Practice Guidelines
Recommended Childhood and Adolescent Immunization Schedule, United States, 2005
The 2005 Recommended Childhood and Adolescent Immunization Schedule (see accompanying charts), which is approved by the Advisory Committee on Immunization Practices (ACIP), the American Academy of Pediatrics (AAP), and the American Academy of Family Physicians (AAFP), is similar to the July to December 2004 schedule. One item change should be noted: influenza vaccine is now recommended for routine use in children six through 23 months of age. This is indicated by the yellow bar for influenza located above the red dotted line for children six to 23 months of age; it also is recommended for children two years of age and older who have risk conditions such as asthma.
Hospitalization rates from influenza are highest among preschoolers, especially infants zero to one year of age. Among children aged zero to two years, the influenza-related hospitalization rates range (depending on the exact age) from about 800 to 1,900 per 100,000 for children who have high-risk conditions compared with 186 to 1,038 per 100,000 for healthy children.1-3 One study4 found rates of 144 to 187 per 100,000 children aged zero to 23 months.2,4 Furthermore, one team showed that healthy children aged six months to three years had rates of influenza-associated hospitalization as high or higher than rates among children aged three to 14 years who had high-risk conditions.1,3 One study3 found that for every 100 children, an annual average of six to 15 outpatient visits and three to nine courses of antibiotics were attributable to influenza. Recently, neurologic complications of influenza in children have been more widely recognized, including encephalopathy and death.
Influenza is common among children. The illness attack rate is highest in children, at 14 to 40 percent yearly, with attack rates typically over 30 percent in preschool-aged children.5-7
Trivalent inactivated influenza vaccine (TIV) has moderate efficacy in young children and good efficacy in older children. A study8 of children aged one through 15 years found TIV to be 77 to 91 percent efficacious against influenza type A respiratory illness with efficacy defined by seroconversion of 44 to 49 percent among children one to five years of age, 74 to 76 percent among children six to 10 years of age, and 70 to 81 percent among children 11 to 15 years of age. Another study9 found an efficacy rate of 56 percent against influenza illness among children aged three to nine years. In the first year of a third study,10 efficacy was 66 percent against culture-confirmed influenza among children six to 24 months of age.
Because TIV is not live, it cannot cause influenza. Influenza vaccine can cause local reactions such as soreness at the injection site. In young children who have not been exposed to influenza vaccine, fever, malaise, and myalgia can occur. In one trial, fever occurred in 11.5 percent of children one to five years of age and in 5 percent of children aged six to 15 years.8 One study11 from the Vaccine Safety Datalink found that no serious reactions were associated with influenza vaccination among 251,600 children younger than 18 years of age who received over 438,000 doses of inactivated influenza vaccine. The Centers for Disease Control and Prevention's (CDC's) Vaccine Information Statement on Influenza has been updated and is available on the CDC Web site at http://www.cdc.gov/nip/publications/VIS/default.htm.
Useful Web sites for current immunization information include the following: the CDC National Immunization Program Web site (http://www.cdc.gov/nip); the AAFP Web site (http://www.aafp.org/x10615.xml), which contains AAFP clinical policies on immunization; the Group on Immunization Education of the Society of Teachers of Family Medicine's Web site (http://www.immunizationed.org), which is a site developed by family physician educators and has free Palm OS and Windows applications of the childhood schedule; the Immunization Action Coalition Web site (http://www.immunize.org); and the National Network for Immunization Information Web site (http://www.immunizationinfo.org).
The Author
Richard K. Zimmerman, M.D., M.P.H., is associate professor in the Department of Family Medicine and Clinical Epidemiology at the University of Pittsburgh (Pa.) School of Medicine. Dr. Zimmerman was chair of the Influenza Working Group of the ACIP during the development of the Recommended Adult Immunization Schedule, United States, 2005.
REFERENCES
1. 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.
2. Harper SA, Fukuda K, Uyeki TM, Cox NJ, Bridges; Centers for Disease Control and Prevention (CDC) Advisory Committee on Immunization Practices (ACIP). Prevention and control of influenza: recommendations of the Advisory Committee on Immunization Practices (ACIP) [Published correction in MMWR Recomm Rep 2004;53:743]. MMWR Recomm Rep 2004;53(RR-6):1-40.
3. 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.
4. 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.
5. Sullivan KM, Monto AS, Longini IM Jr. Estimates of the U.S. health impact of influenza. Am J Public Health 1993;83:1712-6.
6. Glezen WP. Considerations of the risk of influenza in children and indications for prophylaxis. Rev Infect Dis 1980;2:408-20.
7. Glezen WP, Taber LH, Frank AL, Gruber WC, Piedra PA. Influenza virus infections in infants. Pediatr Infect Dis J 1997;16:1065-8.
8. Neuzil KM, Dupont WD, Wright PF, Edwards KM. Efficacy of inactivated and cold-adapted vaccines against influenza A infection, 1985 to 1990: the pediatric experience. Pediatr Infect Dis J 2001;20:733-40.
9. Clover RD, Crawford S, Glezen WP, Taber LH, Matson CC, Couch RB. Comparison of heterotypic protection against influenza A/Taiwan/86 (H1N1) by attenuated and inactivated vaccines to A/Chile/83-like viruses. J Infect Dis 1991;163:300-4.
10. Hoberman A, Greenberg DP, Paradise JL, Rockette HE, Lave JR, Kearney DH, et al. Effectiveness of inactivated influenza vaccine in preventing acute otitis media in young children: a randomized controlled trial. JAMA 2003;290:1608-16.
11. France EK, Glanz JM, Xu S, Davis RL, Black SB, Shinefield HR, et al. Safety of the trivalent inactivated influenza vaccine among children: a population-based study. Arch Pediatr Adolesc Med 2004;158:1031-6.
Practice Guideline Briefs
Definition of Metabolic Syndrome
There has been disagreement in the medical community over the definition of the metabolic syndrome. The National Heart, Lung, and Blood Institute collaborated with the American Heart Association to examine the issues associated with the definition. Their report is available online at http://www.circulationaha.org.
The metabolic syndrome seems to have three potential etiologies: obesity and disorders of adipose tissue; insulin resistance; and a constellation of independent factors (e.g., molecules of hepatic, vascular, and immunologic origin) that mediate specific components of the metabolic syndrome. Other factors such as aging, proinflammatory state, and hormonal changes also have been implicated.
The clinical criteria for the diagnosis of metabolic syndrome, as defined in the National Cholesterol Education Program's Adult Treatment Panel III (ATP III) report, include waist circumference of more than 102 cm (40 in) in men and more than 88 cm (35 in) in women; triglyceride levels of at least 150 mg per dL (1.70 mmol per L); high-density lipoprotein cholesterol levels of less than 40 mg per dL (1.04 mmol per L) in men and less than 50 mg per dL (1.30 mmol per L) in women; blood pressure of at least 130/85 mm Hg; and fasting glucose levels of at least 110 mg per dL (6.10 mmol per L).
ATP III did not include impaired glucose tolerance, as detected by an oral glucose tolerance test (OGTT) or two-hour postglucose challenge, in the risk factors for metabolic syndrome. Its added value for determining cardiovascular risk appears small, and the benefit did not outweigh the inconvenience and cost of administering the OGTT in clinical practice. However, conference participants suggested adding OGTT at the physician's discretion in patients without diabetes with ATP III-defined metabolic syndrome or two or more metabolic risk factors. In the absence of impaired fasting glucose, impaired glucose tolerance could count as a risk factor to define metabolic syndrome.
DVDs on Childhood Overweight and Obesity
The U.S. Department of Health and Human Services has developed two DVDs to teach children and their parents about smart eating and physical activity, and to educate physicians about the best ways to prevent and treat obesity in children. The American Academy of Family Physicians and the American Academy of Pediatrics are encouraging physicians to view the DVDs and offer copies of the family version to their patients. The DVDs are available by calling 800-358-9295, or visiting http://www.ahrq.gov/child/dvdobesity.htm.
"Max's Magical Delivery: Fit for Kids” is a 30-minute tool designed for families and children ages five to nine years to provide them with fun ways to incorporate physical activity and healthy foods into their daily lives.
"Childhood Obesity: Combating the Epidemic” is a 55-minute tool for physicians and other health care professionals to help them learn new methods for assessing and treating childhood overweight and obesity. Continuing medical education credits are available for physicians who view the DVD. Additional information is available online at http://www.discoveryhealthcme.com.
CDC Report on Asthma
Asthma prevalence varies widely among different races, according to a report from the Centers for Disease Control and Prevention. "Asthma Prevalence and Control Characteristics by Race/Ethnicity-United States, 2002” is available online at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5307a1.htm.
Data from a telephone survey of U.S. adults showed that the highest rates of asthma occurred in non-Hispanics of multiple races (15.6 percent), American Indians and Alaska natives (11.6 percent), blacks (9.3 percent), and non-Hispanic whites (7.6 percent). The lowest rates were observed in Native Hawaiians and Pacific Islanders (1.3 percent), Asians (2.9 percent), and Hispanics (5.0 percent).
Minorities also reported more emergency department (ED) visits for treatment of their asthma. Blacks and Hispanics were most likely to visit the ED (37.2 and 26.0 percent of current asthma patients, respectively); non-Hispanics of multiple races and whites had the lowest rates of ED visits for asthma treatment (13.5 and 14.5 percent, respectively).
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