Vaccination in Children: Approach to the Care of Normal Infants and Children: Merck Manual Professional

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Approach to the Care of Normal Infants and Children

Vaccination in Children

Effectiveness of vaccination

Vaccination schedule

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Approach to the Care of Normal Infants and Children

Vaccination in Children

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Effectiveness of vaccination: Vaccination has been profoundly effective in preventing serious disease (see Table 11: Approach to the Care of Normal Infants and Children: Case Rates of Some Diseases Preventable by Vaccines). Many health care practitioners currently in practice have seen few or no cases of diseases that were once extremely common and fatal.

Table 11

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Case Rates of Some Diseases Preventable by Vaccines
Disease	Average Cases/Yr Before Vaccine Development	Cases in 2003
Diphtheria	175,885	1
Haemophilus influenzae type b	20,000 (estimated)	259
Measles	503,282	56
Mumps	152,209	231
Pertussis	147,271	11,647
Polio (paralytic)	16,316	0
Rubella	47,745	7
Smallpox	48,164	0
Tetanus	1,314	20
Adapted from Parents' Guide to Childhood Immunizations. Department of Health and Human Services, Centers for Disease Control and Prevention, 2005.

Vaccination schedule: Vaccination follows a schedule recommended by the Centers for Disease Control and Prevention, the American Academy of Pediatrics, and the American Academy of Family Physicians (see Table 12: Approach to the Care of Normal Infants and Children: Recommended Immunization Schedule for Ages 0–6 yr, Table 13: Approach to the Care of Normal Infants and Children: Recommended Immunization Schedule for Ages 7–18 yr, and Table 14: Approach to the Care of Normal Infants and Children: Catch-up Immunization Schedule for Ages 4 mo–18 yr). The latest recommendations can be obtained at www.cdc.gov/vaccines/; vaccination status should be reassessed at every visit. For adverse effects and details of administration of specific vaccines, see Immunization (see Immunization: Routine Vaccinations).

Table 12

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Recommended Immunization Schedule for Ages 0–6 yr
Age
Vaccine	Birth	1 mo	2 mo	4 mo	6 mo	12 mo	15 mo	18 mo	19–23 mo	2–3 yr	4–6 yr
Hepatitis B (HepB)^a	HepB	HepB			HepB
Rotavirus (RV)^b			RV	RV	RV^b
Diphtheria, tetanus, pertussis (DTaP)^c			DTaP	DTaP	DTaP	See footnote c	DTaP				DTaP
Haemophilus influenzae type b (Hib)^d			Hib	Hib	Hib^d	Hib
Pneumococcal vaccine^e			PCV	PCV	PCV	PCV				PPSV
Inactivated polio virus (IPV)^f			IPV	IPV	IPV						IPV
Influenza^g					Influenza (yearly)
Measles, mumps, rubella (MMR)^h						MMR		See footnote h			MMR
Varicellaⁱ						Varicella		See footnote i			Varicella
Hepatitis A (HepA)^j						HepA (2 doses)				HepA series
Meningococcal conjugate vaccine (MCV)^k										MCV
?= Range of recommended ages for all children except certain high-risk groups. ?= Range of recommended ages for certain high-risk groups.
This schedule includes recommendations in effect as of December 15, 2009. Any dose not administered at the recommended age should be administered at a subsequent visit, when indicated and feasible. The use of a combination vaccine is generally preferred over separate injections of its equivalent component vaccines. Considerations should include provider assessment, patient preference, and the potential for adverse events. Providers should consult the relevant Advisory Committee on Immunization Practices statement for detailed recommendations at http://www.cdc.gov/vaccines/pubs/acip-list.htm . Clinically significant adverse events that follow immunization should be reported to the Vaccine Adverse Event Reporting System (VAERS) at http://www.vaers.hhs.gov or by telephone, 800-822-7967. If children fall behind or start late, a catch-up schedule should be followed.
^a Hepatitis B vaccine (HepB). Minimum age is at birth.
At birth: Administer monovalent HepB to all newborns before hospital discharge. If the mother is hepatitis B surface antigen (HBsAg)–positive, administer HepB and 0.5 mL of hepatitis B immune globulinSome Trade Names HEPAGAM B HYPERHEP B S/D NABI-HB (HBIG) within 12 h of birth. If the mother's HBsAg status is unknown, administer HepB within 12 h of birth. Determine the mother's HBsAg status as soon as possible, and if it is HBsAg-positive, administer HBIG (no later than age 1 wk).
After the birth dose: The HepB series should be completed with either monovalent HepB or a combination vaccine containing HepB. The 2nd dose should be administered at age 1 or 2 mo. Monovalent HepB vaccine should be used for doses administered before age 6 wk. The final dose should be administered no earlier than age 24 wk. Infants born to HBsAg-positive mothers should be tested for HBsAg and antibody to HBsAg 1–2 mo after completion of at least 3 doses of the HepB series, at age 9–18 mo (generally at the next well-child visit). Administration of 4 doses of HepB to infants is permissible when a combination vaccine containing HepB is administered after the birth dose. The 4th dose should be administered no earlier than age 24 wk.
^b Rotavirus vaccine (RV). Minimum age is 6 wk. Administer the first dose at age 6–14 wk (maximum age: 14 wk 6 days). Vaccination should not be initiated for infants aged ≥15 wk 0 days. The maximum age for the final dose in the series is 8 mo 0 days. If Rotarix® is administered at ages 2 and 4 mo, a dose at 6 mo is not indicated.
^c Diphtheria and tetanus toxoids and acellular pertussis vaccine (DTaP). Minimum age is 6 wk. The 4th dose may be administered as early as age 12 mo, provided at least 6 mo have elapsed since the 3rd dose. Administer the final dose in the series at age 4–6 yr.
^d Haemophilus influenzae type b conjugate vaccine (Hib). Minimum age is 6 wk. If PRP-OMP (PedvaxHIB® or ComVax® [HepB-Hib]) is administered at ages 2 and 4 mo, a dose at age 6 mo is not indicated. TriHiBit® (DTaP/Hib) and Hiberix® (PRP-T) should not be used for doses at ages 2, 4, or 6 mo for the primary series but can be used as the final dose in children aged 12 mo–4 yr.
^e Pneumococcal vaccine. Minimum age is 6 wk for pneumococcal conjugate vaccine (PCV) and 2 yr for pneumococcal polysaccharide vaccine (PPSV). PCV is recommended for all children aged < 5 yr. Administer 1 dose of PCV to all healthy children aged 24–59 mo who are not completely vaccinated for their age. Administer PPSV ≥ 2 mo after the last dose of PCV to children aged ≥ 2 yr with certain medical conditions, including a cochlear implant (see Morbidity and Mortality Weekly Review 46 [RR-8], 1997).
^f Inactivated poliovirus vaccine (IPV). Minimum age is 6 wk. The final dose in the series should be administered on or after the 4th birthday and at least 6 mo after the previous dose. If 4 doses are administered before age 4 yr, a 5th dose should be administered at age 4–6 yr (see Morbidity and Mortality Weekly Review 58 [30]:829–30, 2009).
^g Influenza vaccine (seasonal). Minimum age is 6 mo for trivalent inactivated influenza vaccine (TIV) and 2 yr for live-attenuated influenza vaccine (LAIV). Administer annually to children aged 6 mo–18 yr. Healthy children aged 2–6 yr who do not have medical conditions that predispose them to influenza complications may be given either LAIV or TIV, except LAIV should not be given to children aged 2–4 yr who have had wheezing in the past 12 mo. Children receiving TIV should receive 0.25 mL if they are aged 6–35 mo or 0.5 mL if they are aged ≥ 3 yr. Administer 2 doses (separated by at least 4 wk) to children aged < 9 yr who are receiving influenza vaccine for the first time or who were vaccinated for the first time during the previous influenza season but only received 1 dose. For recommendations for use of influenza A (H1N1) 2009 monovalent vaccine, see Morbidity and Mortality Weekly Review 58 (RR-10), 2009.
^h Measles, mumps, and rubella vaccine (MMR). Minimum age is 12 mo. Administer the 2nd dose routinely at age 4–6 yr. However, the 2nd dose may be administered before age 4, provided at least 28 days have elapsed since the first dose.
ⁱ Varicella vaccine. Minimum age is 12 mo. Administer the 2nd dose routinely at age 4–6 yr. However, the 2nd dose may be administered before age 4, provided at least 3 mo have elapsed since the first dose. For children aged 12 mo–12 yr, the minimum interval between doses is 3 mo. However, if the 2nd dose was administered at least 28 days after the first dose, it can be accepted as valid.
^j Hepatitis A vaccine (HepA). Minimum age is 12 mo. Administer to all children aged 1 yr (ie, 12–23 mo). Administer 2 doses at least 6 mo apart. Children not fully vaccinated by age 2 yr can be vaccinated at subsequent visits. HepA is also recommended for older children if they live in areas where vaccination programs target older children, if they are at increased risk of infection, or if immunity against hepatitis A is desired for them.
^k Meningococcal vaccine. Minimum age is 2 yr for meningococcal conjugate vaccine (MCV4) and for meningococcal polysaccharide vaccine (MPSV4). Administer MCV4 to children aged 2–10 yr with persistent complement component deficiency, anatomic or functional asplenia, or certain other conditions placing them at high risk. Administer MCV4 to children previously vaccinated with MCV4 or MPSV4 after 3 yr if the first dose was administered at age 2–6 yr (see Morbidity and Mortality Weekly Review 58:1042–1043, 2009).
PRP-OMP = Neisseria meningitidis polyribosyl ribitol phosphate/outer membrane protein; PRP-T = PRP conjugated to inactivated tetanus toxoid. Adapted from the Centers for Disease Control and Prevention: Recommended Immunization Schedule for Persons Aged 0 Through 6 Years, United States, 2010. Available at www.cdc.gov/vaccines/recs/schedules/default.htm.

Recommended Immunization Schedule for Ages 0–6 yr

Age
Vaccine	Birth	1 mo	2 mo	4 mo	6 mo	12 mo	15 mo	18 mo	19–23 mo	2–3 yr	4–6 yr

Hepatitis B (HepB)^a	HepB	HepB			HepB
Rotavirus (RV)^b			RV	RV	RV^b
Diphtheria, tetanus, pertussis (DTaP)^c			DTaP	DTaP	DTaP	See footnote c	DTaP			DTaP
Haemophilus influenzae type b (Hib)^d			Hib	Hib	Hib^d	Hib
Pneumococcal vaccine^e			PCV	PCV	PCV	PCV			PPSV
Inactivated polio virus (IPV)^f			IPV	IPV	IPV					IPV
Influenza^g					Influenza (yearly)
Measles, mumps, rubella (MMR)^h						MMR		See footnote h		MMR
Varicellaⁱ						Varicella		See footnote i		Varicella
Hepatitis A (HepA)^j						HepA (2 doses)			HepA series
Meningococcal conjugate vaccine (MCV)^k									MCV
?= Range of recommended ages for all children except certain high-risk groups. ?= Range of recommended ages for certain high-risk groups.
This schedule includes recommendations in effect as of December 15, 2009. Any dose not administered at the recommended age should be administered at a subsequent visit, when indicated and feasible. The use of a combination vaccine is generally preferred over separate injections of its equivalent component vaccines. Considerations should include provider assessment, patient preference, and the potential for adverse events. Providers should consult the relevant Advisory Committee on Immunization Practices statement for detailed recommendations at http://www.cdc.gov/vaccines/pubs/acip-list.htm . Clinically significant adverse events that follow immunization should be reported to the Vaccine Adverse Event Reporting System (VAERS) at http://www.vaers.hhs.gov or by telephone, 800-822-7967. If children fall behind or start late, a catch-up schedule should be followed.
^a Hepatitis B vaccine (HepB). Minimum age is at birth.
At birth: Administer monovalent HepB to all newborns before hospital discharge. If the mother is hepatitis B surface antigen (HBsAg)–positive, administer HepB and 0.5 mL of hepatitis B immune globulinSome Trade Names HEPAGAM B HYPERHEP B S/D NABI-HB (HBIG) within 12 h of birth. If the mother's HBsAg status is unknown, administer HepB within 12 h of birth. Determine the mother's HBsAg status as soon as possible, and if it is HBsAg-positive, administer HBIG (no later than age 1 wk).
After the birth dose: The HepB series should be completed with either monovalent HepB or a combination vaccine containing HepB. The 2nd dose should be administered at age 1 or 2 mo. Monovalent HepB vaccine should be used for doses administered before age 6 wk. The final dose should be administered no earlier than age 24 wk. Infants born to HBsAg-positive mothers should be tested for HBsAg and antibody to HBsAg 1–2 mo after completion of at least 3 doses of the HepB series, at age 9–18 mo (generally at the next well-child visit). Administration of 4 doses of HepB to infants is permissible when a combination vaccine containing HepB is administered after the birth dose. The 4th dose should be administered no earlier than age 24 wk.
^b Rotavirus vaccine (RV). Minimum age is 6 wk. Administer the first dose at age 6–14 wk (maximum age: 14 wk 6 days). Vaccination should not be initiated for infants aged ≥15 wk 0 days. The maximum age for the final dose in the series is 8 mo 0 days. If Rotarix® is administered at ages 2 and 4 mo, a dose at 6 mo is not indicated.
^c Diphtheria and tetanus toxoids and acellular pertussis vaccine (DTaP). Minimum age is 6 wk. The 4th dose may be administered as early as age 12 mo, provided at least 6 mo have elapsed since the 3rd dose. Administer the final dose in the series at age 4–6 yr.
^d Haemophilus influenzae type b conjugate vaccine (Hib). Minimum age is 6 wk. If PRP-OMP (PedvaxHIB® or ComVax® [HepB-Hib]) is administered at ages 2 and 4 mo, a dose at age 6 mo is not indicated. TriHiBit® (DTaP/Hib) and Hiberix® (PRP-T) should not be used for doses at ages 2, 4, or 6 mo for the primary series but can be used as the final dose in children aged 12 mo–4 yr.
^e Pneumococcal vaccine. Minimum age is 6 wk for pneumococcal conjugate vaccine (PCV) and 2 yr for pneumococcal polysaccharide vaccine (PPSV). PCV is recommended for all children aged < 5 yr. Administer 1 dose of PCV to all healthy children aged 24–59 mo who are not completely vaccinated for their age. Administer PPSV ≥ 2 mo after the last dose of PCV to children aged ≥ 2 yr with certain medical conditions, including a cochlear implant (see Morbidity and Mortality Weekly Review 46 [RR-8], 1997).
^f Inactivated poliovirus vaccine (IPV). Minimum age is 6 wk. The final dose in the series should be administered on or after the 4th birthday and at least 6 mo after the previous dose. If 4 doses are administered before age 4 yr, a 5th dose should be administered at age 4–6 yr (see Morbidity and Mortality Weekly Review 58 [30]:829–30, 2009).
^g Influenza vaccine (seasonal). Minimum age is 6 mo for trivalent inactivated influenza vaccine (TIV) and 2 yr for live-attenuated influenza vaccine (LAIV). Administer annually to children aged 6 mo–18 yr. Healthy children aged 2–6 yr who do not have medical conditions that predispose them to influenza complications may be given either LAIV or TIV, except LAIV should not be given to children aged 2–4 yr who have had wheezing in the past 12 mo. Children receiving TIV should receive 0.25 mL if they are aged 6–35 mo or 0.5 mL if they are aged ≥ 3 yr. Administer 2 doses (separated by at least 4 wk) to children aged < 9 yr who are receiving influenza vaccine for the first time or who were vaccinated for the first time during the previous influenza season but only received 1 dose. For recommendations for use of influenza A (H1N1) 2009 monovalent vaccine, see Morbidity and Mortality Weekly Review 58 (RR-10), 2009.
^h Measles, mumps, and rubella vaccine (MMR). Minimum age is 12 mo. Administer the 2nd dose routinely at age 4–6 yr. However, the 2nd dose may be administered before age 4, provided at least 28 days have elapsed since the first dose.
ⁱ Varicella vaccine. Minimum age is 12 mo. Administer the 2nd dose routinely at age 4–6 yr. However, the 2nd dose may be administered before age 4, provided at least 3 mo have elapsed since the first dose. For children aged 12 mo–12 yr, the minimum interval between doses is 3 mo. However, if the 2nd dose was administered at least 28 days after the first dose, it can be accepted as valid.
^j Hepatitis A vaccine (HepA). Minimum age is 12 mo. Administer to all children aged 1 yr (ie, 12–23 mo). Administer 2 doses at least 6 mo apart. Children not fully vaccinated by age 2 yr can be vaccinated at subsequent visits. HepA is also recommended for older children if they live in areas where vaccination programs target older children, if they are at increased risk of infection, or if immunity against hepatitis A is desired for them.
^k Meningococcal vaccine. Minimum age is 2 yr for meningococcal conjugate vaccine (MCV4) and for meningococcal polysaccharide vaccine (MPSV4). Administer MCV4 to children aged 2–10 yr with persistent complement component deficiency, anatomic or functional asplenia, or certain other conditions placing them at high risk. Administer MCV4 to children previously vaccinated with MCV4 or MPSV4 after 3 yr if the first dose was administered at age 2–6 yr (see Morbidity and Mortality Weekly Review 58:1042–1043, 2009).
PRP-OMP = Neisseria meningitidis polyribosyl ribitol phosphate/outer membrane protein; PRP-T = PRP conjugated to inactivated tetanus toxoid. Adapted from the Centers for Disease Control and Prevention: Recommended Immunization Schedule for Persons Aged 0 Through 6 Years, United States, 2010. Available at www.cdc.gov/vaccines/recs/schedules/default.htm.

Table 13

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Recommended Immunization Schedule for Ages 7–18 yr
Age
Vaccine	7–10 yr	11–12 yr	13–18 yr
Tetanus, diphtheria, pertussis (Tdap)^a		Tdap	Tdap
Human papillomavirus (HPV)^b	See footnote b	HPV (3 doses)	HPV series
Meningococcal conjugate vaccine (MCV)^c	MCV	MCV	MCV
Influenza^d	Influenza (yearly)
Pneumococcal polysaccharide vaccine (PPSV)^e	PPSV
Hepatitis A (HepA)^f	HepA series
Hepatitis B (HepB)^g	HepB series
Inactivated poliovirus (IPV)^h	IPV series
Measles, mumps, rubella (MMR)ⁱ	MMR series
Varicella^j	Varicella series
? = Range of recommended ages for all children except certain high-risk groups.
? = Range of recommended ages for catch-up immunization.
? = Range of recommended ages for certain high-risk groups.
This schedule includes recommendations in effect as of December 15, 2009. Any dose not administered at the recommended age should be administered at a subsequent visit, when indicated and feasible. The use of a combination vaccine is generally preferred over separate injections of its equivalent component vaccines. Considerations should include provider assessment, patient preference, and the potential for adverse events. Providers should consult the relevant Advisory Committee on Immunization Practices statement for detailed recommendations at http://www.cdc.gov/vaccines/pubs/acip-list.htm. Clinically significant adverse events that follow immunization should be reported to the Vaccine Adverse Event Reporting System (VAERS) at http://www.vaers.hhs.gov or by telephone, 800-822-7967. If children fall behind or start late, a catch-up schedule should be followed.
^a Tetanus and diphtheria toxoids and acellular pertussis vaccine (Tdap). Minimum age is 10 yr for Boostrix® and 11 yr for Adacel®. Administer at age 11 or 12 yr to patients who have completed the recommended childhood DTP/DTaP vaccination series and have not received a tetanus and diphtheria toxoid (Td) booster dose. Patients aged 13–18 yr who have not received Tdap should receive a dose. A 5-yr interval from the last Td dose is encouraged when Tdap is used as a booster dose; however, a shorter interval may be used if pertussis immunity is needed.
^b Human papillomavirus vaccine (HPV). Minimum age is 9 yr. Two HPV vaccines are licensed: a quadrivalent vaccine (HPV4) for the prevention of cervical, vaginal, and vulvar cancers in females and genital warts in females and males and a bivalent vaccine (HPV2) for the prevention of cervical cancers in females. HPV vaccines are most effective (for males and females) when given before exposure to HPV through sexual contact. HPV4 or HPV2 is recommended for the prevention of cervical precancers and cancers in females. HPV4 is recommended for the prevention of cervical, vaginal, and vulvar precancers and cancers and genital warts in females. Administer the first dose to females at age 11 or 12 yr. Administer the 2nd dose 1 to 2 mo after the first dose and the 3rd dose 6 mo after the first dose (at least 24 wk after the first dose). Administer the series to females at age 13–18 yr if not previously vaccinated. HPV4 may be administered in a 3-dose series to males aged 9–18 yr to reduce their likelihood of acquiring genital warts.
^c Meningococcal conjugate vaccine (MCV4). Administer at age 11 or 12 yr or, if not previously vaccinated, at age 13–18 yr. Administer to previously unvaccinated college freshmen living in a dormitory. Administer to children aged 2–10 yr with persistent complement component deficiency, anatomic or functional asplenia, or certain other conditions placing them at high risk. Administer to children previously vaccinated with MCV4 or MPSV4 who remain at increased risk after 3 yr (if the first dose was administered at age 2–6 yr) or after 5 yr (if the first dose was administered at age ≥ 7 yr). An additional dose is not recommended for people whose only risk factor is living in on-campus housing (see Morbidity and Mortality Weekly Review 58:1042–1043, 2009).
^d Influenza vaccine (seasonal). Administer annually to children aged 6 mo–18 yr. Healthy people aged 7–18 yr who are not pregnant and who do not have medical conditions predisposing them to influenza complications may be given either LAIV or TIV. Administer 2 doses (separated by at least 4 wk) to children aged < 9 yr who are receiving influenza vaccine for the first time or who were vaccinated for the first time during the previous influenza season but only received 1 dose. For recommendations for use of influenza A (H1N1) 2009 monovalent vaccine, see Morbidity and Mortality Weekly Review 58 (RR-10), 2009.
^e Pneumococcal polysaccharide vaccine (PPSV). Administer to children with certain medical conditions, including a cochlear implant. A single revaccination should be administered after 5 yr to children with functional or anatomic asplenia or an immunocompromising condition (see Morbidity and Mortality Weekly Review 46 [RR-8], 1997).
^f Hepatitis A vaccine (HepA). Administer 2 doses at least 6 mo apart. HepA is recommended for children aged > 23 mo if they live in areas where vaccination programs target older children, if they are at increased risk of infection, or if immunity against hepatitis A is desired for them.
^g Hepatitis B vaccine (HepB). Administer the 3-dose series to children not previously vaccinated. A 2-dose series (separated by at least 4 mo) of adult formulation Recombivax HB® is licensed for children aged 11–15 yr.
^h Inactivated poliovirus vaccine (IPV). The final dose in the series should be administered on or after the 4th birthday and at least 6 mo after the previous dose. If both OPV and IPV were administered as part of a series, a total of 4 doses should be administered, regardless of the child's current age.
ⁱ Measles, mumps, and rubella vaccine (MMR). If not previously vaccinated, administer 2 doses or the 2nd dose for children who have received only 1 dose, with at least 28 days between doses.
^j Varicella vaccine. For children aged 7–18 yr without evidence of immunity (see Morbidity and Mortality Weekly Review 56 [RR-4], 2007), administer 2 doses if children were not previously vaccinated or the 2nd dose if only 1 dose has been administered. For children aged 7–12 yr, the minimum interval between doses is 3 mo. However, if the 2nd dose was administered at least 28 days after the first dose, it can be accepted as valid. For children aged ≥ 13 yr, the minimum interval between doses is 28 days.
PRP-OMP = Neisseria meningitidis polyribosyl ribitol phosphate/outer membrane protein; PRP-T = PRP conjugated to inactivated tetanus toxoid.
Adapted from the Centers for Disease Control and Prevention: Recommended Immunization Schedule for Persons Aged 7 Through 18 Years, United States, 2010. Available at www.cdc.gov/vaccines/recs/schedules/default.htm.

Recommended Immunization Schedule for Ages 7–18 yr

Age
Vaccine	7–10 yr	11–12 yr	13–18 yr

Tetanus, diphtheria, pertussis (Tdap)^a		Tdap	Tdap
Human papillomavirus (HPV)^b	See footnote b	HPV (3 doses)	HPV series
Meningococcal conjugate vaccine (MCV)^c	MCV	MCV	MCV
Influenza^d	Influenza (yearly)
Pneumococcal polysaccharide vaccine (PPSV)^e	PPSV
Hepatitis A (HepA)^f	HepA series
Hepatitis B (HepB)^g	HepB series
Inactivated poliovirus (IPV)^h	IPV series
Measles, mumps, rubella (MMR)ⁱ	MMR series
Varicella^j	Varicella series
? = Range of recommended ages for all children except certain high-risk groups.
? = Range of recommended ages for catch-up immunization.
? = Range of recommended ages for certain high-risk groups.
This schedule includes recommendations in effect as of December 15, 2009. Any dose not administered at the recommended age should be administered at a subsequent visit, when indicated and feasible. The use of a combination vaccine is generally preferred over separate injections of its equivalent component vaccines. Considerations should include provider assessment, patient preference, and the potential for adverse events. Providers should consult the relevant Advisory Committee on Immunization Practices statement for detailed recommendations at http://www.cdc.gov/vaccines/pubs/acip-list.htm. Clinically significant adverse events that follow immunization should be reported to the Vaccine Adverse Event Reporting System (VAERS) at http://www.vaers.hhs.gov or by telephone, 800-822-7967. If children fall behind or start late, a catch-up schedule should be followed.
^a Tetanus and diphtheria toxoids and acellular pertussis vaccine (Tdap). Minimum age is 10 yr for Boostrix® and 11 yr for Adacel®. Administer at age 11 or 12 yr to patients who have completed the recommended childhood DTP/DTaP vaccination series and have not received a tetanus and diphtheria toxoid (Td) booster dose. Patients aged 13–18 yr who have not received Tdap should receive a dose. A 5-yr interval from the last Td dose is encouraged when Tdap is used as a booster dose; however, a shorter interval may be used if pertussis immunity is needed.
^b Human papillomavirus vaccine (HPV). Minimum age is 9 yr. Two HPV vaccines are licensed: a quadrivalent vaccine (HPV4) for the prevention of cervical, vaginal, and vulvar cancers in females and genital warts in females and males and a bivalent vaccine (HPV2) for the prevention of cervical cancers in females. HPV vaccines are most effective (for males and females) when given before exposure to HPV through sexual contact. HPV4 or HPV2 is recommended for the prevention of cervical precancers and cancers in females. HPV4 is recommended for the prevention of cervical, vaginal, and vulvar precancers and cancers and genital warts in females. Administer the first dose to females at age 11 or 12 yr. Administer the 2nd dose 1 to 2 mo after the first dose and the 3rd dose 6 mo after the first dose (at least 24 wk after the first dose). Administer the series to females at age 13–18 yr if not previously vaccinated. HPV4 may be administered in a 3-dose series to males aged 9–18 yr to reduce their likelihood of acquiring genital warts.
^c Meningococcal conjugate vaccine (MCV4). Administer at age 11 or 12 yr or, if not previously vaccinated, at age 13–18 yr. Administer to previously unvaccinated college freshmen living in a dormitory. Administer to children aged 2–10 yr with persistent complement component deficiency, anatomic or functional asplenia, or certain other conditions placing them at high risk. Administer to children previously vaccinated with MCV4 or MPSV4 who remain at increased risk after 3 yr (if the first dose was administered at age 2–6 yr) or after 5 yr (if the first dose was administered at age ≥ 7 yr). An additional dose is not recommended for people whose only risk factor is living in on-campus housing (see Morbidity and Mortality Weekly Review 58:1042–1043, 2009).
^d Influenza vaccine (seasonal). Administer annually to children aged 6 mo–18 yr. Healthy people aged 7–18 yr who are not pregnant and who do not have medical conditions predisposing them to influenza complications may be given either LAIV or TIV. Administer 2 doses (separated by at least 4 wk) to children aged < 9 yr who are receiving influenza vaccine for the first time or who were vaccinated for the first time during the previous influenza season but only received 1 dose. For recommendations for use of influenza A (H1N1) 2009 monovalent vaccine, see Morbidity and Mortality Weekly Review 58 (RR-10), 2009.
^e Pneumococcal polysaccharide vaccine (PPSV). Administer to children with certain medical conditions, including a cochlear implant. A single revaccination should be administered after 5 yr to children with functional or anatomic asplenia or an immunocompromising condition (see Morbidity and Mortality Weekly Review 46 [RR-8], 1997).
^f Hepatitis A vaccine (HepA). Administer 2 doses at least 6 mo apart. HepA is recommended for children aged > 23 mo if they live in areas where vaccination programs target older children, if they are at increased risk of infection, or if immunity against hepatitis A is desired for them.
^g Hepatitis B vaccine (HepB). Administer the 3-dose series to children not previously vaccinated. A 2-dose series (separated by at least 4 mo) of adult formulation Recombivax HB® is licensed for children aged 11–15 yr.
^h Inactivated poliovirus vaccine (IPV). The final dose in the series should be administered on or after the 4th birthday and at least 6 mo after the previous dose. If both OPV and IPV were administered as part of a series, a total of 4 doses should be administered, regardless of the child's current age.
ⁱ Measles, mumps, and rubella vaccine (MMR). If not previously vaccinated, administer 2 doses or the 2nd dose for children who have received only 1 dose, with at least 28 days between doses.
^j Varicella vaccine. For children aged 7–18 yr without evidence of immunity (see Morbidity and Mortality Weekly Review 56 [RR-4], 2007), administer 2 doses if children were not previously vaccinated or the 2nd dose if only 1 dose has been administered. For children aged 7–12 yr, the minimum interval between doses is 3 mo. However, if the 2nd dose was administered at least 28 days after the first dose, it can be accepted as valid. For children aged ≥ 13 yr, the minimum interval between doses is 28 days.
PRP-OMP = Neisseria meningitidis polyribosyl ribitol phosphate/outer membrane protein; PRP-T = PRP conjugated to inactivated tetanus toxoid.
Adapted from the Centers for Disease Control and Prevention: Recommended Immunization Schedule for Persons Aged 7 Through 18 Years, United States, 2010. Available at www.cdc.gov/vaccines/recs/schedules/default.htm.

Table 14

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Catch-up Immunization Schedule for Ages 4 mo–18 yr
Vaccine	Minimum Age for Dose 1	Minimum Interval Between
Vaccine	Minimum Age for Dose 1	Doses 1 and 2	Doses 2 and 3	Doses 3 and 4	Doses 4 and 5
For ages 4 mo–6 yr
Hepatitis B (HepB)^a	Birth	4 wk	8 wk (and at least 16 wk after the first dose)	—	—
Rotavirus (RV)^b	6 wk	4 wk	4 wk^b	—	—
Diphtheria, tetanus, pertussis (DTaP)^c	6 wk	4 wk	4 wk	6 mo	6 mo^c
Haemophilus influenzae type b (Hib)^d	6 wk	4 wk if the first dose is administered at age < 12 mo 8 wk (as the final dose) if the first dose is administered at age 12–14 mo No further doses needed if the first dose is administered at age ≥15 mo	4 wk^dif current age is < 12 mo 8 wk (as the final dose)^d if current age is ≥ 12 mo and the first dose is administered at age < 12 mo and the 2nd dose is administered at age < 15 mo No further doses needed if the previous dose is administered at age ≥ 15 mo	8 wk (as the final dose) Only necessary for children aged 12–59 mo who received 3 doses before age 12 mo	—
Pneumococcal vaccine^e	6 wk	4 wk if the first dose is administered at age < 12 mo 8 wk (as the final dose for healthy children) if the first dose is administered at age ≥ 12 mo or current age is 24–59 mo No further doses needed for healthy children if the first dose is administered at age ≥ 24 mo	4 wk if current age is < 12 mo 8 wk (as the final dose for healthy children) if current age is ≥ 12 mo No further doses needed for healthy children if previous dose is administered at age ≥ 24 mo	8 wk (as the final dose) Only necessary for children aged 12–59 mo who received 3 doses before age 12 mo or for high-risk children who received 3 doses at any age
Inactivated polio virus (IPV)^f	6 wk	4 wk	4 wk	6 mo	—
Measles, mumps, rubella (MMR)^g	12 mo	4 wk	—	—	—
Varicella^h	12 mo	3 mo	—	—	—
Hepatitis A (HepA)ⁱ	12 mo	6 mo	—	—	—
For ages 7–18 yr
Tetanus, diphtheria (Td) Tetanus, diphtheria, pertussis (Tdap)^j	7 yr^j	4 wk	4 wk if the first dose is administered at age < 12 mo 6 mo if the first dose is administered at age ≥ 12 mo	6 mo if the first dose is administered at age < 12 mo	—
Human papillomavirus (HPV)^k	9 yr	Routine dosing intervals recommended^k
Hepatitis A (HepA)ⁱ	12 mo	6 mo	—	—	—
Hepatitis B (HepB)^a	Birth	4 wk	8 wk (and at least 16 wk after first dose)	—	—
Inactivated polio virus (IPV)^f	6 wk	4 wk	4 wk	6 mo	—
Measles, mumps, rubella (MMR)^g	12 mo	4 wk	—	—	—
Varicella^h	12 mo	3 mo if age is < 13 yr 4 wk if age is ≥ 13 yr	—	—	—
Note: For children whose vaccinations were started late or are > 1 mo behind, the table provides catch-up schedules and minimum intervals between doses. A vaccine series does not need to be restarted, regardless of the time that has elapsed between doses. Use the section appropriate for the child's age. Information about reporting reactions after immunization is available online at vaers.hhs.gov/index or by telephone, 800-822-7967. Suspected cases of vaccine-preventable diseases should be reported.
^a Hepatitis B vaccine (HepB). Administer the 3-dose series to children who were not previously vaccinated. A 2-dose series (separated by at least 4 mo) of adult-formulation Recombivax HB® is approved for children aged 11–15 yr.
^b Rotavirus vaccine (RV). The maximum age for the first dose is 14 wk 6 days. Vaccination should not be initiated for infants aged ≥ 15 wk 0 days. The maximum age for the final dose in the series is 8 mo 0 days. If Rotarix® was administered for the first and 2nd doses, a 3rd dose is not indicated.
^c Diphtheria and tetanus toxoids and acellular pertussis vaccine (DTaP). The 5th dose is not necessary if the 4th dose was administered at age ≥ 4 yr.
^d Haemophilus influenzae type b conjugate vaccine (Hib). Hib vaccine is not generally recommended for people aged ≥ 5 yr. There are no efficacy data to support a recommendation for use of Hib vaccine in older children and adults. However, studies suggest good immunogenicity in patients who have sickle cell disease, leukemia, or HIV infection or who have had a splenectomy; administering 1 dose of Hib vaccine to these patients if they have not previously received Hib vaccine is not contraindicated. If the first 2 doses were PRP-OMP (PedvaxHIB® or ComVax® [HepB-Hib) and administered at age ≤ 11 mo, the 3rd (and final) dose should be administered at age 12–15 mo and at least 8 wk after the 2nd dose. If the first dose was administered at age 7–11 mo, administer the 2nd dose at least 4 wk later and a final dose at age 12–15 mo.
^e Pneumococcal vaccine. Administer 1 dose of pneumococcal conjugate vaccine (PCV) to all healthy children aged 24–59 mo if they have not received at least 1 dose of PCV on or after age 12 mo. For children aged 24–59 mo with medical conditions, administer 1 dose of PCV if 3 doses were received previously, or administer 2 doses of PCV at least 8 wk apart if < 3 doses were received previously. Administer pneumococcal polysaccharide vaccine (PPSV) to children aged ≥ 2 yr with certain medical conditions, including a cochlear implant, at least 8 wk after the last dose of PCV (see Morbidity and Mortality Weekly Review 46 [RR-8], 1997).
^f Inactivated poliovirus vaccine (IPV). The final dose in the series should be administered on or after the 4th birthday and at least 6 mo after the previous dose. A 4th dose is not necessary if the 3rd dose was administered at age ≥ 4 yr and at least 6 mo after the previous dose. In the first 6 mo of life, minimum age and minimum intervals are recommended only if the infant is at risk of imminent exposure to circulating poliovirus (eg, traveling to a polio-endemic region, during an outbreak).
^g Measles, mumps, and rubella vaccine (MMR). Administer the 2nd dose routinely at age 4–6 yr. However, the 2nd dose may be administered before age 4, provided at least 28 days have elapsed since the first dose. For children not previously vaccinated, administer 2 doses with at least 28 days between doses.
^h Varicella vaccine. Administer the 2nd dose routinely at age 4–6 yr. However, the 2nd dose may be administered before age 4, provided at least 3 mo have elapsed since the first dose. For ages 12 mo–12 yr, the minimum interval between doses is 3 mo. However, if the 2nd dose was administered at least 28 days after the first dose, it can be accepted as valid. For ages ≥ 13 yr, the minimum interval between doses is 28 days.
ⁱ Hepatitis A vaccine (HepA). HepA is recommended for children aged > 23 mo if they live in areas where vaccination programs target older children, if they are at increased risk of infection, or if immunity against hepatitis A is desired for them.
^j Tetanus and diphtheria toxoids vaccine (Td) and tetanus and diphtheria toxoids and acellular pertussis vaccine (Tdap). Doses of DTaP are counted as part of the Td/Tdap series. Tdap should be substituted for a single dose of Td in the catch-up series or as a booster for children aged 10–18 yr; use Td for other doses.
^k Human papillomavirus vaccine (HPV). Administer the series to females at age 13–18 yr if not previously vaccinated. Use recommended routine dosing intervals for series catch-up (ie, the 2nd and 3rd doses should be administered at 1–2 mo and 6 mo after the first dose). The minimum interval between the first and 2nd doses is 4 wk. The minimum interval between the 2nd and 3rd doses is 12 wk, and the 3rd dose should be administered at least 24 wk after the first dose.

Catch-up Immunization Schedule for Ages 4 mo–18 yr

Vaccine	Minimum Age for Dose 1	Minimum Interval Between
		Doses 1 and 2	Doses 2 and 3	Doses 3 and 4	Doses 4 and 5

For ages 4 mo–6 yr
Hepatitis B (HepB)^a	Birth	4 wk	8 wk (and at least 16 wk after the first dose)	—	—
Rotavirus (RV)^b	6 wk	4 wk	4 wk^b	—	—
Diphtheria, tetanus, pertussis (DTaP)^c	6 wk	4 wk	4 wk	6 mo	6 mo^c
Haemophilus influenzae type b (Hib)^d	6 wk	4 wk if the first dose is administered at age < 12 mo 8 wk (as the final dose) if the first dose is administered at age 12–14 mo No further doses needed if the first dose is administered at age ≥15 mo	4 wk^dif current age is < 12 mo 8 wk (as the final dose)^d if current age is ≥ 12 mo and the first dose is administered at age < 12 mo and the 2nd dose is administered at age < 15 mo No further doses needed if the previous dose is administered at age ≥ 15 mo	8 wk (as the final dose) Only necessary for children aged 12–59 mo who received 3 doses before age 12 mo	—
Pneumococcal vaccine^e	6 wk	4 wk if the first dose is administered at age < 12 mo 8 wk (as the final dose for healthy children) if the first dose is administered at age ≥ 12 mo or current age is 24–59 mo No further doses needed for healthy children if the first dose is administered at age ≥ 24 mo	4 wk if current age is < 12 mo 8 wk (as the final dose for healthy children) if current age is ≥ 12 mo No further doses needed for healthy children if previous dose is administered at age ≥ 24 mo	8 wk (as the final dose) Only necessary for children aged 12–59 mo who received 3 doses before age 12 mo or for high-risk children who received 3 doses at any age
Inactivated polio virus (IPV)^f	6 wk	4 wk	4 wk	6 mo	—
Measles, mumps, rubella (MMR)^g	12 mo	4 wk	—	—	—
Varicella^h	12 mo	3 mo	—	—	—
Hepatitis A (HepA)ⁱ	12 mo	6 mo	—	—	—
For ages 7–18 yr
Tetanus, diphtheria (Td) Tetanus, diphtheria, pertussis (Tdap)^j	7 yr^j	4 wk	4 wk if the first dose is administered at age < 12 mo 6 mo if the first dose is administered at age ≥ 12 mo	6 mo if the first dose is administered at age < 12 mo	—
Human papillomavirus (HPV)^k	9 yr	Routine dosing intervals recommended^k
Hepatitis A (HepA)ⁱ	12 mo	6 mo	—	—	—
Hepatitis B (HepB)^a	Birth	4 wk	8 wk (and at least 16 wk after first dose)	—	—
Inactivated polio virus (IPV)^f	6 wk	4 wk	4 wk	6 mo	—
Measles, mumps, rubella (MMR)^g	12 mo	4 wk	—	—	—
Varicella^h	12 mo	3 mo if age is < 13 yr 4 wk if age is ≥ 13 yr	—	—	—
Note: For children whose vaccinations were started late or are > 1 mo behind, the table provides catch-up schedules and minimum intervals between doses. A vaccine series does not need to be restarted, regardless of the time that has elapsed between doses. Use the section appropriate for the child's age. Information about reporting reactions after immunization is available online at vaers.hhs.gov/index or by telephone, 800-822-7967. Suspected cases of vaccine-preventable diseases should be reported.
^a Hepatitis B vaccine (HepB). Administer the 3-dose series to children who were not previously vaccinated. A 2-dose series (separated by at least 4 mo) of adult-formulation Recombivax HB® is approved for children aged 11–15 yr.
^b Rotavirus vaccine (RV). The maximum age for the first dose is 14 wk 6 days. Vaccination should not be initiated for infants aged ≥ 15 wk 0 days. The maximum age for the final dose in the series is 8 mo 0 days. If Rotarix® was administered for the first and 2nd doses, a 3rd dose is not indicated.
^c Diphtheria and tetanus toxoids and acellular pertussis vaccine (DTaP). The 5th dose is not necessary if the 4th dose was administered at age ≥ 4 yr.
^d Haemophilus influenzae type b conjugate vaccine (Hib). Hib vaccine is not generally recommended for people aged ≥ 5 yr. There are no efficacy data to support a recommendation for use of Hib vaccine in older children and adults. However, studies suggest good immunogenicity in patients who have sickle cell disease, leukemia, or HIV infection or who have had a splenectomy; administering 1 dose of Hib vaccine to these patients if they have not previously received Hib vaccine is not contraindicated. If the first 2 doses were PRP-OMP (PedvaxHIB® or ComVax® [HepB-Hib) and administered at age ≤ 11 mo, the 3rd (and final) dose should be administered at age 12–15 mo and at least 8 wk after the 2nd dose. If the first dose was administered at age 7–11 mo, administer the 2nd dose at least 4 wk later and a final dose at age 12–15 mo.
^e Pneumococcal vaccine. Administer 1 dose of pneumococcal conjugate vaccine (PCV) to all healthy children aged 24–59 mo if they have not received at least 1 dose of PCV on or after age 12 mo. For children aged 24–59 mo with medical conditions, administer 1 dose of PCV if 3 doses were received previously, or administer 2 doses of PCV at least 8 wk apart if < 3 doses were received previously. Administer pneumococcal polysaccharide vaccine (PPSV) to children aged ≥ 2 yr with certain medical conditions, including a cochlear implant, at least 8 wk after the last dose of PCV (see Morbidity and Mortality Weekly Review 46 [RR-8], 1997).
^f Inactivated poliovirus vaccine (IPV). The final dose in the series should be administered on or after the 4th birthday and at least 6 mo after the previous dose. A 4th dose is not necessary if the 3rd dose was administered at age ≥ 4 yr and at least 6 mo after the previous dose. In the first 6 mo of life, minimum age and minimum intervals are recommended only if the infant is at risk of imminent exposure to circulating poliovirus (eg, traveling to a polio-endemic region, during an outbreak).
^g Measles, mumps, and rubella vaccine (MMR). Administer the 2nd dose routinely at age 4–6 yr. However, the 2nd dose may be administered before age 4, provided at least 28 days have elapsed since the first dose. For children not previously vaccinated, administer 2 doses with at least 28 days between doses.
^h Varicella vaccine. Administer the 2nd dose routinely at age 4–6 yr. However, the 2nd dose may be administered before age 4, provided at least 3 mo have elapsed since the first dose. For ages 12 mo–12 yr, the minimum interval between doses is 3 mo. However, if the 2nd dose was administered at least 28 days after the first dose, it can be accepted as valid. For ages ≥ 13 yr, the minimum interval between doses is 28 days.
ⁱ Hepatitis A vaccine (HepA). HepA is recommended for children aged > 23 mo if they live in areas where vaccination programs target older children, if they are at increased risk of infection, or if immunity against hepatitis A is desired for them.
^j Tetanus and diphtheria toxoids vaccine (Td) and tetanus and diphtheria toxoids and acellular pertussis vaccine (Tdap). Doses of DTaP are counted as part of the Td/Tdap series. Tdap should be substituted for a single dose of Td in the catch-up series or as a booster for children aged 10–18 yr; use Td for other doses.
^k Human papillomavirus vaccine (HPV). Administer the series to females at age 13–18 yr if not previously vaccinated. Use recommended routine dosing intervals for series catch-up (ie, the 2nd and 3rd doses should be administered at 1–2 mo and 6 mo after the first dose). The minimum interval between the first and 2nd doses is 4 wk. The minimum interval between the 2nd and 3rd doses is 12 wk, and the 3rd dose should be administered at least 24 wk after the first dose.

Last full review/revision February 2010 by Eve R. Colson, MD; Rachel L. Chapman, MD; Melissa R. Held, MD

Content last modified February 2012

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