The 2011 recommended childhood and adolescent immunization schedules have been approved by the American Academy of Pediatrics, the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention, and the American Academy of Family Physicians (schedules have been provided following this article and online as Supplemental Information). These schedules are revised annually to reflect current recommendations for use of vaccines licensed by the US Food and Drug Administration and include the following changes from last year:
Guidance for administration of the hepatitis B vaccine series for children who did not receive the recommended birth dose. A minimum age for dose 3 of hepatitis B vaccine has been added to the catch-up schedule, noting that the final (third or fourth) dose in the hepatitis B series should be administered no earlier than 24 weeks of age.
Information on the use of the 13-valent pneumococcal conjugate vaccine (PCV13). A PCV series begun with 7-valent PCV (PCV7) should be completed with PCV13. A single supplemental dose of PCV13 is recommended for all children 14 through 59 months of age who have received an age-appropriate series of PCV7. A single supplemental dose of PCV13 is recommended for all children 60 through 71 months of age with underlying medical conditions who have received an age-appropriate series of PCV7. The supplemental dose of PCV13 should be administered at least 8 weeks after the previous dose of PCV7. A single dose of PCV13 may be administered to children 6 through 18 years of age who have functional or anatomic asplenia, HIV infection or other immunocompromising conditions, cochlear implant, or cerebrospinal fluid leak. The pneumococcal polysaccharide vaccine (PPSV) should be administered to children 2 years of age or older with certain underling medical conditions at least 8 weeks after the last dose of PCV. A single revaccination with the PPSV should be administered after 5 years to children with functional or anatomic asplenia or an immunocompromising condition.
Guidance for administration of 1 or 2 doses of influenza vaccine on the basis of the child's history of receipt of monovalent 2009 H1N1 vaccine. Administer 2 doses (separated by at least 4 weeks) to children 6 months through 8 years of age 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. Children 6 months through 8 years of age who received no doses of monovalent 2009 H1N1 vaccine or in whom the dosing schedule is unknown should receive 2 doses of 2010–2011 seasonal influenza vaccine.
Guidance regarding a booster dose of quadrivalent meningococcal conjugate vaccine (MCV4). Adolescents should be routinely immunized, preferably at 11 through 12 years, with a booster dose at 16 years of age. Adolescents who receive their first dose at 13 through 15 years of age should receive a booster at 16 through 18 years of age. For people 2 through 54 years of age who are at increased risk of meningococcal disease, a 2-dose primary series should be administered 2 months apart. For information regarding immunization of older adolescents and adults, see the adult immunization schedule at www.cdc.gov/vaccines/recs/provisional/default.htm.
Children 7 through 10 years of age who are not fully immunized against pertussis (including those never vaccinated or with unknown pertussis vaccine status) should receive a single dose of tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine (Tdap). If further doses are needed to fully immunize against tetanus and diphtheria, children 7 through 10 years of age should be vaccinated according to the catch-up schedule. Adolescents 13 through 18 years of age who have not received the Tdap vaccine should receive a dose followed by a tetanus and diphtheria toxoids vaccine (Td) booster dose every 10 years thereafter. The reference regarding a specified time interval between the Td and Tdap vaccines has been removed from the schedule for children 7 through 18 years of age.
Guidance for use of Haemophilus influenzae type b vaccine in people 5 years of age and older at increased risk. One dose of Haemophilus influenzae type b vaccine should be considered for people 5 years of age or older who have sickle cell disease, leukemia, or HIV infection or who have had a splenectomy.
Guidance for the use of human papillomavirus vaccine (HPV). The quadrivalent vaccine (HPV4) and the bivalent vaccine (HPV2) are recommended for prevention of cervical precancers and cancers in females. HPV4 also is recommended for prevention of genital warts in females. HPV4 may be administered in a 3-dose series to males 9 through 18 years of age to reduce their likelihood of acquiring genital warts.
Clinically significant adverse events that follow immunization should be reported to the Vaccine Adverse Event Reporting System (VAERS). Guidance about how to obtain and complete a VAERS form can be obtained on the Internet at www.vaers.hhs.gov or by calling 800-822-7967. Additional information can be found in the 2009 Red Book1 and at Red Book Online (www.aapredbook.org). Statements from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention that contain details of recommendations for individual vaccines, including recommendations for children with high-risk conditions, are available at www.cdc.gov/vaccines/pubs/ACIP-list.htm. Information on new vaccine releases, vaccine supplies, interim recommendations resulting from vaccine shortages, and statements on specific vaccines can be found at www.aapredbook.org/news/vaccstatus.shtml and www.cdc.gov/vaccines/pubs/ACIP-list.htm.
COMMITTEE ON INFECTIOUS DISEASES, 2010–2011
Michael T. Brady, MD, Chairperson
Henry H. Bernstein, DO
Carrie L. Byington, MD
Kathryn M. Edwards, MD
Margaret C. Fisher, MD
Mary P. Glode, MD
Mary Anne Jackson, MD
Harry L. Keyserling, MD
David W. Kimberlin, MD
Yvonne A. Maldonado, MD
Walter A. Orenstein, MD
Gordon E. Schutze, MD
Rodney E. Willoughby, MD
LIAISONS
Robert Bortolussi, MD – Canadian Paediatric Society
Marc A. Fischer, MD – Centers for Disease Control and Prevention
Bruce Gellin, MD – National Vaccine Program Office
Richard L. Gorman, MD – National Institutes of Health
Lucia Lee, MD – Food and Drug Administration
R. Douglas Pratt, MD – Food and Drug Administration
Jennifer S. Read, MD – National Institutes of Health
Jane Seward, MBBS, MPH – Centers for Disease Control and Prevention
Jeffrey R. Starke, MD – American Thoracic Society
Jack Swanson, MD – Committee on Practice Ambulatory Medicine
Tina Q. Tan, MD – Pediatric Infectious Diseases Society
EX OFFICIO
Carol J. Baker, MD – Red Book Associate Editor
Sarah S. Long, MD – Red Book Associate Editor
H. Cody Meissner, MD – Red Book Associate Editor
Larry K. Pickering, MD – Red Book Editor
CONSULTANTS
Lorry G. Rubin, MD
STAFF
Jennifer Frantz, MPH, [email protected]
All policy statements from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.
References
Competing Interests
This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication.
Comments
Re: Cost-effectiveness of meningococcal immunization
To the editor: Dr. Lee has identified an issue relating to meningococcal immunization which engendered extensive discussion among members of the ACIP as well as among members of the Committee on Infectious Diseases. The goal of the 2005 meningococcal immunization recommendation was to protect persons aged 16 to 21 years, when meningococcal disease rates peak. The recommendation to administer vaccine at 11 through 12 years was intended to strengthen the pre-adolescent vaccination platform based on the expectation that protection would last for at least 10 years. After licensure of the meningococcal conjugate vaccine in 2005, data on bactericidal antibody persistence and vaccine effectiveness indicated many vaccinees may not be protected more than 5 years. Therefore, persons immunized at age 11 or 12 years may experience waning immunity and may not be protected by ages 16 through 21 years, when the risk for meningococcal disease is greatest. The second option of a single dose at age 14 or 15 years would likely protect most adolescents through the higher risk period at ages 16 through 21 years. However, as adolescents grow older they are less likely to visit a healthcare provider for preventive care. Also, vaccination at 14 or 15 years would leave younger adolescents unprotected. The third option of adding a booster dose to the current recommended schedule likely will extend protection through 21 years as well as continue protection for children starting at 11 or 12 years.
An economic analysis comparing the 3 vaccination strategies concluded that administering a booster dose has a cost per quality adjusted life year saved similar to that of a single dose at 11 years of age or at 15 years of age but is estimated to prevent twice the number of cases and deaths (MMWR 2011; 60:72). However, as Dr. Le points out, regardless of which schedule was recommended, the meningococcal vaccine program results in one of the highest costs per quality adjusted life year saved of all routinely recommended vaccines. In addition, it is important to note that meningococcal disease rates rise in all persons between 16 and 21 years, not only among college freshman domiciled in dormitories.
H. Cody Meissner, M.D.
Conflict of Interest:
author of article
Response to letter to editor
To the editor: Several thoughtful points are raised in the letter by Dr. Levy regarding the Recommended Childhood and Adolescent Immunization Schedules—United States 2011. First, it is important to note that no change has occurred in the recommended age for administration of the measles, mumps and rubella vaccine (MMR) and the varicella vaccine (V) in the 2011 schedule. In fact, the recommended age for administration of these two vaccines has not changed since publication of the 2007 immunization schedules when two doses of V were first recommended for children 12 months through 12 years of age. Second, the decision regarding the age at which a specific vaccine is recommended is complex and is based on a number of considerations including age-specific risks for a specific vaccine preventable disease, the age at which a child will respond to a vaccine with an appropriate immune response, the potential for interference by passively transferred maternal antibodies, factors relating to “crowding” of the immunization schedule, programmatic issues (complexity of the schedule, school requirements), types of vaccines available (various combinations) and waning immunity.
The first dose of MMR and V should be administered at 12 through 15 months and as Dr. Levy correctly notes, there is flexibility in the immunization schedule for timing of the second dose of MMR and V (or MMRV). Routine administration of second dose of MMR and V (or MMRV) before the recommended age of 4-6 years is unlikely to result in an inadequate immune response in the vaccinee, as long as the first dose is administered after 12 months of age and the minimal interval of 28 days is maintained for MMR and 3 months between V vaccines. The most important objective is to ensure compliance with the vaccine schedule for administration of all 11 vaccines recommended during the first 6 years of life. H. Cody Meissner, M.D. Michael T. Brady, M.D.
Conflict of Interest:
author of article
Cost-effectiveness of meningococcal immunization
ACIP and the AAP Committee on Infectious Diseases recently issued a recommendation for a 2-dose meningococcal vaccine at 11 and 16 years (1, 2). However, because of the very low incidence of vaccine-serotype diseases and because serological studies enrolled only small numbers of subjects (3), this recommendation was based on data with wide confidence intervals. A cost-analysis of three different immunization regimens gives an estimate cost per quality-adjusted life year (QALY) gained of $121,000 for a single dose given at 15 year-olds; $157,000 for a 2-dose regimen given to all 11- and 16-year olds; and $281,000 for a single dose given at all 11-year olds, respectively (4). The number of annual deaths prevented was estimated to be 14, 24 and 9, for each of the respective strategies.
Except for universal yearly adolescent influenza vaccination, the QALY figures for the meningococcal vaccine sharply contrast with those of other adolescent immunization programs, which ranges from $10,000 to $45,000 (4), and also exceed by many folds other public health preventative recommendations, such as cancer screening, and treatment of many common chronic diseases.
At a time when our society is struggling with many health priorities and limited financial resources, we should ask for the best value in our healthcare expenditures. After re-examining the epidemiology and cost analysis of vaccine-serotype cases and disease prevention, perhaps a sound decision would be to return to the initial recommendation to use the meningococcal vaccine mainly for college-bound high-schoolers, college students in dormitories, and other hosts at increased risks for disease.
Chinh T Le, MD, FAAP Corvallis, Oregon
References: 1. Centers for Disease Control and Prevention: Mortality and Morbidity Weekly Report, Vol. 60/No.3, January 28, 2011 2. Committee on Infectious Diseases, AAP, “Recommended Childhood and Adolescent Immunization Schedules - United States, 2011. PEDIATRICS Vol. 127 No. 2 February 2011, pp. 387-388 3. Advisory Committee on Immunization Practices, October 27, 2010. Available at http://www.cdc.gov/vaccines/recs/acip/downloads/mtg-slides- oct10/02-5-mening-mcv4.pdf, accessed January 30, 2011 4. Advisory Committee on Immunization Practices, October 27, 2010. Available at http://www.cdc.gov/vaccines/recs/acip/downloads/mtg-slides- oct10/02-3-mening-CostEffect.pdf . Accessed January 30, 2011
Conflict of Interest:
None declared
The Second MM&R and Varicella : Administer at Which Visit?
February 2, 2011
Many years ago the Journal of Pediatrics had a section in which it published brief commentaries based on clinical experience called “Experience and Reason-Briefly Recorded”. If it was still in existence I believe that this commentary would best fit in that category.
In the Policy Statement Published online February 1, 2011 [PEDIATRICS Vol. 127 No. 2 February 2011, pp. 387-388 (doi:10.1542/peds.2010-3203)], Recommended Childhood and Adolescent Immunization Schedules—United States, 2011, some changes to the timing of the administration of the second dose of the MM&R and Varicella vaccines were incorporated. In footnotes # 8 and # 9 of the “Recommended Immunization Schedule for Persons Aged 0 Through 6 Years—United States” I noted that for both of these immunizations the second dose may be given before four years of age. Along with this recommendation were the appropriate delineations of minimal time intervals from the first dose.
Those of us in primary care pediatrics who have had to address the problem of having parents comply with the recommended timing of office visits have used various methods to ensure compliance with routine check ups in the first five years of life. While our focus as pediatricians has always been on preventive maintenance, many parents view the history update and the physical examination as superfluous and bring their children to our offices for the “shot”. The parents are not displeased to hear a positive report on the health of their infant or child, or the discovery of a correctable (in most cases) problem and the solution. However, the need that brought them to the office was the importance of the immunizations. When I tell them the date of the next appointment, the almost universal question that arises is, “What shots are due?” This is in spite of the fact that every parent is give a written immunization schedule at the first office visit. The least attended routine visit in my practice in the first five years of life is the three year check up at which no immunizations are due. The lesson to be absorbed is that as we all know, many parents come to the office visits for the immunizations, not because it is good medical practice to have the infant/child examined on a regular basis.
With this in mind, I believe that the AAP and the Committee on Infectious Disease should consider recommending that the second dose of the MM&R and Varicella be routinely given at three years of age, not at four years as is now the case. If the first doses of the MM&R and Varicella vaccines are given at one year of age or any time prior to two and one-half years of age, there is no proscription for the three year old dosing. The four year old visit would still have the DTaP and IVP requirement. This would decrease the number of injections at the four year visit and give the parents a “shot” for which to make an appointment at three years of age. I plan to make this change in my office as I write this letter.
Thank you for your attention to this matter,
Neil S. Levy, DO, MBA, FACOP, FAAP, ABAM 1717 Chadwick Court, Ste. B Hurst, Texas 76054 (817) 283-2500
Conflict of Interest:
None declared