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Vaccine update 2010: Keeping up with the changes

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VACCINE UPDATE FOR ADOLESCENTS

A number of vaccines are now available and recommended for routine use in adolescents.9 These include HPV vaccine for girls, quadrivalent meningococcal conjugate vaccine (MCV4), and combined tetanus toxoid, reduced-dose diphtheria toxoid, and acellular pertussis (Tdap). All these are now recommended routinely at age 11 or 12. Seasonal influenza vaccine is recommended annually through age 18.

For the next decade, a catch-up varicella booster will also be recommended for adolescents because of waning varicella immunity from a single dose. Adolescents should also receive some catch-up vaccines if they did not receive them in childhood and should be considered for some vaccines that are recommended on the basis of risk. Table 2 lists the vaccines that should be considered during a clinical visit for those age 11 through 18 years.

Meningococcal conjugate vaccine for all at age 11–18

In 2007, the ACIP recommended MCV4 for all at age 11 through 18 at the earliest opportunity. 10 For those who remain at high risk (Table 3) and who were vaccinated with either MCV4 or the meningococcal polysaccharide vaccine (MPSV4), a booster is recommended after 3 years (if vaccinated before age 7), and after 5 years if vaccinated age 7 and up. College freshman who were vaccinated with MCV4 do not need a booster dose.

There is some evidence that MCV4 may be linked to a small risk of Guillain-Barré syndrome. Although this link has not been conclusively proven, a history of Guillain-Barré syndrome calls for caution in using MCV4. For those who have a history of this syndrome but need protection against meningococcal infection, the MPSV4 is an alternative.11

Pertussis: A Tdap booster at age 11–18

From Broder KR, et al; ACIP. Preventing tetanus, diphtheria, and pertussis among adolescents: use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccines recommendations of the ACIP. MMWR Recomm Rep 2006; 55(RR–3):1–34

Figure 1.

The incidence of pertussis in the United States declined dramatically after pertussis vaccine was introduced in the 1940s. Before then, the disease caused an average of 160,000 cases (150 per 100,000 population) and 5,000 deaths each year. Figure 112 shows how pertussis incidence declined steadily over 3 decades to reach a low of 1,010 cases in 1976. However, while other vaccine-preventable diseases such as polio, measles, rubella, diphtheria, and tetanus have declined to only a few cases each year or have been totally eliminated, pertussis has made a slight comeback. The number of cases began to increase in the 1980s and reached 7,000 to 8,000 per year between 1996 and 2000. There were 11,647 cases in 2003.

In addition, a greater percentage of cases now occurs in adolescents and young adults. Half of reported cases are now in those age 10 years and older. Most nonimmunized or incompletely immunized infants who develop pertussis were exposed to the disease by older household members, not by same-age cohorts. Since the disease presents as nonspecific cough in adolescents, it is often not diagnosed, and the incidence is probably much higher than the reported number of cases would indicate.

These trends were cause for public health concern and led to the development of pertussis-containing vaccine products for adolescents and adults. Two Tdap products are available: one is licensed for those ages 10 to 64 (Boostrix), the other for ages 11 to 64 (Adacel). Since 2005, the ACIP has recommended a single dose of Tdap for those age 11 to 18, preferably at 11 or 12 years.12 The optimal interval from the last tetanus-diphtheria shot is 5 years, but a shorter interval is acceptable. Thereafter, boosters with the tetanus toxoid and reduced-dose diphtheria toxoid (Td) vaccine are recommended every 10 years. If an adolescent has not previously received a complete series of a tetanus-diphtheria product, he or she should be given the recommended number of doses, only one of which should be Tdap, the others Td. The number and timing of doses can be found at www.cdc.gov/mmwr/preview/mmwrhtml/rr55e223a5.htm.

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