Shots Adults Shouldnt Do Witho

SHOTS ADULTS SHOULDN’T DO WITHOUT, Carol Ballentine

Reprinted from the June, 1986 issue of “FDA Consumer,” a publication of the Food and Drug Administration.

As people pass from childhood to adult status, they put away childish things–skipping rope on sidewalks, wandering through long summer days with “nothing to do,” dressing up in old clothes hidden away in the attic. But there is one item that adults may put away as childish which they shouldn’t-
-vaccinations.

Today, college campuses are experiencing severe outbreaks of measles because many students are not properly vaccinated. An estimated 10 percent to 15 percent of young adults are also susceptible to rubella (German measles), and limited outbreaks are occurring in universities, colleges and workplaces, particularly hospitals. Only half of those over 50 are immunized against tetanus and diphtheria. And among the elderly, pneumonia and influenza are the fifth leading cause of death. (About 90 percent of the deaths attributed to these two diseases occur in adults over 65.)

The vaccines that can help protect against these diseases are all underused by adults. One reason for this neglect is that too many adults think immunization shots are only for kids and maybe international travelers. According to the commissioner of the Food and Drug Administration, Dr. Frank E. Young, “Although prevention of a disease is clearly better and cheaper than its treatment, adults in good health, though extremely conscientious about immunizing their children, can be remarkably unaware of the status of their own immunizations.”

Young went on to add that health professionals themselves are guilty when it comes to keeping their adult patients, and themselves, adequately protected against infectious disease. “While pediatric medicine is centered on a program of comprehensive immunizations, treatment of adults too often neglects immunization as an important component of sound preventive care. The fact that only 10 percent of the health professionals at risk have been immunized against hepatitis B indicates that medical people themselves have not sufficiently emphasized prevention.”

Immunization comes mostly at the end of a needle–which may be why adults prefer not to think about it. (There is an occasional exception, such as the oral polio vaccine on the sugar cube.) For the most part, the needle contains a vaccine, a substance made from the killed or weakened microorganisms (such as bacteria or viruses) that cause a particular disease. In the body, the vaccine causes the formation of antibodies that give immunity to the disease.

Some diseases, such as tetanus, are caused not by microorganisms themselves, but by toxins produced by these microbes. For those diseases, instead of making a vaccine from the microbe, the toxin can be modified–usually with chemicals or heat–to make it nontoxic but still capable of stimulating production of antitoxin (an antibody that acts against a toxin). This substance, called a toxoid, can then be injected to produce immunity.

Recently, guidelines for adult immunization were published by two national health organizations, the U.S. Centers for Disease Control and the American College of Physicians. Both groups made recommendations for people in special categories, such as those in certain occupations or with certain lifestyles, those who have health conditions that put them at risk, and pregnant women. They also recommended the routine use of six vaccines for healthy adults in general:

TETANUS-DIPTHERIA TOXOID: Since 1977, surveys of immunity have estimated that 11 percent of adults 18 to 39 years old–and over half those over 60– are not protected against tetanus. The percentage of those unprotected against diphtheria is even higher. (There are few reported cases of diphtheria, but of 15 cases that occurred between 1980 and 1983, 11 were people over 19.) Both diseases can have severe consequences. Tetanus, also called “lockjaw,” can be fatal in the young and elderly. The respiratory form of diphtheria can progress to inflammation of the nerves and the lining of the heart and, in some cases, can cause death.

All adults should receive a tetanus-diphtheria booster every 10 years. Those who have not received the primary series of immunizations (which is usually administered before entering school as the combined diphtheriapertussis -tetanus, or DPT, toxoid), should get it.

MEASLES VACCINE: One young adult out of 20 may be susceptible to measles. Adults born before 1957 probably had the disease as children and are therefore immune, but all those born after 1956 should be vaccinated with the live measles vaccine unless they have had the disease. Also, individuals who were vaccinated with the killed measles vaccine, which was only in use between 1963 and 1967, should be revaccinated with the more effective live vaccine. (In the United States, between 600,000 and 900,000 people received the killed vaccine.) College students in particular should be immunized against measles.

Measles can cause encephalitis (inflammation of the brain) or death in one out of every 1,000 people. In pregnant women, the disease increases the risk of spontaneous abortion, premature labor, and low birth-weight in their babies.

MUMPS VACCINE: Serologic (blood) surveys show that most people have been infected with mumps by age 20, and are thus immune. However, vaccination is recommended for susceptible adults, particularly men. In 20 percent of post-pubertal males, a condition called orchitis, meaning inflammation of the testes, occurs as a complication of mumps; in some cases, orchitis can cause sterility. Mumps can lead to deafness in one out of every 15,000 people and can increase the rate of spontaneous abortion in the first trimester of pregnancy.
RUBELLA (GERMAN MEASLES) VACCINE: The primary reason to immunize adults against rubella is to prevent fetal infection. In up to 80 percent of fetuses, infection during the first trimester can lead to congenital rubella syndrome, commonly characterized by cardiac, visual and hearing defects and mental retardation.

Routine immunization against rubella is recommended for all adults, particularly women and college students, unless they have had the disease. Women should not be vaccinated if they are pregnant and should be advised not to become pregnant for three months after the vaccination.

For adults susceptible to measles, mumps and rubella, a combined vaccine is available.

INFLUENZA VACCINE: Everyone over 65 should be vaccinated against influenza. Approximately 60 percent to 80 percent of all influenza deaths are in this age group. In addition, immunization is recommended for people of all ages who suffer certain debilitating conditions, such as heart, lung or kidney disease, diabetes mellitus, anemia, suppressed immunity, or severe asthma.

The flue shot, unfortunately, is an annual event. This is for two reasons: First, influenza viruses are continually changing, and thus the vaccines are also often changed; and second, immunization immediately before the flue season provides the best protection–antibodies wane with time. The vaccines vary in effectiveness from year to year because no one knows for sure which viruses will attack, so a certain amount of guesswork is involved in deciding which antigens (substances that produce antibodies) to use. The choice is made annually by FDA’s Center for Drugs and Biologics and its technical advisory groups, with input from the National Institutes of Health and CDC.

PNEUMOCOCCAL VACCINE: Unlike the influenza virus, a person need only be vaccinated against pneumococcal disease once. The vaccine contains purified materials of Streptococcus pneumoniae, the bacteria that cause pneumococcal pneumonia, which is the most common bacterial form of the disease.

Again, immunization is recommended for all adults over 65, because they are most likely to die from pneumococcal pneumonia and its complications. Vaccination is also advised for adults with certain medical conditions, including chronic lung or heart disease, diabetes mellitus, alcoholism, cirrhosis, and suppressed immunity.

In addition to these six vaccines, the Centers for Disease Control and the American College of Physicians made specific recommendations for people in certain situations and with certain health conditions.

People with particular lifestyles or who hold certain high-risk jobs, for example, are more likely to get hepatitis B virus infection, a disease transmitted through blood, semen and saliva. Homosexually active men and intravenous drug abusers run a high risk of getting the disease: 10 percent to 20 percent of both groups acquire the virus each year, and at any one time up to 80 percent show evidence of having been infected. Health-care workers also have a greater chance of contracting the infection, particularly those who have frequent contact with blood or infected body tissues. This group includes surgeons, gynecologists, dentists, cardiologists, blood bank personnel, intravenous therapy nurses, and clinical laboratory staff who work directly with blood. Staff in institutions for the mentally retarded–as well as the residents–also run an increased risk of hepatitis B infection because of exposure to human bites and open skin lesions and saliva.

The hepatitis B vaccine, licensed by FDA in 1982, is expensive–about $100 for the three shots needed to confer immunity. But for those in the highrisk groups, the price should be worth it. Although most people in the United States have only a 5 percent chance of getting hepatitis B viral infection, those in the highest risk groups (such as homosexually active men and intravenous drug abusers) almost certainly will get it unless they are immunized. Each year, almost 100,000 Americans contract this disease, which can progress to chronic hepatitis, cirrhosis, and liver cancer. Each year some 4,000 people die of hepatitis B virus-related cirrhosis, and 800 die of hepatitis B virus-related liver cancer.

Routine polio vaccination is not recommended for adults in the United States–most are already immune. But there are a few exceptions. Healthcare workers should be immunized, as should people traveling to developing countries (see below). Also, susceptible adults run a small risk of getting polio when children in the household are given the oral polio vaccine. These adults may simply take extra precautions, such as washing thoroughly after changing the child’s diapers, or may choose to be immunized before the child is.

Pregnant women form a class all their own when it comes to vaccinations. In general, they should avoid ANY unnecessary drugs or procedures, including vaccines, that might affect the fetus. If vaccination is necessary, however, the risk can be minimized by administering only vaccines made of inactivated microbes and delaying administration until the second or third trimester.

Pregnant women should consult with their physicians about immunization against tetanus and diphtheria. Neonatal tetanus causes significant illness and mortality in offspring of mothers who have been inadequately immunized. Also, women should be immunized against hepatitis B if they are in a high- risk category; the virus can cause severe disease in the mother and chronic infection in the newborn, and the vaccine poses no known risk to the fetus. Similarly, there is no evidence that vaccines for influenza and pneumococcal pneumonia will harm the fetus, so vaccination is indicated in pregnant women with health problems such as congenital heart disease or lung disease.

Although live virus vaccines ordinarily should not be given to pregnant women, two vaccines–those for polio and yellow fever–should be administered if the woman is traveling to a high-risk area or will otherwise be exposed to these diseases. In such circumstances, the risk of the diseases is far greater than that posed by the vaccines. However, the measles-mumps-rubella vaccine, also live, should not be given to a pregnant woman, but may be administered after delivery.

There are other occupations besides human health care that put workers at extra risk of certain diseases. Those who should be immunized for protection from such occupational hazards include:

veterinarians and animal handlers, against rabies (about 25,000 people each year receive preventive immunization for rabies),
sanitation and sewage workers, against tetanus and diphtheria,
people who work with imported animal hides, wool and hair, against anthrax, an infectious bacterial disease transmitted by such animal products (the vaccine is available from the Biologic Products Program, Michigan Department of Public Health).

The last quarter century has seen wonderful advances in immunization. Measles cases have dropped from 400,000 a year before the first vaccine was licensed in 1963 to only several thousand cases a year now. Similar success rates have occurred with vaccines against mumps, licensed in 1967, and rubella, licensed in 1969. The vaccines against hepatitis B, influenza, and pneumococcal pneumonia have been developed within the past decade. Adults should not ignore these very useful tools for ensuring good health.

As FDA Commissioner Young said, “A very large portion of the adult population ASSUMES that it is immunized or not threatened by preventable infectious diseases. In reality, this is far from the case. Immunization is not child’s play. It is important to all of us.”

THE SHOTS HEARD ‘ROUND THE WORLD

People traveling to many foreign countries–particularly developing nations-
-should put “vaccination” on their travel list, right along with “toothpaste” and “passport.”

The risk of acquiring measles, mumps and rubella, for instance, is far greater outside the United States because in most countries these diseases are uncontrolled. About half of imported measles cases reported from 1980 to 1983 occurred in citizens returning to the United States. Polio viruses are also extremely common in developing countries, as are diphtheria and pneumococcal pneumonia. Travelers should make sure they are immune to these diseases.

The destination and travel route largely determine what immunizations are necessary. There are, for instance, areas in Africa, Asia, and Central and South America where typhoid fever is common, and travelers to these areas should be vaccinated against it. (The vaccine does not provide 100 percent immunity, however. Even after vaccination, travelers should be careful about what they eat or drink since the bacteria are found in food and water.) Travelers to other areas may need to be vaccinated against such diseases as plague, rabies, or hepatitis A.

There are two diseases for which vaccination might be legally required, depending on the traveler’s route and destination: cholera and yellow fever.

Cholera occurs throughout much of Asia, the Middle East, Africa, and some parts of Europe. Like typhoid, it is acquired primarily from contaminated food and water. Although the risk of getting the disease is very slight, some countries require evidence of cholera vaccination for entry and may quarantine unvaccinated persons if they come from areas of cholera. Travelers can get a validated international certificate of vaccination against cholera from most city, county and state health departments, as well as many private clinics and physicians’ offices.

Yellow fever, transmitted by mosquitoes, occurs only in Africa and South America. In recent years, fatal cases of yellow fever have occurred in unvaccinated tourists. People traveling to areas where the disease exists must be vaccinated with a vaccine approved by the World Health Organization and administered at an approved Yellow Fever Vaccination Center, which can be located through state or local health departments.

Information about vaccination requirements for travelers is available from health departments, travel agencies, and international airlines and shipping lines.