437 - Adult Vaccine Schedule Update, A-fib Screening, Going Off-Line
Take 3 – Practical Practice Pointers©
From the Centers for Disease Control and Prevention (CDC)
1) 2022 Vaccine Schedule and more on Pneumococcal Vaccine
The CDC released the 2022 vaccination schedule last week. We covered the change in pneumococcal recommendations last week, but there were a few important details to those recommendations that need reviewing. The rest of the changes included the addition of dengue vaccine and some minor clarifications to other vaccines.
Pneumococcal vaccine additional guidance:
· If your patient has immunocompromising conditions, cochlear implant or CSF leak, the interval between PCV13 or PCV15 and PPSV23 can be a minimum of 8 weeks
· There is an only-one-PCV-in-adulthood rule that is not well articulated in the recommendations.
o So, if you have given PCV13 before age 65,
§ Follow that after one year with PPSV23 (after 8 weeks for immunocompromised, cochlear implants or CSF leak), another PPSV23 in five years if under age 65, then another PPSV23 after age 65 if it has been five years since the last PPSV23.
o If you have given PCV15 before age 65,
§ Follow that after one year with PPSV23 (after 8 weeks for immunocompromised, cochlear implants or CSF leak). After age 65, stay tuned – see comments.
o If you give PCV20 for whatever reason before age 65, no further pneumococcal vaccinations are required.
· PCV20 can be substituted for a PPSV23 if the latter is not available. Using a PCV 20 will terminate any pneumococcal vaccination schedule.
Other vaccine guidance/updates to the schedule:
· There is now an appendix for both the Child/Adolescent and Adult schedules that lists contraindications and precautions for all vaccines (rather than using the Notes section for that information).
· Dengue (DEN4CYD) vaccine
o Indicated for ages 9-16 years, with evidence of prior infection, who live in endemic areas (Puerto Rico, American Samoa, the U.S. Virgin Islands, the Federated States of Micronesia, the Republic of Marshall Islands, and the Republic of Palau).
o The vaccine is given in three doses, six months apart.
o Severe immune deficiency and allergy to the vaccine are contraindications, precautions exist for pregnancy, immune suppression, and acute febrile illness.
· Hepatitis B virus (Hep B) vaccine
o Post-vaccination serology testing and revaccination (if anti-HBs < 10mlU/mL) is recommended for: 1) Infants born to HBsAg-positive mothers, 2) Hemodialysis patients, 3) Other immunocompromised persons
o Hep B vaccine is universally recommended for ages 19-59 and is recommended for age 60+ with certain risk factors (liver disease, sexual exposure, HIV, risk for bloodborne pathogen exposure, injection drug use, incarceration, or travel to endemic countries).
· Human Papilloma Virus (HPV) vaccine
o 3 doses are recommended for patients who are immunocompromised (including HIV), regardless of age.
· Measles, Mumps, Rubella & Varicella (MMRV) vaccines
o For dose #1 in children aged 12–47 months, it is best to administer MMR and varicella vaccines separately. However, MMRV may be used if parents or caregivers express a preference for it.
· Recombinant Zoster Virus (RZV) vaccine
o Currently no recommendation for RZV use in pregnancy. Consider delaying RZV until after pregnancy.
o RZV is recommended in people who are/will be immune compromised because of disease or treatment.
Vaccines are getting more complicated as we find we can prevent more and more disease. I strongly recommend having copies of the most current schedule available in practice, and/or using the available apps to keep things straight. The recommendations for pneumococcal vaccines after 65 when patients have received a PCV15 before 65 are unclear. I will investigate and report back soon.
· Murthy N. Advisory Committee on Immunization Practices Recommended Immunization Schedule for Adults Aged 19 Years or Older — United States, 2022. MMWR Morb Mortal Wkly Rep. 2022;71. Link
· Wodi AP. Advisory Committee on Immunization Practices Recommended Immunization Schedule for Children and Adolescents Aged 18 Years or Younger — United States, 2022. MMWR Morb Mortal Wkly Rep. 2022;71. Link
From the USPSTF and the Guidelines
2) Screening (or Not) for Atrial Fibrillation
Atrial fibrillation (AF) is the most common cardiac arrhythmia. The prevalence of AF increases with age, from less than 0.2% in adults younger than 55 years to about 10% in those 85 years or older, with a higher prevalence in men than in women. AF is a major risk factor for ischemic stroke and is associated with a substantial increase in the risk of stroke. Approximately 20% of patients who have a stroke associated with AF are first diagnosed with AF at the time of the stroke or shortly thereafter.
AF can be persistent or paroxysmal, and symptomatic or asymptomatic. As implantable cardiac devices and the use of portable or wearable cardiac monitoring devices have become more common, a new category of AF, called subclinical AF, has emerged. Subclinical AF refers to device-detected AF that is asymptomatic and not clinically apparent. It may be detected by intracardiac, implantable, or wearable cardiac monitors. The duration of subclinical AF can vary, ranging from a few seconds to more than 24 hours. Atrial fibrillation burden refers to the amount or percentage of time that is spent in AF. Atrial fibrillation burden is often described as low or high, although there is no exact definition or consensus about what constitutes low vs high AF burden. The stroke risk associated with subclinical AF, particularly low-burden or short-duration AF, is less well understood.
The USPSTF recently updated and reconfirmed their 2018 recommendation regarding screening for atrial fibrillation in adults over the age of 50, concluding that evidence is lacking, and the balance of benefits and harms of screening for AF in asymptomatic adults cannot be determined (I recommendation).
Specifically, the Task Force determined:
· Inadequate evidence to assess whether 1-time screening strategies identify adults > 50 with previously undiagnosed AF more effectively than usual care.
· Adequate evidence that intermittent and continuous screening strategies identify adults > 50 with previously undiagnosed AF more effectively than usual care.
Benefits of early detection, intervention, and treatment:
· Inadequate direct evidence of the benefits of screening for AF
· Inadequate evidence on the benefits of treatment of screen-detected AF, particularly paroxysmal AF of short duration
Harms of early detection, intervention, and treatment:
· Inadequate direct evidence on the benefits of screening for AF.
· Adequate evidence that treatment of AF with anticoagulant therapy is associated with small to moderate harm, particularly an increased risk of bleeding.
The USPSTF noted that the American Heart Association 2014 guidelines for the primary prevention of stroke indicated “Active screening for AF in the primary care setting in patients >65 years of age by pulse assessment followed by ECG as indicated can be useful (Class IIa; Level of Evidence B).”
Recall that an “insufficient” recommendation does not mean “don’t do” or “is harmful,” it just means that the evidence does not support doing it as a global recommendation. Given the rapid expansion of wearable technology, the greater challenge clinically will be how to guide patients who have subclinical atrial fibrillation, particularly since we really can’t counsel them on risks and benefits. One option would be to calculate a CHA₂DS₂-VASc score ( MD Calc: A-fib Stroke Risk ) which, even though not designed for this clinical circumstance, could help guide the discussion.
USPSTF. Screening for atrial fibrillation. USPSTF recommendation statement. JAMA 2022 Jan 25;327(4):360-367. Link
From PeerRxMed (www.PeerRxMed.org)
3) Going Off-Line: Disconnecting … to Connect ….
“Almost everything will work again if you unplug it for a few minutes … including you.” Anne Lamotte, author
I wish you could have seen their faces. Twenty healthcare leaders looking as though they’d each individually been told the end was near. But the actual concern was nothing of the sort. It was February of 2018 and I was attending a leadership well-being retreat, and as we began the initial morning session, the facilitator made one simple request. “For the duration of the day, I’d like for you to put your cell phones on airplane mode and leave them in this cell phone ‘nursery’ (a basket).” He continued, now with a twinkle in his eye and wide grin. “Please know your babies will be just fine. I’ll put the basket right over here in the corner of the room, and if you’d like to come over on the break and just hold and coddle your phone or check to see if there is an emergency, that will be fine. Just don’t use it otherwise.”
At that moment, there was complete silence in the room, a collective look of complete dread (likely including me), and then then some nervous laughter, as if he really wasn’t serious. But he was, and concluded, “It was just over 10 years ago, with the release of the first iPhone, that these devices that you now believe you can’t live without became mainstream, and for many here, you’ve not unplugged since. Today, you have that opportunity.”
And we did. For three days, we reluctantly “unplugged” each morning at 8:00 and “reconnected” again at 5:00. By the end of the 3rd day, we realized the actual “reconnection” began to happen when airplane mode went to “on.” In that space, we “showed up” differently for ourselves and each other, and as a result, we were able to hear both our own and each other’s voices in an entirely new way. There became a depth and richness of interconnection that would likely not have happened otherwise. It was a profound time. And the fact that I’m sharing this story 4 years later indicates that for me, the impact was lasting.
When was the last time you “unplugged,” even for 1 day, and not just from your phone, but from other electronics (including your EHR) as well? Well, here’s an opportunity for you to do so, and join multitudes of others for the 13th annual National Day of Unplugging on March 4-5 (Link). Started in 2009, this “going off-line” awareness campaign promotes a respite from technology for up to 24-hours. Its intention is to help raise our awareness as to how we use our technology (or how it uses us …).
Why not give it a try?! Sometime in the next week, “disconnect” for a defined period of time (a day?) – no phone, no computer, no television, no radio, and no “smart watch.” Spend that time “noticing” your response. For some of you, doing so may be such a shock to your senses such that you are unable to do it for very long. Consider that important information. Then share with someone, such as your PeerRxMed partner, what you observed. In doing so, perhaps you’ll recognize that your “smart technology” may be smart, but it is in no way wise … and realize the wisdom of doing this much more often than once a year.
Mark and John
Carilion Clinic Department of Family and Community Medicine
Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.