Practice Guidelines

ACIP Releases 2007-08 Adult Immunization Schedule

DOUG CAMPOS-OUTCALT, MD, MPA, University of Arizona College of Medicine, Phoenix, Arizona

JONATHAN L. TEMTE, MD, PhD, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin

The annual update of the harmonized adult immunization schedule was recently published in Morbidity and Mortality Weekly Report1 and is reproduced in this issue of American Family Physician (Figures 1 and 2). It represents the work of vaccine experts at the Centers for Disease Control and Prevention (CDC) and the Advisory Committee on Immunization Practices (ACIP), as well as the collaboration of several partner organizations, including the American Academy of Family Physicians. The adult and child immunization schedules are updated each year to reflect the development, licensure, and ACIP recommendations on new vaccine products and expanded recommendations on preexisting ones. Adherence to all three schedules helps to ensure that individuals and communities can gain maximum benefits from one of the most effective public health interventions: vaccines.

Changes in this year's adult schedule are few. They include the addition of quadrivalent human papillomavirus vaccine (Gardasil) for women up to 26 years of age, and herpes zoster virus vaccine (Zostavax) for adults 60 years and older; both vaccines were approved by the U.S. Food and Drug Administration since the last adult schedule was released.2 In addition, the schedule reflects the new recommendation of a second dose of varicella vaccine for young adults who have received only one dose.

The publication of the harmonized schedule should serve as a reminder that rates of adult immunization with recommended vaccines remain suboptimal, far below rates achieved in children. The immunization goals set for 2010 include having 90 percent of adults 65 years and older and 60 percent of adults with asthma or diabetes immunized against influenza annually and against pneumococcal pneumonia.3 As a nation, we are far below these goals.4 The CDC recommends that all health care workers receive influenza vaccine in addition to vaccines against other infectious agents that can be spread in the health care setting.4,5 Again, the evidence is that we perform poorly in this area.4

There are several reasons why our adult immunization rates are so poor. Payment for adult vaccines is much more problematic than it is for children because there is no adult equivalent of the Vaccines for Children Program, which guarantees funding for vaccines for eligible children. Federal funding for adult vaccine programs is woefully inadequate; it does not keep pace with the increasing number of vaccines and the number of adults who lack insurance coverage for immunizations. Unlike vaccines for children and adolescents, many vaccines for adults are indicated based on the presence of risk factors and not age, which adds the variables of physician and patient memory to the compliance formula. Historically, universal vaccine recommendations have resulted in much higher adherence rates than risk-specific ones.

What can physicians do to improve the rate of immunizations among our staff and adult patients? After reviewing the evidence on immunizations, the Task Force on Community Preventive Services recommended the following interventions for physicians to increase vaccination rates: patient recall and reminder systems; patient education as part of a multicomponent intervention; expanded clinic hours for immunizations; measurement of performance and provision of feedback to physicians; and the use of standing orders to allow staff to vaccinate patients.6

Physicians also must ensure that their clinical setting and staff are not sources of infectious diseases that spread to patients and the community. Good office infection-control practices are essential; this includes ensuring that we and our staff are fully immunized. The CDC now recommends that staff adherence to influenza vaccination should be used as a quality measure.4

Family physicians are an important component of the nation's immunization system. To fulfill this role, we must do all we can to ensure the highest possible level of adherence to immunization recommendations by patients, staff, and ourselves.

EDITOR'S NOTE: The authors serve as liaisons to ACIP for the AAFP, and Dr. Temte is a member of the Harmonized Schedule Working Group.

Address correspondence to Doug Campos-Outcalt, MD, MPA, at dougco@email.arizona.edu. Reprints are not available from the authors.

Author disclosure: Nothing to disclose.

REFERENCES

1. Centers for Disease Control and Prevention, Advisory Committee on Immunization Practices. Recommended adult immunization schedule-United States, October 2007-September 2008. Morb Mortal Wkly Rep 2007;56:Q1-4.

2. Markowitz LE, Dunne EF, Saraiya M, Lawson HW, Chesson H, Unger ER, for the Centers for Disease Control and Prevention (CDC); Advisory Committee on Immunization Practices (ACIP). Quadrivalent human papillomavirus vaccine: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 2007;56(RR-2):1-24.

3. U.S. Department of Health and Human Services. Healthy people 2010. Accessed September 19, 2007, at: http://www.healthypeople.gov/document/html/objectives/14-29.htm.

4. Fiore AE, Shay DK, Haber P, Iskander JK, Uyeki TM, Mootrey G, et al., for the Advisory Committee on Immunization Practices (ACIP), Centers for Disease Control and Prevention (CDC). Prevention and control of influenza. Recommendations of the Advisory Committee on Immunization Practices (ACIP), 2007. MMWR Recomm Rep 2007;56(RR-6):1-54.

5. Immunization Action Coalition. Healthcare personnel vaccination recommendations. Accessed September 19, 2007, at: http://www.immunize.org/catg.d/p2017.pdf.

6. Centers for Disease Control and Prevention. Guide to community preventive services. Vaccines. Accessed September 19, 2007, at: http://www.thecommunityguide.org/vaccine/default.htm.

Practice Guideline Briefs

AHA Releases Recommendations on Preparticipation Screening in Student Athletes

There has been a recent increase in sudden deaths among young competitive athletes with undetected cardiovascular disease (CVD) in the United States and Europe. Because many official recommendations from athletic governing bodies are inconsistent and lack standardization, and therefore may be medically insufficient, the American Heart Association (AHA) has issued recommendations that address the benefits, limitations, and medical implications of preparticipation screening in high school and college athletes.

CVD is a common cause of sudden death in young athletes; hypertrophic cardiomyopathy is the most common cause of death of athletes, representing one third of all deaths. These deaths occur most often in basketball and football players in the United States. Identifying these abnormalities through preparticipation cardiovascular screening could prevent sudden death in this population.

There is a need for uniform guidelines for preparticipation screening of young athletes, so the AHA recommends that a national standard for cardiovascular evaluations be developed for high school and college athletes. To raise suspicion of CVD in young athletes, the AHA recommends that a personal and family medical history be taken and a physical examination be performed (Table 1). Uniform guidelines may identify more athletes with cardiac disease, ensure the safety of competitive sports, and positively affect the health of these athletes. In addition, providing a practical screening strategy for a large population of young athletes will ensure that complete family and personal medical histories are taken, which may identify CVD that could progress or cause sudden death.

Table 1. Recommended Elements of Preparticipation Cardiovascular Screening in Young Athletes

Medical history Family Death from heart disease in one or more relatives younger than 50 years Disability from heart disease in a close relative younger than 50 years Hypertrophic or dilated cardiomyopathy, long QT syndrome or other ion channelopathies, Marfan syndrome, or clinically important arrhythmias in any family member Personal Elevated systemic blood pressure Excessive exertional and unexplained dyspnea or fatigue associated with exercise Exertional chest pain or discomfort History of heart murmur Unexplained syncope or near-syncope Physical examination Brachial artery blood pressure (measured while seated) Femoral pulses to exclude coarctation of the aorta Heart murmur Physical stigmata of Marfan syndrome

note: A positive response to any item listed may be sufficient evidence to provide a referral for a cardiovascular examination. Adapted with permission from Maron BJ, Thompson PD, Ackerman MJ, Balady G, Berger S, Cohen D, et al. Recommendations and considerations related to preparticipation screening for cardiovascular abnormalities in competitive athletes: 2007 update. Circulation 2007;115:1646.

Preparticipation screening examinations should be performed in an environment conducive to optimal auscultation of the heart; however, performing echocardiography or electrocardiography is optional. Physical examinations should be mandatory for all competitive athletes before they are allowed to play organized sports. For high school athletes, these evaluations should be given every two years. College athletes also should complete family and personal medical histories before they are allowed to compete; these histories should be updated and the athlete's blood pressure should be measured every three years. Changes in medical status may mean that further testing is required or that another physical examination should be performed.

Cardiovascular athletic screening should be performed only by physicians and other health care professionals who are trained to recognize signs of CVD. Parents should be responsible for completing their child's medical history, and student athletes with any identified abnormalities should be referred to a subspecialist.

The AHA notes that restricting young athletes who are at risk of cardiac disease is justified by the tremendous impact of sudden deaths in this population.

SHERRI DAMLO

Answers to This Issue's Clinical Quiz Q1. B Q2. C Q3. B Q4. D Q5. C Q6. A Q7. C Q8. A, B, C, D Q9. A, D Q10. A, B, D Q11. A, B, C

Copyright © 2007 by the American Academy of Family Physicians. This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact afpserv@aafp.org for copyright questions and/or permission requests.