Influenza, Hepatitis Vaccines 2019 ACIP Schedule Recommendations

The Advisory Committee on Immunization Practices (ACIP) develops the vaccine schedules for adults in the United States, Below is an assessment of the ACIP schedule for influenza, hepatitis A and hepatitis B, which also include an assessment of adult vaccine coverage in the United States over the last few years. The results of this assessment are not encouraging.

Below is the review of the new schedule for influenza and hepatitis A and B, published by Medscape.

“Influenza is 1 of the most important and common vaccinations available, but rates of influenza vaccine coverage for adults at age 19 years and older were 43.5% in 2015 to 2016, with little change in this statistic from the 2014 to 2015 influenza season. Adults at age 70 years and older were more likely to receive the influenza vaccine; 70.4% did so in 2015 to 2016. However, this figure represents a 3.1% decrease from 2014 to 2015. Approximately half of pregnant women, a key target group at higher risk for the complications of influenza, were vaccinated in 2017 to 2018. Black and Hispanic adults are less likely than white adults to receive the influenza vaccine.

Meanwhile, 66.9% of adults at age 65 years or older had received a pneumococcal vaccine, but the respective rate among individuals between 19 and 64 years who are considered at high risk for pneumococcal infection was just 24.0%. Rates of coverage for the human papillomavirus vaccine in 2016 among adults between 19 and 21 years of age were 51.6% among women and 21.2% among men. The good news is that these rates had increased substantially since 2015.

The current guidelines highlight new vaccines and vaccine schedules that promote wider completion of recommended immunizations.

Study Synopsis and Perspective

New recommendations for influenza, hepatitis A, and hepatitis B vaccines are highlighted in the 2019 Recommended Adult Immunization Schedule. The recommendations, published online by the Centers for Disease Control and Prevention's (CDC's) ACIP on February 4 in the Annals of Internal Medicine and on the CDC website, also include streamlined formatting, bolder headings, and more colorful graphics.


For the 2018 to 2019 season, any licensed influenza vaccine appropriate for the patient's age and health status now may be administered. That recommendation supersedes those for the previous 2 seasons, in which the use of the intranasal live attenuated influenza vaccine (LAIV) was not recommended.

The change came about after an August 24, 2018, report on seasonal influenza to the CDC, in which data showed that although LAIV was not as effective as inactivated vaccines against the H1N1 type, its effectiveness did not differ markedly for influenza B and the H3N3types. "It's been added back and has its own row in the table of options, so if you're healthy and not pregnant, you can go needle-free again," Atlanta, Georgia, internist Sandra Adamson Fryhofer, MD, told Medscape Medical News.

Dr Fryhofer is the American Medical Association's liaison to ACIP and a member of its Adult Immunization Work Group.

LAIV is now a recommended option for adults aged 19 to 49 years, except for those who have an immunocompromising condition such as HIV infection. Other contraindications are anatomical or functional asplenia, pregnancy, end-stage renal disease, close contact with severely immunocompromised persons in a protected environment, or receipt of influenza antiviral medications in the previous 48 hours. In addition, those with cerebrospinal fluid leakage or a cochlear implant and those with a history of Guillain-Barré syndrome within 6 weeks of a previous influenza vaccine should not receive the vaccine.

Dr Fryhofer also noted that for the 2018 to 2019 influenza season, the manufacturers altered the strains slightly to make them more immunogenic and increase effectiveness. As of mid-November 2018, there had been a 6.8% increased uptake of vaccination during this influenza season among children and a 6.4% increase among adults during the previous season, with final vaccination rates for the seasons to come in September.

As for the growing number of antiviral medications, she said, "There's a new single-dose antiviral being marketed as a new option, but the best way to get a head start against flu is to get vaccinated."

Hepatitis A

Homeless individuals are the latest addition to the list of those who should be routinely vaccinated against hepatitis A. They can receive a 2-dose series of single-antigen hepatitis A vaccine or a 3-dose series of combination hepatitis A and B vaccine. The addition came after the CDC received reports of an outbreak of hepatitis A in multiple states in October 2018. There were 2500 cases, and most occurred among people who were homeless, drug users, or both, Dr Fryhofer said.

"Homelessness was independently associated with a 2 to 3 times [higher] risk of infection and a 2 to 4 times [higher] risk of severe outcomes, including hospitalization and death," she explained.

Dr Fryhofer cautioned, however, that it may be challenging for itinerant teams of health workers on the street and in shelters to deliver 2 doses of a vaccine "But a single dose is also effective. The people who work with the homeless think this can be done," she added.

Other populations at increased risk for hepatitis A virus infection or severe hepatitis A disease should receive routine vaccination. These include those with chronic liver disease or clotting factor disorders, travelers in countries with high- or intermediate-prevalence of rates of endemic hepatitis A, and people in close personal contact with an adoptee (eg, a babysitter or new household member) in the first 60 days after arrival from a jurisdiction with high hepatitis A endemicity, such as certain developing countries. Other vaccination candidates are men who have sex with men, injection or noninjection drug users, and those working with hepatitis A virus in a laboratory or nonhuman primates infected with hepatitis A. Those who are not at particular risk but who desire immunization may also request the vaccine.

Hepatitis B

For adults aged 19 years and older, ACIP recommends use of a new yeast-based single-antigen recombinant hepatitis B vaccine, which contains the novel cytosine-phosphate-guanine oligodeoxynucleotide 1018 adjuvant. Approved by the US Food and Drug Administration in November 2017, the vaccine offers the advantage of a more rapid dosing schedule and a shorter time to protection. "It's effective with 2 doses given 1 month apart and can also be used as part of a series with older vaccines," Dr Fryhofer said. It costs about twice as much as its older counterparts, however.

There is an absence of safety data on use during pregnancy, and pregnant women should not receive this vaccine.

In another change, the new recommendations use the trade names of vaccines for easier recognition and prescribing. ACIP stresses, however, that this usage is for identification purposes only and does not imply endorsement by ACIP or the CDC.

Dr Fryhofer said the revamped design of the tables is "visually more appealing, and the more vibrant colors and bigger, bolder headings invite you to get involved. But if you want to print out the color charts, make sure your printer's ink isn't low or it won't turn out the way you want it."

Study Highlights

  • The LAIV is again recommended as an option among adults through age 49 years. LAIV was not recommended by ACIP for the 2016 to 2017 and 2017 to 2018 influenza seasons, primarily because of a lack of efficacy against influenza A H1N1.

  • However, the inactivated influenza vaccine should be used instead of LAIV among adults who are immunocompromised, have anatomical or functional asplenia, are pregnant, or have close contact with individuals with immunocompromise.

  • LAIV is given "Precaution" status among patients with end-stage renal disease, heart or lung disease, chronic liver disease, or diabetes.

  • A history of Guillain-Barré syndrome is not itself an absolute contraindication against influenza vaccination, but adults who developed Guillain-Barré syndrome within 6 weeks of receiving a previous influenza vaccine generally should not be vaccinated.

  • Adults with a previous reaction to eggs limited to hives may receive any recommended influenza vaccine. Those with a more serious allergic reaction to eggs may still receive any influenza vaccine, provided they receive the vaccination in a location that can recognize and manage severe allergic reactions.

  • A new hepatitis B vaccine that uses a unique adjuvant was approved in November 2017. It can accelerate the immunization schedule for hepatitis B, as 2 doses at least 4 weeks apart can provide protection, whereas older regimens require 3 vaccinations over the course of 6 months.

  • The new vaccine can be substituted into a 3-dose vaccination program already initiated, but the only 2-dose regimen acceptable to prevent hepatitis B infection features 2 doses of this vaccine specifically.

  • Pregnant women should not receive this vaccine because of a lack of safety data in this population.

  • ACIP has added homelessness as an indication for the 2-dose hepatitis A vaccine. Other indications for hepatitis A vaccination include the presence of chronic liver disease or clotting disorders, travel to countries with endemic hepatitis A infection, close contact with an international adoptee in the first 60 days after travel from a country with endemic hepatitis A infection, men who have sex with men, and persons who use illicit drugs.

  • Pregnancy is a relative contraindication to use of the serogroup B meningococcal vaccine. It should only be used if the potential benefits outweigh risks. In contrast, there is no contraindication to the use of the serogroups A, C, W, and Y meningococcal vaccine in pregnancy.

Clinical Implications

  • The overall influenza vaccine coverage rate for adults in 2015 to 2016 was 43.5%, with little change in this statistic from the 2014 to 2015 influenza season: 70.4% of older adults received the influenza vaccine, as did half of pregnant women; 66.9% of adults at age 65 years or older had received a pneumococcal vaccine in 2016, but the respective rate among individuals aged between 19 and 64 years who are considered at high risk for pneumococcal infection was just 24.0%.

  • LAIV is again recommended as an option for generally healthy adults younger than 50 years who desire influenza vaccination. A new vaccine against hepatitis B can establish efficacy in just 2 doses 4 weeks apart. Homeless adults should receive the hepatitis A vaccine.

  • Implications for the Healthcare Team: The healthcare team should actively promote vaccination and develop systems of care that support wider application of vaccines among adults.”

Excerpt copied from Medscape for educational purposes,

Authors: Authors:News Author: Diana Swift; CME Author: Charles P. Vega, MD

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