Disease- and population-specific vaccines: Clinical guidance

Despite overwhelming evidence of the safety and effectiveness of the HPV vaccine, vaccination rates remain low. The AAFP urges physicians to strongly recommend the HPV vaccine to their patients.

What you say, and how you say it, matters. A physician's recommendation is the single best predictor of vaccination. It is recommended that physicians bundle, and not single out the HPV vaccine in discussions with patients on the importance of receiving vaccinations. The bundling approach has been shown to normalize and increase acceptance of the HPV vaccine and demonstrate the importance of the HPV vaccine. The current HPV immunization schedule is provider- and patient-friendly and is consistent with adolescents’ well visits.

Among women who have not been previously infected with a targeted HPV type, 2vHPV and 4vHPV have over 95% efficacy in preventing cervical pre-cancers caused by HPV16 and HPV18.

In males, 4vHPV demonstrated 90% efficacy in preventing genital warts, and 75% efficacy in preventing anal pre- cancers in men caused by HPV16 and HPV18.

The 9vHPV was compared to the 4vHPV. Few cases of disease caused by HPV types 6, 11, 16 and 18 were seen in either group. The immunogenicity of HPV 9 was comparable to HPV4, which inferred efficacy for HPV types 6, 11, 16 and 18. In subjects who were not infected at the start of the study and received all three doses (per protocol), efficacy for prevention of genital pre-cancers caused by the five additional HPV types covered in HPV 9 was 96.7%.

Sources

Ylitalo KR, Lee H, Mehta NK. Health care provider recommendation, human papillomavirus vaccination, and race/ethnicity in the U.S. National Immunization Survey. Am J Public Health. 2013;103(1):164-169.

Petrosky E, Bocchini JA, Hariri S, et al. Use of 9-valent human papillomavirus (HPV) vaccine: updated HPV vaccination recommendations of the Advisory Committee on Immunization Practices. MMWR. 2015;64(11):300-304

While measles, mumps and rubella (MMR) vaccination rates overall remain strong, there can be pockets of low community vaccination coverage due to vaccine hesitancy and vaccine misinformation. As a result of decreased vaccination coverage, communities can become vulnerable to measles outbreaks.

A recent WHO report indicates that measles vaccination coverage has steadily declined since the beginning of the COVID-19 pandemic, increasing the risk of outbreaks.

Family physicians should encourage all their patients to be up to date on MMR vaccinations and other recommended vaccines. Important talking points to share when discussing the MMR vaccine with patients:

Some parents may consider refusing or delaying vaccinations because they are concerned about the number of vaccines given in a child’s first two years of life. Encourage your patients to follow the recommended immunization schedules, which are based on the best available data and designed to maximize benefit and minimize risk.

Health care professionals should also be vigilant about identifying and reporting suspected measles cases.

Step 1: Consider measles in a patient with fever, rash and other symptoms of measles such as cough, runny nose or conjunctivitis—especially if the person recently traveled internationally or was exposed to a person with fever and rash.

Step 2: Promptly isolate patients with suspected measles to avoid the spread of the disease, and immediately report suspected measles cases to the local or state health department.

Step 3: Obtain specimens for testing from patients with suspected measles, including viral specimens for genotyping, which can help determine the source of the virus.

Meningococcal disease is an uncommon but potentially life-threatening infection caused by Neisseria meningitidis bacteria. It can present as meningitis or sepsis and progresses rapidly, even in otherwise healthy individuals. Despite advances in care, the case-fatality rate remains 10–15%, and up to 20% of survivors experience long-term complications such as hearing loss, neurologic impairment, or limb loss.

In the United States, disease incidence is low (20 to 50 cases annually in recent years). However, outbreaks continue to occur particularly among very young children and people ages 16 to 23, and in community settings, such as college campuses. Although there are at least 13 types of Neisseria meningitidis, most serious cases are caused by the A, B, C, W, and Y serogroups.
Vaccination is the most effective tool for meningococcal prevention. Two types of vaccines are currently licensed in the U.S.:

Meningococcal vaccines should be covered by most commercial and public insurance plans. The Vaccines for Children (VFC) program covers qualified children under the age of 18.

References

Hambrosky J, Kroger A, Wolfe S, eds. CDC. Epidemiology and Prevention of Vaccine Preventable Diseases. 13th ed. Washington, D.C. Public Health Foundation; 2015.

Cohn A, MacNeil JR, Clark TA, et al. Prevention and control of meningococcal disease: recommendations of the Advisory Committee on Immunization Practices. MMWR. 2013;62(RR02):1-22.

MacNeil J, Rubin L, Temitope F, Ortega-Sanchez I. Use of serogroup B meningococcal vaccines in adolescents and young adults: recommendations of the Advisory Committee on Immunization Practices. MMWR. 2015;64(41):1171-1176.

Leading Edge: Meningococcal vaccines and teens

In the first episode of the AAFP’s Leading Edge series, our family physician host Mike Richardson, M.D., is joined by Paritosh Kaul, FAAP, FSAHM, a pediatrician and adolescent medicine specialist, to discuss proposed changes to the meningococcal vaccination schedule that the Advisory Committee on Immunization Practices is expected to consider. In their discussion, they review new research, including studies that explore the different vaccination models and the performance of the current vaccination schedule.

Watch the full episode to learn more about how the proposed changes may impact the disease burden and primary care practice.

Pertussis is on the rise, and outbreaks are occurring across the United States. Infants are most at risk of contracting pertussis and having severe, potentially life-threatening complications from the infection. In fact, the incidence rate of pertussis among infants is higher than the rate in any other age group, and the majority of pertussis-related deaths occur in infants younger than 3 months of age.

Public health efforts are focused on protecting infants until they are old enough to receive their own vaccines to build immunity against pertussis. The Tdap vaccine is safe for both mother and baby at any time during pregnancy, but vaccination is recommended between 27 to 36 weeks of gestation because the maternal immune response to the vaccine peaks approximately two weeks after administration. This recommended timing optimizes passive antibody transfer to the baby and provides the best protection at birth. Early evidence shows that infants whose mothers are vaccinated with Tdap during pregnancy are less likely to develop pertussis during the critical first few months of life. One study from the United Kingdom suggests that up to 90% of infants are protected against pertussis when the mother is vaccinated during pregnancy.

Studies suggest that postpartum Tdap vaccination in women is not effective in reducing pertussis in infants 6 months of age or younger.

Your pregnant patients turn to you as a trusted prenatal care provider. A strong recommendation from you is the best predictor of vaccination, ensuring children are born with protection against pertussis.

Streptococcus pneumoniae (pneumococcus) remains a leading infectious cause of serious illness among older adults in the United States, where it results in hospitalization or death for thousands each year. Pneumococcal disease can cause severe infections of the lungs (pneumonia), bloodstream (bacteremia), and lining of the brain and spinal cord (meningitis). Vaccinations are the best way to prevent pneumococcal disease.

Approximately 20% to 25% of IPD cases and 10% of community-acquired pneumonia cases in adults aged 65 years and older are caused by PCV13 serotypes and are potentially preventable with the use of PCV13 in this population

Use of PCV13 since 2010 among children in the United States has reduced pneumococcal infections indirectly among adults. By 2013, the incidence of invasive pneumococcal disease (IPD) caused by serotypes unique to PCV13 among adults 65 years and older had declined by approximately 50% compared with 2010, when PCV13 replaced PCV7 in the pediatric immunization schedule.

Immunization is a vital component of prenatal care, offering protection from preventable diseases to pregnant patients and their fetuses. Infants are at high risk for pertussis infection and death in the first months of life.¹ Maternal immunoglobulins produced in response to the Tdap vaccine cross the placenta to provide passive immunity to the fetus, significantly reducing pertussis hospitalizations and death in infants in the first two months of life.^2,3 Prenatal Tdap vaccination protects infants 85% more effectively than postpartum vaccination.⁴ Influenza disproportionately impacts patients of reproductive age, leading to adverse pregnancy outcomes, including fetal loss and preterm delivery.⁵ Prenatal influenza vaccination also results in passive immunity for the fetus—critical protection before the infant reaches six months and is eligible for vaccination.

References

1. Van Rie A, Wendelboe AM, Englund JA. Role of maternal pertussis antibodies in infants. Pediatr Infect Dis J. 2005;24(5 Suppl):S62-65.
2. Baxter R, Bartlett J, Fireman B, Lewis E, Klein NP. Effectiveness of vaccination during pregnancy to prevent infant pertussis. Pediatrics. 2017;139(5):e20164091.
3. Winter K, Cherry JD, Harriman K. Effectiveness of prenatal tetanus, diphtheria, and acellular pertussis vaccination on pertussis severity in infants. Clin Infect Dis. 2017;64(1):9-14.
4. Winter K, Nickell S, Powell M, Harriman K. Effectiveness of prenatal versus postpartum tetanus, diphtheria, and acellular pertussis vaccination in preventing infant pertussis. Clin Infect Dis. 2017;64(1):3-8.
5. Creanga AA, Johnson TF, Graitcer SB, et al. Severity of 2009 pandemic influenza A (H1N1) virus infection in pregnant women. Obstet Gynecol. 2010;115(4):717-726.