Practice Guidelines
Recommended Childhood and Adolescent Immunization Schedule, United States, 2006
The Centers for Disease Control and Prevention's (CDC's) Advisory Committee on Immunization Practices (ACIP), the American Academy of Family Physicians, and the American Academy of Pediatrics have released the 2006 recommended immunization schedule for children and adolescents (see accompanying charts).
A key change this year is the recommendation for all children one year of age to be vaccinated against hepatitis A. In October 2005, a CDC advisory committee recommended that all children in the United States receive hepatitis A vaccine. Vaccination previously had been recommended only in children from states with the highest rates of hepatitis A. However, approximately two thirds of cases now are reported from states in which hepatitis A vaccination was not recommended. The ACIP recommends that children receive the first dose of a two-dose series of hepatitis A vaccine between one and two years of age.
In 1999, the ACIP recommended routine hepatitis A vaccination for children living in 11 states with the highest rates of hepatitis A (i.e., Alaska, Arizona, California, Idaho, Nevada, New Mexico, Oklahoma, Oregon, South Dakota, Utah, and Washington). During the period before vaccine was available, the average incidence of hepatitis A in these states had been at least 20 cases per 100,000 persons, about twice the national average. In 1999, the ACIP also recommended that vaccination be considered in an additional six states in which the average incidence had been at least 10 but less than 20 cases per 100,000 persons (i.e., Arkansas, Colorado, Missouri, Montana, Texas, and Wyoming). During the period before the vaccine was available, approximately two thirds of all cases of hepatitis A infection nationwide were reported in these 17 states.
Another change in the 2006 recommendations is the replacement of tetanus and diphtheria toxoid vaccine with tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis absorbed (Tdap) vaccine in children 11 years and older. The U.S. Food and Drug Administration recently licensed two Tdap vaccines for adolescents and adults. Boostrix, manufactured by GlaxoSmithKline, was licensed in May 2005 for use in adolescents 10 through 18 years of age. Adacel, manufactured by Sanofi Pasteur, was licensed in June 2005 for use in persons 11 through 64 years of age. Boostrix and Adacel are the first pertussis vaccines licensed for use in adolescents and adults.
Reported cases of pertussis have increased from 1,020 cases in 1976 to 25,827 cases in 2004, a 40-year high. Reported pertussis-related deaths among infants increased from approximately 10 per year in the 1990s to about 20 per year since 2000.
Practice Guideline Briefs
Controlling Obesity: School, Work, and Leisure
The Centers for Disease Control and Prevention's (CDC's) Task Force on Community Preventive Services reviewed school- and worksite-based strategies for the short-term prevention and control of overweight and obesity. The full report, "Public Health Strategies for Preventing and Controlling Overweight and Obesity in School and Worksite Settings," was published in the October 7, 2005, issue of Morbidity and Mortality Weekly Report (MMWR) Recommendations and Reports and is available online at http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5410a1.htm.
The task force found insufficient evidence to make recommendations on school-based interventions. However, the report suggests interventions that result in small but positive changes may be useful, such as programs that combine nutrition and physical activity elements, allocation of additional time for physical education during the school day, inclusion of noncompetitive sports such as dance, and reduction of sedentary activities such as watching television.
For worksite-based strategies, the task force recommends the use of combined nutrition and physical activity programs, and it suggests that employers be given evidence on the effectiveness and cost-effectiveness of worksite interventions to control overweight and obesity. Cost-effectiveness data can be found on the Community Guide Web site at http://www.thecommunityguide.org/obese.
The task force concluded that much more research is needed to enable the control and reversal of obesity trends. Topics for potential study include parental involvement, outcomes of environmental changes such as making stairs more accessible and providing easy access to nutritious food, the combination of work and community-based interventions, and strategies for maintaining initial weight-loss success.
leisure-time inactivity
According to another CDC report, participation in physical activity outside the workplace has improved in the past decade. The report, "Trends in Leisure-Time Physical Inactivity by Age, Sex, and Race/Ethnicity-United States, 1994-2004," was published in the October 7, 2005, issue of MMWR and is available online at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5439a5.htm.
The report states that the percentage of the U.S. population that participates in no physical activity outside of regular work decreased between 1994 and 2004 in every age group. However, more than 30 percent of adults 70 years or older are inactive, and the CDC recommends that public health messages focus on raising awareness of opportunities for physical activity. The report also suggests that community programs be made more accessible to racial minorities to reduce disparities among ethnic groups.
This schedule indicates the recommended ages
for routine administration of currently licensed childhood vaccines, as of
December 1, 2005, for children through age 18 years.Anydose not administered at
the recommended age should be administered at any subsequent visit when
indicated and feasible.
Indicates
age groups that warrant special effort to administer those vaccines not
previously administered. Additional vaccines may be licensed and recommended
during the year. Licensed combination vaccines may be used when ever any
components of the combination are indicated and other components of the vaccine
are not contraindicated and if approved by the Food and Drug Administration for
that dose of theseries. Providers should consult the respective ACIP statement
for detailed recommendations. Clinically significant adverse events that follow
immunization should be reported to the Vaccine Adverse Event Reporting System
(VAERS). Guidance about how to obtain andcomplete a VAERS form is available at
www.vaers.hhs.gov or by
telephone,800-822-7967.
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Range of recommended ages
11 - 12 year old assessment1. Hepatitis B vaccine (HepB). AT BIRTH: All newborns should receive monovalent HepB soon after birth and before hospital discharge. Infants born to mothers who are HBsAg-positive should receive HepB and 0.5 mL of hepatitis B immune globulin (HBIG) within 12 hours of birth. Infants born to mothers whose HBsAg status is unknown should receive HepB within 12 hours of birth. The mother should have blood drawn as soon as possible to determine her HBsAg status; if she is HBsAg-positive, the infant should receive HBIG as soon as possible (no later than one week of age). For infants born to HBsAg-negative mothers, the birth dose can be delayed in rare circumstances, but only if a physician's order to withhold the vaccine and a copy of the mother's original HBsAg-negative laboratory report are documented in the infant's medical record. FOLLOWING THE BIRTH DOSE: The HepB series should be completed with monovalent HepB or a combination vaccine containing HepB. The second dose should be administered at one to two months of age. The final dose should be administered at 24 weeks of age or later. It is permissible to administer four doses of HepB (e.g., when combination vaccines are given after the birth dose); however, if monovalent HepB is used, a dose at four months of age is not needed. Infants born to HbsAg-positive mothers should be tested for HBsAg and antibody to HBsAg after completion of the HepB series at nine to 18 months of age (generally at the next well-child visit after completion of the vaccine series).
2. Diphtheria and tetanus toxoids and acellular pertussis vaccine (DTaP). The fourth dose of DTaP may be administered as early as 12 months of age, provided that six months have elapsed since the third dose and the child is unlikely to return at 15 to 18 months of age. The final dose in the series should be given at age four years or older. Tetanus and diphtheria toxoids and acellular pertussis vaccine (Tdap, adolescent preparation) is recommended at age 11 to 12 years for those who have completed the recommended childhood DTP/DTaP vaccination series and have not received a Td booster dose. Adolescents 13 to 18 years of age who missed the 11- to 12-year Td/Tdap booster dose also should receive a single dose of Tdap if they have completed the recommended childhood DTP/DTaP vaccination series. Subsequent tetanus and diphtheria toxoids (Td) are recommended every 10 years.
3. Haemophilus influenzae type b conjugate vaccine (Hib). Three Hib conjugate vaccines are licensed for infant use. If PRP-OMP (PedvaxHIB or ComVax [Merck]) is administered at ages two and four months, a dose at age six months is not required. DTaP/Hib combination products should not be used for primary immunization in infants two, four, or six months of age but can be used as boosters after any Hib vaccine. The final dose in the series should be administered at age 12 months or older.
4. Measles, mumps, and rubella vaccine (MMR). The second dose of MMR is recommended routinely at age four to six years but may be administered during any visit, provided that at least four weeks have elapsed since the first dose and 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 age 11 to 12 years.
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 13 years and older should receive two doses administered at least four weeks apart.
6. Meningococcal vaccine (MCV4). MCV4 should be given to all children at the 11- to 12-year-old visit, as well as to unvaccinated adolescents at high school entry (15 years of age). Other adolescents who wish to decrease their risk for meningococcal disease also may be vaccinated. All college freshmen living in dormitories should also be vaccinated, preferably with MCV4, although meningococcal polysaccharide vaccine (MPSV4) is an acceptable alternative. Vaccination against invasive meningococcal disease is recommended for children and adolescents two years and older with terminal complement deficiencies or anatomic or functional asplenia and certain other high risk groups (see MMWR 2005;54[RR-7]:1-21); use MPSV4 for children two to 10 years of age and MCV4 for older children, although MPSV4 is an acceptable alternative.
7. Pneumococcal vaccine. The heptavalent pneumococcal conjugate vaccine (PCV) is recommended for all children two to 23 months of age and for certain children 24 to 59 months of age. The final dose in the series should be given at age 12 months or older. Pneumococcal polysaccharide vaccine (PPV) is recommended in addition to PCV for certain high-risk groups. See MMWR 2000;49(RR-9):1-35.
8. Influenza vaccine. Influenza vaccine is recommended annually for children six months and older with certain risk factors (including, but not limited to, asthma, cardiac disease, sickle cell disease, human immunodeficiency virus, diabetes, and conditions that can compromise respiratory function or handling of respiratory secretions or that can increase the risk for aspiration), health care professionals, and other persons (including household members) in close contact with persons in groups at high risk (see MMWR 2005;54[RR-8]:1-55). In addition, healthy children six to 23 months of age and close contacts of healthy children zero to five months of age are recommended to receive influenza vaccine because children in this age group are at substantially increased risk for influenza-related hospitalizations. For healthy persons five to 49 years of age, the intranasally administered, live, attenuated influenza vaccine (LAIV) is an acceptable alternative to the intramuscular trivalent inactivated influenza vaccine (TIV). See MMWR 2005;54(RR-8):1-55. Children receiving TIV should be administered a dosage appropriate for their age (0.25 mL if six to 35 months of age or 0.5 mL if three years or older). Children eight years and younger who are receiving influenza vaccine for the first time should receive two doses (separated by at least four weeks for TIV and at least six weeks for LAIV).
9. Hepatitis A vaccine (HepA). HepA is recommended for all children at one year of age (i.e., 12 to 23 months). The two doses in the series should be administered at least six months apart. States, counties, and communities with existing HepA vaccination programs for children two to 18 years of age are encouraged to maintain these programs. In these areas, new efforts focused on routine vaccination of one-year-old children should enhance, not replace, ongoing programs directed at a broader population of children. HepA is also recommended for certain high-risk groups (see MMWR 1999;48[RR-12]:1-37).
The Childhood and Adolescent Immunization Schedule is approved by: Advisory Committee on Immunization Practices www.cdc.gov/nip/acip • American Academy of Pediatrics www.aap.org • American Academy of Family Physicians www.aafp.org
1. Diphtheria, tetanus, pertussis. The fifth dose is not necessary if the fourth dose was administered after the fourth birthday.
2. Inactivated polio virus (IPV). For children who received an all-IPV or all-oral poliovirus (OPV) series, a fourth dose is not necessary if the third dose was administered at age four years or older. If OPV and IPV were administered as part of a series, a total of four doses should be given, regardless of the child's current age.
3. Hepatitis B. Administer the three-dose series to all children and adolescents younger than 19 years if they were not previously vaccinated.
4. Measles, mumps, rubella. The second dose is recommended routinely at age four to six years but may be administered earlier if desired.
5. H. influenzae type b. Vaccine is not generally recommended for children five years and older.
6. H. influenzae type b. If current age is less than 12 months and the first two doses were PRP-OMP (PedvaxHIB or ComVax [Merck]), the third (and final) dose should be administered at age 12 to 15 months and at least eight weeks after the second dose.
7. Pneumococcal vaccine. Vaccine is not generally recommended for children five years and older.
8. Tetanus, diphteria (Td). Adolescent tetanus, diphtheria, and pertussis vaccine (Tdap) may be substituted for any dose in a primary catch-up series or as a booster if age appropriate for Tdap. A five-year interval from the last Td dose is encouraged when Tdap is used as a booster dose. See ACIP recommendations for further information.
9. IPV. Vaccine is not generally recommended for persons 18 years and older.
10. Varicella vaccine. Administer the two-dose series to all susceptible adolescents 13 years and older.
Report adverse reactions to vaccines through the federal Vaccine Adverse Event Reporting System. For information on reporting reactions followingimmunization, please visit www.vaers.hhs.gov 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.
For additional information about vaccines, including precautions and contraindications for immunization and vaccine shortages, please visit the National Immunization Program Website at www.cdc.gov/nip or contact 800-CDC-INFO (800-232-4636) (In English, En Español — 24/7 )
Emergency Contraception: AAP Review
In a statement published in the October 2005 issue of Pediatrics, the American Academy of Pediatrics (AAP) recommends that education and counseling about emergency contraception be incorporated into the annual preventive visits of adolescent patients when issues of sexuality are addressed. Physicians also should provide community-specific guidance on access and availability of emergency contraception and consider writing an advance prescription. The full policy statement, "Emergency Contraception," is available online at http://www.pediatrics.org/cgi/content/full/116/4/1026.
Emergency contraception is approximately 80 percent effective for preventing pregnancy when the first dose is taken within 72 hours of sexual intercourse. Two medications have been approved by the U.S. Food and Drug Administration (FDA) for use as emergency contraception-a combination estrogen/progestin pill (Preven) and a progestin-only formulation (Plan B). In addition, the off-label use of combination oral contraceptives at higher dosages (e.g., two doses taken 12 hours apart, each containing at least 100 mcg of ethinyl estradiol and at least 0.50 mg of levonorgestrel) has been declared safe and effective by the FDA Reproductive Health Advisory Committee.
Emergency contraception is indicated when unprotected or inadequately protected sex has taken place within the previous 72 to 120 hours (although the FDA approves the use only within 72 hours). The AAP states that progestin-only emergency contraception may be prescribed over the telephone, but an office visit should be scheduled for 10 to 14 days after use to exclude pregnancy and to provide contraceptive advice and screening for sexually transmitted diseases.
The AAP report suggests that an antiemetic agent taken one hour before estrogen-containing medication may decrease the risk and severity of nausea. The progestin-only method is better tolerated and may be more effective than combination methods. Because of the short duration of use, combination emergency contraception may be offered to patients with chronic conditions in whom estrogen-containing oral contraceptives are contraindicated. There are no contraindications for the use of progestin-only emergency contraception. Almost all patients menstruate within three weeks of taking emergency contraception; patients who have not menstruated within three weeks should be tested for pregnancy.
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| Copyright © 2006 by the American
Academy of Family Physicians. |
