Journal Issue: Children and Divorce Volume 4 Number 1 Spring/Summer 1994
Recommendations regarding the routine immunization of healthy infants and children have traditionally been developed and promulgated by the Committee on Infectious Diseases (CID) of the American Academy of Pediatrics (AAP) and by the Advisory Committee on Immunization Practices (ACIP) of the U.S. Centers for Disease Control (CDC) and Prevention.1 Although effort is expended to ensure that recommendations from these two bodies are not discrepant, their recommendations do not always agree. Recommendations for immunization for children through 5 years of age as of January 1994 are summarized in Figure 1.
Unfortunately, immunization recommendations are complex and can be confusing to health professionals and parents alike. In part, problems arise because multiple doses of disease-specific vaccines and thus multiple interactions with providers are required to achieve adequate levels of immunity. Also, vaccines are not all given on the same schedule, and recommendations change primarily because of the availability of new vaccines and new criteria for vaccination.2
There are also alternative recommendations for children at high risk for specific diseases such as those who are HIV positive or immunocompromised, for children beginning immunization at or after 15 months but before 7 years of age, and for those beginning immunization after 7 years of age (primarily new immigrants).4
There have been several recent important changes in the childhood immunization schedule.2 In response to measles outbreaks among older children in the mid-1980s, it is now recommended that children be reimmunized against measles either at school entry (age 5 to 6 years) or at entry into middle or junior high school (age 11 to 12 years). Because of the continuing occurrence of hepatitis B among adults despite the availability since 1982 of an effective and safe vaccine, universal childhood immunizations against hepatitis B with HBV vaccine are now recommended. There are however, two alternative schedules recommended for HBV vaccinations:( l) at birth, 1 to 2 months, and 6 to 18 months; or (2) at 1 to 2 months, 4 months, and 6 to 18 months.
In early October 1993, the ACIP revised its recommended childhood immunization schedule for OPV and MMR vaccinations. The committee recommended that the third dose of OPV be administered at 6 months rather than 15 months of age. This change simplifies the immunization schedule because OPV can now be given to infants on the same schedule as DTP and Hib vaccines (see Figure 1). In addition, the recommendation regarding the first dose of MMR was liberalized to 12 to 15 months of age from 15 months to allow more "flexibility" in timing the delivery of this vaccine.5
The situation with regard to immunization for Haemophilus influenzae type b disease, an important cause of meningitis in young children, is complex. Four Hib vaccines and a combination vaccine that combines Hib vaccine with DTP are currently licensed in the United States.6
Current recommendations are that Hib immunization begin at 2 months of age in a schedule of three or four immunizations with completion by 12 to 15 months of age depending on which vaccine is given. Confusion over the administration of Hib vaccine may arise because parents and providers may not know on subsequent visits which product and schedule the child began with. Recently published recommendations from the CID attempt to minimize confusion by providing detailed protocols for children of different ages, for the different vaccines, and for the possible combinations of different vaccines.
The new combined vaccine, Tetramune, that protects infants against diphtheria, tetanus, and pertussis (whooping cough) as well as Haemophilus influenzae type b, is to be administered in the form of shots at 2, 4, 6, and 15 months of age. Combined vaccines (such as DTP and MMR) reduce the number of shots infants receive and simplify the immunization schedule. Accordingly, the new four-in-one vaccine should improve immunization rates, but it may be a while before it is possible to evaluate the utility of this new vaccine.
Because recommendations with regard to immunization of young children for Haemophilus influenzae type b and hepatitis B virus infections are very recent, the adequacy of the vaccination status of preschool-age children has historically been measured by the rate at which these children have been adequately immunized for diphtheria, tetanus, pertussis (whooping cough), polio, measles, mumps, and rubella (German measles).
These are the measures of vaccination status highlighted in this article. Attention to this so-called basic subset of vaccines should, however, not be interpreted as suggesting that immunization of young children for Haemophilus influenzae type b and hepatitis B virus infections is not important.