Adult Immunization Schedule by Age

5 Jun

Recommended Adult Immunization Schedule by  Age  Group and Medical Conditions

United States, 2003–2004

Summary of Recommendations Published by

The  Advisory Committee on

Immunization Practices

Department of  Health and Human Services

Centers for  Disease Control and Prevention

Recommended Childhood and Adolescent Immunization Schedule United States, January - June 2004

This  schedule indicates the  recommended ages  for routine administration of currently licensed childhood vaccines, as of December 1, 2003, for children through age 18 years. Any dose not given  at the  recommended age  should be given  at any  subsequent visit  when indicated and  feasible.         Indicates age  groups that warrant special effort to administer those vaccines not previously given. Additional vaccines may be licensed and  recommended during the  year. Licensed combination vaccines may  be used whenever any  components of the  combination are  indicated and  the  vaccine’s  other components are  not  contraindicated. Providers should consult the  manufacturers’ package inserts for detailed recommendations. Clinically significant adverse events that follow immunization should be reported to the  Vaccine Adverse Event Reporting System (VAERS). Guidance about how to obtain and  complete a VAERS  form can be found  on the  internet: http://www.vaers.org/ or by calling 1-800-822-7967.

1. Hepatitis B (HepB) vaccine. All infants should receive the  first dose of hepatitis B vaccine soon affer birth and  before  hospital discharge; the first dose may also be given  by age 2 months if the infant’s mother is hepatitis B surface antigen (HBsAg) negative. Only monovalent HepB  can be used for the  birth dose. Monovalent or combination vaccine containing HepB  may be used to complete the  series. Four doses  of vaccine may be administered when a birth dose is given. The second dose should be given  at least 4 weeks after the  first dose, except for combination vaccines which cannot be administered before age

6 weeks. The third dose should be given  at least

16 weeks after the  first dose and  at least

8 weeks after the second dose. The last does in the vaccination series (third or fourth dose) should not be administered before  age

24 weeks.

Infants born  to HBsAg-positive mothers should receive HepB  and  0.5 mL of Hepatitis B

Immune Globulin (HBIG)  within 12 hours of birth at separate sites. The  second dose  is recommended at age

1 to 2 months. The  last dose  in the immunization series should not  be administered before  age  24 weeks. These infants should be tested for HBsAg  and antibody to HBsAg  (anti-HBs) at age  9 to 15 months.

Infants born to mothers whose  HBsAg status is unknown should receive the  first dose of the  HepB  series within 12 hours of birth. Maternal blood should be drawn as soon as possible to determine the  mother’s HBsAg status; if the HBsAg test is positive, the  infant should receive HBIG  as soon as possible (no later than age  1 week).  The second dose  is recommended at age 1 to 2 months. The  last dose  in the immunization series should not  be administered before  age  24 weeks.

2. Diphtheria and tetanus toxoids and acellular pertussis (DTaP) vaccine. The  fourth dose  of DTaP may  be administered as  early as  age  12 months, provided 6 months have elapsed since  the third dose  and  the  child  is unlikely to return at age  15 to 18 months. The  final dose  in the  series should be given  at age

³4 years. Tetanus and  diphtheria toxoids (Td) is recommended at age 11 to 12 years if at last 5 years have elapsed since  the last dose of tetanus and  diphtheria toxoid- containing vaccine. Subsequent routine Td boosters are  recommended every  10 years.

3. Haemophilus Influenzae type b (Hib) conjugate vaccine. Three Hib  conjugate vaccines are  licensed for infant use. If PRP- OMP  (PedvaxHIB or ComVax [Merck] is administered at ages  2 and  4 months, a dose at age 6 months is not reqeired. DTaP/ Hib  combination products should not  be used for primary immunization in infants at ages  2, 4 or 6 months but  can  be used as boosters following any  Hib vaccine. The find  dose  in the  series should be given  at age  ³12 months.

4. Measles, mumps, and rubella vaccine (MMR). The  second dose  of MMR is recommended routinely at age 4 to 6 years but  may  be administered during any  visit, provided at least 4 weeks have elapsed since  the  first dose  and  both  doses  are administered beginning at or after age

12 months. Those  who have not previously received the  second dose  should complete the  schedule by the  11- to 12-year-old visit.

5. Varicella vaccine. Varicella vaccine is recommended at any  visit  at or after age

12 months for susceptible children (i.e., those who lack  a reliable history of chickenpox). Susceptible persons age ³13 years should receive 2 doses,  given  at least

4 weeks apart.

6. Pneumococcal vaccine. The heptavalent pneumococcal conjugate vaccine (PCV) is recommended for all children age  2 to 23 months. It is also recommended for certain children age 24 to 59 months. The final dose

in the  series should be given  at age  ³12 months. Pneumococcal polysaccharide vaccine (PPV)  is recommended in addition to PCV  for certain high-risk groups. See MMWR 2000;49(RR-9):1–38.

7. Hepatitis A vaccine. Hepatitis A vaccine is recommended for children and adolescents is selected states and  regions and  for certain high-risk groups; consult your  local  public health authority. Children and  adolescents in these states, regions, and high-risk groups who  have not  been  immunized against hepatitis A can  begin  the  hepatitis A immunization series during any  visit. The 2 doses  in the  series should be administered at least 6 months apart. See  MMWR 1999;48(RR-12):1–37.

8. Influenza vaccine. Influenza vaccine is recommended annually for children age ³6 months with certain risk factors (including but  not  limited to children with asthma, cardiac disease, sickle  cell disease, human immunodeficiency virus infection, and diabetes; and  household members of persons in  high-risk groups [see  MMWR

2003;52 (RR-8):1–36]) and  can  be administered to all  others wishing to obtain immunity. In  addition, healthy children age 6 to 23 months are  encouraged to receive influenza vaccine if feasible, because children in  this age  group are  at substantially increased risk of influenza- related hospitalizations. For  healthy persons age 5 to 49 years, the  intranasally administered live-attenuated influenza vaccine (LAIV) is an acceptable alternative to the  intramuscular trivalent inactivated influenza vaccine (TIV). See  MMWR

2003;52(RR-13):1–8. Children  receiving TIV should be administered a dosage appropriate for their age  (0.25  mL  if age 6 to 35 months or 0.5  mL  if age ³3 years). Children age  £ 8 years who  are receiving influenza vaccine for the  first time should receive 2 doses  (separated by at least 4 weeks for TIV and  at least 6 weeks for LAIV).

For  additional information about vaccines, including precautions and  contraindications  for immunization and  vaccine shortages, please visit  the  National Immunization Program Web site  at www.cdc.gov/nip/ or call the  National Immunization Information Hotline at 800-232-2522 (English) or 800-232-0233 (Spanish)

Approved by  the Advisory Committee on  Immunization Practices (www.cdc.gov/nip/ acip), the American Academy of  pediatrics (www.aap.org), and the American Academy of  Family Physicians (www.aafp.org).

For  Children and Adolescents Who  Start Late or  Who  Are  >1 Month Behind

The  tables below  give  catch-up schedules and  minimum intervals between doses  for children who  have delayed immunizations. There is no need  to restart a vaccine series regardless of the  time that has  elapsed between doses.  Use the  chart appropriate for the  child’s  age.

For  Children and Adolescents Who  Start Late or  Who  Are  >1 Month Behind

The  tables below  give  catch-up schedules and  minimum intervals between doses  for children who  have delayed immunizations. There is no need  to restart a vaccine series regardless of the  time that has  elapsed between doses.  Use the  chart appropriate for the  child’s  age.

1.  DTaP: The  fifth  dose  is not  necessary if the  fourth dose  was  given  after the  fourth birthday.

2.  IPV: For  children who received an  all-IPV or all-oral poliovirus (OPV) series, a fourth dose  is not  necessary if third dose was  given  at age ³4 years. If both  OPV and  IPV were  given  as part of a series, a total of 4 doses  should be given, regardless of the  child’s  current age.

3.  HepB: All Children and  adolescents who  have not  been  immunized against hepatitis B should begin  the

HepB  immunization series during any  visit. Providers should make special efforts to immunize children

who were  born  in, or whose  parents were  born  in, areas of the  world  where hepatitis B virus infection is moderately or highly endemic.

4.  MMR: The  second dose  of MMR is recommended routinely at age  4 to 6 years but  may  be given  earlier if desired.

5.  Hib: Vaccine is not  generally recommended for children age  ³5 years.

6.  Hib: If curent age <12 months and  the  first 2 doses  were  PRP-OMP (PedvaxHIB or ComVax [Merck]), the  third (and final) dose  should be given  at age  12 to 15 months and  at least 8 weeks after the  second dose.

7.  PCV: Vaccine is not  generally recommended for children age  ³5 years.

8.  Td: For  children age  7 to 10 years, the  interval between the  third and  booster dose  is determined by the  age  when the  first dose was  given.  For adolescents age 11 to 18 years, the  interval is determined by the  age when the  third dose was  given.

9.  IPV: Vaccine is not  generally recommended for persons age  ³18 years.

10.  Varlicella: Give  2-dose  series to all  susceptible adolescents age  ³13 years.

Reporting Adverse Reactions Disease Reporting Report abverse reactions to vaccines through the  federal Vaccine Adverse Event Report suspected cases of Reporting System. For  information on reporting reactions following immunization,  vaccine-preventable diseases please visit  www. vaers.org or call  the  24-hour national toll-free information    to your  state or local line  (800)822-7967.     health department.

For  additional information about vaccines, including precautions and  contraindications for immunization and  vaccine shortages, please visit  the National Immunization Program Web site  at www.cdc.gov/nip or call the National Immunization Information Hotline at 800-232-2522 (English) or 800-232-0233 (Spanish).

* Covered by the  Vaccine injury Compensation Program For  Information on how to file a claim  call 800-338-2382. Please also  disit www.hrq.gov/otp/vicp. To file a claim  for vaccine injury contact: U.S.  Court of Federal Claims, 717  Madison Place, H.W.,  Washington D.C. 20005, 202-219-9657.

This  schedule indicates the  recommended age  groups for routine administration of currently licensed vaccines for persons 19 years of age  and  older.  Licensed combination vaccines may  be used whenever any  components of the  combination are  indicated and  the  vaccines other components are  not  contraindicated Providers should consult the  manufactures’ package inserts for detailed recommendations.

Report all  clinically significant post-vaccination reactions to the  Vaccine Adverse Event Reporting System (VAERS).  Reporting forms  and  instructions on filing  a VAERS  report are  available by calling 800-822-7967 or from  the  VAERS  website at www.vaers.org.

For  additional information about the  vaccines listed above  and  contraindications for immunization, visit  the National Immunization Program Website at www.cdc.gov/nip/ or call the  National Immunization Hotline at 800-232-2522 (English) or 800-232-0233 (Spanish).

Approved by the  Advisory Committee on Immunization Practices (ACIP),  and  accepted by the  American College of Obstetridans and  Gynecologists (ACOG) and  the  American of Family Physicians (AAFP)

A. For  women without chronic diseases/conditions, vaccinate If pregnancy will be at 2nd or 3rd trimester during influenza season. For  women with chronic deseases/conditions, vaccinate at any  time during the  pregnancy.

B. Although chronic liver  disease and  alcoholism are not  indicator conditions for influenza vaccination, give 1 dose annually if the  patent is ³50 years, has other indications for influenza vaccine, or if the patient requests vaccination.

C. Asthma a is an  indication condition for influenza but  not  for pneumococcal vaccination.

D. For  all  persons with chornic liver  disease.

E. For  persons < 65 years revaccinate once  after 5 years or more  have elapsed since  initial vaccination.

F. Persons with impaired humoral immunity but intact cellular immunity may  be vaccinated, MMWR 1999;48 (RR-06):1–5.

G. Hemodialysis patients: Use  special formulation of vaccine (40 ug/mL)  or two 1.0 ml 20 ug doses  given at one  site. Vaccinate early in the  course of renal disease. Assess antibody iters to hep  B surface antigen (anti-HBs) levels  annually. Administer additional doses  if anti-HBs levels  decline to < 10 milliinternational units (mlU)/mL.

H. There are  no data specially on risk of severe or complicated influenza infections among persons with asplenia. However, Influenza is a risk factor for secondary bacterial infections that may cause severe disease in asplenics.

I.  Administer meningococcal vaccine and  consider Hib vaccine.

J.  Elective splenectomy: vaccinate at least 2 weeks before  surgery.

K. Vaccinate as close to diagnosis as possible when CD4 cell counts are  highest.

L. Withhold MMR or other measles containing vaccines from  HIV-infected persons with evidence of severe immunosuppression. MMWR 1998;47 (RR-8):21–22; MMWR 2002:51 (RR-02);22–24.

Live  virus vaccines for  measles, mumps, rubella were introduced in  the  1960s  and, after widespread implementa- tion in the  United States, annual reported cases of these infec- tions declined by  more   than 98%  (26).  The  most   recent recommendations by the  Centers for Disease Control and  Pre- vention (CDC) suggest vaccination with the  first MMR dose at

12–15  months and  the  second dose  at 4–6  years of age  (27). Two doses  confer 92% immunity, which is sufficient to prevent epidemics.

Special Considerations

Pregnancy. Because these vaccines consist of live atten- uated viruses, they should not be administered to preg- nant women or those planning to become  pregnant in the  next 3 months. The  theoretical risk of congenital rubella syndrome after immunization has  been the pri- mary concern. However, a study of 321 women who had received the  rubella vaccine 3 months before  or after conception revealed no congenital malformations  com- patible with congenital rubella infection (27).

Immunosuppressed. Immunization is also  contraindi- cated in immunosuppressed patients, although it can be administered to individuals with asymptomatic HIV in- fection as well as persons with mild immunosuppression. Healthy individuals. In  healthy individuals, minor ill- nesses with or without fever are  not a contraindication to vaccination.

Patients with a history of anaphylactic hypersensi- tivity to neomycin. These persons should not receive the  MMR vaccine.

Egg  allergy. The vaccine can be administered to patients with an allergy to eggs, since the risk for severe anaphy- lactic reactions is exceedingly low (28,29).  It is recom- mended that these patients be observed for 90 minutes after immunization (29). Khahoo and  Loch (28) report that most  severe cardiorespiratory  allergic reactions were reported in children who were most  likely  allergic to the  gelatin or neomycin in the  vaccine rather than ovalbumin.

Measles

Measles virus has  been noted to be the  most  infectious disease of humankind, in terms of the  minimal number of virions nec- essary to produce infection (30). An estimated 75% of suscep- tible  family contacts who  are  exposed to  a  case  of measles develop the  disease (31). Because humans are  the  only reser- voir  for measles virus, global  eradication is technically feasi- ble. A meeting cosponsored by the World Health Organization, CDC, and  the  Pan American Health Organization convened in

1996  and  adopted the  goal  of global  eradication by a  target date during 2005–2010 (32).  Due  to  universal childhood immunization in the  United States, measles is no longer con- sidered an  indigenous disease in this country. In 2001, a total of 116  confirmed measles cases were  reported—54 interna- tionally imported and  62 indigenous (37 import linked and  25 unknown sources). In 2002, a total of only 37 cases of measles were  confirmed, which represents  a  record low  number of reported cases. It is important, however, to guard against com- placency with these encouraging figures. In 2003, 39 cases had been  confirmed by August, which should serve as a reminder of the  continuing need  for vaccination (33).

Lack  of compliance with routine MMR vaccination in the past led  to  a  resurgence of measles infection in  the  United States from 1989–1991, with some deaths reported (32). More- over, greater than 1 million children die of measles each  year in Third World  countries (34). The  current measles vaccine is a  further attenuated version of the  live  preparations  previ- ously  available, resulting in fewer  adverse reactions in recipi- ents. It is produced by culturing the  Moraten virus strain in chick  embryo cells.  Measles vaccination produces a  mild  or inapparent infection which is noncommunicable. Both  humoral and  cellular immune responses develop as a result (35). After receiving two  doses  of vaccine, 95–99%  of recipients develop serologic evidence of immunity to measles (36,37).  Immunity is thought to be life-long, similar to that acquired after infection with the  wild-type virus (38). Measles infection has  rarely been reported in patients with previously documented postimmuni- zation seroconversion (39,40). In a recent measles outbreak in

Campania, Italy, low vaccination rates (76%) were  cited  as the main cause (41).

Adverse Effects

Adverse effects  after measles vaccination are  typically mild.

Fever. Five  to 15 percent of recipients develop a fever  of at least 103°F  for  1–2  days, generally between 5–12 days  after immunization (42). These individuals are largely asymptomatic, but  some  may  develop a  tran- sient viral exanthem (26).

Encephalitis. An associated encephalitis or encephalop- athy has  rarely been  reported after immunization, and occurs  in less  than 1 per  1 million vaccinees (43).

Subacute  sclerosing  panencephalitis. There have been  early concerns about the  association of measles vaccination and  subacute sclerosing pancencephalitis (SSPE), since this complication may occur with natural infection. A small number of reports have described the  occurrence of SSPE in  persons with a  history of vaccination but  no known history of infection (44–46). More  recent evidence indicates that at least some  of those cases had  unrecognized natural  measles infec- tion  prior to  vaccination, and  the  SSPE was  directly related to the  infection (27). Widespread measles im- munization has  nearly eliminated SSPE in the  United States, and  the  live measles vaccine does  not  increase the  risk for this complication (27).

More  recently, the  measles vaccine has  been  administered as an  aerosolized vaccine. Aerosol  administration has  fewer  side effects  than injection inoculation. Immunogenicity is superior in the  aerosol administration when compared with traditional injections. Thus the  potential efficacy  and  cost  warrant fur- ther studies of aerosol measles immunizations (47).

Mumps

The live attenuated mumps vaccine (Jeryl-Lynn strain) is pre- pared in chick  embryo cell culture. Immunization produces a

mild  subclinical infection that  is  noncommunicable. Early clinical studies have shown that 97% of children and  93% of adults develop serological evidence of immunity after vaccina- tion  (48–50). Outbreak-based studies, however, have reported lower  efficacy  rates, ranging from  75–95%  protection from infection (51–54). Although the  duration of immunity in vac- cine  recipients is not  completely known, serologic and  epide- miologic evidence suggests that immunity persists for at least

30 years (55–58).

Adverse Effents

Adverse reactions  are  generally mild  and  uncommon after mumps vaccination.

Fever, parotitis, and exanthem. Low-grade fever, mild parotitis, and  a viral exanthem have been  reported. Neurological effects. Serious reactions such  as adverse

neurological effects  are  extremely rare and  have not been  causally associated with the  mumps vaccine (59).

Rubella

Three different live  attenuated  rubella vaccine strains were initially developed and  licensed in  the  United States. These were  all replaced in 1979  by the  RA 27/3 (rubella abortus 27, explant 3) vaccine which is grown in human diploid fibroblast cell culture. This  vaccine produces nasal antibodies as well as higher and   more  persistent  antibody titers,  which better mimic  the  immune protection developed after natural  infec- tion  (60,61).

Vaccination induces an  antibody response in  more  than

97%  of recipients (49,62).  Immunity in  vaccine recipients is thought to  be lifelong, and  has  been  shown to  persist for  at least 16 years (63,64).

Adverse Effects

Adverse effects  after rubella vaccination are  typically mild.

Fever, lymphoadenopathy, or  exanthem. 5–15%  of vaccinated children  develop fever, lymphadenopathy,

or a viral exanthem, typically between 5–12 days  after vaccination (50,65).

Arthralgia /arthritis. Arthralgias and  arthritis are  a frequent complication in  adult vaccinees, particularly women, and  may  develop in 25–40%  of this population group (66–68). Occurrences in children are  rare (0.5%) (66). These joint  symptoms typically begin  within the first 3 weeks after vaccination and  remit within 11 days. The knees and  the  fingers are  most  frequently in- volved,  but  any  joint  may  be affected (67).

Special Considerations

Pregnancy and vaccination rates. Failure to achieve

50–60%  immunity to  rubella by  vaccination leaves women of childbearing age  susceptible to  developing rubella infection during pregnancy. This  often  causes congenital rubella in children born of mothers who con- tract rubella during early pregnancy. For  example, ru- bella  immunization in Greece was classed as “optional,” but  less  than 50% of the  children were  vaccinated. An epidemic in  Greece in  1993  affected more  women of childbearing age  than ever  before. This,  in  turn, was followed  by the  births of the  largest number of babies with congenital rubella ever  recorded in Greece (69).

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