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Practice Guidelines

ACIP Releases 2011 Schedules DOUG CAMPOS-OUTCALT, MD, MPA, University of Arizona College of Medicine, Phoenix, Arizona

older who are in close contact with . Guideline source: Centers for Disease Control and Prevention, Advisory Committee on Immunization Practices This is an off-label recommendation. • Administration of Tdap for children Literature search described? No seven to 10 years of age who have not com- Evidence rating system used? No pleted a series of diphtheria and tetanus tox- Published source: Morbidity and Mortality Weekly Report. In press. oids and acellular pertussis (DTaP). This is an off-label recommendation. • Elimination of the recommended inter- Coverage of guidelines Each year the Advisory Committee on Immu- val between administration of tetanus and from other organizations nization Practices (ACIP) of the Centers for diphtheria vaccine (Td) and Tdap. does not imply endorse- ment by AFP or the AAFP. Disease Control and Prevention updates There are several clarifications in the the recommended immunization schedules footnotes of this year’s schedules, including for children, adolescents, and adults. These explanations for the spacing of the three- schedules describe the recom- dose primary series of mended for routine administration in each (HepB) for infants who did not receive a age group and include revisions and new dose immediately after birth; the timing of recommendations adopted by ACIP in the the third HepB dose; situations in which previous 12 months. children younger than nine years need two There are only a few new recommenda- doses of vaccine; the availability tions in this year’s schedules, most notably of two human papillomavirus to universal administration of influenza vac- prevent cervical cancer (quadrivalent and cine for all persons six months and older, bivalent)3; and the availability of the quad- and the replacement of the 7-valent pneu- rivalent human papillomavirus vaccine for mococcal (Prevnar) with prevention of genital warts in men. a 13-valent product (Prevnar 13) for infants Over time, vaccines have been one of the and children.1,2 most effective public health interventions. ACIP has incorporated several other Many of today’s physicians have never seen changes to the schedules, even though they a patient with , rubella, , or have not yet been published. These changes other diseases that in the past were lead- include: ing causes of morbidity and mortality. One • Administration of quadrivalent menin- could say that vaccines are a victim of their gococcal conjugate vaccine (MCV4) in a own success—the better they work, the less two-dose primary series, instead of a single they are appreciated. With the absence of dose, for children with high-risk immuno- vaccine-preventable diseases, the benefit of compromising conditions. vaccines goes unnoticed, while exaggerated • Administration of a booster dose of and false claims of harm receive increasing MCV4 at age 16 for persons who were vac- attention and concern about safety becomes cinated at 11 to 12 years of age, or four to the most important issue to parents. Fam- five years after the first dose for persons vac- ily physicians now need to spend more time cinated at 13 to 15 years of age. reassuring patients and families of the safety • Administration of tetanus , and effectiveness of vaccines. reduced diphtheria toxoid, and acellular per- As more vaccines are licensed and protec- tussis vaccine (Tdap) for adults 65 years and tion against more infectious diseases becomes Downloaded from the American Family Physician Web site at www.aafp.org/afp. Copyright© 2011 American Academy of Family Physicians. For the private, noncom- 318 mercialAmerican use of one Family individual Physician user of the Web site. All other rights reserved.www.aafp.org/afp Contact [email protected] for copyrightVolume questions 83, Number and/or permission3 ◆ February requests. 1, 2011 Recommended Adult Immunization Schedule · 2011 Note: These recommendations must be read with the footnotes that follow containing number of doses, intervals between doses, and other important information. Figure 1. Recommended adult immunization schedule, by vaccine and age group AGE GROUP VACCINE 19–26 years 27–49 years 50–59 years 60–64 years >65 years

Influenza1,* 1 dose annually

Tetanus, diphtheria, pertussis Substitute 1-time dose of Tdap for Td booster; then boost with Td every 10 yrs Td booster every 10 yrs (Td/Tdap)2,*

Varicella3,* 2 doses

Human papillomavirus (HPV)4,* 3 doses (females)

Zoster5 1 dose

Measles, mumps, rubella (MMR)6,* 1 or 2 doses 1 dose

Pneumococcal (polysaccharide)7,8 1 or 2 doses 1 dose

Meningococcal9,* 1 or more doses

Hepatitis A10,* 2 doses

Hepatitis B11,* 3 doses

*Covered by the Vaccine Injury Compensation Program. For all persons in this category who meet the age Recommended if some other risk factor is No recommendation requirements and who lack evidence of present (e.g., based on medical, occupational, (e.g., lack documentation of or have lifestyle, or other indications) no evidence of previous )

Report all clinically significant postvaccination reactions to the Reporting System (VAERS). Reporting forms and instructions on filing a VAERS report are available at http://www.vaers.hhs.gov or by telephone, 800-822-7967. Information on how to file a Vaccine Injury Compensation Program claim is available at http://www.hrsa.gov/vaccinecompensation or by telephone, 800-338-2382. Information about filing a claim for vaccine injury is avail- able through the U.S. Court of Federal Claims, 717 Madison Place, N.W., Washington, D.C. 20005; telephone, 202-357-6400. Additional information about the vaccines in this schedule, extent of available data, and contraindications for vaccination also is available at http://www.cdc.gov/vaccines or from the CDC-INFO Contact Center at 800-CDC- INFO (800-232-4636) in English and Spanish, 24 hours a day, 7 days a week.

Figure 2. Vaccines that might be indicated for adults based on medical and other indications

Asplenia12 Immuno- HIV Diabetes, (including compromising failure, infection3,6,12,13 heart disease, elective conditions end-stage renal chronic splenectomy) Healthcare (excluding human Chronic liver disease, INDICATION CD4+ T lympho- lung disease, and persistent disease personnel receipt of cyte count chronic complement virus hemodialysis component [HIV])3,5,6,13 alcoholism <200 >200 deficiencies VACCINE cells/µL cells/µL

1,* 1 dose TIV or Influenza 1 dose TIV annually LAIV annually

Tetanus, diphtheria, pertussis Td Substitute 1-time dose of Tdap for Td booster; then boost with Td every 10 yrs (Td/Tdap)2,*

Varicella3,* Contraindicated 2 doses

Human papillomavirus (HPV)4,* 3 doses for females through age 26 yrs

Zoster5 Contraindicated 1 dose

Measles, mumps, rubella (MMR)6,* Contraindicated 1 or 2 doses

Pneumococcal (polysaccharide)7,8 1 or 2 doses

Meningococcal9,* 1 or more doses

Hepatitis A10,* 2 doses

Hepatitis B11,* 3 doses

*Covered by the Vaccine Injury Compensation Program. For all persons in this category who meet the age Recommended if some other risk factor is No recommendation requirements and who lack evidence of immunity present (e.g., on the basis of medical, occupa- (e.g., lack documentation of vaccination or have tional, lifestyle, or other indications) no evidence of previous infection)

These schedules indicate the recommended age groups and medical indications for which administration of currently licensed vaccines is commonly indicated for adults ages 19 years and older, as of February 4, 2011. For all vaccines being recommended on the adult immunization schedule, a vaccine series does not need to be restarted, regardless of the time that has elapsed between doses. Licensed combination vaccines may be used whenever any components of the combination are indicated and when the vaccine’s other components are not contraindicated. For detailed recommendations on all vaccines, including those used primarily for travelers or that are issued during the year, consult the manufacturers’ package inserts and the complete statements from the Advisory Committee on Immunization Practices (http:// www.cdc.gov/vaccines/pubs/acip-list.htm). The recommendations in this schedule were approved by the Centers for Disease Control and Prevention’s (CDC) Advisory Committee on Immunization Practices (ACIP), the American Academy of Family Physicians (AAFP), the American College of u.s. department of health and human services Obstetricians and Gynecologists (ACOG), and the American College of Physicians (ACP). centers for disease control and prevention Footnotes Recommended Adult Immunization Schedule—UNITED STATES · 2011 For complete statements by the Advisory Committee on Immunization Practices (ACIP), visit www.cdc.gov/vaccines/pubs/ACIP-list.htm. 1. Seasonal influenza vaccination Annual vaccination against influenza is recommended for all persons aged 6 months and older, including all adults. Healthy, nonpregnant adults aged less than 50 years without high-risk medical conditions1. Seasonal can receive influenza either vaccination intranasally administered live, attenuated influenzaEvidence vaccine (FluMist), of immunity or inac totivated . in adults Other includespersons should any of receive the the . Adults aged 65Annual years vaccinationand older can against receive the influenza standard is seasonal recommended influenza forvaccine all orfollowing: the high-dose 1) documentation (Fluzone) seasonal of 2 influenzadoses of vaccine. varicella Additional vaccine atinformation least about influenza vaccination is availablepersons at http://www.cdc.gov/vaccines/vpd-vac/flu/default.htm aged 6 months and older, including all adults.. Healthy, 4 weeks apart; 2) U.S.-born before 1980 (although for healthcare 2. Tetanus, diphtheria,nonpregnant and acellular adults aged pertussis less than (Td/Tdap) 50 years withoutvaccination high-risk personnel and pregnant women, birth before 1980 should not be Administer a one-timemedical dose conditions of Tdap canto adults receive aged either less than intranasally 65 years who administered have not received considered Tdap previously evidence or forof immunity);whom vaccine 3) history status isof unknown varicella to based replace on one of the 10-year Td boosters, and as soonlive, asattenuated feasible to influenza all 1) postpartum vaccine women, (FluMist), 2) orclose inactivated contacts ofvaccine. infants youngerdiagnosis than age or verification12 months (e.g., of varicella grandparents by a healthcareand child-care provider providers), (for and 3) healthcare personnel with directOther patient persons contact. should Adults receive aged 65 the years inactivated and older vaccine. who have Adults not previously aged areceived patient Tdap reporting and who a history have close of or contact having with an an atypical aged case, less a mildthan 12 months also should be vaccinated. Other adults aged 65 years and older may receive Tdap. Tdap can be administered regardless of interval since the most recent tetanus or diphtheria-containing vaccine. 65 years and older can receive the standard seasonal influenza case, or both, healthcare providers should seek either an epidemi- Adults with uncertainvaccine or or incomplete the high-dose history (Fluzone)of completing seasonal a 3-dose influenza primary vaccination vaccine. seriesologic with link Td-containing with a typical vaccines varicella should case beginor to aor laboratory-confirmed complete a primary vaccination series. For unvaccinated adults,Additional administer information the first 2 doses about at influenzaleast 4 weeks vaccination apart and isthe available third dose at 6–12 case months or evidenceafter the second. of laboratory If incompletely confirmation, vaccinated if it (i.e., was less performed than 3 doses), administer remaining doses. Substitutehttp://www.cdc.gov/vaccines/vpd-vac/flu/default.htm. a one-time dose of Tdap for one of the doses of Td, either in the primaryat the time series of or acute for the disease); routine booster,4) history whichever of herpes comes zoster first. based on If a woman is pregnant and received the most recent Td vaccination 10 or more years previously, administer Td during the second or third trimester. If the woman received the most recent Td vaccination2. less Tetanus, than 10 years diphtheria, previously, and administer acellular Tdap pertussis during the (Td/Tdap)immediate postpartumdiagnosis period. or verification At the clinician’s of herpes discretion, zoster Tdby maya healthcare be deferred provider; during pregnancy and Tdap substituted in the immediatevaccination postpartum period, or Tdap may be administered instead of Td toor a pregnant 5) laboratory woman evidence after an informed of immunity discussion or laboratory with the confirmationwoman. The ACIP statementAdminister for recommendations a one-time dose for administering of Tdap to adults Td as agedprophylaxis less than in wound 65 managementof disease. is available at http://www.cdc.gov/vaccines/pubs/acip-list.htm. 3. Varicella vaccinationyears who have not received Tdap previously or for whom vaccine Pregnant women should be assessed for evidence of varicella All adults withoutstatus evidence is unknown of immunity to replace to varicella one ofshould the 10-year receive 2Td doses boosters, of single-antigen and immunity. varicella Womenvaccine if who not previous do not havely vaccinated evidence or ofa second immunity dose should if they have received only 1 dose, unless theyas have soon a medicalas feasible contraindication. to all 1) postpartum Special women,consideration 2) close should contacts be given of to thosereceive who the 1) first have dose close of contact varicella with vaccine persons uponat high completion risk for severe or ter disease- (e.g., healthcare personnel and family contacts of persons with immunocompromising conditions) or 2) are at high risk for exposure or transmission (e.g., teachers; child-care employees; residents and staff members of institutionalinfants younger settings, than including age 12 correctionalmonths (e.g., institutions; grandparents college and students; child- militarymination personnel; of pregnancy adolescents and and before adults discharge living in households from the healthcarewith children; nonpregnant women of childbearingcare age; providers), and international and 3) healthcaretravelers). personnel with direct patient facility. The second dose should be administered 4–8 weeks after Evidence of immunitycontact. to Adults varicella aged in adults 65 years includes and anyolder of thewho following: have not 1) previously documentation the of first2 doses dose. of varicella vaccine at least 4 weeks apart; 2) U.S.-born before 1980 (although for healthcare personnelreceived and Tdappregnant and women, who have birth closebefore contact1980 should with not an be infant considered aged evidence4. Human of immunity); papillomavirus 3) history (HPV) of varicella vaccination based on diagnosis or verification of varicella by a healthcare provider (for a patient reporting a history of or having an atypical case, a mild case, or both, healthcare providers should seek either an epidemiologic link with a typical varicella case or toless a laboratory-confirmed than 12 months also case should or evidence be vaccinated. of laboratory Other confirmation, adults aged if it was performedHPV vaccination at the time with of acute either disease); quadrivalent 4) history (HPV4) of herpes vaccine zoster orbased on diagnosis or verification of herpes65 zoster years by and a healthcare older may provider; receive or Tdap. 5) laboratory Tdap can evidence be administered of immunity orbivalent laboratory vaccine confirmation (HPV2) of is disease. recommended for females at age 11 or Pregnant womenregardless should beof assessedinterval sincefor evidence the most of varicellarecent tetanusimmunity. or Womendiphtheria- who do 12not years have evidenceand catch-up of immunity vaccination should for receive females the firstaged dose 13 throughof varicella 26 vaccine upon completion or terminationcontaining of pregnancy vaccine. and before discharge from the healthcare facility. The years.second dose should be administered 4–8 weeks after the first dose. 4. Human papillomavirusAdults with (HPV) uncertain vaccination or incomplete history of completing a Ideally, vaccine should be administered before potential expo- HPV vaccination3-dose with either primary quadrivalent vaccination (HPV4) series vaccine with or Td-containingbivalent vaccine vaccines(HPV2) is recommendedsure to HPV for through females at sexual age 11 activity; or 12 y ears however, and catch-up females vaccination who are for females aged 13 through 26 years. should begin or complete a primary vaccination series. For unvac- sexually active should still be vaccinated consistent with age- Ideally, vaccine should be administered before potential exposure to HPV through sexual activity; however, females who are sexually active should still be vaccinated consistent with age-based recommendations.cinated adults, Sexually administer active females the first who 2 doseshave not at beenleast infected 4 weeks with apart any of thebased four recommendations.HPV vaccine types (types Sexually 6, 11, active 16, and females 18, all of who which have HPV4 not prevents) or any of the two HPV vaccineand thetypes third (types dose 16 6–12and 18, months both of after which the HPV2 second. prevents) If incompletely receive the full benefitbeen infected of the vaccination. with any of Vaccination the four HPV is less vaccine beneficial types for females(types 6, who 11, have already been infected with one orvaccinated more of the (i.e., HPV less vaccine than types. 3 doses), HPV4 or administer HPV2 can remainingbe administered doses. to persons16, and with 18, a allhistory of which of genital HPV4 warts, prevents) abnormal or any Papanicolaou of the two test,HPV or vac positive- HPV DNA test, because these conditionsSubstitute are not a one-timeevidence of dose previous of Tdap infection for onewith ofall thevaccine doses HPV of types. Td, cine types (types 16 and 18, both of which HPV2 prevents) receive HPV4 may be administered to males aged 9 through 26 years to reduce their likelihood of genital warts. HPV4 would be most effective when administered before exposure to HPV through sexual contact.either in the primary series or for the routine booster, whichever the full benefit of the vaccination. Vaccination is less beneficial for A complete seriescomes for first.either HPV4 or HPV2 consists of 3 doses. The second dose should femalesbe administered who have 1–2 alreadymonths afterbeen the infected first dose; with the one third or dose more should of the be administered 6 months after the first Ifdose. a woman is pregnant and received the most recent Td vaccina- HPV vaccine types. HPV4 or HPV2 can be administered to persons Although HPVtion vaccination 10 or more is not years specifically previously, recommended administer for Td persons during with the the second medical indicationswith a history described of genital in Figure warts, 2, “Vaccines abnormal that Papanicolaoumight be indicated test, for or adults based on medical and other indications,” it may be administered to these persons because the HPV vaccine is not a live-virus vaccine. However, the immune response and might be less for persons withor thirdthe medical trimester. indications If the womandescribed received in Figure the 2 than most in personsrecent Td who vac do- notpositive have the HPV medical DNA indications test, because described these or conditions who are immunocompetent. are not evidence cination less than 10 years previously, administer Tdap during the of previous infection with all vaccine HPV types. immediate postpartum period. At the clinician’s discretion, Td may HPV4 may be administered to males aged 9 through 26 years to be deferred during pregnancy and Tdap substituted in the immedi- reduce their likelihood of genital warts. HPV4 would be most effec- ate postpartum period, or Tdap may be administered instead of Td tive when administered before exposure to HPV through sexual to a pregnant woman after an informed discussion with the woman. contact. The ACIP statement for recommendations for administering Td A complete series for either HPV4 or HPV2 consists of 3 doses. as prophylaxis in wound management is available at http://www. The second dose should be administered 1–2 months after the first cdc.gov/vaccines/pubs/acip-list.htm. dose; the third dose should be administered 6 months after the 3. Varicella vaccination first dose. All adults without evidence of immunity to varicella should receive Although HPV vaccination is not specifically recommended 2 doses of single-antigen varicella vaccine if not previously vacci- for persons with the medical indications described in Figure 2, nated or a second dose if they have received only 1 dose, unless “Vaccines that might be indicated for adults based on medical they have a medical contraindication. Special consideration should and other indications,” it may be administered to these persons be given to those who 1) have close contact with persons at high risk because the HPV vaccine is not a live-virus vaccine. However, the for severe disease (e.g., healthcare personnel and family contacts immune response and vaccine efficacy might be less for persons of persons with immunocompromising conditions) or 2) are at high with the medical indications described in Figure 2 than in persons risk for exposure or transmission (e.g., teachers; child-care employ- who do not have the medical indications described or who are ees; residents and staff members of institutional settings, including immunocompetent. correctional institutions; college students; military personnel; ado- 5. Herpes zoster vaccination lescents and adults living in households with children; nonpregnant A single dose of is recommended for adults women of childbearing age; and international travelers). aged 60 years and older regardless of whether they report a

320 American Family Physician www.aafp.org/afp Volume 83, Number 3 ◆ February 1, 2011 Practice Guidelines

previous episode of herpes zoster. Persons with chronic medical less than 65 years unless they have underlying medical conditions conditions may be vaccinated unless their condition constitutes a that are PPSV indications. However, public health authorities may contraindication. consider recommending PPSV for American Indians/Alaska Natives 6. Measles, mumps, rubella (MMR) vaccination and persons aged 50 through 64 years who are living in areas Adults born before 1957 generally are considered immune to where the risk for invasive pneumococcal disease is increased measles and mumps. All adults born in 1957 or later should have 8. Revaccination with PPSV documentation of 1 or more doses of MMR vaccine unless they One-time revaccination after 5 years is recommended for have a medical contraindication to the vaccine, laboratory evi- persons aged 19 through 64 years with chronic renal failure or dence of immunity to each of the three diseases, or documentation ; functional or anatomic (e.g., sickle of provider-diagnosed measles or mumps disease. For rubella, cell disease or splenectomy); and for persons with immunocompro- documentation of provider-diagnosed disease is not considered mising conditions. For persons aged 65 years and older, one-time acceptable evidence of immunity. revaccination is recommended if they were vaccinated 5 or more Measles component: A second dose of MMR vaccine, adminis- years previously and were aged less than 65 years at the time of tered a minimum of 28 days after the first dose, is recommended primary vaccination. for adults who 1) have been recently exposed to measles or are in 9. Meningococcal vaccination an outbreak setting; 2) are students in postsecondary educational should be administered to persons with institutions; 3) work in a healthcare facility; or 4) plan to travel inter- the following indications: nationally. Persons who received inactivated (killed) measles vac- Medical: A 2-dose series of meningococcal conjugate vaccine is cine or of unknown type during 1963–1967 should recommended for adults with anatomic or functional asplenia, or be revaccinated with 2 doses of MMR vaccine. persistent complement component deficiencies. Adults with HIV Mumps component: A second dose of MMR vaccine, adminis- infection who are vaccinated should also receive a routine 2-dose tered a minimum of 28 days after the first dose, is recommended for series. The 2 doses should be administered at 0 and 2 months. adults who 1) live in a community experiencing a mumps outbreak Other: A single dose of meningococcal vaccine is recommended and are in an affected age group; 2) are students in postsecondary for unvaccinated first-year college students living in dormitories; educational institutions; 3) work in a healthcare facility; or 4) plan microbiologists routinely exposed to isolates of Neisseria menin- to travel internationally. Persons vaccinated before 1979 with either gitidis; military recruits; and persons who travel to or live in coun- killed or mumps vaccine of unknown type who are tries in which meningococcal disease is hyperendemic or epidemic at high risk for mumps infection (e.g. persons who are working in (e.g., the “meningitis belt” of sub-Saharan Africa during the dry a healthcare facility) should be revaccinated with 2 doses of MMR season [December through June]), particularly if their contact with vaccine. local populations will be prolonged. Vaccination is required by the Rubella component: For women of childbearing age, regardless government of Saudi Arabia for all travelers to Mecca during the of birth year, rubella immunity should be determined. If there is no annual Hajj. evidence of immunity, women who are not pregnant should be vac- Meningococcal conjugate vaccine, quadrivalent (MCV4) is pre- cinated. Pregnant women who do not have evidence of immunity ferred for adults with any of the preceding indications who are aged should receive MMR vaccine upon completion or termination of 55 years and younger; meningococcal polysaccharide vaccine pregnancy and before discharge from the healthcare facility. (MPSV4) is preferred for adults aged 56 years and older. Revaccina- Healthcare personnel born before 1957: For unvaccinated tion with MCV4 every 5 years is recommended for adults previously healthcare personnel born before 1957 who lack laboratory evi- vaccinated with MCV4 or MPSV4 who remain at increased risk for dence of measles, mumps, and/or rubella immunity or laboratory infection (e.g., adults with anatomic or functional asplenia, or per- confirmation of disease, healthcare facilities should 1) consider sistent complement component deficiencies). routinely vaccinating personnel with 2 doses of MMR vaccine at the 10. Hepatitis A vaccination appropriate interval (for measles and mumps) and 1 dose of MMR Vaccinate persons with any of the following indications and any vaccine (for rubella), and 2) recommend 2 doses of MMR vaccine at person seeking protection from hepatitis A virus (HAV) infection: the appropriate interval during an outbreak of measles or mumps, Behavioral: Men who have sex with men and persons who use and 1 dose during an outbreak of rubella. Complete information drugs. about evidence of immunity is available at http://www.cdc.gov/ Occupational: Persons working with HAV-infected primates or vaccines/recs/provisional/default.htm. with HAV in a research laboratory setting. 7. Pneumococcal polysaccharide (PPSV) vaccination Medical: Persons with chronic liver disease and persons who Vaccinate all persons with the following indications: receive clotting factor concentrates. Medical: Chronic lung disease (including ); chronic car- Other: Persons traveling to or working in countries that have high diovascular diseases; diabetes mellitus; chronic liver diseases; or intermediate endemicity of hepatitis A (a list of countries is avail- ; chronic alcoholism; functional or anatomic asplenia able at http://wwwn.cdc.gov/travel/contentdiseases.aspx). (e.g., sickle cell disease or splenectomy [if elective splenectomy is Unvaccinated persons who anticipate close personal contact planned, vaccinate at least 2 weeks before surgery]); immunocom- (e.g., household or regular babysitting) with an international promising conditions (including chronic renal failure or nephrotic adoptee during the first 60 days after arrival in the United States syndrome); and cochlear implants and cerebrospinal fluid leaks. from a country with high or intermediate endemicity should be Vaccinate as close to HIV diagnosis as possible. vaccinated. The first dose of the 2-dose series Other: Residents of nursing homes or long-term care facilities should be administered as soon as adoption is planned, ideally 2 or and persons who smoke cigarettes. Routine use of PPSV is not rec- more weeks before the arrival of the adoptee. ommended for American Indians/Alaska Natives or persons aged Single-antigen vaccine formulations should be administered in a

February 1, 2011 ◆ Volume 83, Number 3 www.aafp.org/afp American Family Physician 321 Practice Guidelines

2-dose schedule at either 0 and 6–12 months (Havrix), or 0 and 6–18 users or men who have sex with men; correctional facilities; end- months (Vaqta). If the combined hepatitis A and hepatitis B vaccine stage renal disease programs and facilities for chronic hemodialy- (Twinrix) is used, administer 3 doses at 0, 1, and 6 months; alterna- sis patients; and institutions and nonresidential day-care facilities tively, a 4-dose schedule may be used, administered on days 0, 7, for persons with developmental disabilities. and 21–30, followed by a booster dose at month 12. Administer missing doses to complete a 3-dose series of hepa- 11. Hepatitis B vaccination titis B vaccine to those persons not vaccinated or not completely Vaccinate persons with any of the following indications and any vaccinated. The second dose should be administered 1 month after person seeking protection from hepatitis B virus (HBV) infection: the first dose; the third dose should be given at least 2 months Behavioral: Sexually active persons who are not in a long-term, after the second dose (and at least 4 months after the first dose). If mutually monogamous relationship (e.g., persons with more than the combined hepatitis A and hepatitis B vaccine (Twinrix) is used, one sex partner during the previous 6 months); persons seeking administer 3 doses at 0, 1, and 6 months; alternatively, a 4-dose evaluation or treatment for a sexually transmitted disease (STD); Twinrix schedule, administered on days 0, 7, and 21 to 30, followed current or recent injection-drug users; and men who have sex with by a booster dose at month 12 may be used. men. Adult patients receiving hemodialysis or with other immunocom- Occupational: Healthcare personnel and public-safety workers promising conditions should receive 1 dose of 40 μg/mL (Recom- who are exposed to blood or other potentially infectious body bivax HB) administered on a 3-dose schedule or 2 doses of 20 μg/ fluids. mL (Engerix-B) administered simultaneously on a 4-dose schedule Medical: Persons with end-stage renal disease, including at 0, 1, 2, and 6 months. patients receiving hemodialysis; persons with HIV infection; and 12. Selected conditions for which Haemophilus influenzae type persons with chronic liver disease. b (Hib) vaccine may be used Other: Household contacts and sex partners of persons with 1 dose of should be considered for persons who chronic HBV infection; clients and staff members of institutions for have sickle cell disease, leukemia, or HIV infection, or who have had persons with developmental disabilities; and international travelers a splenectomy, if they have not previously received Hib vaccine. to countries with high or intermediate prevalence of chronic HBV 13. Immunocompromising conditions infection (a list of countries is available at http://wwwn.cdc.gov/ Inactivated vaccines generally are acceptable (e.g., pneumo- travel/contentdiseases.aspx). coccal, meningococcal, influenza [inactivated influenza vaccine]) Hepatitis B vaccination is recommended for all adults in the fol- and live vaccines generally are avoided in persons with immune lowing settings: STD treatment facilities; HIV testing and treatment deficiencies or immunocompromising conditions. Information on facilities; facilities providing drug-abuse treatment and prevention specific conditions is available at http://www.cdc.gov/vaccines/ services; healthcare settings targeting services to injection-drug pubs/acip-list.htm.

available, the increasing complexity of the lished corrections appear in MMWR Recomm Rep. 2010; 59(35):1147 and MMWR Recomm Rep. 2010;59(31): vaccination schedules is a challenge for family 993]. MMWR Recomm Rep. 2010;59(RR-8):1-62. physicians, as are the logistics of maintaining 2. Centers for Disease Control and Prevention. Licensure a full array of vaccines in the clinical setting.4 of a 13-valent pneumococcal conjugate vaccine (PCV13) Hopefully, family physicians will find cre- and recommendations for its use among children—Advi- sory Committee on Immunization Practices (ACIP), 2010. ative ways to continue providing vaccines in MMWR Morb Mortal Wkly Rep. 2010;59(9):258-261. the medical home. If not, others will step in 3. Centers for Disease Control and Prevention. FDA to provide this effective and essential service. licensure of bivalent human papillomavirus vaccine (HPV2, ) for use in females and updated HPV EDITOR’S NOTE: The author serves as liaison to ACIP for the vaccination recommendations from the Advisory Com- AAFP. mittee on Immunization Practices (ACIP) [published correction appears in MMWR Morb Mortal Wkly Rep. Author disclosure: Dr. Campos-Outcalt has been a 2010;59(36):1184]. MMWR Morb Mortal Wkly Rep. speaker for the Faces of Influenza program, which is 2010;59(20):626-629. supported in part by Pasteur, maker of an influ- 4. Campos-Outcalt D, Jeffcott-Pera M, Carter-Smith P, enza vaccine. He is also an advisory board member and Schoof BK, Young HF. Vaccines provided by family speaker on the topic of immunizations, supported by the physicians. Ann Fam Med. 2010;8(6):507-510. ■ Foundation via funding from the vaccine industry. Address correspondence to Doug Campos-Outcalt, MD, MPA, at [email protected]. Reprints are not avail- Answers to This Issue’s CME Quiz able from the author. Q1. D Q6. C REFERENCES Q2. B Q7. D Q3. E Q8. A, D 1. Fiore AE, Uyeki TM, Broder K, et al.; Centers for Disease Control and Prevention. Prevention and control of influ- Q4. A Q9. E enza with vaccines: recommendations of the Advisory Q5. A, C Committee on Immunization Practices (ACIP), 2010 [pub-

322 American Family Physician www.aafp.org/afp Volume 83, Number 3 ◆ February 1, 2011