2012 Immunization Schedules for Children 0 Through 18 Years of Age

1. 2012 Immunization Schedules for Children 0 Through 18 Years of Age Iyabode (Yabo) Beysolow, MD, MPH, Medical Officer, Immunization Services Division, CDC

2. Childhood and Adolescent Immunization Schedules Published at least annually since 1995 Child and adolescent schedules published by AAP, AAFP, and CDC in January or February of each year 2012 schedule published in Morbidity and Mortality Weekly Report, Pediatrics and American Family Physician in February 2012 Good afternoon and Thank you Andrew. Immunization schedules are an integral part of immunization practice. Because immunization recommendations change frequently, the schedules for the United States are revised annually. The development of the immunization schedules is a collaborative effort. The schedules for children and adolescents birth through 18 years are developed by the three principle groups that make pediatric immunization recommendations in the United States. � These groups are the Advisory Committee on Immunization Practices or ACIP; the American Academy of Pediatrics; and the American Academy of Family Physicians. The schedule represents the concurrence of all three groups for vaccination of children and adolescents. Each year, the (ACIP) reviews the recommended childhood immunization schedule to ensure that the schedule reflects current recommendations for licensed vaccines. In October 2011, ACIP approved the childhood immunization schedule for 2012, which includes several changes from 2011. The updated 2012 schedules were published in February 2012 in the MMWR, and in Pediatrics, and American Family Physician Journals. Good afternoon and Thank you Andrew. Immunization schedules are an integral part of immunization practice. Because immunization recommendations change frequently, the schedules for the United States are revised annually. The development of the immunization schedules is a collaborative effort. The schedules for children and adolescents birth through 18 years are developed by the three principle groups that make pediatric immunization recommendations in the United States. � These groups are the Advisory Committee on Immunization Practices or ACIP; the American Academy of Pediatrics; and the American Academy of Family Physicians. The schedule represents the concurrence of all three groups for vaccination of children and adolescents. Each year, the (ACIP) reviews the recommended childhood immunization schedule to ensure that the schedule reflects current recommendations for licensed vaccines. In October 2011, ACIP approved the childhood immunization schedule for 2012, which includes several changes from 2011. The updated 2012 schedules were published in February 2012 in the MMWR, and in Pediatrics, and American Family Physician Journals.

3. 2012 Schedules Basic layout of the schedules is unchanged Three schedules 0 through 6 years 7 through 18 years �Catch-up� 4 months through 6 years 7 through 18 years .. No changes were made to the basic layout of the 2012 Immunization Schedules for Children and Adolescents. There are three schedules, including: one for children 0 through 6 years; a second for those 7 through 18 years; and a �Catch-Up� Schedule broken down into 2 age groups, the first for those 4 months through 6 years and the second for those 7 through 18 years of age. .. No changes were made to the basic layout of the 2012 Immunization Schedules for Children and Adolescents. There are three schedules, including: one for children 0 through 6 years; a second for those 7 through 18 years; and a �Catch-Up� Schedule broken down into 2 age groups, the first for those 4 months through 6 years and the second for those 7 through 18 years of age.

4. Changes to the Schedules Concerns: Increasing complexity of the schedule Limited space for footnotes Solutions: In order to improve footnote readablity: Redundancy between footnotes and figures eliminated Reference to respective MMWR documents for more details The schedules are developed using a process in which input is first obtained from working group members during monthly telephone calls and then reviewed by Subject Matter experts. ACIP recommendations published since January 2011 were added to the schedule for 2012. The annual immunization schedules are intended to be a concise summary of current ACIP recommendations. New policy and recommendations are not made with the schedules. It is often very challenging to condense complex immunization recommendations into just a few sentences. The changes to the footnotes reflect the increase in complexity of the vaccine schedule and the limited amount of space for footnotes. An effort has been made to maintain or increase the font size of the footnotes wherever possible. To accommodate the limited space for footnotes and to improve footnote readability, several changes were made. First, redundancy was eliminated between the footnotes and the figures. Information displayed in the figure is not shown in the footnotes. Secondly, references were provided to direct the reader to the respective MMWR document for detailed information that cannot be accommodated in the footnotes. The schedules are developed using a process in which input is first obtained from working group members during monthly telephone calls and then reviewed by Subject Matter experts. ACIP recommendations published since January 2011 were added to the schedule for 2012. The annual immunization schedules are intended to be a concise summary of current ACIP recommendations. New policy and recommendations are not made with the schedules. It is often very challenging to condense complex immunization recommendations into just a few sentences. The changes to the footnotes reflect the increase in complexity of the vaccine schedule and the limited amount of space for footnotes. An effort has been made to maintain or increase the font size of the footnotes wherever possible. To accommodate the limited space for footnotes and to improve footnote readability, several changes were made. First, redundancy was eliminated between the footnotes and the figures. Information displayed in the figure is not shown in the footnotes. Secondly, references were provided to direct the reader to the respective MMWR document for detailed information that cannot be accommodated in the footnotes.

5. And Finally, In previous years, each of the three schedules was intended to stand alone. For 2012, Vaccination providers are being advised to use all three schedules (Figures 1, 2, and 3) and their respective footnotes together and not separately. An attempt was made to remove Redundant footnotes across schedules and place on only 1 schedule. By making reference to information in another schedule, it is possible to conserve space. Providers Can now download a version with all 3 schedules in one booklet from the CDC webpages in 2 ways: And Finally, In previous years, each of the three schedules was intended to stand alone. For 2012, Vaccination providers are being advised to use all three schedules (Figures 1, 2, and 3) and their respective footnotes together and not separately. An attempt was made to remove Redundant footnotes across schedules and place on only 1 schedule. By making reference to information in another schedule, it is possible to conserve space. Providers Can now download a version with all 3 schedules in one booklet from the CDC webpages in 2 ways:

6. CDC Vaccines Webpagehttp://www.cdc.gov/vaccines/recs/schedules/child-schedule.htm#printable First on the CDC vaccines webpage as shown here:

7. MMWR webpagehttp://www.cdc.gov/mmwr/ And Secondly, on the MMWR webpageAnd Secondly, on the MMWR webpage

8. Changes to Recommended Immunization Schedule for Persons Aged 0 Through 6 years Now lets move onto specific changes to the schedules: Beginning with the 0 through 6 yr schedule Figure 1 was updated in the following manner: 1. The meningococcal conjugate vaccine purple bar was extended to reflect licensure of one of the meningococcal conjugate vaccines, Menactra (MCV4-D), down to age 9 months. 2. Also in Figure 1, updates were made to the : Hepatitis A yellow bar � by replacing the �2 doses� wording. It now says Dose 1. The HepA footnote in this schedule further states when the second dose is recommended. ( The wording �2 doses� that was in this bar previously has been a source of confusion for providers and managed care companies. Because of the span of the bar and the wording it was interpreted to mean that the 2 doses had to be completed by 2 years of age. This was never the intent of this recommendation. Hence, the wording has been removed and the footnotes updated to reflect this.) You will also notice the new purple hashed bar in the Hep A vaccine row for those 2 years and older. This reflects the guidance in this age group for all children at high-risk to receive a dose of HepA vaccine and also allows completion of the series for children not at high risk. HepA vaccination in this age group, that is those over 2 years old, is not a routine recommendation, however HepA vaccine may be given to anyone desiring immunity against Hepatitis A virus.. Now lets move onto specific changes to the schedules: Beginning with the 0 through 6 yr schedule Figure 1 was updated in the following manner: 1. The meningococcal conjugate vaccine purple bar was extended to reflect licensure of one of the meningococcal conjugate vaccines, Menactra (MCV4-D), down to age 9 months. 2. Also in Figure 1, updates were made to the : Hepatitis A yellow bar � by replacing the �2 doses� wording. It now says Dose 1. The HepA footnote in this schedule further states when the second dose is recommended. ( The wording �2 doses� that was in this bar previously has been a source of confusion for providers and managed care companies. Because of the span of the bar and the wording it was interpreted to mean that the 2 doses had to be completed by 2 years of age. This was never the intent of this recommendation. Hence, the wording has been removed and the footnotes updated to reflect this.) You will also notice the new purple hashed bar in the Hep A vaccine row for those 2 years and older. This reflects the guidance in this age group for all children at high-risk to receive a dose of HepA vaccine and also allows completion of the series for children not at high risk. HepA vaccination in this age group, that is those over 2 years old, is not a routine recommendation, however HepA vaccine may be given to anyone desiring immunity against Hepatitis A virus..

9. 2012 Schedule � 0 Through 6 YearsHepatitis B Footnote (footnote 1) Consolidated footnote: For infants born to hepatitis B surface antigen (HBsAg)-positive mothers, administer HepB and 0.5 mL of hepatitis B immune globulin (HBIG) within 12 hours of birth. These infants should be tested for HBsAg and antibody to HBsAg (anti-HBs) 1 to 2 months after completion of at least 3 doses of the HepB series, at age 9 through 18 months (generally at the next well-child visit). Next for Hepatitis B, 2 of the older footnotes were consolidated.. They address mgmt of infants born to HepBsAG positive mothers and also addresses when providers should test these patients. Please note that the original version of the schedule printed early in Feb 2012 did not include this highlighted statement � the current version on the CDC webpage does include it and the MMWR has printed an erratum to this effect. Next for Hepatitis B, 2 of the older footnotes were consolidated.. They address mgmt of infants born to HepBsAG positive mothers and also addresses when providers should test these patients. Please note that the original version of the schedule printed early in Feb 2012 did not include this highlighted statement � the current version on the CDC webpage does include it and the MMWR has printed an erratum to this effect.

10. 2012 Schedule � 0 Through 6 YearsInfluenza Footnote (footnote 7) New footnotes: For children aged 6 months through 8 years: 1.) For the 2011-12 season, administer 2 doses (separated by at least 4 weeks) to (a) those who are receiving influenza vaccine for the first time or (b) to those who did not receive at least 1 dose of the 2010-11 vaccine. 2.) For the 2012-13 season, follow dosing guidelines in the 2012 ACIP Influenza vaccine recommendations. For the influenza vaccine footnotes, new bullets to address dosing in children 6 months through 8 years old not only for this current season but also for the upcoming 2012-13 season were added. For the upcoming 2012-13 season, we are basically referring providers to the 2012 ACIP Influenza recommendations which will be published later this year. This current year�s schedule spanned both influenza seasons and we did not have this information available to us in Feb 2012. Hence providers are referred to the upcoming ACIP influenza Statement for dosing recommendations for the 2012-13 season. For the influenza vaccine footnotes, new bullets to address dosing in children 6 months through 8 years old not only for this current season but also for the upcoming 2012-13 season were added. For the upcoming 2012-13 season, we are basically referring providers to the 2012 ACIP Influenza recommendations which will be published later this year. This current year�s schedule spanned both influenza seasons and we did not have this information available to us in Feb 2012. Hence providers are referred to the upcoming ACIP influenza Statement for dosing recommendations for the 2012-13 season.

11. Influenza Vaccine strains for the 2012-13 Season WHO: Feb 23, 2012 recommendations for Northern Hemisphere�s 2012-2013 influenza vaccine to contain: an A/California/7/2009 (H1N1)pdm09-like virus; an A/Victoria/361/2011 (H3N2)-like virus; a B/Wisconsin/1/2010-like virus (from the B/Yamagata lineage of viruses) FDA (VRBPAC): Feb 28 2012 agreed with recommendation Also you may be aware that 2 of the influenza vaccine strains will be different for the 2012-13 season�. The h3n2 and b strains. We do not know yet what changes, if any, will be made to the current recommendations for dosing for children 6 months through 8 years of age.Also you may be aware that 2 of the influenza vaccine strains will be different for the 2012-13 season�. The h3n2 and b strains. We do not know yet what changes, if any, will be made to the current recommendations for dosing for children 6 months through 8 years of age.

12. Influenza ACIP Recommendations Guidance on vaccination of persons with history of egg allergy Still pertaining to influenza vaccine, new recommendations were made in 2011 for vaccination of persons with a history of egg allergy. This Language was not included on the 2012 Schedule, however providers are advised to follow these new recommendations in the full MMWR document.Still pertaining to influenza vaccine, new recommendations were made in 2011 for vaccination of persons with a history of egg allergy. This Language was not included on the 2012 Schedule, however providers are advised to follow these new recommendations in the full MMWR document.

13. 2012 Schedule � 0 Through 6 YearsMMR Footnote (footnote 8) New bullet added: The second dose may be administered before age 4 years, provided at least 4 weeks have elapsed since the first dose. Administer MMR vaccine to infants aged 6 through 11 months who are traveling internationally. This dose should be repeated at 12 months or older and at least 4 weeks after the previous dose. These children should also receive a third dose at age 4 to 6 years. Moving onto MMR vaccine, Guidance is now provided on the schedule for use of MMR vaccine in certain infants 6 through 11 months of age. This recommendation is important for infants 12 months of age or younger who travel outside the United States because of the risk of contracting measles when traveling internationally. This was meant to remind providers and parents of this risk and the need to vaccinate at this age prior to travel, then again at 12 months of age and the need for a third dose at 4-6 years old.Moving onto MMR vaccine, Guidance is now provided on the schedule for use of MMR vaccine in certain infants 6 through 11 months of age. This recommendation is important for infants 12 months of age or younger who travel outside the United States because of the risk of contracting measles when traveling internationally. This was meant to remind providers and parents of this risk and the need to vaccinate at this age prior to travel, then again at 12 months of age and the need for a third dose at 4-6 years old.

14. 2012 Schedule � 0 Through 6 YearsMCV4 Footnote (footnote 11) New footnotes: For children ages 9 through 23 months with persistent complement component deficiency, residents of or travelers to countries with hyperendemic or epidemic disease and children present during outbreaks caused by a vaccine serogroup, administer 2 primary doses of MCV4-D ideally at 9 months and 12 months old or at least 8 weeks apart. New footnotes have been added for Meningococcal conjugate vaccines to address dosing of children 9 through 23 months of age. The first of the 2 new footnotes address the new recommendations for use of MCV4 in high risk infants in this age group, specifically infants with: persistent complement component deficiency, residents of or travelers to countries with hyperendemic or epidemic disease and children present during outbreaks caused by a vaccine serogroup,New footnotes have been added for Meningococcal conjugate vaccines to address dosing of children 9 through 23 months of age. The first of the 2 new footnotes address the new recommendations for use of MCV4 in high risk infants in this age group, specifically infants with: persistent complement component deficiency, residents of or travelers to countries with hyperendemic or epidemic disease and children present during outbreaks caused by a vaccine serogroup,

15. 2012 Schedule � 0 Through 6 YearsMCV4 Footnote (footnote 11) New footnotes: For children 24 months and older with persistent complement component deficiency who have not been previously vaccinated or with anatomic/functional asplenia, administer 2 primary doses of either MCV4 at least 8 weeks apart, and 1 dose every 5 years thereafter. For children older than 2 years of age who are at high risk, recommendations for use of MCV4 are also included on the schedule. For children older than 2 years of age who are at high risk, recommendations for use of MCV4 are also included on the schedule.

16. 2012 Schedule � 0 Through 6 YearsMCV4 Footnote (footnote 11) For children with anatomic/functional asplenia, if MCV4-D (Menactra) is used, administer MCV4-D (Menactra) at a minimum age of 2 years old and at least 4 weeks after completion of all PCV doses. To avoid interference with the immunologic response to the infant series of PCV These footnotes also address recommendation for use of one of the MCV4 vaccines and PCV13 in children with asplenia. The recommendation states the need to wait until the child is at least 2 years old and to ensure that there has been at least a 4 week interval since completion of all PCV doses before administering Menactra, MCV4-D vaccine. This recommendation was made in order to avoid interference with the immunologic response to the infant series of PCV based on prelicensure studies. Pneumococcal disease poses such a high risk of morbidity and mortality in children with asplenia and hence this recommendation was made. These footnotes also address recommendation for use of one of the MCV4 vaccines and PCV13 in children with asplenia. The recommendation states the need to wait until the child is at least 2 years old and to ensure that there has been at least a 4 week interval since completion of all PCV doses before administering Menactra, MCV4-D vaccine. This recommendation was made in order to avoid interference with the immunologic response to the infant series of PCV based on prelicensure studies. Pneumococcal disease poses such a high risk of morbidity and mortality in children with asplenia and hence this recommendation was made.

17. Changes to Figure 2. Recommended Immunization Schedule for Persons Aged 7 Through 18 Years We will now move onto the changes for the 7 through 18 year schedule� Like the adult schedule, Figure 2. has been updated to include the number of doses required for each vaccine. Information regarding the recommended age for the booster dose of MCV 4 was added to the figure. (16 years old).We will now move onto the changes for the 7 through 18 year schedule� Like the adult schedule, Figure 2. has been updated to include the number of doses required for each vaccine. Information regarding the recommended age for the booster dose of MCV 4 was added to the figure. (16 years old).

18. 2012 Schedule � 7 Through 18 YearsHPV Footnote (footnote 2) 2. Human papillomavirus vaccine (HPV). (Minimum age: 9 years) Either HPV4 or HPV2 is recommended in a 3-dose series for females aged 11 or 12 years. HPV4 is recommended in a 3-dose series for males aged 11 or 12 years. For HPV vaccine, in Oct 2011, ACIP voted for the routine use of HPV4 in males age 11-12 years old with catch-up vaccination for those 13 through 18 years old.For HPV vaccine, in Oct 2011, ACIP voted for the routine use of HPV4 in males age 11-12 years old with catch-up vaccination for those 13 through 18 years old.

19. 2012 Schedule � 7 Through 18 YearsIPV Footnote (footnote 8) New bullet added: The final dose in the series should be administered at least 6 months following the previous dose. If both OPV and IPV were administered as part of a series, a total of 4 doses should be administered, regardless of the child�s current age. IPV is not routinely recommended for U.S. residents aged 18 years or older. a new bullet for inactivated poliovirus vaccine, or IPV, was added to clarify that IPV is not routinely recommended for US residents 18 years or older � this is depicted on the grid by the bar ending before the 18 yr mark, however the footnote was added to improve clarity on this matter. a new bullet for inactivated poliovirus vaccine, or IPV, was added to clarify that IPV is not routinely recommended for US residents 18 years or older � this is depicted on the grid by the bar ending before the 18 yr mark, however the footnote was added to improve clarity on this matter.

20. Changes to the 2012 �Catch-up� Schedule Finally we will discuss changes to the 2012 Catch-up schedule. As you can see, a few changes were made to the Figure including: Reminding providers to use this schedule in conjuction with the 0-6 and 7 through 18 year old schedules and the addition of meningococcal conjugate vaccines to the figure---MCV4 vaccines were not included in the past, but now with newer recommendations that involve Catch up this had to be done. The Catch up Schedule now depicts the minimum age for MCV4 administration as well as the minimum interval between doses. Finally we will discuss changes to the 2012 Catch-up schedule. As you can see, a few changes were made to the Figure including: Reminding providers to use this schedule in conjuction with the 0-6 and 7 through 18 year old schedules and the addition of meningococcal conjugate vaccines to the figure---MCV4 vaccines were not included in the past, but now with newer recommendations that involve Catch up this had to be done. The Catch up Schedule now depicts the minimum age for MCV4 administration as well as the minimum interval between doses.

21. 2012 �Catch-up� ScheduleMCV Footnote (footnote 6) 6. Meningococcal conjugate vaccines, quadrivalent (MCV4). Minimum age 9 months for Menactra (MCV4-D); 2 years for Menveo (MCV4-CRM) Refer to Figure 1. �Recommended Immunization Schedule for Persons Ages 0 through 6 Years� and Figure 2. �Recommended Immunization Schedule for Persons Ages 7 through 18 Years� for further guidance. For the MCV4 footnote , As mentioned earlier, rather than repeat all the information relevant to Catch-up, in this schedule, providers are referred to the respective age schedule footnotes..�.For the MCV4 footnote , As mentioned earlier, rather than repeat all the information relevant to Catch-up, in this schedule, providers are referred to the respective age schedule footnotes..�.

22. Removal of Hepatitis B footnote The Hep B footnote has been removed and the wording relevant to the Catch- up schedule, specifically the minimum age for the 3rd dose of Hep B in infancy is now included in the Figure. The Hep B footnote has been removed and the wording relevant to the Catch- up schedule, specifically the minimum age for the 3rd dose of Hep B in infancy is now included in the Figure.

23. Removal of HepA footnote Information in Figure 3 and 0-6 yr and 7-18 yr Schedules The Hepatitis A footnote was also removed as the wording is already discussed in the 0 through 6 and 7 through 18 year schedules. The Hepatitis A footnote was also removed as the wording is already discussed in the 0 through 6 and 7 through 18 year schedules.

24. 2012 �Catch-up� Schedule IPV Footnote (footnote 5) For the IPV footnote the first Bullet was Removed. This bullet addressed the minimum age for the final dose and the Words were inserted into the table instead. Again as we did with the 7 through 18 year schedule, we added a bullet to state that IPV is not routinely recommended for persons 18 years of age and older�For the IPV footnote the first Bullet was Removed. This bullet addressed the minimum age for the final dose and the Words were inserted into the table instead. Again as we did with the 7 through 18 year schedule, we added a bullet to state that IPV is not routinely recommended for persons 18 years of age and older�

25. Footnotes Please remind providers to read the footnotes!!! Finally, we would like to highlight the importance of the footnotes!! The lower halves of all three schedules contain footnotes. The footnotes provide important details about the schedule such as minimum intervals and ages. We encourage providers to ALWAYS read the footnotes carefully, And to read the footnotes on each new edition of the schedules because footnote content changes often. Thank you for your time. Finally, we would like to highlight the importance of the footnotes!! The lower halves of all three schedules contain footnotes. The footnotes provide important details about the schedule such as minimum intervals and ages. We encourage providers to ALWAYS read the footnotes carefully, And to read the footnotes on each new edition of the schedules because footnote content changes often. Thank you for your time.