Rafael Harpaz

Advisory Committee on Immunization Practices recommended immunization schedule for adults aged 19 years or older - United States, 2014.

In October 2015, the Advisory Committee on Immunization Practices (ACIP)* approved the Recommended Immunization Schedule for Adults Aged 19 Years or Older, United States, 2016. This schedule provides a summary of ACIP recommendations for the use of vaccines routinely recommended for adults aged 19 years or older in two figures, footnotes for each vaccine, and a table that describes primary contraindications and precautions for commonly used vaccines for adults. Although the figures in the adult immunization schedule illustrate recommended vaccinations that begin at age 19 years, the footnotes contain information on vaccines that are recommended for adults that may begin at age younger than age 19 years. The footnotes also contain vaccine dosing, intervals between doses, and other important information and should be read with the figures.

Herpes zoster vaccine in older adults and the risk of subsequent herpes zoster disease.

CONTEXT Approximately 1 million episodes of herpes zoster occur annually in the United States. Although prelicensure data provided evidence that herpes zoster vaccine works in a select study population under idealized circumstances, the vaccine needs to be evaluated in field conditions. OBJECTIVE To evaluate risk of herpes zoster after receipt of herpes zoster vaccine among individuals in general practice settings. DESIGN, SETTING, AND PARTICIPANTS A retrospective cohort study from January 1, 2007, through December 31, 2009, of individuals enrolled in the Kaiser Permanente Southern California health plan. Participants were immunocompetent community-dwelling adults aged 60 years or older. The 75,761 members in the vaccinated cohort were age matched (1:3) to 227,283 unvaccinated members. MAIN OUTCOME MEASURE Incidence of herpes zoster. RESULTS Herpes zoster vaccine recipients were more likely to be white, women, with more outpatient visits, and fewer chronic diseases. The number of herpes zoster cases among vaccinated individuals was 828 in 130,415 person-years (6.4 per 1000 person-years; 95% confidence interval [CI], 5.9-6.8), and for unvaccinated individuals it was 4606 in 355,659 person-years (13.0 per 1000 person-years; 95% CI, 12.6-13.3). In adjusted analysis, vaccination was associated with a reduced risk of herpes zoster (hazard ratio [HR], 0.45; 95% CI, 0.42-0.48); this reduction occurred in all age strata and among individuals with chronic diseases. Risk of herpes zoster differed by vaccination status to a greater magnitude than the risk of unrelated acute medical conditions, suggesting results for herpes zoster were not due to bias. Ophthalmic herpes zoster (HR, 0.37; 95% CI, 0.23-0.61) and hospitalizations coded as herpes zoster (HR, 0.35; 95% CI, 0.24-0.51) were less likely among vaccine recipients. CONCLUSIONS Among immunocompetent community-dwelling adults aged 60 years or older, receipt of the herpes zoster vaccine was associated with a lower incidence of herpes zoster. The risk was reduced among all age strata and among individuals with chronic diseases.

Herpes Zoster Incidence Among Insured Persons in the United States, 1993–2006: Evaluation of Impact of Varicella Vaccination

BACKGROUND herpes zoster (HZ) is caused by reactivation of latent varicella zoster virus and is often associated with substantial pain and disability. Baseline incidence of HZ prior to introduction of HZ vaccine is not well described, and it is unclear whether introduction of the varicella vaccination program in 1995 has altered the epidemiology of HZ. We examined trends in the incidence of HZ and impact of varicella vaccination on HZ trends using a large medical claims database. METHODS medical claims data from the MarketScan databases were obtained for 1993-2006. We calculated HZ incidence using all persons with a first outpatient service associated with a 053.xx code (HZ ICD-9 code) as the numerator, and total MarketScan enrollment as the denominator; HZ incidence was stratified by age and sex. We used statewide varicella vaccination coverage in children aged 19-35 months to explore the impact of varicella vaccination on HZ incidence. RESULTS HZ incidence increased for the entire study period and for all age groups, with greater rates of increase 1993-1996 (P < .001). HZ rates were higher for females than males throughout the study period (P < .001) and for all age groups (P < .001). HZ incidence did not vary by state varicella vaccination coverage. CONCLUSIONS HZ incidence has been increasing from 1993-2006. We found no evidence to attribute the increase to the varicella vaccine program.

Elimination of New Chronic Hepatitis B Virus Infections: Results of the Alaska Immunization Program

An immunization assessment and a serologic survey were conducted to evaluate the effectiveness of a hepatitis B immunization program in eliminating hepatitis B virus (HBV) transmission among Alaska Natives in a region in which HBV infection is endemic. Hepatitis B vaccine coverage was 93% among 567 children </=10 years old residing in the study villages, and catch-up vaccine coverage among 582 susceptible persons 11-30 years old was 62%. None of 271 tested children </=10 years old were chronically infected with HBV, and just 4 (1.5%) had evidence of resolved infection. In contrast, 16% of 332 persons 11-30 years old (those born before implementation of routine infant hepatitis B vaccination) were chronically infected. A hepatitis B immunization program that includes prevention of perinatal HBV infection, routine infant vaccination, and catch-up vaccination of older children and adults can eliminate new chronic HBV infections in a population with a high rate of chronic infection.

Mumps Outbreak in Orthodox Jewish Communities in the United States

BACKGROUND By 2005, vaccination had reduced the annual incidence of mumps in the United States by more than 99%, with few outbreaks reported. However, in 2006, a large outbreak occurred among highly vaccinated populations in the United States, and similar outbreaks have been reported worldwide. The outbreak described in this report occurred among U.S. Orthodox Jewish communities during 2009 and 2010. METHODS Cases of salivary-gland swelling and other symptoms clinically compatible with mumps were investigated, and demographic, clinical, laboratory, and vaccination data were evaluated. RESULTS From June 28, 2009, through June 27, 2010, a total of 3502 outbreak-related cases of mumps were reported in New York City, two upstate New York counties, and one New Jersey county. Of the 1648 cases for which clinical specimens were available, 50% were laboratory-confirmed. Orthodox Jewish persons accounted for 97% of case patients. Adolescents 13 to 17 years of age (27% of all patients) and males (78% of patients in that age group) were disproportionately affected. Among case patients 13 to 17 years of age with documented vaccination status, 89% had previously received two doses of a mumps-containing vaccine, and 8% had received one dose. Transmission was focused within Jewish schools for boys, where students spend many hours daily in intense, face-to-face interaction. Orchitis was the most common complication (120 cases, 7% of male patients ≥12 years of age), with rates significantly higher among unvaccinated persons than among persons who had received two doses of vaccine. CONCLUSIONS The epidemiologic features of this outbreak suggest that intense exposures, particularly among boys in schools, facilitated transmission and overcame vaccine-induced protection in these patients. High rates of two-dose coverage reduced the severity of the disease and the transmission to persons in settings of less intense exposure.

The Impact of the Varicella Vaccination Program on Herpes Zoster Epidemiology in the United States: A Review

Speculation that a universal varicella vaccination program might lead to an increase in herpes zoster (HZ) incidence has been supported by modeling studies that assume that exposure to varicella boosts immunity and protects against reactivation of varicella-zoster virus (VZV) as HZ. Such studies predict an increase in HZ incidence until the adult population becomes predominantly composed of individuals with vaccine-induced immunity who do not harbor wild-type VZV. In the United States, a varicella vaccination program was implemented in 1995. Since then, studies monitoring HZ incidence have shown inconsistent findings: 2 studies have shown no increase in overall incidence, whereas 1 study has shown an increase. Studies from Canada and the United Kingdom have shown increasing rates of HZ incidence in the absence of a varicella vaccination program. Data suggest that heretofore unidentified risk factors for HZ also are changing over time. Further studies are needed to identify these factors, to isolate possible additional effects from a varicella vaccination program. Untangling the contribution of these different factors on HZ epidemiology will be challenging.

Barriers to the Use of Herpes Zoster Vaccine

BACKGROUND The herpes zoster vaccine is the most expensive vaccine recommended for older adults and the first vaccine to be reimbursed through Medicare Part D. Early uptake has been 2% to 7% nationally. OBJECTIVE To assess current vaccination practices, knowledge and practice regarding reimbursement, and barriers to vaccination among general internists and family medicine physicians. DESIGN Mail and Internet-based survey, designed through an iterative process and conceptually based on the Health Belief Model. SETTING National survey conducted from July to September 2008. PARTICIPANTS General internists and family medicine physicians. MEASUREMENTS Survey responses on current vaccination practices, knowledge and practice regarding reimbursement, and barriers to vaccination. RESULTS Response rates were 72% in both specialties (301 general internists and 297 family medicine physicians). Physicians in both specialties reported similar methods for delivering vaccine, which included stocking and administering the vaccine in their offices (49%), referring patients to a pharmacy to purchase the vaccine and bring it back to the office for administration (36%), and referring patients to a pharmacy for vaccine administration (33%). Eighty-eight percent of providers recommend herpes zoster vaccine and 41% strongly recommend it, compared with more than 90% who strongly recommend influenza and pneumococcal vaccines. For physicians in both specialties, the most frequently reported barriers to vaccination were financial. Only 45% of respondents knew that herpes zoster vaccine is reimbursed through Medicare Part D. Of respondents who began administering herpes zoster vaccine in their office, 12% stopped because of cost and reimbursement issues. LIMITATIONS Survey results represent reported but not observed practice. Surveyed providers may not be representative of all providers. CONCLUSION Physicians are making efforts to provide herpes zoster vaccine but are hampered by barriers, particularly financial ones. Efforts to facilitate the financing of herpes zoster vaccine could help increase its use. PRIMARY FUNDING SOURCE Centers for Disease Control and Prevention.

Examination of Links Between Herpes Zoster Incidence and Childhood Varicella Vaccination

BACKGROUND Introduction of a universal varicella vaccine program for U.S. children in 1996 sparked concern that less-frequent exposure to varicella would decrease external boosting of immunity to varicella zoster virus and thereby increase incidence of herpes zoster (HZ). OBJECTIVE To determine whether the varicella vaccination program has influenced trends in HZ incidence in the U.S. population older than 65 years. DESIGN Retrospective study of Medicare claims. SETTING Medicare, 1992 through 2010. PARTICIPANTS 2 848 765 beneficiaries older than 65 years. MEASUREMENTS Annual HZ incidence from 1992 through 2010; rate ratios (RRs) for HZ incidence by age, sex, and race or ethnicity; and state-level varicella vaccination coverage. RESULTS 281 317 incident cases of HZ occurred. Age- and sex-standardized HZ incidence increased 39% from 10.0 per 1000 person-years in 1992 to 13.9 per 1000 person-years in 2010 with no evidence of a statistically significant change in the rate of increase after introduction of the varicella vaccination program. Before introduction of this program, HZ incidence was higher in women (RR, 1.21 [95% CI, 1.19 to 1.24]) than men and was lower in black persons (RR, 0.51 [CI, 0.48 to 0.53]) and Hispanic persons (RR, 0.76 [CI, 0.72 to 0.81]) than white persons. In a model adjusted for sex, age, and calendar year from 1997 to 2010, HZ incidence did not vary by state varicella vaccination coverage (RR, 0.9998 [CI, 0.9993 to 1.0003]). LIMITATION Uncertain level and consistency of health-seeking behavior and access and uncertain accuracy of disease coding. CONCLUSION Age-specific HZ incidence increased in the U.S. population older than 65 years even before implementation of the childhood varicella vaccination program. Introduction and widespread use of the vaccine did not seem to affect this increase. This information is reassuring for countries considering universal varicella vaccination. PRIMARY FUNDING SOURCE None.

U.S. Physicians’ Perspective of Adult Vaccine Delivery

Context Vaccination rates in adults are low, even though more than 95% of Americans who die of vaccine-preventable disease each year are adults. General internists and family medicine physicians were surveyed about vaccine perceptions and practices. Contribution Barriers related to vaccine delivery included lack of regular assessment of vaccine status, insufficient stocking of some vaccines, and financial disincentives for vaccination in the primary care setting. Use of electronic tools to record and prompt vaccination was low. Most physicians surveyed accepted vaccination outside of the medical home but believed communication between themselves and alternate vaccinators was suboptimal. Implication System changes are necessary to improve adult vaccination in the United States. The Editors Vaccination remains underutilized in adults. An annual average of more than 30 000 Americans die of vaccine-preventable diseases, mostly influenza, and more than 95% of these persons are adults (1). The Advisory Committee on Immunization Practices recommends 12 vaccines for adults, including vaccines recommended universally, vaccines for persons who did not receive them in childhood (catch up), and vaccines for those in high-risk groups (2). According to recent estimates (3, 4), only 62% and 65% of adults aged 65 years or older received a pneumococcal or influenza vaccine, respectively; only 20% of high-risk adults aged 19 to 64 years received a pneumococcal vaccine; and only 16% of adults aged 60 years or older received a herpes zoster vaccine. All of these percentages are well short of Healthy People 2020 goals (5). None of the studies that examined reasons for low rates of adult vaccination (612) comprehensively examined adult vaccination. Furthermore, the context of adult vaccination has changed in recent years: There are newly recommended adult vaccines, some vaccines are now covered by Medicare Part D (a pharmaceutical benefit), and the site of vaccine delivery has shifted away from primary care settings. Almost half of adult seasonal influenza vaccinations in the 20102011 season occurred in health departments, pharmacies, work places, or other nonmedical locations (13), but physician perceptions regarding collaboration with alternate vaccinators have only been documented limitedly (14). Given the increase in the number of vaccines recommended for adults and the increasing importance of alternative sites for vaccine delivery, we sought to describe the following among U.S. primary care physicians: practices regarding assessing vaccination status and stocking of recommended adult vaccines; barriers to stocking and administering vaccines; characteristics of physicians who report greater financial barriers to delivering vaccines; and practices, experiences, and attitudes regarding vaccination outside of the medical home. Methods Study Setting From March to June 2012, we administered a survey to a network of primary care physicians (Supplement). The Human Subjects Review Board at the University of Colorado Denver approved this study as exempt research that did not require written informed consent. Supplement. Survey on Adult Immunization and Preventive Care Study Sample The Vaccine Policy Collaborative Initiative conducted this study (15). The Initiative was designed collaboratively with the Centers for Disease Control and Prevention (CDC) to perform rapid-turnaround surveys to assess physician attitudes about vaccine issues. We developed a network of primary care physicians for this program by recruiting general internists (GIMs) and family medicine physicians (FMs) from the memberships of the American College of Physicians (ACP) and the American Academy of Family Physicians (AAFP). We conducted quota sampling (16) to ensure that network physicians were similar to the ACP and AAFP memberships with respect to region, urban versus rural location, and practice setting (GIMs only). We previously demonstrated that survey responses from network physicians compared with those of physicians randomly sampled from American Medical Association physician databases (which reflect all practicing physicians and not just members of the American Medical Association) had similar demographic characteristics, practice attributes, and attitudes about a range of vaccination issues (16). Survey Design We developed a survey appraising physician practices regarding assessment of vaccination status for and stocking of the 11 adult vaccines routinely recommended in 2012 (17), as well as referral practices to alternate vaccinators when vaccines were not stocked. We used 4-point Likert scales for questions assessing attitudes about the role of different adult vaccine providers (strongly agree to strongly disagree) and barriers to stocking and administering vaccines in the practice (major barrier to not a barrier) (18). For brevity, certain questions were asked in a generic manner and were not related to specific vaccines. After an advisory panel of GIMs (n= 6) and FMs (n= 7) pretested the survey, we modified it on the basis of their feedback. The survey was then piloted by 86 primary care physicians (63 GIMs and 23 FMs) and further modified according to this feedback. Survey Administration According to physician preference, we sent the survey either over the Internet (Verint; Melville, New York) or through the U.S. Postal Service. We sent the Internet group an initial e-mail with up to 8 e-mail reminders, and we sent the mail group an initial mailing and up to 2 additional reminders. Nonrespondents in the Internet group were also sent a mail survey in case of problems with e-mail correspondence. We patterned the mail protocol on Dillmans tailored design method (19). Statistical Analysis We pooled Internet and mail surveys together for analyses because other studies have found that physician attitudes are similar when obtained by either method (2022). We compared respondents with nonrespondents on all available characteristics using Wilcoxon and chi-square analyses. Characteristics of nonrespondents were obtained from the recruitment survey for the sentinel networks. We found financial barriers to be commonly reported and therefore assessed whether certain characteristics of primary care physicians were associated with perceiving more financial barriers because this information could lead to actionable policymaking. To assess associations with perception of financial barriers and to avoid issues associated with multiple comparisons, we created a financial barriers scale composed of 8 financial barrier survey questions (Table 1). We combined the scores of these 8 variables (not a barrier= 0; minor barrier= 1; moderate barrier= 2; major barrier= 3) and divided that sum by the number of questions answered. We excluded respondents who had answered fewer than 5 of the 8 questions on financial barriers. A Cronbach was calculated to determine the internal consistency of the financial barriers scale. We used this scale as the outcome measure to evaluate associations between financial barriers and demographic and practice characteristics (sex, age, region, practice location, practice setting, number of providers in the practice, and proportion of patients with Medicare Part D and Medicaid) in a multivariable linear regression model for each specialty. Analyses were done by using SAS, version 9.2 (SAS Institute, Cary, North Carolina). Table 1. Perceived Barriers to Stocking and Administering Vaccines for Adult Patients in Respondents Practice Role of the Funding Source Investigators at the CDC were involved with the survey design, analysis, and the decision to submit the manuscript for publication. Results Survey Response Rates and Respondent Characteristics Response rates were 79% for GIMs (352 of 443) and 62% for FMs (255 of 409). All questions had fewer than 8% missing items, with most having fewer than 5% missing. The number of missing items did not differ between GIMs and FMs or between physicians who responded by Internet and those who responded by mail. No GIMs and only 2 FMs were from the same practice site. Respondents and nonrespondents did not differ significantly by sex, age, region, practice location, practice setting, or number of providers in the practice. Table 2 displays characteristics of respondents and their practices and patient populations. Table 2. Comparison of Respondents and Nonrespondents and Additional Characteristics of Respondents Practices Current Practices Regarding Assessing Need for and Stocking of Routinely Recommended Adult Vaccines Almost all physicians reported assessing patients vaccination status at annual visits (GIMs and FMs, 97%) or initial visits (GIMs, 94%; FMs, 89%), whereas fewer physicians (GIMs, 29%; FMs, 32%) reported doing so at every visit. The most commonly reported method for assessing immunization status was to check the medical record (GIMs, 95%; FMs, 96%). Although most physicians reported asking patients about vaccination status verbally (GIMs, 89%; FMs, 90%), by questionnaire (GIMs, 57%; FMs, 52%), or by having a staff member ask (GIMs, 57%; FMs, 66%), very few (GIMs, 1%; FMs, 2%) relied exclusively on patient-supplied information. A minority used immunization information systems (IISs) (GIMs, 8%; FMs, 36%). Forty-six percent of GIMs and 48% of FMs reported that it was moderately/very difficult to determine an adult patients vaccination status for vaccines other than seasonal influenza. Almost all physicians reported assessing the vaccination status for seasonal influenza; pneumococcal; tetanus and diphtheria (Td); tetanus, diphtheria, and acellular pertussis (Tdap); and zoster vaccines. Fewer reported assessing the status for the remainder of the recommended vaccines (Figure 1). Family physicians were more likely than GIMs to assess the need for hepatitis A; hepatitis B; measles, mumps, and rubella (MMR); human papillomavirus; meningococcal; and varicella vaccines. Figure 1. Percentage of physicians w

Herpes Zoster and Postherpetic Neuralgia Surveillance Using Structured Electronic Data

OBJECTIVE To develop electronic algorithms for rapid, automated surveillance for herpes zoster and postherpetic neuralgia (PHN) using codified electronic health data. PATIENTS AND METHODS We attempted to identify every case of herpes zoster and PHN arising between January 1 and December 31, 2008, within the electronic medical record of a 560,000-patient ambulatory practice using an array of diagnosis codes; intervals between herpes zoster encounters; and prescriptions for analgesics, anticonvulsants, and antidepressants. We assessed the sensitivity and positive predictive value (PPV) of each screening criterion by medical record review and then integrated multiple criteria into combination algorithms to optimize sensitivity and PPV. We applied the optimized algorithms to the practices historical data spanning January 1, 1996, to December 31, 2008, to assess for changes in the annual incidence of PHN. RESULTS The International Classification of Diseases, Ninth Revision, code 053 detected herpes zoster with 98% sensitivity and 93% PPV. A combination algorithm including diagnosis codes, visit intervals, and prescriptions detected PHN with 86% sensitivity and 78% PPV. Between 1996 and 2008, the age- and sex-adjusted annual incidence of PHN rose from 0.18 to 0.47 cases per 1000 patients, and the proportion of herpes zoster patients progressing to PHN rose from 5.4% to 17.6%. CONCLUSION Novel algorithms incorporating multiple streams of electronic health data can reasonably detect herpes zoster and PHN. These algorithms could facilitate meaningful public health surveillance using electronic health data. The incidence of PHN may be increasing.