作者：Laurie Barclay, MD
出處：WebMD醫學新聞
January 9, 2009 — 免疫實務諮詢委員會(ACIP)公佈2009年成人疫苗接種建議時程表，發表於1月9日的每週死亡率與發病率報告；美國家庭醫師學會、美國婦產科醫學會、美國醫師學會都附議ACIP核准這個2009年的時程表。
ACIP聲明的作者寫道，ACIP每年回顧成人疫苗接種建議時程表，以確保此時程表可以符合現有的合法疫苗。2008年10月時，ACIP核准2009年成人疫苗接種時程表。沒有新增的疫苗種類；不過，多醣型肺炎疫苗之補充說明內加入多種適應症，人類乳突病毒[HPV]、水痘、與腦膜炎球菌疫苗加入一些澄清事項，A型和B型肝炎疫苗的補充說明加入時程表資訊。
2009年版的變動如下：
* 對於HPV，健康照護人士不會因為職業上的曝露而增加風險，但建議他們根據表定年紀接種疫苗，9歲開始可以接種HPV疫苗。
* 曾經接種一劑水痘疫苗的成人必須接種第二劑。
* 多醣型肺炎疫苗的新增適應對象包括氣喘與抽菸者；使用於阿拉斯加原住民與美洲印地安人的疫苗已經獲得驗證。
* 新增時程表資訊包括4次劑量的A/B型肝炎混合疫苗。
* 對於腦膜炎球菌疫苗，施打間隔是5年。
下列疫苗有一些特定建議：
* 破傷風、白喉、非細胞性百日咳混合疫苗(Tetanus, diphtheria, and acellular pertussis，Td/Tdap)：對未曾接受過Tdap的19至64歲成人，應以一劑Td代替。對於不確定或者未完成初步疫苗接種的成人，應給予一系列初步疫苗；包括三劑量的破傷風與白喉毒素混合疫苗，前兩劑之間隔至少四週，第三劑離第二劑 6-12個月。在這三劑量的初步系列中，Tdap可以替代其中任何一劑的Td劑量。完成初步疫苗接種10年以上的成人，應給予追加一劑破傷風與白喉毒素混合疫苗。可以依照指示使用Tdap或者Td疫苗。懷孕期間也建議給予Td/Tdap疫苗，Td作為傷口處置之預防用。
* HPV疫苗：建議所有11至26歲女性施打，不論有無性行為或者臨床曾有HPV感染證據，以及未完成此系列疫苗者。理想的話，最好在未曾有性行為等潛在HPV感染風險之前即給予，9歲就可以施打。完整劑量包括三劑，第二劑在第一劑之後兩個月打、第三劑在第一劑之後第6個月打。
* 水痘疫苗：除非有醫療上的禁忌，每個沒有免疫力的成人都應施打。如果未曾施打、或者尚未施打第二劑，應給予兩劑量的單一抗原水痘疫苗。建議密切接觸重病患者或者傳染高風險者更應考慮施打。無水痘免疫力的孕婦，應在產後出院前接種第一劑的水痘疫苗，之後4至8週接受第二劑。
* 帶狀疱疹疫苗(單一劑量)：不論有無帶狀疱疹病史，建議60歲以上成人施打，除非有特殊禁忌症。
* 麻疹、腮腺炎、德國麻疹(MMR) 疫苗：1957年與之後出生之成人應接種一劑以上，除非有醫療禁忌、有施打一劑以上之紀錄、曾診斷有麻疹、或者檢驗有免疫力。第二劑MMR建議給予最近曝露於麻疹或者處於爆發群中的成人、之前接種的是麻疹死菌疫苗者、或者於1963至1967年間接種不知名類型麻疹疫苗者，以及高中畢業以上之學生、健康照護機構工作者、計畫出國旅行者。生育年齡的婦女不論年紀都應評估德國麻疹免疫力，並且提醒有關先天性德國麻疹症候群的資訊。沒有免疫力的婦女應於產後出院前接受MMR。
* 流感疫苗：應給予醫療適應症、職業上有風險者或者其他適用對象。醫療適應症包括心血管或者肺部慢性疾病、慢性代謝疾病、免疫許可狀況，或者危及呼吸功能或呼吸風險增加等。所有健康照護人員以及照顧5歲以下幼童者都應施打流感疫苗，護理之家與其他長照輔助機構之住民、有高風險傳染流感者、以及其他希望降低自己的流感風險者都可施打流感疫苗。50歲以下健康無高風險醫療狀況、未懷孕之成人、未接觸特殊照護機構內的嚴重免疫不佳患者，可以接受經鼻吸入的流感活性疫苗(FluMist，MedImmune公司)或者不活性疫苗，此外，應使用不活性疫苗。
* 多醣型肺炎疫苗(PPSV)：應給予慢性肺部、心血管或者肝病患者；糖尿病患；慢性酒癮者；慢性腎衰竭或者腎病症候群者；功能性或者解剖上無脾臟者；免疫狀況妥協者；人工電子耳植入者；或者腦脊液外漏者。一有HIV診斷，應盡速給予此疫苗。其他PPSV適應症包括護理之家與其他長照輔助機構之住民、抽菸者。公衛當局應考量建議居住在侵犯性肺炎風險增加區域的50至64歲阿拉斯加原住民與美國印第安人施打。
* 再度施打一次PPSV：慢性腎衰竭或者腎病症候群之後5年者、功能性或者解剖上無脾臟者、免疫狀況妥協者、65歲以上且前次施打已經5年以上者。
* A型肝炎疫苗：適用於慢性肝病患者、接受凝血因子濃縮劑者、男男性行為者、非法藥物濫用者、實驗室中曝露於A型肝炎病毒感染靈長類樣本之工作者、前往A型肝炎高度或中度流行之國家旅行或工作者、尋求免於A型肝炎病毒感染者。單一抗原疫苗配方應給予兩次劑量，在0和6至12個月(Havrix，GlaxoSmithKline藥廠)或者0和6至18個月(Vaqta，Merck藥廠)。複方A型和B型肝炎疫苗(Twinrix，GlaxoSmithKline藥廠)應給予三劑，在0、1和6個月，或者給予四劑，在第0、7和21至30天、之後在12個月時給予追加。
* B型肝炎疫苗：適用於末期腎病患者、HIV感染或者慢性肝病患者；健康照護人士與公共安全工作者或其他有體液或血液感染風險者；非長期單一性伴侶者；評估或治療性病者；目前或最近注射施打藥物者；男男性行為者。其他適應症與對象和特殊配方適應症詳列其中。
* 腦膜炎球菌疫苗：應給予解剖或功能性無脾臟成人、或者末端補體成分缺乏症、住於宿舍之大學新鮮人、經常接觸腦膜炎球菌的微生物學家、新兵、以及高流行率之國家或地區。
* b型嗜血流行病感冒(Hib)疫苗：一般不建議用於5歲以上者，但是可以考慮用於鐮刀型細胞疾病、白血病、HIV感染、無脾臟等。
* 免疫妥協狀況：一般可以接受無活性疫苗，避免活菌疫苗。
ACIP作者寫道，這些時程表包括現有核准用於19歲以上者之疫苗的建議年齡群以及醫療適應症，於2009年1月1日開始適用；核准的複方疫苗可用於所含單方的適應症且非屬禁忌者。
Advisory Committee on Immunization Practices Issues 2009 Adult Immunization Schedule
By Laurie Barclay, MD
Medscape Medical News
January 9, 2009 — The Advisory Committee on Immunization Practices (ACIP) has issued the recommended adult immunization schedule for 2009, published in the January 9 issue of the Morbidity and Mortality Weekly Report. The 2009 schedule has been approved by the American Academy of Family Physicians, the American College of Obstetricians and Gynecologists, and the American College of Physicians, in addition to the ACIP.
"The [ACIP] annually reviews the recommended Adult Immunization Schedule to ensure that the schedule reflects current recommendations for the licensed vaccines," the ACIP statement authors write. "In October 2008, ACIP approved the Adult Immunization Schedule for 2009. No new vaccines were added to the schedule; however, several indications were added to the pneumococcal polysaccharide vaccine footnote, clarifications were made to the footnotes for human papillomavirus [HPV], varicella, and meningococcal vaccines, and schedule information was added to the hepatitis A and hepatitis B vaccine footnotes. "
Changes for 2009 are as follows:
For HPV, healthcare personnel are not at increased risk because of occupational exposure, but they should be vaccinated as recommended based on age. Vaccination for HPV may begin at 9 years of age.
Adults who previously received only 1 dose of varicella vaccine should receive a second dose.
Additional indications for pneumococcal polysaccharide vaccination are asthma and cigarette smoking. Vaccine use in Alaska Natives and American Indians has been clarified.
Additional schedule information is included for the 4-dose combined hepatitis A/hepatitis B vaccine.
For meningococcal vaccine, the revaccination interval is 5 years.
Some specific recommendations for each of the vaccinations follow.
Tetanus, diphtheria, and acellular pertussis (Td/Tdap) vaccination: For adults aged 19 through 64 years who have not previously received a dose of Tdap, Tdap should replace a single dose of Td. A primary vaccination series should be given to adults with uncertain or incomplete history of primary vaccination; this consists of 3 doses of tetanus and diphtheria toxoid–containing vaccines, with the first 2 doses given at least 4 weeks apart and the third dose 6 to 12 months after the second. In the 3-dose primary series, Tdap can substitute for any 1 of the Td doses of Td. A booster dose of tetanus and diphtheria toxoid–containing vaccine should be given to adults who completed a primary series 10 or more years previously. Tdap or Td vaccine may be used, as indicated. Recommendations are also given for Td/Tdap vaccination during pregnancy and for Td as prophylaxis in wound management.
HPV vaccination: Recommended for all females aged 11 through 26 years, regardless of sexual activity or clinical evidence of previous HPV infection, who have not completed the vaccine series. Ideally, vaccination should be given before potential exposure to HPV through sexual activity and may be given as early as age 9 years. The complete series consists of 3 doses, with the second dose given 2 months after the first dose and the third dose 6 months after the first dose.
Varicella vaccination: Should be given to all adults who lack evidence of immunity unless they have a medical contraindication. Patients should receive 2 doses of single-antigen varicella vaccine if not previously vaccinated or the second dose if they have received only 1 dose. Special consideration is recommended for those with close contact with persons at high risk for severe disease or high risk for exposure or transmission. Pregnant women without evidence of varicella immunity should receive the first dose of varicella vaccine on completion or termination of pregnancy and before discharge from the healthcare facility, and they should receive the second dose 4 to 8 weeks after the first dose.
Herpes zoster vaccination (single dose): Recommended for adults aged 60 years and older regardless of prior history of herpes zoster, unless they have a specific contraindication.
Measles, mumps, rubella (MMR) vaccination: 1 or more doses should be given to adults born during or after 1957 unless they have a medical contraindication, documentation of 1 or more doses, history of measles diagnosed by a healthcare provider, or laboratory evidence of immunity. A second dose of MMR is recommended for adults recently exposed to measles or in an outbreak setting, previously vaccinated with killed measles vaccine, or vaccinated with an unknown type of measles vaccine during 1963 to 1967, as well as for those who are students in postsecondary educational institutions, work in a healthcare facility, or plan international travel. Women of childbearing age, regardless of birth year, should be assessed for rubella immunity and counseled regarding congenital rubella syndrome. Women without evidence of immunity should receive MMR vaccine on completion or termination of pregnancy and before discharge from the healthcare facility.
Influenza vaccination: Should be given to those with medical, occupational, or other indications. Medical indications are chronic disorders of the cardiovascular or pulmonary systems, chronic metabolic diseases, immunocompromising conditions, or any condition that compromises respiratory function or that increases risk for aspiration. All healthcare personnel and caregivers of children younger than 5 years old should receive influenza vaccination, as should residents of nursing homes and other long-term care and assisted-living facilities, persons likely to transmit influenza to persons at high risk, and others who wish to decrease their risk of getting influenza. Healthy, nonpregnant adults younger than 50 years without high-risk medical conditions who are not contacts of severely immunocompromised persons in special care units can receive either intranasally administered live, attenuated influenza vaccine (FluMist, MedImmune) or inactivated vaccine, but others should receive the inactivated vaccine.
Pneumococcal polysaccharide (PPSV) vaccination: Should be given to those with chronic lung, cardiovascular, or liver disease; diabetes mellitus; chronic alcoholism; chronic renal failure or nephrotic syndrome; functional or anatomic asplenia; immunocompromising conditions; cochlear implants; or cerebrospinal fluid leaks. Vaccination should occur as close to HIV diagnosis as possible. Other indications for PPSV are being a resident of nursing homes or other long-term care facility and being a cigarette smoker. Public health authorities may consider recommending PPSV for Alaska Natives and American Indians aged 50 through 64 years living in areas with increased risk for invasive pneumococcal disease.
One-time revaccination with PPSV: Recommended after 5 years for persons with chronic renal failure or nephrotic syndrome, functional or anatomic asplenia, or immunocompromising conditions, or for persons aged 65 years and older if they were vaccinated 5 or more years previously at younger than 65 years.
Hepatitis A vaccination: Indicated for persons with chronic liver disease, those who receive clotting factor concentrates, men who have sex with men, illegal drug users, laboratory workers exposed to hepatitis A virus–infected primates, persons traveling to or working in countries with high or intermediate endemicity of hepatitis A, and those seeking protection from hepatitis A virus infection. Single-antigen vaccine formulations should be given in 2 doses either at 0 and 6 to 12 months (Havrix, GlaxoSmithKline) or at 0 and 6 to 18 months (Vaqta, Merck). Combined hepatitis A and hepatitis B vaccine (Twinrix, GlaxoSmithKline) should be given in 3 doses at 0, 1, and 6 months or in 4 doses on days 0, 7, and 21 to 30, followed by a booster dose at month 12.
Hepatitis B vaccination: Indicated for persons with end-stage renal disease, HIV infection, or chronic liver disease; for healthcare personnel and public-safety workers exposed to blood or other potentially infectious body fluids; for sexually active persons not in a long-term, mutually monogamous relationship; for persons seeking evaluation or treatment for a sexually transmitted disease; for current or recent injection-drug users; and for men who have sex with men. Other indications and settings are also listed, as well as special formulation indications.
Meningococcal vaccination: Should be given to adults with anatomic or functional asplenia or terminal complement component deficiencies, first-year college students living in dormitories, microbiologists routinely exposed to meningococcus, military recruits, and those in hyperendemic or epidemic countries.
Haemophilus influenzae type b (Hib) vaccine: Generally not recommended for persons aged 5 years and older but may be considered in those with sickle cell disease, leukemia, HIV infection, or asplenia.
Immunocompromising conditions: Inactivated vaccines generally are acceptable, but live vaccines should be avoided.
"These schedules indicate the recommended age groups and medical indications for which administration of currently licensed vaccines is commonly indicated for adults ages 19 years and older, as of January 1, 2009," the ACIP authors write. "Licensed combination vaccines may be used whenever any components of the combination are indicated and when the vaccine's other components are not contraindicated."
Morb Mortal Wkly Rep. 2009;57(53). |
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