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On the basis of current recommendations for use of Food and Drug Administration-licensed vaccines, childhood and adolescent immunization schedules are revised annually. The updated recommendations for 2017 have been approved by the American Academy of Pediatrics (AAP), the Advisory Committee on Immunization Practices (ACIP), the American Academy of Family Physicians, and the American College of Obstetricians and Gynecologists.
Adolescence is a dynamic period during which effective preventive interventions can foster safe behaviors and the development of healthy lifestyle choices. Timely vaccination is a cornerstone of preventive adolescent health care and should be reviewed at every visit and updated as needed, yet barriers to completing adolescent immunizations persist.
Synopsis and Perspective
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 ACIP of the Centers for Disease Control and Prevention (CDC), was published online 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 AAP Committee on Infectious Diseases and the CDC for this schedule, outlined 4 significant changes in the vaccine recommendations for children from birth to age 18 years.
Previous recommendations indicated that 11- and 12-year-old children should receive 3 doses of the HPV vaccine. Now, sufficient data have demonstrated that children aged 9 years until their 15th birthday can receive 2 doses and have a protective response equal to that seen with 3 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, 3 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 ages 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.
Also new with this schedule is that 1 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 roughly 1000 babies are infected each year because the vaccine was not administered, was administered too late, or postexposure prophylaxis does not work. Pediatricians, he said, sometimes assume incorrectly that the mother tests 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 3 or 4 doses within 24 hours of being born.
Live Attenuated Influenza Vaccine
This year, live attenuated influenza vaccine (LAIV) is no longer recommended as an option for children.
Although 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 3 influenza seasons.
A single lifetime dose of the tetanus/diphtheria/pertussis vaccine (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 age 2 months.
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 the following:
- A column was added for 16-year-old adolescents 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.
- MenACWY is now recommended for children with HIV.
- A new table addresses the vaccines that may be indicated for children and adolescents who have a specific condition, such as kidney, heart, or liver disease or diabetes, or for those 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 greatest barriers is when healthcare providers do not offer 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.
- Children 9 to 15 years old may now receive 2 doses of the HPV vaccine, rather than the 3 doses that were previously recommended for children 11 to 12 years, as protection appears to be equal with the 2- or 3-dose series.
- However, children receiving their first HPV vaccine dose on or after their 15th birthday should still receive 3 doses of the HPV vaccine.
- HPV vaccination may begin at ages 9 to 10 years even in the absence of high-risk conditions.
- Within 24 hours of birth, rather than by age 2 weeks as previously recommended, all newborns should receive the first of 3 doses of monovalent hepatitis B vaccine.
- The updated statement no longer recommends LAIV for children under any circumstances, as it has been completely ineffective in the previous 3 influenza seasons.
- Everyone should receive a single lifetime dose of Tdap, and women (including teens) should be vaccinated again with each pregnancy, as early as possible in the 27- to 36-week gestational window, to protect the infant from pertussis.
- Although this disease causes the most severe complications before age 2 months, Tdap cannot be administered to infants younger than 2 months.
- To highlight the need for a MenACWY booster at age 16 years, the new schedule contains a separate column for this age group.
- The updated schedule recommends that HIV-positive children receive MenACWY.
- A new table specifies vaccines indicated for children and adolescents with renal, cardiovascular, or hepatic disease; diabetes; or cochlear implant.
- The 2017 catch-up immunization schedule remains unchanged.
- A separate clinical report describes barriers to adherence with the recommended schedule for adolescents.
- Lack of clear, consistent, and enthusiastic guidance regarding recommended vaccinations, especially the HPV vaccine, appears to confuse and frustrate parents and is one of the strongest barriers to HPV vaccination.
- Each year, youth 15 to 24 years old account for nearly half of the 14 million new HPV infections.
- The former 3-dose schedule for the HPV vaccine series used to be a prominent barrier to completion, especially because it is a painful vaccination.
- This year's (2017) change to 2 doses for children beginning vaccination before their 15th birthday should help overcome this barrier.
- Clinicians should be educated about the HPV vaccine and promote it as a routine vaccine for both sexes, as healthcare provider recommendation has been shown to be the strongest predictor of starting HPV vaccination.
- Other predictors of parents accepting HPV immunization include a family history of cervical cancer or HPV infection, family and community support, education regarding HPV vaccine, healthcare provider access to an immunization registry, and parental Internet use to obtain health information.
- With increasing age, youth are less likely to attend medical visits, and they and their parents may be unaware that they still require vaccination.
- Insufficient vaccine supply may also present a barrier to vaccination compliance, as can online and social media misinformation about vaccines.
- Therefore, the authors recommend educating adolescents and their parents on the importance of vaccination, infection risk and complications, and withstanding peer-pressure or fear of injection.
- An updated ACIP pediatric immunization schedule affects timing for Tdap vaccination of pregnant teens, discourages LAIV use, and reduces the number of HPV vaccine doses for some children.
- Lack of clear, consistent, and enthusiastic guidance by clinicians regarding recommended vaccinations, especially the HPV vaccine, appears to confuse and frustrate parents and is one of the strongest barriers to vaccination.
- Implications for the Healthcare Team: Clinicians should be educated about the HPV vaccine and promote it as a routine vaccine for both sexes.