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. Dr. Deresinski serves on the speakers bureau for Merck, Pfizer, Wyeth, Ortho-McNeil (J&J), Schering-Plough, and Cubist, does research for the National Institute of Health, and is an advisory board member for Schering-Plough, Ortho-McNeil (J&J), and Cepheid. This article originally appeared in the February issue of Infectious Disease Alert. At that time it was reviewed by Connie Price, MD, Assistant Professor, University of Colorado School of Medicine; she reports no financial relationship to this field of study.

Source: Centers for Disease Control and Prevention. Recommended adult immunization schedule — United States, 2010. Morbid Mortal Weekly Rep MMWR 2010;59:1-4.

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 FDA approved Cervarixâ, a bivalent vaccine containing the oncogenic HPV types 16 and 18, for the prevention of cervical cancer and precancerous lesions in females ages 10-25. Gardasilâ, 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 ages 9-26 for the prevention of genital warts caused by HPV types 6 and 11, and ACIP has now endorsed this use, if 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 1 or more doses of vaccine with certain exceptions.

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 4 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 health care facility; or 6) plan to travel internationally.

Similarly, adults born during or after 1957 should receive 1 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 unvaccinat-ed persons who anticipate close contact with an inter-national adoptee should consider vaccination against hepatitis A virus infection.

Meningococcus

Menomuneâ, a polysaccharide meningococcal vaccine, was licensed in 1978, while Menactraâ, a conjugate vaccine was approved in 2005. Each is quadrivalent, providing protection against meningococcal subtypes A, C, Y, and W-135. Menactra, although expected to provide longer-lasting protection than Menomune, received approval only for individuals ages 2-55, while the latter is approved for those age 2 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 ages < 55 years, while Menomune is preferred for adults ages > 55 years. Revaccination with Menactra after 5 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 influenza Type B

Conjugate Haemophilus influenzae type B (Hib) vaccine is effective in and approved for the prevention of related infection in children age 6 weeks to 5 years. 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: "Administering one dose of Hib vaccine to these high-risk persons who have not previously received Hib vaccine is not contraindicated."