COMMENTARY

Adult Immunization 2016: What's New?

Sandra Adamson Fryhofer, MD

Disclosures

February 01, 2016

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A New Year, A New Schedule

Welcome to Medicine Matters. The topic is the Advisory Committee on Immunization Practice's (ACIP's) 2016 Adult Immunization Schedule, published in the Annals of Internal Medicine.[1]

It's a new year and that means a new (adult immunization) schedule from ACIP, which is soon boiled down to a pair of color-coded graphics and helpful footnotes. Think of the schedule as a cheat sheet to help you protect your patients.

The 2016 schedule includes major updates for three vaccinations: HPV vaccination, pneumococcal vaccination, and the new meningococcal B vaccination.

HPV Vaccination

The new schedule addresses how to prescribe the new 9-valent HPV vaccine (which covers five additional virus strains linked to 10% of HPV-related cancers overall, more in women than in men). Any of the three vaccines (the 2-, 4-, or 9-valent vaccines) can be used for females, but only the 4- and 9-valent vaccines should be used for males. Three HPV vaccine doses are recommended routinely starting at age 11 or 12. Vaccinate through age 26 for all females, through age 21 for all males, and through age 26 for immunocompromised males, including those with HIV and men who have sex with men. Pay close attention to the minimum intervals between vaccine doses. (It's in the footnotes.)

Additional 9-valent vaccination is not addressed in the new schedule. Here's what ACIP says on its website: "There is no ACIP recommendation for routine additional 9-valent HPV vaccination for anyone who has already completed a bivalent or quadrivalent vaccination series. Studies show no serious safety concerns with additional 9-valent vaccination. However, there may be higher rates of injection site swelling and redness."

Pneumococcal Vaccination

The US Food and Drug Administration (FDA) has approved only two pneumococcal vaccines for adults: conjugate PCV13 (Prevnar®) and polysaccharide PPSV23 (Pneumovax®). They work in different ways. Refer to footnote 8 for who needs what and when. The two pneumococcal vaccinations should not be given at the same time. Timing, order, and interval between vaccinations matter. Here is the major change for pneumococcal vaccination: The new schedule aligns intervals between vaccinations with ACIP's latest evidence-based recommendations. For most healthy adults, the interval for PCV 13 and then PPSV23 has been extended to at least a year. That correlates well with Medicare coverage for dual pneumococcal vaccination for seniors. However, the ACIP-recommended interval for PCV13 and then PPSV23 for adults of all ages with immunocompromising conditions, cerebrospinal fluid leaks, or cochlear implants, has not changed. It's still at least 8 weeks. This falls outside Medicare coverage allowance, which may mean more out-of-pocket costs for some seniors. For patients who need both, PCV13 should be given first. However, if PPSV23 is given first, ACIP still says to wait at least a year before giving PCV13. The interval of 5 years between PPSV23 vaccinations for those needing revaccination has also not changed.

Meningococcal Vaccination

The meningococcal graphic and footnote have had a total makeover. Meningococcal vaccination has only one footnote (footnote 11) but two rows on the graphic: a row for the older meningococcal vaccines covering A, C, W, and Y and a new row for the new meningococcal B vaccines. The products are not interchangeable and the same product has to be used to complete the two- or three-dose series. The brand names (Trumenba® and Bexsero®) are used in the footnote to help clear up confusion. Although FDA licensed the vaccines only for those aged 10-25, ACIP expanded use of meningococcal B vaccines to anyone age 10 or older at increased risk for meningococcal B infection (for example, during a meningococcal B outbreak). Patients with anatomic or functional asplenia or complement deficiencies need a meningococcal B vaccine series along with conjugate MenACWY vaccine (two doses at least 2 months apart). At-risk microbiologists (those who might be exposed through work) also need both types of meningococcal vaccinations. Both vaccines may be given at the same time on the same day but at different anatomic sites.

Take a close look at footnote 11, especially the bullet points addressing young adults. Young adults aged 16-23 may be vaccinated with meningococcal B vaccine. The "may" means it is at clinicians' discretion and is thus a category B recommendation. It is not a blanket recommendation for everyone. This would be in addition to making sure that first-year college students aged 21 or younger have received a dose of MenACWY vaccine on or after their 16th birthday (a category A recommendation, meaning that it is recommended for all in this age group). Meningococcal B is to blame for several recent meningococcal outbreaks on college campuses.

I have reviewed some highlights and major changes, but please take time to take a close look at the footnotes. Keep the new schedule handy for quick reference. And remember: "V" doesn't just mean victory. It means vaccinate!

For Medicine Matters, I'm Dr Sandra Fryhofer.

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