Update on recommendations from the Advisory Committee on Immunization Practices

The Advisory Committee on Immunization Practices advises the CDC and the Secretary of the Department of Health and Human Services on vaccine use in the civilian population in the United States.

ACIP vaccine recommendations are provisional until accepted by the CDC director and published in the Morbidity and Mortality Weekly Report.

The committee meets three times annually at the CDC Global Communications Center in Atlanta. Meetings are open to the public and also are broadcast live on the Internet. Information about ACIP structure and function can be found at www.cdc.gov/vaccines/recs/acip/.

During the ACIP meeting held on Feb. 24-25, several recommendations were made and other topics were discussed. Many of these topics, as well as others, will likely be revisited at this month’s ACIP meeting, scheduled for June 23-24.

• The ACIP recommended that pneumococcal conjugate vaccine 13-valent (PCV13) be administered to all children 2 through 59 months of age and to children 60 through 71 months of age who have underlying medical conditions that increase their risk of pneumococcal disease or complications from pneumococcal disease. Infants and children not immunized or incompletely immunized with pneumococcal conjugate vaccine 7-valent should begin or complete the schedule with PCV13 as shown in the childhood and adolescent immunization schedule. In addition, recommendations for use of PCV13 in children 6 through 18 years of age with high-risk conditions and pneumococcal polysaccharide vaccine 23- valent (PPSV23) in children 2 through 18 years of age who are at increased risk for invasive pneumococcal disease due to underlying medical conditions are provided. Underlying medical conditions include:

1. Immunocompetent children with chronic lung or heart disease, diabetes mellitus or cochlear implants;
2. Children with functional or anatomic asplenia (sickle cell disease or other hemoglobinopathies), congenital or acquired asplenia or spleen dysfunction;
3. Immunocompromised people, including children with HIV, chronic renal failure, diseases associated with immunosuppressive chemotherapy or radiation therapy, including malignant neoplasms, leukemia, lymphoma, Hodgkin disease or solid organ transplantation; and
4. Congenital immunodeficiency.

Complete recommendations for PCV13 use have been published (MMWR. 2010; 59:258-61). The ACIP also voted to include PCV13 in the Vaccines for Children Program.

• Seasonal influenza vaccination recommendations were expanded to include all adults beginning with the 2010-2011 influenza season. All people 6 months of age and older without contraindications are now recommended to receive annual influenza vaccination. CDC’s annual influenza vaccine recommendations will be published this summer and will include dosage schedules for children younger than 9 years who may have received various numbers of doses of 2009 H1N1 vaccine and seasonal influenza vaccines.
• A published report (N Engl J Med. 2010; 362:314-19) and review of several cases of prolonged excretion of rotavirus after immunization with pentavalent rotavirus vaccine (RV5) in infants with severe combined immune deficiency (SCID) prompted the FDA to add SCID as a contraindication to receipt of rotavirus vaccines. This condition is rare and not usually diagnosed in infants before receipt of rotavirus vaccine. A table outlining general approaches to immunization of children with various primary and secondary immune deficiencies can be found in the 2009 Red Book and in CDC’s General Recommendations on Immunization.

During the February ACIP meeting, quadrivalent human papillomavirus (HPV4) vaccine for use in women 27 through 46 years of age was discussed.

Other topics discussed during the meeting were meningococcal vaccines for use in infants, the ongoing mumps outbreak in the northeast United States (MMWR. 2010; 59(05):125-129), vaccine supply (www.cdc.gov/vaccines/vac-gen/shortages/default.htm), and plans for implementation of an evidence-based format to be applied to all future ACIP recommendations.

During the October ACIP meeting, three doses of bivalent human papillomavirus (HPV2) vaccine were recommended for females beginning at 11 through 12 years of age for prevention of cervical cancer. HPV2 contains HPV types 16 and 18 and is the second HPV vaccine licensed by the FDA for prevention of cervical cancer.

At the same meeting, the ACIP recommended that a three-dose series of HPV4 vaccine, which contains types 6, 11, 16 and 18, may be given to males 9 through 26 years of age to reduce the likelihood of acquiring genital warts. This vaccine was not recommended to be given routinely to males in this age group. The recommendations for use of HPV2 and HPV4 vaccines for these indications can be found at www.cdc.gov/vaccines/recs/provisional/downloads/hpv-vac-dec2009-508.pdf and will also be published in MMWR.

Once a vaccine recommendation is made by the ACIP, information is disseminated through several mechanisms. Within three weeks of the ACIP meeting, provisional recommendations are posted on the ACIP website (www.cdc.gov/vaccines/recs/acip/). After CDC clearance and approval by the CDC director, the official recommendations are published in MMWR as a policy note, two to three months after the ACIP meeting or as a longer version with more background data in MMWR as a recommendations and report document, generally within eight to 12 months of ACIP approval. A listing of provisional recommendations and of final publication of recommendations in MMWR can be found at www.cdc.gov/vaccines/recs/provisional/default.htm#acip.

For more information:

• AAP. Immunocompromised children. In: Pickering LKb, Baker CJ, Kimberlin DW, Long SS, eds. Red Book: 2009 Report of the Committee on Infectious Diseases. 28th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2009: 74-75.
• CDC. General recommendations on immunization: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR. 2006;55(No. RR-15) (update scheduled for 2010).
• Smith JC. Immunization Policy Development in the United States: The Role of the Advisory Committee on Immunization Practices. Ann Intern Med. 2009; 150:45-49.

Larry K. Pickering, MD, is an Infectious Diseases in Children Editorial Board member and is senior advisor to the director of the National Immunization Program of the Centers for Disease Control and Prevention (CDC) and Professor of Pediatrics in the Department of Pediatrics at Emory University School of Medicine in Atlanta.

Jean Clare Smith, MD, MPH, is a medical officer with the Immunization Services Division of the Centers for Disease Control and Prevention (CDC) in Atlanta.