the journal of Family Practice

Doug Campos-Outcalt Immunization update: Latest Department of Family and Community Medicine, University of Arizona College recommendations from the CDC of Medicine, Phoenix [email protected] Provisional recommendations for the varicella zoster , plus pertussis, , HPV, and

How effective is the new varicella be found on the manufacturer’s Web site zoster vaccine and when should (www.merck.com/product/usa/pi_circu- adults receive it? lars/z/zostavax/zostavax_pi.pdf). Who should recieve the new Tdap Contraindications to the vaccine in- vaccine? ® Dowdenclude a prior anaphylactic Health reaction Media to gela - The answers to these and other im- tin or neomycin, immune deficiency states, munization-related questions are ad- immune suppressive therapy (including dressed by the CentersCopyright for DiseaseFor Con- personalhigh-dose corticosteroids), use only active tubercu- trol and Prevention (CDC) in a number losis, and pregnancy. Other contraindica- of recently-issued immunization recom- tions include daily use of topical or inhaled mendations. Here, by vaccine, is a quick corticosteroids, low-dose oral corticoste- review of these recommendations. (Sev- roids, and moderate to severe illness. In this Article eral were reviewed in a previous Practice z Recent  Alert.1) Table 1 contains a summary of recent new recommendations. The CDC z Varicella vaccine in kids immunization  Web site (www.cdc.gov) is also a valuable Two doses of varicella vaccine are now recommendations  and readily available resource for all vac- recommended for all children, at ages 12 Page 378 cine-related questions and will have the to 15 months and 4 to 6 years. A com- latest child and adult vaccine schedules. bination vaccine (ProQuad) containing z HPV and  , measles, rubella, and varicella Page 380 (MMRV) is now available for ages 12 z Varicella zoster (provisional) months through 12 years and should re- The Advisory Committee on Immuniza- duce the total number of injections chil- tion Practices (ACIP) has recommended dren will need. that adults who are 60 years of age and A catch-up second dose of varicella older receive a single dose of live attenu- vaccine is recommended for children, ad- ated varicella zoster virus vaccine (Zos- olescents, and adults who have received tavax), even if they report a past episode only 1 dose. The vaccine is contraindi- of herpes zoster. This vaccine prevents cated during pregnancy, and pregnant herpes zoster and postherpetic neural- women should be assessed for varicella gia; it is 65% effective at ages 60 to 69 immunity and provided 2 doses of vac- years, 41% effective at ages 70 to 79, but cine postpartum if they are nonimmune. only 18% effective at age 80 and above. The interval between the first and sec- Complete prescribing information can ond does of varicella vaccine should be

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For mass reproduction, content licensing and permissions contact Dowden Health Media. the journal of Family Practice table 1 z Pertussis Recent immunization recommendations A new tool is now available to assist in controlling pertussis: the tetanus toxoid, Infants and children reduced diphtheria toxoid, and acellular • Universal routine vaccine between age 1–2 years with 2 doses 6 months apart pertussis vaccine (Tdap). Two products • Universal routine rotavirus vaccine 2, 4, and 6 months are available: one licensed for use among • Two-dose varicella series patients ages 11 to 64 (Adacel) and one Adolescents for patients between the ages of 10 and • Tdap at age 11–12 18 (Boostrix). • Tdap at age 13–18 if the last Td was administered >5 years previously and no previous Recommendations for the prevention DTaP was administered of tetanus, diphtheria, and pertussis us- • HPV vaccine at age 11–12, 3 doses, women only ing Tdap were published by the CDC in 2 • Catch-up varicella December 2005. A single dose of Tdap

Adults is now recommended for preadolescents (ages 11 to 12) and for all adults (ages • Tdap to replace the next scheduled Td booster, one time only 19 to 64) who have not received Tdap • Tdap as single dose for adults caring for children age <6 months previously, to replace the next scheduled • Tdap for health care workers dose of Td. Adults who have, or expect • HPV vaccine for women to age 26, 3 doses to have, close contact with infants should • Varicella vaccine catch-up (those born after 1980 and no proof of immunity) receive a Tdap dose before the next • Varicella zoster vaccine for those age 60 years and above scheduled Td, if they have not received Pregnancy Tdap previously. A 2-year interval from • Screen for varicella immunity in those without proof of immunity. the last Td is suggested but a shorter in- Immunize postpartum those nonimmune terval is acceptable. • Tdap either during preconception period or immediately postpartum, Pregnant women should receive the if no Tdap was previously received. vaccine preconception or postpartum but the CDC does not recommend adminis- at least 3 months in those under age 13 tering the vaccine during pregnancy. All fast track years, and 4 to 8 weeks in those older. health care workers who have exposure Avoid storing  Those who have immunity to vari- to patients should receive Tdap as soon cella and do not need vaccination include as feasible. Once again, less than a 2-year Tdap near DTaP as those born in the US before 1980; those interval from the last Td is acceptable. these products are with previous varicella or her- Contraindications to Tdap include easily confused pes zoster, diagnosed by a healthcare allergy to any vaccine component and provider; or anyone with laboratory evi- encephalopathy (coma or prolonged sei- dence of immunity. zures) within 7 days of receiving a per- With the addition of all the new vari- tussis-containing vaccine. The vaccine cella vaccine products, it is important not should be used with caution in anyone to confuse them. Varicella zoster vaccine who has suffered Guillain-Barré syn- is licensed only for adults age 60 and drome less than 6 weeks after receiving above; combination MMRV vaccine is a vaccine containing tetanus toxoid. The licensed for ages 12 months through 12 vaccine should be deferred with moder- years but should not be used in children ate to severe illness and should not be with HIV infection. Single-antigen vari- administered less than 10 years from the cella vaccine can be used in HIV-infected last Td if an Arthus reaction has occurred children if their CD4 T-lymphocyte count following a Td vaccine. is less than 15%. For more complete in- Table 2 contains information on teta- formation on the use of varicella vaccine nus prophylaxis in wound management.2 in HIV-infected children, see the CDC’s If a vaccine containing tetanus toxoid is Web site at www.cdc.gov/mmwr/PDF/rr/ recommended, Tdap is preferred if the rr4806.pdf. patient has not received one previously.

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table 2 Tetanus prophylaxis in wound management (ages 19–64 years)

Clean, minor wound All other wounds* History of adsorbed tetanus toxoid Tdap or Td† TIg tdap or Td† tIG

Unknown or <3 Yes No Yes Yes

≥3 No‡ No No** No

*Such as, but not limited to, wounds contaminated with dirt, feces, soil, and saliva; puncture wounds; avulsions; and wounds resulting from missiles, crushing, burns, and frosbite. † Tdap is preferred to TD for adults who have never received Tdap. Td is preferred to tetanus toxoid (TT) for adults who received Tdap previously or when Tdap is not available. If TT and tetanus immunoglobulin (TIG) are both used, tetanus toxoid adsorbed rather than tetanus toxoid for booster use only (fluid vaccine) should be used. ‡ Yes, if ≥10 yeas since the last tetanus toxoid-containing vaccine dose. ** Yes, if ≥5 years since the last tetanus toxoid-containing vaccine dose. Source: CDC, MMWR Recomm Rep 2005.2

One word of caution: Avoid storing z Rotavirus Tdap near DTaP, which is licensed for To combat this significant cause of mor- children through age 6. These products bidity and mortality among infants and are easily confused. children, the CDC now recommends that a new live, oral vaccine that contains 5 reassortant (RotaTeq) be giv- z Hepatitis A en as a routine childhood vaccine.4 The Hepatitis A vaccine is now recommended vaccine should be administered during for all children between the ages of 1 to 2 infancy at age 2, 4, and 6 months. The years, using 2 doses given 6 months apart. first dose should be between weeks 6 and This recommendation was reviewed in a 12, the next 2 spaced 4 to 10 weeks apart. previous Practice Alert.1 All 3 doses should be received before the fast track age of 32 weeks. To learn more Rotavirus vaccine is 74% effective in z preventing all rotavirus gastroenteritis and about the  The CDC continues to recommend risk- 98% effective in preventing severe rotavi- quadrivalent  based immunization against hepatitis B rus gastroenteritis.4 It is contraindicated in human virus (HBV) in adults.3 The new recom- those who have had a severe allergic reac- virus (HPV)  mendations state that: tion to the vaccine and should be used with • Universal HBV vaccine should be caution in children with altered immuno- vaccine, see  provided for all adults (who have not pre- competence, acute gastroenteritis, and the March 2007 viously received it) at health care settings moderate-to-severe illness. Even though issue of JFP with high-risk populations, including it’s a modified live virus, it can be used in STD clinics, HIV testing and treatment infants even if someone in the household facilities, drug abuse treatment settings, is pregnant or immune-deficient. health care facilities providing care to IV drug users and men who have sex with men, and correctional facilities. z Human papilloma virus • At other health care facilities, all pa- The quadrivalent human papilloma virus tients should be informed about the risks (HPV) vaccine was licensed by the US of hepatitis B infection and who should Food and Drug Administration (FDA) in be vaccinated, and HBV vaccine should June 2006; the CDC released its recom- be provided to all those at risk and all mendations for its use in March 2007.5 those requesting the vaccine. The vaccine should be administered

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table 3 The vaccine is administered intra- associated with HPV—US, 2003 muscularly in 3 doses at months 0, 2, and 6. The minimum interval between % attributable doses 1 and 2 is 4 weeks and between Cancer Cases to oncogenic HPV doses 2 and 3, 12 weeks. It is contrain- Cervix* 11,820 100 dicated in those with allergies to yeast Anus† 4187 90 and other vaccine components. It can be coadministered with other † 3507 40 but should be deferred for moderate to Vagina† 1070 40 severe illness. The most common side Penis† 1059 40 effects are pain, swelling, and redness

Oral cavity/† 29,627 ≤12 at the injection site; fever occurs at a rate slightly above placebo. The vaccine *A total of 70% of these cancers are attributable to HPV types 16 or 18. has not been tested for safety for use in † Majority of these cancers are attributable to HPV type 16. pregnancy, but inadvertent administra- Sources: US Cancer Statistics Working Group. United States Cancer Statistics: 2003. In- cidence and Mortality. Altanta, Ga: US Department of Health and Human Services, CDC, tion during pregnancy has not led to and the National Cancer Institute; 2006; Parkin M. The global health burden of infection- any documented adverse effects. n associated cancers in the year 2002. Int J Cancer 2006; 118:3030–3044.

Correspondence routinely to all girls aged 11 to 12 and Doug Campos-Outcalt, MD, MPA, 55 E. Van Buren, can be started as early as age 9. The vac- Phoenix, AZ 85004. [email protected] cine should also be given to women ages 13 to 26 who have not previously re- References ceived the vaccine. 1. Campos-Outcalt D. Are you up to date with new im- HPV is responsible for over 6 mil- munization recommendations? J Fam Pract 2006; 55:232–234. lion new per year, although 2. CDC. Preventing tetanus, diphtheria and pertussis: only a small proportion of these infec- use of tetanus toxoid, reduced diphtheria toxoid, and tions involve types that pose high risk acellular pertussis vaccine. Recommendations of the Advisory Committee on Immunization Practices fast track 5,6 for . The virus is as- (ACIP) and Recommendation of ACIP, supported by Since the vaccine sociated with cervical cancer, genital the Healthcare Infection Control Practices Advisory , anal cancer, and possibly oral Committee (HICPAC), for Use of Tdap Among Health- doesn’t protect Care Personnel. MMWR Recomm Rep 2005; 55(RR- and pharyngeal cancer. Table 3 shows 17):1–33. from all HPV  the number of each type of cancer that 3. CDC. A comprehensive immunization strategy to occurs in the US each year and the pro- eliminate transmission of Hepatitis B Virus infection in subtypes, Pap the United States. Recommendations of the Advisory smear testing  portion attributed to HPV. There are Committee on Immunization Practices (ACIP) Part II: over 11,000 new cases of cervical can- Immunization of Adults. MMWR Recomm Rep 2006; is still needed cer and 3700 deaths from the disease 55(RR-16):1–25. 7,8 4. CDC. Prevention of rotavirus gastroenteritis among each year. infants and children. Recommendations of the Advi- The HPV vaccine is produced in sory Committee on Immunization Practices (ACIP). yeast using recombinant DNA technol- MMWR Recomm Rep 2006; 55(RR-12):1–13. ogy and contains virus-like products 5. CDC. Quadrivalent human papilloma virus vaccine. Recommendations of the Advisory Committee on Im- of 4 HPV subtypes (6, 11, 16, and 18) munization Practices (ACIP). MMWR Recomm Rep that are responsible for between 60% 2007; 56(RR-2):1–24. and 80% of cervical cancers in the US. 6. Dunne EF, Unger ER, Sternberg M, et al. Prevalence of HPV infection among females in the United States. It prevents persistent HPV infection, JAMA 2007; 297:813–819. genital warts, and cervical, vaginal and vulvar precancerous lesions due to the 4 subtypes contained. Since the vaccine does not completely protect from cervi- cal cancer, Pap smear testing is still rec- ommended after vaccination.

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