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.

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 DTaP note was revised to include a “special situations” section containing information about the recommendation for use of DTaP in wound management.

The Hib note was revised to indicate that for catch-up vaccination, no further doses are recommended if a previous dose was administered at age 15 months or older.

The “birth dose” section of the HepB note contains additional text clarifying the recommendation for infants with birth weight of <2000 grams who have HBsAg-negative mothers.

The HPV note was revised to include recommendations for interrupted schedules.

The “special situations” section of the Influenza note has been revised for persons who have egg allergy with symptoms other than hives, and for situations where LAIV4 should not be used.

The MenACWY note contains information about use of MenQuadfi, and the “special situations” section contains information about use of Menveo in infants who received dose 1 at age 3–6 months.

The Tdap note was revised to include a “special situations” section containing information about the recommendation for use of Tdap in wound management.

• Added MenQuadfi (MenACWY-TT) to the list of meningococcal ACWY vaccines
• Removed any reference to zoster vaccine live (ZVL, Zostavax) since it is no longer on the market
• Added American Academy of Physician Assistants (AAPA) as an approving partner
• Added links to FAQs for ACIP Shared Clinical Decision-Making Recommendations

The HepA note was revised to include dosing for the accelerated Twinrix (HepA-HepB) schedule of 3 doses at 0, 7, and 21-30 days, followed by a booster dose at 12 months for travel in countries with high or intermediate endemic hepatitis A

The HepB note was revised to include shared clinical decision-making for HepB vaccines in persons with diabetes 60 years or older

The HPV note was revised to indicate that HPV vaccination is recommended for all persons through age 26 years. A bullet was added stating that no additional doses of HPV are recommended after completing a series at the recommended dosing intervals using any HPV vaccine. Under “Shared Clinical Decision-Making,” the text was modified to say “Some adults aged 27–45 years: based on shared clinical decision-making, 2- or 3-dose series as above.” Under “Special situations,” added a bullet stating “Age ranges recommended above for routine and catch-up vaccination or shared clinical decision-making also apply in special situations,” and a bullet stating “Immunocompromising conditions, including HIV infection: 3-dose series as above, regardless of age at initial vaccination”.

In “Special Situations,” regarding an “Egg allergy more severe than hives,” this text was added: “If using an influenza vaccine other than Flublok or Flucelvax, administer in medical setting under supervision of health care provider who can recognize and manage severe allergic reactions.” Two additional bullets were added: “Severe allergic reactions to vaccines can occur even in the absence of a history of previous allergic reaction. All vaccination providers should be familiar with the office emergency plan and certified in cardiopulmonary resuscitation,” and “A previous severe allergic reaction to influenza vaccine is a contraindication to future receipt of the vaccine.” Lastly, an additional bullet about LAIV4 and antivirals was added: “LAIV4 should not be used if influenza antiviral medications oseltamivir or zanamivir was received within the previous 48 hours, peramivir within the previous 5 days, or baloxavir within the previous 17 days”.

• Under “Special Situations” for MenACWY, added MenQuadfi (MenACWY-TT) vaccine to all relevant sections. For MenACWY booster doses, added “Booster dose recommendations for groups listed under ‘Special Situations’ and in an outbreak setting (e.g. in community or organizational settings, and among men who have sex with men) and additional meningococcal vaccination information, see https://www.cdc.gov/mmwr/volumes/69/rr/rr6909a1.htm.”
• For Men B booster doses, added “Booster dose recommendations for groups listed under ‘Special Situations’ and in an outbreak setting (e.g. in community or organizational settings, and among men who have sex with men) and additional meningococcal vaccination information, see https://www.cdc.gov/mmwr/volumes/69/rr/rr6909a1.htm”.

• In the Pneumococcal note, updated the link for routine vaccination in persons aged ≥65 years (https://www.cdc.gov/mmwr/volumes/68/wr/mm6846a5.htm?s_cid=mm6846a5_w). Under the Shared clinical decision-making section, reordered the bullets as follows:
  • PCV13 and PPSV23 should not be administered during the same visit
  • If both PCV13 and PPSV23 are to be administered, PCV13 should be administered first
  • PCV13 and PPSV23 should be administered at least 1 year apart

Updated the information for wound management: “Wound management: Persons with 3 or more doses of tetanus toxoid-containing vaccine: For clean and minor wounds, administer Tdap or Td if more than 10 years since last dose of tetanus toxoid-containing vaccine; for all other wounds, administer Tdap or Td if more than 5 years since last dose of tetanus toxoid-containing vaccine. Tdap is preferred for persons who have not previously received Tdap or whose Tdap history is unknown. If a tetanus toxoid-containing vaccine is indicated for a pregnant woman, use Tdap. For detailed information, see https://www.cdc.gov/mmwr/volumes/69/wr/mm6903a5.htm”.

In the Zoster note, removed references to prior receipt of ZVL (zoster vaccine live or Zostavax) dose when considering vaccination of persons aged ≥50 years with RZV (recombinant zoster vaccines or Shingrix) and deleted bullet about ZVL for persons aged ≥60 years since ZVL is no longer available in the U.S. market.