Updates to adult immunization schedule

Each year in January, the CDC publishes an adult immunization schedule, updating information relating to the vaccines that are relevant to the adult population in the United States. That’s right — vaccines are not just for kids!

The CDC also released a report card on the status of adult immunization and, no surprise, we still have a long way to go to achieve optimal protection of US adults against an array of diseases that are vaccine-preventable. The schedule is designed to help us do a better job delivering vaccines to our patients.

The adult immunization schedule consists basically of two color-coded charts; one indicates which vaccines are recommended according to patient age, and the other provides vaccine indications according to patients’ underlying medical conditions. Thus, you can check out your patients’ need for vaccines in two ways that complement each other. In addition to the charts, there are footnotes that provide further concise explanatory comments. The schedule presents vaccines for routine use; vaccines for international travel are not included here.

The charts are modeled after those long used by pediatricians. Indeed, they often are tacked up in pediatric examination rooms for easy reference. In my experience, the charts take a little practice before you can use them with comfort and speed. Try them for a day or two — I think you’ll like them.

This year, there are two noteworthy tweaks to the schedule. The pneumococcal conjugate vaccine (PCV13; Prevnar13, Wyeth) was licensed by the FDA for use in adults aged at least 50 years and appears in the schedule for the first time. This is the same pneumococcal vaccine that now is used universally in young children. At present, the CDC recommends its use in adults aged 19 to 64 years who are immunocompromised, asplenic or who have end-stage renal disease (including hemodialysis, cerebrospinal fluid leaks and cochlear implants). Such patients should receive both the conjugate and the polysaccharide vaccines. A footnote provides guidance as to sequence and intervals. I’ve already been asked several times about other adults. Because ACIP has not yet promulgated recommendations for the use of conjugate vaccine in that larger group, my advice is to stay tuned and, in the meantime, continue to use that old standby, pneumococcal polysaccharide vaccine, as we have been doing all along — check it out in the schedule.

The other noteworthy change has to do with the tetanus-diphtheria-acellular pertussis vaccine. Motivated by the steadily increasing problem of pertussis around the country, as well as accumulating safety and immunogenicity data, the schedule now expands routine Tdap vaccination to include adults aged 65 years and older. It also makes more explicit the recommendation to vaccinate pregnant women during each pregnancy, preferably during the third trimester, to enhance the transfer of antibodies through the placenta so that the newborn infant will have a measure of protection during its first vulnerable months of life.

A personal note here: It is my distinct impression that most internists and family physicians have not yet realized that essentially every adult in their practice is eligible to receive Tdap. It is the pertussis component that is driving the recommendation. Pertussis is resurgent. Our best means of curtailing its further spread is to have a very immune population. Check out the schedule: A one-time dose of Tdap is indicated for all adults.

A few other observations:

Hepatitis B vaccine is a greatly underused vaccine. Last year, for the first time, hepatitis B vaccine was recommended for all adults up to age 59 years with diabetes (and, with physician’s discretion, also in older adults with diabetes). This recommendation is, in my experience, still largely unknown among those with diabetes and those who provide them medical care. Well, now you know. And, while I’m at it, hepatitis B vaccine has long been indicated for all adults “who are not in a long-term mutually monogamous relationship.” This is an indication that is honored more in the breech than the observance. There is plenty of room for improved provision of this simple, important preventive service.
The shortage of zoster vaccine has abated. It is indicated for all adults aged 60 years and older. Yes, I know that for patients aged 65 years and older, it is not easy to wrestle with Medicare, Part D to provide this vaccine. Here at Vanderbilt, we write our patients a prescription and they take it to our pharmacy where the vaccine is administered. Let’s work on getting the Medicare rule changed, so we can give the vaccine efficiently in our offices; in the meantime, let’s get our patients protected.
Lastly, have a look in the mirror. We health care providers need to set an example. Are we and our families up-to-date in our vaccinations? Recall that in addition to our personal health, vaccination of health care workers is a patient safety issue.

So, roll up those sleeves — your own and those of your patients! Let the adult immunization schedule be your guide to improved adult vaccination in your practice.