• CDC, AAFP Release 2020 Immunization Schedules

    Family Physician Expert Discusses Updates

    February 07, 2020 05:01 pm Chris Crawford – The CDC and its Advisory Committee on Immunization Practices, together with the AAFP and other medical professional organizations, have released the 2020 adult and childhood immunization schedules

    AAFP liaison to the ACIP Pamela Rockwell, D.O., of Ann Arbor, Mich., told AAFP News that changes to the adult and child/adolescent schedules that family physicians should be aware of include

    • approving use of the tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine when tetanus and diphtheria is indicated;
    • revoking the recommendation for routine use of pneumococcal conjugate vaccine for immunocompetent adults older than 65; and
    • recommendation of the HPV vaccine for men and women through age 26, and with shared clinical decision-making for patients ages 27-45.

    Both schedules have been streamlined, and changes to the content, notes and color graphics in each have helped harmonize them with one another, as Rockwell told AAFP News after the October 2019 ACIP meeting.

    More Adult Immunization Schedule Updates

    Rockwell said that among changes to the notes in the adult immunization schedule regarding the hepatitis A and hepatitis B vaccines were

    • clarification of the definition of chronic liver disease to include chronic conditions such as hepatitis B and C infection and cirrhosis,
    • minor changes for the pregnancy indication,
    • the addition of a recommendation to vaccinate in settings of exposure and
    • removal of clotting factor disorders as an indication for HepA vaccination.

    The measles, mumps and rubella vaccine note was revised to clarify recommendations for health care personnel, with separate bullets for personnel born in 1957 or later with no evidence of immunity and those born before 1957 with of evidence of immunity, she said.

    "For health care personnel born before 1957 with no evidence of immunity, consideration for a two-dose series of MMR vaccine is now recommended," Rockwell added.

    The serogroup B meningococcal vaccine note was revised to add a subsection calling for shared clinical decision-making for adolescents and young adults ages 16-23 at average risk for meningococcal disease, she noted. Changes made to the "Special situations" subsection aimed at high-risk patients, (e.g., those with complement component deficiency or who are on complement inhibitor therapy, those with functional or anatomic asplenia, microbiologists at risk of occupational exposure) include adding use of the complement inhibitor ravulizumab as an indication for MenB immunization, as well as a recommendation to administer a booster dose of MenB vaccine one year after the primary series and then revaccinate every two to three years if the risk for meningitis B remains.

    Story Highlights

    Finally, Rockwell said the varicella vaccine note has been updated to indicate that vaccination may be considered for patients with HIV infection who have no evidence of varicella immunity as long as their CD4 count is 200 cells/µL or higher.

    More Child/Adolescent Schedule Updates

    For the child/adolescent schedule, the note for the Haemophilus influenzae type B vaccine was revised to indicate that catch-up vaccination is not recommended for previously unvaccinated children age 5 or older who are not at high risk, Rockwell said.

    The HepA vaccine note was revised to recommend routine catch-up immunization for all children and adolescents ages 2-18 who have not previously received the vaccine with a two-dose series. In addition, all individuals ages 1 and older who experience homelessness should be vaccinated, as well as adults with HIV infection. 

    The "Special situations" section of the HepB vaccine note now contains information regarding populations for whom revaccination may be recommended, Rockwell said.

    Additionally, guidance has been added to the quadrivalent meningococcal conjugate vaccine note about adolescent vaccination for children who received MenACWY vaccine before age 10.

    Included in the updated MenB vaccine note: Booster doses are now recommended for patients 10 and older who are at high risk for contracting the disease because of immunological deficits or increased exposure and people determined by public health officials to be at increased risk during an outbreak, Rockwell said. 

    Within the poliovirus vaccine note, she continued, detailed information has been added regarding which oral polio vaccine doses may be counted toward U.S. vaccination requirements.

    And in addition to the updated guidance to allow either Td or Tdap use, Rockwell said the Tdap vaccine note was edited to reflect recent updates to the clinical guidance for children ages 7-18 who received doses of Tdap or diphtheria, tetanus toxoids and acellular pertussis vaccine at age 7-10 years. 

    "A dose of Tdap or DTaP administered at 10 years of age may now be counted as the adolescent Tdap booster," Rockwell said. "A dose of Tdap or DTaP administered at 7 through 9 years of age should not be counted as the adolescent dose, and Tdap should be administered at 11-12 years of age." 

    She added that the DTaP vaccine note has been updated to say that the fifth dose is not necessary if the fourth dose was administered at age 4 or older and was given at least six months after third dose.

    Lastly, Rockwell said the CDC has developed catch-up guidance job aids to assist health care professionals in interpreting Table 2 in the child/adolescent immunization schedule. The aids feature easy-to-read tables on pneumococcal conjugate vaccine, Hib-containing products, inactivated polio vaccine and Tdap-containing products.

    Don't Forget Flu Vaccine 

    The CDC continues to recommend that everyone age 6 months and older get a flu vaccine as the influenza season rages on. It's worth noting that nationally, the proportion of influenza A(H1N1)pdm09 viruses circulating is rising compared with influenza B viruses, which unexpectedly surged early in the season.

    According to Rockwell, the influenza vaccine note has been updated to include a bulleted list indicating when live attenuated influenza vaccine should not be used and minor edits to the guidance for patients with a history of Guillain-Barré syndrome.

    "The flu vaccine can prevent millions of illnesses and doctor visits for flu-like symptoms," she said. "The CDC reports that last year, the flu vaccine is estimated to have prevented 6.2 million influenza illnesses, 3.2 million influenza-associated medical visits, 91,000 influenza-associated hospitalizations and 5,700 influenza-associated deaths, reducing one's personal incidence of seeking care for influenza by 40% to 60%." 

    She pointed out the CDC estimates that so far this season, there have been at least 19 million flu illnesses, 180,000 hospitalizations and 10,000 deaths from flu. Furthermore, outpatient influenza-like illness and laboratory data remain elevated and increased again this week. 

    Studies have shown that vaccinated patients hospitalized with influenza have reduced symptoms, reduced incidence of death, reduced cardiac symptoms and require fewer inpatient days, Rockwell said.

    "A strong recommendation to vaccinate using presumptive language is key to improving vaccination rates," Rockwell concluded. "For those who hesitate, acknowledge concerns while countering vaccine misinformation with facts and easy-to-understand data, and offer personal stories to help overcome vaccine hesitancy."