Primary Care Corner with Geoffrey Modest: Adult and Pedi 2016 Immunization Schedules

By Dr. Geoffrey Modest

The Advisory Committee on Immunization Practices and CDC just published their immunization recommendations for adults and kids.

  1. 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.

 

  1. 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)

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