Guideline source: Centers for Disease Control and Prevention, Advisory Committee on Immunization Practices
Literature search described? No
Evidence rating system used? No
Published source: Morbidity and Mortality Weekly Report [in press]
The 2008 recommended immunization schedules for children and adolescents are unveiled in this issue of American Family Physician. There are no significant additions to this year's schedule. Rather, formatting has been simplified and footnotes have been updated for hepatitis B, pneumococcal, meningococcal, and influenza vaccines. Two changes are of note: the expanded age ranges for quadrivalent meningococcal conjugate vaccine (MCV4; Menactra) and for live, attenuated influenza vaccine (LAIV; Flumist).
MCV4 replaces the meningococcal polysaccharide vaccine (Menomune) as the preferred vaccine for children two to 10 years of age with terminal complement deficiencies, anatomic or functional asplenia, or certain other high-risk conditions. In addition, MCV4 is recommended for any previously unimmunized adolescent 11 to 18 years of age.1 Because adolescents present less often to their physicians for well care, any visit should be considered an opportunity to provide MCV4, the quadrivalent human papillomavirus vaccine (Gardasil), and tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine (Tdap; Adacel), as well as a second dose of varicella vaccine.
The approval of LAIV by the Advisory Committee on Immunization Practices (ACIP), as well as the vaccine's recommendation by the U.S. Food and Drug Administration and coverage by the Vaccines for Children Program, can only help to improve influenza immunization rates for young children in the United States. Based on the 2005 National Immunization Survey, only 20.6 percent of children six to 23 months of age were fully immunized for influenza.2 Estimated rates for full immunization in older children (24 to 59 months) ranged from 3.0 to 26.9 percent.3
During the 2006–07 influenza season, 73 children died of the disease.4 However, the morbidity and mortality associated with influenza can be significantly reduced in children. The number needed to vaccinate (NNV) to prevent one hospitalization for younger children (six to 23 months) is 1,031 to 3,050.5 For children 24 to 59 months of age, the NNV is estimated at 4,255 to 6,897.5 Furthermore, one outpatient visit is prevented for every 12 to 42 children immunized, regardless of age.5
In a rare head-to-head, double-blind, randomized controlled vaccine trial involving children six to 59 months of age, LAIV significantly outperformed trivalent inactivated vaccine (TIV).6 Two findings from this study were notable. First, only 491 culture-confirmed cases of influenza were identified in the 7,852 vaccine recipients (infection rate = 6.3 percent), regardless of type. Second, LAIV recipients had a 55 percent decrease in influenza infection compared with TIV recipients (P < .001).
LAIV is a nasal spray vaccine and is refrigerator stable. The following conditions are contraindications or pre-cautions for the use of LAIV in young children:
concomitant aspirin therapy
history of recurrent wheezing
medical conditions predisposing the patient to influenza complications.7
The widespread use of vaccines has profoundly altered children's health. A recent review underscores the declines in the prevalence of vaccine-preventable diseases (more than 92 percent) and deaths (more than 99 percent) in the United States.8 However, compared with the prevaccine prevalence of most vaccine-preventable diseases and their associated mortality rates, contemporary influenza remains an outlier, with extremely high prevalence and moderate mortality. New vaccines and new approaches can help address influenza's challenge, but they require coupling with the efforts of the medical community and within the medical home9 to ensure the health and safety of children.
editor's note: The authors serve as liaisons to ACIP for the AAFP, and Dr. Temte is a member of the Harmonized Schedule Working Group.