pediatric immunization schedule 2020

The CDC just published the 2020 vaccination schecdule for kids: see https://pediatrics.aappublications.org/content/early/2020/01/31/peds.2019-3995 , or https://www.cdc.gov/vaccines/schedules/hcp/imz/child-adolescent.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fvaccines%2Fschedules%2Fhcp%2Fchild-adolescent.html ) Most of the changes since 2019 are only clarifications included in their footnotes, as follows (will not include just formatting changes):

--DTaP: dose 5 is not necessary if dose 4 was administered at age 4 or older and was administered at least 6 months after dose 3
-- Tdap: an option to use this for booster doses, as well as any remaining doses for catch up series
    -- children age 7 to 9: if they receive a Tdap or a DTaP, they should receive routine Tdap at ages 11 to 12
    -- children aged 10-18: if they receive a Tdap at age 10, no need for booster at age 11-12; if they received DTaP, this counts as the adolescent Tdap booster
-- H. influenzae type B: catch up vaccination is not recommended for children 5 years or older who are not at high risk
-- hepatitis A: routine catch up vaccination until age 18
-- hepatitis B: "revaccination is not generally recommended for people with a normal immune status who were vaccinated as infants, children, adolescents, or adults. Revaccination may be recommended for infants born to HBsAg-positive mothers, hemodialysis patients, or other immunocompromised persons"
-- polio: only trivalent OPV is okay for US vaccination requirements. doses of oral polio vaccine are counted only if given before April 1, 2016
--MenACWY:
    -- children in whom boosters are not recommended in the setting of an ongoing increased risk of meningococcal disease (e.g. travel to a country where meningococcal disease is endemic): give vaccine according to the recommended adolescent schedule with dose 1 at age 11- 12 and dose 2 at age 16
    -- children in whom boosters are recommended in the setting of an ongoing increased risk (e.g. those with complement deficiency, HIV, or asplenia): follow the booster schedule for persons at increased risk


Commentary: 
-- for the commentary of the new guidelines on substituting Tdap for Td as the routine booster, see http://gmodestmedblogs.blogspot.com/2020/02/adult-immunization-schedule-2020.html
-- for concerns about measles vaccine deniers and the incredibly contagious and potentially horrible consequences of a measles infection, see http://gmodestmedblogs.blogspot.com/2020/02/measles-infection-diminishes-other.html
-- HPV vaccination (this part was basically written by Rebecca Perkins MD, our local but also national HPV expert):  CDC has noted a drop in invasive cervical cancers in the 15 to 24-year-old age group following implementation of HPV vaccination, which is terrific news (see hpv cervical ca incidence young US women amjprevmed2018 in dropbox, or  doi: 10.1016/j.amepre.2018.03.013). Vaccination appears to be more effective than screening to prevent cancer in this age group. Therefore we should follow the CDC guidelines and really promote the 2-dose vaccine schedule for females and males 9-14 years old, where the vaccine is especially immunogenic and it is only 2 shots: see http://gmodestmedblogs.blogspot.com/2016/11/2-dose-hpv-vaccine-for-girls-and-boys.html  There are some data hinting that 1 dose may be enough, and studies are ongoing to see whether a single dose may produce a sufficient antibody response to provide lifelong protection (eg see hpv vaccine 1 dose cancer2020 in dropbox, or DOI: 10.1002/cncr.32700). However, we do not have enough evidence at this time on the long-term protection of one dose, so should continue to follow CDC recommendations. 
-- Hepatitis A: as per my review of the adult guidelines, i do think that everyone should be immune to hepatitis A: see http://gmodestmedblogs.blogspot.com/2020/02/adult-immunization-schedule-2020.html

-- Hepatitis B: the hepatitis B vaccine is about 90% effective immunologically (though 1/2 of the remaining 10% do mount an immune response if given a second series). but the incidence of hepatitis B infection in the US is low (3409 cases reported to CDC in 2017, with incidence of 1.1/100K people, though estimates of perhaps 22,200 total cases in the US) and mostly in high risk groups (sex partners of those with Hep B, MSM, injection drug users, household contacts, health care workers, etc), cohort data suggest that those who got the initial vaccination series seem to be protected overall, and the CDC does not recommend giving booster vaccinations except in those who are on hemodialysis or are immunocompromised (including HIV). And, given the pretty low incidence of Hep B infections here, there is no need to check anti-HBs levels after immunization. Of note, these anti-HBs levels do tend to fall off over time, so low levels may not be correlated with lack of immunity (see https://www.cdc.gov/hepatitis/hbv/hbvfaq.htm): ie, the vast majority who are vaccinated are protected, even though their antibody levels wane (this is more of an issue for non-high risk adults: if they have had appropriate vaccination, basically assume that they are protected, though it seems reasonable to me to check their HBsAg if they are from high risk countries to make sure they are not chronic carriers (eg had perinatal transmission of the virus or were vaccine non-responders) and therefore need surveillance for liver cancer, and that family members etc are adequately vaccinated).

geoff​

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