COMMENTARY

The 2014 Adult Immunization Schedule: What Has Changed?

Sandra Adamson Fryhofer, MD

Disclosures

February 04, 2014

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Hello. I'm Dr. Sandra Fryhofer. Welcome to Medicine Matters. The topic: adult immunization in 2014, published in the Annals of Internal Medicine.[1] Here's why it matters.

Each year, as many as 50,000 adult Americans die of vaccine-preventable diseases. That's why adult immunization is timely and important. This year's adult schedule is more about refinement and clarification than major changes, with one exception: Hib, Haemophilus influenzae type B vaccination. Hib now has its own bar on the graphic and footnote. Hib is not just for kids; it's for a small subset of adults, too. And for those patients -- persons with functional or anatomic asplenia, including sickle cell -- Hib vaccine could be lifesaving. Patients planning elective splenectomy should preferably receive it at least 14 days before surgery. After successful stem cell transplant, patients need 6 doses over 6 months, each dose at least 1 month apart. Hib vaccination is not routinely recommended for HIV patients because their risk for Hib infection is low.

Another graphic change: a new pneumococcal vaccine order. PCV13, the new conjugate vaccine, is now listed above PPSV23, the polysaccharide vaccine. The switch acts as a timing trigger, a reminder to give conjugate vaccine first, before polysaccharide vaccine, to previously unvaccinated people who need both vaccines. This includes immunocompromised adults age 19 years and older, including those with chronic renal failure, nephrotic syndrome, functional or anatomic asplenia, cerebrospinal fluid leaks, or cochlear implants. They should be given polysaccharide PPSV23 vaccine at least 8 weeks later. For those needing both vaccines and who have already been vaccinated with polysaccharide PPSV23 vaccine, you have to wait at least 1-2 years before giving conjugate PCV13 vaccine. The footnote also includes a reminder that PCV13 is an FDA-approved vaccine only for adults age 50 years and older, so giving it to immunocompromised adults under 50 years of age, while recommended by the Advisory Committee on Immunization Practices (ACIP), is an off-label use.

Next is meningococcal vaccination. The recommendation is basically the same but the messaging is quite different. The new footnote clarifies who needs 1 dose, who needs 2 doses, and which vaccine to use. In general, the conjugate vaccine is preferred for adults age 55 years and younger. The polysaccharide MPSV4 vaccine is preferred for those age 56 years and above, but only if they are to receive just 1 dose. If more than 1 dose is needed or anticipated, the conjugate vaccine (MCV4) is the way to go for adults of all ages. And don't forget first-year college students up through age 21 years who didn't receive meningococcal vaccination on or after their 16th birthday. Another clarification: HIV-positive individuals should not be routinely vaccinated with meningococcal vaccine, but those who do get vaccinated should receive 2 doses of conjugate MCV4 vaccine.

Other highlights that are not new but are still important:

Pertussis prevention designed to prevent tiny tots

Tdap vaccination, the tetanus, diphtheria, acellular pertussis booster for all adults, including those age 65 years and older. Pregnant women should receive Tdap booster in each and every pregnancy in the third trimester, preferably between 27 and 36 weeks. Repeat maternal vaccination is also an off-label use.

For the shingles vaccine, ACIP says to wait until at least age 60 years of age to administer, even though it's FDA approved for adults starting at age 50 years. This is a live-virus vaccine, so don't give it to pregnant women and don't give it to anyone with severe immunodeficiency.

The recommendations for influenza vaccination for everyone over 6 months old still stands. Recommendations for egg-allergic individuals have been clarified. The inactivated shot is fine for anyone with mild (ie, hives only) egg allergy. The new-technology flu shot, RIV, the recombinant influenza vaccine (Flublok® -- and believe it or not, the brand name is actually listed in the footnote), contains no egg protein whatsoever and can be given to adults age 18-49 years with egg allergy of any severity.

Vaccines are one of the great public health success stories of the last 100 years. Protect yourselves and protect your patients. Please keep vaccinating.

For Medicine Matters, I'm Sandra Fryhofer.

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