adult immunization schedule 2020
the
CDC just published their updated, 2020 immunization schedule for adults. there
are a few changes from last year:
- 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.
- hepatitis
A: now includes all with HIV.
- HPV:
should do catch-up vaccines in all adults (ie, including males) til age
26, and shared clinical decision-making through age 45
- 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
- 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)
- 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
- 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
--there continue to be outbreaks: see http://gmodestmedblogs.blogspot.com/2019/06/increasing-measles-and-hepatitis.html
--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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