5 Jun

Measles, mumps, and  rubella are  described in  Chapter 3. Each of these viruses has  its own vaccine to be described later. The  vaccination for these three classic childhood diseases is typically given  as  a  combination MMR  vaccine (Table 4.3). Combination vaccines tend to require fewer  total immuniza- tions to  achieve a  satisfactory efficacy  rate, are  usually less expensive, and  provide a  greater opportunity to  inoculate masses of people  in a short period of time (25).

Footnotes for

Recommended Adult Immunization Schedule

by  Age  Group and Medical Conditions, United States, 2003–2004

1. Tetanus and diphtheria (Td)—Adults in- cluding pregnant women with uncertain histo- ries  of a complete primary vaccination series should receive a primary series of Td. A pri- mary series for adults is 3 doses:  the  first 2 doses  given  at least 4 weeks apart and  the  3rd dose,  6–12  months after the  second. Adminis- ter 1 dose  if the  person had  received the  pri- mary series and  the  last vaccination was  10 years ago or longer. Consult MMWR 1991;  40 (RR-10): 1–21  for administering Td as prophy- laxis  in wound management. The  ACP Task Force  on Adult Immunization supports a sec- ond  option for Td use  in adults: a single Td booster at age  50 years for persons who have completed the  full  pediatric series, including the  teenage/young adult booster.

Guide for Adult Immunization. 3rd  ed. ACP 1994:20.

2. Influenza vaccination—Medical indica- tions: chronic disorders of the  cardiovascular or  pulmonary systems including asthma; chronic metabolic diseases including diabe- tes  mellitus, renal dysfunction, hemoglobin- opathies, or  immunosuppression (including Immunosuppression caused by medications or by human immunodefidency virus [HIV]), requiring regular  medical follow-up or  hos- pitalization during the  preceding year; women who  will  be in  the  second or  third trimester of pregnancy during the  influenza season. Occupational indications: health- care  workers. Other indications: residents of nursing homes and  other long-term care  fa- cilities; persons likely  to transmit influenza to persons at high-risk (in-home care  givers to persons with medical indications, household contacts and out-of-home caregivers of children birth to 23 months of age,  or children with asthma or other indicator conditions for influ- enza vaccination, household members and  care givers of elderly and  adults with high-risk con- ditions); and anyone who wishes to be vaccinated. For  healthy persons aged  5–49  years without high  risk conditions, either the  inactivated vac- cine or the  intranasally administered influenza vaccine (Flumist) may  be given.

MMWR 2003;  52 (RR-B):1–36; MMWR 2003;53 (RR-13):1–8.

3. Pneumococcal polysaccharide vacci na- tion—Medical indications: chronic disorders of the  pulmonary system (excluding asthma), car- diovascular diseases, diabetes mellitus, chronic liver  diseases including liver  disease as a result of alcohol  abuse (e.g., cirrhosis), chronic renal fail- ure or nephratic syndrome, functional or an atom- ic asplenia (e.g., sickle cell disease or splenectomy), immunosuppressive conditions (e.g., congen- ital  immunodeficiency, HIV  infection,

leukemia, lymphoma, multiple myeloma, Hodgkins disease, generalized malignancy, organ or  bone  marrow transplantation), chemotherapy with alkylating agents, anti- metabolites, or long-term systemic corticos- teroids. Geographic/other indications: Alas- kan Natives and  certain American Indian populations. Other indications: residents of nursing homes and  other long-term care  fa- cilities.

MMWR 1997;  45(RR-8):1–24.

4. Revaccination with pneumococcal polysaccharide  vaccine—One time revac- cination after 5 years for persons with chronic renal failure or nephrotic syndrome, func- tional or anatomic asplenia (e.g., sickle  cell disease or splenectomy), immunosuppressive conditions (e.g., congenital immunodeficien- cy, HIV  infection, leukemia, lymphoma, mul- tiple myeloma, Hodgkins disease, generalized malignancy, organ or bone marrow transplan- tation), chemotherapy with alkylating agents, antimetabolites, or long-term system- ic corticosteroids. For  persons 65 and  older, one-time revaccination if they were  vaccinat- ed 5 or more  years previously and  were  aged less  than 65 years at the  time of primary vaccination.

MMWR 1997;  46(RR-8):1–24.

5. Hepatitis B vaccination—Medical indica- tions: hemodialysis patients, patients who receive dotting-factor concentrates.Occupa- tional indications; health-care workers and public-safety workers who have exposure to blood  in  the  workplace, persons in  training in schools  of medicine, dentistry, nursing, lab oratory technology, and  other allied health pro

fessions. Behavioral indications: injecting drug users, persons with more  than one sex partner in  the  previous 6 months, persons with a recently acquired sexually-transmit- ted  disease (STD), all clients in STD clinics, men  who  have sex  with men.  Other indica- tions: household contacts and  sex  partners of persons with chronic HBV  infection, cli- ents and  staff  of institutions for the  devel- opmentally disabled, international

travelers who will be in countries with high or intermediate prevalence of chronic HBV infection for more  than 6 months, inmates of correctional facilities. MMWR 1991;  40 (RR-13):1–19. (

6. Hepatitis A vaccination—For the combined HepA-HepB vaccine use  3 doses  at 0, 1, 6 months). Medical indications: persons with dotting-factor disorders or chronic liver disease. Behavioral indications: men who have sex with

Footnotes for

Recommended Adult Immunization Schedule

by  Age  Group and Medical Conditions, United States, 2003–2004

men, users of injecting and  noninjecting illegal drugs. Occupational indications: persons work- ing  with HAV-infected primates  or with HAV in a research laboratory setting. Other indica- tions: persons traveling to or working in coun- tries that have high  or intermediate endemicity of hepatitis  A.

MMWR 1999;  48 (RR-12):1–37, (


7. Measles, Mumps, Rubella vaccination (MMR)—Measles component: Adults born  be- fore  1957  may  be considered immune to mea- sles. Adults born in or after 1957 should receive at least one  dose  of MMR unless they have a medical contraindication, documentation of at least one dose  or other acceptable evidence of immunity. A second dose  of MMR is recom- mended for adults who:

• are  recently exposed to measles or in an outbreak setting

• were  previously vaccinated with killed mea- sles  vaccine

• were  vaccinated with an  unknown vaccine between 1963  and  1967

• are  students in post-secondary educational institutions

• work  in health care  facilities

• plan to travel internationally

Mumps component: 1 dose  of MMR should be adequate for protection. Rubella component: Give  1 dose  of MMR to women whose  rubella vaccination history is unreliable and  counsel women to avoid becoming pregnant for 4 weeks after vaccination. For  women of child-bearing age,  regardless of birth year, routinely deter- mine  rubella immunity and  counsel women re- garding congenital rubella syndrome. Do not vaccinate pregnant women or those planning to become  pregnant in the  next 4 weeks. If pregnant and  susceptible, vaccinate as early in postpartum period as  possible.

MMWR 1998;  47 (RR-8):1–57; MMWR 2001; 50:1117.

8. Varicella vaccination—Recommended for all persons who do not have reliable clinical history of varicella infection, or serological evidence of varicella zoster virus (VZV) infection who may be at high  risk for exposure or transmission.

This  includes, health-care workers and  family contacts or immunocompromised persons, those who  live  or work  in  environments where transmission is likely  (e.g.,  teachers of young  children, day  care  employees, and residents and  staff  members in institutional settings), persons who  live  or work  in  envi- ronments where VZV transmission can occur (e.g.,  college  students, inmates and  staff members of correctional institutions, and military personnel), adolescents and  adults living  in  households with children, women who are  not  pregnant but  who may  become pregnant in  the  future, international trav- elers who  are  not  immune to  infection. Note:  Greater than 95% of U.S. born  adults are  immune to VZV. Do not  vaccinate preg- nant women or  those planning to  become pregnant in  the  next 4 weeks. If pregnant and  susceptible, vaccinate as  early in  post- partum period as  possible.

MMWR 1996; 45 (RR-11):1–36; MMWR 1999; 48 (RR-6):1–5.

9. Meningococcal vaccine (quadrivalent polysaccharide for  serogroups A, C, Y, and W-135)—Consider vaccination for per- sons  with medical indications: adults with terminal complement component deficien-

cies,  with anatomic or functional asplenia. Other indications: travelers to countries in which  disease is hyperendemic or epidemic (*meningitis belt*  of sub-Saharan Africa, Mecca,  Saudi Arabia for Hajj).  Revaccina- tion  at 3–5  years may  be indicated for per- sons  at high  risk for infection (e.g., persons residing in areas in which disease is epidem- ic). Counsel college  freshmen, especially those who  live  in  dormitories, regarding meningococcal disease and  the  vaccine so that they can  make an  educated decision about receiving the  vaccination. MMWR 2000;  49 (RR-7):1–20.

Note: The  AAFP  recommends that colleges should take the  lead  on providing education on meningococcal infection and  vaccination and  offer it to those who are  interested. Phy- sicians need  not  initiate discussion of the meningococcal quadravalent polysaccharide vaccine as  part of routine medical care.

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