09:02 AM

486 - Adult Immunizations 2023, Teen Health, “Soul Friend” Colleagues

Take 3 – Practical Practice Pointers©

From the Centers for Disease Control and Prevention

1)  Adult Immunization Schedule Changes for 2023


We covered the changes to the 2023 Child and Adolescent Immunization Schedule in the previous pointer, and now we review the change to the adult schedule. It is increasingly important to get familiar with the adult immunizations schedule, because of the frequent changes and updates to age-based vaccines, and as our vaccine armamentarium grows to protect adults with various health risks from more infectious threats.

There were multiple small changes (as usual) to wording and instructions to clarify certain table entries and notes.  The substantive changes/updates:

·       COVID-19 – FDA approved/ACIP recommended vaccines were added to the schedule, and links to information about emergency use authorization for non-FDA-approved vaccine products were included.

·       Hepatitis B –The ACIP recommended in 2022 that ALL adults aged 19 through 59 be vaccinated for Hep B, and that those 60 and older may be vaccinated for certain risk factors (liver disease, HIV infection, or risk of exposure from sexual activity, IV drugs, or percutaneous/mucosal sources). A new vaccine, PreHevbrio, was added for routine immunization for hepatitis B. PreHevbrio is a new recombinant vaccine that is recommended as an option for adult vaccination.

·       Influenza – Wording was added to support the recommendation of universal high-dose influenza immunization for all people 65 and older, but if high-dose vaccine is not available, it is acceptable to give standard dose to accomplish vaccination. In addition, further information was added to the notes about avoiding live attenuated influenza vaccine in patients whose household contacts are immunosuppressed. Finally, patients who have egg allergy other than hives should receive egg-derived vaccine in a medical setting (or egg-free if available).

·       MMR – A third dose of MMR is recommended in the setting of a local mumps outbreak to boost immunity.

·       Meningococcal B – For Trumenba (three dose Men B vaccine), if the third dose was administered earlier than the recommended 4 months spacing, a fourth dose (after another 4 months) is recommended.

·       Pneumococcal – Notes about the recommendations for PCV15 and PCV 20 were added to the schedule. We covered those in Take 3 #436.

·       Poliovirus – In general, polio immunization is not recommended for adults, but may be considered if the patient will be coming into contact with polio (through travel, outbreaks, etc.).

·       Zoster – Reinforced the need to not routinely check varicella/zoster virus immunity titers prior to Zoster vaccination (99% of people in the US have been exposed) but gives guidance about what to do if you have access to varicella titers. If a titer is low/negative in an adult, varicella immunization (1 or 2 doses, depending on whether previously vaccinated, and separated by 4-8 weeks) should be provided. This should then be followed (again after 8 weeks) by the recombinant zoster vaccination schedule. If the titer is positive, it is recommended to vaccinate for zoster according to the age-based recommendations.

·       As in the child schedule, information about which vaccines are covered by the Vaccine Injury Compensation Fund and which ones by the Countermeasures Injury Compensation Program (mainly COVID-19 vaccines) is now included on the schedule.

John’s Comments:

No big changes here except for the routine Hep B vaccination in adults. More clinics will likely switch to Heplisav-B for their hepatitis B since it only requires two doses. See our Take3 # 363 (back in 2020) for information about it and how to integrate it into your schedules. We will have to keep some recombinant Hepatitis B (either Energix or Recombivax) because neither Heplisav-B nor PreHevbrio are recommended in pregnancy for now due to lack of safety data (and recall that HPV vaccine is not recommended in pregnancy either).


·       Murthy N, Wodi AP, Cineas S, Ault KA, Advisory Committee on Immunization Practices. Recommended Adult Immunization Schedule, United States, 2023*. Ann Intern Med. Published online February 10, 2023:M23-0041. Link


Second Pointer - make first two lines H3From the CDC

2)  Update on Teen Risk Behavior


The CDC recently released “The Youth Risk Behavior Survey Data Summary & Trends Report: 2011–2021”, which provides the most recent surveillance data, as well as 10-year trends, on health behaviors and experiences among U.S. high school students related to adolescent health and well-being.  This report is developed by the CDC Division of Adolescent and School Health (DASH) to highlight the national Youth Risk Behavior Survey (YRBS) data collected every two years among a nationally representative sample.

The report notes several positive trends for adolescent health and well-being, including decreased risky sexual behavior (i.e., ever and current sexual activity and having four or more lifetime sexual partners) and substance use (i.e., ever used select illicit drugs, ever misused prescription opioids, current alcohol use, and current marijuana use).  There was also saw a decrease in the proportion of youth who were bullied at school.  Unfortunately, almost all other indicators in the report, including protective sexual behaviors (i.e., condom use, sexually transmitted disease (STD) testing, and HIV testing), experiences of violence, mental health, and suicidal thoughts and behaviors worsened significantly.

Across almost all measures of substance use, experiences of violence, mental health, and suicidal thoughts and behaviors, female students are faring more poorly than male students. These differences, and the rates at which female students are reporting such negative experiences, are stark.  In 2021, nearly 30% of female students drank alcohol during the past 30 days.  Almost 20% of female students experienced sexual violence.  by anyone during the past year and 14% had ever been physically forced to have sex. Additionally, almost 60% of female students experienced persistent feelings of sadness or hopelessness (double that of boys) during the past year, 30% had seriously considered attempting suicide, and nearly 25% made a suicide plan (go back and read that paragraph again and let it sink in). 

As in previous reports, there were disparities among students who identify as lesbian, gay, bisexual, questioning, or another non-heterosexual identity (LGBQ+) or who have had any same-sex sexual partners compared to their peers.  LGBQ+ students and those who have any same sex partners were more likely than their peers to have used or misused all substances included in this report (i.e., ever used select illicit drugs, ever or current prescription opioid misuse, and current alcohol, marijuana, and electronic vapor product use). They were also significantly more likely to experience all forms of violence.  The differences in terms of mental health, compared to their peers, were also substantial.  Close to 70% of LGBQ+ students experienced persistent feelings of sadness or hopelessness during the past year and more than 50% had poor mental health during the past 30 days.  Almost 25% attempted suicide during the past year.

Mark’s Comments:

If a picture is worth a thousand words, then the one below speaks volumes and demands a call to action. 












Certainly, from an emotional health perspective, our teens are “failing to thrive.  The data is stark and sobering, particularly for females.  Keep this in mind as you care for adolescents in your practice. The CDC has also identified schools as having a unique opportunity to positively impact some of these trends.  Suggested actions (2nd reference) include implementing quality health education, connecting young people to needed services, and making school environments safer and more supportive, with a strong focus on improving school connectedness.


·       Centers for Disease Control and Prevention.  Youth Risk Behavior Survey:  Data Summary and Trends Report 2011-2021.  Published 13 February 2023.  Link

·       CDC:  Adolescent Health – What Works in Schools. Updated 15 September 2021.  Link

From PeerRxMed ( www.PeerRxMed.org )

3)  We All Need a “Soul Friend” Colleague 

“Friendship is always an act of recognition …. If you realize how vital to your whole spirit friendship actually is, you will take time for it.”  John O’Donohue


After last week's blog, I’ve been continuing to reflect on the word colleague, and the deeper, richer possibility the word contains, particularly when viewed through the lens of its synonyms, which include comrade, teammate, companion, helper, workmate, and friend.   In my pondering, I was reminded of the work of the late Irish author and poet John O’Donohue and his writing about anam cara.   In the Celtic world, an anam cara was a “soul friend.”   O’Donohue wrote that being an anam cara requires a purposeful presence.  It is that intentionality of heart that sets the true anam cara apart from a traditional friendship or collegial relationship, as relationships between acquaintances or associates involve little of the openness, honesty, trust, or vulnerability that characterizes this deeper type of friendship.  

I’ve concluded we all need anam cara – “ soul friends” – in our professional lives.  The work we do is too challenging, too taxing to not have someone traveling with us who ‘gets it” and “gets us,” and can help us make sense of all we do as well as support us as we weave it into the fabric of our lives.   The author and poet David Whyte was an anam cara to John O’Donohue, and he writes of such friendship: “ … the ultimate touchstone of friendship is … witness, the privilege of having been seen by someone and the equal privilege of being granted the sight of the essence of another, to have walked with them and to have believed in them, and sometimes just to have accompanied them for however brief a span, on a journey impossible to accomplish alone.” 

But how can we enable this to happen? 

I have two PeerRxMed partners, one who I’ve known as a work colleague for 28 years, and one who I met for the first time less than 5 years ago.  Both these relationships have incredible depth, richness, and transparency to them – they have become soul friendships.  This has happened because of our willingness to be open and to share of our inner journey, and of our willingness to be present to hear about the journey of the other, perhaps in ways that we have been hesitant to do so with colleagues in the past.  

Being willing to share some of our inner life on this professional journey called medicine is not always easy, but it is worth it.  If you haven’t opened yourself up to that level of friendship with a colleague, perhaps it’s time to give it a try.   Your PeerRxMed partner is the perfect person to take some “relational risk” and allow yourself to be “seen” in new ways.   And if you have opened up more, you already know – we all need a soul friend colleague ….

To that end, below is a blessing written by John O’Donohue that I dedicate to all the PeerRxMed partners around the world.   May you be blessed with such anam cara colleagues.

A Friendship Blessing (John O’Donohue)

May you be blessed with good friends.
May you learn to be a good friend to yourself.
May you be able to journey to that place in your soul where
there is great love, warmth, feeling, and forgiveness.
May this change you.
May it transfigure that which is negative, distant, or cold in you.
May you be brought in to the real passion, kinship, and affinity of belonging.
May you treasure your friends.
May you be good to them and may you be there for them;
may they bring you all the blessing, challenges, truth,
and light that you need for your journey.
May you never be isolated.
May you always be in the gentle nest of belonging with your anam ċara. 


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.

Email: mhgreenawald@carilionclinic.org