All newborns born to HBsAg-negative mothers, should receive their first hepatitis B vaccination within 24 hours of birth, and a third dose of a mumps-containing vaccine may be warranted during outbreaks, according to newly updated immunization guidelines.
The 2018 immunization schedule, updated annually, was recently approved by the American Academy of Pediatrics (AAP) along with the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC), the American Academy of Family Physicians (AAFP), and the American College of Obstetricians and Gynecologists (ACOG).1 The revised schedule includes the update to the hepatitis B guidelines, as well as several other revisions
Third mumps vaccine dose for outbreaks
H. Cody Meissner, MD, professor of Pediatrics at Tufts University School of Medicine and director of the Division of Pediatric Infectious Disease at Tufts Medical Center, Boston, Massachusetts, says providers should be aware of the new wording in regard to a third mumps-containing vaccination and the change regarding the timing of the first dose of the hepatitis B vaccine for newborns.
“The issue of a third dose of a mumps-containing vaccine is one people are asking about,” Meissner says. “The CDC has now said that if there is a cluster or ongoing outbreak of mumps disease in a closed setting among individuals who have already received 2 doses of MMR, then there may be a role for a third dose for a mumps-containing vaccine.”
A third dose of a mumps-containing vaccine has been discussed in the past, and the newest recommendations suggest public health authorities should be consulted when a clinician believes a third dose is warranted.
“That determination of need for a third dose should be made by the local department of public health, noting that a third dose may be recommended by public health authorities to ensure that a larger number of high-risk individuals can be protected," Meissner says.
However, should a provider notice an uptick in mumps cases, it would be prudent to reach out to public health officials if no previous alerts had been received about an outbreak, he adds.
The benefit from a third dose is still uncertain, Meissner says, because data have not clearly demonstrated efficacy from a third dose. “It’s been difficult to generate data to show that a third dose is protective. When a third dose has been administered, it’s usually timed around the cessation of an outbreak,” Meissner says, noting that it’s difficult to conclude whether these outbreaks ended because of a natural end in the virus cycle, or whether third vaccine doses played a role.
It is worth noting that immunity achieved from initial mumps-containing vaccines seems to wane around 10 years, Meissner says, so individuals who were vaccinated a decade or more ago may be at a higher risk of a breakthrough infection and therefore benefit more from a third vaccine dose during a cluster. The circulating viruses are changing, too, Meissner adds. The strain in the measles-mumps-rubella (MMR) vaccine is a genotype A strain, while most of the recent circulating viruses have been non-A strains.
“It seems that there are some antigenic changes in the presently circulating strain,” Meissner says.
Looking toward next flu season
In regard to other immunizations, there were only minor changes to recommendations for the flu vaccine, and Meissner says it’s too soon to say what impact this year’s harsh flu season will have on development or compliance for next year's vaccine. “It’s always hard to predict what’s going to happen with influenza next year,” he says.
However, one influenza recommendation that is not changed is the continued lack of recommendation for use of the live-attenuated flu vaccine (LAIV), which was available as a nasal spray several years ago but not endorsed for 2018 because of lack of efficacy over 3 influenza seasons.2
“Many children would prefer to have a nasal spray rather than an intramuscular injection,” Meissner says. The intranasal formulation was pulled from the pediatrician’s arsenal in 2016.
Meissner says data from the CDC indicates vaccination rates have not been negatively impacted by the lack of an intranasal option. “Vaccination rates didn’t change when the intranasal option was lost, so there has been no adverse impact on vaccine uptake,” he says.
Now the ACIP has ruled that an improved formulation of the child-friendly nasal vaccine can be used as a first-line option for the 2018-2019 flu season for which the H1N1 strain is expected to be dominant.3 The advisory panel noted that the intranasal vaccine might have provided better protection against this year's H3N2 strain than the 2 vaccines recommended by the CDC, which were only 36% effective overall.