The CDC and its Advisory Committee on Immunization Practices (ACIP), together with the AAFP and other medical professional organizations, have released the 2015 adult and childhood immunization schedules, which feature a number of notable changes for family physicians that include updated recommendations for use of pneumococcal 13-valent conjugate vaccine (PCV13; Prevnar 13) in older adults and live attenuated influenza vaccine (LAIV; FluMist) in young children.
AAFP liaison to the ACIP Jamie Loehr, M.D., of Ithaca, N.Y., told AAFP News that the release of the schedules offers another valuable conversation entry point to discuss the importance of vaccination with your patients.
"The recent outbreak of measles at (Disneyland), with spread to several states and Mexico, shows how easy it is for the disease to spread geographically," he said. "Truly, measles is just a plane ride away. Family physicians might use this example to revisit the issue with vaccine-hesitant parents."
Loehr summarized the adult schedule changes in a Practice Guidelines article(78 KB PDF) for American Family Physician (AFP), saying that the most significant change involves PCV13.
- The 2015 adult and childhood immunization schedules include updated recommendations for use of pneumococcal 13-valent conjugate vaccine in older adults and live attenuated influenza vaccine (LAIV; FluMist) in young children.
- At the upcoming Feb. 25-26 ACIP meeting, the group will re-evaluate its current LAIV recommendation based on previous evidence combined with preliminary data collected from the 2014-15 season.
- The FDA approved a meningitis B vaccine last October, and a second option will face approval soon. In addition, a nine-valent HPV vaccine is likely to be approved in the near future.
Last August, the ACIP held a special meeting that focused on the pneumococcal vaccine, during which it voted to recommend routine immunization with PCV13 for adults age 65 or older, plus a dose of the 23-valent pneumococcal polysaccharide vaccine (PPSV23; Pneumovax) for these patients six to 12 months after PCV13 vaccination.
Loehr said the logistics of the recommendation are a bit complicated.
"So someone walks in who just turned 65 last month -- it's very easy -- you give them PCV13," he said. "Or if someone has never had a pneumococcal vaccine, they could be 72, and the decision is straightforward to give them the PCV13 vaccine," with a dose of PPSV23 to be given subsequently.
However, Loehr added, if a patient is 67 and had the PPSV23 vaccine two years ago, the new ACIP recommendation still calls for administration of the PCV13 vaccine.
Since the meeting last summer, Loehr said CMS has updated its regulations(www.cms.gov) to allow coverage of both pneumococcal vaccines for adults 65 and older as long as the two vaccines are administered a year apart.
In his AFP article, Loehr noted that the key wording is "Medicare will cover ... (a) different, second pneumococcal vaccine one year after the first vaccine was administered (that is, 11 full months have passed following the month in which the last pneumococcal vaccine was administered)."
So, although the ACIP recommends a second vaccine as early as six months in some circumstances, Medicare won't reimburse both unless the two vaccines are a year apart.
Other adult immunization schedule highlights include:
- Recent, current or upcoming surgery or anesthesia is not a contraindication or precaution to giving a vaccine.
- For pregnant patients, the tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccine is recommended with each pregnancy between 27 and 36 weeks' gestation.
According to Loehr, adult vaccination rates remain extremely low, and most adults don't even realize they need vaccines. He noted that for vaccine-hesitant patients, the CDC recommends using the SHARE mnemonic:
- Share the reasons why the recommended vaccine is right for each patient,
- Highlight positive personal experiences with immunizations,
- Address patient questions and concerns in plain, understandable language,
- Remind patients that vaccine-preventable diseases still exist in the United States and
- Explain the potential costs of getting the disease (e.g., health effects, lost productivity and financial costs).
Childhood and Catch-up Schedules
He pointed to the preferential recommendation ACIP members made last June that called for administering LAIV rather than inactivated influenza vaccine (IIV) in children ages 2-8 years. However, at its October meeting, the committee heard a presentation of 2013-14 vaccine efficacy data that indicated LAIV was less effective than IIV against influenza A (H1N1) virus.
For now, the CDC has not changed any of its recommendations regarding influenza vaccination. At the upcoming Feb. 25-26 ACIP meeting, the group will re-evaluate its LAIV recommendation based on that earlier evidence combined with preliminary data collected from the 2014-15 season and may adjust the recommendation accordingly, Loehr said.
Given that possibility, he suggested clinics wait until after the ACIP meeting to order their flu vaccines for the fall of 2015. If the recommendation were to change, physicians could then adjust their orders for the 2015-16 season.
Also in the childhood schedule, Loehr pointed out that the footnotes for meningitis vaccination were extensively modified. The meningococcal vaccine is recommended for use in children at high risk for invasive meningococcal disease and should be given at ages 2, 4, 6 and 12 months, he said. However, each of the three available vaccines has a different indication based on the child's age and medical condition. The footnotes now break the recommendations down by specific condition and vaccine, which Loehr said should make it easier to decide which vaccine to use in each situation.
Among other notable topics Loehr touched on in his AFP summaries:
- The CDC offers a comprehensive Storage and Handling of Immunobiologics toolkit(www.cdc.gov) that details safe storage and handling practices for clinical offices.
- Family physicians should be aware that there is a small association between febrile seizures and concomitant administration of influenza plus PCV13 and/or diphtheria, tetanus and acellular pertussis (DTaP) vaccines.
- The number of vaccinations required to produce one extra febrile seizure is about 2,200. Thus, weighing the benign nature of febrile seizures against the benefits of the vaccines, the ACIP has not recommended any change in practice at this time.
Finally, Loehr pointed to a handful of vaccines that could be coming to your office in 2015. The FDA approved a meningitis B vaccine last October, and a second option will face approval soon. In addition, a nine-valent HPV vaccine is likely to be approved in the near future. The ACIP probably will begin considering recommendations for appropriate use of these vaccines at the upcoming February meeting, he said.
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