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Adult Immunizations 

Adult Immunizations
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Adult Immunizations
Author(s):

Priya Sampathkumar

DOI:
10.1093/med/9780199827626.003.0044
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date: 09 July 2020

I. General Information About Vaccines

  1. A. Safety

    1. 1. No vaccine is 100% effective or completely safe

    2. 2. All vaccines are associated with risks and benefits that need to be balanced against each other

      1. a. Personal benefits: protection from illness, improved quality of life, and prevention of death

      2. b. Societal benefits: creation of herd immunity, prevention of disease outbreaks, and a decrease in health care costs

      3. c. Vaccination risks range from minor, local adverse events to rare, severe, and life-threatening problems

      4. d. Use of vaccines in pregnancy is summarized in Box 44.1

  2. B. Timing and Spacing of Vaccinations

    1. 1. Commonly available vaccines for adults are listed in Box 44.2

    2. 2. Vaccines are recommended for the youngest age group of people at risk of the disease for whom safety and efficacy data are available

    3. 3. Detailed schedules are published by the Centers for Disease Control and Prevention (CDC) National Immunization Program for both adults and children (Figures 44.1- 44.3)

    4. 4. These schedules should be adhered to as much as possible

  3. C. Multidose Vaccine Series

    1. 1. Do not shorten the recommended minimum intervals between doses

      1. a. Risks are associated with administering vaccines before the recommended minimum age or at intervals less than the recommended minimum interval

        1. 1) Suboptimal response to the vaccine

        2. 2) Increased local or systemic reactions

      2. b. The CDC Advisory Committee on Immunization Practices (ACIP) recommends that vaccines be considered valid if they are given within 4 days before the minimum interval or age

        1. 1) Exception: rabies vaccine

      3. c. Doses given 5 or more days before the minimum interval or age should not be considered valid

        1. 1) Doses should be repeated, spaced after the invalid dose by the recommended minimum interval

    2. 2. Lengthening the recommended intervals between doses is acceptable

      1. a. If intervals between doses of a series are longer than recommended, it is not necessary to restart the series again or to give extra doses

    3. 3. Interchangeability of vaccines from different manufacturers

      1. a. It is not necessary to restart a series if the brand used previously is not available or is not known

  4. D. Administration of Multiple Vaccines During the Same Visit

    1. 1. Each vaccine should be given in a separate syringe except for combination vaccines approved by the US Food and Drug Administration (FDA)

    2. 2. Since inactivated vaccines do not interfere with the immune response to other inactivated vaccines or to live vaccines, an inactivated vaccine can be given at the same time or at any time before or after another inactivated vaccine or live vaccine

    3. 3. If 2 live parenteral vaccines are needed (eg, varicella and yellow fever), administration should be on the same day or separated by at least 4 weeks

    4. 4. Live oral vaccines (eg, oral typhoid, oral polio) can be given at any interval before or after inactivated or live parenteral vaccines

  5. E. Spacing of Antibody-Containing Products and Vaccines

    1. 1. If the product containing antibody is given first, wait a minimum of 3 months to give live vaccine

      1. a. Blood and blood products (immune globulin, whole blood, plasma, packed red cells, and platelets) can inhibit the immune response to live vaccines for 3 months or more

      2. b. Administration of live vaccines should therefore be delayed by a minimum of 3 months after administration of an antibody-containing product

      3. c. A longer wait may be necessary after administration of a hyperimmune product such as hepatitis A immunoglobulin or high-dose intravenous immunoglobulin

      4. d. Exceptions

        1. 1) Yellow fever vaccination does not need to be delayed after blood product administration since blood products available in the United States are unlikely to contain clinically significant titers of yellow fever antibodies

        2. 2) Zoster vaccine can be given at the same time as (or at any interval after) blood or other antibody-containing blood product

          • a) The reason is that persons with a history of varicella maintain high levels of antibody to varicella-zoster virus indefinitely

          • b) These levels are comparable to those found in donated blood and antibody-containing blood products

    2. 2. For all other live vaccines, if the live vaccine is given first, the antibody-containing product should be deferred for at least 14 days after the live vaccine

      1. a. Usually vaccine virus replication and stimulation of immunity occurs 1 to 2 weeks after vaccination

      2. b. If an antibody-containing product is administered within 14 days of a live vaccine, either repeat the vaccine dose after the recommended interval or check serology to ensure that the vaccine worked

    3. 3. Inactivated vaccines: administered simultaneously or separated by any interval from antibody-containing products

a Oral polio vaccine is no longer used in the United States.

Figure 44.1. Recommended Immunization Schedule for Persons Aged 0 Through 6 years, United States, 2010. Detailed footnotes accompanying this figure are published at http://www.cdc.gov/vaccines/recs/schedules/downloads/child/2010/10_0–6yrs-schedule-pr.pdf. PCV indicates pneumococcal conjugate vaccine; PPSV, pneumococcal polysaccharide vaccine.

Figure 44.1.
Recommended Immunization Schedule for Persons Aged 0 Through 6 years, United States, 2010. Detailed footnotes accompanying this figure are published at http://www.cdc.gov/vaccines/recs/schedules/downloads/child/2010/10_0–6yrs-schedule-pr.pdf. PCV indicates pneumococcal conjugate vaccine; PPSV, pneumococcal polysaccharide vaccine.

Figure 44.3. Recommended Immunization Schedule for Adults, United States, 2010. Detailed footnotes accompanying this figure are published at http://www.cdc.gov/vaccines/recs/schedules/downloads/adult/2010/adult-schedule.pdf. Td indicates tetanus and diphtheria toxoids; Tdap, tetanus, diphtheria, and acellular pertussis.

Figure 44.3.
Recommended Immunization Schedule for Adults, United States, 2010. Detailed footnotes accompanying this figure are published at http://www.cdc.gov/vaccines/recs/schedules/downloads/adult/2010/adult-schedule.pdf. Td indicates tetanus and diphtheria toxoids; Tdap, tetanus, diphtheria, and acellular pertussis.

Figure 44.2. Recommended Immunization Schedule for Persons Aged 7 Through 18 Years, United States, 2010. Detailed footnotes accompanying this figure are published at http://www.cdc.gov/vaccines/recs/schedules/downloads/child/2010/10_7–18yrs-schedule-pr.pdf.

Figure 44.2.
Recommended Immunization Schedule for Persons Aged 7 Through 18 Years, United States, 2010. Detailed footnotes accompanying this figure are published at http://www.cdc.gov/vaccines/recs/schedules/downloads/child/2010/10_7–18yrs-schedule-pr.pdf.

II. Specific Vaccines for Adults in the United States

  1. A. Hepatitis A Vaccine

    1. 1. Characteristics

      1. a. Inactivated viral vaccine

      2. b. Schedule: 2 doses at 0 and 6 months, intramuscularly

      3. c. For combined hepatitis A and B vaccine (Twinrix), schedule is 3 doses at 0, 1, and 6 months

      4. d. Duration of protection: lifelong

      5. e. Very efficacious: protective efficacy is 94% to 100%

    2. 2. Indications

      1. a. Persons with clotting factor disorders or chronic liver disease

      2. b. Men who have sex with men

      3. c. Users of illegal drugs

      4. d. Persons working in laboratories where they may be exposed to hepatitis A

      5. e. Persons traveling to countries where hepatitis A is endemic

      6. f. Any person who wants immunity to hepatitis A

      7. g. Recently added to vaccines recommended in childhood

    3. 3. Side effects and precautions

      1. a. Injection site pain and induration

  2. B. Hepatitis B Vaccine

    1. 1. Characteristics

      1. a. Inactivated vaccine

      2. b. Schedule: 3 doses at 0, 1, and 6 months, intramuscularly

      3. c. Duration of protection: several years

    2. 2. Indications

      1. a. Chronic hemodialysis (use special formulation: 40-mcg dose instead of usual 20-mcg dose)

      2. b. Persons who receive clotting factor concentrates

      3. c. Health care and public safety workers who have occupational exposure to blood

      4. d. Injection drug users

      5. e. Persons with more than 1 sex partner in the past 6 months

      6. f. Men who have sex with men

      7. g. Household contacts and sex partners of persons with chronic hepatitis B infection

      8. h. Inmates of correctional facilities and residents and staff of institutions for the developmentally disabled

      9. i. International travelers who will spend more than 6 months in countries that have a high prevalence of chronic hepatitis B virus infection

    3. 3. Side effects and precautions

      1. a. Injection site pain and swelling

      2. b. Systemic symptoms are rare

  3. C. Human Papillomavirus Vaccine

    1. 1. Characteristics

      1. a. There are more than 40 types of human papillomaviruses (HPVs)

        1. 1) HPV types 6 and 11: responsible for 90% of genital warts

        2. 2) HPV types 16 and 18: responsible for 70% of cervical cancers

      2. b. Two types of HPV vaccine have been approved by the FDA

        1. 1) Quadrivalent vaccine (HPV4) (Gardasil) protects against HPV types 6, 11, 16, and 18

        2. 2) Bivalent vaccine (HPV2) (Cervarix) protects against HPV types 16 and 18

      3. c. Quadrivalent vaccine

        1. 1) Noninfectious subunit vaccine

        2. 2) Consists of immunogenic viral proteins stripped free from whole virus particles (in this case, virus-like particles of the major capsid [L1] protein of HPV) and then purified from other irrelevant components, thereby decreasing the risk of adverse reactions and residual infectious virus

        3. 3) Approved for males and females 9 to 26 years old

        4. 4) Schedule: 3 doses at 0, 2, and 6 months, intramuscularly

        5. 5) Duration of protection: 4 years or more

        6. 6) Series should be started before sexual activity begins, but women who are sexually active should still be vaccinated

        7. 7) Does not provide protection against all types of HPV viruses that cause cervical cancer; therefore, patients should continue to receive routine screening for cervical cancer

      4. d. Bivalent vaccine

        1. 1) Approved for use only in females 10 to 25 years old

        2. 2) Same schedule as for quadrivalent vaccine (ie, 0, 2, and 6 months)

    2. 2. Indications

      1. a. Routine vaccination is recommended for adolescents 11 to 12 years old

      2. b. HPV vaccination is also recommended for females 13 to 26 years old who previously have not received the vaccine

      3. c. Vaccination can be given as early as age 9 at the discretion of the physician

    3. 3. Contraindication to HPV vaccine: pregnancy

    4. 4. Side effects and precautions

      1. a. Injection site pain, redness, and itching

      2. b. Mild to moderate fever

  4. D. Influenza Vaccine

    1. 1. Characteristics

      1. a. Typically contains 2 strains of influenza A virus and 1 strain of influenza B virus

      2. b. A new vaccine incorporating the new virus strains needs to be administered annually because of antigenic drift in circulating viruses

      3. c. Vaccine efficacy varies, depending on the age and immunocompetence of the vaccine recipient and on the degree of similarity between the vaccine virus and the circulating influenza viruses

      4. d. Vaccine efficacy is lowest in persons who are elderly or immunocompromised

      5. e. Two types of influenza vaccines are available (Table 44.1)

        1. 1) An inactivated vaccine administered as an intramuscular injection

        2. 2) A live attenuated influenza vaccine (LAIV) administered as an intranasal spray

      6. f. Both vaccines contain the same viral antigens

      7. g. Viruses for both vaccines are grown in eggs

    2. 2. Indications for annual vaccination

      1. a. As of 2010, ACIP recommends that everyone older than 6 months receive an annual influenza vaccine

      2. b. Vaccine is especially important for several groups

        1. 1) Women who will be pregnant during the influenza season

        2. 2) Children younger than 18 years

        3. 3) Adults and children with chronic cardiac or pulmonary disease, including asthma

        4. 4) Adults and children who have chronic metabolic disease, renal disease, hemoglobinopathy, or immunodeficiency

        5. 5) Adults and children who have an underlying condition that compromises respiratory function or that increases the risk of aspiration

        6. 6) Residents of long-term care facilities

        7. 7) Caregivers and household contacts of persons at high risk of influenza-related complications, as listed above

        8. 8) Health care workers

    3. 3. Contraindications

      1. a. Severe egg allergy

      2. b. LAIV only: age younger than 2 years or older than 50, immunosuppression, chronic medical problems, or pregnancy

  5. E. Measles, Mumps, and Rubella Vaccine

    1. 1. Characteristics

      1. a. Live, attenuated vaccine

      2. b. Schedule: 2 doses separated by at least 4 weeks, anytime after first birthday

      3. c. Dose: 0.5 mL subcutaneously

      4. d. In the United States, the first dose is generally given at age 12 to 15 months and the second dose at age 4 to 6 years

    2. 2. Indications

      1. a. One dose of measles, mumps, and rubella (MMR) vaccine is recommended for all adults born during or after 1957 unless they have a medical contraindication, history of measles based on health care provider diagnosis, or evidence of immunity

      2. b. Indications for second dose of MMR vaccine for adults born after 1957

        1. 1) Recent exposure to measles or an outbreak situation

        2. 2) Previous vaccination with a killed measles vaccine or with an unknown type of vaccine in 1963 to 1967

        3. 3) Student in postsecondary institution

        4. 4) Health care worker

        5. 5) Upcoming international travel

      3. c. The above recommendations were made primarily to ensure measles immunity, but a mumps outbreak in Iowa (2005–2006) was a reminder that the other components of the vaccine are also important

    3. 3. Contraindications

      1. a. Pregnancy

      2. b. Severe immunosuppression

    4. 4. Side effects and precautions

      1. a. Fever

      2. b. Rash

      3. c. Parotid swelling

      4. d. Joint pain and swelling, primarily due to the rubella component; typically occurs only in adults who lack immunity to rubella

  6. F. Meningococcal Vaccine

    1. 1. Characteristics

      1. a. Protects against meningococcal disease caused by Neisseria meningitidis

      2. b. Protects against 4 most common Neisseria serotypes: A, C, Y, and W135

      3. c. Two types of vaccine

        1. 1) Quadrivalent meningococcal conjugate vaccine (MCV4): Menactra and Menveo

          • a) Menactra is approved for persons aged 11 to 55 years; Menveo, for persons aged 2 to 55 years

          • b) Given as a single intramuscular injection

          • c) Longer-lasting protection compared with polysaccharide vaccine

          • d) In 2009, the ACIP recommended revaccination with meningococcal conjugate vaccine every 5 years for persons at increased risk of meningococcal disease for prolonged periods

        2. 2) Meningococcal polysaccharide vaccine (MPSV4): Menomune

          • a) Approved for use in children older than 2 years and in adults (no upper age limit)

          • b) Given subcutaneously as a single dose

          • c) Provides protection for 3 to 5 years

          • d) Revaccination is recommended every 3 to 5 years if risk factor for meningococcal disease is still present

    2. 2. Indications for vaccination with meningococcal vaccine

      1. a. Anatomical or functional asplenia or terminal complement deficiency

      2. b. First-year college students living in dormitories

      3. c. Military recruits

      4. d. Laboratory workers or microbiologists who are routinely exposed to meningococci

      5. e. Travelers to countries in which meningococcal disease is hyperendemic or endemic

        1. 1) Meningitis belt of sub-Saharan Africa

        2. 2) Travelers to Mecca during the annual Hajj

    3. 3. Indications for revaccination with meningococcal vaccine

      1. a. Persons who previously received the polysaccharide vaccine need revaccination every 3 to 5 years if the risk factor for meningococcal disease is still present

        1. 1) Includes college freshmen if their previous dose of meningococcal vaccine was the polysaccharide vaccine and was received more than 5 years ago

        2. 2) Revaccination of college freshmen is not necessary if they previously received the conjugate vaccine (MCV4)

      2. b. Persons who received the conjugate vaccine should be revaccinated every 5 years only if they are in 1 of the following groups (which have the highest risk of meningococcal infection)

        1. 1) Persons with persistent complement deficiencies or functional or anatomical asplenia

        2. 2) Microbiologists who routinely work with Neisseria meningitidis in the laboratory

        3. 3) Travelers to or residents of countries where meningococcal disease is hyperendemic or epidemic

    4. 4. Side effects and precautions

      1. a. Mild injection site pain and redness

      2. b. Brief fever in less than 5%

      3. c. Cases of Guillain-Barré syndrome reported after vaccination with MCV4; no causal link found

  7. G. Pneumococcal Vaccine

    1. 1. Characteristics

      1. a. Inactivated vaccine

      2. b. Polyvalent polysaccharide vaccine

      3. c. Contains 23 Streptococcus pneumoniae capsular antigens that represent at least 85% to 90% of the serotypes (including the most drug-resistant serotypes) that cause invasive pneumococcal disease in children and adults in the United States

      4. d. Schedule

        1. 1) Single dose, with revaccination necessary in some instances (see below)

        2. 2) If elective splenectomy is planned, vaccinate at least 2 weeks preoperatively for maximal benefit

    2. 2. Indications for vaccination with pneumococcal vaccine

      1. a. All persons older than 65 years

      2. b. Indications for persons 2 to 64 years old

        1. 1) Chronic pulmonary disease, diabetes mellitus, cardiovascular disease, or chronic liver or kidney disease

          • a) All smokers who are 19 years or older (new recommendation in 2008)

          • b) All asthmatic patients who are 19 years or older (new recommendation in 2008)

        2. 2) Anatomical or functional asplenia

        3. 3) Immunosuppressive conditions, including congenital immunodeficiency, human immunodeficiency virus infection, generalized malignancy, organ or bone marrow transplant, and immunosuppressive therapy

        4. 4) Cochlear implants

        5. 5) Cerebrospinal fluid leaks

        6. 6) Residents of nursing homes and other long-term care facilities

        7. 7) Alaskan natives and certain Native American populations

    3. 3. Indications for 1-time revaccination after 5 years (these indications are different from those for the first dose of pneumococcal vaccine)

      1. a. Chronic renal failure, asplenia, or immunosuppressive conditions

      2. b. Age older than 65 years if person was younger than 65 years at primary vaccination

    4. 4. Side effects and precautions

      1. a. Local: redness and pain at injection site

      2. b. Systemic: fever, myalgias

  8. H. Tetanus and Diphtheria Toxoids Vaccine

    1. 1. Characteristics

      1. a. Schedule

        1. 1) Primary series: 0, 1, and 6 months

        2. 2) Booster every 10 years

    2. 2. Indications

      1. a. Routine: booster every 10 years after primary series has been completed

      2. b. Wound management: tetanus and diphtheria (Td) booster recommended if wound is contaminated with soil and if latest Td was given more than 5 years earlier

    3. 3. Side effects and precautions

      1. a. Pain and swelling at injection site

      2. b. Vaccine should be avoided in persons with a history of Guillain-Barré syndrome within 6 weeks after receipt of a vaccine containing tetanus toxoid or a history of Arthus reaction to tetanus toxoid vaccine administered within the previous 10 years

  9. I. Tetanus, Diphtheria, and Acellular Pertussis Vaccine

    1. 1. Characteristics

      1. a. Protects against pertussis, tetanus, and diphtheria

      2. b. Two tetanus, diphtheria, and acellular pertussis (Tdap) products are licensed in the United States; they are similar in composition

        1. 1) Boostrix: licensed for use in persons 10 to 64 years old

        2. 2) Adacel: licensed for use in persons 11 to 64 years old

    2. 2. Indications

      1. a. Single dose of Tdap should replace the next scheduled booster of Td for all adults 19 to 64 years old

      2. b. Persons in contact with infants (who are at highest risk of serious complications of pertussis): health care workers, parents of newborns, grandparents, persons 65 years or older, and childcare providers

        1. 1) Ideally, Tdap should be received at least 4 weeks before contact with infants

      3. c. For adults receiving a primary tetanus series, Tdap should be substituted for 1 of the Td doses

    3. 3. Side effects and precautions

      1. a. Injection site redness, pain, and swelling

        1. 1) Side effects may be increased in persons who recently received Td

        2. 2) In general, a 2-year Td-Tdap interval is recommended unless the benefits of vaccination (eg, close contact with a neonate) outweigh the risk of side effects

      2. b. Vaccine should not be given to persons with a history of serious allergic reaction to any of the vaccine components or a history of encephalopathy not attributable to any other cause within 7 days after receipt of a pertussis-containing vaccine

      3. c. Contraindications to Td apply to this vaccine also

  10. J. Varicella Vaccine

    1. 1. Characteristics

      1. a. Live attenuated viral vaccine

      2. b. Schedule: 2 doses separated by 4 to 8 weeks

    2. 2. Indications

      1. a. All adults without evidence of immunity to varicella

        1. 1) Evidence of immunity

          • a) Birth in the United States before 1966

          • b) History of chicken pox or herpes zoster

          • c) Evidence of previous vaccination with 2 doses of varicella vaccine separated by at least 4 weeks

          • d) Positive serology

      2. b. Vaccination is especially important for persons who have close contact with others at high risk of severe disease: health care workers and family contacts of immunocompromised persons

    3. 3. Contraindications

      1. a. Immunosuppression

      2. b. Pregnancy (women should be cautioned not to become pregnant within 4 weeks of vaccination)

      3. c. Allergy to gelatin, neomycin, or a previous dose of varicella vaccine

    4. 4. Side effects and precautions

      1. a. Injection site pain and swelling in 33% of recipients

      2. b. Fever in less than 10%

      3. c. Rash in less than 5% (rash is usually mild and can occur up to 1 month after vaccination)

      4. d. Vaccine strain virus can be transmitted to household contacts who are highly immunosuppressed (eg, bone marrow transplant recipients); close contact should be avoided for 4 weeks after vaccination

  11. K. Zoster Vaccine

    1. 1. Characteristics

      1. a. Licensed in 2006 for the prevention of herpes zoster in persons older than 60 years

      2. b. Live attenuated vaccine

      3. c. Contains the same vaccine strain as the varicella vaccine

      4. d. Contains 14 times the viral antigen as the varicella vaccine

      5. e. Is not interchangeable with the varicella vaccine

      6. f. Schedule: single dose given as subcutaneous injection

    2. 2. Indication

      1. a. Adults older than 60 years without prior history of shingles

    3. 3. Contraindications

      1. a. Immunosuppression

      2. b. Allergic reaction to neomycin, gelatin, or other vaccine component

      3. c. Pregnancy

      4. d. Active untreated tuberculosis

      5. e. Persons in close contact with pregnant women who are not immune to varicella

Table 44.1 Comparison of Live Attenuated Influenza Vaccine (LAIV) and Trivalent Inactivated Vaccine (TIV)

Factor

LAIV

TIV

Type of vaccine

Live, attenuated

Inactivated

Route

Intranasal spray

Intramuscular injection

Age group for which vaccine is approved

2–2 y

>6 mo

Contraindicated if person is immunosuppressed or has chronic health conditions

Yes

No

Contains egg proteins

Yes

Yes

Frequency of administration

Annual

Annual

Suggested Reading

National Center for Immunization and Respiratory Diseases. General recommendations on immunization: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2011 Jan 28;60(2):1–64.Find this resource:

Pickering LK, Baker CJ, Freed GL, Gall SA, Grogg SE, Poland GA, et al. Immunization programs for infants, children, adolescents, and adults: clinical practice guidelines by the Infectious Diseases Society of America. Clin Infect Dis. 2009 Sep 15;49(6):817–40.Find this resource: