Rates of recommended vaccination for adults in the United States are low: less than one quarter of those who should receive vaccination against hepatitis B or herpes zoster are routinely inoculated; uptake of the human papillomavirus (HPV) vaccine has been disappointing with only 6% to 37% of men and women aged 19 to 26 years receiving even one dose in the series.1 In 2013, there were more than 26,000 cases of pertussis and approximately 17,000 individuals were infected with pneumococcus; there were more than 3000 cases of hepatitis B and nearly 250 cases of meningococcal disease (strains ACYW or B).2 Td and Tdap coverage in 2013 was limited to 57.5% and ~29% of the population, respectively.3
A few more facts:
- Less than 20% of persons aged ≥19 years have ever received a dose of Tdap.1
- Only 60% of patients aged ≥65 have received any pneumococcal vaccine.1
- Only 29% of adolescents have completed meningococcal vaccination (MenAC-WY); 40% have completed the HPV series; 88% have received a single dose of Tdap.2
Persons with diabetes not otherwise at risk for hepatitis B have twice the risk of acquiring the disease versus persons who do not have diabetes.
The sooner after the diagnosis of diabetes an individual is vaccinated against hepatitis B the better. Although the study in the supporting reference looked at the absence of other typical risk factors for acquiring hepatitis B, there is more to the story. Twenty-nine hepatitis B outbreaks in diabetics were investigated. Twenty-five out of 29 were a consequence of contaminated blood glucose monitors.4 Protecting diabetics against hepatitis B infections by vaccination is an important primary care responsibility. Preventing hepatitis B in the study’s at-risk cohort (ages 20-59) saved $75,100 per every adjusted life year.4
Who should NOT receive the vaccine against herpes zoster?
Organ transplant recipients, pregnant women, and patients receiving 20 mg prednisone or more a day or receiving biological therapy for rheumatoid arthritis should NOT receive the live vaccine. Patients infected with HIV who have a CD4 count of ≤200 cells/µL should not be given live zoster vaccine.5 Patients with HIV and CD$ T-cell count of (≥500 cells/µL) would be eligible for the immunization.
The human papillomavirus (HPV) vaccine
- HPV is not a live vaccine, so it can be given to those with lower CD4 counts, at the discretion of the treating physician.
- Safety of the vaccine during pregnancy is unknown, however, so it should not be administered to pregnant women.
- The 9-valent HPV vaccine can be given to males.
- Patients with latex allergy should not be given HPV vaccine.
How to handle asplenic patients
Pneumococcus, Haemophilus influenza B, and Meningococcus are caused by encapsulated organisms so therefore a threat to persons without a spleen. Influenza vaccination is recommended in asplenic individuals. Asplenic individuals are at risk for fatal sepsis. As a result, they also receive precautions when they experience fever similar to those for persons exposed to meningococcus.
The pneumococcal vaccination in patients with end-stage renal disease (ESRD)
- One half of pneumonia pathogens in ESRD patients are pneumococcal.
- Mortality associated with pneumonia in patients with ESRD is >10 times higher than in patients not dependent upon dialysis.
- Pneumonia triples cardiovascular events in ESRD patients.
- Less than 50% of ESRD patients are vaccinated against pneumococcus.
Readings & Resources (click to view)
1. Williams WW, Lu PJ, O’Halloran A, et al; Centers for Disease Control and Prevention (CDC). Vaccination coverage among adults, excluding influenza vaccination – United States, 2013. MMWR Morb Mortal Wkly Rep. 2015;64:95-102. https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6404a6.htm
2. Adams D, Fullerton K, Jajorsky R, et al. Summary of notifiable infectious diseases and conditions –United States, 2013. MMWR Morb Mortal Wkly Rep. 2015;62:1-122. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6253a1.htm
3. Lu P-J, O’Halloran A, Ding H, et al. National and state-specific Td and Tdap vaccination of adult populations. Am J Prev Med. 2016; 50:616-626. http://www.ncbi.nlm.nih.gov/pubmed/?term=Am+J+Prev+Med.+2016%3B+50%3A616-626.
4. 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 Dec 23;60:1709-11.
5. Rubin LG, Levin MJ, Ljungman P, et al. 2013 IDSA clinical practice guideline for vaccination of the immunocompromised host. Clin. Inf. Dis. 2014; 58:e44. http://cid.oxfordjournals.org/content/58/3/e44.long
CDC. Vaccine information for adults. HIV Infection and Adult Vaccination. http://www.cdc.gov/vaccines/adults/rec-vac/health-conditions/hiv.html
Rubin LG, Schaffner W. Clinical practice: Care of the asplenic patient. N Engl J Med. 2014; 371:349-356. http://www.nejm.org/doi/full/10.1056/NEJMcp1314291
Soni R, Horowitz B, Unruh M. Immunization in end-stage renal disease: opportunity to improve outcomes. Semin Dial. 2013;26:416-426. http://onlinelibrary.wiley.com/doi/10.1111/sdi.12101/abstract;jsessionid=6BEAD64A884CB7B5B807E2409778A01B.f03t03