{"id":591,"date":"2015-02-12T11:00:15","date_gmt":"2015-02-12T11:00:15","guid":{"rendered":"http:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/?p=591"},"modified":"2017-08-21T11:59:10","modified_gmt":"2017-08-21T11:59:10","slug":"primary-care-corner-with-geoffrey-modest-md-2015-immunization-schedules-adult-and-pedi","status":"publish","type":"post","link":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/2015\/02\/12\/primary-care-corner-with-geoffrey-modest-md-2015-immunization-schedules-adult-and-pedi\/","title":{"rendered":"Primary Care Corner with Geoffrey Modest MD: 2015 immunization schedules — adult and pedi"},"content":{"rendered":"

By: Dr. Geoffrey Modest<\/strong><\/p>\n

The new annual guidelines for 2015 were published for adults and children\/adolescents by the ACIP (Advisory Committee on Immunization Practices).<\/p>\n

Adults<\/strong>\u00a0(see\u00a0Ann Intern Med. 2015;162:214-223<\/strong>, which includes the immunization schedules as\u00a0Tables)\u200b:<\/p>\n

–As per usual, there are\u00a0great summary tables. Figure 1 is the color-coded list of vaccines for different ages, with comments on whether the vaccines are\u00a0routinely 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),\u00a0as well as for other indications (health care workers, MSM). And a plethora of footnotes\u00a0clarify both figures.<\/p>\n

–Major changes over last year (there are only a few):<\/p>\n

\n–adds PCV13 for all adults over age 65<\/strong>, 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<\/a>.\u00a0Per prior recommendations, those with immunocompromising conditions but less than 65yo (including those with\u00a0HIV, chronic renal failure, nephrotic\u00a0syndrome, 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\u00a05 years after last\u00a0PPSV23).\u00a0If not immunocompromised,\u00a0give PCV13 first for those >65yo, then PPSV23 after 6-12 months later. Their figure 3 and\u00a0Table 2 go\u00a0through the algorithm for different situations. So\u00a0far, 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,\u00a0smokers)<\/p>\n

–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\u00a026% of those with diabetes have received Hepatitis B vaccine<\/p>\n

–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)\u00a0are now considered “precautions” — ie, LAIV\u00a0can be given\u00a0if perceived risks outweigh benefits, as, for example, the patient is at high risk but refuses to get\u00a0a shot.<\/p>\n

 <\/p>\n

Children and adolescents –til age 18<\/strong>\u00a0(see\u00a0DOI: 10.1542\/peds.2014-3955<\/strong>\u200b).\u00a0For the table and important footnotes\u00a0on\u00a0immunization schedules<\/a> (not included in the Pediatrics article).<\/p>\n

 <\/p>\n

\"050826-N-9407V-003\"<\/a><\/p>\n

–the tables and footnotes are all very clear and self-explanatory (and printable for future reference)<\/p>\n

–there have\u00a0been only minor changes<\/p>\n

–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.\u00a0\u00a0LAIV continues to be recommended in kids because of increased efficacy vs inactivated vaccine. However, LAIV \u00a0should 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\u00a0established. 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\u00a0contraindication to giving\u00a0LAIV in those 5yo and older<\/strong>, 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).\u00a0\u00a0Also, do\u00a0not give LAIV in those on antiviral meds in previous 48 hours. I will not go into details of how many doses of LAIV\u00a0are required (which is a bit complicated and may well change yearly\u00a0depending on that\u00a0year’s anticipated flu strains and the components included in the vaccine).<\/p>\n

–MMR: infants 6-11 months traveling abroad should receive one dose before going, then the regular 2 doses beginning age 12-15 months<\/p>\n

–meningococcal vaccine: no change in general recommendation of first dose age 11-12 and booster at age 16 (though this is relatively new). Those\u00a0age 11-18 with HIV should\u00a0get 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\u00a0second at age 16-18 with minimum of 8 weeks between doses. \u00a0No booster if first dose after age 16.<\/p>\n

–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\u00a0change: the\u00a04th dose does NOT need to be repeated if at least 4 months after 3rd dose.<\/p>\n

–PCV13: in those with high risk conditions (chronic heart\/lung disease, including asthma on high-dose oral steroids;\u00a0diabetes;\u00a0HIV; other immunocompromising conditions), give\u00a0PCV13 prior to PPSV23. See\u00a0details in\u00a0their footnote for full list of\u00a0high-risk kids.<\/p>\n

 <\/p>\n

So, the reason I am posting this is mostly\u00a0because it is important to have an accessible copy of the most recent guidelines on-hand in primary care. But the issue of vaccinations\u00a0is 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\u00a0people who\u00a0strongly 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\u00a0the vaccine). even the first study in Lancet suggesting an association was retracted….\u00a0the\u00a0general immunization\u00a0issues are:<\/p>\n

 <\/p>\n

–unimmunized\u00a0kids who now get measles could themselves\u00a0experience significant sequelae, including death<\/p>\n

–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 —\u00a0eg, those immunocompromised\u00a0(who are also at much\u00a0higher risk of bad outcomes than those who are\u00a0immunocompetent), those allergic to a component of the vaccine, or those vaccinated who do not mount a protective immunologic response.<\/p>\n

–the US does not fare well in international comparisons. The WHO compiled a list of measles immunization rates<\/a> in 2013, finding the US at 91%, but outflanked by many resource-rich\u00a0countries and lots of resource-poor countries (Vietnam\u00a098%, Tanzania 99%, Turkey\u00a098%, 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\u00a0of herd immunity and protecting all: ie,\u00a0promoting\u00a0the concept of “public health” and aggressively rebutting the immunization deniers (of note, in the WHO survey, the\u00a0US has been as high as 98%\u00a0in the past)\u200b.<\/p>\n

 <\/p>\n","protected":false},"excerpt":{"rendered":"

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\u00a0(see\u00a0Ann Intern Med. 2015;162:214-223, which includes the immunization schedules as\u00a0Tables)\u200b: –As per usual, there are\u00a0great summary tables. Figure 1 is the color-coded list of vaccines for different ages, with comments on […]<\/p>\n

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