A: The dose should be repeated. If the expired dose is a live virus vaccine, wait at least 4 weeks 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. If you prefer, you can perform serologic testing to check for immunity for certain vaccinations (e.g., measles, mumps, rubella, varicella, and hepatitis A).
A: In general, a vaccine should not be prepared until the provider is ready to administer it to a patient. This is because once the syringe cap is removed or a needle is attached, the sterile seal is broken. However, if a sterile seal has been broken, staff should be sure to maintain the syringe at the appropriate temperature and either use it or discard it at the end of the clinic day. This issue is addressed in the CDC Storage and Handling Toolkit, available at www.cdc.gov/vaccines/hcp/admin/storage/toolkit/storage-handling-toolkit.pdf, page 38.
A: ACIP discourages the practice of prefilling vaccine into syringes, primarily because of the increased possibility of administration and dosing errors. An exception may be considered when only a single type of vaccine is to be administered during a clinic (for example, influenza). Another reason to discourage the practice in general is that some vaccines have a very limited shelf life after reconstitution. If the reconstituted vaccine is not used within the designated time period, it must be discarded. A chart of the time allowed between reconstitution and use, “Vaccines with Diluents: How to Use Them,” is available at www.immunize.org/catg.d/p3040.pdf. For more information on prefilling syringes, please read www.immunize.org/technically-speaking/20110901.asp.
A: No. The 3-dose series (at 0, 1–2 and 6 months) is intended to rapidly induce immunity to serogroup B meningococcal bacteria. If a microbiologist or other person at increased risk has received 2 doses of Trumenba separated by 6 months, their vaccine series can be considered to be complete.
A: There are various requirements for the use of vaccines after reconstitution. Some manufacturers’ package inserts require that the vaccine be used or discarded in varying time frames ranging from 24 hours after reconstitution to immediately after reconstitution. While the specific time frames are simple to interpret, there can be some confusion as to what the requirement of “immediately” actually means.
CDC considers “immediately” to be the reasonable time it takes to prepare and transport the vaccine to the patient to be administered. This would include any limited documentation that may be related to this process. It is up to the judgment of a provider to determine if a vaccine has not been used in the appropriate time. Some manufacturers have indicated to providers that “immediately” can be up to 30 minutes. The definition of “immediately” varies from manufacturer to manufacturer. Some do not have the data to put forth a general time frame as to what “immediately” means. CDC recommends that the provider contact the manufacturer any time (s)he has any question about whether or not the vaccine has been used in the appropriate time frame.
A: Routine polio vaccination of U.S. residents 18 years of age and older—including those working in healthcare or in healthcare-related training—is not recommended. Polio vaccination is recommended for all travelers to countries with wild poliovirus (WPV) or vaccine-derived poliovirus (VDPV) circulation. Countries are considered to have WPV or VDPV circulation if they have evidence during the previous 12 months of ongoing endemic circulation (WPV only), a polio outbreak, or environmental evidence (through sewage sampling) of WPV or VDPV circulation. For additional information on countries with WPV or VDPV circulation and vaccine recommendations, consult the travel notices on the CDC Travelers’ Health website (www.cdc.gov/travel) or the weekly update of reported WPV and VDPV cases at the Global Polio Eradication Initiative website (www.polioeradication.org/Dataandmonitoring/Poliothisweek.aspx).
Adults who are traveling to areas where WPV or VDPV is actively circulating and who are unvaccinated, incompletely vaccinated, or whose vaccination status is unknown should receive a series of 3 doses: 2 doses of IPV administered at an interval of 4–8 weeks; a third dose should be administered 6–12 months after the second. If 3 doses of IPV cannot be administered within the recommended intervals before protection is needed, the following alternatives are recommended:
If more than 8 weeks is available before protection is needed, 3 doses of IPV should be administered at least 4 weeks apart.
If less than 8 weeks but more than 4 weeks is available before protection is needed, 2 doses of IPV should be administered at least 4 weeks apart.
If less than 4 weeks is available before protection is needed, a single dose of IPV is recommended.
If less than 3 doses are administered, the remaining IPV doses to complete a 3-dose series should be administered when feasible, at the intervals recommended above, if the person remains at increased risk for poliovirus exposure.
If an adult at risk previously received only one or two documented doses of polio vaccine (either OPV or IPV), he or she should receive the remaining dose(s) of IPV, regardless of the interval since the last dose. It is not necessary to restart the vaccination series.
Adults who have completed a routine series of polio vaccine are considered to have lifelong immunity to poliomyelitis, but data on duration of immunity are lacking. As a precaution, adults 18 years of age or older who are traveling to areas where WPV or VDPV is actively circulating and who have received a routine series with either IPV or OPV in childhood should receive another dose of IPV before departure. For adults, available data do not indicate the need for more than a single lifetime booster dose with IPV.
A 22-year-old female is going to pharmacy school, and the school wants her to have a second dose of MMR vaccine. She had the first dose as a child and developed measles within 24 hours of receiving the vaccine. Recent serologic testing showed she is immune to mumps and measles but not immune to rubella. Can I give her a second dose of the MMR with her having measles after the first dose?
Yes. As a healthcare professional, this person should get a second dose of MMR to ensure she is immune to rubella. There is no harm in providing MMR to a person who is already immune to one or more of the components. If she developed measles only one day after receiving her first MMR, she must have been exposed to the disease prior to vaccination.
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 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.
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 FDA in June 2016. ACIP has not yet published recommendations for Vaxchora. However, at the 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 one 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.