Major vaccines addressed in updated ACIP guidelines

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.

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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.

NEXT: Changes for hepatitis B vaccination

Changes for hepatitis B vaccination

The updated recommendations also make a change to the timing of infant hepatitis B vaccination in an effort to reduce the number of preventable neonatal cases of hepatitis B.

Despite the fact that properly administered hepatitis B vaccine and hepatitis B immune globulin are extremely effective at preventing neonatal hepatitis B, there are still about 1000 neonatal cases in the United States each year, Meissner says. Babies born to mothers with known hepatitis B infections generally receive appropriate prophylaxis at birth, but in cases in which the mother was not tested properly or testing was falsely interpreted, infected babies might not receive the vaccine until a week or 2 after birth-and that’s too late.

“We have a pretty effective way of preventing hepatitis B transmission,” Meissner says. “The problem is you have to know the mother is infected in order to provide appropriate prophylaxis."

Testing can be confusing, Meissner says, or test results from the mother might not be relayed in a timely fashion to the pediatrician. To reduce the chance for error, the new recommendations state that all babies with a birth weight equal to or greater than 2000 grams who are born to a HBsAg-negative mother should receive the first dose of hepatitis B vaccine during the first 24 hours after birth.

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“It sets up a safety net for cases when results were misread or incorrectly ordered,” Meissner says. "The intention is to reduce the number of hepatitis B-infected babies to as low a number as possible."

More updates

Another update included in the guidelines is a recommendation for 2 doses of the human papillomavirus (HPV) vaccine for adolescents and children who receive the first dose before their 15th birthday.

There were no overall changes to the schedule of vaccinations recommended for children aged 0 to 18 years, although there were 2 changes to the catch-up schedule for children aged 4 months to 18 years who began their immunizations late or are behind on vaccinations by 1 month or more. These changes include a maximum age for the first dose of the rotavirus vaccine (14 weeks, 6 days) and the last dose (8 months, 0 days). The inactivated poliovirus catch-up schedule is also clarified to note that a final dose of inactivated poliovirus vaccine is recommended on or after the 4th birthday and at least 6 months after the previous dose. The schedule indicated for children aged 18 years and younger with medical indications also now includes a reference for administration of live vaccines to children with human immunodeficiency virus (HIV).                                         

The 2018 catch-up immunization schedule provides minimum intervals between doses for children whose vaccinations have been delayed. Additionally, the Haemophilus influenzae type b (Hib)vaccine MenHibrix (Hib-MenCY) has been removed from the vaccine schedule because the vaccine is no longer available, and all remaining doses have expired, according to the new recommendations.

REFERENCES

1. Centers for Disease Control and Prevention. Recommended immunization schedule for children and adolescents aged 18 years or younger, United States, 2018. Available at: https://www.cdc.gov/vaccines/schedules/downloads/child/0-18yrs-child-combined-schedule.pdf. Updated February 6, 2018. Accessed February 16, 2018.

2. Petrou I. Live attenuated influenza vaccine “shelved” for poor efficacy. Contemporary Pediatrics. Available at: http://contemporarypediatrics.modernmedicine.com/contemporary-pediatrics/news/live-attenuated-influenza-vaccine-shelved-poor-efficacy . Published September 20, 2016. Accessed February 16, 2018.

3. Rahhal N. Green light for nasal flu spray next season after two-year ban- and experts claim it could have lowered death rate this year. DailyMail.com Available at: http://www.dailymail.co.uk/health/article-5419269/US-panel-say-OK-use-nasal-flu-vaccine-again.html. Published February 21, 2018. Accessed February 22, 2018.

Ms Zimlich is a freelance writer in Cleveland, Ohio. She writes regularly for Contemporary Pediatrics and sister publications Managed Healthcare Executive and Medical Economics. She has nothing to disclose in regard to affiliations with or financial interests in any organizations that may have an interest in any part of this article.