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Home , Mumps, Rubella, Zoster vaccine

nizations during childhood. This assumption does not take into account for , newer vaccines that were not available , , decades ago—or the possibility that some Varicella, and Herpes people were only partially immunized, such as by receiving only 1 in a Zoster: 3-vaccine series. Also often overlooked Guidelines for Adults are the facts that to certain dis - eases can wane over time and that elderly individuals face increased susceptibility Tami Hendriksz, DO to disease as a result of immunosenes - Philip Malouf, MD cence. Measles, mumps, rubella, varicella James E. Foy, DO (ie, ), and herpes zoster (ie, ) are all preventable illnesses with dangerous complications that can affect adults and impact public health. 2 Thus, it is crucial that healthcare providers be aware of the indications and importance of the available vacci - Although are most commonly associated with the pediatric population, it is impor- nations against these diseases. tant for healthcare professionals to be familiar with the vaccines that are recommended for adults. The authors discuss 3 vaccines—the measles, mumps, and rubella (MMR) vaccine, the Measles, Mumps, and Rubella , and the herpes zoster vaccine—including information about the diseases Vaccine and complications that they protect against. Two doses, separated by 4 weeks, of both Measles is a highly contagious viral ill - the MMR and varicella vaccines are recommended for all adults who do not have immu- ness that, until recently, was virtually nization or contraindications. All adults aged 60 years or older should receive a single dose eradicated in the . 3 The dis - of the herpes zoster vaccine unless they have contraindications. These 3 vaccines offer pro- ease can be severe, with complications tection from illnesses that can have serious sequelae and substantial public health implica- ranging from diarrhea and bronchop - tions. neumonia to subacute sclerosing panen - 2 J Am Osteopath Assoc. 2011;111(10 suppl 6):S10-S12 cephalitis and spontaneous . Complications from measles are esti - mated to be fatal in 1 or 2 of every 1000 accinations are most commonly not all preventable diseases occur exclu - reported cases in the United States. 2 Pneu - Vassociated with children, and physi - sively in children. Many illnesses, dis - monia and acute are the com - cians often think primarily of pediatric abilities, and deaths that occur in adults plications that are the most common patients when asked about immuniza - could be prevented by , causes of measles-related deaths. 2 tion schedules. There is good reason for and there are vaccines recommended Before the became this perception, because the majority of for young adults, middle-aged people, licensed for use in the United States in available vaccinations are recommended and elderly individuals. The adult 1963, there was an average of 500,000 for use in the pediatric population. How - immunization schedule currently rec - new cases of the illness reported every ever, it is important to remember that ommended by the Advisory Committee year in the nation. 2 However, it is esti - on Immunization Practices (ACIP) of the mated that virtually all children in the Centers for Disease Control and Pre - United States acquired measles prior to vention (CDC) lists 10 vaccines for 14 the introduction of the vaccine. 2 Since Tami Hendriksz, DO; Philip Malouf, MD; and James infectious diseases in adults aged 19 the vaccine became available, the E. Foy, DO, are from the Division of Pediatrics at years or older ( Figure ). 1 Of these vac - reported of measles in the Touro University California, College of Osteopathic cines, the focus of the present article is on United States has been reduced by 98%. 2 Medicine in Vallejo. Financial Disclosures: None reported. the measles, mumps, and rubella (MMR) During the past 2 decades, however, Address correspondence to Tami Hendriksz, vaccine, the varicella vaccine, and the outbreaks of measles have occurred in DO, Division of Pediatrics, Touro University Cali - herpes zoster vaccine. the United States. In the first 19 weeks of fornia, College of Osteopathic Medicine, 1310 Club Dr, Vallejo, CA 94592-1187. Many adults assume that they 2011, 118 cases of measles were reported E-mail: [email protected] received all of their necessary immu - in the United States—the highest number reported for that period since 1996. 3 Of those 118 patients, 105 (89%) were unvac - This supplement is supported cinated and 53 (45%) were aged 20 years by an independent educational grant from Merck & Co, Inc. or older. 3 The majority of the cases (89%)

S10 • JAOA • Supplement 6 • Vol 111 • No 10 • October 2011 Hendriksz et al • Immunization Guidelines for Adults Age Group, y Vaccine 19-26 27-49 50-59 60-64 ⩾65 1 dose annually Tetanus, diphtheria, pertussis Substitute 1-time dose of Tdap for Td booster; Td booster every (Td/Tdap) then boost with Td every 10 years 10 years Varicella 2 doses Human papillomavirus 3 doses (women) Zoster 1 dose* Measles, mumps, rubella (MMR) 1 or 2 doses 1 dose* Pneumococcal (polysaccharide) 1 or 2 doses* 1 dose Meningococcal 1 or more doses* A 2 doses* 3 doses*

Figure. The 2011 adult immunization schedule, by vaccine and age group, as recommended by the Committee on Immunization Practices of the Centers for Disease Control and Prevention. 1 *Recommended if some other risk factor is present.

were associated with importations (ie, been vaccinated with an inactivated (ie, and toxic shock syndrome. 4,5 Other com - US residents traveling abroad and for - killed ) vaccine, or an unknown type plications caused by VZV include eign visitors). 3 Even if all of vaccine, for measles or mumps should bleeding problems, , of measles is eliminated within the be revaccinated with 2 doses of the MMR encephalitis, and viral . 5 Com - United States, cases of measles resulting vaccine. 1 pared with children, adolescents and from importations would continue to Immunity to rubella should be adults are at increased risk of severe com - occur. 3 It is for this reason that adults determined for all women of child - plications from varicella and of the devel - need to remain current with their MMR bearing age. 1 If women who are not preg - opment of herpes zoster. 4 vaccinations, and physicians need to nant show no evidence of immunity to All adults should stay up-to-date with increase awareness of the risk of measles rubella, they should be immunized with immunizations against VZV. Two vaccines among their patients who travel abroad. the MMR vaccine. 1 Pregnant women against VZV are available—varicella virus The CDC recommends MMR vac - who show no evidence of immunity to vaccine live (Varivax; Merck & Co Inc, cination for all adults born after 1957 rubella should receive the MMR vaccine Whitehouse Station, New Jersey), to pre - who do not have documentation of pre - upon completion or termination of the vent varicella; and zoster vaccine live viously receiving 1 or more doses of the and before discharge from (Zostavax; Merck & Co Inc), to protect MMR vaccine. 1 (People born before 1957 the healthcare facility. 1 against herpes zoster. 4-6 The concentra - are generally considered to be immune tion of attenuated varicella virus in the against measles and mumps.) Exceptions Varicella-Zoster Virus herpes zoster vaccine is 14 times that in to this recommendation include indi - The varicella-zoster virus (VZV) causes a the varicella vaccine. 4 The herpes zoster viduals who have medical contraindica - preventable that affects both vaccine cannot be used in children and tions to the vaccine, laboratory evidence children and adults, and it can lead to cannot be used in place of varicella vac - of immunity to all 3 diseases, or docu - substantial morbidity and mortality. Vari - cine. 6 Similarly, the varicella vaccine mentation of provider-diagnosed measles cella is the result of a primary infection cannot be used in place of the herpes or mumps. 1 with VZV. Like other members of the zoster vaccine. 6 The CDC recommends that adults herpesvirus group, VZV can persist in receive a second dose of the MMR vac - the sensory nerve ganglia as a latent Varicella Vaccine cine at least 28 days after the first dose if infection after the primary infection. 4 The indications for the varicella vaccine any of the following conditions apply to Herpes zoster is the result of reactiva - include all adults who do not show evi - them: they have recently been exposed to tion of the virus. dence of immunity to varicella, unless the measles or or live in a Both varicella and herpes zoster can they have a medical contraindication setting at risk for outbreaks; they are stu - occur in adults and cause potentially dan - (eg, allergic reaction to a vaccine com - dents in a postsecondary educational gerous sequelae. Severe complications ponent, severe immunodeficiency, cur - institution; they plan to travel interna - of VZV infection may include bacterial rent pregnancy). 1 Evidence of immunity tionally; or they work in a healthcare pneumonia, necrotizing fasciitis, to VZV in adults can be demonstrated in facility. 1 In addition, anyone who has osteomyelitis, septic , septicemia, a number of ways, including documen -

Hendriksz et al • Immunization Guidelines for Adults JAOA • Supplement 6 • Vol 111 • No 10 • October 2011 • S11 tation of 2 doses of varicella vaccine at most commonly in people aged 50 years herpes zoster vaccines, including their least 4 weeks apart; evidence of a his - or older and in individuals who are indications and contraindications and tory of varicella or herpes zoster based immunosuppressed (whether from ill - their benefits in regard to disease burden on diagnosis or verification by a health - ness or ). 4 and public health. Healthcare profes - care provider; and laboratory confirma - Clinical trials have shown that the sionals should also educate their patients tion of the diseases or protective titers. 1 herpes zoster vaccine reduces the risk of about the benefits of . With Anyone born in the United States before herpes zoster by about 51% and the risk appropriate use, these vaccines will help 1980 is assumed to have immunity to of by about 67%. 4 protect the public against transmission varicella-zoster infection. 1 It is important to note that this vaccine of dangerous and costly diseases. Groups for whom varicella vacci - cannot be used as treatment for patients nation is especially important because of with active cases of herpes zoster, and it References high risk for exposure, transmission, or will not alter the course of concurrent 1. Centers for Disease Control and Prevention. Rec - 4 ommended adult immunization schedule—United severe disease include the following: postherpetic neuralgia. Although the States, 2011. MMWR Morb Mortal Wkly Rep . healthcare personnel; family contacts of vaccine has been found to be most effec - 2011;60(4):1-4. people with immunocompromising con - tive in people aged 60 to 69 years, it also 2. Atkinson W, Wolfe , Homborsky J, eds; Centers ditions; teachers at and employees of provides some protection in older indi - for Disease Control and Prevention. 4 and Prevention of Vaccine-Preventable Diseases . childcare institutions; residents and staff viduals. Research suggests that the pro - 12th ed. Washington, DC: Public Health Founda - of correctional institutions; college stu - tective effects of the herpes zoster vac - tion; 2011. dents; military personnel; nonpregnant cine persist for at least 6 years, although 3. Centers for Disease Control and Prevention. women of childbearing age; adults and the effects may last longer. 4 Ongoing Measles: United States, January-May 20, 2011. adolescents living with children; and studies are being conducted to determine MMWR Morb Mortal Wkly Rep . 2011;60(20):666- 668. international travelers. 1 As with the more accurately the length of time that MMR vaccine, pregnant women who the vaccine protects against herpes zoster. 4 4. Shingles vaccination: what you need to know. Centers for Disease Control and Prevention Web have no evidence of immunity to VZV Similar to the MMR and varicella site. http://www.cdc.gov/vaccines/vpd-vac/shin - should receive the varicella vaccine on vaccines, the herpes zoster vaccine is con - gles/vacc-need-know.htm. Accessed August 2, 2011. completion or termination of pregnancy traindicated in individuals who have had 5. Vaccines and preventable diseases: varicella dis - and before discharge from the health - an adverse reaction to components of the ease, clinical questions & answers. Centers for Dis - 1 ease Control and Prevention Web site. http: care facility. vaccine; in pregnant women; and in //www.cdc.gov/vaccines/vpd-vac/varicella/dis-faqs patients who have blood cancers or -clinic.htm. Accessed August 2, 2011. Herpes Zoster Vaccine human immunodeficiency virus or who 6. Vaccines and preventable diseases: herpes zoster The indications for the herpes zoster vac - are taking medications that weaken the vaccination for health care professionals. Centers cine are different than those for the vari - immune system (eg, for Disease Control and Prevention Web site. http: 4 //www.cdc.gov/vaccines/vpd-vac/shingles/hcp cella vaccine. A single dose of the herpes agents, steroids). -vaccination.htm. Accessed August 2, 2011. zoster vaccine is recommended for all adults aged 60 years or older, regardless Conclusion of whether they report previous episodes Healthcare professionals should be of herpes zoster. 1 Herpes zoster occurs familiar with the MMR, varicella, and

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S12 • JAOA • Supplement 6 • Vol 111 • No 10 • October 2011 Hendriksz et al • Immunization Guidelines for Adults