The Advisory Committee on Immunization Practices (ACIP) and Centers for Disease Control and Prevention (CDC) have approved and released 2019 recommendations for the adult immunization schedule in the United States. An overview of the recommended schedule can be found in a new edition of the Annals of Internal Medicine.
ACIP Vaccine Recommendations: Overview
In the 2019 update, the ACIP provides 3-step instructions on how to use the recommended vaccine schedule, a brand new Recommended Adult Immunization Schedule by Age Group (Table 1) and Recommended Adult Immunization Schedule by Medical Condition and Other Indications (Table 2), as well as recommendations for the influenza and hepatitis A and B vaccines, and an overview of vaccination coverage rates since 2015.
The new schedule features a simplified cover page that contains 3-step instructions on how to use the schedule. The new versions of Tables 1 and 2 use the same colors as previous iterations but have changes for improved cognition and notes pages with a larger font, made possible by the removal of the table of contraindications and precautions for vaccines recommended for adults. The cover page refers readers to www.cdc.gov/vaccines/hcp/acip-recs/general-recs to access the information on vaccine contraindications and precautions.
Part of the ACIP update included recommendations for the live attenuated influenza vaccine (LAIV). Although LAIV was not recommended in the US during the 2016 to 2017 or 2017 to 2018 influenza seasons, any licensed flu vaccine is now recommended for the 2018 to 2019 season if it is appropriate for the age and health status of the patient being immunized. Individuals who are not recommended to receive the LAIV are those with immunocompromised conditions (eg, HIV infection), an anatomical or functional asplenia, are pregnant, have received influenza antiviral medications in the previous 48 hours, have a cerebrospinal fluid leak, or have a cochlear implant. In the 2019 ACIP recommendations, routine administration of LAIV is recommended on an annual basis in all individuals aged ≥6 months who do not have contraindications to receiving the vaccine.
Hepatitis B Vaccination
The single-antigen recombinant hepatitis B vaccine with a novel cytosine-phosphate-guanine 1018 oligodeoxynucleotide adjuvant (Heplisav-B®, Dynavax®) was recommended in February 2018 by the ACIP for preventing hepatitis B in adults. Heplisav-B is administered in 2 doses that are ≥4 weeks apart, a regimen approved by the US Food and Drug Administration in November 2017. Heplisav-B may be used as a substitute with a different hepatitis B vaccine in a 3-dose series, “but a valid 2-dose series requires 2 doses of Heplisav-B with at least 4 weeks between them,” the ACIP task force wrote in their paper. The ACIP did recommend Heplisav-B in pregnant women with an indication for the immunization due to the lack of safety data on the vaccine in this population. The ACIP also noted that indications for the hepatitis C vaccine were similar to those for the hepatitis B vaccine and may be administered in a 2- or 3-dose series depending on the vaccine.
Hepatitis A Vaccine
While the ACIP recommended the addition of homelessness as an indication for hepatitis A vaccination with either a 2-dose series of single-antigen vaccine or a 3-dose series of hepatitis A and B in 2018, additional populations have been included in the update. Populations with an increased risk for the hepatitis A virus or severe hepatitis A disease include individuals with chronic liver disease or clotting factor disorders, have close personal contact with an international adoptee in the first 60 days after arrival from a country with high hepatitis A virus prevalence, are travelers in countries with high or intermediate hepatitis A virus prevalence, are men who have sex with men, routinely use injection or non-injection drugs, and individuals who work with hepatitis A virus in a laboratory setting. Any individual who wants to be vaccinated against the hepatitis A virus may also be vaccinated.
The tetanus, diphtheria, pertussis (Tdap) vaccine should be administered as 1 dose followed by a booster every 10 years for all ages. In individuals born in 1957 or later and individuals with HIV and a CD4 count >200 cell/μL for more than 6 months, the measles, mumps, rubella vaccine should be administered in 2 doses at least 4 weeks apart. In addition, the varicella vaccine should be given in 2 doses in people born in 1980 or later. A total of 2 doses of the zoster recombinant vaccine is recommended in individuals aged ≥50 years, whereas the live zoster vaccine should be administered as 1 dose in individuals aged ≥65 years. The 2019 update also included recommendations on human papillomavirus vaccination in males (2 or 3 doses depending on age at initial vaccination and identified risk factors), pneumococcal conjugate and pneumococcal polysaccharide, and vaccines for meningococcal bacteria.
New Recommendation Displays
In Table 2 of the recommendations, the ACIP provides 2 new recommendations, categorized by colors: pink (Delay vaccination until after pregnancy if vaccine indicated) and orange (Precaution—vaccine might be indicated if benefit of protection outweighs risk of adverse reaction).
The ACIP recommendations also offered an overview of adult vaccination coverage rates, which, overall, have remained low in the US despite modest increases in 2016. According to the ACIP, influenza coverage rates for the 2015 to 2016 influenza season remained similar to those in the 2014 to 2015 season in individuals aged ≥19 years (43.5%). Conversely, coverage rates decreased to 70.4% during the same period in individuals aged ≥65 years. However, a 3.3% increase in the 2016 pneumococcal vaccination coverage rate in adults aged ≥65 years was observed from 2015.
ACIP Take Home Message
“By consistently using the Recommended Adult Immunization Schedule, United States, 2019, and implementing the standards for adult immunization practice,” the ACIP task force wrote, “health care providers can reduce the burden of illnesses, hospitalizations, and mortality associated with vaccine-preventable diseases among their adult patients.”
Hunter P, Kim D for the Adult Immunization Work Group, Advisory Committee on Immunization Practices. Centers for Disease Control and Prevention (CDC). Recommended Adult Immunization Schedule, United States, 2019. www.cdc.gov/vaccines/acip/meetings/downloads/slides-2018-10/Adult-Imz-Hunter-Kim-508.pdf. October 24, 2018. Accessed February 1, 2019.