What's New on the Child and Adolescent Immunization Schedules William L. Atkinson, MD, MPH National Center for Immunization and Respiratory Diseases William L. Atkinson, MD, MPH National Center for Immunization and Respiratory Diseases

2 Childhood Immunization Schedules Published at least annually since 1995 Child and adolescent schedules published by AAP, AAFP, and CDC in January of each year Schedules for children 0 through 6 years and 7-18 years separated in 2007 Published at least annually since 1995 Child and adolescent schedules published by AAP, AAFP, and CDC in January of each year Schedules for children 0 through 6 years and 7-18 years separated in 2007

5 Immunization Schedule for Persons Aged 0 Through 6 Years

6 Immunization Schedule for Persons Aged 7 Through 18 Years

7 Catch-up Immunization Schedules

8 Changes in the 2010 Schedule Combination vaccine statement Age and interval for the last dose in the IPV series Meningococcal conjugate revaccination Use of HPV2 for females and permissive use of HPV4 for males Permissive use of hepatitis A vaccine for children older than 23 months Combination vaccine statement Age and interval for the last dose in the IPV series Meningococcal conjugate revaccination Use of HPV2 for females and permissive use of HPV4 for males Permissive use of hepatitis A vaccine for children older than 23 months

9 Immunization Schedule for Persons Aged 0 Through 6 Years

10 Changes in the 2010 Schedule Combination vaccine statement –Licensed combination vaccines may be used whenever any components of the combination is indicated and other components of the vaccine are not contraindicated and if approved by the Food and Drug Administration for that dose of the series. Combination vaccine statement –Licensed combination vaccines may be used whenever any components of the combination is indicated and other components of the vaccine are not contraindicated and if approved by the Food and Drug Administration for that dose of the series.

11 Changes in the 2010 Schedule Combination vaccine statement 2010 –The use of a combination vaccine generally is preferred over separate injections of its equivalent component vaccines. Considerations should include provider assessment, patient preference, and the potential for adverse events. –Wording approved by ACIP in June 2009 and posted on the ACIP website on August 28 –Will be included in the 2010 revision of the General Recommendations on Immunization Combination vaccine statement 2010 –The use of a combination vaccine generally is preferred over separate injections of its equivalent component vaccines. Considerations should include provider assessment, patient preference, and the potential for adverse events. –Wording approved by ACIP in June 2009 and posted on the ACIP website on August 28 –Will be included in the 2010 revision of the General Recommendations on Immunization

12 Changes in the 2010 Schedule Combination vaccine statement Age and interval for the last dose in the IPV series Meningococcal conjugate revaccination Use of HPV2 for females and permissive use of HPV4 for males Permissive use of hepatitis A vaccine for children older than 23 months Combination vaccine statement Age and interval for the last dose in the IPV series Meningococcal conjugate revaccination Use of HPV2 for females and permissive use of HPV4 for males Permissive use of hepatitis A vaccine for children older than 23 months

13 Polio Vaccine Policy in the U.S. Recommended schedule of IPV is 4 doses at 2, 4, 6-18 months and 4-6 years Use of certain combination vaccines that contain IPV could result in 4 doses of IPV by 18 months of age ACIP, AAP, and AAFP were concerned that this schedule could lead to suboptimum long-term polio immunity Recommended schedule of IPV is 4 doses at 2, 4, 6-18 months and 4-6 years Use of certain combination vaccines that contain IPV could result in 4 doses of IPV by 18 months of age ACIP, AAP, and AAFP were concerned that this schedule could lead to suboptimum long-term polio immunity

14 Factors Affecting the Response to IPV Age Maternal antibody level at the time of the first dose –the lower the maternal antibody level the higher the seroconversion rate Longer intervals between doses –an interval of at least 6 months between the next to last and last dose provides the best immunologic effect Age Maternal antibody level at the time of the first dose –the lower the maternal antibody level the higher the seroconversion rate Longer intervals between doses –an interval of at least 6 months between the next to last and last dose provides the best immunologic effect

15 New IPV Recommendations No change in the routine IPV schedule of four doses at ages 2 months, 4 months, 6 through 18 months, and 4 through 6 years Minimum interval between the next- to-last and last doses is now 6 months Minimum age for the final IPV dose is now 4 years No change in the routine IPV schedule of four doses at ages 2 months, 4 months, 6 through 18 months, and 4 through 6 years Minimum interval between the next- to-last and last doses is now 6 months Minimum age for the final IPV dose is now 4 years MMWR 2009;58(No. 30):829-30

16 New IPV Recommendations When 4 (or more) doses of IPV are administered before the 4th birthday, an additional dose of age appropriate IPV should be given on or after the 4th birthday Minimum interval from next-to-last to last dose should always be at least 6 months (even if the series is 3 doses) When 4 (or more) doses of IPV are administered before the 4th birthday, an additional dose of age appropriate IPV should be given on or after the 4th birthday Minimum interval from next-to-last to last dose should always be at least 6 months (even if the series is 3 doses) MMWR 2009;58(No. 30):829-30

18 Changes in the 2010 Schedule Combination vaccine statement Age and interval for the last dose in the IPV series Meningococcal conjugate revaccination Use of HPV2 for females and permissive use of HPV4 for males Permissive use of hepatitis A vaccine for children older than 23 months Combination vaccine statement Age and interval for the last dose in the IPV series Meningococcal conjugate revaccination Use of HPV2 for females and permissive use of HPV4 for males Permissive use of hepatitis A vaccine for children older than 23 months

Meningococcal ACIP Statement: Revaccination after MCV4 In its 2005 recommendations for MCV4, ACIP made no recommendation about revaccination pending the availability of additional data Serologic data are now available from the manufacturer that show significant decline in antibody 3-5 years after vaccination although few “breakthrough” cases have been reported In its 2005 recommendations for MCV4, ACIP made no recommendation about revaccination pending the availability of additional data Serologic data are now available from the manufacturer that show significant decline in antibody 3-5 years after vaccination although few “breakthrough” cases have been reported MMWR 2005;54(RR-7)

20 MCV4 Revaccination Recommendations* Children through age 18 years who received their first dose of MCV4 or MPSV4 at ages 2 through 6 years and remain at increased risk for meningococcal disease should receive an additional dose of MCV4 three years after their first dose MMWR 2009;58(No. 37)

21 MCV4 Revaccination Recommendations Persons through age 55 years who received a dose of MCV4 or MPSV4 after age 6 years and remain at increased risk for meningococcal disease should receive an additional dose of MCV4 five years after their previous dose MMWR 2009;58(No. 37)

22 MCV4 Revaccination Recommendations High-risk persons who should be revaccinated with MCV4: –persistent complement component deficiency –anatomic or functional asplenia –Microbiologists with prolonged exposure to Neisseria meningitidis –frequent travelers to or persons living in areas with high rates of meningococcal disease High-risk persons who should be revaccinated with MCV4: –persistent complement component deficiency –anatomic or functional asplenia –Microbiologists with prolonged exposure to Neisseria meningitidis –frequent travelers to or persons living in areas with high rates of meningococcal disease MMWR 2009;58(No. 37)

23 MCV4 Revaccination Recommendations MCV4 revaccination is NOT recommended for persons whose only risk factor is living in on-campus housing (i.e., college student living in a dormitory) MMWR 2009;58(No. 37)

25 Changes in the 2010 Schedule Combination vaccine statement Age and interval for the last dose in the IPV series Meningococcal conjugate revaccination Use of HPV2 for females and permissive use of HPV4 for males Permissive use of hepatitis A vaccine for children older than 23 months Combination vaccine statement Age and interval for the last dose in the IPV series Meningococcal conjugate revaccination Use of HPV2 for females and permissive use of HPV4 for males Permissive use of hepatitis A vaccine for children older than 23 months

26 HPV Vaccines HPV4 (Gardasil, Merck) –contains HPV types 16, 18, 6 and 11 –approved for the prevention of cervical, vaginal and vulvar cancers (in females) and genital warts (in females and males) HPV2 (Cervarix, GSK) –contains HPV types 16 and 18 –approved for the prevention of cervical cancers in females HPV4 (Gardasil, Merck) –contains HPV types 16, 18, 6 and 11 –approved for the prevention of cervical, vaginal and vulvar cancers (in females) and genital warts (in females and males) HPV2 (Cervarix, GSK) –contains HPV types 16 and 18 –approved for the prevention of cervical cancers in females

27 HPV Vaccine Recommendations* HPV4 or HPV2 is recommended for the prevention of cervical precancers and cancers in females HPV4 is recommended for the prevention of cervical, vaginal and vulvar precancers and cancers and genital warts in females Administer the first dose to females at age 11 or 12 years HPV4 or HPV2 is recommended for the prevention of cervical precancers and cancers in females HPV4 is recommended for the prevention of cervical, vaginal and vulvar precancers and cancers and genital warts in females Administer the first dose to females at age 11 or 12 years *ACIP provisional recommendations, October 2009

28 HPV Vaccine Recommendations* Administer the series to females at age 13 through 18 years if not previously vaccinated HPV4 may be administered in a 3- dose series to males aged 9 through 18 years to reduce their likelihood of acquiring genital warts Administer the series to females at age 13 through 18 years if not previously vaccinated HPV4 may be administered in a 3- dose series to males aged 9 through 18 years to reduce their likelihood of acquiring genital warts *ACIP provisional recommendations, October 2009

29 Changes in the 2010 Schedule Combination vaccine statement Age and interval for the last dose in the IPV series Meningococcal conjugate revaccination Use of HPV2 for females and permissive use of HPV4 for males Permissive use of hepatitis A vaccine for children older than 23 months Combination vaccine statement Age and interval for the last dose in the IPV series Meningococcal conjugate revaccination Use of HPV2 for females and permissive use of HPV4 for males Permissive use of hepatitis A vaccine for children older than 23 months

30 ACIP Website