Stanley E. Grogg, DO, FACOP, FAAP, interprets the footnotes and addresses commonly asked questions about MMR, VAR and more, in part two of the new immunization blog series.
By Stanley E. Grogg, DO, FACOP, FAAP; AOA Liaison Member to the CDC’s Advisory Committee on Immunization Practices (ACIP)
Each year, at the end of February or early March, the immunization schedules are published by the U.S. Centers for Disease Control and Prevention (CDC). Many times, a healthcare provider (HCP) needs more information than is found in the immunization schedule table. Most of the “specific” answers are found in the footnotes of the immunization schedules. This is part two of a blog series meant to serve as guidelines for caring for your patients and their immunizations. Read part one for information about COVID-19, Hemophilus B (HiB), Hepatitis A (HEPA), Hepatitis B Vaccine (HEPB) and Human Papillomavirus (HPV) and influenza vaccines.
Measles, Mumps, Rubella (MMR)1 (Figure 1)
Q: When should adults receive the MMR, a live virus vaccine?
A: Adults should receive an MMR if they do not have any evidence of immunity to measles, mumps, or rubella. If they were born before 1957, then it is presumed the patient had measles, mumps and rubella diseases. HCPs born in or after 1957 should have an MMR unless they have documentation of receipt of MMR or laboratory evidence of immunity. Since most HCPs have not seen measles, mumps or rubella enough to make the diagnosis, an opinion by a HCP does not count as having had measles, mumps or rubella.
Q: When should a woman receive a rubella vaccination?
A. A non-pregnant woman of childbearing age with no evidence of immunity to rubella should receive one dose of MMR. There are no vaccines in the United States of single entities of measles, mumps or rubella.6 If during pregnancy, a woman has no evidence of immunity to rubella, an MMR should be given as one dose after pregnancy and before discharge from the healthcare facility. If an MMR is given to a woman and she finds out she was pregnant, this is not a cause for concern, according to ACIP guidance.
Q: When should an HIV-infected individual receive an MMR vaccine?
A: An HIV-infected person with CD4 count ≥ 200 cells/mm3 for at least six months and with no evidence of immunity to measles, mumps or rubella should receive a two-dose series at least four weeks apart.
Q: When should an HCP receive an MMR?
A: An HCP born in 1957 or later with no evidence of immunity to measles, mumps or rubella should receive a two-dose series at least four weeks apart.
Q: What is the recommendation for an HCP born before 1957 during a measles outbreak if they do not have serology evidence of Measles antibodies?
A: During a local outbreak of measles, all healthcare personnel, including those born before 1957, are recommended to have two doses of MMR vaccine at the appropriate interval if they lack laboratory evidence of measles.
Q: When is the MMR contraindicated?
A: There are three conditions in which the MMR is contraindicated due to being a live virus:
- During pregnancy
- If an individual has an HIV infection with a CD4 count < 200 cells
- If the individual has a severe immunocompromising condition
Pneumococcal Vaccines (Conjugated and Polysaccharide)1 (Figure 2)
Q: What are the two types of pneumococcal vaccines available in the United States?
A: The two types of pneumococcal vaccines available in the United States are the 13 valent vaccine (PCV13), known as Prevnar13 by Pfizer, and a polysaccharide vaccine (PPSV23), known as Pneumovax23 by Merck.
Q: What are the indications in adults for PPSV23 and PCV13?
A: For immunocompetent individuals and those 65 years of age and older, give a single dose of PPSV23. If the same individual received a previous PPSV23 before 65 years of age, administer one dose of PPSV23 at least five years after the previous dose. One dose of PCV13 can be given to an individual based on shared clinical decision-making.
If a PCV13 is given to a patient at 65 years old, then a PPSV23 should be administered one year later. Patients with chronic medical conditions—such as chronic heart, lung, and liver disorder, including diabetes (types 1 and 2); alcoholism; and cigarette smokers—should receive one dose of PPSV23 if 19–64 years of age.
At age 19 years or older, patients with immunocompromising conditions, such as congenital or acquired immunodeficiency, HIV infection, chronic renal failure, leukemia, lymphoma, Hodgkin disease, generalized malignancy, iatrogenic immunosuppression—including drug or radiation therapy, solid organ transplant, multiple myeloma, anatomical or functional asplenia—and active cerebrospinal fluid leak(s) or cochlear implants, should be administered one dose of PCV13 followed by one dose of PPSV23 at least eight weeks later. Another dose of PPSV23 should be given at least five years after previous PPSV23. At and/or after 65 years of age, administer only one dose PPSV23. PCV13 and PPSV23 should not be administered during the same visit. PCV13 is preferred to be administered first and PPSV23 one year later.
At the February 2021 ACIP meeting, additional serotypes of the conjugated vaccines, PCV20 by Pfizer and PCV15 by Merck7, were discussed and expected to be available in 2021 or 2022.
Tetanus, Diphtheria and Pertussis Vaccines1 (Figure 2)
Q: Should one use the Tdap or Td for wound management?
A: Either a tetanus and diphtheria vaccine (Td) or tetanus, diphtheria and acellular pertussis vaccine (Tdap) can be used as a booster if it has been 10 years or longer since the patient’s last tetanus shot.
Q: If an HCP only has Tdap in the office, can it be used for the tetanus booster?
A: It can be used for tetanus vaccines and boosters. If one is catching up with tetanus vaccination, make sure the patient has had at least one dose of Tdap, then either Td or Tdap can be given every 10 years.
Q: How should an HCP proceed for an adult who did not receive the primary vaccination series for tetanus, diphtheria or pertussis?
A: The HCP should give one dose of Tdap followed by one dose of either Td or Tdap, at least four weeks after the first dose of Tdap. Another dose of Td or Tdap should be administered 6–12 months after the last Td or Tdap. Either Td or Tdap should be given every 10 years, thereafter.
Q: During each Pregnancy, should the patient receive one dose of Tdap?
A: Yes, preferably in the early part of gestational weeks 27–36. This protects the fetus, mother and newborn from developing a pertussis infection.
Q: A patient presents with a laceration and has a history of three or more doses of tetanus-toxoid-containing vaccine. What is the recommended tetanus prevention?
A: For clean and minor wounds, administer Tdap or Td if more than 10 years since last dose of tetanus-toxoid-containing vaccine; for all others (e.g., dirty wounds), administer Tdap or Td if more than five years since last dose of tetanus-toxoid-containing vaccine. Tdap is the preferred for the first dose for persons who have not previously received Tdap or whose Tdap history is unknown.
Q: How long after a wound could a patient still receive a Td or Tdap?
A: Appropriate tetanus prophylaxis should be administered as soon as possible following a wound but should be given even to patients who present late for medical attention. This is because the incubation period is quite variable; most cases occur within eight days, but the incubation period can be as few as three days or as many as 21 days. For patients who have been vaccinated against tetanus previously but who are not up to date, there is likely to be little benefit in administering human tetanus immune globulin more than one week or so after the injury. However, for patients thought to be completely unvaccinated, human tetanus immune globulin should be given up to 21 days following the injury; Td or Tdap should be given concurrently to such patients.
Varicella (Chickenpox) Vaccine (VAR)1 (Figure 2)
Q: When should an adult receive a VAR?
A: If a person has no evidence of immunity to varicella, then a two-dose series is indicated, 4–8 weeks apart. If the person previously only received one VAR, then the person only needs one additional dose. If a person has evidence of immunity, was U.S.-born before 1980—except for pregnant women and HCPs—and has documentation of two doses of varicella-containing vaccines at least four weeks apart, a diagnosis or verification of history of a varicella or herpes zoster infection diagnosed by an HCP, and/or laboratory evidence of immunity or disease, no further VAR is needed. If a patient received a combination of MMR and VAR (MMRV, by Merck), this counts as a dose of VAR. If during pregnancy, a patient has no evidence of immunity to varicella, VAR should be administered after the pregnancy and preferably before discharge from a health care facility.
Q: Can VAR be given to an HCP or a patient who is exposed to varicella and has no known immunity?
A: Varicella vaccine is effective in preventing chickenpox or reducing the severity of the disease if used within 72 hours (three days), and possibly up to five days after exposure. However, not every exposure to varicella leads to infection, so for future immunity, varicella vaccine should be given, even if more than five days have passed since the exposure.
Q: If an HCP has no evidence of immunity to varicella, what should be given?
A: An HCP with no evidence of immunity to varicella should receive one dose of VAR if previously given a dose of a varicella-containing vaccine or a two-dose series 4–8 weeks apart or if they previously did not receive any varicella-containing vaccine, regardless of whether U.S.-born before 1980.
Q: If a patient is positive for HIV infection with a CD4 count ≥ 200 cells/mm3 and no evidence of immunity to varicella what should be done?
A: VAR vaccination may be considered and given as two doses, three months apart. VAR is contraindicated for persons with HIV infection with CD4 count <200 cells/mm3. For severe immunocompromising conditions, VAR is contraindicated because VAR is a live virus.
Recombinant Zoster Vaccine (RZV)1 (Figure 2)
Note: Shingrix by GSK is the only Zoster vaccine available in the United States.
Q: When is RZV indicated?
A: Routine vaccination of RZV is indicated at age 50 years or older as a two-dose series two–six months apart. Presently the use of RZV for severe immunocompromising conditions, such as HIV infection with CD4 count < 200 cells/mm3, is under review.7
Q: Should a person who received two doses of varicella vaccine be vaccinated with Shingrix when they turn 50?
A: In its 2018 zoster vaccine recommendations, the ACIP states that Shingrix may be used in adults age 50 years or older irrespective of prior receipt of varicella vaccine or live zoster vaccine (Zostavax).6
Giving Other Vaccines With COVID-19 Vaccines5 (Figure 2)
Q: Can other vaccines be given with COVID-19 vaccines?
A: Yes, CDC officials now say it is OK to get the COVID-19 vaccine at the same time as other vaccines.
- CDC’s Vaccine 2021 Schedules webpage: https://www.cdc.gov/vaccines/schedules/downloads/adult/adult-combined-schedule.pdf (Accessed 4/2/2021)
- Single Vaccines of Measles, Mumps and Rubella Are Not Available in the U.S.: https://www.cdc.gov/vaccines/hcp/clinical-resources/mmr-faq-12-17-08.html#:~:text=ACIP%20recommends%20that%20%E2%80%9Ccombined%20measles,against%20all%20three%20diseases%20(measles%2C. (Accessed 4/3/2021)
- PCV20 Discussion at the February 2021 ACIP meeting: https://www.cdc.gov/vaccines/acip/meetings/downloads/slides-2021-02/24-25/03-Pneumococcal-Watson.pdf (Accessed 4/2/2021)
- PCV15 Discussion at the February 2021 ACIP meeting: https://www.cdc.gov/vaccines/acip/meetings/downloads/slides-2021-02/24-25/04-Pneumococcal-Buchwald.pdf (Accessed 4/6/2021)
- Giving COVID-19 Vaccinations With Other Immunizations: https://www.verywellhealth.com/cdc-getting-other-vaccines-with-covid-19-vaccine-5184818 (Accessed 5/21/2021)
- Use of Shingrix in Patients Who Have Had Varicella Vaccine and/or Zostavax Previously: https://www.immunize.org/askexperts/experts_zos.asp (Accessed 6/24/2021)
- Use of Shingrix in immunosuppressed patients: https://www.immunize.org/askexperts/experts_zos.asp (Assessed 6/24/2021)
Note: The CDC website is a public domain website, is not subject to copyright and may be freely used or reproduced without obtaining copyright permission. https://www.cdc.gov/other/agencymaterials.html. (Accessed 05/22/2021)