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Editorial: Childhood immunization: Read the fine print


Keeping track of changes in immunization recommendations is the best way to be certain that our patients receive maximal benefit.



Childhood immunization: Read the fine print

Ongoing goals for the nation's immunization program are to provide protection against a widening array of infections and to do that as efficiently and with as much flexibility as possible. The Recommended Childhood Immunization Schedule for 2002, included in this issue (see Updates), demonstrates that increased protection and increased flexibility both come at a cost: namely, having to read the fine print. As always, what's presented in small type is important, even though it gives the reader a headache. This year, the fine print emphasizes several points:

• Combination vaccines provide an opportunity to reduce the number of injections infants must receive, but not all combinations are equally protective at all points in the immunization series. In particular, the first dose of hepatitis B vaccine, which should be given before discharge from the neonatal nursery, should be monovalent vaccine, and the combined Haemophilus influenzae type B­DTaP (diphtheria and tetanus toxoids-acellular pertussis) vaccine should not be used as the primary infant series.

• Booster doses can be administered over a range of ages, but enough time must elapse after the initial series to allow for the appropriate immunologic "boost": namely, at least five years should pass between the initial DTaP series and the booster Td dose, and at least four weeks between the initial measles-mumps-rubella (MMR) vaccine and the booster dose.

• Recent information from the Centers for Disease Control and Prevention indicates that varicella vaccine should be given either at the same visit (but at a different site) than the MMR vaccine is given or at least 30 days later.1 Administration of varicella vaccine within 30 days of the MMR vaccine may inadequately protect the child from varicella.

• The new immunization schedule carries with it a temporary (we hope) caveat: The current shortage of 7-valent conjugate vaccine against Streptococcus pneumoniae (Prevnar) has led to a recommendation that physicians defer the booster (fourth) dose in healthy infants as long as the supply is limited. Children younger than 5 years who are at high risk of invasive disease caused by S pneumoniae should continue to be immunized as recommended. For infants whose fourth dose has been deferred, physicians are asked to develop a system for recall once supplies return to an adequate level.

Guidance about best immunization practices will continue to evolve as more vaccines are developed and additional studies reveal opportunities to combine vaccines. Keeping track of changes in recommendations—even though those changes are found in the difficult fine print—is the best way to be certain that our patients receive maximal benefit.


1. Simultaneous administration of varicella vaccine and other recommended childhood vaccines—United States, 1995­1999. MMWR Morbid Mortal Wkly Rep 2001;50(47):1058

Julia A. McMillan, MD, editor-in-chief of Contemporary Pediatrics, is professor of pediatrics, vice chair for pediatric education, and director of the residency training program, Johns Hopkins University School of Medicine, Baltimore.


Editorial: Childhood immunization: Read the fine print. Contemporary Pediatrics 2002;2:9.

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