Updated AAP Guidelines for Meningococcal Immunization in Children and Adolescents

The Committee on Infectious Diseases of the American Academy of Pediatrics (AAP) has issued a policy statement that includes guidelines for the routine use of the newly approved tetravalent meningococcal conjugate vaccine (MCV4) and updated guidelines for the use of the standard tetravalent meningococcal polysaccharide vaccine (MPSV4). The full policy statement was published in the August 2005 issue of Pediatrics and is available online at http://www.pediatrics.org/cgi/content/full/116/2/496.

The U.S. Food and Drug Administration approved MCV4 in 2005 for use in persons 11 to 55 years of age. The new vaccine has several advantages over the older MPSV4, including a booster response after the second dose, longer duration of immunity, and effectiveness against most strains that commonly infect persons 11 years and older.

The AAP committee has made the following recommendations about meningococcal immunization:

• MCV4 or MPSV4 should be used in patients 11 years and older to prevent meningococcal disease outbreaks, although MPSV4 should be used in patients two to 10 years of age.

• Physicians should discuss immunization with patients during a routine office visit at 11 to 12 years of age.

• Two age groups should receive routine immunization with MCV4: (1) children 11 to 12 years of age during their routine office visit, and (2) adolescents when they turn 15 years of age or when they start high school, whichever comes first.

• College freshmen should receive MCV4 if they plan to live in dormitories.

• Patients who are at high risk of meningococcal disease (i.e., those with terminal complement deficiency, those with anatomic or functional asplenia, and those who travel to or reside in high-risk countries) should receive MCV4 if they are 11 years or older.

• Patients with human immunodeficiency virus infection may choose to receive MCV4 if they are 11 years or older.

• Patients who wish to decrease their risk of developing meningococcal disease may choose to receive MCV4 if they are 11 years or older.

• It may be appropriate to revaccinate adolescents with MCV4 three to five years after initial immunization with MPSV4.

ACOG Recommendations for Medical Management of Abortion

The American College of Obstetricians and Gynecologists (ACOG) has released evidence-based guidelines for medical abortion. The recommendations were published in the October 2005 issue of Obstetrics & Gynecology.

Comparisons of regimens for medical abortion are summarized in the accompanying table. Medical contra-indications to abortion with mifepristone (Mifeprex) regimens include confirmed or suspected ectopic pregnancy or undiagnosed adnexal mass, long-term systemic corticosteroid therapy, chronic adrenal failure, severe anemia, coagulopathy or anticoagulant therapy, current use of an intrauterine device, and mifepristone intolerance or allergy. Misoprostol (Cytotec) should not be used in women with uncontrolled seizure disorders or in those with an allergy or intolerance to misoprostol or other prostaglandins.

Social or psychological contraindications to medical abortion are more common than medical contraindications. Women are not good candidates for medical abortion if they do not wish to take responsibility for their own care, are anxious to have the abortion over quickly, cannot return for follow-up visits, or cannot understand the instructions. Other nonmedical criteria to be considered include access to a telephone and to 24-hour emergency medical treatment. Counseling should include a description of cramping and bleeding and should indicate that the process may not be completed for several weeks. Counseling also must include discussion of pregnancy options to ensure that a woman is certain about her decision to have an abortion. If she is uncertain, the decision about abortion technique must be delayed, even if the delay means that she will not be able to choose a medical method.

Intervention guidelines vary for women who have a persistent gestational sac detected by ultrasonography without evidence of embryonic cardiac activity or continuing development. Protocols used in mifepristone studies define a retained sac two weeks after mifepristone administration as an indication for suction evacuation. However, studies using methotrexate and misoprostol suggest that intervention for a nonviable pregnancy is unnecessary and that expulsion will occur, on average, between 22 and 29 days after the methotrexate is administered. For this reason, mifepristone studies in the United States over the past six years have allowed approximately 36 days to elapse before recommending surgical intervention.

ACOG made the following recommendations based on good, consistent scientific evidence:

• Medical abortion should be considered a medically acceptable alternative to surgical abortion in selected, carefully counseled, and informed women.

• The protocol of administering 600 mg of mifepristone orally followed approximately 48 hours later by 400 mcg of misoprostol orally, which is approved by the U.S. Food and Drug Administration (FDA) for medical abortion, is safe and effective up to seven weeks’ gestation (calculated from the first day of the last menstrual period).

• Compared with the FDA-approved regimen, mifepristone/misoprostol regimens using 200 mg of mifepristone orally and 800 mcg of misoprostol vaginally are associated with a decreased rate of continuing pregnancies, decreased time to expulsion, fewer side effects, improved complete abortion rates, and lower cost for women with pregnancies up to nine weeks’ gestation.

• A methotrexate/misoprostol regimen is appropriate for medical abortion only in pregnancies up to seven weeks’ gestation. Women using this regimen may wait up to four weeks for complete abortion to occur.

• Mifepristone/misoprostol regimens using 200 mg of mifepristone orally and 800 mcg of misoprostol vaginally generally are preferred to regimens using methotrexate and misoprostol or misoprostol only.

• A patient may administer misoprostol safely and effectively, orally or vaginally, in her home as part of a medical abortion regimen.

The following recommendations were based on limited scientific evidence:

• Because the teratogenicity of medical abortifacients becomes an important issue if the pregnancy continues, patients must be informed of the need for a surgical abortion in the event of a failed medical abortion.

• Gestational age should be confirmed by clinical evaluation or ultrasonography.

The following recommendations were based on consensus and expert opinion:

• Surgical curettage must be available on a 24-hour basis for women with hemorrhage, even though less than 1 percent of women undergoing a medical abortion will need curettage because of excessive bleeding.

• Pretreatment Rho(D) immunoglobulin (RhoGAM) should be administered if indicated.

• No data exist to support the universal use of prophylactic antibiotics for medical abortion.