency particulate air filtration, and frequent air changes.
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Travel Vaccines
Q: When not given on the same day, is the interval between yellow fever and MMR vaccines 4 weeks (28 days) or 30 days? I have seen the yellow fever and live virus vaccine recommendations published both ways.
A: The ACIP General Best Practices Guidelines for Immunization (see www.cdc.gov/vaccines/hcp/acip-recs/general-recs/timing.html) makes the generic recommendation that live parenterally or nasally administered vaccines not given on the same day should be separated by at least 28 days. ACIP recommends that yellow fever vaccine be given at the same time as other live viral vaccines. Otherwise, the clinician should wait 30 days between vaccinations, as the immune response to a live non-yellow fever vaccine might be impaired if administered less than 28 days after yellow fever vaccine, and the immune response to yellow fever vaccine might be impaired if administered within 30 days of another live viral vaccine. Because of concern about protection from yellow fever, CDC recommends postponing travel if the 30 day interval cannot be established between the two vaccines.
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Vaccine Storage and Handling
Q: What type of thermometers should be used for measuring temperatures in a vaccine storage unit? What type of thermometers should NOT be used for this purpose?
A: CDC recommends that vaccines be monitored using a "digital data logger" (DDL). A DDL provides the most accurate storage unit temperature information, including details on how long a unit has been operating outside the recommended temperature range (referred to as a "temperature excursion"). Unlike a simple minimum/maximum thermometer, which only shows the coldest and warmest temperatures reached in a unit, a DDL provides detailed information on all temperatures recorded at preset intervals. Many DDLs use a buffered temperature probe, which is the most accurate way to measure actual vaccine temperatures. Temperatures measured by a buffered probe match vaccine temperatures more closely than those measured by standard thermometers, which tend to reflect only air temperature. Temperature data from a DDL can either be downloaded to a computer using special software or retrieved from a website. The software or website may also allow you to set the frequency of temperature readings. Reviewing DDL data is critical for vaccine viability, so it is important to decide whether independent software or a website program works best for your facility.
Temperature monitoring devices that are NOT recommended include alcohol or mercury thermometers, even if placed in a fluid-filled, biosafe, liquid vial; bimetal stem devices; devices used for food; chart recorders; infrared devices; and devices that do not have a current and valid Certificate of Calibration Testing. Please note that some devices sold in hardware and appliance stores are designed to monitor temperatures for household food storage. They are not calibrated and not accurate enough to ensure vaccines are stored within the correct temperature range. Using these devices can pose a significant risk of damaging vaccines.
More detailed information on temperature monitoring is available in CDC's Vaccine Storage and Handling Toolkit, found at www.cdc.gov/vaccines/hcp/admin/storage/toolkit/storage-handling-toolkit.pdf, pages 9–10.
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Q: Please provide guidance for transporting our vaccine to an off-site location.
A: Vaccines from your supply should not be routinely transported. In instances where the transport of vaccine from your supply is necessary, take appropriate precautions to protect your supply. Vaccines should only be transported using appropriate packing materials that provide the maximum protection. CDC provides detailed guidance on the transport of vaccines in the Vaccine Storage and Handling Toolkit, available at www.cdc.gov/vaccines/hcp/admin/storage/toolkit/storage-handling-toolkit.pdf, pages 21–24.
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Q: What should we do if a dose of expired vaccine is given to a patient?
A: The dose should be repeated. If the error was detected on the same clinic day, you can repeat the dose that day. If the error is detected more than one day later and if the expired dose is a live virus vaccine, you must wait at least 28 days after the previous (expired) dose was given before repeating it. If the expired dose is not a live vaccine, the dose should be repeated as soon as possible. An exception to this is for recombinant zoster vaccine (RZV, Shingrix, GSK); the repeat dose should be given 4 weeks after the invalid dose. If you prefer, you can perform serologic testing to check for immunity for certain vaccinations (e.g., measles, rubella, hepatitis A, diphtheria, varicella, and tetanus).
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Q: Where can I get the most up-to-date information about vaccine storage and handling?
A: CDC publishes a comprehensive Vaccine Storage and Handling Toolkit (updated January 2019) covering topics such as vaccine storage units, temperature monitoring devices, inventory management, vaccine transport, and emergency vaccine storage and handling. The toolkit also contains troubleshooting guides to assist with vaccine storage unit issues or temperature excursions. This terrific resource is available online at www.cdc.gov/vaccines/hcp/admin/storage/toolkit/storage-handling-toolkit.pdf.
In addition, IAC maintains many free, downloadable print materials on vaccine storage and handling at www.immunize.org/handouts/vaccine-storage-handling.asp.
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Zoster Vaccines
Q: I am having trouble getting RZV (Shingrix) for my patients. What should I do during the shortage?
A: Due to high levels of demand for recombinant zoster vaccine (RZV, Shingrix, GSK), the manufacturer has implemented order limits and providers have experienced shipping delays. It is anticipated that order limits and shipping delays will continue throughout 2019. Additionally, GSK will continue to release doses to all customer types on a consistent and predictable schedule during 2019. (See www.cdc.gov/vaccines/hcp/clinical-resources/shortages.html#note4).
Clinicians and patients should make every effort to ensure that 2 doses of RZV are administered within the recommended interval of 2 to 6 months. If more than 6 months have elapsed since the first dose of RZV, administer the second dose when possible. Do not restart the vaccine series, and do not substitute zoster live-attenuated vaccine (ZVL, Zostavax, Merck) for the second dose of RZV. If you are out of RZV and a patient needs a second dose, the Vaccine Finder may be helpful for patients to locate other providers that have RZV in stock. The Vaccine Finder can be accessed on the CDC website at www.cdc.gov/vaccines/adults/find-vaccines.html.
CDC still recommends that ZVL (Zostavax) may be used in healthy adults 60 years and older in certain cases, such as when a person prefers ZVL or requests vaccination and RZV is unavailable. Patients who have received ZVL are recommended to subsequently receive RZV. Age and time since receipt of ZVL may be considered to determine when to vaccinate with RZV. The minimum interval between ZVL and RZV is 8 weeks.
Additional information for clinicians about RZV is available on the CDC website at www.cdc.gov/vaccines/vpd/shingles/hcp/index.html.
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Q: Should people who haven't had chickenpox be vaccinated with zoster vaccine?
A: Serologic studies indicate that almost everyone born in the United States before 1980 has had chickenpox even though many cannot recall having had chickenpox (www.cdc.gov/mmwr/preview/mmwrhtml/rr5705a1.htm). As a result, there is no need to ask people age 50 years and older for their varicella disease history or to perform a laboratory test for serologic evidence of prior varicella disease. A person age 50 years or older who has no medical contraindications is eligible for RZV regardless of their memory of having had chickenpox.
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Q: If a person was exposed to shingles by a spouse within the last few days, is there a recommended waiting period before the exposed person can receive zoster vaccine?
A: There is no waiting period in such a situation. Zoster vaccine can be given right away or at any time to any person for whom the vaccine is recommended. Shingles is not caused by exposure to another person with shingles. However, exposure to someone with shingles can possibly cause chickenpox in a person with no immunity to varicella zoster virus (VZV) from either vaccination or prior chickenpox infection. Zoster is caused by the reactivation of VZV in people who have already had a prior VZV infection.
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Q: Should healthcare personnel in long-term care facilities be tested to see if they have had chickenpox before taking care of someone who has received ZVL?
A: All healthcare personnel should ensure they are immune to varicella regardless of the setting in which they work and regardless of their patients' receipt of live zoster vaccine. For healthcare personnel, accepted evidence of varicella immunity includes any of the following: 1) documentation of age-appropriate vaccination with a varicella vaccine, 2) laboratory evidence of immunity or laboratory confirmation of disease; 3) diagnosis or verification of a history of varicella disease by a healthcare provider; or 4) diagnosis or verification of a history of herpes zoster by a healthcare provider.
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Q: How should zoster vaccine be transported to an off-site clinic location?
A: RZV is stored at refrigerator temperature. Transport of refrigerated vaccines is described in detail in CDC's Vaccine Storage and Handling Toolkit, available at www.cdc.gov/vaccines/hcp/admin/storage/toolkit/storage-handling-toolkit.pdf, pages 21–24. Providers should also review the vaccine package inserts for the specific vaccines being transported.
Neither CDC nor the vaccine manufacturer recommends transporting live varicella-containing vaccines. If these vaccines must be transported (for example, during an emergency), CDC recommends transport in a portable freezer unit that maintains the temperature between -50°C and -15°C (-58°F and +5°F). Portable freezers may be available for rent in some places. If live varicella-containing vaccines must be transported and a portable freezer unit is not available, do NOT use dry ice. Dry ice may subject varicella-containing vaccines to temperatures colder than -50°C (-58°F).
Live varicella-containing vaccines may be transported at refrigerator temperature between 2°C and 8°C (between 36°F and 46°F) for up to 72 continuous hours prior to reconstitution. ZVL stored between 2°C and 8°C (between 36°F and 46°F) that is not used within 72 hours of removal from a freezer should be discarded. Instructions for transporting vaccines are available in CDC's Vaccine Storage and Handling Toolkit at www.cdc.gov/vaccines/hcp/admin/storage/toolkit/storage-handling-toolkit.pdf, pages 21–24. Providers should also review the vaccine package inserts.
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How to submit a question to Ask the Expert
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.
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