- Pneumococcal vaccine
is recommended for all immunocompetent individuals who are age
65 years and older or otherwise at increased risk for pneumococcal
disease. There is insufficient evidence to recommend for or
against pneumococcal vaccine for high-risk immunocompromised
individuals, but recommendations for vaccinating these persons
may be made on other grounds.
- The series of combined
tetanus-diphtheria toxoids (Td) should be completed for
adults who have not received the primary series, and all adults
should receive periodic Td boosters.
- Vaccination against
measles and mumps should be provided to all adults born
after 1956 who lack evidence of immunity. A second measles vaccination
is recommended for adolescents and young adults in settings
where such individuals congregate (e.g., high schools and colleges).
-
Hepatitis B vaccine is recommended for all young adults
not previously immunized and for all persons at high risk for
infection (see Clinical Intervention).
Hepatitis A vaccine is recommended for persons at high risk
for hepatitis A virus (HAV) infection (see Clinical Intervention).
- Varicella
vaccine is recommended for susceptible adults, including
women of childbearing age not previously infected or vaccinated.
Influenza
Vaccine
Inactivated (killed-virus) influenza vaccine containing antigens
identical or similar to currently circulating influenza A and
B viruses has been shown in controlled trials to be 70-80% effective
in preventing influenza illness or reducing severity of influenza
illness in healthy children, adolescents, and adults under age
65.1-5 The vaccine has also been reported to reduce clinical symptoms
in health care workers,6 which may translate into a reduction
in transmission to high-risk patients.
Influenza vaccine should be administered annually to all persons
ages 65 and older and to persons 6 months of age or older who
are residents of chronic care facilities or suffer from chronic
cardiopulmonary disorders, metabolic diseases (including diabetes
mellitus), hemoglobinopathies, immunosuppression, or renal dysfunction
("B" recommendation). Influenza vaccine is also recommended
for health care providers for high-risk patients ("B"
recommendation). In persons at high risk for influenza A (e.g.,
during institutional outbreaks), amantadine or rimantadine prophylaxis
(200 mg/day orally) may be started at the time of vaccination
and continued for 2 weeks ("B" recommendation). A lower
dose (less than or equal to 100 mg/day) of amantadine is recommended
for persons with reduced creatinine clearance and those 65 years
of age and older. A reduced dosage (100 mg/day) of rimantadine
is indicated for those with reduced renal or hepatic function
and for elderly nursing home residents and may also be necessary
in healthy persons 65 years and older who experience side effects.
Amantadine and rimantadine are most useful as short-term prophylaxis
for high-risk persons who have not yet received the vaccine or
are vaccinated after influenza A activity in the community has
already begun; when the vaccine may be ineffective due to major
antigenic changes in the virus; for unimmunized persons who provide
care for high-risk persons; to supplement protection provided
by vaccine in persons who are expected to have a poor antibody
response; and for high-risk persons in whom the vaccine is contraindicated
(i.e., those with anaphylactic hypersensitivity to egg protein).
If vaccine is contraindicated, amantadine or rimantadine should
be started at the beginning of the influenza season and continued
daily for the duration of influenza activity in the community.
Pneumococcal Vaccine
Trials in relatively healthy institutionalized elderly (greater
than or equal to 50-55 years of age) have demonstrated significant
reductions in the incidence of pneumonia and in mortality.9 Other
trials of the vaccines in high-risk populations, all adequately
designed and conducted, have been unable to detect significant
reductions in pneumococcal or all-cause pneumonia or mortality.10
A meta-analysis combining five trials in high-risk populations
also reported no effects of vaccine on pneumococcal pneumonia,
all-cause pneumonia, or mortality.8 The sample sizes were much
smaller than for the analyses in low-risk populations, but effect
estimates for most outcomes did not suggest important benefits.
There is little evidence of serious adverse effects from this
vaccine, although erythema, induration, or pain at the injection
site occur in about one third to one half of patients. Fever,
myalgia, and severe reactions occur in no more than 1% of patients.7
Most evidence indicates little difference in adverse reactions
to revaccination compared to initial vaccination.
Pneumococcal vaccine is recommended for all immunocompetent individuals
who are aged 65 years and older or otherwise at increased risk
for pneumococcal disease ("B" recommendation). High-risk
groups include institutionalized persons greater than or equal
to 50 years of age, persons greater than or equal to 2 years of
age with certain medical conditions, including chronic cardiac
or pulmonary disease, diabetes mellitus, and anatomic asplenia
(excluding sickle cell disease), and persons greater than or equal
to 2 years of age who live in special environments or social settings
with an identified increased risk of pneumococcal disease (e.g.,
certain Native American and Alaska Native populations). Routine
revaccination is not recommended, but it may be appropriate to
consider revaccination in immunocompetent individuals at highest
risk for morbidity and mortality from pneumococcal disease (e.g.,
persons greater than or equal to 75 years of age or with severe
chronic disease) who were vaccinated more than 5 years previously.
Revaccination with the 23-valent vaccine may be appropriate for
high-risk persons who previously received the 14-valent vaccine.
There is insufficient evidence to recommend for or against pneumococcal
vaccine as an efficacious vaccine for immunocompromised individuals,
but recommendations for vaccinating these persons may be made
on other grounds, including high incidence and case-fatality rates
of pneumococcal disease and minimal adverse effects from the vaccine
("C" recommendation). Immunocompromised conditions associated
with high risk for pneumococcal disease include alcoholism, cirrhosis,
chronic renal failure, ne-phrotic syndrome, sickle cell disease,
multiple myeloma, metastatic or hematologic malignancy, acquired
or congenital immunodeficiency (including HIV infection), and
other conditions associated with immunosuppression, such as organ
transplant. It may be appropriate to consider periodic revaccination
in these high-risk immunocompromised patients, who are likely
to have poor initial antibody response and rapid decline of antibodies
after vaccination.
Tetanus and Diphtheria Vaccine
The efficacy of the tetanus and diphtheria toxoids is established
on the basis of clinical studies and decades of experience with
universal childhood immunization.12 A primary series of three
doses of Td, followed by a booster dose, is highly effective in
producing protective antibody titers lasting as long as 15-25
years and results in anamnestic responses with booster immunization
as much as 20-30 years later.13 In Sweden, a five-dose regimen
(primary series plus boosters at age 8-10 and 18 years) resulted
in greater than 90% of subjects having protective tetanus antitoxin
levels at age 50 years, slightly fewer than at age 30. Tetanus
is unlikely in Americans who have received a primary vaccination
series, although clinical immunity may wane somewhat after 10-20
years.11 Td often produces mild local inflammation, occasionally
Arthus-type reactions and peripheral neuropathy (following frequent
boosters), and rarely, anaphylaxis.
The Td vaccine series should be completed for patients who have
not received the primary series, and all adults should receive
periodic Td boosters ("A" recommendation). For persons
not previously immunized, the recommended schedule for the primary
Td series is 0, 2, and 8-14 months. The optimal interval for booster
doses is not established. The standard regimen is to provide a
Td booster at least once every 10 years, but in the U.S., intervals
of 15-30 years between boosters are likely to be adequate in persons
who received a complete five-dose series in. For international
travelers, an interval of 10 years between boosters is recommended.
Measles, Mumps, and Rubella (MMR) Vaccine
A single dose of measles vaccine is 95% effective in producing
long-term immunity.15,16 Seropositivity rates remain high at least
10-15 years following vaccination. Adult infections occur primarily
in persons who have not been naturally infected or appropriately
vaccinated in the past,14 as well as those who were vaccinated
before age 15 months. Revaccinating young adults in settings such
as schools and colleges may be effective in reducing the incidence
in adults. As with measles, persons born before 1957 can generally
be considered immune to mumps and need not be vaccinated. Adverse
effects of measles or combined measles-mumps-rubella (MMR) vaccine
in adults are usually mild and self-limited.17
MMR vaccine should be administered to all persons born after
1956 who lack evidence of immunity to measles (receipt of live
vaccine on or after the first birthday, laboratory evidence of
immunity, or a history of physician-diagnosed measles) ("A"
recommendation). A second measles vaccination is recommended for
adolescents and young adults in settings where such individuals
congregate (e.g., high schools, technical schools, and colleges),
if they have not previously received a second dose ("B"
recommendation). The combined MMR vaccine is preferable to monovalent
measles vaccine, since many recipients may also be susceptible
to mumps or rubella due to inadequate vaccination or primary vaccine
failure. Susceptible individuals should be vaccinated against
mumps ("B" recommendation). Administration of the MMR
or measles vaccine during pregnancy is not recommended.
Hepatitis B Vaccine
Plasma-derived hepatitis B vaccine, which became available in
1982, has 85-95% protective efficacy when administered in three
intramuscular doses to immunocompetent patients.18 Injection into
the buttocks has been associated with a suboptimal immune response,
and therefore the deltoid muscle is the preferred injection site.20
Local soreness at the injection site is a common side effect.19
Hepatitis B vaccine is recommended for all young adults not previously
immunized ("A" recommendation). Hepatitis B vaccine
is also recommended for susceptible adults in high-risk groups,
including men who have sex with men, injection drug users and
their sex partners, persons who have a history of sexual activity
with multiple partners in the previous 6 months or have recently
acquired another sexually transmitted disease, international travelers
to countries where HBV is of high or intermediate endemicity,
recipients of certain blood products (including hemodialysis patients),
and persons in health-related jobs with frequent exposure to blood
or blood products ("A" recommendation). The recommended
regimen for the recombinant hepatitis B vaccine is to administer
10 or 20 mcg (depending on vaccine product) intramuscularly in
the deltoid muscle at the current visit and at 1 and 6 months
later. Clinicians should consider testing antibody response to
the vaccine in individuals at very high risk from hepatitis B
who are likely to have an inadequate antibody response (i.e.,
chronic renal dialysis patients, injection drug users, HIV-infected
patients).
Hepatitis A Vaccine
Hepatitis A vaccine is recommended for all high-risk adults
("B" recommendation). High-risk groups include persons
living in, traveling to, or working in areas where the disease
is endemic and periodic hepatitis A outbreaks occur (e.g., Alaska
Native, Pacific Islander, and Native American communities, certain
religious communities, countries with high or intermediate endemicity),
men who have sex with men, users of injection or street drugs
(depending on local epidemiology), military personnel, and certain
hospital and laboratory workers. Hepatitis A vaccine may also
be considered for institutionalized persons (e.g., in prisons
and institutions for the developmentally disabled) and workers
in these institutions and in day care centers. Where tracking
or identification of high-risk patients is not practical or cost-effective,
universal vaccination may be a reasonable policy given the minimal
adverse consequences of the vaccine. At this writing, the only
licensed hepatitis A vaccine is Havrix® (SmithKline Beecham
Pharmaceuticals). Two doses (1,440 ELISA units/dose) at 0 and
6-12 months are recommended for persons over age 18 years. The
need for periodic booster doses of the vaccine has not been established.
For persons requiring immediate protection against hepatitis A
(e.g., travelers to high-risk areas who have not previously been
vaccinated), clinicians may wish to consider giving IG simultaneously
with the first dose of hepatitis A vaccine, although the clinical
efficacy of this approach has not been established. IG can also
be recommended as an efficacious intervention for short-term (less
than or equal to 5-6 months) preexposure prophylaxis against hepatitis
A. While some evidence suggests that the vaccine may be more efficacious
than IG, the clinical efficacies of these two interventions have
not been directly compared. Other factors to consider in choosing
between these two interventions include patient preference, the
likely duration of exposure, the need for immediate vs. long-term
protection, and cost.
Varicella Vaccine
Two doses of varicella vaccine delivered 4-8 weeks apart are
recommended for healthy adults with no history of varicella infection
or previous vaccination ("B" recommendation). Vaccination
efforts should be targeted to susceptible health care workers
and family contacts of immunocompromised individuals, and may
also be targeted to susceptible adults who live or work in environments
with a high likelihood of varicella transmission (e.g., day care
centers, residential institutions, colleges, military bases).
Given the high prevalence of immunity in adults with no history
of chickenpox and the results of cost-effectiveness analysis,
clinicians may wish to offer serologic testing for varicella susceptibility
to history-negative adults who are likely to comply with return
visits.
References
1. Meiklejohn G. Effectiveness of monovalent influenza A-prime
vaccine during the 1957 influenza A-prime epidemic. Am J Hyg 1958;67:237-249.
2. Hoskins TW, Davies JR, Allchin A, et al. Controlled trial
of inactivated influenza vaccine containing the A/Hong Kong strain
during an outbreak of influenza due to the A/England/42/72 strain.
Lancet 1973;ii:116-120.
3. Hammond ML, Ferris AA, Faine S, et al. Effective protection
against influenza after vaccination with subunit vaccine. Med
J Aust 1978;1:301-303.
4. Edmondson WP Jr, Rothenberg R, White PW, et al. A comparison
of subcutaneous, nasal, and combined influenza vaccination. II.
Protection against natural challenge. Am J Epidemiol 1971;93:480-486.
5. Edwards KM, Dupont WD, Westrich MK, et al. A randomized controlled
trial of cold-adapted and inactivated vaccines for the prevention
of influenza A disease. J Infect Dis 1994;169:68-76.
6. Weingarten S, Staniloff H, Ault M, et al. Do hospital employees
benefit from the influenza vaccine? A placebo-controlled clinical
trial. J Gen Intern Med 1988;3:32-37.
7. Austrian R. Surveillance of pneumococcal infection for field
trials of polyvalent pneumococcal vaccines. Report DAB-VDP-12-84.
Bethesda: National Institutes of Health, 1980.
8. Fine MJ, Smith MA, Carson CA, et al. Efficacy of pneumococcal
vaccination in adults: a meta-analysis of randomized controlled
trials. Arch Intern Med 1994;154:2666-2677.
9. Kaufman P. Pneumonia in old age. Active immunization against
pneumonia with pneumococcus polysaccharide: results of a six year
study. Arch Intern Med 1947;79:518-531.
10. Klastersky J, Mommen P, Cantraine F, et al. Placebo controlled
pneumococcal immunization in patients with bronchogenic carcinoma.
Eur J Cancer Clin Oncol 1986;22:807-813.
11. Centers for Disease Control. Tetanus surveillance - United
States, 1989-1990. MMWR 1992;41(SS-8):1-9.
12. Centers for Disease Control. Diphtheria, tetanus, and pertussis:
recommendations for vaccine use and other preventive measures.
Recommendations of the Immunization Practices Advisory Committee
(ACIP). MMWR 1991;40(RR-10):1-28.
13. Simonsen O, Bentzon MW, Kjeldsen K, et al. Evaluation of
vaccination requirements to secure continuous antitoxin immunity
to tetanus. Vaccine 1987;5:115-122.
14. Centers for Disease Control and Prevention. Measles - United
States, 1994. MMWR 1995;44:486-487, 493-494.
15. Markowitz E, Preblud SR, Katz SL. Measles vaccine. In: Plotkin
SA, Mortimer EA, ed. Vaccines. 2nd ed. Philadelphia:WB Saunders,1994.
16. Markowitz LE, Orenstein WA. Measles vaccine. Pediatr Clin
North Am 1990;37:603-625.
17. Centers for Disease Control. Measles prevention: recommendations
of the Immunization Practices Advisory Committee (ACIP). MMWR
1989;38(Suppl 9):1-18.
18. Szmuness W, Stevens CE, Harley EJ, et al. Hepatitis B vaccine:
demonstration of efficacy in a controlled clinical trial in a
high-risk population in the United States. N Engl J Med 1980;303:833-841.
19. Andre FE. Overview of a 5-year clinical experience with a
yeast-derived hepatitis B vaccine. Vaccine 1990;8(suppl):S74-S78.
20. Shaw FE Jr, Guess HA, Roets JM, et al. Effect of anatomic
injection site, age, and smoking on the immune response to hepatitis
B vaccination. Vaccine 1989;7:425-430.
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