Population-Specific Vaccines: Recommendations and Requirements

Unfortunately, when it comes to individuals taking care of themselves, it becomes clear just how much of a reactive society we live in. Preventive care is preached, but rarely practiced. This is evident not only in lifestyle choices, but in the decision to forgo doctor visits to receive regular checkups and needed vaccinations. While the reasons are varied, part of the problem with vaccination rates is that no national immunization law exists; states enact their own laws, and those laws vary. In addition, laws pertain only to children, enacted to control the spread of infectious diseases in schools, and in some cases to young adults entering college. For teens and adults, the main problem is a lack of awareness of what is recommended for the various population age groups.

What Is Required?

Most individuals born in the U.S. are immunized against vaccinepreventable diseases in the weeks and months after birth as a result of routine immunization schedules. These “childhood immunizations consist of a series of intramuscular or subcutaneous injections or oral dosing of inactivated bacteria, toxoids, live attenuated viruses or inactive viral antigens against 14 diseases: influenza, pneumococcal, diphtheria, tetanus, pertussis, measles, mumps, rubella, polio, Haemophilus influenza b, hepatitis A and B, varicella and rotavirus. Most of the immunizations are given as combined vaccines during routine well-child checks in the first two years of life.”¹

All 50 states have laws requiring vaccination against diptheria, measles, rubella and polio prior to attendance in K-12. Washington, D.C., and 49 of the 50 states require tetanus vaccination, 44 states and D.C. require pertussis vaccination, and 48 states and D.C.require mumps vaccination. In addition, 48 states have requirements for vaccination prior to Head Start enrollment. Only 32 states have requirements for immunization prior to college attendance.²

Despite these laws, there still are children who do not receive these immunizations. A recent study shows that this has a lot to do with convenience and communication. The study, conducted at Columbia University Medical Center and reported on May 5, 2009, by Reuters (www.reuters.com), found that children whose parents have difficulty scheduling appointments or who have a tough time communicating with their child’s doctor are more likely to be under-immunized.

Another reason for this is due to exemption for children with medical contraindications to immunizations, as well as religious and philosophical exemptions. While the numbers of students on record for exemptions is very low, data show that states with the simplest procedures for exemption had the highest rates of exemption, and there are health implications associated with those exemptions.2 For instance, children with personal exemptions were 22 times more likely to have measles during the years 1987 through 1998, and nearly six times more likely to have pertussis.

What Is Recommended?

Because there are no laws governing immunization for adults, the number of individuals not protected against vaccine-preventable diseases is widespread. But, this is not the main reason for lack of immunization. Even if individuals were immunized as children, most don’t get immunized as adults because they don’t know whether they have previously been vaccinated or whether a followup vaccine is needed later in life. In addition, they don’t know that they should ask their doctors what is recommended. According to the Centers for Disease Control and Prevention (CDC), even if individuals get vaccinated as a child, most of the vaccinations don’t last forever, and they are needed again to maintain immunity. Further exacerbating this lack of awareness is that most doctors don’t ask their patients if and when they’ve been immunized, and they fail to tell them what immunizations are needed to protect against infectious diseases.

Infectious Disease Vaccinations

All individuals require some vaccinations at intervals throughout their lives. And the case for ensuring they are up to date with these vaccines is simple: “Some of the illnesses, once contracted, do not have a cure, and all may cause tremendous health problems or even death.”3 The following vaccine-preventable diseases are those that are recommended by the major health organizations.

Influenza. Flu viruses change all the time. Flu shots are needed between September and mid-November each year to give an individual’s body time to build the proper defense. The flu shot both prevents and controls the flu.

Pneumococcal disease. Pneumonia is a serious disease affecting the lungs, and the bacteria that form from this disease can attack other parts of the body, including the brain, which can cause meningitis. The CDC recommends that people over the age of 65 get the pneumococcal vaccine one time. If an individual has received this vaccine before age 65, and it has been longer than five years, the CDC recommends a second shot. Individuals ages 2 through 64 who have diabetes or chronic heart, lung, liver or kidney disorders should also get a pneumococcal vaccine.

Diphtheria, tetanus and pertussis. While tetanus is not spread from person to person, it is caused by a toxin that enters through the skin. Common signs include headache and muscle stiffness in the jaw initially, and then stiffness in the neck, difficulty swallowing, muscle spasms, sweating and fever. Diphtheria, on the other hand, is also caused by a toxin, but it can also spread from an infected person to the nose or throat of others. In some instances, it can lead to breathing problems, heart failure, paralysis and sometimes death; in others, it can cause sores on the skin that are painful, red and swollen. Pertussis (whooping cough) has recently been on the rise, and is easily spread and most dangerous in babies younger than 1 year old. In 2008, 19,000 whooping cough cases in adolescents and adults were reported to the CDC. Most children receive a combined diphtheria-tetanus-pertussis (DTP) vaccine, and adolescents and adults need a Tdap vaccine followed by a Td booster every 10 years.

Chickenpox. Also known as varicella, chickenpox is extremely contagious, spread through the air when people sneeze or cough, or through an infected person’s chickenpox sores. Most children are vaccinated against chickenpox at 15 months old. People ages 13 years and older who were not vaccinated as children need two doses of the chickenpox vaccine. Once chickenpox is contracted, it is very rare but possible to get it again. It’s more common for people who have had it to develop shingles later in life, caused by a reactivation of the same virus.

Measles, mumps and rubella. Most adults today are immune to measles, mumps and rubella either because they have had the diseases as children or they have been vaccinated against them. People born in or after 1957 have likely received at least one dose of the measles-mumps-rubella (MMR) vaccine. However, those born before 1957 who don’t think they’ve been vaccinated should be, and healthcare workers and individuals who travel outside of the U.S. are advised to get a second dose.

Polio. While polio has been eliminated from the Western Hemisphere, it has not been eradicated in the rest of the world. Most children are vaccinated against polio in four different doses, the first three before 18 months of age, and the last before 6 years old. Teens who have not completed their series of polio vaccines and are not yet 18 years old are advised to complete them.

Haemophilus influenzae type b. Hib disease is caused by a bacteria and usually strikes children under 5 years old. A child can get Hib disease by being around other children or adults, as the germs spread from person to person. If the germs stay in a child’s nose and throat, the child probably will not get sick. But if the germs spread into the lungs or the bloodstream, they can cause serious problems. Before the vaccine, Hib disease was the leading cause of bacterial meningitis among children under 5 years old in the United States. All children should be immunized with the Hib vaccine. And while children over 5 years old usually do not need Hib vaccine, some older children or adults with special health conditions should get it.

Meningococcal disease. Meningitis has seen a resurgence in the U.S. Approximately 2,600 people in the U.S. are diagnosed with meningitis, and about 10 percent to 15 percent of those people die. Meningitis is a viral or bacterial infection of the fluid of a person’s spinal cord and the fluid that surrounds the brain, and is spread through the exchange of respiratory and throat secretions (i.e., coughing, kissing). Symptoms include high fever, headache and stiff neck, which can develop over several hours, or they may take one to two days. Other symptoms may include nausea, vomiting, discomfort looking into bright lights, confusion and sleepiness. All teens ages 11 through 18, as well as college freshmen living in dormitories and individuals with special medical conditions, should be vaccinated against this disease. (See the related story on meningitis in this issue on page 58.)

Hepatitis A and B. Approximately 12.5 million Americans have been infected with hepatitis B virus at some point in their lifetime, and about 5,000 people die each year from hepatitis B-related liver disease.5 The number of new infections per year is declining due to routine hepatitis B vaccination in children and adolescents. But, even if vaccinated as a child, vaccines to protect against hepatitis A and B are recommended for individuals in high-risk groups, such as healthcare workers, those who live in households and/or have sex with people with chronic hepatitis B, those with multiple sex partners, people with a recently acquired sexually transmitted disease, men who have sex with men and injecting drug users.

Rotavirus. Rotavirus is the most common cause of severe diarrhea among children, and approximately 55,000 children in the United States are hospitalized each year, while more than 600,000 children die from it annually worldwide. The disease is characterized by vomiting and watery diarrhea for three to eight days, and fever and abdominal pain occur frequently. Repeat infections can occur, but they tend to be less severe than the original infection. Three doses of the rotavirus vaccine is recommended in children at ages 2, 4 and 6 months.

Shingles. Although shingles typically occurs in adults later in life, caused by a reactivation of the chickenpox virus, adults of all ages have been known to get this disease. One dose of the shingles vaccine is recommended only for adults age 60 and over. (See the related article on shingles on page 52.)

Human papillomavirus. HPV, known to cause cervical cancer, is now believed to cause other women’s cancers like vulvar and vaginal. The three-dose HPV vaccine is recommended for all females ages 11 to 26, and could be given to females as young as 9 years old.

Many organizations, including the Centers for Disease Control and Prevention, Immunization Action Coalition, American Academy of Pediatrics and most state health departments, publish immunization schedules. While some are more in-depth than others, even listing medical conditions as factors, all follow the same general guidelines. Listed in Table 1 are the recommendations and requirements set forth for the different populations.

Keeping Up-to-Date Records

To keep current on vaccinations, physicians should stress to their patients the need to keep up-to-date vaccination records. No central repository of immunization records exists. Parents are given the only records that exist when their children are immunized, although some schools retain immunization records of children who attended, but usually for only a year or two. If an individual has served in the military, immunization records would have been required for them. Yet, again, those records are the property of the individual. Physician offices may also keep records of patients who have been vaccinated.

One way physicians can encourage patients to keep records is to provide vaccination record cards for patients to write immunizations and the dates they were received. This card should be kept in a safe place, yet a copy of the card should be made and placed in the individual’s purse or wallet.

A new free service from Google — Google Health — may offer an easy solution to maintaining immunization records, as well as a complete repository for all kinds of personal health information. At www.google.com/health, it’s possible to create online personal health profiles, including health conditions, medications, allergies and lab results by importing medical records from hospitals and pharmacies. Sharing health records within an approved care network is another feature, as well as browsing an online health services directory to find services that are integrated with Google Health. Competitor offerings include Microsoft’s HealthVault and the Indivo project (an open-source project managed by the Children’s Hospital Informatics Program).

If individuals can’t locate a record of whether they’ve been immunized for a particular disease, “there is a blood test called the antibody titer that can detect the presence of antibodies against the disease in question. If the level of these antibodies is high enough, it is a good indication that they have immunity to the disease and do not need another vaccination.”⁴

Vaccination Is a Shared Responsibility

There are many social and economic costs of vaccine-preventable diseases. While great strides have been made in the medical community to protect individuals against these diseases, everyone must do their part to ensure that vaccination rates continue to rise. According to the U.S. Department of Health and Human Services’ Healthy People 2010 report on immunization and infectious diseases, vaccination rates have continued to rise among all populations. Among the Healthy People 2010 objectives are total elimination for congenital rubella syndrome, diphtheria, Haemophilus influenzae type b, measles, mumps, polio, rubella and tetanus; 41 percent improvement for pertussis; 99 percent improvement for hepatitis B; and 99 percent improvement for varicella. To accomplish this, physicians play a pivotal role by emphasizing the need for all populations to get their recommended and required vaccinations.