Posted by: Joe Sheffler
02 November 2010
The Advisory Committee on Immunization Practice (ACIP) met in Atlanta, GA, on October 27-28, 2010. Complete minutes of the meeting will be published on the CDC National Center for Immunization and Respiratory Diseases (NCIRD) website (www.cdc.gov/vaccines/recs/acip).
The first discussion was on meningococcal vaccine in patients with increased risk of disease, particularly patients with complement deficiency, HIV, or asplenia. Evidence was presented that the recommended one-dose schedule is inadequate to provide protection in these patients. A two-dose vaccination series, 2 months apart, was highly immunogenic. The committee voted and approved this schedule change.
Evidence also was presented that a single dose of meningococcal vaccine at 11 to 12 years of age did not provide adequate protection through college. Studies show the vaccine does not protect for more than 5 years. Cost-effectiveness data for vaccination of adolescents with the current recommendation of a single dose at age 11 to 12 years is the least cost-effective model; a single dose at age 15 years would prevent the greatest number of cases per dose given, and a dose at 11 years with a booster at 16 years would prevent the most number of cases. Since vaccination of adolescents began, the total number of cases in those 11 to 22 years of age during a 4-year period has decreased from 214 (2000-04) to 141 (2005-09) cases-a decrease of 34%. Vaccine effectiveness has been estimated at 78%. In summary, the low incidence of disease and low vaccination coverage have limited the power of these studies. The working group also recognized that this age group presents programmatic difficulties as a result of low number of provider visits and high vaccine cost. The committee, following a great deal of discussion and public comment, voted to keep the first dose at 11 to 12 years of age and to add a booster dose at age 16 or 5 years after the previous dose if they received the vaccine at an older age. Of note, the vote was close: 6 members were for and 5 were against the change.
Hepatitis B vaccine
Hepatitis B vaccination in high-risk adults was discussed. Vaccination coverage is improving but is still below desired levels. It was reported that 75% of health care workers have received only one dose of hepatitis B vaccine and 68% received all three doses. The ACIP working group on hepatitis B vaccination reviewed the incidence of hepatitis in people with diabetes (which is higher than the general population) and came to several conclusions: (1) infection control practices are not sufficient to prevent the disease, (2) seroprevalence of hepatitis B is increased in diabetes, and (3) vaccination is likely to substantially reduce the risk in people with diabetes. One area of concern is the practice of assisted monitoring of blood glucose (AMBG). The settings in which AMBG is performed include nursing homes, assisted-living facilities, hospitals, clinics, senior centers, health fairs, correctional facilities, schools, camps, and shelters. Risk of exposure increases at settings where shared-use monitors and lancet devices are used. Not changing gloves between patients also increases the risk. The working group will continue to discuss the issue surrounding hepatitis B and diabetes. Future discussions will include declining seroprotection and cost effectiveness in older patients, age criteria for vaccination, whether all patients with diabetes should be vaccinated or only certain identified groups, and if titers should be drawn following vaccination.
The incidence of pertussis is increasing. In addition, several outbreaks have occurred around the United States. The California Department of Health received reports of increase in pertussis cases in March 2010. The health department immediately began efforts to increase vaccination rates with tetanus-diphtheria-acellular pertussis (Tdap) vaccine. Intensive education efforts regarding diagnosis, treatment, recommendations for vaccination, and cocooning were put in place to meet their goal of protecting infants. Barriers started to arise concerning availability of Tdap, confusing guidelines about minimal intervals between tetanus-diphtheria (Td) and Tdap, licensing of Tdap for children aged 7 to 9 years, and emergency departments not following Tdap recommendations for wound management. Initially, free vaccine was offered to postpartum women and other infant contacts. In July, recommendations were expanded beyond ACIP recommendations to include women of childbearing age (including during pregnancy), all persons who have contact with infants, persons older than 64 years, underimmunized children aged 7 to 9 years, and wound management (which was an existing ACIP recommendation). The minimal interval between Td and Tdap was eliminated. From March to mid-October, a total of 6,978 cases and 10 infant deaths have been reported. The health department discovered during its investigations that a large pool of susceptible persons in need of vaccination exists. Although most of the young children were immunized, mandates for middle-school vaccination were implemented in September 2010. The investigation is continuing.
Read the entire article here.