CDC Merges Child, Teen Immunization Schedules for 2013

Perhaps one of the more immediately noticeable changes to the 2013 immunization schedules is that the CDC has pared down the total number of schedules released by combining the previously separate child and adolescent schedules into a single 0- to 18-year schedule (5-page PDF; About PDFs).

Overall, the new childhood and adult (4-page PDF; About PDFs) schedules contain more than a dozen changes, but they should be a bit easier to follow than before, said Jamie Loehr, M.D., of Ithaca, N.Y., the AAFP's liaison to the CDC's Advisory Committee on Immunization Practices (ACIP).

"While the catch-up schedule has not been merged (with the child/adolescent recommendations), the footnotes for what used to be all three schedules are now combined," Loehr said. "There is a lot of overlap, and the ACIP felt that it was better to have all of the routine vaccines on one page rather than on different, separate pages. They tested that theory and found that the catch-up schedule is different enough that it should be on its own separate page, but the visual advantage of being able to see the whole 18 years at once outweighed the benefits of having two separate (child and adolescent) schedules."

Each of the new schedules, which were developed in conjunction with the AAFP and other groups, contain changes that are especially pertinent to family physicians, said Loehr.

Among those changes is a new recommendation that infants ages 6 months through 11 months who are traveling anywhere outside the United States, including to other industrialized countries, should receive measles, mumps and rubella (MMR) vaccine. According to Loehr, "If they are going to France, it is just as important to get them immunized as if they are going to Costa Rica, because there is enough measles, mumps and rubella in European countries for us to say, 'Yes, you should go ahead and do it.'"

Two new tetanus, diphtheria and acellular pertussis (Tdap) vaccine recommendations are contained in the 2013 adult schedule, and the ACIP is calling for all adults ages 65 and older to be offered the vaccine. In addition, all pregnant women should receive a dose of Tdap in the late second or early third trimester of each pregnancy, regardless of their Tdap immunization history.

"Based on new data of waning immunity to pertussis, the new recommendation is to give Tdap during every pregnancy between 28 and 32 weeks," Loehr said.

"For people over 65, the ACIP recommends (GlaxoSmithKline's) Boostrix, because it has that indication on the label. However, if Boostrix is unavailable, off-label use of (Sanofi Pasteur's) Adacel is valid, because we do not want people walking out without the vaccination simply because an office doesn't have the right one."

A new footnote dealing with the administration of the 13-valent pneumococcal conjugate vaccine (PCV13), which is marketed by Pfizer Inc. as Prevnar 13, has been added. Specifically, the 2013 adult schedule contains changes regarding administration of PCV13 and the 23-valent pneumococcal polysaccharide vaccine (PPSV23), which is marketed by Merck and Co. as Pneumovax, in immunocompromised adults age 19 or older, Loehr said.

"For the subset of high-risk people who get both (PCV13 and PPSV23) -- including those with chronic renal failure and nephrotic syndrome, functional or anatomic asplenia, cerebrospinal fluid leaks, or cochlear implants -- there are very specific rules," Loehr said. "If they've had the Pneumovax already, then you give PCV13 a year later. If they haven't had the PPSV23, you give Prevnar 13 first and then the Pneumovax two months later."

Loehr pointed out that, although rare, PCV13 also can cause issues when administered to children who require the Haemophilus influenzae type b-Neisseria meningitidis serogroups C and Y-tetanus toxoid (HibMenCY) vaccine, which is marketed by Sanofi Pasteur as Menactra.

"One specialized footnote that applies to Prevnar 13 is a fairly esoteric one that I have never run into," said Loehr. "You usually don't give Menactra to kids, but if a child has sickle cell disease or anatomic or functional asplenia, you would give (both Menactra) and Prevnar 13. The important thing is that you don't want to give both of them at the same time; you have to separate them by one month."

Two quadrivalent influenza vaccines -- one inactivated and one live virus -- will be available for the 2013-14 influenza season. Loehr said the new quadrivalent products compelled the ACIP to change some of the commonly used terminology used in the footnotes.

"It is going to be a transition year, so what we used to call 'TIV' (trivalent influenza vaccine) is now called 'IIV' (injectable influenza vaccine), versus the acronym for live attenuated influenza vaccine (LAIV), which remains unchanged," he said. "With the new quadrivalent vaccines in the system, we are now going to say 'trivalent IIV' or 'quadrivalent IIV' to differentiate between the two."

Tear-out versions of the 2013 immunization schedules will be available in the Feb. 1 issue of American Family Physician.