Where the Buck Stops for Primary Care: Adult Immunizations
One of the most important roles for primary care practitioners is the review and implementation of necessary immunizations across a broad spectrum of age. Although adherence to the recommended schedule is better in children than in older patients, immunizations are equally crucial for adults.1
Each year the Advisory Committee on Immunization Practices of the CDC revises its recommendations (available at http://www.cdc.gov/vaccines/recs/ACIP/default.htm). Here I review the key changes for adult immunizations for 2010.2
HUMAN PAPILLOMAVIRUS INFECTION
A permissive recommendation was given for administration of the human papillomavirus (HPV) vaccine in young men. Quadrivalent HPV vaccine (not the bivalent vaccine) can reduce HPV-associated genital warts in men. However, a caveat was added to the recommendation. Whether it will be cost-effective to generally use HPV vaccine in men has not been established. In order for cost-effectiveness in men to be achieved, HPV vaccine would have to induce "herd immunity" and thereby reduce the incidence overall of HPV-related disease. Whether it will is not known at this time.
This vaccine is now recommended for unvaccinated persons who provide home or day care for international adoptees. The data to support this recommendation stem from the fact that 99% of these adoptees are from countries where hepatitis A is endemic. In addition, the adoptees are usually younger than 5 years and therefore asymptomatic when they have hepatitis A. The unvaccinated persons who adopt and care for these children are at risk for fulminant hepatitis.
Meningococcal conjugate vaccine is preferred in adults with indications for vaccination who are 55 years or younger; meningococcal polysaccharide vaccine is preferred in those aged 56 years or older. A one-time revaccination is recommended for either age group after 5 years if criteria for increased risk are still present. This recommendation does not apply to those whose only risk factor for infection is residence in on-campus housing.
VACCINATIONS EQUAL QUALITY
Quality indicators include selected vaccine rates. Pneumococcal and seasonal influenza vaccines are both Joint Commission performance measures.3 With quality rapidly becoming part and parcel of health care reform, attention to compliance is critical to primary care. Methods to increase compliance include standing orders, simple chart reminders, and embedded electronic record triggers.
Hopkins and Vyas3 said it best in their summary exhortations: "Vaccines have been demonstrated to be among the most effective strategies for preventing illness in individuals." They suggest that all of us "make immunizations integral to each encounter for physicians that care for adults in primary and specialty care settings." I suspect they realize that the job gets more attention in children already. The gauntlet has been laid down, and primary care is where the response will come from.
1. Centers for Disease Control and Prevention. Healthy People 2010: Objectives for Improving Health. Immunization: leading health indicator. http://www.healthypeople.gov/document/html/uih/uih_4.htm#immuniz. Accessed March 11, 2010.
2. Advisory Committee on Immunization Practices. Recommended adult immunization schedule: United States, 2010. Ann Intern Med. 2010;152:36-39.
3. Hopkins RH Jr, Vyas KS. Adult immunization guidelines: challenges and opportunities. Ann Intern Med. 2010;152:59-60, W-14.