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Practices
Updated ACIP General Recommendations
on Immunization
Summary
of Major Changes
No Vaccination Schedules
Unlike
previous versions of the General Recommendations, this revision does
not include vaccination schedules. Beginning in 1995, the Recommended Childhood Immunization Schedule has been published
annually by Advisory Committee on Immunization Practices (ACIP), the American Academy of
Pediatrics (AAP), and the American
Academy of Family Physicians (AAFP). The 2002 schedule is available on the National Immunization Program website at
http://www.cdc.gov/nip/recs/child-schedule.htm
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4-Day
Grace Period for Timing and Spacing of Vaccines
Since 1994, ACIP has recommended that doses
of vaccine separated by less than the recommended minimum interval
should not be considered part of a primary series. ACIP continues to recommend that vaccine doses should not be given
at intervals less than the minimum intervals or earlier than the minimum
age. An extensive listing of recommended and minimum interval and ages for vaccination is included in
the document. In an effort to
increase the flexibility of the complicated childhood immunization
schedule, ACIP now recommends that vaccine doses administered up to four
days before the minimum interval or age can be counted as valid.
ACIP believes that administering a dose a few days earlier than the
minimum interval or age is unlikely to have a significant negative effect
on the immune response to that dose.
This 4-day "grace
period" should NOT be used when scheduling future vaccination visits. It should be used primarily when reviewing vaccination records.
The 4-day "grace period" may also be useful in situations where a child visits a provider a few days earlier than a scheduled
vaccination appointment. For example, if a child comes to the office or clinic for an ear check 27 days
after his or her second DTaP dose, the provider could administer the third
DTaP at that visit rather than having the child return for vaccination the
next day.
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Non-Simultaneous
Administration of Live Vaccines
Since 1983, ACIP has recommended that
whenever possible, live-virus vaccines not administered on the same day
should be administered at least 30 days apart, because of concern that the
vaccine given first could interfere with response to the vaccine given
second. These concerns were based on two 1965 studies that indicated thet recent measles vaccination
reduced the response to smallpox vaccine. A study recently published in Morbidity
and Mortality Weekly Report (MMWR 2001;50:1058-61) found that children who received
varicella vaccine less than 30 days after MMR vaccination had a 2.5-fold
increased risk of breakthrough varicella (i.e., varicella disease in a
vaccinated person) compared with those who received varicella vaccine
before, simultaneous with, or more than 30 days after MMR.
Until now, ACIP has not provided guidance
on the course of action if two live-virus vaccines were given less than 30 days apart. In the
revised General Recommendations, ACIP recommends that if two live
parenteral vaccines are given less than 28 days apart, the vaccine given
second should not be counted as valid and should be repeated at least 4
weeks later. One exception to
this recommendation is that yellow fever vaccine may be given at any time
after measles vaccine.
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Non-Standard
Route or Site of Administration
In the 1994 revision of the General Recommendations, ACIP recommended
that any vaccination using less than a standard dose or a nonstandard route
or site of administration should not be counted, and the person should be
revaccinated according to age. This recommendation was intended to discourage inappropriate
vaccination practices, such as administration of half doses (a practice
mostly associated with whole cell DTP vaccine), or inappropriate routes of
vaccination (particularly the gluteus). This recommendation also led to repetition of some vaccine doses
given by routes other than those recommended by the manufacturer, but whose
route of administration probably had no significant effect on immunogenicity
(for example, administration of MMR by the intramuscular route rather than
the recommended subcutaneous route). In the revised General Recommendations, ACIP continues to strongly
discourage variation from the recommended route, site, or dose of any
vaccine. However, ACIP now recommends repeating doses only in cases where a reduction in immunogenicity
has been demonstrated: rabies and hepatitis B vaccines administered in the
gluteus, and hepatitis B vaccine administered by any route other than
intramuscular injection (i.e., intradermal or subcutaneous injection).
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Vaccination of Internationally
Adopted Children
Since 1994, ACIP has recommended that vaccines administered outside the United
States could be accepted as valid if they were documented by a written,
dated record. There is conflicting information regarding the accuracy of vaccination records for
internationally adopted children, particularly those adopted from orphanages
in China, Russia, and other eastern European countries, and it is difficult
to determine if a child is protected on the basis of their country of origin
and their records alone. ACIP continues to recommend that vaccines received outside the United States can
usually be accepted if there is written, dated documentation and the age,
spacing and timing is comparable with that recommended in the United States. But it is especially important for the provider to carefully review
the records of children adopted from orphanages, due to potential issues of
authenticity. If there is any doubt about the validity of a vaccination record (for instance, doses dated
before the child's birth or a record of receiving MMR or Hib vaccine, which are not commonly
used in less developed countries), age-appropriate revaccination is
generally recommended. Serologic testing may be considered if the parent or provider does not wish to repeat
all doses, particularly for DTaP if three or more doses are documented. The General
Recommendations provides guidance on selection and interpretation of
these serologic tests.
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Aspiration Before
Injection
Previous versions of the General Recommendations have recommended aspiration
(i.e., gently pulling back on the plunger to check for blood before
injection) prior to injection, particularly before intramuscular injection. No data exist to document the necessity of this procedure. The 2002 General Recommendations on Immunization does not
recommend aspiration before injection.
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Management
of Preterm Infants Whose Mothers' HBsAg Status is Unknown
Neither the current ACIP statement nor the 2002 schedule addresses hepatitis B
post-exposure management of preterm (<2 kg) infants whose mothers'
HBsAg status is unknown.
The revised General Recommendations recommends that preterm infants whose
mothers are HBsAg positive OR whose HBsAg status is unknown should be given both
hepatitis B vaccine and HBIG within 12 hours of birth. For all preterm
infants, the birth dose of hepatitis B vaccine should not be counted, and
the infant should receive 3 additional doses at 1, 2, and 6 months of age.
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