July 03, 2019 03:21 pm Chris Crawford – During the June 26-27 meeting of the CDC's Advisory Committee on Immunization Practices, the group voted to update its recommendations for use of the nine-valent HPV and 13-valent pneumococcal conjugate vaccines.
AAFP liaison to the ACIP Pamela Rockwell, D.O., of Ann Arbor, Mich., told AAFP News other topics considered during the meeting included recommendations for a catch-up schedule for children and adolescents ages 2-18 who hadn't previously received hepatitis A vaccine, as well as guidance for serogroup B meningococcal vaccination boosters for those with special conditions/circumstances.
First up was a vote to recommend that HPV vaccination be based on shared clinical decision-making for patients ages 27-45 who have not been adequately vaccinated.
The question arose after the FDA in October approved the use of Gardasil 9 vaccine for the first time in this age group.
Rockwell said ACIP members discussed at length what guidance would need to be offered to help physicians with decision-making if indeed the recommendation to expand the age range for HPV vaccination was made.
As to the benefits of the expanded recommendation, "It helps those folks who missed out on getting vaccinated as adolescents, as the HPV vaccine wasn't around when they were of that age," Rockwell said.
"I believe clinicians are able to individually understand which patients may be helped by this vaccine," she added. "For example, a 35- or 40-year-old newly divorced woman who had only one previous sexual partner and no history of abnormal Pap smears and who is now going back into the dating world is someone easily identified as one who would benefit from HPV vaccination."
Next, the ACIP voted unanimously to recommend harmonizing the upper age for catch-up HPV vaccination across genders; now, all males ages 21-26 are recommended for catch-up HPV vaccination regardless of risk factors.
"Now, you don't have to think about gender," she said. "It's recommended for all through age 26 for catch-up. Ideally, it's recommended for patients ages 11-12 and for those as young as 9."
The ACIP also voted to recommend shared clinical decision-making on the PCV13 vaccine for people 65 and older who aren't immunocompromised and who haven't previously received PCV13. All those 65 and older are still recommended to receive a dose of 23-valent pneumococcal polysaccharide vaccine.
"This recommendation has been downgraded from an absolute recommendation for those 65 and older in immunocompetent adults down to shared clinical decision-making that they can get the vaccine at age 65 or older," Rockwell said.
Rockwell said there was debate about how this change in recommendation might prove cumbersome when updating EHRs with protocols for giving vaccines.
"Now, clinicians are going to have to decide if their patient needs a PCV13 in addition to PPSV23 or whether their patient only needs PPSV23 and not PCV13," she said. "The fear is that people who have COPD and compromised lungs, for instance, who are not recommended to receive PCV13 by this new decision may potentially be harmed by this recommendation if physicians decide not to offer PCV13 first followed by PPSV23, using shared clinical decision-making."
Rockwell acknowledged that this type of change is hard to effect in real-time practice and can be confusing to physicians who don't have time to review all the reasoning behind the recommendation.
"When the ACIP originally made this recommendation, they said they would go back in four years and review the data to see if the recommendation should be held," she said. "It took five years, but they did that review and found that herd immunity from the little kids getting PCV13 starting in 2010 has made more of an impact than giving only adults the vaccine."
For the HepA vaccine, in addition to voting to recommend a catch-up schedule for patients ages 2-18 who were not previously vaccinated, the ACIP voted to recommend HepA vaccination for all patients with HIV who are age 1 or older and removing those with clotting disorders from the list of groups at high risk for HepA infection.
Many clinicians were already catching kids up on HepA vaccination, but now the recommendation supports their efforts, she added.
"The data shows that in the past 20 years, the improvements in screening for disease in the infusions that people with clotting disorders need to receive have basically made their risk for getting hepatitis the same as anybody else in the community," Rockwell specified about removing clotting disorders from the high-risk list.
As for the serogroup B meningococcal vaccine, the ACIP said that because immunity wanes within one to two years after vaccination, it recommended booster vaccination for patients 10 and older who are at increased risk for MenB disease due to one of the following conditions or circumstances:
The ACIP recommends that the MenB booster dose for these groups be given one year after completing the primary series, followed by an additional booster dose every two to three years thereafter for as long as the increased risk remains.
For the ACIP's upcoming meeting in October, Rockwell said the recently formed Dengue Vaccine Work Group will present its findings in preparation for voting on a vaccine recommendation.
At this most recent meeting, Sanofi presented its new vaccine, Dengvaxia, which prevents infection caused by all four dengue virus serotypes in people ages 9-16 who have laboratory-confirmed previous dengue infection and who live in an endemic area. Risk for severe disease increases with subsequent infection.
In May, the FDA approved a three-dose schedule for the vaccine, with doses given at zero, six and 12 months. The workgroup's recommendations will be for the use of safe and effective dengue vaccines in the United States and its tropical territories.
Although the rabies vaccine was on the schedule for the June meeting, the ACIP ran out of time to discuss it, so it will be included for discussion at the October meeting, Rockwell said.
And finally, Rockwell said the group will vote on recommendations for the influenza vaccine for the next flu season in October, but she anticipates the guidance will be the same as it was for this past season.
Related AAFP News Coverage
ACIP Updates Japanese Encephalitis, Anthrax Vaccine Guidance
Group Considers Data on Various Other Immunization Topics
(3/6/2019)
CDC, AAFP Release 2019 Immunization Schedules
Updates Include Changes for LAIV, Hep A Vaccine
(2/11/2019)