Government Publishes Adult Immunization Schedule

For decades, the U.S. government has provided clear guidelines for pediatric immunizations, saving millions of young lives worldwide in the process. Not so in the case of adults. At times, to be sure, the government has recommended certain immunizations for adults and different medical organizations have put forth differing vaccination schedules. Now, for the first time, the Centers for Disease Control and Prevention (CDC) has put together a set of consensus recommendations on adult immunization. It has also put together useful graphics that explain when and for whom the immunizations are indicated.

In this issue of the Health Letter, we reprint those graphics in their entirety, along with some rather technical footnotes that accompany the charts. You should show this information to your doctor, in case he or she hasn’t seen it. Figure 1 is the recommended immunization schedule for adults without particular medical conditions. Regardless of the circumstances, the CDC recommends everyone should have a tetanus booster every ten years, everyone 50 and over should receive an influenza vaccination (this recommendation may vary from year to year) and everyone 65 and over should receive a pneumococcal vaccine if they have not done so already. You should note, however, that there is no evidence that 50-to 64-year-olds benefit from influenza vaccination if they do not have an underlying medical condition such as heart or lung disease. Other vaccines (e.g., hepatitis A, hepatitis B, chicken pox) are recommended under the conditions described in Figure 1. Figure 2 describes adult recommendations for those with particular medical conditions such as diabetes, heart disease, kidney failure and cancer.

The failure to undergo adult immunization is a missed opportunity to prevent needless suffering. For example, only 60 percent of adults 65 and older received the influenza vaccination in 2000 and only 45 percent have ever received the pneumococcal vaccine. We urge you to follow these recommendations. Should you experience an adverse event that you suspect may be due to vaccination, you should report it to the Vaccine Adverse Event Reporting System (phone: 800-822-7967). Reporting forms are also available on the web at http://www.vaers.org .

*Covered by the Vaccine Injury Compensation Program.

† Tetanus and diphtheria (Td): A primary series for adults is 3 doses: the first 2 doses given at least 4 weeks apart and the 3rd dose, 6-12 months after the second. Administer 1 dose if the person had received the primary series and the last vaccination was 10 years ago or longer. MMWR 1991; 40 (RR-10): 1-21. The ACP Task Force on Adult Immunization supports a second option: a single Td booster at age 50 years for persons who have completed the full pediatric series, including the teenage/young adult booster.

§ Influenza vaccination: Medical indications: chronic disorders of the cardiovascular or pulmonary systems including asthma; chronic metabolic diseases including diabetes mellitus, renal dysfunction, hemoglobinopathies, immunosuppression (including immunosuppression caused by medications or by human immunodeficiency virus [HIV]), requiring regular medical follow-up or hospitalization during the preceding year; women who will be in the second or third trimester of pregnancy during the influenza season. Occupational indications: health care workers. Other indications: residents of nursing homes and other long-term care facilities; persons likely to transmit influenza to persons at high-risk (in-home care givers to persons with medical indications, household contacts and out-of-home caregivers of children birth to 23 months of age, or children with asthma or other indicator conditions for influenza vaccination, household members and care givers of elderly and adults with high-risk conditions); and anyone who wishes to be vaccinated

¶ chronic disorders of the pulmonary system (excluding asthma), cardiovascular diseases, diabetes mellitus, chronic liver diseases including liver disease as a result of alcohol abuse (e.g., cirrhosis), chronic renal failure or nephrotic syndrome, functional or anatomic asplenia (e.g., sickle cell disease or splenectomy), immunosuppressive conditions (e.g., congenital immunodeficiency, HIV infection, leukemia, lymphoma, multiple myeloma, Hodgkins disease, generalized malignancy, organ or bone marrow transplantation), chemotherapy with alkylating agents, anti-metabolites, or long-term systemic corticosteroids. Geographic/other indications: Alaskan Natives and certain American Indian populations. Other indications: residents of nursing homes and other long-term care facilities.

** Revaccination with pneumococcal polysaccharide vaccine: one time revaccination after 5 years for persons with chronic renal failure or nephrotic syndrome, functional or anatomic asplenia (e.g., sickle cell disease or splenectomy), immunosuppressive conditions (e.g., congenital immunodeficiency, HIV infection, leukemia, lymphoma, multiple myeloma, Hodgkins disease, generalized malignancy, organ or bone marrow transplantation), chemotherapy with alkylating agents, anti-metabolites, or long-term systemic corticosteroids. For persons 65 and older, one-time revaccination if they were vaccinated 5 or more years previously and were aged less than 65 years at the time of primary vaccination

†† Hepatitis B vaccination: Medical indications: hemodialysis patients, patients who receive clotting-factor concentrates. Occupational indications: health-care workers and public-safety workers who have exposure to blood in the workplace, persons in training in schools of medicine, dentistry, nursing, laboratory technology, and other allied health professions. Behavioral indications: injecting drug users, persons with more than one sex partner in the previous 6 months, persons with a recently acquired sexually-transmitted disease (STD), all clients in STD clinics, men who have sex with men. Other indications: household contacts and sex partners of persons with chronic HBV infection, clients and staff of institutions for the developmentally disabled, international travelers who will be in countries with high or intermediate prevalence of chronic HBV infection for more than 6 months, inmates of correctional facilities

§§ Hepatitis A vaccination: For the combined Hep A-Hep B vaccine use 3 doses at 0, 1, 6 months. Medical indications: persons with clotting-factor disorders or chronic liver disease. Behavioral indications: men who have sex with men, users of injecting and noninjecting illegal drugs. Occupational indications: persons working with HAV-infected primates or with HAV in a research laboratory setting. Other indications: persons traveling to or working in countries that have high or intermediate endemicity of hepatitis A.

¶¶ Measles, Mumps, Rubella Vaccination (MMR): Measles component: Adults born before 1957 may be considered immune to measles. Adults born in or after 1957 should receive at least one dose of MMR unless they have a medical contraindication, documentation of at least one dose or other acceptable evidence of immunity. A second dose of MMR is recommended for adults who:

• are recently exposed to measles or in an outbreak setting

• were previously vaccinated with killed measles vaccine

• were vaccinated with an unknown vaccine between 1963 and 1967

• are students in post-secondary educational institutions

• work in health care facilities

• plan to travel internationally

Mumps component: 1 dose of MMR should be adequate for protection.

Rubella component: Give 1 dose of MMR to women whose rubella vaccination history is unreliable and counsel women to avoid becoming pregnant for 4 weeks after vaccination. For women of child-bearing age, regardless of birth year, routinely determine rubella immunity and counsel women regarding congenital rubella syndrome. Do not vaccinate pregnant women or those planning to become pregnant in the next 4 weeks. If pregnant and susceptible, vaccinate as early in postpartum period as possible.

*** Varicella vaccination: Recommended for all persons who do not have reliable clinical history of varicella infection, or serological evidence of varicella zoster virus (VZV) infection; health-care workers and family contacts of immunocompromised persons, those who live or work in environments where transmission is likely (e.g., teachers of young children, day care employees, and residents and staff members in institutional settings), persons who live or work in environments where VZV transmission can occur (e.g., college students, inmates and staff members of correctional institutions, and military personnel), adolescents and adults living in households with children, women who are not pregnant but who may become pregnant in the future, international travelers who are not immune to infection. Note: Greater than 90% of U.S. born adults are immune to VZV. Do not vaccinate pregnant women or those planning to become pregnant in the next 4 weeks. If pregnant and susceptible, vaccinate as early in postpartum period as possible.

††† Meningococcal vaccine (quadrivalent polysaccharide for serogroups A, C, Y, and W-135). Consider vaccination for persons with medical indications: adults with terminal complement component deficiencies, with anatomic or functional asplenia. Other indications: travelers to countries in which disease is hyperendemic or epidemic (“meningitis belt” of sub-Saharan Africa, Mecca, Saudi Arabia for Hajj). Revaccination at 3-5 years may be indicated for persons at high risk for infection (e.g., persons residing in areas in which disease is epidemic). Counsel college freshmen, especially those who live in dormitories, regarding meningococcal disease and the vaccine so that they can make an educated decision about receiving the vaccination.

Note: The American Academy of Family Physicians recommends that colleges should take the lead on providing education on meningococcal infection and vaccination and offer it to those who are interested. Physicians need not initiate discussion of the meningococcal quadrivalent polysaccharide vaccine as part of routine medical care.

* Covered by the Vaccine Compensation Program.

A. If pregnancy is at 2nd or 3rd trimester during influenza season.

B. Although chronic liver disease and alcoholism are not indicator conditions for influenza vaccination, give 1 dose annually if the patient is > 50 years, has other indications for influenza vaccine, or if the patient requests vaccination.

C. Asthma is an indicator condition for influenza but not for pneumococcal vaccination.

D. For all persons with chronic liver disease.

E. Revaccinate once after 5 years or more have elapsed since initial vaccination.

F. Persons with impaired humoral but not cellular immunity may be vaccinated.

G. Hemodialysis patients: Use special formulation of vaccine (40 ug/mL) or two 1.0 mL 20 ug doses given at one site. Vaccinate early in the course of renal disease. Assess antibody titers to hep B surface antigen (anti-HBs) levels annually. Administer additional doses if anti-HBs levels decline to <10 milliinternational units
(mlU)/ mL.

H. Also administer meningococcal vaccine.

I. Elective splenectomy: vaccinate at least 2 weeks before surgery.

J. Vaccinate as close to diagnosis as possible when CD4 cell counts are highest.

K. Withhold MMR or other measles containing vaccines from HIV-infected persons with evidence of severe immunosuppression.