INHALATION DEVICES — Metered-dose inhalers (MDIs) require coordination of inhalation with hand-actuation of the device. Valved holding chambers (VHCs) or spacers help some patients, especially young children and the elderly, use MDIs effectively. VHCs have one-way valves that prevent the patient from exhaling into the device, minimizing the need for coordinated actuation and inhalation. Spacers are tubes or chambers placed between the canister and a face mask or mouthpiece, which also avoids the need to coordinate actuation and inhalation. Both VHCs and spacers retain the larger particles emitted from the MDI, decreasing their deposition in the oropharynx and leading to a higher proportion of small respirable particles being inhaled.

The FDA has approved a nasal spray fixed-dose combination (Dymista – Meda) of the H₁-antihistamine azelastine (Astelin, Astepro, and generics) and the corticosteroid fluticasone propionate (Flonase, and generics) for treatment of seasonal allergic rhinitis (SAR) in patients ≥12 years old who need both medications for symptomatic relief. It is the first nasal spray to be approved in the US that contains both an H₁-antihistamine and a corticosteroid.

The US Advisory Committee on Immunization Practices (ACIP) has recommended that adults with immunocompromising conditions receive the 13-valent pneumococcal conjugate vaccine (PCV13; Prevnar 13), even if they have already received the older 23-valent unconjugated vaccine (PPSV23; Pneumovax 23). Prevnar 13, initially approved by the FDA for use in infants and young children, has been licensed since December 2011 for adults ≥50 years old.

The FDA has licensed a 13-valent conjugate pneumococcal vaccine (PCV13; Prevnar 13 – Pfizer) for the prevention of invasive pneumococcal disease (IPD) in infants and children <6 years old. It replaces Prevnar (PCV7). An unconjugated 23-valent polysaccharide vaccine (PPSV23; Pneumovax 23 – Merck) is FDA-approved for use in adults.

Rotarix, an oral live-attenuated rotavirus vaccine, has been approved by the FDA for prevention of rotavirus gastroenteritis in infants and children. Rota-Shield was withdrawn from the market because of an association with intussusception. RotaTeq, an oral live, human-bovine reassortant rotavirus vaccine, is recommended by the American Academy of Pediatrics as a routine immunization.

Medical Letter consultants have brought to our attention some confusion that has accompanied the release of Adacel, a combination of tetanus toxoid, diphtheria toxoid and acellular pertussis antigens (Tdap) recently approved for use as a booster in adolescents and adults 11-64 years old (Med Lett Drugs Ther 2006; 48:5). Another Tdap vaccine, Boostrix, is approved for use in adolescents 10-18 years old. Some adults have inadvertently been immunized with Daptacel or Infanrix (DTaP), which are intended for active immunization of infants and children 6 weeks to 6 years old. Such mix-ups were reported by the Institute for Safe Medication Practices (www.ismp.org) in the August 24 and December 2006 issues of its newsletter.

The problem with giving these pediatric vaccines to adults is that they contain more diphtheria and pertussis antigens than the adult vaccine, and adults may have untoward reactions to these higher antigen levels. One consultant who inadvertently gave the pediatric vaccine to 80 adults reports that a few developed fever to 102ºF, and several developed severe erythema and swelling at the injection site. In the absence of a comparative trial, whether these reactions were due to the higher antigen load can only be a matter of speculation.

The reasons for the mix-ups, according to the Institute, include the similarities in the brand names and packaging of Adacel and Daptacel in addition to the similar component antigens in the 2 products (the components of Adacel are listed in a different order and are labeled as “reduced” diphtheria toxoid and acellular pertussis). The manufacturer of Adacel and Daptacel intends to make changes in the packaging and labeling to clarify the differences between the products. The inadvertent administration of Infanrix to adults was caused by an electronic order entry program’s failure to differentiate between the adult and pediatric vaccines.

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Since the publication of our article on influenza vaccine (October 9, 2006), a fourth inactivated vaccine (FluLaval - GlaxoSmithKline) has been approved by the FDA for use in people ≥18 years old. It is sold in 5-mL multi-dose vials. Each 0.5-mL intramuscular dose contains 25 mcg of mercury.

Annual immunization against influenza A and B is the most effective method of preventing infection and has been shown to reduce associated complications.

The US Advisory Committee on Immunization Practices (ACIP) has recommended the addition of a routine second dose of varicella vaccine for children <13 years old. Varicella vaccine has been used in the US since 1995, but varicella outbreaks have continued to occur among school children vaccinated with a single dose. In one such outbreak, the attack rate was 100% in unvaccinated children and 18% in those previously vaccinated.1 In vaccinated children, the typical maculopapular-vesicular rash of varicella may be only maculopapular with few or no vesicles, but these children could still transmit virus to susceptible contacts.

A live attenuated varicella-zoster vaccine (Zostavax - Merck) has been approved by the FDA for prevention of herpes zoster (HZ; zoster; shingles) in persons ≥60 years old. Each dose of Zostavax contains about 14 times as much varicella-zoster virus (VZV) as Varivax, which has been used in the US since 1995 to vaccinate against varicella (chicken pox).

A recombinant quadrivalent human-papillomavirus-like particle vaccine, Gardasil (Merck), has been approved by the FDA for use in girls and women 9-26 years old to prevent diseases associated with infection with human papillomavirus (HPV) types 6, 11, 16, and 18, including genital warts, precancerous cervical, vaginal or vulvar lesions, and cervical cancer.

The FDA has recently approved RotaTeq (Merck), an oral live, human-bovine reassortant rotavirus vaccine, for use in infants to prevent rotavirus gastroenteritis, a frequent cause of severe diarrhea in infancy.

Although immunization programs have produced high vaccination rates in US infants and children, similar successes have not been achieved in adults. Vaccines recommended for routine use in adults are reviewed here. Immunizations for travel were reviewed in a recent issue.

A large mumps outbreak that began in Iowa in December 2005 has spread. About 40% of the cases have been in people 18-25 years old, many of whom are college students and had been vaccinated against the disease.

Patients planning to travel to other countries often ask physicians for information about immunizations and prevention of diarrhea and malaria. More detailed advice for travelers is available from the Centers for Disease Control and Prevention at 877-FYI-TRIP (877-394-8747) or www.cdc.gov/travel.

The FDA has licensed Adacel (Aventis Pasteur) and Boostrix (GlaxoSmithKline), two new combination vaccines that include tetanus toxoid, diphtheria toxoid and acellular pertussis antigens (Tdap), for use as a booster in adolescents and adults. In the past, older children and adults were not re-immunized against pertussis because of concerns about reactions to the whole-cell vaccine previously used in younger children. The CDC Advisory Committee on Immunization Practices (ACIP) and the American Academy of Pediatrics (AAP) have recommended that either of the new Tdap vaccines replace routine tetanus-diphtheria (Td) boosters in adolescents 11-18 years old, and Adacel should replace Td boosters in adults 19-64 years old.

The FDA has approved a conjugated polysaccharide vaccine, Menactra (Sanofi-Pasteur), for protection against disease caused by Neisseria meningitidis in people 11-55 years old, and the manufacturer has applied for approval for use in children 2 to 10 years old. An unconjugated meningoccocal polysaccharide vaccine (Menomune - Sanofi-Pasteur) has been licensed in the US since 1981.

A vaccine to prevent both Hepatitis A and Hepatitis B (Twinrix), previously licensed in Canada and Europe, is now available in the US for adults.

Patients planning to travel to other countries often ask physicians for advice about immunizations and prevention of diarrhea and malaria. More detailed advice for travelers is available from the CDC at 877-FYI-TRIP (877-394-8747) or www.cdc.gov/travel.

Patients planning to travel to other countries often ask physicians for advice about immunizations and prevention of diarrhea and malaria. Legal requirements for entry and epidemiological conditions in different countries vary from time to time, often unpredictably, but some reasonable recommendations can be made. More detailed information is available in Health Information for International Travel, published annually by the Centers for Disease Control (CDC), which can be obtained from the Superintendent of Documents, US Government Printing Office, Washington, DC 20402. Up-to-date automated information is available by telephone from the CDC (404-332-4559).