Immunization: Not to be Taken for Granted

Immunization is considered to be one of the 10 greatest public health achievements of the 20th century. Smallpox is now eradicated, polio is eliminated in all but two countries, and measles and rubella are considered eliminated as an endemic disease in the Western hemisphere. While vaccination in children is considered an excellent return on investment and is well-funded, adult vaccination has much less uptake. Pediatric vaccines eliminate disease whereas adult vaccines reduce occurrence and severity. Adult vaccine guidelines are also not as clearly communicated to the public.

The current uptake of the influenza vaccine in the USA is 66% in those over 65 years old, and 40% in those aged 50-64. The pneumococcal vaccine has a 62% uptake in those over 65 and 20% in those aged 19-64 who are at high risk. The Herpes Zoster vaccine uptake in the population over age 65 is 16%. The goal for all of these vaccinations is to have 90% of target populations immunized. Attitude, cost and accessibility all contribute to this discrepancy.

The influenza vaccine has just been released and all health professionals were encouraged to be vaccinated to prevent spread to vulnerable patients. We were reminded that the virus can be spread prior to the onset of symptoms. A new high-dose trivalent vaccine has been released for patients over age 65, which has four times more vaccine per dose and prevents 24% more cases of influenza. Although this may be the best option for our compromised inflammatory arthritis patients, it has not been studied in this population. A recombinant flu vaccine is also available which is not produced in eggs, allowing for patients with an egg allergy to be immunized.

The pneumococcal vaccine recommended for immunocompromised patients over age 19 is the conjugate vaccine PCV13, followed 8 weeks later by the polysaccharide vaccine PPSV23. The Hepatitis B vaccine is suggested for many special populations including those who are sexually active and not in a mutual monogamous long-term relationship. Patients with diabetes aged 19-59 are also recommended to the have the Hepatitis B vaccine. As there are treatments but no cure for Hepatitis B, many rheumatologists suggest vaccination for all patients before initiating DMARD/biologic treatment as there is significant blunting of the effectiveness of this vaccine while on therapy.

Immunize Canada has published guidelines for adult vaccination for those over age 50. These guidelines have a low level of implementation, similar to what is seen in the USA. The take home message of the session is that it requires vigilance on the part of general practitioners and specialists alike to not just suggest vaccination but to go a step further and prescribe it!!

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