by Molly Walker
Staff Writer, MedPage Today February 06, 2017
• The live attenuated influenza vaccine (FluMist) is not recommended for either adults or children during the 2016-2017 flu season.
• Note that regarding potential HPV vaccine hesitancy and to improve vaccine uptake among adolescents, one strategy for pediatricians would be to emphasize that HPV immunization prevents cancer.
FluMist is out and amended requirements for the HPV vaccine in certain populations are in, according to 2017 changes to the vaccination schedule.
The CDC’s Advisory Committee on Immunization Practices (ACIP) has reiterated its recommendation against using the live attenuated influenza vaccine (FluMist) for either adults or children.
But two doses of the HPV vaccine are now recommended for children and adolescents under the age of 15 years, although three doses are still recommended for adults and adolescents who did not start their vaccination series prior to age 15, they noted.
Also, changes to vaccinations against meningococcal disease were made.
All of these updates were approved at ACIP meetings, and are now published in the Annals of Internal Medicine.
In addition, the American Academy of Pediatrics’ (AAP) Committee on Infectious Diseases released its 2017 recommendations for children and adolescents simultaneously in Pediatrics.
Meningococcal Vaccine
The ACIP recommended changes to the schedule for MenB-FHbp vaccine (Trumenba), which protects against serogroup B among people, including adolescents and young adults, at increased risk of contracting the disease.
Among adults at increased risk or during outbreaks of serogroup B meningococcal disease, the three-dose vaccine should be administered at 0, 1-2 and 6 months. “Healthy” adolescents and adults may receive a two-dose series of MenB-FHbp at 0 and 6 months.
However, the ACIP noted that there was no change to the vaccination interval for the MenB-4C vaccine (Bexsero).
The ACIP also recommended immunizing people with HIV infection with the 2-dose MenACWY vaccine. Adults should receive these vaccines 2 months apart, and should be revaccinated every 5 years.
Other populations that should receive vaccination against meningococcal disease include:
• Adults with anatomical or functional asplenia or persistent complement component deficiencies (2-dose MenACWY and either 2-dose MenB-4C or three-dose MenB-FHbp)
• Microbiologists routinely exposed to Neisseria meningitidis isolates (1 dose MenACWY and 2-dose MenB-4C or three-dose MenB-FHbp)
• Adults at risk of an outbreak of meningococcal disease (one dose MenACWY or 2-dose MenB-4C or three-dose MenB-FHbp, depending on the outbreak strain)
• Healthy young adults ages 16 to 23 years, “on the basis of clinical discretion” (two-dose MenB-4C or two-dose MenB-Fhbp)
HPV Vaccine
Few changes were made to the HPV vaccination series in adults. The ACIP recommended a three-dose vaccination series for women from ages 19 to 26 years, and men through age 21 years (at 0, 1-2 and 6 month intervals), though men ages 22 to 26 years may also receive the three-dose series at the same intervals.
But women and men who initiated HPV vaccination prior to age 15 only need two doses total for a complete series. This means that adults with one dose of HPV vaccine prior to age 15 only need one more dose, and adults who initiated the HPV series prior to age 15 and received two doses at least 5 months apart are now considered fully protected against the disease.
Influenza Vaccine
The ACIP stated that “changes are related to concerns regarding low effectiveness of the live attenuated influenza vaccine … against influenza A(H1N1)pdm09 in the U.S. during the 2013–2014 and 2015–2016 influenza seasons.” Last June, it issued an interim recommendation against using the product.
The committee also noted that people with an egg allergy receiving the influenza vaccine should receive age-appropriate inactivated influenza vaccine (IIV) or recombinant influenza vaccine (RIV). Those people with more severe allergic symptoms other than hives should receive the vaccine at “an inpatient or outpatient medical setting and supervised by a healthcare provider” who can recognize severe allergic reactions.
Hepatitis Vaccine
Finally, adults with various chronic liver conditions, including hepatitis C, cirrhosis, fatty liver disease and alcoholic liver disease, should receive the hepatitis B (HepB) vaccination.
AAP Advice
The AAP committee recommended that children receive two doses of HPV vaccine prior to age 15, or three doses of the HPV vaccine if the series starts after age 15, or if the child has certain immunocompromising conditions. They also reiterated the ACIP’s recommendations for the MenACWY vaccine in HIV-infected children, as well as the MenB vaccine for adolescents and young adults ages 16 to 23 if deemed necessary by the clinician.
Other recommendations included:
• All newborns should receive a monovalent dose of hepatitis B vaccine within 24 hours of birth, and infants born to mothers who test positive for hepatitis B surface antigen should be tested for hepatitis B surface antigen and its associated antibodies at 9 to 12 months after birth.
• Pregnant adolescents should receive one dose of tetanus, diphtheria, and pertussis (Tdap) vaccine, as early as possible in the 27 to 34 week gestation period, and children receiving Tdap as a catch-up series at ages 7 to 10 years may either receive Tdap or Td for their adolescent dose at age 11 or 12 years.
• Haemophilus b conjugate vaccine (Hiberix) may be used for the primary vaccination series for haemophilus influenzae type B (Hib) as Comvax is no longer commercially available, committee members noted.
Improving HPV Vax Uptake
Along with the AAP recommendations, two clinical reports, by Henry H. Bernstein, DO, and Joseph A. Bocchini Jr., MD, addressed potential vaccine hesitancy and improve vaccine uptake among adolescents.
Although the AAP has addressed these issues in a recent clinical report, and offered strategies for pediatricians to communicate with vaccine-hesitant parents, the first report also highlighted the need to advocate for HPV immunization in adolescents.
The authors argued that because HPV vaccination rates lag behind other vaccines, clinicians should emphasize that HPV immunization prevents cancer — “a major reason that parents accept the vaccine,” they stated. They also said that clinicians should discuss both the vaccine schedule and the age of administration with parents.
Moreover, they wrote that the vaccination should not be delayed, because “attempting to predict when the adolescent will become sexually active is difficult and impractical,” and recommended a “now or never” mentality when trying to argue for the immunization of adolescents.
Other strategies include co-administering the HPV vaccine with other vaccines, as well as stating that the HPV vaccine is “part of the routine immunization schedule,” the authors stated.
The second report touched on barriers that may prevent HPV vaccination efforts, such as “Internet and media sources that give false information about vaccines,” racial and economic disparities, and financial difficulties, Bernstein and Bocchini explained.
They cited a 2015 study that found HPV vaccination coverage was higher among non-Hispanic and Hispanic males compared with non-Hispanic white males, and cited increased education about the benefits of the vaccine as a way to combat this.
The HPV vaccine is also currently the most expensive of the vaccines included in the Vaccines for Children program, the authors noted, which may mean “limited availability of in-network healthcare providers in some rural jurisdictions” and some grandfathered plans not required to follow the Affordable Care Act preventive care provisions.
They recommended collaboration with the AAP, which can provide resources for clinicians facing either financial issues or issues with vaccine supply.