A back to school immunization primer for teens

September 2005

Now that we have vaccines for teenagers and recommendations for an adolescent visit, a back to school visit is the perfect time to make sure that teenagers are up-to-date on all of their immunizations.

We now have a recommendation for the new quadravalent meningococcal conjugate (MCV4) vaccines, Menomune-A,C,Y,W-135 and Menactra (Sanofi Pasteur).

This and the combined tetanus, diphtheria and acellular pertussis (Tdap, Boostrix, GlaxoSmithKline and Adacel, Sanofi Pasteur) vaccine for those 11 and older are to be given at the same visit along with other indicated vaccines (www.cdc.gov/nip/pr/pr_tpap_jun2005.htm). Those who have not had varicella or the vaccine should be given varicella vaccine. After a child’s 12th birthday, two doses will be required. Those who are not completely immunized against hepatitis B should be. Their risk may be increased due to sexual activity or injection drug use in the ensuing years. These vaccines can also be given at the same visit.

It is hoped by 2008, that all 11- to 12-year-olds will receive MCV4 vaccine. In the interim, in addition to all 11- and 12-year-olds, those students entering high school should also be given the vaccine. As there is an increased risk of meningococcal disease in college students living in dormitories, particularly entering freshman, it is recommended that this be communicated to those students and/or parents as well. As of the end of last year, 33 states mandated that this be done and 10 have mandated that certain of these students be immunized against meningococcus.

MCV4 is preferred to meningococcal polysaccharide vaccine for college students. At the current time, there is a shortage of MCV4, which is expected to be short term (www.cdc.gov/nip/news/shortages/default.htm). Neither Tdap nor meningococcal vaccines are known to have an adverse effect on pregnancy. As for other class C drugs and vaccines, it is recommended that pregnant women who receive the vaccine report this to their physicians or the manufacturer so that a registry may be compiled.

Tdap recommendations

On June 30, 2005, the Advisory Committee on Immunization Practices recommended that Tdap be used in lieu of dT for all those between ages 11 and 18, including those who previously have had pertussis (www.cdc.gov/nip/pr/pr_tdap_jun2005.htm). Boostrix is approved for people ages 11 to 18, while Adacel is approved for those between ages 11 and 64.

For those who have completed their primary series of a diphtheria, pertussis and tetanus vaccines, a single dose of vaccine is recommended. For those adolescents who already have received dT, a five-year interval before giving Tdap is recommended. However, in situations where the risk of pertussis is great, eg, during an outbreak or following intimate exposure, the interval may be shorter recognizing that reactions to vaccine may be increased. Thus, the two risks need to be weighed.

For wound prophylaxis, Tdap should be given in lieu of dT when indicated. However, in an adolescent who has received Tdap, dT should be given.

Certain children may not have had a primary series of pertussis vaccine because of contraindications to pertussis vaccine or for other reasons. However, it is important that the cautions and contraindications be reviewed for all teenage vaccinees prior to administration of vaccines. Conditions may have arisen since the primary series was given in those who have received the primary series that may now need to be considered in the decision to give vaccine. For those who have had none of the primary immunizing series and now can receive the vaccine, three doses are recommended, one of which should be Tdap and the others dT. The first two should be a month apart and the last six months later. For those who have received a full series of diphtheria and tetanus immunization but not pertussis and are eligible now to receive pertussis vaccine, a single dose of Tdap is recommended.

Let us hope we can convince those who determine reimbursement for vaccine administration to consider the time invested in making the decision of what vaccine is to be given and to whom.