Read "Ask the Experts" Q&As about changes in vaccine recommendations, vaccine
shortages, recently approved vaccines, and more
Many readers of Needle Tips, Vaccinate Adults,
and Vaccinate Women consistently rank "Ask the Experts" as their favorite
feature in these publications. As a thank-you to our loyal IAC Express
readers, we have decided to periodically publish an Extra Edition with new
"Ask the Experts" Q&As answered by CDC experts.
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IAC thanks William L. Atkinson, MD, MPH, and Andrew T. Kroger, MD, MPH,
medical epidemiologists at the National Center for Immunization and
Respiratory Diseases, CDC, for agreeing to answer the following questions.
Many of these Q&As were published previously in the December 2008 issue of
Needle Tips. If you did not receive this issue as a print publication or did
not read it online, these questions will be new to you. If you have read "Ask
the Experts" in the last issue of Needle Tips, look for new, previously
unpublished questions at the beginning of this Extra Edition.
We encourage you to reprint any of these Q&As in your own newsletters. Please
credit the Immunization Action Coalition and the Centers for Disease Control
and Prevention. Information about proper citations can be found at
You can access more "Ask the Experts" Q&As in our online archive at
Editor's note: Information about submitting a question to "Ask the Experts"
is provided at the end of this Extra Edition.
NEW "ASK THE EXPERTS" Q&As
Q: Where can I find more information to educate parents when they ask about
alternative vaccination schedules?
A: Paul Offit, MD, and Charlotte Moser, BS, Vaccine Education Center,
Children's Hospital of Philadelphia, published an article in the January 2009
issue of the AAP journal "Pediatrics" titled "The Problem with Dr Bob's
Alternative Vaccine Schedule." "Pediatrics" has made the entire article
available online at
The Vaccine Education Center has also recently released a tear sheet for
parents titled "Too Many Vaccines? What you should know." To access this
resource, go to:
http://www.chop.edu/vaccine/images/vec_tomany.pdf (English) or
Health professionals can order two 50-sheet pads in each language at no
charge. Additional pads are available for $3, plus shipping. For additional
ordering information, go to:
The American Academy of Pediatrics published a helpful commentary in the
January 2009 "AAP News" titled "Adhering to vaccine schedule is best way to
protect children from disease." To access the contents of this article, go
AAP posted a Q&A piece for parents on its website that explains why it's
important to vaccinate children on time. Titled "The Childhood Immunization
Schedule: Why Is It Like That?" the piece is located at
CDC maintains a web page titled "Frequently Asked Questions about Multiple
Vaccinations and the Immune System." To access it, go to:
Q: The new recommendations for rotavirus vaccine scheduling state
that the series should be completed by 8 months 0 days. Can
vaccine be given on the 8-month birthday?
A: Yes. Doses of rotavirus vaccine should be administered on or
before age 8 months 0 days; i.e., the infant is no older than 8
months 0 days from date of birth.
For example, if the child was born on February 4, the last dose
should be given on or before October 4 (and no later).
Q: I heard there was a change in the recommendations as to who can
receive Boostrix brand Tdap vaccine. What are the specifics?
A: On December 4, 2008, FDA approved GlaxoSmithKline's request to
supplement their license for Boostrix. The vaccine is now approved
for use as a one-time booster for people ages 10-64 years.
Previously, it was approved for use in people ages 10-18 years.
Adacel, sanofi pasteur's brand of Tdap vaccine, is licensed for
people ages 11-64 years.
Q: I'm wondering whether we should re-vaccinate adult patients and
employees with a second dose of influenza vaccine in the spring if
they got their first dose early in the fall.
A: CDC does not recommend a second dose of influenza vaccine for
anyone during the course of a single influenza season with the
following exception. Give 2 doses (separated by at least 4 weeks)
to children who are younger than age 9 years who are receiving
influenza vaccine for the first time or who were vaccinated for the
first time during the previous influenza season but received only 1
Q: I understand there is a now a shortage of hepatitis B vaccine
for children and possibly for adults. Could you please tell me
A: Hepatitis B vaccine for pediatric use is in short supply at this
time but recommendations for its use are unchanged. The information
below about the hepatitis B vaccine shortages is available on CDC's
website at http://www.cdc.gov/vaccines/vac-gen/shortages
In February 2009, both Merck and GSK experienced an inability to
fill orders for pediatric hepatitis B vaccine, resulting in
backorders. CDC has released doses from its monovalent pediatric
hepatitis B vaccine stockpiles to each manufacturer to support
private and public sector vaccine usage through March. Merck
expects supplies of pediatric Recombivax HB to be limited during
the remainder of 2009 and does not expect to return to a full
supply until some time in 2010. GSK expects to be able to meet the
U.S. market demand for monovalent hepatitis B vaccine through the
end of May with its pediatric hepatitis B vaccine (Pediatric
Engerix-B), and is working closely with CDC to determine how much
additional monovalent hepatitis B product can be supplied to the
U.S. market during the second half of 2009.
In December 2008, Merck communicated with CDC that it expected to
deplete available adult and dialysis formulations of their
hepatitis B vaccine, Recombivax HB, in the first quarter of 2009.
Once depleted, these formulations will be unavailable for the
remainder of 2009. Supply of GSK's adult hepatitis B vaccine (Adult
Engerix-B) and adult hepatitis A/hepatitis B combination vaccine
(Twinrix) is sufficient to meet demand for routine adult usage of
this vaccine as well as for CDC's ongoing High Risk Adult Hepatitis
Q: Are there other vaccine shortages or delays I should know about?
A: ProQuad (MMRV) will not be available in 2009. There is adequate
supply of Varivax (varicella vaccine) to fully implement the
recommended 2-dose immunization schedule for all age groups.
Zostavax (zoster vaccine) is available for ordering; however, the
manufacturer is experiencing shipping delays. Merck anticipates a
return to normal shipping times for Zostavax in mid-2009.
Find up-to-date information on vaccine shortages and delays on
CDC's website at http://www.cdc.gov/vaccines/vac-gen/shortages
Q: I've heard that some people are "brown-bagging" zoster vaccine,
i.e., picking up a dose in a local pharmacy and carrying it to
their provider's office for administration. What is CDC's opinion
on this practice?
A: CDC strongly discourages the practice of patients' transporting
vaccine from a pharmacy to a doctor's office, as does the American
Pharmacists Association. Zoster vaccine must be transported on dry
ice, with strict adherence to stringent vaccine transport
Q: Should a healthy person age 60+ years receive zoster vaccine if
they are going to be in contact with an unvaccinated infant or an
A: Neither situation is a contraindication to zoster vaccination. A
person who gets vaccinated with zoster vaccine who has close
household or occupational contact with people who are at risk for
developing severe varicella or zoster infection need not take any
precautions after receiving zoster vaccine. The only exception is
in the rare instance when a person develops a varicella-like rash
after receiving zoster vaccine. A vaccine rash is expected to
occur less frequently after zoster vaccine is given than after
varicella vaccine is given. If a rash develops, the vaccinated
person should restrict contact with an immunocompromised person if
the immunocompromised person is susceptible to varicella.
"ASK THE EXPERTS" Q&As FROM DECEMBER 2008 "NEEDLE TIPS"
Q: If the vaccine expiration date is written as month/year, how do
we know the exact date of expiration?
A: Vaccine may be used through the last day of the month indicated
on the expiration date. After that, do not use it. Monitor your
vaccine supply carefully so that vaccines do not expire.
Q: If we gave a dose of expired vaccine in error, what is the
proper timing for repeating the dose?
A: The dose should be repeated. If the expired dose is a live virus
vaccine, you should wait at least 4 weeks after the 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.
Q: Where can I find Vaccine Information Statement (VIS)
translations in Spanish and other languages? We have many patients
from outside the U.S. in our practice.
A: You're in luck. The Immunization Action Coalition (IAC) has
dozens of translations of most VISs at http://www.immunize.org/vis
Q: I'm unclear about when to use the multi-vaccine VIS versus the
A: The multi-vaccine VIS is a 4-page alternative VIS that you can
use in place of the individual VISs for any or all of the 6
vaccines routinely given to infants (i.e., DTaP, IPV, Hib, PCV,
HepB, and rotavirus). It is not designed to be used with
adolescents or adults (risk factors that apply only to older
persons are not included on this VIS). Use of this VIS saves paper
and staff time. When giving the multi-vaccine VIS to a parent,
check the boxes on the first page that correspond to the vaccines
you plan to administer at the current visit. The multi-vaccine VIS,
as well as all other VISs in English and more than 30 languages,
are available on IAC's website at http://www.immunize.org/vis
English-language VISs are available on CDC's website at
Q: We sometimes have differences of opinion among our staff in
determining the minimum interval or age for administering vaccines.
Recommendations are sometimes written in months, weeks, or days.
Can you help clarify?
A: This is a common source of frustration. Customarily, if the dosing interval is 4 months or more, it is common to use calendar
months (e.g., 6 months from October 1 is April 1). If the interval
is less than 4 months, it is common to convert months into days or
weeks (e.g., 1 month = 4 weeks = 28 days).
Q: Is it okay to store blood products in the same unit as vaccines?
A: CDC's vaccine storage and handling toolkit states "If possible,
other medications and other biologic products should not be stored
inside the vaccine storage unit. If there is no other choice, these
products must be stored below the vaccines on a different shelf.
This prevents contamination of the vaccines should the other
Q: Does CDC still have a vaccine handling and storage toolkit?
A: Yes. You can access it from CDC's website at
http://www2a.cdc.gov/vaccines/ed/shtoolkit. The toolkit contains 2
videos on CD-ROM (How to Protect Your Vaccine Supply and Top 10
Storage and Handling Errors); an interactive game; and resources
including forms, checklists, posters, and contact information.
Single copies of the CD-ROM can be ordered from CDC at
Q: What is the maximum number of IM or SC doses of vaccines that a
child can receive at a single visit? Is it okay for a child to
receive 3 live vaccines at one visit (e.g., MMR, VAR, and LAIV)?
A: All vaccines can be administered at the same visit. There is no
limit to the number of IM or SC injections that can be given at a
single visit. So, an age-appropriate child can get MMR, VAR, and
LAIV vaccines during a single visit. If live parenteral (injected)
vaccines (MMR, VAR, MMRV, zoster, and/or yellow fever) and LAIV are
not administered during the same visit, they should be separated by
4 weeks or more. For details, consult CDC's "General
Recommendations on Immunization" at
Q: Do Occupational Safety and Health Administration (OSHA)
guidelines require the use of gloves when administering vaccines?
A: OSHA regulations do not require gloves during vaccine
administration, unless the administering person is likely to come
into contact with potentially infectious body fluids or has an open
lesion on their hand.
Q: When a parent is unable to produce documentation but insists
that their child received the vaccine doses, what should we do?
A: Vaccination providers frequently encounter persons who do not
have adequate documentation of vaccinations. Providers should only
accept written, dated records as evidence of vaccination. With the
exception of influenza vaccine and pneumococcal polysaccharide
vaccine (PPSV), self-reported doses of vaccine without written
documentation should not be accepted. An attempt to locate missing
records should be made whenever possible--by contacting previous
healthcare providers, reviewing state or local immunization
information systems, and searching for a personally held record.
However, if records cannot be located or will definitely not be
available anywhere because of the patient's circumstances, children
without adequate documentation should be considered susceptible and
should be started on the age-appropriate vaccination schedule.
Serologic testing for immunity is an alternative to vaccination for
certain antigens (e.g., measles, rubella, hepatitis A, and
In general, although it is not ideal, receiving extra doses of
vaccine poses no medical problem. Receiving excessive doses of
tetanus toxoid (e.g., DTP, DTaP, DT, Tdap, or Td) can increase the
risk of a local adverse reaction, however. For details, consult
CDC's "General Recommendations on Immunization" at
Q: Some parents are requesting that we space out their infant's
vaccinations because they are concerned that receiving multiple
vaccinations at a single office visit might overwhelm the infant's
immune system. What do you think about using alternative schedules?
A: Vaccine recommendations are determined after extensive studies
in large clinical trials. They include studies on how vaccine
recipients respond to multiple vaccines given simultaneously. The
overall aim is to provide early protection for infants and children
against vaccine-preventable diseases that could endanger their
health and life. No scientific evidence exists to support that
delaying vaccinations or separating them into individual antigens
is beneficial for children. Rather, this practice prolongs
susceptibility to disease, which could result in a greater
likelihood of the child becoming sick with a serious or life-threatening disease. There could also be added expense (e.g.,
multiple office visits), additional time off from work for parents,
and increased likelihood that the child will fail to get all
Q: If a patient or parent refuses recommended vaccinations, is it
necessary for them to sign a refusal form, or is the provider's
A: The American Academy of Pediatrics states that healthcare
providers may decide it is in their best interest to formally
document a parent's refusal to accept vaccination for their (minor)
child. To read a discussion on this topic and to access a prototype
refusal form, go to
Q: Is it necessary to routinely obtain a pregnancy test before
administering any vaccines to young women?
A: No. Pregnancy tests are not routinely recommended. However,
females of childbearing age should be asked about the possibility
of their being pregnant prior to being given any vaccine for which
pregnancy is a contraindication or precaution. The patient's answer
should be documented in the medical record. If the patient is
uncertain if she is pregnant, a test should be performed before
administering live virus vaccines (e.g., measles-mumps-rubella
[MMR], varicella [VAR], LAIV [live attenuated influenza vaccine,
Q: What guidance is there for preventing patients from fainting
A: All providers who administer vaccinations should be aware of the
potential for syncope (fainting) after vaccination and take
appropriate measures to prevent it. Thus, clinicians should (1)
make sure that people who are being vaccinated are always seated;
(2) be aware of symptoms that precede fainting (weakness,
dizziness, pallor, etc.); and (3) take appropriate measures to
prevent injuries if such symptoms occur. [Note: IAC has two
pertinent educational pieces for healthcare professionals: "Medical
Management of Vaccine Reactions in Children and Teens" at
http://www.immunize.org/catg.d/p3082a.pdf and "Medical Management
of Vaccine Reactions in Adult Patients" at
Since 2005, VAERS has received an increased number of reports of
syncope. Fainting among girls and young women ages 11-18 accounted
for most of the increase. Serious injuries have occurred, including
one fatality from intracranial hemorrhage caused by head trauma.
The May 2, 2008, MMWR included a summary of findings on the
increase in fainting after vaccination (see
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5717a2.htm). In people
for whom vaccination time and fainting time were reported, it was
discovered that 52% of fainting episodes occurred within 5 minutes
of vaccination and 70% occurred within 15 minutes. Vaccine
providers should strongly consider observing vaccinated people for
15 minutes after vaccination, in accordance with ACIP General
Recommendations (see http://www.cdc.gov/mmwr/PDF/rr/rr5515.pdf).
This is particularly important when vaccinating adolescents and
Q: Please describe the newly licensed rotavirus vaccine, Rotarix.
A: FDA licensed Rotarix (GSK) on April 3, 2008. It is approved for
oral administration as a 2-dose series to infants at ages 2 and 4
months. The lyophilized (freeze-dried) vaccine is reconstituted
with a 1-mL liquid diluent and administered from a prefilled oral
Q: How do the two rotavirus vaccines differ?
A: The rotavirus vaccination series consists of either two 1-mL
doses of Rotarix (GSK) given at ages 2 and 4 months or three 2-mL
doses of RotaTeq (Merck) given at ages 2, 4, and 6 months. CDC has
revised its recommendations to make the schedule less confusing:
the maximum age for the first dose of both vaccines is 15 weeks 0
days and the series should be completed on or before the time the
infant turns 8 months 0 days. CDC's recommendations for rotavirus
vaccine are available at http://www.cdc.gov/mmwr/PDF/rr/rr5802.pdf
Q: Now that there are two licensed vaccines for rotavirus that have
different schedules, how can we keep track of which vaccine an
infant might have previously received?
A: That may be difficult at first. The generic abbreviation for the
rotavirus vaccine was recently changed to "RV" (it used to be
"Rota"). CDC has also developed abbreviations to distinguish the
two RV vaccines. Rotarix is now abbreviated as RV1 (a monovalent
vaccine containing a live, attenuated human G1P virus), and
RotaTeq as RV5 (a pentavalent vaccine comprising 5 live reassortant
rotaviruses). Immunization providers should use these new
abbreviations when recording the vaccine they administered.
Q: If we don't know which rotavirus vaccine an infant previously
received, how should we complete the schedule?
A: If you have any doubt about which vaccine the infant previously
received and the infant is at an age when the vaccine can still be
given, give a total of 3 doses of rotavirus vaccine.
Q: Please describe the new combination vaccine Pentacel and how it
should be used.
A: On June 20, 2008, FDA licensed Pentacel (sanofi pasteur), a
DTaP-IPV/Hib combination vaccine. It is approved for use as a 4-dose series in infants and children at ages 2, 4, 6, and 1518
months. It should not be used for any dose in the primary series
for children age 5 years or older or as the booster dose for
children ages 4-6 years. The DTaP-IPV component is supplied as a
sterile liquid, which is used to reconstitute lyophilized (freeze-dried) ActHIB vaccine. The two components of the vaccine should be
stored together in the carton to reduce vaccine administration
errors. The DTaP-IPV component should never be administered alone.
Q: Can we give Pentacel to a child who has previously received
separate injections of one or more of these antigens?
A: Yes, as long as minimum intervals are maintained.
Q: Can I use Pentacel to give the 12-15 month booster dose of Hib
vaccine to children not at high risk of Hib complications, even
though there is a Hib vaccine shortage?
A: No. During the Hib vaccine shortage, you should not give
Pentacel as dose #4 of the series to children at low risk
Administer a single dose of DTaP for dose #4.
Q: Can we give Pentacel if we don't know the type of DTaP vaccine
the child previously received?
A: Yes. CDC recommends that whenever feasible, only one
manufacturer's DTaP product be used for the entire pertussis
series, but that vaccinations should not be deferred if the DTaP
product previously given is unavailable or unknown.
Q: Please tell us about the new combination vaccine Kinrix and the
recommendations for its use.
A: On June 24, 2008, FDA licensed Kinrix (GSK), a combination DTaP
and IPV vaccine. It is approved for use as the fifth dose of DTaP
and the fourth dose of IPV in children ages 4 through 6 years who
received DTaP (Infanrix) and/or DTaP-HepB-IPV (Pediarix) as the
first three doses and DTaP (Infanrix) as the fourth dose. It should
not be given to children younger than age 4 years.
Q: When administering combination vaccines like Kinrix and
Pentacel, which VISs should be used?
A: You can use either the individual VISs that exist for the
separate antigens or you can use the multi-vaccine VIS. Remember to
check the appropriate boxes on the front page of the multi-vaccine
Q: We have a 13-year-old patient who was given DT (pediatric) as a
preschooler after she had experienced excessive crying following a
dose of DTP. Now, we are wondering if we can give her Tdap since we
know she may not be protected against pertussis.
A: Yes, you can. Many of the precautions to DTaP (e.g., temperature
of 105 degrees F or higher, collapse or shock-like state,
persistent crying lasting 3 hours or longer, seizure with or
without fever) do not apply to Tdap. This issue is discussed in
CDC's Tdap recommendations, available at
Q: We gave Tdap to a child who was just short of their 10th
birthday. What should we do?
A: Use of Tdap in children ages 7-9 years is considered off-label
and is not recommended; however, the dose can be counted and does
not need to be repeated with Td.
Q: When a patient seen in the ER needs tetanus protection, which
vaccine should be given, Td or Tdap?
A: Adolescents and adults ages 11-64 years who require a tetanus
toxoid-containing vaccine as part of wound management should
receive a single dose of Tdap instead of Td, if they have not
previously received Tdap. If Tdap is not available, or was
previously administered, these persons should receive Td.
Q: When will the Hib vaccine shortage be over?
A: It is anticipated that the Hib vaccine supply will improve in
the last quarter of 2009.
Q: Can a woman complete the HPV series after age 26 years?
A: The series should be completed, even if this means that the
series is completed after a woman turns 27.
Q: We've heard stories in the media lately about severe reactions
to the HPV vaccine. Is there any substance to these stories?
A: No. In summer 2008 some concerns were raised over two issues--reports of deaths and reports of Guillain-Barre syndrome (GBS)
following vaccination with Gardasil. As of August 2008, Merck
reported it had distributed more than 20 million doses of Gardasil
in the United States. The Vaccine Adverse Events Reporting System
(VAERS) had received reports of 27 deaths. CDC reported that there
was not a common pattern to the deaths; if there had been a common
pattern, it would suggest the deaths might be caused by the
vaccine. Occurrences of GBS, a rare neurological disorder, have
been reported through VAERS. FDA and CDC reviewed the reports and
found no evidence that Gardasil increased the rate of GBS above
what is expected in the population. CDC, working with the FDA and
other immunization partners, will continue to monitor the safety of
Gardasil. You can find complete information on this and other
vaccine safety issues at http://www.cdc.gov/vaccinesafety
Q: Who is recommended to be vaccinated against meningococcal
A: CDC recommends routine vaccination against meningococcal disease
for the following groups:
- All previously unvaccinated adolescents ages 11 through 18 years
- All previously unvaccinated college freshmen who will be living
- All persons ages 2 years and older with anatomic or functional
asplenia, or terminal complement component deficiencies
- All persons ages 2 years and older who travel to or reside in
countries in which N. meningitidis is hyperendemic or epidemic,
particularly if contact with the local population will be
prolonged; this includes anticipated travel to Mecca, Saudi
Arabia, for the annual Hajj
- Any person working as a microbiologist with routine exposure to
isolates of N. meningitidis
- Military recruits, and
- Any other person wishing to decrease their risk for
Q: Why isn't hepatitis A vaccine recommended for sewage and solid
waste disposal workers?
A: Existing data do not support the use of hepatitis A vaccine
routinely in this setting. In published reports of three serologic
surveys conducted among U.S. wastewater workers and appropriate
comparison populations, no substantial or consistent increase in
the prevalence of anti-HAV was identified among wastewater workers.
No work-related instances of HAV transmission have been reported
among wastewater workers in the United States.
Q: Who is recommended to receive 2 doses of varicella vaccine?
A: All persons without evidence of varicella immunity age 12 months
and older should receive 2 doses of varicella vaccine. For children
ages 12 months through 12 years, the minimum interval between doses
is 3 months; for persons age 13 years and older, the minimum
interval is 4 weeks.
Q: I understand that Varivax, ProQuad, and Zostavax each have
different concentrations of antigen. Would you tell me how they
A dose of Varivax has 1,530 plaque forming units (PFUs), ProQuad
contains 9,800 PFUs (7 times higher than Varivax), and Zostavax
contains 19,400 PFUs (13 times higher than Varivax).
Q: Can we give zoster vaccine to elderly patients who have cancer
or an immunosuppressed condition?
A: No. Zoster vaccine is contraindicated in persons with primary or
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
You can email your question about vaccines or immunization to IAC
at firstname.lastname@example.org As we receive hundreds of emails each month,
we cannot guarantee that we will print your specific question in
the "Ask the Experts" feature. However, you will get an answer. To
see if your question has already been answered, you can first check
the "Ask the Experts" online archive at
You can also email CDC's immunization experts directly at
email@example.com There is no charge for this service.
If you have a question about IAC materials or services, email
Please forward these "Ask the Experts" Q&As to your co-workers and
suggest they subscribe to IAC Express at