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Canadian Immunization Guide
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Vaccine | Dosing schedule (no record or unclear history of immunization) | Booster schedule (primary series completed) |
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Tetanus and diphtheria given as Td; and pertussis given as Tdap | Doses 1 and 2, 4-8 weeks apart and dose 3 at 6-12 months later; one of the doses should be given as Tdap for pertussis protection | Td every 10 years; 1 dose should be given as Tdap if not previously given in adulthood |
Measles, mumps and rubella given as MMR | 1 dose for adults born in or after 1970 without a history of measles or those individuals without evidence of immunity to rubella or mumps; second dose for selected groups | Not routinely required |
Varicella | Doses 1 and 2, at least 4 weeks apart for susceptible adults (no history of natural disease or seronegativity) | Not currently recommended |
There are several specific groups of adults for whom certain vaccines are recommended because of the presence of risk factors for disease, and these are summarized in Table 6. In many cases, individual factors, and in particular the presence of underlying co-morbid illnesses, define groups that specifically benefit from certain vaccines. However, there are two commonly encountered groups of healthy adults who require assessment for a series of vaccines: health care workers and international travelers. In both of these groups, the priority should be to ensure that routinely recommended immunizations are completed and booster doses provided as indicated.
Health care workers, including hospital employees, other staff who work or study in hospitals (e.g., students in health care disciplines and contract workers), other health care personnel (e.g., those working in clinical laboratories, nursing homes and home care agencies) and child care workers, are at risk of exposure to communicable diseases because of their contact with patients or material from individuals with infections, both diagnosed and undiagnosed.
Hepatitis B is the most important vaccine-preventable infectious occupational disease for health care workers. The risk of being infected is a consequence of the prevalence of virus carriers in the population receiving care, the frequency of exposure to blood and other body fluids and the contagiousness of hepatitis B virus. Hepatitis B vaccine is recommended for health care workers and others who may be exposed to blood or blood products, or who may be at increased risk of sharps injury, bites or penetrating injuries (for example, clients and staff of institutions for the developmentally challenged). Annual Influenza immunization is recommended for all health care personnel who have contact with individuals in high-risk groups. Such personnel include physicians, nurses and others in both hospital and outpatient settings; employees of chronic care facilities; and providers of home care, visiting nurses and volunteers. Influenza immunization of health care workers has been shown to reduce the mortality and morbidity of patients under their care in long-term settings and to reduce worker illness and absenteeism during the Influenza season. Other vaccines may be indicated for certain workers at particularly high risk of exposure, such as laboratory workers in specialized reference or research facilities. These include but are not limited to typhoid, meningococcal, BCG, rabies, and smallpox vaccines. An individualized risk-benefit assessment is required.
International travelers represent another defined group requiring specific vaccine consideration. Ensuring that traveling adults have completed a primary series of routine vaccinations is the first priority (Table 6). This is particularly important because many vaccine-preventable diseases remain endemic in developing countries. Although completion of primary polio vaccination is adequate in most adults, a one-time polio booster (> 10 years since primary vaccination) is recommended for adults who have not had a previous booster and are traveling to polio-endemic countries. It is also important that travelers who are in specific risk groups for routine vaccines (such as pneumococcal and Influenza vaccines in those ≥ 65) receive the ones indicated. With travel-specific vaccines, an individualized approach is required that considers a patient's health status, risk of exposure and complications from vaccine-preventable illness, as well as location and duration of travel. Most commonly these include consideration for immunization against yellow fever, Japanese encephalitis, typhoid, cholera, meningococcal disease, rabies, and hepatitis A and B, as listed in Table 6.
Adults ≥65 years of age and those with conditions that increase their chances of complications should receive one dose of pneumococcal vaccine and yearly Influenza vaccine. Opportunities to increase Influenza vaccination should be taken; it is estimated that less than one-half of high-risk Canadians receive Influenza vaccine annually. Increasing the rate of Influenza vaccination of health care workers and household contacts of individuals with increased risk of Influenza complications will not only affect the vaccinated individuals but may also result in substantial secondary benefit to others.
Hepatitis A vaccination is recommended for those at increased risk of exposure (see Hepatitis A Vaccine chapter). Universal immunization against hepatitis B is recommended in childhood in Canada, and opportunities should be provided for adults to receive hepatitis B vaccine. Adults who are at increased risk of exposure to hepatitis B by virtue of their occupation, lifestyle or environment should receive the vaccine at the earliest possible clinical encounter. Patients may be vaccinated simultaneously for hepatitis A and B using a combined vaccine. Because of their increased risk for complications, all non-immune patients with chronic liver disease should be vaccinated against hepatitis A and B.
Cholera vaccine should be considered for high-risk travelers to cholera-endemic countries (please refer to the Immunization of Travellers chapter).
Meningococcal C conjugate vaccines are recommended for immunization of young adults to prevent the increased risk of serogroup C meningococcal disease in these age groups. Meningococcal vaccine is recommended for certain groups with increased risk of meningococcal disease (please refer to the Meningococcal Vaccine chapter). Such individuals include those with functional or anatomic asplenia; persons with complement, properdin or factor D deficiency; military recruits; research, industrial and clinical laboratory personnel who are routinely exposed to Neisseria meningitidis cultures; and travelers to high-risk areas. In cases in which risk is restricted to group C disease, monovalent serogroup C meningococcal conjugate vaccine may be preferred. Meningococcal vaccine is also used for outbreak management.
Although oral poliovirus vaccine is no longer used in Canada, individuals who have received a primary vaccination series with this vaccine are considered immune. Immunization of adults against poliovirus should be considered for those at increased risk (see Poliomyelitis Vaccine chapter).
Rabies vaccine should be offered, before exposure, to those individuals at high risk as a result of occupational or travel exposure to rabid animals. These may include veterinarians, laboratory workers, animal control and wildlife workers, spelunkers, trappers and hunters, and travelers to endemic countries where there may be limited access to safe and effective post-exposure prophylaxis.
Typhoid vaccine is recommended for high-risk international travelers, including those with prolonged (> 4 weeks) exposure in an endemic region or those with shorter duration of stay in particularly high-risk situations (please refer to the Typhoid Vaccine chapter). Although routine vaccination of health care workers is not required, laboratory workers who frequently handle live cultures of Salmonella typhi should be vaccinated.
Naturally occurring smallpox has been eradicated worldwide, and as a result vaccination is highly restricted. Laboratory workers who handle vaccinia or other orthopoxviruses should be considered for vaccination.
Table 6. Adult Immunization Schedule - Specific Risk Situations
Vaccine or toxoid | Indication | Schedule |
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Influenza | Adults ≥ 65 years; Adults < 65 years at high risk of Influenza-related complications, their household contacts, health care workers, and all those wishing to be protected against influenza. | Every autumn using current recommended vaccine formulation |
Pneumococcal polysaccharide | Adults ≥ 65 years; Adults < 65 who have conditions putting them at increased risk of pneumococcal disease | 1 dose |
Hepatitis A | Occupational risk, life-style, travel and living in areas lacking adequate sanitation. Outbreak control, post-exposure immunoprophylaxis. Patients with chronic liver disease. | 2 doses 6-12 months apart |
Hepatitis B | Occupational risk, life-style, post-exposure immunoprophylaxis. Patients with chronic liver disease. | 3 doses at 0, 1 and 6 months |
Bacille Calmette- Guérin (BCG) | Rarely used. Consider for high-risk exposure in selected cases. | 1 dose |
Cholera | High-risk exposure in travelers to endemic area(s) | 1 oral dose of live attenuated vaccine; 2 doses at least 1 week apart but not greater than 6 weeks of oral inactivated vaccine |
Japanese encephalitis | Travel to endemic area(s) or other exposure risk | 3 doses at days 0, 7 and 30 |
Poliomyelitis | Travel to endemic area(s) or other risk group | Primary series doses 1 and 2, 4-8 weeks apart and dose 3 at 6-12 months later; 1 booster dose if > 10 years since primary series |
Meningococcal conjugate | Young adults | 1 dose |
Meningococcal polysaccharide | High-risk exposure groups | 1 dose |
Rabies, pre-exposure use | Occupational or high-risk travelers | 3 doses at days 0, 7 and 21 |
Typhoid | High-risk travelers to endemic area(s) or other high-risk exposure | Parenteral capsular polysaccharide 1 dose; live attenuated 3-4 oral doses depending on preparation |
Yellow fever | Travel to endemic area(s) or if required for foreign travel | 1 dose with booster every 10 years if required |
Smallpox | Laboratory staff working with vaccinia or other orthopoxviruses | 1 dose |
Canadian Association for the Study of the Liver. Canadian Consensus Conference on the Management of Viral Hepatitis. Canadian Journal of Gastroenterology 2000;14(Suppl B):5B-20B.
Committee to Advise on Tropical Medicine and Travel (CATMAT). Statement on poliomyelitis vaccination for international travellers (evidence-based medicine recommendations). Canada Communicable Disease Report 1995;21(16):145-48.
Committee to Advise on Tropical Medicine and Travel (CATMAT); National Advisory Committee on Immunization (NACI). Statement on new oral cholera and travellers' diarrhea vaccination. Canada Communicable Disease Report 2005;31(ACS-7):1-11.
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National Advisory Committee on Immunization (NACI). Statement on recommended use of meningococcal vaccines. Canada Communicable Disease Report 2001;27(ACS-6):2-36.
National Advisory Committee on Immunization (NACI). Statement on smallpox vaccination. Canada Communicable Disease Report 2002;28(ACS-1):1-12.
National Advisory Committee on Immunization (NACI). Prevention of pertussis in adolescents and adults. Canada Communicable Disease Report 2003;29(ACS-5):1-9.
National Advisory Committee on Immunization (NACI). Update on varicella. Canada Communicable Disease Report 2004;30(ACS-1):1-26.
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Last Updated: 2007-07-18 |