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 2011 Adult Immunization Schedule

Each year, updated recommendations for adult immunization protocols are approved by a group of organizations that includes The Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices (ACIP), The American Academy of Family Physicians, The American College of Obstetricians and Gynecologists, and The American College of Physicians. Figure 1 provides the recommended adult immunization schedule listed by vaccine and age group. Figure 2 includes vaccines that might be indicated for adults based on medical and other indications. Following those Figures are footnotes which should be read for each of the immunizations depicted in the Figures.

The changes in the 2011 adult immunization schedule, which I discuss below individually, are as follows:

• Recommendation for seasonal influenza vaccine for all persons 6 months and older.
• Use of Tdap (Tetanus, Diphtheria and  acellular Pertussis ) among persons 65 years and older.
• Removal of the reference to a specified interval between Td and Tdap vaccination.
• Addition of a routine 2-dose schedule of MCV4 (meningococcal conjugated vaccine) for certain persons at high risk for meningococcal disease.
• Clarifications in footnotes for HPV (Human Papilloma Virus), MMR (Measles, Mumps, Rubella), PPSV (Pneumococcal polysaccharide vaccine ) and Hib (Haemophilus influenza type B).

SEASONAL INFLUENZA VACCINE FOR ALL PERSONS 6 MONTHS AND OLDER

Last year was the first year that the annual vaccination against influenza was recommended for all those aged 6 months and older. It is now indicated for all adults: for those under age 50 in certain categories of health, an intranasal live vaccine is available; for those over 65 a high-dose influenza vaccine is available which provides a higher level of antibody production. It is not known yet whether this decreases the risk of flu in those who receive it, and there is an increased incidence of minor side effects such as a sore arm after that dose. Several professional societies have recently published mandatory influenza vaccine policies for healthcare workers. These societies include The American College of Physicians, The Infectious Diseases Society of America, The Society for Healthcare Epidemiology of America, and The American Academy of Pediatrics. The nearly 100 healthcare settings across the nation that have implemented mandatory influenza vaccination for healthcare workers can be found at www.immunize.org/honor-roll.

USE OF Tdap AMONG PERSONS 65 AND OLDER

• In response to an increased incidence of pertussis  (whooping cough) in the United States, the ACIP voted on the following new recommendations for the use of Tdap vaccine:
• Tdap can be given regardless of the interval since the last tetanus booster was given. There is NO need to wait the previous 2-5 years to administer Tdap following a dose of Td.
• Adolescents should receive a 1-time dose of Tdap (instead of Td) at the 11-12 year old visit.
• Adolescents and adults younger than age 65 years who have not received a dose of Tdap, or for whom vaccines status is unknown, should be immunized as soon as feasible (as stated above, Tdap can be administered regardless of  the interval since the previous tetanus dose.)
• Adults age 65 years and older who have not previously received a dose of Tdap, and who have or anticipate having close contact with children younger than 12 months of age (e.g. grandparents, other relatives, child care providers, and healthcare personnel), should receive a one-time dose to protect infants as well as themselves. This again can be administered regardless of the interval since the previous Td dose.
• Other adults 65 years and older who are not in contact with an infant, and who have not previously received a dose of Tdap, may receive a single dose of Tdap in place of a dose of Td.
• Children ages 7-10 years who are not fully immunized against pertussis (i.e. , did not complete a series of pertussis-containing vaccine before their 7th birthday) should receive a one-time dose of Tdap.

ADDITION OF A ROUTINE 2-DOSE SCHEDULE OF MCV4 FOR CERTAIN PERSONS AT HIGH RISK FOR MENINGOCOCCAL DISEASE

The ACIP also voted in October 2010 to recommend providers administer the initial dose of MCV4 to all adolescents at age 11-12 years with a booster dose at age 16 years. The peak age for meningococcal disease is 16-21 years. In 2005, the ACIP reasoned that higher MCV4 vaccination rates could be achieved if administering the dose were coupled with giving the Tdap booster dose at the 11-12 year old visit. Current data now indicate that the protection by the MCV4 wanes within five years following vaccination. For this reason, the ACIP is now recommending the booster dose at age 16 to provide protection during the peak years of vulnerability. MCV4 (meningococcal conjugated vaccine) is not approved by the FDA for people 56 years of age and older, who should instead receive meningococcal polysaccharide vaccine (MPSV4). Persons aged 2-54 years with persistent complement component deficiency or asplenia, and adolescents with HIV, should receive 2 doses of MCV4 given 2 months apart.

CLARIFICATIONS IN THE FOOTNOTES FOR HPV, MMR, PPSV AND Hib

The human papillomavirus (HPV) vaccination with either quadrivalent vaccine (HPV4) or bivalent vaccine (HPV2) is recommended for females at age 11 or 12 years, with catch-up vaccination recommended for females age 13-26 years. Females who have not been infected with any of the virus types in the HPV vaccine should receive the full benefit of the vaccination. Those with a history of genital warts, abnormal Papanicolaou (Pap) test, or positive HPV DNA test, should still receive the vaccine because these conditions are not evidence of previous infection with ALL HPV types in the vaccine. The HPV4 vaccine may also be administered to males age 9 through 26 years of age to reduce their likelihood of genital warts and decrease spread to females. A complete series consists of three doses of vaccine. A second dose should be given one to two months after the first dose; the third dose should be administered six months after the first dose. The HPV vaccine is not a live-virus vaccine.

MEASLES, MUMPS, RUBELLA (MMR) VACCINATION

Adults born before 1957 are considered immune to measles and mumps. All those born in 1957 or later should have documentation of one or more doses of MMR vaccine. For rubella, documentation of provider-diagnosed disease is not considered acceptable evidence of immunity. Healthcare personnel born before 1957 that were unvaccinated and lack laboratory evidence of measles, mumps and/or rubella immunity should be considered for routine immunization with two doses of MMR vaccine at the appropriate interval for measles and mumps and 1 dose of MMR vaccine for rubella. It is recommended that those not previously immunized nor with laboratory evidence of the disease receive two doses of MMR vaccine during an outbreak of measles or mumps, and one during an outbreak of rubella.

PNEUMOCOCCAL POLYSACCHARIDE (PPSV) VACCINATION

Medical indications now include chronic lung disease (including asthma), chronic cardiovascular diseases, diabetes mellitus, chronic liver diseases, cirrhosis, chronic alcoholism, functional or anatomic asplenia, immunocompromising conditions (including chronic renal failure or nephrotic syndrome), cochlear implants and cerebrospinal fluid leaks. It is also recommended to promptly vaccinate those who become HIV positive. Others who should be vaccinated with PPSV include residents of nursing homes and persons who smoke. Revaccination with PPSV is recommended for those age 65 and older if they were vaccinated five or more years previously and were aged less than 65 years at the time of the primary vaccination.

HIB VACCINE

One dose of Hib vaccine should be given to persons who have sickle cell disease, leukemia, or HIV infection or who have had a splenectomy, if they have not had previous Hib vaccine.

ZOSTER (SHINGLES) VACCINE

The official ACIP recommendation is for a single dose of Zoster vaccine for those 60 years of age or older, whether or not they have had a prior episode of Herpes zoster. Recurrent cases of shingles can occur, although many times this is felt to be confused with the diagnosis of Herpes simplex virus-mediated zosteriform simplex. This can be confirmed by laboratory testing but is infrequently done. Pneumococcal vaccine should not be administered at the same time as zoster vaccine, as the response may be blunted.

It is estimated that one episode of Herpes zoster would be prevented for every 71 patients vaccinated. From 10% to 30% of people develop shingles during their lifetime, and as many as 50% of people who live to age 85 will have shingles at some point in their life. Twenty per cent of patients with shingles develop post herpetic neuralgia. Anti-viral therapy reduces the severity and duration of an episode of shingles but does not prevent post herpetic neuralgia.

Other general recommendation updates by the ACIP have been published recently in the Morbidity and Mortality Weekly Report. Major revisions since 2006 include: new tables of precautions and contraindications to vaccination; conditions that may be mistaken for contraindications (e.g., diarrhea, minor upper respiratory-tract illness with or without fever, and current antibiotic therapy); new advice for vaccinating patients who have received a hematopoietic cell transplant; and updated storage recommendations.