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Adult Vaccination +HOW TO TREAT Adult vaccination Adult vaccination receives less attention than the childhood vaccination schedule, and its importance may be overlooked at times. The purpose of this article is to summarise the vaccines recommended for use in adults. It is structured to answer the question “What vaccines should I consider for this patient in front of me?” Understanding iron metabolism helps doctors and patients There is no comprehensive adult vaccination schedule dult vaccination is the poor • the introduction of new antigens cination schedule. The only vaccina- cousin of childhood vaccina- • the introduction of pneumococcal Written by tion visits being recommended are tion. Over the last 30 years, conjugateThe liver vaccine, human papillomavi- Stewart Reid, the visits at age 45 and 65 years for considerable efforts have A rusis (HPV) the main vaccine and rotavirus vaccine. general tetanus-diphtheria (Td) vaccine and gone into refining the childhood vaccina- Also, considerable improvements in practitioner, the annual influenza vaccine from tion schedule, resulting in: coverage“orchestrator” have been made with the help Ropata age 65 years (also for those with spe- • a reduction in the number of visits of theof National iron Immunisation Register, Medical cific medical indications). No effort is in the 1990s a legacyregulation. of the meningococcal group B Centre, made to measure adult immunisation • the greater use of combination vaccination programme (MeNZB). Lower Hutt coverage except for an approximation vaccines since 2000 There is no comprehensive adult vac- Continued on page 2 HOW TO TREAT+Adult vaccination Continued from page 1 of the uptake of the annual influen- CASE VIGNETTE 1 Panel 1 za vaccine. Routine adult Vaccination of adults – particularly Varicella vaccination in an adult who has vaccinations; as patients age and immune sene- been exposed? and funding scence intervenes – is less effective in disease prevention than is the case A 42-year-old father asks to have the chickenpox vaccine School leaver to age 20 years with childhood vaccination. Never­­- because he has no history of chickenpox and his daughter has uCatch-up of childhood immunisa- theless, adult vaccination remains just been diagnosed with it. He is advised he is probably immune, tions: MMR, hepatitis B, tetanus (Td); of considerable potential benefit, as 70 to 90 per cent of adults with no history are immune, and he funded as it provides a reduction in disease should have a blood test to check for susceptibility. uHPV; funded for females to age 20 incidence and an amelioration of However, he does not have the blood test and suffers a quite uMeningococcal, varicella disease severity. Adults suffer from severe chickenpox illness, probably ameliorated by his taking significant morbidity and mortal ity aciclovir 800mg five times daily. Adults aged 20 to 65 years from vaccine-preventable diseases Two doses of varicella vaccine are required for this age group. uTdap, influenza, HPV, hepatitis A, (VPDs). I would suggest the optimum approach, where household shingles, varicella; influenza vaccine exposure has occurred, is to vaccinate and draw blood for funded for those at high risk Vaccine-preventable testing simultaneously, and if varicella IgG is positive, omit the diseases in adults second dose. Adults aged 65 years and older HPV-related diseases result in death uPneumococcal, Tdap, influenza, from various cancers: cervical, anal shingles; influenza vaccine funded and oropharyngeal. For example, in of those who live to age 85 years will be 2010, there were 180 reported cases affected. Pregnancy of cervical cancer and 52 deaths.1 Perhaps the largest burden of VPDs in uTdap, influenza; funded On average, up to two cases of teta- the elderly is that due to pneumococcal Occupational risk nus occur each year, predominately in disease, although the burden has been uMMR, hepatitis B, varicella, Tdap, adults. Of the 21 cases between 2001 reduced in recent years by the implemen- influenza, hepatitis A, meningococcal, and 2012, 17 were in adults, the vast tation of universal childhood pneumo- polio, BCG; employer funded majority of whom were either unvac- coccal vaccination resulting in reduced cinated or had unknown vaccination exposure of the elderly to the pneumo- Travellers status.1 coccal types included in the vaccine. uCatch-up of childhood immunisations Pertussis remains a significant Nevertheless, the rate of invasive pneu- plus diphtheria-tetanus ADT booster, problem in adults with almost half of mococcal disease (IPD) remains high- hepatitis A, hepatitis B, typhoid, yellow the reported cases occurring in adults est in those aged 65 years and older: a fever, rabies, Japanese encephalitis, aged more than 30 years.1 The impor- reported rate of 30.8 cases per 100,000 meningococcal ACYW135, polio; tance of pertussis in adults, however, population.1 not funded is in the potential transmission of the The purpose of this article is to sum- infection to infants too young to be marise the vaccines recommended for vaccinated. use in adults. It is structured to answer Influenza causes deaths in adults; the question “What vaccines should I attempts in recent years to improve consider for this patient in front of me?” the coverage of influenza vaccine in The article discusses healthy adults those aged over 65 years have like- aged 18 to 20 years, 20 to 65 years ly reduced influenza-related deaths. and 65 years and older; pregnant Nevertheless, more than half of the patients; individuals at risk because of reported influenza deaths between occupation; and those who are travel- 2000 and 2011 occur red in those Adults ling. Outside the scope of this article aged 65 years and older.1 The 126 are those with impaired immunity; this reported deaths probably signifi- suffer from group, in any case, is well covered in the cantly underestimates the true num- significant Immunisation Handbook 2014. And while ber caused by influenza – see later, morbidity travel vaccines are covered here, remem- “Adults aged 65 and older”. and mortal ity ber vaccination is only part (at times Shingles causes significant mor- from vaccine- a very small part) of the travel-related bidity in older age groups in New consultation. Zealand, and a recent publication preventable Panel 1 provides a summary list of indicates that the incidence in New diseases the vaccines that may be recommend- Zealand is similar to that report- (VPDs) ed to those in the various age groups, in ed internationally.2 The lifetime risk pregnancy, at occupational risk and prior of shingles is one in three, and half to travel. 2 HOW TO TREAT www.nzdoctor.co.nz Adult vaccination+HOW TO TREAT School leaver to age 20 years: Time to catch up on missed vaccines The late teens is also an Currently funded age during which hepatitis Catch-up childhood B transmission is likely vaccines are funded, and the HPV vaccine is funded for females up to age 20 years he first concern with the school leaver to 20 years age group is to Tensure all childhood vaccines have been received, and to offer any catch-up doses that may be required. Two doses of measles-mumps-rubel- la (MMR) vaccine should have been ad- ministered, and if not documented, a catch-up dose should be offered. This is particularly important for women, who should be immune to rubella prior to pregnancy. If not immune, women should receive two doses of rubella- provides against genital warts and the proteins derived from a genetic anal- containing vaccine as an adult, after cancers associated with HPV: anal, oro- ysis of meningococci and the outer which no further dose is required.3 pharyngeal, penile. It is important to membrane protein that was the key Check also that the age-11-year dose remember the risk of all of these condi- antigen in MeNZB. For those aged more of tetanus-diphtheria-acellular pertussis tions is much greater in men who have than 11 years, two doses one month (Tdap) vaccine has been administered, sex with men (MSM); any men so identi- apart are recommended. During the and offer a catch-up dose if necessary. fied should be offered vaccination. period 2008 until 2012, group B caused The late teens is also an age during In my view, it is simply a matter of time approximately 50 per cent of menin- which hepatitis B transmission is like- (and the sooner the better) until univer- gococcal disease in the 15 to 19-year ly, so ensure three doses of hepatitis B sal adolescent HPV vaccination is fund- age group and approximately 70 per vaccine were administered in infancy. If ed, quite likely using two rather than cent in those aged 20 years and older. needed, refer to the catch-up schedules three doses. When it becomes available, I would be in the Immunisation Handbook 2014. Meningococcal vaccination should likely to recommend the group B vac- The vaccine for HPV is important for also be considered for this age group. cine in addition to group C conjugate women as it provides such a high level of In New Zealand, the main groups vaccine for those moving to communal protection against infection with high- causing disease in this age group are accommodation. risk HPV types and the consequences menin gococcal groups B and C. Varicella vaccine could also be con- of those infections. The duration of At present, no group B vaccine is avail- sidered for this age group if there is no immunity is not known and is limited able in New Zealand, but there are two prior history of chickenpox. As two simply by the length of time the vaccine conjugate group C vaccines available. doses are required, it is not funded has been available. Current data indicate I would recommend group C vaccine for and many adults (70 to 90 per cent) clinical protection is stable for at least individuals leaving home and moving to with no history of chickenpox are im- eight years and likely much longer.4 communal accommodation.
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