Immunization Update - A Focus on Medical Indications

Transcription

1 Chapman University From the SelectedWorks of Jeff Goad Summer September, 2017 Immunization Update - A Focus on Medical Indications Jeff Goad, Chapman University Jelena Lewis, Chapman University Available at:

2 The Improving Consultant patient care through drug education September 2017 Volume XXVI Number 8 Immunization Update A Focus on Medical Indications for Vaccines in Adults Jelena Lewis, PharmD and Jeff Goad PharmD, MPH 2 Hours CE Introduction The Healthy People 2020 report, published by the US Department of Health and Human Services, includes targets for reducing vaccine-preventable disease rates and increasing vaccination rates in all age groups. 1 According to the report, for each birth cohort (group of individuals born in the same year), immunization with the routine childhood vaccination schedule prevents 14 million cases of disease and reduces direct healthcare costs by $9.9 billion. 1 Vaccines are one of the most cost-effective clinical preventive services; however, thousands of people in the US do not receive them and suffer even die from vaccine preventable diseases. From 2010 through 2014, flu-related deaths in the US ranged from 12,000 to 56,000 per year. Pneumococcal pneumonia leads to about 19,000 deaths every year, and as many as 1.4 million people currently suffer from Hepatitis B, with liver cancer as a potential complication. 2 There have been a number of recent measles 3 and pertussis outbreaks in communities with pockets of unvaccinated and under-vaccinated children. 4 In order to meet the Healthy People 2020 targets, all healthcare providers should stay up-to-date on vaccine recommendations and play an active role in immunizations. The Centers for Disease Control and Prevention (CDC) and its Advisory Committee on Immunization Practices (ACIP) update their recommendations for routine immunizations annually, while vaccine-specific recommendations are typically updated every 3-5 years (except influenza, which is updated yearly). 5-8 Additionally, the CDC publishes the General Recommendations on Immunization and the Epidemiology and Prevention of Vaccine-Preventable Diseases (known as The About The Authors Jelena Lewis, PharmD is an Assistant Professor of Pharmacy Practice at Chapman University School of Pharmacy. She is also a faculty-in-residence at St. Jude Heritage Medical Group where she provides chronic disease state management. Jeff Goad, PharmD, MPH is Professor and Chair of the Department of Pharmacy Practice, Chapman University School of Pharmacy. He is a national faculty and advisory board member for the APhA Pharmacy Based Immunization Training Program and chair of the APhA Travel Medicine Advanced Competency Training Course. The Bottom Line Healthcare providers must be able to screen and vaccinate patients based on both routine recommendations and medical indications. Key resources include: -The - CDC's Advisory Committee on Immunization Practices, which publishes an annual adult immunization schedule with recommendations based on age, medical history, and other considerations. -The - Healthy People 2020 report, which includes targets for vaccine-preventable disease rates and increasing vaccination rates in all age groups. Specific medical conditions may: 1) contraindicate the use of a vaccine due to an increased risk for adverse events, and/or 2) confer an increased risk or severity of disease from vaccinepreventable illnesses. Considerations when recommending vaccines for adults include: conditions that reduce immunocompetence (including HIV infection and asplenia), chronic medical conditions (including diabetes, cardiovascular disease, and chronic lung, liver, and kidney disease), and special populations (including pregnant women and men who have sex with men). Vaccine components implicated in allergic reactions include egg protein, latex, gelatin, and neomycin. A severe allergic reaction (eg, anaphylaxis) after a vaccine dose or to a vaccine component is a contraindication for that vaccine. Persons with a history of egg allergy who experience only hives after exposure can receive recommended (ie, inactivated or recombinant), age-appropriate influenza vaccine without specific precautions. Disclosure: Dr. Lewis reports no financial relationship with the manufacturer(s) or provider(s) of any commercial product(s) or service(s) that appear in this issue. Dr. Goad reports being on the speakers bureau for Merck & Co., Inc. 1

3 Continuing Education Objectives ACPE# H06-P CA BRN# Discuss vaccine-specific indications and contraindications for patients with altered immunocompetence (including HIV infection and asplenia). 2. Discuss vaccine-specific indications and contraindications for patients with diabetes, cardiovascular disease, and chronic lung, liver, or kidney disease. 3. Describe vaccine-specific recommendations for pregnant women, men who have sex with men, and for patients with egg allergy. Pink Book ), which are considered core references for vaccine providers. 8,9 The updated ACIP-recommended immunization schedule for adults, including a summary of changes from the 2016 schedule, was published in the Annals of Internal Medicine in February 2017, 6 and is also available online at adult.html. 10 The schedules for children and adolescents are available online at mm6605e1.htm. 5 It should be noted that the ACIP recommends annual influenza vaccination for all adults regardless of medical history, using an age-appropriate inactivated or recombinant vaccine. 6,10 Live attenuated influenza vaccine (LAIV) is no longer recommended. Although LAIV was still available during the flu season, it will likely not be available in Beyond age-based recommendations, the CDC publishes recommended vaccinations for adults based on medical conditions, lifestyle, occupation, and travel. This review will focus on specific recommendations and considerations for adults 19 years of age and older who have altered immunocompetence, common chronic medical conditions, and certain health concerns. Selected vaccines are listed in Table 1, and vaccination recommendations for adults with certain conditions are shown in Table 2. A table listing routine, age-based ACIP-recommended vaccinations for adults is included in the Appendix on page 12. Further information can be found in various CDC/ACIP sources Altered Immunocompetence In 2017, the CDC's General Best Practices Guidelines for Immunization incorporated the Infectious Diseases Society of America's 2013 Clinical Practice Guidelines for Vaccination of the Immunocompromised Host. Altered immunocompetence (ie, immunosuppression or an immunocompromising condition) is categorized as either a primary or secondary immunodeficiency. Primary immunodeficiencies include inherited conditions, such as X-linked agammaglobulinemia, severe combined immunodeficiency disease, and chronic granulomatous disease. Secondary immunodeficiencies include acquired conditions such as HIV infection, hematopoietic malignancies, treatment with radiation, and treatment with immunosuppressive agents (eg, alkylating agents or antimetabolites). Other conditions associated with secondary immunodeficiency include asplenia, chronic kidney disease, and treatment with monoclonal antibodies or high-dose systemic corticosteroids (the equivalent of prednisone 20 mg or more per day, or 2 mg/kg or more per day, for 14 days or longer). 8,9 It is important to identify a patient's immunocompetence status before the administration of vaccinations in order to protect the patient from (1) an increased risk of adverse events following vaccination and/or (2) the increased chance of an inadequate immune response. In immunocompetent individuals, antigens introduced by vaccinations are quickly cleared by the immune system and stimulate immune responses to create memory B and T cells specific to individual pathogens. Persons with compromised immunocompetence may be unable to launch an appropriate immune response. Live vaccines may cause severe adverse reactions in immunocompromised people due to uncontrolled replication of the vaccine bacteria or viruses. Thus, live vaccines should not be routinely given to people with most types of altered immunocompetence. People with asplenia and certain other immunocompromising conditions (eg, HIV infection with CD4+ count 200 cells/μl or chronic kidney disease) are exceptions and can be given live vaccines, unless they are receiving immunosuppressive therapy. 9 Because of an increased risk for complications from vaccine-preventable disease, immunosuppressed persons should receive certain inactivated vaccines, even though the altered immune system may not mount an adequate immune response. 8,9 Pneumococcal vaccines, both the 13-valent conjugate vaccine (PCV13) and 23-valent polysaccharide vaccine (PPSV23), are recommended for all immunocompromised and asplenic persons 19 years of age and older. Rates of invasive pneumococcal disease (IPD) in persons with certain immunocompromising conditions can be 20 times the rate among people without those conditions. According to the CDC, 50% of the IPD cases among immunocompromised adults in 2010 were caused by serotypes found in PCV 13, and an additional 21% were caused by serotypes found in PPSV When both PCV13 and PPSV23 are indicated, PCV13 should be given first. Individuals who have not previously received PCV13 or PPSV23 at the time altered The Rx Consultant (ISSN ) is published monthly except August for $127 per year by CEN, Inc. PO Box 1516, Martinez, CA Periodicals Postage Paid at Martinez, CA and additional mailing offices. POSTMASTER: Send address changes to THE RX CONSULTANT, P.O. Box 1516, Martinez, CA

4 Table 1. Selected Routine Vaccinations 6,7,13 Vaccine Hepatitis A Havrix TM, Vaqta Brand Names Hepatitis B Recombivax HB, Engerix-B Hepatitis A and B Twinrix Haemophilus influenzae type b (Hib) Human Papillomavirus, 9-valent (9vHPV) Influenza vaccine, inactivated (IIV) Influenza vaccine, inactivated, cell culture-based Influenza vaccine, inactivated, adjuvanted (aiiv) Influenza vaccine, recombinant (RIV) Meningococcal group B vaccine Meningococcal quadrivalent conjugate vaccine (MCV4) Measles, mumps, rubella (MMR) - live vaccine Pneumococcal conjugate vaccine, 13-valent (PCV13) Pneumococcal polysaccharide vaccine, 23-valent (PPSV23) Tetanus, diphtheria, + acellular pertussis ActHIB, Hiberix Gardasil 9 Trivalent (IIV3): Afluria, Fluvirin, Fluzone High-Dose Quadrivalent (IIV4): Afluria, Fluarix, FluLaval, Fluzone, Fluzone Intradermal Trivalent (RIV3) and Quadrivalent (RIV4): Flublok MenACWY-D (Menactra ); MenACWY-CRM (Menveo ) M-M-R II Prevnar 13 Varicella - live vaccine Varivax Zoster - live vaccine Zostavax Quadrivalent (cciiv4): Flucelvax Trivalent (aiiv3): Fluad MenB-FHbp (Trumenba ), MenB-4C (Bexsero ) Pneumovax 23 Td: Tenivac Tdap: Adacel, Boostrix immunocompetence is identified should get a single dose of PCV13 followed by a dose of PPSV23 at least 8 weeks later. An additional dose of PPSV23 is recommended 5 years after the first PPSV23 dose in immunocompromised persons aged years, and again at age 65 or older, if at least 5 years have passed since the previous dose. 6,10,12 The 3-dose hepatitis B (HB) vaccination series produces a protective antibody response in nearly all healthy adults under 60 years of age. 9 In older adults and immunocompromised individuals, there is a reduced humoral response to HB vaccination. After age 40, approximately 90% of recipients respond to a 3-dose series; by age 60, only 75% of recipients develop protective antibody titers. 9 In immunocompromised persons, post-vaccination testing for serological response is recommended 1-2 months after administration of the final dose of the series. Patients who do not respond to the initial series should get a second 3-dose series. 9 For those who have ongoing risk of exposure (eg, hemodialysis patients), antibody levels should then be monitored annually, and booster doses given when the levels fall below 10 miu/ml. 9 The recommended dosing regimen for adult dialysis patients and other immunocompromised persons is 40 mcg of Recombivax HB (40 mcg/ml) given on a 0, 1, and 6 month schedule, or 40 mcg of Engerix-B (40 mcg/2 ml) given as a single 2 ml dose or 2 one ml doses on a 0, 1, 2, and 6-month schedule. 6,9 There are limited data showing that alternative schedules (eg, doubling the dose or giving additional doses) might improve response rates. 14 HIV Infection In general, immunization recommendations for individuals with other immunocompromising conditions also apply to HIV-infected persons. 8,9 However, there are a few key differences based on CD4+ counts, a laboratory marker that indicates the degree of immunosuppression. 6 For HIV-infected individuals with CD4+ counts below 200 cells/μl or with AIDS or clinical manifestations of HIV infection, the same contraindications to live vaccines apply as for individuals with other immunocompromising conditions. For HIV-infected individuals who are asymptomatic, with a CD4+ count of 200 cells/µl or higher, varicella and MMR vaccines, (but not MMRV 8 ) can be given (if not previously received) to prevent severe complications associated with these diseases. 6,10 Individuals with HIV who are 60 years old or older with a CD4 count >200 cells/μl, can receive the zoster vaccine. 8 Persons with asymptomatic or symptomatic HIV infection should be vaccinated with PCV13, PPSV23, and the hepatitis B series (if not previously received) as soon as possible after their diagnosis. 6,10 The recommended regimens for PCV13 and PPSV23 in persons with asymptomatic or symptomatic HIV infection (including revaccination after 5 years) are the same as for individuals with other immunocompromising conditions. 6,10,12 Chronic infection with hepatitis B is more likely in immunocompromised individuals, including HIV-infected patients. In this population, hepatitis B is linked with an increased risk for liver-related disease and death. The CDC reports that 25% and 15% of individuals who become chronically infected during and after childhood, respectively, die prematurely from cirrhosis or liver cancer. 14 The recommendations discussed above regarding 3

5 post-vaccination testing for serologic response also apply to HIV-infected individuals. 14 HIV infection is an indication for routine vaccination with quadrivalent meningococcal conjugate vaccine. 6,10 The meningococcal pure polysaccharide vaccine is no longer marketed in the US. There are currently 4 meningococcal vaccine formulations for adults: 2 conjugate formulations (MenACWY-D [Menactra ] and MenACWY-CRM [Menveo ]) and 2 serogroup B meningococcal vaccines (MenB- 4C [Bexsero ] and MenB-FHbp [Trumenba ]). HIV-infected adults who have not previously been vaccinated should receive a 2-dose primary series of quadrivalent meningococcal conjugate vaccine (MenACWY) at least 2 months apart, and should be revaccinated every 5 years. 6,10,15 Although the MenACWY is not licensed for patients over age 55, the CDC recommends it for HIV-infected persons 56 years of age or older. 15 Meningococcal disease in HIV infected patients is primarily caused by serogroups C, W and Y, which are in the quadrivalent meningococcal conjugate vaccine. The serogroup B meningococcal vaccine is not routinely recommended for adults with HIV infection. 6,10 Haemophilus influenzae type b (Hib) vaccination is not routinely recommended for HIV-infected adults because their risk for H. influenzae type b infection is low. 6,10 Asplenia Asplenia (either functional or anatomic, including elective splenectomy) is a form of altered immunocompetence linked to an increased risk of sepsis caused by polysaccharide encapsulated bacteria, specifically pneumococci, Haemophilus influenzae, and Neisseria meningitidis. 16 Unlike other conditions causing altered immunocompetence, patients with asplenia can receive live vaccines. 6,8 The recommendations and dosing regimens for PCV13 and PPSV23 (including revaccination after 5 years) are the same for individuals with asplenia as for those with other immunocompromising conditions (discussed above), because of the increased burden of IPD. 6,8,10,12 Two doses of a MenACWY vaccine should be administered at least 2 months apart to all adults with asplenia. Revaccination with the conjugate vaccine every 5 years is also recommended for asplenic adults due to waning vaccine effectiveness. 6,10 Since the pure polysaccharide meningococcal vaccine is no longer available, a conjugate vaccine is recommended. These patients should also receive a serogroup B meningococcal vaccine with either a 2-dose series of MenB-4C at least 1 month apart or a 3-dose series of MenB-FHbp at 0, 1-2, and 6 months. 6,10 While the CDC generally recommends that vaccines be given simultaneously, MenAC- WY-D should be given at least 4 weeks after PCV13 to avoid suboptimal pneumococcal antibody production in people with asplenia. 8 One dose of Hib vaccine should be given to people with asplenia who have not previously received the Hib vaccine series. Additionally, for individuals undergoing elective splenectomy, Hib vaccination is recommended 14 or more days before splenectomy if they have not previously received the Hib vaccine. 6,10 Chronic Medical Conditions Diabetes Diabetes mellitus is a complex, chronic disease that often requires a multifaceted management approach to improve outcomes and prevent hospitalizations. Along with routine vaccinations, specific recommendations from the ACIP and American Diabetes Association (ADA) for patients with diabetes include influenza, PPSV23, and hepatitis B virus vaccines. 6,10,17 Diabetes has been linked to an increased risk of hospitalization for influenza and its complications. 18 It is imperative that patients with diabetes get a flu vaccination every year. People with diabetes may also have an increased risk for pneumococcal bacteremia particularly hospitalacquired bacteremia, for which mortality rates as high as 50% have been reported. 18 Therefore, anyone with diabetes (over 2 years of age) should receive a dose of PPSV At age 65 or older, people with diabetes should receive PCV13, followed by PPSV23 at least 1 year later and at least 5 years after the most recent PPSV23 dose. 6,10,17 Between 1996 and 2011, 29 outbreaks of HB virus (HBV) in long-term care facilities were reported to the CDC. The majority of these outbreaks involved patients with diabetes who received assisted blood glucose monitoring, in which the monitoring was performed by a health care professional with responsibility for multiple patients. 19 In response to these outbreaks, the ACIP now recommends that all people with diabetes who are 19 through 59 years old, and not previously vaccinated, receive the 3-dose hepatitis B (HB) vaccination series as soon as possible after a diagnosis of diabetes is made. 6,10,17 Vaccinating patients age 60 or older is allowed; however, the decision to vaccinate depends on the provider s clinical judgment. 6,10,17 Factors to consider in making this decision include the need for assisted blood glucose monitoring (especially in long term care facilities), the risk of developing a chronic complication if HBV infection were to occur, and the likelihood of an adequate immune response to vaccination. 19 4

6 Table Adult Medical and Other Indications-Based Immunization Schedule * Vaccine Indication Pregnancy Immunocompromising conditions A HIV infection CD4+ cell count < 200 cells/µl 200 cells/µl Men who have sex with men (MSM) Kidney failure, ESRD, or on dialysis Chronic heart or lung disease; chronic alcoholism Asplenia Chronic liver disease Diabetes Healthcare personnel Influenza Tetanus, diphtheria, pertussis (Td/Tdap) Varicella Tdap each pregnancy Contraindicated annually Substitute 1-time dose of Tdap for Td booster; then boost with Td every 10 yrs 2 doses Human papillomavirus (HPV) - female Human papillomavirus (HPV) - male Zoster Measles, mumps, rubella (MMR) Pneumococcal 13-valent conjugate (PCV13) 3 doses through age 26 yrs Contraindicated Contraindicated 3 doses through age 26 yrs 3 doses through age 26 yrs 3 doses through age 21 yrs 1 or 2 doses depending on indication Pneumococcal polysaccharide (PPSV23) Meningococcal conjugate vaccine Meningococcal Group B Hepatitis A Hepatitis B Haemophilus influenzae type b (Hib) 1, 2, or 3 doses depending on indication 2 or 3 doses depending on vaccine 3 doses 3 doses 3 doses 3 doses 3 doses post-hsct only) 1 or more doses depending on indication 2 or 3 doses depending on vaccine * These recommendations are intended to be read along with the footnotes available at adult/adult-combined-schedule.pdf, which contain important information including dosing schedules and considerations for special populations. Adapted from Centers for Disease Control and Prevention (CDC). Recommended immunization schedule for adults aged 19 years and older, United States, 2017 A Excludes human immunodeficiency virus (HIV) and asplenia Abbreviations: ESRD, end-stage renal disease; HSCT, hematopoietic stem cell transplant Contraindication No recommendation For all adults who meet the age requirement and who lack documentation of vaccination or have no evidence of previous infection; zoster vaccine recommended regardless of prior episode of zoster Recommended if an additional risk factor (eg, medical, lifestyle, occupational, or other indication) is present Cardiovascular Disease (CVD) Risk reduction for patients with CVD (eg, atherosclerotic heart disease) includes ensuring that all routine vaccinations are up to date both because CVD can increase the risk of certain vaccine-preventable diseases and their complications, and because some vaccine-preventable diseases (eg, influenza) can increase the risk of CV events. 20 Serious influenza-related complications are more common among patients with than without CVD. 21 Recently, a meta-analysis of randomized trials in patients at high 5

7 CV risk showed a 36% decrease in the relative risk of CV events with influenza vaccination, compared with placebo or control. 22 The ACIP recommends one dose of PPSV23 for patients age with chronic heart disease (including heart failure and cardiomyopathy, but not hypertension alone). Patients age 65 or older with chronic heart disease should also receive PCV13, followed by an additional dose of PPSV23 at least 1 year after PCV13 and at least 5 years after the most recent PPSV23 dose. 6,10 Chronic Lung Disease An increased risk of invasive pneumococcal disease (IPD) among patients with COPD is well established. A casecontrol study in Tennessee found that adults with asthma are also at increased risk. 23 Both ACIP and the Global Initiative for Chronic Obstructive Lung Disease (GOLD) recommend PPSV23 for adults with COPD. 6,10,24 ACIP also recommends PPSV23 to prevent IPD in adults ( 19 years) with asthma and in adults who smoke cigarettes. 6,10 PCV13, however, is recommended for adults aged only for conditions that reduce immunocompetence. 6,10 For individuals age 65 and older, the recommendations for PCV13 and PPSV23 are the same for those with chronic lung disease as for those with CVD. 6,10 Chronic Liver Disease (CLD) Individuals with CLD, including cirrhosis, have an increased risk of IPD. 25 Those age should receive a dose of PPSV23; for those age 65 and older, recommendations for PCV13 and PPSV23 are the same as for patients with CVD. 6,10 The overall case-fatality rate for patients with hepatitis A virus (HAV) infection is approximately 0.3% to 0.6%, increasing to 1.8% among adults over the age of 50 years. 26 Although individuals with CLD are not at increased risk for acquiring HAV infection, they are at increased risk for fulminant hepatitis, acute liver failure, and death if infected with HAV. 26 In the 1990s, cases of HAV transmission occurred during transfusion of clotting factor concentrates. 26 Although the risk of transmission has since been reduced by improved screening and viral inactivation procedures, as well as high hepatitis A vaccine coverage, 26 persons with CLD and individuals who receive clotting factor concentrates should still receive the hepatitis A vaccination series. 6,10 Persons with CLD are not at increased risk for acquiring HBV infection or for acute liver failure due to HBV infection. However, people with hepatitis C virus (HCV) who acquire HBV are more likely to develop progressive liver disease. 14 Despite a low risk for HBV infection, persons with CLD - including, but not limited to, cirrhosis, alcoholic liver disease, fatty liver disease, autoimmune hepatitis, HCV infection, and an alanine aminotransferase (ALT) or aspartate aminotransferase (AST) level more than twice the upper limit of normal - should receive the hepatitis B vaccination series. 6,10 Chronic Kidney Disease (CKD) Patients with CKD have altered immune competence, resulting in an impaired response to vaccinations (lower seroconversion rates, lower peak antibody titers, and faster decline of antibody levels), compared with immunocompetent individuals. Infectious diseases are a common cause of death in patients with end-stage kidney disease. It is imperative that immunization strategies be discussed and formulated early in the course of progressive kidney disease to maximize the likelihood that the patient will develop vaccine-induced immunity. 27 This approach is particularly important if transplantation and chronic immunosuppressive therapy, which would contraindicate live vaccines, are being considered. 27 Recommendations for pneumococcal vaccinations for patients with chronic kidney failure or nephrotic syndrome are the same as those for patients with other causes of altered immunocompetence. 6,10 However, most people with CKD (regardless of stage) have sufficient immune function to safely receive all live vaccines for which there is no inactivated alternative (eg, MMR, varicella, and zoster). 6,10 The ACIP also recommends that patients who are undergoing dialysis, and those with end stage kidney disease that may result in dialysis, should receive the hepatitis B vaccination series because of the potential for exposure to contaminated environmental surfaces and dialysis equipment, and the increased exposure to blood products. 6,10,27 Dialysis may also lead to an inadequate and shortened immune response; thus the HB vaccine is often given in a higher dose and/or in more than 3 doses, with antibody monitoring 1-2 months after completing the series. 9 Refer to the section on altered immunocompetence for hepatitis B vaccine dosing and antibody monitoring recommendations in hemodialysis patients, as they are the same. Special Conditions & Populations Pregnancy There is no evidence that vaccinating a pregnant woman with an inactivated vaccine causes harm to the fetus. Live vaccines pose a theoretical risk to the developing fetus and are usually contraindicated during pregnancy. 6,10,28 Inactivated (not recombinant) influenza vaccine and Tdap are important vaccinations for pregnant women. The current recommendation for pregnant women is to 6

8 receive a Tdap dose during each pregnancy, regardless of the interval since previous Tdap or Td immunization. Tdap should preferably be given between 27 and 36 weeks gestation, 6,10,28,29 and recent evidence suggests it is best given earlier in that window to maximize pertussis antibody transfer to the fetus. 30 Influenza can be more severe during the 2nd and 3rd trimesters of pregnancy, with an increased risk of hospitalization. 9 It is important for women who are or will be pregnant (in any trimester) during flu season to get their annual influenza vaccination (with an inactivated vaccine). 9,28 Men Who Have Sex with Men (MSM) Men who have sex with men (MSM) are at an increased risk for infection with human papillomavirus (HPV). Genital warts and anal cancer are often linked with HPV infection, which is why vaccination is imperative (when age-appropriate) in this population. 31 HPV9 is the only HPV vaccine currently available in the US. It is an inactivated 9-valent vaccine that contains 7 cancer-causing HPV types (16, 18, 31, 33, 45, 52, and 58) accounting for approximately 67% of invasive HPV-associated cancers in males, and 2 HPV types (6 and 11) that cause 90% of anogenital warts. 31 Vaccination is routinely recommended for all males years of age, and may also be given to those aged years. For MSMs, vaccination through age 26 is recommended. 6,32 ACIP currently recommends a 2-dose HPV vaccine schedule, separated by 6 to 12 months, for adolescents who start the vaccination series before their 15th birthday. 31 Individuals who start the series on or after their 15th birthday, and those with certain immunocompromising conditions such as cancer, HIV infection, or taking immunosuppressive medications should receive the standard 3-dose HPV schedule. The ACIP also recommends that MSM receive both the hepatitis A and hepatitis B vaccine series, because hepatitis A and B viruses can be sexually transmitted. 6,10,33 Healthcare Personnel Recommended vaccines for healthcare personnel who were not previously vaccinated include a dose of Tdap, 2 doses of MMR, 2 doses of varicella, and a 3-dose hepatitis B series. Healthcare providers should also get an annual influenza vaccination as soon as it is available. For the hepatitis B vaccine, serologic evidence of immunity is usually required by healthcare facilities at least 1 month after the 3rd dose. 6,10,34 Allergies / Anaphylaxis A severe allergic reaction (such as anaphylaxis) after a previous dose of a vaccine, or to a vaccine component, is a strict contraindication for that vaccine. 6,10 Vaccine components that have been implicated in allergic reactions include egg protein, latex, gelatin, and neomycin. 35,36 (See the table, "Selected Vaccine Components That Can Cause Allergic Reactions" in the Patient Connection.) Manufacturers may occasionally change their vaccine formulations; thus, healthcare providers should check the respective vaccine product s package insert to identify potentially problematic components. The Immunization Action Coalition (IAC) compiles the package inserts for all available vaccines in the US on its website. 13 The influenza vaccine is manufactured using either egg-based, cell culture-based, or recombinant processes. There are 2 formulations that are not grown in eggs, the cell culture-based quadrivalent IIV (cciiv4) vaccine Flucelvax and the recombinant influenza vaccine (RIV3 and RIV4) Flublok. However, Flucelvax is not considered completely egg-free 37 because the original seed virus was grown in eggs. Individuals who can eat lightly cooked eggs (such as scrambled eggs) without a reaction are unlikely to be allergic to eggs and may receive any influenza vaccine per the usual protocol. 37 Persons with a history of egg allergy who experience only hives after exposure can receive recommended (ie, inactivated or recombinant) age-appropriate influenza vaccine without specific precautions. 6,10,37 Individuals who report more severe reactions to eggs (eg, anaphylaxis, angioedema, respiratory distress, lightheadedness, recurrent vomiting) may receive any age-appropriate influenza vaccine in a setting where equipment and personnel are available to manage severe allergic reactions. 6,10,37 Providers may prefer to administer an egg-free recombinant vaccine for people 18 years and older with severe egg allergy. However, the ACIP does not express a preference for any specific vaccine product when indicated. 37 Vaccine providers should monitor patients for 15 minutes after injection of any vaccine in case an adverse reaction occurs. Chief Editor: Terry M. Baker, PharmD; Managing Editor: Tracy Farnen, PharmD; Associate Editors: James Chan,PharmD, PhD, Ron Finley, RPh, Angie Graham, PharmD, Julio R. Lopez, PharmD, FCSHP, Pamela Mausner, MD, Christopher J. Stock, PharmD, BCPP; Candy Tsourounis, PharmD; Senior Editorial Advisor: Gerard Hatheway, PharmD, PhD; Editorial Advisors: Helen Berlie, Pharm.D., CDE; Belinda M. Danielson, RPh, Christopher M. DeSoto, PharmD; Cynthia Chan Huang, PharmD; Fred S. Mayer, RPh, MPH, Fred Plageman, PharmD; Continuing Education Coordinator: Ashrani Chandra 7

9 Patient Connection September 2017 Immunization Update: A Focus on Medical Indications for Vaccines in Adults I m 40 years old and don t get to the doctor very often. How would I know what vaccinations I should get? Adults need periodic vaccinations throughout their lives. The recommended vaccines for adults are based on age, existing medical conditions (if any), and past medical history. People with a higher likelihood of developing certain infections or passing them on to others also have recommended vaccinations. This includes residents of long-term care facilities such as nursing homes, travelers who leave the country, healthcare workers, daycare workers, and food handlers. To get an understanding of what vaccinations you might need, visit this Centers for Disease Control and Prevention (CDC) website: www2a.cdc.gov/nip/adultimmsched and fill out the Adult Vaccine Quiz online. You can discuss the results with your healthcare provider, who can advise you on the vaccinations that you should have. For other CDC vaccine recommendations (including for people with medical conditions), see the box on the right. I was just diagnosed with type 2 diabetes. What vaccinations do I need to get? Because people with diabetes are more likely to develop complications from the flu, the American Diabetes Association (ADA) and the CDC recommend that people with diabetes get a flu shot every year. In addition to staying up-to-date with routine vaccinations, all adults with diabetes should get the pneumococcal polysaccharide vaccine (Pneumovax 23, or PPSV23), which protects against certain serious bacterial infections, including pneumonia and sinus infections. If you are age 65 or older, you should first get the pneumococcal conjugate vaccine (Prevnar 13, or PCV13), followed by PPSV23 at least 1 year later, and at least 5 years after the most recent PPSV23 dose. If you are age 19 through 59, the ADA and CDC recommend that you also be vaccinated with the hepatitis B series (Engerix-B or Recombivax HB ), which protects against a serious liver infection caused by the hepatitis B virus. If you are 60 or older, your health care provider can assess your risk for hepatitis B infection and give the vaccine if he or she feels you need it. I m planning a pregnancy and I had a routine tetanusdiptheria (Td) vaccine about 1 year ago. Do I need to be revaccinated with Tdap? What other vaccines do I need? Yes, you should be revaccinated with Tdap (Adacel or Boostrix ) because it includes the whooping cough (pertussis) vaccine, in addition to tetanus and diphtheria. Given during pregnancy, it is your baby s best protection against pertussis a serious infection that can cause hospitalization or even death in infants. The CDC recommends that pregnant women get a Tdap dose during each pregnancy between weeks 27 and 36, preferably during the earlier part of this time period. Before getting pregnant, make sure you are up to date on all your vaccines. The measles, mumps, rubella (MMR) vaccine should be given, unless you can confirm that you have already had it (most people get it during childhood). Rubella is a viral disease that can cause miscarriage or birth defects if you get it while pregnant. If you need to get vaccinated for rubella, avoid becoming pregnant until at least 1 month after getting the MMR and, ideally, until you have had a blood test showing that you are immune. Inactivated flu vaccine is another important vaccine to get. It can be given before or during pregnancy. My 12-year old son had a meningococcal vaccine. Should I have one? Two types of meningococcal vaccines are currently available meningococcal conjugate vaccines (Menactra or Menveo ) and serogroup B meningococcal vaccines (Bexsero or Trumenba ). Generally, 11- to 12-year olds should get a meningococcal conjugate vaccine, with a booster dose given at 16 years old. Teens and young Resources for More Information Centers for Disease Control and Prevention (CDC) 1600 Clifton Rd. Atlanta, GA (800) Vaccines and Immunizations --Adults with Health Conditions (asplenia, diabetes, heart disease, stroke, or other cardiovascular disease, HIV infection, liver disease, lung disease including asthma, kidney disease, weakened immune system) Immunization Action Coalition For the Public 2250 University Ave. West, suite 415 North, Saint Paul, MN (651) Vaccine Information You Need Vaccine Adverse Events Reporting System (VAERS) P.O. Box 1100, Rockville, MD (800)

10 adults, especially college students, have an increased chance of getting meningococcal disease. The CDC recommends meningococcal conjugate vaccine for firstyear college students (age 21 or younger) who live in residence halls, if they were not vaccinated at or after age 16. The serogroup B vaccine protects against a rare type of meningococcal disease. It is not routinely recommended, but may be given to teens and young adults ages Meningococcal vaccine (one or both types) is recommended for certain adults with an increased chance of getting meningococcal disease, including those who: are taking a medication called Soliris (conjugate and serogroup B vaccines) have a damaged spleen or missing a spleen (conjugate and serogroup B vaccines) have HIV infection (conjugate vaccine) are microbiologists routinely exposed to meningococcal bacteria - a bacteria that can cause meningitis (conjugate and serogroup B vaccines) are traveling to or live in countries where meningococcal disease is common (conjugate vaccine) are part of a population identified to be at increased risk because of a meningococcal disease outbreak (conjugate OR serogroup B vaccine depending on the type of disease outbreak) are military recruits (conjugate vaccine) I m allergic to latex - what vaccines should I avoid? It depends on how serious your latex allergy is. More serious symptoms of latex allergy can include sneezing, runny nose, watery/itchy eyes, cough, wheezing, hoarseness, abdominal (belly) cramps, weakness, fast heartbeat, and/or hives. The most serious kind of reaction, called anaphylaxis, is life-threatening. Signs and symptoms of anaphylaxis can include swelling of the lips, face, and/or throat; difficulty breathing; chest pain; fast, slow or irregular heartbeat; low blood pressure; dizziness; and loss of consciousness. Several types of vaccines come in vials or syringes that contain natural rubber, which is made from latex. If you ve had a severe allergic reaction to latex, such as anaphylaxis, you should not get these vaccines. Tell your healthcare provider he or she can check the package insert to see whether a particular vaccine is safe for you. If you ve had only nonserious latex reactions, such as contact allergy, you can get these vaccines safely. If you re not sure, talk to your provider. Can I be allergic to other things in vaccines? Besides latex, a number of vaccine components can cause allergic reactions. Some of these are listed in the table at right. Tell your healthcare providers about any allergies you have to medications or foods before you get a vaccination. Serious allergic reactions can occur within minutes to hours after getting a vaccination. If you suspect a serious reaction, call 911 right away. The CDC and FDA collect information about possible vaccine side effects through the Vaccine Adverse Events Reporting System (VAERS). Reports are welcome from any concerned individual; see the Resources box on the other side of this page for contact information. My mother told me that I had hives after eating eggs as a child, and I haven t eaten eggs since. Can I still get a flu shot this season? If hives is the only allergic symptom you had after eating eggs, you can safely get a flu shot. If you had a reaction to eggs involving other symptoms, such as trouble breathing, lightheadedness, or vomiting; or if you needed emergency medical attention, you may still receive a recommended flu vaccine. However, the vaccine should be given in a medical setting supervised by a health care provider who is able to recognize and manage severe allergic conditions. Two flu vaccines, Flucelvax and Flublok, are manufactured without the use of eggs. However, Flucelvax is not considered completely egg free. Talk with your provider about which vaccine is best for you. Some Vaccine Components That Can Cause Allergic Reactions * Component Vaccines Egg protein Influenza (except Flublok ) A, Yellow Fever Gelatin Neomycin Influenza (Flumist ) MMR, Varicella, Zoster, Yellow Fever DTaP-IPV, Hep A, IPV, MMR, Varicella, Zoster, Influenza (Afluria, Fluvirin, Fluad ) Polymyxin B IPV, DTaP-IPV, Influenza (Afluria, Fluvirin ) Streptomycin Latex IPV Vaccines supplied in vials or syringes that contain natural rubber; check package inserts Abbreviations: DTaP-IPV = diptheria, tetanus, acellular pertussis and inactivated polio vaccine; Hep A = hepatitis A vaccine; IPV = inactivated polio vaccine; MMR = measles, mumps, rubella * The list of vaccines containing specific components are not comprehensive. Manufacturers may also change their vaccine formulations. Providers should check package inserts for current information. A For recommendations about influenza vaccination in patients with egg allergy, see the accompanying issue - the section on Allergies / Anaphylaxis. This page was prepared as a patient education aid. It is not intended to replace a healthcare provider s knowledge, judgement and advice, or for direct use by patients without a healthcare provider s involvement. Supplement to The Rx Consultant. Copyright September 2017, Continuing Education Network, Inc.

11 Conclusion The ACIP recommendations are important tools for healthcare providers working to achieve the Healthy People 2020 objectives and to reduce deaths and disease caused by vaccine-preventable diseases. Providers must stay up-to-date on current ACIP recommendations. It is important to recognize the complexity of these recommendations beyond the routine, age-based recommendations for adults. Having a medical condition or being a member of a special population can increase an individual s risk from certain vaccine-preventable diseases, and may serve as an indication or contraindication for specific vaccines. Whenever possible, providers should get a complete medical history and proactively vaccinate patients accordingly. References 1. U.S. Department of Health and Human Service; Office of Disease Prevention and Health Promotion. Healthy People 2020: Immunization and infectious diseases (site last updated June 21, 2017). Available at: (accessed June 21, 2017). 2. Centers for Disease Control and Prevention (CDC). Vaccine-preventable adult diseases. Last updated December 16, Available at: adults/vpd.html (accessed August 2, 2016). 3. Centers for Disease Control and Prevention (CDC). Measles cases and outbreaks. Last updated July 25, Available at: (accessed August 2, 2017). 4. Centers for Disease Control and Prevention (CDC). Pertussis (whooping cough). Questions and answers. Last updated January 10, Available at: cdc.gov/pertussis/outbreaks/faqs.html (accessed August 2, 2017). 5. Robinson CL, Romero JR, Kempe A, et al; Advisory Committee on Immunization Practices recommended immunization schedule for children and adolescents aged 18 years or younger United States, MMWR Morb Mortal Wkly Rep 2017;66: Available at: (accessed June 21, 2017). 6. Kim DK, Riley LE, Harriman KH, et al.; Advisory Committee on Immunization Practices. Recommended immunization schedule for adults aged 19 years or older, United States, Ann Intern Med 2017;166: Centers for Disease Control and Prevention (CDC). ACIP vaccine recommendations and guidelines. Vaccine-specific ACIP recommendations (last updated May 23, 2017). Available at: (accessed June 14, 2017). 8. Kroger AT, Duchin J, Vázquez M. General best practice guidelines for immunization. Best practices guidance of the Advisory Committee on Immunization Practices (ACIP). Last updated April 20, Available at: hcp/acip-recs/general-recs/index.html (accessed May 26, 2017). 9. Centers for Disease Control and Prevention (CDC). Epidemiology and Prevention of Vaccine-Preventable Diseases. Hamborsky J, Kroger A, Wolfe S, eds. (13th ed.). Washington D.C. Public Health Foundation, Available at: vaccines/pubs/pinkbook/index.html (accessed June 17, 2017). 10. Centers for Disease Control and Prevention (CDC). Recommended immunization schedules for adults. United States, Available at: schedules/hcp/adult.html (accessed May 29, 2017). 11. Centers for Disease Control and Prevention (CDC). Vaccines: Adults with Chronic Health Conditions. Available at: html (accessed May 26, 2017). 12. Centers for Disease Control and Prevention (CDC). Use of 13-valent pneumococcal conjugate vaccine and 23-valent pneumococcal polysaccharide vaccine for adults with immunocompromising conditions: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep 2012;61: Immunization Action Coalition. FDA product approval: vaccine index (package inserts for US licensed vaccines). Available at: (accessed May 26, 2017) 14. Centers for Disease Control and Prevention (CDC). A comprehensive immunization strategy to eliminate transmission of hepatitis B virus infection in the United States: recommendations of the Advisory Committee on Immunization Practices (ACIP) Part II: immunization of adults. MMWR 2006;55(RR-16):1-33; quiz CE MacNeil JR, Rubin LG, Patton M, et al. Recommendations for use of meningococcal conjugate vaccines in HIV-infected persons Advisory Committee on Immunization Practices, MMWR Morb Mortal Wkly Rep 2016;65: Brigden ML. Detection, education and management of the asplenic or hyposplenic patient. Am Fam Physician 2001;63(3): , American Diabetes Association. Standards of medical care in diabetes Section 3. Comprehensive medical evaluation and assessment of comorbidities. Diabetes Care 2017;40 (Suppl 1):S Erratum in: Diabetes Care pii: dc17er Smith SA, Poland GA. Use of influenza and pneumococcal vaccines in people with diabetes. Diabetes Care 2000;23: Centers for Disease Control and Prevention (CDC). Use of hepatitis B vaccination for adults with diabetes mellitus: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep 2011;60: Centers for Disease Control and Prevention (CDC). Heart disease, stroke, or other cardiovascular disease and adult vaccination (last updated November 1, 2016). Available at: html (accessed June 14, 2017). 21. Centers for Disease Control and Prevention (CDC). Flu and heart disease & stroke. Last updated August 25, Available at: index.htm (accessed August 2, 2017). 22. Udell JA, Zawi R, Bhatt DL, et al. Association between influenza vaccination and cardiovascular outcomes in high-risk patients: a meta-analysis. JAMA 2013;310: Talbot TR, Hartert TV, Mitchel E, et al. Asthma as a risk factor for invasive pneumococcal disease. N Engl J Med 2005;352: Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease (2017 report). Available at: (accessed June 15, 2017) Centers for Disease Control and Prevention (CDC). Prevention of pneumococcal disease: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 1997;46(RR-8): Fiore AE, Wasley A, Bell BP; Advisory Committee on Immunization Practices (ACIP). Prevention of hepatitis A through active or passive immunization: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 2006;55(RR-7): Janus N, Vacher L-V, Karie S, et al. Vaccination and chronic kidney disease. Nephrol Dial Transplant 2008;23(3): doi: /ndt/gfm Centers for Disease Control and Prevention (CDC). Guidelines for vaccinating pregnant women. August Available at: hcp/guidelines.html (accessed May 29, 2017). 29. Centers for Disease Control and Prevention (CDC). Updated recommendations for use of tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine (Tdap) in pregnant women--advisory Committee on Immunization Practices (ACIP), MMWR 2013;62(7): Liang JL; National Center for Immunization & Respiratory Diseases, Pertussis Vaccines Work Group. Guidance on the use of Tdap during pregnancy; October 19, Available at: pertussis-02-liang.pdf (accessed June 18, 2017). 31. Centers for Disease Control and Prevention (CDC). Ask the Experts: Diseases & Vaccines. Available at: (accessed June 18, 2017). 32. Meites E, Kempe A, Markowitz LE. Use of a 2-dose schedule for human papillomavirus vaccination updated recommendations of the Advisory Committee on Immunization Practices. MMWR Morb Mortal Wkly Rep 2016;65: Centers for Disease Control and Prevention (CDC). Sexual transmission and viral hepatitis (last updated December 11, 2015). Available at: (accessed June 19, 2017). 34. Centers for Disease Control and Prevention (CDC). Recommended vaccines for healthcare workers (last updated April 20, 2017). Available at: vaccines/adults/rec-vac/hcw.html (accessed June 20, 2017). 35. Chung EH. Vaccine allergies. Clin Exp Vaccine Res 2014;3: Centers for Disease Control and Prevention (CDC). Vaccine excipient & media summary. In: Hamborsky J, Kroger A, Wolfe S, (eds.) Epidemiology and Prevention of Vaccine-Preventable Diseases (13th edition); appendix B. Washington, DC Public Health Foundation, Last updated January 6, Available at: gov/vaccines/pubs/pinkbook/downloads/appendices/b/excipient-table-2.pdf (accessed May 29, 2017). 37. Centers for Disease Control and Prevention (CDC). Prevention and control of seasonal influenza with vaccines. Recommendations of the Advisory Committee on Immunization Practices--United States, MMWR 2016;65(5);