Vaccines and Cocktails: Some Chilling Similarities

A good cocktail requires some mixing to achieve its intended taste and temperature. Fourteen vaccines used in the United States also require mixing of a flash frozen powder with a liquid. Some cocktails need to be imbibed relatively quickly after preparation, such as frozen and carbonated drinks. Others, such as martinis, can be premixed, stored away for hours and then chilled before use. Similarly, different vaccines, once reconstituted, have various “shelf” lives per the package inserts. Most of us have at one time or another drawn up a vaccine only to have the patient or parent change their mind about getting that vaccine that day. Since it is difficult to charge for a vaccine not given, it is important for providers to be familiar with the shelf lives of the vaccines they use regularly so that perhaps they can be given to someone else before the “expiration date.”  Let’s look at 2 possible scenarios.

Scenario 1.

A 13-month-old boy is in your office for his 12-month well child check. He is doing well and you order your usual package of vaccines given at this visit-Prevnar, Hib, MMR, and Varivax. About 4 minutes later your nurse taps on the door and says he needs to speak with you. He asks, “Were you aware that the 13-month-old got an IM shot of gamma globulin at the health department last month because there was an outbreak of hep A at his day care? And, I already reconstituted the MMR and Varivax vaccines?” Your astute nurse has saved you once again. You were not aware this was true of gamma globulin, but most live vaccines should not be given within at least 2 months after the administration of intramuscular IG. Fortunately, this is your first patient of the day. You tell the nurse to immediately refrigerate the two reconstituted vaccines and check the schedule to see if another child will be coming in that day who will need an MMR and/or Varivax.

1. In what time frame do these reconstituted vaccines need to be given?

A. Both need to be given within 30 minutes

B .Varivax needs to be given within 30 minutes and MMR within 8 hours

C. Both need to be given within 8 hours

D. Both can be given in the same workday, even if it is longer than 8 hours

For answer, discusison, next scenario, please click here.

Answer: B. Both MMR and Varivax need to be given within 30 minutes of reconstitution.  

Both vaccines should also be protected from light.

Scenario 2.

Your flu vaccine shipment has arrived in full (for a change), but now storage space in your refrigerator is at a premium. You go to look and notice that the vials of diluent for several of the vaccines are taking up a lot of room.  You know that not all vaccine diluents need to be refrigerated so some of these could be removed and stored at room temperature.

2. Which of the following vaccines is/are reconstituted with a diluent that must remain refrigerated?

A. Varivax

B. MMR

C. Proquad

D. Pentacel

E. Rotarix

For answer and discussion, please click here.

Answer: D. Pentacel

Some diluents are plain water, some are saline water in different concentrations and both of these can be either refrigerated or stored at room temperature. Other diluents contain active antigens such as the diluent for Pentacel which contains the DTAP and IPV antigens and the lyophilized powder contains the Hib component. Diluents for the other vaccines listed above are basically just water. Pentacel is also one of the two vaccines in the routine schedule that have to be given immediately after reconstitution. The other is MenHibrix.

I know some of us who deal with whining children all day look forward to a different kind of whine after getting home. I suspect nurses who deal with screaming children receiving injections all day may need something a little stronger. After mixing vaccines all day, preparing a cocktail will be a welcome change.