The Vaccine Mix and Match Game

[[{"type":"media","view_mode":"media_crop","fid":"60675","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_7720203980436","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"7670","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"height: 294px; width: 300px; float: right;","title":" ","typeof":"foaf:Image"}}]]How do you like your M&Ms? All one color or do you like the “mix and match” approach? Most of us like to mix and match the colors as we plop them in our mouths. Those of us with a little OCD may just eat one color at a time. And yes, there is a vaccine connection to be made.

When it comes to vaccines that require more than one dose and more than two manufacturers produce a similar product, clinicians usually have the choice to mix and match. Some examples: there are two companies marketing rotavirus vaccines, a different two making pertussis vaccines, and five companies producing flu vaccines.

Let’s imagine a flu scenario: Flu-vaccine-naïve children under the age of 9 years need two doses of flu vaccine separated by 30 days. Assume you have an 8-year-old in your office who received his first ever flu vaccine 5 weeks earlier. He received a dose of quadravalent Fluzone. You do not have any quadravalent Fluzone in your office, but do have the below listed vaccines.

1. Which of the following would NOT be appropriate to give him?

A. Quadravalent Flumist (assume it is back on the market and ACIP approved)

B. Trivalent Fluviran

C. Quadravalent Flulaval

D. Trivalent Flublok

E. Any of the above would be fine to use

Answer, discussion, and next question>>

Image©pringletta/Shutterstock.com

The correct answer is D. Trivalent Flublock would NOT be appropriate in this case

Flublok, a recombinant vaccine that is totally egg-free, is only approved for individuals age ≥18 years. Any of the others would be fine to use, per the CDC. Ideally, one would use a quadravalent vaccine for both doses, but the CDC suggests giving whatever you have in the office out of fear the child wouldn't get the second dose. Data suggest that efficacy is low with only a single dose of inactivated vaccine in a vaccine-naive child age < 8 years.

The CDC does state a preference for finishing a series with the same vaccine from the same manufacturer. After all, the studies needed for licensure were all done with the exact same vaccine. At the same time, the CDC recognizes the impracticality of mandating that a series be completed with only the same vaccine. For example, pediatric offices have two choices of combination vaccines:  Pentacel by Sanofi and Pediarix by GSK. These two have different pertussis and Haemophilusinfluenzae antigens but expert opinion says that you can follow one with the other and all the doses “count.” Most pediatricians barely have enough room in their refrigerators now for all the vaccines without having to also store all the vaccines they don't routinely use.

It can also be a little confusing when 2 competing vaccines have different schedules. The Merck Hib vaccine requires a total of 3 doses; the other two Hib vaccines require 4. If you have to mix, then 4 doses will be needed.

One more mix and match question>> 

Two quadravalent meningococcal vaccines compete:  Menveo and Menactra. Healthy children receiving this vaccine need just one dose but children with certain immune problems need two doses separated by 2 months.

Two meningococcal B vaccines have recently been approved, Bexsero and Trumemba. Both require multiple doses and target different antigens.

Two rotavirus vaccines also require multiple doses. One, Rotateq has 5 rotavirus antigens. The other, Rotarix, has 2.

2. Now: Per the CDC, which of the below CANNOT be mixed and matched?

A. Menveo and Menactra

B. Bexsero and Trumemba

C. Rotateq and Rotarix

D. They can all be used interchangeably

Answer and discussion>>

The correct answer is B. Bexsero and Trumemba can NOT be mixed and matched.

You can always mix up your M and Ms, eg, green followed by yellow or red. Most of the time, you can “mix” your different vaccines, but not the meningococcal B vaccines. That's when a red light for stop should pop up in your head.

https://www.cdc.gov/vaccines/vpd/mening/hcp/administering-vaccine.html

https://www.cdc.gov/flu/protect/vaccine/vaccines.htm

https://www.cdc.gov/mmwr/volumes/65/rr/rr6505a1.htm