Advisory Committee on Immunization Practices Issues 2009 Adult Immunization Schedule

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Advisory Committee on Immunization Practices Issues 2009 Adult Immunization

Schedule

Laurie Barclay, MD

January 9, 2009 — The Advisory Committee on Immunization Practices (ACIP) has

issued the recommended adult immunization schedule for 2009, published in the

January 9 issue of the Morbidity and Mortality Weekly Report. The 2009 schedule

has been approved by the American Academy of Family Physicians, the American

College of Obstetricians and Gynecologists, and the American College of

Physicians, in addition to the ACIP.

" The [ACIP] annually reviews the recommended Adult Immunization Schedule to

ensure that the schedule reflects current recommendations for the licensed

vaccines, " the ACIP statement authors write. " In October 2008, ACIP approved the

Adult Immunization Schedule for 2009. No new vaccines were added to the

schedule; however, several indications were added to the pneumococcal

polysaccharide vaccine footnote, clarifications were made to the footnotes for

human papillomavirus [HPV], varicella, and meningococcal vaccines, and schedule

information was added to the hepatitis A and hepatitis B vaccine footnotes. "

Changes for 2009 are as follows:

For HPV, healthcare personnel are not at increased risk because of occupational

exposure, but they should be vaccinated as recommended based on age. Vaccination

for HPV may begin at 9 years of age.

Adults who previously received only 1 dose of varicella vaccine should receive a

second dose.

Additional indications for pneumococcal polysaccharide vaccination are asthma

and cigarette smoking. Vaccine use in Alaska Natives and American Indians has

been clarified.

Additional schedule information is included for the 4-dose combined hepatitis

A/hepatitis B vaccine.

For meningococcal vaccine, the revaccination interval is 5 years.

Some specific recommendations for each of the vaccinations follow.

Tetanus, diphtheria, and acellular pertussis (Td/Tdap) vaccination: For adults

aged 19 through 64 years who have not previously received a dose of Tdap, Tdap

should replace a single dose of Td. A primary vaccination series should be given

to adults with uncertain or incomplete history of primary vaccination; this

consists of 3 doses of tetanus and diphtheria toxoid–containing vaccines, with

the first 2 doses given at least 4 weeks apart and the third dose 6 to 12 months

after the second. In the 3-dose primary series, Tdap can substitute for any 1 of

the Td doses of Td. A booster dose of tetanus and diphtheria toxoid–containing

vaccine should be given to adults who completed a primary series 10 or more

years previously. Tdap or Td vaccine may be used, as indicated. Recommendations

are also given for Td/Tdap vaccination during pregnancy and for Td as

prophylaxis in wound management.

HPV vaccination: Recommended for all females aged 11 through 26 years,

regardless of sexual activity or clinical evidence of previous HPV infection,

who have not completed the vaccine series. Ideally, vaccination should be given

before potential exposure to HPV through sexual activity and may be given as

early as age 9 years. The complete series consists of 3 doses, with the second

dose given 2 months after the first dose and the third dose 6 months after the

first dose.

Varicella vaccination: Should be given to all adults who lack evidence of

immunity unless they have a medical contraindication. Patients should receive 2

doses of single-antigen varicella vaccine if not previously vaccinated or the

second dose if they have received only 1 dose. Special consideration is

recommended for those with close contact with persons at high risk for severe

disease or high risk for exposure or transmission. Pregnant women without

evidence of varicella immunity should receive the first dose of varicella

vaccine on completion or termination of pregnancy and before discharge from the

healthcare facility, and they should receive the second dose 4 to 8 weeks after

the first dose.

Herpes zoster vaccination (single dose): Recommended for adults aged 60 years

and older regardless of prior history of herpes zoster, unless they have a

specific contraindication.

Measles, mumps, rubella (MMR) vaccination: 1 or more doses should be given to

adults born during or after 1957 unless they have a medical contraindication,

documentation of 1 or more doses, history of measles diagnosed by a healthcare

provider, or laboratory evidence of immunity. A second dose of MMR is

recommended for adults recently exposed to measles or in an outbreak setting,

previously vaccinated with killed measles vaccine, or vaccinated with an unknown

type of measles vaccine during 1963 to 1967, as well as for those who are

students in postsecondary educational institutions, work in a healthcare

facility, or plan international travel. Women of childbearing age, regardless of

birth year, should be assessed for rubella immunity and counseled regarding

congenital rubella syndrome. Women without evidence of immunity should receive

MMR vaccine on completion or termination of pregnancy and before discharge from

the healthcare facility.

Influenza vaccination: Should be given to those with medical, occupational, or

other indications. Medical indications are chronic disorders of the

cardiovascular or pulmonary systems, chronic metabolic diseases,

immunocompromising conditions, or any condition that compromises respiratory

function or that increases risk for aspiration. All healthcare personnel and

caregivers of children younger than 5 years old should receive influenza

vaccination, as should residents of nursing homes and other long-term care and

assisted-living facilities, persons likely to transmit influenza to persons at

high risk, and others who wish to decrease their risk of getting influenza.

Healthy, nonpregnant adults younger than 50 years without high-risk medical

conditions who are not contacts of severely immunocompromised persons in special

care units can receive either intranasally administered live, attenuated

influenza vaccine (FluMist, MedImmune) or inactivated vaccine, but others should

receive the inactivated vaccine.

Pneumococcal polysaccharide (PPSV) vaccination: Should be given to those with

chronic lung, cardiovascular, or liver disease; diabetes mellitus; chronic

alcoholism; chronic renal failure or nephrotic syndrome; functional or anatomic

asplenia; immunocompromising conditions; cochlear implants; or cerebrospinal

fluid leaks. Vaccination should occur as close to HIV diagnosis as possible.

Other indications for PPSV are being a resident of nursing homes or other

long-term care facility and being a cigarette smoker. Public health authorities

may consider recommending PPSV for Alaska Natives and American Indians aged 50

through 64 years living in areas with increased risk for invasive pneumococcal

disease.

One-time revaccination with PPSV: Recommended after 5 years for persons with

chronic renal failure or nephrotic syndrome, functional or anatomic asplenia, or

immunocompromising conditions, or for persons aged 65 years and older if they

were vaccinated 5 or more years previously at younger than 65 years.

Hepatitis A vaccination: Indicated for persons with chronic liver disease, those

who receive clotting factor concentrates, men who have sex with men, illegal

drug users, laboratory workers exposed to hepatitis A virus–infected primates,

persons traveling to or working in countries with high or intermediate

endemicity of hepatitis A, and those seeking protection from hepatitis A virus

infection. Single-antigen vaccine formulations should be given in 2 doses either

at 0 and 6 to 12 months (Havrix, GlaxoKline) or at 0 and 6 to 18 months

(Vaqta, Merck). Combined hepatitis A and hepatitis B vaccine (Twinrix,

GlaxoKline) should be given in 3 doses at 0, 1, and 6 months or in 4 doses

on days 0, 7, and 21 to 30, followed by a booster dose at month 12.

Hepatitis B vaccination: Indicated for persons with end-stage renal disease, HIV

infection, or chronic liver disease; for healthcare personnel and public-safety

workers exposed to blood or other potentially infectious body fluids; for

sexually active persons not in a long-term, mutually monogamous relationship;

for persons seeking evaluation or treatment for a sexually transmitted disease;

for current or recent injection-drug users; and for men who have sex with men.

Other indications and settings are also listed, as well as special formulation

indications.

Meningococcal vaccination: Should be given to adults with anatomic or functional

asplenia or terminal complement component deficiencies, first-year college

students living in dormitories, microbiologists routinely exposed to

meningococcus, military recruits, and those in hyperendemic or epidemic

countries.

Haemophilus influenzae type b (Hib) vaccine: Generally not recommended for

persons aged 5 years and older but may be considered in those with sickle cell

disease, leukemia, HIV infection, or asplenia.

Immunocompromising conditions: Inactivated vaccines generally are acceptable,

but live vaccines should be avoided.

" These schedules indicate the recommended age groups and medical indications for

which administration of currently licensed vaccines is commonly indicated for

adults ages 19 years and older, as of January 1, 2009, " the ACIP authors write.

" Licensed combination vaccines may be used whenever any components of the

combination are indicated and when the vaccine's other components are not

contraindicated. "

Morb Mortal Wkly Rep. 2009;57(53).

[Guest guest]

http://www.medscape.com/viewarticle/586529

Printer-Friendly Email This

Advisory Committee on Immunization Practices Issues 2009 Adult Immunization

Schedule

Laurie Barclay, MD

January 9, 2009 — The Advisory Committee on Immunization Practices (ACIP) has

issued the recommended adult immunization schedule for 2009, published in the

January 9 issue of the Morbidity and Mortality Weekly Report. The 2009 schedule

has been approved by the American Academy of Family Physicians, the American

College of Obstetricians and Gynecologists, and the American College of

Physicians, in addition to the ACIP.

" The [ACIP] annually reviews the recommended Adult Immunization Schedule to

ensure that the schedule reflects current recommendations for the licensed

vaccines, " the ACIP statement authors write. " In October 2008, ACIP approved the

Adult Immunization Schedule for 2009. No new vaccines were added to the

schedule; however, several indications were added to the pneumococcal

polysaccharide vaccine footnote, clarifications were made to the footnotes for

human papillomavirus [HPV], varicella, and meningococcal vaccines, and schedule

information was added to the hepatitis A and hepatitis B vaccine footnotes. "

Changes for 2009 are as follows:

For HPV, healthcare personnel are not at increased risk because of occupational

exposure, but they should be vaccinated as recommended based on age. Vaccination

for HPV may begin at 9 years of age.

Adults who previously received only 1 dose of varicella vaccine should receive a

second dose.

Additional indications for pneumococcal polysaccharide vaccination are asthma

and cigarette smoking. Vaccine use in Alaska Natives and American Indians has

been clarified.

Additional schedule information is included for the 4-dose combined hepatitis

A/hepatitis B vaccine.

For meningococcal vaccine, the revaccination interval is 5 years.

Some specific recommendations for each of the vaccinations follow.

Tetanus, diphtheria, and acellular pertussis (Td/Tdap) vaccination: For adults

aged 19 through 64 years who have not previously received a dose of Tdap, Tdap

should replace a single dose of Td. A primary vaccination series should be given

to adults with uncertain or incomplete history of primary vaccination; this

consists of 3 doses of tetanus and diphtheria toxoid–containing vaccines, with

the first 2 doses given at least 4 weeks apart and the third dose 6 to 12 months

after the second. In the 3-dose primary series, Tdap can substitute for any 1 of

the Td doses of Td. A booster dose of tetanus and diphtheria toxoid–containing

vaccine should be given to adults who completed a primary series 10 or more

years previously. Tdap or Td vaccine may be used, as indicated. Recommendations

are also given for Td/Tdap vaccination during pregnancy and for Td as

prophylaxis in wound management.

HPV vaccination: Recommended for all females aged 11 through 26 years,

regardless of sexual activity or clinical evidence of previous HPV infection,

who have not completed the vaccine series. Ideally, vaccination should be given

before potential exposure to HPV through sexual activity and may be given as

early as age 9 years. The complete series consists of 3 doses, with the second

dose given 2 months after the first dose and the third dose 6 months after the

first dose.

Varicella vaccination: Should be given to all adults who lack evidence of

immunity unless they have a medical contraindication. Patients should receive 2

doses of single-antigen varicella vaccine if not previously vaccinated or the

second dose if they have received only 1 dose. Special consideration is

recommended for those with close contact with persons at high risk for severe

disease or high risk for exposure or transmission. Pregnant women without

evidence of varicella immunity should receive the first dose of varicella

vaccine on completion or termination of pregnancy and before discharge from the

healthcare facility, and they should receive the second dose 4 to 8 weeks after

the first dose.

Herpes zoster vaccination (single dose): Recommended for adults aged 60 years

and older regardless of prior history of herpes zoster, unless they have a

specific contraindication.

Measles, mumps, rubella (MMR) vaccination: 1 or more doses should be given to

adults born during or after 1957 unless they have a medical contraindication,

documentation of 1 or more doses, history of measles diagnosed by a healthcare

provider, or laboratory evidence of immunity. A second dose of MMR is

recommended for adults recently exposed to measles or in an outbreak setting,

previously vaccinated with killed measles vaccine, or vaccinated with an unknown

type of measles vaccine during 1963 to 1967, as well as for those who are

students in postsecondary educational institutions, work in a healthcare

facility, or plan international travel. Women of childbearing age, regardless of

birth year, should be assessed for rubella immunity and counseled regarding

congenital rubella syndrome. Women without evidence of immunity should receive

MMR vaccine on completion or termination of pregnancy and before discharge from

the healthcare facility.

Influenza vaccination: Should be given to those with medical, occupational, or

other indications. Medical indications are chronic disorders of the

cardiovascular or pulmonary systems, chronic metabolic diseases,

immunocompromising conditions, or any condition that compromises respiratory

function or that increases risk for aspiration. All healthcare personnel and

caregivers of children younger than 5 years old should receive influenza

vaccination, as should residents of nursing homes and other long-term care and

assisted-living facilities, persons likely to transmit influenza to persons at

high risk, and others who wish to decrease their risk of getting influenza.

Healthy, nonpregnant adults younger than 50 years without high-risk medical

conditions who are not contacts of severely immunocompromised persons in special

care units can receive either intranasally administered live, attenuated

influenza vaccine (FluMist, MedImmune) or inactivated vaccine, but others should

receive the inactivated vaccine.

Pneumococcal polysaccharide (PPSV) vaccination: Should be given to those with

chronic lung, cardiovascular, or liver disease; diabetes mellitus; chronic

alcoholism; chronic renal failure or nephrotic syndrome; functional or anatomic

asplenia; immunocompromising conditions; cochlear implants; or cerebrospinal

fluid leaks. Vaccination should occur as close to HIV diagnosis as possible.

Other indications for PPSV are being a resident of nursing homes or other

long-term care facility and being a cigarette smoker. Public health authorities

may consider recommending PPSV for Alaska Natives and American Indians aged 50

through 64 years living in areas with increased risk for invasive pneumococcal

disease.

One-time revaccination with PPSV: Recommended after 5 years for persons with

chronic renal failure or nephrotic syndrome, functional or anatomic asplenia, or

immunocompromising conditions, or for persons aged 65 years and older if they

were vaccinated 5 or more years previously at younger than 65 years.

Hepatitis A vaccination: Indicated for persons with chronic liver disease, those

who receive clotting factor concentrates, men who have sex with men, illegal

drug users, laboratory workers exposed to hepatitis A virus–infected primates,

persons traveling to or working in countries with high or intermediate

endemicity of hepatitis A, and those seeking protection from hepatitis A virus

infection. Single-antigen vaccine formulations should be given in 2 doses either

at 0 and 6 to 12 months (Havrix, GlaxoKline) or at 0 and 6 to 18 months

(Vaqta, Merck). Combined hepatitis A and hepatitis B vaccine (Twinrix,

GlaxoKline) should be given in 3 doses at 0, 1, and 6 months or in 4 doses

on days 0, 7, and 21 to 30, followed by a booster dose at month 12.

Hepatitis B vaccination: Indicated for persons with end-stage renal disease, HIV

infection, or chronic liver disease; for healthcare personnel and public-safety

workers exposed to blood or other potentially infectious body fluids; for

sexually active persons not in a long-term, mutually monogamous relationship;

for persons seeking evaluation or treatment for a sexually transmitted disease;

for current or recent injection-drug users; and for men who have sex with men.

Other indications and settings are also listed, as well as special formulation

indications.

Meningococcal vaccination: Should be given to adults with anatomic or functional

asplenia or terminal complement component deficiencies, first-year college

students living in dormitories, microbiologists routinely exposed to

meningococcus, military recruits, and those in hyperendemic or epidemic

countries.

Haemophilus influenzae type b (Hib) vaccine: Generally not recommended for

persons aged 5 years and older but may be considered in those with sickle cell

disease, leukemia, HIV infection, or asplenia.

Immunocompromising conditions: Inactivated vaccines generally are acceptable,

but live vaccines should be avoided.

" These schedules indicate the recommended age groups and medical indications for

which administration of currently licensed vaccines is commonly indicated for

adults ages 19 years and older, as of January 1, 2009, " the ACIP authors write.

" Licensed combination vaccines may be used whenever any components of the

combination are indicated and when the vaccine's other components are not

contraindicated. "

Morb Mortal Wkly Rep. 2009;57(53).