Practice Guidelines
2007 Childhood and Adolescent Immunization Schedules: Evolution or Intelligent Design?
Guideline source: Advisory Committee on Immunization Practices, American Academy of Pediatrics, American Academy of Family Physicians
Literature search described? No
Evidence rating system used? No
Published sources: Morbidity and Mortality Weekly Report, January 2007; Pediatrics, January 2007; American Family Physician, January 1, 2007
Available at: http://www.cdc.gov/mmwr
See related editorial on page 28.
Many family physicians may be surprised to learn that the recommended immunization schedule for children and adolescents is in early adulthood (at age 25). The first childhood immunization schedule was released in 19831 and provided guidance to physicians as to which of the four vaccines recommended at the time (i.e., diphtheria and tetanus toxoids and pertussis [DTP], oral poliovirus vaccine [OPV], measles, mumps, and rubella [MMR], and tetanus and diphtheria toxoid [Td]) to administer at each of seven age ranges (i.e., two, four, six, 15, and 18 months, four to six years, and 14 to 16 years). All told, a child born in 1983 would receive 11 vaccine doses between birth and 18 years of age.
In 1995 the schedule became "harmonized," gaining endorsement from three sponsoring organizations: the Advisory Committee on Immunization Practices (ACIP; http://www.cdc.gov/nip/acip), the American Academy of Pediatrics (AAP; http://www.aap.org), and the American Academy of Family Physicians (AAFP; http://www.aafp.org). As part of this arrangement, the schedule is now published simultaneously during January in Morbidity and Mortality Weekly Report, Pediatrics, and American Family Physician.
The recommended schedule continues to provide guidance to busy physicians. Today, American children receive 39 recommended vaccine doses by age 18, a 3.5-fold increase over the past 25 years. This explosion of antigens has been associated with a 6.3-fold increase in vaccination-related costs. The estimated 1983 private market cost for one child to receive all recommended vaccines was $254 (adjusted to present day, excluding administrative costs); this amount has grown to $1,601 ($1,744 when optional annual influenza vaccine is added for children six to 18 years of age).2 The vaccine cost alone to fully immunize each U.S. birth cohort (approximately 4 million children) is an estimated $6.4 billion.
The recent expansion of the recommended vaccines includes 14 additional vaccine doses as follows:
• Meningococcal vaccine (one dose at 11 or 12 years of age)3
• Tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccine (one dose at 11 or 12 years of age)3
• Hepatitis A vaccine (two doses six months apart at one to two years of age)3
• Three additional doses of influenza vaccine (starting at six months of age; two doses in the first season, then one dose annually through 59 months of age)3
• Rotavirus vaccine (three doses at two, four, and six months of age)3
• Human papillomavirus vaccine (three doses at 11 or 12 years of age)4
• Second dose of varicella vaccine (at four to six years of age)4
Such changes present a challenge to the clinically active family physician; the complicated array of antigens and timing for administration can make one's head swim. Fortunately, this expansion also has shaped the evolution of the recommended schedules. This is where the recommended immunization schedules become essential clinical tools.
Readers of American Family Physician will note that the childhood and adolescent schedule has been divided into two distinct schedules; this "reproductive activity" should not be unexpected for an entity now in early adulthood. This evolution of the recommended schedule has not been random, however, but rather has been guided by intelligent design.
ACIP maintains a Harmonized Schedule Working Group, which is charged with designing, revising, and editing the annual schedule of recommended immunizations. The AAFP is represented on the working group by one of its ACIP liaisons, and the resultant schedules are reviewed by the AAFP Commission on Science and approved by the AAFP Board of Directors. For the two new schedules, the working group also used focus groups to evaluate possible formats for the harmonized schedules. Thus, 69 health care professionals were engaged, and a clear preference for the resulting schedules emerged. Moreover, the health care professionals were thrilled that their views were assessed, valued, and used.
The original recommended immunization schedule had a strong reinforcing effect on what we now consider to be the routine childhood schedule of preventive care or well-child visits. Well-child examinations at two, four, six, 15, and 18 months and at four to six years are practically etched in stone. The establishment of the seven- to 18-year schedule, which contains the 11- to 12-year immunization platform, provides ample opportunity and reinforcement for the thoughtful and evidence-based creation of a routine health promotion visit at the beginning of adolescence. Furthermore, this routine visit must be harmonized and embraced across all specialties providing care to younger adolescents. The arrival of the new recommended immunization schedules serves as a call for the evolution of preventive care for children and adolescents to be guided by intelligent and thoughtful design.
editor's note: The author serves as liaison to ACIP for the AAFP and is a member of the Harmonized Schedule Working Group.
Address correspondence to Jonathan Temte, M.D., Ph.D., at jon.temte@fammed.wisc.edu. Reprints are not available from the author.
REFERENCES
1. Centers for Disease Control and Prevention. General recommendations on immunization. MMWR Morb Mortal Wkly Rep 1983;32:1-8, 13-7.
2. Centers for Disease Control and Prevention. CDC Vaccine price list. Accessed December 9, 2006, at: http://www.cdc.gov/nip/vfc/cdc_vac_price_list.htm.
3. Centers for Disease Control and Prevention. ACIP Recommendations. Accessed December 9, 2006, at: http://www.cdc.gov/nip/publications/acip-list.htm.
4. Centers for Disease Control and Prevention. ACIP Provisional recommendations. Accessed December 9, 2006, at: http://www.cdc.gov/nip/recs/provisional_recs/default.htm.
Practice Guideline Briefs
ACOG Endorses Ultrasonography for Management of Alloimmunization
Advances in ultrasonography have led to new methods of management of alloimmunization in pregnant women and may allow for a more thorough and less invasive workup with fewer maternal and fetal risks, according to a practice bulletin by the American College of Obstetricians and Gynecologists (ACOG).
In a study of 111 fetuses at risk for anemia secondary to red cell alloimmunization, researchers used Doppler ultrasonography to measure peak systolic velocity in the fetal middle cerebral artery. Values of more than 1.5 times the median for gestational age were predictive of moderate to severe fetal anemia (sensitivity = 100 percent; specificity = 88 percent). However, ACOG notes that correct technique is critical and that this procedure should be used only by physicians with adequate training and clinical experience.
The initial management of a pregnancy involving an alloimmunized patient is determination of the paternal erythrocyte antigen status. If the father is negative for the erythrocyte antigen in question and if it is certain that he is, indeed, the father, further assessment and intervention are unnecessary.
Administration of Rho(D) immune globulin (Rhogam) is indicated only in Rh-negative women who were not previously sensitized. At the first prenatal visit, all pregnant women should be tested for ABO blood group and Rh-D type, and they should be screened for erythrocyte antibodies. These assessments should be repeated in each subsequent pregnancy. The American Association of Blood Banks also recommends repeated antibody screening before administration of Rho(D) immune globulin at 28 weeks' gestation, at the time of any event in the pregnancy, and in the postpartum period.
The full ACOG report was published in the August 2006 issue of Obstetrics & Gynecology.
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