Adult Vaccine Recommendations Change for Flu, Hepatitis A and B

By Marilynn Larkin

NEW YORK (Reuters Health) - Newly released adult recommendations from the Advisory Committee on Immunization Practices (ACIP) include changes for the administration of the influenza, hepatitis A and hepatitis B vaccines, as well as a new look to make the immunization schedule easier to use.

"The schedule has never had such a complete makeover. The new format is more colorful and visually appealing; the font is a bit bigger and the headings are much bolder," Dr. Sandra Fryhofer, Liaison to ACIP and former president of the American College of Physicians, said in an email to Reuters Health.

Other format changes include a cover page with links to complete ACIP recommendations, as well as information on disease outbreaks and travel vaccines; a table of vaccines that now includes trade names; and concise notes (rather than lengthy footnotes) for each vaccine, listed in alphabetical order.

As for changes to the schedule itself, published online February 4 in Annals of Internal Medicine,Dr. Fryhofer highlighted the following:

- Influenza: "A live attenuated vaccine (LAIV) is back as an option for non-pregnant healthy adults through age 49," she said. "LAIV has its own row (in the recommendations) that gives contraindications and precautions for specific medical conditions."

However, she added, "the vaccination recommendation has NOT changed: everyone six months and older needs flu vaccination every year."

- Hepatitis A: Homelessness is now an indication for this vaccine, as San Diego health officials have presented data linking homelessness with a two-to-three times higher odds of hepatitis A infection, and a two-to-four times higher odds of severe Hep A outcomes - specifically, hospitalization and death.

- Hepatitis B: "The new single antigen recombinant hepatitis B vaccine, Hep B- CpG (Heplisav), with its novel adjuvant, has been added to the schedule for adults 18 and older," she said.

"No safety data is yet available on its use in pregnancy," she noted. "Pregnant women needing hepatitis B vaccination should be given one of the older hepatitis B vaccines."

Heplisav has the advantage of rapid dosing: two doses one month apart. A Heplisav dose can also be used as a substitute in a three-dose schedule with a different hepatitis B vaccine.

The downside, she said, is that the list price for Heplisav "is almost double the price per dose of other hepatitis B vaccines."

Background information in the schedule documents that adult vaccination rates are low, she added, and that "racial and ethnic disparities need particular attention, as their coverage tend to lag behind whites in every vaccine category."

The vaccination status of adult patients should be assessed "at every clinical encounter," she said. "As many as 50,000 to 90,000 adults dies each year from vaccine-preventable diseases, including pneumococcal, influenza and hepatitis B."

"Lead by example," Dr. Fryhofer urged. "Make sure you are up to date on your vaccinations."

Dr. Walter Orenstein, associate director of the Emory Vaccine Center and professor of medicine, Emory University School of Medicine in Atlanta, also stressed that "immunization coverage levels for vaccines recommended for adults are much lower than for vaccines recommended for children."

"For example, pneumococcal vaccine is recommended for all adults 65 years of age or older and for younger adults below age 65 with high-risk conditions," he told Reuters Health by email. "The coverage rates are substantially below 90%, levels that we achieve for most recommended vaccines for young children."

Noting that adult uptake of the influenza vaccine is also "disappointing," Dr. Orenstein summarized the adult recommendations: "All adults should be vaccinated against influenza annually, receive a booster of a tetanus-containing vaccine every 10 years, two different types of pneumococcal vaccine when they turn 65, and a vaccine to prevent shingles (zoster recombinant vaccine) when they reach 50 years of age."

"All pregnant women should receive the influenza vaccine, which protects them and their newborn babies, as well as a dose of a vaccine that protects their newborns against pertussis at a time when the babies are vulnerable to whooping cough and are too young to get vaccinated against the disease themselves," he said.

Additional vaccines are recommended for adults who did not receive vaccines in childhood or have certain medical conditions, he noted, as outlined in the schedule.

SOURCE: https://bit.ly/2RGw4HW

Ann Intern Med 2019.

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