ACIP Recommends HepA Vaccine for Homeless Patients

During the Oct. 24-25 meeting(www.cdc.gov) of the CDC's Advisory Committee on Immunization Practices (ACIP), the group voted to add a new policy recommending that everyone ages 1 and older who is experiencing homelessness routinely be immunized against hepatitis A (HepA).

Other topics included how the use of 13-valent pneumococcal conjugate vaccine (PCV13; Prevnar 13) in children is likely providing adequate coverage and successfully reducing invasive pneumococcal disease (IPD) incidence overall, including in older adults, AAFP liaison to the ACIP Pamela Rockwell, D.O., of Ann Arbor, Mich., told AAFP News.

Hepatitis A

The hepatitis A vaccine work group explained in a presentation at the meeting that since 2016, HepA outbreaks have occurred in 11 states with more than 7,500 cases, about 4,400 hospitalizations and 74 deaths.

Homelessness was found to be independently associated with two to three times higher odds of infection with HepA and two to three times higher chance of severe outcomes such as hospitalization or death, Rockwell said.

So, the ACIP voted unanimously to recommend adding homeless individuals to the list of those who are at increased risk of HepA infection or severe HepA disease. That list now includes

• travelers,
  
• men who have sex with men,
  
• users of injection and non-injection drugs,
  
• people with clotting-factor disorders,
  
• people who work with nonhuman primates,
  
• people who anticipate close personal contact with an international adoptee,
  
• people with chronic liver disease and
  
• homeless individuals.

In addition, the ACIP voted to adopt Vaccine for Children program resolution updates to correct and streamline language related to the HepA catch-up vaccination recommendation voted on at the February ACIP meeting.

Pneumococcal Disease

First off, the pneumococcal vaccine work group offered a four-year review of the 2014 ACIP recommendation to give PCV13 in series with the 23-valent pneumococcal polysaccharide vaccine (PPSV23; Pneumovax 23) for adults ages 65 and older.

As background, Rockwell said overall IPD incidence was drastically lower in 2016-2017 after PCV13 was recommended for use in children in 2010, which appeared to have had sustained indirect effects.

"It appears that maybe giving it to the kids has had enough of an indirect effect to protect older adults that we may not have to continue to give PCV13 to them," she said.

So now at either the February or June 2019 ACIP meeting, the group plans to vote on whether to continue giving the PCV13 vaccine to older adults, Rockwell said. This will be based on further study of the benefits, risks, values, acceptability, resource use and feasibility of PCV13.

"If the recommendation for PCV13 use in older adults is recanted, I think that shows how well the ACIP works, that it continually looks at the evidence to maximize resources and do the right thing for public health," she said.

Redesigned Immunization Schedules

Rockwell said the ACIP is cleaning up both the adult and childhood immunization schedules.

The group did a needs assessment using qualitative interviews, asking physicians and other health care professionals what they liked and disliked about the schedules and how they used them in their practices. The ACIP used those notes to make improvements that will be incorporated in the 2019 immunization schedules.

"The goal was to improve usability of the schedules," Rockwell said. "For example, they increased the font size, as the footnotes were so tiny that people couldn't read them."

Footnotes are now called "notes," which the ACIP emphasized family physicians should read so they don't make mistakes in recommending vaccines, Rockwell said.

Additionally, for better readability, there are fewer vaccines and health conditions per table.

For both schedules, the ACIP updated the influenza vaccine notes to include use of live attenuated influenza vaccine (LAIV; FluMist).

For the childhood schedule, the ACIP updated the content within the vaccine notes for HepA; hepatitis B (HepB); polio (IPV); measles, mumps and rubella (MMR); meningococcal; and tetanus, diphtheria and acellular pertussis (Tdap).

For the adult schedule, the group decided to make indications clearer by reducing the number of colors used, Rockwell said.

The ACIP also updated the HepA section with the addition of homelessness as an indication for people at risk for HepA infection. The HepB section was updated as well to include use of the CpG-adjuvanted HepB vaccine.

And transgender patients were added to the list of people who are at increased risk for HPV and should get the HPV vaccine through age 26.

General Best Practices Guidelines

The ACIP's General Recommendations have been renamed General Best Practice Guidelines for Immunization(www.cdc.gov) and will no longer exist in a static CDC Morbidity and Mortality Weekly Report.

Now, this resource is accessible online and regularly updated, Rockwell said. Also, CME credit can be obtained for visiting the website every two years.

"It goes over everything from proper vaccine technique to precautions to contraindications, etc.," she said. "It's turning into a great document that's been cleaned up -- a great resource."

Rockwell, who participates in the General Best Practices work group, said recent updates included one based on a question from a physician who said they knew they couldn't give certain vaccines to patients who are immunocompromised, but wanted to know what to do if the vaccine administrator is immunocompromised.

The General Best Practices Guidelines advises that based on current available evidence, vaccine administrators who have conditions that would preclude a patient from receiving a vaccine would not be precluded from administrating the vaccine in question.

"As more and more questions come up regarding best practices, I think they will be addressed in this document," Rockwell said. "We spent a lot of time trying to clarify recommendations, making them all sound similar as they pertain to individual vaccines, so physicians don't have to reinterpret the language used every time they investigate different vaccine recommendations."

Additional Notes

The ACIP's October meeting also included results from the CDC PREVENT study that concluded influenza vaccines have the potential to prevent 40 percent of influenza-associated hospitalizations during pregnancy. Rockwell said this likely is a conservative estimate.

The pertussis work group is considering evidence for a recommendation to allow any tetanus and diphtheria toxoid-containing vaccine (Tdap or Td) to be used for

• decennial Td booster in adults and
  
• tetanus prophylaxis as needed for wound management.

Rockwell said she recently received the Tdap vaccine as her decennial Td booster and was glad she did because in one day last month, she diagnosed pertussis in a woman in her mid-20s and later saw two children younger than age two months who hadn't yet received any of their recommended childhood vaccines, including for pertussis.

In addition, a new rabies vaccine work group started meeting in October with plans to present at one of next year's meetings on the rabies vaccine's effectiveness and cost.

Upcoming Meetings

Finally, Rockwell said business at upcoming ACIP meetings in 2019 could include a possible vote at the February meeting on expanded indication for the nine-valent HPV vaccine (HPV9; Gardasil 9) to age 45, which was approved by the FDA on Oct. 6.

"Evidence shows that the uptick of the HPV vaccine is not limited by age," she said. "If you are young or old, you will still respond to the vaccine very well.

"However, the older you get, the risk of you being exposed to one or more HPV strains increases, and that's what lowers the vaccine uptake as you get older."

If the ACIP recommends HPV vaccine up to age 45, then insurance companies will cover the cost as long as the Affordable Care Act is in effect, Rockwell said.

The CDC's current recommendation for HPV9 is a two-dose schedule for patients ages 11-12, but dosing can begin as early as age 9. The second dose should be administered six to 12 months after the first dose, with a minimum interval of five months.

Routine vaccination for previously unvaccinated females through age 26 and for previously unvaccinated males through age 21 is recommended, Rockwell said. Routine vaccination for males with high-risk conditions or who wish to be vaccinated between ages 22-26 also is recommended. For patients ages 15-26 initiating the HPV9 vaccine series, the recommended immunization schedule is three doses given at zero, one to two, and six months.

Furthermore, patients in this older age range who initiated the series before age 15 with one or two doses but did not complete the series require only one additional dose for adequate immunization.

"Personally, in my practice, I've had divorced women older than age 26 who now know they are going to go out into the dating world and they have asked for the HPV vaccine, knowing they have to pay out of pocket," Rockwell said, noting again that insurance could cover the vaccine for an expanded population with an ACIP recommendation.

The meningococcal work group will present the latest data and a Grading of Recommendations, Assessment, Development and Evaluation report at the February 2019 meeting on booster doses of the meningococcal B vaccine for patients ages 10 and older who are at increased risk.

The Japanese encephalitis (JE) work group plans to present a final vote at the February meeting on whether the Japanese encephalitis chimeric virus vaccine should be recommended for patients ages 2 months or older who are at risk for travel-related exposure to the JE virus.

Related AAFP News Coverage
CDC Releases Guidance for 2018-19 Influenza Season
AAFP Gives Preferential Recommendation for IIV
(9/6/2018)

ACIP Reaffirms LAIV Recommendation for 2018-19 Flu Season
Group Creates Guidelines for Anthrax Vaccine Use
(6/27/2018)

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