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The 2002 immunization schedule is here: What's changed?

The latest version of the Recommended Childhood Immunization Schedule, released in January by the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention, the AAP, and the American Academy of Family Physicians, may look a bit different than its predecessors (see chart), but the alterations are largely in design. No new vaccines are included and most dosing recommendations remain unchanged.

In the 2002 version:

• Green bars indicate the timing of "catch-up" vaccinations for children who have fallen behind or started immunizations late.

• A vertical bar gives emphasis to the immunization needs of preadolescents.

• Vaccines recommended for special populations (hepatitis A in certain parts of the country, 7-valent pneumococcal conjugate [Prevnar] for children 2 years and older who are at high risk, and influenza) are set off by a dotted line.

• The influenza vaccine appears in the chart for the first time. The recommendation covers children at elevated risk, but clinicians are encouraged to offer the vaccine to all children whose parents want to provide them with immunity.

• The design of the chart clearly encourages routine vaccination of all newborns against hepatitis B virus before discharge from the nursery, rather than at 1 or 2 months of age.

What is different this year is what the AAP and the ACIP call a "caveat," in which interim recommendations are offered on how to cope with the current shortage of Prevnar. Because supplies are, at the moment, inadequate to carry out fully the recommendations of the schedule, pediatricians are advised to limit the vaccine in healthy children to the first three doses and to postpone the fourth (booster) shot until supplies are replenished (according to the manufacturer of Prevnar the shortage will be resolved by the middle of 2002). Pediatricians are urged to keep a diary of deferred immunizations and to contact those children for immunization as soon as the shortage is over. Children at high risk should, however, receive the full series.

In response to a similar shortage of diphtheria and tetanus toxoids-acellular pertussis (DTaP) vaccine, ACIP published a notice to readers in the January 4, 2002, issue of Morbidity and Mortality Weekly Report stating that the shortage will continue into the middle of this year—posing a danger to infants younger than 6 months who have not completed the three-dose primary series. ACIP recommends that, as long as the shortage continues, pediatricians who do not have enough vaccine to cover all their patients with the full (five-dose) schedule give priority to vaccinating infants with the first three doses, deferring, if necessary, the fourth and fifth doses. In areas where the shortage of DTaP is severe, public health officials may choose to institute community-wide deferral of the fourth and, if necessary, fifth dose. What should pediatricians do when the DTaP shortage ends? Recall all children who missed a dose and administer the vaccine to them. Vaccination of children 4 to 6 years old is needed to ensure immunity against pertussis, diphtheria, and tetanus during elementary school years.

Schools where children learn

A widely accepted explanation for why so many American school children fail is socioeconomic handicap. Poor children and children who belong to a disadvantaged ethnic minority, the argument goes, are so far behind when they arrive in kindergarten that they are doomed to fail. Attempts by school reformers to reverse that situation are therefore futile, and "throwing money" at the situation won't help.

Not so at all, says the Education Trust, a nongovernmental organization dedicated to improving the outcome of public education. The children aren't the problem—the schools are; better schools can do a better job. Education Trust has persuasive data to back up its argument: Using statewide test scores provided by the US Department of Education, it identified 4,500 public schools that have both standardized reading and math test scores in the top third of their state's rankings and a student body of largely poor and minority students. Most of them were neighborhood schools, where "cherry-picking" unusually bright or talented students isn't an option.

The trust's report, Dispelling the Myth Revisited, evaluated more than 1 million test scores in 47 states and the District of Columbia. A complete, state-by-state listing of achievement levels and demographic data are included, and is available in a searchable, interactive database on the trust's Web site (www.edtrust.org ).

Surveys of principals at these high-achieving schools reveal characteristics that they believe account for the success of their schools:

• State standards—for curriculum design, student assessment, and teacher evaluation

• More instruction time in reading and math

• Investment in professional development for teachers

• Comprehensive monitoring of students' performance and help for those who are struggling to keep them from falling behind

• Parents' involvement in their child's education

• State- or district-operated systems of accountability, with real consequences for school staff who don't measure up

• Assessments to guide instruction and as part of everyday teaching.

Advertising can be dangerous to a child's health

More than ever, children and teenagers need to be taught to be skeptical about advertising they see in print or on television. Two new campaigns are particularly disturbing because of the threat they pose to children's health:

• The National Broadcasting Company (NBC) now accepts and airs advertisements for liquor after 9 p.m. on its network programming—when adolescents who may be tempted to drink and drive can easily see them.

• Advertisements for Brown and Williamson's Advance cigarettes and Vector Tobacco's Omni brand are appearing in print media. The implicit message of both campaigns is that these new brands are not as carcinogenic as older brands that have been associated with lung cancer.

The American Medical Association has stated that it deplores these attempts to seduce American youngsters to adopt behaviors so dangerous to their health, and has published strong public statements urging NBC and both tobacco companies to desist. Pediatricians can't go wrong by adding their voice to this chorus, whenever they have an opportunity to talk to teens.

Judith Asch-Goodkin
Contributing Editor

Eye On Washington

Christmas and New Year celebrations are over, the president is back from Texas, and Congress is again in session, ready to tackle issues set aside in the wake of the September 11 catastrophe. Before adjourning for the holidays, Congress passed the Education Act, which will probably turn out to be the last bipartisan legislation of the session. President Bush signed the bill with a flourish as soon as he returned to town. Almost immediately afterwards, representatives of both parties resumed bickering over who is to blame for the looming federal deficit, which will make it unlikely that fundamental health and welfare problems will be tackled in the near future.

Health care, in particular, is likely to get short shrift. Fundamental reforms of Medicare and Medicaid programs and control over prescription drug prices are intractably difficult issues, made both more pressing and difficult to solve in an economic downturn.

But if basic reform is unlikely, medical pork—in the form of federal grants to specific hospitals, medical schools, and clinics "earmarked" in the budget by influential members of Congress—seems to be plentiful. Last year, in a thoroughly bipartisan process, Congressional conferees specified funds for more than 600 medical providers—without their undergoing the kind of evaluation that federal grant programs administered by government agencies ordinarily insist on. Meanwhile, with reform stalled and so much pork being passed around the table, the nation's expenditures for health care continued to surge, up 6.9% in 2000 to $1.3 trillion.

Luckily for ordinary citizens, Congressional immobility doesn't prevent the health-care bureaucracy from going about its often useful business. Recent items of note:

The Task Force on Community Preventive Services strongly recommended fluoridation of community water supplies and school-based dental sealant programs to prevent tooth decay. Data on fluoridation presented in a report of the task force show that these interventions are effective; the task force urges that they be adopted.

The 2001 Monitoring the Future Surveyissued by the Department of Health and Human Services and conducted by the University of Michigan's Institute for Social Research found that cigarette smoking by teens declined for the fifth year in a row. A downturn in teens' use of ecstasy and heroin was also noted.

The General Accounting Office (GAO), the investigative arm of Congress, issued a report calling on universities and federal authorities to do a better job of preventing financial conflicts of interest that can taint biomedical research and harm human subjects. GAO studies at Yale, the University of California at Los Angeles, the University of North Carolina, the University of Washington, and Washington University of St. Louis found that information compiled by the schools on research and financial interests was held in different offices and different formats, making it "challenging" to police potential conflicts of interest.

The Secretary of Health and Human Services (HHS) has been authorized to classify HHS documents as "secret," a perquisite restricted until now to defense and national security agencies. According to an HHS spokesperson, the authority marks HHS's new standing as a "homeland security agency."

Director of the Centers for Disease Control and Prevention Jeffrey P. Koplan, MD, MPH, refused to advise postal workers and members of US Senators' office staffs who have been exposed to anthrax whether to be immunized with anthrax vaccine. With becoming modesty, Dr. Koplan justified his reluctance: "We have inadequate science upon which to base such a strong directive recommendation."

The National Center for Health Statistics advises clinicians to use new growth charts issued in 2000 by the center in conjunction with the CDC for routine monitoring of growth in infants, children, and adolescents. The new charts are based on a more recent cross-section of the ethnic and economic makeup of children living in the United States. The charts also take into account differences between breastfed and formula-fed babies and include body mass index data for children 2 to 20 years of age. [These growth charts are discussed and displayed in the June 2001 issue in "Understanding growth patterns in short stature".]

CALENDAR

April 3–6, Society of Behavioral Medicine, Washington, D.C. For information, e-mail sbm@tmahq.com.

April 3–6, National Pediatric Infectious Disease Seminar, New Orleans. For information, call meeting organizer at 317-488-1234.

April 11–14, Society for Research on Adolescence Biennial Meeting, New Orleans. For information, e-mail socresadol@umich.edu.

April 17–20, Super-CME 2002, Orlando, Fla. For more information, go to the American Academy of Pediatrics Web site, www.aap.org/profed/supercme .

April 18–21, International Conference on Infant Studies, Toronto, Ont. For information, e-mail sandra.treehub@utoronto.ca.

April 27–May 8, Annual Meeting of the Pediatric Academic Societies, Baltimore, Md. For information, e-mail info@aps-spr.org.

May 3–5, Annual Meeting, Ambulatory Pediatrics Association, Baltimore, Md. For information, call 703-556-9222.

May 6–8, Annual Conference on Vaccine Research, Baltimore, Md. For information, e-mail info@nfid.org.

Updates.

Contemporary Pediatrics

2002;2:13.