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 visits. 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.

• Added dengue vaccine to the child and adolescent schedule
• Added an appendix listing the contraindications and precautions for each vaccine type in the child and adolescent schedule
• Added a QR code to the cover page that links to the online version of the schedule

Dengue note was added to provide guidance for areas with endemic dengue and pre-vaccination laboratory testing.

The Hib note was revised to include recommendations for using Vaxelis for routine and catch-up vaccination.

The hepatitis A note was revised to clarify the recommended age for routine vaccination.

The hepatitis B note was revised to clarify the recommendation for post-vaccination serologic testing and revaccination

The HPV note was revised to clarify the number of doses for persons with immunocompromising conditions.

The “Special situations” section in the Influenza note was condensed by moving information on contraindications and precautions for influenza vaccines to the newly created appendix.

The MenACWY note was updated to include language stating MenACWY vaccines may be administered simultaneously with MenB vaccines if indicated, but at a different anatomic site, when feasible.

The MMR note was updated to include information on recommendations for use of MMRV.

The Varicella note was updated to include information on recommendations for use of MMRV.

• Added PCV15 and PCV20 to the list of pneumococcal vaccines and removed PCV13.
• Added Society for Healthcare Epidemiology of America (SHEA) as an approving partner.
• Added an appendix listing the contraindications and precautions for each vaccine type in the adult immunization schedule.
• Added a QR code to the cover page that links to the online version of the schedule.

The hepatitis B note now states that HepB vaccine is universally recommended for all adults aged 19 through 59 years, and the 2-, 3-, or 4- dose regimens are listed. Additionally, the risk-based recommendations for adults 60 years of age and older are listed. A note was added to state that “anyone age 60 years or older who does not meet risk-based recommendations may still receive Hepatitis B vaccination.”

Minor edits were made in the HPV note to increase clarity in the language in the “Routine vaccination” and “Special Situations” sections.

The language was edited to clarify the age as “19 years or older,” to be consistent with the schedule. A hyperlink to the 2021-2022 influenza recommendations and a bullet for the 2022-2023 influenza recommendations were added. The “Special situations” section in the Influenza note was condensed by moving information on contraindications and precautions for influenza vaccines to the newly created appendix.

A note was added at the end of section that states, “MenB vaccines may be administered simultaneously with MenACWY vaccines if indicated, but at a different anatomic site, when feasible.”

The MMR “special situations” section now includes CD4 percentages in addition to CD4 counts in the HIV infection bullet to harmonize language with the child/adolescent schedule.

The “Routine vaccination” section now states that anyone aged 65 years or older “who have not previously received a pneumococcal conjugate vaccine or whose previous vaccination history is unknown should receive 1 dose of PCV15 or 1 dose of PCV20. If PCV15 is used, this should be followed by a dose of PPSV23.” Similarly, the “Special situations” section has changed, and this section states that anyone “aged 19 through 64 years with certain underlying medical conditions or other risk factors who have not previously received a pneumococcal conjugate vaccine or whose previous vaccination history is unknown should receive 1 dose of PCV15 or 1 dose of PCV20. If PCV15 is used, this should be followed by a dose of PPSV23.” Guidance for dosing intervals between PCV15 and PPSV23 and for patients who have previously received PCV13 or PPSV23 in the past is also included. Notes are added at the end listing all the underlying medical conditions or risk factors that would make those aged 19 through 64 years eligible to receive pneumococcal vaccination.

The Varicella “special situations” section now includes CD4 percentages in addition to CD4 counts in the HIV infection bullet were added to harmonize language with the child/adolescent schedule.

The Zoster “Special situations” section pregnancy bullet was revised to increase clarity. This bullet now states “There is currently no ACIP recommendation for RZV use in pregnancy. Consider delaying RZV until after pregnancy.” Additionally, the immunocompromising conditions bullet was revised to reflect the new ACIP recommendations for zoster vaccination. This bullet now states “RZV is recommended for use in persons aged 19 years and older who are (or will be) immunodeficient or immunosuppressed because of disease or therapy.”