Changes to Tdap, Flu Vaccine Recommendations Among 2011 Immunization Schedules' Highlights

More than a dozen changes are reflected in the 2011 child, adolescent and adult immunization schedules developed by the CDC, the AAFP and other groups, but one family physician expert points to a single revision as being particularly significant for AAFP members who routinely provide vaccinations to patients of all ages.

According to Doug Campos-Outcalt, M.D., M.P.A., the AAFP's liaison to the CDC's Advisory Committee on Immunization Practices, or ACIP, perhaps the most important change in the new schedules, which were released Feb. 1, is a recommendation for off-label use of tetanus, diphtheria and acellular pertussis, or Tdap, vaccine in two specific patient groups.

During its Oct. 27-28, 2010, meeting, the ACIP voted to recommend that children ages 7 through 10 years who did not complete the recommended childhood series of diphtheria and tetanus toxoids and acellular pertussis, or DTaP, vaccine receive a catch-up dose of Tdap. ACIP members also recommended at that time that adults ages 65 and older who have close contact with infants receive a dose of Tdap. A dose also may be given to anyone else in this age group who desires the vaccine and has not previously received Tdap.

"Tdap is a very underutilized vaccine for adults," said Campos-Outcalt, who is associate head of the department of family and community medicine at the University of Arizona College of Medicine, Phoenix. "We have very low use of that vaccine. People just aren't thinking of it."

The purpose of the new recommendations, Campos-Outcalt told AAFP News Now, is to protect infants, in whom pertussis can cause particularly severe illness.

Several states had pertussis outbreaks last year, at least one of which still is ongoing. As of Jan. 7, California had more than 8,300 reported cases in its lingering outbreak (5-page PDF; About PDFs), which has resulted in hundreds of hospitalizations and 10 infant deaths.

The updated Tdap recommendations also state that the vaccine can be used regardless of the interval since previous immunization with a vaccine that contains tetanus or diphtheria toxoid.

In addition to the Tdap revisions, the ACIP recommended changes for meningococcal vaccination at its October meeting, including that a second dose of quadrivalent meningococcal conjugate vaccine, or MCV4, be added to the primary series for high-risk children. That recommendation also is reflected in the 2011 childhood schedule.

Another change in the 2011 adolescent schedule also was driven by the ACIP's actions during its October meeting. Previously, all adolescents were recommended to receive one dose of MCV4 at age 11 or 12 years (or at 13-18 years if not previously vaccinated). The committee voted in October to recommend a booster dose at age 16 for adolescents who received their first dose at the preteen (age 11 or 12) visit. Those who received their initial dose at ages 13-15 should get a booster dose three to five years after that first dose but prior to age 18, the committee said.

Campos-Outcalt pointed out two other significant changes included in the 2011 immunization schedules:

Campos-Outcalt emphasized that this season's flu vaccine is a good match to the strains circulating in North America, but he added that uptake could be better. Vaccinating the general population not only protects those who receive the vaccine, it also can help prevent spreading the disease to those at increased risk for complications from the flu, including children ages 5 years and younger and adults 65 and older.

"Most people get the flu and get over it," said Campos-Outcalt. "It's the very old and very young who tend to have problems with it. For whatever reason, we don't have very high adherence to recommendations. There's a lot of apathy in the general population."

Historically, that apathy has extended to health care personnel, who are recommended to receive flu vaccine to protect themselves, their co-workers and their patients. Uptake by health care workers has hovered for years at less than 50 percent, but Campos-Outcalt said rates are starting to climb.

The Society for Healthcare Epidemiology of America released a position paper last year that called for mandatory influenza vaccination for health care workers, and the American Academy of Pediatrics released a similar policy statement at about the same time.

There are signs, according to Campos-Outcalt, that more health care institutions are encouraging or requiring vaccination for employees. "Workplaces are being more aggressive about it," he said. "We're still not where we need to be."

Other changes to the adult immunization schedule include reordering to keep all universally recommended vaccines together and the addition of a statement clarifying that a vaccine series does not need to be restarted, regardless of the time that has elapsed between doses.

Additional changes to the child and adolescent schedules include the addition of guidance for the hepatitis B vaccine schedule for children who did not receive a birth dose, as well as revised guidance for catch-up doses (1-page PDF; About PDFs) of Haemophilus influenzae type b vaccine in people ages 5 years and older.

Finally, it's worth noting that on Jan. 28, the FDA revised the license for Novartis' MCV4 vaccine, which is marketed as Menveo, lowering the minimum age for administration from 11 years to 2 years. Sanofi Pasteur's MCV4 vaccine, which is marketed as Menactra, already was licensed for use in children as young as 2 years.

The FDA's action resulted in changes in the footnotes of both the childhood and adolescent schedules. Those changes are reflected in the schedules posted online, but they came too late to be updated in printed journals, including American Family Physician.