Adult Immunizations: Update on Recommendations

UPDATE IN OFFICE MANAGEMENT

Adult Immunizations: Update on Recommendations Huan Pham, MD,a Stephen A. Geraci, MD,b Mary Jane Burton, MDa,c a

Division of Infectious Diseases and bDivision of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Mississippi School of Medicine, Jackson; cG.V. (Sonny) VA Medical Center, Jackson, Miss.

ABSTRACT The Advisory Committee for Immunization Practices recommends universal influenza vaccination for 2010-2011. Older adults should be offered protection against herpes zoster, and younger adults should receive immunization against human papilloma virus and pertussis. Hepatitis B vaccination should be encouraged in non-immune adults. Recommendations also address vaccinations for tetanus/diphtheria, hepatitis A, pneumococcus, measles/mumps/rubella, and meningococcus. Published by Elsevier Inc. • The American Journal of Medicine (2011) 124, 698-701 KEYWORDS: Immunizations; Influenza vaccine; Meningococcal vaccine; Pneumococcal vaccine

Although immunization is one of the most effective public health measures to prevent disease, vaccination rates in adult populations remain low. The Advisory Committee on Immunization Practices recently expanded the indications for influenza and human papilloma virus vaccination1 and provides guidance on administration of new and existing vaccines.

GUIDELINE SUMMARY AND VACCINE SAFETY Currently recommended vaccines, along with their common adverse effects, are listed in Table 1. Typical reactions for injectable vaccines include erythema and soreness at the administration site. Severe reactions are reported rarely. In the majority of cases, the risk of illness from the targeted pathogen is far greater than that from vaccination. Epidemiologic studies have found no causal association between Guillain-Barré syndrome and any of the currently licensed vaccines.2 Live attenuated preparations (measles/mumps/ rubella, varicella, varicella-zoster, and intranasal influenza vaccines) should not be given to immunocompromised persons or pregnant women. Funding: None. Conflict of Interest: None of the authors have any conflicts of interest associated with the work presented in this manuscript. Authorship: All authors had access to the data and played a role in writing this manuscript. Requests for reprints should be addressed to Mary Jane Burton, MD, Medical Service (111), G.V. Sonny Montgomery VA Medical Center, 1500 East Woodrow Wilson Avenue, Jackson, MS 39216. E-mail address: [email protected].

0002-9343/$ -see front matter Published by Elsevier Inc. doi:10.1016/j.amjmed.2010.07.032

Influenza Vaccine There are 2 types of influenza vaccines: the trivalent inactivated influenza vaccine and the live attenuated influenza vaccine. Provisional recommendations expanded inactivated vaccine for use in all adults, whereas live vaccine is licensed for use in healthy, non-pregnant adults aged 49 years or less.1 A higher dose formulation of inactivated vaccine, Fluzone High Dose (Sanofi Pasteur, Inc, Swiftwater, Pa) is now available for adults aged 65 years or more. High-dose inactivated vaccine immunization induces greater antibody responses but with higher rates of local reactions;3 however, pending comparative clinical efficacy studies, the high-dose product is not preferred. The 2010-2011 influenza vaccines will contain the 2009 pandemic influenza A (H1N1) monovalent vaccine.

Pneumococcal Polysaccharide Vaccine The 23 polyvalent pneumococcal polysaccharide vaccine is recommended for any person aged 2 years or more with chronic cardiovascular diseases (except hypertension), chronic pulmonary diseases (including asthma), diabetes, asplenia, chronic liver disease, alcoholism, tobacco use, and cerebrospinal fluid leaks. Pneumococcal vaccine also is indicated in persons aged 65 years or more who are unvaccinated or were vaccinated 5 years or more previously. A 1-time revaccination 5 years after the first dose is recommended for persons at high risk for serious pneumococcal disease.4

Pham et al Table 1

Adult Immunizations

699

Recommended Vaccinations for 2010-2011 Indications

Route

TIV

All adults

IM

LAIV

Healthy adults aged ⱕ 49 y

Intranasal

High-dose TIV

Adults aged ⱖ 65 y

IM

PPV

Adults aged ⱖ 65 years, ⬍65 y with chronic medical conditions*

IM

Varicella

Adults without immunity

SC

Zoster Td

Adults aged ⱖ 60 y All adults

SC IM

1 dose Initial 3-dose series, booster every 10 y

Tdap

Adults aged ⬍ 65 y

IM

Once in place of Td booster

Hepatitis A vaccine

Chronic liver disease, MSM, illegal drug users, recipients of clotting factors, travelers to endemic regions Healthcare workers, chronic liver disease, end-stage renal disease, MSM, multiple sexual partners, HIV-infected persons without immunity Males and females aged 9-26 y (Gardisil, Merck & Co, Inc, Whitehouse Station, NJ) Females aged 9-26 y (Cervarix, GlaxoSmithKline, London, UK) Previously unvaccinated adults

IM

2 doses, 0 and 6-12 mo

Same as Td ⫹ previous encephalopathy within 7 d of prior pertussis vaccination Allergy to vaccine

IM

3 doses, 0, 1 and 6-12 mo

IM

Hepatitis B vaccine

Human papilloma virus

Measles/mumps/rubella

Meningococcal vaccine

College freshman, military recruits, travelers to endemic regions, asplenic persons

Frequency

Annually

Once; can give a second dose after 5 y if first dose given before age 65 y 1 dose

Contraindications

Adverse Reactions

Severe allergy to vaccine or eggs Predisposing condition to influenza complications,* including pregnancy and immunocompromised state; also allergy to TIV or eggs Same as TIV

Injection site reactions Nasal congestion, cough

Allergic reaction to vaccine

Allergy to gelatin or other vaccine components; immunocompromised state,* pregnancy Same as above Previous allergic reaction to vaccine

Increased local site reactions Injection site reactions, more frequent with second dose Injection site reactions, varicellalike rash

Same as above Injection site reactions, body aches, fever Same as Td

Recommended in Pregnancy Yes No

No No

No

No Yes

No

Injection site reactions

No

Allergy to yeast or vaccine component

Injection site reactions

Limited data demonstrate no risk during pregnancy

3 doses, 0, 1, and 6 mo

Allergy to yeast or vaccine component

Local site reactions

No

SC

2 doses, ⱖ28 d apart

1 dose, second dose after 2 y in high-risk groups

Local site reactions, rash, fever, urticaria Local site reactions, occasionally fever

No

SC

Pregnancy, immunocompromised state Allergy to rubber latex or vaccine components

No

HIV ⫽ human immunodeficiency virus; IM ⫽ intramuscular; LAIV ⫽ live attenuated influenza vaccine; MSM ⫽ men who have sex with men; PPV ⫽ pneumococcal polysaccharide vaccine; SC ⫽ subcutaneous; Td ⫽ tetanus/diphtheria; Tdap ⫽ tetanus/diphtheria/acellular pertussis; TIV ⫽ trivalent inactivated vaccine. *For more details, see Centers for Disease Control, “General recommendations on immunization: Recommendations of the Advisory Committee on Immunization Practices” at www.cdc.gov/vaccine/pubs/acip-list.htm.

Varicella and Varicella-Zoster Vaccine Varicella vaccination is recommended to healthy persons aged 13 years or more without evidence of immunity, particularly healthcare practitioners, household contacts of immunocompromised individuals, non-pregnant women of

childbearing age, and persons with frequent exposure to children and international travelers.5 Varicella-zoster vaccination is recommended in healthy adults aged 60 years or more with or without a history of herpes zoster.6 Testing for varicella immunity before vac-

700 cination is unnecessary. To ensure optimal benefit, varicellazoster and pneumococcal vaccinations should be administered at least 4 weeks apart. Patients who are prescribed acyclovir, famciclovir, or valacyclovir should stop these medications 24 hours before to 14 days after immunization with either the varicella or varicella-zoster vaccine.

The American Journal of Medicine, Vol 124, No 8, August 2011 of the quadrivalent vaccine in males of the same age group.1 Neither formulation is recommended in pregnancy, although a negative pregnancy test is not required before vaccination. The quadrivalent vaccine can be administered to nursing mothers.10

Measles/Mumps/Rubella Tetanus/Diphtheria Toxoid and Tetanus/Diphtheria/Acellular Pertussis Vaccines Tetanus/diphtheria toxoid as a booster every 10 years is indicated for all unvaccinated adults and those previously vaccinated.7 Patients presenting with a dirty or major wound more than 5 years after their last injection should be revaccinated. A single dose of tetanus/diphtheria/acellular pertussis should be given in place of the tetanus/diphtheria booster in adults aged less than 65 years. Targeted populations for the pertussis-containing vaccine include healthcare personnel and those exposed to infants aged less than 12 months. Although tetanus/diphtheria can be given during pregnancy, present guidance recommends delaying routine vaccination antepartum and administering the tetanus/diphtheria/acellular pertussis vaccine immediately after delivery.

Hepatitis A Vaccine Hepatitis A vaccine is recommended for travelers to endemic areas, men who have sex with men, illegal drug users, recipients of transfused clotting factors, and those with chronic liver disease.8 Most experts vaccinate human immunodeficiency virus-infected individuals who lack demonstrable immunity, although this is not stated in the published recommendations. Routine post-vaccination serologic testing is not recommended.

Hepatitis B Vaccine For adults who do not have protective antibodies, hepatitis B vaccine should be routinely offered. Although the vaccine is specifically recommended to individuals with risks for contracting hepatitis B, any adult who desires protection should be given the vaccine.9 Post-vaccination serologic testing is recommended 1 to 2 months after the last injection for the following groups: healthcare and public safety workers, patients receiving hemodialysis, human immunodeficiency virus-infected persons, other immunocompromised individuals, and other persons at high risk for contracting hepatitis B. Individuals who do not respond serologically should be revaccinated.

Measles/mumps/rubella vaccination is recommended for all previously unvaccinated adults, especially women of childbearing age.11 The duration of protection is long-term, if not life-long,12 and routine post-vaccination serologic testing is not recommended. Women should avoid pregnancy for 3 months after administration.

Meningococcal Vaccine There are 2 meningococcal vaccines licensed for use in the United States: MPSV4 (consisting of groups A, C, Y, and W135) and MCV4 (containing the same four groups and conjugated to diphtheria toxoid). The MCV4 is preferred among persons aged 11 to 55 years.13 A 1-time vaccination with either preparation is recommended for all adolescents aged 11 years or more, those with terminal complement component deficiencies or asplenia, previously unvaccinated college freshmen, military recruits, and travelers to endemic regions. Routine revaccination is not recommended; however, persons who remain at risk for meningococcal infection should receive a second dose 2 to 3 years after the previous vaccine.

CONCLUSIONS Currently recommended vaccines are safe and effective at preventing infectious diseases and their complications. Recent Advisory Committee on Immunization Practices recommendations expand use of the trivalent influenza vaccine to include all adults and permits use of the quadrivalent human papillomavirus vaccine in males ages 9 to 26 years. Vaccination against hepatitis B should be routinely offered to non-immune adults. A 1-time dose of tetanus/diphtheria/ acellular pertussis vaccine should be given to persons aged less than 65 years. Healthy adults aged 60 years or more should be offered varicella-zoster immunization. Providers should be aware of the indications for new and previously recommended vaccines to improve immunization rates in adult populations.

References Human Papillomavirus Vaccine There are 2 human papillomavirus vaccines available: a quadrivalent vaccine (Gardasil, Merck & Co, Inc, Whitehouse Station, NJ) containing viral types 6, 11, 16, and 18, and a bivalent vaccine containing types 6 and 18 (Cervarix, GlaxoSmithKline, London, UK). A 3-dose intramuscular series for either vaccine is recommended (0, 2, and 6 months).1 Either formulation is recommended for females aged 9 to 26 years; provisional recommendations permit use

1. ACIP Provisional Recommendations. Available at: http://www.cdc. gov/vaccines/recs/provisional/default.htm. Accessed June 5, 2010. 2. Haber P, Sejvar J, Mikaeloff Y, DeStefano F. Vaccines and GuillainBarre syndrome. Drug Safety. 2009;32:309-323. 3. Falsey AR, Treanor JJ, Tornieporth N, et al. Randomized, doubleblind controlled phase 3 trial comparing the immunogenicity of highdose and standard-dose influenza vaccine in adults 65 years of age and older. J Infect Dis. 2009;200:172-180. 4. CDC. Prevention of pneumococcal disease: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR. 1997;46(RR-8):1-24.

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5. CDC. Prevention of varicella recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR. 2007;56(RR-4): 1-40. 6. CDC. Prevention of herpes zoster recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR. 2008;57(RR5):1-30. 7. CDC. Preventing tetanus, diphtheria, and pertussis among adults: use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine: recommendations of the Advisory Committee on Immunization Practices (ACIP) and recommendations of the ACIP, supported by the Healthcare Infection Control Practices Advisory Committee (HICPAC), for use of Tdap among health-care personnel. MMWR. 2006;55(RR-17):1-33. 8. CDC. Prevention of hepatitis A through active or passive immunization: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR. 2006;55(RR-7):1-23.

701 9. CDC. A comprehensive immunization strategy to eliminate transmission of hepatitis B virus infection in the United States: recommendations of the Advisory Committee on Immunization Practices (ACIP) Part II: immunization of adults. MMWR. 2006;55(RR-16):1-25. 10. CDC. Quadrivalent human papillomavirus vaccine: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR. 2007(RR-2);56:1-24. 11. CDC. Measles, mumps, and rubella—vaccine use and strategies for elimination of measles, rubella, and congenital rubella syndrome and control of mumps: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR. 1998(RR-8);47:1-57. 12. Markowitz LE, Preblud SR, Fine PE, Orienstein WA. Duration of live measles vaccine-induced immunity. Pediatr Infect Dis J. 1990;9:101-110. 13. CDC. Prevention and control of meningococcal disease: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR. 2005(RR-07);54:1-21.