AAP Issues Recommended Childhood and Teen Immunization Schedules

The American Academy of Pediatrics (AAP) has issued 2011 immunization schedules recommended for childhood and adolescents and published a policy statement describing the new schedules online February 1 in Pediatrics. The Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention and the American Academy of Family Physicians have also approved the new recommendations, which were written by the Committee on Infectious Diseases, chaired by Michael T. Brady, MD.

Highlights of the new schedules include guidance on hepatitis B vaccine administration to children who did not receive the recommended birth dose, and new recommendations on the use of 13-valent pneumococcal conjugate vaccine (PCV13), which replaced the 7-valent pneumococcal conjugate vaccine (PCV7).

Because of recent outbreaks of pertussis nationwide, the new recommendations offer guidance for a dose of tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine (Tdap) in 7- to 10-year-old children who have not been adequately immunized against pertussis. The updated schedules now recommend a booster dose of the conjugated meningococcal vaccine to improve protection of adolescents throughout the greatest period of risk for meningococcal disease. Instructions on dosing of influenza vaccine are now based on a history of receiving monovalent 2009 H1N1 vaccine. The policy statement also offers guidance on administering human papillomavirus (HPV) vaccines to boys 9 to 18 years old to lower their risk of acquiring genital warts.

Spesific Updated Changes

Specific changes in the 2011 schedules from last year include the following:

• For children who did not receive the recommended birth dose of hepatitis B vaccine, the new recommendations offer guidance for administering the hepatitis B vaccine series. The catch-up schedule now includes a minimal age for dose 3 of hepatitis B vaccine, so that the final (third or fourth) dose in the series should be given no sooner than age 24 weeks.
• New recommendations are included on the use of PCV13, so that a PCV series started with PCV7 should be completed with PCV13. All children 14 through 59 months old who received an age-appropriate series of PCV7 should receive a single supplemental dose of PCV13. All children 60 through 71 months old with underlying medical conditions who have received an age-appropriate series of PCV7 should receive a single supplemental dose of PCV13. The supplemental PCV13 dose should be given at least 8 weeks after the previous dose of PCV7. Children 6 through 18 years old with functional or anatomic asplenia, HIV infection or other immunocompromising conditions, cochlear implant, or cerebrospinal fluid leak may be given a single dose of PCV13. Children at least 2 years old who have certain underlying medical conditions should be given the pneumococcal polysaccharide vaccine (PPSV) no sooner than 8 weeks after the last dose of PCV. Children with functional or anatomic asplenia or an immunocompromising condition should receive a single revaccination with PPSV after 5 years.
• On the basis of the child's history of receiving monovalent 2009 H1N1 vaccine, the new recommendations offer guidance for administering 1 or 2 doses of influenza vaccine. Children 6 months through 8 years old who are receiving influenza vaccine for the first time or who were vaccinated for the first time during the previous influenza season but only received 1 dose at that time should receive 2 doses at least 4 weeks apart. Two doses of 2010-2011 seasonal influenza vaccine should be given to children 6 months through 8 years old who received no doses of monovalent 2009 H1N1 vaccine or in whom the dosing schedule is unknown.
• Adolescents should be routinely immunized with quadrivalent meningococcal conjugate vaccine (MCV4), preferably at ages 11 through 12 years, and the new recommendations call for a booster dose at age 16 years. Adolescents given their first dose at ages 13 through 15 years should receive a booster dose at ages 16 through 18 years. A 2-dose primary series should be given 2 months apart to people at ages 2 through 54 years who are at higher risk for meningococcal disease.
• A single dose of Tdap should be given to children 7 through 10 years old who are not fully immunized against pertussis, including those who were never vaccinated or those with unknown pertussis vaccination status. Children 7 through 10 years old should be vaccinated according to the catch-up schedule if further doses are needed for complete immunization against tetanus and diphtheria. If adolescents 13 through 18 years old have not received the Tdap vaccine, they should receive a dose followed by a tetanus and diphtheria toxoids vaccine (Td) booster dose every 10 years thereafter. For children 7 through 18 years old, there is no longer a specified interval between the Td and Tdap vaccines.
• The policy statement contains guidance for use of Haemophilus influenzae type b vaccine in persons at least 5 years old who are at greater risk. Clinicians should consider giving 1 dose of Haemophilus influenzae type b vaccine to persons who are at least 5 years old who have sickle cell disease, leukemia, or HIV infection or in children who have undergone splenectomy.
• To prevent cervical precancerous lesions and cancers in girls, the new guidelines recommend the quadrivalent HPV vaccine (HPV4) and the bivalent vaccine (HPV2). To help prevent genital warts, HPV4 is also recommended for girls, and boys 9 through 18 years old may be given a 3-dose series of HPV4.

 "Clinically significant adverse events that follow immunization should be reported to the Vaccine Adverse Event Reporting System (VAERS)," the statement authors conclude. "Guidance about how to obtain and complete a VAERS form can be obtained on the Internet at http://vaers.hhs.gov/index 

Clinical Context

The AAP, the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention, and the American Academy of Family Physicians have approved the 2011 recommended childhood and adolescent immunization schedules. The annual revisions include recommendations for vaccines licensed by the US Food and Drug Administration and updates from the previous year.

This policy statement from the AAP Committee on Infectious Diseases describes the 2011 immunization updates, the recommended immunization schedules for persons aged 0 through 6 years and aged 7 through 18 years, and the catch-up immunization schedule for persons aged 4 months through 18 years who start late or are more than 1 month behind in immunizations.

Study Highlights

• Hepatitis B vaccine schedule now includes a minimum age of 24 weeks for the final (third or fourth) dose (or third dose on the catch-up schedule).
• The PCV13 recommendations for children who have previously received PCV7 include the following:
  • 1 dose of PCV13 for children aged 14 through 59 months who received age-appropriate PCV7 series
  • 1 dose of PCV13 for children aged 60 through 71 months with underlying medical conditions who received age-appropriate PCV7 series
  • At least an 8-week interval between PCV13 and PCV7
  • 1 dose of PCV13 for children aged 6 to 18 years with functional or anatomic asplenia, HIV infection or other immunocompromised conditions, cochlear implant, or cerebrospinal fluid leak
• The PPSV is recommended for children 2 years or older with certain medical conditions at least 8 weeks after the last PCV dose; revaccination is recommended after 5 years to children with functional or anatomic asplenia or immunocompromised conditions.
• Influenza vaccine schedule of 2 doses at least 4 weeks apart is recommended for children ages 6 months through 8 years if they fulfill the following criteria:
  • Are receiving influenza vaccine for the first time
  • Were vaccinated for the first time in the previous influenza season with only 1 dose
  • Received no doses of monovalent 2009 H1N1 vaccine
  • Have unknown vaccination record
• The MCV4 schedule now includes a booster dose:
  • 1 routine MCV4 dose at ages 11 through 12 years, with booster dose at age 16 years
  • If the first MCV4 dose is given at ages 13 through 15 years, a booster dose recommended at ages 16 through 18 years
  • In patients aged 2 through 54 years at increased risk for meningococcal disease, a 2-dose primary series 2 months apart
• Tdap and Td recommendations include the following:
  • 1 dose of Tdap for children aged 7 through 10 years who are not fully immunized against pertussis or have unknown vaccine status, with Td catch-up doses if needed
  • Tdap substitutes for 1 dose of Td in the catch-up series for children aged 7 through 10 years or a booster for children aged 11 through 18 years
  • 1 dose of Tdap for adolescents aged 11 through 18 years who have not received Tdap followed by a Td booster every 10 years
  • No longer a specified interval between Td and Tdap vaccines for children aged 7 through 18 years
• Haemophilus influenzae type b vaccine in 1 dose should be considered for persons 5 years of older with sickle cell disease, leukemia, HIV infection, or splenectomy.
• Recommendations for HPV vaccine include the following:
  • HPV4 and HPV2 vaccines are recommended for prevention of cervical precancers and cancers in girls.
  • HPV4 is recommended for prevention of genital warts in girls.
  • A 3-dose series of HPV4 may be given to boys aged 9 through 18 years to decrease the risk for genital warts.
• Clinically significant adverse events after immunizations should be reported to VAERS.

Clinical Implications

• The 2011 recommendations for the meningococcal conjugate vaccine in children and adolescents include routine immunization at ages 11 through 12 years with booster dose at age 16 years or a booster dose at ages 16 through 18 years if the first dose was received at ages 13 through 15 years. Persons aged 2 through 54 years at increased risk for meningococcal disease should receive a 2-dose primary series 2 months apart.
• The 2011 recommendations for the Tdap vaccine in children and adolescents include (1) a Tdap dose at ages 7 through 10 years if not fully immunized and Td if further catch-up doses are needed, and (2) a Tdap dose at ages 11 through 18 years if not already received followed by a Td booster every 10 years. No specific interval between Td and Tdap vaccines is recommended.

  

Pediatrics. Published online January 24, 2011