Keeping Up With Vaccinations: New Guidelines Include Several Changes

Harvard Health Letters

If you've seen a clinician in the past few months, you were probably reminded to get a flu shot. You should be vaccinated against the flu every year because the viruses that cause influenza -- and the vaccines that protect you from those viruses -- change from year to year. But there's more to staying current with your vaccinations than that.

For one thing, you can't assume that the vaccines you received as a child will protect you for the rest of your life. Some childhood immunizations require a periodic booster shot. Work, travel, and changing personal circumstances can expose you to unusual infectious diseases. In addition, overall immunity can fade with age, increasing your susceptibility to serious disease caused by common infections. Moreover, from time to time, there are new vaccines -- and new recommendations for receiving older vaccines.

Every year, the Advisory Committee on Immunization Practices (ACIP) of the U.S. Centers for Disease Control and Prevention (CDC) reviews and, if necessary, changes its Adult Immunization Schedule. The 2011 schedule was approved in October 2010 and published in the Feb. 1, 2011, issue of Annals of Internal Medicine. No new vaccines have been added, but the ACIP has recommended some changes. Here's a quick summary:

-- Expanded flu vaccination coverage. An annual seasonal flu shot is now recommended for all adults. (Earlier advice had been to vaccinate all adults ages 50 and over, but among those ages 19 to 49, only those in certain high-risk groups.) Healthy adults under age 50 who are not pregnant can receive either live attenuated influenza vaccine in a nasal spray (FluMist) or an injection of the inactivated influenza vaccine. Everyone else should receive the inactivated vaccine.

A high-dose formulation designed to boost immune response is now available for people ages 65 and older. According to an editorial accompanying the Annals article, this high-dose shot has some disadvantages -- higher cost and increased reaction at the injection site.

-- Tetanus, diphtheria, and pertussis (Tdap) for grandparents, too. Because of a rise in pertussis-related infant deaths since 2000, the ACIP is recommending expanded use of the Tdap vaccine to include people ages 65 and over, especially those who are in contact with children less than a year old. They should take this vaccine no matter how much or little time has passed since they last received a tetanus and diphtheria (Td)-containing shot.

--Second meningococcal vaccine dose. A second dose of meningococcal vaccine, given two months after the first dose, is now recommended for adults whose ability to fight infection and illness is compromised by a removed or damaged spleen or by a complement component deficiency (an immune system disorder). A single dose is still recommended for people in other risk groups: people ages 65 and over, college students in dormitories, military recruits, and people who are exposed to meningococcal disease through work or travel.

--The CDC still recommends vaccination against shingles (herpes zoster) and its associated pain (post-herpetic neuralgia) for everyone ages 60 and over. Many women have asked Harvard Women's Health Watch whether they need the shingles vaccine (Zostavax) if they've already had an episode of shingles. The answer is yes, though there are some people who should not have the vaccine.

Research shows that Zostavax reduces both the odds of getting shingles (by 55 percent) and the severity of any episode that does occur. However, fewer than 7 percent of eligible people have been vaccinated. Health officials concede there are barriers to wider use, including the cost ($150 to $200, which might not be covered by insurance or Medicare) and stringent storage and handling requirements (the vaccine must be stored frozen and used within 30 minutes of reconstitution). Also, there have been intermittent supply problems. The net effect is that the vaccine isn't always available when you want it.

How do you know which vaccines you need? The CDC provides an online quiz (www2.cdc.gov/nip/adultimmsched) to help you decide which vaccines are appropriate for you.

Finally, you can get complete information about vaccines and vaccine schedules at www.cdc.gov/vaccines. If you think your immunizations aren't up to date, discuss it with your clinician at your next office visit. And be sure to check in with your clinician well before traveling outside the country for any additional shots you may need. (For travel health and immunization information, go to www.cdc.gov/travel.)

VACCINES

The following list summarizes the CDC's 2011 Adult Immunization Schedule for people age 50 and over:

1. Seasonal influenza vaccine: 1 dose per year (see note 1)

Who should get it: Everyone should be vaccinated annually in the fall or winter. If you're sick with a fever, wait until you recover before getting your flu shot. Talk to your clinician before getting the vaccine if you've ever had a severe allergic reaction to eggs or to a previous flu shot or if you have a history of Guillain-Barre syndrome that occurred after receiving a flu shot.

2. Tetanus, diphtheria, pertussis (Td/Tdap): 3-dose series and a booster every 10 years; one-time Tdap given earlier to people in contact with infants.

Who should get it: Unvaccinated adults under age 65 should receive an initial 3-dose series with 2 doses of Td and 1 of Tdap, then regular Td boosters every 10 years, including one with Tdap. A one-time dose of Tdap should be given as soon as possible to health care providers and anyone in close contact with infants (such as grandparents and child care providers). Adults ages 65 and over who've never received Tdap and who have close contact with infants should also be vaccinated with Tdap, no matter when they last received a Td-containing vaccine. Talk to your clinician before getting the vaccine if you've ever had Guillain-Barre syndrome. Don't get Td or Tdap if you've ever had a severe allergic reaction to any vaccine.

3. Varicella (chickenpox): 1 or 2 doses

Who should get it: If you've never had chickenpox, or you were vaccinated but received only one of the two recommended doses of varicella vaccine, talk to your clinician about whether you need the vaccine. Don't get this vaccine if you've ever had a severe allergic reaction to it, or to gelatin or the antibiotic neomycin.

4. Zoster (shingles): 1 dose

Who should get it: The shingles vaccine is recommended for adults ages 60 and over, whether or not they've had shingles before. Tell your clinician if you have severe allergies. Don't get this vaccine if you've ever had a severe allergic reaction to gelatin or the antibiotic neomycin, or if you have a weakened immune system.

5. Measles, mumps, rubella (MMR): 1 or 2 doses

Who should get it; Anyone born after 1956 who hasn't been vaccinated needs at least 1 dose of MMR. You may need a second dose if you're a health care worker or plan to travel internationally. Don't get this vaccine if you've ever had a severe reaction to gelatin, the antibiotic neomycin, or a previous dose of MMR.

6. Pneumococcal polysaccharide (PPSV): 1 or 2 doses

Who should get it: Adults ages 65 and over who've never been vaccinated should receive 1 dose. Others who should be vaccinated (with 1 or 2 doses) include adults who smoke cigarettes, live in long-term care facilities, have a cochlear implant, or have certain medical conditions, including lung disease, cardiovascular disease, or diabetes. Don't get this vaccine if you've had a severe allergic reaction to any vaccine.

7. Meningococcal: 1 or 2 doses (see Note 2))

Who should get it: Adults without a working spleen and those with HIV or complement component deficiencies should receive 2 doses. People ages 65 and over and anyone exposed to meningococcal disease through work or travel should receive 1 dose. Don't get this vaccine if you've had a severe allergic reaction to any vaccine.

8. Hepatitis A: 2-dose series

Who should get it: Adults who should be vaccinated include anyone who is exposed to hepatitis A through work, lifestyle, or travel and anyone with chronic liver disease or a clotting factor disorder. Don't get this vaccine if you've had a severe allergic reaction to any vaccine.

9. Hepatitis B: 3-dose series

Who should get it: Adults who should be vaccinated include anyone who is exposed to hepatitis B through work, lifestyle, or travel and anyone with end-stage renal disease, chronic liver disease, or HIV infection. Don't get this vaccine if you've had a severe allergic reaction to any vaccine.

Note 1: Only inactivated influenza vaccine for adults ages 50 and over; a high-dose version (Fluzone) is available for those ages 65 and over.

Note 2: Meningococcal conjugate vaccine quadrivalent for adults under age 56; meningococcal polysaccharide vaccine for those ages 56 and over.

SOURCES: "Recommended Adult Immunization Schedule: United States, 2011," Annals of Internal Medicine (Feb. 1, 2011), Vol. 154, No. 3, pp. 168--74; "Who should not get vaccinated with these vaccines," www.cdc.gov/vaccines/vpd-vac/should-not-vacc.htm, accessed Feb. 5, 2011. -- Harvard Women's Health Watch

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Health - Keeping Up With Vaccinations: New Guidelines Include Several Changes