Recommendations for combination vaccines modified

NEW YORK CITY – The American Academy of Pediatrics Committee on Infectious Diseases and CDC Advisory Committee on Immunization Practices have altered slightly their preference to combination vaccines for most children.

“There has been a combination vaccine statement for a long time that gave preference to combination vaccines over the individual component vaccines. In the 2010 revision of this statement, the use of a combination vaccine series is now considered generally preferred over separate injections of the equivalent component vaccines,” Dennehy said during a presentation.

Penelope H. Dennehy, MD, presented a review of these recommendations at the 23rd Annual Infectious Diseases in Children Symposium. Dennehy is director of the division of pediatric infectious disease at Hasbro Children’s Hospital, and professor and vice chair for academic affairs in the department of pediatrics at Alpert Medical School, at Brown University, in Providence, RI.

The main immunization changes included measles, mumps, rubella (MMR, MMR II, Merck) and measles, mumps, rubella and varicella (MMR-V, Proquad, Merck) vaccine recommendations; age and interval for the last dose in the inactivated polio vaccine (IPV) series; meningococcal conjugate revaccination; use of HPV2 (Cervarix, GlaxoSmithKline) for girls/women and permissive use of HPV4 (Gardasil, Merck) for boys/men; 2010/2011 influenza vaccine recommendations; and recommendations for 13-valent pneumococcal conjugate vaccine (PCV-13, Prevnar13, Wyeth).

Reasons for change

Considerations for making the changes, according to Dennehy, included provider assessment, the number of injections, vaccine availability, likelihood of improved coverage and patient return, and storage and cost consideration. Patient preference and the potential for adverse events were also considered.

The potential for adverse events has driven this change in the combination statement, particularly, the increased risk for febrile seizures with MMR-V, according to Dennehy. Among children aged 12 to 23 months, fever and seizure increased 7 to 10 days after all measles-containing vaccines; MMRV increased fever and seizure about two times as much as MMR plus varicella; and one additional febrile seizure will occur 7 to 10 days after vaccination as compared with MMR plus varicella, for every 2,300 MMR-V doses given.

New ACIP recommendations included that for the first dose of MMR and varicella given during ages 12 to 47 months, either MMR-V or separate MMR and varicella could be used. For the first dose of MMR and varicella given in children aged older than 4 years, the use of MMRV is preferred. MMR-V is preferred for the second dose given at any age. In addition, personal or family history of seizures is a new precaution for use of MMR-V vaccine.

Factors affecting changes in polio vaccine policy were age, maternal antibody level at time of first dose and longer intervals between doses. New IPV recommendations included that the minimum interval from next-to-last to last dose should always be at least six months and that the minimum age is 4 years for the final IPV dose.

Changes in recommendations for MCV4 included that patients at high risk should be revaccinated, but that it is unnecessary to revaccinate healthy adolescents who received a routine dose of MCV4 if their only risk for meningococcal disease is living in a college dormitory.

A few of the HPV vaccine recommendations include that HPV4 or HPV2 is recommended for the prevention of cervical precancers and cancers in girls/women, and that the first dose should be administered in girls aged 11 to 12 years. Additionally, HPV4 may be administered in a three-dose series to boys aged 9 to 18 years to decrease the risk for acquiring genital warts.

Primary changes and updates in the 2010 recommendations for influenza vaccine include that routine vaccination is recommended for all patients aged 6 months. Dennehy also presented information showing changes for the 2010-2011 influenza season for children aged 6 months to 8 years, including that children who did not receive at least one dose of H1N1 2009 monovalent vaccine should receive two doses of a 2010-2011 season influenza vaccine, regardless of previous history.

Finally, Dennehy also presented recommended transition schedules from PCV7 (Prevnar7, Wyeth) to PCV13 vaccination among infants and children.

“Because of the many changes, the new 2011 immunization schedules will not be published until February 2011. They will most likely appear online before that print date, however, on the ACIP website,” Dennehy added. – by Christen Cona

For more information:

Dennehy PH. What’s new in vaccines. Presented at: the 23rd Annual Infectious Diseases in Children Symposium; Nov. 20-21, 2010; New York City.

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