A case-based approach to immunizations for young adults aged 18-26

Transcription

1 A case-based approach to immunizations for young adults aged Jessica Shannon Castonguay, DO, MPH Vaccinations are intended to decrease disease among an at-risk population. Though there is generally good uptake of childhood immunizations, as many as 1 in 10 children do not receive recommended vaccines. 1 SHUTTERSTOCK.COM 12 AOA Health Watch Outbreaks, Outcomes, Recommendations December 2014

2 Many factors may influence whether a young adult has a complete immunization record. First, immunization schedules are routinely updated as new vaccines are developed and new evidence is elucidated. Additionally, parents may have concerns about possible side effects and delay or refuse some vaccination. Likewise, teens are often healthy and do not present for annual well care, which decreases the chances that catchup immunizations can be given. Recent outbreaks of mumps, measles, and pertussis in the adolescent and young adult populations can be traced back to incomplete vaccination. Outbreaks often occur on college campuses or among military recruits. These settings, where new people come together and have close interaction, are primed for outbreaks among underimmunized young adults. This highlights the need for providers to monitor the immunization status of their 18- to 26-year-old patients at all visits. Providers likely to encounter this group include internists, family practitioners, student health providers, and adolescent medicine providers. The Centers for Disease Control and Prevention (CDC) Advisory Committee on Immunization Practices (ACIP) continually updates recommendations for vaccination of young adults aged 18 through 26 in the United States. Vaccine schedules are made based on expert opinion of groups such as the American Academy of Pediatrics, the American Academy of Family Physicians, and the American College of Obstetrics and Gynecology. Recommendations depend upon the age and sex of the patient, their medical and immunization history, and any risk factors based on their social and career choices. 2 Most recommendations for this age group are for college students, military recruits, and pregnant women. In fact, the American College Health Association has guidelines that mirror ACIP recommendations for college students. 3 There are also recommendations for individuals who work in certain careers, such as health care or corrections, where exposure and transmission of pathogens might be more common. Additionally, it is important to emphasize the need for vaccination among close contacts of immunocompromised persons who may be unable to receive immunization themselves. Case 1 A 20-year-old male with a history of asthma, well controlled on inhaled corticosteroids, presents to your walkin hours with acute onset of fever, muscle aches, pharyngitis, shortness of breath, and fatigue. It is holiday break and he was last seen in the summer before heading back to college. At that time, he was well, you refilled his asthma medications, and recommended that he get influenza vaccine in the fall, either at your office or at student health. Today, he tells you that he has never gotten the flu shot and did not think it was really needed. He is febrile, looks ill, and is wheezing on exam. Influenza is a respiratory virus that is spread in droplets when infected individuals talk, cough, or sneeze. It is believed that a person can be contagious up to 1 day before having symptoms and continues to shed active virus for up to 1 week. The severity of influenza varies from year to year and is dependent on the strain of influenza that is circulating, how closely the vaccine matches the current year s strain, and the availability and uptake of vaccination. 4 Influenza immunization is recommended for all people aged 6 months or older. For otherwise healthy individuals aged 18 years or older, there are a number of options, including inactivated influenza vaccine (traditional flu shot), recombinant influenza vaccine (brand FluBlok), and live attenuated influenza vaccine (nasal mist). 4 All persons aged 18 years or older, including those with hives-only reaction to eggs and pregnancy, may receive inactivated influenza vaccine. Those with egg allergy should be monitored in office for 30 minutes after vaccine administration. 4 For those with more severe egg allergy, including anaphylaxis, recombinant influenza vaccine is recommended because it contains no egg product. 4 Live attenuated influenza vaccine is not recommended for those with egg allergy, who are pregnant, immunocompromised, or currently wheezing. It may increase wheezing in those with asthma who are not currently wheezing. 4 A health care practitioner administers the quadrivalent live attenuated intranasal vaccine (LAIV). Using a small syringe, she delivers the vaccine mist into the patient s left nostril. Source: CDC. December 2014 Outbreaks, Outcomes, Recommendations AOA Health Watch 13

3 Infants and youth are routinely vaccinated against Streptococcus pneumoniae. Invasive pneumococcal disease is less likely after childhood and until the age of 65 years. Certain medical conditions such as asthma or behaviors such as smoking have been shown to increase the risk of invasive pneumococcal disease, such as bacteremia and meningitis. Two pneumococcal vaccines are available, PCV13 and PPSV23. 5 Administer PPSV23 to adults aged years with chronic medical conditions, including those who have asthma or are immunosuppressed. 5 Administer PPSV23 to adults aged years who smoke cigarettes. Smoking cessation should be discussed. 5 Do not routinely administer PPSV23 to Alaska Natives or American Indians aged <65 years unless they have medical indications described above. 5 Administer a booster dose of PPSV23 5 years after the first dose for persons aged years with functional or anatomic asplenia and for persons with immunocompromising conditions. 5 Case 2 A 25-year-old female presents with a chief complaint of vomiting. This started 4 weeks ago with a runny nose and mild cough-associated subjective fever. Over the last 2 weeks, the cough has gotten worse, leading to post-tussive emesis. Aside from the coughing and vomiting, she feels well, but cannot go to work at a local fast food restaurant like this. She is requesting something for this cough. She is afebrile. You do witness a paroxysm of coughing that ends with significant gagging and a small emesis. Upon review of her chart, you note that when she was 11, she received a tetanus-diptheria (Td) booster. Typically, children receive a primary series for tetanus, pertussis, and diphtheria (DTaP) by age 1 and boosters at kindergarten (DTaP) and ages (tetanus, diphtheria, and pertussis; Tdap). Subsequently, a Td is recommended every 10 years thereafter. If an individual is 11 years or older and has not received Tdap, this should and can be administered regardless of the date of the most recent Td vaccination. 6 Those with past immunization may still have symptoms of pertussis; however, the course is generally shorter and less severe. The main concern is preserving herd immunity to prevent infection of young children, especially those younger than 1 year. Complications of pertussis are serious and include pneumonia, seizure, apnea, and death. 6 Those ages years who have never been vaccinated If you are this age, 2014 Recommended Immunizations for Adults by Age Talk to your healthcare professional about these vaccines: years years years years years 65+ years Influenza (Flu) 1 Get a flu vaccine every year Tetanus, diphtheria, pertussis (Td/Tdap) 2 Varicella (Chickenpox) 3 Get a Tdap vaccine once, then a Td booster vaccine every 10 years 2 doses HPV Vaccine for Women 3,4 3 doses HPV Vaccine for Men 3,4 3 doses 3 doses Zoster (Shingles) 5 1 dose Measles, mumps, rubella (MMR) 3 1 or 2 doses Pneumococcal (PCV13) 7 1 dose Pneumococcal (PPSV23) 7 1 or 2 doses 1 dose Meningococcal Hepatitis A 3 Hepatitis B 3 Haemophilus influenzae type b (Hib) 1 or more doses 2 doses 3 doses 1 or 3 doses Boxes this color show that the vaccine is recommended for all adults who have not been vaccinated, unless your healthcare professional tells you that you cannot safely receive the vaccine or that you do not need it. Boxes this color show when the vaccine is recommended for adults with certain risks related to their health, job or lifestyle that put them at higher risk for serious diseases. Talk to your healthcare professional to see if you are at higher risk. No recommendation FOOTNOTES: 1. Influenza vaccine: There are several flu vaccines available talk to your healthcare professional about which flu vaccine is right for you. 2. Td/Tdap vaccine: Pregnant women are recommended to get Tdap vaccine with each pregnancy in the third trimester to increase protection for infants who are too young for vaccination, but at highest risk for severe illness and death from pertussis (whooping cough). People who have not had Tdap vaccine since age 11 should get a dose of Tdap followed by Td booster doses every 10 years. 3. Varicella, HPV, MMR, Hepatitis A, Hepatitis B vaccine: These vaccines are needed for adults who didn t get these vaccines when they were children. 4. HPV vaccine: There are two HPV vaccines, but only one, HPV (Gardasil ), should be given to men. Gay men or men who have sex with men who are 22 through 26 years old should get HPV vaccine if they haven t already started or completed the series. 5. Zoster vaccine: You should get the zoster vaccine even if you ve had shingles before. 6. MMR vaccine: If you were born in 1957 or after, and don t have a record of being vaccinated or having had these infections, talk to your healthcare professional about how many doses you may need. 7. Pneumococcal vaccine: There are two different types of pneumococcal vaccines: PCV13 and PPSV23. Talk with your healthcare professional to find out if one or both pneumococcal vaccines are recommended for you. 14 AOA Health Watch Outbreaks, Outcomes, Recommendations December 2014

4 should receive the 3-dose primary series, which should include at least 1 Tdap. 6 Adults with unknown or incomplete records should be vaccinated according to the catch-up schedule for Tdap. This should include at least 1 Tdap vaccination. 6 All women who are pregnant should receive Tdap during their pregnancy, usually between 27 and 36 weeks. This is thought to boost antibody production, which then may be passed to the infant through the placenta and during breastfeeding. 6 Individuals should continue to be immunized with Td every 10 years. 6 Case 3 A 21-year-old female presents to your office for her initial cervical cancer screening. She has been sexually active since the age of 16. She has had 3 Catch-up HPV immunizations are recommended for females up to age 26 and males up to age 21. previous male partners with whom she has used condoms intermittently. She has been with her current partner for more than 1 year and they no longer use condoms. She has been screened annually for sexually transmitted infections (STIs) and has been negative. She uses combined oral contraceptives for birth control. On external exam, you note several flesh-colored, raised, verrucous lesions surrounding the vaginal opening. Human papillomavirus (HPV) is the most common STI in the United States. This family of viruses causes cervical cancer, some cancers of the vulva, vagina, and anus, oropharyngeal cancers, and genital warts. There are 2 HPV vaccines available: a bivalent for strains 16 and 18 (HPV2) and a quadrivalent for strains 6, 11, 16, and 18 (HPV4). Human papillomavirus type 2 (HPV2) is only recommended for use in women because it offers protection for the 2 most common strains causing cervical cancer. Human papilloma virus type 4 (HPV4), however, also includes coverage for strains responsible for most genital warts and is recommended for both males and females. 7 HPV4 is also indicated for the prevention of anal cancer in both men and women. It is recommended that this 3-shot series be administered at ages Unfortunately, there is sometimes Talk to your healthcare professional about these vaccines: Influenza (Flu) 1 Tetanus, diphtheria, pertussis (Td/Tdap) 2 Pregnancy 1 dose Tdap each pregnancy Weakened immune system (not human immunodeficiency virus [HIV]) HIV Infection CD4 count is less than 200 CD4 count is 200 or greater Kidney disease or poor kidney function Asplenia (if you do not have a spleen or it does not work well) Get a flu vaccine every year Heart disease, chronic lung disease, chronic alcoholism Get Tdap vaccine once, then a Td booster every 10 years Varicella (Chickenpox) 3 SHOULD NOT GET VACCINE 2 doses HPV Vaccine for Women 3, Recommended Immunizations for Adults by Medical Condition If you have this health condition, 3 doses through age 26 years HPV Vaccine for Men 3,4 3 doses through age 26 years 3 doses through age 21 years Zoster (Shingles) 5 SHOULD NOT GET VACCINE 1 dose for those 60 years and older Measles, mumps, rubella (MMR) 3,6 SHOULD NOT GET VACCINE 1 or 2 doses Diabetes (Type 1 and Type 2) Pneumococcal (PCV13) 7 1 dose 1 dose Pneumococcal (PPSV23) 7 1 or 2 doses 1 or 2 doses Meningococcal 1 or more doses 1 or more doses 1 or more doses Chronic Liver Disease Hepatitis A 3 2 doses 2 doses Hepatitis B 3 3 doses 3 doses 3 doses 3 doses Haemophilus influenzae type b (Hib) post-hsct recipients only 1 or 3 doses 1 or 3 doses Boxes this color show that Boxes this color show when Boxes this color indicate the the vaccine is recommended the vaccine is recommended adult should NOT get this No recommendation for all adults who have not for adults with certain risks vaccine. been vaccinated, unless your related to their health, job healthcare professional tells or lifestyle that put them at you that you cannot safely higher risk for serious diseases. receive the vaccine or that you Talk to your healthcare do not need it. professional to see if you are at higher risk. FOOTNOTES: 1. Influenza vaccine: There are several flu vaccines available talk to your healthcare professional about which flu vaccine is right for you. 2. Td/Tdap vaccine: Pregnant women are recommended to get Tdap vaccine with each pregnancy in the third trimester to increase protection for infants who are too young for vaccination but at highest risk for severe illness and death from pertussis (whooping cough). People who have not had Tdap vaccine since age 11 should get a dose of Tdap followed by Td booster doses every 10 years. 3. Varicella, HPV, MMR, Hepatitis A, Hepatitis B vaccine: These vaccines are needed for adults who didn t get these vaccines when they were children. 4. HPV vaccine: There are two HPV vaccines, but only one, HPV (Gardasil ), should be given to men. Gay men or men who have sex with men who are 22 through 26 years old should get HPV vaccine if they haven t already started or completed the series. 5. Zoster vaccine: You should get the zoster vaccine even if you ve had shingles before. 6. MMR vaccine: If you were born in 1957 or after, and don t have a record of being vaccinated or having had these infections, talk to your healthcare professional about how many doses you may need. 7. Pneumococcal vaccine: There are two different types of pneumococcal vaccines: PCV13 and PPSV23. Talk with your healthcare professional to find out if one or both pneumococcal vaccines are recommended for you. December 2014 Outbreaks, Outcomes, Recommendations AOA Health Watch 15

5 SHUTTERSTOCK.COM resistance for this vaccine because it is transmitted through sexual activity. This resistance, from guardians and providers alike, is related to the sensitive nature by which this virus is contracted. The result of this is that the opportunity for prevention of HPVrelated disease may have been withheld from many 18- to 26-year-olds. 7 In females aged who have not received vaccination, HPV2 or HPV4 is recommended as a 3-shot series. 7 In males aged who have not received vaccination, HPV4 is recommended as a 3-shot series. 7 In males aged who have sex with men, HPV4 is recommended. 7 Individuals who may have incomplete immunization to HPV should complete their series. 7 In immunocompromised individuals aged 18-26, complete immunization is recommended. 7 Pregnant women should not be vaccinated against HPV. If a pregnancy is present, completion of the HPV series should be delayed until the postpartum period. 7 Case 4 An 18-year-old male soccer player presents to urgent care with acute onset of headache, photophobia, and nausea. He denies a history of migraine. He lives in the freshman dormitories with a teammate. He is febrile, in some distress, and cannot touch his chin to his chest. This case is suspicious for bacterial meningitis, and in this age group, the likely pathogen is Neisseria meningitidis. The majority of disease is caused by serogroups B, C, and Y in the United States with a smaller portion accounted for by group W. Serogroup A is more common in developing countries. 8 Although bacterial meningitis is less common than other types of meningitis, the morbidity and mortality associated with it can be devastating. According to the CDC, up to 15% of cases are fatal. Of those that recover from meningococcal disease, nearly 20% have serious complications, such as loss of mental capacity, permanent hearing loss, or amputation of digits or limbs. 8 Transmission is through direct contact with respiratory secretions, rather than through respiratory droplets such as influenza. Groups at risk are those that live in close quarters, such as military recruits or college freshman living in dormitories, those that have close personal contact, such as kissing, or those that share food and drink. Patients with asplenia or some complement deficiencies are also at higher risk of infection. 8 There are 2 types of meningococcal vaccines: the quadrivalent meningococcal conjugate vaccine (MenACWY) and the meningococcal polysaccharide vaccine 4 (MPSV4). MenACWY (brand Menactra and Menveo) is recommended for individuals under the age of Individuals entering college, living in the dormitory, and aged should receive a dose of MenACWY if they did not 16 AOA Health Watch Outbreaks, Outcomes, Recommendations December 2014

6 have one after the age of Military recruits aged should receive a 1-time dose of MenACWY. 8 Young adults with anatomic or functional asplenia or complement deficiency should receive a 2-dose primary series of MenACWY. They should receive a booster every 5 years. 8 Microbiologists aged exposed to N. meningitidis through their research should receive a 1-time dose of MenACWY. They should receive a booster every 5 years with continued exposure. 8 Case 5 A 22-year-old female elementary education major presents to the student health center with an itchy rash. She has been doing her student teaching in a local third-grade classroom. Two days ago, she felt run down, and then yesterday she noted itchy bumps on her face and neck. Today when she woke, the lesions on her head looked like there was water inside of them and there were more bumps appearing on her back and abdomen. On exam, she is febrile and has crops of lesions. The vesicles are atop an erythematous base. Review of her chart shows that she received 1 dose of varicella vaccine at age 12 months. Chickenpox is caused by the varicella zoster virus. It is usually a selflimited infection. The most common complication is secondary infection of excoriated lesions with Staphylococcus or Streptococcus species. This can Meningococcemia with purpura rash. Source: CDC. In general, young people do not routinely see their primary care provider, so it may be several years between preventive health care visits. If an individual presents for a visit, the importance of reviewing their immunization record cannot be overstated. lead to further complications, such as sepsis. Pulmonary complications include viral or bacterial pneumonia. Infected individuals may progress to varicella encephalitis or aseptic meningitis. Postherpetic neuralgia is a complication of zoster, which may last more than 1 year after the episode. 9 There are several groups at high risk for developing severe complications or for transmission of the virus. Family members and those spending significant time with immunocompromised individuals should be immunized to reduce the chance of transmitting varicella. Careers including health care, teaching, child care, and corrections are at high risk for exposure and transmission of varicella, and immunization should be recommended. Other groups that warrant strong recommendation for varicella vaccination include adults and adolescents who live with children under the age of 6, those that live with nonimmune pregnant women, college students, and military recruits. 9 It is recommended that children are vaccinated against varicella at ages months and again at 4-6 years. This can be accomplished with varicella vaccine or with a combination measles, mumps, and rubella (MMR)-varicella product. Individuals aged years are considered immune to varicella if there is documentation of varicella vaccine given at appropriate intervals, if there is history of varicella disease, or if varicella titers are positive. 9 In individuals without evidence of varicella immunity, a 2-dose primary series is recommended. 9 In individuals with incomplete varicella immunization, a single booster dose should be given. 9 For those with close contacts who are high risk for severe complication, immunization should be recommended and emphasized. 9 Women who are pregnant and do not have evidence of immunity should receive varicella vaccination at termination or completion of the pregnancy before leaving the health care facility. The second dose should be given 1-2 months later. 9 Case 6 A 19-year-old male presents with headache, body aches, fatigue, and decreased appetite for a few days. His roommate thought his left cheek looked puffy, but he thought that he just slept on it funny. He states that he comes in today because his testicles are very sore. On exam, he is febrile and his parotid glands are enlarged and tender as is his left testicle. In the United States, mumps is part of a multipathogen vaccine December 2014 Outbreaks, Outcomes, Recommendations AOA Health Watch 17

7 Mumps with swelling mostly above jaw. Source: CDC. including measles and rubella (MMR). Measles, mumps, rubella, and varicella, as discussed above, is another option. The primary 2-shot series is administered at ages months and again at ages 4-6 years. 10 Measles, or rubeola, is a respiratory illness that causes cough, coryza, and conjunctivitis. Individuals aged 20 or older are at increased risk of complication from this illness, including pneumonia, encephalitis, and death. As of August 2014, there were 592 confirmed cases in the United States across 21 states. The closest year in recent history was 2011, when there were 118 cases. The majority of these cases come from unimmunized individuals who travel to endemic countries or have contact with an individual who carries the virus to the United States with them. 10,11 Mumps is often a mild infection; however, complications are more common in those that have reached puberty. Complications can occur with or without parotitis and include orchitis, oophoritis, encephalitis, and deafness. Outbreaks usually occur where individuals are crowded, such as dormitories and classrooms, or where they share food and equipment, such as sports teams. In 2014, 4 US universities have reported outbreaks of mumps. It is believed that the outbreaks occur because vaccination with the 2-shot series is only 88% effective; this drops to 78% if only 1 shot was given. This is not to say that mumps immunization is not worthwhile; herd immunization helps decrease the size and duration of these outbreaks. 10,12 Rubella, or German measles, is usually a mild infection with rash and fever. When women who are nonimmune become pregnant, their fetus is at risk for birth defects should they become infected. Congenital defects could include cataracts, hearing impairment, mental retardation, cardiac defects, and liver and spleen damage. 10 There may be increased risk of exposure or transmission of measles, mumps, or rubella among certain groups. Those who are in close contact with immunocompromised individuals should receive special To provide the best preventive health to patients, it is imperative that immunizations are updated at every office visit. consideration for vaccination. Students attending colleges or other post high school educational institutions, health care personnel, and international travelers should receive 2 doses of MMR vaccine. 10 Any person currently aged years is considered nonimmune unless there is documented administration of at least 1 MMR vaccine or immunity to each component of the vaccine. Medical records supporting previous infection with measles, mumps, or rubella are not sufficient to assume immunity. 10 For college students, those who work in health care facilities, or those who will travel out of the country, routine immunization is recommended. This should include 2 doses of MMR spaced at least 28 days apart. 10 For all women, rubella immunity should be determined. If rubella nonimmune and not pregnant, MMR vaccination should be administered. If rubella nonimmune and pregnant, MMR vaccination should be administered after termination or completion of the pregnancy and before discharge from the health care facility. 10 Despite the appearance of good health, many young adults do not have complete immunity from vaccinepreventable disease. In general, young people do not routinely see their 18 AOA Health Watch Outbreaks, Outcomes, Recommendations December 2014

8 Despite the appearance of good health, many young adults do not have complete immunity from vaccine-preventable disease. primary care provider, so it may be several years between preventive health care visits. If an individual presents for a problem visit, the importance of reviewing their immunization record cannot be overstated. To provide the best preventive health to patients, it is imperative that immunizations are updated at every office visit. The personal and public health benefit would be pronounced. More information about young adult immunizations is available from the Immunization Action Coalition and from the CDC. References 1. Centers for Disease Control and Prevention. National Immunization Survey, html. Accessed October 8, Centers for Disease Control and Prevention. General recommendations on immunization: recommendations of the Advisory Committee on Immunization Practices (ACIP) MMWR Morb Mortal Wkly Rep. 2011;60(2):3-4,14, American College Health Association Vaccine Preventable Diseases Advisory Committee. Recommendations for institutional prematriculation immunizations. acha.org/publications/docs/acha_ripi_ April_2014.pdf. Accessed September 3, Centers for Disease Control and Prevention. Prevention and control of seasonal influenza with vaccines: Recommendations of the Advisory Committee on Immunization Practices (ACIP)-United States, influenza season MMWR Morb Mortal Wkly Rep. 2014;63(32): Centers for Disease Control and Prevention. Updated recommendations for prevention of invasive pneumococcal disease among adults using the 23-valent pneumococcal polysaccharide vaccine (PPSV23) MMWR Morb Mortal Wkly Rep. 2010;59(34): Centers for Disease Control and Prevention. Updated recommendations for use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis (Tdap) vaccine from the Advisory Committee on Immunization Practices (ACIP) MMWR Morb Mortal Wkly Rep. 2011;60(1): Centers for Disease Control and Prevention. Human papillomavirus vaccination: recommendations of the Advisory Committee on Immunization Practices (ACIP) MMWR Morb Mortal Wkly Rep. 2014;63(5): Centers for Disease Control and Prevention. Prevention and control of meningococcal disease: recommendations of the Advisory Committee on Immunization Practices (ACIP) MMWR Morb Mortal Wkly Rep. 2011;62(2):7-10, Centers for Disease Control and Prevention. Prevention of varicella: recommendations of the Advisory Committee on Immunization Practices (ACIP) MMWR Morb Mortal Wkly Rep. 2007;56(RR4):2-7, 9-13, Centers for Disease Control and Prevention. Prevention of measles, rubella, congenital rubella syndrome, and mumps, 2013: summary recommendations of the Advisory Committee on Immunization Practices (ACIP) MMWR Morb Mortal Wkly Rep. 2013;62(4) p 2-7, Centers for Disease Control and Prevention. Measles cases and outbreaks. html. Accessed September 28, Centers for Disease Control and Prevention. Mumps cases and outbreaks. gov/mumps/outbreaks.html#outbreaks Accessed September 28, Varicella with different stages of crops of rash. Source: CDC. Jessica Shannon Castonguay, DO, MPH, is a practicing physician at the Adolescent Health Center at Akron Children s Hospital and clinical assistant professor in the Department of Pediatrics at the Northeast Ohio Medical University. Dr Castonguay can be reached at JCastonguay@chmca.org. December 2014 Outbreaks, Outcomes, Recommendations AOA Health Watch 19