Updates on Adult Immunizations

Special Feature

By Stan Deresinski, MD, FACP, Clinical Professor of Medicine, Stanford, Associate Chief of Infectious Diseases, Santa Clara Valley Medical Center, is Editor for Infectious Disease Alert.

Source: Centers for Disease Control and Prevention. Recommended adult immunization schedule -— United States, 2010. MMWR 2010;59(1). http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5901a5.htm

The u.s. advisory committee on immunization Practices (ACIP) has published its annual updated recommendations for routine immunizations of adults. The changes from the recommendations for 2009 are not extensive, but they are important.

Human Papillomavirus (HPV)

In October 2009, the US FDA approved Cervarix, a bivalent vaccine containing the oncogenic HPV types 16 and 18, for the prevention of cervical cancer and precancerous lesions in females ages 10 years through 25 years. Gardasil, a quadrivalent vaccine containing HPV types 6 and 8, which cause genital warts, in addition to types 16 and 18, has been available for several years with approval for use in the same general age group of females. Approval was also granted last October for its use in the vaccination of boys and men 9 through 26 years of age for the prevention of genital warts caused by HPV types 6 and 11, and ACIP has now endorsed this use, it may be "administered" appropriately, cautioning that its efficacy is greatest when administered before initiation of sexual activity.

Measles, Mumps

Adults born before 1957 continue to be considered likely to be immune to measles and mumps as the result of natural exposure, while those born during or after that year should receive one or more doses of vaccine with certain exceptions, which are clarified by ACIP in this document.

Measles

Those born during or after 1957 do not require MMR if they have a medical contraindication (e.g., significant immunocompromise), documentation of prior vaccination, laboratory evidence of immunity, or documentation of measles diagnosed by a physician. In an unchanged recommendation, ACIP states that a second dose of MMR vaccine, administered four weeks after the first dose, is recommended for adults who 1) have been recently exposed to measles or are in an outbreak setting; 2) have been vaccinated previously with killed measles vaccine; 3) have been vaccinated with an unknown type of measles vaccine during 1963-1967; 4) are students in postsecondary educational institutions; 5) work in a healthcare facility; or 6) plan to travel internationally.

Mumps

Similarly, adults born during or after 1957 should receive one dose of MMR vaccine unless they have 1) a medical contraindication; 2) documentation of vaccination with 1 or more doses of MMR vaccine; 3) laboratory evidence of immunity; or 4) documentation of physician-diagnosed mumps. Also in an unchanged recommendation, a second dose of MMR vaccine, administered 4 weeks after the first dose, is recommended for adults who 1) live in a community experiencing a mumps outbreak and are in an affected age group; 2) are students in postsecondary educational institutions; 3) work in a health-care facility; or 4) plan to travel internationally.

Hepatitis A Virus

ACIP has added a recommendation that unvaccinated persons who anticipate close contact with an international adoptee should consider vaccination against hepatitis A virus infection.

Meningococcus

Menomune, a polysaccharide meningococcal vaccine was licensed in 1978, while Menactra, a conjugate vaccine was approved in 2005. Each is quadrivalent, providing protection against meningoccal subtypes A, C, Y, and W-135. Menactra, although expected to provide longer-lasting protection than Menomune, received approval only for individuals 2 through 55 years of age, while the latter is approved for those two years of age and older, without an upper limit. Adhering to these formal strictures, ACIP now states that Menactra is preferred for adults with indications for vaccination who are aged > 55 years, while Menomune is preferred for adults aged > 56 years. Revaccination with Menactra after five years is recommended for adults previously vaccinated with Menactra or Menomune who remain at increased risk for infection (e.g., adults with anatomic or functional asplenia). Persons whose only risk factor is living in on-campus housing are not recommended to receive an additional dose.

Haemophilus influenzae Type B

Conjugate Haemophilus influenzae type B (Hib) vaccine is effective in and approved for the prevention of related infection in children 6 weeks through 5 years of age. Only a small minority of Haemophilus infections in adults are due to type B, and the vaccine is specific to this type. Nonetheless, the vaccine is immunogenic in adults, and its use has been suggested in specific populations thought to be at increased risk, such as those with sickle cell disease leukemia, or HIV infection and those who are asplenic. ACIP does not specifically recommend the use of the vaccine in such individuals but now states that "Administering one dose of Hib vaccine to these high-risk persons who have not previously received Hib vaccine is not contraindicated."