Chapter 116. Immunization Principles and Vaccine Use (Part 7) docx

to use a new tetanus toxoid/reduced-dose diphtheria toxoid plus acellular pertussis combination vaccine Tdap formulated for adolescents and adults in place of Td; to provide meningococc

Chapter 116 Immunization Principles

and Vaccine Use

(Part 7)

As noted above, the number of licensed vaccines and the strategies for their best use change constantly as new products, new indications, and new information become available The Advisory Committee on Immunization Practices (ACIP) regularly amends immunization recommendations to reflect the evolution of vaccines and vaccination policy in the United States Changes for 2006 include the following points:

to implement standing orders to administer hepatitis B vaccine—soon after birth and before hospital discharge—to all infants except those with documented hepatitis B–negative mothers;

to target adults at high risk for hepatitis B vaccination;

to use a new tetanus toxoid/reduced-dose diphtheria toxoid plus acellular pertussis combination vaccine (Tdap) formulated for adolescents and adults in place of Td;

to provide meningococcal conjugate vaccine (MCV4) to all children

at 11–12 years of age, to unvaccinated adolescents at age 15, and to all college freshmen living in dormitories;

to administer hepatitis A vaccine to all children at 1 year of age;

to administer three doses of the newly licensed rotavirus vaccine at 2,

4, and 6 months of age, with the first dose given by 12 weeks of age and the last

by 32 weeks of age;

to immunize children 6 months to 5 years of age with influenza vaccine and to expand routine use of the vaccine for their household contacts and out-of-home caregivers;

to administer Tdap to protect health care personnel from pertussis and to reduce their potential to transmit nosocomial infections, assigning the highest priority to those who have direct contact with infants <1 year old; and

to administer HPV vaccine routinely to girls at 11–12 years of age

Vaccines for Routine Use

Infants and Children

It is current practice for all children in the United States to receive DTaP, poliovirus, MMR, Hib, hepatitis B, and varicella vaccines and to receive pneumococcal conjugate, hepatitis A, and rotavirus vaccines in the absence of specific contraindications (Fig 116-1; www.cdc.gov/vaccines/vpd-vac/vaccines-list.htm) Annual influenza seasonal vaccine is recommended for all children 6 months to 5 years old and to other children who have certain risk factors or who reside with persons with certain chronic disorders In several European countries, meningococcal C conjugate vaccine is routinely recommended for children

Teenagers

It is now recommended that all adolescents routinely receive quadrivalent meningococcal conjugate vaccine for serogroups A, C, Y, and W135 and the new-formulation Tdap vaccine Girls should be given HPV vaccine, ideally at the age

of 11–12 years but certainly before becoming sexually active (Fig 116-1;

www.cdc.gov/vaccines/recs/schedules/teen-schedule.htm)

Adults, Including College Students

(Fig 116-2) Immunization recommendations for adults (≥18 years old) fall into four categories: (1) routine vaccines for all adults; (2) vaccines for high-risk exposure groups (health care and other institutional workers, prisoners, students,

military personnel, travelers to endemic areas, injection drug users, and men who have sex with men); (3) vaccines for persons at high risk for severe outcomes of infection (pregnant women; the elderly; persons with chronic medical conditions, including diabetes, alcoholism, immunodeficiency, and renal, hepatic, respiratory,

or cardiac disease); and (4) vaccines for household contacts of persons in group 3

Because a substantial proportion of adults in the United States no longer have protective levels of antibodies to tetanus or diphtheria, all adults should receive routine booster doses of Td every 10 years For those under age 65 years, one-time substitution of Tdap suitable for adults (Adacel, Sanofi-Pasteur) in place

of the usual Td booster is recommended Pregnant women who received their last

Td booster >10 years previously may receive Td during the second or third trimester; those boosted <10 years previously (and as recently as 2 years before) should receive Tdap after delivery Adults who have contact with infants <12 months of age should receive a single dose of Tdap—ideally at least 2 weeks before contact begins—if the most recent Td booster was ≥2 years earlier If not previously immunized, adults require a primary immunizing course of Td Young adults without laboratory evidence or a reliable history of past vaccination or disease should be immunized against measles, mumps, rubella, and varicella A second dose of MMR vaccine is recommended for groups with a higher risk of exposure and for health care workers with certain other indications Unless they have documented proof of immunity, rubella vaccine should be given to all

nonpregnant women of childbearing age Rubella-susceptible pregnant women should be vaccinated as early as possible in the postpartum period Live-virus vaccines, such as MMR and varicella vaccines, are contraindicated in pregnant women and immunosuppressed individuals Routine immunization against polio (with inactivated vaccine) is not recommended for adults unless they are at particular risk of exposure because of travel to the remaining endemic areas College students, particularly freshmen living in dormitory settings, are at increased risk of meningococcal meningitis, as are military recruits; individuals in both of these groups should be offered the meningococcal polysaccharide or conjugate vaccine for serogroups A, C, Y, and W-135