You've just finished seeing one of your patients (a 56 y/o female with well controlled DM Type II) for her every 6 months check-up. You've covered various issues such as medication refills, routine labs, scheduled a mammogram, diet, exercise, etc. Is there anything else you should do for her before she leaves?

Of course, there is, By George! What about immunizations, esp. now being flu season.

Even though the 2001-2002 flu vaccine may be slightly delayed, it shouldn't be delayed long and DoD should get their full order. You'll have to coordinate with local immunization clinics to determine the availability of specific vaccines since most/many are being reserved for active duty personnel in a deployed or deployable situation to maintain optimal military readiness. See the attached hyperlink for additional details - http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5022a4.htm

Don't let the opportunity to get patients up-to-date with their immunizations get away! The same should apply to inpatients also. If someone is an inpatient, take that opportunity to get them up-to-date with the immunizations, providing there's no medical reason or contraindication (doubtful) to doing such.

Immunocompetent Adult immunization schedule/recommendations

- Influenza vaccine - 0.5ml IM q year. The optimal time to vaccinate persons in high-risk groups is usually from October through November, because influenza activity in the United States generally peaks between late December and early March. This year's recommendation continues to extend the lower age for an "all patients" immunization from 65 years of age to 50 years of age. In the past, all patients over 65 should receive the vaccine every year and all patients under age 65 WITH concurrent health problems (ex. Diabetes, cancer, heart disease, etc). Flu vaccine provides healthy individuals about 70-90% protection and about 50% protection in elderly individuals. A recent meta analysis concludes the flu vaccine: has a 56% efficacy in preventing respiratory illness, 50% efficacy in preventing hospitalization, and 68% efficacy in preventing death. Don't forget health care workers. This not only protects the health care worker but help limit/prevent the possibility that they may serve as a vector in transmitting the disease from one patient to another.

- Pneumococcal vaccine - 0.5ml IM/SC. Generally, one dose a lifetime is sufficient. 40,000 people a year die from pneumococcal infections. All patients over age 65 should receive the vaccine. Those under age 65 with concurrent medical conditions (ex. Diabetes, heart disease, cancer, etc) should also receive the vaccine. If a patient had received a dose of pneumococcal vaccine before age 65 and that was > 5-7 years ago, a one-time booster dose should be given. All persons with who are having a splenectomy, organ transplant, etc. should (ideally) receive the vaccine 4 weeks before the procedure, if clinical conditions allow.

- Tetanus and Diphtheria (Td) booster - 0.5ml IM every 10 years throughout life

- Mumps, Measles and Rubella - 0.5ml SC - should generally have received all doses by this age BUT travelers to foreign countries, persons entering post-secondary educational institutions, adults or health care workers at risk of exposure born after 1956 without proof of immunization on or after the first birthday. If already had one dose, a second dose should be given at least one month after the first dose.

- Hepatitis B vaccine - 0.5ml IM for three doses at 0, 1, and 6 months. A fourth MAY be indicated in selected patients. Added to pediatric immunization schedule. Indicated for anyone with routine exposure to at risk or infected patients and those with exposure to blood or blood contaminated fluids, inmates, homosexual men, heterosexuals with multiple partners, IV drug abusers, etc.

- Poliovirus (IPV - inactivated polio virus [injectable], OPV - oral polio vaccine [attenuated]) - Routine vaccination of patients > 18 years is not generally indicated unless: traveling to endemic or epidemic areas, contact with virus, health care workers working with patients with 'wild' polio virus infection, unvaccinated adults with children who are receiving OPV. IPV - 0.5ml SC/IM for 3 doses. Dose 1 and 2 at 4-8 week intervals, and 3^rd dose 6-12 months after the first. IPV is the recommended vaccine for polio immunization because as a killed virus vaccine the risk of vaccine associated polio is non-existent. OPV, as an attenuated vaccine, presents a risk of vaccine associated polio. Most regimens are for all IPV, esp. the first 2-3 doses. According to the CDC, OPV is no longer recommended for use in the US.

- Varicella vaccine - 0.5ml SC - all susceptible health care workers, persons of any age without a history of disease or are seronegative, susceptible persons living in households with children, etc. For those over 30 years of age, two doses separated by 4-8 weeks.

- Hepatitis A - 0.5ml IM - for persons traveling to endemic or epidemic areas, IV drug abusers, clotting factor disorders, chronic liver disease, homosexual men, etc.

Depending on conditions, environment, exposures, and travel, other vaccines may be indicated. For additional on the above and other vaccination recommendations, visit the following websites:

http://www.cdc.gov/nip/publications/pink/ - CDC reference - Epidemiology and prevention of vaccine-preventable diseases

http://www.cdc.gov/nip/publications/ACIP-list.htm - Advisory Committee on Immunization Practices (ACIP)

http://www.immunofacts.com/ - Immunofacts - maintained by LTC (Dr.) John Grabenstein - current Deputy Director for Clinical Operations, Anthrax Vaccine Immunization Program Agency

http://www.anthrax.osd.mil - for specific answers about the Anthrax vaccine

A recent article in Pharmacotherapy details a pharmacist-run flu immunization program and also gives some good stats on effectiveness of flu vaccine. Van Amburgh JA, et al. Pharmacotherapy 2001;21:1115-22.

The most recent version of the Medical Letter discusses 2001-2002 influenza prevention and includes a discussion of oral antivirals (amantadine, rimantidine) and the neuraminidase inhibitors (zanamivir, oseltamivir). Medical Letter 2001;43:81-2.