Public Health

A simpler approach for a hard task: getting adults vaccinated

The recommended adult immunization schedule has received a significant makeover for 2019, driven by input from physicians and other health professionals who have sometimes had difficulty making sense of the dozens of vaccines, antigen groups and special-indication categories that must be considered when assessing the vaccination needs of patients with more complicated medical histories.

The 2019 recommended schedule from the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices (ACIP) also includes important updates regarding vaccination for influenza and hepatitis A and B. The recommendations were published this week in Annals of Internal Medicine.

Between 50,000 and 100,000 Americans die each of year of vaccine-preventable diseases such as flu, pneumonia and hepatitis C. According to the most recent data, only 43.5 percent of U.S. adults were  immunized against influenza, with the rate higher among seniors (70.4 percent) and lower among African-Americans (39.5 percent) and Hispanics (33.1 percent) compared with whites (46.3 percent).

When it was first published in 2002, the adult immunization schedule included information on eight vaccines and six special-indication categories such as HIV infection and pregnancy. The 2019 schedule, by comparison, offers recommended uses for 17 vaccine types and 10 special-indication categories.

Usability testing of the the 2017 adult immunization schedule found that few of health professionals interviewed routinely accessed the sometimes critical footnotes available. Most also were not aware that the adult immunizations schedule had a table of contraindications and precautions.

This year’s changes are designed to address the shortcomings, said Sandra A. Fryhofer, MD, an Atlanta general internist who serves as the AMA’s liaison to ACIP.

“Although the schedule has gone through some small annual changes in the past, it’s never had such a complete makeover,” said Dr. Fryhofer, a member of the AMA’s Board of Trustees. “When you look at the new schedule compared with last year’s, there’s a lot more pizzazz, it’s much more visually appealing, and it’s easier to find things.”

Each vaccine is now listed alongside its trade name, and the document also includes web links for more information about ACIP’s recommendations.

“The figures are gone, replaced by colorful tables,” Dr. Fryhofer. “Table 1 gives recommendations by age group and table 2 gives recommendations by medical indications and other conditions, with an expanded color code.”

Yellow means recommended if meets age requirement. Purple means recommended for adults with an additional risk factor, or another indication. Orange means use precaution. Pink is added for delay until after pregnancy. Red means contraindicated. The “no recommendation” boxes are now grey rather than white.

And those rarely viewed, difficult-to-use footnotes are gone.

“It used to be that you had a footnote subscript, and you had to take that number and match it up with the footnotes to find information for the vaccine. The footnotes have been replaced with notes and they are in alphabetical order by vaccine name, which makes them much easier to find. The notes are also more concise.”

The new design was tested with 251 internists and family physicians who liked the new design’s color scheme and simplified approach.

“Changes were needed,” Dr. Fryhofer said. “When you look at the immunization coverage rates, we need all the help we can get. Let’s hope this new schedule can help physicians increase adult coverage rates.”

New advice on flu and hepatitis A, B

After two seasons of being “not recommended,” the live attenuated influenza vaccine (LAIV), marketed as FluMist by AstraZeneca, is back on the schedule and recommended as an option for healthy nonpregnant adults through 49 years old, with a few exceptions as noted below.

LAIV is contraindicated for those who are pregnant or immunocompromised, and for those with HIV. It’s contraindicated for those with functional or anatomic asplenia. It’s also contraindicated for close contacts and caregivers of severely immunocompromised people. It should be used with precaution in those with kidney, heart, and lung problems including asthma, those with chronic liver disease, and those with metabolic problems including diabetes.

LAIV should not be given to anyone who has had flu antivirals in the last 48 hours and it also should not be given to anyone with cerebrospinal fluid leaks or a cochlear implant.

For the hepatitis A vaccine, the 2019 schedule now recommends homelessness as an indication for routine immunization. The recommendation comes on the heels of a hepatitis A outbreak among the homeless population of San Diego that infected nearly 600 people and killed 20 between March 2017 and January 2018.

San Diego health officials found homelessness was independently associated with a two to three times higher odds of Hep A infection and a two to four times higher odds of severe hepatitis A outcomes, specifically hospitalization and death.

For hepatitis B, ACIP has issued a non- preferential recommendation for the new single-antigen recombinant hepatitis B vaccine, hep B CpG (marketed as Heplisav-B by Dynavax). This vaccine has a novel cytosine-phosphate-guanine 1018 oligodeoxynucleotide adjuvant and was approved by the Food and Drug Administration in 2017.

The hep B CpG vaccine has the advantage of a rapid dosing schedule:  two doses at least four weeks apart, as compared with the schedule for the older hep B vaccines of a three-dose series over six months.