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Childhood immunizations in 2014
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The 2014 routine immunization schedule for children and adolescents has been released. The biggest change to the schedule relates to meningococcal vaccination of high-risk infants.
With the new infant labeling for MenACWY-CRM (Menveo, Novartis) approved in August, there are now three separate meningococcal conjugate vaccines approved for use in infants and toddlers. This can be more than a little confusing, so here’s a breakdown of each product:
MenACWY-D (Menactra, Sanofi Pasteur):
- Two-dose series at age 9 to 23 months.
- Licensed in September 2010.
Hib-MenCY-TT (MenHibRix, GlaxoSmithKline):
- Four-dose series at age 2, 4, 6 and 12 to 15 months.
- Licensed in June 2012.
MenACWY-CRM (Menveo, Novartis):
- Four-dose series at age 2, 4, 6 and 12 months.
- Licensed in August 2013.
These vaccines are recommended for children with several high-risk conditions, including anatomic or functional asplenia; persistent complement component deficiency; and children residing or traveling to hyperendemic regions or the hajj.
Children with anatomic or functional asplenia who are younger than 19 months should receive a four-dose series with Menveo or MenHibrix. Eligible children aged 19 to younger than 24 months who have not completed the primary series should receive two primary doses of Menveo spaced 3 months apart. Unvaccinated children aged at least 24 months may receive two doses of Menveo or Menactra (if given at least 4 weeks after last 13-valent pneumococcal conjugate vaccine [Prevnar 13, Pfizer] dose).
Michael J. Smith
Children younger than 19 months with persistent complement component deficiency should receive a four-dose series with Menveo or MenHibrix. Children who initiate vaccination at age 7 to 23 months with Menveo should receive a two-dose series, with the second dose in the second year of life and at least 3 months after the first dose.
Children who initiate vaccination at age 9 to 23 months with Menactra should receive a two-dose series of Menactra given at least 3 months apart. Finally, children aged at least 24 months, who have not received a complete series of MenHibrix, Menveo or Menactra, may receive two primary doses of Menactra or Menveo.
Why the subtle difference between children with asplenia and complement deficiency? Early studies of concomitant Menactra and PCV13 use demonstrated poorer PCV immunogenicity in children who received Menactra as compared with those who received PCV alone. As a result, the Advisory Committee on Immunization Practices had previously recommended that children at increased risk for both meningococcal and pneumococcal disease (eg, children with asplenia) receive Menactra at age 2 years, after completion of the primary PCV series. In contrast, children with no additional risk factors for invasive pneumococcal disease (eg, complement deficiency) may be immunized with Menactra as early as age 9 months.
Regarding children residing or traveling to hyperendemic regions or the hajj, pediatricians should remember that MenHibrix does not suffice because it does not confer immunity to serogroup A or W-135. Children in this high-risk group must receive Menveo or Menactra — even if they have completed the MenHibrix series.
Finally, pediatricians should be aware that children at risk during a community outbreak due to a vaccine serogroup should receive an age and formulation-appropriate series.
Additional changes worth noting
There are additional changes to the footnotes for other routinely recommended vaccines. For hepatitis B vaccine, the footnote now reads that hepatitis B immune globulin should be administered to infants who weigh at least 2,000 g as soon as possible within the first week of life if they are born to hepatitis B surface antigen (HBsAg)-positive mothers.
For rotavirus vaccine, trade names are now included in footnotes for clarity.
The diphtheria-tetanus-acellular pertussis vaccine footnote now reads that children aged at least 7 years who are not fully immunized with DTaP vaccine should receive one dose of tetanus-diphtheria-acellular pertussis vaccine as part of the catch-up series. This may count as the adolescent dose. Although Tdap is recommended, inadvertent DTaP administration to children aged 7 to 18 years may count as the adolescent dose of Tdap. The footnotes also reiterate that repeat doses of Tdap are not recommended except during pregnancy. Remember that pregnant adolescents should receive Tdap during weeks 27 to 36 of each pregnancy.
For Haemophilus influenzae type b (Hib) vaccine, clarification of dosing is now included for each specific Hib vaccine. Also, specific catch-up recommendations for children with high-risk conditions are provided.
For pneumococcal vaccine, the footnote now reads that, when possible, all doses of PCV13 should be administered before 23-valent pneumococcal polysaccharide vaccine (PPSV23; Pneumovax 23, Merck) in high-risk patients. The minimum interval for PPSV23 is 8 weeks after last PCV13 dose. Specific recommendations are given for catch-up PCV13 in high-risk children aged 24 to 71 months. Finally, guidelines for vaccination of high-risk individuals aged 6 to 18 years with PPSV23 (including revaccination after 5 years) are clarified.
There are no major changes for influenza vaccine — just remember to refer to the 2014-2015 ACIP recommendations when they are available.
For hepatitis A vaccine, clarification of high-risk individuals who should be vaccinated outside of the routine schedule have been outlined in the footnotes
For HPV vaccines, timing of third dose has been clarified in the footnotes.
References:
CDC. MMWR. 2011;60:1391-1392.
Committee on Infectious Diseases. Pediatrics. 2014;133:357-363.
For more information:
Michael J. Smith, MD, MS, is in the Pediatric Infectious Diseases Practice Group at the University of Louisville Physicians. He can be reached at: michael.smith.4@louisville.edu.
Disclosure: Smith reports no relevant financial disclosures.