Practice Guidelines

The 2000 Harmonized Immunization Schedule



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Am Fam Physician. 2000 Jan 1;61(1):232-239.

The collaboration of the Advisory Committee on Immunization Practices (ACIP), the American Academy of Pediatrics (AAP) and the American Academy of Family Physicians (AAFP) continues with the 2000 harmonized immunization schedule (see page 234). Several important changes occurred this year.

Recommended Childhood Immunization Schedule, United States—January 2000 to December 2000 [corrected]

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A sufficient supply of thimerosal-free hepatitis B vaccine is now available to vaccinate all infants with at least the first dose. Therefore, the first dose of hepatitis B vaccine should be given in the range of birth through two months of age.

Diphtheria, tetanus, acellular pertussis vaccine (DTaP) is recommended because it has about one fourth to one half the adverse effects of diphtheria, tetanus, whole cell pertussis vaccine (DTwP). The Vaccines for Children Program will no longer supply DTwP, and my practice no longer stocks DTwP.

Use of the all-inactivated poliovirus vaccine (IPV) schedule is now recommended for several reasons. First, wild poliomyelitis has not been contracted indigenously in the United States since 1979. In 1994, North and South America were declared free of indigenous poliomyelitis; the last case occurred in Peru in 1991. Second, oral poliovirus vaccine (OPV) has a slight risk of vaccine-associated paralytic poliomyelitis (VAPP). While the sequential IPV-OPV schedule eliminates VAPP in immunocompetent recipients, the schedule does not eliminate VAPP in immunocompromised persons or in contacts of vaccine recipients. Third, IPV cannot cause VAPP. Fourth, the majority of parents would rather have their child undergo more injections than risk their child contracting VAPP.1

A fifth reason is that data show a high acceptance rate (91 percent) of an IPV-starting schedule among parents who bring their children to public health vaccine clinics, including clinics that serve inner-city, disadvantaged areas, without decreases in immunization rates.2 When the decision was made to recommend a schedule with more IPV, patients of public health clinics had been one of the major concerns. Sixth, it is easier to administer and store one vaccine (IPV) than to explain the choices to parents and stock two vaccines.

Rotavirus vaccine is no longer recommended because of the association with intussusception; the manufacturer has withdrawn rotavirus vaccine from the market.

Because of hepatitis A outbreaks, the ACIP recommends using the hepatitis A vaccine in high-risk locales and states; local health officials should be consulted to determine high-risk areas.3 The vaccine is not licensed for use in patients younger than 24 months of age. The exact age for vaccination is set at the local or state level. In a few years, when combination vaccines containing hepatitis A are available for use in infants, national recommendations will probably be made.

Because the number of injections has increased, pain at the injection site is an important consideration; pain can be reduced by using vapocoolant sprays before the injection4 and by using combination vaccines. Explaining to parents that additional injections reduce the risk of VAPP and of diseases such as hepatitis may lead to a higher rate of parental acceptance.

If the vaccination schedule is interrupted, it is not necessary to restart. Instead, the schedule should be resumed using minimal intervals between doses to catch up as quickly as possible (see the accompanying table).

Minimal Interval Between Vaccine Doses for Use When Immunization Is Behind Schedule*

Vaccine type Minimal interval between dose 1 and 2 Minimal interval between dose 2 and 3 Minimal interval between dose 3 and 4

Hepatitis B

1 month

2 months†

DTP/DTaP (DT)‡

4 weeks

4 weeks

6 months

Hib (primary series)

HbOC

1 month

1 month

2 months and ≥12 months old§

PRP-T

1 month

1 month

2 months and ≥12 months old§

PRP-OMP

1 month

2 months and ≥12 months old§

Poliovirus

4 weeks

4 weeks

No earlier than 4 years

MMR∥

1 month∥


DTP/DTaP (DT) = diphtheria and tetanus toxoids and whole-cell pertussis vaccine/diphtheria and tetanus toxoids and acellular pertussis vaccine (diphtheria and tetanus toxoids vaccine); Hib = Haemophilus influenzae type b conjugate vaccine; HbOC = oligosaccharides conjugated to diphtheria CRM197 toxin protein; PRP-T = polyribosylribitol phosphate polysaccharide conjugated to tetanus toxoid; PRP-OMP = polyribosylribitol phosphate polysaccharide conjugated to a meningococcal outer membrane protein; MMR = measles-mumps-rubella vaccine.

*—The minimal acceptable intervals may not correspond with the optimal recommended ages and intervals for vaccination. For current recommended routine schedules see the annual Recommended Childhood Immunization Schedule on page 234.

—This final dose of hepatitis B vaccine is recommended at least four months after the first dose and no earlier than six months of age.

‡ —The total number of doses of diphtheria and tetanus toxoids should not exceed six each before the seventh birthday.

§—The booster dose of Hib vaccine that is recommended following the primary vaccination series should be administered no earlier than 12 months of age and at least two months after the previous dose of Hib vaccine.

∥—Although the age for measles vaccination may be as young as six months in outbreak areas where cases are occurring in children less than one year of age, children initially vaccinated before the first birthday should be revaccinated at 12 to 15 months of age and an additional dose of vaccine should be administered at the time of school entry or according to local policy.

Adapted from Epidemiology and prevention of vaccine-preventable diseases. 5th ed. Atlanta: Centers for Disease Control and Prevention, 1999.

Minimal Interval Between Vaccine Doses for Use When Immunization Is Behind Schedule*

View Table

Minimal Interval Between Vaccine Doses for Use When Immunization Is Behind Schedule*

Vaccine type Minimal interval between dose 1 and 2 Minimal interval between dose 2 and 3 Minimal interval between dose 3 and 4

Hepatitis B

1 month

2 months†

DTP/DTaP (DT)‡

4 weeks

4 weeks

6 months

Hib (primary series)

HbOC

1 month

1 month

2 months and ≥12 months old§

PRP-T

1 month

1 month

2 months and ≥12 months old§

PRP-OMP

1 month

2 months and ≥12 months old§

Poliovirus

4 weeks

4 weeks

No earlier than 4 years

MMR∥

1 month∥


DTP/DTaP (DT) = diphtheria and tetanus toxoids and whole-cell pertussis vaccine/diphtheria and tetanus toxoids and acellular pertussis vaccine (diphtheria and tetanus toxoids vaccine); Hib = Haemophilus influenzae type b conjugate vaccine; HbOC = oligosaccharides conjugated to diphtheria CRM197 toxin protein; PRP-T = polyribosylribitol phosphate polysaccharide conjugated to tetanus toxoid; PRP-OMP = polyribosylribitol phosphate polysaccharide conjugated to a meningococcal outer membrane protein; MMR = measles-mumps-rubella vaccine.

*—The minimal acceptable intervals may not correspond with the optimal recommended ages and intervals for vaccination. For current recommended routine schedules see the annual Recommended Childhood Immunization Schedule on page 234.

—This final dose of hepatitis B vaccine is recommended at least four months after the first dose and no earlier than six months of age.

‡ —The total number of doses of diphtheria and tetanus toxoids should not exceed six each before the seventh birthday.

§—The booster dose of Hib vaccine that is recommended following the primary vaccination series should be administered no earlier than 12 months of age and at least two months after the previous dose of Hib vaccine.

∥—Although the age for measles vaccination may be as young as six months in outbreak areas where cases are occurring in children less than one year of age, children initially vaccinated before the first birthday should be revaccinated at 12 to 15 months of age and an additional dose of vaccine should be administered at the time of school entry or according to local policy.

Adapted from Epidemiology and prevention of vaccine-preventable diseases. 5th ed. Atlanta: Centers for Disease Control and Prevention, 1999.

Pneumococcal conjugate vaccine and new combination vaccines have been tested and may be licensed sometime in the year 2000.

Dr. Zimmerman is an associate professor in the Department of Family Medicine and Clinical Epidemiology at the University of Pittsburgh (Pa.) School of Medicine, with a secondary appointment in the Department of Health Services Administration. He is the AAFP liaison to the Advisory Committee on Immunization Practices and is a member of the AAFP Commission on Clinical Policies and Research.

Address correspondence to Richard K. Zimmerman, M.D., M.P.H., Department of Family Medicine and Clinical Epidemiology, University of Pittsburgh, 3550 Terrace St., Pittsburgh, PA 15261.

REFERENCES

1. Thoms ML, Bodnar PZ, O'Donovan JC, Gouel EG, Walcher JR, Halsey NA. Parental knowledge and choice regarding live and inactivated poliovirus vaccines. Arch Pediatr Adolesc Med. 1997;151:809–12.

2. Desai S, Kolasa M, Bisgard K, et al. Is the new poliovirus immunization recommendation acceptable to parents? Abstracts of the 32nd National Immunization Conference proceedings. Atlanta: July 21–24, 1998.

3. Prevention of hepatitis A through active or passive immunization: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep. 1999;48:1–37.

4. Cohen Reis E, Holubkov R. Vapocoolant spray is equally effective as EMLA cream in reducing immunization pain in school-aged children. Pediatrics. 1997;100:E5.


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