Recommendations and Resources for Active Patients
Raymond A. Strikas, MD; Judy V. Schmidt, EdD, RN; Donna L. Weaver, MN, RN; Charles R. Wolfe
THE PHYSICIAN AND SPORTSMEDICINE - VOL 29 - NO.10 - OCTOBER 2001
In Brief: Although childhood vaccination rates are at an all-time high, those for adolescents and adults are suboptimal. All adolescents and adults should be immunized against measles, mumps, rubella, varicella, tetanus, and diphtheria, and many should also receive hepatitis A, hepatitis B, influenza, and pneumococcal vaccines. In addition, active patients who engage in outdoor activities may benefit from vaccination against Lyme and meningococcal disease. Regular, strenuous exercise and foreign travel may increase the risk of some infectious diseases. Athletes often see a physician only for sports physical exams and injuries, so it is important for providers to take the opportunity to vaccinate patients during these visits.
As teens and young adults prepare to return to school and college, requests for sports physicals increase, and these encounters provide an excellent opportunity to review each patient's immunization status, educate patients and parents about immunization recommendations, and provide needed vaccines.
Vaccines represent one of the 20th century's top 10 public health achievements (1). Because of vaccines, smallpox has been eradicated worldwide, and physicians are on the verge of doing so for polio. Most healthcare providers, patients, and parents have never seen a child die from meningitis caused by Haemophilus influenzae type B or a person confined to an iron lung because of polio. Yet, despite tremendous strides in the US childhood immunization program, vaccination rates for adolescents and adults remain less than optimal (1). Healthcare providers face the challenges to (1) raise and maintain high immunization rates, (2) implement new and ever-changing immunization recommendations, and (3) address patients' and parents' growing concerns about adverse reactions and vaccine safety. We present the current recommendations of the Advisory Committee on Immunization Practices (ACIP) for vaccinating adolescents and adults (table 1), issues to consider regarding physically active patients, and immunization resources available on the Internet (table 2).
No vaccine recommendations include special advice for athletes and outdoor enthusiasts. The ACIP recommendations (written in collaboration with numerous experts from medical organizations, government agencies, and research centers) are applicable to all adults and adolescents, including outdoor and sports-minded persons. Certain aspects of the athletic lifestyle may make the case for immunizations more compelling. For instance, the frequent close contact of athletes that occurs in team sports during practices, travel to competitions, and in actual competition provide increased rationale for immunizing against influenza, hepatitis A, and, in some areas of the country, Lyme disease (2,3). When discussing the universally recommended vaccines such as tetanus/diphtheria (Td) and measles, mumps, and rubella (MMR), athletes may be more easily persuaded by information related to their sport, activity, or lifestyle, such as frequent group housing or travel.
Timing of Vaccination
A proactive approach by the provider in timing immunizations will benefit athletes and outdoor enthusiasts. Active patients may overlook prevention or immunization until the season is upon them. Receiving an immunization immediately before travel, competition, or intense exertion is less than ideal, especially when it may not offer optimal protection or cause a sore arm or other adverse effect. This seemingly obvious factor of timely prevention should not be ignored. Thorough patient counseling and scheduling of recommended vaccination is especially important for elite athletes who may be at risk of recurrent infection (4). It is prudent to encourage immunizations according to the recommended vaccine schedule before intensive training or travel begins, to protect against preventable diseases in individuals who may have decreased immunity and increased risk of respiratory infection. The AMA Guidelines for Adolescent Preventive Services recommend assessment of immunization status during regular comprehensive exams as well as preparticipation exams (2,5).
Numerous studies have discussed immune response changes as the body experiences varying levels of physiologic stress, such as from athletic training, immunization timing, and immune response. It is known that immunocompromised individuals have a poorer vaccine response than physically active or inactive immunocompetent persons (6). While regular, moderate exercise enhances immunity in most people, those who experience intense, prolonged peaks of exertion may have suppressed concentrations of lymphocytes, as well as suppressed natural killer and lymphokine-activated killer cytotoxicity and secretory IgA in mucosa (7). Some studies report that this phenomenon is increased when the athlete initiates a new phase of exercise without allowing adequate recovery time (7,8). However, it is yet unproven that prolonged, severe exercise alters the antibody response to vaccines. Bruunsgaard et al (9) reported decreased skin test responses to tetanus and diphtheria toxoids and pneumococcus polysaccharide vaccine in 22 subjects in the days immediately following a half-ironman triathlon. Although this demonstrated impaired cell-mediated immunity, the antibody production measured 2 weeks after vaccination revealed no impairment.
Current research shows an increased incidence of respiratory infection in elite, overtrained athletes, and some experts suspect decreased immunity following prolonged intense physical exercise, but no exact finding or fully understood mechanism has been shown to demonstrate clearly either decreased immunity or decreased antibody response. Still under study are the threshold levels of intensity and duration during certain types of exercise, the hypothesized cellular and humoral responses that may lead to decreased immune function, and the contributing cofactors of dietary behavior, lifestyle factors, and coping ability (4,7-10).
Current ACIP Recommendations
Hepatitis A. Hepatitis A is the most frequently reported type of hepatitis in the United States. More than 30,000 cases were reported in 1997 (11). Because half of hepatitis A infections are asymptomatic and many cases are not reported, about 180,000 cases are estimated to occur each year (11). The clinical course of acute hepatitis A includes abrupt onset of signs and symptoms, including fever, malaise, anorexia, nausea, abdominal discomfort, and jaundice (12). Illness usually lasts less than 2 months, although up to 15% of patients have symptoms for up to 6 months (12). Up to 22% of patients are hospitalized, and fulminant infection causes about 100 deaths per year in the United States (11).
There is no chronic form of hepatitis A. The infection is transmitted primarily by the fecal-oral route, and, of particular relevance for many athletes, international travelers are at increased risk of hepatitis A. Other groups at risk include children younger than 2 years old living in states that have hepatitis A rates at least twice the national average (including Arizona, Alaska, Oregon, New Mexico, Utah, Washington, Oklahoma, South Dakota, Idaho, Nevada, and California), men who have sex with men, intravenous drug users, people who work with nonhuman primates, those with chronic liver disease, and those receiving factor 8 and 9 coagulant concentrates (11).
The vaccine is an inactivated product, available in both pediatric (through age 18) and adult formulations. The vaccines were 94% to 100% effective in preventing infection in clinical trials (11). Two doses of the appropriate formulation, given 6 to 12 months apart, are recommended for those at risk. As with all vaccines we discuss, there is no need to restart the series or repeat doses if a prolonged lapse occurs between doses. Reported adverse events have been limited to local reactions at the injection site (50% of recipients). Mild systemic complaints (headache, malaise, fever, fatigue) have been reported by 17% or less of recipients (11).
Hepatitis B. Hepatitis B virus (HBV) infection is an established cause of acute and chronic hepatitis, cirrhosis, and primary hepatocellular carcinoma. The number of reported cases of hepatitis B in the United States peaked in the 1980s at about 26,000/yr (12). Reported cases have declined since then, to a provisional total of 6,646 in 2000 (13). However, surveillance data suggest that approximately 80,000 people are infected annually (https://www.cdc.gov/ncidod/diseases/hepatitis/b/faqb.htm). The clinical course of acute hepatitis B is similar to that of other types of viral hepatitis. In addition, 10% of infected adults develop chronic infection, which accounts for most morbidity and mortality from HBV infection (12). Between 4,000 and 5,500 people die of hepatitis B-related cirrhosis and liver cancer each year in the United States (12).
The infection is transmitted by parenteral or mucosal exposure to infected body fluids, particularly blood, semen, and vaginal secretions. Saliva can be a vehicle for transmission through bites, but other salivary exposures, such as kissing, are unlikely modes of transmission (12). There appears to be no transmission of HBV via tears, sweat, urine, or stool. Adults at increased risk of infection include men who have sex with men, injection drug users, immigrants from areas with high HBV endemicity, staff and patients in institutions for the developmentally disabled, hemodialysis patients, household contacts of HBV carriers, heterosexuals with multiple partners, and healthcare workers who have regular contact with blood or body fluids (14).
Hepatitis B vaccine is an inactivated vaccine, available in pediatric and adult formulations. It is more than 80% effective in preventing infection in those who receive the complete series of three doses (12). The recommended vaccination schedule for high-risk adults is three doses, with the second and third doses 1 and 6 months after the first. In addition, the vaccine is recommended for all children, and for all adolescents (from 11 through 19 years old) not previously vaccinated (14,15). For 11- to 15-year-old patients only, a two-dose schedule, with the second dose 4 to 6 months after the first, was approved in 1999 for one vaccine type (16). Pregnant women who are at increased risk of HBV infection should be vaccinated (14). No special recommendations exist for vaccination of athletes because no cases of hepatitis B have been attributed to sports activities in the United States (unpublished data from the Centers for Disease Control and Prevention) (2).
The most commonly reported adverse reaction is pain at the site of injection in up to 29% of adults (12). Systemic complaints (fatigue, headache, and irritability) have been reported by up to 17% of adults (12). More serious reactions have very rarely been reported.
Influenza. Epidemics of influenza occur nearly every year in the United States, usually between December and March, and account for an average of 20,000 excess deaths and 114,000 hospitalizations (17). More than 90% of the deaths and most of the hospitalizations occur among patients age 65 years or older. Each year, 10% to 20% of the population is infected resulting in millions of clinical illnesses, and usually significant school and work absenteeism.
Classic influenza is characterized by abrupt onset of fever, myalgia, pharyngitis, and nonproductive cough (17). Complications include pneumonia (primary viral or secondary bacterial), myocarditis, exacerbations of chronic illnesses (eg, pulmonary, cardiac, diabetes), and death. Aerosols or droplets from the respiratory tract of infected patients transmit influenza viruses (12). Those with the highest risk of complications include people in long-term care facilities, those age 50 years or older, anyone with chronic illnesses (including pulmonary, cardiovascular, renal, immunosuppressive, and metabolic diseases [notably diabetes mellitus] and hemoglobinopathies), and women in the second and third trimesters of pregnancy (17).
In the United States the specific components of influenza vaccines change every year. The vaccines contain proteins of three inactivated viruses—two type A (H1N1 and H3N2) and one type B—and they provide immunity for approximately 1 year, depending on the recipient's age and health status. Vaccine effectiveness also varies with different populations, and according to how similar vaccine strains are to circulating strains. The vaccines are up to 90% effective in preventing illness in young, healthy adults, but as little as 30% effective in preventing influenza in frail older patients (17). Among older patients, the vaccine can prevent 50% to 60% of hospitalizations and 80% of deaths (17).
Annual vaccination with one dose of influenza vaccine is recommended for high-risk adults, healthcare workers, and others in regular contact with high-risk people (including household members). Foreign travelers may wish to be vaccinated, as might anyone who wishes to reduce the risk of influenza infection and its complications (17). Therefore, it is reasonable to offer influenza vaccine to athletes. Local reactions such as soreness, erythema, and induration are the most common adverse events following vaccination, occurring in 10% to 64% of those vaccinated (17). Nonspecific systemic symptoms (fever, chills, malaise, and myalgias) are much less common, occurring in less than 1% of those vaccinated (12). No consistent risk for Guillain-Barré syndrome following influenza vaccination has been documented since the 1976 swine vaccination program (17).
Pneumococcal disease. Streptococcus pneumoniae is the most common bacterial cause of pneumonia and meningitis in the United States. Each year, S pneumoniae accounts for approximately 3,000 cases of meningitis, 25,000 cases of bacteremia, 140,000 hospitalized cases of nonbacteremic pneumonia, and as many as 12,500 deaths from pneumococcal pneumonia (18,19). Transmission of the bacteria occurs by direct person-to-person contact via droplets, or autoinoculation in persons already carrying the bacteria in their respiratory tracts. Persons at increased risk of pneumococcal infection include those age 65 years or older, children younger than 2 years old, and patients with asplenia or splenic dysfunction, immunosuppression, or other chronic illnesses (20). Certain Native American populations are also at increased risk (20).
Two types of pneumococcal vaccine are approved for use in the United States. Pneumococcal polysaccharide vaccine (PPV) is recommended for use in high-risk patients older than 2 years old, and pneumococcal conjugate vaccine is routinely recommended for all children younger than 2 (21). PPV will be the focus because only this vaccine is recommended for adults.
PPV contains polysaccharides from 23 serotypes of S pneumoniae, which cause 88% of invasive pneumococcal disease in the United States (20). PPV is 60% to 70% effective in preventing invasive pneumococcal disease in adults; however, its effectiveness in preventing noninvasive pneumococcal disease, such as pneumonia, in high-risk populations is uncertain (20).
A single dose of PPV is recommended for those in high-risk groups. One revaccination is recommended 5 or more years after primary vaccination for those at highest risk of fatal infection (eg, those with asplenia or human immunodeficiency virus infection), those with rapid antibody loss (eg, patients with chronic renal failure, multiple myeloma, or nephrotic syndrome), and people age 65 or older who received the first dose of PPV more than 5 years earlier and before age 65 (20). From 30% to 50% of patients vaccinated report pain, swelling, or erythema at the injection site, and these reactions are more common after a second dose (20). Moderate systemic reactions (eg, fever, myalgias) occur in less than 1% of vaccinees, and more severe systemic adverse events are rare (12).
Measles, mumps, and rubella. Very few cases of measles or mumps now occur in the United States—only 81 cases of measles and 323 cases of mumps in 2000 (13)—although adults account for a growing proportion of both diseases (22). Measles can lead to serious complications, including bronchopneumonia, encephalitis, and death (22). Mumps can lead to meningitis, encephalitis, and death, and up to 38% of postpubertal men who get mumps develop orchitis (22). Rubella is of particular concern to women of childbearing age because children born to women infected through the 20th week of pregnancy often have severe birth defects (congenital rubella syndrome). About 70% of adult women who get rubella develop transient arthritis or arthralgia, mainly in the fingers, wrists, and knees (12). Rubella can also lead to encephalitis, hemorrhagic manifestations (usually thrombocytopenic purpura), and death (22). There were 152 cases of rubella in the United States in 2000 (13).
Two doses of the MMR vaccine are routinely given to children. Most adults in the United States are assumed to be immune to these diseases—those born before 1957 who had the disease and those born in 1957 or later who were vaccinated. Anyone born in 1957 or later who has never had either the vaccine or the diseases should get at least one dose. Those at increased risk (college students, healthcare personnel, and international travelers) should receive a second dose. Women of childbearing age who have no documentation of receiving rubella vaccine or having had rubella should be vaccinated.
Fever is the most common adverse event associated with MMR vaccine; up to 15% of recipients are affected (12). Some people also develop a mild rash or irritation of the joints. Allergic reactions and other severe reactions are rare.
Varicella. An estimated 4,000,000 cases of varicella (chickenpox) occurred each year before the licensure of varicella zoster vaccine in 1995. Adults age 20 years or older account for only about 7% of cases, but these patients are much more prone to serious complications, including bacterial infections, central nervous system manifestations, pneumonia, and death (12). The virus can remain dormant in the body and reactivate years later as zoster, or shingles.
Most adults are immune to varicella as a result of childhood infection (12). Susceptible adolescents and adults who have close contact with people at high risk for serious complications (eg, healthcare workers, family contacts of immunocompromised persons) should be vaccinated, as should those who have a high risk of exposure (eg, teachers, nonpregnant women of childbearing age, military personnel, international travelers). The recommended schedule for those 13 or older is two doses, with the second dose at least 4 weeks after the first (12).
Pain, redness, and swelling at the injection site are the most common side effects (affecting 24% to 32% of recipients 13 or older). Other reactions include mild fever (about 10%), mild rash at the injection site (1% to 3%), and mild, generalized rash (up to 6%) (12). More serious reactions are uncommon.
Tetanus and diphtheria. Death rates are up to 20% for diphtheria and 30% for tetanus, but both are uncommon in the United States. A maximum of only 3 cases of diphtheria per year from 1980 through 1999 and 50 to 100 cases of tetanus per year during the 1990s were reported (12). Diphtheria bacteria produce a toxin that is absorbed into the bloodstream and distributed to the tissues of the body. The disease can be characterized by the site affected: anterior nasal, tonsillar/pharyngeal, laryngeal, cutaneous, ocular, or genital (12). Most complications—mainly myocarditis, neuritis, and death—are attributable to the effects of the toxin.
Tetanus may be of particular interest to athletes because, rather than being transmitted from person to person, the organism is found in contaminated soil and enters the body through wounds. Like diphtheria, the tetanus bacilli produce a toxin in infected people. Tetanus toxin acts on the central nervous system and causes severe muscle contractions and spasms. Pneumonia is a common complication, and the muscle contractions can be strong enough to break bones. Most deaths from tetanus occur in people older than 50 (23).
Adults or adolescents who did not receive a complete diphtheria/tetanus/pertussis vaccine series as children should complete the series with adult Td vaccine, regardless of how much time has passed. Adult Td vaccine contains less diphtheria toxoid than the childhood preparation and no pertussis vaccine, which is licensed only for patients up to age 7. All adults, including those who received the childhood series, should get a Td booster every 10 years throughout life. Tetanus toxoid may be given as postexposure prophylaxis for wound management (23).
Adverse events associated with Td vaccine consist primarily of local reactions (pain, redness, etc) at the injection site; fever and other systemic reactions are uncommon. Severe systemic reactions such as generalized urticaria, brachial neuritis, and Guillain-Barré syndrome have been reported but are very rare (24). Occasionally, an adult who has received frequent doses of tetanus toxoid will experience an Arthus reaction, consisting of painful swelling of the arm (12).
Lyme disease. Lyme disease is caused by the tick-borne bacterium Borrelia burgdorferi, and it primarily affects the skin, heart, joints, and nervous system. About 12,000 cases are reported annually in the United States (3). Eighty-eight percent of cases occur in the Northeast, the upper Midwest, and northern California, the areas inhabited by ticks of the Ixodes ricinus complex that carry the disease (3). People playing or working in wooded areas are at highest risk. Symptoms include an expanding skin lesion around the site of the tick bite and systemic complaints including fatigue, myalgias, arthralgias, headache, fever chills, and stiff neck. Complications can include secondary skin lesions, mild hepatitis, meningitis, encephalitis, and myocarditis. Arthritis affects about 60% of untreated patients, and about 10% of these cases become chronic (25). Lyme disease is seldom fatal.
Prevention of Lyme disease through vector control and personal protective measures is an important element of disease control, but a vaccine for Lyme disease was licensed in 1999 for people between the ages of 15 and 70. The vaccine is recommended as a three-dose primary series (an initial dose, with subsequent doses 1 month and 12 months later) for those in endemic areas at risk of exposure who engage in activities that result in frequent or prolonged exposure to tick-infested habitat (3). State and local authorities can provide more detailed information about Lyme disease risk within specific areas. In clinical trials, Lyme disease vaccine was associated only with mild reactions (local reactions, fever, chills, myalgia). Pregnant women should not receive the vaccine, nor should anyone with a history of treatment-resistant Lyme arthritis. Boosters are not recommended.
Meningococcal disease. Each year 2,400 to 3,000 cases of meningococcal disease occur in the United States (0.8 to 1.3 per 100,000 population) (26). The case-fatality ratio is 10%, and 11% to 19% of survivors have sequelae (eg, neurologic disability, limb loss, and hearing loss). Persons who have certain medical conditions, particularly deficiencies in the terminal common complement pathway and anatomic or functional asplenia, are at increased risk of developing meningococcal disease. College freshmen who live in dormitories have a higher rate of meningococcal disease (4.6 per 100,000) than any age-group in the population except children younger than 2 years old (27). There are no data suggesting an increased risk of meningococcal disease in athletes without other risk factors.
A single dose of quadrivalent (A, C, Y, W-135) polysaccharide vaccine is routinely recommended for high-risk groups, including those who have terminal complement component deficiencies and those who have anatomic or functional asplenia, for travelers to certain countries in Africa during December to June, and for certain laboratory personnel (26).
While the vaccine is not routinely recommended for college freshmen, providers should inform freshmen (particularly those who live in dormitories) and their parents about meningococcal disease and the benefits of vaccination (27). Freshmen who want to reduce their risk for meningococcal disease should either be vaccinated or directed to a site at which the vaccine is available. The level of increased risk among freshmen does not warrant changes in living situations. If indications still exist for vaccination, revaccination may be considered 3 to 5 years after patients have had the initial dose.
Several contraindications and precautions are common to all vaccines. Patients who have had severe allergic or anaphylactic reactions to a dose of any vaccine should not get subsequent doses. Anyone with a known anaphylactic allergy to any of a vaccine's components (eg, gelatin for varicella or MMR vaccine, baker's yeast for hepatitis B vaccine, eggs for influenza vaccine) should not receive that vaccine. In addition, live attenuated vaccines (eg, MMR, varicella) should not be given to pregnant women, severely immunosuppressed patients, or anyone who has recently had a transfusion or received any other blood product (12). Vaccination of people with moderately-to-severely acute illnesses should be deferred until they are no longer acutely ill (12).
Dr Strikas is a medical epidemiologist, Dr Schmidt is a public health educator, Ms Weaver is a nurse educator, and Mr Wolfe is a health education and information specialist, all with the National Immunization Program at the Centers for Disease Control and Prevention in Atlanta. Address correspondence to Donna L. Weaver, MN, RN, National Immunization Program, Centers for Disease Control and Prevention, 1600 Clifton Rd, NE, Mailstop E-52, Atlanta, GA 30333; e-mail to [email protected].
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