Vaccines
Maria G. Tanzi, PharmD
Older adult patients presenting for both the influenza and recombinant herpes zoster vaccine can receive these vaccinations together, according to CDC. These vaccines should be administered at different anatomical sites, and data show no evidence for interference in the immune response to either vaccine or any additional safety concerns. CDC notes that simultaneously administering all vaccines for which a person is eligible increases the probability that a child, adolescent, or adult will be fully vaccinated by the appropriate age.
“Providers, which include pharmacists, should act on every opportunity to vaccinate patients with recommended immunizations,” according to Stephan Foster, PharmD, FAPhA, APhA liaison for CDC’s Advisory Committee on Immunization Practices (ACIP). “ACIP currently recommends that immunocompetent patients 50 years of age or older receive the two-dose series of the recombinant zoster vaccine (i.e., Shingrix—GlaxoSmithKline) and an annual influenza vaccine.”
Clinical data with influenza vaccine
Concomitant administration of recombinant herpes zoster vaccine with the quadrivalent inactivated influenza vaccine ([IIV4] Fluarix Quadrivalent—GlaxoSmithKline) was studied in a large Phase III, open-label, randomized clinical trial in adults aged 50 and older.
In the coadministration group, 413 patients were given the recombinant herpes zoster vaccine and the IIV4 at day 0, followed by a second dose of the recombinant herpes zoster vaccine at month 2. The control group consisted of 415 patients given IIV4 at month 0 and the recombinant herpes zoster vaccine at months 2 and 4.
Patients’ mean age was 63.4 years, and approximately 60% in each group had received an influenza vaccination in the previous season.
The results, which were published in the December 2017 issue of the Journal of Infectious Diseases, showed that the immunogenicity of either vaccine was not affected by coadministration. In addition, there was no clinically meaningful effect on the local reactogenicity of either vaccine. Adverse events were similar between the two groups, but general reactions occurred more frequently with coadministration.
Overall, the authors concluded that coadministration did not raise any safety concerns and that their results support concomitant administration of these two vaccines. They wrote that coadministration “could benefit older adults by increasing opportunities to provide vaccination against herpes zoster and influenza in a single clinic visit.”
Novel adjuvant considerations
Foster highlighted that the recombinant zoster vaccine has a novel adjuvant (AS01B) and that the immunogenicity and safety of simultaneous or sequential administration of two vaccines containing novel (nonaluminum) adjuvants has not yet been evaluated.
For example, Fluad, the inactivated influenza vaccine by Seqirus, contains the novel adjuvant MF59 and is approved specifically for patients ages 65 years and older. Foster noted that the ideal interval between giving such vaccines is not currently known.
Current ACIP recommendations state that because of limited data on the safety of simultaneous administration of two or more vaccines containing novel adjuvants and the availability of nonadjuvanted influenza vaccine options, selection of a nonadjuvanted influenza vaccine may be considered in situations in which influenza vaccine and another vaccine containing a novel adjuvant are to be administered concomitantly.
However, ACIP reinforced that vaccination should not be delayed if a specific product is not available. Foster stated that if two products with novel adjuvants are to be used, the vaccines should be given in separate arms.
Other studies
An additional study, published in the July 2018 issue of Vaccine, evaluated coadministration of the recombinant zoster vaccine with the 23-valent pneumococcal polysaccharide vaccine ([PPSV23] Pneumovax23—Merck) in adults aged 50 years and older. The results of this study were similar to the data presented above, with 865 adults vaccinated and coadministration resulting in no immunologic interference for the two vaccines and no new safety concerns.
The authors noted that select general symptoms were reported more frequently when the first dose of the recombinant zoster vaccine and PPSV23 were coadministered. However, no differences were apparent between groups after the second zoster dose.
The effects of coadministration of the recombinant zoster vaccine with the tetanus toxoid, reduced diphtheria toxoid, and Tdap (Boostrix—GlaxoSmithKline) are currently being evaluated.
Simultaneous administration of other vaccines
Live vaccines. Although most live and inactivated vaccines can be given simultaneously on the same day, pharmacists should be aware of select considerations.
Live parenteral or live I.N. influenza vaccines can be given on the same day; but if they are not, administration should be separated by a minimum 4-week interval. This interval is recommended because the immune response to one of the vaccines may be impaired. If two live parenteral vaccines or a live I.N. influenza vaccine is given less than 4 weeks apart, the vaccine given second should be repeated.
An exception to this rule is live vaccines administered orally (e.g., oral typhoid and rotavirus), as they are not believed to interfere with each other if not given simultaneously. Also, live oral vaccines may be given at any time before or after live parenteral vaccines or the live I.N. influenza vaccine, as these vaccines are not expected to affect one another.
Select situations. There are special circumstances in which select vaccines should not be given on the same day. The first is for patients with functional or anatomic asplenia. In these patients, administration of the quadrivalent meningococcal conjugate vaccine (MCV4)-D ([MenACWY-D] Menactra—Sanofi Pasteur) and pneumococcal conjugate vaccine ([PCV13] Prevnar 13—Pfizer) should be separated by at least 4 weeks. This recommendation is based on data showing that the MCV4 interferes with the antibody response to the PCV13. ACIP currently recommends that PCV13 be administered first, followed 4 weeks later by the MCV4.
Two other vaccines that should be separated are the PCV13 and PPSV23. In general, PCV13 should be administered first, followed by PPSV23 at least 8 weeks later. However, if PPSV23 was administered first, PCV13 should be administered no earlier than 8 weeks later for a child and 1 year later in adults ages 19 and older.
General immunization pearls
The majority of vaccines can be given on the same day, and pharmacists should assess patients for recommended vaccines and strongly recommend those that are needed. Pharmacists should inform patients that the efficacy and safety of coadministered vaccines, such as the recombinant herpes zoster and influenza vaccines, are similar to the safety and efficacy of the vaccines administered separately.
Vaccination should not be deferred because multiple vaccines are needed, and patients should understand that there is no upper limit for the number of vaccines that can be administered during a single visit.
Pharmacists should keep in mind that individual vaccines should not be mixed in the same syringe unless indicated by FDA, and vaccinations given on the same day should be administered to different anatomical sites. Documentation of vaccine administration and communication with other members of the health care team are also essential for providing collaborative care that ensures all of the patient’s immunization needs are met.
Other general immunization pearls for multiple vaccination
- Give the patient the current vaccine information statement (VIS) for each vaccine administered.
- Answer any questions the patient may have, and discuss expectations with the patient.
- Maintain a permanent record of the immunizations given that includes
–Date vaccines were administered
–Manufacturer of each vaccine and lot number
–Anatomical site of administration and dose for each vaccine
–Date of each VIS and date provided
–Name and title of the person administering the vaccines and address of facility where the permanent record will reside
- Provide the patient with an updated immunization record card.
- Report immunizations to the state or local immunization information systems (IIS).
- Send notification of the vaccination to the patient’s primary care provider, if known, and inform the provider that the vaccination will be submitted to the state’s IIS and the patient’s health insurance, if applicable.
- Report adverse events to the Vaccine Adverse Event Reporting System
- (https://vaers.hhs.gov) and the patient’s primary care provider.
- If a follow-up vaccination is needed to complete the series, inform the patient, schedule the vaccination, and/or insert the reminder need within the pharmacy’s reminder recall system.