Posted on May 15, 2018 in: Professional Practice
By Jamie George, B.H.S., Pharm.D. candidate 2019, Department of Pharmacy Practice, Wayne State University and Joseph Fava, Pharm.D., clinical assistant professor, Department of Pharmacy Practice, Wayne State University, Detroit
Immunization recommendations are continuously updated by the Advisory Committee on Immunization Practices (ACIP) and published by the Centers for Disease Control and Prevention (CDC). New immunization schedules are published annually based on these recommendations. The following is a summary of the major updates from ACIP as of March 2018.
Adults (aged 19 years and older)
In October 2017, the FDA approved Shingrix® (zoster vaccine recombinant, adjuvanted – GlaxoSmithKline [GSK] – Belgium, abbreviated by the CDC as ‘RZV’) which led to the revision of the current recommendations for vaccination against herpes zoster. Table 1 shows a comparison between Zostavax® (zoster vaccine live – Merck & Co., Inc. – United States, abbreviated by the CDC as ‘ZVL’) recommendations compared to those of RZV. Overall, RZV has been recommended over ZVL as the preferred vaccine for the prevention of herpes zoster, by a slim eight to seven majority of ACIP voting members.1,2
Table 1. Comparison of ZVL and RZV.
ZOSTAVAX® (ZVL) RECOMMENDATIONS
SHINGRIX® (RZV) RECOMMENDATIONS
Ages 50-59 years
One dose of ZVL
Approved by FDA, but not recommended by CDC2
2 doses of RZV separated by two to six months1
Ages 60+ years
One dose of ZVL2
Previously received ZVL
Should wait at least two months after receipt of ZVL to administer RZV1
Contraindicated (live vaccine)2
Patients on low-dose immunosuppressive medications, those anticipating immunosuppression and those recovering from an immunocompromising illness, may receive RZV.11
Previous episode of herpes zoster
One dose of ZVL
Do not administer during an acute episode of herpes zoster; delay vaccination until after acute stage is over and symptoms subside1
No specific amount of time needed to wait before administration.12
Two key differences should be noted with regard to storage and administration of herpes zoster vaccines: 1) unlike ZVL, which is administered subcutaneously, RZV should be administered intramuscularly, preferably in the deltoid region of the upper arm, and 2) RZV is to be stored refrigerated (36-46 degrees F), unlike ZVL which is stored frozen (-58 to five degrees F).3,4
In February 2017 the meningococcal polysaccharide vaccine MPSV4 (Menomune® - Sanofi Pasteur Inc. – U.S.) was discontinued in the United States. This was the only meningococcal vaccine that was FDA-approved for ages 56 years and older. Despite only having FDA approval in patients up to 55 years of age, the CDC now recommends that patients 56 years and older who are at increased risk for meningococcal disease should receive a meningococcal conjugate vaccine (MCV).5,6
In February 2018, ACIP voted in favor of the intranasal live attenuated influenza vaccine (LAIV) for the 2018-2019 flu season.7 This recommendation is pending approval from the CDC and will be published in the Morbidity and Mortality Weekly Report (MMWR) once finalized.
The FDA and ACIP approved HEPLISAV-B® (Dynavax Technologies Corp. – U.S.) for use against all subtypes of Hepatitis B for ages 18 years and older. This new vaccine is administered as a two-dose series, which has potential to improve rates of series completion compared to the conventional three-dose series.8
Children (aged 0-18 years)
Measles, mumps, and rubella (MMR)
Footnotes now give guidance on a third dose during a mumps outbreak. Children > 12 months who received < two doses of a mumps-virus containing vaccine and identified at increased risk during an outbreak should receive an additional dose.9 This change also applies to adult patients and is reflected in the adult schedule footnotes.
Table 2 shows additional minor changes to the childhood immunization schedule for 2018.
Table 2. Additional Changes to Schedule for Children (Aged 0-18 years)9,10
Hepatitis B (HepB)
Footnotes now include information about vaccination in infants < 2,000 grams with hepatitis B surface antigen (HBsAG)-negative mothers.
Catch-up recommendations were clarified for children four years and older, and the footnotes now include guidance for those who received the oral vaccine previously as part of their series.
The maximum ages for the first and last doses have been specified and added to the catch-up schedule.
MenACWY and MenB footnotes are now separated for clarity.
The HIV disease state parameters (CD4 cell counts) for using live vaccines are clearer.
This review provides a brief summary of updated vaccine recommendations as of March 2018. Pharmacist immunizers must stay up-to-date on schedule updates, evidence and product availability. One of the easiest ways to do this is through the following electronic resources:
· CDC’s Vaccines & Immunizations webpage
· Immunization Action Coalition’s (IAC) Ask the Experts webpage
· American Pharmacist Association’s Immunization Center webpage
1. Dooling KL, Guo A, Patel M, et al. Recommendations of the Advisory Committee on Immunization Practices for Use of Herpes Zoster Vaccines. MMWR. 2018;67(3):103-108.
2. Centers for Disease Control and Prevention. What Everyone Should Know about Zostavax. CDC website. https://www.cdc.gov/vaccines/vpd/shingles/public/zostavax/
index.html. Feb. 28, 2018.
3. Zostavax [package insert]. Whitehouse Station, NJ: Merck Sharp & Dohme Corp.; 2018.
4. Shingrix [package insert]. Research Triangle Park, NC: GlaxoSmithKline; 2017.
5. Centers for Disease Control and Prevention. Meningococcal: Who Needs to Be Vaccinated? CDC website. https://www.cdc.gov/vaccines/vpd/mening/hcp/who-vaccinate-hcp.html. Feb. 28, 2018.
6. Kim DK, Riley LE, and Hunter P. Advisory Committee on Immunization Practices Recommended Immunization Schedule for Adults Aged 19 Years or Older — United States, 2018. MMWR. 2018;67:1-3.
7. Centers for Disease Control and Prevention. Advisory Committee on Immunization Practices (ACIP). CDC website. https://www.cdc.gov/vaccines/acip/index.html. March 29, 2018.
8. Dynavax’s HEPLISAV-B™ [Hepatitis B Vaccine (Recombinant), Adjuvanted] Recommended by CDC Advisory Committee on Immunization Practices for the Prevention of Hepatitis B in Adults. GlobeNewswire website. https://globenewswire.com/news-release/2018/02/21/1372711/0/en/Dynavax-s-HEPLISAV-B-Hepatitis-B-Vaccine-Recombinant-Adjuvanted-Recommended-by-CDC-Advisory-Committee-on-Immunization-Practices-for-the-Prevention-of-Hepatitis-B-in-Adults.html. March 2, 2018.
9. Robinson CL, Romero JR, Kempe A, et al. Advisory Committee on Immunization Practices Recommended Immunization Schedule for Children and Adolescents Aged 18 Years or Younger — United States, 2018. MMWR. 2018;67(5):156-157.
10. Centers for Disease Control and Prevention. Recommended Immunization Schedule for Children and Adolescents Aged 18 Years or Younger, United States, 2018. CDC website. https://www.cdc.gov/vaccines/schedules/hcp/imz/child-adolescent.html. March 2, 2018.
10. Centers for Disease Control and Prevention. Frequently Asked Questions About Shingrix. CDC website. https://www.cdc.gov/vaccines/vpd/shingles/hcp/shingrix/faqs.html. May 5, 2018.
11. Centers for Disease Control and Prevention. Frequently Asked Questions About Shingrix. CDC website. https://www.cdc.gov/vaccines/vpd/shingles/hcp/shingrix/faqs.html. May 5, 2018.
12. Centers for Disease Control and Prevention. Shingrix Recommendations. CDC website. https://www.cdc.gov/vaccines/vpd/shingles/hcp/shingrix/recommendations.html. May 5, 2018.