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What you need to know about immunizing your adult patients

Some communicable diseases expose adults to special risk; others are concentrated in certain populations. Do you know which adults need immunization—and when?

May 2009 · Vol. 21, No. 05


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The statistics are troubling: Fifty thousand American adults die each year from vaccine-preventable diseases. Hundreds of thousands more are hospitalized and miss work because of infections that could be prevented with vaccines. Yet most Americans continue to think of vaccines as benefiting only children. And busy physicians wonder how they will fit yet another responsibility—educating the patient about her need for vaccination against some infectious diseases—into an already overloaded schedule.

“Vaccines are as crucial to long-term health as are screenings for certain cancers,” says William Schaffner, MD, president-elect of the National Foundation for Infectious Diseases (NFID) and Chairman of the Department of Preventive Medicine at Vanderbilt University School of Medicine. “Unfortunately, many adults associate vaccinations with childhood, or assume influenza is the only vaccine they need.”

In an effort to raise awareness about the importance of adult immunization, and provide resources for busy clinicians, the NFID recently launched a comprehensive Web site ( that includes critical information on adult diseases and the vaccines recommended to protect against them, as well as patient-oriented educational materials.

In addition, the NFID issued a call to action, “Saving lives: Integrating vaccines for adults into routine care,” with support from leading health organizations, including ACOG.

This article describes:

  • the risk to your patients of 12 communicable diseases
  • recommendations on vaccination against these diseases
  • resources to help you educate your patients and streamline the vaccination process.

“Unfortunately, adult vaccines are not on patients’ radar,” said Susan J. Rehm, MD, NFID Medical Director and Vice Chair of the Department of Infectious Disease at Cleveland Clinic. “Increased education is needed to help ensure that adults understand the importance of vaccination and know which vaccines they should receive. Health-care providers also must commit to recommending vaccination for their adults patients.”

General recommendations

In general, immunization recommendations can be broken down as follows:

  • all adults should be immunized against influenza, pneumococcal disease, human papillomavirus (HPV) (females), tetanus, diphtheria, pertussis, and zoster once they reach the proper age
  • some adults should be immunized against hepatitis B, measles, mumps, rubella, and varicella, depending on their history and level of risk
  • a few adults should be immunized against hepatitis A and meningococcal virus.

Immunizations contraindicated during pregnancy are:

  • varicella
  • zoster
  • measles, mumps, rubella (MMR).

There is no recommendation for HPV vaccine during pregnancy at this time.

The Centers for Disease Control and Prevention (CDC) adult immunization schedule for 2009 is available online at and is summarized in TABLES 1 and 2.


Adult immunization schedule, by vaccine and age group*


Age group


19–26 yrs

27–49 yrs

50–59 yrs

60–64 yrs

≥65 yrs

Tetanus, diphtheria, pertussis (Td/Tdap)

<blu>Substitute 1-time dose of Tdap for Td booster; then boost with Td every 10 years</blu>

<blu>Td booster every 10 years</blu>

Human papillomavirus (HPV)

<blu>3 doses (females)</blu>

No recommendation


<blu>2 doses</blu>


No recommendation

<blu>1 dose</blu>

Measles, mumps, rubella (MMR)

<blu>1 or 2 doses</blu>

<ora>1 dose</ora>


<ora>1 dose annually</ora>

<blu>1 dose annually</blu>

Pneumococcal (polysaccharide)

<ora>1 or 2 doses</ora>

<blu>1 dose</blu>

Hepatitis A

<ora>2 doses</ora>

Hepatitis B

<ora>3 doses</ora>


<ora>1 or more doses</ora>

SOURCE: Centers for Disease Control and Prevention1

* This schedule has been approved by the Advisory Committee on Immunization Practices, the American Academy of Family Physicians, the American College of Obstetricians and Gynecologists, and the American College of Physicians.


<blu>All persons in the age group who lack evidence of immunity</blu>

<ora>Individuals who have a risk factor</ora>


Immunization during pregnancy



Tetanus, diphtheria, pertussis

Td is recommended in individuals who lack (Td/Tdap) evidence of immunity

Human papillomavirus (HPV)

No recommendation





Measles, mumps, rubella (MMR)



Trivalent influenza vaccine (annually) is recommended

Pneumococcal (polysaccharide)

Recommended in individuals who have a risk factor

Hepatitis A

Recommended in individuals who have a risk factor

Hepatitis B

Recommended in individuals who have a risk factor


Recommended in individuals who have a risk factor

SOURCE: Centers for Disease Control and Prevention1

A dozen preventable diseases


Flu kills more Americans every year than all other vaccine-preventable diseases combined—roughly 36,000 people. The vast majority of these deaths (90%) occur in people 65 years of age and older, but influenza can aggravate chronic medical conditions, including congestive heart failure, asthma, and diabetes, in younger people, and can lead to bacterial pneumonia and sinus and ear infections.

HPV is the starting point for you to take a larger role in adult immunization

The Centers for Disease Control and Prevention (CDC) now recommends that the pertussis vaccine (a component of the tetanus-diphtheria-pertussis, or Tdap, shot) be given to every new mother who has not been recently vaccinated as soon after delivery as possible. The reason? To protect the newborn from this potentially deadly disease. (See below for the specific recommendation.)

But who, exactly, should be responsible for the actual vaccination? You? Or the general practitioner? And what if you are the only physician the woman is seeing at this time in her life?

ObGyn practices don’t typically manage immunization in adult patients, observes Mark A. Kane in an article in the International Journal of Gynecology and Obstetrics2—largely because stocking and restocking perishable vaccines is costly and a heavy draw on staff time in a setting that emphasizes other services. With the advent of the HPV vaccine, however, the ObGyn began to play a more direct role in adult immunization—at least in regard to one disease. But that doesn’t mean that you should relegate yourself to a less-than-vital role in ensuring protection for your patients against other infectious diseases, as well.

“ObGyn practitioners may use HPV vaccine in their practice but, more importantly, they should become the most powerful and effective advocates for its use, because they are the physicians who see and understand the devastating consequences of cervical cancer firsthand,” says Kane.2

“The ObGyn community has not been highly involved in immunization, and the immunization community knows little about cervical cancer, HPV, or the importance and availability of HPV vaccine,” he continues. “Therefore, a major effort must be undertaken to build a bridge between these communities, and to educate the larger health care community, decision makers, the media, and the public.”

A similar effort could help ensure that each woman is vaccinated against pertussis shortly after delivery of her infant—and against other preventable diseases at the appropriate time. Whether you administer the actual shot is not as important as your taking the lead in educating the patient about the importance of adult immunization so that she is motivated to see the appropriate practitioner.

Flu is easily spread when an infected person coughs or sneezes, and can be transmitted 1 day before symptoms develop up to 5 days after a person becomes ill.

The CDC recommends vaccination for about 85% of the US population each year as soon as the vaccine becomes available and throughout flu season. It takes about 2 weeks after vaccination for the vaccine to become effective.

Two types of vaccine. They are the trivalent inactivated vaccine (TIV), which is injected, and the live attenuated influenza vaccine (LAIV), which is given as a nasal spray. The TIV can be given to people 6 months of age and older—even those who have chronic medical conditions. LAIV is approved for healthy people 2 to 49 years old.

Recommendation. Vaccinate the following groups:

  • all people who want to reduce their risk of getting or transmitting the flu
  • adults 50 years of age and older
  • children 6 months through 18 years of age
  • women who will be pregnant during the flu season
  • individuals who have a chronic pulmonary (including asthma), cardiovascular (except hypertension), kidney, liver, blood, or metabolic disorder (including diabetes mellitus)
  • immunosuppressed people (even when the immunosuppression is caused by a medication or HIV)
  • individuals who have any condition that can compromise respiratory function and the handling of respiratory secretions, or conditions that increase the risk of aspiration
  • residents of a nursing home or other chronic-care facility
  • people who live with or care for someone at high risk for complications of the flu.

TIV and LAIV are both contraindicated in anyone who has a severe hypersensitivity to eggs or any component of the vaccine. LAIV should be avoided in pregnant women, anyone 50 years of age or older, or younger adults who have an underlying condition such as asthma or another chronic lung disorder, chronic cardiovascular disease, diabetes or another metabolic disease, renal dysfunction, hemoglobinopathy, or immunodeficiency.

Human papillomavirus

HPV is the most common sexually transmitted infection in the United States and the cause of cervical cancer. About 20 million Americans are infected, with more than six million new infections each year, almost 75% of them in adult and adolescent females younger than 24 years of age. Eighty percent of all women will be infected by age 50, and at least 50% of all sexually active adults will be infected in their lifetime.

Most people infected with HPV do not know that they have the disease. The virus can be spread even when there are no symptoms. Some people will develop visible genital warts. Disappearance of the warts does not mean that the virus has left the body; transmission to others remains possible.

Recommendation. Vaccinate all women up to 26 years of age who have not previously been vaccinated or who have not completed the full three-dose series. The vaccine prevents infection with HPV strains 6, 11, 16, and 18. Types 16 and 18 cause 70% of all cervical cancers, and types 6 and 11 cause roughly 90% of all genital warts.

Even women who are already infected with HPV can benefit from vaccination because the vaccine may protect them against other strains of the virus.

Vaccination against HPV does not reduce the need to get regular Pap tests.

The vaccine is contraindicated in people who are hypersensitive to yeast or any component of the vaccine.

Meningococcal disease

Meningococcal disease is a serious, potentially deadly infection that affects 1,400 to 2,800 Americans each year. Even when treatment is rapid, 10 to 14% of patients die, and up to 20% of survivors suffer permanent disability.

The most common forms of meningococcal disease are meningitis and bacteremia. Today, Streptococcus pneumoniae and Neisseria meningitidis are the leading causes of bacterial meningitis.

The disease is spread by direct contact with respiratory secretions (through coughing, sneezing, kissing). Close household contacts face a greatly heightened risk of developing the infection.

Recommendation. Vaccinate all people 11 through 18 years old as well as:

  • college freshmen who live in a dormitory
  • military recruits
  • individuals who have an impaired spleen, no spleen, or terminal complement disorder
  • microbiologists who are routinely exposed to Neisseria meningitidis
  • people who travel or live in countries where the disease is common.

The preferred vaccine for people 2 to 55 years of age is meningococcal conjugate vaccine (MCV). For individuals over age 55, or when the MCV is not available, the meningococcal polysaccharide vaccine (MPSV) is an acceptable alternative. Neither vaccine is approved in children younger than 2 years.


Adults face a much greater risk of contracting severe disease than children do. Adults account for only 5% of reported chickenpox cases in the United States but approximately 35% of deaths. They also have a greater risk of serious complication, including bacterial infection of the skin, swelling of the brain, and pneumonia.

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