Keeping up with immunizations for adults

A 58-year-old man with a history of irritable bowel syndrome and diabetes presents for an evaluation in early November. He is taking metformin and insulin glargine 10 units. He smokes 1 pack per day. He believes that his childhood immunizations were completed, but he has no records. He thinks his last “shot” was 15 years ago when he cut his hand on some wood.

Which immunizations, if any, would be most appropriate for this patient?

The explosion of new vaccines, new formulations, and new combinations made available in recent years makes managing immunizations a challenge. This article reviews common immunizations and current recommendations for their appropriate use.

Immunization recommendations (Table 1) are made predominantly by the Advisory Committee on Immunization Practices (ACIP) of the US Centers for Disease Control and Prevention (CDC). The last 15 years have seen the arrival of new vaccines (eg, varicella, hepatitis A, pneumococcal, and human papillomavirus), new formulations (eg, intranasal influenza), and new combinations.

To keep clinicians abreast of new indications, the ACIP issues immunization schedules annually for children and adults, available online and downloadable for easy reference.¹ For adults, the ACIP provides schedules based on age and medical condition. The schedule for medical conditions offers specific information regarding immunization and pregnancy, human immunodeficiency virus (HIV) infection, kidney failure, heart disease, asplenia, and other conditions. The ACIP also provides guidance on contraindications; for example, pregnant and immunocompromised patients should not receive the live-attenuated vaccines, ie, zoster, varicella, and combined measles, mumps, and rubella [MMR]).

Adult awareness of vaccines is low, as are vaccination rates: in people older than 60, the vaccination rate is about 70% for influenza, 60% for pneumococcus, 50% for tetanus, and 15% for zoster. The lack of vaccine awareness and the availability of new vaccines and indications have made it difficult to manage immunizations in the primary care setting. The electronic medical record is useful for tracking patient vaccine needs. Ideally, keeping up with immunizations should be a routine part of visits provided by a physician’s care team and does not always require direct physician coordination.

TETANUS, DIPHTHERIA, PERTUSSIS EVERY 10 YEARS

Tetanus (also called “lockjaw”) is a nervous system disorder characterized by muscle spasms. Caused by infection with Clostridium tetani, it is a rare disease in the United States thanks to widespread immunization, and it causes fewer than 50 cases annually. Worldwide, the incidence is about 1 million cases a year with 200,000 to 300,000 deaths.

Diphtheria (formerly sometimes called “throat distemper”) is caused by the gram-positive bacillus Corynebacterium diphtheriae and can occur as a respiratory illness or as a milder cutaneous form. The last outbreak in the United States was in Seattle in the 1970s, with the last reported case in 2003. The ACIP recommends booster shots for tetanus and diphtheria every 10 years following completion of the primary series.

Pertussis or whooping cough, caused by Bordetella pertussis infection, is a highly contagious disease increasingly seen in adults in the United States. It causes few deaths but high morbidity, with coughing that can persist up to 3 months. Coughing can be severe enough to cause vomiting, a characteristic sign.

In July 2012, the CDC reported that the United States was at a 50-year high for pertussis, with 18,000 cases reported and 8 deaths.² In Washington State alone, more than 2,520 cases had been seen through June 16 of that year, a 1,300% increase over the previous year. Rates were high in older children and adolescents despite previous vaccination, suggesting an early waning of immunity.

The ACIP recommends a single dose of the combination of high-dose tetanus and low-dose diphtheria and pertussis vaccines (Tdap) for all adults regardless of age and for all pregnant women with each pregnancy between 27 and 36 weeks of gestation. A dose of Tdap counts as the tetanus-diphtheria booster shot that is recommended every 10 years.

The patient described above is due for his tetanus-diphtheria booster and so should be given Tdap.