Vaccine Update for Healthcare Providers

Technically Speaking

Deborah L. Wexler, MD, Executive Director, Immunization Action Coalition

• Recommendations for use of meningococcal vaccines in high-risk infants and children April 2013 
• What to do if the wrong dose of a vaccine is administered March 2013 
• CDC’s 2013 immunization schedules and IAC’s easy-to-use summaries Feb. 2013 
• Expanded Tdap Recommendations: Administer Tdap to Pregnant Women during Each Pregnancy Jan. 2013 

Recommendations for use of meningococcal vaccines in high-risk infants and children

The recommendations and available products for meningococcal vaccination of high-risk infants and children have evolved since 2007 when ACIP first recommended vaccination of children age 2 to 10 years who are at increased risk for meningococcal disease. Published on March 22, 2013, the current recommendations summarize and compile all previous meningococcal recommendations. The current recommendations are complex; for example, in the recommendations for vaccinating people in certain risk groups, the number of recommended vaccine doses and products varies, and includes some off-label use. This column offers an overview of the meningococcal recommendations for vaccinating high-risk infants and children, and provides links to some valuable resources that will help healthcare professionals make appropriate vaccination decisions.

It is important to understand the differences between vaccines available for meningococcal immunization. The nomenclature for meningococcal vaccines is based on both the number of serotypes included in the vaccine and whether the vaccine is conjugate or polysaccharide. Menomune® (Sanofi Pasteur), the only polysaccharide meningococcal vaccine, is known as MPSV4, with the 4 denoting the number of serotypes in the vaccine. Two different licensed quadrivalent meningococcal conjugate vaccines — Menactra® (MCV4-D, Sanofi Pasteur) and Menveo® (MCV4-CRM, Novartis) — are known as MCV4. All three vaccines (the polysaccharide and both conjugates) include the same 4 serotypes (A, C, W and Y). Licensed in June 2012, MenHibrix® (Hib-MenCY; GSK) is indicated to prevent invasive disease caused by Neisseria meningitidis serogroups C and Y and Haemophilus influenzae type b (Hib). MenHibrix® protects only against meningococcal serogroups C and Y; it does not protect against serogroups A and W. In general, ACIP recommends routine meningococcal vaccination of children age 2 months and older who are at increased risk for meningococcal disease, including:

• Children age 2 months and older with certain medical conditions, such as anatomical or functional asplenia or complement component deficiency; and
• Children age 9 months and older who travel to or reside in countries in which meningococcal disease is hyperendemic or epidemic, particularly if contact with the local population will be prolonged.

The recommended product, dosing schedule and interval for booster dose(s) vary based on many factors. For example, a 12-month-old infant traveling to Saudi Arabia should get two doses of MCV4-D, three months apart, but an infant with asplenia should get Hib-MenCY at ages 2, 4, 6, and 12–15 months. Due to these complexities, providers who use these vaccines should consider printing the following resources for reference when needed. These resources also include information about routine meningococcal vaccination of adolescents and recommendations for vaccinating high-risk adults.

• “Prevention and Control of Meningococcal Disease: Recommendations of the Advisory Committee on Immunization Practices (ACIP).” MMWR 2013; 62[No. RR-2]
• “Meningococcal Vaccination Recommendations by Age and/or Risk Factor” (a summary table)

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What to do if the wrong dose of a vaccine is administered

Sometimes healthcare personnel inadvertently administer the wrong dose of a vaccine to a child or adult patient. This often happens with vaccines that come in both pediatric and adult formulations, such as hepatitis A and hepatitis B vaccines, which are available in both 0.5 mL and 1.0 mL formulations. Routinely used injectable influenza vaccines come in two dosing amounts as well, with 0.25 mL for use in children younger than age 3 years and 0.5 mL for people age 3 years and older. Below is some guidance on what to do when such dosing errors occur, and how to avoid these errors in the future.

If you administer too large a dose

If you’ve administered too large a dose (e.g., you’ve given an “adult” dose to a child) instead of the correct dose of hepatitis A, hepatitis B, or influenza vaccine, inform the patient, parent or guardian of the administration error and document it in the medical record. This dose counts as valid. Although it is unlikely that your patient will suffer any untoward side effects from receiving a “double dose” of vaccine, using larger-than-recommended dosages can result in excessive local or systemic concentrations of antigens or other vaccine constituents. When errors of this nature occur, it is important to assess how the error happened and to implement strategies to ensure they will not be repeated. Administering larger-than-recommended doses of any vaccine does not negate the need for subsequent recommended doses.

If you administer too small a dose

If you’ve administered a pediatric dose or half dose of a vaccine in error, consider the dose invalid and repeat it. Giving less than a full dose might result in inadequate protection. Revaccinate the patient with the appropriate dose according to recommendations specific to inactivated and live-virus vaccines. You may give the additional dose during the same visit if the error is discovered while the patient is still in the office.

If you administer the wrong brand of influenza vaccine

If you’ve administered an injectable influenza vaccine product that is not licensed for use in a child the age of the child you have vaccinated, this is an administration error. In such a case, if you administered the correct dosage to the child, even though it is the wrong product, consider the dose valid and do not repeat it. Inform the patient, parent or guardian of the error and document it in the medical record.

Resources that can help

Here are examples of some strategies you can implement to prevent administering the wrong dose of vaccine:

• Store pediatric and adult vaccines in different locations within the refrigerator and clearly mark the vaccine storage containers as “pediatric” or “adult.”
• Put the age indication on the container that holds the vaccine boxes in the refrigerator.
• Consult the following resources, including “The Rights of Medication Administration.” These resources will help you avoid future errors.
  • Hepatitis A & B Vaccines—Be sure your patient gets the correct dose!
    from the Immunization Action Coalition
  • Influenza Vaccine Products for the 2012–13 Influenza Season
    from the Immunization Action Coalition
  • Vaccine Administration: “The Rights of Medication Administration”
    which is included in CDC’s “Epidemiology and Prevention of Vaccine-Preventable Diseases, aka The Pink Book”

Finally, remember you can report vaccine administration errors confidentially to the National Vaccine Error Reporting Program, which is part of the Institute for Safe Medication Practices.

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CDC’s 2013 immunization schedules and IAC’s easy-to-use summaries

Early each year, CDC publishes updated versions of the recommended U.S. immunization schedules to reflect changes that occurred throughout the previous year. This year, for the first time, schedules for children, teens and adults were all published simultaneously. If you have not seen them, consult the January 28, 2013 supplement issue of Morbidity and Mortality Weekly (MMWR). Although the updates for 2013 were not vast, it is important that your office staff, as immunization providers, is aware of the updates and implement appropriate procedural changes if necessary.

To make your job easier, the Immunization Action Coalition (IAC) has designed two user-friendly documents that summarize guidance in the current CDC recommendations: Summary of Recommendations for Child/Teen Immunization and Summary of Recommendations for Adult Immunization. Every year, IAC updates both summaries to reflect the new and updated recommendations made throughout the year by CDC’s Advisory Committee on Immunization Practices (ACIP). The summaries distill hundreds of pages of ACIP recommendations for child, teen and adult immunization into two handy, easy-to-use documents.

Formatted as a four-page reference table of essential immunization information for healthcare professionals, each summary incorporates information from the most current U.S. immunization schedules. This includes the spacing between doses, schedules for catch-up vaccination, routes of administration, and contraindications and precautions for all routinely recommended vaccines in the United States. The child/teen summary covers vaccines recommended for people from birth through age 18 years, and the adult schedule covers vaccines recommended for people 19 years and older.

With new vaccines being licensed and the recommended immunization schedules growing more complex, it is difficult to keep all the details in one’s mind. Supplying all vaccine providers in your healthcare setting with copies of the summaries will help them follow the ACIP recommendations and avoid such scheduling errors as giving vaccines too close together or administering them by the wrong route. In addition, the summaries include pithy general advice, such as "any vaccine can be given with another" and "mild illness is not a contraindication," which will help you avoid missing opportunities to vaccinate.

The summaries have long proved their value--for almost two decades, they have been the most popular downloads from IAC's busy website for healthcare professionals, www.immunize.org. They have been reprinted in textbooks and state health department newsletters and distributed at countless medical, nursing, and public health conferences. Take a look at the freshly updated 2013 Summary of Recommendations for Child/Teen Immunization and Summary of Recommendations for Adult Immunization. Print the summaries on card stock and place them in every exam room for easy reference--you'll be glad you did!

Summary of Recommendations for Child/Teen Vaccination
Summary of Recommendations for Adult Vaccination
Access to more than 250 ready-to-copy IAC materials for healthcare professionals and patients

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Expanded Tdap Recommendations: Administer Tdap to Pregnant Women during Each Pregnancy

At its October 2012 meeting, CDC’s Advisory Committee on Immunization Practices (ACIP) voted to expand its recommendation for the use of Tdap vaccine during pregnancy to provide further protection to pregnant women and infants from pertussis (whooping cough). The new recommendations call for administering Tdap to every pregnant woman during each pregnancy, regardless of previous Tdap vaccination history. Optimal timing for administering the dose is at 27 through 36 weeks’ gestation to maximize the maternal antibody response and the passive antibody transfer to the infant.

If Tdap is not administered during pregnancy and has not been administered at any time before the current pregnancy, Tdap should be given to the mother immediately postpartum, before leaving the hospital or birthing center.

Providers of prenatal care should implement a Tdap immunization program for all pregnant women to assure that all pregnant women and their babies are protected from pertussis.

Prior to this new guidance, the ACIP recommendation for the use of Tdap vaccine in pregnant women was to administer the vaccine during the latter half of pregnancy, beginning as early as the 20th week, to those pregnant women who were previously unvaccinated. Tdap was to be given as a one-time dose.

The recommendations voted on in October 2012 were published in December 2012 on the CDC website in a document titled Provisional Updated Recommendations on Use of Tetanus Toxoid, Reduced Diphtheria toxoid and Acellular Pertussis Vaccine (Tdap) for Pregnant Women*

More Information on the Importance of Administering Tdap in Pregnancy

Of the 27,550 cases of pertussis reported in 2010, 3,350 were in infants younger than 6 months of age, and 25 of those infants died. According to studies of pertussis cases in infants, the source of infection can be traced to the mother in 30 percent to 40 percent of cases.

Administering the Tdap dose likely provides protection against pertussis in early life, before and during the time the baby is receiving his or her first three doses of DTaP vaccine. Tdap will also protect the mother at the time of delivery, making her less likely to transmit pertussis to her infant.

Related Resources

• CDC Media Advisory, October 24, 2012: ACIP Recommends Tdap Immunization for Pregnant Women
• Provisional Updated Recommendations on Use of Tdap for Pregnant Women
• Tdap for Pregnant Women: Information for Providers - CDC web page

*ACIP provisional recommendations become official CDC recommendations once they are accepted by the director of CDC and the Secretary of Health and Human Services and are published in MMWR. In the interim, ACIP provisional recommendations are made available by CDC so that providers have guidance to follow when implementing new recommendations.

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