ACIP Updates: Adult Vaccination Recommendations for 2017

As of February 7, 2017, immunization recommendations for adults 19 years or older have been updated by the Advisory Committee on Immunization Practices (ACIP). These updated guidelines, for recommendations originally published in October 2016, cover influenza, human papilloma virus (HPV), hepatitis B virus (HBV), and meningococcal vaccinations.

INFLUENZA VACCINATION

The 2017 ACIP recommendations reiterate statements published in the current influenza season guidelines recommending against use of the live attenuated influenza vaccine (LAIV) for the season based on concerns of the vaccine’s low effectiveness against the 2009 influenza A H1N1 pandemic strain during 2 prior seasons (2013-2014 and 2015-2016). The 2017 ACIP guideline reaffirms that LAIV should not be used in any patient for the 2016-2017 influenza season. Other changes relate to vaccination of egg-allergic patients. It is important for patients with egg allergy symptoms more severe than hives to receive an influenza vaccine at an inpatient or outpatient medical setting under the supervision of a health care provider who is able to recognize and manage severe allergic reactions. This level of reactions includes angioedema, respiratory distress, lightheadedness, recurrent vomiting, and any previous reaction to eggs or egg protein that required administration of epinephrine.

HPV VACCINATION

This treatment series still consists of 2 doses for those who receive their first dose before the age of 15 and 3 doses for those who receive their first dose after the age of 15. Changes to vaccination guidelines related to HPV are limited to patients who did not complete a series with the HPV vaccine during adolescence.

ACIP now recommends that men up to 21 years of age and women up to 26 years of age who did not receive the HPV vaccine during adolescence receive 3 doses, at months 0, 1-2, and 6. Although 21 is the preferred upper age limit for HPV vaccination in men, the guidelines note that men aged 22 to 26 may also be vaccinated with a 3-dose series of the HPV vaccine. After the age of 26, HPV vaccination is no longer recommended for women or men.

Women and men up to 26 years of age who initiated treatment with the HPV vaccine before the age of 15 and who received 2 doses of the vaccine at least 5 months apart are considered adequately vaccinated and do not require an additional HPV vaccine. However, patients up to age 26 who started receiving the HPV vaccine before the age of 15 but received only a single dose or just 2 doses less than 5 months apart are not considered fully vaccinated. These patients should receive an additional dose of the HPV vaccine.

HBV VACCINATION

ACIP recommends that adults with chronic liver disease who have elevated levels of liver enzymes (ie, aspartate aminotransferase or alanine aminotransferase levels higher than 2 times the upper limit of normal) receive a series of the HBV vaccine. Potential chronic liver disease conditions include hepatitis C virus infection, cirrhosis, fatty liver disease, alcoholic fatty liver disease, and autoimmune hepatitis. Patients with these or other chronic liver disease conditions may be advised of the new recommendation and referred to a physician for further evaluation.

MENINGOCOCCAL VACCINATION

In a change from 2016, ACIP has added recommendations for meningococcal vaccination for 2 groups of patients: those with HIV and those with asplenia or persistent complement component deficiencies. ACIP also updated guidance for dosing of the 2 meningococcal group B vaccines available in the United States, Trumenba and Bexsero.

In adults with asplenia (either anatomical asplenia or functional asplenia) and those with persistent complement component deficiencies, 2 doses of the conventional MenACWY vaccine for meningococcal disease caused by serogroups A, C, W, and Y, administered at least 2 months apart, should be administered every 5 years. In addition, these patients may receive either a 2-dose series of Bexsero or a 3-dose series of Trumenba.

Like patients with asplenia or persistent complement component deficiencies, adults with HIV who have not been previously vaccinated with MenACWY should receive 2 doses of the conventional MenACWY vaccine administered at least 2 months apart, with revaccination every 5 years. However, unlike patients with asplenia or persistent complement component deficiencies, patients with HIV are not required to receive meningococcal B vaccines because meningitis serogroups C, W, and Y are the predominant strains that affect patients with HIV.

Microbiologists routinely exposed to Neisseria meningitidis should receive a single dose of the MenACWY vaccine every 5 years while they are at risk. They should also receive either a 2-dose series of Bexsero or a 3-dose series of Trumenba for coverage against serogroup B meningitis.

For adults, such as those with the conditions stated above, who are at high risk of developing meningococcal disease caused by serogroup B organisms and during outbreaks of this disease, a 3-dose series of Trumenba should be administered at 0, 1-2, and 6 months. However, in healthy adolescents and young adults who are not at increased risk of developing serogroup B meningococcal disease, a 3-dose series of Trumenba is no longer recommended. For this group, doses of Trumenba should be administered at months 0 and 6 only. For Bexsero, the recommendation for administration in healthy adolescents and young adults is unchanged.

During outbreaks of meningitis, adults should receive a single dose of MenACWY if the outbreak is attributable to any of those 4 serogroups. However, a full 2-dose series of Bexsero or a 3-dose series of Trumenba should be administered if the outbreak is due to serogroup B meningitis.

In addition to use during outbreaks, routine vaccination with Trumenba or Bexsero is recommended in young adults. Specifically, ACIP recommends that patients aged 16 to 23 years receive either 2 doses of Bexsero (at least 1 month apart) or Trumenba (at least 6 months apart) for short-term protection against serogroup B meningococcal disease. Although the upper ACIP-approved age limit for vaccination against meningococcal serogroup B is 23 years, the preferred age range is 16 to 18 years.

CONCLUSIONS

Key practice points for the updated ACIP recommendations for 2017 include the following:

• The LAIV should not be administered in any patient for the 2016-2017 season.
• The HPV vaccine series should be administered to women up to 26 years and men up to 21 years; it may also be administered to men aged 22 to 26 years.
• If a patient has received 2 doses of the HPV vaccine, with the first dose administered before the age of 15 and the second dose administered at least 5 months later, the patient is considered fully vaccinated against HPV.
• Patients with chronic liver disease and elevated liver enzymes should receive a full series of the hepatitis B vaccine.
• In patients with HIV and those with asplenia or persistent complement component deficiencies, a primary series of the MenACWY vaccine (2 doses given at least 2 months apart) should be administered once every 5 years.
• A 2-dose series of Bexsero or a 3-dose series of Trumenba for coverage against serogroup B meningitis should be administered in patients with asplenia or persistent complement component deficiencies, but it is not recommended in patients with HIV.
• In healthy adolescents and young adults who are not at increased risk of developing meningococcal disease, a 3-dose series of Trumenba (ie, at months 0, 1-2, and 6) is no longer recommended. Instead, doses of Trumenba in healthy adolescents and young adults should be administered at months 0 and 6 only.
• ACIP recommends that patients aged 16 to the upper limit of 23 years (preferred age range: 16 to 18 years) receive either 2 doses of Bexsero (at least 1 month apart) or Trumenba (at least 6 months apart) for short-term protection against serogroup B meningococcal disease.

Michael R. Page, PharmD, RPh, has worked as a community pharmacist at CVS Pharmacy and is currently a clinical editor at Pharmacy Times®.

REFERENCES

• Kim DK, Riley LE, Harriman KH, Hunter P, Bridges CB; Advisory Committee on Immunization Practices. Recommended immunization schedule for adults aged 19 years or older, United States, 2017. Ann Intern Med. 2017;166(3):209-219. doi: 10.7326/M16-2936.