The Centers for Disease Control and Prevention (CDC)’s Advisory Committee on Immunization Practices (ACIP) recently released updated recommendations. This article highlights three significant new recommendations related to maternal and infant hepatitis B screening and vaccination, preventing herpes zoster with the new recombinant herpes zoster vaccine, and the provision of an additional mumps-containing vaccine dose in the setting of an outbreak. Links to the 2018 new immunization schedules, new vaccine information sheets (VIS) and other resources are at the end of this article.

New Recommendations for Mothers and Infants to Prevent Perinatal Hepatitis B Transmission

In January, the ACIP published “Prevention of Hepatitis B Virus Infection in the United States” which includes new and updated recommendations related to perinatal hepatitis B.

The following is a selection of ACIP recommendations related to the prevention of perinatal hepatitis B.¹ An asterisk (*) denotes a new or updated recommendation. Full recommendations are found in the ACIP document.

Hepatitis B testing of pregnant women

• All pregnant women should be tested for hepatitis B surface antigen (HBsAg).
• All HBsAg-positive pregnant women should be tested for hepatitis B virus deoxyribonucleic acid (HBV DNA).*

Infants

• Universal vaccination of infants (birth dose):
  • All medically stable infants ≥2000 grams should receive hepatitis B vaccination within 24 hours of birth* followed by completion of the vaccine series.
  • Infants <2,000 grams should receive 1 dose of hepatitis B vaccination at chronological age one month or at hospital discharge.
• Infants born to HBsAg positive women should be given hepatitis B vaccine and hepatitis B immune globulin (HBIG) within 12 hours of birth regardless of birth weight, followed by completion of the vaccine series and post-vaccination serologic testing.
  • Infants who do not respond to the initial vaccination series who were born to HBsAg positive women should be revaccinated with one dose of hepatitis B vaccine.*
• Infants whose mother’s HBsAg status remains unknown indefinitely (e.g., infants confidentially surrendered shortly after birth) should receive post – vaccination serologic testing.* 

Providers are encouraged to review the ACIP’s “Prevention of Hepatitis B Virus Infection in the United States”  for more detailed information on the recommendations above as well as new recommendations for vaccinating persons with chronic liver disease and post – exposure prophylaxis.

CDC Recommends Routine Vaccination of People 50 Years Old and Older with New Herpes Zoster Vaccine

On January 26, 2018, the ACIP published recommendations on the use of herpes zoster vaccines. The CDC now recommends the new recombinant zoster vaccine (RZV), Shingrix®, as preferred over the live zoster vaccine (ZVL), Zostavax®, for the prevention of herpes zoster and related complications. The two dose RZV, licensed in October 2017, is more effective and provides a more sustained immunity than the single dose ZVL.²

The CDC recommends two doses of RZV separated by 2 to 6 months for immunocompetent adults age 50 years and older³:

• Whether or not they report a prior episode of herpes zoster
• Whether or not they report receiving a prior dose of ZVL
• Who have chronic medical conditions (e.g., chronic renal failure, diabetes mellitus, rheumatoid arthritis, chronic pulmonary disease), unless a contraindication or precaution exists. Similar to ZVL, RZV may be used for adults who:
  • are taking low-dose immunosuppressive therapy
  • are anticipating immunosuppression
  • have recovered from an immunocompromising illness
• Who are getting other adult vaccines in the same doctor’s visit, including those routinely recommended for adults age 50 years and older, such as influenza and pneumococcal vaccines. (The safety and efficacy of concomitant administration of two adjuvanted vaccines, such as RZV and the adjuvanted inactivated influenza vaccine, trivalent [Fluad], have not been evaluated).
• It is not necessary to screen, either verbally or by laboratory serology, for evidence of prior varicella infection.

View the CDC health care provider Shingrix Recommendations for more information on RZV timing considerations and contraindications.

Third Dose of Mumps-Containing Vaccine Now Recommended in Outbreak Situations

With the increase in mumps outbreaks and outbreak-associated mumps cases in the US, the ACIP now recommends that during an outbreak, one dose of mumps-containing vaccine (MMR or MMRV) be administered to previously vaccinated persons who public health officials identify as being at increased risk.⁴ The rationale is that, with waning immunity and the high intensity of exposure in close – contact settings typical of many mumps outbreaks, the risk for disease is much higher. Two doses of MMR or MMRV vaccine currently appear to be sufficient for mumps control in the general population. The full ACIP recommendations, Use of a Third Dose of Mumps Virus–Containing Vaccine in Persons at Increased Risk for Mumps During an Outbreak, provide more detailed information on this new recommendation.

Timely reporting of potential mumps cases is vital to the prevention and control of outbreaks. Providers are encouraged to read the October 2017 Rx for Prevention Continuing Medical Education (CME) article, "Recognizing and Managing Mumps in Adults", for details on the presentation, work-up, and management of mumps in adults. For questions regarding mumps or to report, please contact the Los Angeles County Department of Public Health (DPH) Vaccine Preventable Disease Control Program at 213-351-7800 during business hours or the on – call staff after hours at 213-974-1234.

2018 Recommended Immunization Schedules and New Vaccine Information Sheets (VIS)

The Recommended Immunization Schedules for Persons Aged 0 through 18 Years and Adults 19 Years and Older are available on the CDC website: www.cdc.gov/vaccines/schedules/hcp. Please note: when reviewing the schedules, the footnotes contain important information such as vaccine intervals, exceptions to the vaccine schedule, and information regarding vaccination of special populations.

Please share the updated schedules with all health care personnel in your facility, especially those staff who provide immunization services. Please replace any copies of the 2017 schedule posted in your facility with the new 2018 version.

In addition, please note that there are several new VIS from the CDC that should replace older versions:

• Measles/Mumps/Rubella (MMR) VIS
• Measles/Mumps /Rubella & Varicella (MMRV) VIS
• Rotavirus VIS
• Varicella (Chickenpox) VIS
• Live Zoster (Shingles) VIS
• Recombinant Zoster(Shingles) VIS

For more information on the immunization schedule, including recommended routine intervals, and contraindications and precautions to vaccines, visit the DPH Vaccine Preventable Disease Control Program health care provider website at http://www.publichealth.lacounty.gov/ip/providers.htm.

Additional Learning

CDC Current Issues in Immunizations – CME credit may be available

• Live webinar on March 21, 2018

  Updates on Child, Adolescent and Adult Immunization Schedules https://www.cdc.gov/vaccines/ed/ciinc/index.html  Registration is pending.

• Archived webinar and PowerPoint presentations from November 8, 2017: Hepatitis A and Herpes Zoster Vaccines https://www2.cdc.gov/vaccines/ed/ciinc/archives/17/11_18.asp  

References

1. Shille, S., Bellozzi, C., Reingold, A, et. al. Prevention of Hepatitis B Virus Infection in the United States: Recommendations of the Advisory Committee on Immunization Practices. MMWR Recomm Rep 2018;67(1):1 – 31. DOI: www.cdc.gov/mmwr/volumes/67/rr/rr6701a1.htm. Accessed February 20, 2018.
2. Dooling, KL, Guo, A, Patel M, et al. Recommendations of the Advisory Committee on Immunization Practices for Use of Herpes Zoster Vaccines. MMWR Morb Mortal Wkly Rep 2018;67:103-108. DOI: www.cdc.gov/mmwr/volumes/67/wr/mm6703a5.htm?s_cid=mm6703a5_w. Accessed February 20, 2018
3. Centers for Disease Control and Prevention. Shingrix Recommendations. https://www.cdc.gov/vaccines/vpd/shingles/hcp/shingrix/recommendations.html. Updated February 7, 2018. Accessed February 27, 2018.
4. Marin, M., Marlow, M., Moore, K., et. al. Recommendation of the Advisory Committee on Immunization Practices for Use of a Third Dose of Mumps Virus–Containing Vaccine in Persons at Increased Risk for Mumps During an Outbreak. MMWR 67:33 – 38. DOI:www.cdc.gov/mmwr/volumes/67/wr/mm6701a7.htm. Accessed on February 21, 2018