Notes from the National Guideline Clearinghouse (NGC) and the Institute for Clinical Systems Improvement (ICSI):
- For a description of what has changed since the previous version of this guidance, refer to Summary of Changes Report -- October 2008.
- The recommendations for immunizations are presented in the form of immunization schedules and an algorithm with a total of 30 components accompanied by detailed annotations. Clinical highlights and immunization schedules are provided below for: Immunization Schedule for Infants, Children, and Adolescents – Routine and High Risk and Immunization Schedule for Adult – Routine and High Risk. An algorithm for In-Clinic Immunization is provided in the original guideline document.
- Vaccine shortages continue to occur in the United States and are the result of a number of factors including companies leaving the vaccine market, manufacturing or production problems, unexpected demand for new vaccines or to changes in vaccine recommendations. On occasion, shortages necessitate temporary changes in recommendations for their use. Information about the shortages including projected duration and recommendations for temporary changes in the immunization schedule are provided by the Advisory Committee on Immunization Practices. The work group recommends that all practitioners be kept abreast of the latest national information on vaccine shortage available at the Centers for Disease Control and Prevention Web site at http://www.cdc.gov/vaccines/news/default.htm.
- Vaccines administered outside the United States can generally be accepted as valid if the schedule was similar to that recommended in the United States (i.e., minimum ages and intervals). Only written documentation should be accepted as evidence of previous vaccination. Written records are more likely to predict protection if the vaccines, dates of administration, intervals between doses, and the person's age at the time of vaccination are comparable to United States recommendations. If a question exists about whether vaccines administered outside the United States were immunogenic, repeating the vaccinations is usually safe and avoids the need to obtain and interpret serologic tests. If avoiding unnecessary injections is desired, serologic testing might be helpful in determining which vaccinations are needed.
Clinical Highlights
- Utilize all clinical encounters as opportunities to assess a patient's immunization status. (Annotations #15, 16, 17; Aim #1 - see the original guideline document)
- Administer at each clinical encounter all immunizations that are due or overdue unless true contraindications exist. (Annotations #20, 22, 23, 26; Aim #2 - see the original guideline document)
- Educate patients (parents, if applicable) regarding the importance of infant, childhood, adolescent, and adult immunizations, the recommended schedule and the need to maintain a personal record of immunizations and childhood diseases. (Annotation #28 - see the original guideline document)
- Document reasons for not administering immunizations that are clinically indicated, and flag the record for a recall appointment. (Annotations #23, 24 - see the original guideline document)
- Document the future plan for administering immunizations. (Annotation #15, 26, 28; Aim #3 - see the original guideline document)
*Immunization Schedule for Infants, Children, and Adolescents – Routine and High Risk
| Vaccine |
Birth |
1 mo |
2 mos |
4 mos |
6 mos |
12 mos |
15 mos |
18 mos |
24 mos |
4-6 yrs |
11-12 yrs |
15-18 yrs |
| DTaP |
|
|
X |
X |
X |
X |
|
X |
Tdap |
|
| IPV |
|
|
X |
X |
X |
|
X |
|
|
| MMR (MMRV) |
See Annotation #3 in the original guideline document for information on combined measles, mumps, rubella and varicella vaccine (MMRV). |
X |
|
|
X |
|
|
| Varicella |
X |
|
|
X |
|
X
Verify second dose completed
|
| Pneumococcal (PCV7) |
|
|
X |
X |
X |
X |
|
|
|
|
|
| Hib |
|
|
X |
X |
X |
X |
|
|
|
|
|
| Rotavirus |
|
|
X |
X |
X |
|
|
|
|
|
|
Hep B
Schedule 1
|
X |
X |
|
X |
|
|
|
|
|
Hep B
Schedule 2
|
|
X |
X |
X |
|
|
|
|
| Influenza |
|
|
|
X
annually
|
| Hep A |
|
|
|
|
X
2 doses minimum 6 months interval |
|
|
|
| Meningococcal |
|
|
|
|
|
|
X |
X
if previously not received
|
| Human Papilloma Virus (HPV) (females) |
|
|
|
|
X
(3-dose series)
|
X
(Catch up if appropriate, 3-dose series)
|
Abbreviations: DTaP, diphtheria, tetanus, acellular pertussis; Hep A, hepatitis A; Hep B, hepatitis B; Hib, Haemophilus influenzae type b; IPV, inactivated poliovirus vaccine; MMR, measles, mumps, and rubella; MMRV, measles, mumps, rubella, varicella; Tdap, tetanus-diphtheria-acellular pertussis
*Please check manufacturer specifications for dosing, as all time intervals may not be needed.
For additional information on immunizing high-risk patients, see Annotation #14 in the original guideline document.
*Immunization Schedule for Adults -- Routine and High-Risk
| Vaccine |
19-26 Years |
27-39 Years |
40-64 Years |
65 Years and Older |
| Td/Tdap |
Tdap if previously not immunized, 1 dose Td booster every 10 years, substitute one dose of Tdap for Td |
Td booster |
| IPV |
Immunize if not previously immunized |
| MMR |
Persons born during or after 1957 should have 1-dose measles; a second dose may be required in special circumstances (see Annotation #3 in the original guideline document). |
|
| Varicella |
X
Verify second dose completed
|
For all adults who do not have evidence of immunity to varicella, give two doses of varicella vaccine with at least 28 days between the first and second doses. (See Annotation #4 in the original guideline document.) |
| Pneumococcal (PPV23) |
Immunize high risk groups once. Re-immunize those at risk of losing immunity once after 5 years. |
Immunize at 65 if not done previously. Re-immunize once if 1st received >5 years ago and before age 65 or an appropriate immunocompromising condition is present. |
| Hep B |
Universal immunization |
Immunize those at high risk. |
| Influenza |
Annually during flu season for individuals age 50 and older, those at high risk, and others. |
| Hep A |
Immunize those in risk groups |
| Meningococcal |
X |
Immunize those in risk groups |
| Human Papilloma Virus (HPV) (females) |
X
Catch up, if appropriate
|
|
|
|
| Herpes Zoster/Shingles |
|
|
Immunize at age 60 and older |
Abbreviations: Hep A, hepatitis A; Hep B, hepatitis B; IPV, inactivated polio vaccine; MMR, measles, mumps, rubella; Td, tetanus, diphtheria; Tdap, tetanus-diphtheria-acellular pertussis
*Please check manufacturer specifications for dosing, as all time intervals may not be needed.
For additional information on immunizing high-risk patients, see Annotation #14 in the original guideline document.
The Centers for Disease Control and Prevention (CDC) updates immunizations recommendations in January, July, and October -- please refer to the CDC website http://www.cdc.gov/vaccines for the most current schedule.
