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362.Full.Pdf AMERICAN ACADEMY OF PEDIATRICS Committee on Infectious Diseases Policy Statement: Recommendations for the Prevention of Pneumococcal Infections, Including the Use of Pneumococcal Conjugate Vaccine (Prevnar), Pneumococcal Polysaccharide Vaccine, and Antibiotic Prophylaxis ABSTRACT. Heptavalent pneumococcal conjugate vac- lular pertussis; HbOC, Haemophilus influenzae type b conjugate cine (PCV7) is recommended for universal use in chil- vaccine; HIV, human immunodeficiency virus; AOM, acute otitis dren 23 months and younger, to be given concurrently media. with other recommended childhood vaccines at 2, 4, 6, and 12 to 15 months of age. For children 7 to 23 months he purpose of this report is to provide recom- old who have not received previous doses of PCV7, ad- ministration of a reduced number of doses is recom- mendations for use of the heptavalent pneumo- mended. Two doses of PCV7 are recommended for chil- Tcoccal conjugate vaccine (PCV7), Prevnar (Led- dren 24 to 59 months old at high risk of invasive erle Laboratories, Pearl River, NY; Wyeth-Ayerst pneumococcal infection—including children with func- Pharmaceuticals, Marietta, PA), and 23-valent pneumo- tional, anatomic, or congenital asplenia; infection with coccal polysaccharide (23PS) vaccines. In addition, rec- human immunodeficiency virus; and other predisposing ommendations for the continuing use of antibiotic pro- conditions—who have not been immunized previously phylaxis in children with sickle cell disease (SCD) and with PCV7. Recommendations have been made for use of asplenia will be given, and the use of antibiotics and 23-valent pneumococcal polysaccharide (23PS) vaccine in vaccines in children who attend out-of-home care will high-risk children to expand serotype coverage. High- be discussed. The American Academy of Pediatrics’ risk children should be given vaccines at the earliest possible opportunity. Use of antibiotic prophylaxis in Committee on Infectious Diseases provided recom- children younger than 5 years with functional or ana- mendations for pneumococcal polysaccharide vaccines 1 tomic asplenia, including children with sickle cell dis- in 1985. Revised recommendations and supporting ease, continues to be recommended. Children who have data for the use of pneumococcal vaccines and antibi- not experienced invasive pneumococcal infection and otic prophylaxis have been reviewed recently2,3 and have received recommended pneumococcal immuniza- accompany these recommendations. tions may discontinue prophylaxis after 5 years of age. Initially, there may be delays in acquiring adequate The safety and efficacy of PCV7 and 23PS in children 24 supplies of PCV7 or providers may have logistic or months or older at moderate or lower risk of invasive pneu- resource constraints in administering pneumococcal mococcal infection remain under investigation. Current US vaccine. Data supporting the administration of PCV7 to Food and Drug Administration indications are for admin- istration of PCV7 only to children younger than 24 months. healthy, moderate-risk or high-risk children older than Data are insufficient to recommend routine administration 24 months are limited and confined to evaluations of of PCV7 for children at moderate risk of pneumococcal safety and immunogenicity in small groups of children. invasive infection, including all children 24 to 35 months For the purposes of the current recommendations, chil- old, children 36 to 59 months old who attend out-of-home dren at high risk are defined as those with annual rates care, and children 36 to 59 months old who are of Native of invasive pneumococcal infection of at least 150 cases American (American Indian and Alaska Native) or African per 100 000, whereas children at moderate risk have American descent. However, all children 24 to 59 months rates of at least 20 cases per 100 000. The administration old, regardless of whether they are at low or moderate risk, of PCV7 is of highest priority for infants and toddlers may benefit from the administration of pneumococcal im- 23 months and younger and children at high risk be- munizations. Therefore, a single dose of PCV7 or 23PS vaccine may be given to children 24 months or older. The cause of underlying disease. Currently, there are insuf- 23PS is an acceptable alternative to PCV7, although an ficient safety, efficacy, and immunogenicity data on enhanced immune response and probable reduction of na- which to base a recommendation for universal immu- sopharyngeal carriage favor the use of PCV7 whenever nization of any children older than 24 months, other possible. than those who are at high risk. The US Food and Drug Administration approved PCV7 (Prevnar) in February ABBREVIATIONS. PCV7, heptavalent pneumococcal conjugate 2000 and has indicated PCV7 for use only in children vaccine; 23PS, 23-valent pneumococcal polysaccharide; SCD, younger than 24 months. sickle cell disease; DTaP, diphtheria and tetanus toxoids and acel- RECOMMENDED IMMUNIZATION OF ALL The recommendations in this statement do not indicate an exclusive course CHILDREN 23 MONTHS AND YOUNGER of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate. The PCV7 vaccine is recommended for routine PEDIATRICS (ISSN 0031 4005). Copyright © 2000 by the American Acad- administration to all children 23 months and emy of Pediatrics. younger at 2, 4, 6, and 12 to 15 months (Table 1). Each 362 PEDIATRICS Vol.Downloaded 106 No. 2from August www.aappublications.org/news 2000 by guest on September 29, 2021 .5-mL dose of PCV7 should be administered intra- 1. For high-risk children who have received 4 doses muscularly. The initial 2-month dose should be given of PCV7, a dose of 23PS vaccine is recommended no earlier than 6 weeks of age. Infants of very low at 24 months of age, to be given at least 6 to 8 birth weight (Յ1500 g) should be immunized at the weeks after the last dose of PCV7. time that they attain a chronological age of 6 to 8 2. For high-risk children who have received 1 to 3 weeks, regardless of their calculated gestational age. doses of PCV7 before 24 months of age, a single All doses of PCV7 may be administered concurrently additional dose of PCV7 should be given at least 6 with other childhood immunizations, including all to 8 weeks after the last dose of PCV7. This should diphtheria and tetanus toxoids and acellular pertus- then be followed by a dose of 23PS vaccine at least sis (DTaP) vaccines, all Haemophilus influenzae type b 6 to 8 weeks later. An additional dose of 23PS conjugate vaccines, both hepatitis B vaccines, inacti- vaccine should be given no earlier than 3 to 5 vated poliovirus vaccine, measles-mumps-rubella years after the initial dose of 23PS vaccine. vaccine, and varicella vaccine, using a separate sy- 3. For high-risk children 24 to 59 months old who ringe for the injection of each vaccine and adminis- have received only a single previous dose of 23PS tering each vaccine at a different site. vaccine, there are minimal data regarding the All children 23 months and younger who have not safety of subsequent doses of pneumococcal con- received doses of PCV7 before 6 months of age should be given catch-up doses according to the schedules in jugate vaccines. However, 2 doses of PCV7 are Table 1. Children 7 to 11 months old who have not recommended, to be given at an interval of 6 to 8 previously received doses of PCV7 should receive 2 weeks. Administration of the PCV7 immunization doses at least 6 to 8 weeks apart, followed by a third series should begin no earlier than 6 to 8 weeks dose at 12 to 15 months of age or at least 6 to 8 weeks after the last dose of 23PS vaccine. An additional after the second dose. Children 12 to 23 months old dose of 23PS vaccine is recommended 3 to 5 years who were not previously immunized should receive 2 after the first dose of 23PS vaccine. doses at least 6 to 8 weeks apart. 4. For high-risk children 24 to 59 months old who Infants should begin the PCV7 immunization se- have received no previous doses of either 23PS ries in conjunction with other required vaccines at vaccine or PCV7, 2 doses of PCV7 are recom- the time of the first regularly scheduled health main- mended, to be given at an interval of 6 to 8 weeks, tenance visit after at least 6 weeks of age. Children 23 followed by a single dose of 23PS vaccine no less months or younger who begin a catch-up PCV7 im- than 6 to 8 weeks after the last dose of PCV7. An munization series at 7 months or older should start at additional dose of 23PS vaccine is recommended 3 the time of their next clinic visit, including those to 5 years after the last dose. visits not related to well-child care unless contrain- dicated (eg, moderate or severe febrile illness) (Evi- Minimal safety and immunogenicity data are dence grade I). available regarding the use of combined regimens of RECOMMENDED IMMUNIZATION OF CHILDREN PCV7 and 23PS vaccine, and no data exist regarding 24 TO 59 MONTHS OLD AT HIGH RISK OF the efficacy of these regimens for the prevention of INVASIVE PNEUMOCOCCAL DISEASE pneumococcal disease. Currently available immuno- The PCV7 vaccine is recommended for all children genicity data suggest that PCV7 induces a primary 24 to 59 months old who are at high risk for invasive immune response that will provide immune memory pneumococcal infection (Table 2). High-risk children for the boosting of antibody to some serotypes con- include children with SCD and other types of func- tained within 23PS vaccine. Because 23PS vaccine tional or anatomic asplenia, human immunodeficiency provides a potentially expanded serotype coverage, virus (HIV) infection, or primary immunodeficiency its use is recommended for high-risk children. How- and children who are receiving immunosuppressive ever, previous experience with pneumococcal poly- therapy.
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