Practice Guidelines
Recommended Childhood and Adolescent Immunization
Schedule, United States, 2003 and Update on Childhood Immunizations
RICHARD K. ZIMMERMAN, M.D., M.P.H., University of
Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
The 2003 Recommended Childhood and Adolescent Immunization
Schedule (Figure 1) is similar to the 2002 schedule, except
for four changes: a name change to reflect inclusion of adolescents,
clarifications in the footnotes for hepatitis A and hepatitis B, encouragement
for influenza vaccination of healthy children six to 23 months of age, and
inclusion of a harmonized catch-up schedule for children who are behind in
immunizations (Tables 1 and 2). The catch-up schedule offers
specific guidance regarding the minimum time between doses as well as the
number of doses for those who are behind schedule.
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| Recommended Childhood and Adolescent Immunization Schedule--United
States, 2003 |
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1. Hepatitis B vaccine (Hep
B). All infants should receive the first dose of hepatitis B vaccine soon
after birth and before hospital discharge; the first dose may also be given by
age 2 months if the infant's mother is HBsAg-negative. Only monovalent
hepatitis B vaccine can be used for the birth dose. Monovalent or combination
vaccine containing Hep B may be used to complete the series. Four doses of
vaccine may be administered when a birth dose is given. The second dose should
be given at least 4 weeks after the first dose, except for combination
vaccines, which cannot be administered before age 6 weeks. The third dose
should be given at least 16 weeks after the first dose and at least 8 weeks
after the second dose. The last dose in the vaccination series (third or fourth
dose) should not be administered before age 6 months.
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 age 1 to 2 months. The last dose in the vaccination series
should not be administered before age 6 months. These infants should be tested
for HBsAg and anti-HBs at 9 to 15 months of age.
Infants born to mothers whose HBsAg status
is unknown should receive the first dose of the hepatitis B vaccine series
within 12 hours of birth. Maternal blood should be drawn as soon as possible 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 age 1 week). The second
dose is recommended at age 1 to 2 months. The last dose in the vaccination
series should not be administered before age 6 months.
2. Diphtheria and tetanus
toxoids and acellular pertussis vaccine (DTaP). The fourth dose of DTaP may
be administered as early as age 12 months, provided 6 months have elapsed since
the third dose and the child is unlikely to return at age 15 to 18 months. Tetanus and diphtheria toxoids (Td) is recommended at age 11
to 12 years if at least 5 years have elapsed since the last dose of tetanus and
diphtheria toxoid-containing vaccine. Subsequent routine Td boosters are
recommended every 10 years.
3. Haemophilus influenzae type b (Hib)
conjugate vaccine. Three Hib conjugate vaccines are licensed for infant
use. If PRP-OMP (PedvaxHIB or ComVax [Merck]) is administered at ages 2 and 4
months, a dose at age 6 months is not required. DTaP/Hib combination products
should not be used for primary immunization in infants at ages 2, 4, or 6
months, but can be used as boosters following any Hib vaccine.
4. Measles, mumps, and rubella
vaccine (MMR). The second dose of MMR is recommended routinely at age 4 to
6 years but may be administered during any visit, provided at least 4 weeks
have elapsed since the first dose and that both doses are administered
beginning at or after age 12 months. Those who have not previously received the
second dose should complete the schedule by the 11 to 12-year-old visit.
5. Varicella vaccine.
Varicella vaccine is recommended at any visit at or after age 12 months for
susceptible children (i.e., those who lack a reliable history of chickenpox).
Susceptible persons aged >=13 years should receive two doses, given at least
4 weeks apart.
6. Pneumococcal vaccine.
The heptavalent pneumococcal conjugate vaccine (PCV) is recommended for all
children aged 2 to 23 months. It is also recommended for certain children aged
24 to 59 months. Pneumococcal polysaccharide vaccine (PPV)
is recommended in addition to PCV for certain high-risk groups. See MMWR
2000;49(RR-9):1-38.
7. Hepatitis A vaccine.
Hepatitis A vaccine is recommended for children and adolescents in selected
states and regions, and for certain high-risk groups; consult your local public
health authority. Children and adolescents in these states, regions, and
high-risk groups who have not been immunized against hepatitis A can begin the
hepatitis A vaccination series during any visit. The two doses in the series
should be administered at least 6 months apart. See MMWR 1999;48(RR-12):1-37.
8. Influenza vaccine.
Influenza vaccine is recommended annually for children aged >= 6 months with
certain risk factors (including but not limited to asthma, cardiac disease,
sickle cell disease, HIV, diabetes, and household members of persons in groups
of high risk; see MMWR 2002;51[RR-3];1-31), and can be administered to all
others wishing to obtain immunity. In addition, healthy children aged 6 to 23
months are encouraged to receive influenza vaccine if feasible because children
in this age group are at substantially increased risk for influenza-related
hospitalizations. Children aged <= 12 years should receive vaccine in a
dosage appropriate for their age (0.25 mL if aged 6 to 35 months or 0.5 mL if
aged >= 3 years). Children aged <= 8 years who are receiving influenza
vaccine for the first time should receive two doses separated by at least 4
weeks.
For additional information about vaccines,
including precautions and contraindications for immunization and vaccine
shortages, please visit the National Immunization Program Web site at
www.cdc.gov/nip or call the National
Immunization Information Hotline at 800-232-2522 (English) or 800-232-0233
(Spanish).
Approved by the Advisory Committee on
Immunization Practices (www.cdc.gov/nip/acip), the American
Academy of Pediatrics (www.aap.org), and the
American Academy of Family Physicians (www.aafp.org).
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Among children zero to two years of age,
influenza-related hospitalization rates range from about 186 to 1,038 per
100,000 for healthy children to 800 to 1,900 per 100,000 for those with
high-risk conditions, depending on exact age.1-3 Izurieta and
colleagues found rates of 144 to 187 per 100,000 children zero to 23 months of
age.3,4 One study showed that healthy children six months to less
than three years of age had rates of influenza-associated hospitalization as
high or higher than rates among children three to 14 years of age with
high-risk conditions.1,2 In one study,5 influenza was
second only to respiratory syncytial virus in causing hospitalizations in
persons with chronic underlying illness. Neuzil and colleagues1
found that for every 100 children, an annual average of six to 15 outpatient
visits and three to nine courses of antibiotics are attributable to influenza.
The illness attack rate is highest in children at 14 to 40 percent yearly, with
attack rates typically higher than 30 percent in preschool-aged
children.6-8
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TABLE 1
Catch-up Schedule for
Children Four Months Through Six Years of Age
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Minimum
interval between doses
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| Dose one
(minimum age) |
Dose one to dose
two |
Dose two to dose
three |
Dose three to dose
four |
Dose four to
dose five |
| DTaP (6 weeks) |
4 weeks |
4 weeks |
6 months |
6 months* |
| IPV (6 weeks) |
4 weeks |
4 weeks |
4 weeks† |
|
| Hep B‡ (birth) |
4 weeks |
8 weeks (and 16 weeks after
first dose) |
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| MMR (12 months) |
4 weeks§ |
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| Varicella (12 months) |
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| Hib|| (6 weeks) |
4 weeks: if first dose
given at age <12 months
8 weeks (as final dose): if first dose given at
age 12 to 14 months
No further doses needed: if first dose given at age
>=15 months |
4 weeks¶: if current
age <12 months
8 weeks (as final dose)¶: if current age >=12
months and second dose given at age <15 months
No further doses needed:
if previous dose given at age >=15 months |
8 weeks (as final dose):
this dose only necessary for children aged 12 months to 5 years who received
three doses before age 12 months |
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| PCV# (6 weeks) |
4 weeks: if first dose
given at age <12 months and current age <24 months
8 weeks (as final
dose): if first dose given at age >=12 months or current age 24 to 59 months
No further doses needed: for healthy children if first dose given at age
>=24 months |
4 weeks: if current age
<12 months
8 weeks (as final dose): if current age >=12 months
No
further doses needed: for healthy children if previous dose given at age
>=24 months |
8 weeks (as final dose):
this dose only necessary for children aged 12 months to five years who received
three doses before age 12 months |
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*--DTaP: The fifth dose is not
necessary if the fourth dose was given after the fourth birthday.
†--IPV: For children who
received an all-IPV or all-OPV series, a fourth dose is not necessary if third
dose was given at age >=4 years. If OPV and IPV were given as part of a
series, a total of four doses should be given, regardless of the child's
current age.
‡--Hep B: All children
and adolescents who have not been immunized against hepatitis B should begin
the hepatitis B vaccination series during any visit. Providers should make
special efforts to immunize children who were born in, or whose parents were
born in, areas of the world where hepatitis B virus infection is moderately or
highly endemic.
§--MMR: The second dose
of MMR is recommended routinely at age 4 to 6 years, but may be given earlier
if desired.
||--Hib: Vaccine is not
generally recommended for children aged >=5 years.
¶--Hib: If current age
<12 months and the first two doses were PRP-OMP (PedvaxHIB or ComVax), the
third (and final) dose should be given at age 12 to 15 months and at least 8
weeks after the second dose.
#--PCV: Vaccine is not
generally recommended for children aged >=5 years.
NOTE: Report adverse reactions
to vaccine through the federal Vaccine Adverse Event Reporting System. For
information on reporting reactions following vaccines, please visit
www.vaers.org or call the 24-hour national toll-free information line
800-822-7967. Report suspected cases of vaccine-preventable diseases to your
state or local health department. |
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Influenza vaccine can cause local reactions such as
soreness at the injection site. In young children not previously exposed to
influenza vaccine, fever, malaise, and myalgia also can occur. Because
inactivated influenza vaccines are not live, they cannot cause influenza. At
the October 2002 Advisory Committee on Immunization Practices (ACIP) meeting, a
study was presented from the Vaccine Safety Datalink that found that no serious
reactions were associated with influenza vaccination among 251,600 children
younger than 18 years, including 8,446 children six to 23 months of age, who
received more than 438,000 doses of inactivated influenza vaccine.
Based on the hospitalization rates caused by
influenza in young children, the high annual illness attack rate, and the
safety of vaccination, the ACIP encourages vaccination of healthy children six
through 23 months of age, beginning in the Fall of 2002.3 The
Centers for Disease Control and Prevention's (CDC) Vaccine Information
Statement on influenza has been updated to reflect this change (www.cdc.gov/nip/publications/VIS/default.htm).
Before making a full recommendation to vaccinate all children six to 23 months
of age annually (which is expected within the next two years), several issues
need to be resolved, including parent and physician education, reimbursement,
and efficient delivery mechanisms of influenza vaccine to young children.
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TABLE 2
Catch-up Schedule for
Children Seven Through 18 Years of Age
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Minimum
interval between doses
|
| Dose one to dose
two |
Dose two to dose
three |
Dose three to booster
dose |
| Td: 4 weeks |
Td: 6 months |
Td*:
6 months: if first
dose given at age <12 months and current age <11 years
5 years: if
first dose given at age >=12 months and third dose given at age <7 years
and current age >=11 years
10 years: if third dose given at age >=7
years |
| IPV†: 4 weeks |
IPV†: 4 weeks |
IPV† |
| Hep B: 4 weeks |
Hep B: 8 weeks (and 16
weeks after first dose) |
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| MMR: 4 weeks |
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| Varicella‡: 4 weeks
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*--Td: For children 7 to 10
years of age, the interval between the third and booster dose is determined by
the age when the first dose was given. For adolescents 11 to 18 years of age,
the interval is determined by the age when the third dose was given.
†--IPV: Vaccine is not
generally recommended for persons aged >=18 years.
‡--Varicella: Give
two-dose series to all susceptible adolescents aged >=13 years.
NOTE: Report adverse reactions
to vaccines through the federal Vaccine Adverse Event Reporting System. For
information on reporting reactions following vaccines, please visit
www.vaers.org or call the 24-hour national toll-free information line
800-822-7967. Report suspected cases of vaccine-preventable diseases to your
state or local health department. |
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Although vaccine shortages for tetanus, influenza,
and varicella vaccines have resolved, shortages of conjugated pneumococcal
vaccine continue. The ACIP recommends that children at highest risk (e.g.,
children with sickle cell disease) be vaccinated according to the normal
schedule. During the shortage, the ACIP recommends that healthy infants and
children younger than 24 months receive a decreased number of pneumococcal
conjugate vaccine doses based on the age at which vaccination is begun and the
estimated amount of vaccine available to the practice, as tabled at
www.cdc.gov/mmwr/preview/mmwrhtml/mm5050a4.htm.
Smallpox vaccination is not recommended for
children in a pre-exposure situation because of the risk of adverse reactions.
Studies from the 1960s reveal a death rate of one per 1 million primary
vaccinations; rates of adverse reactions are highest among persons younger than
five years. Adverse reactions include generalized vaccinia, inadvertent
inoculation to other places on the body, eczema vaccinia that typically occurs
among persons with a history of eczema, progressive vaccinia in persons with
impaired T-cell function, postvaccine encephalitis (typically among infants and
the elderly), transmission of vaccine virus to others, and death.
Useful Web sites for current information include
www.immunizationed.org, which is a
site developed by family physician educators and has free Palm OS and CE
applications of the childhood and adult immunization schedules,
www.immunize.org, www.aafp.org/x10615.xml, which contains the American
Academy of Family Physicians' clinical policies on immunization,
www.cdc.gov/nip, and
www.immunizationinfo.org.
Dr. Zimmerman is an associate professor in the
Department of Family Medicine and Clinical Epidemiology at the University of
Pittsburgh School of Medicine with a secondary appointment in the Department of
Behavioral and Community Health Sciences. He is a voting member of the Advisory
Committee on Immunization Practices.
Address correspondence to Richard K. Zimmerman, M.D.,
M.P.H., Department of Family Medicine, University of Pittsburgh, 3518 Fifth
Ave., Pittsburgh, PA 15261 (e-mail: zimmer@pitt.edu).
REFERENCES
- Neuzil KM, Mellen BG, Wright PF, Mitchel EF Jr, Griffin MR. The
effect of influenza on hospitalizations, outpatient visits, and courses of
antibiotics in children. N Engl J Med 2000;342:225-31.
- Neuzil KM, Wright PF, Mitchel EF Jr, Griffin MR. The burden of
influenza illness in children with asthma and other chronic medical conditions.
J Pediatr 2000;137:856-64.
- Bridges CB, Fukuda K, Uyeki TM, Cox NJ, Singleton JA. Prevention
and control of influenza. Recommendations of the Advisory Committee on
Immunization Practices (ACIP). MMWR Recomm Rep 2002;51(RR-3):1-31.
- Izurieta HS, Thompson WW, Kramarz P, Shay DK, Davis RL, DeStefano
F, et al. Influenza and the rates of hospitalization for respiratory disease
among infants and young children. N Engl J Med 2000;342:232-9.
- Glezen WP, Greenberg SB, Atmar RL, Piedra PA, Couch RB. Impact of
respiratory virus infections on persons with chronic underlying conditions.
JAMA 2000;283:499-505.
- Sullivan KM, Monto AS, Longini IM Jr. Estimates of the U.S. health
impact of influenza. Am J Public Health 1993;83:1712-6.
- Glezen WP. Considerations of the risk of influenza in children and
indications for prophylaxis. Rev Infect Dis 1980;2:408-20.
- Glezen WP, Taber LH, Frank AL, Gruber WC, Piedra PA. Influenza
virus infections in infants. Pediatr Infect Dis J 1997;16:1065-8.
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