2008 childhood immunization schedule gets some revisions

January 2008

[ Download the 2008 immunization schedule (PDF) ]

Although similar to the previous year’s format, the 2008 recommended childhood immunization schedule presents a few updated elements.

The main change to the format of the schedule, however, is the removal of the green catch-up bars for the hepatitis B and Haemophilus influenzae type b conjugate vaccines from the routine immunization chart for children aged 0 to 6 years.

In place of these bars, there is now a second line in the title that refers users to the catch-up schedule when vaccinating those children who fall behind in their vaccination or who start the series later than recommended.

These changes were recommended by the Advisory Committee on Immunization Practices childhood immunization schedule work group and were based on focus group discussions in 2006.

“They [the immunization providers] mentioned that they would like to see routine schedules focused on recommended vaccines and that the catch-up bars were distracting,” Angela Calugar, MD, MPH, member of the childhood immunization schedule work group, told Infectious Diseases in Children. “Many practices develop their own schedule using the routine timeline only.”

Collaborative efforts

Some of the suggestions that providers offered for improving the schedule dealt with the hepatitis B vaccine birth dose, clarifications for the indications of the pneumococcal conjugate vaccine (PCV7; Prevnar, Wyeth), providing further details for children with special medical conditions and options for a black-and-white only copy machine.

A number of providers also suggested that the work group include brand names in the schedules, but this is something that the work group tries to avoid as much as possible because of ACIP guidelines, according to Calugar.

In an effort to include the most up-to-date information for immunization providers, the childhood immunization schedule work group also considered all of the new vaccines in the pipeline, as well as any new indications that had been recommended for the existing vaccines.

“Updating the immunization schedules requires multiple activities,” Calugar said at the October meeting of the ACIP. “We recognize the importance of the feedback from immunization providers and other users, and also the schedules’ harmonization with other stakeholders.”

Upon hearing and discussing Calugar’s presentation of the work group’s recommended changes, the ACIP voted unanimously to approve the new schedule at its October meeting.

New for 2008

In addition to the removal of the green catch-up bars for the hepatitis B and Hib vaccines, other changes to the immunization schedule include:

• The PCV7 footnote was updated to better reflect the revised ACIP recommendations for incompletely vaccinated children aged between 24 and 59 months, including those with underlying medical conditions.
• Live-attenuated influenza vaccine (LAIV [Flumist, MedImmune]) is now recommended for children aged as young as 2 years. Children aged younger than 9 years who are receiving either the live or the inactivated influenza vaccine for the first time, or who were vaccinated for the first time last season but received only one dose, are recommended to have two doses of influenza vaccine separated by at least four weeks. Other updates to the influenza vaccine footnote were incorporated, as well, to better reflect the latest ACIP recommendations, according to Calugar.
• Changes for MCV4 (Menactra, Sanofi Pasteur) relate to its new age recommendation for children aged 2 to 10 years with terminal complement deficiencies or anatomic or functional asplenia, as well as for certain other high-risk groups. An additional update for this vaccine emphasizes the catch-up schedule for children aged 13 to 18 years; use of the meningococcal polysaccharide vaccine for all age groups is an acceptable alternative for MCV4.

Many of these recommendations affect only a small segment of patients, according to Stan L. Block, MD, professor of clinical pediatrics at the University of Louisville and the University of Kentucky and president of the Kentucky Pediatric Research Institute. One that may have more of an effect, however, is that which pertains to the LAIV vaccine.

“The big change here is that kids aged 2 through 5 are now allowed to get the intranasal vaccine, which has a huge effect on many practices for the benefit of the kids,” said Block, also an Infectious Diseases in Children editorial board member.

At press time, the final version of the 2008 recommended childhood immunization schedule was scheduled to be printed in the January 11 edition of the Morbidity and Mortality Weekly Report and is also published in this issue.

Children with HIV

At the June 2007 ACIP meeting, the childhood immunization schedule work group discussed its efforts to collaborate with the adult immunization schedule work group on a number of topics.

One of the issues that the two groups discussed was that of drafting an immunization schedule geared specifically toward children with HIV.

In an effort led by Jane Seward, MBBS, MPH, acting deputy director of the National Center for Immunizations and Respiratory Diseases’ division of viral diseases, a schedule has now been created for children living with HIV aged 0 to 6 years and for children aged 7 to 18 years with HIV.

According to Seward, these schedules are part of a much broader document that contains recommendations from the CDC, the NIH and the IDSA titled, “Guidelines for the prevention and treatment of opportunistic infections among HIV-exposed and infected children.”

The schedules are based on the existing childhood immunization schedules, covering all of the same ACIP recommendations, the same order of use and the same footnote language modified to be appropriate for children with HIV. However, these edits should make it easier to determine which schedule applies to this population of children.

“It’s just like the other schedules, but it’s specifically for children with HIV,” Seward said in an interview. “So, for something like influenza vaccine, instead of showing up as high risk, it would be colored yellow, which is the routine recommendation color. All children with HIV are at high risk for flu, so they should routinely get vaccinated.”

Although there are not many children that will be affected by these schedules due to the low rate of HIV in the United States, there does seem to be a demand for this type of schedule, according to Seward.

“This new schedule will allow providers who treat a large number of patients with HIV with a much more convenient method of accessing immunization information that applies specifically to their patient population,” Amy Middleman, MD, MPH, associate professor of pediatrics in the section of adolescent medicine and sports medicine at Baylor College of Medicine in Houston, and a member of the Infectious Diseases in Children Editorial board, said in an interview.

“It will be a great bonus because it will save a lot of looking through pages and constant re-referencing of the Morbidity and Mortality Weekly Report. It’s going to streamline the process of protecting HIV-infected youth, and that is always a good thing.”

Currently the recommended immunization schedule for children with HIV is in the clearance process. The final versions will most likely not be available until after the first quarter of 2008 has ended. Although an online version will eventually be made available, it will not coincide with the online publication of the 2008 childhood immunization schedule, Seward said.

For more information:

• Calugar A. Immunization schedules for persons aged 0-18 years: 2008 drafts. Presented at: ACIP meeting; Oct. 24-25, 2007; Atlanta.
• CDC. Recommended immunization schedules for persons aged 0 to 18 Years — United States, 2007. MMWR. 2007;55:Q1-Q4.