Hep C Discussion Forum

Updated ACIP Recommendations Nix LAIV, Expand HBV Vaccination

Diana Swift - February 06, 2017

The final 2017 adult vaccination schedule has been issued by the Advisory Panel on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC).

Published in the February 6 issue of in the Morbidity and Mortality Weekly Report and the Annals of Internal Medicine, the recommendations include new or updated information on the use of influenza, human papillomavirus (HPV), hepatitis B (HBV), and meningococcal vaccines. It also provides more complete details on vaccinating adults with immunocompromising medical conditions and at-risk populations, such as men who have sex with men.

The 2017 document also features simpler graphics and more accessible and consistent wording and abbreviations, which are designed to be simpler and more informative.

The revisions were voted on at ACIP's October 2016 meeting and become the agency's official 2017 recommendations with the February 6 publication. David Kim, MD, the CDC's deputy associate director for adult immunizations, outlined key changes in the final 2017 schedule in an interview with Medscape Medical News.

He noted that concerns about egg allergy and the weak efficacy of the live attenuated influenza vaccine (LAIV) led to the following new recommendations.

First, LAIV should not be used during the 2016 to 2017 influenza season.

In addition, adults with mild egg allergy symptoms such as hives should receive age-appropriate inactivated influenza vaccine or recombinant vaccine. Those with severe symptoms such distressed breathing and angioedema should be vaccinated in a medical setting, where severe allergic reactions can be managed.

For HPV vaccination, the new guidelines stress that adults who did not begin HPV vaccination before age 15 years still require three doses, not the two-dose regimen ACIP approved last year for children and adolescents. Females and males can receive these shots through age 26 years, using a dosing schedule of 0, 1 to 2, and 6 months.

"One of the important new additions is the expanded recommendation on [HBV] vaccination for adults with chronic liver disease," Dr Kim said.

Adults with HCV infection have joined the list of those who should receive the HBV vaccine.

Other chronic liver conditions such as cirrhosis, fatty liver disease, alcoholic liver disease, autoimmune hepatitis, and an alanine aminotransferase or aspartate aminotransferase level greater than twice the upper limit of normal also warrant vaccination with a HBV series.

However, the presence of an immunocompromising condition is no longer a specific indication for HBV vaccination.

In terms of meningococcal disease, the new guidelines call for the routine vaccination of all HIV-infected adults with a two-dose primary meningococcal conjugate vaccine that covers A, C, W, and Y serotypes. The doses should be at least 2 months apart, with revaccination every 5 years.

For meningococcal serogroup B disease, vaccination is not specifically recommended for patients with HIV, as all adults at risk for this infection are advised to receive either two-dose MenB-C (Bexsero, GlaxoSmithKline) or three-dose MenB-FHbp (Trumenba, Pfizer).

Finally, healthy adolescents and young adults not at increased risk for meningococcal B disease can now receive just two doses of MenB-FHbp vaccine at 0 and 6 months for short-term protection. The previous recommendation was three doses at 0, 6, 2, and 6 months.

"Missed opportunities for vaccinating adults may result in part from limited familiarity or challenges with the complexity of the adult immunization schedule among health care providers," Dr Kim and his coauthors write. They referred to a recent survey that showed that 149 of 588 general internists and family physicians said that age-based recommendations for vaccinating adults were difficult to follow, and 172 of 587 respondents found recommendations according to medical condition hard to follow.

"Additional data are needed to assess health care providers' range of familiarity with the adult immunization schedule and identify ways to improve its utility and usability," the authors write. They propose a systematic approach to adult immunization using evidence-based strategies such as standing orders, patient reminders, and recalls for missed vaccinations, as well as prompts to healthcare professionals with electronic medical record alerts.

"These proven amplifiers for adult vaccination, along with the implementation of the adult immunization practice standards, should help health care providers and health care systems reduce racial and ethnic disparities in vaccination levels for adults and reduce their risk for illness, disability, and death from vaccine preventable diseases," the authors write.

The CDC's immunization schedules are updated annually and reviewed and approved by its partners: the American College of Physicians, the American College of Family Physicians, the American College of Obstetrics and Gynecology, and the American College of Nurse-Midwives.

The ACIP panel will meet February 22 and 23 to discuss a broad agenda, including vaccination for HBV, influenza, herpes zoster, mumps and measles, and meningococcal disease.

Morb Mortal Wkly Rep. 2017;66. Ann Intern Med. 2017;166:209-218.