SPECIAL REPORT: Adult Vaccination

INTRODUCTION[[{"type":"media","view_mode":"media_crop","fid":"52682","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_4119933236350","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"6543","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"float: right;","title":" ","typeof":"foaf:Image"}}]]

Primary care is the hub for the prevention of so-called vaccine-preventable diseases (VPD) in adults. Every patient encounter is an opportunity to make sure the complex population of people you see in your practice remains protected from the deadly diseases we have conquered with vaccines and that not one will pass along infection to those who for whatever reason cannot resist a specific VPD.  

So just how well are we performing in this front-line practice setting? I wish I could say things were better.

Rates of recommended vaccination for adults in the United States are low: less than one quarter of those who should receive vaccination against hepatitis B or herpes zoster are routinely inoculated; uptake of the human papillomavirus (HPV) vaccine has been disappointing with only 6% to 37% of men and women aged 19 to 26 years receiving even one dose in the series.¹ In 2013, there were more than 26,000 cases of pertussis and approximately 17,000 individuals were infected with pneumococcus; there were more than 3000 cases of hepatitis B and nearly 250 cases of meningococcal disease (strains ACYW or B).² Td and Tdap coverage in 2013 was limited to 57.5% and ~29% of the population, respectively.³ 

A few more facts:

 â–º Less than 20% of persons aged ≥19 years have ever received a dose of Tdap.¹

 â–º Only 60% of patients aged ≥65 have received any pneumococcal vaccine.¹

 â–º Only 29% of adolescents have completed meningococcal vaccination (MenAC-WY); 40% have completed the HPV series; 88% have received a single dose of Tdap.²

The bottom line: we have work to do.

This Patient Care Special Report on Adult Vaccination doesn’t offer a step-by-step review of the Advisory Committee on Immunization Practices (ACIP) annually updated schedule of vaccine recommendations. That’s available any time on the CDC's website.

Instead you will be challenged in a series of multiple choice quizzes to engage your clinical knowledge of the specific vaccination needs of a variety of populations – some of these you may know by rote, but others we hope will make you stop and think. For example:

 â–º What vaccines are critical for your patients with type 2 diabetes? What are the particular vulnerabilities in this population?

 â–º What is the most effective approach to herpes zoster vaccination in older adults to avoid post herpetic neuralgia? In what order should the 23- and 13-valent pneumococcal vaccines be given in the over-65 years population?

 â–º What is currently true and what false about meningococcal vaccination for young adults aged 19-21? Who should and who shouldn’t receive the HPV vaccine?

 â–º What do you know about immunization in special populations, eg, pregnant women, immunocompromised patients, patients with advanced renal disease?

The less-than-robust statistics regarding vaccinations should give all of us resolve to do much, much better. We hope, as you work through the challenges in this Special Report, that your awareness will be raised, your curiosity piqued, and your resolve to double-down on updating all your current patients’vaccine status will be renewed.

This is the time to do better with a simple and long-lived medical practice that provides substantial long-term benefits.

Continue to Adult Vaccination Special Report Pre-test

Images:
1. Meningococcus ©Royaltystockphoto/Shutterstock.com
2.  Inflluenza ©mathagraphics/Shutterstock.com 
3.  Human immunodeficiency virus ©xrender/Shutterstock.com
4.  Human papillomavirus 16 ©Katyrena Kan/Shutterstock.com

PRE-TEST

The Quizzes that make up this Special Report will broaden your knowledge of and your thinking about vaccination for your adult patients. But first, see what you already do know about vaccines and the needs of special populations by taking our short pre-test. You’ll see these questions again after the final installment of the report, so you might want to take notes.

ANSWER AND DISCUSSION »

Answer: A

The sooner after the diagnosis of diabetes an individual is vaccinated against hepatitis B the better. Although the study in the supporting reference looked at the absence of other typical risk factors for acquiring hepatitis B, there is more to the story. Twenty-nine hepatitis B outbreaks in diabetics were investigated. Twenty-five out of 29 were a consequence of contaminated blood glucose monitors.¹ Protecting diabetics against hepatitis B infections by vaccination is an important primary care responsibility. Preventing hepatitis B in the study’s at-risk cohort (ages 20-59) saved $75,100 per every quality adjusted life year.¹

ANSWER AND DISCUSSION »

Answer: A, B, and D should not receive the live vaccine.

Patients infected with HIV who have a CD4 count of ≤200 cells/µL should not be given live zoster vaccine.² The group in option C (≥500 cells/µL) would be eligible for the immunization.

ANSWER AND DISCUSSION »

Answer: B and D are True

HPV is not a live vaccine, so it can be given to those with lower CD4 counts, at the discretion of the treating physician.³ Safety of the vaccine during pregnancy is unknown, however, so it should not be administered to pregnant women.

ANSWER AND DISCUSSION »

Answer: A, B, and C

Note that influenza vaccination is also recommended in asplenic individuals. Asplenic individuals are at risk for fatal sepsis. As a result, they also receive precautions when they experience fever similar to those for persons exposed to meningococcus.⁴

ANSWER AND DISCUSSION »

Answer: All statements are true.⁵

Part I and Part II of this Special Report on Adult Vaccination will feature a quiz on vaccinations relevant to patients with diabetes mellitus and to older adults, respectively. Watch your email for eNewsletters from Patient Care and visit our homepage at www.patientcareonline.com to check for updates.

References:

Introduction: Adult Vaccination

1. Williams WW, Lu PJ, O’Halloran A, et al; Centers for Disease Control and Prevention (CDC). Vaccination coverage among adults, excluding influenza vaccination – United States, 2013. MMWR Morb Mortal Wkly Rep. 2015;64:95-102. https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6404a6.htm

2. Adams D, Fullerton K, Jajorsky R, et al. Summary of notifiable infectious diseases and conditions –United States, 2013. MMWR Morb Mortal Wkly Rep. 2015;62:1-122. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6253a1.htm

3. Lu P-J, O’Halloran A, Ding H, et al. National and state-specific Td and Tdap vaccination of adult populations. Am J Prev Med. 2016; 50:616-626. http://www.ncbi.nlm.nih.gov/pubmed/?term=Am+J+Prev+Med.+2016%3B+50%3A616-626.

Pre-test

1. Centers for Disease Control and Prevention (CDC).Use of hepatitis B vaccination for adults with diabetes mellitus: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep. 2011 Dec 23;60:1709-11.

2. Rubin LG, Levin MJ, Ljungman P, et al. 2013 IDSA clinical practice guideline for vaccination of the immunocompromised host. Clin. Inf. Dis. 2014; 58:e44. http://cid.oxfordjournals.org/content/58/3/e44.long

3. CDC. Vaccine information for adults. HIV Infection and Adult Vaccination.  http://www.cdc.gov/vaccines/adults/rec-vac/health-conditions/hiv.html

4. Rubin LG, Schaffner W. Clinical practice: Care of the asplenic patient. N Engl J Med. 2014; 371:349-356. http://www.nejm.org/doi/full/10.1056/NEJMcp1314291

5. Soni R, Horowitz B, Unruh M. Immunization in end-stage renal disease: opportunity to improve outcomes. Semin Dial. 2013;26:416-426. http://onlinelibrary.wiley.com/doi/10.1111/sdi.12101/abstract;jsessionid=6BEAD64A884CB7B5B807E2409778A01B.f03t03