Practice Guidelines

Recommended Childhood and Adolescent Immunization Schedule, United States, July to December, 2004

RICHARD D. CLOVER, M.D., University of Louisville School of Public Health and Information Sciences, Louisville, Kentucky

HERBERT F. YOUNG, M.D., M.A., American Academy of Family Physicians, Leawood, Kansas

The Advisory Committee on Immunization Practices (ACIP), the American Academy of Family Physicians, and the American Academy of Pediatrics have released the Recommended Childhood and Adolescent Immunization Schedule (see accompanying chart on page 2472) for July to December 2004. This year is the first time in many years that separate January to June and July to December schedules have been issued.

Recommended Childhood and Adolescent Immunization Schedule1--United States, July-December 2004 1. Indicates the recommended ages for routine administration of currently licensed childhood vaccines, as of April 1, 2004, for children through age 18 years. Any dose not given at the recommended age should be given at any subsequent visit when indicated and feasible.  Indicates age groups that warrant special effort to administer those vaccines not given previously. Additional vaccines may be licensed and recommended during the year. Licensed combination vaccines may be used whenever any components of the combination are indicated and the vaccine's other components are not contraindicated. Providers should consult the manufacturers' package inserts for detailed recommendations. Clinically significant adverse events that follow vaccination should be reported to the Vaccine Adverse Event Reporting System (VAERS). Guidance about how to obtain and complete a VAERS form is available at http://www.vaers.org or by telephone, 1-800-822-7967. 2. Hepatitis B vaccine (HepB). All infants should receive the first dose of HepB 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 HepB vaccine can be used for the birth dose. Monovalent or combination vaccine containing HepB may be used to complete the series; 4 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 24 weeks. Infants born to HBsAg-positive mothers should receive HepB 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 1-2 months. The last dose in the vaccination series should not be administered before age 24 weeks. These infants should be tested for HBsAg and anti-HBs at 9-15 months of age. Infants born to mothers whose HBsAg status is unknown should receive the first dose of the HepB 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 1-2 months. The last dose in the vaccination series should not be administered before age 24 weeks. 3. Diphtheria and tetanus toxoids and acellular pertussis vaccine (DTaP). The fourth dose of DTaP may be administered at age 12 months provided that 6 months have elapsed since the third dose and the child is unlikely to return at age 15-18 months. The final dose in the series should be given at age >=4 years. Tetanus and diphtheria toxoids (Td) is recommended at age 11-12 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. 4. 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 vaccination in infants at ages 2, 4, or 6 months but can be used as boosters after any Hib vaccine. The final dose in the series should be given at age >=12 months. 5. Measles, mumps, and rubella vaccine (MMR). The second dose of MMR is recommended routinely at age 4-6 years but may be administered during any visit, provided at least 4 weeks have elapsed since the first dose and both doses are administered beginning at or after age 12 months. Those who have not received the second dose previously should complete the schedule by the visit at age 11-12 years. 6. Varicella vaccine (VAR). 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 2 doses given at least 4 weeks apart. 7. Pneumococcal vaccine. The heptavalent pneumococcal conjugate vaccine (PCV) is recommended for all children aged 2-23 months. It is also recommended for certain children aged 24-59 months. The final dose in the series should be given at age >=12 months. Pneumococcal polysaccharide vaccine (PPV) is recommended in addition to PCV for certain high-risk groups. See MMWR 2000;49(No. RR-9):1-35. 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, and diabetes), health care workers, and other persons (including household members) in close contact with persons in groups at high-risk (see MMWR 2004;53[No. RR-]:in press) and can be administered to all others wishing to obtain immunity. In addition, healthy children aged 6-23 months and close contacts of healthy children aged 0-23 months are recommended to receive influenza vaccine, because children in this age group are at substantially increased risk of influenza-related hospitalizations. For healthy persons aged 5-49 years, the intranasally administered live, attenuated influenza vaccine (LAIV) is an acceptable alternative to the intramuscular trivalent inactivated influenza vaccine (TIV). See MMWR 2003;52(No. RR-13):1-8. Children receiving TIV should be administered a dosage appropriate for their age (0.25 mL if 6-35 months or 0.5 mL if >=3 years). Children aged <=8 years who are receiving influenza vaccine for the first time should receive 2 doses (separated by at least 4 weeks for TIV and at least 6 weeks for LAIV). 9. 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 and MMWR 1999;48(No.RR-12):1-37. 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. Additional information about vaccines, including precautions and contraindications for vaccination and vaccine shortages is available at http://www.cdc.gov/nip or from the National Immunization Information Hotline, 800-232-2522 (English) or 800-232-0233 (Spanish). Approved by the Advisory Committee on Immunization Practices (http://www.cdc.gov/nip/acip), the American Academy of Pediatrics (http://www.aap.org), and the American Academy of Family Physicians (http://www.aafp.org).

The primary reason for the second schedule this year was the addition of a formal recommendation that infants six to 23 months of age routinely be immunized against influenza. This recommendation replaces the language contained in the schedule for the past several years that vaccination was encouraged, when feasible, in this age group.

In addition to immunizing infants six to 23 months of age unless contraindications are present, immunization of household contacts and out-of-home caregivers of children less than 24 months of age is recommended. This immunization of household contacts is especially important for infants younger than six months of age because there is not currently any vaccine licensed for this age group.

The recommendation for using immunizations to protect infants less than 24 months of age comes from scientific studies showing that young children have a risk of complications, hospitalizations, and deaths comparable with other high-risk groups such as the elderly and persons with specific underlying health conditions. These data are nicely summarized by the ACIP in their recommendations for the prevention and control of influenza.¹ Vaccination is particularly important for children in this age group who are at higher than normal risk for complications of influenza because of comorbidities. An updated paper from the ACIP is expected this month.

The Vaccine for Children program is a federally funded program that covers influenza vaccine for infants six to
23 months of age, children and adolescents two to 18 years of age who have risk factors, and children who are household contacts of people with risk factors.

In preparation for implementing the new recommendations, physicians will need to order their vaccine as early as possible. They also should remember that children who are younger than nine years and are receiving the vaccine for the first time require two doses. The second immunization should be given one month or more after the first dose. The ACIP states that children at high risk for the complications of influenza, including those who are six to 23 months of age, can be immunized at the same time they receive other recommended immunizations.¹

Information about influenza for health care professionals and patients, including patient education materials in multiple languages, is available from the CDC at: http://www.cdc.gov/flu.

Richard D. Clover, M.D., is dean of the School of Public Health and Information Sciences at the University of Louisville, Louisville, Ky. He is chair of the American Academy of Family Physician's (AAFP) Commission on Clinical Policies and Research. Dr. Clover is the AAFP liaison to the Advisory Committee on Immunization Practices.

Herbert F. Young, M.D., M.A., is director of the AAFP Division of Scientific Activities and the staff executive of the Commission on Clinical Policies and Research at the AAFP headquarters, Leawood, Kan.

REFERENCE

1. Bridges CB, Harper SA, Fukuda K, Uyeki TM, Cox NJ, Singleton JA. Prevention and control of influenza. Recommendations of the Advisory Committee on Immunization Practices (ACIP) [Published erratum in MMWR Morb Mortal Wkly Rep 2003;52:526]. MMWR Recomm Rep 2003;52(RR-8):1-34.

AAFP and ACP Release Practice Guideline on Management of Newly Detected Atrial Fibrillation

Genevieve W. Ressel

The Joint Panel of the American Academy of Family Physicians (AAFP) and the American College of Physicians (ACP), in collaboration with the Johns Hopkins Evidence-Based Practice Center, systematically reviewed the available evidence on the management of newly detected atrial fibrillation and developed recommendations for adult patients with first-detected atrial fibrillation. The full report was published in the December 16, 2003 issue of Annals of Internal Medicine.

The guideline recommends pharmacologic management options for newly detected atrial fibrillation in adult patients, which is defined as the presence of symptoms or electrocardiographic evidence of atrial fibrillation. This guideline does not apply to patients with postoperative or postmyocardial infarction atrial fibrillation, patients with class IV heart failure, patients already taking antiarrhythmic drugs, or patients with valvular disease. The recommendations focus on rate control versus rhythm control, stroke prevention and anticoagulation, electrical cardioversion versus pharmacologic cardioversion, the role of transesophageal echocardiography in guiding therapy, and maintenance therapy.

Rate Control vs. Rhythm Control

Rate control with chronic anticoagulation is the recommended strategy for the majority of patients with atrial fibrillation. Rhythm control has not been shown to be superior to rate control (with chronic anticoagulation) in reducing morbidity and mortality and may be worse in some patient subgroups compared with use of rate control. Rhythm control is appropriate when based on other special considerations, such as patient symptoms, exercise tolerance, and patient preference.

Anticoagulation

Patients with atrial fibrillation should receive chronic anticoagulation with adjusted-dose warfarin, unless they are at low risk of stroke or have a specific contraindication to the use of warfarin (i.e., thrombocytopenia, recent trauma or surgery, alcoholism).

Aspirin may be useful for patients with atrial fibrillation and a low risk of stroke, but the evidence is inconclusive. There is currently insufficient evidence to support the use of low-molecular-weight heparin or other antiplatelet agents in the management of atrial fibrillation.

Efficacy of Different Agents for Rate Control

For patients with atrial fibrillation, the following drugs are recommended for their demonstrated efficacy in rate control during exercise and while at rest: atenolol, metoprolol, diltiazem, and verapamil (drugs listed alphabetically by class). Digoxin is only effective for rate control at rest and only should be used as a second-line agent for rate control in atrial fibrillation.

Side effect profiles for all medications should be reviewed with patients and can provide guidance in the choice of agents for individual patients. Combinations of digoxin plus diltiazem, atenolol, or betaxolol also have been shown to be effective at rest and with exercise. These combinations may be better reserved for situations when single-agent therapy has failed.

Acute Conversion

For patients who elect to undergo acute cardioversion to achieve sinus rhythm in atrial fibrillation, direct-current and pharmacologic conversion are appropriate options. While there are good data to support both options, there are no data on the efficacy of one method over the other because no head-to-head trials have compared them. Long-term effectiveness in maintaining sinus rhythm is moderate to low for both methods. Adequate safety data are not available to make recommendations about the setting of cardioversion.

Role of Echocardiography in the Acute Conversion of Atrial Fibrillation

Transesophageal echocardiography with prior short-term anticoagulation followed by early acute cardioversion (in the absence of intracardiac thrombus) with postcardioversion anticoagulation versus delayed cardioversion with pre- and postanticoagulation are appropriate management strategies for patients who elect to undergo cardioversion. The choice between the two strategies should be based on patient preference and clinical situation, including contraindications to transesophageal echocardiography or availability of this technology.

Maintenance Therapy

Most patients who convert to sinus rhythm from atrial fibrillation should not be placed on maintenance therapy because the risks outweigh the benefits. In a select group of patients whose quality of life is compromised by atrial fibrillation, the recommended pharmacologic agents for rhythm maintenance are amiodarone, disopyramide, propafenone, and sotalol (drugs listed in alphabetical order). The choice of agent predominantly depends on specific risk of side effects based on patient characteristics.

All agents have some potential for minor and serious side effects, suggesting the need for careful consideration of the relative risks and benefits of an aggressive approach to maintaining sinus rhythm versus the alternate strategy of rate control and stroke prevention before beginning therapy.