Thursday, February 13, 2014

The 2014 Child/Teen Immunization Schedule: Changes You Should Know

William T. Basco, Jr., MD, MS
February 03, 2014extracts 

Hepatitis A Vaccine Changes

Hepatitis A vaccine is routinely given at 12-23 months of age, but the previous footnotes were not specific as to which older children are considered "high risk" and therefore should receive the vaccine. The new footnotes provide clearer recommendations. Those specific recommendations now include children who may travel to countries that have a high or intermediate degree of endemic infection. Other recommended populations that might be cared for by pediatric providers include males who have sex with other males, users of illicit drugs (injectable or not), and patients with clotting factor disorders or chronic liver disease.

Human Papillomavirus Vaccine Changes

There are no global changes to the recommendations for human papillomavirus (HPV) vaccine. For pediatric providers, however, it is worth remembering that only the quadrivalent HPV vaccine is recommended for boys, whereas either the bivalent or quadrivalent HPV vaccine can be used for girls.  The third dose should be administered at least 12 weeks after the second dose and at least 24 weeks after the first dose.

Meningococcal Vaccine Changes

There is no change to the recommendation that 11- to 12-year olds should universally receive the vaccine and that a booster should be administered at 16 years of age. Changes in the meningococcal vaccine recommendations are mostly limited to expanded indications for the quadrivalent conjugate meningococcal vaccine MenACWY-CRM (meningococcal groups A, C, and Y and W-135 oligosaccharide diphtheria CRM197 conjugate vaccine; Menveo®) among younger children considered at high risk for meningococcal disease.
It is probably also worth reminding pediatric providers that certain older children should receive the meningococcal vaccine. Indicated populations include those with complement deficiencies or anatomical or functional asplenia, as well as children traveling to areas in Africa where meningitis is endemic or those undertaking the Hajj. Specific catch-up recommendations for children with high-risk conditions are also provided and require accessing additional CDC documents.

Pneumococcal Vaccine Changes

First, one of the most interesting changes is the addition of a clear statement about when pneumococcal polysaccharide vaccine (PPSV23) should be given relative to pneumococcal conjugate vaccine (PCV13): The footnotes state clearly that children in need of PPSV23 should receive the recommended PCV13 doses before receiving PPSV23. The PPSV23 dose should also be given at least 8 weeks after completion of PCV13series or catch-up. That sequencing was often probably the case for most children who received the polysaccharide vaccine, but there needs to be a continual emphasis on trying to complete the PCV13 series for all children before considering who should receive PPSV23.
Second, it is worth emphasizing that we are still seeing some children < 59 months of age who received pneumococcal vaccination as PCV7. Providers should ensure that children who received part of their pneumococcal vaccination as PCV7 receive the appropriate PCV13 follow-up doses. 
The footnotes also contain details on which children should receive PPSV23. For children 24 through 71 months of age, several chronic conditions indicate a need for PPSV23, including chronic cardiac disease; chronic lung disease; diabetes mellitus; cerebrospinal fluid leak; cochlear implants; sickle cell disease and other hemoglobinopathies; other asplenia; or immune suppression, including from HIV, renal failure, or receipt of immunosuppressive drugs.
Of all the indicated populations in a pediatric practice, the most prevalent is probably asthmatics who have received systemic steroids. That is a group of personal interest to me as a researcher, and one that we probably underemphasize for receipt of PPSV23.
Finally, the footnotes expand upon the description of who should receive a second dose of PPSV23 vaccine after age 5 years; it is worth noting that children with diabetes, chronic heart, lung, and liver disease are not among that group. The recommendation for a second PPSV23 dose is confined to those with immune-compromising conditions, now listed in the footnotes.

Tdap Vaccine Changes

In regard to Tdap, additional clarifications are provided in the footnotes. The universal recommendation that everyone 11 years of age or older receive at least 1 Tdap vaccination is still present. However, there is no current recommendation for further booster doses with Tdap, except among pregnant women. Pregnant women should receive Tdap with each pregnancy, preferably during the 27- to 36-week gestational age period.
A previous recommendation that warrants emphasis is the recommendation that Tdap be used for any child older than 7 years who needs a tetanus booster as part of wound management or as the first dose of a catch-up series, provided that they did not already receive a Tdap booster. They should not receive a second Tdap booster, however, if they have received one after age 7 years. As a reminder, this section also contains detailed recommendations for how to handle an older child who inadvertently receives DTaP and how this might affect the decision to later boost with Tdap.
For all vaccines, additional detail on indicated populations or indications for travelers can be found at the ACIP's vaccine-specific site.

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