Keeping up with immunizations for adults
ABSTRACTThis paper discusses recommendations from the US Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices for vaccinating adults against influenza, tetanus, measles, mumps, rubella, varicella, hepatitis A and B, human papillomavirus, shingles (zoster), pneumonia, and meningitis.
KEY POINTS
- Information on immunization schedules, including an app for mobile devices, is available at www.cdc.gov/vaccines/schedules/hcp/adult.html.
- Vaccination rates in adults are low, and appropriate vaccinations should be encouraged. The electronic medical record can help remind us when vaccinations are due.
- The live-attenuated vaccines, ie, zoster, varicella, and combined measles, mumps, and rubella, are contraindicated during pregnancy and in immunocompromised patients.
PNEUMOCOCCAL VACCINE FOR THOSE AGE 65 AND OLDER OR AT RISK
Two formulations are now available for pneumococcal immunization. The standard is a 23-valent polysaccharide vaccine (PPSV23; Pneumovax) indicated for people age 65 and older.
Patients under age 65 can receive PPSV23 if they have chronic lung disease, chronic cardiovascular disease, diabetes, chronic liver disease, or alcoholism or are a resident of a nursing home or an active smoker.
Our patient is a candidate for PPSV23 since he smokes and has diabetes.
The other formulation is a conjugate 13-valent vaccine (PCV13; Prevnar 13). Patients over age 19 at high risk should be given PCV13 plus the PPSV23 8 weeks later. Those who already received PPSV23 should be given PCV13 vaccine more than 1 year later. Candidates for PCV13 are those with immunocompromising conditions (including chronic renal failure and nephrotic syndrome), functional or anatomic asplenia, cerebrospinal fluid leaks, or cochlear implants.
The current revaccination schedule for PPSV23 is as follows:
- One-time revaccination 5 years after the first dose in patients with chronic renal failure, nephrotic syndrome, asplenia, or an immunosuppressive condition
- One-time revaccination for patients age 65 or older if they were younger than 65 when first immunized (with one or two doses of PPSV23) and 5 years have passed
- No revaccination is needed for people vaccinated with PPSV23 after age 65.
HUMAN PAPILLOMAVIRUS VACCINE
Human papillomavirus is the most common sexually transmitted infection in the United States and is strongly associated with cervical cancer. Immunization is now indicated for both sexes, generally between the ages of 9 and 26. Two vaccines are available: the quadrivalent formulation (Gardasil) for males or females and the bivalent formulation (Cervarix) for females only.
Immunization should be given in three doses: at 0, 1 to 2 months, and 6 months. It can be given to patients who are immunocompromised as a result of infection (including HIV infection), disease, or medications, or who have a history of genital warts, an abnormal Papanicolaou test, or a positive human papillomavirus DNA test.
It is hoped that immunization will lead to a significant decrease in cervical cancer rates. Eradication is unlikely because other papillomavirus strains also can lead to cancer, so cancer screening is still warranted. For men who have sex with men, it is hoped that immunization will prevent condyloma and anal cancer.
CHICKENPOX AND SHINGLES VACCINES
Varicella vaccine (Varivax) contains a live-attenuated virus to protect against chickenpox. It is recommended for all adults who have no evidence of immunity. Immunity is assumed with a history of chickenpox, being born before 1980, or having positive titers. Vaccination should be emphasized for those who come in contact with patients at high risk of severe disease (eg, health care workers, family contacts of immunocompromised patients) and in individuals with a high risk of personal exposure (eg, teachers, day care workers).
The vaccine is given in two doses, 4 to 8 weeks apart. Women who are pregnant or who may get pregnant within 4 weeks should not be vaccinated.
The shingles vaccine (Zostavax) is a larger dose of the varicella vaccine and reduces the incidence of shingles by 50% and postherpetic neuralgia by 66%.4 It was approved by the US Food and Drug Administration in May 2006 for people starting at age 50, but was recommended by ACIP in October 2006 for people age 60 and older; as a result, some insurance companies deny coverage for patients ages 50 through 59.
The shingles vaccine can be given to patients who have already had shingles. Pregnancy and severe immunodeficiency are contraindications.
Our patient, 58 years old, could be considered for shingles vaccine if covered by his insurance company or if he wishes to pay for it.
MENINGOCOCCUS VACCINE
Meningococcal immunization is recommended for people at high risk: college students who plan to live in dormitories, adults without a spleen or with complement deficiencies or HIV infection, or travelers to the “meningitis belt” of sub-Saharan Africa.
Two types of meningococcal vaccine are available: the conjugate quadrivalent vaccine (MCV4) for people age 55 and younger, and the polysaccharide quadrivalent vaccine (MPSV4) for people over age 56.
