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2. disease

How to Improve Adult Immunization Coverage Burden of Vaccine‐Preventable Disease and Barriers to Vaccination Unlike childhood vaccination, whereby more than 90% of children receive most recommended vaccines,1 adult vaccination is much less successful in the United States (US). As a result, adults continue to suffer or die from vaccine‐preventable diseases. Over the past 3 decades influenza‐associated deaths have ranged from 3349 to 48,614 annually, with approximately 90% of these deaths occurring in the elderly.2 Population estimates for invasive pneumococcal disease are approximately 44,000 cases and 5000 deaths per year.3 Hepatitis B infects up to 1.4 million persons, with many completely unaware that they are infected.4 Human papillomavirus (HPV) infects approximately 6.2 million people annually,5 while herpes zoster (shingles) affects 1 million people each year, with approximately 1 in 3 persons infected during their lifetime.6 Adult vaccination rates are far below targets set by Healthy People 2020. 9 Table 1 summarizes the estimated proportion of adults that received vaccinations by selected age group, high‐risk status, and race.7,8 Coverage of adult immunization was less than two‐thirds for most vaccines and was lowest for the herpes zoster and HPV vaccines. The percentage of adults who had received the influenza vaccine was well below the Healthy People 2020 targets of 80% for healthy adults 18 to 64 years and 90% for high‐
risk adults 18 to 64 years.9 The percentage of adults 60 years or older who received the zoster vaccine in 2009 was 10%, one‐third of the Healthy People 2020 objective of 30%.9 Disparities of race/ethnicity clearly exist with minorities less likely to receive vaccines than Caucasians. DBC Pri-Med, LLC • 101 Huntington Avenue, Boston, MA 02199 • Pri-Med.com
Table 1. Estimated Proportion of Adults Receiving Vaccinations by Selected Age Group, Race, and High‐Risk Status Characteristic Sample Size Percentage Influenza 18–49 years 116,113 30% 50–64 years 128,820 44% ≥ 65 years 132,636 67% Pneumococcal 19–64 years 7624 18% ≥ 65 years 5209 60% Caucasian 3577 64% African American 781 46% Hispanic 551 39% Tetanus (past 10 years) 19–64 years 13,946 64% 50–64 years 6349 63% ≥ 65 years 5069 53% Tetanus, including pertussis (past 5 years) 19–64 years 14,824 8% Human papillomavirus Females 19–26 years, Total 1718 21% Caucasian 838 22% African American 320 20% Hispanic 397 15% Males, 19–26 years 1474 < 1% Herpes zoster (shingles), ≥ 65 years Caucasian 4978 17% African American 1079 4% Hispanic 796 4% Hepatitis A 19–49 years 12,607 11% Traveled outside US 4595 17% High risk 981 15% Chronic liver conditions 100 20% Hepatitis B 19–49 years, high risk 1023 42% 19–59 years, with diabetes 1045 23% ≥ 60 years, with diabetes 1480 11% Adult vaccination is also necessary for reducing spread of disease. For example, pertussis, which can be life‐threatening in infants and young children, is commonly DBC Pri-Med, LLC • 101 Huntington Avenue, Boston, MA 02199 • Pri-Med.com
transmitted to children by unprotected adults. A study that identified the source of pertussis in infants found that mothers were the source in 32% of cases, while other family members accounted for another 43% of cases.10 Unfortunately, only 8% of adults, ages 19 to 64 years, had received the pertussis booster within the previous 5 years (Table 1). Unvaccinated health care providers (HCPs) were found to contribute to the spread of disease in patients11 and family members. Several barriers affect adult immunization in the US. A survey of more than 2000 consumers and 200 HCPs found that common barriers included lack of physician recommendations and belief that healthy people did not require immunization; barriers for HCPs included consumer hesitation about side effects, consumers’ fear of needles, and inadequate insurance coverage.12 HCP lack of knowledge and training in vaccine use have also been identified as barriers to adult vaccination.13 A survey conducted by the National Foundation for Infectious Diseases (NFID) found an important disconnect between physicians’ and consumers’ interpretation of vaccine recommendations for adults.14 In this survey, 87% of physicians reported discussing vaccines with their patients; however, only 18% of consumers reported talking regularly with their doctors about vaccines; 31% reported talking about them occasionally; and 21% reported not recalling ever discussing vaccines with their doctors. Recommended Vaccination Schedule for Adults Each year, the Centers for Disease Control and Prevention (CDC) publish an updated Adult Immunization Schedule in their Morbidity and Mortality Weekly Report (MMWR). This schedule is based on input from the Advisory Committee on Immunization Practices (ACIP), a group of medical and public health experts who review the most current evidence on safety and efficacy of vaccinations.15 As new vaccines enter the marketplace, ACIP incorporates them into the adult immunization schedule. The schedule includes the age at which the vaccine should be given; the number of doses required; the intervals between doses; and precautions, indications, and DBC Pri-Med, LLC • 101 Huntington Avenue, Boston, MA 02199 • Pri-Med.com
contraindications. Unfortunately, the ACIP immunization schedule is underutilized, with one survey finding that only 50% of HCPs rely on these guidelines.12 Table 2 presents an abbreviated schedule for adult immunization based on ACIP recommendations.16 The actual schedule published by the ACIP is far more detailed and should be reviewed in addition to this abbreviated version. Table 2. Abbreviated Adult Immunization Schedule Adapted from ACIP Recommendations16 Vaccine 19–49 years 50–64 years Influenza > 65 years 1 dose annually, especially those “at risk,”† (eg, health care workers) Pneumococcal (polysaccharide) 1 dose for “at risk” adults 1 dose Pneumococcal (conjugate) 1 dose for immunocompromised adults in addition to vaccination with pneumococcal polysaccharide vaccine. Measles, mumps, and rubella 2 doses Born in US before 1957—assume (MMR) native immunity Varicella (chickenpox) 2 doses, if no Born in US before 1980—assume documented disease native immunity, except for health care workers and pregnant women Herpes zoster (shingles) No recommendation Healthy, aged 60+, 1 dose Tetanus, diphtheria, and Primary series, then Td every 10 years; substitute Tdap for 1 pertussis (Td/Tdap) dose Human papillomavirus (HPV) Women < 26 years, No recommendation 3 doses Men < 26 years, HPV4 only recommended Hepatitis A 2 doses for “at risk” adults Hepatitis B 3 doses for “at risk” adults Meningococcal 1 or more doses for “at risk” adults †“At risk” = Pa ents with health, job, or lifestyle risks that put them at even higher risk for serious diseases. DBC Pri-Med, LLC • 101 Huntington Avenue, Boston, MA 02199 • Pri-Med.com
Influenza Vaccine Each year the influenza vaccine is engineered to protect against influenza viruses that research suggests will be most common for that season. Protection with the vaccine lasts approximately 1 year. For these reasons, annual vaccination is required. Trivalent influenza vaccine (TIV) is traditional inactivated (killed) vaccine given via intramuscular administration and is indicated for anyone older than 6 months of age.16 An intradermal TIV, which uses a smaller needle, is indicated for 18‐ to 64‐year‐old adults.16 Live, attenuated (weakened) influenza vaccine (LAIV) is administered intranasally and is indicated for healthy people under age 50.16 A quadrivalent LAIV was licensed in the US in February 2012 and may replace the trivalent LAIV formulation for the 2013–2014 season; it will not be available for the 2012–2013 season.17 A high‐dose TIV is available for older adults (65 years and older) that uses the same production process as TIV, but may be more effective. Local reactions, which are usually mild in severity, are more frequent with high‐dose TIV. High‐priority populations for influenza vaccine include pregnant women, older adults, persons with medical comorbidities, and persons who are living in long‐term care, institutionalized, or over‐crowded living conditions. All health care workers should receive the influenza vaccine because they are at high risk for disease and are at high risk to transmit it to others. Patients should receive the vaccine as soon as it is available each year (usually September or October), but vaccination given at any time during the influenza season is beneficial. Adults require a single dose of vaccine, and it may be given with other vaccinations. Egg allergy is listed as a relative contraindication to all influenza vaccines in product labeling. However, the American Academy of Allergy, Asthma and Immunology; the American College of Allergy, Asthma and Immunology; and the Joint Council of Allergy, Asthma and Immunology jointly published a practice parameter update in which they DBC Pri-Med, LLC • 101 Huntington Avenue, Boston, MA 02199 • Pri-Med.com
recommend use of influenza vaccines in patients with egg allergy if clinically indicated.18 ACIP has also noted that reactions are rare and that persons with an egg allergy who have experienced only mild reactions should receive the influenza vaccine with the following safety measures: use of TIV rather than LAIV; administration by an HCP who is familiar with potential reactions of egg allergy; and observation for at least 30 minutes following immunization.19 Patients with a history of anaphylaxis, or in whom the severity of their reaction is uncertain, should be referred to an allergist experienced in food allergy and anaphylaxis.18,19 Pneumococcal Polysaccharide and Pneumococcal Conjugate Vaccine The pneumococcal polysaccharide vaccine is 50% to 80% effective for invasive pneumococcal disease (ie, bacteremia, meningitis, or infection of other normally sterile sites) among immunocompetent older adults and adults with underlying illnesses.20 The vaccine’s effectiveness against “pneumonia” is debatable. Pneumococcal vaccine is recommended in all adults 65 years and older and in adults 19 to 64 years who have chronic or immunosuppressing medical conditions (including asthma) or who smoke cigarettes.16 Revaccination is not recommended for most adults; however, revaccination is recommended in adults age 19 to 64 years, 5 years after their first dose in the presence of functional or anatomic asplenia or immunocompromising conditions.20 In 2011, the US Food and Drug Administration (FDA) approved pneumococcal conjugate vaccine in adults 50 years and older to prevent pneumococcal pneumonia and invasive disease caused by Streptococcus pneumoniae. ACIP recommends routine use of pneumococcal conjugate vaccine in adults aged 19 and older with immunocompromising conditions, functional or anatomic asplenia, cerebrospinal fluid leaks, or cochlear implants.21 The conjugate form of the vaccine should be used in addition to the polysaccharide vaccine. DBC Pri-Med, LLC • 101 Huntington Avenue, Boston, MA 02199 • Pri-Med.com
Human Papillomavirus HPV has been causally associated with genital warts and numerous cancers, including cervical, anal, penile, vulvar, and vaginal.22 Two HPV vaccines are currently available in the US: bivalent (HPV2) and quadrivalent (HPV4). 
HPV2 is indicated in females 9 through 25 years for prevention of cervical cancer.23 ACIP recommends the vaccine for females beginning at age 11 or 12 years.16 
HPV4 is indicated in females 9 through 26 years for prevention of cervical, vulvar, vaginal, and anal cancer caused by HPV types 16 and 18, and genital warts caused by HPV types 6 and 11. HPV4 is also indicated for males 9 through 26 years for prevention of anal cancer and genital warts.24 ACIP recommends the vaccine for females and males beginning at age 11 or 12 years.16 Individuals should be vaccinated before exposure to HPV through sexual contact; however, vaccination is still recommended in persons who are already infected with HPV as vaccination may protect from infection with other HPV types. HPV vaccine will not cure HPV types already acquired.16 Pregnant women should not receive the HPV vaccine. Persons who are immunosuppressed (from disease or medications) may receive the HPV vaccine because it is not a live virus; however, the immune response may be less than in immunocompetent persons.16 Local reactions may occur with this vaccine, and bronchospasms have been reported.25 Patients should be reminded that vaccination does not preclude the necessity for routine cervical cancer screening. Combined Tetanus, Diphtheria, and Acellular Pertussis Vaccines Two combination vaccines to prevent tetanus, diphtheria, (Td) and acellular pertussis (Tdap) are recommended for adults. Tdap is similar to Td but contains acellular pertussis DBC Pri-Med, LLC • 101 Huntington Avenue, Boston, MA 02199 • Pri-Med.com
vaccine. Td should be given to adults as a booster shot every 10 years or, in some cases, after exposure to tetanus.26 Older adults are at higher risk of tetanus than children, and risk of death is higher among patients 65 years and older.27 Particular emphasis should be given to patients with diabetes, chronic wounds, or intravenous drug use history.27 One dose of Td should be replaced with one (and only one) dose of Tdap for adults and then returning to regular Td dosing schedule.26 The vaccine—which may be given less than 10 years following the last Td dose and as little as 2 years—has been demonstrated to be safe and effective.28 Special emphasis should be placed on adults with close infant contact (eg, health care workers, parents, childcare workers). Tdap is recommended during pregnancy or immediately postpartum in non‐immune mothers. Herpes Zoster Herpes zoster (shingles) is characterized by a localized, painful rash and occurs most often in older or immunocompromised persons due to reactivation of latent varicella (chickenpox) years following the initial varicella infection. A person’s lifetime risk of shingles is approximately 32% and increases with age.6 Zoster can lead to numerous complications, including chronic pain (postherpetic neuralgia, or PHN), vasculopathy, meningoencephalitis, myelopathy, cerebellitis, and various ocular disorders.29 PHN is the most common of these complications and occurs in approximately 40% of patients over age 60 with zoster.29 PHN pain is constant, severe, stabbing, or burning lasting at least 3 months, and sometimes years after the rash is gone.29 Zoster vaccine has been approved by the FDA for use in healthy adults over 50 years of age. ACIP recommends vaccination for healthy adults over 60, regardless of zoster history.16 The American College of Rheumatology also recommends that the zoster vaccine be given before biologic disease‐modifying anti‐rheumatic drugs are initiated.30 DBC Pri-Med, LLC • 101 Huntington Avenue, Boston, MA 02199 • Pri-Med.com
Zoster vaccine is contraindicated in persons who are pregnant, have an anaphylactic hypersensitivity to neomycin or gelatin, or have known severe immunodeficiency. Occasionally, a mild varicella‐like rash may develop at the vaccine site. Because the zoster vaccine is a frozen powdered formulation, it must be administered within 60 minutes of reconstitution. Protection from zoster is at least 4 years, and no booster is recommended.6 Measles, Mumps, and Rubella and Varicella Measles, mumps, and rubella (MMR) and varicella (V) vaccines are routinely recommended in children; therefore, most persons born before 1957 are assumed to be immune to measles, mumps, and rubella, and most persons born before 1980 are assumed to be immune to varicella.16 Both vaccines are administered as a live‐virus 2‐
dose vaccine series. Contraindications for MMR vaccine include egg allergy and for varicella include neomycin and gelatin therapy. High‐risk groups should be vaccinated if they haven’t received their second dose of vaccine and include health care workers; education, daycare, and institutional employees; women of childbearing age (vaccinate pre‐pregnancy or postpartum); and persons traveling internationally. These vaccines can be given in a single shot (MMRV) or in 2 shots (MMR and V). Adults who require protection from these diseases should receive MMR and V as separate shots.31 Hepatitis A and B Vaccination for hepatitis A and B has been recommended in all US children since 2007 (hepatitis A) and 1995 (hepatitis B). Both vaccines have selective recommendations for adults, and a comprehensive list of indications for hepatitis A and B is provided in the ACIP adult immunization schedule.16 Indications for hepatitis B vaccine include persons with diabetes mellitus; chronic liver disease; end‐stage renal disease; recipients of clotting factors; human immunodeficiency virus (HIV); more than 1 sexual partner in a 6‐
month period; men who have sex with men (MSM) and patients being treated for DBC Pri-Med, LLC • 101 Huntington Avenue, Boston, MA 02199 • Pri-Med.com
sexually transmitted disease; household and sexual contacts of hepatitis B patients; health care workers; international travelers; current or recent injection‐drug users; correctional facility inmates and staff; and developmental disability facility patients and staff. Indications for hepatitis A include persons with chronic liver disease, MSM, injection‐drug users, travelers to endemic areas, recipients of clotting factors, and laboratory workers. An important new recommendation for hepatitis B is in patients with diabetes.32 Persons under 60 years of age should be vaccinated as soon as possible after diabetes diagnosis; persons 60 and older should be vaccinated at the physician’s discretion because there is less evidence for efficacy and cost‐effectiveness in older adults. Both hepatitis vaccines are given as a series and it is not necessary to restart the series if completion of the series is delayed. Vaccines can be given individually or together as a combination vaccine. Meningococcal Meningococcal vaccination prevents the highly contagious gram‐negative bacterial infection, but does not prevent type B meningitis. There are 2 types of meningococcal vaccines: a conjugate vaccine (MCV4) and a polysaccharide vaccine (MPSV4). The conjugate vaccine is preferred for primary vaccination and a booster may be given selectively after 5 years if high‐risk conditions persist. The MPSV4 is the only meningococcal vaccine approved for adults over 55 years.33 Indications for meningococcal vaccine include college freshmen who will live in a dormitory with no previous vaccination, and persons with asplenia (anatomic or functional), terminal complement deficiencies, HIV, travelers to “at‐risk” areas, and microbiologists with potential occupational meningococcal contact.16 DBC Pri-Med, LLC • 101 Huntington Avenue, Boston, MA 02199 • Pri-Med.com
Strategies for Increasing Adult Vaccination Several strategies can be used to increase adult vaccination in clinical practice. The most important strategies are provider recommendations and implementation of a standing orders program for adult vaccination. As noted previously, one of the most common barriers for adult immunization was lack of physician recommendations.12 In the NFID survey, 88% of consumers reported that a strong recommendation from their physician would motivate their decisions regarding vaccination.14 Clinicians must become champions for immunization as a strong recommendation can be highly persuasive to a patient. Implementation of a standing orders program is also important for increasing adult vaccination rates. Standing orders allow nurses, pharmacists and other licensed health care personnel to assess a patient’s immunization status, determine eligibility, and administer vaccinations without an individualized physician’s order. These programs should be implemented where allowed by state law and must include a protocol approved by an institution, physician, or authorized practitioner.34 Unfortunately, standing orders are underutilized, with a recent survey indicating that only 42% of primary care physicians reported consistent use of standing orders programs.35 Examples of standing orders for administering specific vaccines are available from www.immunize.org/standing‐orders/ and as they are part of the public domain, can be used free of charge without concern of copyright infringement. Other strategies can also be useful for increasing adult vaccination rates. These include HCP reminders (ie, provider reminders inform clinicians who administer vaccinations that an individual patient is due for a specific vaccination), assessment and feedback for vaccination providers, and provider education.36 Immunization status should be assessed at every opportunity such as routine health care and wellness visits and office visits for minor illnesses. Ensuring that all members of DBC Pri-Med, LLC • 101 Huntington Avenue, Boston, MA 02199 • Pri-Med.com
the health care team deliver a consistent message about the importance of immunization is also critical. Conclusion Disease prevention cannot be overemphasized, and vaccination is a core component of any preventative service package. Although immunization can substantially reduce serious illness and death, adult immunization coverage remains woefully inadequate in the US, particularly for minorities. HCPs are obligated to become ardent advocates for immunization. Immunization should be a prominent part of the practice of every primary care physician in order to prevent disease and save lives. References 1. Immunization Work Group of the National and Global Public Health Committee of the Infectious Diseases Society of America. Actions to strengthen adult and adolescent immunization coverage in the United States: policy principles of the Infectious Diseases Society of America. Clin Infect Dis. 2007;44(12):e104‐e108. 2. Centers for Disease Control and Prevention (CDC). Estimates of deaths associated with seasonal influenza—United States, 1976‐2007. MMWR. Morb Mortal Wkly Rep. 2010;59(33):1057‐1062. 3. Centers for Disease Control and Prevention. Active Bacterial Core Surveillance (ABCs) Report: Emerging Infections Program Network, Streptococcus pneumoniae, 2010. Available at: http://www.cdc.gov/abcs/reports‐findings/survreports/spneu09.pdf. Accessed December 16, 2012. 4. Centers for Disease Control and Prevention. Viral hepatitis surveillance—United States, 2009. Available at: http://www.cdc.gov/hepatitis/statistics/2009surveillance/index.htm. Accessed December 16, 2012. 5. Centers for Disease Control and Prevention. HPV Vaccine Monitoring. Available at: http://www.cdc.gov/std/hpv/monitoring‐rpt.htm. Accessed December 16, 2012. 6. Harpaz R, Ortega‐Sanchez IR, Seward JF; Advisory Committee on Immunization Practices (ACIP) Centers for Disease Control and Prevention (CDC). Prevention of herpes zoster: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR. Recomm Rep. 2008;57(RR‐5):1‐30. 7. Centers for Disease Control and Prevention (CDC). Adult vaccination coverage—United States, 2010. MMWR. Morb Mortal Wkly Rep. 2012;61(4):66‐72. 8. Centers for Disease Control and Prevention. Final state‐level influenza vaccination coverage estimates for the 2010–11 season—United States, National Immunization Survey and Behavioral Risk Factor Surveillance System, August 2010 through May 2011. Available at: http://www.cdc.gov/flu/professionals/vaccination/coverage_1011estimates.htm. Accessed December 16, 2012. DBC Pri-Med, LLC • 101 Huntington Avenue, Boston, MA 02199 • Pri-Med.com
9. Healthy People 2020: Immunization and Infectious Diseases. Washington, DC: US Department of Health and Human Services; 2000. Available at: http://www.healthypeople.gov/2020/topicsobjectives2020/overview.aspx?topicid=23. Accessed December 16, 2012. 10. Bisgard KM, Pascual FB, Ehresmann KR, et al. Infant pertussis: who was the source? Pediatr Infect Dis J. 2004;23(11):985‐989. 11. Salgado CD, Giannetta ET, Hayden FG, et al. Preventing nosocomial influenza by improving the vaccine acceptance rate of clinicians. Infect Control Hosp Epidemiol. 2004;25(11):923‐928. 12. Johnson DR, Nichol KL, Lipczynski K. Barriers to adult immunization. Am J Med. 2008;121(7 Suppl 2):S28‐S35. 13. Tan TQ, Bhattacharya L, Gerbie MV. Awareness, perceptions and knowledge of recommended adult vaccines among a nationwide sample of adult primary care providers. J Reprod Med. 2011;56(7‐8):301‐307. 14. National Foundation for Infectious Disease (NFID). Survey: Disconnect in What Doctors Think They Say About Vaccines and What Patients to Hear. November 2010. Available at: http://www.adultvaccination.com/newsroom/Events/2010‐cdc‐vaccination‐rates‐
news‐conference/2010‐Survey‐Backgrounder.pdf. Accessed December 16, 2012. 15. Smith JC, Snider DE, Pickering LK; Advisory Committee on Immunization Practices. Immunization policy development in the United States: the role of the Advisory Committee on Immunization Practices. Ann Intern Med. 2009;150(1):45‐49. 16. Centers for Disease Control and Prevention (CDC).Recommended adult immunization schedule—United States, 2012. MMWR Morb Mortal Wkly Rep. 2012;61(4):1‐7. 17. Centers for Disease Control and Prevention (CDC). Seasonal Influenza (Flu): Influenza vaccine information, by age group—United States, 2012‐13 influenza season. Available at: http://www.cdc.gov/flu/protect/vaccine/vaccines.htm. Accessed December 16, 2012. 18. Greenhawt MJ, Li JT, Bernstein DI, et al. Administering influenza vaccine to egg allergic recipients: a focused practice parameter update. Ann Allergy Asthma Immunol. 2011;106(1):11‐16. 19. Centers for Disease Control and Prevention (CDC). Prevention and control of influenza with vaccines: recommendations of the Advisory Committee on Immunization Practices (ACIP)—United States, 2012‐13 influenza season. MMWR. Morb Mortal Wkly Rep. 2012;61(32):613‐618. 20. Centers for Disease Control and Prevention (CDC); Advisory Committee on Immunization Practices. Updated recommendations for prevention of invasive pneumococcal disease among adults using the 23‐valent pneumococcal polysaccharide vaccine (PPSV23). MMWR Morb Mortal Wkly Rep. 2010;59(34):1102‐1106. 21. Centers for Disease Control and Prevention (CDC).Use of 13‐valent pneumococcal conjugate vaccine and 23‐valent pneumococcal polysaccharide vaccine for adults with immunocompromising conditions: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR. Morb Mortal Wkly Rep. 2012;61(40):816‐819. 22. Cutts FT, Franceschi S, Goldie S, et al. Human papillomavirus and HPV vaccines: a review. Bull World Health Organ. 2007;85(9):719‐726. 23. Cervarix [package insert]. Research Triangle Park, NC: GlaxoSmithKline; 2012. 24. Gardasil [package insert]. Whitehouse Station, NJ: Merck & Co., Inc.; 2010. DBC Pri-Med, LLC • 101 Huntington Avenue, Boston, MA 02199 • Pri-Med.com
25. Markowitz LE, Dunne EF, Saraiya M, et al. Quadrivalent Human Papillomavirus Vaccine: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR. Recomm Rep. 2007;56(RR‐2):1‐24. 26. Centers for Disease Control and Prevention (CDC). Updated recommendations for use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis (Tdap) vaccine from the Advisory Committee on Immunization Practices, 2010. MMWR. Morb Mortal Wkly Rep. 2011;60(1):13‐15. 27. Centers for Disease Control and Prevention (CDC). Tetanus surveillance—United States, 2001‐2008. MMWR. Morb Mortal Wkly Rep. 2011;60(12):365‐369. 28. Lodolce AE. Shortened interval between tetanus vaccines. Ann Pharmacother. 2012;46(6):884‐888. 29. Gilden D. Efficacy of live zoster vaccine in preventing zoster and postherpetic neuralgia. J Intern Med. 2011;269(5):496‐506. 30. Singh JA, Furst DE, Bharat A, et al. 2012 update of the 2008 American College of Rheumatology recommendations for the use of disease‐modifying antirheumatic drugs and biologic agents in the treatment of rheumatoid arthritis. Arthritis Care Res (Hoboken). 2012;64(5):625‐639. 31. Centers for Disease Control and Prevention. MMRV (measles, mumps, rubella & varicella) Vaccine: What You Need to Know. Vaccine Information Statement (Interim) 5/21/10. Available at:: http://www.cdc.gov/vaccines/pubs/vis/downloads/vis‐mmrv.pdf. Accessed December 16, 2012. 32. Centers for Disease Control and Prevention (CDC). Use of hepatitis B vaccination for adults with diabetes mellitus: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep. 2011;60(50):1709‐1711. 33. Centers for Disease Control and Prevention. Meningococcal Vaccines: What You Need to Know. Vaccine Information Statement (Interim) 10/14/2011. Available at:: http://www.cdc.gov/vaccines/pubs/vis/downloads/vis‐mening.pdf. Accessed December 16, 2012. 34. The Guide to Community Preventive Services. Targeted Vaccinations: Standing Orders. Available at:: www.thecommunityguide.org/vaccines/targeted/standingorders.html. Accessed December 16, 2012. 35. Zimmerman RK, Albert SM, Nowalk MP, et al. Use of standing orders for adult influenza vaccination: a national survey of primary care physicians. Am J Prev Med. 2011;40(2):144‐148. 36. Task Force on Community Preventive Services. Recommendations to improve targeted vaccination coverage among high‐risk adults. Am J Prev Med. 2005;28(5 Suppl):231‐237. DBC Pri-Med, LLC • 101 Huntington Avenue, Boston, MA 02199 • Pri-Med.com