1. Test your knowledge of vaccine-preventable disease in adults, and the Advisory Committee on Immunization Practices (ACIP) Recommended Adult Immunization Schedule.

2. The Centers for Disease Control and Prevention (CDC) ACIP provides the recommended adult immunization schedule in 2 formats: one based on age, and the other based on medical and other risk factors. This table shows vaccine recommendations according to age. The current adult schedule includes 10 vaccines, covering 14 infectious diseases. Not all vaccines apply to all adults, of course, with zoster vaccine, for example, having a narrow age indication.

3. This version of the ACIP recommended adult immunization schedule shows vaccine recommendations by medical and other indications. The recommendations are more fully developed in the footnotes that accompany the schedule.

4. Although proof of childhood immunization is a requirement to enter schools in many states, adults have no such broad mandates for vaccination. Many of today's adults were not vaccinated as children, either because newer vaccines were not available when they were children, or those that were available were not required. Unless an employer requires vaccination for a worker to keep his or her job, it really is up to the provider to offer the vaccine, and up to the patient whether to receive it.

5. Adults are vaccinated for their own health and for the health of those around them, particularly older adults and the very young who may be vulnerable to vaccine-preventable diseases. Pertussis, for example, often causes severe illness in infants too young to be vaccinated, and typically causes milder disease in adults. For these young children and for older adults, whose advancing age makes them more susceptible to serious disease caused by common infections, indirect – or herd – immunity is an important prevention strategy. Women who are pregnant, or intend to be, should be fully immunized to protect themselves and their infants. The benefit of some vaccinations is also in preventing the clinically important conditions that can occur years after initial infection, such as hepatocellular carcinoma associated with hepatitis B virus infection, and cervical cancer associated with HPV.
Age-related changes in immunity have clinical relevance toward an impaired response to influenza infection and immunization, so it is important that those who come in contact with the elderly are vaccinated. Average influenza mortality is much higher for adults 65 years and older.

6. Despite the availability of vaccines for adults in the United States, vaccine-preventable diseases still exist and cause a tremendous burden. Older adults are particularly affected by influenza and invasive pneumococcal disease.

7. As shown in the preceding slide, approximately 1 million cases of herpes zoster occur annually in the United States, and 50% of cases occur in those who are 60 years or older. Incidence, duration, and severity of postherpetic neuralgia, the most common complication of herpes zoster infection, increases with increasing age. Postherpetic neuralgia can last weeks or months and occasionally persists for many years. It rarely occurs among persons younger than 40 years but occurs in up to 50% (and possibly more) of persons 60 years of age and older. The pain can be severe and debilitating. Other complications of herpes zoster include ophthalmic involvement with acute or chronic ocular sequelae, bacterial superinfection of the lesions, cranial and peripheral nerve palsies, and visceral involvement. The vaccine may prevent disease, or if it occurs, may lessen the severity of illness.

8. The chest radiograph of a 49-year-old woman with pneumococcal pneumonia reveals a left lower lobe opacity with pleural effusion.

10. Using vaccines to protect adult patients from disease is best guided by your knowledge of the patient, the immunization schedule, and effective answers to patient questions.

11. The current recommended adult immunization schedule consists of a color-coded table of vaccine recommendations by age and medical or other conditions. Yellow highlight indicates a vaccine that is recommended for all persons in a category who lack evidence of immunity. Purple highlight signifies that a vaccine is recommended for persons with a risk factor as described in the footnotes section and risk-based table of the schedule. Red highlight indicates a contraindication.

12. A close-up view of the pneumococcal vaccine recommendation, for example, displays at a glance the age recommendation (65 years and older), and whether the vaccine is indicated by the presence of certain risk factors detailed in both the second table, and the schedule's detailed footnotes.

13. This view demonstrates the risk factors that are indications for the pneumococcal vaccine in adults younger than 65 years. The vaccine is recommended for persons 18 years or older who have any of the risk factors listed above the yellow bar.

14. Footnotes to the recommended adult immunization schedule inform clinical decision-making about vaccination in specific populations. While the tables show at a glance the age and risk factor recommendations as shown in the preceding slides for pneumococcal vaccine, the footnotes provide a more granular look at the indications for vaccination.

15. Because many adults lack either a record or memory of vaccines received in childhood, catch-up vaccinations on the adult recommended schedule include tetanus, diphtheria, and pertussis (Tdap) (3 doses); varicella; measles, mumps, and rubella (MMR); and HPV. Note that other vaccines that should be considered in a catch-up situation include inactivated poliovirus.

16. Test your immunization IQ with the details of 3 different patients
Test your immunization IQ with the details of 3 different patients. How does your knowledge of the patient's family, health behavior, and work life, together with the ACIP recommendations, inform your decisions about which vaccinations to recommend?

17. Elena is a 40-year-old woman from Mexico who has a history of asthma but is otherwise healthy. She has come to your office for a health screen for a school cafeteria job.

19. Tdap, influenza, and pneumococcal vaccines are appropriate for Elena
Tdap, influenza, and pneumococcal vaccines are appropriate for Elena. Because she does not recall receiving the 3-dose primary vaccination series with Td-containing vaccine, Elena should begin the series of 1 dose of Tdap and 2 doses of Td. She should also receive the annual influenza vaccine. (Because of her asthma, Elena should receive the trivalent inactivated vaccine [TIV] rather than the live attenuated influenza vaccine [LAIV].) Elena's asthma is an indication for her to receive pneumococcal vaccine.

20. Arthur is 65 years of age, recently retired, and newly eligible for Medicare. He has come to your office to see a physician for the first time in many years for a physical examination. He has no medical records and reports that he has smoked for many years. History, physical examination, and initial tests reveal mild emphysema and diabetes.

22. Arthur's age (65 years), emphysema, and diabetes are indications for 4 vaccines. Influenza, pneumococcal, and Tdap are priorities given Arthur's lung disease. He recalls getting a tetanus booster several years ago after an injury, so he needs only Tdap, and not the catch-up Td series. Because he was born before 1957, Arthur does not need the MMR vaccine.

23. Corinne is a 30-year-old pregnant woman whose household includes 2 young children. It is the start of the school year, and Corinne reports never having received a seasonal influenza vaccine.

25. Corinne should receive the seasonal influenza and Tdap vaccines
Corinne should receive the seasonal influenza and Tdap vaccines. Because pregnancy is a contraindication for LAIV, Corinne should receive an age-appropriate TIV for influenza. ACIP recommends that pregnant women who have never received the Tdap vaccine should be vaccinated during the second trimester (after 20 weeks gestation) or during the third trimester. If Tdap is indicated but not administered during pregnancy, it should be given in the immediate postpartum period.

26. The next several slides provide responses to common patient misperceptions and myths regarding vaccines and vaccine-preventable diseases.

27. ACIP recommends that all persons 6 months of age and older without a contraindication be vaccinated annually against influenza. People who are generally healthy who do get the flu are more likely to transmit the virus to other people during the period beginning 1-2 days before noticing any symptoms through the first 4 or 5 days after onset of symptoms. They may unknowingly pass the virus on to a person for whom the risks for complications, hospitalization, and death are higher: people 65 years or older, young children, and people of any age with certain medical conditions. Healthy people who get the flu can themselves develop serious complications, and it is difficult to predict those at risk for these complications.

28. Neither the injectable (inactivated) vaccine nor the live attenuated (nasal spray) vaccine can cause influenza. The nasal spray influenza vaccine contains live weakened viruses that can produce mild symptoms that are similar to those of a cold but are not the flu. The injectable influenza vaccine contains killed viruses and cannot cause influenza disease. Following vaccination, some people will experience mild fever and muscle ache. These symptoms do not represent influenza infection.

29. A person's immunity to certain diseases wanes over time, including immunity to tetanus and diphtheria, and a Td booster shot every 10 years is recommended. Adults who lack documentation of receiving the basic series should receive a primary 3-dose series of Td vaccine. If the person has not received a vaccine that contains pertussis, the primary series of vaccination should consist of 1 dose of Tdap and 2 doses of Td, properly spaced. The recent pertussis outbreaks in the United States remind us that many adults lack immunity to pertussis and may transmit the disease.

30. Shingles recurrence is relatively common and data suggest that rates of shingles recurrence appear comparable to rates of first shingles occurrence in immunocompetent individuals. For persons who are candidates for zoster vaccine, experts recommend that the vaccine be administered 2-3 years after an episode of shingles.

31. No serious problems have been identified with shingles vaccine
No serious problems have been identified with shingles vaccine. It may cause headaches and reactions at the injection site. Rashes similar in appearance to shingles and chickenpox have been reported rarely after administration of the zoster vaccine. The risk of a vaccine causing serious harm is very low. Shingles vaccine should not be given to a person who has allergy to its components, has a weakened immune system, is undergoing prolonged use of high-dose steroids or cancer treatment such as radiation or chemotherapy, or who has cancer of the bone marrow or lymph system.