New recommendations for influenza, hepatitis A, and hepatitis B vaccines are highlighted in the 2019 Recommended Adult Immunization Schedule. Published online by the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC) on February 4 in Annals of Internal Medicine and on the CDC website, the recommendations also include streamlined formatting, bolder headings, and more colorful graphics. Influenza For the 2018-2019 season, any licensed influenza vaccine appropriate for a patient’s age and health status may be now administered. The recommendation supersedes those for the previous two seasons, in which the use of the intranasal live attenuated influenza vaccine (LAIV), such as FluMist Quadrivalent (AstraZeneca), was not recommended. The change came about after an August 24, 2018, report on seasonal influenzato the CDC showed that although LAIV was not as effective as inactivated vaccines against H1N1, its effectiveness did not differ markedly for influenza B and H3N3. "It's been added back and has its own row in the table of options, so if you're healthy and not pregnant, you can go needle-free again," Atlanta internist Sandra Adamson Fryhofer, MD, told Medscape Medical News. Fryhofer is the American Medical Association's liaison to ACIP and a member of its Adult Immunization Work Group. LAIV is now a recommended option for adults ages 19 to 49 years, except for those who have an immunocompromising condition such as HIV infection. Other contraindications are anatomical or functional asplenia, pregnancy, end-stage renal disease, close contact with severely immunocompromised persons in a protected environment, or receipt of influenza antiviral medications in the previous 48 hours. In addition, those with cerebrospinal fluid leakage or a cochlear implant and those with a history of Guillain-Barré syndrome within 6 weeks of previous influenza vaccination should not receive the vaccine. Fryhofer also noted that for the 2018-2019 flu season the manufacturers altered the strains slightly to make them more immunogenic and increase effectiveness. As of mid-November 2018, there had been a 6.4% increased uptake of vaccination during this flu season among children and a 6.4% increase among adults over the previous season, with final vaccination rates for the seasons to come in September. As for the growing number of antiviral medications, she said, "There's a new single-dose antiviral being marketed as a new option, but the best way to get a head start against flu is to get vaccinated." Hepatitis A Homeless individuals are the latest addition to the list of those who should be routinely vaccinated against hepatitis A. They can receive a two-dose series of single-antigen hepatitis A vaccine (Havrix, GlaxoSmithKline; Vaqta, Merck) or a three-dose series of combination hepatitis A and B vaccine (Twinrix, GlaxoSmithKline). The addition came after the CDC received reports of an outbreak of hepatitis A in multiple states in October 2018. There were 2500 cases and most occurred among people who were homeless, drug users, or both, Fryhofer said. "Homelessness was independently associated with a two-to-three times [higher] risk of infection and a two-to-four times [higher] risk of severe outcomes, including hospitalization and death," she explained. Fryhofer cautioned, however, that it may be challenging for itinerant teams of health workers on the street and in shelters to deliver two doses of a vaccine "but a single dose is also effective. The people who work with the homeless think this can be done," she added. Other populations at increased risk for hepatitis A virus infection or severe hepatitis A disease should receive routine vaccination. These include those with chronic liver disease or clotting factor disorders, travelers in countries with high- or intermediate-prevalence of rates of endemic hepatitis A, and people in close personal contact with an adoptee (eg, a babysitter or new household member) in the first 60 days after arrival from a jurisdiction with high hepatitis A endemicity, such as certain developing countries. Other vaccination candidates are men who have sex with men, injection or noninjection drug users, and those who work with hepatitis A virus in a lab or nonhuman primates infected with hepatitis A. Those who are not at particular risk but who desire immunization may also request the vaccine. Hepatitis B For adults aged 19 years and older, ACIP recommends use of a new yeast-based single-antigen recombinant hepatitis B vaccine (Heplisav-B, Dynavax), which contains the novel cytosine-phosphate-guanine oligodeoxynucleotide 1018 adjuvant. Approved by the US Food and Drug Administration in November 2017, the vaccine offers the advantage of a more rapid dosing schedule and a shorter time to protection. "It's effective with two doses given 1 month apart and can also be used as part of a series with older vaccines," Fryhofer said. It costs about twice as much as its older counterparts, however. There is an absence of safety data on use during pregnancy, and pregnant women should not receive Heplisav-B. In another change, the new recommendations use the trade names of vaccines for easier recognition and prescribing. ACIP stresses, however, that this usage is for identification purposes only and does not imply endorsement by ACIP or the CDC. Fryhofer said the revamped design of the tables is "visually more appealing, and the more vibrant colors and bigger, bolder headings invite you to get involved. But if you want to print out the color charts, make sure your printer's ink isn't low or it won't turn out the way you want it." The authors have disclosed no relevant financial relationships. Ann Intern Med. Published online February 4, 2019. Full text CDC website. ACIP recommendations. Source
