Practice Guidelines - January 1, 2000 - American Academy of Family Physicians

Practice Guidelines

The 2000 Harmonized Immunization Schedule
RICHARD KENT ZIMMERMAN, M.D., M.P.H.
University of Pittsburgh School of Medicine
Pittsburgh, Pennsylvania

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.

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 on page 239).

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

Recommended Childhood Immunization Schedule, United States--January 2000 to December 2000

NOTE: On October 22, 1999, the Advisory Committee on Immunization Practices (ACIP) recommended that Rotashield (RRV-TV), the only U.S.-licensed rotavirus vaccine, no longer be used in the United States (MMWR, Volume 48, Number 43, November 5, 1999). Parents should be reassured that their children who received rotavirus vaccine before July are not at increased risk for intussusception now.
This schedule has been approved by the ACIP, the American Academy of Pediatrics (AAP) and the American Academy of Family Physicians (AAFP). It indicates the recommended ages for routine administration of currently licensed childhood vaccines as of November 1, 1999. Licensed combination vaccines may be used whenever any components of the combination are indicated and its other components are not contraindicated. Providers should consult the manufacturers' package inserts for detailed recommendations.
*--Vaccines are listed under routinely recommended ages. Clear bars indicate range of recommended ages for immunization. Any dose not given at the recommended age should be given as a "catch-up" immunization at any subsequent visit when indicated and feasible. Shaded ovals indicate vaccines to be given if previously recommended doses were missed or given earlier than the recommended minimum age.
†--Infants born to hepatitis B surface antigen (HBsAg)-negative mothers should receive the first dose of hepatitis B (Hep B) vaccine by age two months. The second dose should be given at least one month after the first dose. The third dose should be administered at least four months after the first dose and at least two months after the second dose, but not before six months of age for infants. Infants born to HBsAg-positive mothers should receive hepatitis B vaccine and 0.5 mL hepatitis B immune globulin (HBIG) within 12 hours of birth at separate sites. The second dose is recommended at one to two months of age and the third dose at six months of age. Infants born to mothers whose HBsAg status is unknown should receive hepatitis B vaccine within 12 hours of birth. Maternal blood should be drawn at the time of delivery to determine the mother's HBsAg status; if the HBsAg test is positive, the infant should receive HBIG as soon as possible (no later than one week of age). All children and adolescents (through 18 years of age) who have not been immunized against hepatitis B may begin the series during any visit. Special efforts should be made to immunize children who were born in or whose parents were born in areas of the world with moderate or high endemicity of hepatitis B virus infection
‡--The fourth dose of diphtheria and tetanus toxoids and acellular pertussis vaccine (DTaP) may be administered as early as 12 months of age, provided six months has elapsed since the third dose and if the child is unlikely to return at age 15 to 18 months. Tetanus and diphtheria toxoids (Td) immunization is recommended at 11 to 12 years of age if at least five years has elapsed since the last dose of DTP, DTaP or DT. Subsequent routine Td boosters are recommended every 10 years
§--Three Haemophilus influenza type b (Hib) conjugate vaccines are licensed for infant use. If PRP-OMP (PedvaxHIB and COMVAX) is administered at two and four months of age, a dose at six months is not required. Because clinical studies in infants have demonstrated that using some combination products may induce a lower immune response to the Hib vaccine component, DTaP/Hib combination products should not be used for primary immunization in infants at two, four or six months of age, unless it is approved by the U.S. Food and Drug Administration for these ages
||--To eliminate the risk of vaccine-associated paralytic polio (VAPP), an all-inactivated poliovirus vaccine (IPV) schedule is now recommended for routine childhood polio vaccination in the United States. All children should receive four doses of IPV at two months, four months, six to 18 months, and four to six years. Oral poliovirus vaccine (OPV), if available, may be used only for the following special circumstances: (1) mass vaccination campaigns to control outbreaks of paralytic polio; (2) unvaccinated children who will be traveling in less than four weeks to areas where polio is endemic or epidemic; (3) children of parents who do not accept the recommended number of vaccine injections. These children may receive OPV only for the third or fourth dose, or both; in this situation, health care providers should administer OPV only after discussing the risk for VAPP with parents or caregivers; (4) during the transition to an all-IPV schedule, recommendations for the use of remaining OPV supplies in physicians' offices and clinics have been issued by the AAP (see Pediatrics, December 1999)
¶--The second dose of measles-mumps-rubella (MMR) vaccine is recommended routinely at four to six years of age but may be administered during any visit, provided at least four weeks has elapsed since receipt of the first dose and that both doses are administered beginning at or after 12 months of age. Those who have not previously received the second dose should complete the schedule by the 11- to 12-year-old visit
#--Varicella (Var) vaccine is recommended at any visit on or after the first birthday for susceptible children, i.e., those who lack a reliable history of chickenpox (as judged by a health care provider) and who have not been immunized. Susceptible persons 13 years of age or older should receive two doses, given at least four weeks apart
**--Hepatitis A (Hep A) is shaded to indicate its recommended use in selected states and/or regions; consult your local public health authority. (Also see MMWR October 1, 1999;48(RR-12):1-37.)
This schedule is provided by the American Academy of Family Physicians only as an assistance for physicians making clinical decisions regarding the care of their patients. As such, they cannot substitute for the individual judgment brought to each clinical situation by the patient's family physician. As with all clinical reference resources, they reflect the best understanding of the science of medicine at the time of publication, but they should be used with the clear understanding that continued research may result in new knowledge and recommendations.

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

Vaccine type
Minimal interval between dose 1 and 2
Minimal intervalbetween dose 2 and 3
Minimal intervalbetween 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.

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

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.

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.

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.

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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