Immunization Update
John D. Grabenstein, RPh, PhD, FAPhA
The phrase “ACIP-recommended” reflects a consensus that a vaccination is encouraged for everyone within a certain age or in certain risk groups. “ACIP-recommended” translates into broad, routine recommendations. For routine, catch-up, and risk-based recommendations from ACIP, the default approach as pharmacists care for their patients is to vaccinate unless contraindicated.
Yet the words “shared clinical decision making” (SCDM) tell a slightly different story. The full phrase is “recommended vaccination on the basis of shared clinical decision making,” reflecting situations where a more nuanced discussion of needs or of risks and benefits is warranted. ACIP makes SCDM recommendations when some individuals would benefit from vaccination, but broad vaccination of people in that group is unlikely to help most members of the group.
SCDM vaccinations are recommended for some, but not all, within a particular age group or risk group. The provider and the patient will come to a mutual decision about whether that vaccine is warranted for that person. If the pharmacist assessed X-number of patients on any given day with an SCDM conversation, there may be some cases where they and the patient agree vaccination is the right thing to do and some cases where the vaccine and the patient are not the right fit.
Then again, individual pharmacist–patient conversations about vaccinations can happen without the SCDM label applied. With any vaccination, including SCDM ones, it is ultimately the patient’s decision after comparing benefits and risks of the disease and the vaccine.
ACIP revises its recommendations from time to time, causing the SCDM list to lengthen or shorten as scientific evidence accumulates. At its June 2024 meeting, for example, ACIP shifted its recommendations for respiratory syncytial virus vaccines from SCDM to routine for certain age, health, or residence cohorts.
For fall 2024, four vaccines have SCDM criteria for some of their uses. These are reviewed below, listing various criteria that would favor vaccination or not. Pharmacists and other vaccine providers may customize their approach to these vaccines with each individual to assure the reasoned criteria are understood by each vaccine candidate.
What’s the best approach to vaccinating? Is the pharmacist more likely to wait for the patient to ask about vaccination or more likely to proactively suggest it? Either approach fits with SCDM vaccinations. But never forget about the vulnerable patients who don’t realize that vaccination could prevent them from developing a serious disease. They don’t know to ask for a pharmacist’s help. Proactivity could make all the difference in helping them staying healthy. That’s true for both routine and SCDM vaccinations. ■
SCDM vaccination recommendations from ACIP, fall 2024
For adolescents and young adults 16–23 years old, meningococcal B (MenB) vaccine
Favoring vaccination:
- Desire to avoid a rare infection with severe consequences (e.g., high rates of death or permanent disability).
- Risk of MenB is increased among college students, especially first-year students and those who attend a 4-year university, live on campus, or participate in sorority or fraternity activities.
- On the contrary:
- Antibody wanes within 1–2 years after completing the primary series, so benefit may be short-lived.
For adults 27–45 years old, HPV vaccine
Favoring vaccination:
- Desire to avoid HPV-related cancers.
- Sexually active adults not in a long-term, mutually monogamous sexual relationship.
- Plans to have sex with a new partner in the future.
On the contrary:
- New HPV infection is less common in older adults than in younger adults.
Comment: Requires willingness to discuss sexuality. Risk awareness could be triggered by patient’s comments about divorce, being “back in the dating scene,” and similar subjects.
For adults ≥60 years old with diabetes mellitus, hepatitis B (HepB) vaccine
Favoring vaccination:
- Desire to avoid severe liver disease.
- People with diabetes who may measure blood glucose with shared glucometers (e.g., congregate living settings).
On the contrary:
- Hepatitis B infection is less common in adults ≥60 years old than in younger adults.
For adults ≥65 years old previously given both PCV13 (at any age) and PPSV23 (at age ≥65 years) pneumococcal conjugate vaccine (PCV20)
Favoring vaccination:
- Higher valence pneumococcal vaccines protect against specific serotypes not included in earlier vaccines.
- Pneumococcal vaccinations given years ago can wane in effectiveness as years go by (e.g., ≥5 years).
- Risk of pneumococcal disease is elevated in people with certain chronic diseases or who live in nursing homes or other long-term care facilities.
On the contrary:
- Their risk of pneumococcal disease was lowered by prior vaccinations.
Resources on SCDM
- CDC gateway to ACIP recommendations: www.cdc.gov/vaccines/hcp/acip-recs/
- ACIP Shared Clinical Decision-Making Recommendations: www.cdc.gov/vaccines/acip/acip-scdm-faqs.html (includes links to summary job aids for each of the vaccination situations described above)