The Best of 2015's Pediatric Viewpoints

Most Widely Read Viewpoints of 2015

As 2015 comes to a close, I would like to revisit some of the most widely read pediatric viewpoints in 2015. These articles represent a mix of topics -- much like the varied dilemmas that outpatient pediatric providers face daily. However, the popularity of these articles and number of readers only demonstrate how prevalent these conditions are in outpatient practice.

The 2015 Child/Teen Immunization Schedule: Changes You Should Know

This was the most read pediatric viewpoint of 2015. It is no surprise that pediatric providers wanted to know all about vaccine updates. The 2015 immunization schedule did not contain many changes, but there were several interesting advances. At the beginning of 2015, the Advisory Committee on Immunization Practices at the Centers for Disease Control and Prevention (CDC) released their 2015 recommendations for adolescent and child vaccines online,^[1] allowing for real-time updates as any recommendations or products change. Although the schedule charts are no longer published in Pediatrics, color PDFs of the recommended schedules and the usual accompanying footnotes can be downloaded and printed from the CDC and placed on the office wall.

One of the biggest changes in 2015 was the move to online, hyperlinked schedules, with embedded footnote links. Both the routine and catch-up online vaccine schedules are divided into smaller age groups, allowing more detail to be incorporated in the schedules, which obviates the need to always refer to the footnotes. Each catch-up vaccine schedule is appropriately indexed with hyperlinks to its own footnotes and other resources. Each numerical footnote on the schedule is hyperlinked to the corresponding text, allowing quick navigation to the needed information. As an example, details about "aging out" of specific vaccines (eg, the recommendation to administer only one Haemophilus influenzae B vaccine after 15 months) were previously conveyed in the footnotes. Now these age-out provisions are shown directly on the charts.

Influenza vaccine. Most of the changes to the influenza vaccination schedule are clarifications and some additional contraindications. Previously, the guidance included contraindications for asthma, a history of wheezing in the previous 12 months, or any underlying medical condition that predisposed to influenza complications. This year's detailed contraindications are specific to the live-attenuated influenza vaccine (LAIV) and include:

Persons who have experienced severe allergic reactions to LAIV, to any of its components, or to a previous dose of any other influenza vaccine;
Children aged 2 to 17 years receiving aspirin or aspirin-containing products;
Persons who are allergic to eggs;
Pregnant women;
Immunosuppressed persons;
Children aged 2 to 4 years with asthma or who had wheezing in the past 12 months; or
Persons who have taken influenza antiviral medications in the previous 48 hours.

The updated schedule charts graphically offer additional details about which vaccines should be given at ages 6 months to 2 years (inactivated only), the fact that many children aged 6 months to 9 years will need two vaccines, and the fact that children aged ≥ 9 years need only one vaccine. These details represent an improvement over the 2014 influenza vaccine chart.

Measles, mumps, rubella (MMR). The chart for the MMR immunization schedule now displays a purple bar that hyperlinks to a footnote, detailing specific MMR vaccination recommendations for infants aged < 12 months. Children aged < 12 months who travel internationally should receive one dose before departure. However, these children will still require the usual two-dose schedule as they age, beginning at the age of 12 months. In a similar vein, any child aged 12 months or older and traveling internationally should receive two doses of MMR vaccine starting at 12 months, given at least 4 weeks apart, and completed before departure.

Meningococcal vaccine. There are no 2015 changes to the recommendations for which patients should receive the meningococcal vaccine on a routine basis or for the "high-risk" groups who should also receive it. The high-risk groups include children with functional or anatomic asplenia, children with persistent complement component deficiency, and children traveling to endemic areas. The major change is in the footnote display. The new footnote section for meningococcal vaccine is chartlike, with clearer recommendations for which product (MenACWY-CRM, MenACWY-D, or Hib-MenCY-TT) should be administered according to the child's age.

Viewpoint

To close out the 2015 vaccine recommendations, I thought that it would be worth reviewing recent guidance from the CDC about meningococcus serogroup B vaccines.^[2] This interesting short article reviews current data for the two vaccine preparations available in the United States (MenB-FHbp and MenB-4C) for use in patients aged 10 to 25 years. The article points out the rather unique nature of accelerated US Food and Drug Administration approval using vaccine titers as the principle outcome rather than field trials of clinical efficacy. Rest assured, however, that the process required postlicensure studies, so we will eventually see clinical data on the efficacy of these vaccines in US children and adolescents. In the US, 50 to 60 cases of meningococcus serogroup B disease and 10 deaths are reported every year. Although many providers associate serogroup B disease with college outbreaks, the incidence among college students in the US is 0.09/100,000 compared with 0.21/100,000 among noncollege 18- to 23-year-olds and 0.14/100,00 in the US general population.

MenB vaccines are recommended only for persons aged 10 years or older who are at increased risk for serogroup B disease (persistent complement component deficiencies, anatomic or functional asplenia, microbiologists working with Neisseria meningitidis, and individuals at risk during an outbreak of serogroup B disease). MenB vaccines may be given to all persons aged 16 to 23 years, but are not expressly recommended. Other recommendations include:

The ideal age for administering MenB vaccines is 16 to 18 years;
The vaccine may be given with other vaccines, but preferably at a separate anatomical site;
The vaccine is not generally recommended (but may be given if warranted by risk) for pregnant and lactating women, mainly owing to a lack of data.

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