COMMENTARY

7 Key Changes in ACIP 2020 Adult Immunization Schedule

Sandra Adamson Fryhofer, MD, MACP, FRCP

Disclosures

February 03, 2020

This transcript has been edited for clarity.

I'm Dr Sandra Adamson Fryhofer, liaison to the Advisory Committee on Immunization Practices (ACIP), with a discussion of ACIP's 2020 Adult Immunization Schedule, published in the Annals of Internal Medicine.

The 2020 schedule has the same general format as the 2019 schedule. Page 1 has a list of vaccines, abbreviations, and brand names. There is also a link to complete ACIP vaccine-specific recommendations.

Table 1 outlines specific vaccine recommendations for different age groups.

Table 2 clarifies recommendations for specific medical conditions and other indications.

Most of the color palette key remains the same:

  • Yellow: give if meets age requirement

  • Purple: give only if an additional risk factor

  • Orange: use precaution

  • Pink: delay until after pregnancy

  • Red: contraindicated/not recommended

  • Gray: ACIP has not issued a recommendation

This year's schedule has a new color:

  • Blue: ACIP's new "shared clinical decision-making" option is indicated

Table 1 has partial blue bars for three vaccines:

Meningococcal B vaccination (MenB). A blue bar for patients ages 19 through 23 years is now included for the MenB vaccine. A notation has been added to the purple bar for this vaccine, directing clinicians to check the notes section about the need for boosters. After completing an initial MenB series, a 1-year booster is now recommended for those with complement deficiency, complement inhibitor use, asplenia (including sickle cell), and for microbiologists at risk for laboratory exposure. An additional MenB dose is also needed every 2-3 years for those still at risk. The same product must be used for all doses.

Pneumococcal conjugate vaccine (PCV13). The PCV13 recommendation for immunocompetent seniors, aged 65 and older, is blue because it now requires shared clinical decision-making. (ACIP's comprehensive PCV13 statement has additional guidance for making this shared clinical decision.) The recommendation for PCV13 for immunocompromised patients, those with cochlear implants, and those with cerebrospinal fluid leaks has not changed. The ACIP recommendation for pneumococcal polysaccharide vaccine (PPSV23) has not changed, and a dose is still recommended for all adults 65 and older.

Human papilloma virus (HPV) vaccine. The US Food and Drug Administration has expanded the upper age for HPV vaccine from age 26 up to age 45. Shared clinical decision-making is recommended for this older age group. ACIP's most recent comprehensive HPV vaccine recommendation statement has a helpful box outlining specific considerations to help shape the outcome of this shared clinical decision. HPV vaccine is a prophylactic vaccine. It works best if given before exposure to the virus. Older adults with multiple lifetime sex partners are more likely to have been already infected with HPV vaccine-type strains. At any age, having a new sex partner is a risk factor for getting a new HPV infection. Those in a mutually monogamous relationship are not likely to get a new HPV infection.

There are several other 2020 changes.

  • For tetanus boosters, Tdap can now be used any time Td is indicated.

  • For hepatitis A vaccination, persons living with HIV now need hepatitis A vaccination. Coinfection with hepatitis A increases HIV replication. It takes longer for those with HIV to clear the hepatitis A virus, which could potentially increase the risk for hepatitis A transmission to others.

  • Patients with clotting factor disorders have been taken off the list of those who should receive hepatitis A vaccine. Recombinant clotting factor concentrates are now sterilized with new and more effective techniques. As a result, the risk of getting hepatitis A from concentrates is no different from that of the general population.

The vaccine-specific notes have been reorganized with subheadings for routine vaccination, shared clinical decision-making, and special situations. The notes are a great quick reference. The schedule also has links to more comprehensive vaccine-specific recommendations.

Sandra Adamson Fryhofer MD, MACP, FRCP, is a board-certified doctor of internal medicine in Atlanta and adjunct associate professor of medicine at Emory University School of Medicine. She is a liaison to the Advisory Committee on Immunization Practices (ACIP) and serves on ACIP Working Groups for several vaccines.

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