February 05, 2018
The Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC) has issued its 2018 Recommended Immunization Schedule for Adults Aged 19 or Older.
Key changes in the updated schedule relate to the new herpes zoster vaccine, as well as to the measles, mumps, and rubella (MMR) vaccine. The new schedule is published online today in Annals of Internal Medicine and on the CDC website.
Following the US Food and Drug Administration's October 2017 approval of recombinant zoster vaccine (RZV; Shingrix, GlaxoSmithKline) to prevent shingles in adults age 50 years and older, the ACIP now recommends RZV as follows:
- Give two doses of RZV 2 to 6 months apart to adults age 50 years and older with competent immune systems regardless of a history of herpes zoster or receipt of the zoster vaccine live (ZVL; Zostavax, Merck & Co).
- Give two doses of RZV 2 to 6 months apart to previous recipients of ZVL at least 2 months after ZVL.
- For persons age 60 years and older, administer RZV or ZVL, with RZV the preferred option.
"RZV is an excellent new vaccine providing excellent protection," David Kim, MD, the CDC's deputy director for adult immunization, told Medscape Medical News. "It has long duration and does not wane, and because of its longer protection we incorporated the recommendation for those age 50 and older instead of just the age 60 and older group."
RVZ may produce more reactions, however. It contains a new immune adjuvant, AS01B, and so far has been tested in clinical trials only in the United States, Sandra Adamson Fryhofer, MD, an internal medicine physician in Atlanta, Georgia, and adjunct associate professor of medicine at Emory University School of Medicine, told Medscape Medical News. "So there's a theoretical concern that when it's used in the general population, there could be some unforeseen adverse events. It is reactogenic, so we need to warn our patients to expect a reaction," she cautioned.
Dr Fryhofer, who is the American College of Physicians' liaison to ACIP, referred to one study in which 80% of patients had a reaction — mainly fatigue, muscle aches, and injection site pain — and 17% had a grade 3 reaction with symptoms severe enough to inhibit daily activities. "But getting a reaction is better than getting shingles," she said. "So we have to tell our patients that that if they react to the first dose, they won't necessarily have a reaction to the second dose, and they do need that second dose."
Dr Fryhofer has been administering RZV since last month, and so far none of her patients have reported significant problems.
However, because the clinical trials of RZV excluded individuals who were pregnant or have immunocompromising conditions, ACIP advises healthcare providers to delay giving RZV to pregnant women or adults with immunocompromising conditions, including HIV infection. After further planned discussions, ACIP will release recommendations on the use of RZV in adults with immunocompromising conditions.
In another new recommendation, the 2018 ACIP guideline endorses administering an additional dose of MMR during a mumps outbreak to at-risk adults previously vaccinated with two (or fewer) doses of a mumps-containing vaccine. "But this is not a decision for individual healthcare providers to make for their patients. It should hinge on the recommendation of public health authorities during a mumps outbreak," Dr Kim said.
While the 2018 schedule has been streamlined for easier use, the authors advise doctors to pay close attention to the detailed footnotes for the colored charts in Figures 1 and 2 of the report. These offer useful information on dosing intervals for vaccination series and special patient populations, such as pregnant women and patients with HIV infection.
The authors also note that more needs to be done to encourage vaccine uptake in adults. Despite modest increases in vaccination coverage rates observed in some adult groups in 2015, overall vaccination coverage rates for US adults remain low. Except for a steady rise in zoster vaccination among persons age 60 years and older, no sustained increases in vaccination coverage have occurred in the past few years.
That persistently low uptake prompted the National Vaccine Advisory Committee to update its practice standards in 2014 to promote immunization as part of routine adult care. Strategies include offering vaccines to patients during clinical visits for other issues, standing orders in charts for routine vaccination, and documenting and assessing vaccination status in local and state immunization information systems.
"We need to promote adult immunization not only to prevent disease but also to reduce its severity and prevent complications," Dr Kim said. "Keeping patients up to date on their immunizations is as important as making sure their medication lists are up to date. We're essentially talking about the same thing."
Coauthor Dr Riley reports receiving personal fees from the private sector outside the submitted work. The other authors have disclosed no relevant financial relationships.