Tuesday, January 19, 2010

[New Information] Adult Immunization Schedule for 2010 Issued From ACIP

January 6, 2010 — The Advisory Committee on Immunization Practices (ACIP) of the US Centers for Disease Control and Prevention has issued clinical guidelines for the adult immunization schedule for 2010, according to a report in the January 5, 2010, issue of the Annals of Internal Medicine.
The American Academy of Family Physicians, American College of Obstetricians and Gynecologists, and American College of Physicians have also approved this adult immunization schedule for 2010.

"The...ACIP annually reviews the Recommended Adult Immunization Schedule to ensure that the schedule reflects current recommendations for the licensed vaccines," write Carol Friedman, DO, from the National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention in Atlanta, Georgia, and colleagues. "In October 2009, ACIP approved the Adult Immunization Schedule for 2010, which includes several changes. A bivalent human papillomavirus vaccine (HPV2) was licensed for use in females in October 2009."
Changes in the 2010 schedule from the previous schedule include the following:
  • Revision to the HPV footnote now states that HPV2 has been licensed for use in women. For women aged 19 through 26 years, either HPV2 or quadrivalent (HPV4) can be used for vaccination. ACIP has also used a permissive recommendation for use of HPV4 in men.
  • Revision to the measles, mumps, rubella (MMR) footnote now notes in the beginning of the footnote that adults born before 1957 generally are immune. Further revisions clarify which adults born during or after 1957 do not need 1 or more doses of MMR for the measles and mumps components.
  • New interval dosing information states that a second dose of MMR should be given 4 weeks after the first dose. Another revision to this footnote highlights that women in whom rubella vaccination is not documented should receive a dose of MMR. A new section added to this footnote provides guidelines for vaccinating healthcare personnel born before 1957 routinely and during outbreaks.
  • Revision to the influenza footnote has added the term seasonal to differentiate seasonal from pandemic influenza.
  • Revision to the hepatitis A footnote now includes an indication for administering this vaccine to unvaccinated persons who expect to be in close contact with an international adoptee.
  • Revision to the hepatitis B footnote now includes schedule information for the 3-dose hepatitis B vaccine.
  • Revision to the meningococcal vaccine footnote explains that the meningococcal conjugate vaccine is preferred for adults not older than 55 years and that the meningococcal polysaccharide vaccine is preferred for adults who are at least 56 years or older. For adults previously vaccinated with meningococcal conjugate vaccine or meningococcal polysaccharide vaccine, revaccination with meningococcal conjugate vaccine is recommended. The revised footnote also offers a new example of who is at increased risk, and additional information explains who does not need to be revaccinated.
  • Revision to the selected conditions portion of the H influenzae type B footnote now elucidates which high-risk persons can receive 1 dose of H influenzae type B vaccine.
In an accompanying editorial, Robert H. Hopkins Jr, MD, and Keyur S. Vyas, MD, from the University of Arkansas for Medical Sciences in Little Rock, note that changes in each year's schedule are driven by advances in knowledge of vaccines and vaccine-preventable disease. They discuss changes in recommendations for HPV, influenza, MMR, hepatitis A, meningococcal disease, and H influenzae type B.
Drs. Hopkins and Vyas also offer possible strategies to improve vaccine administration rates, which are currently measured as evidence-based quality indicators. These include mandatory vaccination; standing orders for vaccination for persons meeting specific criteria; electronic medical record reminders; and provision of vaccination rate feedback to individual providers, with or without associated incentives.
"Vaccines have been demonstrated to be among the most effective strategies for preventing illness in individuals as well as for protecting the health of the public," Drs. Hopkins and Vyas write. "Unfortunately, deaths from vaccine-preventable illnesses still occur in the United States....The importance of immunization cannot be overemphasized; it should be imparted directly to our patients, as well as to students and residents early in their training, as an essential component of the comprehensive care of adults in ambulatory and inpatient settings."
Members of the ACIP have disclosed various financial relationships with MedImmune, Sanofi Pasteur, Novartis, and/or Wyeth. Drs. Hopkins and Vyas have disclosed no relevant financial relationships.
Ann Intern Med. 2010;152:36-40, 59-61.

Study Highlights

  • HPV2 was recently licensed for use in women aged 19 through 26 years to reduce the risk for cervical cancer in young women.
  • This vaccine is now an option for use and protects against the 2 strains of HPV associated with more than 70% of cervical cancer, but it does not contain the 2 strains that account for genital warts.
  • The ACIP recommends the use of either this HPV2 vaccine or the HPV4 vaccine in young women to reduce the risk for cervical cancer.
  • The ACIP also gave a permissive recommendation for the use of HPV4 vaccine to reduce the risk for genital warts in men, but questions remain about the cost-effectiveness of vaccination in men.
  • The influenza vaccination recommendations are now noted as seasonal influenza recommendations to distinguish them from pandemic influenza vaccines such as the 2009 H1N1 or other vaccines.
  • At-risk groups including adults exposed to measles and mumps in an outbreak, healthcare workers, students in postsecondary education institutions, and international travelers should receive 2 doses of the MMR vaccine.
  • The interval between the 2 doses is 4 weeks for measles and mumps.
  • Healthcare facilities should consider MMR vaccination for unvaccinated workers born before 1957 who do not have laboratory evidence of immunity.
  • Women who do not have documentation of rubella vaccination should receive a dose of MMR.
  • Hepatitis A vaccination is recommended for unvaccinated persons who will be providing day or home care for international adoptees.
  • This is because more than 99% of international adoptees are from countries with endemicity of hepatitis A infection, and adoptees younger than 5 years are likely to be asymptomatic.
  • Meningococcal conjugate vaccine is preferred for adults 55 years and younger with indications.
  • The meningococcal polysaccharide vaccine is recommended for adults 56 years and older with an indicated condition.
  • The hepatitis B vaccine footnote now includes information for the 3-dose hepatitis B vaccine.
  • There is now no recommendation for the H influenzae type B vaccine in persons older than 5 years.
  • 1 dose of the H influenzae type B vaccine is not contraindicated, but neither is it routinely recommended for unvaccinated persons with sickle cell disease, leukemia, HIV disease, or splenectomy who have not been previously vaccinated.

Clinical Implications

  • The 2010 ACIP adult immunization recommendations include changes in recommendations for the HPV, hepatitis A, MMR, meningococcal, and H influenzae type B vaccines.
  • The HPV2 or HPV4 vaccine is recommended for women to protect against cervical cancer, whereas the HPV4 vaccine is now permitted for men for protection against genital warts.

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