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ID expert offers overview of adult immunizations for the internist

BOSTON ─ At a session on immunizations for adults presented here at the ACP Internal Medicine Meeting, William Schaffner, MD,  MACP, professor of preventive medicine and infectious diseases at Vanderbilt University School of Medicine in Nashville, urged physicians to be advocates for immunization and to not just recommend vaccines, but to give them.

In particular, Schaffner focused on currently recommended vaccines for adults, including influenza, Tdap and zoster.

Influenza

“When it comes to influenza vaccine, it used to be easy,” Schaffner said. “It was like Henry Ford and his model T: you could have any color you like as long as it’s black; there was only one influenza vaccine. But, oh dear, now we have a choice, and as that German proverb says, ‘the person who has a choice has difficulty.’”

According to Schaffner, it is recommended that everyone receive vaccination against influenza. Among patients aged 65 years and older, the high-dose trivalent vaccine is recommended, as it has been shown to provide 24% more protection in this population vs. the conventional trivalent vaccine. Because the risk for complications due to influenza are particularly high for pregnant women, similar to those seen among people age 65 years and older, it is recommended they are immunized during flu season. Another reason to vaccinate pregnant women against influenza: Antibodies pass the placenta and provide protection to infants for the first 6 months of life, before they can be vaccinated themselves.

Various formulations of the flu vaccine are available, including inactivated, injected trivalent and quadrivalent vaccines; cell culture and recombinant vaccines for patients with egg allergy; an inactivated, intradermal vaccine for those with a fear of needles; and a live attenuated nasal spray.

Tdap

In the last 10 years, the U.S. has seen an increase in pertussis cases, a disease that is most problematic among middle and high school students, young adults and infants. Most recently, experts have discovered the immune response associated with the tetanus/diphtheria/pertussis (Tdap) vaccine is waning, leading to vaccine skepticism, Schaffner said.

In adults, Tdap is recommended in a single dose to replace one dose of Td for all adults. It is especially important to vaccinate adults who come in close contact with infants, as well as pregnant women and health care workers, Schaffner noted. 

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Zoster

The lifetime risk for zoster, which is reactivated varicella (chicken pox), is about 33% and increases with age; by age 85 years, the risk is 50%, according to Schaffner. The most common complication of zoster is post-herpetic neuralgia, which can range from mild to excruciating and occurs in about one-third of patients with shingles.

Immunization against herpes zoster is recommended among all adults aged 60 years and older, unless they are notably immunocompromised by disease or treatment, Schaffner said. Among patients who have already had shingles, it is recommended — based on expert opinion vs. strong data — they are immunized after 1 year.

The vaccine is licensed by the FDA for use in adults beginning at age 50 years. However, according to the CDC Advisory Committee on Immunization Practices (ACIP), immunization lasts for 7 to 10 years, after which time the data regarding reimmunization are scarce and not very promising, Schaffner said.

Pneumococcal vaccines

The well-known pneumococcal polysaccharide vaccine (PPSV23) protects against 23 pneumococcal types. However, a pneumococcal conjugate vaccine that protects against 13 pneumococcal types (PCV13) was recently licensed for adults aged older than 60 years, leaving clinicians with questions on how to use each vaccine.

According to Schaffner, PCV13 is being universally used in children, with profound effects against invasive bacteremic pneumococcal disease in this population. An added, unanticipated bonus: The vaccine prevents pneumococcal carriage. That is, children who are vaccinated with PCV13 cannot infect adults they have contact with, further preventing invasive disease among adults.

“There’s been a profound indirect effect: You immunize the kids and you protect the whole population,” Schaffner said.

Nonetheless, according to data there are about 5,000 cases of potentially preventable community-acquired pneumonia possible among adults aged 65 years and older over the next several years, he said.

“So, despite this profound indirect effect there still is ongoing pneumococcal disease in people due to these serotypes.”

Results of a large trial from the Netherlands called CAPITA, demonstrate that the incidence of community-acquired pneumonia decreased by 45% when adults aged older than 65 years were immunized with the conjugate vaccine. In addition, there was a 75% reduction in invasive disease.

As of August 2014, the ACIP recommends adults aged 65 years and older with no prior immunization history receive PCV13 followed by PPSV23 approximately 1 year later. Schaffner noted Medicare will pay for both vaccines if 11 months have passed between the two immunizations. Among those already vaccinated with PPSV23, immunization with PCV13 should follow if 1 year or more has passed.

Hepatitis B, HPV, meningitis

Additional immunizations for adults include the hepatitis B, human papillomavirus (HPV) and meningococcal vaccines.

Hepatitis B is recommended among all patients who are not in long-term, monogamous relationships, as well as those with diabetes aged 60 years and younger. Among patients with diabetes aged older than 60 years, the ACIP recommends considering vaccination.

Regarding HPV, Schaffner advised clinicians to be on the lookout for recommendations regarding a new 9-valent HPV vaccine that is expected to come on the market soon.

Lastly, all adolescents should be immunized with the meningococcal conjugate vaccine (MCV4) and all college students with the meningococcal B vaccine.

“The adult immunization schedule is published annually in the Annals of Internal Medicine, and it’s also available online at the CDC website,” Schaffner said. “Get comfortable using it; it will help you indicate and determine which vaccines are indicated for your patients coming in, so I recommend you have a look at that. [I] urge you to be an immunization advocate; review the patient’s immunization history frequently, and don’t recommend vaccines, give them.” – by Stacey L. Adams

Reference:

Schaffner W. Clinical triad: Immunizations for adults, travelers and health care workers. Presented at: ACP Internal Medicine Meeting; April 30-May 2, 2015; Boston.

Disclosure:

Schaffner reports he is a member of the Data Safety Monitoring Board for Experimental Vaccines at Merck.