Education Columns

Donald B. Middleton, MD, UPMC St. Margaret, Pittsburgh, PA

Every family physician should have a favorite source for information about immunizations. The Society of Teachers of Family Medicine’s Group on Immunization Web site provides ready access to instructive vaccination cases and to the “point of care” immunization program, Shots 2010, which is now online and is compatible with iPhones. One can also link to this program through the Centers for Disease Control and Prevention (CDC) Web site (click “Other Versions” on any vaccine schedule).

The CDC offers a wealth of information, although on occasion finding exactly what you need may be a bit daunting. The Immunization Action Coalition (IAC) (www.immunize.org/) may lead to more rapid access of information or to answers for more specific questions.

Shots 2010 includes graphic presentation of the three unified CDC schedules for children, adolescents, and adults; the catch-up schedule; and the medical and employment indications for adult vaccines. It also has the epidemiology of and pictures of vaccine preventable diseases to share with patients.

Unfortunately, primary care clinicians are not keeping pace with the recommended vaccine schedules. Some vaccinations, particularly Zostavax to prevent shingles, have been given to few individuals. All adults age 60 and over should be vaccinated against herpes zoster. The use of standing orders in your office allows the nursing staff to give certain vaccines, and this should lead to greater compliance with vaccination recommendations.

In 2008, The World Health Organization reported that 164,000 persons died from measles worldwide. Most primary care physicians in the United States have never seen a case of measles. The only explanation for this extraordinary fact is MMR vaccine. As experts in preventive health, all the family physicians should strive for full immunization for each of our patients.

Changes in the childhood and adolescent schedule for 2010 are outlined on the CDC Web site. The combination vaccine, ProQuad including MMRV, is due to be back on the market in February 2010. MMRV is an excellent vaccination for the booster dose scheduled for children ages 4–6 years. It causes a very slight increase in febrile seizures when used for the 12–15-month-old visit, so some are recommending the continued use of two separate shots, one MMR and one varicella.

Vaccination with pneumococcal polysaccharide vaccine (PPV) has not met recommendations. PPV is indicated for all individuals age 19 years and above who have certain chronic medical conditions, including diabetes mellitus, heart failure, COPD, renal disease, and cirrhosis. The newest recommendations also include both asthma and smoking. Data suggests that smokers get the greatest benefit from PPV. Individuals 65 years and over need only one PPV for the remainder of their lives, but the need for additional PPV is undergoing further study.

Family physicians should also concentrate on HPV vaccination for women between ages 19–26 years, a group who have been markedly under-vaccinated for HPV disease. For HPV the 2010 changes in the adult schedule mirror those in the adolescent schedule. Either bivalent HPV vaccine (Cervarix) or quadrivalent HPV vaccine (Gardasil) can be given to women up to the age of 27 years. The ACIP also issued a permissive recommendation for use of Gardasil in males to prevent warts up until the age of 27 years.

A second HPV vaccine is now on the scene. Cervarix contains both HPV 16 and 18 mixed with a potent adjuvant that induces high levels of antibody. Both Cervarix and Gardasil (HPV types 6 and 11, responsible for more than 90% of genital warts, and types 16 and 18) are indicated for young girls and women, ages 9 through 26 years.

Anogenital warts are the most common sexually transmitted disease in the United States; about 1% of sexually active adults in the United States have genital warts at any given time. The potential benefit of using Gardisil to reduce the spread of warts to boys is striking. The Advisory Committee on Immunization Practices (ACIP) has given a permissive recommendation for the administration of Gardasil to boys age 9–18 years to reduce the likelihood of acquiring genital warts.

The busy family physician must stay abreast of these changes and look to guidance from organizations such as STFM, CDC, and IAC for timely updates.