Key changes to Adult and Child Immunization schedule for 2020

By Dr. Liji Thomas, MDFeb 5 2020

The new Childhood and Adolescent Immunization Schedule and the Adult Immunization Schedule for 2020 is out, just released by the Advisory Committee on Immunization Practices (ACIP). This is an annual event following its yearly revision.

Image Credit: Jes2u.photo / Shutterstock

The layout

While the basic format remains the same, the cover page gives instructions on the use of the schedule to identify the vaccination needs of adults and gives the list of vaccines that are routinely recommended. There are also online links to an app containing CDC vaccine schedules.

Each section gives information on the routine vaccines, special instructions, vaccine indications and doses with the recommended frequency intervals. Some vaccines have revised or new recommendations.

The schedule also equips healthcare providers with links to information on how to maintain surveillance of vaccine-preventable disease, which means identifying cases and responding to disease outbreaks. Links to vaccination requirements for travellers and information about vaccines are also provided.

It also gives advice on the right way to report cases suspected of having these diseases to the relevant authorities. Instructions on reporting vaccine-associated adverse events to the Vaccine Adverse Event Reporting System are also included. It also describes the Vaccine Injury Compensation Program.

Reactions to the changes

A new color, blue, has been added to indicate vaccines to be given after shared decision making.

This is one change that has not been generally acceptable. It may be relevant in vaccines such as that used to prevent herpes zoster. But with some like PCV13 that are not even disease-causing agents in the USA of today, shared decision-making is irrelevant. Many doctors think this takes too much time, since they are typically in a far better position than the patient to decide if the vaccine is required or not.

Changes for children and teenagers

The changes that have been made in the present schedule include:

• Hepatitis A vaccine now recommended as a catch-up vaccine for all people 2-18 years old, rather than an option for older children.
• Meningococcal B vaccine should be discussed with adolescents between 16 and 18 years who are not at increased risk for the disease.
• Any child aged 10 or above must receive a booster dose if at least a year has passed since the vaccine course was completed.
• Catch-up vaccination is advised for vaccines covering serogroups ACWY.

Changes for adults

Table 1 shows both routine and catch-up immunizations by age for adults. There is only one column for adults aged 19-26 years, and for HPV vaccination, males and females are treated alike. The blue bar for shared decision making in the new schedule applies to;

• HPV vaccination between 27-45 years
• Meningococcal B vaccination between 16 and 23 years for people not at increased risk
• PCV13 vaccination in healthy seniors aged 65 years or more

Meningococcal B vaccine

Patients between 19 and 23 years are now not routinely recommended to take the vaccine, but participate in shared decision making.

Adults who are at increased risk, such as those with complement deficiency, who are on complement inhibitor therapy, without a spleen, and for clinical microbiologists with risk of laboratory exposure, should now receive a meningococcal B booster at 1 year after the vaccination is complete. If still at risk the dose should be repeated every 2-3 years. The schedule states that the same product should be used each time.

Pneumococcal conjugate vaccine PCV13

With the pneumococcal conjugate vaccine PCV13, people above 65 years who have normal immunity should be told about the vaccine and asked if they want to take it. It is not routinely recommended in the schedule, because the strains that the vaccine protects against are no longer widespread. It is still recommended for those with weakened immunity, cochlear implants, and cerebrospinal leaks.

In certain groups, it may be regularly offered even now because of the potentially increased risk for exposure to the vaccine strains and the above-average benefit expected. These include:

• Residents of long-term nursing or care facilities
• Residents in areas where few children have received PCV13
• Travelers visiting places where childhood vaccination does not include PCV13

It may also be considered, though without evidence of much benefit, in people with chronic heart, lung and liver disease, diabetes or alcoholism, smokers and people with multiple health issues, who have a higher-than-average burden of pneumonia and sepsis with PCV13-type strains.

Meanwhile, older adults (65 years and above) should still receive the pneumococcal polysaccharide vaccine PPSV23.

Human papilloma virus (HPV) vaccine

Human papilloma virus (HPV) vaccine can now be advised up to the age of 45 in some patients. Also, adult males and females are recommended to have catch-up HPV immunization up to the age of 26 years, up from the previous upper limit of 21 years for males and 26 years for females. In most cases sexually active adults between 27 and 45 years who have had multiple partners are already infected with the strains found in the vaccine, which makes it not useful. However, new infections are more likely in any individual who has a new sex partner, especially if the previous partnership was monogamous on both sides. Doctors should discuss the vaccine and allow the patient to help decide whether to take it or not. The most effective preventive measure is to be in a monogamous relationship with another partner who is also monogamous.

Hepatitis A vaccine

Individuals with HIV above the age of 1 year should be vaccinated against Hepatitis A because infection with the latter in an HIV-infected patient stimulates HIV replication. Moreover, the hepatitis A virus lingers much longer in an HIV patient, encouraging higher rates of transmission.

Hepatitis A vaccine is no longer required for patients receiving clotting factor disorders because of the safe and effective sterilization methods now used for recombinant clotting factor concentrates. This means their risk is no higher than that of other people.

Influenza vaccine

Routine influenza vaccination is recommended for all individuals 6 months or above lacking contraindications for the 2019-2020 season.

Hepatitis B vaccine

In addition to previous indications, Hepatitis B may now be considered in pregnant women who are at risk for this infection, or who may have a related pregnancy complication.

Td, Tdap vaccines

Tdap vaccine may now be substituted freely for Td booster vaccine.