Advisory Committee on Immunization Practices Recommended Immunization Schedule for Adults Aged 19 Years or Older - United States, 2020.

At its October 2019 meeting, the Advisory Committee on Immunization Practices (ACIP)* voted to recommend approval of the 2020 Recommended U.S. Adult Immunization Schedule for Persons Aged 19 Years and Older. The 2020 adult immunization schedule, available at https://www.cdc.gov/vaccines/schedules/index.html,† summarizes ACIP recommendations in two tables and accompanying notes. This 2020 adult immunization schedule has been approved by the CDC Director, the American College of Physicians, the American Academy of Family Physicians, the American College of Obstetricians and Gynecologists, and the American College of Nurse-Midwives. Health care providers are advised to use the tables and the notes together.

Very delayed CSF leak in patients after craniotomy for resection of skull base tumors.

OBJECTIVE: Cerebrospinal fluid (CSF) leak is a potentially dangerous neurosurgical complication. Delayed CSF leak has already been described after trauma, radiation therapy and endonasal transsphenoidal surgery for Sella turcica pathologies. Still, very few reported cases describe delayed CSF leak after craniotomy for tumors. We present our experience with patients showing delayed CSF leak after skull base tumor resection. METHODS: Data for all tumors resected from the skull base region from January 2004 to December 2018 was retrieved from the surgeon's prospective database and supplemented with a retrospective file review. Patients who presented CSF leak within the first 12 months after surgery and those with a history of trauma or radiation-based treatment to the skull base region were excluded from the study. Epidemiology, clinical presentation, previous surgical approach, pathology, interval between craniotomy and CSF leak and proposed treatment were analyzed. RESULTS: Overall, more than two thousand patients underwent surgery for resection of skull base tumors during the study period. Six patients (two male, four female; mean age 57.5 years, range 30-80) presented with delayed CSF leak, including five (83%) who presented with bacterial meningitis. After skull base tumor resection, CSF leak developed in a mean of 72 months (range 12-132). Three patients underwent retrosigmoid craniotomy, two for resection of cerebellopontine angle epidermoid cyst and one for resection of a petro tentorial meningioma; one had trans petrosal retrolabyrinthine craniotomy for resection of a petroclival epidermoid cyst; one had far lateral craniotomy for resection of a foramen magnum meningioma; and one had pterional craniotomy for resection of a cavernous sinus meningioma. All patients underwent surgical re-exploration and repair. CSF leak was managed with mastoid obliteration in five patients and skull base reconstruction with fat graft in one. CONCLUSION: Recognition of very delayed CSF leak as a potential complication after resection of skull base tumors may be useful tool in long-term patient management. In our experience, these patients usually present with bacterial meningitis. Surgical options should be considered as a definitive treatment.

American College of Rheumatology Guidance for COVID-19 Vaccination in Patients With Rheumatic and Musculoskeletal Diseases: Version 5.

OBJECTIVE: To provide guidance to rheumatology providers on the use of COVID-19 vaccines for patients with rheumatic and musculoskeletal diseases (RMDs). METHODS: A task force was assembled that included 9 rheumatologists/immunologists, 2 infectious diseases specialists, and 2 public health physicians. After agreeing on scoping questions, an evidence report was created that summarized the published literature and publicly available data regarding COVID-19 vaccine efficacy and safety, as well as literature for other vaccines in RMD patients. Task force members rated their agreement with draft consensus statements on a 9-point numerical scoring system, using a modified Delphi process and the RAND/University of California Los Angeles Appropriateness Method, with refinement and iteration over 2 sessions. Consensus was determined based on the distribution of ratings. RESULTS: Despite a paucity of direct evidence, statements were developed by the task force and agreed upon with consensus to provide guidance for use of the COVID-19 vaccines, including supplemental/booster dosing, in RMD patients and to offer recommendations regarding the use and timing of immunomodulatory therapies around the time of vaccination. CONCLUSION: These guidance statements are intended to provide direction to rheumatology health care providers on how to best use COVID-19 vaccines and to facilitate implementation of vaccination strategies for RMD patients.

American College of Rheumatology Guidance for COVID-19 Vaccination in Patients With Rheumatic and Musculoskeletal Diseases: Version 4.

OBJECTIVE: To provide guidance to rheumatology providers on the use of COVID-19 vaccines for patients with rheumatic and musculoskeletal diseases (RMDs). METHODS: A task force was assembled that included 9 rheumatologists/immunologists, 2 infectious disease specialists, and 2 public health physicians. After agreeing on scoping questions, an evidence report was created that summarized the published literature and publicly available data regarding COVID-19 vaccine efficacy and safety, as well as literature for other vaccines in RMD patients. Task force members rated their agreement with draft consensus statements on a 9-point numerical scoring system, using a modified Delphi process and the RAND/University of California Los Angeles Appropriateness Method, with refinement and iteration over 2 sessions. Consensus was determined based on the distribution of ratings. RESULTS: Despite a paucity of direct evidence, statements were developed by the task force and agreed upon with consensus to provide guidance for use of the COVID-19 vaccines, including supplemental/booster dosing, in RMD patients and to offer recommendations regarding the use and timing of immunomodulatory therapies around the time of vaccination. CONCLUSION: These guidance statements are intended to provide direction to rheumatology health care providers on how to best use COVID-19 vaccines and to facilitate implementation of vaccination strategies for RMD patients.

American College of Rheumatology Guidance for COVID-19 Vaccination in Patients With Rheumatic and Musculoskeletal Diseases: Version 2.

OBJECTIVE: To provide guidance to rheumatology providers on the use of coronavirus disease 2019 (COVID-19) vaccines for patients with rheumatic and musculoskeletal diseases (RMDs). METHODS: A task force was assembled that included 9 rheumatologists/immunologists, 2 infectious disease specialists, and 2 public health physicians. After agreeing on scoping questions, an evidence report was created that summarized the published literature and publicly available data regarding COVID-19 vaccine efficacy and safety, as well as literature for other vaccines in RMD patients. Task force members rated their agreement with draft consensus statements on a 9-point numerical scoring system, using a modified Delphi process and the RAND/University of California Los Angeles Appropriateness Method, with refinement and iteration over 2 sessions. Consensus was determined based on the distribution of ratings. RESULTS: Despite a paucity of direct evidence, 74 draft guidance statements were developed by the task force and agreed upon with consensus to provide guidance for use of the COVID-19 vaccines in RMD patients and to offer recommendations regarding the use and timing of immunomodulatory therapies around the time of vaccination. CONCLUSION: These guidance statements, made in the context of limited clinical data, are intended to provide direction to rheumatology health care providers on how to best use COVID-19 vaccines and to facilitate implementation of vaccination strategies for RMD patients.

American College of Rheumatology Guidance for COVID-19 Vaccination in Patients With Rheumatic and Musculoskeletal Diseases: Version 3.

OBJECTIVE: To provide guidance to rheumatology providers on the use of coronavirus disease 2019 (COVID-19) vaccines for patients with rheumatic and musculoskeletal diseases (RMDs). METHODS: A task force was assembled that included 9 rheumatologists/immunologists, 2 infectious disease specialists, and 2 public health physicians. After agreeing on scoping questions, an evidence report was created that summarized the published literature and publicly available data regarding COVID-19 vaccine efficacy and safety, as well as literature for other vaccines in RMD patients. Task force members rated their agreement with draft consensus statements on a 9-point numerical scoring system, using a modified Delphi process and the RAND/University of California Los Angeles Appropriateness Method, with refinement and iteration over 2 sessions. Consensus was determined based on the distribution of ratings. RESULTS: Despite a paucity of direct evidence, 74 draft guidance statements were developed by the task force and agreed upon with consensus to provide guidance for use of the COVID-19 vaccines in RMD patients and to offer recommendations regarding the use and timing of immunomodulatory therapies around the time of vaccination. CONCLUSION: These guidance statements, made in the context of limited clinical data, are intended to provide direction to rheumatology health care providers on how to best use COVID-19 vaccines and to facilitate implementation of vaccination strategies for RMD patients.

Frequency and cost of live vaccines administered too soon after prior live vaccine in children aged 12 months through 6 years, 2014-2017.

OBJECTIVE: To identify number of children who received live vaccines outside recommended intervals between doses and calculate corrective revaccination costs. METHODS: We analyzed >1.6 million vaccination records for children aged 12 months through 6 years from six immunization information system (IIS) Sentinel Sites from 2014-15 when live attenuated influenza vaccine (LAIV, FluMist® Quadrivalent) was recommended for use, and from 2016-17, when not recommended for use. Depending on the vaccine, insufficient intervals between live vaccine doses are less than 24 or 28 days from a preceding live vaccine dose. Private and public purchase costs of vaccines were used to determine revaccination costs of live vaccine doses administered during the live vaccine conflict interval. Measles, mumps, rubella (MMR), varicella, combined MMRV, and LAIV were live vaccines evaluated in this study. RESULTS: Among 946,659 children who received at least one live vaccine dose from 2014-15, 4,873 (0.5%) received at least one dose too soon after a prior live vaccine (revaccination cost, $786,413) with a median conflict interval of 16 days. Among 704,591 children who received at least one live vaccine dose from 2016-17, 1,001 (0.1%) received at least one dose too soon after a prior live vaccine (revaccination cost, $181,565) with a median conflict interval of 14 days. The live vaccine most frequently administered outside of the recommended intervals was LAIV from 2014-15, and varicella from 2016-17. CONCLUSIONS: Live vaccine interval errors were rare (0.5%), indicating an adherence to recommendations. If all invalid doses were corrected by revaccination over the two time periods, the cost within the IIS Sentinel Sites would be nearly one million dollars. Provider awareness about live vaccine conflicts, especially with LAIV, could prevent errors, and utilization of clinical decision support functionality within IISs and Electronic Health Record Systems can facilitate better vaccination practices.

Dermatological lesions near the smallpox vaccination site after scab detachment.

Lesions arising after scab detachment at the smallpox vaccination site have been described in the medical literature. We investigated reports of postscab lesions among US civilian volunteers vaccinated against smallpox from January through August 2003. We conducted enhanced surveillance, using a standard questionnaire, for reports of skin lesions appearing at or near the smallpox vaccination site after scab detachment. We identified 21 reports; 19 of the case patients responded to our questionnaire. The lesions (scab and/or fluid) of 7 case patients were tested for vaccinia virus by use of polymerase chain reaction and/or immunohistochemistry; all were found to be negative. We contacted 18 case patients 11 months after the initial lesion appearance; 10 (56%) of the 18 reported having another lesion appear after the initial postscab lesion had resolved. Lesions were heterogeneous in morphology, clinical appearance, and histology. The evidence from our case series and follow-up suggests that these lesions are self-limited, without significant clinical sequelae.

General recommendations on immunization: recommendations of the Advisory Committee on Immunization Practices (ACIP).

This report is a revision of General Recommendations on Immunization and updates the 2002 statement by the Advisory Committee on Immunization Practices (ACIP) (CDC. General recommendations on immunization: recommendations of the Advisory Committee on Immunization Practices and the American Academy of Family Physicians. MMWR 2002;51[No. RR-2]). This report is intended to serve as a general reference on vaccines and immunization. The principal changes include 1) expansion of the discussion of vaccination spacing and timing; 2) an increased emphasis on the importance of injection technique/age/body mass in determining appropriate needle length; 3) expansion of the discussion of storage and handling of vaccines, with a table defining the appropriate storage temperature range for inactivated and live vaccines; 4) expansion of the discussion of altered immunocompetence, including new recommendations about use of live-attenuated vaccines with therapeutic monoclonal antibodies; and 5) minor changes to the recommendations about vaccination during pregnancy and vaccination of internationally adopted children, in accordance with new ACIP vaccine-specific recommendations for use of inactivated influenza vaccine and hepatitis B vaccine. The most recent ACIP recommendations for each specific vaccine should be consulted for comprehensive discussion. This report, ACIP recommendations for each vaccine, and other information about vaccination can be accessed at CDC's National Center for Immunization and Respiratory Diseases (proposed) (formerly known as the National Immunization Program) website at http//:www.cdc.gov/nip.

Medical examiners, coroners, and biologic terrorism: a guidebook for surveillance and case management.

Medical examiners and coroners (ME/Cs) are essential public health partners for terrorism preparedness and response. These medicolegal investigators support both public health and public safety functions and investigate deaths that are sudden, suspicious, violent, unattended, and unexplained. Medicolegal autopsies are essential for making organism-specific diagnoses in deaths caused by biologic terrorism. This report has been created to 1) help public health officials understand the role of ME/Cs in biologic terrorism surveillance and response efforts and 2) provide ME/Cs with the detailed information required to build capacity for biologic terrorism preparedness in a public health context. This report provides background information regarding biologic terrorism, possible biologic agents, and the consequent clinicopathologic diseases, autopsy procedures, and diagnostic tests as well as a description of biosafety risks and standards for autopsy precautions. ME/Cs' vital role in terrorism surveillance requires consistent standards for collecting, analyzing, and disseminating data. Familiarity with the operational, jurisdictional, and evidentiary concerns involving biologic terrorism-related death investigation is critical to both ME/Cs and public health authorities. Managing terrorism-associated fatalities can be expensive and can overwhelm the existing capacity of ME/Cs. This report describes federal resources for funding and reimbursement for ME/C preparedness and response activities and the limited support capacity of the federal Disaster Mortuary Operational Response Team. Standards for communication are critical in responding to any emergency situation. This report, which is a joint collaboration between CDC and the National Association of Medical Examiners (NAME), describes the relationship between ME/Cs and public health departments, emergency management agencies, emergency operations centers, and the Incident Command System.

Superinfection following smallpox vaccination (Vaccinia), United States: surveillance January 2003 through January 2004.

BACKGROUND: Superinfection is an adverse event following smallpox vaccination. The clinical presentation is similar to that of a large normal vaccine reaction or "robust take," and the frequency is unknown. METHODS: We retrospectively reviewed all reported severe local reactions consistent with superinfection among United States civilian smallpox vaccinees from January 2003 through January 2004. We applied a standard case definition and estimated the frequency of superinfection following smallpox vaccination. RESULTS: We identified 48 reported cases for further review among 39,350 [corrected] smallpox vaccinees. Two (4%) of the 48 reported cases met the case definition for superinfection; neither of the patients had a pathogenic organism isolated from their infection site. Both were treated with antibiotics and resolved their infection. Of the 46 cases determined not to be superinfection, 41 (89%) were temporally consistent with a large normal vaccine reaction. Thirty (75%) of 40 reported case patients for whom data were available received antibiotic therapy. CONCLUSIONS: Superinfection following smallpox vaccination is rare. Most of the reported superinfection cases were probably large normal smallpox vaccine reactions. Educating providers about the normal response to smallpox vaccine may decrease the overdiagnosis of superinfection and the unnecessary use of antimicrobials.

Report from the CDC. Vaccines in women.

Women's healthcare providers are encouraged to incorporate immunizations into their clients' care. Because women often rely on their healthcare provider for primary and preventive care, that provider may dramatically improve clients' quality of life by decreasing the risk of vaccine-preventable diseases. Women often assume responsibility for the entire family's health, and educating women can prevent disease in the household. Women's healthcare providers should offer and promote these vaccines: hepatitis B, varicella, measles/mumps/rubella, and combined tetanus/diphtheria toxoids for adolescent and young adult women, inactivated influenza vaccine during pregnancy, and pneumococcal, influenza, and tetanus/diphtheria vaccines for the adult or elderly woman. Education should include the importance of vaccines and the rationale for their necessity during each stage of life. Several strategies for implementing and supporting an immunization program have been shown to improve adult immunization rates. These include employing such protocols as standing orders, screening for adult immunizations at each office encounter, and using previously developed immunization documentation forms. The Advisory Committee on Immunization Practices (ACIP) recommendations, vaccine information statements (VIS), and storage and handling guidelines are readily available at low or no cost through CDC and professional organizations or immunization interest group websites. The current adult vaccine schedule assists providers to determine the need for vaccines by displaying graphically both age and medical risk factors.