ID Consult

Physician, Vaccinate Thyself


 

As physicians who care for children, it's easy for us to become so focused on vaccinating the children in our practices that we neglect our own immunizations. But it's critically important to get vaccinated, not only for our own sakes but for the sake of our patients.

There have been several additions to the adult immunization schedule in the last few years, so I thought it would be useful to review the ones that pediatricians should consider for themselves, and also consider offering to the parents and other caregivers of our pediatric patients:

Tetanus-diphtheria-acellular pertussis. Most physicians are aware that we're now seeing a resurgence of pertussis around the country. The focus has been on California, but there are other pockets as well that have not received as much attention, including recent outbreaks in Ohio and Michigan. But pertussis is also endemic in the United States, so that although we tend to see peaks every 3 years or so, there is no year when it isn't circulating. Most pediatricians also are aware of and endorse the concept of “cocooning” newborns younger than 6 months of age who have not yet received all three doses of DTaP by vaccinating all the people around the infant, including parents, siblings, grandparents, babysitters, child care providers, and yes, physicians who care for children.

The Tdap vaccine is the adolescent-adult formulation containing the same amount of tetanus and diphtheria as the Td vaccine but with lower amounts of pertussis antigen than the pediatric DTaP. The Centers for Disease Control and Prevention recommends Tdap for adults of any age who have not previously received it (including those aged 65 and older) who are in contact with infants younger than age 12 months, and for health care personnel of all ages, including doctors. Last fall, the CDC removed the 2-year interval requirement, so that now Tdap can be given regardless of the interval since the previous Td. After an adult receives one dose of Tdap, a booster of Td should be given every 10 years thereafter.

I recently asked 10 pediatricians if they had received the Tdap, and 8 said no. They ranged in age from those just out of residency to 68 years. Reasons included simply not getting around to it, thinking they didn't need it, or believing that they were already protected from the DTaP they received in childhood. In fact, immunity against pertussis wanes, and DTwP (whole-cell pertussis) and DTaP vaccines don't last forever, which is part of the reason we're seeing these outbreaks.

Influenza. I meet physicians all the time who tell me they haven't received a flu shot. Older physicians sometimes will cite the fear of Guillain-Barré syndrome that initially arose with the 1976 swine flu vaccine debacle. That fear never really went away, and was reignited with the 2009 vaccine that was rapidly manufactured against pandemic H1N1. Many people, including some physicians, fear that the vaccine was not tested sufficiently before it was brought to market during the pandemic. Of course, most of these same physicians do immunize their patients with the vaccine.

The other reason I hear from physicians for not getting the flu vaccine is the mistaken belief that their immune system is strong enough to resist influenza. Although it may be true that as a group, physicians who see sick people all day long are more resistant to viral infections than is the general population, some still may be susceptible. And those who do contract influenza will be contagious for a few days before symptoms appear, even with the use of antivirals.

Pneumococcus. Currently, the only pneumococcal vaccine recommended for adults is the 23-valent polysaccharide vaccine (Pneumovax). It is recommended for everyone aged 65 and older, and for people younger than 65 years who have chronic illness or other risk factors, including chronic cardiac or pulmonary disease (including asthma), chronic liver disease, alcoholism, diabetes, cerebrospinal fluid leaks, and cigarette smoking, as well as candidates for or recipients of cochlear implants and people living in special environments or social settings (including American Indian/Alaska Natives aged 50–64 years if vaccination is recommended by local public health authorities). Certainly, physicians can fall into most of these groups (although we hope not the smoking category).

But stay tuned for the 13-valent conjugate pneumococcal vaccine to be licensed and recommended for adults aged 50 and older. In December 2010, Pfizer announced that it submitted supplemental applications to both the U.S. Food and Drug Administration and the European Medicines Agency (EMA) to expand the use of Prevnar 13 to adults aged 50 years and older for the prevention of pneumococcal disease caused by the 13 serotypes contained in the vaccine. The FDA is expected to respond in October 2011.

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