+HOW TO TREAT Adult

Adult vaccination receives less attention than the childhood , and its importance may be overlooked at times. The purpose of this article is to summarise the 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 , human papillomavi- Stewart Reid, the visits at age 45 and 65 years for considerable efforts have A rusis (HPV) the main vaccine and . general tetanus-diphtheria (Td) vaccine and gone into refining the childhood vaccina- Also, considerable improvements in practitioner, the annual 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 ; 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 mortality­ aciclovir 800mg five times daily. Adults aged 20 to 65 years from vaccine-preventable diseases Two doses of 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- 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 occur­red 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 mortal­ity 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.

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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 menin­gococcal groups B and C. Varicella vaccine could also be con- of those . 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. Two quadri- Males should mune, a blood test for immunity prior 7 The HPV vaccine generates immune valent (ACYW135) conjugate meningo- consider to vaccination is recommended. memory and robust anamnestic respon­ coccal vaccines are also available and could Vaccination with varicella vaccine ses have been demonstrated – also to be offered to provide broader protection having the post exposure has been found to be eight years – suggesting stable, long- (see later for travel considerations). HPV vaccine effective in preventing or amelio- term protection is likely.5,6 A group B vaccine (Bexsero) is licensed as well rating illness, if the vaccine is given Males should consider having the HPV in Australia and may become available within three and possibly five days of vaccine as well, given the protection it here. It contains four antigens: three exposure.8 www.nzdoctor.co.nz HOW TO TREAT 3 HOW TO TREAT+Adult vaccination

Healthy adults aged 20 to 65 years can be too easily forgotten

Currently funded

Tetanus-diphtheria (Td) vaccine but not its administration is funded, and certain high-risk patient groups are funded for some vaccines – see the Immunisation Handbook 2014

or healthy 20 to 65-year-old Varicella people, consider also the vac- vaccine should Fcines for catch-up listed in the be considered section for the school leaver to 20 for those with years age group. no history of Adults should be offered Tdap vac- chickenpox cine to reduce the risk of exposure of infants to pertussis. This applies to parents, older siblings, grandparents offered rather than Td. with chronic liver disease. It is also an and other adults who may expose in- Influenza vaccination should be offer­ important, frequently recommended fants too young to be vaccinated to ed to high-risk adults; see the Immunis­ travel vaccine, and is recommended for pertussis. Special considerations re- ation Handbook 2014 for a list of those for those in certain occupations – see later, garding vaccination against pertussis whom it is funded. Adults may be offered “Pregnancy and occupational risk”. apply in pregnant women – see later, influenza vaccine as a result of their Varicella vaccine should be considered “Pregnancy and occupational risk”. employment (eg, in healthcare or educa- for those with no history of chickenpox, Tdap instead of Td vaccine should tion), particularly if involved in the care but the same considerations regard- be offered following injury or prior of young children – see later, “Pregnancy ing testing apply to this age group as for to travel if the above consideration and occupational risk”. I would not, those aged 18 to 20 years. applies. No minimum time interval however, hesitate to offer influenza Shingles vaccine (Zostavax) is licenced following a dose of Td is required if vaccine to any adult who requests it. for use in people aged from 50 years. It the administration of Tdap is to pre- HPV vaccine is licensed for women up offers 70 per cent protection against vent the potential exposure of infants to the age of 45 years, and men to age 26 shingles when administered between to pertussis. years. Given the high level of protection the ages of 50 and 60 years. This drops While 10-yearly administration of it offers against HPV-related disease, it to 60 per cent for those aged between 60 a tetanus -containing vaccine should be offered to women who have and 70 years and 40 per cent between simplifies tetanus-related wound had abnormal smears and MSM, the 70 and 80 years. Above 80 years of age, management, it is not routinely rec- recommendation being stronger for the protection against shingles is only ommended. Instead, a number of younger individuals. 18 per cent, but the protection against years ago, a pragmatic decision was Note, the HPV vaccine is a prophy- severe illness remains.9,10 For example, made to recommend two ages at HPV vaccine lactic and not a therapeutic vaccine (ie, the efficacy of the vaccine in maintain- which tetanus immunisation status ...should be it does not protect against HPV types ing activities of daily living remains at should be reviewed and updated: ages offered to with which the individual is already approximately 60 per cent, comparable 11 45 and 65 years. women who infected). with other age groups. When conducting this immuni- should be offered It appears that the duration of protec- sation review, remember to consid- have had to adults (and children) who have been tion of a single dose of shingles vaccine er whether a booster – or a course abnormal in contact with an individual who is in- is around seven to 10 years, and the re- if there is no prior vaccine history smears fected with hepatitis A (this use is fund- sponse to a subsequent dose is neither – is required, and whether at least ed). It should be offered to those who are impaired nor enhanced by the receipt of one dose of Tdap vaccine should be infected with hepatitis B or C and those a prior dose.12

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At 65 years and older, infectious illness can take a greater toll

CASE VIGNETTE 2

How long to delay giving Zostavax after shingles?

A female patient aged 68 years, who six months ago had an attack of ophthalmic shingles, wants to avoid another attack and requests the shingles vaccine. When should it be given? There is no clear answer to this question. Second attacks of shingles can occur, though recurrences are probably less likely in the first year or two after an attack. Reasonable advice might be to vaccinate one to three years after an attack of shingles; this may be too early, however. The duration of protection following vaccination appears to be between seven and 10 years. The response to a second vaccine dose 10 years after a first dose is the same as the response seen in individuals of the same age receiving their first dose. So I would advise that this patient receives her second dose in her late seventies.

efficacy of PCV 13 against vaccine- type IPD was 75 per cent (95 per cent Grandparents can CI: 41.4 – 90.8 per cent) and against be a source of vaccine-type pneumococcal pneumo- pertussis infection nia was 45 per cent (95 per cent CI: for their grandchildren 21.8 – 62.5 per cent).14 The main argument against this recommendation is the cost of the ry illnesses, 53 per cent of pneumonias, two vaccines. For the individual, the Currently funded 50 per cent of all hospitalisations and cost including administration of the 68 per cent of deaths.”13 On the basis two vaccines is likely to be around Influenza vaccine is funded, of this evidence, influenza vaccine is $400 and, given the modest benefit, and so is Td vaccine but strongly recommended. is difficult to justify. Nevertheless, not its administration Pneumococcal vaccination for those those who can afford it may choose aged 65 years and older is recommend- to receive the modest benefit. ed but not funded. What is advised is Another expensive vaccine is that or the considerations around tet- one dose of the pneumococcal conju- against shingles – described earlier, anus-containing vaccines, see the gate vaccine PCV 13 (Prevenar 13) fol- “Healthy adults aged 20 to 65 years”. Fprevious section. And, remember, lowed a minimum of eight weeks later Annual The argument for the use of shingles grandparents can be a source of pertussis by the pneumococcal polysaccharide influenza vaccine gets stronger with increas- infection for their grandchildren. vaccine PPV 23 (Pneumovax 23).1 vaccine is ing patient age. Shingles severity and Annual influenza vaccine is recom- However, there is controversy about recommended associated morbidity increases with mended for all people aged 65 years the effectiveness of the polysaccharide age and, although the vaccine is less and older. To quote the Immunisation vaccine in preventing IPD. for all people effective at preventing shingles as Handbook 2014: “A 1995 meta-analy- Data exist to support the use of PCV aged 65 years age increases, it remains effective at sis of 20 cohort studies in older people 13 in adults aged 65 years and older. and older reducing its severity. (See “How to estimated that influenza vaccine pre- In a study conducted in the Netherlands treat: Shingles”, New Zealand Doctor, vented 56 per cent of upper respirato- on approximately 85,000 adults, the 30 July 2014 for more details.)15 www.nzdoctor.co.nz HOW TO TREAT 5 HOW TO TREAT+Adult vaccination

Pregnancy and occupational risk

CASE VIGNETTE 3

Tdap vaccine in every pregnancy?

A colleague asks if a patient who is currently 26 weeks’ gestation should receive Tdap vaccine in this pregnancy. She received Tdap two and four years ago. The answer is yes, she should receive it. Tdap vaccine is recommended in every pregnancy because when given between 28 and 38 weeks the baby receives some passive antibody, which may provide protection until is adminis- tered to the infant.

CASE VIGNETTE 4

Two doses of hepatitis A vaccine one week apart

A 25-year-old man inadvertently receives a second dose of Currently funded Currently funded hepatitis A vaccine one week after the first. What should be done? The patient should be fully informed, and the second dose In pregnancy, Tdap and Funded occupational should be ignored. An alternative approach might be to test his influenza vaccines are vaccines are only those hepatitis A IgG at six months and if positive give no further doses, funded funded by the employer but repeat his hepatitis A IgG after a further three to five years.

t is important that two vaccines he use of vaccines for employ- vaccine (probably the quadrivalent con- are administered in pregnancy: ment-related situations is deter- jugate vaccine) depending on potential Iinfluenza and Tdap. Tmined by potential exposure risk, exposure. Influenza is a more severe illness the potential to infect the vulnerable, Caregivers and other individuals who in pregnancy, and women who are susceptible others and the need to main- work with children require similar pro- pregnant during the influenza season tain the provision of essential services tection to healthcare workers. should be offered vaccine from when when absence from work could put the Emergency personnel should be pro- the vaccine becomes available and the community at risk. tected against tetanus and hepatitis B second trimester has commenced. If The mode of transmission of infection and, because they are part of an essen- influenza is circulating, offer the vac- determines risk: is it airborne, through tial service, should receive annual influ- cine to women in their first trimester, contact with infectious droplets, via enza vaccination. as recommended in the Immunisation faecal-oral routes or through exposure Armed forces personnel may require Handbook 2014. to body fluids? some travel-related vaccines depend- Tdap vaccine should be adminis- In addition, for some infections, the ing on potential deployment – see later, tered between 28 and 38 weeks’ ges- risk of transmission to hospitalised pa- All healthcare “Travel vaccination”. tation in every pregnancy, for two tients who may be immunocompro- Individuals who work with animals reasons. First, the vaccine is to protect mised is significant. Thus, all healthcare workers may require influenza, BCG and hep- mothers, who are the most frequent workers should be immune to hepatitis should be atitis A vaccines, again dependent on source of infant pertussis. Second, if B, measles, mumps, rubella and varicel- immune to potential exposure. administered in the third trimester, la, and receive annual influenza vaccina- hepatitis B, Individuals who work with body fluids the infant receives passive maternal tion. If healthcare workers have contact measles, (eg, undertakers) require to be protect- antibody and some protection against with children, they should also receive ed against hepatitis B. Those who work pertussis if exposure does occur. Tdap for the pertussis component and mumps, with sewage require protection against There is also evidence to suggest hepatitis A vaccine. rubella hepatitis A and polio. For sex work- high levels of maternal antibody do Laboratory staff may require, in ad- and varicella ers, hepatitis B and HPV vaccines are not impair an infant’s response to dition to the above, inactivated polio- recommended. See also table 4.6 in the infant doses of pertussis vaccine.16 virus vaccine (IPV), and meningococcal Immunisation Handbook 2014.

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Travel vaccination requires a sound assessment of risk

outbreak of typhoid. ously unvaccinated individual, this Currently funded Many younger travellers from New requires rabies immunoglobulin and Zealand have already received hepatitis B four or five doses of .17 Travel vaccines are vaccine in childhood but, if not, it is ad- Rabies immunoglobulin is in limit- not funded visable they receive it. For older travel- ed supply and is difficult to access in lers, I generally inform them that the risk many countries where significant ra- of hepatitis B relates to sexual transmis- bies risk exists. Individuals are like- ost travellers to countries sion and/or intravenous drug use, and ly to have to inter­rupt their itinerary other than Western Europe, let them decide whether it is required. and travel (possibly back home) to MNorth America and Australia is advised for obtain proper post-exposure prophy- are recommended to receive some vac- travellers to parts of South America and laxis. Compre­hensive travel insurance cines. However, vaccination is only part Africa; detailed maps of risk areas are is essential. – and, at times, a very small part – of a available on the Centers for Disease Post-exposure prophylaxis requires travel-related consultation. Con­­trol (CDC) and World Health Organ­ only two doses of rabies vaccine in First, it is important to ensure all trav- ization (WHO) websites. those who have received pre-expo- ellers have received the routine child- If an individual is visiting an area sure vaccination.17 Pre-exposure vac- hood vaccines, in particular two doses where the risk of infection exists, the de- cine involves three doses of vaccine of a measles-containing vaccine. If not, a cision to offer yellow fever vaccine is easy. on days zero, seven and 21 to 28. dose of MMR vaccine should be offered, However, there are also border-crossing The rabies vaccine may be admin- unless the individual was born before issues to consider. Some nations require istered at a reduced dose if given 1969 and is considered immune. evidence on entry of yellow fever vacci- intradermally – to reduce the cost – Measles may not be controlled in some nation if an individual is travelling from a though this use is off-label and, in my parts of the world, and this approach country with a risk of yellow fever trans- view, requires a blood test one week reduces the possibility of the importa- mission. However, for many countries, after the third vaccine dose to ensure tion of measles into New Zealand. only part of the country is in the yellow sero­conversion (>0.5IU/ml). With ra- Second, for most travellers, I would ad- fever risk area, and the traveller who does bies, certainty is everything. vise a dose of Td or Tdap vaccine if it is not visit the risk area has no risk of ex- Once an individual has received more than 10 years (or close to 10 years) posure and therefore no risk of infection. pre-exposure pro­phylaxis, it is prob- since receipt of a prior dose of a tetanus- As yellow fever vaccine carries a rare ably not required ever again but, of containing vaccine. Minor injuries are risk of a yellow fever-like illness which course, post-exposure doses on days common, and this approach simplifies may be fatal, this makes the decision to zero and three are required in the tetanus-related wound man­agement. offer vaccine when there is no risk of dis- event of a potential exposure. For ease problematic. this reason and because parents may Specific travel-related An additional problem is nations do be inclined to pay for it, I encour­ vaccines not have to agree with the WHO rec- age young travellers to Africa, Asia Hepatitis A vaccine is recommended for ommendation that some countries (eg, or South America to receive pre- all travellers other than those going to Tanzania) have low or no risk of yellow exposure vaccine. There remains the Australia, Western Europe and North fever, and this may lead to difficulties for concern, however, that the young- America. If born in an endemic country those transiting through such a nation er traveller may not be so insistent in or for those with a history of prior hepati- after visiting one of the “low” or “no-risk” obtaining post-exposure treatment tis, I would usually offer blood testing for countries. as the older traveller. immunity prior to vaccination. A second This situation, of no risk of disease but A comprehensive review of the pre- dose at least six months after the first a vaccination required for border cross- Measles vention and management of rabies dose offers long-term protection against ing, is a frequent problem for those au- may not be can be found in the 17 January 2015 17 hepatitis A, possibly lifelong. An interval thorised to provide yellow fever vaccine, controlled issue of the British Medical Journal. of several years between doses does not but it is important that others who pro- Japanese encephalitis is a viral in- require repeating the first dose. vide travel medicine advice are aware of in some fection carried by mosquitoes and is should be considered this potential problem. parts of the leading cause of vaccine-prevent- for travellers visiting rural areas in Africa, Clinical rabies is universally fatal but the world able encephalitis in Asia. It is passed Asia and Central and South America, or post-exposure prophylaxis is highly ef- to humans by the bite of an infected any country where there is currently an fective if received promptly. In a previ- mosquito, but fewer than 1 per cent of www.nzdoctor.co.nz HOW TO TREAT 7 HOW TO TREAT+Adult vaccination

these infections result in illness. References 10. Schmader KE, Levin MJ, Gnann JW Jr In those who do develop illness, the 1. Ministry of Health. Immunisation et al. Efficacy, safety, and tolerability of her- incubation period for Japanese en- Handbook 2014. Wellington: Ministry of pes in persons aged 50–59 cephalitis is five to 15 days after the Health, 2014. Available online at www.health. years. Clin Infect Dis 2012;54(7):922–28. bite, and the outcome is often severe, govt.nz/publicationimmunisation-hand- 11. Schmader KE, Johnson GR, Saddier with 20 to 30 per cent dying from the book-2014 P et al. Effect of a zoster vaccine on herpes illness. Thirty to 50 per cent of survi- 2. Reid S, Ah Wong B. The incidence of zoster-related interference with functional vors incur nervous system damage. herpes zoster (shingles) over five years at status andhealth-related quality-of-life The main mosquito vector usually a large New Zealand general practice. measures in older adults. J Am Geriatr Soc breeds in rice fields and so potential NZ Med J 19 December 2014;127:1407. 2010;58:1634–41. exposure is more likely in rural 3. Ministry of Health. Immunisation 12. Levin MJ et al. 20th IAGG World travellers.18 Handbook 2014. (Section 18.5.2). Congress of Gerontology and Geriatrics, Vaccination for Japanese encepha- Wellington: Ministry of Health, 2014. Seoul, Korea, 23–27 June 2013 (poster litis is available in New Zealand but is 4. Ferris D, Samakoses R, Block SL presentation). very expensive and so is probably un- et al. Long-term study of a quadrivalent 13. Gross PA, Hermogenes AW, Sacks derutilised. However, it is a vaccine- human papillomavirus vaccine. Pediatrics HS et al. The efficacy of influenza vaccine preventable disease, and the risks 2014;134:e657–65. in elderly persons: a meta-analysis and should be discussed with travellers 5. Olsson S, Villa LL, Costa RL et al. review of the literature. Ann Intern Med visiting areas where it occurs. Induction of immune memory following 1995;123(7):518–27. Quadrivalent meningococcal con- administration of a prophylactic quadri- 14. Bonten M, et al. Community Acquired jugate vaccine (two doses eight weeks valent human papillomavirus (HPV) types Pneumonia Trial in Adults apart) is available and should be of- 6/11/16/18 L1 virus-like particle (VLP) (CAPiTA) [abstract no. 0541]. Pneumonia fered to those travelling to the men- vaccine. Vaccine 2007;25(26):4931–39. 2014;3:95. Available online at http://bit. ingitis belt in sub-Saharan Africa or to 6. Smolen K, Gelinas L, Franzen L et al. ly/1rsocKp the Hajj in Saudi Arabia. Age of recipient and number of doses 15. Reid S. How to treat: Shingles. New IPV should be offered to those differentially impact human B and T cell Zealand Doctor, 30 July 2014. Auckland: travelling to Nigeria, Pakistan or immune memory responses to HPV Medimedia Ltd, 2014 Afghanistan, or any other countries vaccination. Vaccine 2012;30(24):3572–79. 16. Pollock L et al. The relationship between where polio is occurring. IPV is not 7. American Academy of Pediatrics. specific antibody titres at birth and the required for those who have received Varicella-zoster infections. In: Pickering LK, response to primary immunisation (abstract). a dose as an adult within the last 10 Baker CJ, Kimberlin DW et al. (eds). Red 31st Annual European Society for Paediatric years. l Book: 2012 report of the Committee on Infectious Diseases Meeting, Milan, 28 May– Infectious Diseases (29th). Elk Grove Village 1 June, 2013. (IL): American Academy of Pediatrics, 2012. 17. Crowcroft N, Thampi N. The prevention CONCLUSION 8. Ministry of Health. Immunisation and management of rabies. BMJ 2015; Handbook 2014. (Section 21.8). Wellington: 350:g7827. • Adult vaccination is a Ministry of Health, 2014. 18. Centers for Disease Control and Preven- challenging area for practition- 9. Oxman MN, Levin MJ, Johnson GR et al. tion. CDC Health Information for International ers because of the age range A vaccine to prevent herpes zoster and post Travel 2014. (Chapter 3: Infectious diseases and variety of circumstances herpetic neuralgia in older adults. N Engl J related to travel). New York: Oxford Universi- that require careful considera- Med 2005;352:2271–84. ty Press, 2014. tion, whereas childhood vacci- nation is largely proscribed with a comprehensive schedule. This publication has been reprinted with the support of Medicines New • Apart from Tdap and Zealand to provide an update on adult influenza vaccines in pregnan- vaccination. The content is entirely cy, annual influenza vaccine independent and based on published for those aged 65 years and studies and the author’s opinion. older, and tetanus-containing Medicines New Zealand, PO Box 10-447, The Terrace, Wellington 6143, vaccine at ages 45 and 65 Phone +64 4 499 4277. years, adult vaccination is not well proscribed. This article has been reprinted from New Zealand Doctor newspaper, 15 April 2015. The views expressed are not necessarily those of the publisher or sponsor. • This article has hopefully Produced by Medimedia Ltd, publisher of New Zealand Doctor, helped to demystify adult PO Box 31348, Milford, Auckland 0741. vaccination and made the Ph (09) 488 4278, Fax (09) 489 6240 practitioner’s approach to it simpler. © Medimedia Ltd, 2015.

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