9 Key Changes: The 2021 Adult Immunization Schedules

This transcript has been edited for clarity.

I'll review changes in the Advisory Committee on Immunization Practices (ACIP) Adult Immunization Schedule for 2021, published in the Annals of Internal Medicine.

Each year, ACIP updates its summary of recommended immunizations for adults. This past year, ACIP more than tripled its usual number of meetings (10 meetings rather than the usual three). Seven of these meetings were dedicated exclusively to COVID-19 vaccine review and vaccine allocation recommended plans.

Thus, the first addition to the 2021 schedule is really no surprise. COVID vaccines are included in the vaccine notes section with a hyperlink to ACIP's interim recommendations for use of COVID-19 vaccines.

Section 3203 of the CARES Act requires coverage of COVID-19 vaccines recommended by ACIP. Specific language in the schedule is needed to ensure that any administration fees will be covered by insurance.

For the first time, ACIP workgroups for the adult and for the child/adolescent schedules have been combined in an effort to harmonize the look of the graphics and the language in the notes, wherever possible.

The color-code key used to designate vaccines that should be "delayed until after pregnancy" has been replaced with a red asterisk. Other color codes remain the same:

Yellow: Recommended
Purple: Give if additional risk factor is present
Orange: Precaution
Blue: Recommendation based on shared clinical decision-making
Red: Not recommended/contraindicated; vaccine should not be administered. An asterisk also adds language: Vaccinate after pregnancy
Grey: No recommendation/not applicable

New for 2021

Say goodbye to zoster vaccine live (ZVL; Zostavax). It's been taken off the schedule. As of July 2020, it is no longer available in the United States. Remaining supplies expired in November 2020.

A new adult vaccine, MenQuadfi, provides another MenACWY vaccine product choice.

Table 1. Vaccines by Age Group. Download PDF here

Td or Tdap is now split into color codes purple and yellow. The yellow bar indicates need for routine booster every 10 years. The addition of purple indicates Tdap in each pregnancy and Td or Tdap for wound prophylaxis. Specifics about tetanus for wound management are included in the notes, along with a link to the full recommendation.

Table 2. Vaccines by Medical Condition and Other Indications. Download PDF here

Here, there are two overarching changes. Pink is out, and blue is in to indicate shared decision-making, replacing yellow for varicella vaccination for those living with HIV with CD4 counts of 200 cells/mm³and higher. Shared clinical decision-making is needed for the use of this live virus vaccine in immunocompromised patients.

Hepatitis B vaccination for patients with diabetes aged 60 and older is now coded blue, indicating shared clinical decision-making. For patients with diabetes under 60, hepatitis B vaccination is still coded yellow, indicating that all patients aged 60 and younger with diabetes should receive it.

There are substantial changes to the pregnancy column of Table 2. The 2020 use of pink to indicate delaying the vaccine until after pregnancy has been replaced with red, meaning the vaccine is not recommended during pregnancy. This applies to the HPV vaccine as well as to other live virus vaccines: MMR, varicella, and LAIV. The recombinant zoster vaccine (RZV; Shingrix) is now coded grey, meaning no recommendation is made.

Vaccine Notes

The "Vaccine Notes" section contains editorial changes aimed at harmonizing language between the child/adolescent schedule and the one for adults.

Under the influenza vaccination note, the section on those with egg allergy has been revised. Previous language stated that persons with history of severe egg allergy needed to be in a medical setting when given the vaccine. New language states that this medical setting caveat is not necessary for those with severe egg allergy to receive the egg-free Flublok or egg-free Flucelvax.

The variety of flu antivirals with differing half-lives led to additional language about the time interval between LAIV and flu antivirals: LAIV should not be used if the patient has received antiviral medication (oseltamivir or zanamivir) in the previous 48 hours, peramivir in the previous 5 days, or baloxavir in the previous 17 days.

For travelers, an accelerated dosing schedule has been added for hepatitis A/B (Twinrix) before travel, with an option for doses at 0, 7, and 21-30 days followed by a booster at 12 months.

Interim Recommendations

CDC interim clinical recommendations suggest aiming for a 2-week window between COVID vaccine and other vaccine doses, if you can. This will help give mRNA COVID vaccines their very best chance of inducing a protective immune response. However, giving a tetanus booster for wound management or a dose of MMR or hepatitis A vaccine during a measles or hepatitis A outbreak is acceptable. We don't want to delay implementation of mRNA COVID vaccines.

Vaccines don't save lives; vaccinations do!

For Medicine Matters, I'm Dr Sandra Fryhofer.

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