In the final part of the immunization series, Stanley E. Grogg, DO, FACOP, FAAP, interprets footnotes and addresses questions regarding influenza vaccines, MMR vaccines, varicella vaccines, Hepatitis A vaccines and various Meningococcal serogroup vaccines for children and adolescents.
By Stanley E. Grogg, DO, FACOP, FAAP; AOA Liaison Member to the CDC’s Advisory Committee on Immunization Practices (ACIP)
Each year, toward the end of February, the pediatric immunization schedules are published by the U.S. Centers for Disease Control and Prevention (CDC). Many times, a healthcare provider (HCP) needs more information than what is found in the immunization schedule table. Parts one and two for adult vaccine questions, as well as part one of the pediatric vaccine series, have been published in recent ACOFP blogs.
This blog discusses many of the questions that healthcare providers (HCP) often ask about pediatric influenza, measles, mumps, rubella, varicella, hepatitis A, human papillomavirus and the meningococcal immunizations. The use of trade names is for identification purposes only and does not imply endorsements by the ACIP or CDC. To stay up to date on immunizations, the CDC Vaccine Schedule app can be downloaded at no cost.
Influenza Vaccines (Table 3, Footnote 3)
Q: What is the minimum age for starting influenza vaccines in pediatric patients?
A: The minimum age for the injectable influenza vaccine (IIV) is six months. The live attenuated influenza vaccine (LAIV4) or nasal influenza vaccine—known as FluMist by AstraZeneca—is recommended starting at age two. (Footnote 3)
Q: Should a child younger than eight years old receive one or two doses of the influenza vaccination?
A: For children aged 6 months to 8 years old who have received fewer than two influenza vaccine doses before July 1, 2020—or whose influenza vaccination history is unknown—should receive two doses, separated by at least four weeks. One dose is appropriate for children aged 6 months to 8 years if they have received at least two doses before July 1, 2020. One dose annually is all sufficient for all persons aged nine years and older. (Footnote 3)
Q: What month should influenza vaccinations be completed with pediatric patients?
A: The CDC recommends flu vaccines by the end of October or before flu season begins spreading in the community. Receiving vaccines later, however, can still be beneficial and vaccination should continue to be offered throughout the flu season—even into January or later.1
Q: Which influenza vaccine is recommended for someone who has anaphylaxis to egg?
A: Although any flu vaccine appropriate for age and health status of the patient can be given, if using an influenza vaccine other than a recombinant influenza vaccine (RIV4), such as Flublok by Sanofi, or a cell-based vaccine (ccIIV4), such as Flucelvax by Seqirus, which are not derived from eggs, administer in a medical setting under supervision of a healthcare provider who can recognize and manage severe allergic reactions. (Footnote 3)
Q: Can LAIV4 be given to an immunocompromised child?
A: No. LAIV4 is a live attenuated vaccine and could result in an immunocompromised child contracting influenza. Other contraindications to LAIV4 include a history of severe allergic reaction to a previous dose of LAIV4 or a previous dose of any influenza vaccine—or to any vaccine component, excluding egg—and if the patient is receiving a salicylate-containing medication. Several other complications are now listed, including children age 2–4 years old with a history of wheezing, anatomic or functional asplenia; those who have close contacts or caregivers of severely immunosuppressed persons; pregnancy; patients with cochlear implants; cerebrospinal fluid-oropharyngeal communication; children under two years old; and those receiving recent antiviral medication. (Footnote 3)
Measles, Mumps and Rubella (MMR) Vaccines (Tables 1 and 2, Footnote 2)
Q: What is the recommended age for a MMR vaccine in children?
A: The MMR vaccine minimum age is 12 months old, unless traveling internationally. Typically, the MMR vaccine is given at 12–15 months old and at 4–6 years old. Dose two may be administered as early as four weeks after the first dose. (Table 1, Footnote 2)
Q: A child visits the office at age five for a pre-school check-up. On evaluation of the vaccine record, the mother states that she has waited to give her child the MMR vaccine because she heard it is a live virus and she did not want to give her child measles. After reassurance, she accepted the MMR vaccine for her child. What is your recommendation for administration for the catch-up of the MMR? (Table 2, Footnote 2)
A: Unvaccinated children and adolescents should be given two doses at least four weeks apart. (Table 2)
Q: A mother is planning to visit her parents in France and is bringing her 7-month-old child. she states there have been some measles reported in the area to which she is traveling. What is your recommendation?
A: Infants 6–11 months old who are traveling internationally should be given one dose of the MMR vaccine before departure and should be revaccinated with a two-dose series, receiving the first dose at age 12–15 months and dose two as early as four weeks later, if the child remains in a high-risk area. If a child is unvaccinated and aged 12 months or older, they should have a two-dose series at least four weeks apart before departure. (Footnote 2) If the child returns to the United States before 12 months of age, they should be given a routine vaccine at 12–15 months old and carry on with a booster at 4–6 years of age.
Q: A 14-month-old child is brought to the HCP’s office because of exposure to measles at daycare yesterday. Would giving the child an MMR vaccine be appropriate?
A: Yes. People exposed to measles who cannot readily show that they have evidence of immunity against measles should be offered post-exposure prophylaxis (PEP). To potentially provide protection or modify the clinical course of disease among susceptible persons, either administer the MMR vaccine within 72 hours of initial measles exposure or immunoglobulin (IG) within six days of exposure. Do not administer the MMR vaccine and IG simultaneously, as this practice invalidates the vaccine.5
Q: If the 14-month-old in the above scenario was exposed to mumps instead of measles, would the MMR prevent the child from getting the mumps?
A: No. Unlike with measles, the MMR vaccine is not effective at helping protect people who have recently been exposed with mumps PEP. However, vaccination after exposure is not harmful and may prevent later disease if re-exposed.6
Varicella Vaccine (Table 1, Footnote 4)
Q: An 11-month-old comes to the office for a check-up. can the infant receive his chickenpox vaccine?
A: No, the minimum age is 12 months for administration of the varicella vaccine. (Table 1, Footnote 4)
Q: Can the varicella vaccine be given to prevent post-exposure varicella?
A: Yes; the ACIP recommends that after being exposed to varicella or herpes zoster, people who do not have evidence of immunity and are eligible for vaccination, should be given VARV within 3–5 days of exposure. This may prevent varicella or make it less severe. Even if it has been more than five days, the vaccine should still be offered. This will provide protection against varicella if a person is exposed again in the future.4
Q: Can the VARV be given as a combination vaccine with MMR at 12 months, saving one injection?
A: Yes, but because the combined MMR + varicella (MMRV) vaccine has been shown to be associated with an increased risk of febrile seizure occurring 5–12 days following vaccination—at a rate of 1 in 2,300–2,600 in children 12–23 months old, compared with separate MMR and varicella vaccines administered simultaneously—the CDC recommends that separate MMR and varicella vaccines be used for the first dose, although providers or parents may opt to use the combined MMRV for the first dose after receiving counseling about this risk. MMRV is preferred for the second dose (at any age) or the first dose if given at four years of age or older. (Footnote 2)
Q: An 11-year-old-male who has been homeschooled until now. He needs one more MMR dose and the Varicella vaccine. Can the MMRV be used?
A: Yes, the MMRV can be used until 12 years of age. (Footnote 2)
Q: A 8-year-old patient comes to a HCP’s office for a physical. His immunization record shows that he is lacking both the MMR and varicella vaccines. After a discussion with his parents, it was found that the father was hesitant to give live viral vaccines when his son was younger. After discussion with the HCP, the father agrees to have his son immunized with an MMRV. How long after the first vaccination should the child wait for his second MMRV?
A: For 7–12-year-olds, the routine interval between MMRV is three months. After age 13, the patient should have two vaccinations: the MMR vaccine and a separate varicella vaccine. The routine interval between the MMR and varicella is 4–8 weeks. (Footnotes 2 and 4)
Hepatitis A (HepA) Vaccine (HAV)
Q: A physician is volunteering at a clinic for underserved patients. A mother and her 10-year-old daughter arrive for a check-up. The HCP determines the family is homeless and sleeping under a bridge. Neither the mother nor the daughter have received a HEPA vaccine. What are the CDC recommendations in this scenario?
A: HAV is highly safe and effective, and a complete HepA vaccine series provides long-term protection against HepA virus infection. Person-to-person HepA outbreaks among people using drugs or experiencing homelessness are widespread and ongoing. All people one year or older experiencing homelessness should be routinely immunized against HepA. Routine HAV is a two-dose series with a minimum interval between vaccines of six months, beginning at one year.2
Q: A family with their 7-month-old child is traveling to Mexico to see relatives. The area in Mexico where the family lives has a history of HEPA infections. What should the HCP recommend for the 7 month old infant?
A: A 6–11-month-old infant who is traveling internationally to endemic HepA areas should receive one dose of HAV before departure and be re-vaccinated with two doses—separated by at least six months—at 12–23 months old. (Footnote 3)
Q: A 16-year-old-boy comes to a HCP’s office because he was exposed to HEPA. Can a HAV be administered to prevent the boy from developing HEPA?
A: Yes, PEP should be administered as soon as possible within two weeks of exposure to all unvaccinated people at least one year old who have recently been exposed to HepA.3
Human Papillomavirus (HPV) Vaccine (Tables 1 and 2, Footnote 3)
Q: A mother brings her 9-year-old son into your office and requests an HPV vaccine for him. What is the ACIP recommendation?
A: It’s ok. Although HPV is typically recommended at 11–12 years of age, it can be given as early as nine years old. Because of their robust immune systems, adolescents aged 9–14 years only require two vaccinations at 0 and 6–12 months later. At 15 years and older, three doses are required. A patient does not need to start the vaccination series over if they miss doses, only continue with the series. (Footnote 3)
Q: An HIV-positive 11-year-old is in the HCP’s office for a check-up. his Mother wants to know if it is ok for him to receive the HPV vaccine. how many doses should the HCP inform the mother are needed?
A: Immunocompromised conditions, including HIV, require three doses.(Footnote 3)
Q: A 10-year-old female is brought to the office because of sexual abuse. Should this patient receive the HPV immunization?
A: Yes, all females who have been sexually abused should receive the HPV vaccine. (Footnote 3)
Meningococcal serogroup A, C, W, Y (MenACWY) Vaccines (Tables 1 and 2, Footnote 2)
Q: Are there several MenACWY vaccines with different minimal ages recommended for use?
A: Yes. There are three different MenACWY vaccines approved by the U.S. Food and Drug Administration (FDA) with different minimal ages recommended for use, including:
2 months old for MenACWY-CRM (Menveo by Glaxo Smith Kline) (GSK)
9 months old for MenACWY-D (Menactra by Sanofi Pasteur)
2 years old for MENACWY-TT (MenQuadfi by Sanofi Pasteur) (Footnote 2)
Q: When are the first and second doses of MenACWY recommended?
A: The first dose of MenACWY is recommended at 11–12 years of age. A booster dose is recommended at 16 years old. (Footnote 2)
Q: An 18-year-old patient is going to college and will be living in the dormitory. He did not receive a MenACWY immunization. What is the CDC’s recommendation?
A: Those patients 16–18 years of age, who did not receive a MenACWY, should receive only one dose of one of the MenACWY. All first-year college students who live in residential housing (if not previously vaccinated at age 16 or older) or military recruits should receive one dose of a MenACWY vaccination (Menveo, Menactra or MenQuadfi). (Footnote 2)
Q: A neonate is found to have sickle cell disease. Should this patient, who most likely will have a non-functioning spleen early in life, be started on one of MenACWY vaccines before 11–12 years of age?
A: Yes. Because of the varying ages of approved use by the FDA for the different MenACWY vaccines, the indication to give the MenACWY at young age vary as well:
Menveo (GSK): Administer dose one at eight weeks of age with a four-dose schedule at 2, 4, 6 and 12 months. If started at other ages or for catch up, see Table 1 and Footnote 2.
Menactra (Sanofi): Administer as a two-dose series at least eight weeks apart at age 24 months or older. Menactra must be administered at least 4 weeks after the completion of the pneumococcal conjugate vaccine (PCV13) series. With the approval and manufacture of the PCV20, this recommendation may change. (Footnote 2)
MenQuadfi (Sanofi): Administer dose one at 24 months or older as a two-dose series at least eight weeks apart. (Footnote 2)
Q: A mother is taking her 3-year-old son to visit family in the African meningitis belt. Should the 3-year-old receive any MenACWY vaccines?
A: Yes. Children two years of age or older should receive one of dose of any of the MenACWY immunizations if traveling to the African meningitis belt. For recommendation for younger children traveling to the African meningitis belt, see Footnote 2.
Q: A 5-year-old child with an HIV infection is brought to the office for a well-child evaluation. the Mother asks how often should her child receive a MenACWY booster. What recommendation should the HCP suggest?
A: The HCP should suggest that the five-year-old child receive a booster dose now—three years after completion of the primary series—and should receive a booster dose every five years. Those at increased risk need regular booster doses. For children younger than seven years old, administer a booster dose three years after completion of the primary series. For children seven years old or older, administer a booster dose five years after completion of the primary series and every five years thereafter. High-risk children include complement component deficiencies, functional or anatomic asplenia and HIV infection. High-risk children two years of age or older should not receive Menactra (Sanofi) at the same time as PCV13. They should either receive Menveo (GSK) or wait and receive Menactra four weeks after PCV13. Children can receive Menactra before or concomitantly with DTaP vaccine.7 (Footnote 2)
Q: What should be the recommendation by a HCP for a classroom exposed to a meningococcal serotype C outbreak?
A: In outbreak situations, any child with close exposure to the child with a meningococcal serotype C infection, in addition to prophylactic antibiotics, should receive one of the MenACWY vaccinations.7 (Footnote 2)
Meningococcal Serogroup B (MenB) Vaccination (Table 1, Footnote 2)
Q: What are the indications for MenB vaccination?
A: The ACIP has recommended MenB vaccination be given after shared clinical decision-making at age 16–23 years old and is preferred at age 16–18 years old, the highest risk time to contact MenB disease. The youngest age approved for the MenB vaccine is 10 years old for high-risk individuals. (Footnote 2)
Q: Who are considered high-risk patients?
A: High-risk patients for MenB are those with anatomic or functional asplenia, including sickle cell disease, persistent complement component deficiency and complement inhibitor use, such as soliris and ravulizumab. (Footnote 2)
Q: What vaccines are available to protect against MenB?
A: There are two FDA approved MenB vaccines: Bexsero (MenB-4C) by GSK—recommended as a two-dose series at least one month apart for both high-risk and low-risk individuals—and Trumena (MenB-FHbp) by Pfizer—as a three-dose series at 0, 1–2 months and 6 months for high-risk people or as a two-dose series, at 0 and at least six months apart, for low-risk individuals. (Footnote 2) Read more about the MenB booster vaccine dose recommendations for high-risk patients and for outbreak settings.
Q: Can Bexsero and Trumenba be interchanged?
A: No. Bexsero and Trumenba are two different types of vaccines and should NOT be interchanged. (Footnote 2)
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