Practice Guidelines ACIP Releases 2011 Immunization Schedules DOUG CAMPOS-OUTCALT, MD, MPA, University of Arizona College of Medicine, Phoenix, Arizona older who are in close contact with infants. 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 vaccine (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 toxoids 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 immunizations recom- dose primary series of hepatitis B vaccine 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 influenza vaccine; the availability tions in this year’s schedules, most notably of two human papillomavirus vaccines 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 conjugate vaccine (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 measles, rubella, polio, 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 toxoid, 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 UNITED STATES · 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 immunity present (e.g., based on medical, occupational, (e.g., lack documentation of vaccination or have lifestyle, or other indications) no evidence of previous infection) Report all clinically significant postvaccination reactions to the Vaccine Adverse Event 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 Kidney failure, infection3,6,12,13 heart disease, elective conditions end-stage renal chronic splenectomy) Healthcare Pregnancy (excluding human Chronic liver disease, INDICATION CD4+ T lympho- lung disease, and persistent disease personnel immunodeficiency 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 varicella vaccine. in adults Other includes persons shouldany of receivethe the inactivated vaccine. Adults aged 65Annual years vaccinationand