Search

Streptococcus pneumoniae causes approximately 3,300 cases of meningitis, 100,000 to 135,000 cases of pneumonia requiring hospitalization and 6 million cases of otitis media annually in the United States. Pneumococcal conjugate vaccine, approved in 2000 for use in the United States, was designed to cover the seven serotypes that account for about 80 percent of invasive infections in children younger than six years. This vaccine demonstrated 100 percent efficacy against invasive pneumococcal disease in the primary analysis of a large randomized, double-blind, controlled trial. In the follow-up analysis, performed eight months after the trial ended, efficacy against invasive disease was found to be 94 percent for the included serotypes. When initiated during infancy, the four-dose vaccination schedule is set at two, four, six and 12 to 15 months of age. The American Academy of Family Physicians recommends routine vaccination of infants, catch-up vaccination of children younger than 24 months and catch-up vaccination of children 24 to 59 months of age with high-risk medical conditions such as sickle cell disease and congenital heart disease.

The American Academy of Family Physicians now recommends that all persons 50 years of age and older receive an annual influenza vaccination, because the rates of morbidity and mortality associated with influenza are high and vaccination is cost-effective. Reasons for lowering the recommended age for routine vaccination from 65 to 50 years of age include reductions in office visits, hospitalizations, time taken off work and associated costs. In working adults 18 to 64 years of age, the cost savings were estimated at $46.85 per person vaccinated. Furthermore, the fatality rate from influenza begins to rise at age 45 and is highest in persons with multiple chronic medical conditions. As in the past, recommendations target persons at high risk for complications, such as those with cardiac disease, lung disease and diabetes, as well as health care workers and residents of nursing homes. Severe allergy to eggs is a contraindication to influenza vaccination.

As a result of the success of immunization, indigenous wild poliomyelitis has disappeared from the United States. Of 142 confirmed cases of paralytic poliomyelitis reported in the United States from 1980 to 1996, 134 were classified as vaccine-associated paralytic poliomyelitis (VAPP). Persons with VAPP have a disabling illness, and this has caught the attention of the lay media. The risk of VAPP is one case per 750,000 doses distributed for the first dose of oral poliovirus vaccine (OPV) and one case per 2.4 million doses of OPV distributed overall. Because of this risk, most parents prefer a vaccine schedule that starts with inactivated poliovirus vaccine (IPV), even though extra injections are required. IPV does not cause VAPP. New studies show that high immunization rates can be achieved in disadvantaged populations with a schedule starting with IPV. The American Academy of Family Physicians now recommends that the first two doses of poliovirus vaccine should be IPV; that is, either an all-IPV schedule or a sequential schedule of two doses of IPV followed by two doses of OPV. OPV is no longer recommended for the first two doses and is acceptable only under special circumstances, such as when parents do not accept the recommended number of injections.

Vaccination has dramatically reduced the number of annual cases of pertussis, diphtheria, measles and congenital rubella syndrome. Although side effects of immunizations can occur, serious adverse events are rare for all vaccines commonly used in the United States. Infantile spasms and sudden infant death syndrome are not associated with childhood vaccines. Compared with whole-cell pertussis vaccine, acellular pertussis vaccines are significantly less likely to produce moderate reactions such as fever, fussiness, pain, drowsiness, anorexia and local redness or swelling. Despite the documented safety and efficacy of childhood vaccines, concerns about vaccine safety increase when diseases such as measles, pertussis and rubella are no longer common. Parents need to be reminded that their child is susceptible to these diseases, that these diseases are preventable by reasonably safe and effective immunizations and that their child needs a series of vaccines at regular intervals by the age of two years. Since 1994, all physicians have been required by law to use the Vaccine information Statements for measles-mumps-rubella vaccine, diphtheria and tetanus toxoids and pertussis vaccine, poliovirus vaccines and tetanus and diphtheria toxoids for adults.

The recently released varicella vaccine is effective and cost-effective. Routine immunization with one dose of varicella vaccine is now indicated for all children 12 months to 18 months of age. Catch-up immunization for children 18 months to 12 years of age is indicated if the child does not have a history of chickenpox. For susceptible persons over 12 years of age, two doses given four to eight weeks apart are recommended. Because the varicella vaccine contains live virus, proper evaluation for contraindications is necessary. The varicella vaccine should be administered subcutaneously and is sensitive to heat.

Occupational indications for hepatitis B vaccine include employment in health care services, public safety organizations (e.g., police force) and institutions for the developmentally disabled. Hepatitis B vaccine should also be given to persons having multiple sexual partners, persons abusing injectable drugs, persons receiving hemodialysis and persons recently found to have a sexually transmitted disease. Unimmunized adults should receive enhanced inactivated polio vaccine, not oral polio vaccine. Office procedures that facilitate immunizations include the provision of educational information to patients, standing orders to allow nursing personnel to administer vaccines and feedback to physicians about immunization status and rates.

Vaccine-preventable diseases cause needless sickness and death in adult Americans. Most adults 65 years of age or older have not been immunized against influenza or pneumococcal disease. In addition to an age of 65 years or older, indications for influenza and pneumococcal vaccines include chronic obstructive pulmonary disease, hemodynamically significant cardiac disease and infection with the human immunodeficiency virus. Many adults in the United States also are not sufficiently protected against tetanus, diphtheria, measles, mumps and rubella.

Family physicians can play a key role in reversing the resurgence of vaccine-preventable illnesses by making sure that patients are fully immunized. Childhood immunization schedules have recently changed. A second dose of measles, mumps and rubella (MMR) vaccine should be given at age four to six years. It has been recommended that hepatitis B vaccine be administered routinely to all infants in the United States. Both hepatitis B vaccine and hepatitis B immunoglobulin should be given to offspring of hepatitis B carriers. Haemophilus b conjugate vaccine (HbCV) should be administered to all infants, beginning at two months of age. Vaccines can be safely administered to patients with mild illnesses, allergic rhinitis, low-grade fever or penicillin allergy, as well as to those taking antibiotics. If indicated, several vaccines, such as diphtheria, tetanus and pertussis, oral poliovirus, HbCV and MMR, can be given simultaneously.