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Pediatric Vaccinations: Do You Know the Recommended Schedules?
Mundeep Kainth, DO, MPH; Olivia Wong, DO | September 29, 2020
| Contributor Information
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Image from Omland T, Lie KA, Akre H, et al. PLoSOne. 2014;9(6):e99114. [Open access.] PMID: 24918765, PMCID: PMC4053369.
Pediatric Vaccinations: Do You Know the Recommended Schedules?
Mundeep Kainth, DO, MPH; Olivia Wong, DO | September 29, 2020 | Contributor Information
This image is an endoscopic view of laryngeal papilloma in a child with recurrent respiratory papillomatosis, a disease caused by the human papillomavirus (HPV).
Vaccination programs in the United States have been successful at eliminating or significantly reducing many infectious diseases.[1] In 2017, the most recent data available in children aged 19-35 months from the Centers for Disease Control and Prevention (CDC), US vaccination rates were above 90% for four of the most common vaccine-preventable diseases (VPDs): polio (≥3 doses of the inactivated poliovirus vaccine [IPV]); measles, mumps, and rubella (MMR) (≥1 dose); hepatitis B (HepB) (≥3 doses); and varicella (≥1 dose).[2] 2017 Vaccination rates in teens aged 13-17 years were over 90% for MMR (≥2 doses), HepB (≥3 doses), and varicella (≥1 dose),[3] whereas in 2019, the most recent data available in this older age group, 90% or higher vaccination rates were met for Tdap (≥1 dose), MMR (≥2 doses), HepB (≥3 doses), and varicella (those without a history of varicella disease, ≥1 dose and ≥2 doses; those with varicella disease or who received ≥2 doses of the vaccine).[4]
Despite the effectiveness of vaccines, disease outbreaks can still occur in our modern day, often as a result of nonimmunization or underimmunization among children and adults, as well as from exposure to infections brought into the country by unvaccinated travelers who visit and return from high-risk or endemic regions.[5] Do you know the current recommended pediatric vaccination schedules, including those for children/teens who fall behind or start late?
Table courtesy of Olivia Wong, DO.
Pediatric Vaccinations: Do You Know the Recommended Schedules?
Mundeep Kainth, DO, MPH; Olivia Wong, DO | September 29, 2020 | Contributor Information
Immunity to diseases can occur via active immunity (the immune system produces lymphocytes and/or antibodies following exposure to antigens) and passive immunity (immunity is acquired by the transfer of antibodies from a previously immunized person or someone who has recovered from a disease).[6,7] Active immunity develops over a period of days to weeks and provides long-lasting protection; it can occur naturally via exposure to a pathogen, or it can be acquired from vaccination with a killed or weakened form of the pathogen. In contrast, passive immunity provides immediate, short-term protection (weeks to months); this can occur naturally via maternal-fetal transfer of antibodies, or it may be acquired through injection of serum from immune individuals.[6,7]
Community or herd immunity refers to the indirect protection of unimmunized individuals against certain diseases from exposure to a percentage of immune persons in a population (ie, the spread of disease is limited).[6,7] The proportion of a population that needs to be vaccinated (vaccination rate) to provide community immunity varies depending on the disease.[8]
Pediatric Vaccinations: Do You Know the Recommended Schedules?
Mundeep Kainth, DO, MPH; Olivia Wong, DO | September 29, 2020 | Contributor Information
This table shows VPDs that children from birth to age 18 years should be vaccinated against based on recommendations from the CDC's Advisory Committee on Immunization Practices (ACIP).[9] The complete schedule is available as a color .pdf file.
Factors that affect the optimal response to a vaccine include the vaccine type and the recipient's age and immune status.[9] Recommendations for when vaccines are administered are based on the age-specific disease risks, age-specific risks for complications, and age-specific vaccination responses, as well as possible effects on the passive maternal-fetal immune response. In general, vaccines are recommended for the youngest age group that is at risk for a disease.[9]
Image from the CDC.
Pediatric Vaccinations: Do You Know the Recommended Schedules?
Mundeep Kainth, DO, MPH; Olivia Wong, DO | September 29, 2020 | Contributor Information
Readers should always carefully review the current immunization schedules and accompanying footnotes, as well as the most recent guidelines recommendations.
Changes in the 2020 child and adolescent immunization (birth to 18 years) schedule include new/revised ACIP recommendations for the HepA, meningococcal B, and Tdap vaccines.[9,10]
For example, it highlights the HepA vaccine routine catch-up schedule, including completing a two-dose series, and notes that initiating HPV vaccine at age 9-10 years is at the clinician's discretion.[9,10] Moreover, information for the influenza vaccine routine vaccination section was reformatted to more clearly outline circumstances when one or two doses are recommended. Additionally, it includes conditions under which the intranasal live-attenuated influenza vaccine (LAIV) should not be used.[9,10]
Image from Zhuang H, Peng YL, Chen TW, et al. BMC Gastroenterol. 2011;11:78. [Open access.] PMID: 21702993, PMCID: PMC3141754.
Pediatric Vaccinations: Do You Know the Recommended Schedules?
Mundeep Kainth, DO, MPH; Olivia Wong, DO | September 29, 2020 | Contributor Information
This sonogram depicts hepatocellular carcinoma in the right liver lobe of a 10-year-old boy with hepatic cirrhosis after hepatitis B infection. A diffusely distributed heterogeneous mass (arrow) with no septa or liquefaction is revealed in the setting of cirrhosis.
Hepatitis B
In 2017, the CDC estimated 91.4% (target: 90%) of US children aged 19-35 months had received at least three doses of HepB vaccine[2]; for US teens aged 13-17 years, it was 91.9%[3] (2019: 91.6%[4]). However, the HepB birth dose coverage was 73.6%, remaining below the 85% target.[2]
Give the first dose of monovalent HepB vaccine within 24 hours of birth to all medically stable newborns weighing at least 2 kg born to mothers negative for hepatitis B surface antigen (HBsAg).[9] Give preterm infants weighing below 2 kg born to HBsAg-negative mothers the first dose of vaccine 1 month after birth or at hospital discharge. If the maternal HBsAg status is positive, give the infant HepB and hepatitis B immunoglobulin (HBIG) within 12 hours of birth. If the maternal HBsAg status is unknown, give HepB to the infant within 12 hours, regardless of birth weight; also administer HBIG if the infant weighs less than 2 kg.[9]
Give the second HepB dose at age 1-2 months (≥4 weeks after the first dose) (use monovalent HepB if age <6 weeks); give the third dose at ages 6-18 months (≥8 weeks after the second dose; ≥16 weeks after the first dose). Do not give the final (third or fourth) dose any earlier than age 24 weeks. Four doses of HepB is allowed when an infant receives a combination vaccine containing HepB after the birth dose.[9]
Catch-up: For unvaccinated children, use a three-dose HepB series.[9] For children aged 11-15 years, a two-dose series (≥4-month interval) of an adult vaccine formulation (Recombivax HB) is available.
Illustration of a rotavirus and its structural proteins from National Institute of Allergy and Infectious Diseases (NIAID).
Pediatric Vaccinations: Do You Know the Recommended Schedules?
Mundeep Kainth, DO, MPH; Olivia Wong, DO | September 29, 2020 | Contributor Information
Rotavirus
Rotavirus vaccination rates among US children aged 19-35 months who received at least two doses continue to steadily increase but remain below the 80% target rate. Coverage was 73.2% in 2017.[2]
All infants should receive doses of the rotavirus vaccine at age 2 and 4 months (RV1: Rotarix; RV5: RotaTeq).[9] If the three-dose series is used (RotaTeq), the third dose is given at age 6 months. The minimum interval between doses is 4 weeks. If Rotateq was used or if it is unknown which vaccine product was given for any of the doses, the infant should receive a total of three doses of RotaTeq.[9]
Catch-up: Do not administer the vaccines earlier than age 6 weeks; do not administer the first dose in a series later than age 14 weeks, 6 days; and do not administer the final dose in a series later than age 8 months, 0 days.[9]
Images from (1) de Jong PR, de Heer-Groen T, Schroder CH, Jansen NJ. Cases J. 2009;2:7003. [Open access.] PMID: 19829891, PMCID: PMC2709971 (left); and (2) Nataprawira HM, Somasetia DH, Sudarwati S, Kadir M, Sekarwana N. Case Rep Emerg Med. 2013;2013:125043. [Open access.] PMID: 23738154, PMCID: PMC3659513 (right).
Pediatric Vaccinations: Do You Know the Recommended Schedules?
Mundeep Kainth, DO, MPH; Olivia Wong, DO | September 29, 2020 | Contributor Information
Left: A 4-year-old boy with generalized tetanus who received mechanical ventilation, deep sedation, and extensive cardiorespiratory monitoring in the pediatric intensive care unit. Right: An anteroposterior chest radiograph in a 7-week-old girl with pertussis reveals bilateral pneumonia and no cardiac enlargement. She required mechanical ventilation.
Diphtheria, Tetanus, Pertussis
Despite vaccination efforts, the US target four-dose DTaP vaccination rate of 90% has not yet been achieved. Since 1998, at least 81.5% of children aged 19-35 months received a minimum of four doses of DTaP.[11] In 2017, the rate was 83.2%.[2] The highest rates of reported pertussis remain among infants younger than 1 year, the age group at greatest risk for severe disease and death.[12,13] Children 7-10 years old are the second largest age group to be affected and contribute to disease transmission, followed by those aged 11-19 years and 1-6 years.[12,13]
Administer the five-dose series of the DTaP vaccine at ages 2, 4, 6, and 15-18 months, as well as at age 4-6 years.[9] Do not give the vaccine earlier than age 6 weeks (4 years for Kinrix or Quadracel). The fourth dose can be given as early as age 12 months if there has been at least a 6-month interval from the third dose.[9]
Inadvertent DTaP dose: If a child aged 12 months or older inadvertently received an early fourth DTaP dose—and it was separated from the third dose by at least 4 months—it does not need to be repeated.
Catch-up: If the fourth DTaP dose was given at age 4 years or older, do not administer the fifth dose.[9]
Image of the classic dirty-white pseudomembrane of diphtheria from Wikimedia Commons/Dileepunnikri.
Pediatric Vaccinations: Do You Know the Recommended Schedules?
Mundeep Kainth, DO, MPH; Olivia Wong, DO | September 29, 2020 | Contributor Information
Tetanus, Diphtheria, Pertussis
An estimated 90.2% of US teens age 13-17 years received at least one dose of Tdap in 2019, which met or exceeded the target of 80% for the ninth year of the national survey.[12]
Give one dose of the Tdap vaccine to all children aged 11-12 years and to pregnant teenage girls (preferably early during gestational weeks 27-36 to maximize passive antibody transfer to the fetus), regardless of when they last received a tetanus/diphtheria toxoid (Td)-containing vaccine.[9] Do not administer Boostrix or Adacel before age 10 years.
Catch-up: For those aged 7-18 years who did not receive at least four DTaP doses, administer Tdap as one catch-up dose; if additional doses are needed, give the Td or Tdap dose. Children aged 7-9 years who received a catch-up dose of Tdap can receive a second Tdap dose at age 11-12 years; those aged 10 years who received a catch-up dose of Tdap do not need a Tdap dose at age 11-12 years.[9]
Inadvertent DTaP doses: If a child aged 7-9 years inadvertently received a DTaP dose, it can count as part of the catch-up series (ie, count as the teen Tdap dose or may give a Tdap booster dose at age 11-12 years). If this occurs in a child/teen aged 10-18 years, count the DTaP dose as the teen Tdap booster.[9]
Image courtesy of Medscape.
Pediatric Vaccinations: Do You Know the Recommended Schedules?
Mundeep Kainth, DO, MPH; Olivia Wong, DO | September 29, 2020 | Contributor Information
Postintubation image of a cherry red epiglottis in a child with acute epiglottitis is shown.
H influenzae Type B
About 92.8% of children aged 19-35 months in 2017 received their primary Hib series compared to 80.7% who received the full series (target: 90% coverage).[2]
Routinely administer Hib vaccine to infants at age 2 and 4 months (the first dose can be given as early as age 6 weeks) with a three-dose (PedvaxHib) or four-dose primary vaccine series (ActHIB, Hiberix, Pentacel).[9] In a four-dose primary series, the third dose can be given at age 6 months. A single booster dose of any Hib vaccine should be given at age 12-15 months (≥8 weeks from the previous dose).
Image from CDC.
Pediatric Vaccinations: Do You Know the Recommended Schedules?
Mundeep Kainth, DO, MPH; Olivia Wong, DO | September 29, 2020 | Contributor Information
This is an inferior view of a brain infected with gram-negative H influenzae bacteria.
Catch-up: The catch-up schedule for administering the Hib vaccine depends on which vaccine was administered, how many doses were given, and the recipient's age at the time of the dose(s).[9] (Please review the current immunization schedules and accompanying footnotes as well as the most recent guidelines recommendations.)
For those who received their first Hib dose at age 7-11 months, give the second dose at least 4 weeks later and the third, final dose at age 12-15 months or 8 weeks after dose 2 (whichever is later). If the first dose was received at age 12-14 months, give the second, final dose at least 8 weeks after dose 1. If dose 1 was given before age 12 months and dose 2 before age 15 months, give the third, final dose 8 weeks after dose 2.[9]
If two doses of PedVaxHIB were received before age 12 months, give the third, final dose at age 12-29 months and at least 8 weeks after dose 2. Unvaccinated children aged 15-59 months should receive only one Hib vaccine dose. Previously unvaccinated children aged 60 months or older who are not otherwise at high risk do not need a catch-up vaccination.[9]
At-risk children: The Hib vaccination schedule also provides detailed guidance for children aged 12-59 months who are at high risk for invasive H influenzae disease, including immunocompromised children (functionally/anatomically asplenic, immunoglobulin deficient/early component complement deficient, human immunodeficiency virus [HIV] positive, stem cell transplant and/or chemotherapy/radiotherapy recipient).[9]
Image from King P. ClinTransl Med. 2012;1(1):10. [Open access.] PMID: 23369277, PMCID: PMC3567431.
Pediatric Vaccinations: Do You Know the Recommended Schedules?
Mundeep Kainth, DO, MPH; Olivia Wong, DO | September 29, 2020 | Contributor Information
This is a computed tomography (CT) scan from a patient with severe lower lobe bronchiectasis and recurrent isolation of H influenzae from sputum samples.
Influenza (Flu)
The US target vaccination rate of 70% has not yet been reached for seasonal influenza.[14] Fewer than 50% of children/teens aged 6 months to 17 years were vaccinated in the 2010-2011, 2011-2012, and 2016-17 flu seasons, but between the 2012-2013 and 2015-2016 flu seasons, at least 50% of this age group received the annual vaccine.[14]
Vaccination coverage with at least one dose of flu vaccine during the 2018-2019 season was 62.6% among children aged 6 months through 17 years, an increase of 4.7 percentage points from the 2017-2018 flu season and 3.6 percentage points higher than the 2016-2017 season's coverage.[15] During the 2018-2019 influenza season, vaccination coverage among US children aged 2-17 years who received care from federally funded health centers was 62.6%.[16]
CT scan from a patient with a lung abscess that required surgical removal. H influenzae was isolated from the lung tissue. Image from King P. ClinTransl Med. 2012;1(1):10. [Open access.] PMID: 23369277, PMCID: PMC3567431.
Pediatric Vaccinations: Do You Know the Recommended Schedules?
Mundeep Kainth, DO, MPH; Olivia Wong, DO | September 29, 2020 | Contributor Information
All children aged 6 months and older who do not have contraindications should routinely receive the annual influenza vaccine.[9] Give two doses of the inactivated vaccine (IIV) (≥4-week interval between doses) to children aged 6 months through 8 years who have received fewer than two influenza vaccine doses before July 1, 2019, or who have an unknown influenza vaccination history. For children aged 6 months-8 years who received at least two influenza vaccine doses before July 1, 2019, give one dose. Children aged 9 years and older receive one IIV dose; those aged 18 years can receive the recombinant vaccine [RIV].[9]
Intranasal influenza vaccine (LAIV) is also available for patients aged 2-49 years for the 2020-2021 season.[17] All three components for the trivalent influenza vaccine have been changed for the 2020-2021 season. For the quadrivalent vaccines, three of four components have been changed.[17]
The 2020-2021 influenza season will coincide with the continued or recurrent circulation of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (the novel coronavirus associated with coronavirus disease 2019 [COVID-19]). Vaccination to reduce the prevalence of influenza illness will reduce symptoms that might be confused with those of COVID-19. Prevention of and reduction in the severity of influenza illness and reduction of outpatient illnesses, hospitalizations, and intensive care unit admissions through influenza vaccination also could alleviate stress on the US healthcare system.[17]
Image from Science Photo Library/Photostock-Israel.
Pediatric Vaccinations: Do You Know the Recommended Schedules?
Mundeep Kainth, DO, MPH; Olivia Wong, DO | September 29, 2020 | Contributor Information
This chest radiograph from a 2-year-old child reveals a right lower lobe pneumonia.
Pneumococcal Disease
The 90% target vaccination rate for US children aged 19-35 months to receive at least four doses of pneumococcal vaccine has not yet been achieved.[18] However, the vaccination rate has been steadily rising since 2002; between 2008 and 2018, it has been at least 80%.[18] In 2018, coverage was 83.3%%.[18]
The four-dose pneumococcal conjugate vaccine (PCV13) should be routinely given to children at ages 2, 4, 6, and 12-15 months.[9] The earliest PCV13 dose may be given at age 6 weeks.
Catch-up: Underimmunized but healthy children aged 24-59 months should also receive one PCV13 dose.[9]
At-risk children: The PCV immunization schedule also provides detailed guidance for the use of PCV13 and 23-valent pneumococcal polysaccharide vaccine (PPSV23) in children aged 2-5 years and 6-18 years who have underlying medical conditions and immune compromise.[9] Do not give PPSV23 before age 2 years. When both PCV13 and PPSV23 are indicated, first give PCV13. Do not give PCV13 and PPSV23 during the same visit. (Please review the current immunization schedules, associated footnotes, and most recent guidelines recommendations.)
Images from Joseph B, Watts H. J Child Orthop. 2015;9(5):325-38. [Open access.] PMID: 26362170, PMCID: PMC4619376.
Pediatric Vaccinations: Do You Know the Recommended Schedules?
Mundeep Kainth, DO, MPH; Olivia Wong, DO | September 29, 2020 | Contributor Information
The image depicts an equino-cavo-varus deformity in a teen with polio.
Polio
Polio vaccination rates from 2002 to 2018 met/exceeded the 90% target rate in US children aged 19-35 months who received at least three vaccine doses.[19] In 2018, coverage was 93.6%.[19]
IPV is a series of four doses routinely given at ages 2, 4, and 6-18 months, and 4-6 years.[9] The first dose can be given as early as age 6 weeks; the final dose should be given on/after the fourth birthday (≥6 months after the previous dose). Four or more IPV doses can be given before age 4 years when using a combination vaccine containing IPV; a dose is still recommended on/after the fourth birthday (≥6-month interval between doses).[9]
Catch-up: Follow the minimum age and minimum intervals for administering IPV during the first 6 months of life for infants who may become acutely exposed to circulating poliovirus (ie, travel to a polio-endemic region, during an outbreak).[9] Children who received four or more doses before age 4 years should receive one more dose at age 4-6 years (≥6 months after the previous dose); those who received the third dose at age 4 years or older do not receive a fourth dose.[9,20]
Note: Regardless of a child's current age, those who received either the oral vaccine (OPV) or both the OPV and IPV as part of a series should be given a total of four doses (≥4 weeks between doses in the series, with the final dose at age 4-6 years [≥6 months after the previous dose]).[9] If the child received only OPV, with all doses before age 4 years, give one dose of IPV at age 4 years or older (≥4 weeks from the last oral dose). Only the trivalent oral vaccine (tOPV) counts toward US vaccination requirements (until April 1, 2016, tOPV was routinely given in all OPV-using nations).[9,21]
Images from Dave Haygarth (left) and Merle jaJoonas (center), both via Flickr; and Science Source/Dr P Marazzi (right).
Pediatric Vaccinations: Do You Know the Recommended Schedules?
Mundeep Kainth, DO, MPH; Olivia Wong, DO | September 29, 2020 | Contributor Information
An infant with measles (left) and one with mumps (center) are shown. The rash of rubella can be seen on a boy's chest (right).
Measles, Mumps, Rubella
Since 1998, at least 90% of US children aged 19-35 months have received one or more doses of MMR vaccine (90% target met)[22]; coverage was 92.1% in 2018.[22] About 91.9% of US teens aged 13-17 years received at least two doses of MMR vaccine in 2018 (90% target met).[4]
The MMR vaccine is routinely given as two doses at age 12-15 months and at 4-6 years.[9] The second dose may be given earlier than age 4 years if there is at least a 4-week interval from the first dose.
For children who will be traveling internationally, before departure, (1) give one dose to infants aged 6-11 months and then another two doses at least 4 weeks apart at age 12-15 months (use age of 12 months if traveling to high-risk regions), or (2) give two doses to infants aged 12 months and older (first dose on/after age 12 months; second dose at ≥4-week interval).[9]
Catch-up: All school-aged children/teens should have had two doses of MMR (≥4 weeks between doses).[9] The maximum age for use of the MMRV (MMR + varicella) vaccine is 12 years.
Adapted image from the CDC.
Pediatric Vaccinations: Do You Know the Recommended Schedules?
Mundeep Kainth, DO, MPH; Olivia Wong, DO | September 29, 2020 | Contributor Information
In recent years, a number of measles and mumps outbreaks have occurred in the United States, primarily as a result of unimmunized or underimmunized children and teens coming into contact with infected people—usually travelers who became infected in endemic areas and then brought the disease back home.[23,24] Media reports and celebrity comments that state an association between autism and the MMR vaccine may also fuel misinformation and cause parents to refuse vaccinating their children—despite the fact that much research has thoroughly debunked such claims.
In 2014, there were 667 confirmed US measles cases from 27 states. Another high incidence was in 2019 with 1282 confirmed cases from 31 state.[23] As of August 19, 2020, there have been 12 confirmed cases in 7 jurisdictions (ie, any US state, New York City, and the District of Columbia).[23]
Before the advent of US mumps vaccination programs, there were about 186,000 cases reported annually, with underreporting likely.[24] Since the beginning of the vaccination era, there has been a 99% reduction in mumps cases. However, outbreaks with over 6100 cases were reported in 2006, 2016, and 2017, followed by 2,251 cases in 2018 and 3,474 cases in 2019.[24] From January 1 to 25, 2020, 16 states reported mumps infection in 70 individuals.
Image of (left) a varicella eruption on a child's head from ILJR, and (right) a varicella blister from Zeimusu, both via Wikimedia Commons.
Pediatric Vaccinations: Do You Know the Recommended Schedules?
Mundeep Kainth, DO, MPH; Olivia Wong, DO | September 29, 2020 | Contributor Information
Varicella (Chickenpox)
Varicella outbreaks occur periodically in the United States, with international travel a risk for acquiring the disease due to its high incidence and low vaccination rates abroad. With the exception of a slight dip to 89.6% in 2009,[25] the US target varicella vaccination rate of 90% has been reached since 2007 for children aged 19-35 months to receive at least one dose of the varicella vaccine (VAR).[2,26] In 2018, coverage was 92% for this age group.[26] About 94.9% of US teens aged 13-17 years received at least one VAR dose in 2018, and 89.6% received two or more doses (target: 90%).[4]
VAR is routinely given in two doses at ages 12-15 months and 4-6 years.[9] The second dose may be given earlier than age 4 years if there is at least a 3-month interval from the first dose; however, if the first two doses are separated by at least 4 weeks, the second dose is considered valid.[9]
Catch-up: All those aged 7-18 years without evidence of immunity should receive two doses of VAR vaccine (for ages 7-12 years, ≥3-month dosing interval is preferred but a separation of ≥4 week is acceptable; for ages ≥13 years, the minimum dosing interval is ≥4-week).[9] The maximum age for use of the MMRV vaccine is 12 years.
Adapted image from HealthyPeople.gov, Office of Disease Prevention and Health Promotion (ODPHP).
Pediatric Vaccinations: Do You Know the Recommended Schedules?
Mundeep Kainth, DO, MPH; Olivia Wong, DO | September 29, 2020 | Contributor Information
Hepatitis A
The US target vaccination rate of 85% has not yet been reached for children aged 19-35 months to receive at least two doses of HepA vaccine, but coverage has been steadily increasing.[27] In 2018, 62.1% of this age group was given two or more doses of the vaccine.[27] For teens aged 13-17 years, 73.6% had completed a two-dose series in 2018 and 77.1% in 2019.[4]
Administer the HepA vaccine in two routine doses beginning at age 12 months.
Catch-up: All unvaccinated children through 18 years should receive two HepA vaccine doses, separated by at least 6 months.[9] If a child received one dose at age 12 months or older, give a second dose at least 6 months after the first one. Teens aged 18 years and older may be given the combined HepA and HepB vaccine (Twinrix) as a three-dose (0, 1, 6 months) or four-dose series (0, 7, and 21-30 days, followed by a dose at 12 months).[9]
At-risk children: For unimmunized children traveling to or living in high or intermediate endemic areas, give one dose to infants aged 6-11 months before departure, and then revaccinate them between ages 12 and 23 months with two doses separated by at least 6 months.[9] For those aged 12 months and older who are unvaccinated, the first dose may be given as soon as travel is considered.
Adapted image from the CDC.
Pediatric Vaccinations: Do You Know the Recommended Schedules?
Mundeep Kainth, DO, MPH; Olivia Wong, DO | September 29, 2020 | Contributor Information
Human Papillomavirus
About 14 million people, including teens, become infected with HPV annually.[28] Moreover, an estimated 35,000 people in the United States every year are affected by a cancer caused by HPV infection (eg, anal, oropharyngeal, other head and neck cancers, vulvar, vaginal, cervical) as well as genital warts (ie, condyloma acuminata).[28]
Among US males and females aged 13-17 years, the percentage of those receiving three or more doses of the HPV vaccine has steadily improved toward the target vaccination rate of 80%.[3,4] Between 2016 and 2019, among those in this age group who received the complete HPV vaccine series, the range of coverage for girls was 49.5-56.8%; for boys, it was 37.5-51.8%.[3,4]
As of late 2016, the nine-valent formulation (HPV9, Gardasil 9) is the only HPV vaccine available in the United States.[29] All children aged 11-12 years should receive a two-dose HPV vaccine series.[9] The second dose is given 6-12 months after the first dose. Children as young as 9 years may receive the vaccine series.
Left image of HPV war ts in the throat from Wikimedia Commons/GalliasM. Right image of differentiated vulvar intraepithelial neoplasia from Leonard B, Kridelka F, Delbecque K, et al. Biomed Res Int. 2014;2014:480573. [Open access.] PMID: 24719870; PMCID: PMC3956289.
Pediatric Vaccinations: Do You Know the Recommended Schedules?
Mundeep Kainth, DO, MPH; Olivia Wong, DO | September 29, 2020 | Contributor Information
All previously undervaccinated teens through age 18 years should receive the catch-up HPV vaccine: For teens aged 9-14 years, the vaccination schedule is the same as that for children aged 11-12 years (0, 6-12 months, with ≥5 month interval; repeat dose if given too soon); for teens receiving their first dose at age 15 years or older, give three HPV vaccine doses, with the second dose 1-2 months after the first one, followed by the third dose 6 months after the first (from dose 1 to 2, ≥4-week interval; from dose 2 to 3, ≥12-week interval; from dose 1 to 3, ≥5-month interval; repeat dose if given too soon).[9]
If a child/teen has completed a valid vaccination series with any HPV vaccine, no further doses are needed.[9]
Note: HPV vaccination is not recommended during pregnancy, but pregnancy testing is not needed before HPV vaccination; if the vaccine series has been started during pregnancy, no intervention is needed (delay the remaining HPV vaccine doses till after the pregnancy).[9]
At-risk children: Begin the vaccination series at age 9 years for children with a history of sexual abuse/assault. Immunocompromised children/teens (eg, HIV positive) should receive the three-dose series at 0, 1-2, and 6 months regardless of their age at vaccine initiation.[9]
Images from Kerneis S, Mahe E, Heym B, Sivadon-Tardy V, Bourgeois F, Hanslik T. Cases J. 2009;2:7103. [Open access.] PMID: 19829911, PMCID: PMC2740133.
Pediatric Vaccinations: Do You Know the Recommended Schedules?
Mundeep Kainth, DO, MPH; Olivia Wong, DO | September 29, 2020 | Contributor Information
A 16-year-old boy had cutaneous lesions secondary to chronic meningococcemia. Left: Pustules on the index finger (top) and foot (bottom). Right: Inflammatory papules of the leg.
Meningococcal Disease
After a steady rise, the total percentage of US teens aged 13-17 years receiving at least one dose of meningococcal vaccine (MenACWY) finally reached the 80% target in 2015 (80.8%).[3,4,30,31] Coverage for one dose in 2019 remains high at 88.9%%, but only 53.7% of teens aged 17 years received two or more MenACWY doses.[9]
MenACWY-CRM (Menveo) and MenACWY-D (Menactra) are quadrivalent conjugate vaccines that offer protection against Neisseria meningitidis serogroups A, C, W-135, and Y.[32] Healthy children receive one routine MenACWY vaccine dose at age 11-12 years and a booster dose at age 16 years.[9]
(For children/teens aged 2 months-18 years at high/increased risk for meningococcal disease, please review the current immunization schedules, detailed accompanying footnotes, and the most recent guidelines for recommendations on use of the MenACWY or MenB vaccines. MenB vaccines are recombinant formulations that offer protection against N meningitidis serogroup B infections [MenB-4C (Bexsero); MenB-FHbp (Trumenba)].[33,34])
Image of a 4-month old female with gangrene of the hands and lower extremities caused by meningococcemia from the CDC.
Pediatric Vaccinations: Do You Know the Recommended Schedules?
Mundeep Kainth, DO, MPH; Olivia Wong, DO | September 29, 2020 | Contributor Information
Catch-up: For teens never vaccinated against meningococcus, give one dose of Menactra or Menveo at age 13-18 years. In previously unvaccinated teens, a booster dose at age 16-18 years is only given to those who received the first dose at age 13-15 years (≥8-week dosing interval); no booster dose is needed for those who received their first dose at age 16 years or older.[9]
Clinical discretion (MenB vaccines): The MenB vaccines Bexsero and Trumenba are not part of the primary immunization schedules, but they are recommended for those aged 10 years or older who are underimmunized and at increased/high risk of meningococcal disease.[9] (Please review the current immunization schedules, detailed associated footnotes, and the most recent guidelines for MenB vaccination guidance in this group of at-risk persons.)
A two-dose series of either Bexsero (separated by ≥1 month) or Trumenba (≥6-month interval) may be given to healthy teens aged 16-18 years (and young adults aged 19-25 years[33,34]) who are not at increased risk for meningococcal disease. Use the same vaccine product for all doses in a series; Bexsero and Trumenba are not interchangeable. If the second dose of Trumenba was given at a dosing interval shorter than 6 months, give a third dose that is at least 4 months after the second dose).[9]
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Contributor Information
Authors
Mundeep Kainth, DO, MPH
Assistant Professor, Pediatric Infectious Diseases
Northwell Health
New Hyde Park, New York
Disclosure: Mundeep Kainth, DO, MPH, has disclosed no relevant financial relationships.
Olivia Wong, DO
Section Editor
Medscape Drugs & Diseases
New York, New York
Disclosure: Olivia Wong, DO, has disclosed no relevant financial relationships.
Reviewer
Mary Windle, PharmD
Editor-in-Chief
Medscape Drug Reference;
Managing Editor
Medscape from WebMD
Omaha, Nebraska
Disclosure: Mary Windle, PharmD, has disclosed no relevant financial relationships.
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References
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