March Madness
PIC QUESTION OF THE WEEK: 3/29/10 Q: Can herpes zoster vaccine (Zostavax速) be administered simultaneously with inactivated influenza vaccine? A: The appropriate timing and spacing of multiple vaccines is of concern because improper spacing may reduce optimal immune response. Inactivated vaccines are generally not affected by existing antibody to an antigen; however, the response to a live attenuated vaccine may be reduced by circulating antibody from another recently administered live vaccine. The Centers for Disease Control and Prevention (CDC) recommends that all vaccines can be administered at the same visit, thus Zostavax速 can be given simultaneously with influenza vaccine. If multiple vaccines must be administered intramuscularly, the Advisory Committee on Immunization Practices (ACIP) recommends that each vaccine be administered in a different limb. If this is not possible, injection sites should be separated by at least an inch. If one injectable (herpes zoster, varicella, MMR, MMRV, yellow fever) or intranasal live vaccine (e.g. LAIV) is not given simultaneously with another live vaccine, the second live vaccine should be separated by at least four weeks. If the second vaccine is given within the four week refractory period, it should be repeated in four weeks or confirmed to be effective via serologic testing (serologic testing is not recommended following LAIV, varicella, or zoster vaccines). Oral live vaccines (typhoid and rotavirus) are not believed to interfere with each other or any injectable live vaccine. The following table summarizes the general recommendations of the ACIP regarding the simultaneous and non-simultaneous administration of vaccines. For further information as well as recommendations on the administration of vaccines with antibody-containing products (e.g. immune globulin, etc.), the reader should refer to the references below. Recommendations for the Spacing of Live and Inactivated Vaccines* Vaccine Combination Recommendation for Administration Two or more inactivated vaccines Can be administered simultaneously or at any point after initial vaccine1 One live vaccine and one or more inactivated vaccines Can be administered simultaneously or at any point after initial vaccine2 Two or more live vaccines Can be administered simultaneously. If not, wait a minimum of 4 weeks between administrations3 *
Adapted from the ACIP General Recommendations on Immunization Some experts suggest a 1-month interval between tetanus toxoid, reduced diphtheria toxoid, and reduced acellular pertussis vaccine and quadrivalent meningococcal conjugate vaccine if they are not administered simultaneously 2 The Zostavax速 product information recommends against administering simultaneously with Pneumovax 23速 due to decreased varicella zoster virus antibodies 3 Live oral vaccines (e.g., Ty21a typhoid vaccine and rotavirus vaccine) can be administered simultaneously or at any interval before or after inactivated or live injectable vaccines 1
References: Centers for Disease Control and Prevention. Epidemiology and Prevention of Vaccine-Preventable Diseases. Atkinson W, Wolfe S, Hamborsky J, et al., eds. http://www.cdc.gov/vaccines/pubs/pinkbook/downloads/genrec.pdf. Accessed March 23, 2010. Centers for Disease Control and Prevention. General Recommendations on Immunization: Recommendations of the Advisory Committee on Immunization Practices (ACIP). http://www.cdc.gov/mmwr/PDF/rr/rr5515.pdf. Accessed March 23, 2010. Photo by: bp6316: used under Creative Commons License; http://www.flickr.com/photos/ bp6316/3369506340/ (Accessed March 22, 2010) Michael T. Stachera and John J. Leffler, Pharm.D. Candidates The PIC Question of the Week is a publication of the Pharmaceutical Information Center, Mylan School of Pharmacy, Duquesne University, Pittsburgh, PA 15282 (412.396.4600).