How to update patients on recommended vaccinations

I recently had a patient ask me about the herpes zoster vaccine. Unfortunately, he was my patient because he had a severe herpes zoster infection. He had not had the vaccine, and asked if he could have avoided his current situation had he had the vaccine.

I did not want to give him the bad news, but I did want to be able to answer my patient’s questions about adult vaccines. The Centers for Disease Control and Prevention (CDC) has published guidelines for all adult vaccines
The following are its recommendations.

Types of vaccinations
The CDC recommends that all patients receive the influenza vaccine annually to fight the seasonal flu outbreak. This comes in two forms: inactivated influenza vaccine (IIV) and the  recombinant influenza vaccine (RIV).
The list of currently available vaccines can be found on the CDC website.1 Care should be taken in pregnant patients2 and those with egg allergies.

It is recommended that one dose of Tdap be administered during each pregnancy, preferably during gestational weeks 27-36.

Precautions include any sign of encephalopathy within one week of previous-pertussis containing vaccine that was not due to another identifiable cause, or history of Guillain-Barré syndrome within six weeks of last vaccine.

Precautions
Adults with allergic reactions more severe than hives should receive vaccines in a medical setting under the supervision of a healthcare provider who can manage allergic conditions that may arise. There is one additional precaution, which is a history of Guillain-Barré syndrome after a previous influenza vaccination.

The tetanus, diphtheria, and acellular pertussis vaccination (Tdap ) is routinely given at 11 to 12 years of age. The number of reported pertussis cases has increased since the 1980s, especially among adolescents and adults.3

Immunity to pertussis weakens five to 10 years after childhood vaccination, leaving adolescents and adults susceptible to pertussis infection if not repeated.
In 2005, 25,616 cases of pertussis were reported in the United States. Among the reportable bacterial vaccine-preventable diseases in theUnited States for which universal childhood vaccination has been recommended, pertussis is the least well-controlled.3

One dose of tetanus and diptheria (Td) booster should be given every 10 years. Theoretically, that means at age 22, 32, 42, 52, 62, 72, and so on. for those who document RTO 7/19 and not RTO one year. 

Exceptions
The measles, mumps, and rubella vaccine (MMR) and varicella vaccine (VAR) are indicated for all patients except those who are pregnant and immunocompromised. The MMR vaccine is not necessary in patients born before 1957 who are not healthcare professionals, have documentation of receipt of MMR, or have laboratory evidence of immunity or previous disease. 

The varicella vaccine is not necessary in patient born in the U.S. prior to 1980 except for healthcare professionals.

HPV vaccine
The human papillomavirus vaccine (HPV) should be given in three doses through age 26 and is recommended for adolescents. HPV infection causes cervical, vaginal, and vulvar cancers in women; penile cancers in men; and oropharyngeal and anal cancers and genital warts in both men and women.4

There has been some concern about this vaccine in particular, with serious side effects reported in the media.5 A PubMed search for side effects and complications found no case studies associated with adverse events.
One systematic review of all randomized controlled trials found the most commonly reported adverse events were pain and swelling. This was followed by fatigue, fever, gastrointestinal symptoms, and headache.6 
A July 2018 study found no association between the vaccine and an increase in autoimmune disease.7

Pneumococcal
Pneumococcal vaccination is performed using two different vaccines in those age 65 or older.  The first to be given is the 13-valent pneumococcal conjugate vaccine (PCV13), followed by the 23-valent pneumococcal polysaccharide vaccine (PPSV23) with at least one year in between. 

Special populations who should be vaccinated against pneumonia include patients with chronic heart, lung, and liver diseases; alcoholism; diabetes mellitus;and cigarette smokers.   
Herpes, recombinant zoster
Herpes zoster incidence increases with age: five cases per 1,000 adults age 50–59 years to 11 cases per 1,000 adults age ≥ 80 years. The risk of herpetic neuralgia also increases with age.8   

The recombinant zoster vaccine (RZV) vaccine should be given in two doses after the age of 50 to prevent shingles. This is regardless of past episode of herpes zoster, or receipt of zoster vaccine live at an earlier age.
The RZV type is preferred to the zoster vaccine live (RZL) prior to age 60. After 60 years of age, either vaccine may be used. Note that the RZL is contraindicated in pregnant women and patients with severe immunodeficiency.

Hepatitis
Hepatitis vaccines are recommended for high-risk patients or those who want to be protected.  High-risk patients include those with chronic liver disease, HIV infection, adults younger than age 60 years with diabetes mellitus, adults in predialysis care or receiving dialysis, recent or current IV drug users, healthcare and public safety workers at risk for exposure to blood or blood-contaminated body fluids and sexual exposure risks, especially men who have sex with men. 

Meningococcal
Meningococcal vaccination is recommended for patients at high risk every five years. Two doses are recommended for patients with anatomical or functional asplenia, including sickle cell disease and other hemoglobinopathies, HIV infection, persistent complement component deficiency, and patients taking Soliris (eculizumab, Alexion).

One dose every five years  is suggested for patients who travel to or live in countries where meningococcal disease is hyperendemic or epidemic-such as locations in the African meningitis belt-or during the Hajj, an annual Islamic pilgrimage to Mecca.

Those at risk for a meningococcal disease outbreak include certain serogroups, and microbiologists routinely exposed to Neisseria meningitis, as well as military recruits and first-year college students living in residential housing.

Hib vaccination
Haemophilus influenzae type b vaccine (Hib) is recommended for adults with anatomical or functional asplenia, including sickle-cell disease or undergoing elective splenectomy, as well as patients undergoing hematopoietic stem cell transplant (HSCT).

This information can be remembered by organizing by age group, as listed below.

Adolescent
• Meningococcal vaccine
• Tetanus and iptheria (Tdap) vaccine
• HPV vaccine
• Pneumococcal is high risk

Young adults (20-49 years old)
• Td boosters every 10 years
• MMR if not taken as child
• VAR if not taken as child
• HPV if not taken as child
• Hepatitis as indicated

Older adults (older than 49 years old)
• Herpes Zoster (even if had shingles)
• Pneumococcal

The CDC offers a self-quiz to determine what vaccines should be obtained.⁹
Results can be taken the to the primary care physician to stimulate discussion on what should be administered.

References:

1. Centers for Disease Control and Prevention, National Center for Immunization and Respiratory Diseases. Influenza vaccines-United States, 2018-18 influenza season. Available at: https://www.cdc.gov/flu/protect/vaccine/vaccines.htm. Accessed 11/5/18.
2. National Center for Immunization and Respiratory Diseases. Resources for educating pregnant women. Available at: https://www.cdc.gov/vaccines/pregnancy/hcp/resources.html. Accessed 11/5/18.
3. Kretsinger K, Broder KR, Cortese MM, Joyce MP,Ortega-Sanchez I,Lee GM, Tiwari T, Cohn AC, Slade BA, Iskander JK, Mijalski CM, Brown KH, Murphy TV, Centers for Disease Control and Prevention, Advisory Committee on Immunization Practices, Healthcare Infection Control Practices Advisory Committee.  Preventing tetanus, diphtheria, and pertussis among adults: use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine: recommendations of the Advisory Committee on Immunization Practices (ACIP) and recommendation of ACIP, supported by the Healthcare Infection Control Practices Advisory Committee (HICPAC), for use of Tdap among health-care personnel. MMWR Recomm Rep. 2006 Dec 15;55(RR-17):1-37.
4. Viens LJ, Henley SJ,Watson M,Markowitz LE, Thomas CC, Thompson TD, Razzaghi H, Saraiya M. Human papillomavirus-associated cancers-United States, 2008–2012. MMWR Morb Mortal Wkly Rep.2016 Jul 8;65(26):661-6.
5. Faasse K, Porsius JT, Faasse J, Martin LR. Bad news: The influence of news coverage and Google searches on Gardasil adverse event reporting. Vaccine. 2017 Dec 14;35(49 Pt B):6872-6878. doi: 10.1016/j.vaccine.2017.10.004.
6. Goncalves AK,Cobucci RN,Rodrigues HM,de Melo AG, Giraldo PC. Safety, tolerability and side effects of human papillomavirus vaccines: a systematic quantitative review. Braz J Infect Dis. 2014 Nov-Dec;18(6):651-9.
7. Skufca J, Ollgren J, Artama M, Ruokokoski E, Nohynek H, Palmu AA. The association of adverse events with bivalent human papilloma virus vaccination: A nationwide register-based cohort study in Finland. Vaccine. 2018 Sep 18;36(39):5926-5933.