Childhood immunization standards and recommendations in the United States (Figs. 94-1 and 94-2) are formulated by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention (ACIP), the American Academy of Pediatrics, and the American Academy of Family Physicians. In the United States, due to state laws requiring immunization for school entry, approximately 95% of children entering kindergarten are vaccinated for the common infectious diseases. The ACIP recommends that children in the United States routinely receive vaccines against 16 diseases (see Fig. 94-1). This schedule includes up to 21 injections in four to five visits by 18 months of age. Children and adolescents who are at increased risk for pneumococcal infections should receive the pneumococcal polysaccharide vaccine, as well. Children who are behind in immunization should receive catch-up immunizations as rapidly as feasible. Infants born prematurely, regardless of birth weight, should be vaccinated at the same chronologic age and according to the same schedule as full-term infants and children (see Fig. 94-2). The single exception to this practice is providing hepatitis B vaccine for infants weighing less than 2000 g if the mother is hepatitis B virus surface antigen (HBsAg)-negative at 1 month instead of at birth. Vaccines for adolescents should be given at 11 to 12 years of age (see Fig. 94-1), with completion of any vaccine series at 13 to 18 years of age and a booster for N. meningitidis at 16 years of age.
Vaccines should be administered after obtaining informed consent. The National Childhood Vaccine Injury Actrequires that all health care providers provide parents or patients with copies of Vaccine Information Statements prepared by the Centers for Disease Control and Prevention ( http://www.cdc.gov/vaccines/pubs/vis/default.htm ) before administering each vaccine dose.
Most vaccines are administered by intramuscular or subcutaneous injection. The preferred sites for administration are the anterolateral aspect of the thigh in infants and the deltoid region in children and adults. Multiple vaccines can be administered simultaneously at anatomically separate sites (different limbs, or separated by >1 in.) without diminishing the immune response. MMR and varicella vaccines should be administered simultaneously or more than 30 days apart. Administration of blood products and immunoglobulin can diminish response to live virus vaccines if administered before the recommended interval.
General contraindications to vaccination include serious allergic reaction (anaphylaxis) after a previous vaccine dose or to a vaccine component, immunocompromised states or pregnancy (live virus vaccines), and moderate or severe acute illness with or without fever. History of anaphylactic-like reactions to eggs is a contraindication to influenza and yellow fever vaccines, which are produced in embryonated chicken eggs. Current preparations of measles and mumps vaccines, which are produced in chick embryo fibroblast tissue culture, do not contain significant amounts of egg proteins and may be administered without testing children with history of egg allergy. Mild acute illness, with or without fever, convalescent phase of illness, recent exposure to infectious diseases, current antimicrobial therapy, breastfeeding, mild to moderate local reaction or low-grade to moderate fever after previous vaccination, and history of penicillin or other nonvaccine allergy or receiving allergen extract immunotherapy are not contraindications to immunization.