By Dr. Geoffrey Modest
The Advisory Committee on Immunization Practices and CDC just published their immunization recommendations for adults and kids.
- Adults. For those >18 years old, see Ann Intern Med.2016;164(3):184, or go to http://www.cdc.gov/vaccines/schedules/downloads/adult/adult-combined-schedule.pdf for a nice color chart and the rather extensive footnotes, ideal for hanging in the immunization room by the refrigerator. Changes from 2015 include:
- Simplification of the rather complex relationship between the pneumococcal vaccines: for immunocompetent people over 65yo, give PCV13 first, then at least one year later (had been 6-12 months), give PPSV23; if they already got PPSV23, wait one year at least to give the PCV13. In those immunocompromised (functional/anatomic asplenia, CSF leaks, cochlear implants, HIV, etc.), and >18yo, give PCV13 first, then can follow with PPSV23 at least 8 weeks later; if they already got PPSV23, then wait at least one year for the single dose of PCV13.In those who should get a PPSV23 booster since they got the first dose <65 yo, they should wait at least 5 years to the next PPSV23 dose. They also note that those with immunocompromise/asplenia can receive up to a total of 3 doses of PPSV23. And they deleted the recommendation that adults 19-64 who are in nursing homes get PPSV23 (though, I wonder about the real utility of this: probably most have an indication for PPSV23 from asthma, COPD, diabetes, heart failure, alcoholism, smoking, etc. Also, I wonder about actual second-hand smoke exposure, though my understanding is that JCAHO requires some isolation of smoking areas. Sorry, but this simplification actually is simpler than last year’s…
- Meningococcal B vaccine has been added: give to those >10 yo at increased risk of serogroup B infections (asplenia, complement deficiencies, local outbreaks of serogroup B). Can be given to adults aged 16-23 (preferably 16-18) to get short-term protection. A 2-dose series administered at least 1 months apart (the 2 different meningococcal B vaccines are not interchangeable). No recommendation about revaccination (vs the regular meningococcal vaccine for serogroups A,C,W,Y; where there should be revaccination every 5 years in those who remain at increased risk). See pedi schedule below for other details.
- For the regular meningococcal vaccine, the conjugate A,C,W,Y (MenACWY) is preferred for adults <56yo, and for those >56 who have had prior meningococcal vaccine who need revaccination (whether they got the MenACWY or the polysaccharide MPSV4 vaccine). The MPSV4 vaccine is preferred in those >56 who have never been vaccinated and need a single dose only (as with a recent outbreak). HIV is not an indication for meningococcal vaccine (despite outbreak in New York in 2014, which spurred some of us, like me, to vaccinate my HIV-positive patients)
- HPV vaccine: they added the 9-valent vaccine (9vHPV). Can be used as the routine vaccine, given as 1 of the 3 recommended vaccines for females (others: 2vHPV and 4vHPV), or as 1 of the 2 for males (other: 4vHPV). The age recommendations have not changed: women beginning age 11-12 until age 26; men till age 21, though okay to give for 22-26 yo and recommended in that group for MSM.
- And, they reinforce some of their newer recommendations, such as the importance of giving a Tdap to women for each pregnancy, preferably at 27-36 weeks’ gestation, and an influenza vaccine, to protect the woman and the to-be-born.
- Pedi. The updated 2016 pediatric immunization schedules were just released (see DOI: 10.1542/peds.2015-4531). For a chart of the immunizations as well as the catch-up schedule, see http://www.cdc.gov/vaccines/schedules/hcp/child-adolescent.html. Also ideal to hang the color charts in the immunization room near the refrigerator. Summary of changes in brief:
- They added a blue bar to the already colorful chart, which indicates the range of recommended ages of a vaccine for certain high risk groups
- See above re: the 9-valent HPV vaccine (9vHPV)
- HPV: new purple bar (for ages of recommended vaccines in high risk groups), they added age 9-10 for children at high risk because of a history of sexual abuse (though, I wonder about the 5 year olds, etc……)
- Meningococcal B vaccine (detailed above): begin at 10 years old if at increased risk, may otherwise consider in those 16-18.
- Pneumococcal polysaccharide vaccine (PPSV23): moved to bottom of the list since not routinely indicated for anyone (but should be given to kids aged 6-18 with underlying immunocompromise, hemoglobinopathies, HIV, renal failure, nephrotic syndrome, etc.); in general, give PCV13 first, then PPSV23 at last 8 weeks later.
- They clarified that in infants born to mothers with hepatitis B surface antigen (and the infant therefore gets immunized starting within 12 hours of birth), to check the infant for anti-HbsAg and HBsAg at least 1 months after final vaccine dose and between 9-18 months old (at time of regular well-child visit). They do not comment further, but I would suggest repeating the 3 doses again if there is a negative surface antigen and antibody in the kid, as we do with adults who are at high hepatitis B risk.
- If a kid inadvertently gets a 4th DTaP early, but it was given at least 4 months but less than 6 months after the 3rd dose, no need to repeat (a logical correlate here, it seems to me, is that it might be reasonable to give this 4th dose earlier to a kid who will not be around for the usual 4th dose timing between 15-18 mos old, e.g. if they will be out of the country during that time)