Immunizing the College Student: REFERENCES:

September 1, 2007

ABSTRACT: College is a time of new exposures, risk-taking, and adventure. Thus, protection with proper immunization is paramount. Pediatricians should offer the recommended vaccines whether required for college entry or not. When the young adult comes to the office to have the college health form completed and signed, seize the opportunity to tout the benefits of pre-college vaccination.

College life can increase the young adult's exposure to infectious disease. Living in close quarters in dormitories with national and international students who have been vaccinated to varying degrees, engaging in high-risk behaviors, and studying abroad are among the reasons for the increased risk.

Resources are available to aid the clinician in providing medical advice and determining vaccine requirements for the college student who will travel abroad.1,2 Vacationing in exotic places during "spring break" or studying in some foreign countries may necessitate the administration of nonroutine vaccines (such as the typhoid vaccine), but those are not addressed in this article.

Here, routinely recommended vaccinations for the young adult entering college in the United States are highlighted.

RECOMMENDED VACCINES

Most states have immunization requirements for entry into college. The 3 vaccines of particular interest at the pre-college visit include Tdap (tetanus and diphtheria toxoids and acellular pertussis), MCV4 (meningococcal conjugate vaccine), and HPV (human papillomavirus) vaccine.

HPV. HPV vaccine is the newest vaccine to be added to the list. Although proof of protection against tetanus and meningococcal infection is a common requirement for college, HPV vaccination is presently only required in a few states (ie, Texas and New Mexico) for sixth-grade girls.3 Although Tdap, MCV4, and HPV vaccines are now recommended at the pre-middle school visit, the current population of unimmunized college students can be immunized now. Ideally, these vaccines will have already been administered at the pre-middle school well child visit.

Tdap. Tdap(Adacel, Boostrix) administration, in place of Td (teta- nus and diphtheria toxoid), should be promoted at this age. Craig and colleagues4 reported that 13% of college students in their study who had prolonged cough met the CDC's case definition for pertussis.

Although it is suggested that an interval of at least 5 years between Td and Tdap administration is necessary to reduce the risk of local and systemic reactions, the AAP policy statement asserts that data support the safety of an interval of at least 2 years.5

MCV4. College freshmen living in dormitories are among those at increased risk for contracting Neisseria meningitidis meningitis.6,7 Therefore, MCV4 (Menactra) is recommended for this group before matriculation. MPSV4 (Menomune, the older polysaccharide vaccine) is equally effective and is an acceptable alternative for the previously unvaccinated college student. Harrison and colleagues8 found that almost one third of all N meningitidis meningitis cases in the 1990s involved 15 to 24 year olds. More than 80% of these infections were secondary to serogroups contained in the vaccine.

In the future, individuals will already be vaccinated with MCV4 by the time the pre-college doctor's visit is scheduled. A 2005 AAP policy statement has set a goal of immunizing all adolescents with MCV4 at age 11 years by 2008.6 Until that time, pediatricians should be vigilant in offering this vaccine to college students--especially freshmen who plan to live in a dormitory.

HPV. HPV vaccine (Gardasil) should be offered to the unimmunized female college student. Vaccination is recommended for females aged 13 to 26 years who have not been vaccinated or completed the 3-dose series. The goal is to vaccinate girls before sexual activity commences. Contrary to popular belief by some adolescents and adults, sexual activity does not just refer to vaginal intercourse. Other sexual practices can spread HPV infection. Oral HPV infection has been shown to be strongly associated with oropharyngeal cancer.9 A female patient who already has genital warts or an abnormal Pap test will also benefit from this vaccine because it protects against 4 different genotypes.10

CATCH-UP VACCINES

Because immunization practices vary in different states and countries, the pre-college visit becomes a "catch-up on vaccines" visit to ensure adequate protection of the college student.

IPV. Inactivated polio vaccine is generally not recommended for those 18 years or older.11 Those aged 7 to 18 years who have never been vaccinated with IPV may receive 3 doses given 1 month apart.

HIB and PCV. If the student has not been vaccinated with Hae- mophilus influenzae type b conjugate vaccine or the pneumococcal conjugate vaccine by this time, no further action is needed, since neither is routinely administered after the age of 5 years.

PPV and influenza. Pneumococcal polysaccharide vaccine can be given at the pre-college age for high-risk individuals (ie, those with asplenia or terminal complement deficiency). Protection against influenza is also a necessity in the student with underlying illness, but healthy persons will also benefit from yearly flu vaccine administration.

Varicella, hepatitis A and B, and MMR. Adequate vaccination with varicella; hepatitis A and B; and measles, mumps, rubella vaccines should also be ensured by this age. The Advisory Committee on Immunization Practices (ACIP) presently recommends that students at all grade levels, including college, should be protected against varicella.12 Those without evidence of immunity should receive 2 doses of varicella vaccine at an interval of 4 to 8 weeks.

In 2006, the CDC recommended the routine use of hepatitis A vaccine in all children 12 months or older.13 Hepatitis B vaccine is recommended for all children and teenagers younger than 19 years and those not previously vaccinated at any age.14 Initiation of immunization with hepatitis B vaccine is also recommended, even if completion of the entire series is not guaranteed.

It is common in the pediatric clinic to see a patient who has received an incomplete series of hepatitis B vaccines (because of past shortages or various other reasons). The current recommendation is to complete the series with the appropriate number of missing doses but not to restart the entire series, even if years have elapsed in between doses. This recommendation is the same for the hepatitis A vaccine.

Catch-up vaccination for protection against MMR is also important for the college student. The CDC recommends 2 doses of MMR at least 4 weeks apart for any person previously unimmunized who is a student in a post-secondary school.15 *

1. Nield LS. Advising the adolescent traveler. Clin Fam Pract. 2005;7:761-762.

2. Centers for Disease Control and Prevention. CDC International Travel Information. Available at: http://www.cdc.gov/travel/. Accessed July 31, 2007.

3. Riley L. Follow-up data show HPV vaccine effica-cy remains high. Infect Dis Child. 2007;20:29, 32.

4. Craig AS, Wright SW, Edwards KM, et al.

Outbreak of pertussis on a college campus. Am J Med. 2007;120:364-368.

5. American Academy of Pediatrics Committee on Infectious Diseases. Prevention of pertussis among adolescents: recommendations for use of tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccine. Pediatrics. 2006; 117:965-978.

6. American Academy of Pediatrics Committee on Infectious Diseases. Prevention and control of meningococcal disease: recommendations for use of meningococcal vaccines in pediatric patients. Pediatrics. 2005;116:496-505.

7. Centers for Disease Control and Prevention. Prevention and control of meningococcal disease. MMWR. 2005;54(RR07):1-21.

8. Harrison LH, Dwyer DM, Maples CT, Billman L. Risk of meningococcal infection in college students. JAMA. 1999;281:1906-1910.

9. D'Souza G, Kreimer AR, Viscidi R, et al. Case-

control study of human papillomavirus and oropha-ryngeal cancer. N Engl J Med. 2007;356:1944-1956.

10. Middleman AB. Immunization update: pertussis, meningococcus, and human papillomavirus. Adolesc Med Clin. 2006;17:547-563.

11. American Academy of Pediatrics. Catch-up immunization schedules for children and adolescents who start late or who are > 1 month behind, continued. In: Pickering LK, Baker CJ, Long SS, McMillan JA, eds. Red Book: 2006 Report of the Committee on Infectious Diseases. 27th ed. Elk Grove Village, Ill: American Academy of Pediatrics; 2006:30. Table 1.7.

12. Centers for Disease Control and Prevention. ACIP provisional recommendations for prevention of varicella. Available at: http://www.cdc.gov/ vaccines/vpd-vac/varicella/default.htm. Accessed July 31, 2007.

13. Centers for Disease Control and Prevention. Prevention of hepatitis A through active or passive immunizations: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR. 2006;55(RR-7):1-23.

14. Centers for Disease Control and Prevention. A comprehensive immunization strategy to eliminate transmission of hepatitis B virus infection in the United States. MMWR. 2005;54(RR-16):1-23.

15. Centers for Disease Control and Prevention. Clarification: Vol 51, No 40. MMWR. 2003;52:345. Appeared in JAMA. 2003;290:190.