COMMENTARY

2019 ACIP Child and Adolescent Immunization Schedule: Key Changes

William T. Basco, Jr, MD, MS

Disclosures

February 05, 2019

The 2019 joint statement by the Advisory Committee on Immunization Practices (ACIP) of the US Centers for Disease Control and Prevention (CDC), the American Academy of Pediatrics, the American Academy of Family Physicians, and the American College of Obstetricians and Gynecologists was released on February 5, 2019. As usual, there are some new things in the schedule this year ("hellos"), things leaving the schedule this year ("goodbyes"), and things that fall into the category of "reminders."

The Biggest Changes

Hellos. Say hello again to live attenuated influenza vaccine (LAIV)! After bidding "farewell" to the LAIV as a recommended preparation in 2017, it is now recommended again for children 24 months old and older for the 2018-2019 influenza season.

As a reminder, the following children should not receive LAIV:

  • Children < 2 years old;

  • Pregnant adolescents;

  • Any eligible child on aspirin or other salicylates;

  • Children with immune suppression;

  • Children 2-4 years old who experienced asthma or wheezing in the 12 months prior to vaccination;

  • Children who received influenza antiviral medications < 48 hours before vaccination.

Other patients are considered "precautionary" for use of the LAIV, including:

  • Patients with asthma who are ≥ 5 years old;

  • Children with a history of lung, heart, kidney, or other disease that puts them at increased risk for serious complications from influenza.

The change in recommendation from the previous two influenza seasons is due to the addition of a new H1N1 strain that is expected to improve the vaccine's effectiveness against H1N1 viruses. The CDC makes a point of not specifically recommending either LAIV or inactivated influenza vaccine for patients who are eligible to receive either preparation.

As a reminder, purple bars on Figure 1 show recommended ages for vaccines that are indicated only for "high-risk" groups. Say hello, then, to two new purple bars. The first is for hepatitis A vaccine, now recommended for infants 6-11 months old who are traveling internationally. The second new recommended vaccine for a high-risk group is to consider Tdap for pregnant girls 13-18 years old.

Goodbyes. The goodbye of greatest significance appears to be removal of specific recommendations on using measles, mumps, rubella (MMR) or meningococcal vaccines in the cases of mumps or meningococcus outbreaks, respectively. The guidelines instead suggest that practitioners seek guidance from local health departments during respective outbreaks.

Reminders. The first reminder is that initiation of human papillomavirus (HPV) vaccine at ages 9-14 make a patient eligible for the two-dose series, given 6-12 months apart. Any individual who starts the series after turning 15 should continue with the previous three-dose series.

Another reminder is that children who receive a Tdap or DTaP at ages 7-10, either inadvertently or as part of a catch-up plan, should still receive a Tdap dose at 11-12 years old.

It's always good to remember that every pregnant adolescent should receive one dose of Tdap, administered between 27 and 36 weeks of gestation.

And finally, remember that Table 1 is the recommended schedule. Colored bars indicate the level of recommendation for different vaccines:

  • Yellow bars indicate the ranges of recommended vaccines for all children.

  • Green bars indicate ranges of recommended ages for catch-up vaccines.

  • Purple bars indicate recommended age ranges for vaccines indicated only for high-risk groups.

  • Blue bars indicate vaccines that may be given to non-high-risk groups at patient/provider discretion.

Table 2 is the catch-up schedule for patients 4 months to 18 years. For many of the vaccines, such as Haemophilus influenzae type b, pneumococcus, and pertussis, the number of vaccines needed varies depending on the age of the person.

Table 3 gives vaccine-specific recommendations for people 0-18 years old with various chronic medical conditions. This table gives guidance on which vaccines to consider during pregnancy, for children with immunocompromising conditions (including recommendations specific to HIV infection), kidney failure, heart disease, chronic lung disease, chronic liver disease, asplenia, cochlear implants, and potential chronic medical conditions associated with immune alteration.

As a reminder, the CDC site contains many helpful visual aids, including those suitable to print and hang in the office, links to phone applications that are free to download, parent-friendly vaccine reminder schedules in several languages, and even online "quizzes" that parents or providers complete to determine which vaccines a child may need.

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