Marilyn Bulloch, PharmD, BCPS, FCCM
Marilyn Novell Bulloch, PharmD BCPS, is an Associate Clinical Professor of Pharmacy Practice at the Auburn University School of Pharmacy and an Adjunct Associate Professor at the University of Alabama-Birmingham School of Medicine and the University of Alabama College of Community Health Sciences . She completed a post-graduate pharmacy practice residency at the University of Alabama-Birmingham Hospital and a post-graduate specialty residency in critical care pharmacy at Charleston Area Medical Center in Charleston, West Virginia. Dr. Bulloch also completed a Faculty Scholars Program in geriatrics through the University of Alabama-Birmingham Geriatric Education Center in 2011. She serves on multiple committees and in leadership positions for many local, state, and national pharmacy and interdisciplinary medical organizations.
August is National Immunization Awareness Month. While much attention is paid to children and older adults, vaccinations specific to early adulthood often get overlooked. Between the ages of 18 and 26 years, a transition from adolescence to going to college, joining the military, getting a job, and becoming an adult occurs. Many school systems require up-to-date vaccinations, but after high school, adults are often times left with little to no vaccine requirements.1 Those not pursuing careers, training, or other experiences that mandate certain vaccinations may not be as apt to continue to seek immunization for vaccine-preventable diseases.1-2
In a survey of United States college students, only 8-39% were found to receive an annual influenza vaccine.2 Young adults may mistakenly believe that they are not as at risk for influenza complications. However, during the 2009 H1N1 influenza pandemic, young adults were at significantly higher risk for disease morbidity and mortality than older adults.3-4 While one-third of older adults had immunity from exposure to H1N1 viruses earlier in life, few young adults had any immunity and H1N1 was not yet part of the annual influenza vaccine.4 A vaccine against H1N1 was not available until late in the season after infection rates peaked in the US. That year, 80% of influenza-related deaths occurred in patients younger than 65 years.4
Examples like the 2009 pandemic underscore the need to advocate for even our healthiest of patients to stay up-to-date on all vaccinations. Currently, the CDC recommends that some of or all people age 18 to 26 years be immunized against the human papillomavirus (HPV), tetanus, diphtheria, pertussis, influenza, and meningococcal bacteria.
Approximately 4000 of all cancer deaths each year are attributed to HPV.6 Since the release of the HPV vaccine, the incidence of HPV infections has decreased by 71%, the occurrence of cervical precancers due to HPV by 40% in young women, and the occurrence of cancer due to HPV in both genders has been reduced annually by 94%.7-8 The CDC currently recommends vaccination until age 26 years in females and age 21 years in males.5 It is important for pharmacists to recognize that anyone requesting this vaccine, who did not get a first dose before the age of 15 years, will require a 3-dose vaccine series rather than the 2-dose series given to adolescents. The doses should be administered on the 0, 1-2, and 6 month schedule. 5 There is currently no maximum interval between doses; therefore if a patient began the series before age 15 years, they only need to complete the 2-dose series at this time.5
Tetanus is another vaccine-preventable disease for which young adults should receive immunization. Currently there are 2 'tetanus vaccines' available. The main distinction between Tdap (tetanus, diphtheria, and pertussis) and Td (tetanus and diphtheria) is the added protection against pertussis with Tdap.9 Most young adults will have received Tdap since turning age 11 years; if not, a single dose should be given. Immunity against tetanus and diphtheria persists for approximately 10 years in more than 90% of people.9-10 Therefore, the Td vaccine should be given every 10 years, unless vaccination with Tdap occurs instead. Pertussis immunity wanes quicker, providing protection to only 3-4 of every 10 people within 4 years. However, repeated vaccination with pertussis-containing vaccines is not necessary for all adults. The exception is for those exposed to infants in the first few months of life ,because they lack their own immunity to pertussis.9 Although it usually does not result in critical disease in young adults, pertussis can be particularly harmful to infants; as a result, Tdap is recommended for pregnant women during weeks 27 to 36 of pregnancy, and for all adults who will be in close contact with infants.5 Finally, the Tdap or Td are recommended for any deep puncture wound occurs if it has been 5 or more years since the patient’s last vaccination.10
Another preventable infection, meningitis, is transmitted through the air. Shared living environments common in early adulthood, such as college dorms and military barracks, increase the risk for contracting the disease.11 In 2017, 350 cases of meningitis were reported in the United States. The highest incidence after infancy was in those aged 16 to 23 years, with an incidence rate of 0.28 per 100,000 cases.12 The MenACWY (meningococcal ACWY) vaccination protects against bacterial meningitis A, C, W, and Y serotypes. One dose should be given to college students living in dorms and all individuals enlisting in the military, if not previously vaccinated after age 16. 5,13 Patients should be revaccinated every 5 years as long as exposure remains to allow for waning immunity.5,13 It is essential that these patients receive the vaccine. Despite incentive programs, some college students choose not to get the vaccine. However, college campuses can breed a large number of cases which can be transmitted throughout a community quickly.14 As of August 2019, the CDC is monitoring outbreaks at 3 major universities in the US.12 With the fall semester just beginning, it is unknown if these outbreaks will spread to other schools.
A teenager’s 18the birthday does not reduce their risk of contracting a vaccine-preventable disease, but does make them more susceptible to not staying up-to-date with recommended vaccines. Pharmacists are easily accessible, so it is important know what vaccines young adults ages 18 to 26 years need to help ensure they remain up-to-date and reduce preventable disease.
- Adult vaccination and effective vaccine storage. K2 Scientific. https://k2sci.com/news/adult-vaccination-and-effective-vaccine-storage/. Published Nov 8,2019. Accessed Aug 7, 2019.
- Addressing the challenges of influenza vaccination on US college campuses: a report by the National Foundation for Infectious Disease. National Foundation for Infectious Diseases. http://www.nfid.org/publications/reports/college-flu-summit-report.pdf. Updated May 2016. Accessed Aug 8, 2019.
- Lemaitre M, Carrat F. Comparative age distribution of influenza morbidity and mortality during seasonal influenza epidemics and the 2009 H1N1 pandemic. BMC Infect Dis [internet]. 2010 [cited 2019 Aug 22];10(162):1-5. Available from: https://bmcinfectdis.biomedcentral.com/track/pdf/10.1186/1471-2334-10-162
- 2009 H1N1 pandemic. Centers for Disease Control and Prevention. https://www.cdc.gov/flu/pandemic-resources/2009-h1n1-pandemic.html. Updated Jun 11, 2019. Accessed Aug 22, 2019.
- Centers for Disease Control and Prevention. Recommended adult immunization schedule for ages 19 years or older. CDC website. https://www.cdc.gov/vaccines/schedules/downloads/adult/adult-combined-schedule.pdf. Published 2019. Accessed Jul 30, 2019.
- Centers for Disease Control and Prevention. Vaccine preventable adult diseases. CDC website. https://www.cdc.gov/vaccines/adults/vpd.html. Updated May 2, 2016. Accessed Aug 1, 2019.
- Centers for Disease Control and Prevention. HPV vaccine safety. CDC website. https://www.cdc.gov/hpv/parents/vaccinesafety.html. Updated Apr 29, 2019. Accessed Aug 8, 2019.
- Centers for Disease Control and Prevention. Human Papillomavirus (HPV) reasons to get vaccinated. CDC website. https://www.cdc.gov/hpv/parents/vaccine/six-reasons.html. Updated Mar 26, 2019. Accessed Aug 7, 2019.
- Centers for Disease Control and Prevention. Vaccines and preventable diseases what everyone should know. CDC website. https://www.cdc.gov/vaccines/vpd/dtap-tdap-td/public/index.html. Updated Dec 17, 2018. Accessed Aug 6, 2019.
- Centers for Disease Control and Prevention. Tetanus for clinicians. CDC website. https://www.cdc.gov/tetanus/clinicians.html. Updated Feb 28, 2019. Accessed Aug 6, 2019.
- Centers for Disease Control and Prevention. Meningococcal disease. CDC website. https://www.cdc.gov/meningococcal/index.html. Updated May 31, 2019. Accessed Aug 7, 2019.
- Centers for Disease Control and Prevention. Meningococcal disease surveillance. CDC website. https://www.cdc.gov/meningococcal/surveillance/index.html. Updated May 31, 2019. Accessed Aug 7, 2019.
- Ostergaard L, Van der Wielen M, Bianco V, Miller JM. Persistence of antibodies for 42 months following vaccination of adolescents with a meningococcal serogroups A, C, W-135, and Y tetanus toxoid conjugate vaccine (MenACWY-TT). Int J Infect Dis [internet]. 2013 [cited 2019 Aug 5];17:e173-6. Available from: https://doi.org/10.1016/j.ijid.2012.10.001
- Van D, McLaws M, Crimmins J, MacIntyre CR, Seale H. University life and pandemic influenza: attitudes and intended behavior of staff and students towards pandemic (H1N1) 2009. BMC Public Health [internet]. 2010 [cited 2019 Aug 23];10(130):1-9. Available from: https://bmcpublichealth.biomedcentral.com/track/pdf/10.1186/1471-2458-10-130.