Key Points for Practice
• Tdap vaccine may be used instead of Td in situations where Td is currently recommended.
• Hepatitis A vaccination is routinely recommended for all children and adolescents two to 18 years of age, adults with HIV, and patients one year and older who are experiencing homelessness.
• HPV vaccination is now recommended for men and women through age 26 and recommended with shared clinical decision-making for people 27 to 45 years of age.
• PCV13 is no longer routinely recommended for all immunocompetent adults older than 65, but it is recommended with shared clinical decision-making.
From the AFP Editors
The 2020 adult and childhood/adolescent immunization schedules have been approved by the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC) and are accessible at https://www.aafp.org/patient-care/immunizations/schedules.html. Several updates were made to the adult immunization schedule cover page, tables, graphics, and notes sections, with revisions and edits for clarification and to foster more harmonization with the childhood/adolescent schedules. Two significant changes to the adult schedule include recommendations for human papillomavirus (HPV) vaccine for men and women through age 26, with shared clinical decision-making recommended for HPV vaccination in people 27 to 45 years of age, and revocation of the recommended routine use of pneumococcal conjugate vaccine (PCV13) for immunocompetent adults older than 65. One significant change to both schedules pertains to tetanus-containing vaccines.
Tetanus, Diphtheria, and Pertussis Vaccines
ACIP voted unanimously at the October 2019 meeting to allow either the tetanus and diphtheria (Td) or the tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccine in almost all situations where currently only Td vaccine is recommended. The evidence framework used in making this recommendation included the review of published and unpublished data on the safety of closely spaced Tdap vaccines in the catch-up immunization schedule showing no substantive safety concerns including in pregnant women. It also acknowledged that there is widespread physician use of Tdap instead of Td, the potential for more flexibility to give either vaccine, and additional benefit for pertussis control. Either Tdap or Td vaccine is now recommended without preference for the 10-year Td booster, tetanus prophylaxis for wound management, and catch-up immunization for people seven years and older, including pregnant women. ACIP also unanimously approved this Tdap recommendation within the Vaccine for Children program.
Children seven to nine (younger than 10) years of age who receive Tdap inadvertently or for catch-up immunization should be given an adolescent Tdap dose at 11 to 12 years of age. Because both Tdap vaccines available in the United States are licensed for use beginning at 10 years of age, children who receive a dose of Tdap at 10 years or older do not have to repeat the Tdap dose at 11 to 12 years of age.
Additional Changes to Adult Immunization Schedule
HEPATITIS A VACCINATION
All people one year and older experiencing homelessness should routinely receive the hepatitis A vaccine.1 Adults living with HIV also should be vaccinated.
Routine recommendations for HPV vaccination of adolescents have not changed. Catch-up HPV vaccination is now recommended for all men and women through 26 years of age, with two or three doses depending on age at initial vaccination. Shared clinical decision-making regarding vaccination for people 27 to 45 years of age is recommended.2
MEASLES, MUMPS, AND RUBELLA VACCINATION
In health care workers with no evidence of immunity to measles, mumps, and rubella, a two-dose series at least four weeks apart for measles or mumps, or at least one dose for rubella, is recommended.
After a planned four-year review of accrued evidence showed indirect effects from PCV13 use in children reduced the incidence of PCV13-type disease to historically low levels among older adults, ACIP changed the recommendation of PCV13 use in adults. PCV13 is no longer routinely recommended for all immunocompetent adults 65 years and older. Shared clinical decision-making is now recommended for all people in this age group who do not have an immunocompromising condition, cerebrospinal fluid leak, or cochlear implant, and who have not previously received PCV13. The vaccine should also be considered for people residing in areas with low pediatric PCV13 uptake; those traveling to settings with no pediatric PCV13 program; those with chronic heart, lung, and/or liver disease, diabetes mellitus, or alcoholism; and those who smoke.
ACIP continues to recommend PCV13 in a series with pneumococcal polysaccharide vaccine (PPSV23) for all adults 19 years and older (including those 65 years and older) with immunocompromising conditions, cerebrospinal fluid leaks, or cochlear implants. ACIP continues to recommend a single dose of PPSV23 for adults 65 years and older.3
MENINGOCOCCAL B VACCINATION
Shared clinical decision-making is recommended for people 19 to 23 years of age at average risk. For those at high risk (e.g., patients with complement component deficiency, patients on complement inhibitor therapy, those with functional or anatomic asplenia, microbiologists at risk of occupational exposure to meningococcus), booster doses following the primary series are recommended at one year and then repeated every two to three years if risk continues.
Varicella vaccination is indicated for adults with HIV infection, if CD4 count is 200 cells per μL or greater.
Additional Changes to the Childhood/Adolescent Schedule
Updates to the childhood/adolescent schedule included changes to all tables, and content or clarifying changes for multiple notes on several vaccines.
HEPATITIS A VACCINATION
Vaccination is now recommended routinely for catch-up in all children and adolescents two to 18 years of age instead of catch-up only if desired.
MENINGOCOCCAL B VACCINATION
Booster doses one year following the primary series are recommended for those at increased risk and repeated every two to three years if still at risk.
Physicians and other vaccine providers can reduce vaccine hesitancy among patients by giving a strong recommendation to vaccinate and acknowledging patient concerns by citing the growing body of literature demonstrating vaccine safety. One resource available is the CDC’s vaccination video series (https://www.cdc.gov/vaccines/howirecommend/index.html). Physicians can also highlight the increasing number of vaccine-preventable disease outbreaks globally and across the country, and reference new literature showing that contracting measles can be more harmful than the effects of the vaccine itself. The long-term effects of a measles virus infection reduce a patient’s resistance to other diseases, a theory known as immune amnesia, and vaccination against measles prevents this loss of immune memory and helps maintain long-term resistance to other infectious pathogens.4,5
Editor’s Note: The author serves as liaison to ACIP for AAFP.