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Am Fam Physician. 2003;68(12):2453-2457

The cooperation continues between the American Academy of Family Physicians (AAFP), the Advisory Committee on Immunization Practices (ACIP), and the American College of Obstetricians and Gynecologists (ACOG) with the publication of the Recommended Adult Immunization Schedule, United States, 2003–2004(Figures 1 and 2). This is the second year that a family physician has led the Working Group on Adult Immunizations at the ACIP (Richard D. Clover, M.D., led the group last year). The schedule, although similar to last year's schedule, has some changes in formatting, footnotes, and clarity of language. Annual updates to the schedule are planned.

One part of the schedule lists immunizations indicated by age, particularly influenza, tetanus and diphtheria toxoids, and pneumococcal polysaccharide vaccine. Fortunately, supplies for all of these vaccines are good this year. A new live, attenuated influenza vaccine (LAIV; FluMist) for healthy persons five to 49 years of age should be available in addition to the older inactivated vaccine. A major advantage of LAIV is that it is administered intranasally. LAIV contains cold-adapted viruses that do not replicate well in the lower airways. However, exacerbations of asthma were noted after vaccination in some age groups; thus, the safety of LAIV has not been established in persons with asthma. LAIV is contraindicated in immunodeficient persons. The efficacy is good in children 60 to 84 months of age and in adults 18 to 49 years of age; hence, LAIV is licensed for healthy persons five to 49 years of age; safety and efficacy have not been established in the elderly. Although the optimal influenza vaccination season is October and November, inactivated influenza vaccine or LAIV can be given December through March for those who were not vaccinated during the fall. Vaccine information statements for influenza vaccines as well as all other routine vaccines can be downloaded free from

Several developments relate to pneumococcal polysaccharide vaccine. The payment by Medicare Part B for pneumococcal polysaccharide vaccine increased from $13.10 to $18.62, effective October 1, 2003. Billing information for Medicare for influenza and pneumococcal vaccinations can be obtained at Influenza vaccination during the fall is a prime opportunity to assess pneumococcal polysaccharide vaccination status and check for indications for it. The Centers for Medicare and Medicaid Services now allow the use of standing orders in hospitals to give influenza and pneumococcal polysaccharide vaccines.

The other part of the schedule lists immunizations indicated and contraindicated by medical conditions. Because the influenza mortality rate is primarily determined by the number of high-risk conditions, influenza vaccination of high-risk persons and their close contacts is particularly important.

A key development this year was publication of the revised edition of the Standards for Adult Immunization Practices,1 which discusses ways to ensure optimal immunization of adults against vaccine-preventable diseases.

Information on immunizations by family physician leaders for family physicians can be found at, which includes free handheld personal digital assistant software in Palm and Windows formats and links to recent articles on immunization.2 Educational materials for case-based learning for residents and students can be found at Materials for offices about adult immunization can be found at,,,,, and

Coverage of guidelines from other organizations does not imply endorsement by AFP or the AAFP.

This series is coordinated by Michael J. Arnold, MD, Assistant Medical Editor.

A collection of Practice Guidelines published in AFP is available at

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