Immunization Update

Jean-Venable “Kelly” R. Goode, PharmD

 

Immunization recommendations are complex, change frequently, and can be difficult to implement. Each year, ACIP recommendations and updates are summarized and consolidated into an immunization schedule to support health care providers with putting the recommendations into practice.

ACIP’s recommendations, which are published annually in CDC’s Morbidity and Mortality Weekly Report as well as on CDC’s website, are divided into two schedules: one for children and adolescents 18 years and younger, and the other for adults over 18 years. 

Pharmacists must be knowledgeable about ACIP recommendations and know how to use the most current schedule to apply recommendations to the care of patients. APhA is one of the organizations—the only pharmacy organization—that recommends and approves the Adult Immunization Schedule.  

The ACIP Immunization Schedule Workgroup meets regularly to review and refine the schedule to reflect the most current ACIP recommendations and has worked to harmonize the two schedules as appropriate. Each schedule consists of a cover page, a table for recommended vaccines by age, a table for vaccine recommendations by medical condition, notes for applying recommendations, an appendix containing information about contraindications and precautions, and an addendum.

In 2023, the Addendum section was added to incorporate new and updated ACIP recommendations that occur before the annual schedule update. The Addendum section is especially important for pharmacists practicing in states where recommendations must be on the schedule before pharmacists can implement the recommendations.

Pharmacists can expect the Addendum section to be updated at least three times per year after each ACIP meeting (February, June, and October). The Child and Adolescent Immunization schedule contains an additional table for the recommended catch-up immunization schedule for children and adolescents who start late or who are more than 1 month behind with immunizations. All sections of the immunization schedule should be used to determine vaccine needs, especially the Notes section.

Recommended Child and Adolescent Immunization Schedule for ages 18 years or younger, United States 2024

How to use the schedule:

1. Determine recommended vaccine by age (Table 1 in the guideline);
2. Determine recommended interval for catch-up vaccination (Table 2 in the guideline);
3. Assess need for additional vaccines by medical condition or other indication (Table 3 in the guideline);
4. Always review vaccine types, frequencies, intervals, andconsiderations for special situations (Notes);
5.  Review contraindications and precautions for vaccine types (Appendix);
6. Review new or updated ACIP guidance (Addendum).

New and updated vaccine recommendations (as of 11/16/23)*

Respiratory syncytial virus (RSV) monoclonal antibody (RSV-mAb): A new addition to the vaccine schedule. The Routine Immunization section provides the recommendations for the use of nirsevimab in infants less than 8 months old.  The Special Situations section outlines recommendations for age-eligible children who are undergoing cardiac surgery with cardiopulmonary bypass and for children 8 to 19 months old who are at an increased risk for severe RSV disease. Timing of immunization is included, and provides guidance for jurisdictions with RSV seasonality that differs from most of the continental United States.

Pneumococcal vaccinePneumococcal vaccine: PCV13 was deleted from the schedule. All sections were updated with the recommendations for the use of pneumococcal conjugate vaccines, 15-valent (PCV15), 20-valent (PCV20), and pneumococcal polysaccharide 23-valent (PPSV23). ACIP updated the list of medical conditions that increase the risk for invasive pneumococcal disease to include chronic kidney disease, chronic liver disease, and moderate persistent or severe persistent asthma.

Poliovirus vaccine (IPV): Information was added that most adolescents aged 18 years who were born and raised in the United States can assume to be vaccinated against poliovirus as children. The Special Situations section was revised to say that adolescents who completed the primary series and are at an increased risk for exposure to poliovirus may receive a one-time, lifetime IPV booster.

COVID-19 vaccineCOVID-19 vaccine: ACIP updated the schedule to reflect current recommendations for children and adolescents (general population and moderately or severely immunocompromised) to receive the 2023–2024 COVID-19 vaccine. The number of doses needed and intervals between doses are based on previous vaccine history, immunocompromise states, and vaccine product. Hyperlinks are included to the current COVID-19 vaccine schedules and Emergency Use Authorization indications.

Influenza vaccineInfluenza vaccine: Recommendations for annual influenza vaccination for those 6 months or older have not changed. The Special Situations section describes recommendations that a person with a history of egg allergy of any severity can be vaccinated with any influenza vaccine indicated for the recipient’s age with no additional safety considerations. Hyperlinks were added to the influenza vaccine recommendations.

Meningococcal vaccineMeningococcal vaccine: Menactra (MenACWY-D) was removed from the schedule since it is no longer distributed in the United States. Information is included on the use of the new pentavalent meningococcal (MenACWT-TT/MenB-FHbp, Penbraya). 

Meningococcal B vaccineMeningococcal B vaccine: Recommendations are summarized for MenACWT-TT/MenB-FHbp, Penbraya. A resource with a hyperlink to assist health care providers with shared clinical decision-making is provided. 

Mpox vaccineMpox vaccine: A new addition to the schedule. Recommendations including sexual risk factors and considerations during pregnancy are included for the use of Jynneos (Bavarian Nordic) in adolescents aged 18 years.

Other schedule changes include clarification of the recommendations for diphtheria, tetanus, and acellular pertussis vaccine, Haemophilus influenzae type b vaccine, human papillomavirus vaccine, measles, mumps, and rubella vaccine, serogroup B meningococcal vaccine, and tetanus, diphtheria, and acellular pertussis vaccine. The schedule by medical indication was revised to highlight additional vaccination recommendations for each medical condition and the legend colors were harmonized with the adult immunization schedule.

Recommended Adult Immunization Schedule for ages 19 years and older, United States 2024

How to use the schedule:

1. Determine recommended vaccine by age (Table 1);
2. Assess need for additional vaccines by medical condition or other indication (Table 2);
3. Always review vaccine types, frequencies, intervals, and considerations for special situations (Notes);
4. Review contraindications and precautions for vaccine types (Appendix);
5. Review new or updated ACIP guidance (Addendum).

New and updated vaccine recommendations (as of 2/29/24)*

COVID-19 vaccineCOVID-19 vaccine: ACIP updated the schedule with the recommendation that all adults receive at least 1 dose of the 2023–2024 COVID-19 vaccine.  The number of doses needed and the intervals between doses are based on the patient’s previous vaccine history, immunocompromise states, and vaccine product. The current Addendum section reflects that individuals 65 years or older should receive an additional dose.  The Notes section has two parts: Routine Vaccination, which describes recommendations for the general population; and a Special Situations section for individuals who are moderately or severely immunocompromised. Look for an Addendum section update after the June 2024 ACIP meeting.

Influenza vaccineInfluenza vaccine: Recommendations for annual influenza vaccination for those 6 months or older have not changed. However, the Notes section was changed under the Special Situations section to state that persons with a history of egg allergy can be vaccinated with any influenza vaccine indicated for the recipient’s age and health status.  Look for an Addendum section update as influenza vaccine season approaches. Look for an Addendum section update after the June 2024 meeting.

RSV vaccineRSV vaccine: A new addition to the vaccine schedule. The Notes section describes routine vaccination and special situations.  Routine vaccination describes the use of Abrysvo (Pfizer, Inc.) in pregnancy from September through January during 32–36 weeks’ gestation. A sub-bullet was also added that either maternal RSV vaccination or infant immunization with nirsevimab (RSV antibody) is recommended to prevent RSV infection in infants. The Special Situations section reflects the shared clinical-decision making for adults 60 years or older with either Abrysvo (Pfizer, Inc.) or Arexvy (GSK). A resource with a hyperlink to assist health care providers with shared clinical decision-making is provided. Risk factors and medical conditions that increase a person’s risk for severe RSV disease are also listed.

Poliovirus vaccine (IPV):Poliovirus vaccine (IPV): The Routine Vaccination section was revised for adults who are known or suspected to be unvaccinated or incompletely vaccinated. They must complete the 3-dose IPV primary vaccine series.  A statement was added that most adults born and raised in the United States can assume that they were vaccinated against polio as children. The Special Situations section states that adults who have completed the primary series and are at an increased risk for exposure to poliovirus may receive a one-time, lifetime IPV booster.

Meningococcal vaccineMeningococcal vaccine: Menactra (MenACWY-D) was removed from the schedule since it is no longer distributed in the United States. A resource hyperlink is provided that assists health care providers with shared clinical decision-making for Meningococcal B vaccine. Information on the use of the new pentavalent meningococcal (MenACWT-TT/MenB-FHbp, Penbraya) is included in the Notes section.

Mpox vaccineMpox vaccine: A new addition to the schedule. Mpox is a risk-based recommendation, and  risk factors are listed that warrant routine vaccination with Jynneos (Bavarian Nordic).  Information is included about the use of Jynneos for health care providers and individuals who are pregnant.

Other schedule changes include clarification of the recommendations for hepatitis A vaccine; hepatitis B vaccine; human papillomavirus vaccine; measles, mumps and rubella vaccine; pneumococcal vaccines; and tetanus, diphtheria and pertussis vaccines. ■

Immunization schedule resources

The most current immunization schedules are available at www.cdc.gov/ vaccines/schedules. CDC also has an application for the schedules at www.cdc.gov/vaccines/schedules/hcp/schedule-app.html. Other applications that feature the schedule are the Vaccine Handbook App and Vaccines on the Go: What You Should Know (Children’s Hospital of Philadelphia). Other vaccine resources include the PneumoRecs VaxAdvisor www.cdc.gov/vaccines/vpd/pneumo/hcp/pneumoapp.html.

Pharmacists should use the Recommended Child and Adolescent Immunization Schedule for ages 18 years and younger, United States 2024 (www.cdc.gov/vaccines/schedules/downloads/child/0-18yrs-child-combined-schedule.pdf) and the Recommended Adult Immunization Schedule for ages 19 years and older, United States 2024 (www.cdc.gov/vaccines/schedules/downloads/adult/adult-combined-schedule.pdf) as the roadmap for ensuring patients are up to date on all recommended vaccines and improve immunization rates across the lifespan. ■