New Immunization Guideline & Travel

New Immunization Schedule, 2014

2014 Immunization schedule have been approved by the AAP, the Advisory Committee on Immunization Practices of the Centers for Disease Control & Prevention, and the American Academy of Family Physicians.

Important Changes in last 2 years:

1)Clarification for administration of Hep B & HBIG to infants <2000g & infants >2000g who are born to hepatitis B surface antigen positive mothers.

  1. First dose of Hep B given within 12 hours
  2. Second dose should be administered between 1-2 months. IF giving <6 weeks needs to be monovalent Hep B
  3. Infants should be tested for HbsAg & antibody to HbsAg (anti-HBs) 1-2 months after completion of the series (9-18 months)

2)Clarification is provided for Tdap use for children 7-10 y/o who are not fully immunized with childhood Dtap series

  1. Tdap should be substituted for single dose of Td in the catch-up series for children 7-10 years.
  2. Tdap can be administered regardless of the interval since the last tetanus and diphtheria containing vaccine.
  3. Tdap should be administered in pregnant adolescents week 27-36 weeks regardless of time since last Td or Tdap

3)Guidance for the use of the HIB in people 5+ y/o, those at high risk

  1. Consider for unvaccinated persons 5 y/o or older who have sickle cell disease, leukemia, HIV, incomplete vaccination, receipt of hematopoietic stem cell transplant, receipt of chemotherapy or radiation treatment, or anatomic/functional asplenia
  2. Describes timing of vaccination in relation to patients undergoing chemotherapy, Hematopoietic stem cell transplant, elective splenectomy

4)Guidance for the use of Measles, Mumps, Rubella vaccination in children 6-11 months of age who are traveling internationally

  1. Administer MMR to infants 6-11 months who are traveling internationally. They should then be revaccinated with 2 doses at 12-15 months (4 weeks + after 1st dose) & 4-6 y/o

5)Hepatitis A footnotes have been clarified to emphasize administration of a second dose 6-18 months after the first dose & persons at increased risk.

6)Guidance for administration of meningococcal vaccination: MCV4-d (Menactra) or MCV4-CRM (Menveo)

  1. 9-23 months: administer 2 doses, 8 weeks apart for:
  2. Persistent complement component deficiency
  3. Residents of or travelers to countries with hyper-endemic or epidemic disease
  4. Who are present during outbreaks cause by a vaccine serogroup
  5. 24+ months: administer 2 doses, 8 weeks apart for:
  6. Persistent complement component deficiency
  7. Anatomic/functional asplenia (if Menactra used start @ 2 y/o, 4 week after all PCV doses given)
  8. Booster vaccination for children at 16 y/o
  9. Minimum of 8 weeks between doses if administered at 15
  10. If first dose administered @ 16 or older, no booster needed

7)PCV 13 & PPSV23 footnote has been updated to itemize recommendations at increased risk

  1. All PCV13 doses should be administered before PPSV23 if possible
  2. Children 2-5 with following chronic conditions should receive 1 dose of PCV13 if 3 doses were received previously & 2 doses of PCV13 (8 weeks apart) if fewer than 3 doses have been received. Administer PPSV 8 weeks after most recent dose of PCV13
  3. Chronic heart disease (Cyanotic, heart failure), CLD (including asthma if treated with high dose oral steroids), DM, CSF leak, cochlear implant, sickle cell disease or other hemoglobinopathy, anatomical/functional asplenia, HIV infection, CRF, nephrotic syndrome, diseases associated with immune suppression or radiation (malignant neoplasms, leukemia, lymphoma, Hodgkin disease, solid organ transplant, or immunodefiency)

***In speaking with cards their preference is kids who are still cyanotic who are chronically ill, heart failure be given this**

  1. Children 6-18 with same risk factors administer 2 doses of PCV13 if PCV13 or PPSV23 has not been administered. If PCV13 has been received then administer PPSV23 8 week after last PCV13. If PPSV23 has been administered, but not PCV13 give PCV13 8 weeks after PPSV23
  2. Single revaccination with PPSV23should be administered 5 years after last dose to those at high risk

8)IPV footnote has been updated to note that IPV is not recommended to patients 18 y/o+

Travel:

We will go through some cases to help you get comfortable accessing information for travel. However, you may also recommend a travel clinic that specializes in vaccinations for travel.

Travel clinics:

  • Campus Health Travel Clinic: 621-2292
  • 6th Floor Travel Clinic: 626-7900, 694-8888

The CDC has a great website to reference for the most up to date information including most up to date travel notices, vaccination information, & travel by destination at:

Please review Chapter 7, International Travel with Infants & Children, in the 2014 Yellow Book through the CDC website. The Yellow book is an excellent resource published every 2 years, which advises International travelers about health risks. Melissa Moore has included some of this information in her previous monthly emails as well. Here is the direct link to the chapter:

Please use the above links to complete the following cases:

Case 1: You have a family that is going to be traveling to an urban area of the Philippines to visit family. Their son is 7 months now & they will be traveling in 2 months. What would you recommend?

Case 2: You have a family that would like to visit their extended family in Amapa, Brazil. They have 10 m/o & 3 y/o children. What would you recommend for vaccinations?

Case 3: You are examining a 10 y/o male for his yearly physical. His family indicates that they will travel to an urban city in China this summer to visit family. What recommendations do you have today?

Case 4: You are evaluating a 19 y/o patient who will be traveling to Port-au-Prince Haiti as a missionary for the next several months. What recommendations do you have for her?

Answer Case 1: The Philippines currently have an outbreak of Measles.

  • Recommend MMR vaccination. They will then need 2 more vaccinations, one at 12-15 months and the last at 4-6 y/o as this first dose will not count. For children 12 months or older, should get 2 doses with a 28 day minimum interval prior to travel to an endemic area.
  • He is too young for Hepatitis A vaccination (12+ months) & Typhoid (2+ years)
  • Have them check with family that there is no outbreak or an endemic area for Japanese Encephalitis
  • Ask about activities planned to see if they would need Rabies
  • No malaria is currently found in Urban areas of Philippines
  • Ensure his routine vaccinations are up to date, including Hep B (reference Yellow Book schedule for administration intervals).
  • Educate about non-vaccine preventable diseases: Chikungunya, Dengue, TB

Answer Case 2:

  • Ensure vaccinations up to date for Hep AHep B
  • Yellow fever vaccination is recommended for children >9 months for that area
  • Malaria chemoprophylaxis is recommended for this area of Brazil. You can recommend atovaquone-proguanil 1-2 days before entering endemic area through 7 days after leaving. Weight dependent dosing. Less data on mefloquine in children <20kg, doxycycline not recommended for children <8 y/o. Chloroquine resistance. For more information on malaria drugs see the CDC website @:
  • Typhoid vaccination(>2 y/o if using polysaccharide vaccine, >6 y/o for oral vaccination)
  • Consider Rabies pre-exposure vaccination- low threshold given higher risk: 3 doses at 0, 7, and 21or 28 days

Answer Case 3:

  • Check to see if up to date on Hep A, Hep B, polio in addition to his routine vaccinations.
  • Typhoid vaccinationrecommended: oral series, 4 doses vs injection 1 dose
  • Japanese encephalitis if visiting farming areas or endemic areas
  • Malaria chemoprophylaxis only if visiting rural areas listed
  • Consider Rabies pre-exposure vaccination- low threshold given higher risk: 3 doses at 0, 7, and 21or 28 days

Answer Case 4:

  • An outbreak of Cholera has been ongoing since Oct 2010, although decreasing. Recommend prescription antibiotic in case of diarrhea, water purification tablets, oral rehydration salts. She should protect herself by drinking safe water/ice, washing hands often with soap & water, cooking food well. Antibiotics: 300mg doxycycline x 1 for adults, azithromycin for children.
  • Ensure vaccinations up to date for Hep A & B
  • Typhoid vaccination: oral vs injection. Oral is 4 doses, 48 hours between doses. Injection is a single dose.
  • Malaria chemoprophylaxis is indicated (No drug resistance): Atovaquone-proguanil (daily), chloroquine (once weekly), doxycycline (daily), or mefloquine (once weekly)
  • Consider Rabies pre-exposure vaccination depending on activity- doses at 0, 7, and 21or 28 days

Another article to review for additional information is a Peds In Review article-International Travel with Children: Tips for Physicians & Families.

References:

  1. Committee on Infectious Diseases. Policy Statement: Recommended Childhood & Adolescent Immunization Schedule- United States, 2012. Pediatrics 2012; 129(2): 385
  2. Committee on Infectious Diseases. Policy Statement: Recommended Childhood & Adolescent Immunization Schedule- United States, 2014. Pediatrics 2014; 133: 357
  3. Centers for Disease Control and Prevention.
  4. Ferguson LE, Yetman RJ. International Travel with Children: Tips for Physicians and Families. Pediatrics in Review 2006; 27 (3): e1-e22.

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