The Advisory Committee on Immunization Practices (ACIP) made a number of major new recommendations last year. These new recommendations address:
- expanded use of hepatitis A virus (HAV) vaccine
- preferences for combination vaccines
- timing of poliovirus vaccine doses
- resumption of the normal Haemophilus influenzae Type b (Hib) schedule, as shortages have resolved
- the use of a new bivalent human papilloma virus (HPV2) vaccine in women and quadrivalent (HPV4) vaccine in men
- a reduced-dose schedule for rabies postexposure prophylaxis
- proof of immunity against mumps, measles, and rubella for health care workers
- recommendations for meningococcal vaccine boosters.
Adoptive families need more protection against HAV
Each year, approximately 18,000 children are adopted from foreign countries, almost all of them born in countries with high or intermediate rates of HAV, 85% of them under 5 years of age.1 Identifying adoptees with an acute HAV infection is problematic, because in this age group, fewer than 10% of infected children manifest jaundice.1 The Centers for Disease Control and Prevention (CDC) has recorded a small number of cases of acute HAV infection traced back to exposure to adoptees, and there is some evidence that 1% to 6% of new international adoptees have acute, and infectious, HAV.1
In response to these data, the most recent ACIP recommendation expands indications for HAV vaccine to include anyone who will be in close personal contact—living in the same household or providing regular babysitting—with an adoptee from any country with high or intermediate endemic rates of HAV. The vaccine should be given within the first 60 days of the adoptee’s arrival in the United States.1The first dose of the 2-dose series should be given as soon as the adoption is planned, ideally 2 or more weeks before exposure to the adoptee.
This new recommendation adds to earlier expansions of indications for HAV vaccine, which include universal use in children, use in postexposure prophylaxis, and preexposure protection for travelers.2,3
ACIP still prefers combination vaccines, with caveats
Increasing numbers of vaccine products with multiple antigens have reduced the number of injections needed to complete the recommended childhood immunization schedule. These new products also create a situation in which parents and physicians have to choose between using the combination products or staying with component vaccines that contain fewer antigens, but necessitate a larger number of injections.
When ACIP considered this dilemma, committee members gave the general preference to combination vaccines. At the same time, the committee acknowledged that many considerations—storage, costs, number of injections, vaccine availability, vaccination status, likelihood of improved coverage, likelihood of return visits, patient preference, and the potential for adverse events—factor into the decision.4
MMRV is a special case. One combination product received special attention because of the potential for increased rates of febrile seizures. Combined measles, mumps, rubella, and varicella (MMRV) vaccine is currently in short supply, but when the supply improves it will provide 1 less injection to immunize against 4 childhood viral infections at each of 2 visits. However, there is good evidence that in children 1 to 2 years of age who are receiving the first dose of MMRV, there is an additional incidence of febrile seizures of 1 in every 2300 to 2600, compared with children receiving separate doses of MMR and varicella vaccines.5 There is no increased risk for older children or for the second dose.
ACIP considered this risk and recommends discussing the benefits and risks of MMR and varicella separately vs using the MMRV combination vaccine. The committee notes: “Use of MMR and varicella vaccines avoids [the] increased risk for fever and febrile seizures following MMRV vaccine.”5
IPV combination dosing is clarified
The inclusion of inactivated poliovirus (IPV) antigen into new combination vaccine products has caused some confusion over the recommended dosing schedule of polio vaccine. ACIP has now clarified that for the recommended 4-dose IPV schedule, the fourth dose should be administered after age 4 and at least 6 months after dose 3. In addition, the minimal intervals (4 weeks) in the first 6 months of life should be used only for those traveling overseas.6
Resume normal Hib schedule
With the licensure of a new Hib product (Hiberix, GlaxoSmithKline) for the booster dose of Hib starting at age 15 months, the supply of Hib vaccine has stabilized. Supply is now adequate to resume all 4 doses in the routine schedule and to recall all children who had their booster dose deferred. Children can be vaccinated with Hib through the age of 59 months (prior to their fifth birthday).7