• ACIP Updates Pertussis Vaccine Recommendation

    Immunization Schedules Also Revised

    October 30, 2019 01:31 pm Chris Crawford – During the Oct. 23-24 meeting of the CDC's Advisory Committee on Immunization Practices, the group voted to update its recommendation for the pertussis vaccine.

    AAFP liaison to the ACIP Pamela Rockwell, D.O., of Ann Arbor, Mich., told AAFP News other business conducted during the meeting included updates to the adult and child/adolescent immunization schedules.

    Pertussis Vaccine

    Rockwell said the ACIP voted unanimously to change its policy to say that either the tetanus-diphtheria or the tetanus, diphtheria and pertussis vaccine can be used for

    • the decennial Td booster,
    • tetanus prophylaxis for wound management and
    • additional doses of the catch-up immunization schedule for patients age 7 or older.


    Story Highlights

    The pertussis workgroup concluded that using Tdap in place of Td presented no substantive safety concerns, and thus, the benefits of doing so outweighed the harms. The group added that many physicians already give Tdap instead of Td and the economic impact was not a major consideration in its decision.

    "This means that insurance companies will now cover Tdap in situations that they haven't before," Rockwell said. "This is especially beneficial for Medicare patients, as only Td was covered as a booster before. Now that it's a choice of Td or Tdap, Tdap will be covered."

    Next, the ACIP will evaluate the spacing of booster doses for continued protection against tetanus and diphtheria, she added.

    Adult Immunization Schedule

    The ACIP approved both the adult and the child/adolescent immunization schedules with revisions.

    For the adult immunization schedule, updates were made to the tables and notes.

    Now light blue in Table 1 of the adult schedule indicates "shared decision-making" recommendations and gray indicates "not applicable." This was revised to be consistent with the colors in the child/adolescent tables and to make them easier to read, Rockwell said.

    As for the adult schedule notes, she said updates included defining chronic liver disease and who it affects, including patients with chronic conditions such as hepatitis B and C or cirrhosis.

    The HPV vaccine notes have been updated to include all adults up to age 26 and then shared clinical decision-making for ages 27-45, Rockwell said.

    The ACIP also clarified who should and shouldn't receive MedImmune's live attenuated influenza vaccine (FluMist).

    "LAIV shouldn't be used for pregnant patients; those with a cochlear implant; anatomical or functional asplenia; or are immunocompromised for any cause, including from medication or HIV infection," she said, among the many reasons the vaccine would be contraindicated. "It also would be interesting for family physicians to know LAIV shouldn't be given to people who have received antiviral influenza medicines in the previous 48 hours."

    For the measles, mumps and rubella vaccine, the ACIP decided health care personnel born in 1957 or later who have no evidence of immunity need a two-dose series at least four weeks apart, Rockwell said. Those born before 1957 who have no evidence of immunity can consider a two-dose series of MMR vaccine.

    "The key is now, health care professionals are being asked to prove we have immunity," she said.

    Child/Adolescent Immunization Schedule

    The ACIP made many changes to the three tables and notes in the child/adolescent immunization schedule, Rockwell said.

    For Table 1, the routine immunization schedule, the ACIP reorganized the location of some vaccines to make the table more intuitive.

    "For example, they moved meningococcal B vaccine to be by the meningococcal ACWY vaccine," Rockwell said.

    For Table 2, the catch-up immunization schedule, the ACIP revised "meningococcal" to say "MenACWY," since MenB has been moved to its own line item.

    For Table 3, the medical indications schedule, Rockwell said the ACIP again reorganized the table to be more intuitive and placed vaccines that are applicable next to each other. This table also now has a gray box to indicate "not applicable."

    MenACWY was highlighted in yellow in the pregnancy box to indicate that it should be given, based on the ACIP's determination that pregnancy isn't a reason to withhold MenACWY if it is indicated, she said.

    Rockwell said there were many edits to the notes section of the child/adolescent immunization schedule, including guidance and reference links added for the Tdap; MenB; MenACWY; poliovirus; influenza; HepA; HepB; Haemophilus influenzae type B; and diphtheria, tetanus and pertussis vaccines.

    Influenza Vaccine

    The ACIP received an update on the current influenza season. Rockwell said as of late October, national activity remained low.

    "So far, influenza A (H3N2) has been predominating, but it's too early to tell what will predominate the rest of the season," she said.

    The components for the 2019-20 Northern Hemisphere flu vaccine were analyzed and found to be appropriate at this time, she added.

    Also of interest, a new high-dose, quadrivalent influenza vaccine for those age 65 and older is in phase 3 trials, which Rockwell said was exciting.

    "It has been shown to be more effective than the current trivalent high-dose vaccine," she said. "Assuming licensure, it will effectively replace the trivalent vaccine for next year."

    Currently, Rockwell said researchers are looking at the efficacy, effectiveness and safety of the quadrivalent vaccine compared to the eight flu vaccine options now available to patients age 65 and older -- which is everything except LAIV.

    "We may have more guidance on which vaccine is best to recommend to those over 65 years of age in the future," she added.

    Additional Notes

    The ACIP learned that Rockwell said Merck & Co. Inc. is pursuing licensure of a recombinant, vesicular stomatitis virus-based Ebola virus vaccine, which is currently being used in the Democratic Republic of the Congo with a ring vaccination strategy.

    "For the ring vaccination strategy, you find out who has Ebola, you vaccinate them, their contacts, and then the next ring of the contacts of all their contacts, and then you go to a third ring of the contacts of the contacts of the contacts," she said. "So, three rings of vaccination. That's how the World Health Organization is handling the outbreak in the DRC."

    The ACIP also discussed a new orthopoxvirus vaccine called "Jynneos" that the FDA approved Sept. 24 as the first live, non-replicating vaccine to prevent smallpox and monkeypox.

    "This probably will be best served for military members or those with occupational exposure," Rockwell said.

    Finally, the rabies vaccine workgroup said it will examine whether a two-dose rabies vaccine schedule would be as effective as the current three-dose series, as clinical trials have shown no difference in the response to the two schedules.

    "They're also looking at if a booster dose at one year is associated with long-term immunogenicity," she said. "They will present their findings next year."

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