Among the changes affecting the newly released 2014 recommended immunizations schedules, perhaps one of the biggest is what family physicians won't see this year. For the first time, the familiar figures, footnotes and tables have not been published in full in the CDC's Morbidity and Mortality Weekly Report. Instead, electronic versions of the schedules(www.cdc.gov) have been posted to the Vaccines and Immunizations section of the CDC website so they can be swiftly revised if errors or omissions are discovered.
In conjunction with this innovation, the agency also has introduced a content syndication feature that allows external websites to link directly to the CDC-hosted schedules so users always have the most-up-to-date information.
The combined schedule for individuals ages 0 through 18 years and catch-up schedule(5 page PDF) and the adult schedule(4 page PDF) also are available on the AAFP website as PDF files.
What's New or Improved?
As for changes to the actual content of the schedules, most involve clarification of existing recommendations, with just a few exceptions. Where appropriate, brand names are included for each vaccine because they are more familiar to most clinicians and staff.
For example, in the child and adolescent schedule(www.cdc.gov), the legend and footnote for the meningococcal conjugate vaccine row have been updated to reflect a recent recommendation to use quadrivalent meningococcal conjugate (MenACWY-CRM) vaccine (Menveo) in infants as young as age 2 months. Previously, only bivalent meningococcal conjugate vaccine and Haemophilus influenza type b conjugate (Hib-MenCY) vaccine (MenHibrix) was recommended for infants this young.
- Most changes to the 2014 recommended immunization schedules involve refinement and clarification of existing recommendations, with just a few exceptions.
- The adult schedule, for example, now recommends a single dose of Haemophilus influenzae type b vaccine for people with functional or anatomic asplenia and those who have sickle cell disease if they have not been vaccinated previously.
- New research shows that rates for a number of adult immunizations remain well below target levels, and researchers point to possible missed opportunities to vaccinate as a chief cause.
Other changes include:
- influenza vaccine footnotes have been updated to guide dosing for children ages 6 months through 8 years during the 2013-14 and 2014-15 seasons,
- pneumococcal vaccine footnotes have been updated to guide vaccination of people with high-risk conditions, and
- hepatitis A vaccine footnotes have been updated to provide guidance for unvaccinated people who are at increased risk for infection.
The catch-up schedules for Hib conjugate vaccine, pneumococcal conjugate vaccine, and tetanus, diphtheria and acellular pertussis (Tdap) vaccine also have been clarified.
The adult schedule(www.cdc.gov) contains a number of changes pertaining to Hib vaccine. Specifically, a single dose of the vaccine now is recommended for people with functional or anatomic asplenia and those who have sickle cell disease if they have not been vaccinated previously. For patients scheduled to undergo elective splenectomy, the dose should be given at least 14 days before the procedure.
In addition, hematopoietic stem cell transplant recipients should receive a three-dose regimen six to 12 months after successful transplantation, regardless of vaccination history. Doses should be given at least four weeks apart.
Also new this year, physicians no longer need to consider Hib vaccine for individuals with HIV infection, because the likelihood of Hib infection is low in this population.
Other changes to the adult schedule include
- moving the row for the pneumococcal conjugate 13-valent vaccine (PCV13) on top of that for the pneumococcal polysaccharide (PPSV23) vaccine as a visual reminder that PCV13 should be administered before PPSV23 in patients for whom both vaccines are recommended (i.e., those with immunocompromising conditions, functional or anatomic asplenia, cerebrospinal fluid leaks, or cochlear implants);
- reordering the respective footnotes for the pneumococcal vaccines to mirror the row sequence, as well as adding language to remind clinicians of the appropriate order of administration when both are indicated;
- modifying the meningococcal vaccine footnote to clarify which patients need either one or two doses of vaccine, as well as to clarify which patients should receive the meningococcal conjugate (MenACWY-D) vaccine (Menactra) versus MenACWY-CRM vaccine;
- adding information about the recombinant influenza vaccine (RIV) and use of RIV and inactivated influenza vaccine (IIV) among egg-allergic patients to indicate that RIV or IIV can be used in patients with hives-only allergy to eggs;
- editing the tetanus and diphtheria toxoids (Td)/Tdap vaccine footnote to harmonize with the language used in the pediatric immunization schedule; and
- simplifying both the human papillomavirus (HPV) vaccine footnote and the herpes zoster vaccine footnote, including removal of the bullet regarding health care personnel.
Low Vaccination Rates, Barriers Persist
Coincidentally, a brace of recently released research reports highlight key issues related to adult immunization: continuing low administration rates and barriers to overcoming them.
According to "Noninfluenza Vaccination Coverage Among Adults -- United States, 2012,"(www.cdc.gov) published Feb. 7 in MMWR, the CDC analyzed data for selected vaccines from the 2012 National Health Interview Survey to assess vaccination coverage among adults ages 19 and older. Included in that analysis were pneumococcal, tetanus toxoid-containing (Td or Tdap), hepatitis A, hepatitis B, herpes zoster, and HPV vaccines.
Compared with 2011, only modest increases were seen in Tdap vaccination among adults ages 19-64 (from an overall 12.4 percent to 15.6 percent), herpes zoster vaccination among those 60 or older (from 15.7 percent to 20.1 percent), and HPV vaccination among women ages 19-26 (from 29.5 percent to 34.5 percent); coverage for the other vaccines did not improve.
A study report(annals.org) published Feb. 4 in the Annals of Internal Medicine may shed some light on barriers to achieving higher rates of adult immunization.
Study authors noted that the ACIP currently recommends 12 vaccines for adults, including vaccines recommended universally, catch-up vaccines and vaccines for high-risk patients. In addition, the context for adult immunization has shifted in recent years, with some vaccines now being covered by Medicare Part D and many patients moving away from primary care settings as the site of vaccination.
Based on survey responses from members of a primary care network comprising family physicians and general internists, the CDC-funded study found
- Almost all physicians reported assessing patients' vaccination status during annual visits or new-patient visits, but less than one-third of respondents reported doing so at every visit. The most common means of assessment was a review of the patient's medical record; only a minority used tools such as immunization information systems (IISs).
- Nearly all physicians assessed vaccination status for seasonal influenza, pneumococcal, Td, Tdap, and zoster vaccines. Fewer reported assessing status for the remaining recommended vaccines.
- Most physicians reported stocking seasonal influenza, pneumococcal, Td and Tdap vaccines; they were less likely to stock hepatitis vaccines; catch-up vaccines (HPV; mumps, measles and rubella; varicella; and meningococcal); and zoster vaccine.
- Characteristics associated with reporting greater financial barriers included private practice setting, fewer than five health care professionals in the practice, Southern region, West region (for FPs only), and Midwest region and having a higher proportion of patients with Medicare Part D (for internists only).
- Most respondents reported referring patients elsewhere for vaccines they did not stock. Patients also were referred to alternative vaccinators because of insurance coverage issues. Typically, patients were referred to a local pharmacy/retail store or the public health department.
Overwhelmingly, the physicians surveyed reported that they considered it their responsibility to see that their patients received all recommended vaccines, even if they themselves did not administer the vaccines. Although most said their patients preferred to be immunized in the physician's office rather than at a pharmacy or retail store, many respondents did see a role for pharmacists in providing immunizations.
The same could not be said for subspecialists, however, with most survey respondents noting that subspecialists who administered vaccines rarely notified the primary care physician.
"Although primary care physicians appear motivated to ensure that patients are up to date on vaccinations, many barriers exist," the authors concluded. "Implementation of system changes, including adopting practices that improve communication between primary care physicians and alternate vaccinators, more widespread use of effective tools (IISs and clinic decision support systems), and removing policy-related barriers, could improve adult vaccination in the United States."
More From AAFP
American Family Physician: Practice Guideline: ACIP Releases 2014 Adult Immunization Schedules (Members/Subscribers Only)
(Feb. 15, 2014)
American Family Physician: Practice Guideline: ACIP Releases 2014 Child and Adolescent Immunization Schedules (Members/Subscribers Only)
(Feb. 1, 2014)
American Family Physician: Editorial: What's New In Childhood Vaccines (Members/Subscribers Only)
(Feb. 1, 2014)