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Supplement Article  |   February 2010
Incorporating adult immunization strategies into your practice
Article Information
Preventive Medicine
Supplement Article   |   February 2010
Incorporating adult immunization strategies into your practice
The Journal of the American Osteopathic Association, February 2010, Vol. 110, S4-S13. doi:
The Journal of the American Osteopathic Association, February 2010, Vol. 110, S4-S13. doi:
Each year far too many adults in the United States develop diseases, become disabled and even die from diseases that might easily have been prevented with vaccines. For example, in November of 2003, residents of Beaver County, Pa., (population over 17,000) suffered the biggest hepatitis A outbreak in U.S. history, with at least 540 cases and three deaths attributed to dirty scallions imported from Mexico. This is one example of an outbreak that could have been prevented with a two-dose hepatitis A vaccine regimen. 
Few people realize as well that almost everyone—children, young adults and even the elderly—could benefit from certain immunizations. In short, contrary to what most of your patients might believe, vaccines aren't just for kids. 
Some misconceptions
Adults often incorrectly assume that the vaccines they may have received as children will protect them for the rest of their lives. While this may be true for some vaccines, physicians should bear in mind that: 
  • some adults were never vaccinated as children
  • some of the newer vaccines may not have been available when your patient was a child
  • immunity can begin to fade over time
  • as we age, we become more susceptible to serious diseases caused by common infections (e.g., influenza, pneumococcus)
According to academic physician, internist and family physician Tyler C. Cymet, DO, who practices in Owings Mills, Md., “one of the problems with vaccines is that we don't know how long they last. The patient may need booster shots five to 10 years after getting the initial dose, which should be taken into account when deciding which vaccines to give and when.” 
Recommendations
The federal Centers for Disease Control and Prevention (CDC) has issued adult immunization recommendations, which have been updated as of 2010. See Figures 1 and 2 on pages 8 and 9. Current details about vaccination recommendations and guidelines are available at the CDC Web site: www.cdc.gov/mmwr/PDF/wk/mm5753-Immunization.pdf. 
Dr. Cymet points out, however, that the reality is often quite different from the ideal situation. In actual practice, physicians will usually base immunization decisions on the particular patient and the reason he or she is making an office visit. 
The CDC recommendations are for ideal conditions and are usually given during general well visits. Dr. Cymet adds that he personally gives only one vaccine and/or other preventive measure, such as a Pap smear, during a 20-to-30 minute patient visit. 
“If the patient is visiting to discuss a serious medical problem, or a particularly concerning symptom, then it is not likely that I will discuss immunizations,” he explains. “That is, unless the symptom is related to an available vaccine.” 
One example of an appropriate vaccine during a non-well visit is someone with battle scars or skin separations or who has been on long-term steroid use, which leaves recipients with thinner skin. For such patients, Dr. Cymet will more than likely recommend a combination tetanus/diphtheria (i.e., Td) shot. In fact, he stresses that the tetanus vaccine is particularly important for patients taking steroids. 
“There are many ways to give a tetanus shot,” he adds, “which may also be given with pertussis” (Tdap). According to recommendations of the CDC, a vaccine including acellular (as opposed to whole-cell) pertussis may be indicated for women who are pregnant or who have recently given birth, for whom a one-time dose of Tdap may be indicated to protect the newborn. 
Other adults who have frequent close contact with infants also pose a risk of spreading pertussis to another infant, and therefore family members and other caregivers of new infants might also be given Tdap shots. The updated recommendations for these and other adult immunizations, including recommended dosages and indications, are on the CDC Web site. 
In addition to the tetanus, diphtheria and acellular pertussis (Td/Tdap) immunizations, the recommended vaccines for most adults include human papillomavirus (HPV), varicella, herpes zoster, MMR (measles, mumps, rubella), influenza, pneumococcal polysaccharide (PPSV), hepatitis A and hepatitis B, and meningococcal vaccination. 
According to Dr. Cymet, a major consideration in making the decision on whether to vaccinate adult patients is that particular patient's risk factors. For example: 
  • Does the individual travel a good deal? In which case, Tdap, rubella and hepatitis A and B immunizations are often routinely included, depending on the areas to be visited. The rubella vaccine is contraindicated however in pregnant women or people who are immunocompromised.
  • Patients with a family history of cervical cancer are also at risk, and in such cases Dr. Cymet recommends immunizing against human papillomavirus (HPV).
  • People who are often around children and have never had chicken pox are candidates for varicella immunization. This vaccine is contraindicated however in pregnant women or immunocompromised men and women.
  • Meningococcal immunizations are recommended also for people who are frequently around large groups of people. For example, in the case of young people going to college or older people attending elder hostels.
  • Since hepatitis B is blood-borne, the hepatitis B vaccine is particularly important for anyone on dialysis who has kidney disease, individuals who are sexually active and IV drug users. Health-care workers, first responders and law enforcement personnel are also at higher risk than the general population.
  • On the other hand, hepatitis A lives and is spread through dirt and feces that can contaminate our food and beverages. For example, fish or shellfish that come from water contaminated by sewage and human waste. Dirty needles and contaminated syringes can also spread both hepatitis A and B. Farmers or people traveling to Third World countries may also be at risk of hepatitis A. Once you have had hepatitis A, however, you develop lifelong immunity and cannot get the disease again. Because of the way it is spread, the hepatitis A virus tends to occur in epidemics and outbreaks.
  • Anyone who has had chicken pox is at risk of developing herpes zoster (shingles). Shingles can occur in people of all ages, but more commonly in those over 60 years of age, and the risk increases as people get older. When shingles develop, a rash or blisters appear on the skin, generally on one side of the body, a sign that the virus has been dormant in the nerve cells, but has reactivated and traveled from the nerves and followed a path out to the skin. Because the nerves along the path become inflamed, shingles can also be painful. Pain that lasts for months after the rash has healed is called post herpetic neuralgia or PHN. For some people, this pain can be severe and chronic.
Another issue that concerns Dr. Cymet is knowing when a physician should check a patient's blood titer to see if a vaccine has worked. “If a patient is reluctant to get a vaccine or is not sure if he or she had been vaccinated as a child and with what shots, I might do a varicella, measles, mumps and rubella titer,” he says. “If they had one of these diseases they may not need it—it all depends on the patient.” The shots are contraindicated however in pregnant women or people who are severely immunocompromised. 
Dr. Cymet also has some thoughts about other recommended vaccines for adults. He noted that because physicians may have trouble getting reimbursed for the herpes zoster vaccine, they may give the patient a prescription for the vaccine and have the patient purchase the vaccine and deal with insurance reimbursement issues, rather than purchase it through the physician's office. 
Patients who would like to receive the vaccine should ask for a prescription, which they can use at pharmacies or health centers that dispense it and then return to their physicians' offices for the injection to be given. 
Patients should be counseled that the vaccine must be kept on ice and should be brought back to the physician's office for administration after purchase in states where pharmacies are not permitted to vaccinate, such as Florida. 
With respect to the influenza vaccine and whether or not to recommend it every year, depends on the individual patient. The CDC recommends the vaccine in particular for people with chronic disorders of the cardiovascular or pulmonary systems, including asthma; chronic metabolic diseases, including diabetes mellitus, renal or hepatic dysfunction, etc., or immunocompromising conditions such as those caused by human immunodeficiency virus (HIV); any condition that compromises respiratory function; and pregnancy during the influenza season. 
The CDC recommendations also include all health-care personnel, including those employed by long-term care and assisted-living facilities, and caregivers of children less than five years old and residents of nursing homes and other long-term care and assisted-living facilities. 
The CDC recommends the pneumococcal polysaccharide (PPSV) vaccination particularly for people with chronic lung disease (including asthma); chronic cardiovascular diseases; diabetes mellitus; chronic liver diseases, cirrhosis; chronic alcoholism, chronic renal failure or nephrotic syndrome; functional or anatomic asplenia (e.g., sickle cell disease or splenectomy) and other immunocompromising conditions. Other indications include residents of nursing homes or other long-term care facilities and people who smoke cigarettes. 
With respect to whether or not to give flu shots, Dr. Cymet suggests that as a rule of thumb, natural immunity is better than artificial immunity since immunity from the flu vaccine lasts only six to 12 months. “Good strong t cells and b cells make a difference,” in a person's ability to be protected against influenza during flu season. Much of course depends on a particular patient's age, risk factors and preferences. This year however, with the unknown issues of H1N1 influenza, he suggested the vaccine to anyone who was in close contact with others who had the H1N1 influenza and to those in whom the disease could have particularly bad outcomes. 

With respect to the influenza vaccine and whether or not to recommend it every year, depends on the individual patient.

 
Recommended Adult Immunization Schedule —United States
The Advisory Committee on Immunization Practices (ACIP) annually reviews the recommended Adult Immunization Schedule to ensure that the schedule reflects current recommendations for the licensed vaccines. 
In October 2009, ACIP approved the Adult Immunization Schedule for 2010, which includes several changes: 
  • A bivalent human papillomavirus vaccine (HPV2) footnote (#2) was licensed for use in females in October 2009. ACIP recommends vaccination of females aged 19-26 with either HPV2 or the quadrivalent human papillomavirus vaccine (HPV4).
  • HPV4 was licensed for use in males in October 2009, and ACIP issued a permissive recommendation for use in males.
  • The measles, mumps, rubella (MMR) footnote (#5) has language added to clarify which adults born during or after 1957 do not need one or more doses of MMR vaccine for the measles and mumps components, and clarifies which women should receive a dose of MMR vaccine.
  • Interval dosing information has been added to indicate when a second dose of MMR vaccine should be administered.
  • Language has been added to highlight recommendations for vaccinating health-care personnel born before 1957 routinely and during outbreaks.
  • The term “seasonal” has been added to the influenza footnote (#6).
  • The hepatitis A footnote (#9) has language added to indicate that unvaccinated persons who anticipate close contact with an international adoptee should consider vaccination.
  • The hepatitis B footnote (#10) has language added to include schedule information for the three-dose hepatitis B vaccine.
  • The meningococcal vaccine footnote (#11) clarifies which vaccine formulations are preferred for adults aged ≤55 years and ≥56 years, and which vaccine formulation can be used for revaccination. New examples have been added to demonstrate who should and should not be considered for revaccination.
  • The selected conditions for Haemophilus influenza type b (Hib) footnote (#13) clarifies which high-risk persons may receive one dose of Hib vaccine.
Approvals and recommendations
The recommended Adult Immunization Schedule has been approved by the Advisory Committee on Immunization Practices, the American Academy of Family Physicians, the American College of Obstetricians and Gynecologists, the American College of Physicians. 
These schedules indicate the recommended age groups and medical indications for which administration of currently licensed vaccines is commonly indicated for adults aged ≥19 years, as of Jan. 1, 2010. 
Licensed combination vaccines may be used whenever any components of the combination are indicated and when the vaccine's other components are not contraindicated. For detailed recommendations on all vaccines, including those that are used primarily for travelers or are issued during the year, consult the manufacturer's package inserts and the complete statements from the Advisory Committee on Immunization Practices (ACIP) http://www.cdc.gov/vaccines/pubs/acip-list.htm). 
Report all clinically significant postvaccination reactions to the Vaccine Adverse Event Reporting System (VAERS). Reporting forms and instructions on filing a VAERS report are available at http://www.vaers.hhs.gov or by telephone, (800) 822-7967. 
Information on how to file a Vaccine Injury Compensation Program claim is available at http://www.hrsa.gov/vaccinecompensation or by telephone, (800) 338-2382. To file a claim for vaccine injury, contact the US Court of Federal Claims, 717 Madison Place, NW, Washington, DC 20005; telephone, (202) 357-6400. 
Additional information about the vaccines in this schedule, extent of available data, and contraindications for vaccination is available at http://www.cdc.gov/vaccines or from the CDC-INFO Contact Center at (800) CDC-INFO (800) 232-4636 in English and Spanish, 24 hours a day, seven days a week. 
Schedule footnotes
1. Tetanus, diphtheria, and acellular pertussis (Td/Tdap) vaccination
Tdap should replace a single dose of Td for adults aged 19 to 64 years who have not received a dose of Tdap previously. 
Adults with uncertain or incomplete history of primary vaccination series with tetanus and diphtheria toxoid-containing vaccines should begin or complete a primary vaccination series. A primary series for adults is three doses of tetanus and diphtheria toxoid-containing vaccines; administer the first two doses at least four weeks apart and the third dose six to 12 months after the second; Tdap can substitute for any one of the doses of Td in the three-dose primary series. The booster dose of tetanus and diphtheria toxoid-containing vaccine should be administered to adults who have completed a primary series and if the last vaccination was received ≥10 years previously. Tdap or Td vaccine may be used, as indicated. 
If a woman is pregnant and received the last Td vaccination ≥10 years previously, administer Td during the second or third trimester. If the woman received the last Td vaccination <10 years previously, administer Tdap during the immediate postpartum period. A dose of Tdap is recommended for postpartum women, close contacts of infants aged <12 months, and all health-care personnel with direct patient contact if they have not previously received Tdap. An interval as short as two years from the last Td vaccination is suggested; shorter intervals can be used. Td may be deferred during pregnancy and Tdap substituted in the immediate postpartum period, or Tdap can be administered instead of Td to a pregnant woman. 
Consult the ACIP statement for recommendations for giving Td as prophylaxis in wound management. 
2. Human papillomavirus (HPV) vaccination
HPV vaccination is recommended at age 11 or 12 years with catch-up vaccination at ages 13 through 26 years. 
Ideally, vaccine should be administered before potential exposure to HPV through sexual activity; however, females who are sexually active should still be vaccinated consistent with age-based recommendations. Sexually active females who have not been infected with any of the four HPV vaccine types (types 6, 11, 16, 18, all of which HPV4 prevents) or any of the two HPV vaccine types (types 16 and 18, both of which HPV2 prevents) receive the full benefit of the vaccination. Vaccination is less beneficial for females who have already been infected with one or more of the HPV vaccine types. HPV4 or HPV2 can be administered to persons with a history of genital warts, abnormal Papanicolaou test, or positive HPV DNA test, because these conditions are not evidence of prior infection with all vaccine HPV types. 
HPV4 may be administered to males aged 9 through 26 years to reduce their likelihood of acquiring genital warts. HPV4 would be most effective when administered before exposure to HPV through sexual contact. 
A complete series for either HPV4 or HPV2 consists of three doses. The second dose should be administered one to two months after the first dose; the third dose should be administered six months after the first dose. 
Although HPV vaccination is not specifically recommended for persons with the medical indications described in Figure 2, “Vaccines that might be indicated for adults based on medical and other indications,” it may be administered to these persons because the HPV vaccine is not a live-virus vaccine. However, the immune response and vaccine efficacy might be less for persons with the medical indications described in Figure 2 than in persons who do not have the medical indications described or who are immunocompetent. Health-care personnel are not at increased risk because of occupational exposure and should be vaccinated consistent with age-based recommendations. 
3. Varicella vaccination
All adults without evidence of immunity to varicella should receive two doses of single-antigen varicella vaccine if not previously vaccinated or the second dose if they have received only one dose, unless they have a medical contraindication. Special consideration should be given to those who 1) have close contact with persons at high risk for severe disease (e.g., health-care personnel and family contacts of persons with immunocompromising conditions) or 2) are at high risk for exposure or transmission (e.g., teachers; child-care employees; residents and staff members of institutional settings, including correctional institutions; college students; military personnel; adolescents and adults living in households with children; nonpregnant women of childbearing age; and international travelers). 
Evidence of immunity to varicella in adults includes any of the following: 1) documentation of two doses of varicella vaccine at least four weeks apart; 2) US-born before 1980 (although for health-care personnel and pregnant women, birth before 1980 should not be considered evidence of immunity); 3) history of varicella based on diagnosis or verification of varicella by a health-care provider (for a patient reporting a history of or having an atypical case, a mild case, or both, health-care providers should seek either an epidemiologic link with a typical varicella case or to a laboratory-confirmed case or evidence of laboratory confirmation, if it was performed at the time of acute disease); 4) history of herpes zoster based on diagnosis or verification of herpes zoster by a health-care provider; or 5) laboratory evidence of immunity or laboratory confirmation of disease. 
Pregnant women should be assessed for evidence of varicella immunity. Women who do not have evidence of immunity should receive the first dose of varicella vaccine upon completion or termination of pregnancy and before discharge from the health-care facility. The second dose should be administered four to eight weeks after the first dose. 
4. Herpes zoster vaccination
A single dose of zoster vaccine is recommended for adults aged ≥60 years regardless of whether they report a prior episode of herpes zoster. Persons with chronic medical conditions may be vaccinated unless their condition constitutes a contraindication. 
5. Measles, mumps, rubella (MMR) vaccination
Adults born before 1957 generally are considered immune to measles and mumps. 
Measles component: Adults born during or after 1957 should receive one or more doses of MMR vaccine unless they have 1) a medical contraindication; 2) documentation of vaccination with one or more doses of MMR vaccine; 3) laboratory evidence of immunity; or 4) documentation of physician-diagnosed measles. 
A second dose of MMR vaccine, administered four weeks after the first dose, is recommended for adults who 1) have been recently exposed to measles or are in an outbreak setting; 2) have been vaccinated previously with killed measles vaccine; 3) have been vaccinated with an unknown type of measles vaccine during 1963-1967; 4) are students in postsecondary educational institutions; 5) work in a health-care facility; or 6) plan to travel internationally. 
Mumps component: Adults born during or after 1957 should receive one dose of MMR vaccine unless they have 1) a medical contraindication; 2) documentation of vaccination with one or more doses of MMR vaccine; 3) laboratory evidence of immunity; or 4) documentation of physician-diagnosed mumps. 
A second dose of MMR vaccine, administered four weeks after the first dose, is recommended for adults who 1) live in a community experiencing a mumps outbreak and are in an affected age group; 2) are students in postsecondary educational institutions; 3) work in a health-care facility; or 4) plan to travel internationally. 
Rubella component: One dose of MMR vaccine is recommended for women who do not have documentation of rubella vaccination, or who lack laboratory evidence of immunity. For women of childbearing age, regardless of birth year, rubella immunity should be determined, and women should be counseled regarding congenital rubella syndrome. Women who do not have evidence of immunity should receive MMR vaccine upon completion or termination of pregnancy and before discharge from the health-care facility. 
Health-care personnel born before 1957: For unvaccinated health-care personnel born before 1957 who lack laboratory evidence of measles, mumps, and/or rubella immunity or laboratory confirmation of disease, health-care facilities should consider vaccinating personnel with two doses of MMR vaccine at the appropriate interval (for measles and mumps) and one dose of MMR vaccine (for rubella), respectively. 
During outbreaks, health-care facilities should recommend that unvaccinated health-care personnel born before 1957, who lack laboratory evidence of measles, mumps, and/or rubella immunity or laboratory confirmation of disease, receive two doses of MMR vaccine during an outbreak of measles or mumps, and one dose during an outbreak of rubella. 
Complete information about evidence of immunity is available at http://www.cdc.gov/vaccines/recs/provisional/default.htm. 
6. Seasonal influenza vaccination
Vaccinate all persons aged ≥50 years and any younger persons who would like to decrease their risk for influenza. Vaccinate persons aged 19 through 49 years with any of the following indications. 
Medical: Chronic disorders of the cardiovascular or pulmonary systems, including asthma; chronic metabolic diseases (including diabetes mellitus); renal or hepatic dysfunction, hemoglobinopathies, or immunocompromising conditions (including immunocompromising conditions caused by medications or HIV); cognitive, neurologic, or neuromuscular disorders; and pregnancy during the influenza season. No data exist on the risk for severe or complicated influenza disease among persons with asplenia; however, influenza is a risk factor for secondary bacterial infections that can cause severe disease among persons with asplenia. 
Occupational: All health-care personnel, including those employed by long-term care and assisted-living facilities, and caregivers of children aged <5 years. 
Other: Residents of nursing homes and other long-term care and assisted-living facilities; persons likely to transmit influenza to persons at high risk (e.g., in-home household contacts and caregivers of children aged <5 years, persons aged ≥50 years, and persons of all ages with high-risk conditions). 
Healthy, nonpregnant adults aged <50 years without high-risk medical conditions who are not contacts of severely immunocompromised persons in special-care units may receive either intranasally administered live, attenuated influenza vaccine (FluMist) or inactivated vaccine. Other persons should receive the inactivated vaccine. 
7. Pneumococcal polysaccharide (PPSV) vaccination
Vaccinate all persons with the following indications. 
Medical: Chronic lung disease (including asthma); chronic cardiovascular diseases; diabetes mellitus; chronic liver diseases, cirrhosis; chronic alcoholism; functional or anatomic asplenia (e.g., sickle cell disease or splenectomy [if elective spletnectomy is planned, vaccinate at least two weeks before surgery]); immunocompromising conditions (including chronic renal failure or nephrotic syndrome); and cochlear implants and cerebrospinal fluid leaks. Vaccinate as close to HIV diagnosis as possible. 
Other: Residents of nursing homes or long-term care facilities and persons who smoke cigarettes. Routine use of PPSV is not recommended for American Indians/Alaska Natives or persons aged <65 years unless they have underlying medical conditions that are PPSV indications. However, public health authorities may consider recommending PPSV for American Indians/Alaska Natives and persons aged 50 through 64 years who are living in areas where the risk for invasive pneumococcal disease is increased. 
8. Revaccination with PPSV
One-time revaccination after five years is recommended for persons with chronic renal failure or nephrotic syndrome; functional or anatomic asplenia (e.g., sickle cell disease or splenectomy); and for persons with immunocompromising conditions. For persons aged ≥65 years, one-time revaccination is recommended if they were vaccinated ≥5 years previously and were aged <65 years at the time of primary vaccination. 
9. Hepatitis A vaccination
Vaccinate persons with any of the following indications and any person seeking protection from hepatitis A virus (HAV) infection. 
Behavioral: Men who have sex with men and persons who use injection drugs. 
Occupational: Persons working with HAV-infected primates or with HAV in a research laboratory setting. 
Medical: Persons with chronic liver disease and persons who receive clotting factor concentrates. 
Other: Persons traveling to or working in countries that have high or intermediate endemicity of hepatitis A (a list of countries is available at http://wwwn.cdc.gov/travel/contentdiseases.aspx). 
Unvaccinated persons who anticipate close personal contact (e.g., household contact or regular babysitting) with an international adoptee from a country of high or intermediate endemicity during the first 60 days after arrival of the adoptee in the United States should consider vaccination. The first dose of the two-dose hepatitis A vaccine series should be administered as soon as adoption is planned, ideally ≥2 weeks before the arrival of the adoptee. 
Single-antigen vaccine formulations should be administered in a two-dose schedule at either 0 and 6 to 12 months (Havrix), or 0 and 6 to 18 months (Vaqta). If the combined hepatitis A and hepatitis B vaccine (Twinrix) is used, administer three doses at 0, 1, and 6 months; alternatively, a four-dose schedule, administered on days 0, 7, and 21 to 30 followed by a booster dose at month 12 may be used. 
10. Hepatitis B vaccination
Vaccinate persons with any of the following indications and any person seeking protection from hepatitis B virus (HBV) infection. 
Behavioral: Sexually active persons who are not in a long-term, mutually monogamous relationship (e.g., persons with more than one sex partner during the previous six months); persons seeking evaluation or treatment for a sexually transmitted disease (STD); current or recent injection-drug users; and men who have sex with men. 
Occupational: Health-care personnel and public-safety workers who are exposed to blood or other potentially infectious body fluids. 
Medical: Persons with end-stage renal disease, including patients receiving hemodialysis; persons with HIV infection; and persons with chronic liver disease. 
Other: Household contacts and sex partners of persons with chronic HBV infection; clients and staff members of institutions for persons with developmental disabilities; and international travelers to countries with high or intermediate prevalence of chronic HBV infection (a list of countries is available at http://wwwn.cdc.gov/travel/contentdiseases.aspx). 
Hepatitis B vaccination is recommended for all adults in the following settings: STD treatment facilities; HIV testing and treatment facilities; facilities providing drug-abuse treatment and prevention services; health-care settings targeting services to injection-drug users or men who have sex with men; correctional facilities; end-stage renal disease programs and facilities for chronic hemodialysis patients; and institutions and nonresidential day-care facilities for persons with developmental disabilities. 
Administer or complete a three-dose series of hepatitis B vaccine to those persons not previously vaccinated. The second dose should be administered one month after the first dose; the third dose should be administered at least two months after the second dose (and at least four months after the first dose). If the combined hepatitis A and hepatitis B vaccine (Twinrix) is used, administer three doses at 0, 1, and 6 months; alternatively, a four-dose schedule, administered on days 0, 7, and 21 to 30 followed by a booster dose at month 12 may be used. 
Adult patients receiving hemodialysis or with other immunocompromising conditions should receive one dose of 40 μg/mL (Recombivax HB) administered on a three-dose schedule or two doses of 20 μg/mL (Engerix-B) administered simultaneously on a four-dose schedule at 0, 1, 2, and 6 months. 
11. Meningococcal vaccination
Meningococcal vaccine should be administered to persons with the following indications. 
Medical: Adults with anatomic or functional asplenia, or persistent complement component deficiencies. 
Other: First-year college students living in dormitories; microbiologists routinely exposed to isolates of Neisseria meningitidis; military recruits; and persons who travel to or live in countries in which meningococcal disease is hyperendemic or epidemic (e.g., the “meningitis belt” of sub-Saharan Africa during the dry season [December through June]), particularly if their contact with local populations will be prolonged. Vaccination is required by the government of Saudi Arabia for all travelers to Mecca during the annual Hajj. 
Meningococcal conjugate vaccine (MCV4) is preferred for adults with any of the preceding indications who are aged ≤55 years; meningococcal polysaccharide vaccine (MPSV4) is preferred for adults aged ≥56 years. Revaccination with MCV4 after five years is recommended for adults previously vaccinated with MCV4 or MPSV4 who remain at increased risk for infection (e.g., adults with anatomic or functional asplenia). Persons whose only risk factor is living in on-campus housing are not recommended to receive an additional dose. 
12. Selected conditions for which Haemophilus influenzae type b (Hib) vaccine may be used.
Hib vaccine generally is not recommended for persons aged ≥5 years. No efficacy data are available on which to base a recommendation concerning use of Hib vaccine for older children and adults. However, studies suggest good immunogenicity in patients who have sickle cell disease, leukemia, or HIV infection or who have had a splenectomy. Administering one dose of Hib vaccine to these high-risk persons who have not previously received Hib vaccine is not contraindicated. 
13. Immunocompromising conditions
Inactivated vaccines generally are acceptable (e.g., pneumococcal, meningococcal, influenza [inactivated influenza vaccine]) and live vaccines generally are avoided in persons with immune deficiencies or immunocompromising conditions. Information on specific conditions is available at http://www.cdc.gov/vaccines/pubs/acip-list.htm.