#526 - Immunizations 2024, Lonely Broken Hearts, Words Create Worlds

From the Centers for Disease Control and Prevention

1) New Immunization Schedules for 2024

The Advisory Committee for Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC) have released the 2024 Immunization schedules for both adults and adolescents/children. You may have noticed that it is not the usual February release, and that is because the CDC has adopted a new strategy for how the recommendations roll out over the year. The ACIP meets at least three times per year, and usually makes at least one recommendation at each meeting. Those recommendations would become official CDC recommendations once they were published in the MMWR (the CDC’s official publication). However, it often took a couple of months for the article to be ready, and the new recommendations would not appear on the schedule until the next February. Now, the schedule committee will immediately place them in a dedicated Addendum to each year’s schedule so that, on any new download, the schedule will be immediately up to date.

As for new adult and child recommendations on the 2024 schedule, we have covered most of them this year, but we will review the important changes. There is always some minor rewording and clarification that occurs as part of the schedule committee’s work throughout the year, which we will not review.

Changes for both schedules:

Updated guidance for COVID-19 vaccines to use only the latest formulation of the vaccine for all vaccination (ages 6 months and older). The specific guidance is slightly different for different ages and brands of vaccine, so checking the schedule carefully is strongly recommended.

• Influenza vaccine notes were updated to completely remove the restriction from influenza vaccination in those with egg allergy. These patients can be vaccinated like anyone else. (Take3 #510)
• Mpox and RSV vaccines were excluded from the Vaccine Injury Compensation Program (VICP). There is a bureaucratic process to include these vaccines under the program and that has not yet been completed.
• Mpox vaccine was added to the Countermeasures Injury Compensation Program. This is a separate compensation program for vaccines that counter epidemics and are not included under the VICP.

Child and Adolescent Schedule Changes:

• Meningococcal ABCWY (pentavalent) has been added to the schedule. It may be used any time you’re giving both MenACWY and MenB in the same visit. Recall that MenACWY is recommended at age 11-12 and 16-18 routinely, but MenB is a shared decision-making recommendation starting at age 16. Those rules still apply, so the pentavalent vaccine just helps if you would be giving both at the same time.
• Pneumococcal vaccine:

o   PCV20 or PCV15 can be used for the infant series (4 doses)

o   For ages 2-5 with chronic conditions (heart, lung, liver, or kidney disease, diabetes, etc.), or immune compromising conditions (asplenia, complement deficiency, medications):

• If no PCV20 has been given, either a PCV20 or a PPSV23 is needed 8 weeks after last PCV.

o   For ages 6-18 with chronic or immune compromising conditions:

• If no PCV20 given as an infant dose, give PCV20 or PPSV23 eight weeks after last PCV. If PPSV23 used, after 5 years, give either PCV20 or another PPSV23. (However, if 1 dose PCV13 and 1 dose PPSV23 given at or after age 6 years, do not give any more pneumococcal vaccine).
• RSV immunization (not vaccination) using monoclonal antibody is recommended in anticipation of RSV season for all infants (whose mothers did not get vaccinated during pregnancy) and for some high-risk children in their second year of life. (Take3 #511)

Adult Schedule Changes:

• Hepatitis A vaccination is allowable for anyone who requests vaccination. However, this recommendation does not constitute a routine recommendation, so insurance coverage is not guaranteed.
• Hepatitis B vaccination is recommended for anyone under age 60 (including catch up for those not vaccinated as children). For patients aged 60 and older, those at high risk (incarceration, liver disease, sexual exposure, HIV, etc.) should be vaccinated. For patients aged 60 or greater with diabetes, vaccination is a shared decision-making recommendation.
• Mpox vaccine is recommended for those at high-risk of acquisition (through sexual behaviors including sex in a commercial sex venue, multiple sexual partners, or sex with others in a geographic area where Mpox is spreading) starting at age 18.
•  Pneumococcal vaccine:

o   Ages 19-64: with chronic conditions or immune compromise, a PCV20 or PCV15 + PPSV23 in one year are indicated. (If PCV15/PPSV23 used, repeat PPSV23 at age 65+ if five years have elapsed since last PPSV23).

o   Age 65+: If no PCV given in adulthood, give PCV20 or PCV15 + PPSV23 in one year. (Take 3 #516)

•  An additional poliovirus vaccine can be given to adults (18 years and older) who have completed their primary series. While most children born and raised in the US can be assumed to have had the vaccination, anyone known to have been incompletely vaccinated should complete the primary polio vaccine three dose series.
• RSV vaccination (with Pfizer’s Abrysvo only) is recommended for all pregnant women who will deliver during RSV season to benefit the babies. (Take3 #516)
• RSV vaccination of high-risk older adults is a shared decision-making recommendation. (Take3 # 506)

John’s Comments: 

Unfortunately, we have not had to worry much about the RSV recommendations for children and pregnant women because of the extremely limited supply of the approved vaccine and antibody preparation for these indications. On the other hand, pharmacies are heavily marketing the over-sixty RSV vaccine directly to patients, really subverting any chance we have of incorporating shared decision-making about this vaccine, which will result in maldistribution of the vaccine.

Fortunately, Carilion has decided to go primarily with the PCV20 option for pneumococcal vaccination, which makes things a lot simpler. So far, it looks like the “only one dose of PCV in adulthood” rule still applies but stay tuned.

The situations with hepatitis A and B vaccinations are confusing, though important. For Hepatitis A, recall that prior to COVID-19, we were facing a local epidemic of Hepatitis A and encouraging vaccination of at-risk populations. That’s less of an issue these days, but if your patient has any liver disease (including fatty liver), it is indicated. Hepatitis B has a new-ish recommendation for catchup vaccination for all adults under 60.

References: 

• Immunization Schedule Changes | CDC. Published November 16, 2023. Accessed January 3, 2024. Link
• Adult Immunization Schedule – Healthcare Providers | CDC. Published November 14, 2023. Accessed January 1, 2024. Link
• CDC. Immunization Schedules for 18 & Younger. Centers for Disease Control and Prevention. Published November 16, 2023. Accessed January 1, 2024. Link

From the Literature and the US Surgeon General

2)  A Lonely Heart Could Lead to a Broken Heart

Social isolation is defined as the objective state of having few or infrequent social contacts.  Loneliness is perceived isolation that is distressing for the individual.  Individuals can lead a relatively isolated life and not feel lonely; conversely, individuals with many social contacts may still experience loneliness.  The US Surgeon General’s office reported that prior to COVID, approximately 50% of US adults reported experiencing loneliness.  Data suggest that social isolation and loneliness may have increased since the start of the COVID‐19 pandemic, particularly among young adults (18–25 years of age), older adults, women, and low‐income individuals

A 2022 scientific statement from the American Heart Association noted the negative effects of social isolation and perceived loneliness on cardiovascular and brain health.  This was followed In May of 2023 by an advisory from the US Surgeon General's office

indicating that loneliness has been found to be associated with a greater risk of cardiovascular disease, dementia, stroke, depression, anxiety, and premature death with an impact estimated to be greater than that associated with obesity and physical inactivity and similar to that caused by smoking up to 15 cigarettes a day.

A recently published study investigated the prospective associations of the loneliness and social isolation scales with CVD risk in persons with diabetes and particularly compared the relative importance of loneliness and social isolation to traditional risk factors (e.g. lifestyle factors and metabolic risk factors) in predicting CVD risk.  Using data from the UK Biobank, more than 18,000 persons with diabetes were followed for a mean of 10.7 years.  The authors found that a higher loneliness scale, but not social isolation scale, was significantly associated with a higher risk of CVD in those with T2D.  Loneliness ranked lower in relative strength for predicting CVD than LDL cholesterol, BMI, and ACR, similar to eGFR, HbA1c, and systolic BP levels, and higher than depression score and lifestyle risk factors such as smoking, physical activity, and diet. 

An accompanying editorial made the following recommendations for clinicians based on the results of this study:

• Consider loneliness as a CVD risk factor
• Use screening instrument to identify loneliness, e.g. UCLA 3-Iten Loneliness Scale
• Refer patient to a therapist for supportive therapy to improve perceived relationship quality by targeting maladaptive cognition

Mark’s Comments:

This study adds to a growing body of literature indicating that identifying and helping to address perceived loneliness appears to be an important opportunity to potentially impact individual and population-level CV risk.  Interestingly (and in line with the 3^rd bullet above), a meta-analysis looking at interventions to reduce loneliness compared the effectiveness of four distinct intervention approaches: improving social skills; enhancing social support; increasing opportunities for social contact; and targeting maladaptive social cognition.  While all interventions showed some positive impact on perceived loneliness, the authors found that addressing maladaptive social cognition had a greater benefit on loneliness compared with the others.  Since all interventions have shown some benefit, I recommend that a multipronged approach looking at the patient context would likely yield even more positive results.

References:

• Wang X et al. Joint association of loneliness and traditional risk factor control and incident cardiovascular disease in diabetes patients. European Heart Journal, Volume 44, Issue 28, 21 July 2023, Pages 2583–2591. Link
•  Kahl K et al.  A lonely heart is a broken heart: it is time for a biopsychosocial cardiovascular disease model.  Eur Heart J 2023 Jul 21;44(28):2592-2594. Link

From PeerRxMed ( www.PeerRxMed.org )

3) Let Your “Word” Help Create Your World in 2024

“Words create worlds.”  – Attributed to many.  “Worlds create words.” – Me

I believe words matter.   Apparently, so do the many others who, as with me, make one of their New Year’s rituals to pick their “word for the year.”  This is a word, short phrase, or quote that represents a personal and/or professional aspiration that will serve as an inspiration, motivation, guide, anchor, or “theme” for the upcoming year.  Mine has traditionally been a “made-up” word, often a combination of words, that energizes me and serves as a compass to help keep me aligned with my stated priorities … it helps me “create my world” for the year.  

Indeed, words are symbols for thoughts and ideas, and we personalize them according to the meaning we associate with them.  One of my favorite books for 2023 was The Dictionary of Obscure Sorrows by John Koenig, which is described as a compendium of invented words that aims to fill holes in our language by giving names to emotions we all feel but don't have a word for.  Words such as sonder, chrysalism, scabulous, and dystoria are now part of my way of understanding my emotional world.  This year the folks at Merriam-Webster added 690 "new words" (or new definitions of previously used words) to their dictionary, many of which we had been already using collectively, such as hallucination, doomscroll, and prosocial.  In these cases, the world we are creating helped necessitate the need for new words to describe it, and by creating a commonly accepted meaning, these allow for us to more effectively communicate with each other. 

In the past 5 years, my self-created words have been “zilience,” “reslove,” “cor,” “bemusedament,” and this past year, “rēpiphany.”  My understanding of rēpiphany helped reawaken my awareness to the many “Holy moments” in my life, reminded me that my life is part of something much larger, and inspired me to show up as my “better self” more often.  My word for this year will be awepique, and next week I’ll share more as to what that word means to me and how it will help frame my world for 2024. 

How about you?  What might be the word or words to help you frame your year – or perhaps for you it’s a picture, quote, song, or poem (or all of the above!).  Consider picking one or more and sharing their meaning with those close to you, including your PeerRx partner.  I’ve found that doing so is great fun, can provide you insights into your psyche, and by inviting others into the conversation, can supercharge your intention by providing some encouragement and accountability around it.     

Looking back one year from now, what kind of world do you want to have helped create in 2024?  Well, it can all start with just one word.  Why not give it a try ….

______________

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