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Canadian Immunization Guide

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Part 3
Vaccination of Specific Populations

Immunization of Adults

Prevention of infection by immunization is not just for children; adults require immunization to restore waning immunity against some vaccine preventable diseases and to establish immunity against other diseases that are more common in adults. In addition, immunization of adults prevents infection and, therefore, subsequent exposure of young children and others at increased risk of vaccine preventable diseases. For example, adults who are in contact with infants should be prioritized to receive pertussis and influenza vaccination to reduce the risk of transmission of these infections to infants who are too young to be fully protected. Some vaccines are needed by all adults and other vaccines may be required due to individual risk resulting from occupation, travel, underlying illness, lifestyle or age.

In recent years, new vaccines such as herpes zoster and human papillomavirus have become available for adults. Despite these advances, the vaccination rates of adults in Canada are low, with the result that many adults remain vulnerable to vaccine preventable diseases.

Common reasons for incomplete immunization in adulthood include:

  • lack of recognition of the importance of adult immunization
  • lack of recommendations from health care providers
  • lack of health care provider's knowledge about adult immunization and recommended vaccines
  • misrepresentation and misunderstanding of the risks of vaccine and benefits of disease prevention in adults
  • lack of understanding of vaccine safety and efficacy
  • missed opportunities for vaccination in health care providers' offices, hospitals and nursing homes
  • lack of publicly funded vaccine and reimbursement to vaccine providers
  • lack of coordinated immunization programs for adults
  • lack of regulatory or legal requirements
  • fear of injections
  • lack of availability of up-to-date records and recording systems

Adult immunization is an emerging issue that has seen an increasing emphasis in clinical care and health professional training programs.

Health Care Provider Responsibilities

Health care providers have a responsibility to ensure that adults under their care have continuing and updated protection against vaccine preventable diseases through appropriate immunization. When considering immunization, the person's medical history will help to determine whether other immunizations are needed in addition to routinely recommended vaccines. Refer to Immunization of Persons with Chronic Diseases and Immunization of Immunocompromised Persons in Part 3 for further information on how health conditions may modify vaccine recommendations.

Health care providers should provide adults under their care with factual information about immunization, including:

  • information about vaccines
  • expert recommendations regarding the use of vaccines
  • benefits and risks of vaccination
  • cost of the vaccine if it is not publicly funded
  • possible consequences of declining a vaccine
  • where vaccine can be obtained if the health care provider is unable to provide the vaccine

When more than one dose of a vaccine is required for optimal protection, the health care provider should arrange follow-up to encourage completion of the vaccine series.

Strategies to Improve Vaccine Uptake in Adults

All adults should be counselled concerning their immunization status. Opportunities for general immunization counselling of adults include:

  • new patient encounters
  • periodic health examinations
  • pregnancy and the immediate post-partum period
  • visits for chronic disease management
  • assessment of new immigrants
  • parents attending their child's vaccination visits
  • hospitalization, especially when diagnosed with a chronic disease
  • management protocols on admission to nursing homes, long-term care institutions, and acute care institutions
  • management protocols on admission to health professional training programs
  • new employee assessments in day care, health care and health care-related facilities
  • persons requesting specific vaccination(s)
  • persons with evidence of risk taking behaviour, such as illicit drug use or a sexually transmitted infection
  • individuals requesting advice concerning travel

Health care providers should regularly review individuals under their care to ensure that the person's immunization status is up to date and that they have been made aware of new vaccines that are or may be indicated for them. Practitioners should routinely audit immunization records during clinical encounters; scheduling record audits on a set birthday, for example, to coincide with a mid-decade birthday (i.e., 25, 35 years of age, etc.), is one effective reminder strategy. Health care institutions should have policies addressing immunization issues for patients and personnel.

Additional effective strategies for increasing the uptake of immunization by adults include patient and health care provider education about indicated prevention practices, and increasing accessibility to immunization through immunization clinics and greater engagement of non-physician staff in the execution of immunization programs. A sample adult immunization record and information resources for adult immunization are available on the Immunize Canada website.

Recommended Immunization for Adults

All adults in Canada without contraindications should be routinely immunized against vaccine preventable diseases. Routinely recommended adult immunizations are summarized in Table 1. Recommended immunization schedules for adults who have no record or an uncertain immunization history are available in Recommended Immunization Schedules in Part 1.

In addition to routinely recommended immunization, certain vaccines are recommended for adults in specific risk situations. These recommendations are summarized in Table 2. International travellers and workers in specific risk situations require assessment of immunization status, completion of routinely recommended vaccine series, and booster doses as necessary. Refer to Immunization of Travellers, Immunization of Workers, Immunization of Immunocompromised Personsand Immunization of Persons with Chronic Diseases in Part 3; and vaccine-specific chapters in Part 4 for additional information.

Diphtheria toxoid-, tetanus toxoid-, containing vaccine

All adults in Canada should be immunized against diphtheria and tetanus. Booster doses of diphtheria and tetanus toxoid-containing vaccine are recommended every 10 years. Refer to Diphtheria Toxoid and Tetanus Toxoid in Part 4 for additional information.

Herpes zoster (shingles) vaccine

Herpes zoster vaccine may be given to adults 50 to 59 years of age and is routinely recommended for adults 60 years of age and older. Adults aged 50 years and older who are known to be varicella zoster virus seronegative should receive univalent varicella (chickenpox) vaccine, rather than herpes zoster (shingles) vaccine. Routine testing of adults aged 50 years and older for varicella zoster virus antibody prior to immunization is not recommended. Refer to Herpes Zoster (Shingles) Vaccine in Part 4 for additional information.

Human papillomavirus vaccine

Bivalent or quadrivalent human papillomavirus (HPV) vaccine is recommended for women up to and including 26 years of age and may be administered to those 27 years of age and older who are at ongoing risk of exposure. Quadrivalent HPV vaccine is recommended for men up to and including 26 years of age and may be administered to men 27 years of age and older who are at ongoing risk of exposure. Refer to Human Papillomavirus Vaccine in Part 4 for additional information.

Influenza vaccine

Seasonal influenza vaccine is recommended annually for all adults without contraindications, with particular focus on individuals who are at high risk of influenza-related complications or hospitalization, who are capable of transmitting influenza to those at high risk, who provide essential community services and who are in direct contact during culling operations with poultry infected with avian influenza. Refer to Influenza Vaccine in Part 4 for additional information.

Measles-mumps- rubella vaccine

Combined measles-mumps-rubella (MMR) vaccine is recommended for vaccination of adults born in or after 1970 susceptible to one or more of these viruses. Although adults born before 1970 are assumed to have acquired natural immunity, those at the greatest risk of measles or mumps exposure, such as travellers, health care workers, students in post-secondary educational settings, and military personnel, may require immunization. If MMR vaccine is indicated for a pregnant woman, it should be provided after delivery, preferably prior to discharge from hospital. Refer to Measles Vaccine, Mumps Vaccine and Rubella Vaccine in Part 4 for additional information including criteria for determining susceptibility/immunity to measles, mumps and rubella.

Meningococcal vaccine

Healthy adults up to and including 24 years of age should receive meningococcal vaccine if it was not received in adolescence. Either a meningococcal conjugate monovalent or a meningococcal conjugate quadrivalent vaccine, depending on local epidemiology and programmatic considerations, is recommended for young adults, even if they have previously been vaccinated as an infant or toddler. In addition, multicomponent meningococcal vaccine may be considered on an individual basis to protect against invasive meningococcal disease caused by relevant serogroup B strains. Adults with specific risk conditions (refer to Table 2) are recommended to receive meningococcal conjugate quadrivalent vaccine, multicomponent meningococcal vaccine or both vaccines, depending on the risk situation. Refer to Meningococcal Vaccine in Part 4 for additional information.

Pertussis-containing vaccine

All adults (18 years of age and older) should receive one dose of acellular pertussis-containing vaccine (tetanus, diphtheria [reduced], acellular pertussis [reduced] [Tdap]) if it was not previously received during adulthood. This vaccine can be administered regardless of the interval since the last dose of tetanus and diphtheria toxoid-containing vaccine. In particular, adults who have not previously received Tdap vaccine in adulthood, and who anticipate having regular contact with an infant, should receive Tdap vaccine, ideally administered at least 2 weeks before contact with the infant. All pregnant women who have not received a dose of pertussis-containing vaccine in adulthood should be encouraged to receive Tdap vaccination following 26 weeks of pregnancy. Refer to Pertussis Vaccine in Part 4 for additional information.

Pneumococcal vaccine

Pneumococcal polysaccharide 23-valent (Pneu-P-23) vaccine is recommended for all adults 65 years of age and older. For additional information about the immunization of adults at highest risk of invasive pneumococcal disease refer to Table 2, Pneumococcal Vaccine in Part 4, and Immunization of Immunocompromised Persons and Immunization of Persons with Chronic Diseases in Part 3.

Poliomyelitis vaccine

All adults in Canada should be immune to polio. For previously unimmunized adults, a primary series of inactivated poliomyelitis vaccine (IPV) should be provided at the time of immunization with a tetanus and diphtheria toxoid-containing vaccine. For adults that have previously received a primary series of tetanus and diphtheria toxoid-containing vaccine, IPV-containing vaccine can be provided at the time of routine tetanus and diphtheria toxoid-containing vaccine booster immunization. Unimmunized or incompletely immunized adults at increased risk of exposure should complete a primary series of IPV-containing vaccine; previously immunized adults at increased risk of exposure should receive a single lifetime booster dose of IPV-containing vaccine. Refer to Table 2 and Poliomyelitis Vaccine in Part 4 for additional information.

Varicella (chickenpox) vaccine

Univalent varicella vaccine is recommended for susceptible adults 18 to 49 years of age. Refer to Varicella (Chickenpox) Vaccine in Part 4 for additional information. For adults 50 years of age and older refer to Herpes Zoster (Shingles) Vaccine in Part 4.

Table 1: Adult Immunization - Recommendations for Routine Immunization in Healthy Adults at Low Risk
Vaccine Recommendations for routine immunization

Refer to vaccine-specific chapters in Part 4 for additional information. Refer to Immunization in Pregnancy and Breastfeeding in Part 3 for recommendations for women who are pregnant or lactating. Refer to Table 2 for recommendations for adults with risk factors.

Table 1 - Abbreviations
HPV

human papillomavirus

HPV2

human papillomavirus bivalent vaccine

HPV4

human papillomavirus quadrivalent vaccine

Diphtheria, Tetanus
  • Primary series for previously unimmunized adults
  • Booster dose every 10 years
Herpes zoster (shingles)
  • 60 years of age and older - 1 dose
  • 50 to 59 years of age - may be given 1 dose
Human papillomavirus (HPV)
  • Women up to and including 26 years of age - bivalent (HPV2) or quadrivalent (HPV4) vaccine
  • Men up to and including 26 years of age - HPV4 vaccine
Influenza

Annually

Measles, Mumps
  • Susceptible adults born in or after 1970 - 1 dose
  • Born before 1970 - consider immune
Meningococcal conjugate

Adults up to and including 24 years of age not immunized in adolescence - 1 dose

Pertussis
  • One dose of acellular pertussis-containing vaccine in adulthood
  • Adults who will be in close contact with young infants should be immunized as early as possible
Pneumococcal polysaccharide 23-valent

65 years of age and older - 1 dose

Polio
  • Primary series for previously unimmunized adults when a primary series of tetanus toxoid- and diphtheria toxoid- containing vaccine is being given or with routine tetanus toxoid- and diphtheria toxoid- containing vaccine booster doses
Rubella
  • Susceptible adults - 1 dose
  • If vaccine is indicated, pregnant women should be immunized after delivery
Varicella (chickenpox)
  • Susceptible adults up to and including 49 years of age - 2 doses; if only one dose was previously received, a second dose should be provided
  • Known seronegative adults 50 years of age and older - 2 doses - routine testing is not advised
 
Table 2: Adult Immunization - Recommendations for Specific Risk Situations
Vaccine Recommendations for risk situationsTable 2- Footnote 1

Refer to vaccine-specific chapters in Part 4 and the Immunization of Immunocompromised Persons and Immunization of Persons with Chronic Diseases in Part 3 for additional information.

Table 2 - Footnote 1

Refer to vaccine-specific chapters in Part 4 for recommendations on post-exposure prophylaxis and outbreak management.

Table 2 - Footnote 2

Choice of meningococcal vaccine(s) varies with risk situation. Refer to Meningococcal Vaccine in Part 4 for additional information.

Table 2 - Abbrevations
BCG

Bacille Calmette-Guérin

HBsAg

hepatitis B surface antigen

HA

Hepatitis A

HB

Hepatitis B

Hib

Haemophilus influenzae type b

HIV

human immunodeficiency virus

HSCT

hematopoietic stem cell transplantation

IPD

invasive pneumococcal disease

IPV

inactivated poliomyelitis vaccine

OPV

oral live poliomyelitis vaccine

TB

tuberculosis

Tdap

tetanus toxoid, diphtheria toxoid (reduced), acellular pertussis (reduced) - containing vaccine

Bacille Calmette-Guérin (BCG)

Consider use for adults:

  • who may be repeatedly exposed to persons with untreated, inadequately treated or drug-resistant active tuberculosis (TB) in conditions in which protective measures against infection are not feasible and when early identification and treatment of latent TB infection are not available
  • who are long-term travellers to high prevalence countries (in exceptional circumstances as noted above)

Cholera and travellers' diarrhea

  • Consider use for cholera prevention in adult travellers to cholera-endemic area(s) at high risk of exposure, including those with occupational risk for exposure (e.g., health care or humanitarian workers in endemic countries)
  • Consider use for prevention of travellers' diarrhea in adults:
    • with chronic diseases at risk for complications
    • at increased risk of acquiring travellers' diarrhea
    • who are immunosuppressed
    • with a history of repeated severe travellers' diarrhea

Haemophilus influenzae type b (Hib)

Recommended following hematopoietic stem cell transplantation (HSCT) and for adults with increased risk of invasive Hib disease:

  • congenital (primary) immunodeficiencies
  • malignant hematologic disorders
  • HIV
  • anatomic or functional asplenia or hyposplenism
  • solid organ transplant recipients
  • cochlear implant recipients

Hepatitis A (HA)

Recommended for adults:

  • travelling to HA endemic areas
  • who are immigrants from HA endemic areas
  • who are household or close contacts of children adopted from HA endemic countries
  • in communities or populations at risk of outbreaks or in which HA is highly endemic
  • who are household or close contacts of proven or suspected cases of HA
  • with occupational or lifestyle risk for exposure
  • with chronic liver disease from any cause, including those infected with hepatitis B and C
  • receiving plasma-derived replacement clotting factors

Hepatitis B (HB)

Recommended for adults:

  • who have immigrated to Canada from areas where there is a high prevalence of HB and are known to be susceptible to HB
  • who are household or sexual contacts of acute HB cases and HB carriers, including close contacts of children adopted from HB endemic countries if the adopted child is HBsAg positive
  • with occupational or lifestyle risk for exposure
  • travelling to HB endemic areas
  • in communities or populations in which HB is highly endemic
  • who are residents of institutions for the developmentally challenged or inmates of correctional facilities
  • with chronic liver disease, including those infected with hepatitis C
  • with chronic renal disease, including patients on chronic dialysis
  • hemophiliacs and other people who receive repeated infusions of blood or blood products
  • who have undergone hematopoietic stem cell transplantation or are awaiting solid organ transplant
  • who have congenital immunodeficiencies
  • who are HIV-infected

Human papillomavirus (HPV)

  • Quadrivalent HPV vaccine may be considered for men and women 27 years of age and older at ongoing risk of exposure
  • Bivalent HPV vaccine may be considered for women 27 years of age and older at ongoing risk of exposure

Influenza

Recommended annually for all adults, with focus on adults:

  • at high risk of influenza-related complications
  • capable of transmitting influenza to individuals at high risk
  • who provide essential community services
  • in direct contact during culling operations with poultry infected with avian influenza

Japanese encephalitis

Recommended for adults:

  • with occupational risk for exposure
  • travelling to endemic area(s) during transmission season with specified exposure risks

Booster dose 12 months after primary immunization for persons at continuous risk

Measles, Mumps

  • Recommended for adults born in or after 1970:
    • If susceptible and at increased risk of exposure (travellers to destinations outside of North America, health care workers, students in post-secondary educational settings, and military personnel) - 2 doses, at least 4 weeks apart.
  • Recommended for adults born before 1970 if:
    • non-immune military personnel or health care workers - 2 doses, at least 4 weeks apart
    • non-immune travellers - 1 dose
    • non-immune students - consider 1 dose

Meningococcal conjugate quadrivalentTable 2 - Footnote 2, Multicomponent meningococcalTable 2 - Footnote 2

Recommended for adultsTable 2 - Footnote 2:

  • with occupational risk for exposure (i.e., laboratory workers; military personnel during recruit training and on deployments during which the risk of infection is elevated)
  • who are travellers:
    • for whom meningococcal vaccine is recommended or required, including travellers to sub-Saharan African and pilgrims to the Hajj in Mecca, Saudi Arabia
    • to an area with a hyperendemic strain or an outbreak that is known to be caused by a serogroup that can be prevented by the vaccine
  • at high risk of meningococcal disease due to medical conditions:
    • anatomic or functional asplenia or hyposplenism (including sickle cell disease)
    • congenital complement, properdin, factor D or primary antibody deficiencies
    • acquired complement deficiency due to receipt of the terminal complement inhibitor eculizumab
    • should be considered for adults who are HIV-infected
  • who are close contacts of a case of invasive meningococcal disease caused by a vaccine preventable serogroup

Pertussis

Irrespective of their immunization history, all pregnant women who are 26 or more weeks gestation may be offered Tdap vaccination in special circumstances, such as an outbreak situation.

Pneumococcal polysaccharide 23-valent

Recommended for adults without immunosuppression:

  • who are residents of long-term care facilities
  • who are at increased risk of IPD due to lifestyle factors:
    • persons with alcoholism
    • smokers
    • persons who are homeless
    • should be considered for individuals who use illicit drugs
  • who are at high risk of IPD due to an underlying medical condition:
    • asthma requiring regular medical care
    • chronic cerebral spinal fluid leak
    • chronic neurologic condition that may impair clearance of oral secretions
    • cochlear implants (including adults who are to receive implants)
    • chronic cardiac or pulmonary disease
    • diabetes mellitus
    • chronic kidney disease
    • chronic liver disease (including hepatic cirrhosis due to any cause)

Recommended for adults with immunosuppression following immunization with pneumococcal conjugate 13-valent vaccine

Pneumococcal conjugate 13-valent

Recommended for adults with immunosuppression:

  • asplenia (functional or anatomic)
  • sickle cell disease or other hemoglobinopathies
  • congenital immunodeficiencies involving any part of the immune system, including B-lymphocyte (humoral) immunity, T-lymphocyte (cell) mediated immunity, complement system (properdin or factor D deficiencies), or phagocytic functions
  • HIV infection
  • immunosuppressive therapy including use of long-term corticosteroids, chemotherapy, radiation therapy, post-organ transplant therapy, and biologic and non-biologic immunosuppressive therapies for rheumatologic and other inflammatory diseases
  • malignant neoplasms including leukemia and lymphoma
  • solid organ or islet cell transplant (candidate or recipient)
  • nephrotic syndrome
  • following HSCT

Polio

Recommended for:

  • adults travelling to, or receiving travellers from, areas where poliovirus is known or suspected to be circulating
  • health care workers who have close contact with individuals who might be excreting wild type or vaccine type poliovirus
  • members of communities or specific population groups with disease caused by polio
  • people who come in close contact with those who may be excreting poliovirus such as people working with refugees, military personnel and people on humanitarian missions in endemic countries
  • laboratory workers handling specimens that may contain poliovirus
  • family or close contacts of internationally adopted infants who may have been or will be vaccinated with oral polio vaccine (OPV)

For previously unimmunized adults - primary series of IPV-containing vaccine

For previously immunized adults - one lifetime booster dose of IPV-containing vaccine

Rabies

Recommended for pre-exposure prophylaxis for adults:

  • with occupational risk of exposure
  • with lifestyle risk of exposure
  • travelling to high-risk areas with specified exposure risks

Smallpox

Recommended only for adults with a specific occupational risk of exposure to the smallpox virus

Typhoid

Recommended for adults:

  • travelling to endemic area(s) with specified exposure risks
  • who have ongoing household or intimate exposure to a S. typhi carrier
  • with occupational risk of exposure

Booster doses if at ongoing risk

Yellow fever

Recommended for healthy adults:

  • less than 60 years of age travelling to areas where there is evidence of yellow fever transmission or if the vaccine is required for foreign travel
  • with occupational risk of exposure

Consider immunization of healthy adults aged 60 years and over travelling to areas where risk of yellow fever is the highest

Selected References

  • Canadian Coalition for Immunization Awareness and Promotion. Adult Immunization. Are you up to date pamphlet from Immunize Canada. May 2012. Accessed February 2015.
  • Canadian Medical Protective Association. New Vaccines - What are your obligations? An article for physicians by physicians. Originally published September 2008, revised January 2009. Accessed February 2015.
  • Committee to Advise on Tropical Medicine and Travel (CATMAT). Statement on new oral cholera and travellers' diarrhea vaccination. Can Comm Dis Rep 2005;31(ACS7):1-12.
  • Committee to Advise on Tropical Medicine and Travel (CATMAT). Poliomyelitis vaccination for international travellers. Can Comm Dis Rep 2003;29(ACS-10):1-7.
  • Coulibaly N, De Serres G. Coverage of anti-tetanus vaccinations in adults in Canada-year 2002. Can J Public Health 2004;95(6):456-9.
  • Health Canada. Smallpox vaccination of laboratory workers. Can Commun Dis Rep 2004;30(19):167-9.
  • Johansen H, Nguyen K, Mao L et al. Influenza vaccination. Health Rep 2004;15(2):33-43.
  • Johnston BL, Conly JM. Routine adult immunization in Canada: recommendations and performance. Can J Infect Dis 2002;13(4):226-231.
  • Lau DT, Hewlett AT. Screening for hepatitis A and B antibodies in patients with chronic liver disease. Am J Med 2005;118 Suppl 10A:28S-33S.
  • Shefer A, Briss P, Rodewald L, et al. Improving immunization coverage rates: an evidence-based review of the literature. Epidemiol Rev 1999;21(1):96-142.
  • Spira AM. Preparing the traveller. Lancet 2003;361(9366):1368-81.
  • Stone EG, Morton SC, Hulscher ME et al. Interventions that increase use of adult immunization and cancer screening services: a meta-analysis. Ann Intern Med 2002;136(9):641-51.

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