Tag: live vaccines

Is There a Grace Period for Getting Vaccines?

You know about the standard immunization schedule.

Looking at the latest immunization schedule from the CDC and AAP, it should be clear that kids don't get 69 vaccines. — What happens if you get a vaccine a few days too early?

You may even know about the minimum ages or minimum intervals between vaccines, but what happens if your child gets a vaccine just a few days early?

Is There a Grace Period for Getting Vaccines?

Fortunately, in most cases, getting a vaccine just a little early isn’t going to mean that the vaccine dose has to be repeated.

“Doses administered too close together or at too young an age can lead to a suboptimal immune response. However, administering a dose a few days earlier than the minimum interval or age is unlikely to have a substantially negative effect on the immune response to that dose. Known as the “grace period”, vaccine doses administered ≤4 days before the minimum interval or age are considered valid; however, local or state mandates might supersede this 4-day guideline.”

General Best Practice Guidelines for Immunization: Best Practices Guidance of the Advisory Committee on Immunization Practices (ACIP)

That’s because the Advisory Committee on Immunization Practices (ACIP) allows a 4-day grace period for most vaccines. So if your child got their vaccines 3 or 4 days before their 1st birthday, instead of on or after turning 12 months old, they would still count!

It is important to keep in mind that:

day 1 is the day before the day that marks the minimum age or minimum interval for a vaccine.
the grace period doesn’t apply to the rabies vaccine
if a vaccine is given 5 or more days too early, beyond the grace period, then the interval to the next dose starts from the day that invalid dose was given. For example, if the second dose of Hib is given two weeks after the first dose (instead of the minimum 4 weeks), then you don’t repeat this invalid dose in two weeks (four weeks from the first dose), but instead wait an additional four weeks from the invalid second dose
you can’t usually add the grace period to an accelerated schedule
live vaccines must be given at least 28 days apart if they are not given at the same time and the grace period can not be used to shorten this interval

Most importantly, in place since 2002, the grace period protects kids from having to repeat vaccines because of minor vaccine scheduling errors.

What Are the Recommended and Minimum Ages and Intervals Between Doses of Vaccines?

Most parents likely don’t think about the minimum age or minimum intervals between vaccines, as they just get their kids vaccinated according to the routine immunization schedule.

Things don’t always go according to schedule though…

Recommended and Minimum Ages for Vaccines

After their birth dose of the hepatitis B vaccine, your baby’s next vaccines are usually at two months.

Can you get them earlier?

When necessary, many vaccines can be given earlier and faster than the standard schedule.

Yes. The minimum age for the first dose of rotavirus, DTaP, IPV, Hib, Prevnar, is 6 weeks.

Some other vaccines can be given earlier than their recommended age too, including:

the first MMR vaccine, which can be given as early as age 6 months in certain high risk situations, like traveling out of the country or in an outbreak situation, although this dose will have to be repeated once the child is 12 months old
the 4th dose of DTaP, which can be given as early as age 12 to 15 months, as long as at least 4 to 6 months have passed since the third dose
the 2nd dose of Varivax, which may be given as early as 1 to 3 months after the first dose
the Tdap vaccine, which can be given as early as age 7 years, instead of the more typical 11 to 12 years
the HPV vaccine, which can be given as early as age 9 years, instead of the more typical 11 to 12 years

Why would you get a vaccine early?

What if you are going to be traveling just before you infant is going to be 2 months old? Or your 9 year old stepped on a rusty nail, and it had been just over 5 years since his last tetanus (DTaP) shot?

Recommended and Minimum Intervals for Vaccines

In addition to earlier ages, you can sometimes get vaccines more quickly, on an accelerated schedule.

For example:

the minimum interval between the 1st and 2nd dose of rotavirus, DTaP, IPV, Hib, Prevnar is 4 weeks, instead of the standard 2 months
the minimum interval between the 2nd and 3rd dose of rotavirus, DTaP, IPV, Hib, Prevnar is 4 weeks, instead of the standard 2 months
the minimum interval between the 1st and 2nd dose of HPV is either 4 weeks (3 dose schedule) or 5 months (2 dose schedule)
the minimum interval between the 2nd and 3rd dose of HPV is 12 weeks
the minimum interval between the 1st and 3rd dose of HPV is 5 months, instead of the standard 6 months

Why give these vaccines more quickly than usual?

The usual reason is that a child is a little behind and is working to get caught up.

Absolute Minimum Ages for Vaccines

It is important to remember that in some cases, there are some hard and fast rules about minimum ages. That means that if you get these vaccines any earlier, they won’t count and you will likely have to repeat them, including getting :

the 3rd dose of hepatitis B before 6 months (24 weeks) or sooner than 8 weeks after 2nd dose and 16 weeks after 1st dose
the first dose of MMR, Varivax or hepatitis A before 12 months
the 4th dose of Hib before 12 months
the 4th dose of Prevnar before 12 months
the 4th dose of DTaP before 12 months
the 5th dose of DTaP before 4 years
the 4th dose of IPV before 4 years

Sticking to the routine schedule helps to avoid vaccine errors, like giving a vaccine too early. In some situations, the 4 day grace period helps if a vaccine is given a little early.

More on Recommended and Minimum Ages and Intervals Between Doses of Vaccines

Can I Get Rotavirus from My Recently Vaccinated Baby?

Your two month old recently got her vaccines, including the rotavirus vaccine.

Now you have diarrhea.

Was it from shedding from your child’s rotavirus vaccine?

Does the Rotavirus Vaccine Shed?

Like some other live virus vaccines, it is well known that the rotavirus vaccine can shed.

And like with most other vaccines, this shedding isn’t usually a cause for concern and definitely isn’t a reason to think about skipping or delaying your child’s vaccines.

Why not?

“All members of the household should wash their hands after changing the diaper of an infant. This minimizes rotavirus transmission, for an undetermined number of weeks after vaccination, from an infant who received rotavirus vaccine.”

General Recommendations on Immunization Recommendations of the Advisory Committee on Immunization Practices (ACIP)

If you wash your hands when you change your child’s diapers after they have been vaccinated, just like you hopefully do anyway, you can avoid any possible contact with any rotavirus vaccine virus that might be shed in your child’s stool.

Can I Get Rotavirus from My Recently Vaccinated Baby?

But what would be the risk of your getting sick if you did come into contact with shedding rotavirus vaccine virus in your child’s diaper?

Would you be at risk to get sick?

Did your baby get sick after getting the actual vaccine?

That’s the thing about shedding that many people don’t understand. These live vaccines are made with attenuated or weakened strains of viruses, so they don’t typically get you sick when you are vaccinated. And they don’t typically get you sick when you are exposed through shedding. In fact, this shedding can sometimes help build herd immunity, as more people get exposed to the weakened strain of vaccine virus.

But can they get you sick?

Yes, if you have a problem with your immune system, which is why there are warnings about giving live vaccines to folks who are immunocompromised. And there used to be warnings about giving the oral polio vaccine to kids if they were around anyone with an immune system problem.

Vaccine viruses could also get you sick if they mutated from their attenuated state and became more virulent. Fortunately, that rarely happens with most vaccines.

“The theoretical risk of HRV and PRV shedding, transmission to, and infection of immunocompromised contacts is much lower than the real risk of wildtype rotavirus infection transmitted from unvaccinated children.”

Anderson on Rotavirus vaccines: viral shedding and risk of transmission

And most importantly, since kids are much more likely to shed virus after natural infections, it is much safer for everyone to get vaccinated and protected with these vaccines.

Surprisingly, even children with asymptomatic natural rotavirus infections can shed virus for several weeks, which is likely why these infections used to spread so easily or without known contacts.

Something that will likely surprise some folks even more is the news that just because someone gets diarrhea after being exposed to the rotavirus vaccine, either because they were vaccinated or through shedding, it doesn’t mean that the vaccine was the cause of the diarrhea!

“Of note, among all six AGE cases which possessed Rotarix-derived strains, four (sample No.1, 5, 6 and 7) were suspected to be caused by other pathogens. Most likely, the infants were infected with other pathogens during the shedding period of Rotarix strain.”

Kaneko et al on Identification of vaccine-derived rotavirus strains in children with acute gastroenteritis in Japan, 2012-2015

When vaccine strain rotavirus have been detected in kids with gastroenteritis, they often have other reasons to have diarrhea.

What does this all mean?

Don’t believe all of the hype anti-vaccine folks push about shedding from vaccines.

Does the FluMist Vaccine Shed?

Anti-vaccine folks like to talk a lot about shedding.

Where do they get the idea that vaccines shed?

Well, there is the fact that some live vaccines, like the rotavirus and oral polio vaccine, do actually shed.

Does the FluMist Vaccine Shed?

Remember, shedding occurs when an infectious agent, typically a virus, can be found in urine, stool, or other bodily secretions. Shedding is not specific to vaccines though. Shedding occurs very commonly after natural infections too, which is one reason they are so hard to control.

So does the Flumist vaccine shed?

Yes, it does, and it isn’t a secret.

There is actually a warning about shedding and Flumist – to avoid contact with severely immunosuppressed persons (e.g., hematopoietic stem cell transplant recipients in a protected enviornment) for seven days after vaccination because of the theoretical risk that their severe immunosuppression might allow the weakened flu strain to somehow cause disease.

This warning obviously doesn’t apply to the great majority of people though.

And it shouldn’t be surprising that it sheds, after all, it is a live virus vaccine that is squirted in your nose!

Why isn’t it usually a problem?

Flumist contains attenuated viral strains of the flu that are temperature-sensitive, so even if you did get infected with the weakened flu strains from Flumist via shedding, they wouldn’t cause disease.

Another way to think about it is that the folks who actually get the Flumist vaccine don’t get the flu, so why would you get the flu if you were simply exposed to the vaccine virus by shedding?

Shedding from the Flumist vaccine doesn't cause disease. — Anti-vaccine folks are sharing this table like they uncovered some secret, but it is important to understand that shedding from the Flumist vaccine doesn’t cause disease. And this table is in package insert for Flumist!

The real concern with shedding is when it leads to folks actually getting sick.

Trying to scare folks about Flumist shedding is just like when they talk about the MMR vaccine, pushing the idea that the rubella vaccine virus might shed into breast milk or measles vaccine virus into urine. Either might happen, but since it won’t cause infection and disease, it certainly isn’t a reason to skip or delay your child’s vaccines.

What to Know About Shedding and Flumist

The Flumist vaccine does indeed shed, but unless you are going to have contact with someone who is severely immunocompromised in a protected environment, this type of shedding isn’t going to get anyone sick and isn’t a reason to avoid this vaccine.

When is Shedding Season?

Have you heard of shedding season?

I’ll give you a hint, we aren’t talking about cats and dogs…

When is Shedding Season?

So it seems that some folks are really worried about vaccines and shedding.

Precautions against viral shedding? Was he giving out smallpox or oral polio vaccines?

While some vaccines do actually shed, it is really only the oral polio vaccine and the smallpox vaccine that we get concerned about with shedding.

And even then, shedding from the oral polio vaccine would only be a concern for someone with an immune system problem. Since the oral polio vaccine contains an attenuated virus, if that attenuated virus shed to someone else, they wouldn’t get polio except in the very rare situation when the virus mutates. Instead, they would get protection against polio. That’s one of the benefits of using the oral polio vaccine!

Still, we don’t use the oral polio vaccine in the United States anymore.

Although the smallpox vaccine can shed, it is from the site of injection, where a scab forms in the days to weeks after getting vaccinated. Covering the site should prevent other people from getting exposed to shed virus and fortunately, this vaccine is only used in very special situations.

And the rotavirus vaccine sheds, but you just have to wash your hands after changing diapers to avoid this attenuated virus. Are you going to get rotavirus if you are exposed to an infant who was recently vaccinated? Infants who get the vaccine don’t get rotavirus, so why would you if you are exposed to them?

And other vaccines?

While some live vaccines might shed in very specific situations, like if they caused a rare vaccine-induced disease, they otherwise don’t shed. That’s why we don’t worry about most folks with immune system problems getting exposed to people who have recently been vaccinated.

Don’t believe me?

Every time there is an outbreak of measles, someone insists that it was caused by a vaccine strain of measles that was shed from someone who was recently vaccinated. How often is that true?

So when is shedding season?

Anti-vaccine folks consider the start of the school year to be shedding season, because that’s when they think kids get caught up on their vaccines. Is that why we see big outbreaks of measles, chicken pox, and rotavirus at the start of the school year?

Oh wait, we don’t…

“Live vaccine virus shedding is a possible source of transmission of vaccine-strain viral infection but how frequently that occurs is unknown. There is no active surveillance of live virus vaccine shedding and most vaccine strain virus infections likely remain unidentified, untested and unreported.”

NVIC on The Emerging Risks of Live Virus & Virus Vectored Vaccines: Vaccine Strain Virus Infection, Shedding & Transmission

Despite the best efforts of anti-vaccine folks to scare parents about shedding, folks should know that this is no shedding season.

Cases of vaccine strain virus infections from shedding are unidentified and unreported because they don’t happen!

This is why some folks believe in shedding season... — This is why some folks believe in shedding season…

Do you need to teach your kids to fist bump instead of shaking hands during shedding season???

Think about it.

If there were a shedding season, then why wouldn’t there be more outbreaks? Because everyone has learned to fist bump and avoid shaking hands in school?

What to Know About Vaccine Shedding and Shedding Season

Shedding season isn’t a real thing.

Vaccines While Immunosuppressed

It seems to be a big surprise to many folks, but kids can get most vaccines when they are immunosuppressed. In fact, they sometimes get extra some extra vaccines, like Pneumovax, because the “incidence or severity of some vaccine-preventable diseases is higher in persons with altered immunocompetence.”

They should also get all of their vaccines if they are around someone who is immunosuppressed.

Surprised?

Vaccines While Immunosuppressed

Which vaccines your kids can get while they are immunosuppressed is going to depend greatly on the reason why they are immunosuppressed.

Are they getting chemotherapy?

Did they just get a stem cell transplant?

Were they born with a specific immunodeficiency, like X-linked agammaglobulinemia, selective IgA deficiency, severe combined immunodeficiency, or chronic granulomatous disease?

Whatever the reason, they likely won’t get a medical exemption to skip all of their vaccines.

“Killed vaccines will not cause infection in immunodeficient or any other children. The fear of increased community-acquired vaccine-preventable diseases should lead to adherence to and completion of recommended immunization schedules in the community to reinforce herd immunity, such that all vaccine-preventable diseases become exceedingly rare.”

Recommendations for live viral and bacterial vaccines in immunodeficient patients and their close contacts

In most cases, immunocompromised kids can get all inactivated vaccines. It is only live vaccines that could pose a problem. Even then, it depends on the specific immunodeficiency as to whether avoiding live vaccines is necessary.

For example, after chemotherapy and a stem cell transplant, kids can usually get live vaccines.

Your doctors can review the latest guidelines to come up with a safe vaccination plan for your child with an immune system problem. If necessary, consultation with an infectious diseases or immunology specialist can also be helpful.

Don’t overlook other causes of possible immunosuppression when getting vaccinated, like taking daily oral steroids for more than two weeks, certain biologic immune modulators, or other medications like methotrexate, azathioprine, 6-mercaptopurine.

“Limited evidence indicates that inactivated vaccines generally have the same safety profile in immunocompromised patients as in immunocompetent individuals. However, the magnitude, breadth, and persistence of the immune response to vaccination may be reduced or absent in immunocompromised persons.”

2013 IDSA Clinical Practice Guideline for Vaccination of the Immunocompromised Host

And keep in mind that just because they can and should get vaccinated, it doesn’t mean that their vaccines are going to work as well as in someone who isn’t immunocompromised.

That’s why herd immunity is so important for these kids.

Vaccines for Close Contacts of Immunocompromised People

What about people who come into contacts with kids and adults who are immunocompromised?

Can they get vaccines?

“Close contacts of patients with compromised immunity should not receive live oral poliovirus vaccine because they might shed the virus and infect a patient with compromised immunity. Close contacts can receive other standard vaccines because viral shedding is unlikely and these pose little risk of infection to a subject with compromised immunity.”

Recommendations for live viral and bacterial vaccines in immunodeficient patients and their close contacts

Yes, close contacts can get vaccinated, especially since we don’t use the oral polio vaccine in the United States anymore.

There are some exceptions for the smallpox vaccine, which few people get, and Flumist, but only in very specific situations, including a recent hematopoietic stem cell transplant.

Johns Hopkins Medicine, which includes the Johns Hopkins University School of Medicine and the The Johns Hopkins Hospital and Health System went out of their way to correct this anti-vaccine misinformation.

Worried about shedding?

You should be worried about getting a vaccine-preventable disease and giving it to those around you with immune system problems. That’s the real risk!

This is the modern anti-vaccine movement - taking an immoral stand against vaccines and putting sick kids at risk for life-threatening disease. — This is the modern anti-vaccine movement – scaring parents and taking an immoral stand against vaccines and putting sick kids at risk for life-threatening disease.

And no, you are not being selfish to expect those around you to get vaccinated.

Vaccines are safe and necessary – for all of us.

When a Vaccine Doesn’t Count and Needs to Be Repeated

Of course, anti-vaccine folks are wrong when they say that vaccines don’t work.

Vaccines work and they work well to protect us from many different vaccine preventable diseases.

At least they do when you get the right vaccine at the right time and it is given properly. If an error is made, sometimes a vaccine dose needs to be repeated.

When a Vaccine Doesn’t Count and Needs to Be Repeated

While it would be unfortunate to have to repeat a vaccine dose, in most cases, if you didn’t, it would leave the child without full protection.

Why might a vaccine dose not count?

The Menomune vaccine has been discontinued, but this label is a good example of things to check before giving a vaccine.

Although it doesn’t happen often, it is possible that:

the wrong vaccine was given
the vaccine was given too early, either before the next dose was due or when the child was too young. Although there is some leeway for when most vaccines can be given, there are still some specific rules to follow, especially the minimum time between doses, the earliest age you can get a dose, and the age requirement for booster doses. (sticking to the standard immunization schedule can help avoid these types of errors)
the vaccine was mixed improperly (many vaccines are now premixed, making this error less likely to occur)
part of the vaccine leaked out when it was being injected, which can happen when kids move, if they aren’t being held well as the shot is being given (rotavirus doses aren’t repeated if a child spits up though)
the vaccine had expired or had not been stored properly
two live vaccines (except for the typhoid vaccine) were given on separate days, but less than 28 days apart (again, sticking to the standard immunization schedule can help avoid this types of error)
the vaccine was given by the wrong route, although depending on the vaccine, this dose might still be valid (most vaccines, except hepatitis B and rabies)

Still, instead of a vaccine dose not counting, the much more common reason for a vaccine dose to be repeated is for folks to lose their vaccine records.

Do You Really Have to Repeat That Vaccine Dose?

Are you worried now that your kids might get a vaccine dose that has to be repeated?

Don’t be. It doesn’t happen very often.

It helps that we don’t actually have a one-size-fits-all immunization schedule and

there is a range of recommended ages for most vaccines
there is a range of recommended ages for catch-up immunization, which is basically an accelerated immunization schedule, which is why infants can typically start getting their vaccines as early as age 6 weeks and get the first few sets as early as 4 weeks apart

Also, you typically have a grace period, during which early vaccine doses will still count.

“…administering a dose a few days earlier than the minimum interval or age is unlikely to have a substantially negative effect on the immune response to that dose. Known as the “grace period”, vaccine doses administered ≤4 days before the minimum interval or age are considered valid…”

AICP on Timing and Spacing of Immunobiologics

The grace period doesn’t count for the rabies vaccine and while it is an ACIP guideline, it might be superseded by local or state mandates. The grace period also can’t be used to shorten the interval between two live vaccines, which must be at least 28 days.

One last way to get away without repeating an invalid dose would be checking your child’s titers.

When Do You Repeat the Invalid Vaccine Dose?

The next question that comes up after you realize that you have to repeat a dose of a vaccine is when should you repeat it?

It depends.

give the correct vaccine as soon as possible if the problem was that the wrong vaccine was given
repeat the dose as soon as possible if the problem was an expired, improperly stored, or a dose that had leaked out
if the dose was given too early, then you need to wait for the appropriate interval or when your child is old enough to get the dose. Keep in mind that when you repeat the dose, you would generally restart counting your interval from the invalid dose, not from the previous dose. That’s because the invalid dose might interfere with mounting a good immune response.

And in all cases, report the error to the ISMP National Vaccine Errors Reporting Program (VERP) or VAERS.

What to Know About Vaccine Errors

Although they aren’t common, vaccine errors sometimes lead to the need to repeat your child’s vaccines.

VAXOPEDIA

Is There a Grace Period for Getting Vaccines?

Is There a Grace Period for Getting Vaccines?

More on the Vaccine Grace Period

What Are the Recommended and Minimum Ages and Intervals Between Doses of Vaccines?

Recommended and Minimum Ages for Vaccines