The recall

September 2003

---Philip A. Brunell, MD

Not the California recall but the recall of children who missed immunizations due to shortages. As children return to school, it is a propitious time to recall those who still lack immunizations and have not been contacted. Some children, because they are older now than they were for their postponed dose, may actually require fewer doses. The minimal intervals between doses for catch-ups as well as other useful information can be found in The Morbidity and Mortality Weekly Report (2003;52[04]:Q1-Q4). The AAP infectious disease committee has approved this schedule. Much of the information is contained in the new 2003 Red Book but the CDC document provides a concise focus on some very important points.

The catch-up schedule for children or adolescents who are over one month behind is presented in two separate tables, one for children between the ages of 4 months to 6 years and another for those who are between 7 and 18 years. The minimal interval between each dose of vaccine also is given. The minimal interval between the first and second dose is four weeks — except if pneumococcal conjugate vaccine (PCV) or Haemophilus influenzae type b (Hib) are given as the final dose in a series and the first dose is given after 12 months of age (or the current age is between 12 and 24 months for PCV). The minimal interval between the second and third doses is a bit more complicated and one needs to refer to the tables. These tables are very useful, as past shortages have resulted in some children not receiving vaccines when they are normally due. These children should now be recalled, if they have not been already, and immunized according to these catch-up schedules.

For hepatitis B, there is a reemphasis on the need to give a birth dose of hepatitis B vaccine (HepB), which should be a monovalent HepB. There are three reasons stated for making the birth dose routine. First, is to avoid errors or omissions in reporting maternal hepatitis B surface antigen status. Infants who receive the birth dose tend to be more likely to stay in the system and get the remainder of their doses on time. This may be as a result of discussion with the new mother about the immunization needs of her infant. Finally, it minimizes the likelihood of horizontal transmission of hepatitis B in households. After the birth dose, the remainder of the series can be given with monovalent or combination vaccines. If the latter are used, those being vaccinated will receive a total of four doses of HepB, which is acceptable.

Live oral polio vaccine no longer is recommended. However, if children have received OPV in the past this can be counted as a dose of polio vaccine when making decisions about the need for subsequent doses. A four-dose schedule is now recommended for children starting in infancy. However, a fourth dose is not needed if only a single type of vaccine, OPV or IPV, was used for the entire series and the third dose of this single type was given after the fourth birthday. However, if a combination of OPV and IPV was given in a single series, a fourth dose should be given regardless of age.

At the present time, all of the vaccines that were in short supply should now be available. Offices should reorder what is required and then recall all of the children who could not receive vaccine because of shortages when they were originally scheduled to receive them. For more information on shortages consult http://www.cdc.gov/nip/news/shortages/default.htm.

Finally, remember the requirement that all health care providers must give parents or patients copies of Vaccine Information Statements before each dose of vaccine listed in the schedule. Instructions for their use can be found at http://www.cdc.gov/nip/publications/vis/vis-instructions.Pdf. The statements themselves can be obtained from state health departments or downloaded from http://www.cdc.gov/nip/publications/acip-list.htm.

You will note there is no change in the recommendations for varicella vaccine, although there had been concern about a greater number of breakthrough cases in children immunized <15 months of age or with asthma.

A retrospective study of children in two HMOs reported in the electronic pages of Pediatrics in August (112[2]:e98-103) could not substantiate the previous report of lower efficacy in children with asthma. The poorer efficacy might be related to the steroids these children received. It appears as though oral steroids, but not inhaled steroids given before immunization may have affected efficacy. However, this requires further clarification as other factors may have contributed to this outcome. In addition, those immunized prior to 15 months of age had a slightly increased risk of failure (RR 1.4) in one of the two HMOs investigated. When varicella vaccine followed MMR within a month but not when given before, the (RR 3.1) risk of varicella vaccine breakthroughs at one of the HMOs was increased. The numbers may have been too small to detect a difference at the second HMO. Both the CDC and Red Book recommend that MMR not be given within a month of varicella vaccine.

Vaccine shortages have resulted in many children receiving incomplete immunization against childhood diseases. It is important that these children are recalled and their immunizations brought up to date. The number and timing of what is needed may have changed now that they are older. Thus, you may find the table helpful in making decisions about with what and when these children need to be immunized.

Please click here to see Table 1 and Table 2. (In adobe Acrobat format)