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Recommended Adult Immunization Schedule: 2013 Updates

Morgan Pendleton, PharmD
PGY2 Hematology/Oncology Pharmacy Resident
Wake Forest Baptist Health, Winston-Salem, NC


The Advisory Committee on Immunization Practices (ACIP) and Infectious Diseases Society of America (IDSA) publish guidelines and recommendations to help practitioners manage vaccine administration. ACIP developed general guidelines based on age and preexisting conditions, while the IDSA’s guidelines address vaccination in patients with a variety of immunocompromised states. IDSA guidelines define the level of immunosuppression to determine appropriate categorization and vaccination of patients receiving chemotherapy, with sickle cell disease, and undergoing hematopoietic stem cell transplantation (HSCT).

One of the updates included in the ACIP and IDSA guidelines was the addition of the pneumococcal conjugate 13-valent vaccine (Prevnar 13®) to the adult vaccination schedule. Data from the Centers for Disease Control and Prevention (CDC) suggest that 50% of invasive pneumococcal disease cases among immunocompromised adults in 2010 were caused by serotypes contained in Prevnar 13® (PCV13) and pneumococcal polysaccharide23-valent vaccine (Pneumovax 23®), with an additional 21% caused by serotypes only contained in Pneumovax 23® (PPSV23).1 A study assessed pneumococcal vaccine–naïve patients who were administered either PPSV23 alone or 1 year after a dose of PCV13. This study found that patients who had PPSV23 administered 1 year after PCV13 had a statistically significant increase in immunogenicity compared with those who received a single dose of PPSV23 based on opsonophagocytic activity and geometric mean antibody titers.1 These results suggest that PCV13 augments the immune response to PPSV23. The authors felt this increase in immune response was due to the development of a memory response to the polysaccharide vaccine.

Oncology pharmacists frequently are asked when it is safe and effective to administer vaccinations in relation to chemotherapy. The IDSA guidelines recommend that inactivated vaccines be administered at least 2 weeks prior to chemotherapy and live vaccines be administered at least 4 weeks prior to chemotherapy.2 IDSA also recommends that vaccines administered during chemotherapy should not be considered valid doses unless there is documentation of appropriate antibody levels. Inactivated vaccines and live vaccines for varicella and measles, mumps, and rubella should be administered as indicated according to the CDC adult schedule starting 3 months after chemotherapy.2,3 Vaccinations should be postponed for 6 months after chemotherapy if regimens include B-cell targeted therapy.2

ACIP now recommends that adults 19 years of age or older who previously have received one or more doses of PPSV23 and have immunocompromising conditions, functional or anatomic asplenia, cerebrospinal fluid leaks, or cochlear implants should be given a PCV13 dose at least 1 year after the last PPSV23 dose was received.3 This recommendation also applies to patients with cancer, but ACIP does not address vaccination after HSCT. The IDSA guidelines include recommendations about vaccination of patients undergoing HSCT. The IDSA recommendations differ slightly from the guidelines published by the American Society for Blood and Marrow Transplantation (ASBMT). The ASBMT guidelines have not been updated since 2009; therefore, they include the pneumococcal conjugate 7-valent vaccine (PCV7) rather than the newer PCV13 vaccine. The ASBMT guidelines recommend administering a three- dose series of a pneumococcal conjugate vaccine with PCV7 prior to the administration of PPSV23 1 year after transplant. A fourth dose of PCV7 is recommended in patients with active graft-versus- host disease (GVHD) at the completion of the three-dose conjugate vaccine series rather than PPSV23.4 The IDSA currently recommends that patients receive three doses of PCV13 starting 3 months after HSCT. PPSV23 should be administered when the three PCV13 vaccine series is complete, unless patients have active GVHD. Patients with active GVHD should receive a fourth dose of PCV13.3The IDSA guidelines address frequently asked questions related to certain chemotherapy regimens, hematologic versus solid tumor malignancies, vaccination of close contacts of immunocompromised patients, and a variety of other topics relating to vaccination. The citations for the ACIP and IDSA guidelines have been included for reference and will hopefully aid you with appropriate and safe vaccination of your patients.2,3

References

1.  U.S. Food and Drug Administration. Vaccines and Related Biological Products Advistory Committee (VRBPAC) Adult Indication Briefing Document: Prevnar 13. Silver Spring, MD: US Department of Health and Human Services, Food and Drug Administration; 2011.

2. Rubin L, Levin M, Ljungman P, et al. 2013 IDSA Clinical practice guideline for vaccination of the immunocompromised host. ClinInfect Dis. 2014 Feb;58(3):e44-100.

3.  Advisory Committee on Immunization Practices. Recommended adult immunization schedule: United States, 2013. Ann Intern Med. 2013:158(3);191-199.

4. Tomblyn M, Chiller T, Einsele H, et al. Guidelines for preventing infectious complications among hematopoietic cell transplantation recipients: a global perspective. Biol Blood Marrow Transplant. 2009;15:1143-1238.

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