Based on three changes in the area of adult immunizations that occurred recently, the CDC’s Advisory Committee on Immunization Practices (ACIP) has approved an updated schedule of recommended adult immunizations for use in the United States. The schedule reflects the recommendation that all adults aged 65 or older receive the 13-valent pneumococcal conjugate vaccine (PCV13), a recent FDA approval to expand the patient age range for receipt of the recombinant influenza vaccine to now include all adults aged 18 and older, and a revision on contraindications and precautions for the live attenuated influenza vaccine. The revision changed the statement “influenza antiviral use within the last 48 hours” from a precaution to a contraindication. It also changed asthma and chronic lung diseases; cardiovascular, renal, and hepatic diseases; and diabetes and other conditions from contraindications to precautions.
“The biggest change in the 2015 schedule is the inclusion of the ACIP recommendation for routine administration of PCV13 in series with the 23-valent pneumococcal polysaccharide vaccine for all adults aged 65 and older,” says David K. Kim, MD, lead author of the schedule, which was published in Annals of Internal Medicine. “Previously, PCV13 was recommended only for adults aged 19 to 64 with certain health conditions that put them at increased risk for pneumococcal disease. The significant morbidity and mortality associated with pneumococcal disease—from pneumonia to blood-borne infections and meningitis—disproportionately affects adults, particularly older adults.”
Of the 40,000 cases of invasive pneumococcal disease (IPD) that occur annually in the U.S., 13,500 occur among adults aged 65 and older. Also, approximately 20% to 25% of IPD cases and 10% of community-acquired pneumonia cases are caused by PCV13 serotypes and could be prevented by using PCV13. “The vaccine can prevent much of the morbidity associated with IPD and, in doing so, prevent death,” adds Dr. Kim. Unfortunately, the 2013 pneumococcal vaccination coverage rate for adults aged 65 and older was less than 60%, and the rate was only about 20% for those aged 19 to 64 who have medical conditions that place them at high risk for pneumococcal disease.
Low Immunization Rates
The poor immunization coverage among U.S. adults expands beyond pneumococcal disease. “For example, in 2013 less than two-thirds of all adults were not current on their tetanus vaccine,” explains Dr. Kim. “Only about one-quarter of adults aged 60 and older receive the zoster vaccine. These examples show that physicians need to promote vaccination for their adult patients.”
Dr. Kim notes that consumer research indicates that patients tend to heed the advice of healthcare providers who recommend vaccines to them. “Clinicians can also promote vaccination by following the Standards for Adult Immunization Practice,” he says. The standards include a four-step process:
♦ Assess immunization of all patients at every clinical encounter.
♦ Strongly recommend to patients the vaccines that they need.
♦ Administer recommended vaccines or refer patients to a vaccination provider.
♦ Document vaccines that have been administered, including those administered by another provider.
“Documentation of administered vaccines should be in the provider’s state vaccine registry, which almost all states possess,” Dr. Kim notes. “These four steps help providers engage their adult patients on vaccines and ensure that their vaccination records can be accessed by any provider.”
Initiating the conversation about vaccination with adult patients can be guided by the information provided in Figure 1, based on patient age, and in Figure 2, depending on patients’ health conditions and other indications. “When reviewing the schedule as depicted in these figures, healthcare providers need to review the footnotes,” explains Dr. Kim. “The footnotes contain the details that clinicians need in order to successfully vaccinate their adult patients, including contraindications, precautions, the order of vaccine intervals, and other nuances. The schedule is a visual tool to assist physicians in delivering the vaccines needed by their patients.”
Physicians believe that vaccines are an important component of overall healthcare, says Dr. Kim. “Therefore, physicians are in a position to have a significant impact on increasing the adult immunization coverage rates, and they have a responsibility to make that happen,” he says. “The 2015 Recommended Adult Immunization Schedule provides recommendations to help clinicians with this task, but they are meaningless unless physicians start the dialog with their adult patients about vaccines.”
Kim D, Bridges C, Harriman K. Advisory Committee on Immunization Practices recommended immunization schedule for adults aged 19 years or older: United States, 2015. Ann Intern Med. 2015;162:214-223. Available at http://annals.org/data/Journals/AIM/932718/0000605-201502030-00009.pdf.
Tomcsyk S, Bennett N, Stoecker C, et al. Use of 13-valent pneumococcal conjugate vaccine and 23-valent pneumococcal polysaccharide vaccine among adults aged ≥65 years: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR. 2014;63;822-825.
Grohskopf L, Olsen S, Sokolow L, et al; Centers for Disease Control and Prevention. Prevention and control of seasonal influenza with vaccines: recommendations of the Advisory Committee on Immunization Practices (ACIP)—United States, 2014-15 influenza season. MMWR. 2014;63:691-697.
Centers for Disease Control and Prevention (CDC); Advisory Committee on Immunization Practices. Updated recommendations for prevention of invasive pneumococcal disease among adults using the 23-valent pneumococcal polysaccharide vaccine (PPSV23). MMWR. 2010;59:1102-1106.