Several participant questions surfaced during the March 8 webinar APhA Immunization Update from the February 2011 ACIP Meeting. Below are the responses given by Stephan L. Foster, PharmD, FAPhA, APhA Liaison Representative to the Advisory Committee on Immunization Practices (ACIP).
Question: Do I give flu shots to AIDS patients?
- Answer: Absolutely. However, administer the inactivated, injectable vaccine and avoid the live, nasal vaccine.
Q: Can pregnant women receive trivalent influenza vaccine (TIV) in all trimesters of pregnancy?
- A: Yes. TIV is recommended for all women, regardless of trimester. Pregnant women are at higher risk for complications from influenza than nonpregnant women.
Q: A patient said she is allergic to eggs, but the flu vaccine has been fine. Should I give her the vaccine?
- A: I would want to know more about her past history of egg allergy and influenza vaccination. If she has had minor reactions and has received the vaccine before, it can be given. If the vaccine is administered, make sure she waits around the pharmacy for 15–30 minutes and that epinephrine is available. If you have any reservations, send her to her physician.
Q: I had a patient who said she had pneumonia shots after age 65 years last year and her physician recommended another pneumo shot this year because of low immune system and chronic disease. Do I give her another one?
- A: CDC strongly recommends that only one pneumococcal vaccination be given after age 65 years if it has been more than 5 years since the previous one. No proof exists that additional vaccination is effective or safe. Most standing orders do not allow pharmacists to give vaccines off label. If you want to do this per prescription of the physician, that would be your decision.
Q: If a patient is getting bevacizumab injections for macular degeneration, does that contraindicate receipt of zoster vaccine? Are patients such as these considered immunocompromised?
- A: Very little or no data are available regarding the immune status of receiving monoclonal antibodies via intraocular injection. I was able to find one BMJ report of herpes simplex infection in the eye following injection for this off-label use. The general recommendations recently published by ACIP state: “Until additional information becomes available, avoidance of live, attenuated vaccines during intermittent or low-dose chemotherapy or other immunosuppressive therapy is prudent, unless the benefit of vaccination outweighs the hypothetical increased risk for an adverse reaction after vaccination.” I would contact the physician for them to make this decision.
Q: Would you please address the storage necessary for shingles vaccine? We only have a refrigerator in our pharmacy.
- A: Zoster vaccine live (Zostavax–Merck) must be stored frozen at –15οC (+5οF) or colder until it is reconstituted for injection. A proper freezer must be used (see General Recommendations on Immunization for details). Without a freezer, you cannot store this vaccine.
Q: You mentioned an increase in hepatitis B resulting from blood glucose meters not being cleaned. Was this an increase in health care personnel or patients?
- A: Patients. This was actually reported in institutionalized patients (i.e., nursing home), but ACIP is determining whether this is the case in all patients with diabetes because of other risk factors. If you are a health professional and are potentially exposed to blood, you should be fully vaccinated with hepatitis B vaccine.
Q: If someone has shingles and wants to get vaccinated, how long should the patient wait between the episode of shingles and receiving the vaccine?
- A: I am assuming that you are referring to the zoster vaccine. With other inactivated vaccines, there is no waiting period if they are indicated. The use of zoster vaccine in patients with a previous history of shingles has not been studied. There are no recommendations from the ACIP on waiting period. It would be prudent to wait until all clinical symptoms of zoster, including postherpetic neuralgia, have resolved.
Q: What is the recommendation for human papillomavirus vaccination in male patients?
- A: ACIP has given a permissive recommendation for vaccination of male patients aged 9–26 years. At the current time, a routine recommendation is not approved, but discussions on this topic continue. FDA has approved the vaccine in males to prevent genital warts and penile and anal cancers.
Q: What is the latest on the herpes zoster vaccine and cost effectiveness with the data that efficacy decreases as age increases?
- A: ACIP felt that it was cost effective in everyone older than 60 years, even though the effectiveness decreases with age. The shingles prevention study showed the vaccine to be 64% effective in the patients aged 60–69 years, 41% effective in those 70–79 years, and 18% effective in those 80 years or older. However, keep in mind that far fewer individuals were studied in the group 80 years or older. The same study demonstrated a decrease in the incidence of postherpetic neuralgia in patients who received the vaccine and developed shingles. This effect was higher in the group 80 years or older compared with the group aged 60–69 years. Because this is such a devastating disease and the incidence of disease increases with age, prevention is important, even if efficacy decreases as age increases.
Q: If the same flu strains are in the vaccine next year, do you think that will affect demand among the general population?
- A: Although it is possible, I do not think the general population considers the circulating strains in their decision to get vaccinated each year. I would tell them that immunity decreases with time since vaccination and that annual vaccination will increase their protective levels.
Q: Can an immunocompromised patient receive Zostavax?
- A: No. This is a live vaccine and is contraindicated in patients who have altered immunocompetence.
Q: What greater protection is achieved in providing prophylactic Tamiflu to patients who already received a seasonal flu shot?
- A: Prophylaxis with antivirals is not generally indicated in patients who have been vaccinated. ACIP states that “chemoprophylaxis with antivirals is not a substitute for vaccination” and states reasons such as potential adverse effects and antiviral resistance. Because vaccination is not 100% effective, treatment with antivirals may be indicated. In addition, if you were aware that the circulating strain is different from the vaccine strains, then prophylaxis may be indicated. The routine use of both is not recommended.
Q: Is it lawful to require an employee to receive the influenza vaccine or make it mandatory for employment?
- A: I want to begin by stating that I am not an attorney and laws vary around the country. Many health systems require influenza vaccination. Also, I have been told that lawsuits are pending currently, although I am not certain of the details. I want to go on record that I would support mandatory vaccination, and I applaud those who have made it happen.
Q: What data are known on the use of Ixiaro in children, and is it being currently studied?
- A: Ixiaro was not studied in children in its original marketing studies and has been given an indication for use in patients 17 years or older. Phase 2 trials have been completed using one-half dose in children 1–3 years of age. Phase 3 trials are currently being done in India. Some practitioners are using it off label, but ACIP recommends mosquito protection.
Stephan L. Foster, PharmD, FAPhA
Professor and Vice Chair
University of Tennessee College of Pharmacy
APhA Liaison Representative to the Advisory Committee on Immunization Practices (ACIP)