COMMENTARY

ACIP 2015 Adult Vaccine Schedule: What You Need to Know

Sandra Adamson Fryhofer, MD

Disclosures

February 02, 2015

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Hello. I'm Dr Sandra Fryhofer. Welcome to Medicine Matters. The topic: adult immunization 2015, published in the Annals of Internal Medicine.[1] Here's why it matters.

Each year, the Advisory Committee on Immunization Practices (ACIP) updates the adult immunization schedule. It's a summary work product of current ACIP recommendations. This year's adult schedule has only one new recommendation from last year's schedule. The new schedule changes pneumococcal vaccination recommendations for seniors.

Pneumococcal conjugate vaccine (PCV13; Prevnar13®) is now recommended for all adults 65 or older, in addition to pneumococcal polysaccharide vaccine (PPSV23, Pneumovax®23). PPSV23 has been recommended for seniors since 1997.[2] PCV13 was FDA approved for adults age 50 years and older in December 2011 through an accelerated approval pathway shortcut which used immunogenicity comparisons to PPSV23 as the basis for licensing.

Beginning in October 2010, all new ACIP recommendations are evidence based.[3] Because rates of invasive pneumococcal disease are higher in immunocompromised adults, last year's schedule included an evidence-based PCV13 recommendation for all immunocompromised adults, age 19 years or older, including those with immunocompromising conditions, anatomic or functional asplenia, cochlear implant, or cerebrospinal fluid leaks.[4]

Older adults are also at increased risk for invasive pneumococcal disease. After reviewing results from CAPiTA (Community Acquired Pneumonia Immunization Trial in Adults),[5] ACIP expanded routine PCV13 for all adults age 65 and older. CAPiTA was a randomized controlled trial, conducted in The Netherlands, in which nearly 85,000 seniors were randomized to receive either PCV13 or placebo. CAPiTA found PCV13 to be 75% effective in preventing vaccine-type invasive pneumococcal disease and 45% effective in preventing vaccine-type nonbacteremic pneumonia.

The timing and order for giving the two vaccines are a little complicated. Polysaccharide and conjugate vaccines induce immune responses in different ways, so the timing interval between giving the two vaccines matters. They cannot be given at the same time. Patients with certain medical conditions also need PPSV23 revaccination.[1] The new schedule has an explanatory "mega-footnote" for pneumococcal vaccination, with a new format that focuses on specific recommendations based on patient age and medical conditions rather than the individual pneumococcal vaccine. There are also several helpful tables and graphics in the Annals article. Please take a close look at these tools because the "how to" details are important.

Here are some basic rules:

For pneumococcal vaccination-naive adults age 65 or older, give PCV13 first. After PCV13, wait 6-12 months to give PPSV23.

For seniors who have already received PPSV23, wait at least a year before giving PCV13.

For those who need PPSV23 revaccination, wait at least 5 years after the last dose of PPSV23 and 6-12 months after receiving PCV13 to revaccinate with PPSV23.

Note: The guidance interval between PCV13 followed by PPSV23 is 6-12 months for seniors but at least 8 weeks for immunocompromised patients.[1,4]

Table 2 in the Annals version of the adult schedule is especially helpful. It gives specifics of pneumococcal vaccination recommendations, including which vaccines to give when and the number of doses needed. The information is organized by patient age, health condition, and pneumococcal vaccination history.

Only one dose of PCV13 is indicated for adults. PCV13 revaccination of adults is not indicated. Depending on health condition and age, some patients may need two or even three doses of PPSV23. Table 2 has all the details. Remember that pneumococcal vaccination with PPSV23 is also recommended for patients under 65 with certain chronic health conditions, including those who smoke, have diabetes, or have asthma.

Even though the change in pneumococcal vaccination for all seniors is all that's new, use the new schedule as an opportunity to brush up on other recommendations. Please make sure to review the entire schedule, including the details found in the footnotes.

Here are a few key points.

Influenza. Everyone 6 months or older needs flu vaccination every year, and there are lots of choices. See the footnote for more details. Pregnant women and patients with mild (hives only) egg allergy should be given the flu shot, but not the live attenuated nasal flu vaccine (LAIV). The recombinant influenza vaccine (RIV; Flublok®) contains no egg protein whatsoever and is an option for adults of all ages with egg allergy of any severity. Read the entire footnote for more details.

Pertussis. Recent pertussis epidemics are a reminder that all adults need a one-time Tdap booster. Pregnant women should receive a Tdap booster in each and every pregnancy, preferably in the late third trimester, between 27 and 36 weeks.

HPV. Three doses of HPV vaccine are recommended for all females age 11-26 and for all males age 11-21. HPV vaccination is also recommended for all males age 22-26 who have sex with other men, and for immunocompromised males age 22-26, including those with HIV. A new 9-valent HPV vaccine (Gardasil®9) was FDA approved in December 2014. Look for future guidance from ACIP.

Herpes zoster. The risk for shingles increases with age. Zoster vaccine is a live virus vaccine and is recommended for adults 60 and older, as long as they are not pregnant or severely immunocompromised. The ACIP recommendation says to vaccinate at age 60 or older, even though FDA licensing begins at age 50.[6]

Measles and mumps. Recent outbreaks of measles and mumps have highlighted the importance of measles-mumps-rubella (MMR) vaccination.[7] Adults born before 1957 are generally considered to be immune to measles and mumps. Adults born after 1957 should have documentation of one or more doses of MMR vaccine. Rubella immunity should be determined for all women of childbearing potential, and if not immune and not pregnant, these women should be vaccinated. Unvaccinated healthcare workers born before 1957 who lack laboratory evidence of immunity need two doses of MMR (at least 28 days apart) for measles and mumps or one dose of MMR for rubella.

Meningococcal. Meningococcal vaccination recommendations have not changed. In October 2014, FDA approved a new meningococcal B vaccine (Trumenba®). Recent meningococcal B outbreaks on college campuses highlight the value of this new vaccine. Look for future ACIP guidance as to how and when to incorporate its use.

Hepatitis A. Hepatitis A vaccination is a must for patients with chronic liver disease, those with close contact with an international adoptee, and for many international travelers. Check the CDC travelers' health website for country-specific details.

Hepatitis B. Don't forget hepatitis B vaccination. Hepatitis B vaccination is recommended for all diabetics 59 and younger and for older diabetics at the discretion of the treating clinician. Hepatitis B vaccination is also recommended for anyone who has had more than one sex partner during the past 6 months.

Haemophilus. Although Haemophilus influenzae type b (Hib) vaccination is not routinely recommended for patients with HIV, patients with functional or anatomic asplenia do need a dose of Hib. Stem cell transplant recipients need three doses, 6-12 months after successful transplant.

These are just some highlights. Be sure to look at the entire schedule and read the fine print in the schedule footnotes for more details. For immunization information "at your fingertips," keep a copy of the new schedule in each of your exam rooms or download the American College of Physicians (ACP) free adult immunization app.

Have a great 2015, and happy vaccinating!

For Medicine Matters, I'm Dr Sandra Fryhofer.

Addendum: The Centers for Medicare & Medicaid Services (CMS) has announced that as of February 2, 2015, it will implement Medicare coverage to allow initial pneumococcal vaccine for Medicare patients who have never received a pneumococcal vaccine under Medicare Part B, and then a different, second pneumococcal vaccine, 1 year after the first vaccine was administered. Please note that the "interval" between the two different pneumococcal vaccines must be 11 or more months, not 8 weeks (for immunocompromised patients) or 6 months (the minimum interval recommended for seniors) as in the ACIP recommendations.[8]

Note: Dr Fryhofer is the ACP liaison to ACIP. She also serves on ACIP working groups for influenza, pneumococcal, and shingles vaccines and for the adult schedule. Additionally, she authored the editorial in Annals of Internal Medicine that discussed the new schedule.

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