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426 P&T •
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Immunization in the United States—Part 1, Childhood Vaccinations
Vaccine Birth 1 mo 2 mos 4 mos 6 mos 9 mos 12 mos 15 mos 18 mos 19–23 2–3 4–6 7–10 11–12 13–15 16–18
mos yrs yrs yrs yrs yrs yrs
Hepatitis B D1 D2 D3
Rotavirus b
D1 D2 D3 b
Influenza (IIV; LAIV) Annual (IIV only), 1 or 2 doses Annual (LAIV or Annual (LAIV or IIV),
IIV) 1 or 2 doses 1 dose only
Measles, mumps, rubella See ACIP F8 D1 D2
Varicella D1 D2
ACIP F = Advisory Committee on Immunization Practices footnote (available at http://tinyurl.com/ACIP2016); B = booster; D = dose; IIV = inactivated influenza
vaccine; LAIV = live, attenuated influenza vaccine; mo = months; yrs = years.
a This schedule includes recommendations in effect as of January 1, 2016. Any dose not administered at the recommended age should be administered at a
subsequent visit, when indicated and feasible. The use of a combination vaccine generally is preferred over separate injections of its equivalent component
vaccines. Vaccination providers should consult the relevant ACIP statement for detailed recommendations, available online at www.cdc.gov/vaccines/hcp/
acip-recs/index.html.
b The number of doses needed in this series varies depending on the brand of vaccine used; see full footnotes for details.
The above recommendations must be read along with the footnotes of this schedule (omitted here for space reasons), which are available at http://tinyurl.com/
ACIP2016. Source: Centers for Disease Control and Prevention
After receiving Food and Drug Administration (FDA) approved by the American Academy of Pediatrics (AAP), the
approval in June 2006, the HPV vaccine demonstrated early American Academy of Family Physicians, and the American
evidence of efficacy in the United States.4 One study found a College of Obstetricians and Gynecologists.10
56% decrease in the prevalence of vaccine-specific HPV among These annual immunization guidelines provide an evidence-
sexually active 14- to 19-year-old females during 2007–2010, based schedule of routine immunizations that are safe and
compared with the prevaccine era of 2003–2006.4 Similarly, after effective, based on age and concurrent medical conditions.8,10
the FDA approved the quadrivalent meningococcal vaccine They describe each vaccine, indications and contraindications,
(MCV4) in 2005, meningococcal meningitis declined markedly background data, and other information, such as catch-up
in children and other age groups.1 immunizations and recommendations for high-risk individuals
or those planning to travel.8–10 Figure 1 presents the current
RECOMMENDED VACCINES FOR vaccination schedule recommended by the ACIP for children
CHILDREN AND ADOLESCENTS and adolescents up to 18 years of age, as of January 1, 2016.8–10
In an effort to reduce childhood morbidity and mortality, Currently, 10 vaccines are included in the standard
the ACIP issues annual recommendations and guidelines for recommendations for children at specific ages between birth
childhood and adolescent immunizations.8–10 This committee and 10 years: hepatitis A (HepA); hepatitis B (HepB); RV;
consists of experts in vaccines, public health, infectious disease, diphtheria, tetanus, and acellular pertussis (DTaP); Hib; PCV13;
and related disciplines.8,9 The official recommendations are also inactivated poliovirus (IPV); inactivated influenza (IIV) or
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Immunization in the United States—Part 1, Childhood Vaccinations
children less than 5 years of age decreased by more than 95% attributed to various causes, including refusal to vaccinate,
within five years after the vaccine was introduced, the overall incomplete vaccination series, waning immunity, and imported
incidence had decreased by only 79% due to the emergence cases.7,12 Vaccine hesitancy and vaccine refusal have been impli-
of nonvaccine serotypes.4 cated in outbreaks of invasive Hib, varicella, pneumococcus,
Since then, PCV13 and a 23-valent (PPSV23) vaccine have measles, and pertussis. Notably, measles, which was declared
become available.10 The ACIP recommendations state that eliminated in the United States in 2000, caused a record number
for routine vaccinations, PCV13 should be administered in of cases in 2014 (23 outbreaks and 644 cases in 27 states).7,14
a four-dose series to patients at ages 2, 4, and 6 months, and Furthermore, in 2015 the United States experienced a large
between 12 and 15 months.10 For children 14 to 59 months old multistate measles outbreak that was thought to originate with
who received a full series of PCV7, a single supplemental dose an overseas traveler who visited Disneyland in California.13 The
of PCV13 is sufficient.10 The ACIP has also issued age- and majority of people contract measles during such outbreaks
condition-specific recommendations for vaccination with PCV13 because they are unvaccinated.13 These cases underscore the
and PPSV23 in children at high risk.10 importance of maintaining high vaccination coverage in the U.S.
population and advising travellers regarding immunization.7
VACCINE COVERAGE IN CHILDREN In 2006, the largest U.S. outbreak of mumps in two decades
AND ADOLESCENTS occurred, with 6,584 cases reported.7 This outbreak took
Coverage for most vaccinations remains high in the U.S. in place mostly in eight Midwestern states and colleges.7 As
children 19 to 35 months old.17 In 2014, immunization series is often true for mumps outbreaks in the U.S., cases mainly
of three or more doses for DTap, IPV, HepB, and PCV were affected people living in close proximity (e.g., dormitories) and
completed in 94.7%, 93.3%, 91.6%, and 92.6% of children in this occurred despite high coverage rates with the two-dose MMR
age group, respectively.17 However, uptake of the HepA vaccine vaccine series.7 Administration of a third dose of MMR during
lagged behind, with just 57.5% of these children completing the mumps outbreaks and the need to develop an improved vaccine
two-dose recommendation that year.17 Less than 1% of children have been discussed; however, the benefit of these additional
in this age group received no vaccinations at all in 2014.17 strategies is unclear.7
According to a 2015 CDC report, overall vaccination cover- Unlike these episodic outbreaks of measles and mumps, the
age in 49 reporting states and Washington, D.C., for children U.S. has had a sustained increase in pertussis cases.7 During
in kindergarten was high in 2014 (based on local vaccination the mid-2000s, despite high vaccination rates, illness in children
requirements), with median coverage of 94.0% for MMR and and teens began to rise, prompting new recommendations for
94.2% for DTap.18 In the states with a two-dose VAR vaccina- a pertussis booster in teenagers.7 Even with these new recom-
tion requirement for school entry (including the District of mendations, rates of pertussis have continued to increase,
Columbia), coverage was 93.6%.18 Median exemption levels evidenced by substantial outbreaks in California in 2010 and
vary by state but were low overall at 1.7%.18 in Washington state in 2011–2012.7 A retrospective study in
In 2014, the immunization rates among adolescents California showed that the cause of the disease resurgence
13 to 17 years of age were 86.0% for Tdap and 79.3% for meningo- was likely waning immunity with acellular pertussis vaccine.7
coccal conjugate vaccine (MenACWY), demonstrating that high
vaccine coverage among adolescents is possible.19 However, VACCINE HESITANCY
coverage for these vaccines varied widely by state, ranging from Some parents consciously choose to not have their children
70.8% in Mississippi to 94.8% in Connecticut for Tdap and from vaccinated, to delay vaccination, or to use alternative immu-
46.0% in Mississippi to 95.2% in Pennsylvania for MenACWY.19 nization schedules.6,9 This has caused a resurgence of many
Despite the ACIP’s recommendations, coverage among infectious diseases due to the loss of herd immunity, which
adolescents for routine HPV vaccination, although improv- puts many communities at risk.6,14
ing slowly, is low.19 Only 60% of girls and 41.7% of boys ages Vaccination is compulsory for school-age children in the
13 to 17 years old began the three-dose HPV series in 2014, and U.S.; however, public health officials are increasingly fearful
series completion was just 69.3% and 57.8% for girls and boys, of the option for parents to claim exemptions from vaccination
respectively.19 These percentages, however, show a modest requirements.9 Because of outbreaks of vaccine-preventable
increase over the previous year.19 disease, rising attention has been focused on vaccine hesitancy,
Adherence to influenza vaccination recommendations is causing some state legislatures to enact new vaccine exemption
also low, with only 59.3% of children ages 6 months through laws.15 Currently, exemptions are allowed due to medical reasons
17 years old receiving this vaccine in the 2014–2015 season.20 in all states; religious grounds in 48 states; and philosophical
Vaccination coverage for the flu decreases with increasing age; objections in 20 states.9,16 It has been estimated that 1% to 3%
whereas 74.6% of children 6 to 23 months old received at least of children are excused from immunization because of these
one dose of influenza vaccine in the 2014–2015 season, only exemptions, but in some communities the exemption rate is
46.6% of adolescents 13 to 17 years of age were vaccinated.20 as high as 20%.9 Even when a low percentage of children are
excused from immunization, the risk of disease outbreaks in
PUBLIC HEALTH CONSEQUENCES schools with exemption rates as low as 2% to 4% increases.9
OF NONCOMPLIANCE Illustratively, in southern Pennsylvania, health care providers
Despite the widespread availability of vaccines, multiple have frequently expressed frustration with morbidity and mortal-
resurgences of measles, rubella, mumps, and pertussis have ity from preventable infectious diseases that are traced to many
occurred since the 1980s.12,14 These resurgences have been Amish parents’ decisions not to have their children immunized.9
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Immunization in the United States—Part 1, Childhood Vaccinations
Currently in the U.S., parents of children and adolescents
Table 2 Health Provider-Based Interventions to
under the age of 18 years must give consent for medical
procedures.9 However, it has been suggested that the age
Improve Vaccination Compliance3,4,6,9,12,14
of informed consent for vaccinations recommended by the Provide Parent and Patient Counseling
CDC be lowered, on the grounds that children have the right • Be informed about vaccinations.
to be protected from disease even when their parents with- • Make strong recommendations.
hold consent.9 Some states are also seeking to mandate the • Provide patients with educational materials.
HPV vaccine, despite opposition on moral grounds by various • Use proven communication strategies.
religious organizations.9 • Dispel myths about side effects.
• Inform parents about research.
Lack of Access Due to Cost and Other Reasons • Give parents time to discuss concerns.
Another major contributor to vaccination noncompliance is • Describe infections that vaccines prevent.
the lack of access to health care due to socioeconomic and other • Describe potential health and financial consequences of vaccine
factors.6 Many parents go through hard times because of job noncompliance.
loss, divorce, home foreclosure, or other financial hardship.6 • Provide a vaccination record with past and future vaccination
Some parents are single, overwhelmed, and overworked, and not visits.
able to keep up with their children’s vaccinations and well-child • Provide patient reminders.
visits.6 If they lose their jobs and health insurance, some parents • Ask vaccine-hesitant parents to sign an exemption form.
don’t know that they could qualify for Medicaid to maintain • Inform parents that a missed dose will not require vaccine series
their health care.6 Families may also have inadequate access to be restarted.
to health care because of lack of transportation or inconvenient
clinic hours.9,12 Additional problems that hinder access to vac- Maximize Opportunities for Vaccination
cinations include child care for children not being vaccinated, • Administer vaccinations during sick or follow-up visits
lack of knowledge, and difficulty in reserving an appointment.9 (postsurgical, posthospitalization).
It is well known that vaccination rates are influenced by • Issue a standing order to allow nurses to administer patient
poverty level.6 There is no difference between children living vaccinations.
under and above the poverty level for MMR, IPV, and Hep B
Offer Combination Vaccines
vaccinations, which are provided under the Vaccines For
Children program.6 However, the vaccination rate for children • Simplifies vaccination regimen.
living below the poverty level lags for newer vaccines and • Minimizes the number of injections.
those that require four doses to complete the series.6 Black • Reduces need for return vaccination visits.
children have a lower vaccination rate for DTaP, Hib, PCV, and • Improves patient adherence.
RV than white children.6 However, this difference disappears Improve Accessibility to Vaccinations
after adjustment for socioeconomic status, which suggests
• Allow same-day appointments or walk-in visits.
that a greater prevalence of poverty for black children could
• Make sure the office staff is friendly and supportive.
explain the decrease in vaccine coverage.6
• Provide convenient office hours.
• Limit patient wait time.
Lack of Information
Language barriers and insufficient knowledge about immuni- Use Electronic Medical Records
zations contribute to reduced immunization adherence.9 Parents • Utilize consolidated electronic immunization records.
may not be aware of the threat of vaccine-preventable illness or • Set electronic alerts for needed vaccinations.
know that effective and safe vaccinations are available against • Follow up on electronic medical record alerts by contacting
these diseases.9,12 In a national survey of 1,600 parents con- patient.
ducted by the National Network for Immunization Information,
many parents indicated that they need more information about
how vaccines work, possible side effects, and changes made Health Provider-Based Interventions
to the guidelines.9 Common reasons cited for the refusal of Studies have consistently shown that absent or weak recom-
HPV and other adolescent vaccines are: “not recommended mendations from health care providers are primary drivers of
(by provider),” “not needed or necessary,” ’‘lack of knowledge,” poor vaccine uptake.3 Consequently, it is important to develop
and “don’t know.”4 interventions that target health care providers and their prac-
tices (Table 2), including patient counseling and automated
MEASURES TO IMPROVE COMPLIANCE EMR-based reminder systems.3 A description of these, as well
The CDC’s Task Force on Community Prevention Services as other provider-based interventions, follows.
has identified three categories for interventions to overcome
vaccine noncompliance: increasing community demand for Patient Counseling
vaccination, enhancing access to vaccination services, and Studies have found that the most important factor influencing
provider-based interventions.9 This section describes health parental decisions about vaccinations is communication with
provider-based and government or community interventions the health care provider.4 Parental and patient education pro-
that may increase vaccination compliance. vided by primary care physicians can be particularly important
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Immunization in the United States—Part 1, Childhood Vaccinations
keep up with appointments; unreliable transportation; relocat-
Table 3 Community- and Government-Based
ing frequently; or having difficult family circumstances.6 For
Interventions to Improve Vaccination Compliance3,4,7,9
parents and patients belonging to this group, the most effective
intervention to increase vaccination rates is to make access to Public Education
vaccinations easier.6 This can be done by allowing patients to • Distribute educational materials that incorporate community input.
be seen on the same day they call to make an appointment.6 • Conduct public messaging campaigns.
Such walk-in visits are usually scheduled for a minor illness, • Use electronic communications to distribute health and safety
but should also include a check of vaccination status.6 If a information.
patient has only a minor illness, vaccinations can be given
during this encounter.6 Supportive staff, convenient office Public Reminder and Recall Strategies
times, and limited wait time for immunizations also contribute • Conduct centralized reminder and recall strategies through public
to vaccine compliance.12 agencies or payers.
• Use electronic communications, such as social media and text
Use EMRs and Practice Alerts messaging, for reminder and recall programs.
Computerized tracking of patient records across health Free Vaccines and Other Financial Incentives
care venues has the potential to improve communication,
reduce immunization errors, and reduce missed opportuni- • Provide free vaccines to uninsured patients.
ties for vaccination.9 Health care systems should therefore • Issue financial incentives, such as gift certificates.
utilize consolidated electronic immunization records to conduct Alternative Public and Private Venues for Vaccination
system-wide and cross-system checks.9
• Day care facilities
Data have shown that practices with electronic reminder
• Drop-in service at walk-in clinics
systems in place can increase immunization rates.12 In one study,
• Pharmacies
establishing a practice alert for HPV vaccination in the EMRs of
• Women, Infants, and Children (WIC) program offices
11 pediatric practices in Philadelphia resulted in a higher propor-
• Emergency departments
tion of parents discussing the vaccine with their child’s provider,
• Inpatient settings
compared to practices that had not instituted the alert (84%
• Home visits
versus 70%).3 In a larger randomized controlled trial, clinician-
focused practice alerts resulted in initial HPV vaccination levels from the parents of middle and high school students where
8 percentage points higher than offices without the intervention the intervention was scheduled was conducted.3 Overall, 67%
(24% versus 16%) and 6 percentage points higher than offices that of these parents recalled receiving the brochure, 90% read it,
had used an educational intervention instead (18%).3 and more than half discussed it with family or friends.3
EMRs also improve efficiency and accuracy by standardizing Brief public messaging interventions directed at parents and
record-keeping regarding immunizations and missed visits.12 adolescents also show promise, particularly around increasing
Office practice staff can use the EMR reminder system to the intention to vaccinate.3 However, the positive effect of brief
identify patients who are not up to date with their immuniza- messages may only have a short-lived impact on behavior.3
tions.6 A notice can then be sent or a call can be made to these Therefore, it is important to evaluate the effect of different
patients to schedule an appointment for a well-child visit and messaging strategies on intention and vaccine receipt when the
vaccinations.6 messages are delivered in a setting where vaccinations can be
administered.3 Messaging can also be useful to inform parents
Community- and Government-Based Interventions that the HPV vaccine is routinely recommended for boys as
Community- and government-based approaches to enhance well as girls.3 Without such awareness, many of these parents
vaccination rates include increasing outreach and educational would not know to have their sons vaccinated.3
programs; using recall and reminder strategies; providing finan-
cial incentives; and offering vaccination at nontraditional sites Public Reminder and Recall Strategies
(Table 3).4 A more detailed discussion of these interventions Parent and clinician “reminders” regarding upcoming vac-
follows. cines and “recall” for vaccines past due are another evidence-
based approach for improving vaccination rates.3 Typically,
Public Education these interventions use mail- or phone-based approaches and
It has not yet been definitively proven that parent-driven are instituted at the practice level.3 However, with advances
or patient-based education can improve immunization rates in EMR and other immunization information systems, a novel
without additional interventions.3 However, it has been shown development in reminder/recall is to “centralize” the process
that the efficacy of these efforts does improve when combined so that a coordinating agency (such as a health department)
with community- or government-based measures.3 Rather can implement it.3 Centralized reminder/recall at the payer
than relying solely on direct parent or patient education, using level for adolescent vaccination is also being examined.3 A
newer educational modalities that incorporate community input centralized reminder/recall approach conducted by a managed
and Web-based tools for information dissemination can be care organization found that both the telephone and postal
particularly effective.3 For example, an educational brochure mail arms of the study achieved immunization levels for each
for parents about adolescent vaccines was created in close of the four vaccines recommended for adolescents that were
collaboration with a focus group.3 Pilot testing of the feedback four to nine percentage points greater than the control group
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