Current Adult and Pediatric Vaccine Recommendation-->可可转移

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Current Adult and Pediatric Vaccine Recommendations

David Phelan, MD, Robert M. Jacobson, MD, Gregory A. Poland, MD, Mayo Clinic

Foundation, Rochester, Minn



[Infect Med 18(8s):FV6-FV14, 2001. © 2001 Cliggott Publishing Co., Division of SCP/Cliggott Communications, Inc.]





Abstract and Introduction



Abstract

Vaccinations are the most cost-effective and efficacious tool for preventing infectious diseases. It is estimated that more than 40,000 lives would be saved each year in the United States if routine vaccines against pneumococcal infection, influenza, and hepatitis B were fully utilized. In addition to standard indications for immunization, adults, children, and adolescents may require vaccination based on occupation, disease, lifestyle, or health condition. Barriers to higher rates of vaccine coverage include missed opportunities to vaccinate during contact with health care providers, fears concerning adverse events, insufficient tracking and information systems, and lack of awareness of the seriousness of certain vaccine-preventable diseases.



Introduction



Each year in the United States, approximately 50,000 adults die of

influenza, pneumococcal infections, and hepatitis B, and 500 children die of vaccine-preventable diseases. This occurs despite the fact that vaccines are a safe, effective, and cost-saving means of disease prevention. It is estimated that more than 40,000 lives would be saved each year if vaccines against these diseases were fully utilized. The current antivaccine sentiments in Western countries have adversely affected immunization coverage rates and require physicians to be well informed about the risks and benefits of vaccines. In this article, we review the status of vaccines that are -- or should be -- administered as part of routine pediatric and

adult health care, including their indications, contraindications, adverse

effects, and any anticipated changes in their formulation or administration.



<snip>

Hepatitis A



Two vaccine preparations, Havrix and VAQTA, are currently licensed in the United States. Both are formalin-inactivated preparations, adsorbed to an aluminum adjuvant and given intramuscularly as a 2-dose series (Table 4).



Immunogenicity of both vaccines in healthy children, adolescents, and adults is excellent, with 52% to 64% of adults protected by 2 weeks and 94% to 100% of adults achieving protection by 1 month. Two large clinical trials in children have shown essentially 100% protection.[8] Protection lasts longer than 5 years and is estimated to last as long as 20 years or more.[8,9] Reduced rates of seroprotection have been seen in patients of all ages with renal transplants, HIV infection, or chronic liver disease. Reduced immunogenicity has not been shown when hepatitis A vaccine is administered with other vaccines, although vaccine-induced antibody titers are lower when administration is concomitant with large doses of immune globulin.



Hepatitis A vaccine is safe and well tolerated. Local reactions have been reported, including soreness at the injection site (56% of patients), headache (14%), and malaise (7%). From 1995 through 1998, more than 8.8 million doses were administered in the United States and 247 adverse events were reported, including (without regard to causality) neurologic, hematologic, and autoimmune syndromes.[9]



Contraindications to immunization include a history of a severe reaction to a prior dose of hepatitis A vaccine or to a vaccine component. Immunization is not necessary in those with preexisting hepatitis A virus antibodies. In the future, hepatitis A vaccine is highly likely to be combined with hepatitis B vaccine as a combined pediatric preparation.





Hepatitis B



Since hepatitis B vaccine became available in 1982, a significant reduction in the incidence of hepatitis B -- 90% to 95% in some populations -- has been noted. Two hepatitis B vaccines are available now, Recombivax HB and Engerix-B (Table 4). Both are formulated from recombinant hepatitis B virus surface antigen (HBsAg), purified, adsorbed on aluminum adjuvant, and preserved with thimerosal (pediatric formulations contain no thimerosal).[10] Following 3 intramuscular doses, protective titers develop in more than 95%

of children, adolescents, and adults up to age 20 years; in 86% of

40-year-olds; and in 47% of persons older than 60 years. Immunogenicity is reduced when vaccine is injected into the gluteus muscle and in smokers, obese persons, immunocompromised persons, and those who have certain HLA types. It is not reduced, however, when the vaccine is given with hepatitis B immune globulin (at different sites) or other concomitant immunizations.[11,12]



Infants born to HBsAg-positive mothers should receive the vaccine, along with 0.5 mL of hepatitis B immune globulin (HBIG), within 12 hours of birth at separate anatomic sites. The second dose is recommended at 1 to 2 months of age (not at 1 to 4 months) and the third dose is to be given at 6 months (not between 6 and 18 months). Infants whose mothers' HBsAg status is unknown should receive vaccine within 12 hours of birth. Maternal blood drawn at delivery will determine the mother's HBsAg status; if the test is positive, the infant should receive HBIG as soon as possible, but no later than at 1 week of age.



Recombinant hepatitis B vaccines are safe and well tolerated. Mild,

self-limited, and transient injection-site reactions occur in up to 29% of

recipients. Fever (temperature higher than 37.7°C [99.9°F]) occurs in 1% to 6% of recipients. Anaphylaxis is rare. No association has been documented between hepatitis B immunization and GBS or other demyelinating syndromes.[13,14] The only contraindication to immunization is a known hypersensitivity to yeast or another vaccine component.[15]



As previously noted, a combination product with hepatitis A vaccine is

highly likely to emerge for use in children. Further combinations involving hepatitis B vaccine are anticipated. Currently, an Hib-hepatitis B combination vaccine is licensed for use in the United States.[6,16,17] Prelicensure testing is under way for a hepatitis A-hepatitis B vaccine and a hexavalent vaccine containing DTaP, hepatitis B vaccine, and Hib vaccine.



<snip>

Immunization Coverage Strategies



It is important that physicians develop effective strategies to ensure that their patients receive indicated immunizations. Physicians' and nurses' attitudes and practices with regard to vaccination greatly influence the actions of their patients. Strategies with proven efficacy in increasing immunization rates include practice-based tracking systems and physician reminder systems. Practice-based tracking systems involve identifying the total number of patients who are at risk and maintaining rosters showing the proportion vaccinated. Physician reminder systems consisting of charts, computerized

lists, or preventive-health checklists may be used to review the need for vaccination and maintain a record of vaccinations. Staff in physicians' offices can be instructed to identify and label medical records of all patients who should receive vaccination.



Ideally, standing-order policies can be implemented whereby the office nurse can identify and immunize those patients needing vaccines as well as at-risk patients who need additional vaccines or who have fallen behind in receiving indicated vaccines.



<snip>



Table 4. Recommendations for hepatitis A and B immunization

      Vaccine Indication Vaccine name and schedule Dose and route

      Usual Interrupted

      Recommendations in children

      Hepatitis A Indicated only in at-risk children older than 2 y Havrix:

0, 6 - 12 mo apart; VAQTA: 0, 6 mo apart At any visit,  6 mo between 1st and 2nd dose 0.5 mL, IM       Hepatitis B Routinely indicated Recombivax HB/Engerix-B: 0 - 2 mo, 1 -  4 mo, and 6 - 18 mo Begin at any visit if not previously vaccinated, 0, 1, 6 mo; 0, 2, and 4 mo Volumes vary depending on brand, age, and indication; IM       Recommendations for adults       Hepatitis A* a.. Travel outside the United States (except northern and western Europe, New Zealand, Australia, Canada, Japan)

      a.. Men who have sex with men

      a.. Injection drug users

      a.. Clotting factor disorders

      a.. Chronic liver disease

      a.. Occupational risk

     Havrix: 0, 6 -12 mo apart; VAQTA: 0, 6 mo apart; travel:  4 wk before leaving or coadminister with immune globulin (0.02 mL/kg) At any visit,  6 mo between 1st and 2nd dose Havrix: 1440 ELISA units/1 mL; VAQTA: 50 units/1 mL; both given IM

      Hepatitis B* a.. Multiple sexual partners

      a.. Household/sexual contact with carrier

      a.. Injection drug users

      a.. Men who have sex with men

      a.. Occupational exposure to blood or body fluids

      a.. Hemodialysis

      a.. Blood product recipients

      a.. Prison inmates

      a.. International travelers to regions where hepatitis B is endemic

      a.. Residents and staff of institutions for developmentally disabled

     Recombivax HB /Engerix-B: adults (20 y or older), 0, 1 - 2, and 4 - 6

mo; immuno-compromised, 0, 1, and 6 mo 1 mo between 1st and 2nd dose; optimally 5 mo between 2nd and 3rd dose; if time interval is delayed between doses, continue with next scheduled dose Recombivax HB: 10 µg/1 mL (adult); Recombivax HB: 40 µg/1 mL (immuno-compromised); Engerix-B: 20 µg/1 mL (adult); both given IM





ELISA, enzyme-linked immunosorbent assay. *Can be given concurrently with all other vaccines but at a separate site; however if measles-mumps-rubella and varicella vaccines are not given at the same time, then they must be given 30 d apart



<snip>



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The authors are in the Mayo Vaccine Research Group of the Mayo Clinic

Foundation, Rochester, Minn. Dr Phelan is a fellow in the division of

infectious diseases. Dr Jacobson is associate professor of pediatric and

adolescent medicine. Dr Poland is professor of medicine.



Full Article at:



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