Q-Notes
for Adult Medicine 
| Home | Drugs | Infectious Disease | |
Immunization |
|
| REF:
Immunization Adult 2011
Immunization Organization Website CDC Immunization Website - the Advisory Committee on Immunization Practices (ACIP) Immunization Childhood 2009 | Immunization_childhood2009-2.pdf
|
|
| Recommended Adult Immunization Schedule: United States, 2009. | |
|
|
| 1. Tetanus, diphtheria, and acellular pertussis (Td/Tdap)
vaccination
Tdap (ADACEL®) should replace a single dose of Td for adults age 19 through 64 years who have not received a dose of Tdap previously. Adults with uncertain or incomplete history of primary vaccination series with tetanus and diphtheria toxoid–containing vaccines should begin or complete a primary vaccination series. A primary series for adults is 3 doses of tetanus and diphtheria toxoid–containing vaccines; administer the first 2 doses at least 4 weeks apart and the third dose 6-12 months after the second. However, Tdap can substitute for any one of the doses of Td in the 3-dose primary series. The booster dose of tetanus and diphtheria toxoid–containing vaccine should be administered to adults who have completed a primary series and if the last vaccination was received 10 or more years previously. Tdap or Td vaccine may be used, as indicated. If a woman is pregnant and received the last Td vaccination 10 or more years previously, administer Td during the second or third trimester. If the woman received the last Td vaccination less than 10 years previously, administer Tdap during the immediate postpartum period. A dose of Tdap is recommended for postpartum women, close contacts of infants age less than 12 months, and all health care personnel with direct patient contact if they have not previously received Tdap. An interval as short as 2 years from the last Td is suggested; shorter intervals can be used. Td may be deferred during pregnancy and Tdap substituted in the immediate postpartum period, or Tdap may be administered instead of Td to a pregnant woman after an informed discussion with the woman. Adults Aged >65 Years: Tdap is not licensed for use among adults aged >65 years. The safety and immunogenicity of Tdap among adults aged >65 years were not studied during U.S. pre-licensure trials. Adults aged >65 years should receive a dose of Td every 10 years for protection against tetanus and diphtheria and as indicated for wound management.
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5517a1.htm (MMWR December 15, 2006 / 55(RR17);1-33) On June 10, 2005, a tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine (Tdap) formulated for use in adults and adolescents was licensed in the United States for persons aged 11--64 years (ADACEL®). To reduce pertussis morbidity among adults and maintain the standard of care for tetanus and diphtheria prevention and to reduce the transmission of pertussis to infants and in health-care settings, the Advisory Committee on Immunization Practices (ACIP) recommends that:
Tetanus Prophylaxis in Wound Management ACIP has recommended administering tetanus toxoid-containing vaccine and tetanus immune globulin (TIG) as part of standard wound management to prevent tetanus . Tdap is preferred to Td for adults vaccinated >5 years earlier who require a tetanus toxoid-containing vaccine as part of wound management and who have not previously received Tdap. For adults previously vaccinated with Tdap, Td should be used if a tetanus toxoid-containing vaccine is indicated for wound care. Adults who have completed the 3-dose primary tetanus vaccination series and have received a tetanus toxoid-containing vaccine <5 years earlier are protected against tetanus and do not require a tetanus toxoid-containing vaccine as part of wound management. An attempt must be made to determine whether a patient has completed the 3-dose primary tetanus vaccination series. Persons with unknown or uncertain previous tetanus vaccination histories should be considered to have had no previous tetanus toxoid-containing vaccine. Persons who have not completed the primary series might require tetanus toxoid and passive vaccination with TIG at the time of wound management. When both TIG and a tetanus toxoid-containing vaccine are indicated, each product should be administered using a separate syringe at different anatomic sites. Adults with a history of Arthus reaction following a previous dose of a tetanus toxoid-containing vaccine should not receive a tetanus toxoid-containing vaccine until >10 years after the most recent dose, even if they have a wound that is neither clean nor minor. If the Arthus reaction was associated with a vaccine that contained diphtheria toxoid without tetanus toxoid (e.g., MCV4), deferring Tdap or Td might leave the adult inadequately protected against tetanus, and TT should be administered (see precautions for management options). In all circumstances, the decision to administer TIG is based on the primary vaccination history for tetanus. Arthus Reactions Arthus reactions (type III hypersensitivity reactions) are rarely reported after vaccination and can occur after tetanus toxoid-containing or diphtheria toxoid-containing vaccines (33,122,125--129; CDC, unpublished data, 2005). An Arthus reaction is a local vasculitis associated with deposition of immune complexes and activation of complement. Immune complexes form in the setting of high local concentration of vaccine antigens and high circulating antibody concentration (122,125,126,130). Arthus reactions are characterized by severe pain, swelling, induration, edema, hemorrhage, and occasionally by local necrosis. These symptoms and signs usually develop 4--12 hours after vaccination; by contrast, anaphylaxis (immediate type I hypersensitivity reactions) usually occur within minutes of vaccination. Arthus reactions usually resolve without sequelae. ACIP has recommended that persons who experienced an Arthus reaction after a dose of tetanus toxoid-containing vaccine not receive Td more frequently than every 10 years, even for tetanus prophylaxis as part of wound management
Adults with History of Incomplete or Unknown Tetanus, Diphtheria, or Pertussis Vaccination Adults who have never been vaccinated against tetanus, diphtheria, or pertussis (no dose of pediatric DTP/DTaP/DT or Td) should receive a series of three vaccinations containing tetanus and diphtheria toxoids. The preferred schedule is a single dose of Tdap, followed by a dose of Td >4 weeks after Tdap and another dose of Td 6--12 months later. However, Tdap can substitute for any one of the doses of Td in the 3-dose primary series. Alternatively, in situations in which the adult probably received vaccination against tetanus and diphtheria but cannot produce a record, vaccine providers may consider serologic testing for antibodies to tetanus and diphtheria toxin to avoid unnecessary vaccination. If tetanus and diphtheria antitoxin levels are each >0.1 IU/mL, previous vaccination with tetanus and diphtheria toxoid vaccine is presumed, and a single dose of Tdap is indicated. Adults who received other incomplete vaccination series against tetanus and diphtheria should be vaccinated with Tdap and/or Td to complete a 3-dose primary series of tetanus and diphtheria toxoid-containing vaccines. A single dose of Tdap can be used in the series.
|
|
| 2. Human
papillomavirus (HPV) vaccination
HPV vaccination is recommended for all females age 11 through 26 years (and may begin at age 9 years) who have not completed the vaccine series. History of genital warts, abnormal Papanicolaou test result, or positive HPV DNA test result is not evidence of prior infection with all vaccine HPV types; HPV vaccination is recommended for persons with such histories. Ideally, vaccine should be administered before potential exposure to HPV through sexual activity; however, females who are sexually active should still be vaccinated consistent with age-based recommendations. Sexually active females who have not been infected with any of the 4 HPV vaccine types receive the full benefit of the vaccination. Vaccination is less beneficial for females who have already been infected with 1 or more of the HPV vaccine types. A complete series consists of 3 doses. The second dose should be administered 2 months after the first dose; the third dose should be administered 6 months after the first dose. HPV vaccination is not specifically recommended for females with the medical indications described in the Figure (bottom). Because it is not a live-virus vaccine, it can be administered to persons with the medical indications noted. However, the immune response and vaccine efficacy might be less for persons with the noted medical indications than in persons who do not have the medical indications described or who are immunocompetent. Health care personnel are not at increased risk because of occupational exposure and should be vaccinated consistent with age-based recommendations.
|
|
| 3. Varicella vaccination
All adults without evidence of immunity to varicella should receive 2 doses of single-antigen varicella vaccine if not previously vaccinated or the second dose if they have received only 1 dose, unless they have a medical contraindication. Special consideration should be given to those who 1) have close contact with persons at high risk for severe disease (e.g., health care personnel and family contacts of persons with immunocompromising conditions) or 2) are at high risk for exposure or transmission (e.g., teachers; child care employees; residents and staff members of institutional settings, including correctional institutions; college students; military personnel; adolescents and adults living in households with children; nonpregnant women of childbearing age; and international travelers). Evidence of immunity to varicella in adults includes any of the following: 1) documentation of 2 doses of varicella vaccine at least 4 weeks apart; 2) U.S.-born before 1980 (although for health care personnel and pregnant women, birth before 1980 should not be considered evidence of immunity); 3) history of varicella based on diagnosis or verification of varicella by a health care provider (for a patient reporting a history of or presenting with an atypical case, a mild case, or both, health care providers should seek either an epidemiologic link to a typical varicella case or to a laboratory-confirmed case or evidence of laboratory confirmation, if it was performed at the time of acute disease); 4) history of herpes zoster based on health care provider diagnosis or verification of herpes zoster by a health care provider; or 5) laboratory evidence of immunity or laboratory confirmation of disease. Pregnant women should be assessed for evidence of varicella immunity. Women who do not have evidence of immunity should receive the first dose of varicella vaccine upon completion or termination of pregnancy and before discharge from the health care facility. The second dose should be administered 4–8 weeks after the first dose.
|
|
| 4. Herpes
zoster vaccination
A single dose of zoster vaccine is recommended for adults age 60 years and older regardless of whether they report a prior episode of herpes zoster. Persons with chronic medical conditions may be vaccinated unless their condition constitutes a contraindication. * ACP Internist News 4-2009 Dr. Poland was also convincing on the merits of the zoster vaccine, which reduces incidence of the disease by half and post-herpetic neuralgia—the very common, very unpleasant complication—by two-thirds. “It’s not a home run in terms of protection, but significantly helpful in reducing the burden of zoster,” he noted. The vaccine is currently recommended for patients 60 and older who are otherwise healthy, regardless of their history of shingles. If patients have had shingles, the expert consensus is to wait at least 12 months before vaccinating, Dr. Poland said.
|
|
| 5. Measles, mumps, rubella (MMR) vaccination
Measles component: Adults born before 1957 generally are considered immune to measles. Adults born during or after 1957 should receive 1 or more doses of MMR unless they have a medical contraindication, documentation of 1 or more doses, history of measles based on health care provider diagnosis, or laboratory evidence of immunity. A second dose of MMR 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. Mumps component: Adults born before 1957 generally are considered immune to mumps. Adults born during or after 1957 should receive 1 dose of MMR unless they have a medical contraindication, history of mumps based on health care provider diagnosis, or laboratory evidence of immunity. A second dose of MMR 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. For unvaccinated health care personnel born before 1957 who do not have other evidence of mumps immunity, administering 1 dose on a routine basis should be considered and administering a second dose during an outbreak should also be strongly considered. Rubella component: 1 dose of MMR vaccine is recommended for women whose rubella vaccination history is unreliable or who lack laboratory evidence of immunity. For women of childbearing age, regardless of birth year, rubella immunity should be determined and women should be counseled regarding congenital rubella syndrome. Women who do not have evidence of immunity should receive MMR vaccine upon completion or termination of pregnancy and before discharge from the health care facility.
|
|
| 6. Influenza
vaccination
Medical indications: Chronic disorders of the cardiovascular or pulmonary systems, including asthma; chronic metabolic diseases, including diabetes mellitus, renal or hepatic dysfunction, hemoglobinopathies, or immunocompromising conditions (including immunocompromising conditions caused by medications or HIV); any condition that compromises respiratory function or the handling of respiratory secretions or that can increase the risk of aspiration (e.g., cognitive dysfunction, spinal cord injury, or seizure disorder or other neuromuscular disorder); and pregnancy during the influenza season. No data exist on the risk for severe or complicated influenza disease among persons with asplenia; however, influenza is a risk factor for secondary bacterial infections that can cause severe disease among persons with asplenia. Occupational indications: All health care personnel, including those employed by long-term care and assisted-living facilities, and caregivers of children younger than 5 years. Other indications: Residents of nursing homes and other long-term care and assisted-living facilities; persons likely to transmit influenza to persons at high risk (e.g., in-home household contacts and caregivers of children younger than 5 years, persons 65 years and older, and persons of all ages with high-risk condition[s]); and anyone who would like to decrease their risk of getting influenza. Healthy, nonpregnant adults younger than 50 years without high-risk medical conditions who are not contacts of severely immunocompromised persons in special care units can receive either intranasally administered live, attenuated influenza vaccine (FluMist) or inactivated vaccine. Other persons should receive the inactivated vaccine.
|
|
| 7. Pneumococcal polysaccharide (PPSV) vaccination
Medical indications: Chronic lung disease (including asthma); chronic cardiovascular diseases; diabetes mellitus; chronic liver diseases, cirrhosis; chronic alcoholism, chronic renal failure, or nephrotic syndrome; functional or anatomic asplenia (e.g., sickle cell disease or splenectomy [if elective splenectomy is planned, vaccinate at least 2 weeks before surgery]); immunocompromising conditions; and cochlear implants and cerebrospinal fluid leaks. Vaccinate as close to HIV diagnosis as possible. Other indications: Residents of nursing homes or other long-term care facilities and persons who smoke cigarettes. Routine use of PPSV is not recommended for Alaska Native or American Indian persons younger than 65 years unless they have underlying medical conditions that are PPSV indications. However, public health authorities may consider recommending PPSV for Alaska Natives and American Indians 50 through 64 years of age who are living in areas in which the risk of invasive pneumococcal disease is increased.
|
|
| 8.
Revaccination with Pneumococcal polysaccharide (PPSV) vaccination
One-time revaccination after 5 years for persons with chronic renal failure or nephrotic syndrome, functional or anatomic asplenia (e.g., sickle cell disease or splenectomy), and persons with immunocompromising conditions. For persons age 65 years or older, 1-time revaccination if they were vaccinated 5 or more years previously and were younger than 65 years at the time of primary vaccination.
* ACP Internist News 4-2009: Administering the vaccine every five years,
as some providers mistakenly do, may actually be harmful. There is no evidence
support for any boosters, except among a few patient groups (those who are
immunocompromised, have organ transplants, or got the vaccine before age
65) who should get a second dose.
|
|
| 9. Hepatitis A vaccination See
Hepatitis A
Medical indications: Persons with chronic liver disease and persons who receive clotting factor concentrates. Behavioral indications: Men who have sex with men and persons who use illegal drugs. Occupational indications: Persons working with hepatitis A virus (HAV)–infected primates or with HAV in a research laboratory setting. Other indications: Persons traveling to or working in countries that have high or intermediate endemicity of hepatitis A (a list of countries is available at http://wwwn.cdc.gov/travel/contentdiseases.aspx) and any person seeking protection from HAV infection. Single-antigen vaccine formulations should be administered in a 2-dose schedule at either 0 and 6–12 months (Havrix) or 0 and 6–18 months (Vaqta). If the combined hepatitis A and hepatitis B vaccine (Twinrix) is used, administer 3 doses at 0, 1, and 6 months; alternatively, a 4-dose schedule, administered on days 0, 7, and 21 to 30 followed by a booster dose at month 12 may be used.
|
|
| 10. Hepatitis
B vaccination See
Hepatitis B
Medical indications: Persons with end-stage renal disease, including patients receiving hemodialysis; persons with HIV infection; and persons with chronic liver disease. Occupational indications: Health care personnel and public-safety workers who are exposed to blood or other potentially infectious body fluids. Behavioral indications: Sexually active persons who are not in a long-term, mutually monogamous relationship (e.g., persons with more than 1 sex partner during the previous 6 months); persons seeking evaluation or treatment for a sexually transmitted disease (STD); current or recent injection-drug users; and men who have sex with men. Other indications: Household contacts and sex partners of persons with chronic hepatitis B virus (HBV) infection; clients and staff members of institutions for persons with developmental disabilities; international travelers to countries with high or intermediate prevalence of chronic HBV infection (a list of countries is available at http://wwwn.cdc.gov/travel/contentdiseases.aspx); and any adult seeking protection from HBV infection. Hepatitis B vaccination is recommended for all adults in the following settings: STD treatment facilities, HIV testing and treatment facilities, facilities providing drug-abuse treatment and prevention services, health care settings targeting services to injection-drug users or men who have sex with men, correctional facilities, end-stage renal disease programs and facilities for chronic hemodialysis patients, and institutions and nonresidential day care facilities for persons with developmental disabilities. If the combined hepatitis A and hepatitis B vaccine (Twinrix) is used, administer 3 doses at 0, 1, and 6 months; alternatively, a 4-dose schedule, administered on days 0, 7, and 21 to 30 followed by a booster dose at month 12 may be used. Special formulation indications: For adult patients receiving hemodialysis or with other immunocompromising conditions, 1 dose of 40 µg/mL (Recombivax HB) administered on a 3-dose schedule or 2 doses of 20 µg/mL (Engerix-B) administered simultaneously on a 4-dose schedule at 0, 1, 2, and 6 months.
|
|
| 11. Meningococcal vaccination
Medical indications: Adults with anatomic or functional asplenia or terminal complement component deficiencies. Other indications: First-year college students living in dormitories; microbiologists who are routinely exposed to isolates of Neisseria meningitidis; military recruits; and persons who travel to or live in countries in which meningococcal disease is hyperendemic or epidemic (e.g., the "meningitis belt" of sub-Saharan Africa during the dry season [December–June]), particularly if their contact with local populations will be prolonged. Vaccination is required by the government of Saudi Arabia for all travelers to Mecca during the annual Hajj. Meningococcal conjugate vaccine (MCV) is preferred for adults with any of the preceding indications who are age 55 years or younger, although meningococcal polysaccharide vaccine (MPSV) is an acceptable alternative. Revaccination with MCV after 5 years might be indicated for adults previously vaccinated with MPSV who remain at increased risk for infection (e.g., persons residing in areas in which disease is epidemic).
|
|
| 12. Selected conditions
for which Haemophilus influenzaetype b (Hib) vaccine may be used
Hib vaccine generally is not recommended for persons 5 years and older. No efficacy data are available on which to base a recommendation concerning use of Hib vaccine for older children and adults. However, studies suggest good immunogenicity in patients who have sickle cell disease, leukemia, or HIV infection or who have had a splenectomy; administering 1 dose of vaccine to these patients is not contraindicated.
|
|
| 13. Immunocompromising conditions
Inactivated vaccines generally are acceptable (e.g., pneumococcal, meningococcal, and influenza [trivalent inactivated influenza vaccine]), and live vaccines generally are avoided in persons with immune deficiencies or immunocompromising conditions. Information on specific conditions is available at http://www.cdc.gov/vaccines/pubs/acip-list.htm.
|
|
| Contents | Drugs | Med News & Journals | Guidelines & Textbooks | Diff-Dx | Resource | | |
2011