What DO the childhood immunization footnotes reveal? Questions and answers Stanley E. Grogg, DO, FACOP, FAAP he Advisory Committee on Immunization Practices (ACIP) recommends the childhood vaccination schedules, which are published each year in the Morbidity and Mortality Weekly Report (MMWR) in early February. 1 The vaccination schedules are provided for persons aged 0-18 years and include a catch-up schedule (Figure 1, p. 6 and 7 and Figure 2, p. 8). Shutterstock.com 4 AOA Health Watch New emphasis on pediatric and adolescent vaccinations October 2013
In 2013, the footnotes were combined with standardized formatting to provide recommendations for each vaccine related to routine vaccination, catch-up vaccination, and vaccination of persons with high-risk medical conditions or under special circumstances. Several new references and links with additional information were added, including vaccination of persons with primary and secondary immunodeficiency. The footnotes help to illustrate the quandaries of the recommended vaccinations. This article reviews some of the common questions asked of the childhood vaccinations. Question: What is the only vaccine recommended for newborns? Answer: Hepatitis B (HepB). The second dose should be administered at age 1 or 2 months. Monovalent HepB vaccine should be used for doses administered before age 6 weeks. The minimum interval between dose 1 and 2 is 4 weeks and between dose 2 and 3 is 8 weeks. The final (third or fourth) dose in the HepB vaccine series should be administered no earlier than age 24 weeks and at least 16 weeks after the first dose. Administration of a total of 4 doses of HepB vaccine is recommended when a combination vaccine containing HepB is administered after the birth dose. Q: What is the maximum age for the administration of the rotavirus (RV) vaccines? A: The maximum age for the final dose in the series for RV vaccination is 8 months, 0 days. The minimum age for starting RV is 6 weeks. Two RV vaccinations are available for RV: RV-1 (Rotarix by GlaxoSmithKline [GSK]) and RV-5 (RotaTeq by Merck). Q: For routine administration of diphtheria and tetanus toxoids and acellular pertussis (DTaP), a 5-dose series is recommended at ages 2, 4, 6, and 15-18 months and 4 through 6 years. If a child only received 3 doses of the DTaP before age 4 years, should he or she receive 2 more doses to complete his or her series? A: No. The fifth dose (booster) of DTaP vaccine is not necessary if the fourth dose was administered at age 4 years or older. Shutterstock.com Q: One dose of tetanus and diphtheria toxoids and acellular pertussis (Tdap) vaccine is recommended routinely at age 11-12 years. Can the Tdap be given to a 7-year-old who had only received 4 doses of DTaP before age 4, since the US Food and Drug Administration approved the present 2 types of Tdap for a minimum age of 10 years for Boostrix (GSK) and 11 years for Adacel (Sanofi) and the DTaP is not recommended after age 6? A: Yes. The ACIP recommends the use of Tdap after 6 years (7 years through any age) and is accepted as the standard of care for vaccinations. For these children, an adolescent Tdap vaccine should not be given. Q: If a DTaP is inadvertently given to a child over age 6 years, does that count as part of the series? A: Yes. An inadvertent dose of DTaP vaccine administered to children aged 7 through 10 years can count as part of the catch-up series. This dose can count as the adolescent Tdap dose, or the child can later receive a Tdap booster dose at age 11-12 years. Q: Is the Haemophilus influenzae type B (Hib) vaccination ever used as a booster after age 5 years? A: Yes. Hib vaccine is not routinely recommended for patients older than age 5 years. However, 1 dose of Hib vaccine should be administered to unvaccinated or partially vaccinated persons aged 5 years or older who have leukemia, malignant neoplasms, anatomic or functional asplenia (including sickle cell disease), human immunodeficiency virus (HIV) infection, or other immunocompromising conditions. Q: What are the high-risk medical conditions for the recommended additional 13-valent pneumococcal conjugate vaccine (PCV13) and 23- valent pneumococcal polysaccharide vaccine immunizations? A: (1) Functional or anatomic asplenia, including sickle cell disease; (2) HIV October 2013 New emphasis on pediatric and adolescent vaccinations AOA Health Watch 5
infection or other immunocompromising condition; (3) cochlear implant; and (4) cerebrospinal fluid leak. Figure 1. Childhood immunization schedule for 2013. Q: A 25-month-old child is in the office for his 2-year-old check-up. He was diagnosed with sickle cell disease shortly after birth and was up to date on immunizations at age 18 months. What pneumococcal vaccine(s), if any, should be given to this child? A: For children 24 through 71 months with certain underlying medical conditions, such as sickle cell disease, administer 1 dose of PCV13 if 3 doses of PCV were received previously OR administer 2 doses of PCV13 at least 8 weeks apart if fewer than 3 doses of PCV were received previously. Q: A patient only received 2 of the recommended doses of the inactivated polio vaccine (IPV) and is now aged 4 years. Does she need 2 more doses of the IPV to complete her series? A: No. A fourth dose is not necessary if the third dose was administered at age 4 years or older and at least 6 months after the previous dose. If 4 or more doses are administered before age 4 years, an additional dose should be administered at age 4 through 6 years. Q: A 2-year-old with a history of asthma comes in for his influenza vaccine. Can he be given the live, attenuated influenza vaccine (LAIV)? A: No. LAIV should NOT be administered to some persons, including (1) those with asthma, (2) children aged 2 through 4 years who had wheezing in the past 12 months, or (3) those who have any other underlying medical conditions that predispose them to influenza complications. Minimum age: 6 months for inactivated influenza vaccine and 2 years for LAIV. Q: Are 2 doses of influenza vaccine recommended for all children aged 6 months through 8 years? A: No. Administer 2 doses (separated by at least 4 weeks) to children who are receiving influenza vaccine for the first time. 2 Q: A 10-month-old infant is traveling with her parents to Europe to visit Source: CDC website. relatives. Does she need a measles, mumps, and rubella (MMR) vaccine? A: Yes. Administer 1 dose of MMR vaccine to infants aged 6 through 11 months before departure from the United States for international travel. These children should be revaccinated with 2 doses of MMR vaccine, the first at age 12 through 15 months and the second dose at least 4 weeks later. Q: Can 2 doses of varicella (VAR) vaccine be administered after age 12 months but before age 4 years? A: Yes. The ACIP recommends the first dose of VAR vaccine at age 12 through 15 months and the second dose at age 4 through 6 years. The second dose may be administered before age 4 years, provided at least 3 months have elapsed since the first dose. If the second dose was administered at least 4 weeks after the first dose, it can be accepted as valid. Q: A 9-year-old child received her hepatitis A vaccine (HepA) at 2 years of age. Should she receive a second dose now? A: Yes. For any person aged 2 years or older who did not receive both of the recommended doses of the HepA vaccine, they should receive a second dose of HepA if immunity against hepatitis A virus infection is desired. 6 AOA Health Watch New emphasis on pediatric and adolescent vaccinations October 2013
Although the first dose of MCV4 is recommended routinely at age 11-12 years, if the first dose is administered at age 13 through 15 years, a booster dose should be administered at age 16 through 18 years with a minimum interval of at least 8 weeks between doses. Q: A 13-year-old adolescent did not receive his meningococcal conjugate (MCV) A, C, W, and Y vaccines (MCV4). If the first MCV is given at this visit, will a booster be necessary? A: Yes. Although the first dose of MCV4 is recommended routinely at age 11-12 years, if the first dose is administered at age 13 through 15 years, a booster dose should be administered at age 16 through 18 years with a minimum interval of at least 8 weeks between doses. If the first dose is administered at age 16 years or older, a booster dose is not needed. Q: Should an adolescent aged 11 years with HIV infection receive the MCV4? A: Yes. They should receive a 2-dose primary series of MCV4, with at least 8 weeks between doses. 3 Q: For vaccination intervals, does 28 days equal a month? A: Not necessarily. For the purposes of calculating intervals between doses, 4 weeks equals 28 days; intervals of 4 months or greater are determined by calendar months. Final notes The CDC footnotes are a very important source for vaccination information. Other October 2013 New emphasis on pediatric and adolescent vaccinations AOA Health Watch 7
Figure 2. Catch-up vaccination schedule for 2013. Source: CDC website. resources for childhood vaccine information include the following: Contraindications and precautions for vaccines 4 Travel vaccine requirements and recommendations 5 Vaccination of persons with primary and secondary immunodeficiencies 6 Keeping up to date on immunization recommendations is the best way of preventing many deadly diseases for the practitioner s patients. References 1. MMWR 2013 Childhood Vaccination Schedules. http://www.cdc.gov/mmwr/preview/mmwrhtml/ su6201a1.htm. Accessed July 6, 2013. 2. Additional guidance for influenza vaccination for children 6 months 8 years of age. www.cdc.gov/mmwr/pdf/wk/mm6132.pdf. Accessed July 6, 2013. 3. Meningococcal vaccines for patients with HIV infection. http://www.cdc.gov/mmwr/ pdf/wk/mm6030.pdf. Accessed July 6, 2013. 4. Contraindications and precautions and additional information about specific vaccinations. http://www.cdc.gov/vaccines/pubs/acip-list.htm. Accessed July 6, 2013. 5. Travel vaccines. http://wwwnc.cdc.gov/travel/ page/vaccinations.htm. Accessed July 6, 2013. 6. Vaccination of persons with primary and secondary immunodeficiencies. http://www.cdc.gov/ mmwr/preview/mmwrhtml/rr6002a1.htm. Accessed July 6, 2013. HW About the Author Stanley E. Grogg, DO, FACOP, FAAP, is an associate dean of clinical research and professor of pediatrics at Oklahoma State University Center for Health Sciences College of Osteopathic Medicine in Tulsa. Dr Grogg also serves as the American Osteopathic Association s representative to the Centers for Disease Control and Prevention s Advisory Committee on Immunization Practices. He can be reached at Stanley.grogg@okstate.edu. 8 AOA Health Watch New emphasis on pediatric and adolescent vaccinations October 2013