Schedule Changes & Guidance

Stay-at-home and shelter-in-place orders have resulted in declines in outpatient pediatric visits and fewer vaccine doses being administered, leaving children at risk for vaccine-preventable diseases. As states develop plans for reopening, healthcare providers are encouraged to work with families to keep or bring children up to date with their vaccinations. Primary care practices in communities affected by COVID-19 should continue to use strategies to separate well visits from sick visitsexternal icon. Examples could include:

• Scheduling sick visits and well-child visits during different times of the day
• Reducing crowding in waiting rooms, by asking patients to remain outside (e.g., stay in their vehicles, if applicable) until they are called into the facility for their appointment, or setting up triage booths to screen patients safely
• Collaborating with healthcare providers in the community to identify separate locations for providing well visits for children

Healthcare providers should identify children who have missed well-child visits and/or recommended vaccinations and contact them to schedule in person appointments, starting with newborns, infants up to 24 months, young children and extending through adolescence. State-based immunization information systems and electronic health records may be able to support this work.

All newborns should be seen by a pediatric healthcare provider shortly after hospital discharge (3 to 5 days of age). Ideally, newborn visits should be done in person during the COVID-19 pandemic in order to evaluate for dehydration and jaundice, ensure all components of newborn screening were completed and appropriate confirmatory testing and follow-up is arranged, and evaluate mothers for postpartum depression. Developmental surveillance and early childhood screenings, including developmental and autism screening, should continue along with referrals for early intervention services and further evaluation if concerns are identified.

More than 114 million children at risk of missing out on measles vaccines, as COVID-19 surges

ATLANTA/GENEVA/NEW YORK, 14 April 2020: As COVID-19 continues to spread globally, over 114 million children in 38 countries may miss out on receiving life-saving measles vaccine. Measles immunization campaigns in 23 countries have already been delayed; more will be postponed.

During this challenging period, the Measles & Rubella Initiative (M&RI) expresses solidarity with families, governments, emergency responders, partners, Gavi, the Vaccine Alliance, the Global Polio Eradication Initiative (GPEI) and other global immunization and health partners in the world’s focus and fight against the threat of COVID-19. The pandemic sweeping the globe requires a coordinated effort and commitment of resources to ensure our staff and frontline health workers around the world are protected, as they face and respond to this new threat. At the same time, we must also champion efforts to protect essential immunization services, now and for the future.

The World Health Organization (WHO) has issued new interim guidelines – endorsed by the Strategic Advisory Group of Experts on Immunization (SAGE) – to help countries to sustain immunization activities during the COVID-19 pandemic. pdf iconexternal iconThe guidelines recommend that governments temporarily pause preventive immunization campaigns where there is no active outbreak of a vaccine-preventable disease. M&RI partners, which include the American Red Cross, the U.S. Centers for Disease Control and Prevention, UNICEF, the United Nations Foundation and WHO, strongly agree with these recommendations. We urge countries to continue routine immunization services, while ensuring the safety of communities and health workers. The recommendations also ask governments to undertake a careful risk-benefit analysis when deciding whether to delay vaccination campaigns in response to outbreaks, with the possibility of postponement where risks of COVID-19 transmission are deemed unacceptably high.

If the difficult choice to pause vaccination is made due to the spread of COVID-19, we urge leaders to intensify efforts to track unvaccinated children, so that the most vulnerable populations can be provided with measles vaccine as soon as it becomes possible to do so. While we know there will be many demands on health systems and frontline workers during and beyond the threat of COVID-19, delivering all immunization services, including measles vaccine, is essential to saving lives that would otherwise be lost to vaccine-preventable diseases.

The M&RI supports the need to protect communities and health workers from COVID-19 through a pause of mass campaigns, where risks of the disease are high. However, this should not mean that children permanently miss out. Urgent efforts must be taken now at local, national, regional and global levels to prepare to close the immunity gaps that the measles virus will exploit, by ensuing that vaccines are available, and that they reach children and vulnerable populations, as quickly as possible, to keep them safe.

Despite having a safe and effective vaccine for over 50 years, measles cases surged over recent years and claimed more than 140,000 lives in 2018, mostly of children and babies – all of which were preventable. Against this already dangerous backdrop, preventive measles vaccination campaigns have now been paused or postponed in 23 countries to help avert further spread of COVID-19. Campaigns expected to take place later in 2020 in an additional 15 countries may not be implemented. Together, more than 114 million children in 38 countries, many of whom live in regions with ongoing measles outbreaks, could be impacted by the suspension of scheduled immunization activities. This staggering number does not include the number of infants that may not be vaccinated because of the effect of COVID-19 on routine immunization services.  Children younger than 12-months of age are more likely to die from measles complications, and if the circulation of measles virus is not stopped, their risk of exposure to measles will increase daily.

The M&RI salutes the heroism of health and emergency workers across the globe, and we recognize the vital role they play in delivering clear, trusted information, as well as preventive and supportive care within their communities. Health workers need to be invested in, protected from infection, and empowered as part of sustainable and functioning primary health systems. They are the first line of defense against global epidemics. We also recognize the role of parents and caregivers in ensuring their children are vaccinated and following physical distancing recommendations in line with national guidance. Finally, we call on countries and local leaders to implement effective communication strategies to engage communities, ensure supply and demand for vaccination remains strong, and help assure a healthy life for every child especially in this challenging time.

About M&RI:

The Measles & Rubella Initiative is a global partnership, founded by the American Red Cross, the Centers for Disease Control and Protection, the United Nations Foundation, UNICEF and the World Health Organization, that is committed to achieving and maintaining a world without measles, rubella and congenital rubella syndrome. Founded in 2001, the Initiative has helped vaccinate over 2.9 billion children and save over 21 million lives by increasing vaccination coverage, improving disease response, monitoring and evaluation, and building public confidence and demand for immunization. The Initiative works closely with Gavi, the Vaccine Alliance to achieve these goals.

More information

• Measles information
  • WHO factsheetexternal icon
  • CDC measles pages

• Latest WHO measles surveillance dataexternal icon
• New interim recommendations for immunization programmesexternal icon
• The Measles & Rubella Initiativeexternal icon

For more details, please contact:

Priyanka Khanna, M&RI Communications Specialist, at pkhanna@unicef.org

Interim guidance to prevent mother-to-child transmission of hepatitis B virus during COVID-19-related disruptions in routine preventive services

This guidance is being provided to ensure that certain safety nets are in place to prevent mother-to-child hepatitis B virus (HBV) transmission in the event of significant COVID-19 pandemic-related disruptions in routine preventive services before, during, and after labor and delivery. The guidance is intended to be used by obstetric and pediatric care staff for consideration while prioritizing the Advisory Committee on Immunization Practices (ACIP) recommendations for prevention of mother-to-child transmission of HBV infection (see https://www.cdc.gov/mmwr/volumes/67/rr/rr6701a1.htm).

Prenatal care of hepatitis B surface antigen (HBsAg)-positive women

Ensure that HBsAg-positive pregnant women are able to advocate for the proper care of their HBV-exposed infants in case labor and delivery occurs at an unplanned facility or is attended by staff that are not knowledgeable about managing HBV-exposed infants:

• Educate HBsAg-positive women on their HBsAg status and the importance of proper preventive care for their infant, including hepatitis B immune globulin (HBIG) and single antigen hepatitis B vaccine at birth, hepatitis B vaccine series completion at six months of age, and post-vaccination serologic testing.
• Supply HBsAg-positive women with documentation of HBsAg laboratory results and ask them to provide this documentation to labor and delivery staff at the time of delivery.

Labor and Delivery Care

• Identify HBsAg status of all women presenting for delivery.
• If a woman’s HBsAg status is positive, HBIG and single antigen hepatitis B vaccine should be administered to her infant within 12 hours of birth.
• If a woman’s HBsAg status is unknown, single antigen hepatitis B vaccine should be administered to her infant within 12 hours of birth. Administration of HBIG should be determined per ACIP recommendations (see https://www.cdc.gov/mmwr/volumes/67/rr/rr6701a1.htm). Infants weighing <2,000 grams should receive HBIG if the mother’s HBsAg status cannot be determined within 12 hours of birth.
• Provide the birth dose of hepatitis B vaccine to all other newborns within 24 hours of birth to prevent horizontal hepatitis B virus transmission from household or other close contacts.

Pediatric care of HBV-exposed infants

• Every effort should be made to ensure HBV-exposed infants complete the hepatitis B vaccine series following the ACIP recommendations (see https://www.cdc.gov/mmwr/volumes/67/rr/rr6701a1.htm). Providers using single-component vaccine who are experiencing immunization service disruption should administer hepatitis B vaccine as close to the recommended intervals as possible, including series completion at  6 months, and follow ACIP recommendations for post-vaccination serologic testing.
• If post-vaccination serologic testing is delayed beyond 6 months after the hepatitis B series is completed, the provider should consider administering a “booster” dose of single antigen hepatitis B vaccine and then ordering post-vaccination serologic testing (HBsAg & antibody to HBsAg [anti-HBs]) 1-2 months after the “booster” dose.

The Hib note was revised to indicate that catch-up vaccination is not recommended for previously unvaccinated children 5 years (60 months) or older who are not at high risk.

The HepA note was revised to include the recommendation that all children and adolescents 2 through 18 years of age who have not previously received hepatitis A vaccine should receive catch-up vaccination and complete a 2-dose series.

The “special situations” section of the HepB note contains information regarding populations for whom revaccination may be recommended.

Guidance regarding adolescent vaccination for children who received MenACWY prior to age 10 years has been added to the MenACWY note.

MenB booster doses are now recommended for persons aged ≥10 years with complement deficiency, those who use complement inhibitors, persons with asplenia, persons who are microbiologists, and persons determined by public health officials to be at increased risk during an outbreak. The MenB note has been updated to include a link to the detailed recommendations.

Within the poliovirus vaccination note, detailed information has been added regarding which OPV doses may be counted toward the U.S. vaccination requirements.

The Tdap note has been updated to allow either Td or Tdap, as an option for decennial tetanus booster doses and catch-up series doses in persons who have previously received Tdap. Additionally, the note has been edited to reflect recent updates to the clinical guidance for children 7 through 18 years of age who received doses of Tdap or DTaP at age 7 through 10 years. A dose of Tdap or DTaP administered at 10 years of age may now be counted as the adolescent Tdap booster. A dose of Tdap or DTaP administered at 7 through 9 years of age should not be counted as the adolescent dose, and Tdap should be administered at 11–12 years of age. The DTaP note has been updated to note that dose 5 is not necessary if dose 4 was administered at age 4 years or older AND at least 6 months after dose 3.

• In Table 1 the number of columns for age ranges has been reduced from five to four as the columns for ages 19-21 years and 22-26 years have been combined. This is due to the change made to recommended catch-up HPV vaccination for all adults through age 26 years.
• A blue color box has been added to the schedule, including a blue footnote key. These indicate that shared clinical decision-making is recommended regarding vaccination. This impacts HPV, pneumococcal conjugate vaccine (PCV13), and meningococcal rows.

The HepA note was revised to include minor changes to the chronic liver disease definition, minor changes for the pregnancy indication, addition of the recommendation for vaccination in settings of exposure, and removal of clotting factor disorders as an indication for HepA vaccination.

The HepB note was revised to include minor changes to the chronic liver disease definition and minor changes for the pregnancy indication.

The HPV note was revised to indicate that HPV vaccination is recommended for all persons through age 26 years. A shared clinical decision-making subsection was added for persons 27-45 years.

The influenza note has been updated to include a bulleted list indicating when LAIV should not be used and minor edits to the guidance for persons with a history of Guillain-Barré syndrome.

The MMR note was revised to clarify recommendations for health care personnel, with a separate bullet for personnel born in 1957 or later with no evidence of immunity and for health care personnel born before 1957 with no evidence of immunity.

The MenB note was revised to include the use of the complement inhibitor ravulizumab as a special situation for MenB administration. A shared clinical decision-making subsection was added that includes a bullet for adolescents and young adults age 16-23 years not at increased risk for meningococcal disease. Under the “Special situations” subsection, the recommendation was added to administer a booster dose of MenB 1 year after the primary series and revaccinate every 2-3 years if the risk remains.

The pneumococcal note has been updated to indicate the updated recommendations for vaccination of immunocompetent (defined in discussion as adults without an immunocompromising condition, CSF leak, or cochlear implants) adults 65 years and older. One dose of PPSV23 is still recommended. Shared clinical decision-making is recommended regarding administration of PCV13 to immunocompetent persons 65 years and older.

The tetanus, diphtheria, and pertussis note has been updated to indicate that Td or Tdap may be used in situations where only Td vaccine is indicated for the decennial tetanus, diphtheria, and pertussis booster vaccination, tetanus prophylaxis for wound management, and catch-up vaccination.

The varicella note has been updated to indicate that vaccination may be considered for persons with HIV without evidence of varicella immunity who have CD4 counts ≥200 cells/µL.