By: Dr. Geoffrey Modest
The new annual guidelines for 2015 were published for adults and children/adolescents by the ACIP (Advisory Committee on Immunization Practices).
Adults (see Ann Intern Med. 2015;162:214-223, which includes the immunization schedules as Tables):
–As per usual, there are great summary tables. Figure 1 is the color-coded list of vaccines for different ages, with comments on whether the vaccines are routinely recommended or recommended for specific groups of patients. Figure 2 is the color-coded list of vaccines indicated for different medical conditions (eg pregnancy, immunosuppression), as well as for other indications (health care workers, MSM). And a plethora of footnotes clarify both figures.
–Major changes over last year (there are only a few):
–adds PCV13 for all adults over age 65, an enhancement over prior version of “recommended if some other risk is present”. It is notable that the incidence of invasive pneumococcal disease has decreased so dramatically (50%), likely from immunizing kids, and I would not be surprised if immunizing adults becomes less necessary over time as more and more of the younger population is immunized (they are planning to review this recommendation in 3 years). For more info, see prior blog post. Per prior recommendations, those with immunocompromising conditions but less than 65yo (including those with HIV, chronic renal failure, nephrotic syndrome, long term systemic steroids) should get PCV-13 as well as PPSV-23 –first give the PCV13, then PPSV23 at least 8 weeks later, then repeat PPSV23 at least 5 years later and again at age 65 (but at least 5 years after last PPSV23). If not immunocompromised, give PCV13 first for those >65yo, then PPSV23 after 6-12 months later. Their figure 3 and Table 2 go through the algorithm for different situations. So far, the PPSV23 vaccine rates in those >65 yo is an abysmal 59.7%, and even worse in those with indication for earlier vaccine (includes cardioresp diseases, liver or renal disease, diabetes, hiv, smokers)
–immunization rates for adults are generally pretty miserable: 24% of those >60yo have had zoster vaccine (though a large part of the issue for my patients is that most Medicare D plans do not cover this expensive vaccine!!), and only 26% of those with diabetes have received Hepatitis B vaccine
–a few minor changes with influenza vaccine recommendations (see their Table 1): recombinant influenza vaccine (RIV) is now okay for all adults >18 (no upper limit of 49). Live-attenuated vaccine (LAIV) is now contraindicated if influenza antivirals given within the last 48 hours. Also, many chronic conditions listed previously as contraindications (asthma, chronic lung/cardiovascular disease, diabetes, chronic renal/liver/hematologic/neurologic/metabolic disorders, and moderate or severe acute illness with or without fever) are now considered “precautions” — ie, LAIV can be given if perceived risks outweigh benefits, as, for example, the patient is at high risk but refuses to get a shot.
Children and adolescents –til age 18 (see DOI: 10.1542/peds.2014-3955). For the table and important footnotes on immunization schedules (not included in the Pediatrics article).
–the tables and footnotes are all very clear and self-explanatory (and printable for future reference)
–there have been only minor changes
–LAIV: continue to use from age 2 years. give 2 doses separated by at least 4 weeks to those getting the vaccine for the first time until age 9, when one dose is adequate. LAIV continues to be recommended in kids because of increased efficacy vs inactivated vaccine. However, LAIV should not be given to kids 2-4 years old who have asthma or a wheezing episode in the past 12 months. for those >5yo, “the safety of LAIV in persons with other underlying medical conditions that might predispose them to complications after wild-type influenza infection (eg, chronic pulmonary, cardiovascular [except isolated hypertension], renal, hepatic, neurologic, hematologic , or metabolic disorders [including diabetes mellitus] has not been established. These conditions, in addition to asthma in persons aged >= 5 years, should be considered precautions for the use of LAIV” (from MMWR, August 15, 2014) — ie, asthma is not a contraindication to giving LAIV in those 5yo and older, so one can consider LAIV in an older kid unwilling to get a shot. Of note a study comparing LAIV with inactivated vaccine in kids aged 6-17 with asthma found no difference in wheezing events after LAIV (see Pediatr Infect Dis J 2006; 25: 860-9). Also, do not give LAIV in those on antiviral meds in previous 48 hours. I will not go into details of how many doses of LAIV are required (which is a bit complicated and may well change yearly depending on that year’s anticipated flu strains and the components included in the vaccine).
–MMR: infants 6-11 months traveling abroad should receive one dose before going, then the regular 2 doses beginning age 12-15 months
–meningococcal vaccine: no change in general recommendation of first dose age 11-12 and booster at age 16 (though this is relatively new). Those age 11-18 with HIV should get 2 doses at least 8 weeks apart. See overall chart in CDC for catch-up vaccines, though for meningococcal vaccine, if get first dose 13-15 years old, then give second at age 16-18 with minimum of 8 weeks between doses. No booster if first dose after age 16.
–DTaP: 5 dose series (age 2,4,6,15-18 months and 4-6 years old). 4th dose can be as early as 12 months if at least 6 months from 3rd dose. A change: the 4th dose does NOT need to be repeated if at least 4 months after 3rd dose.
–PCV13: in those with high risk conditions (chronic heart/lung disease, including asthma on high-dose oral steroids; diabetes; HIV; other immunocompromising conditions), give PCV13 prior to PPSV23. See details in their footnote for full list of high-risk kids.
So, the reason I am posting this is mostly because it is important to have an accessible copy of the most recent guidelines on-hand in primary care. But the issue of vaccinations is even more significant as the new measles outbreak has shown, an outbreak largely attributable to people refusing to have their kids vaccinated. Sort of like the climate change deniers — in both cases, these are people who strongly adhere to positions that fly in the face of abundant scientific evidence to the contrary. measles has been associated with significant mortality in the past. immunization has provided dramatic improvements, with large studies finding no significant association, for example, with autism (the frequently cited reason for those declining the vaccine). even the first study in Lancet suggesting an association was retracted…. the general immunization issues are:
–unimmunized kids who now get measles could themselves experience significant sequelae, including death
–there is a strong social reason to have kids immunized. the “herd immunity” of having a large % of the population immunized protects those who cannot get the vaccine — eg, those immunocompromised (who are also at much higher risk of bad outcomes than those who are immunocompetent), those allergic to a component of the vaccine, or those vaccinated who do not mount a protective immunologic response.
–the US does not fare well in international comparisons. The WHO compiled a list of measles immunization rates in 2013, finding the US at 91%, but outflanked by many resource-rich countries and lots of resource-poor countries (Vietnam 98%, Tanzania 99%, Turkey 98%, Nicaragua 98%, etc etc). I suspect that some of the data from these countries may not be so accurate, but the consistency is pretty dramatic, and the US clearly could do better. To do so would require a broader social orientation to vaccination, stressing the concept and importance of herd immunity and protecting all: ie, promoting the concept of “public health” and aggressively rebutting the immunization deniers (of note, in the WHO survey, the US has been as high as 98% in the past).