- Email: [email protected]
Adult immunization recommendations in the US—New changes and a plea for a global adult immunization schedule
Vaccine 30 (2012) 3489–3491
Contents lists available at SciVerse ScienceDirect
Vaccine journal homepage: www.elsevier.com/locate/vaccine
Editorial
Adult immunization recommendations in the US—New changes and a plea for a global adult immunization schedule
On an annual basis, the Advisory Committee on Immunization Practices (ACIP) updates the Adult Immunization Schedule for persons residing in the United States. These recommendations are provided in two formats: one, a table that lists recommended vaccines by age grouping, and two, a table that lists recommended vaccines by risk factor as well as occupation as a healthcare worker. Both are available on the Centers for Disease Control and Prevention website (http://www.cdc.gov/vaccines/recs/schedules/ downloads/adult/adult-schedule.pdf) in both English and Spanish. Recent summaries of these changes are also available [1,2]. This editorial also provides this information for VACCINE readers, and condenses the changes into a single table for use by our readers. In addition, context and suggestions are provided relevant to the practice of vaccinology in other countries. Importantly, the U.S. Adult Immunization Schedule serves several important purposes; it: • Provides comprehensive, evidence-based recommendations and a schedule for the use of vaccines licensed in the U.S. for adults • Provides a “standard of care” for the clinical use of vaccines for adults in the U.S. • Provides visual aids that simplify a large body of complex information into two graphics that can be readily accessed by practitioners during the clinical encounter • Provides for additional expert review, endorsement, and alignment by multiple medical specialty societies (the American Academy of Family Physicians, the American College of Obstetricians and Gynecologists, the American College of Physicians, and the American College of Nurse-Midwives) Much effort goes into the development of this adult immunization schedule. The process begins with the formation of an ACIP working group, comprised of numerous outside experts and CDC staff with expertise in vaccines. The charge to the working group is to distill the previously issued ACIP recommendations into a clear visual presentation with the most salient points summarized in the footnotes. To do this, new data are evaluated, recent ACIP recommendations are reviewed, and footnotes are developed into summary sentences. Scores of teleconferences and several inperson meetings are held allowing for discussion and refinements. In addition, much effort is put into devising the graphical representation of the recommendations, and new needs discussed. For this year, the process led to the development of (1) formatting of the footnotes into bulleted lists and (2) a new, additional table summarizing contraindications and precautions of currently licensed adult vaccines. This new table, patterned after one in use 0264-410X/$ – see front matter © 2012 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.vaccine.2012.04.065
by the Immunization Action Coalition (www.immunize.org), complements the schedules by showing both the vaccine indications and contraindications together. The pairing of these tables is likely to be very useful to providers and hopefully makes it easier and less confusing to provide vaccines in as safe a manner as possible. For 2012, several changes and clarifications have been made: • A new table has been added (Contraindications and Precautions to Commonly Used Vaccines in Adults). This table was added to provide easily accessible information on the major safety and precautionary issues for each routine adult vaccine. • Changes in figure footnotes have been made to incorporate new recommendations issued by ACIP or to clarify recommendations. The major ones are summarized in Table 1. • Changes in the graphical representations in the figures have been made, making it easier to see “at a glance” what vaccines should be administered by age or by a variety of common medical conditions. An important issue arises in relation to the U.S. Adult Immunization Schedule – why don’t other countries produce similar materials? Or perhaps better, why isn’t there a common, global set of adult immunization recommendations? It is, after all, likely that a common set of well vetted recommendations, published annually with updates, and in easy graphical format, is likely to enhance adult immunization efforts in all countries that participate, decrease confusion about indications and contraindications, and improve vaccination practice safety. An important demographic issue is the population shift toward older persons, in all countries. In developed countries in particular, the elder population is growing, with a current average population age of 35 in the U.S. and 37 in Europe. By 2050, it has been predicted that in Europe the average population age will exceed 50. For this reason, in combination with the clear propensity for older adults to suffer the extremes of morbidity and mortality from vaccine-preventable diseases (VPDs), significant effort needs to be put into establishing clear, concise, evidence-based immunization schedules for adults globally. Other countries do produce such schedules. For example, Canada follows a very similar procedure to the U.S. and publishes an annual update for adult immunization. (http://www.phac-aspc.gc.ca/im/is-cv/index-eng.php#b) as does (http://www.ncirs.edu.au/immunisation/fact-sheets/ Australia Adult%20Vaccination%20Factsheet%20FINAL.pdf). Less clear is the process in Europe. European Union countries do publish “vaccination schedules,” but these are generally simply a tabular format of what vaccines are indicated at what age – with little in
3490
Editorial / Vaccine 30 (2012) 3489–3491
Table 1 Summary of New Recommendations/Clarifications to the U.S. Adult Immunization Recommendations—2012. Vaccine
New Recommendations/Clarifications
Hepatitis B Vaccines
• Recommended that all persons <60 years of age with diabetes receive hepatitis B vaccine. Persons >60 years of age should receive vaccine if living in long-term care settings and requiring assisted blood glucose monitoring.
Human papillomavirus (HPV)
• Recommended routine vaccination of males 11–12 years of age, with catch-up vaccination for males 13–21 who have not been previously immunized. • Recommended HPV vaccine for males 22–26 at high risk for HPV infection (HIV positive, men who have sex with men, those who are immunocompromised). • Only HPV4 should be used in males. • In the CDC’s published recommendations, the yellow bar in Figure 2 was extended to include HCPs who meet the age indications.
Influenza Vaccines
• Additional emphasis given to vaccination of pregnant women with TIV. • Age indications for ID-TIV have been added.
Measles-Mumps-Rubella Vaccine (MMR)
• A footnote was added referring readers to the full ACIP recommendations for the use of MMR vaccine in HCWs during outbreaks.
Meningococcal Vaccines (Meningococcal conjugate vaccine 0 MCV) (Meningococcal polysaccharide vaccine-MPSV) Pneumococcal Polysaccharide Vaccine (PPSV)
• Recommendation that all college freshman ≤ 21 years of age receive a single dose of vaccine if they are living in residence halls and have not received a dose on or after the 16th birthday. • Additional examples of anatomic/functional asplenia were added. • Recommended avoiding use of vaccine during cancer chemotherapy or other immunosuppressive therapy – the interval between vaccination and start of treatment should be at least 2 weeks.
Tetanus-Diphtheria-Acellular Pertussis (Tdap)
• Recommended that pregnant women should preferentially receive Tdap during later pregnancy (≥20 weeks gestation). • Emphasis is given to administration of Tdap vaccine to older adults (≥65 years) who have contact with infants <12 mos (note: ACIP voted in February 2012 that all adults, including those 65+, receive a one-time dose of Tdap).
Zoster Vaccine
• Vaccine is now FDA approved for use in persons ≥50 years of age, although ACIP recommends vaccination be given at age 60.
the way of a separately published and annually updated “adult schedule.” Medical conditions are not included and footnotes with clarifying information are rare. A common, global adult immunization schedule would also focus attention on disease prevention in the looming seismic shift in population age structure, the accompanying huge medical costs associated with these changes, and the need to focus immunization efforts and activities on adults – much as has been done with childhood immunization programs globally over the last half-century. While some country-specific differences in disease epidemiology exist, these are minor compared to the issue of the large morbidity and mortality rates among adults due to VPDs. Articulated another way, in what country are recommendations for Tdap, influenza, pneumococcal, MMR, HPV, or hepatitis A/B vaccines not needed or
of value? Admittedly, via the structure of their governments and financial markets, some countries cannot afford certain vaccines such as zoster vaccine, or perhaps HPV; but footnotes could be inserted providing financial thresholds (GDP?) at which a given vaccine should be offered. Regardless, the mere construction of a global adult immunization schedule, endorsed by participating countries, signals the importance of adult immunization, provides a clear, concise and evidence-based “best practice” that optimizes adult health, and provides a rallying point around which countryspecific and global immunization practices and polices can be constructed and transformed. In addition to establishing guidelines, it is important that countries monitor compliance with recommended immunizations in order to improve implementation. Of note, the World Health Organization and European Union do an excellent job of doing something similar to what we call for in regard to childhood immunization tracking and publishing childhood immunization schedules and coverage rates. In fact, National Childhood Vaccination Schedules (EUVAC.net) and the European Centre for Disease Prevention and Control (ECDC) collate each EU country-specific immunization schedule (http://www.ecdc.europa.eu/en/activities/surveillance/euvac/ schedules/Pages/schedules.aspx). However, nothing similar exists for adult immunization. We believe that at the level of the WHO, a global, adult immunization recommended schedule would be worth consideration and discussion. Benefits would include the likelihood of improving adult vaccination coverage rates, and a decrease in the morbidity, mortality, and attendant economic costs of vaccine-preventable disease in the fastest growing segment of the world’s population. Construction and approval of a global adult immunization schedule would be proactive, forward thinking, and enhance already stated goals of the WHO and most countries. In an era where, at least in developed countries, adult deaths due to VPDs exceed childhood deaths due to VPDs by 250- to 300-fold, it would seem the time is right to focus attention on preventing VPDs among adults. Disclosures Dr. Poland is the chair of a Safety Evaluation Committee for investigational vaccine trials being conducted by Merck Research Laboratories. Dr. Poland offers consultative advice on new vaccine development to Merck & Co., Inc., Avianax, Theraclone Sciences (formally Spaltudaq Corporation), MedImmune LLC, Liquidia Technologies, Inc., Emergent BioSolutions, Novavax, Dynavax, EMD Serono, Inc., Novartis Vaccines and Therapeutics and PAXVAX, Inc. Ms Peterson is an employee of the Immunization Action Coalition (IAC). The IAC receives funding from a variety of sources, but maintains strict editorial independence in all publications and print materials. In 2011, IAC received support for educational programs from Baxter Healthcare Corporation, CSL Biotherapies, GlaxoSmithKline, MedImmune Inc., Merck, Sharp & Dohme Corporation, Novartis Vaccines, Ortho Clinical Diagnostics Inc., Pfizer Inc., and sanofi pasteur. Dr. Gardner has provided consultative advice to Pfizer on the issues of pneumococcal and meningococcal vaccines. Dr. Poland is a liaison member of the ACIP, representing the American College of Physicians. He, Ms. Peterson, and Dr. Gardner are members of the Adult Immunization Working Group that devises the Adult Immunization Schedule for final approval by the ACIP. References [1] Recommended adult immunization schedule: United States, 2012. Annals of Internal Medicine 2012;156(February (3)):211–7. [2] Centers for Disease Contol and Prevention. Recommended Adult Immunization Schedule—United States, 2012. Morbidity and Mortality Weekly Report 2012;61(4).
Editorial / Vaccine 30 (2012) 3489–3491
Gregory A. Poland ∗ VACCINE, Mayo Clinic, Rochester, MN, USA Diane Peterson Immunization Action Coalition, St. Paul, MN, USA Pierce Gardner Stony Brook University School of Medicine, Stony Brook, NY, USA
3491 ∗ Corresponding
author. Tel.: +1 507 284 4968; fax: +1 507 266 4716. E-mail addresses: [email protected] (G.A. Poland), [email protected] (D. Peterson), [email protected] (P. Gardner) 11 April 2012
Contents lists available at SciVerse ScienceDirect
Vaccine journal homepage: www.elsevier.com/locate/vaccine
Editorial
Adult immunization recommendations in the US—New changes and a plea for a global adult immunization schedule
On an annual basis, the Advisory Committee on Immunization Practices (ACIP) updates the Adult Immunization Schedule for persons residing in the United States. These recommendations are provided in two formats: one, a table that lists recommended vaccines by age grouping, and two, a table that lists recommended vaccines by risk factor as well as occupation as a healthcare worker. Both are available on the Centers for Disease Control and Prevention website (http://www.cdc.gov/vaccines/recs/schedules/ downloads/adult/adult-schedule.pdf) in both English and Spanish. Recent summaries of these changes are also available [1,2]. This editorial also provides this information for VACCINE readers, and condenses the changes into a single table for use by our readers. In addition, context and suggestions are provided relevant to the practice of vaccinology in other countries. Importantly, the U.S. Adult Immunization Schedule serves several important purposes; it: • Provides comprehensive, evidence-based recommendations and a schedule for the use of vaccines licensed in the U.S. for adults • Provides a “standard of care” for the clinical use of vaccines for adults in the U.S. • Provides visual aids that simplify a large body of complex information into two graphics that can be readily accessed by practitioners during the clinical encounter • Provides for additional expert review, endorsement, and alignment by multiple medical specialty societies (the American Academy of Family Physicians, the American College of Obstetricians and Gynecologists, the American College of Physicians, and the American College of Nurse-Midwives) Much effort goes into the development of this adult immunization schedule. The process begins with the formation of an ACIP working group, comprised of numerous outside experts and CDC staff with expertise in vaccines. The charge to the working group is to distill the previously issued ACIP recommendations into a clear visual presentation with the most salient points summarized in the footnotes. To do this, new data are evaluated, recent ACIP recommendations are reviewed, and footnotes are developed into summary sentences. Scores of teleconferences and several inperson meetings are held allowing for discussion and refinements. In addition, much effort is put into devising the graphical representation of the recommendations, and new needs discussed. For this year, the process led to the development of (1) formatting of the footnotes into bulleted lists and (2) a new, additional table summarizing contraindications and precautions of currently licensed adult vaccines. This new table, patterned after one in use 0264-410X/$ – see front matter © 2012 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.vaccine.2012.04.065
by the Immunization Action Coalition (www.immunize.org), complements the schedules by showing both the vaccine indications and contraindications together. The pairing of these tables is likely to be very useful to providers and hopefully makes it easier and less confusing to provide vaccines in as safe a manner as possible. For 2012, several changes and clarifications have been made: • A new table has been added (Contraindications and Precautions to Commonly Used Vaccines in Adults). This table was added to provide easily accessible information on the major safety and precautionary issues for each routine adult vaccine. • Changes in figure footnotes have been made to incorporate new recommendations issued by ACIP or to clarify recommendations. The major ones are summarized in Table 1. • Changes in the graphical representations in the figures have been made, making it easier to see “at a glance” what vaccines should be administered by age or by a variety of common medical conditions. An important issue arises in relation to the U.S. Adult Immunization Schedule – why don’t other countries produce similar materials? Or perhaps better, why isn’t there a common, global set of adult immunization recommendations? It is, after all, likely that a common set of well vetted recommendations, published annually with updates, and in easy graphical format, is likely to enhance adult immunization efforts in all countries that participate, decrease confusion about indications and contraindications, and improve vaccination practice safety. An important demographic issue is the population shift toward older persons, in all countries. In developed countries in particular, the elder population is growing, with a current average population age of 35 in the U.S. and 37 in Europe. By 2050, it has been predicted that in Europe the average population age will exceed 50. For this reason, in combination with the clear propensity for older adults to suffer the extremes of morbidity and mortality from vaccine-preventable diseases (VPDs), significant effort needs to be put into establishing clear, concise, evidence-based immunization schedules for adults globally. Other countries do produce such schedules. For example, Canada follows a very similar procedure to the U.S. and publishes an annual update for adult immunization. (http://www.phac-aspc.gc.ca/im/is-cv/index-eng.php#b) as does (http://www.ncirs.edu.au/immunisation/fact-sheets/ Australia Adult%20Vaccination%20Factsheet%20FINAL.pdf). Less clear is the process in Europe. European Union countries do publish “vaccination schedules,” but these are generally simply a tabular format of what vaccines are indicated at what age – with little in
3490
Editorial / Vaccine 30 (2012) 3489–3491
Table 1 Summary of New Recommendations/Clarifications to the U.S. Adult Immunization Recommendations—2012. Vaccine
New Recommendations/Clarifications
Hepatitis B Vaccines
• Recommended that all persons <60 years of age with diabetes receive hepatitis B vaccine. Persons >60 years of age should receive vaccine if living in long-term care settings and requiring assisted blood glucose monitoring.
Human papillomavirus (HPV)
• Recommended routine vaccination of males 11–12 years of age, with catch-up vaccination for males 13–21 who have not been previously immunized. • Recommended HPV vaccine for males 22–26 at high risk for HPV infection (HIV positive, men who have sex with men, those who are immunocompromised). • Only HPV4 should be used in males. • In the CDC’s published recommendations, the yellow bar in Figure 2 was extended to include HCPs who meet the age indications.
Influenza Vaccines
• Additional emphasis given to vaccination of pregnant women with TIV. • Age indications for ID-TIV have been added.
Measles-Mumps-Rubella Vaccine (MMR)
• A footnote was added referring readers to the full ACIP recommendations for the use of MMR vaccine in HCWs during outbreaks.
Meningococcal Vaccines (Meningococcal conjugate vaccine 0 MCV) (Meningococcal polysaccharide vaccine-MPSV) Pneumococcal Polysaccharide Vaccine (PPSV)
• Recommendation that all college freshman ≤ 21 years of age receive a single dose of vaccine if they are living in residence halls and have not received a dose on or after the 16th birthday. • Additional examples of anatomic/functional asplenia were added. • Recommended avoiding use of vaccine during cancer chemotherapy or other immunosuppressive therapy – the interval between vaccination and start of treatment should be at least 2 weeks.
Tetanus-Diphtheria-Acellular Pertussis (Tdap)
• Recommended that pregnant women should preferentially receive Tdap during later pregnancy (≥20 weeks gestation). • Emphasis is given to administration of Tdap vaccine to older adults (≥65 years) who have contact with infants <12 mos (note: ACIP voted in February 2012 that all adults, including those 65+, receive a one-time dose of Tdap).
Zoster Vaccine
• Vaccine is now FDA approved for use in persons ≥50 years of age, although ACIP recommends vaccination be given at age 60.
the way of a separately published and annually updated “adult schedule.” Medical conditions are not included and footnotes with clarifying information are rare. A common, global adult immunization schedule would also focus attention on disease prevention in the looming seismic shift in population age structure, the accompanying huge medical costs associated with these changes, and the need to focus immunization efforts and activities on adults – much as has been done with childhood immunization programs globally over the last half-century. While some country-specific differences in disease epidemiology exist, these are minor compared to the issue of the large morbidity and mortality rates among adults due to VPDs. Articulated another way, in what country are recommendations for Tdap, influenza, pneumococcal, MMR, HPV, or hepatitis A/B vaccines not needed or
of value? Admittedly, via the structure of their governments and financial markets, some countries cannot afford certain vaccines such as zoster vaccine, or perhaps HPV; but footnotes could be inserted providing financial thresholds (GDP?) at which a given vaccine should be offered. Regardless, the mere construction of a global adult immunization schedule, endorsed by participating countries, signals the importance of adult immunization, provides a clear, concise and evidence-based “best practice” that optimizes adult health, and provides a rallying point around which countryspecific and global immunization practices and polices can be constructed and transformed. In addition to establishing guidelines, it is important that countries monitor compliance with recommended immunizations in order to improve implementation. Of note, the World Health Organization and European Union do an excellent job of doing something similar to what we call for in regard to childhood immunization tracking and publishing childhood immunization schedules and coverage rates. In fact, National Childhood Vaccination Schedules (EUVAC.net) and the European Centre for Disease Prevention and Control (ECDC) collate each EU country-specific immunization schedule (http://www.ecdc.europa.eu/en/activities/surveillance/euvac/ schedules/Pages/schedules.aspx). However, nothing similar exists for adult immunization. We believe that at the level of the WHO, a global, adult immunization recommended schedule would be worth consideration and discussion. Benefits would include the likelihood of improving adult vaccination coverage rates, and a decrease in the morbidity, mortality, and attendant economic costs of vaccine-preventable disease in the fastest growing segment of the world’s population. Construction and approval of a global adult immunization schedule would be proactive, forward thinking, and enhance already stated goals of the WHO and most countries. In an era where, at least in developed countries, adult deaths due to VPDs exceed childhood deaths due to VPDs by 250- to 300-fold, it would seem the time is right to focus attention on preventing VPDs among adults. Disclosures Dr. Poland is the chair of a Safety Evaluation Committee for investigational vaccine trials being conducted by Merck Research Laboratories. Dr. Poland offers consultative advice on new vaccine development to Merck & Co., Inc., Avianax, Theraclone Sciences (formally Spaltudaq Corporation), MedImmune LLC, Liquidia Technologies, Inc., Emergent BioSolutions, Novavax, Dynavax, EMD Serono, Inc., Novartis Vaccines and Therapeutics and PAXVAX, Inc. Ms Peterson is an employee of the Immunization Action Coalition (IAC). The IAC receives funding from a variety of sources, but maintains strict editorial independence in all publications and print materials. In 2011, IAC received support for educational programs from Baxter Healthcare Corporation, CSL Biotherapies, GlaxoSmithKline, MedImmune Inc., Merck, Sharp & Dohme Corporation, Novartis Vaccines, Ortho Clinical Diagnostics Inc., Pfizer Inc., and sanofi pasteur. Dr. Gardner has provided consultative advice to Pfizer on the issues of pneumococcal and meningococcal vaccines. Dr. Poland is a liaison member of the ACIP, representing the American College of Physicians. He, Ms. Peterson, and Dr. Gardner are members of the Adult Immunization Working Group that devises the Adult Immunization Schedule for final approval by the ACIP. References [1] Recommended adult immunization schedule: United States, 2012. Annals of Internal Medicine 2012;156(February (3)):211–7. [2] Centers for Disease Contol and Prevention. Recommended Adult Immunization Schedule—United States, 2012. Morbidity and Mortality Weekly Report 2012;61(4).
Editorial / Vaccine 30 (2012) 3489–3491
Gregory A. Poland ∗ VACCINE, Mayo Clinic, Rochester, MN, USA Diane Peterson Immunization Action Coalition, St. Paul, MN, USA Pierce Gardner Stony Brook University School of Medicine, Stony Brook, NY, USA
3491 ∗ Corresponding
author. Tel.: +1 507 284 4968; fax: +1 507 266 4716. E-mail addresses: [email protected] (G.A. Poland), [email protected] (D. Peterson), [email protected] (P. Gardner) 11 April 2012