The 5 Most Significant Changes to 2023 Adult Immunization Schedules

This transcript has been edited for clarity.

Good morning. I am Dr. Sandra Fryhofer. Welcome to Medicine Matters. The subject is the highlights of ACIP’s new adult timetable for 2023, published in the Annals of Internal Medicine, and why this new calendar may be a collector’s item.

It’s a new year, and that means a new ACIP Adult Immunization Schedule – a valuable resource bringing together the most up-to-date ACIP immunization recommendations.

Here are the five biggest changes this year:

• COVID vaccines now front and center

• New focus on polio vaccination

• Inclusion of certain non-vaccine products (such as monoclonal antibody products)

• The group of pharmacists approved the calendar for the first time

• New Shared Clinical Decision-Making Option for Pneumococcal Vaccines

The organization of the schedule remains the same. It always has four sections:

• Table 1: vaccinations by age

• Table 2: Vaccinations by medical condition and other indications

• The Notes section (in alphabetical order of vaccine types)

• Annexed list of vaccine-specific contraindications and precautions

But what’s unique this year is that some of the abbreviations have historical implications. The first change comes as no big surprise in light of what we’ve been through in recent years. COVID vaccines are listed first on the front page by brand name for those authorized and by company name for those still under emergency use authorization in the United States. They are also listed first on charts and in notes.

COVID and mRNA and protein-based vaccines are now assigned official abbreviations based on the platform and valence of the vaccine.

• 1vCOV-mRNA: Comirnaty/Pfizer-BioNTech and Spikevax Moderna COVID-19 vaccines

• 2vCOV-mRNA: bivalent COVID-19 vaccines from Pfizer-BioNTech and Moderna

• 1vCOV-aPS: Novavax COVID-19 vaccine

The absence of COVID viral vector vaccines on the list is also noteworthy. However, the COVID viral vector vaccine (which was available but is not preferred) has a link to the CDC website in the Notes section.

A sad but necessary inclusion has been triggered by the recent polio cases in New York. It was believed that polio was eradicated and we believed that adults no longer needed to be vaccinated against polio. In the new schedule, the poliomyelitis vaccine is shown on the cover page but is not included in the tables. Current polio vaccination recommendations can now be found in the Notes section.

The inclusion of non-vaccine products also has historical significance and could set a precedent. The value of COVID pre-exposure prophylaxis with products including monoclonal antibodies (like Evusheld) for people with moderate or severe immunocompromised is mentioned in the Remarks section.

For the first time ever, the schedule has been endorsed by the American Pharmacists Association, which validates pharmacists as established partners in administering vaccines.

color code key

One aspect of the schedule that hasn’t changed is the color-coded key:

• Yellow: Recommended if the patient meets the age requirement

• Purple: Indicated for people with additional risk factors or other indication

• Blue: Recommended based on shared clinical decision making

• Orange: Caution

• Red: contraindicated or not recommended; the vaccine should not be administered. Overlays on red further clarify whether a vaccine is truly contraindicated or simply not recommended. A red asterisk means vaccinate after pregnancy if indicated.

• Grey: no recommendation or not applicable

Vaccinations by age

Table 1 lists recommended vaccinations by age. There is a major change. COVID vaccines are on the top line of the graph, with the need for both a primary series and reminders highlighted on the overlay. The notes contain hyperlinks to the most recent COVID vaccination recommendations.

Highlights from Table 1:

Pneumococcal vaccination. Vaccination against pneumococcus is systematically recommended from the age of 65. Current recommendations for unvaccinated people have not changed since last year. But on Table 1, the bottom half of the line for 65+ is now blue (and that’s new). This new blue color signifies shared clinical decision-making and applies to people who were previously considered fully vaccinated with the now extinct combination of PCV13 and PPSV23. These patients now have the option of receiving a dose of PCV20 five years after completing their combined PCV13-PPSV23 series. This option is blue because the decision is up to you and your patient.

See notes for more details on pneumococcal vaccination. For example, for those partially vaccinated using lower valence vaccines, there is an option to substitute PCV20 for PPSV23 to broaden and increase the durability of protection.

Pneumococcal vaccination recommendation options are complicated. A new pneumococcal vaccination app can help.

Hepatitis B. For adults under 60, the color code of the hepatitis B vaccine is yellow, which means that it is suitable for everyone. For older patients, the color code is purple. If a patient aged 60 or over wishes hepatitis Vaccine B, they can have it even in the absence of additional indications of risk.

Vaccinations by medical condition or other indications

Other than a few minor word changes to the overlay, the only thing that’s new is the COVID vaccine row.

This table is useful for matching vaccine recommendations with specific medical conditions, including pregnancy, immunosuppression, HIV (with specificities depending on the number of CD4), asplenia, fill in the gapsheart disease, lung disease, alcoholismchronic liver disease, diabetes, healthcare workers and men who have sex with men.

Use this chart to dot the i’s and cross the t’s for vaccination recommendations. For example, take a look at the pregnancy column. Live virus vaccines, including LAIV, MMR and varicella, are contraindicated and coded red. MMR and varicella also have an asterisk, which means vaccinate after pregnancy if indicated. HPV vaccines are not live virus vaccines, but the overlay indicates that they are not recommended during pregnancy. The asterisk indicates that you can vaccinate after pregnancy.

Notes on vaccines

The notes are in alphabetical order and their organization (routine, special situations, and shared clinical decision-making where indicated) has not changed. They are concise and succinct, but sometimes they are not enough. That’s why the vaccine-specific links to more comprehensive recommendations are so handy.

The notes for hepatitis B contain nuances on the specific dosage for vaccination of patients on dialysis, as well as a reminder that the most recent Hepatitis C vaccines such as Heplisav and PreHevbrio are not recommended during pregnancy due to lack of safety data.

For flu, anyone 6 months of age or older still needs to be vaccinated against influenza every year with an influenza vaccine appropriate for their age and health. But for people aged 65 or over, the notes specify the three vaccine versions now preferred: high-dose, recombinant or adjuvanted versions. However, if these are not available, it is better to get the flu shot than to go without.

Under meningococcal vaccines, the scores for MenACWY and MenB are combined. For MenB, the trade names Bexsero and Trumenba are specified because the products are not interchangeable. The booster intervals for those still at risk are different for each type of vaccine: every 5 years for MenACWY boosters and every 2 to 3 years for MenB boosters.

Recent polio cases in New York City have put polio vaccination in the spotlight. ACIP has now re-established its Polio Vaccine Working Group. The new schedule lists polio vaccines on the cover page. Current recommendations have been added to the notes section. Routine vaccination of adults is not necessary, at least for now. However, people at increased risk of exposure to poliomyelitis fall into the category of special situations. For people at increased risk who have completed a series of polio vaccines, a single lifetime IPV booster may be given. For those at increased risk who have not completed their series of polio vaccines, now would be the time to complete the series.

Annex

The final step in using the new schedule is to check the appendix and its list of vaccine-specific contraindications and precautions.

I hope this review of ACIP’s new adult immunization schedule has been helpful. For Medicine Matters, I’m Dr. Sandra Fryhofer.

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