adult immunization schedule 2020




the CDC just published their updated, 2020 immunization schedule for adults. there are a few changes from last year:
  1. influenza for 2019-2020 season: no preferential recommendation for one vaccine over another. the live attenuated intranasal vaccine is okay up to age 49, for most people without imunocompromising conditions including HIV or functional asplenia, but also those pregnant, are caregivers of severely immunocompromised people, have taken antiviral influenza meds in prior 48 hours, or have cochlear implants.
  2. hepatitis A: now includes all with HIV.
  3. HPV: should do catch-up vaccines in all adults (ie, including males) til age 26, and shared clinical decision-making through age 45
  4. MMR: new language that health care workers born after 1957 without evidence of immunity should get 2 MMR doses, 4 weeks apart; those born before 1957 and no evidence of immunity "consider" 2-dose schedule
  5. Meningococcal B: give to those >10yo with complement deficiency, complement inhibitor use, or asplenia; should get booster 1 year after completion of primary series, then every 2-3 years if high risk remains. those deemed to be at higher risk during an outbreak, 1-time booster dose if >1yr since a primary series (though some public health officials may say 6 months)
  6. pneumococcal vaccine (PCV-13): not necessary in everyone at age 65. should be "shared clinical decision-making" in all those without immunocompromising conditions, CSF leaks, or cochlear implants.  PPSV-23 should still be given to all adults >65
  7. Tdap: new recommendation, see below: can substitute Tdap for the 10-yearly Td vaccine, or earlier for tetanus prophylaxis in wound management and in catch-up vaccine schedule. And, should be done in pregnant women with each pregnancy
Commentary:
--for the full recommendations, see:
    --https://www.cdc.gov/vaccines/schedules/hcp/imz/adult.html for the color diagram of potential immunizations, indications, and their schedule
    --https://www.cdc.gov/vaccines/hcp/acip-recs/index.html for the array of vaccines, including for travel
    --https://annals.org/aim/fullarticle/2760656/recommended-adult-immunization-schedule-united-states-2020 for the formal publication in Annals of Intl Medicine, including tables of all of the recommendations, indications, etc

--Influenza:
    --my reading of data from many years ago was that there was significant waning effectiveness of LAIV (the intranasal one) actually beginning by age 30-35 (though it had seemed reasonable to me to assume that LAIV would actually be more effective, since usually live vaccines are more immunogenic, and by getting it in the nose there might be improved IgA immunity in the nasal/GI passage, at the sites of typically getting the flu; so, yet again, the data proved me wrong....). so, at this point i would tend to prefer the IM vaccines in those over 30 or so, unless they are needle-phobic
    --we should give the high-dose vaccine, if available, in those >65. studies have suggested increased immunogenicity (eg see https://www.ncbi.nlm.nih.gov/pubmed/30689467 )
    --we should consider delaying flu vaccine til closer to the onset of flu season. several studies suggest this is the best strategy: see http://gmodestmedblogs.blogspot.com/2018/09/maybe-we-should-delay-giving-flu-vaccine.html
--hepatitis A:
    --i personally think everyone should get immunized because
        --it is a (i think) cheap and an old, tried-and-true vaccine
        --people may travel to other countries where hepatitis A is endemic
        --it can be (and has been) brought into the US from veges from other countries
        --we are seeing loads of patients with non-alcoholic fatty liver disease, often undiagnosed (the ALT, for example, can flucuate a lot and only picks up about 1/2 of cases), and there is, i think, a reasonable recomendation to have all those with inflammatory liver disease be immune to hepatitis A (though studies I’ve were in those with viral hepatitis, where superimposed hep A infection can be fatal. i have not seen studies on people with NAFLD, but seems like a reasonable precaution to make sure people are immune to hep A naturally or get the shots)
--HPV:
    --really important vaccination, including in men, since their cases of HPV-associated oropharyngeal cancer now outnumber those of cervical cancer in women. really important to immunize kids (esp in the 9-14 yo range, where only 2 shots are needed because of much increased immunogenicity). eg see http://gmodestmedblogs.blogspot.com/2019/10/hpv-vaccine-and-herd-immunity-in-men.html ; and see http://gmodestmedblogs.blogspot.com/2018/10/vaccine-approved-to-age-45-tdap-best.html for the initial recommendations to offer vaccine to up to age 45 (though there has been comment that this may not be the best use of resources, and  a recent study found that the actual cost to increase vaccination from the age from 26 to 45 would be exorbitant and the real benefits likely small)
--MMR:
    --as per yesterday's blog, there might be benefit to testing people who live in areas of decreased herd immunity (eg areas in the country where parents decline MMRs for their kids), and immunizing them if their IgG titers are low: see http://gmodestmedblogs.blogspot.com/2020/02/measles-infection-diminishes-other.html
--PCV13:
    --though there have been plummeting cases of pneumococcal disease in the elderly after immunizing kids (and prior to immunizing those >65yo), at least in people who travel to areas where kids do not consistently get PCV13 vaccinations, it seems to me that the potential benefits of this vaccine likely far outweigh the really low risks: see http://gmodestmedblogs.blogspot.com/2019/12/pcv-13-for-all-seniors.html
--Tdap:
    --for their new recommendation, see https://www.cdc.gov/mmwr/volumes/69/wr/mm6903a5.htm?s_cid=mm6903a5_w 
    --my concern, addressed in the MMWR issue, is that there are lots of outbreaks of pertussis. they do comment in the MMWR that it is unclear that q10yr shots will help that, since antibody levels wane quickly (and hence the suggestion for Tdap be given later in pregnancy, to ensure better IgG antibody levels being transferred to the newborns); and clinical pertussis protection seems to wane in 2-4 years. but Tdap still might provide some pertussis protection. and, maybe if there were repeated Tdaps given, the specific antibody response against pertussis might be boosted more and longer-lasting???
    --there are good studies showing Tdap is safe, though it is more expensive. and it is currently being given repeatedly in pregnant women with each pregnancy
    --for a recent blog on the increasing numbers of pertussis cases, see http://gmodestmedblogs.blogspot.com/2018/10/pertussis-epidemics-increasing.html

geoff​

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