Update on Adult Immunizations
July 10, 2012
by Robert M. Wolfe, MD
Journal of the American Board of Family Medicine
The past few years have seen numerous additions and modifications to the current immunization schedules. Starting with the 2010 to 2011 influenza season, the Centers for Disease Control and Prevention have recommended universal annual influenza vaccination for all persons without a contraindication who are 6 months of age and older, including healthy persons aged 19 to 49 years. Hepatitis B vaccination is now recommended for all susceptible diabetics ≤60 years of age. One dose of tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine, adsorbed, is recommended to replace one tetanus and diphtheria toxoids adsorbed (adult) vaccination for all adults, including those 65 years of age or older, who are anticipating contact with infants and unvaccinated pregnant women (preferably during the second or third trimester). All adult vaccines remain underused. This article will summarize the most recent changes in the adult immunization recommendations of the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention.
Rates of vaccination of adults have consistently fallen behind vaccination rates for children and adolescents. The Centers for Disease Control and Prevention (CDC) analyzed data from the 2010 National Health Interview Survey to assess adult vaccination rates and found them to be low for most routinely recommended vaccines. Rates of the 3 vaccines included in Healthy People (HP) 2020—pneumococcal, herpes zoster, and hepatitis B (for health care personnel [HCP])—were well below the respective target levels: for pneumococcal vaccine, rates in 2010 were 59.7% for persons aged >65 years (HP2020 target of 90%) and 18.5% for persons at high risk aged 18 to 64 years (HP2020 target, 60%); for herpes zoster vaccine, rates were 14.4% for persons aged ≥60 years (HP2020 target, 30%); and for the hepatitis vaccine for HCP, the rates were 63.2% (HP2020 target, 90%). For adults for whom tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine, adsorbed (Tdap) status could be assessed, coverage was only 8.2%; for HCP Tdap coverage was 20.3%.1
The CDC estimated that 40,000 to 50,000 vaccine-preventable deaths occur every year in the United States and estimates the health care burden of vaccine-preventable diseases at $10 billion.2 Family physicians are specialists in preventive care and can be leaders in seeing that adult patients get the full benefit of protection against vaccine-preventable diseases. This article summarizes the most significant recent changes in the US adult immunization schedule.
Universal Influenza Immunization
Since the 2010 to 2011 flu season, the CDC has recommended that all persons should be immunized annually against influenza, starting from the age of 6 months, which is the youngest age for which any influenza vaccine is approved. The 2011 to 2012 US seasonal influenza vaccine virus strains are identical to those contained in the 2010 to 2011 vaccine and includes the 2009 pandemic influenza A (H1N1) vaccine virus strain.3
Available Influenza Vaccines
There are 2 types of influenza vaccine available for administration to adults: the trivalent inactivated influenza vaccine (TIV) and the live attenuated influenza vaccine (LAIV). LAIV is administered intranasally and contains the same influenza viruses as TIV. The live viruses in LAIV are temperature sensitive and do not replicate effectively at the human core body temperature; thus, they cannot produce disease. However, the LAIV viruses are adapted to cold, which enables them to replicate in the slightly cooler temperature of the nasopharyngeal mucosa and produce immunity. A recent meta-analysis comparing TIV with LAIV concluded that LAIV seems to be slightly more effective than TIV in children.4 Studies comparing TIV with LAIV in adults have shown conflicting results.5,6 The CDC has stated that both TIV and LAIV have been demonstrated to be effective in children and adults and that there is insufficient data directly comparing the effectiveness of these 2 types of influenza vaccines to identify whether one vaccine might offer a clear advantage over the other in a particular population.3 LAIV is not approved for adults ≥50 years of age and may not be given to pregnant women or persons who are immunocompromised, which includes those with chronic pulmonary (including asthma), cardiovascular (except hypertension), renal, hepatic, neurological/neuromuscular, hematologic, or metabolic (including diabetes) disorders or with immunosuppression (including that caused by medications or HIV).
A new influenza vaccine, trivalent influenza vaccine intradermal (TIVI) (Fluzone Intradermal, Sanofi Pasteur, Swiftwater, PA), was licensed in May 2011. This vaccine is indicated for persons aged 18 through 64 years and is administered intradermally via a single-dose, prefilled microinjection syringe. TIVI contains 9 μg of each flu strain in 0.1 mL total volume versus intramuscular TIV preparations, which contain 15 μg of each strain in 0.5 mL total volume. The preferred site for administration is over the deltoid muscle. The most common adverse reactions are local: erythema, induration, swelling, pain, and pruritus. With the exception of pain, these reactions occurred more frequently than with the intramuscular vaccine but generally resolved within 3 to 7 days.7 The CDC has not indicated a preference for this vaccine over other influenza vaccines.3
Trivalent influenza vaccine high dose (TIVHD; Fluzone High-Dose, Sanofi Pasteur), available since the 2010 to 2011influenza season, contains 60 μg of hemagglutinin per vaccine strain (rather than 15 μg per strain as in other TIV preparations). TIVHD is available as an alternative TIV for persons aged ≥65 years. The rationale for the higher antigen dose is to stimulate a better antibody response in the elderly, who have a weaker response to influenza vaccines because of immunosenescence. The CDC has indicated no preferential recommendation for this vaccine over other influenza vaccines indicated for use in the elderly.3
A web page listing influenza vaccines available in the United States for the current influenza season and their age indications is available athttp://www.immunize.org/catg.d/p4072.pdf (Acquired from Immunization Action Coalition on April 22, 2012); the link is updated continuously to match current recommendations and availability.
Trust for America's Health: Infectious Diseases Society of America, Robert Wood Johnson Foundation, Trust for America's Health. Adult immunization: shots to save lives. Washington, DC: Trust for America's Health, the Infectious Diseases Society of America, and the Robert Wood Johnson Foundation; 2010. Available from: http://healthyamericans.org/report/73/adult-immunization-2010. Accessed May 22, 2012.