COMMENTARY

ACIP 2019 Adult Immunization Schedule: What You Need to Know

Sandra Adamson Fryhofer, MD

Disclosures

February 04, 2019

Hello. I'm Dr Sandra Fryhofer. Welcome to Medicine Matters. The topic: Adult Immunization 2019. The Advisory Committee on Immunization Practices' (ACIP's) new adult schedule is redesigned!

Here's why it matters.

With five adult age ranges, ten medical indication categories, and updated uses for 17 types of vaccines, it's a long time—and a long way—from 2002, when the adult schedule premiered. A long time, with a little tinkering. No longer. This is not the usual, annual, small talk.

The schedule has never had such a complete makeover. Experts from the Human Factors & Ergonomics Society at the Georgia Institute of Technology helped.

What made the revision necessary?

The adult schedule is a great source of important information. But it did not meet its full potential. The verdict from physicians, nurses, PAs, and pharmacists? Not very user-friendly. If people didn't really understand how to use it, they couldn't reap its full benefit. This new work tries to remedy that.

The cover page begins with a step-by-step user's guide. There is a very useful list of vaccines, abbreviations, and trade names. Use of trade names is for identification purposes only; no ACIP or US Centers for Disease Control and Prevention (CDC) endorsement is implied.

And there are lots of hyperlinks. Among others:

There are additional links to CDC disease-specific case identification and outbreaks pages, as well as special links that make it easier to report problems, adverse events, and offer feedback.

Figures are replaced by tables, with bold headings and white font on navy.

Table 1 lists vaccine recommendations by age group.

Table 2 organizes recommendations by medical condition and other indications, with an expanded color-code palette:

  • Yellow means recommended if age requirement is met.

  • Purple means recommended for adults with an additional risk factor or another indication.

  • Orange means use precaution.

  • Pink has been added and indicates delay until after pregnancy.

  • Red means contraindicated.

The "no recommendation" boxes are now gray rather than white. Please note that "no recommendation" does not mean "not recommended."

The color is great. But if you print a hard copy when color ink is low in your printer, or you print in black and white, the color wheel changes can be difficult or impossible to discern. No worries. ACIP added teaser words to the color-coded boxes.

The updated pregnancy column is particularly vibrant:

  • Live vaccines, like live attenuated influenza vaccine (LAIV), measles-mumps-rubella (MMR), varicella, and Zoster Vaccine Live, are in red: Contraindicated.

  • Boxes for human papilloma virus and the recombinant zoster vaccine are pink: Delay vaccination until after pregnancy, if the vaccine is indicated.

  • The pregnancy box for meningococcal ACWY vaccine is purple: Recommended if there is an additional risk factor or indication.

  • Meningitis B during pregnancy is orange: Use precaution.

There's another big change: Forget footnotes. Instead, we have individual notes for each vaccine, listed in alphabetical order, so there is no need for a special key to find the information you need.

The notes are brief and concise. They include vaccine indications, dosing frequency, and intervals. Another added bonus is that the font is bigger and vaccine headings are bolder. But be careful—brevity does seem to take precedence over details, which may mean more frequent checks of the comprehensive ACIP vaccine recommendations for answers to patient-specific questions.

So that's the organizational overview.

What else is new? Updates for influenza, hepatitis A, and hepatitis B.

Influenza. LAIV is back! Back on the schedule with its own row. After two seasons of being not recommended, LAIV is again an option for nonpregnant, healthy adults through age 49. Table 2 designates LAIV's contraindications and precautions for specific medical conditions.

Hepatitis B. A new vaccine! The new, single-antigen, recombinant hepatitis B vaccine, HepB-CpG (brand name Heplisav-B®), has been added to the schedule for adults 18 and older.

This vaccine is pretty new. FDA approved it in November 2017. It contains a novel adjuvant, and no safety data are yet available on its use in pregnancy. So for now, pregnant women needing hepatitis B vaccination should be given one of the older hep B vaccines.

One real advantage of Heplisav? Rapid dosing. Its two-dose schedule permits doses to be given 1 month apart. Another convenience: A Heplisav dose can be used as a substitute in a three-dose schedule with a different hepatitis B vaccine. But at almost double the price per dose of other hepatitis B vaccines, this might be a matter of money.

Hepatitis A. Homelessness is a new indication for administration of this vaccine. This additional indication got the nod at ACIP's October 2018 meeting following presentation of data from San Diego health officials, which found that homelessness was independently associated with two to three times higher odds of hepatitis A infection. Odds of severe hepatitis A infection outcomes, specifically hospitalization and death, were two to four times higher in homeless individuals.

The background paper for the new schedule also updates coverage rates for adult immunizations. Although there have been modest increases in coverage for some vaccines, the overall coverage rate for adults remains low. Racial and ethnic disparities need particular attention.

That's an overview of the new schedule. It is published in the Annals of Internal Medicine.[1] Please take a look at it and use it. I hope it helps.

For Medicine Matters, I'm Dr Sandra Fryhofer.

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