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A. Vaccination Schedule

  1. At Birth
    1. HepB (Hepatitis B Virus Vaccine) #1 - may be given up to 2 months of age
    2. HepB double dose and hepatitis B immune globulin (infants born to HBsAg+ mothers) [3]
    3. See recommendations below
  2. Two Months
    1. HepB #2 - should be given at least 1 month after first dose (range 1-4 months)
    2. DTaP #1
    3. HIB (Haemophilus influenzae type B conjugate vaccine) #1
    4. HIB-DTaP conjugate vaccines are now available [13]
    5. Inactivated Polio Vaccine (IPV) #1 (see below)
    6. Pneumococcal conjugate (heptavalent) vaccine (PCV) #1
  3. Four Months
    1. DTaP #2
    2. HIB #2 (or conbination HIB-DTaP vaccine)
    3. IPV #2
    4. PCV #2
  4. Six Months
    1. HepB #3 (must be >2 months after second dose; range 6-18 months)
    2. DTaP #3
    3. HIB #3 (depends on product; may be given at 12 or 15 months)
    4. IPV #3 (range 6-18 months)
    5. PCV #3
    6. Influenza vaccine approved and recommended for all children 6-23 months of age [41]
  5. Twelve to 15 Months
    1. HepB #3 (if not given at 6 months)
    2. HIB #4 (dose #4 is optional and may not be clinically relevant [19])
    3. IPV #3 (if not given at 6 months)
    4. MMR (Measles / Mumps / Rubella) #1 or MMR+Varicella (Proquad®)
    5. PCV #4
    6. Varicella Vaccine (anytime from 12-18 months if no clinical chicken pox) [12] #1
    7. Varicella now available with MMR as MMR-Var (Proquad®)
  6. Fifteen to 18 Months
    1. DTaP #4
    2. HepB #3 (if not previously given)
    3. IPV #3 (if not given at 12-15 months)
  7. Four to 6 Years
    1. DTaP #5
    2. IPV #4
    3. MMR #2 (waiting until age 12 is no longer recommended) [3]
    4. Hepatitis A Vaccine (HAV) in selected (endemic) areas, 17 states (age >2) [29]
  8. Nine to 26 Years: HPV Vaccine (see below) [52]
  9. Eleven to 12 Years
    1. HepB (booster if needed)
    2. Tetanus and Diphtheria Toxoids - booster (pertussis not needed)
    3. MMR #3 (booster; if not given age 4-6 years)
    4. Varicella Vaccine #2 [53]
  10. Fourteen to 16 Years
    1. Tetanus and Diphtheria Toxoids (if not given at 11-12 years)
    2. Check anti-HBV titers; consider booster
  11. Booster Vaccinations
    1. Tetanus (q 5-10 yr) - booster (with diphtheria) should be given every 10 years
    2. Rubella - pre-pregnancy check titers; boost if not protective
    3. HepB - boost for high risk activity or immunosuppression if titers low
    4. Note: second varicella vaccine now routinely recommended [53]

B. Combination Vaccines [6]

  1. Combined DTaP/HBV/IPV (Pediarix®)
    1. 3 doses
    2. Age 2, 4, 6 months
  2. Combined HBV/HIB (Comvax®)
    1. 3 doses
    2. Age 2, 4, 6 months
  3. Combined Diphtheria, Tetanus, Pertussis (DTaP; Tripedia®, Infarix®, Daptacel®)
    1. 4 doses
    2. Age 2, 4, 6, 15-18 months
  4. Combined MMR + Varicella (Proquad®) for ages 12 months - 12 years

C. Additional Information

  1. Vaccines (including HBV) do not increase risk of or relapse of multiple sclerosis [21,22]
  2. HIB Vaccine (HibTiter®, ActHib®, PedvaxHib®) [3]
    1. Oligocsaccarhide conjugate Hib (HibTiter®)
    2. Polyribosylribitol phosphate-tetanus-toxoid conjugate (PRP-T, ActHIB®, OmniHIB®)
    3. Haemophilus b conjugate vaccine (maningococcal protein conjugate) (PedvaxHIB®)
    4. Three doses are generally required; fourth dose optional
    5. Excellent protection is afforded after 3 doses
    6. Antibody titers wain after 2 years without 4th dose, but clinical protection remains [19]
    7. Nearly 75% reduction in invasive H. influenza B infection in Alaska after vaccine use [16]
    8. Combination DTaP-HIB vaccine is available and effective [13]
    9. HIB disease in Kenya reduced by ~8X observed only 3 years after institution of vaccine [51]
  3. DTaP (Tripedia®, Infanrix®, Daptacel®)
    1. Acellular pertussis vaccine with DT (DTaP) preferred for entire vaccination series
    2. The acellular vaccine is effective in >70% and very well tolerated [7]
  4. Polio (Ipol®)
    1. Inactivated polio vaccine (IPV) is the only form now available in USA
    2. Oral polio vaccine (OPV) has been removed from market
    3. Four doses of IPV is acceptable, as it is less immunogenic than older OPV
  5. MMR
    1. About 20% of children are seronegative for measles after one dose [8]
    2. Therefore, second dose of MMR is given at 4-6 years (many schools require this)
    3. For young persons who have not had second dose, complete series should be given by 12 years
    4. Rubella rates are consistently declining in children [31]
    5. Insuring MMR use may lead to eradication of rubella in USA in near term
    6. Slight (2.7X) increase in risk of febrile seizures in children within 2 weeks of MMR, but no longterm sequellae or increase in epilepsy [40]
    7. No link between MMR vaccination and autism [33,34]
  6. Varicella (VZV) [18]
    1. Susceptbile children may be vaccinated after 1st birthday
    2. Suggested immunization at 11-12 years without reliable history of chicken pox
    3. Two doses required for susceptible children 13 years or older
    4. If only single dose given, then protection wanes substantially after 5 years [5]
    5. Vaccine is 87-97% effective for preventing moderate and severe infection [24,30]
    6. Vaccine reduced cases of hospitalization for VZV >70% in areas with ~80% vaccination levels [25]
    7. Vaccine associated with reduction of hospitalizations by 88%, ambulatory visits by 59% [44]
    8. Very few serious adverse events reported, most with unclear relationship to vaccine
    9. Strongly recommended that vaccination rates be increased [30]
    10. Caution in immunocompromised individuals
  7. Influenza Vaccine [9,41]
    1. Influenzas A and B may occur in up to 30% of children
    2. Trivalent intranasal vaccine was given in 2 doses, 60 days apart [9]
    3. Effective against Influenza A and B (93% reduction in culture confirmed)
    4. Vaccination also reduced overall febrile illnesses and febrile otitis media by 30%
    5. Inactivated influenza vaccine is safe and beneficial in children with asthma [28]
    6. Inactivated standard vaccine is approved and recommended for children 6-23 months [41]
    7. Live attenuated nasal vaccine (FluMist®) is safe and more effective than trivalent killed vaccine in children without history of wheezing/asthma 12-59 months old [55]
    8. Influenza vaccination strongly recommended in all children (currently only inactivated is approved)
  8. Pneumococcal Vaccine [14,27,35]
    1. Conjugated hepta- (7-)valent vaccine recommended for anyone <5 years old
    2. Uses T-lymphocyte dependent immune responses with high vaccination rates
    3. Recommended for ALL infants <2 years old
    4. Also recommended for children 2-5 years old at increased risk for pneumococcus
    5. Strongly consider in any patient with poor immune function
    6. Covers ~80% of invasive childhood pneumococcal infections in USA
    7. Reduced rates of invasive pneumococcal disease in children by 30-70% [36,48,49]
    8. Reduced rates of antibiotic resistant pneumococcal disease in children by ~80% [48]
    9. Reduced all-cause pneumonia admission rates by ~40% and pneumococcal pneumonia ~65% in <2 year olds [55]
    10. Efficacy ~80% in very high risk populations of young children [37]
    11. Approved for prevention of invasive pneumococcal disease and otitis media [35]
    12. In general, the 23-valent nonconjugated vaccine is not as immunogenic as conjugated
    13. Dosage: 3 total for 7-11 months, 2 total for 12-23 months, 1-2 for >23 months
    14. One ore more doses, even given on non-approved schedules, associated with strong benefits in both healthy and chronically ill children [54]
  9. Nonavalent Pneumococcal Vaccine [39]
    1. Diphtheria (CRM197) conjugate 9-valent pneumococcal vaccine
    2. In HIV negative children, reduced incidence of first invasive pneumococcal disease 83%
    3. In HIV+ children, reduced incidence of first invasive pneumococcal disease 65%
    4. Reduced incidence of penicillin and sulfa drug resistant pneumococcal disease 56-67%
  10. Poliovirus Vaccine
    1. Three to 4 doses of inactivated poliovirus vaccine (IPV) are used
    2. Infants in developing countries make poor immune responses to type 3 component
    3. IPV supplemental (4th) dose is beneficial in developing countries for stimulating type 3 [17]
    4. There is a worldwide move to eradicate poliovirus
    5. Oral poliovirus vaccine is no longer available in USA
  11. HAV Vaccine [42]
    1. Routine vaccination now recommended in 17 states with highest incidence of HAV
    2. HAV vaccination in children lead to reduction in disease rates ~75%
    3. Universal vaccination of all toddlers in Israel lead to disease reduction of 95% [43]
  12. Salmonella Typhi Vi Conjugate Vaccine [25]
    1. Typhoid fever is common in developing countries
    2. Older vaccine effective ~70% overall; little efficacy in young children
    3. New capsular polysaccharide vaccine bound to nontoxigenic pseudomonas exotoxin A
    4. This vaccine has enhanced immunogenecity
    5. Requires two injections 6 weeks apart
    6. Vaccine efficacy 91%
  13. Human Papillomavirus Virus (HPV) Vaccine (Gardasil®) [52]
    1. Approved for females 9-26 years old to prevent HPV associated disease
    2. Recombinant quadrivalent vaccine includes types 6, 11, 16 and 18
    3. Prevents genital wars, precancerous cervical, vaginal, vulvar lesions, cervical cancer
    4. Administered as 3 separate 0.5mL intramuscular injections at 0, 2, 6 months
    5. Appears nearly 100% in preventing persistent HPV infection
    6. Need for booster is not yet known
  14. Vaccinating children in an endemic area prevents disease and outbreaks and is safe [29]
  15. Allergies
    1. Anaphylaxis or other hypersensitivity to vaccine is contraindication to further use
    2. Egg Allergy - previously a problem with MMR, influenza, and Yellow Fever vaccines
    3. New MMR vaccines do not contain sufficient egg proteins to induce reactions (safe in all)
    4. Some influenza and Yellow Fever vaccines do contain clinically relevant levels of egg proteins
    5. Therefore, Influenza and Yellow Fever vaccines should not be given to patients with history of severe reactions to eggs
    6. Influenza vaccines with <1.2µg/mL of egg protein appear to be safe in egg allergic patients
  16. Breast Feeding [15]
    1. Reduces morbidity and probably mortality from infectious disease
    2. Breast milk contains immunoglobulins including IgA which is active in newborns
  17. Aggressive vaccination critical in children with cochlear implants (increased meningitis) [38]
  18. Excemption of children from vaccination for any reason significantly increases disease risk [20]

D. Hepatitis B Vaccination Notes [3]

  1. Preferred is three doses for ALL newborns
  2. Begin age 0-2 months (Recombivax HB® 2.5µg or Engerix-B® 10µg)
  3. Followed by 1-4 months and 6-18 months
  4. At least two months between doses
  5. For children born to HBsAg (surface antigen) positive monthers
    1. Recombivax HB® 5µg or Engerix-B® 10µg given initially
    2. Hepatitis B immune globulin should be given within 12 hours of birth
    3. Second dose of vaccine should be given at age 1-2 months
    4. Third dose given at 6 months of age
  6. Hepatitis B immune globulin
    1. Should be given to ALL infants born to HBsAg positive mothers
    2. Should never be delayed for more than 1 week
  7. Unimmunized children and adolescents
    1. Vaccinations can be started at any time
    2. At least month should elapse between first and second doses
    3. Third dose should be given >4 months after 1st dose and >2 months after 2nd dose
  8. Combination of Hepatitis A+B Vaccine now licensed for adults in USA [26]

E. Rotavirus Vaccines

  1. Pentavalent Human-Bovine WC3 Reassortment Vaccine (RotaTeq®) [47,50]
    1. 3 oral doses
    2. Hospitalizations reduced 95% after 3rd dose
    3. Reduced severe diarrhea 98%
    4. No increased risk of intussusception compared with placebo
    5. FDA approved for prevention of rotavirus gastroenteritis in infants
    6. Generally not recommended for patients with immunodeficiency
  2. Attenuated Live Human Rotavirus Vaccine (Rotarix®) [45,46,56]
    1. Attenuated live human rotavirus vaccine RIX4414 G1P(8)
    2. Derived from an attenuated G1 (P8) human isolate called 89-12
    3. Two oral doses of vaccine given
    4. Vaccine reduced incidence of rotavirus ~90%, hospitalizations 85%
    5. Severe diarrhea reduced 90-100%
    6. Mild fever in 20% of vaccinated subjects after first dose only
    7. No increased risk of intussusception compared with placebo
    8. Reduced infections against G1, G2, G3, G4 and G9 serotypes [56]
    9. Not yet approved in USA
  3. Attenuated Rhesus Vaccine (Rotashield®) [10,23]
    1. Causes ~70% of severe diarrheal illness in children in USA
    2. Live, oral vaccine available in USA which prevent ~60% of illness
    3. Vaccine reduced number of severe (hospitalized) illness by ~100%
    4. Withdrawn from market due to increased risk of intussusception [23]

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