Key Vaccine Changes for 2014
Haemophilus influenzae Type B Vaccine: Not Just for Kids
Overall, this year's new adult schedule is more about refinement and clarification than major changes, with one exception: Haemophilus influenzae type b (Hib) vaccination. Hib now has its own bar on the immunization schedule graphic and its own footnote. Hib is not just for kids; it is now recommended for the following subsets of adults:
• Adults with functional or anatomic asplenia, including sickle cell;
• Patients planning elective splenectomy (preferably at least 14 days before surgery); and
• Patients who have undergone successful stem-cell transplant (3 doses over 6 months -- each dose at least 1 month apart).
The footnotes clearly state that Hib vaccination is not routinely recommended for patients with HIV because their risk for Hib infection is low.
Pneumococcal Vaccination: Graphic Switch
There is a graphic change in the schedule for pneumococcal vaccination for adults: PCV13 (the pneumococcal conjugate vaccine) is now listed above PPSV23 (the pneumococcal polysaccharide vaccine). The switch acts as a timing trigger and visual reminder to give the conjugate vaccine first, before the polysaccharide vaccine, to previously unvaccinated adults who need to receive both vaccines. Immunocompromised adults (aged 19 years or older) should receive both the conjugate and polysaccharide vaccines. This includes patients with chronic renal failure, nephrotic syndrome, functional or anatomic asplenia, cerebrospinal fluid leaks, or cochlear implants.
Previously unvaccinated adults in these categories should be given PCV13 first, followed by PPSV23 at least 8 weeks later. However, if a patient has already been vaccinated with PPSV23, the administration of PCV13 should be delayed for at least 1 year.
The corresponding footnote also includes a reminder that PCV13 is FDA-approved only for adults aged 50 years or older. The ACIP recommendation to give it to immunocompromised adults younger than 50 years is therefore an off-label use.
New Messaging for Meningococcal Vaccination
Although meningococcal vaccination recommendations remain the same, the footnote messaging is different. Conjugate meningococcal vaccine (MCV4) is now abbreviated as MenACWY-D (Menactra®). Polysaccharide meningococcal vaccine (MPSV4) is now abbreviated as MenACWY-CRM (Menveo®). This change was made to be consistent with language used in the children's schedule. [2,4]
The footnote clarifies who needs 1 dose and who needs 2, and which vaccine to use. Age-specific choice of vaccination remains the same. The conjugate vaccine, MCV4, is preferred for adults aged 55 years or younger. The polysaccharide vaccine, MPSV4, is preferred for adults aged 56 years or older -- but only in those who are scheduled to receive a single dose.
The choice of vaccine when more than 1 dose is needed or anticipated is also clarified. Conjugate vaccine is preferred for adults of all ages. The footnotes also include a reminder to vaccinate first-year college students through age 21 years who didn't receive meningococcal vaccination on or after their 16th birthday. [1,2]
Another important clarification is about HIV-positive individuals, who should not be routinely vaccinated with the meningococcal vaccine, but those who do get vaccinated should receive 2 doses of conjugate MCV4. [1,2] No mention is made about vaccinating men who have sex with men. In a study published in Annals of Internal Medicine,  officials from the New York City Department of Health and Mental Hygiene urged all men who have sex with men, especially those attending the city's Gay Pride events, to be vaccinated against meningitis.
Not New (but Still Important) Highlights
Pertussis vaccination of adults to protect tiny tots. Tdap (tetanus, diphtheria, acellular pertussis) booster is still recommended for all adults, including those aged 65 years or older. Pregnant women should receive a Tdap booster during each and every pregnancy, in the third trimester, preferably between 27 and 36 weeks. Although not indicated in the footnotes, repeat maternal vaccination is also an off-label use. [1,2]
Shingles vaccine clarification. The adult schedule recommends herpes zoster vaccine (Zostavax®) administration starting at age 60 years, even though it is FDA-approved for adults starting at age 50 years. [1,2] The ACIP Herpes Zoster Work Group presentations at the October 2013 ACIP meeting indicated uncertainty about the duration of protection of a single dose of the zoster vaccine. [6,7]
Decision and cost-effectiveness analyses comparing vaccination programs at age 50, 60, and 70 years were also presented at this meeting, indicating that although vaccinating at age 60 years prevents more zoster cases, delaying vaccination to age 70 years prevents the greatest numbers of cases of postherpetic neuralgia.  The Work Group will continue to evaluate the optimal age for vaccination as well as the need for revaccination. 
The herpes zoster vaccine is a live virus vaccine and should not be given to pregnant women or those with severe immunodeficiency. [1,2]
Finally, influenza. Yearly influenza vaccination recommendations for everyone over 6 months of age still stand. Flu vaccine recommendations for egg-allergic individuals have been clarified in the footnotes. The inactivated injection can be given to individuals with "hives-only" egg allergy. A new-technology flu shot, recombinant influenza vaccine (FluBlok®), contains no egg protein whatsoever and can be given to adults aged 18-49 years with egg allergy of any severity. [1,2]
This year's schedule makes no mention of and expresses no preference for quadrivalent vs trivalent influenza vaccine, or for high-dose (Fluzone® High- Dose) over standard vaccine (Fluzone®) for those aged 65 years or older. [1,2] Results of a 2-year multicenter, randomized, double-blind, controlled trial including 32,000 Canadian and US adults aged 65 years and older were also presented at the October 2013 ACIP meeting. The study showed that the high-dose influenza vaccine was 24% more effective than standard flu vaccine in preventing influenza of any strain in adults aged 65 years or older.  It will be interesting to see whether these new findings and formulation advancements will change future adult influenza immunization recommendations.