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Special Report  |   April 2012
Advisory Committee on Immunization Practices (ACIP) Update, February 2012
Author Affiliations & Notes
  • Stanley E. Grogg, DO
    From the Oklahoma State University Center for Health Sciences College of Osteopathic Medicine in Tulsa. Dr Grogg serves as the American Osteopathic Association's representative to the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices
  • Address correspondence to Stanley E. Grogg, DO, Professor, Department of Pediatrics, Oklahoma State University Center for Health Sciences, 1111 W 17th St, Room 342, Tulsa, OK 74107-1886. E-mail: stanley.grogg@okstate.edu  
Article Information
Geriatric Medicine / Pediatrics / Preventive Medicine
Special Report   |   April 2012
Advisory Committee on Immunization Practices (ACIP) Update, February 2012
The Journal of the American Osteopathic Association, April 2012, Vol. 112, 162-164. doi:10.7556/jaoa.2012.112.4.162
The Journal of the American Osteopathic Association, April 2012, Vol. 112, 162-164. doi:10.7556/jaoa.2012.112.4.162
On February 22 and February 23, 2012, the Advisory Committee for Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC) met in Atlanta, Georgia.1 The Committee, which comprises 15 members, 8 ex officio members, and 30 nonvoting representatives from liaison organizations (including the American Osteopathic Association),2 discussed several vaccines. The primary highlights of the meeting were as follows:
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    Tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccine—The ACIP recommended that adults aged 19 years or older who previously have not received a dose of the Tdap vaccine should receive a single dose of it. Medicare patients are to be covered on part D.
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    Influenza vaccine—As of February 11, 2012, the 2011-2012 influenza season has been mild and sporadic in the United States, with only 3 reported pediatric deaths.3 Oseltamivir and zanamivir remain the recommended medications for the treatment and prophylaxis for patients with influenza A (all subtypes) and B virus infections.
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    13-Valent pneumococcal conjugate vaccine (PCV13)—This vaccine was licensed by the US Food and Drug Administration (FDA) for adults aged 50 years or older on December 30, 2011.4 The ACIP deferred any recommendations until further information is reviewed.
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    Meningococcal vaccination—Recommendations remain unchanged.
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    Measles, mumps, and rubella (MMR) vaccine—A third dose of the MRR vaccine was discussed for use during mumps epidemics. Recommendations remain unchanged.
As the American Osteopathic Association's ACIP representative, I provide a summary of these recommendations and the related discussions from the meeting in the remainder of this article.
Tdap Vaccine
In October 2010, the ACIP recommended that adults aged 65 years or older who are in close contact with an infant should receive a Tdap vaccine; other adults aged 65 years or older may be administered the Tdap instead of the tetanus and diphtheria toxoids (Td) vaccine. At that time, neither of the Tdap products (Adacel [Sanofi Pasteur Ltd, Toronto, Canada] and Boostrix [GlaxoSmithKline Biologicals, Rixensart, Belgium]) were licensed for use in this age group. In July 2011, the FDA approved an expanded age indication for Boostrix to include adults aged 65 years or older. 
A review5 by the ACIP's Pertussis Vaccine Working Group on the epidemiology of pertussis in older adults in the United States revealed a clinically significant resurgence of pertussis in the United States. The administration of Tdap in adolescents has reduced the burden of pertussis. The ACIP believes that the safety and immunogenicity of the Tdap vaccine in persons aged 65 years or older is adequate to mount immune responses likely to provide protection from pertussis. The use of Tdap to prevent pertussis in this patient population is believed to be a cost-effective intervention. 
Based on these discussions, the ACIP recommended that adults aged 19 years or older who previously have not received a dose of the Tdap vaccine should be given a single dose of the vaccine. A Center for Medicare and Medicaid Services representative indicated that Medicare patients will be covered on part D. 
The ACIP's guidance on the use of Tdap products for adults aged 65 years or older is as follows:
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    When feasible, the FDA-approved Tdap vaccine (ie, Boostrix) should be used.
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    A dose of Adacel is considered valid.
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    Providers should not miss an opportunity to vaccinate a patient in this population with Tdap, and they may administer the vaccine that they have available.
Influenza
The 2011-2012 influenza season has been mild, with 3 pediatric deaths related to influenza having been reported as of February 11, 2012.3 The CDC continues to recommend oseltamivir and zanamivir for treatment and chemoprophylaxis for patients with influenza A (all subtypes) and B viral infections. 
The CDC's guidance for the treatment of patients with influenza is as follows:
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    Do not wait for test results to start chemoprophylaxis or treatment for patients who have severe, complicated, or progressive illness; who require hospitalization; who are at higher risk for influenza complications; and who are not at high risk if early treatment can be given based on clinical judgment.
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    The recommended course of therapy is 5 days. Longer courses may be considered for patients who remain severely ill after 5 days of treatment.
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    The recommended course of chemoprophylaxis is 10 days after household exposures and 7 days after most recent exposure in other situations. For control of outbreaks in long-term care facilities and hospitals, prophylaxis for a minimum of 2 weeks and up to 1 week after the last exposure is recommended.
PCV13
The ACIP Pneumococcal Vaccines Working Group discussed the following topics:
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    PCV13 was licensed for adults aged 50 years or older on December 30, 2011, under the accelerated approval pathway, which allows for earlier approval of products for serious and life-threatening illnesses. Accelerated approval is based on a surrogate endpoint—in this case, immuno genicity noninferior to PPV23—that is “reasonably likely to predict clinical benefit.”6
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    A randomized controlled trial of PCV13 against pneumococcal pneumonia (CAPITA trial) is under way in the Netherlands. The results are expected in 2013.
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    PCV13 includes serotypes that cause about 55% of invasive pneumococcal disease; PPV23 includes serotypes causing about 75% of invasive disease.
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    Immunogenicity studies show that PCV13 is as immunogenic as PPV23 in adults, and often more immunogenic for some serotypes.
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    Cost-effectiveness analyses show PCV13 in adults to be cost-effective.
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    As of January 2012, the ACIP concluded that the available data do not support a strong recommendation for routine use of PCV13 among adults aged 50 years or older.
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    A “GRADE” evaluation of evidence for age-based recommendations has occurred.
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    Recommendations for use of PCV13 among immunocompromised individuals who are at very high risk of disease were considered.
A recommendation for adults is expected at the June 2012 ACIP meeting. Presently, the available evidence is believed to be insufficient to recommend routine use of PCV13 among older adults. 
HBV
The HBV working group discussed health care workers' decreasing epidemiology of occupational hepatitis B infection (a decrease that likely was aided by increased use of “sharps” with engineered injury protections) and declining acute and chronic hepatitis B resulting from increased vaccination coverage. Draft options under consideration include the following:
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    no action unless exposed
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    pre-exposure antibodies to hepatitis B surface antigens
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    challenge dose of HBV
Current HBV recommendations were published in Morbidity and Mortality Weekly Report.7
Meningococcal Vaccines
The ACIP's Meningococcal Vaccines Work Group indicated that the FDA had not licensed any vaccine for infants younger than 9 months. Currently, 2 investigational vaccines for infant use are MenACWY-D (Menactra, Sanofi Pasteur Ltd) and MenACWY-CRM (Menveo, Novartis [East Hanover, New Jersey]). 
The MenACWY-D vaccine is indicated as a 2-dose primary series for children aged 9 to 23 months and was approved by the FDA in April 2011.8 The vaccine is not routinely recommended for children aged 2 to 10 years because rates of meningococcal disease are low and antibodies wane quickly. 
Presently available vaccines are the quadravalent polysaccharide vaccine (MPSV4 [Menomune, Sanofi Pasteur]) and the conjugate vaccines (MenACWY-D, approved for patients aged 9 months through 55 years, and MenACWY-CRM, approved for patients aged 2 through 55 years). 
The new grading recommendation assessment of the toddler MenACWY-D vaccine was reviewed. 
MMR Vaccine
The mumps vaccine was licensed in 1967; in 1977, it was recommended for routine use in children aged 12 months and older.9,10 After the mumps vaccine was introduced, the reported incidence of mumps decreased steadily in the United States. In fact, use of the mumps vaccine reduced disease levels more than 95%.9,10 By the early 2000s, an average of fewer than 300 cases were reported annually, with average incidence of 0.1 per 100,000.9,10 
Despite high 2-dose MMR vaccine coverage, the United States experienced mumps outbreaks in 2006 (>6500 cases)9-11 and 2009-2010 (approximately 3500 cases).11 Although the current 2-dose schedule is sufficient for mumps control in the general population, outbreaks can occur in well-vaccinated communities. Intense exposure settings and waning immunity appear to be risk factors for secondary vaccine failure.9-11 
Standard outbreak control measures (eg, isolation of cases and vaccination of eligible contacts) had not been effective in halting mumps outbreaks among highly vaccinated (2-dose) populations. In collaboration with local health departments, the CDC conducted 2 studies that evaluated the impact of a third dose intervention during mumps outbreaks and economic impact of mumps outbreak in Orange County, New York (2009-2010) and Guam (2010). Declines in mumps outbreaks were evident in many age groups but were most pronounced in the age group targeted (ie, 11- to 17-year-olds).12 The number of adverse events reported after vaccination were either lower than or within the range of those reported in prior studies of first- and second-dose MMR vaccine studies.12 
Although the use of a third dose of MMR vaccine to control an outbreak as routine control measures may be effective, findings do not provide conclusive evidence on the impact of a third dose for outbreak control. The ACIP discussed whether it is permissive and reasonable to use a targeted third dose for mumps outbreak control in certain situations. This topic will be discussed at future ACIP meetings after further review by the MMR working group. 
Vaccine Supplies
It is often difficult for physicians to keep track of vaccine supplies in the United States. Physicians can access supply updates at http://www.cdc.gov/vaccines/vac-gen/shortages/default.htm. 
Conclusion
The ACIP meets 3 times per year in February, June, and October to discuss and make recommendations for vaccines approved by the FDA. It is important for osteopathic physicians to check the immunization schedules on a regular basis to stay up to date on the specific changes in recommendations to provide the best preventive care for our patients. 
   Financial Disclosures: Dr Grogg is a primary investigator for vaccine research for GlaxoSmithKline Pharmaceuticals; MedImmune Inc; Merck & Co, Inc; Novartis Pharmaceuticals; Pfizer Inc; and sanofi-aventis. He also serves on the speakers' bureaus for Merck & Co, Inc; Novartis Pharmaceuticals; and sanofi-aventis, and he serves as a consultant for Merck & Co, Inc, and Novartis Pharmaceuticals.
 
References
Meeting of the Advisory Committee on Immunization Practices (ACIP) [agenda]. ACIP Web site. http://www.cdc.gov/vaccines/recs/acip/meetings.htm#agendas/. Updated February 16 , 2012. Accessed March 7, 2012.
Recommendations and guidelines: Advisory Committee on Immunization Practices. Centers for Disease Control and Prevention Web site. http://www.cdc.gov/vaccines/recs/ACIP/#committee. Updated March 6 2012. Accessed March 16, 2012.
Weekly report: influenza summary update. Centers for Disease Control and Prevention Web site. http://www.cdc.gov/flu/weekly/. Accessed March 7, 2012.
FDA expands use of Prevnar 13 vaccine for people ages 50 and older [press release]. US Food and Drug Administration Web site. http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm285431.htm. Accessed March 28, 2012.
Acosta A. Epidemilogy of Pertussis in Adults 65 Years and Older. Atlanta, GA: Centers for Disease Control and Prevention; February 2012. http://www.cdc.gov/vaccines/recs/acip/downloads/mtg-slides-feb12/03-pertussis-Acosta.pdf. Accessed March 17, 2012.
Fast track, accelerated approval and priority review. US Food and Drug Administration Web site. http://www.fda.gov/forconsumers/byaudience/forpatientadvocates/speedingaccesstoimportantnewtherapies/ucm128291.htm. Updated May 28 , 2010. Accessed March 16, 2012.
Centers for Disease Control and Prevention (CDC). Immunization of health-care personnel: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2011;60(RR-7):1-45. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6007a1.htm?s_cid=rr6007a1_w. Accessed March 16, 2012.
Centers for Disease Control and Prevention (CDC). Recommendation of the Advisory Committee on Immunization Practices (ACIP) for use of quadrivalent meningococcal conjugate vaccine (MenACWY-D) among children aged 9 through 23 months at increased risk for invasive meningococcal disease. MMWR Morb Mortal Wkly Rep. 2011;60(40):1391-1392.http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6040a4.htm. Accessed March 28, 2012.
Dayan GH, Quinlisk MP, Parker AAet al. Recent resurgence of mumps in the United States. N Engl J Med. 2008;358(15):1580-1589. [CrossRef] [PubMed]
Barskey AE, Glasser JW, LeBaron CW. Mumps resurgences in the United States: a historical perspective on unexpected elements. Vaccine. 2009;27(44):6186-6195. [CrossRef] [PubMed]
Barskey A. Mumps in the United States: Background and Epidemiology. Atlanta, GA: Centers for Disease Control and Prevention; February 2012. http://www.cdc.gov/vaccines/recs/acip/downloads/mtg-slides-feb12/03-MMR-Barskey.pdf. Accessed March 17, 2012.
Summary and Discussion: Third Dose of MMR Vaccine for Mumps Control. Atlanta, GA: Centers for Disease Control and Prevention; February 2012. http://www.cdc.gov/vaccines/recs/acip/downloads/mtg-slides-feb12/06-MMR-McLean.pdf. Accessed March 17, 2012.