Updated Recommendations for Pediatric Immunization

By Philip R. Fischer, MD

Professor of Pediatrics, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN

SYNOPSIS: Just-released 2024 pediatric and adolescent immunization recommendations and schedules guide current vaccinations. Specifically, there are new recommendations for protection against COVID-19, dengue, mpox, pneumococcus, polio, and respiratory syncytial virus.

SOURCE: American Academy of Pediatrics, Committee on Infectious Diseases. Recommended Childhood and Adolescent Immunization Schedule: United States, 2024. Pediatrics 2024;153:e2023065044.

Each year, the Centers for Disease Control and Prevention (CDC) and multiple professional organizations agree on new childhood immunization schedules and publish their recommendations. As expected, this year’s vaccine schedule has been significantly updated since last year’s recommendations. The organizations approving this updated schedule include:

• the CDC;
• the American Academy of Pediatrics;
• the American Academy of Family Physicians;
• the American College of Obstetricians and Gynecologists;
• the American College of Nurse-Midwives;
• the American Academy of Physician Associates; and
• the National Association of Pediatric Nurse Practitioners.

Detailed recommended pediatric immunization schedules are posted online:

• updated recommendations on the American Academy of Pediatrics website at https://publications.aap.org/redbook/pages/Immunization-Schedules;
• updated recommendations on the CDC website at www.cdc.gov/vaccines/schedules/hcp/child-adolescent.html; and
• a parent-friendly pediatric schedule at www.cdc.gov/vaccines/schedules/index.html.

A parallel updated immunization schedule for adults is available on the CDC website at www.cdc.gov/vaccines/schedules/hcp/adult.html.

Key new recommendations for 2024 are reviewed in this commentary. For special situations, the original sources (as referenced earlier) should be consulted.

What Is a 'Vaccine' Anyway?

As science and practice have advanced, “vaccines” now include more than just pieces of germs that are given to prompt the body to mount an immune response. Thus, headings in the immunization schedule have been changed, as appropriate, from “Vaccine” to “Vaccines and Other Immunizing Agents” so as to include monoclonal antibodies.

Out with the Old, In with the New

The meningococcal vaccine MenACWY (trade name Menactra) has been removed from the schedule since it is no longer distributed in the United States. Other meningococcal vaccines are included in the schedule, including MenACWY-TT/MenB-FHbp (trade name Penbraya). Similarly, pneumococcal conjugate vaccine (PCV)13 for pneumococcus has been removed from the schedule since it is no longer recommended for use in the United States; adequate immunity is obtained by using other vaccines such as PCV20 that are included in the 2024 recommendations.

The updated 2024 recommendations no longer include a warning about influenza vaccination of egg-sensitive individuals. Rather, the new schedule states that influenza vaccine may be given, when indicated, to individuals with a history of egg allergy of any severity. A history of a severe allergic reaction to dry natural latex is no longer a contraindication to the use of Haemophilus influenzae type b vaccination.

New for the First Time

Several newer immunizations now are available and indicated.

Respiratory Syncytial Virus (RSV). In most of the continental United States, babies born October through March whose mothers did not receive RSV immunization at least 14 days prior to delivery should receive an RSV immunization dose of nirsevimab (RSV monoclonal antibody) within the first week of life. Babies born to mothers who did receive a dose of RSV vaccine at least two weeks prior to delivery need not receive their own neonatal dose. Babies born April through September to RSV-unimmunized mothers should get a dose of nirsevimab prior to the beginning of the RSV season. Children born April through September to RSV-immunized mothers need not get their own nirsevimab. Palivizumab is not necessary if the child receives nirsevimab for the relevant RSV season. Infants aged 8-19 months with chronic lung disease requiring steroids or supplemental oxygen, American Indians, and Alaska Natives are at higher risk of RSV illness and also should receive a dose of nirsevimab prior to their second RSV season.

Pneumococcus. The initial series of pneumococcal conjugate vaccine should be with PCV15 or PCV20. Children with some medical conditions (including diabetes and chronic diseases of the kidneys, liver, and lungs, as detailed in the full recommendations) should have an “extra” dose of PCV20 or PCV23 at or after 6 years of age.

COVID-19. Children older than 6 months of age who previously have had COVID vaccine should get at least one dose of a 2023-2024 COVID vaccine formulation. Details of dosing are dependent on details of previous vaccine use, as noted in the full recommendations.

Mpox. Monkeypox (mpox) vaccine is available but only used for older adolescents (18 years of age or older) and adults at special risk of infection.

Some Children Are Special

Travel. Infants traveling internationally at risk of exposure to measles, mumps, rubella, and/or hepatitis A may receive measles/mumps/rubella (MMR) vaccine and/or hepatitis A vaccine as early as 6 months of age. They still would need their full post-first birthday vaccines subsequently. The varicella component of MMR-V need not be given prior to the first birthday.

Immunocompromised. Children with functional asplenia, human immunodeficiency virus (HIV) infection, and some complement deficiencies are candidates for meningococcal vaccination, as are travelers to Saudi Arabia for the Hajj or to the meningitis belt extending across the northern part of sub-Saharan Africa. MenACWY-CRM (trade name Menveo) can be given as early as 2 months of age. MenACWY-TT (trade name MenQuadfi) can be given at or after 2 years of age. MenACWY-TT/MenB-FHbp (trade name Penbraya) and the meningitis B-only vaccines can be used after the 10th birthday.

Dengue. Dengue is endemic in some territories and regions of the United States: Puerto Rico, American Samoa, U.S. Virgin Islands, Federated States of Micronesia, Republic of Marshall Islands, and the Republic of Palau. Dengue vaccine may be used for children aged 9-16 years residing in those areas if they have serological evidence of previous dengue infection. However, dengue vaccine is not indicated for travelers to those areas.

Polio. Adolescents 18 years of age and older may receive a single injectable polio vaccine dose if they previously have had the full childhood series and if they are at increased risk of polio exposure.

Just Do It!

Of course, these good, new recommendations should be applied. With coverage rates of routine immunizations dropping during the COVID-19 pandemic, many children were left unvaccinated. As a consequence, there has been a significant rise in the number of cases of measles in Europe.¹ The United States also is experiencing an increase in measles illnesses, some of which relate to exposures during international travel.² Compliance with the routine and travel-specific immunization recommendations of the CDC can help protect our patients. Clinical vigilance also will be needed when seeing sick children since some newer measles variants can be missed with polymerase chain reaction (PCR) testing.³

References

1. Wong C. Measles outbreaks cause alarm: What the data say. Nature 2024; Jan 31. doi: 10.1038/d41586-024-00265-8. [Online ahead of print].
2. Centers for Disease Control and Prevention. Stay alert for measles cases. CDC Clinician Outreach and Communication Activity. Jan. 25, 2024. https://emergency.cdc.gov/newsletters/coca/2024/012524.html
3. Pérez-Rodríguez FJ, Cherpillod P, Thomasson V, et al. Identification of a measles variant displaying mutations impacting molecular diagnostics, Geneva, Switzerland, 2023. Euro Surveill 2024;29:2400034..