ACIP Updates Language on Immunizing Egg-Allergic Patients

Committee Also Discusses HPV Vaccine Dosing, MenACWY-D for HIV Patients

February 29, 2016 04:52 pm Chris Crawford

During its Feb. 24 meeting, the CDC's Advisory Committee on Immunization Practices (ACIP) voted to update the 2016-2017 influenza vaccine recommendations including changes to the language on immunizing egg-allergic patients.

[Physician giving man a vaccine]

AAFP liaison to the ACIP Margot Savoy, M.D., M.P.H., told AAFP News that included in these new recommendations was the acceptable use of live attenuated influenza vaccine (LAIV; FluMist) as an option for individuals with an egg allergy of any severity, including severe anaphylaxis.

Also, the ACIP removed the requirement to observe egg-allergic patients for 30 minutes post-vaccination, noting that 15 minutes of observation is recommended for all patients receiving vaccines, particularly adolescents for syncope.

"The reason for this change is they realized people who were going to have a reaction (to the vaccine) weren't necessarily going to have it within 30 minutes," Savoy said. "And this reaction is so rare -- it's about one in 1 million -- you probably weren’t going to see it anyway."

Story highlights
  • During its Feb. 24 meeting, the CDC's Advisory Committee on Immunization Practices (ACIP) voted to update the 2016-2017 influenza vaccine recommendations including changes to the language on immunizing egg-allergic patients.
  • ACIP members also heard a presentation from the HPV workgroup comparing the immunogenicity of the two-dose versus three-dose regimens for Merck Inc.'s nine-valent HPV vaccine (HPV9; Gardasil 9).
  • In addition, ACIP members discussed the use of the quadrivalent meningococcal conjugate vaccine (MenACWY-D; Menactra), which protects against serotypes A, C, W and Y, with HIV-infected patients.

There was, however, debate on the wording for how a patient who has severe anaphylaxis from eating eggs should be vaccinated in regard to the setting and immediate availability of a physician. Savoy said the discussion centered around the question of whether anyone medically qualified would be available to help a patient who was vaccinated during a mass vaccination campaign at work or school and had a severe reaction.

But Savoy pointed out that these stipulations for egg-allergic patients might be removed altogether this time next year when the influenza vaccine recommendations are updated again.

"Canada switched its recommendation (on egg-allergic patients) four years ago, and they haven’t seen any uptick in people having severe reactions or problems one way or the other," she said.

The ACIP also voted to remove the algorithm that previously directed physicians in what vaccination route to take with egg-allergic patients because evidence from numerous studies supported the idea of all patients being vaccinated in the same manner.

"This is different than what we have been told previously, so physicians should be aware of this change," Savoy said.

In addition to the egg allergy changes, ACIP members also heard a presentation from the HPV workgroup comparing the immunogenicity of the two-dose versus three-dose regimens for Merck Inc.'s nine-valent HPV vaccine (HPV9; Gardasil 9).

Previous research was presented on the two- and four-valent HPV vaccines but Savoy pointed out that this wasn’t necessarily representative of how the new HPV9 vaccine would perform.

It also was announced that Merck Inc. will retire its HPV4 vaccine in the United States at the end of 2016.

"So people who haven't transitioned (to HPV9) should go ahead and plan on transitioning," Savoy said. "And this shouldn't be an issue because the FDA approved the male use of Gardasil 9."

ACIP members also discussed the use of the quadrivalent meningococcal conjugate vaccine (MenACWY-D; Menactra; Menveo), which protects against serotypes A, C, W and Y, with HIV-infected patients. The meningococcal workgroup proposed that HIV-infected patients be included in the list of "persons at increased risk" for this vaccine, but it wasn't put to vote yet.

"People who have HIV have an incredibly high risk of getting meningococcal meningitis," Savoy said. "And when they do get it, they get the invasive meningitis in serotypes covered by the MenACWY-D vaccine."

However, one of the problems with HIV-infected patients getting the MenACWY-D vaccine is its protection wanes more quickly for them than for other patients, she said.

So the workgroup proposed HIV-infected patients who have not previously been vaccinated should receive a two-dose primary series of MenACWY-D. HIV-infected patients who have previously been vaccinated should receive a booster dose as soon as possible and then continue to receive boosters every three years if they were younger than age 7 at their previous dose and every five years if they were age 7 or older at the previous dose.

The workgroup now will work on a cost effectiveness analysis of this recommendation to present at the June meeting as well as the grade for the recommendation.

Additional Notes

Also at the February ACIP meeting, the cholera workgroup reconvened to discuss an oral cholera vaccine from international vaccine manufacturer PaxVax that is awaiting FDA approval. It was not previously available in the United States but has been used in Australia, Canada and Switzerland. There currently is no cholera vaccine available in the United States.

A representative from PaxVax presented research on the cholera vaccine's efficacy and success in other countries. At the June meeting, Savoy anticipates the workgroup will return with duration of protection information and a new recommendation for pediatric use, as most previous studies focused on adults.

"It seems like a safe and effective vaccine that reduces the risk of getting cholera but still in the United States, it will have limited use and will be used more as a travel vaccine," she said.

Data also were presented on a Japanese encephalitis vaccine expected to be released in the United States soon after final FDA approval is obtained, Savoy said. An updated CDC Morbidity and Mortality Weekly Report is being drafted to add the information that was presented at the meeting.

Up Next

Savoy said for the next couple of ACIP meetings, she anticipates:

  • a continued conversation about the two-dose HPV vaccine,
  • more discussion on the meningitis B vaccine due to additional public comments posted following its grade B recommendation and
  • a possible vote at the June ACIP meeting on the MenACWY-D vaccine and use with HIV-infected patients.

Related AAFP News Coverage
CDC Releases 2016 Immunization Schedules
(2/3/2016)

AAFP Joins Campaign to Boost MCV4 Second-dose Rates
(11/16/2015)

ACIP to Reconfigure Pediatric Immunization Schedule
Meningococcal B Vaccine, Standing Orders for Adult Vaccines Also Discussed

(10/28/2015)


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