Doug Campos-Outcalt, MD, ACIP immunization update MPA Department of Family and Community Medicine, University of Arizona College Here’s what you need to know to keep your patients’ of Medicine, Phoenix immunizations up to date. [email protected] he Advisory Committee on Immuniza- ❚ In response to these data, the most tion Practices (ACIP) made a number recent ACIP recommendation expands in- T of major new recommendations last dications for HAV vaccine to include anyone year. Th ese new recommendations address: who will be in close personal contact—living in the same household or providing regular • expanded use of hepatitis A virus (HAV) babysitting—with an adoptee from any coun- vaccine try with high or intermediate endemic rates Anyone who • preferences for combination vaccines of HAV. Th e vaccine should be given within will be in close • timing of poliovirus vaccine doses the fi rst 60 days of the adoptee’s arrival in the personal contact • resumption of the normal Haemophi- United States.1 Th e fi rst dose of the 2-dose se- with an adoptee lus infl uenzae Type b (Hib) schedule, as ries should be given as soon as the adoption is from any country shortages have resolved planned, ideally 2 or more weeks before expo- with high or • the use of a new bivalent human papil- sure to the adoptee. intermediate loma virus (HPV2) vaccine in women and Th is new recommendation adds to ear- endemic rates quadrivalent (HPV4) vaccine in men lier expansions of indications for HAV vaccine, of hepatitis A • a reduced-dose schedule for rabies post- which include universal use in children, use in should receive exposure prophylaxis postexposure prophylaxis, and preexposure the HAV vaccine. • proof of immunity against mumps, mea- protection for travelers.2,3 sles, and rubella for health care workers • recommendations for meningococcal vaccine boosters. ACIP still prefers combination vaccines, with caveats Increasing numbers of vaccine products with Adoptive families need more multiple antigens have reduced the number protection against HAV of injections needed to complete the recom- Each year, approximately 18,000 children mended childhood immunization schedule. are adopted from foreign countries, almost Th ese new products also create a situation in all of them born in countries with high or in- which parents and physicians have to choose termediate rates of HAV, 85% of them under between using the combination products or 5 years of age.1 Identifying adoptees with an staying with component vaccines that contain acute HAV infection is problematic, because fewer antigens, but necessitate a larger num- in this age group, fewer than 10% of infected ber of injections. children manifest jaundice.1 Th e Centers for When ACIP considered this dilemma, Disease Control and Prevention (CDC) has re- committee members gave the general prefer- corded a small number of cases of acute HAV ence to combination vaccines. At the same infection traced back to exposure to adoptees, time, the committee acknowledged that many and there is some evidence that 1% to 6% of considerations—storage, costs, number of new international adoptees have acute, and injections, vaccine availability, vaccination infectious, HAV.1 status, likelihood of improved coverage, likeli- JFPONLINE.COM VOL 59, NO 3 | MARCH 2010 | THE JOURNAL OF FAMILY PRACTICE 155 TABLE HPV vaccines: A side-by-side comparison HPV4 HPV2 Year licensed 2006 2009 Virus-like particle types 6, 11, 16, 18 16,18 Hypersensitivity-related contraindication Yeast Latex Schedule 0, 2, 6 months 0, 1, 6 months Age range 9-26 years 10-25 years hood of return visits, patient preference, and 6 months of life should be used only for those the potential for adverse events—factor into traveling overseas.6 the decision.4 ❚ MMRV is a special case. One combi- nation product received special attention Resume normal Hib schedule because of the potential for increased rates With the licensure of a new Hib product (Hi- An ACIP- of febrile seizures. Combined measles, berix, GlaxoSmithKline) for the booster dose commissioned mumps, rubella, and varicella (MMRV) vac- of Hib starting at age 15 months, the supply study found that cine is currently in short supply, but when of Hib vaccine has stabilized. Supply is now the 4-dose the supply improves it will provide 1 less adequate to resume all 4 doses in the routine rabies vaccine injection to immunize against 4 childhood schedule and to recall all children who had series achieved viral infections at each of 2 visits. However, their booster dose deferred. Children can be the same there is good evidence that in children 1 to 2 vaccinated with Hib through the age of 59 antibody levels years of age who are receiving the fi rst dose months (prior to their fi fth birthday).7 as the of MMRV, there is an additional incidence 5-dose series. of febrile seizures of 1 in every 2300 to 2600, compared with children receiving separate 2 HPV vaccines are now available doses of MMR and varicella vaccines.5 Th ere With the licensure of an HPV2 vaccine for is no increased risk for older children or for use in women in the United States (Cervarix, the second dose. GlaxoSmithKline), 2 HPV vaccine products ACIP considered this risk and recom- are now available for use.8 An HPV4 vaccine mends discussing the benefi ts and risks of (Gardasil, Merck & Co.) was licensed in 2006. MMR and varicella separately vs using the Th e TABLE compares the composition, dosing MMRV combination vaccine. Th e commit- schedules, and precaution for these 2 prod- tee notes: “Use of MMR and varicella vaccines ucts. Each requires 3 doses, but the age rang- avoids [the] increased risk for fever and febrile es and dosing schedules are slightly diff erent. seizures following MMRV vaccine.”5 Th e HPV4 vaccine contains antigens against HPV types 16 and 18, which cause 70% of cer- vical cancers and precancerous lesions, and IPV combination dosing is clarifi ed types 6 and 11, which cause 90% of anogeni- Th e inclusion of inactivated poliovirus (IPV) tal warts.9 antigen into new combination vaccine prod- Th e HPV2 vaccine contains antigens for ucts has caused some confusion over the HPV types 16 and 18 only and does not pro- recommended dosing schedule of polio vac- tect against warts. Th e bivalent product ap- cine. ACIP has now clarifi ed that for the rec- pears to produce a higher level of antibody ommended 4-dose IPV schedule, the fourth response and may provide better cross protec- dose should be administered after age 4 and tion against other HPV types. ACIP compared at least 6 months after dose 3. In addition, eff ectiveness studies of both vaccines and de- the minimal intervals (4 weeks) in the fi rst cided to show no preference for either vaccine 156 THE JOURNAL OF FAMILY PRACTICE | MARCH 2010 | VOL 59, NO 3 IMMUNIZATION UPDATE for the prevention of cervical cancer and pre- Rabies vaccine: 4 doses cancerous lesions. are suffi cient Th e recommendation is for routine vac- Due to a threatened shortage of rabies vac- cination with an HPV product for all adoles- cine, ACIP commissioned a study to deter- cent girls ages 11 to 12, with catch-up through mine if a 4-dose series might be as eff ective age 26. If a female wants protection against as the licensed 5-dose series. Th e results anogenital warts, HPV4 is recommended. It is showed that a reduced-dose series achieved preferable to complete a 3-dose series with the equivalent antibody levels, so ACIP voted to same product, but if this is not possible, a series recommend 4 doses of vaccine at days 0, 3, can be completed with the other product. Th e 7, and 14 postexposure.12 Th e vaccine should HPV4 vaccine is made using yeast, and pre- be part of a 3-pronged approach to prevent fi lled HPV2 syringes contain latex. Hypersensi- rabies after an exposure, along with rabies tivity to these substances is a contraindication immune globulin administration and wound to their use. Patients who receive either vaccine cleaning.13 Th e 4-dose schedule diff ers from should be observed for 15 minutes after the in- the rabies vaccine package inserts and the jection to prevent injury from syncope. FDA licensure information. ❚ HPV4 in men. Th e HPV4 vaccine has now been licensed in the United States for use in males ages 9 to 26 to prevent anogeni- Tougher immunity criteria tal warts. It may also protect against HPV- for health care personnel ACIP now caused cancers (oral, genital, and anal), but Prior to 2009, criteria for proof of immunity recommends the proof of that is still lacking. ACIP debated to measles, mumps, or rubella among health that individuals whether to recommend HPV4 for boys rou- care workers included serologic testing, his- previously tinely at age 11 to 12 and decided against this. tory of 2 vaccines after age 1, physician-diag- vaccinated with Instead the group voted for a “permissive” nosed disease, or being born prior to 1957. Th e either MCV4 or recommendation that states HPV4 may be new criteria require laboratory confi rmation MPSV4 who are given to adolescents and young men ages 9 to of a physician diagnosis and add a footnote to at prolonged 26 to prevent warts and that protection is bet- the “born before 1957” criterion that states: In- increased risk ter if it is administered before exposure.10 Th is stitutions with unvaccinated health care work- be revaccinated allows vaccine use in young males to be pro- ers who lack laboratory evidence of immunity with MCV4.