Volume 22 – Number 3 August 2012

NEEDLE TIPS (content current as of August 13)

from the Immunization Action Coalition — www.immunize.org

What’s In This Issue

Ask the ExpertsIAC extends thanks to our experts, medical epi-demiologist Andrew T. Kroger, MD, MPH; nurse educator Donna L. Weaver, RN, MN; and medical officer Iyabode Akinsanya-Beysolow, MD, MPH. All are with the National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention (CDC).

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Immunization questions?• CalltheCDC-INFOContactCenterat(800)232-4636or(800)CDC-INFO

• Emailnipinfo@cdc.gov•Callyourstatehealthdept.(phonenumbersatwww.immunize.org/coordinators)

Stay current with FREE subscriptions TheImmunizationActionCoalition’s

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Adult Immunization . . . We’ve got to do better! ......................................................... 1Ask the Experts: CDC answers questions ... 1IAC Express Celebrates 1000 Issues ......... 2Vaccine Highlights: Recommendations, schedules, and more .................................. 4Vaccinations for Adults: You’re never too old to get immunized! ................................. 6Vaccination Handouts for High-Risk Adults .. 7How to Administer IM and SC Vaccine Injections to Adults ...................................... 8Administering Vaccines to Adults: Dose, Route, Site, and Needle Size ..................... 9Hepatitis A, B, and C: Learn the Differences ...10Meningococcal Vaccination Recommen- dations by Age and/or Risk Factor ..............11CDC Information for Health Care Pro- fessionals about Adolescent Vaccines ........12CDC Handouts for Parents about Vaccines for Preteens and Teens ..............................13CDC Poster: Childhood whooping cough ...14CDC Poster: Childhood measles ................15Current Dates of VISs .................................16IAC’s Immunization Resources Order Form ...17

Immunization questionsPneumococcal polysaccharide vaccine (PPSV23) is recommended for all adults who smoke. Are there recommendations for those who use smokeless tobacco products (e.g., chewing tobacco)?No.ACIPdoesnotidentifypeoplewhousesmoke-lesstobaccoproductsasbeingatincreasedriskforpneumococcaldiseaseorasbeinginariskgroupforvaccination.

Now that FDA has licensed Prevnar 13 (PCV13; Pfizer) for adults, does ACIP have recommendations for its use?Todate,ACIPhasnotmaderecommendationsforroutineuseofPCV13foradults;however,atitsJune 2012meeting,ACIP voted to recommendadministering1doseofPCV13toadultsage19andolderwhoareathighestriskforinvasivepneu-mococcal disease.This includes adultswho areimmunosuppressedandthosewithfunctionalor

anatomicasplenia, renaldisease,CSF leak, andcochlearimplants.ACIPvotedtorecommendthatwhenhealthcareprovidersvaccinatehighest-riskpatientswhohaveneverreceivedapneumococcalvaccine,theprovideradministerPCV13first,thenfollowwithadoseofpneumococcalpolysaccha-ridevaccine(PPSV23)8weekslater,andfollow

Followingisasnapshotof2010U.S.adultvac-cinationcoverageforfiveroutinelyrecommendedvaccines:•Amongadultsage19–64yearsforwhomTdapstatusspecificallycouldbeassessed,Tdapvac-cinationcoveragewas8.2%.1

•Among adults age 60 years and older, zoster(shingles)vaccinationcoveragewas14.4%.1

•Among women age 19–26 years, reported re-ceiptof1ormoredosesofHPVvaccinewas20.7%.1

•Amongadultsage18yearsandolder,influenzavaccinationcoverageduringthe2010–11influ-enzaseasonwas40.5%.2

•Amongadultsage65yearsandolder,pneumo-coccalvaccinationcoveragewas59.7%overall,withnotableracialandethnicdisparities.Non-Hispanic whites of this age group had highervaccination coverage (63.5%) compared withHispanics(39%),non-Hispanicblacks(46.2%),andnon-HispanicAsians(48.2%).1

Annually,vaccine-preventablediseasesclaimthelivesofapproximately50,000U.S.adults.Obvi-ously,healthcareprovidersneed tosubstantiallyimprove adult vaccination to reduce the seriousconsequencesofdisease.

Successful vaccination programs need to (1)educatepotentialvaccinerecipients;(2)developpublicitytopromotevaccination;(3)increaseac-cesstovaccinationservicesinmedicalofficesand

Adult Immunization . . . We’ve got to do better!

complementarysettingssuchasworkplacesandpharmacies;(4)usereminder-recallsystems,(5)implementstandingordersprogramsforvaccina-tion;and(6)assesspractice-levelvaccinationratesandprovidefeedbacktostaffmembers.

Whatcanhealthcaresettingsdotoimplementadultvaccination programs that contain the elementslistedabove?Practicalonlineinformationisavail-ableontheImmunizationActionCoalition’snewcompilationofAdultImmunizationResourcesatwww.immunize.org/adult-vaccination.The8-pagelistingprovidesaccesstonumerousdocumentsonclinicoperations,providerandpatienteducation,MedicareandCMS,officeoperations,policy,andproviderandpharmacytraining.

Developed for presentation at the firstNationalAdultImmunizationSummit(NAIS;heldinMay2012), the listingis the initialstepincreatingasearchable database of adult immunization re-sources,whichwillbehousedonIAC’swebsite.ThedatabasewillincluderesourcesandtoolsusedbyNAISadultimmunizationpartnerstoimproveadultvaccinationcoverage.

1 CDC. Adult Vaccination Coverage—United States, 2010.MMWR2012;61;66–71.2 CDC. Final state-level influenza vaccination coverage esti-mates for the 2010–11 season—United States, National Im-munization Survey and Behavioral Risk Factor SurveillanceSystem,August2010throughMay2011.

NEEDLE TIPS •August2012•ImmunizationActionCoalition•(651)647-9009•www.immunize.org•www.vaccineinformation.org 5

Needle Tips correction policyIfyoufindanerror,pleasenotifyusimmediatelybysendinganemailmessagetoadmin@immunize.org.Wepublishnotificationof significanterrors inouremailannouncementservice,IAC Express.Besureyou’resignedupforthisservice.Tosubscribe,visitwww.immunize.org/subscribe.

withaseconddoseofPPSV235yearslater.Forhighest-risk patientswho have already receivedPPSV23,ACIPvotedtorecommendthathealthcareprofessionalswait1yearsincethepreviousdoseofPPSV23beforegivingPCV13toavoidinterferencebetweenthevaccines.MoredetailwillbeincludedwhenMMWRpublishestherecommendations.

I am confused about which adults to vaccinate with Tdap vaccine and which product to use. Please help!CDCpublishedupdatedrecommendationsonTdapvaccinationforadultsinMMWRonJune29,2012,pages468–470.ACIPrecommendsthatALLadultsage19yearsandolderwhohavenotyetreceivedadoseofTdapreceiveasingledose.Tdapshouldbeadministeredregardlessofintervalsincethelasttetanus-ordiphtheria-toxoid–containingvaccine(e.g.,Td).AfterreceivingTdap,peopleshouldre-ceiveTdevery10yearsforroutineboosterimmu-nizationagainsttetanusanddiphtheria,accordingtopreviouslypublishedguidelines.Providersshouldnotmissanopportunitytovac-

cinateadultsage65andolderwithTdap.There-fore,providersmayadministeranyTdapvaccinethey have available. When feasible, providersshouldadministerBoostrix(Tdap;GSK)toadultsage65andolderasitislicensedforthisagegroup.Adacel(Tdap;sanofi)islicensedforuseinpeopleage11through64.However,ACIPconcludedthat

eithervaccineadministeredtoapersonage65orolderisimmunogenicandwillprovideprotection.Adoseofeithervaccineisconsideredvalid.When a tetanus-toxoid–containing vaccine is

neededforwoundmanagementinapersonwhohasnotpreviouslyreceivedTdap,theuseofTdapispreferredoverTd.

Is there guidance for pertussis protection for an adult who cannot receive the tetanus por-tion of the Tdap vaccine because of allergy?Usually,an“allergy”totetanustoxoidisanecdotalandnotatrueanaphylacticreactiontomodernteta-nustoxoid.Patientsoftenclaimtobeallergictotetanustoxoidbecauseof(1)anexaggeratedlocalreaction(whichisnotanallergy)or(2)areactiontoatetanusvaccinereceivedmanyyearsago(prob-ablyserumsicknessfromequinetetanusantitoxin).Ahistoryofoneoftheseeventsisnotacontrain-dicationtomoderntetanustoxoid,Td,orTdap.Onlyanallergist-confirmedanaphylacticallergy

to tetanus toxoid should be accepted as a validcontraindicationtoamoderntetanus-toxoid–con-taining product.A personwho has an allergist-confirmedanaphylacticallergytotetanustoxoidhasnorecourseforpertussisvaccinationbecausenosingle-antigenpertussisvaccineislicensedforuseintheUnitedStates.

Who should get a second dose of Tdap vaccine? Currently,nooneisrecommendedtoreceivemorethan1doseofTdap.Inthefuture,ACIPwilldis-cusstheneedforadministeringadditionaldosesofTdapandthetimingofrevaccinatingpeoplewhohavereceivedTdappreviously.

Why do we vaccinate pregnant women against influenza when it is not recommended to vac-cinate infants younger than age 6 months?ACIP has recommended vaccinating pregnant

womenwithinactivatedinfluenzavaccine(TIV)foranumberofyears.Pregnantwomenareahigh-riskgroupforcomplications,hospitalization,andevendeathfrominfluenzabecauseoftheincreasedphysiologic strain of pregnancy on their heart,lungs,and immunesystem.Vaccinationcanoc-curinanytrimester,includingthefirst.Influenzavaccineisnotrecommendedforchil-

drenyoungerthanage6monthsbecauseitisnot

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Now Available! 2012 Edition The Vaccine Handbook:

A Practical Guide for Cliniciansby Gary S. Marshall, MD

www.immunize.org/vaccine-handbook

S ne

HHS newsOnJune5,theOfficeofInspectorGeneraloftheU.S.DepartmentofHealthandHumanServices(HHS) released a report titled Vaccines for Children Program: Vulnerabilities in Vaccine Management.Foratwo-weekperiodin2011,theInspectorGeneral’sofficeconductedsitevisitsatthepracticelocationsof45VaccinesforChildren(VFC) providers and independently measuredtheproviders'vaccinestorageunit temperatures.Although the majority of storage temperatureswere within the required ranges, VFC vaccinesstoredby76percentofthe45selectedproviderswere exposed to inappropriate temperatures foratleast5cumulativehoursduringthetwo-weekmonitoring period.Access a report summary athttp://oig.hhs.gov/oei/reports/oei-04-10-00430.asp.Thecompletereportisavailableathttp://oig.hhs.gov/oei/reports/oei-04-10-00430.pdf.

Ask the Experts . . . continued from page 1

Vaccine Highlights . . . continued from page 4

•MeningococcalVaccinationRecommendationsby Age and/or Risk Factor www.immunize.org/catg.d/p2018.pdf

•CurrentDatesofVaccineInformationState-mentswww.immunize.org/catg.d/p2029.pdf

• TipsforLocatingOldImmunizationRecordswww.immunize.org/catg.d/p3065.pdf

•KeepYourKidsSafe—GetThemVaccinated Every Fall or Winter!English/Spanish/Arabic/Chinese

NewHandoutsandWebSectionsfromtheImmunizationActionCoalitionIACdevelopedthefollowinghandoutsandwebsectionsforhealthcarestaff

and/orthegeneralpublic.Download,print,anddistributethemfreely.

•H3N2vInfluenzaOutbreakInformation www.immunize.org/influenza/h3n2v

•CocooningandTdapVaccination www.immunize.org/cocooning

• TheVaccineHandbookwww.immunize.org/vaccine-handbook

• TechnicallySpeakingwww.immunize.org/technically-speaking

• PharmacistsandImmunizationwww.immunize.org/pharmacists

ToaccessallIAC’shandouts(morethan250),gotowww.immunize.org/handouts

18 NEEDLE TIPS •August2012•ImmunizationActionCoalition•(651)647-9009•www.immunize.org•www.vaccineinformation.org

Ask the Experts . . . continued from page 5

Andrew T. Kroger, MD, MPH Donna L. Weaver, RN, MN Iyabode Akinsanya-Beysolow, MD, MPH

IAC’s“AsktheExperts”

teamfromCDC

approvedforthisagegroup.Inaddition,therearedatathatindicatethatvaccinatedpregnantwomenpassmaternalantibodiestothefetusinthelastfewweeksofpregnancy;thishelpsprotecttheyounginfant against influenza. Vaccinating pregnantwomenthusprotectswomen,theirunbornbabies,andtheirbabiesafterbirth.

A child received a 0.25 mL dose of inactivated influenza vaccine (TIV) at age 34 months. She is scheduled to return for the second dose at age 36 months. Should she receive a 0.25 mL dose or a 0.5 mL dose?Sheshouldreceivea0.5mLdoseofTIV.Always administer the volume of vac-cineappropriatetotheageofthepatientwhenthepatientpresentsattheclinicforthedose.

If Cervarix (HPV2; GSK) is inadvertently ad-ministered to a male, does the dose need to be repeated with Gardasil (HPV4; Merck)?Yes.Cervarixisrecommendedforuseonlyinfe-males.ThereisnominimumintervalbetweentheinvaliddoseofCervarixandthedoseofGardasil.ACIPrecommendsroutinevaccinationofmales

age 11–12 years with HPV4 administered as a3-doseseries.Thevaccinationseriescanbestart-edatage9years.VaccinationwithHPV4isalsorecommendedformalesage13through21yearswhohavenotbeenvaccinatedpreviouslyorwhohavenotcompletedthe3-doseseries.Malesage22through26yearsmaybevaccinatedwithHPV4;ACIPspecificallyrecommendsroutinevaccinationwithHPV4throughage26yearsforimmunocom-promisedmalesandmenwhohavesexwithmeniftheyhavenotbeenvaccinatedpreviouslyorhavenotcompletedthe3-doseseries.

Is it safe to give the shingles vaccine (Zos-tavax; Merck) to patients age 60 years and older who have had a splenectomy? I am con-cerned because it’s a live virus vaccine.Yes,itissafe.Asplenicpeoplecangetallvaccinesindicated.Immunosuppressionisnotaconsider-ationunlessthepatienthasotherhealthissuesorisundergoingtreatmentsthatsuppresstheimmunesystem.Apatient’sresponsetoshinglesvaccina-tionshouldnotbeaffectedbythelackofafunc-tioningspleen.

If a healthcare worker does not have a history of varicella vaccination or disease but has had a clinically diagnosed case of shingles, does she or he still need varicella vaccination?No. A healthcare provider’s diagnosis or veri-fication of a history of shingles is acceptable

evidenceofimmunitytovaricella.AccordingtoACIP,acceptableevidenceofvaricellaimmunityinhealthcarepersonnel includes (1)documenta-tionof2dosesofvaricellavaccinegivenatleast28days apart, (2) historyof varicella or herpeszosterbasedonphysiciandiagnosis,(3)laboratoryevidenceofimmunity,or(4)laboratoryconfirma-tionofdisease.

ACIP recommends that adolescents who receive the first dose of meningococcal conjugate vaccine (MCV4) at age 13–15 years receive a one-time booster dose at age 16–18

You can find translations of VISs in more than

30 languages at

www.immunize.org/vis

years. Given how hard it is to get teens into a medical office, is it okay to give the doses close together if the opportunity arises? For example, if a patient got the first dose at age 15, and then came back for a sports physical at age 16, could we give the second dose of MCV4 then or should we try to space it out as far as possible (age 18)?Ifthefirstdoseisgivenatage13through15years,youcangivetheboosterdoseasearlyasage16years,withaminimumintervalof8weeksfromthepreviousdose.So,evenifthepatientgotvac-cinatedatage15years11months,youcouldwaitatleast8weeksandthengivetheboosteratage16years1month(orlater)ifyouchosetodoso.

A 12-year-old patient new to our clinic brought immunization records from her previous clinic. Her records show that she received Meno-mune (meningococcal polysaccharide vaccine; MPSV4; sanofi) when she was age 11. Is this considered adequate coverage for the 11–12

year-old dose? Can we wait until she is 16 to give the meningococcal con-jugate vaccine (MCV4) dose?The answer to both of your questionsisyes.YoucancounttheMPSV4doseasvalid.AlthoughMCV4 ispreferred,MPSV4islicensedforthisagegroup,andadoseofeithervaccine(i.e.,MCV4orMPSV4)atage10orolderisconsideredvalid.JustmakesuretheseconddoseisMCV4.

Can you switch brands of rabies vac-cine to complete the 4-dose series?Yes.Thetworabiesvaccineslicensedfor

useintheUnitedStatesareinterchangeable.

To submit an “Ask the Experts” question . . .You can email your questions about immunization to us at admin@immunize.org. IAC will respond to your inquiry. Because we receive hundreds of emails each month, we cannot guarantee that we will use your question in “Ask the Experts.” IAC works with CDC to compile new Q&As for our publications based on commonly asked questions. Most of the questions are thus a composite of several inquiries.

To receive “Ask the Experts” Q&As by email, subscribe to the Immunization Action Coalition’s news service, IAC Express.

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