The reduction of disease through immunization is one of the greatest medical successes of the 20th century. Smallpox has been globally eradicated, and devastating diseases such as poliomyelitis, measles, and diphtheria are now exceedingly rare in the United States and many other countries. Currently, the overwhelming morbidity and mortality from vaccine-preventable disease occurs not in children, but in adults. Each year, an estimated 30,000-50,000 adults die from vaccine-preventable diseases. Most of the mortality in adults is attributable to 2 diseases -- influenza and pneumococcal disease.^[1]

Despite these morbidity and mortality statistics, coverage rates for adult influenza and pneumococcal vaccines are below national standards. National health objectives for 2010 aim to increase influenza and pneumococcal vaccination levels to 90% or greater among persons aged 65 years or older.^[2] In a survey of the past 12 months, only an estimated 67% of such patients received influenza vaccine and just 55.7% had ever received pneumococcal vaccine.^[3] Coverage rates for minority groups and younger patients were even lower. According to the National Vaccine Advisory Committee, the underutilization of vaccines in adults is attributable to several factors, including a limited appreciation of the importance of vaccine-preventable diseases in adults; uncertainties about the safety and efficacy of adult vaccines; risk-based rather than age-based recommendations (ie, different target groups for different vaccines); poor infrastructure for delivery of adult vaccines; and issues regarding payment for adult vaccination.^[4]

In October 2002, for the first time ever, the Centers for Disease Control and Prevention (CDC) published a Recommended Adult Immunization Schedule (Figure 1).^[5] The schedule provides a summary of both age-based and risk-based recommendations, and is designed to simplify vaccine delivery for practitioners who care for adult patients.

Figure 1A. Recommended Adult Immunization Schedule, United States, 2002-2003. Source: Centers for Disease Control and Prevention. Available at http://www.cdc.gov/nip/recs/adult-schedule.pdf. Accessed February 19, 2003. 

Figure 1B. Recommended Immunizations for Adults with Medical Conditions, United States, 2002-2003. Source: Centers for Disease Control and Prevention. Available at http://www.cdc.gov/nip/recs/adult-schedule.pdf. Accessed February 19, 2003. 

This Clinical Update will follow the organization of the 2002-2003 adult immunization schedule, reviewing each disease, vaccine, and recommendations -- with an emphasis on the influenza and pneumococcal vaccines, the 2 vaccines that can prevent the most morbidity and mortality in the adult population. For each disease and vaccine, major indications and recent changes in recommendations will be highlighted.

Footnotes for Figure 1A

1. Tetanus and diphtheria (Td) -- A primary series for adults is 3 doses: the first 2 doses given at least 4 weeks apart and the 3rd dose at 6-12 months after the second. Administer 1 dose if the person had received the primary series and the last vaccination was 10 years ago or longer. MMWR. 1991; 40 (RR-10): 1-21. The ACP Task Force on Adult Immunization supports a second option: a single Td booster at age 50 years for persons who have completed the full pediatric series, including the teenage/young adult booster. Guide for Adult Immunization. 3rd ed. ACP. 1994:20.

2. Influenza vaccination -- Medical indications: chronic disorders of the cardiovascular or pulmonary systems including asthma; chronic metabolic diseases including diabetes mellitus, renal dysfunction, hemoglobinopathies, immunosuppression (including immunosuppression caused by medications or by human immunodeficiency virus [HIV]), requiring regular medical follow-up or hospitalization during the preceding year; women who will be in the second or third trimester of pregnancy during the influenza season.
Occupational indications: healthcare workers. Other indications: residents of nursing homes and other long-term-care facilities; persons likely to transmit influenza to persons at high risk (in-home caregivers to persons with medical indications, household contacts, and out-of-home caregivers of children birth to 23 months of age, or children with asthma or other indicator conditions for influenza vaccination, household members and caregivers of elderly and adults with high-risk conditions); and anyone who wishes to be vaccinated. MMWR. 2002;51(RR-3):1-31.

3. Pneumococcal polysaccharide vaccination -- Medical indications: chronic disorders of the pulmonary system (excluding asthma), cardiovascular diseases, diabetes mellitus, chronic liver diseases including liver disease as a result of alcohol abuse (eg, cirrhosis), chronic renal failure or nephrotic syndrome, functional or anatomic asplenia (eg, sickle cell disease or splenectomy), immunosuppressive conditions (eg, congenital immunodeficiency, HIV infection, leukemia, lymphoma, multiple myeloma, Hodgkin's disease, generalized malignancy, organ or bone marrow transplantation), chemotherapy with alkylating agents, antimetabolites, or long-term systemic corticosteroids. Geographic/other indications: Alaskan Natives and certain American Indian populations. Other indications: residents of nursing homes and other long-term-care facilities. MMWR. 1997;47(RR-8):1-24.

4. Revaccination with pneumococcal polysaccharide vaccine -- 1-time revaccination after 5 years for persons with chronic renal failure or nephrotic syndrome, functional or anatomic asplenia (eg, sickle cell disease or splenectomy), immunosuppressive conditions (eg, congenital immunodeficiency, HIV infection, leukemia, lymphoma, multiple myeloma, Hodgkin's disease, generalized malignancy, organ or bone marrow transplantation), chemotherapy with alkylating agents, antimetabolites, or long-term systemic corticosteroids. For persons aged 65 years and older, 1-time revaccination if they were vaccinated 5 or more years previously and were younger than age 65 years at the time of primary vaccination. MMWR. 1997;47(RR-8):1-24.

5. Hepatitis B vaccination -- Medical indications: hemodialysis patients, patients who receive clotting-factor concentrates. Occupational indications: healthcare workers and public-safety workers who have exposure to blood in the workplace, persons in training in schools of medicine, dentistry, nursing, laboratory technology, and other allied-health professions. Behavioral indications: injection-drug users, persons with more than 1 sex partner in the previous 6 months, persons with a recently acquired sexually transmitted disease (STD), all clients in STD clinics, men who have sex with men. Other indications: household contacts and sex partners of persons with chronic HBV infection, clients and staff of institutions for the developmentally disabled, international travelers who will be in countries with high or intermediate prevalence of chronic HBV infection for more than 6 months, inmates of correctional facilities. MMWR. 1991;40(RR-13):1-25. (www.cdc.gov/travel/diseases/hbv.htm)

6. Hepatitis A vaccination -- For the combined HepA-HepB vaccine use 3 doses at 0, 1, 6 months). Medical indications: persons with clotting-factor disorders or chronic liver disease. Behavioral indications: men who have sex with men, users of injection drugs and noninjection illegal drugs. Occupational indications: persons working with hepatitis A virus (HAV)-infected primates or with HAV in a research laboratory setting. Other indications: persons traveling to or working in countries that have high or intermediate endemicity of hepatitis A. MMWR. 1999;48(RR-12):1-37. (www.cdc.gov/travel/diseases/hav.htm)

7. Measles, Mumps, Rubella vaccination (MMR) -- Measles component: Adults born before 1957 may be considered immune to measles. Adults born in or after 1957 should receive at least 1 dose of MMR unless they have a medical contraindication, documentation of at least 1 dose or other acceptable evidence of immunity. A second dose of MMR is recommended for adults who:

• were recently exposed to measles or in an outbreak setting;
  
  
• were previously vaccinated with killed measles vaccine;
  
  
• were vaccinated with an unknown vaccine between 1963 and 1967;
  
  
• are students in postsecondary educational institutions;
  
  
• work in healthcare facilities; or
  
  
• plan to travel internationally.
  
  

Mumps component: 1 dose of MMR should be adequate for protection. Rubella component: Give 1 dose of MMR to women whose rubella vaccination history is unreliable, and counsel women to avoid becoming pregnant for 4 weeks after vaccination. For women of childbearing age, regardless of birth year, routinely determine rubella immunity and counsel women regarding congenital rubella syndrome. Do not vaccinate pregnant women or those planning to become pregnant in the next 4 weeks. If pregnant and susceptible, vaccinate as early in postpartum period as possible. MMWR. 1998;47(RR-8):1-57.

8. Varicella vaccination -- Recommended for all persons who do not have reliable clinical history of varicella infection, or serologic evidence of varicella zoster virus (VZV) infection; healthcare workers and family contacts of immunocompromised persons, those who live or work in environments where transmission is likely (eg, teachers of young children, daycare employees, and residents and staff members in institutional settings), persons who live or work in environments where VZV transmission can occur (eg, college students, inmates and staff members of correctional institutions, and military personnel), adolescents and adults living in households with children, women who are not pregnant but who may become pregnant in the future, international travelers who are not immune to infection. [Note: Over 90% of US-born adults are immune to VZV. Do not vaccinate pregnant women or those planning to become pregnant in the next 4 weeks. If pregnant and susceptible, vaccinate as early in postpartum period as possible.] MMWR. 1996;45(RR-11):1-36, MMWR. 1999;48(RR-6):1-5.

9. Meningococcal vaccine (quadrivalent polysaccharide for serogroups A, C, Y, and W-135) -- Consider vaccination for persons with medical indications: adults with terminal complement component deficiencies, with anatomic or functional asplenia. Other indications: travelers to countries in which disease is hyperendemic or epidemic ("meningitis belt" of sub-Saharan Africa, Mecca, Saudi Arabia for Hajj). Revaccination at 3-5 years may be indicated for persons at high risk for infection (eg, persons residing in areas in which disease is epidemic). Counsel college freshmen, especially those who live in dormitories, regarding meningococcal disease and the vaccine so that they can make an educated decision about receiving the vaccination. MMWR. 2000;49(RR-7):1-20. [Note: The AAFP recommends that colleges should take the lead on providing education on meningococcal infection and vaccination and offer it to those who are interested. Physicians need not initiate discussion of the meningococcal quadrivalent polysaccharide vaccine as part of routine medical care.]

Footnotes for Figure 1B

A. If pregnancy is at 2nd or 3rd trimester during influenza season.

B. Although chronic liver disease and alcoholism are not indicator conditions for influenza

vaccination, give 1 dose annually if the patient is older than age 50 years, has other indications for influenza vaccine, or if the patient requests vaccination.

C. Asthma is an indicator condition for influenza but not for pneumococcal vaccination.

D. For all persons with chronic liver disease.

E. Revaccinate once after 5 years or more have elapsed since initial vaccination.

F. Persons with impaired humoral but not cellular immunity may be vaccinated. MMWR. 1999;48(RR-06):1-5.

G. Hemodialysis patients: Use special formulation of vaccine (40 micrograms [mcg]/mL) or two 1.0 mL 20 mcg doses given at 1 site. Vaccinate early in the course of renal disease. Assess antibody titers to hep B surface antigen (anti-HBs) levels annually. Administer additional doses if anti-HBs levels decline to < 10 milliinternational units (mlU)/ mL.

H. Also administer meningococcal vaccine.

I. Elective splenectomy: vaccinate at least 2 weeks before surgery.

J. Vaccinate as close to diagnosis as possible when CD4+ cell counts are highest.

K. Withhold MMR or other measles-containing vaccines from HIV-infected persons with evidence of severe immunosuppression. MMWR. 1996;45:603-606, MMWR. 1992;41(RR-17):1-19.

Disease Overview

Tetanus toxoid became universally available in the United States in the mid-1940s. Since that time, its incidences of morbidity and mortality have declined substantially, with fewer than 50 cases reported in the United States each year. The incidence of tetanus is highest and severity greatest in persons 60 years of age and older, factors that likely relate to waning immunity.^[6] Data from the Third National Health and Nutrition Examination Survey (NHANES) demonstrated that only 40% of persons aged 60 years and older had protective levels of tetanus antibody. Antibody levels are lower in blacks and Mexican-Americans as compared with whites.^[7] Among younger persons, cases of tetanus occur disproportionately among those who use intravenous drugs.^[6] Diphtheria is also rare in the United States, with only 49 cases reported from 1980 to 1999.^[7] However, outbreaks of diphtheria continue to occur in countries where the population immunity wanes.

Vaccine Recommendations

Tetanus-diphtheria (Td) vaccine is the only universally recommended vaccine of adulthood.^[5] A primary series for adults is 3 doses: the first 2 doses given at least 4 weeks apart and the third dose 6-12 months after the second. Booster doses should be given every 10 years through adulthood.^[5] Since tetanus is acquired from the environment, there is no population immunity, and thus each individual must be immunized for protection.

Recent Changes in Recommendations

The national distribution of tetanus-containing vaccines in the United States decreased from 1998 to 2001 secondary to vaccine manufacturers dropping out of the market. This necessitated changes in the recommended schedule, and resulted in delays of all routine Td boosters in adolescents and adults. The supply of tetanus-containing vaccines in the United States is now adequate, and all practitioners should take every opportunity to ask about tetanus vaccine status and administer booster doses when appropriate.

Disease Overview

Influenza is an acute respiratory disease that can cause illness in people of all ages. It can produce repeated infections throughout life, is highly communicable, and is responsible for annual epidemics of varying severity. Each year in the United States, influenza infection leads to increased visits to healthcare providers, the overprescribing of antibiotics, and millions of days lost from school and work.^[8] In addition to the acute respiratory presentation, influenza predisposes to a number of complications, particularly cardiopulmonary complications, which account for the excess hospitalizations and deaths that are the hallmark of epidemic influenza. In the United States, it is estimated that influenza accounts for 10,000-40,000 deaths, over 100,000 hospitalizations, and billions of dollars in healthcare costs each year.^[9,10]

Vaccine Recommendations

Both randomized, controlled trials and observational studies of the currently available inactivated influenza vaccine have demonstrated safety and effectiveness among all age groups. Vaccination in healthy children and young and middle-aged adults is 70% to 90% efficacious in preventing clinical illness, caused by the same or a closely related influenza virus. Although this efficacy is diminished in the elderly, vaccination reduces hospitalizations and mortality in this population, and is cost-saving.^[11]

High-Risk Groups

In the United States, the primary target groups recommended for annual vaccination are groups of people who are at increased risk for influenza-related complications, as well as those who live with or care for persons at high risk, and therefore can transmit the illness. Groups recommended to receive influenza vaccine are listed in Table 1.

Table 1. Recommendations of the Advisory Committee on Immunization Practices for the Use of Influenza Vaccine

Target Groups for Vaccination
Persons at high risk for influenza-related complications	Persons aged 65 years or older Residents of nursing homes and other chronic-care facilities that house persons of any age who have chronic medical conditions Adults and children who have chronic disorders of the pulmonary or cardiovascular system, including asthma Adults and children who have required regular medical follow-up or hospitalization during the preceding year because of chronic metabolic diseases (including diabetes mellitus), renal dysfunction, hemoglobinopathies, or immunosuppression (including immunosuppression caused by medications or by human immunodeficiency virus [HIV]) Children and teenagers (aged 6 months to 18 years) who are receiving long-term aspirin therapy and therefore might be at risk for developing Reye's syndrome after influenza Women who will be in the second or third trimester of pregnancy during the influenza season
Persons aged 50-64 years
Persons who can transmit influenza to those at high risk	Physicians, nurses, and other personnel in both hospital and outpatient-care settings Employees of nursing homes and chronic-care facilities who have contact with patients or residents Employees of assisted-living and other residences for persons in high-risk groups Persons who provide home care to persons in high-risk groups Household members (including children) of persons in high-risk groups Household contacts and out-of-home caregivers of children birth to 23 months
Other groups to consider	Breastfeeding mothers Travelers General population

Source: Centers for Disease Control and Prevention. Prevention of influenza: recommendations of the Advisory Committee on Immunization Practices. Available at http://www.cdc.gov/mmwr/PDF/RR/RR5103.pdf. Accessed February 19, 2003.

Persons 65 years of age and older in the United States account for the majority of influenza-related deaths, and have the highest rates of hospitalization due to influenza virus and its complications. Certain younger adults are considered to be "high risk" for more serious complications of influenza infection, including hospitalizations for pneumonia and acute respiratory diseases and exacerbations of underlying chronic diseases. In contrast to influenza-associated deaths, 57% of all influenza-associated hospitalizations occur among persons younger than 65 years. While hospitalization rates among young and middle-age healthy adults range from 2 to 6 per 10,000 persons annually, hospitalization rates among similarly aged high-risk populations range from 36 to over 300 per 10,000 persons annually.^[9] Despite this demonstrated high morbidity among individuals with high-risk conditions, it is estimated that less than 40% of such patients receive influenza vaccine on an annual basis.

The high-risk conditions associated with increased hospitalization rates include chronic lung disease (including asthma), chronic heart disease, chronic renal disease, malignancy, human immunodeficiency (HIV) infection, and diabetes. Pregnant woman, including those without other known risk factors for influenza complications, are also considered to be at high risk for influenza-associated morbidity.

Universal Vaccination for Those Aged 50-64 Years

Nearly 25% of individuals aged 50-64 years have a chronic medical condition that places them at high risk for serious influenza-related morbidity. In addition, there is some evidence that smokers are predisposed to influenza, and, when infected, develop more severe disease. Recently, influenza vaccination has been recommended for the entire age group of 50-64 years to raise the low vaccination rates among those with high-risk conditions, and to provide benefit to those without high-risk conditions.^[8,9]

Healthcare Workers and Close Contacts of High Risk Groups

Recommendations for vaccination of healthcare workers and other groups in close contact with vulnerable populations are based on the premise that groups who are not eligible for vaccine, such as infants aged younger than 6 months, or who are less likely to develop a protective response from vaccination, such as frail elderly persons or immunocompromised persons, will benefit from reducing their exposure to infected contacts.^[9] See Table 1 for a list of the affected groups.

Although it is not an official recommendation, influenza vaccine should be offered to, and considered for, all adults, based on its demonstrated ability to reduce influenza-like illness. While healthy younger adults are not likely to be hospitalized with influenza, 5% to 15% of such adults will be affected each year, leading to a 5-to 7-day illness and missed work, school, and recreational activities.^[8]

Recent Changes in Recommendations

Influenza is a unique vaccine in that its antigen content varies from year to year. Manufacturing of the vaccine cannot begin until strain selection is determined in late winter or early spring. Thus, vaccine may not be available until late summer or early fall, and should ideally be administered before the start of influenza season. Delays in delivery of influenza vaccine have a significant impact on public health. To ensure that high-risk persons, their close contacts, and healthcare workers have access to vaccine, such groups should be targeted for vaccination in October. Large immunization campaigns that target low-risk groups should be organized for early November.

Children younger than 2 years of age, and particularly children younger than 6 months of age, are at increased risk for influenza-related hospitalizations. For this reason, vaccination has been encouraged for children 6-23 months of age, and their close contacts are also recommended to receive vaccine to reduce the risk for transmission.^[9] Parents of young children, daycare workers, or others who work or live with young children should be informed of this recommendation and offered influenza vaccine.

Trivalent Live Intranasal Influenza Vaccine

Recently, the Vaccines and Related Biological Products Advisory Committee of the Food and Drug Administration recommended approval of the trivalent live intranasal influenza vaccine for healthy individuals aged 5-49 years. Whether the vaccine will be approved and available for the 2003 influenza season is uncertain at this time. A randomized, controlled trial of healthy working adults aged 18-64 years demonstrated that the intranasal vaccine was safe and effective.^[12] There are no head-to-head studies comparing the current licensed inactivated vaccine with the trivalent live intranasal vaccine. A randomized, controlled trial using an earlier bivalent (2 antigens) intranasal influenza vaccine product showed roughly equivalent efficacy rates when compared with the trivalent inactivated vaccine in healthy adults.^[13]

Disease Overview

Along with influenza, pneumococcal disease represents the vaccine-preventable disease that accounts for the greatest morbidity and mortality in adults. Adults 65 years of age and over and younger adults with certain underlying medical conditions are at greatest risk for death from invasive pneumococcal disease. Community-based studies have demonstrated that the risk for pneumococcal bacteremia in the elderly is as high as 50-83 cases per 100,000 persons, compared with an incidence of 15-30 cases per 100,000 for the general population.^[14] Likewise, the overall case fatality rate for pneumococcal bacteremia is highest among the elderly, with mortality rates in this age group of 30% to 40%. Pneumococcal disease caused approximately 3400 deaths among persons aged 65 years and older in the United States in 1998.^[15] Racial differences in morbidity and mortality also exist, with black adults having a 3- to 5-fold higher overall incidence of pneumococcal bacteremia than whites. Resistance of Streptococcus pneumoniae to penicillin is increasing worldwide, further emphasizing the need for enhanced prevention.

Vaccine

The pneumococcal polysaccharide vaccine contains the capsular polysaccharides of the 23 pneumococcal types responsible for 85% to 90% of pneumococcal bacteremia. Observational studies have demonstrated that the pneumococcal polysaccharide vaccine is 44% to 85% effective at preventing invasive disease in persons 65 years and over and in younger immunocompromised individuals (eg, those with diabetes mellitus, chronic cardiopulmonary diseases, and asplenia).^[15,16] That pneumococcal polysaccharide vaccine reduces the risk for all-cause pneumonia in older adults is not established, since effectiveness has not been demonstrated in most studies.^[15,16] Therefore, practitioners should understand that pneumococcal vaccine is recommended on the basis of evidence for its effectiveness only against invasive pneumococcal disease, and has been reported to be cost-effective for this indication.^[17]

Pneumococcal polysaccharide should be administered to all patients 65 years and over, and to younger patients with certain medical conditions, including chronic pulmonary diseases (excluding asthma), cardiovascular diseases, diabetes mellitus, chronic liver diseases, chronic renal failure or nephritic syndrome, functional or anatomic asplenia (eg, sickle cell disease or splenectomy), immunosuppressive conditions, and to persons receiving chemotherapy or long-term systemic corticosteroids. All residents of nursing homes and other long-term-care facilities should receive pneumococcal vaccine.^[5]

Revaccination with pneumococcal polysaccharide should be given 1 time after 5 years have elapsed since the first vaccination for persons with chronic renal failure or nephrotic syndrome, functional or anatomic asplenia, immunosuppressive conditions, and to persons receiving chemotherapy or long-term systemic corticosteroids. For persons 65 years and older, a 1-time revaccination should be given if they were vaccinated 5 or more years previously and were younger than 65 years at the time of primary vaccination.^[5,15] Revaccination administered in accordance with the current recommendations is associated with a higher rate of self-limited injection-site reactions compared with first vaccination, and patients should be informed of this risk.^[18]

Recent Changes in Recommendations

There have been no recent changes in recommendations for administration of this vaccine.

Disease

Before 1982, an estimated 200,000-300,000 persons in the United States were infected annually with Hepatitis B virus (HBV), and the average lifetime risk for HBV infection was estimated to be 5%. While vaccination and changes in risk-reduction behaviors among at-risk populations have led to declines in the number of persons infected in the United States, it is estimated that 79,000 persons were infected in 2001.^[19] The prevention of hepatitis B infection has been shown to be the most effective medical and economic means to reduce the incidence of HBV-related chronic liver disease and liver cancer.^[20]

Vaccine Recommendations

Universal hepatitis B immunization for infants and adolescents should translate into a markedly reduced incidence of hepatitis B in the next decade, but challenges remain in identifying adults who are at risk for acquiring hepatitis B and in delivering vaccine to them. In one third of patients, no source of the virus can be determined, emphasizing the difficulty in identifying risk factors as well as the need for more widespread use of the vaccine.

Groups for whom the hepatitis B vaccine is recommended are listed in Table 2.

Table 2. Persons at High Risk for Hepatitis B Virus Infection Who Should Receive Hepatitis B Vaccine

Persons with medical indications	Hemodialysis patients Patients who receive clotting-factor concentrates
Persons with occupational indications	Healthcare workers Public safety workers Persons in training in schools of medicine, dentistry, nursing, laboratory technology, and other allied health professionals
Persons with behavioral indications	Persons with more than 1 sex partner in the previous 6 months Men who have sex with men Persons with a recently acquired sexually transmitted disease All clients in sexually- transmitted disease clinics Injection-drug users
Persons with other indications	Household contacts and sex partners of persons with chronic hepatitis B virus Clients and staff of institutions for the developmentally disabled Inmates of correctional facilities International travelers who will be in countries with high or intermediate prevalence of chronic hepatitis B infection for more than 6 months

Source: Centers for Disease Control and Prevention. Hepatitis B virus: a comprehensive strategy for eliminating transmission in the United States through universal childhood vaccination: recommendations of the Immunization Practices Advisory Committee (ACIP). Available at http://www.cdc.gov/mmwr/preview/mmwrhtml/00033405.htm. Accessed February 19, 2003.

The most common source of acquisition of hepatitis B is sexual contact. It is therefore important to identify persons with high-risk sexual behavior, which includes more than 1 partner of either sex in the past 6 months, anyone with a history of sexually transmitted diseases (STDs), men who have sex with men, and persons having sex with a known infected person. The most efficient source of hepatitis B transmission is through the direct parenteral route, accounting for the increased risk in persons who use intravenous drugs or for patients on hemodialysis or those receiving clotting factors.^[20]

The hepatitis B vaccine is given as a 3-dose series, with the second dose given 1-2 months after the first, and the third dose given 4-6 months after the first. While it is best to complete the series, the first dose of hepatitis B vaccine should always be given when indicated, even to patients for whom follow-up is uncertain. Up to 70% of people receive some protection from 1 dose, and the series can be resumed without starting over if the person returns to clinic. It should be noted that patients with chronic renal disease are recommended to receive a higher dose (40 micrograms/mL) or two 20-microgram doses of hepatitis B vaccine given at 1 site, and antibody levels to hepatitis B surface antigen should be checked annually in such patients.^[5]

Recent Changes in Recommendations

The national health objectives for 2010 call for a reduction of 75% to 90% in acute hepatitis B cases among high-risk adults.^[2] To achieve this goal, adults with behavioral risk factors for HBV infection must be identified and vaccinated. It is recommended that providers who care for such persons integrate hepatitis B vaccination into programs that provide services to persons with risk factors for HBV infection (eg, STD clinics, HIV counseling and testing sites, correctional facilities, and drug treatment clinics).^[19]

Disease Overview

Hepatitis A continues to be one of the most frequently reported vaccine-preventable diseases in the United States. The likelihood of having symptoms of hepatitis A infection increases with increasing age, with jaundice occurring in over 70% of older children and adults. Between 11% and 22% of persons who have hepatitis A are hospitalized, and adults who become ill lose an average of 17 days of work. Each year in the United States, an estimated 100 persons die as a result of acute liver failure due to hepatitis A infection. Of cases reported to the CDC, the case-fatality rate is 1.8% among adults older than 50 years of age. Persons with chronic liver disease are at increased risk for fulminant hepatitis A.^[21]

Vaccine Recommendations

Hepatitis A vaccines are highly immunogenic. Protective antibody levels develop in 94% to 100% of adults 1 month after the first dose. After the second dose, all persons studied had protective levels of antibody in high concentrations. Hepatitis A vaccine is recommended for persons with certain medical indications (clotting-factor disorders or chronic liver disease), behavioral indications (men who have sex with men, users of injection and noninjection illegal drugs), occupational indications (persons working with hepatitis A virus [HAV]-infected primates or with HAV in a research laboratory), and for persons traveling to or working in countries that have high or intermediate endemicity of hepatitis A.^[5,21] Similar to hepatitis B, a risk factor cannot be determined for a substantial proportion of patients who acquire HAV infection.

Vaccination of a person who is immune because of prior infection does not increase the risk for adverse events. However, in populations that have expected high rates of prior HAV infection, prevaccination testing may be considered to reduce costs by not vaccinating persons who have prior immunity. Such populations include adults who were either born in or lived for extensive periods in geographic areas that have a high endemicity of HAV infection (Figure 2); older adolescents and adults in certain population groups (American Indians, Alaskan Natives, and Hispanics); and adults in certain groups that have a high prevalence of infection (eg, injection-drug users).^[21]

Figure 2. Endemicity Patterns of Hepatitis A Virus Infection Worldwide. Source: Centers for Disease Control and Prevention. Available at http://www.cdc.gov/mmwr/PDF/RR/RR4812.pdf. Accessed February 19, 2003.

Recent Changes in Recommendations: Hepatitis A and B Vaccine

In 2001, a licensed combination hepatitis A and B vaccine was approved for persons 18 years and over. Any person in this age group having an indication for both hepatitis A and B vaccination can be administered the combined vaccine. Primary vaccination consists of 3 doses, given on a 0-, 1-, and 6-month schedule, the same schedule as is used for single antigen hepatitis B vaccine.^[22]

Measles

Measles is one of the most contagious diseases in the world; more than 90% of people who are not immune will get measles if they are exposed to the virus. Before measles immunization was available, nearly everyone in the United States got measles. Since then, the incidence of measles in the United States has dramatically decreased. However, outbreaks of measles continue to be reported. In 1997-2000, most measles cases in the United States were associated with exposure to international visitors, or occurred in US residents who were exposed to the measles virus while traveling abroad. Currently in the United States, up to 20% of persons with measles are hospitalized, and 0.1% die of the disease.^[23]

Mumps

Like measles, the incidence of mumps in the United States has declined dramatically since the institution of childhood vaccination programs. While mumps is generally a self-limited disease, complications can occur in adults, including mumps orchitis and meningoencephalitis.^[23]

Rubella

Rubella was likewise common in children and adults before routine vaccination programs. Rubella may cause arthritis, arthralgias, or central nervous system complications in adults. The most serious consequences of rubella occur if a pregnant women is infected, leading to stillbirths, miscarriages, or congenital rubella syndrome. While uncommon now, rubella and its complications have occurred in this country in the past decade, most notably in communities that do not accept immunization and in persons of Hispanic ethnicity, particularly those born outside the United States.^[24]

Vaccine Recommendations

The measles, mumps, and rubella (MMR) immunization is given as a combination vaccine. In regard to measles, adults born before 1957 may be considered immune to measles. Adults born after 1956 should receive at least 1 dose of MMR vaccine unless they have a medical contraindication, documentation of at least 1 dose, or other acceptable evidence of measles immunity. A second dose of MMR is recommended for adults who:

• were recently exposed to measles or in an outbreak setting;
  
  
• were previously vaccinated with killed measles vaccine;
  
  
• were vaccinated with an unknown vaccine between 1963 and 1967;
  
  
• are students in postsecondary educational institutions;
  
  
• work in healthcare facilities; or
  
  
• plan to travel internationally.
  
  

Rubella immunity should be determined routinely for all women of childbearing age, regardless of birth year. Women should be counseled regarding congenital rubella syndrome and given MMR vaccine if they are nonimmune.^[24] Pregnant women should not be vaccinated, and other women of childbearing age should be counseled not to become pregnant in the 4 weeks following vaccination. If a women is pregnant and rubella-susceptible, she should be vaccinated as early in the postpartum period as possible.^[25]

Recent Changes in Recommendation

Based on data indicating that no cases of congenital rubella syndrome had been identified among infants born to women who were vaccinated inadvertently against rubella within 3 months or early in pregnancy, the Advisory Committee on Immunization Practices shortened its recommended period to avoid pregnancy after receipt of rubella-containing vaccine from 3 months to 28 days (4 weeks).^[25]

Contraindications

MMR is a live virus vaccine, and should not be given to pregnant women or persons with impaired immunity. MMR vaccine should also be withheld from HIV-infected persons with evidence of severe immunosuppression.^[5] Women should be counseled to avoid pregnancy in the 4 weeks following receipt of the vaccine. If a woman is pregnant and susceptible, she should be vaccinated as early as possible in the postpartum period.

Disease Overview

Varicella is a highly contagious disease that affected nearly all individuals in the United States prior to the availability of vaccine. While varicella is a self-limited disease in most children, serious complications do occur. Rates of such complications are substantially higher for persons 15 years of age and older and for infants. The most common complications of varicella are bacterial infections of skin lesions, pneumonia, dehydration, encephalitis, and hepatitis.^[26,27]

Vaccine Recommendations

Adolescents and adults who did not have chickenpox and did not receive the vaccine as a child should receive 2 doses of varicella vaccine 4-8 weeks apart. A reliable history of varicella is a valid measure of immunity. In adults, a positive history of varicella is highly predictive of serologic immunity (97% to 99% of persons are seropositive); however, the majority of adults who have negative or uncertain histories are also seropositive (71% to 93%).^[27,28]

Particular attention should be paid to healthcare workers and family contacts of immunocompromised persons, and to those adults with increased exposure to varicella, including:

• those who live or work in environments where transmission of varicella is likely to occur, such as teachers of young children, daycare employees, and residents and staff members in institutional settings;
  
  
• adolescents and adults living in households with children;
  
  
• persons who live or work in environments where varicella zoster virus (VZV) transmission can occur (college students, inmates and staff members of correctional institutions, and military personnel); and
  
  
• international travelers who are not immune to infection.
  
  

Adult practitioners who care for nonpregnant women of childbearing age should routinely ask about history of varicella infection, and if uncertain, immunity should be confirmed with serology or vaccine should be given. Depending on the stage of pregnancy during which varicella was acquired, infection may lead to severe disease in pregnant women, congenital varicella syndrome in the fetus, or neonatal varicella in the newborn.

Recent Changes in Recommendations

There have been no recent changes in recommendations for administration of this vaccine.

Contraindications

Varicella is a live virus vaccine, and should not be given to pregnant women, persons with impaired cellular immunity, or persons with HIV infection.^[5] Women should be counseled to avoid pregnancy in the 4 weeks following receipt of the vaccine. If a woman is pregnant and susceptible, she should be vaccinated as early as possible in the postpartum period.

Disease Overview

Meningococcal disease is a leading cause of meningitis and sepsis. Approximately 3000 cases of meningococcal disease occur annually in the United States. Fatality rates for this disease are approximately 10%, and an estimated 12% of patients have long-term sequelae. Serogroups B, C, and Y cause the majority of disease in the United States.^[29]

Vaccine Recommendations

The meningococcal vaccine currently licensed in the United States is a quadrivalent polysaccharide that protects against serogroups A, C, Y, and W-135. No vaccine against serogroup B is currently available.

Vaccination should be considered for persons with medical indications, including adults with terminal complement component deficiencies and with anatomic or functional asplenia. Other indications include travelers to countries in which disease is hyperendemic or epidemic (ie, the "meningitis belt" of sub-Saharan Africa, Mecca, Saudi Arabia for Hajj).^[30] Revaccination at 3-5 years may be indicated for persons at high risk for infection. College freshmen, especially those who live in dormitories, have an increased risk for meningococcal disease.^[31] It is recommended that healthcare providers and colleges educate students and their parents about the increased risk and potential benefits of immunization.^[30]

Recent Changes in Recommendations

Two probable cases of fatal laboratory-acquired meningococcal disease reported recently, indicating that Neisseria meningitidis isolates pose a risk to laboratory workers. Although primary prevention should focus on laboratory safety, laboratory workers should be informed about the potential benefits and limitations (eg, no serogroup B vaccine, need for revaccination) of vaccination with the quadrivalent meningococcal polysaccharide vaccine.^[32]

Much needs to be done at the national level to achieve adult immunization goals. Better government-sponsored adult immunization programs are needed to provide infrastructure and support for vaccine purchase, vaccine administration, and educational programs.^[33] However, the individual adult healthcare provider can make a difference. A better understanding of vaccine-preventable diseases and vaccine recommendations, and having a tool such as the adult immunization schedule, should increase support for immunizations by adult healthcare providers.

Support for adult immunizations by healthcare providers is crucial. Studies have shown that physician beliefs about vaccine efficacy are associated with their likelihood of strongly recommending vaccination to patients, and that physician recommendation of vaccines can overcome negative attitudes of patients toward vaccines.^[34] Additionally, practitioners may implement strategies that have been proven to increase immunization rates in practices or hospitals, such as standing orders, and patient reminder/recall systems. Additional information on strategies for increasing vaccination rates among adult patients is available from the CDC (www.cdc.gov/nip).

1. Centers for Disease Control and Prevention. Influenza and pneumococcal vaccination levels among persons aged >/= 65 years -- United States, 2001. MMWR. 2002;51:1019-1024.
2. U.S Department of Health and Human Services. Healthy People 2010. 2nd ed. With understanding and improving health and objectives for improving health (2 vols). Washington, DC: U.S. Department of Health and Human Services; 2000.
3. Centers for Disease Control and Prevention. National Center for Health Statistics -- National Interview Survey. 1989-2000. Available at:
   http://www.cdc.gov/nchs/about/major/nhis/released200212/figures04_1-4_3.htm and http://www.cdc.gov/nchs/about/major/nhis/released200212/figures05_1-5_3.htm. Accessed February 19, 2003.
4. National Vaccine Advisory Council. Adult Immunization: A Report by the National Vaccine Advisory Committee. Washington, DC: US Department of Health and Human Services; 1994.
5. Centers for Disease Control and Prevention. Recommended adult immunization schedule -- United States, 2002-2003. MMWR. 2002;51:904-908. Available at:
   http://www.cdc.gov/nip/recs/adult-schedule.pdf. Accessed February 19, 2003.
6. Bardenheier B, Prevots DR, Khetsuriani N, Wharton M. Tetanus Surveillance -- United States, 1995-1997. In: CDC Surveillance Summaries; July 3, 1998. MMWR. 1998;47(No. SS-2):1-14.
7. McQuillan GM, Kruszon-Moran D, Deforest A, Chu SY, Wharton M. Serologic immunity to diphtheria and tetanus in the United States. Ann Intern Med. 2002;136:660-666. 
8. Neuzil KM. Influenza: New insights into an old disease. Curr Infect Dis Rep. 2000;2:224-230. 
9. Centers for Disease Control and Prevention. Prevention and control of influenza: recommendations of the Advisory Committee on Immunization Practices. MMWR. 2002;51(No. RR-3):1-31.
10. Thompson WW, Shay DK, Weintraub E, et al. Mortality associated with influenza and respiratory syncytial virus in the United States. JAMA. 2003;289:179-186. 
11. Nichol KL, Margolis KL, Wuorenma J, Von Sternberg TL. The efficacy and cost effectiveness of vaccination against influenza among elderly persons living in the community. N Engl J Med. 1994;331:778-784. 
12. Nichol KL, Mendelman PM, Mallon KP, et al. Effectiveness of live, attenuated intranasal influenza virus vaccine in healthy, working adults. JAMA. 1999;282:137-144. 
13. Edwards KM, Dupont WD, Westrish MK, Plummer WD Jr, Palmer PS, Wright PF. A randomized controlled trial of cold-adapted and inactivated vaccines for the prevention of influenza A disease. J Infect Dis. 1994;169:68-76. 
14. Centers for Disease Control and Prevention. Prevention of pneumococcal disease: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR. 1997;46(No. RR-8):1-31.
15. Centers for Disease Control and Prevention. Facilitating influenza and pneumococcal vaccination through standing orders programs. MMWR. 2003;52:68-69.
16. Jackson LA, Neuzil KM, Yu O, et al. Effectiveness of pneumococcal polysaccharide vaccine in older adults. N Engl J Med. 2003 (in press).
17. Sisk JE, Moskowitz AJ, Whang W, et al. Cost-effectiveness of vaccination against pneumococcal bacteremia among elderly people. JAMA. 1997;278:1333-1339. 
18. Jackson LA, Benson P, Sneller VP et al. Safety of revaccination with pneumococcal polysaccharide vaccine. JAMA. 1999;281:243-248. 
19. Centers for Disease Control and Prevention. Hepatitis B vaccination among high-risk adolescents and adults -- San Diego, California, 1998-2001. MMWR. 2002;51:618-621.
20. Centers for Disease Control and Prevention. Hepatitis B virus: a comprehensive strategy for eliminating transmission in the United States through universal childhood vaccination: recommendations of the Immunization Practices Advisory Committee (ACIP). MMWR. 1991;40(No. RR-13):1-19.
21. Centers for Disease Control and Prevention. Prevention of hepatitis A through active or passive immunization: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR. 1999;48(No. RR-12):1-37.
22. Centers for Disease Control and Prevention. Notice to Readers: FDA-approval for a combined hepatitis A and B vaccine. MMWR. 2001;50:806.
23. Centers for Disease Control and Prevention. Measles, mumps, and rubella---vaccine use and strategies for elimination of measles, rubella, and congenital rubella syndrome and control of mumps: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR. 1998;47(No. RR-8):1-57.
24. Centers for Disease Control and Prevention. Rubella Outbreak -- Westchester County, New York, 1997-1998. MMWR. 1999;48:560.
25. Centers for Disease Control and Prevention. Notice to readers: revised ACIP recommendation for avoiding pregnancy after receiving a rubella-containing vaccine. MMWR. 2001;50:1117.
26. Seward JF, Watson BM, Peterson CL, et al. Varicella disease after introduction of varicella vaccine in the United States, 1995-2000. JAMA. 2002;287:606-611. 
27. Centers for Disease Control and Prevention. Prevention of varicella: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR. 1996;45 (No. RR-11):1-25.
28. Centers for Disease Control and Prevention. Prevention of varicella: updated recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR. 1999;48(No. RR-6):1-5.
29. Rosenstein NE, Perkins BA, Stephens DS, Popovic T, Jugues JM. Meningococcal disease. N Engl J Med. 2001;344:1378-1388. 
30. Centers for Disease Control and Prevention. Prevention and control of meningococcal disease: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR. 2000;49(No. RR-7):1-10.
31. Rosenstein NE, Capparella JM, Shutt KA, Perkins BA, Collins M. Risk factors for meningococcal disease in college students. JAMA. 2001; 286: 688-693. 
32. Centers for Disease Control and Prevention. Laboratory-acquired meningococcal --United States, 2000. MMWR. 2002; 51;141-144.
33. National Foundation for Infectious Diseases. A report on reaching underserved ethnic and minority populations to improve adolescent and adult immunization rates. NFID. October 2002.
34. Nichol KL, Zimmerman RK. Generalist and subspecialist physicians' knowledge, attitudes and practices regarding influenza and pneumococcal vaccinations for elderly and other high-risk patients: a nation-wide survey. Arch Intern Med. 2001;161:2702-2708. 

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