immunization of children and adolescents according to the acip … · 2012-06-25 · providers...

Immunizationscontinue to be animportant part of

the practice of primarycare in osteopathicmedicine. A clinical

immunization program requiresphysician and staff awareness of

the latest general guidelines foradministration and storing of vaccines,

the potential adverse effects of vaccines, andthe use of combination vaccines.

Immunization of children and adolescents according to the ACIP schedules

2012 updates and suggestions for improving coverage

Carl R. Backes, DO

June 2012 Pediatric and adolescent vaccines 9AOA Health Watch

In addition, osteopathic physicians must besure to comply with the 2012 changes tothe immunization schedules prepared bythe Centers for Disease Control andPrevention’s (CDC) Advisory Committeeon Immunization Practices (ACIP).1To emphasize challenges to immuniza-

tion coverage and suggestions for improvingcoverage, I discuss the following 4 topics inthe present article:

(1) how to improve vaccination rates(2) the need to reemphasize general guidelines for immunizations

(3) key changes in the 2011 ACIPrecommendations

(4) the 3 new ACIP schedules for 2012

How to improve vaccination ratesThe ACIP recommends routine vaccinationto prevent 17 vaccine-preventable diseasesthat occur in infants, children, adolescents,or adults.2 Present overall US vaccinationcoverage among children entering kinder-garten exceeds 90%.3 Nevertheless,problems with vaccination coverage persistbecause of state and local variations in vacci-nation requirements, parental objections,lack of herd immunity, and poor communi-cation by physicians to patients regardingthe necessity of following the 2012 updatedACIP schedules.3 It is important to addresseach of these problems.

Despite US vaccination coverageexceeding 90% for most recommendedvaccines among children entering kinder -garten, the coverage rate is much lower incertain regions. For example, in WashingtonState’s San Juan County, 72% of kinder -garteners were either noncompliant orexempt from vaccination require ments for2010-2011 school year.1 Parental objectionsto vaccinations are a factor in many commu-nities. These objections may be religious orphilosophical in nature, or they may berelated to concerns about vaccine safety orto lack of personal experience with vaccine-preventable diseases, such as polio myelitis,measles, or invasive Haemo philus influenzaetype B disease.4 Each year, approx i mately85,000 cases of vaccine-preventable diseasesoccur in the United States.4 We need tobetter educate parents, including address-ing their concerns and objections, and todevelop intervention strategies. The lack of herd immunity with vaccines

was highlighted by the 9143 cases ofpertussis reported in California in 2010.4Some 80% of those cases occurred amonginfants younger than 6 months, and 10 ofthose infants died.4 From 1990 to 2009 inthe United States as a whole, 200,401 casesof pertussis were reported to the CDC’sNational Notifiable Diseases SurveillanceSystem.5 Coverage with the tetanus, diphtheria, and acellular pertussis (Tdap)

vaccines also remains an ongoing concernfor adolescents aged 11 to 18 years.To be successful in improving vaccine

coverage, it is crucial that we as physiciansimprove our communication with parents.Recently, a survey by Wightman et al6 foundthat 61% of responding pediatricians inWashington State were comfortable usingan altered immunization schedule—thoughan overwhelming majority of respondentssaid they would follow the ACIP-recommended schedules if they were tobecome new parents themselves.6 However,rather than accepting altered vaccineschedules or discharging families from theirvaccine responsibilities, we need to discussvaccine refusals or delays with parents.Furthermore, we should never suggestdisease-prevention alternatives to vaccines,such as dietary or biomedical options.7The following are suggestions for

improving immunization rates amongchildren and adolescents:8,9

� Eliminate socioeconomic barriers anddisincentives to vaccination, and considerincentives for vaccination.3 Disincentivesinclude administration fees and travelneeds. Incentives include rewards forimmunizations completed on schedule.

� Strengthen school entry requirements forvaccinations.3

� Provide alternative locations forimmunizations such as drugstores andschools. Consider immunizing parents andother close family members in pediatricoffices along with children.8

� Address misinformation regardingvaccines.

� Provide accurate, trustworthy informationabout the updated 2012 ACIPimmunization schedules.1

� Implement a program to improve thequality of immunization delivery for under-served children, including family remindersand expansion of access.9

Reemphasis of general guidelinesMost of the following suggestions and infor-mation regarding reemphasis of generalguidelines for immunizations are based on

10 AOA Health Watch Pediatric and adolescent vaccines June 2012

the ACIP recommendations published in2011.2

� Vaccination providers should adhere asclosely as possible to ACIP-recommended2012 vaccination schedules.1

� Vaccine doses should not be administeredat intervals less than the minimum recom-mended intervals, or at any age youngerthan the minimum recommended age.Such alterations can lead to suboptimalimmune responses and necessitateredosing.

� Routine, simultaneous administration ofall age-appropriate vaccines should beperformed for any child for whom nospecific contraindications exist at the time ofthat child’s visit.

� The use of a combination vaccine licensedby the US Food and Drug Administration(FDA) is generally preferred over separateinjections of the equivalent componentvaccines.

� There is no evidence that inactivatedvaccines interfere with the immune system’sresponse to other inactivated vaccines or tolive vaccines.

� Intervals between vaccine doses that arelonger than the recommended intervalstypically do not reduce final antibody con-centrations.

� If a patient’s vaccine records cannot belocated, that patient should be consideredsusceptible and started on the age-appropri-ate vaccination schedule.

� The only contraindication applicable to allvaccines is history of severe hypersensitivityreactions (eg, anaphylaxis) after a previousvaccine dose or exposure to any vaccinecomponent.10

� Vaccination should not be delayedbecause of the presence of mild respiratorytract illness or other illness with or withoutfever.

� Increased syncope reports coincide with 3adolescent vaccines: human papillomavirus(HPV) vaccine, quadrivalent meningococcal

conjugate vaccine (MCV4), and tetanus,diphtheria, acellular pertussis (Tdap)vaccine.

� Reporting adverse events to the VaccineAdverse Event Reporting System (VAERS),cosponsored by the CDC and FDA, is a keymechanism for identifying potential vaccinesafety issues.

�Depending on the particular vaccine, oral,intranasal, or injectable options may beavailable.

� Changing needles between drawingvaccine solution from a vial and injecting itinto a recipient is not necessary unless theneedle has been damaged or contaminated.

� Safety-engineered injection devices canbe used for injectable vaccines in all clinicalsettings.

� Aspiration before injection of vaccines isnot necessary, and a process that includesaspiration might be more painful for infants.

Injection sites and needle sizesRecommended injection sites and needlesizes for intramuscular vaccines are asfollows:

infants aged less than 12 months� anteriolateral aspect of thigh preferred, at 90� angle to skin

� a 1-inch, 22- to 25-gauge needle forinfants aged 1 month or older, to ensureintramuscular administration

� a 5/8-inch needle for neonates youngerthan 1 month and for preterm infants

toddlers, aged 12 months to 2 years� at least a 1-inch needle

children and adolescents, aged 3 to 18years� deltoid muscle preferred

� a 22- to 25-gauge needle, 5/8- to 1-inchlong

Recommended injection information forsubcutaneous vaccines is as follows:

infants aged less than 12 months� 45� angle to the thigh


children older than 12 months� 45� angle to the upper, outer triceps area

Regarding jet injectors: these devices have asterile-dose chamber and nozzle for eachpatient, but concerns exist about localreactions.

Additional guidelinesStorageVaccines licensed for refrigerator storageshould be stored at 35� to 46�F.Temperature monitoring is important. Liveattenuated virus vaccines that should bestored frozen lose potency when exposed tohigher (eg, refrigerator) temperatures, inwhich they degrade more quickly.

Preterm InfantsPreterm infants, regardless of birth weight,should be vaccinated at the same chrono -logical age and schedule as full-terminfants—except for hepatitis B vaccination.Preterm infants should not receive divided,reduced, or delayed vaccines.

Pregnant womenNo evidence exists of risk to the fetus fromvaccinating pregnant women withinactivated vaccines, bacterial vaccines, ortoxoids.

Combination vaccinesCombination vaccines are an advancementin vaccine administration. Adoption ofcomponent-based immunizationadministration (IA) codes is needed to

improve Medicaid reimbursement toproviders using combination vaccines.11

New recommendationsThe 3 immunization schedules updated bythe ACIP in 2012 are for infants andchildren aged up to 6 years (Figure 1),children and adolescents aged 7 to 18 years(Figure 2), and individuals aged 4 months to18 years in need of catch-up immunizationbecause they started late or are more than 1month behind (Figure 3).1Important new or reemphasized

information contained in the revised ACIPimmunization schedules include thefollowing:

� The ACIP clarifies the use of hepatitis B(HepB) vaccine and hepatitis B immuneglobulin (HBIG) for children aged up to 6years (Figure 1). If the mother’s hepatitis Bsurface antigen (HBsAg) status is unknown,the Hep B vaccine should be administeredto infants weighing 2000 g or more, and theHep B vaccine plus HBIG should beadministered to infants weighing less than2000 g, within 12 hours. The mother’sHBsAg status should be determined as soonas possible, and if she is HBsAg-positive,HBIG should be administered to infantsweighing 2000 g or more at no later thanage 1 week. The schedule also clarifies thetiming of Hep B vaccine doses subsequentto the birth dose.12

� The second dose of the hepatitis Avaccine should be administered 6 to 18months after the first dose.12

� The ACIP clarifies the use of the Tdapvaccine for children aged 7 to 10 years whoare not fully immunized with the childhoodTdap vaccination series (Figure 2).13

� Infants do not develop adequateimmunity to the pertussis vaccine untilabout age 6 months, though the primaryvaccine series begins at age 2 months. Thebest way to prevent an infant’s exposure tothe pertussis virus is to make sure that allpeople who are going to have contact withthe infant are properly immunized (ie,cocooning).

�Guidance is offered on the use ofHaemophilus influenzae type B (Hib)

conjugate vaccines for persons aged at least5 years (Figure 3). The Hib vaccines shouldbe considered for unvaccinated personsaged 5 years or older who have sickle celldisease, leukemia, humanimmunodeficiency virus infection, oranatomic/functional asplenia.12

� Influenza vaccine dosing is recommendedfor the 2011-2012 season for children aged6 months through 8 years. Because theinfluenza vaccine cannot be administereduntil the infant is 6 months old, cocooning isrecommended to protect against inadequateimmunity to the influenza virus.1

� Contraindications to use of the live atten-uated influenza vaccine (LAIV) includechildren with asthma, children aged 2through 4 years who have had wheezing inthe past 12 months, and children who havehad any other underlying medicalcontraindications to LAIV.13

�Guidance is provided on the use of themeasles, mumps, and rubella (MMR)vaccine in infants who are traveling interna-tionally (Figure 1). These infants shouldfirst be vaccinated with MMR vaccine whenaged between 6 and 11 months. Theyshould then be revaccinated with 2 doses ofMMR vaccine—the first at age 12 through15 months and at least 4 weeks after theprevious dose, and the second at ages 4through 6 years.1

�During the first 6 months of life,minimum age and minimum intervals foradministration of inactivated poliovirusvaccine (IPV) are needed only if the individ-ual is at risk of imminent exposure to circu-lating poliovirus (ie, travel to a polio-endemic region or during an outbreak)(Figure 3). Polio-endemic regions havebeen reduced to Afghanistan, Nigeria, andPakistan. As of early 2012, there have beenno reported cases of polio in India for morethan 1 year.14. The IPV is not recommendedfor US residents who are aged at least 18years, unless they are traveling to certainpolio endemic parts of the world.

�Guidelines are provided on administrationof a booster dose of MCV4 vaccine and onadministration of MCV4 vaccine to childrenin whom risk of meningococcal disease is


increased (Figure 2). An initial dose ofMCV4 vaccine should ideally be provided atage 11 to 12 years, with a booster dose givenat age 16 years, to achieve the greatestefficacy. Fewer than 50% of individuals whoreceived the MCV4-D (Menactra, Sanofi)vaccine were found to still have vaccinelevels sufficient to provide protection some5 years after receiving the dose.15 No longterm studies are available for MCV4-CRM(Menveo, Novartis) as to the length of pro-tection.

� The recommended use of Menactra(meningococcal polysaccharide diphtheriatoxoid conjugate vaccine; Sanofi PasteurInc, Swiftwater, Pennsylvania) was extendedto children as young as 9 months.15

� Routine immunization with the HPVvaccine is now also recommended for malesaged 9 through 18 years to impact hetero -sexual transmission of HPV, preventdramatic increases of HPV orapharyngealcancer, and avoid HPV transmission male to male cancer and genital warts. PresentlyGardasil (quadrivalent HPV vaccine; Merck & Co. Inc, Whitehouse Station, New Jersey) is the only HPV vaccinerecommended for males12 Females shouldalso be vaccinated between ages 13 and 18years if they were not previously vaccinated(Gardasil or Cervarix [bivalent HPVvaccine]; Merck & Co Inc). Research is ongoing to develop a

licensed vaccine for serogroup B meningo-coccal disease in the United States. Recentdata showed that a 4-component vaccine(4CMenB; Novartis Vaccines, Basel,Switzerland) used in a 2-dose regimen waswell tolerated and provided immunity tohealthy adolescents.1 The 4CMenB vaccinealso was reported to be successful in a mul-ticenter trial with infants.17

Final notesThe following 5 points serve as a summaryof the latest information regardingimmunization of children and adolescents:

�Use all 3 ACIP immunization schedules,being sure to read all the footnotes.

�Only the ACIP immunization schedules,with their 2012 updates, are to be followed.Do not follow any complimentary or alter-

native schedules, which offer only subopti-mal early protection for children.

� Report any clinically significant adverseevents after immunization to the VaccineAdverse Event Reporting System, eitheronline at http://vaers.hhs.gov/index or bytelephone at 1-800-822-7967.

�We, as primary care osteopathicphysicians, represent the best opportunityto influence parents regarding protection oftheir children’s health by staying up to datewith immunization schedules.

� Continued awareness of, and support for,research to eliminate serogroup B meningo-coccal disease is important.

References1. Committee on Infectious Diseases. Recommended

childhood and adolescent immunization schedules-United States, 2012. Pediatrics. 2012;129(2):385-386.

2. National Center for Immunization and RespiratoryDiseases. General recommendations onimmunization—recommendations of the AdvisoryCommittee on Immunization Practices (ACIP).MMWR Recomm Rep. 2011;60(2);1-64.

3. Diekema DS. Improving childhood vaccination rates.N Engl J Med. 2012;366(5):391-393.

4. Keller DM. Pediatric practices discharge families forvaccine refusal. Medscape Medical News [serialonline]. October 20, 2011. http://www.medscape.com/viewarticle/751852. Accessed April 14, 2012.

5. Skoff TH, Cohn AC, Clark TA, Messonnier NE,Martin SW. Early impact of the US Tdapvaccination program on pertussis trends. ArchPediatr Adolesc Med. 2012;166(4):344-349.

6. Wightman A, Opel DJ, Marcuse EK, Taylor JA.Washington State pediatricians’ attitudes towardalternative childhood immunization schedules[published online ahead of print November 28,2011]. Pediatrics. 2011;128(6):1094-1099.

7. A look at complementary and alternative medicine.Healio.com Web site. January 2012. http://www.pediatricsupersite.com/view.aspx?rid=91270.Accessed April 14, 2012.

8. Lessin HS, Edwards KM; Committee on Practice andAmbulatory Medicine; Committee on InfectiousDiseases. Immunizing parents and other closecontacts in the pediatric office setting [publishedonline ahead of print December 26, 2011].Pediatrics. 2012;129(1):e247-e253. http://pediatrics.aappublications.org/content/129/1/e247.long.Accessed April 14, 2012.

9. Fu LY, Weissman M, McLaren R, et al. Improving thequality of immunization delivery to an at riskpopulation: a comprehensive approach [publishedonline ahead of print January 9, 2012]. Pediatrics.2012;129(2):e496-e503. http://pediatrics.aappublications.org/content/129/2/e496.long.Accessed April 14, 2012.

10. Erlewyn-Lajeunesse M, Hunt LP, Heath PT, Finn A.Anaphylaxis as an adverse event followingimmunization in the UK and Ireland. Arch Dis Child[published online ahead of print January 23, 2012].

11. Shen AK, Sobczyk E, Simonsen L, Khan F, Esber A,Andreae MC. Financial impact to providers usingpediatric combination vaccines [published onlineahead of print November 21, 2011]. Pediatrics.2011;128(6):1087-1093.

12. Brady MT, Scudder L. The 2012 immunizationschedules: what’s new? Medscape Pediatrics [serialonline]. February 1, 2012. http://www.medscape.com/viewarticle/757824. Accessed April 13, 2012.

13. Barclay L. AAP updates childhood and adolescentimmunization schedule. Medscape Medical News[serial online]. February 1, 2012. http://www.medscape.com/viewarticle/757879. Accessed April13, 2012.

14. Polio no longer endemic in India. Healio.com Website. February 2012. http://www.pediatricsupersite.com/view.aspx?rid=91301. Accessed April 14,2012.

15. Committee on Infectious Diseases. Meningococcalconjugate vaccines policy update: booster doserecommendations [published online ahead of printNovember 28, 2011]. Pediatrics. 2012;128(6):1213-1218.

16. Santolaya ME, O’Ryan ML, Valenzuela MT, et al;V72P10 Meningococcal B Adolescent Vaccine StudyGroup. Immunogenicity and tolerability of amulticomponent meningococcal serogroup B(4CMenB) vaccine in healthy adolescents in Chile: aphase 2b/3 randomised, observer-blind, placebo-controlled study [published online ahead of printJanuary 18, 2012]. Lancet. 2012;379(9816):617-624.

17. Cohn A, Messonnier NE. Inching toward aserogroup B meningococcal vaccine for infants.JAMA. 2012:307(6);614-615.


Carl R. Backes, DO, is co-director of theDual Pediatric Residency Program anddirector of the Special Care Nursery atDoctor’s Hospital/Ohio Health/NationwideChildren’s Hospital in Columbus, Ohio, andprofessor of pediatrics at Ohio UniversityHeritage College of Osteopathic Medicinein Athens. He can be reached [email protected].

HW


Reproduced with permission from The American Academy of Pediatrics Advisory Committee and Immunization Practices of the Centers for Disease Control and Prevention.

immunization of children and adolescents according to the acip … · 2012-06-25 · providers...

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