New Child Vaccine Schedule Alters Tdap Timing, Cuts HPV Doses

This year's updated schedule for child and adolescent immunizations has several key recommended changes, among them a reduction in the number of doses for the human papillomavirus (HPV) vaccine for some children.

The 2017 schedule, approved by the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC), was published online today on the CDC website and in Pediatrics. The updated schedule was also approved by the American Academy of Family Physicians and the American College of Obstetricians and Gynecologists.

In an interview with Medscape Medical News, Cody Meissner, MD, liaison between the American Academy of Pediatrics (AAP) Committee on Infectious Diseases and the CDC for this schedule, outlined four significant changes in the vaccine recommendations for children from birth to age 18 years.

HPV Vaccine

Previous recommendations indicated that 11- and 12-year-old children should receive three doses of the HPV vaccine. Now, sufficient data have demonstrated that children aged 9 years until their 15th birthday can receive two doses and have a protective response equal to that seen with three doses, Dr Meissner said.

"It is a painful vaccine, and the rates of uptake are not good — only about 30%," Dr Meissner noted. "Hopefully, now that it's two doses, the compliance rates will increase."

However, three doses of the HPV vaccine are still recommended for patients who receive their first dose on or after their 15th birthday.

In the new schedule, a blue bar was added to the HPV row at age 9 to 10 years to show the vaccine series can start at that age, even if the child has no high-risk condition.

Starting at this younger age also helps take the question of sexual activity out of the discussions, which is important, Dr Meissner said.

Hepatitis B

Also new with this schedule is that one dose of the monovalent hepatitis B vaccine is recommended for all newborn children within 24 hours of birth.

Previously, a birth dose was recommended, but that was interpreted to mean the first couple of weeks of life, Dr Meissner explained.

"There are about 25,000 babies a year born to mothers who are chronically infected with hepatitis B. We know that the risk of transmission to a baby from a mother chronically infected can be as high as 90%. And we know, if babies are infected at birth, they have a significant risk of developing cirrhosis or cancer of the liver."

He said about 1000 babies are infected each year because the vaccine was not administered, was administered too late, or post-exposure prophylaxis does not work. Pediatricians, he said, sometimes assume incorrectly that the mother is negative and the vaccination can wait until the first visit.

Therefore, the recommendation has been changed to say that every baby should get the first of three or four doses within 24 hours of being born.

Live Attenuated Influenza Vaccine

This year, live attenuated influenza vaccine (LAIV; FluMist Quadrivalent, AstraZeneca) is no longer recommended as an option for children.

Even though it is still available, Dr Meissner said, "This should not be used under any circumstances during the 2016-2017 influenza season." He noted the LAIV has been substantially less effective than the inactivated influenza vaccine in the last three influenza seasons.

Tdap

A single lifetime dose of Tdap is recommended for everyone except pregnant women.

Each time a woman becomes pregnant, Dr Meissner explained, she should receive Tdap vaccination to protect her infant. The most severe complications for pertussis occur in the first 2 months of a child's life, yet infants cannot receive the pertussis vaccine before 2 months of age.

Therefore, the recommendation is to vaccinate mothers, including adolescent mothers, as early as possible in the 27- to 36-week gestational window. The words "as early as possible" were added because evidence shows that when the immunization is given closer to 27 weeks, "the baby is born with a higher concentration of maternal antibodies," Dr Meissner says.

Other changes to the schedule include:

A column was added for adolescents aged 16 years to separate them from 17- and 18-year-olds to emphasize the need for a quadrivalent meningococcal conjugate vaccine (MenACWY) booster at age 16 years.
Meningococcal ACWY is now recommended for children with HIV.
A new table addresses which vaccines may be indicated for children and adolescents who have a specific condition, such as kidney, heart, or liver disease or diabetes, or who have a cochlear implant.

No changes have been made to the 2017 catch-up immunization schedule.

In an accompanying clinical report, Henry H. Bernstein, DO, MHCM, and Joseph A. Bocchini Jr, MD, both from the AAP's Committee on Infectious Diseases, summarize some of the barriers that should be confronted to complete adolescent vaccine schedules.

Among the biggest barriers is providers not giving consistent, clear, and enthusiastic guidance, particularly with the HPV vaccine, the authors say.

"Parents prefer clear, unambiguous recommendations; offering the HPV vaccine without strongly recommending it appears to confuse and frustrate parents," they write.

Nearly half of the 14 million new HPV infections each year are in 15- through 24-year-olds, they note; children are less likely to come in for medical appointments as they get older, and parents and adolescents may not be aware that teenagers need vaccines.

Also, not having enough vaccines for all patients on hand in the office can work against meeting vaccination goals.

Dr Bernstein and Dr Bocchini also cite misinformation about vaccines rampant on Internet sites and social media.

"Education on the importance of immunizations, infection risk and consequences, and the need to overcome peer-pressure or fear of needles should be key focuses for adolescent patients," they write.

The authors have disclosed no relevant financial relationships.

Pediatrics. Published online February 6, 2017.

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