CDC Updates Immunization Schedules for 2021

February 24, 2021, 10:30 am Michael Devitt — The CDC’s Advisory Committee on Immunization Practices, together with the AAFP and several other medical organizations, released the 2021 adult and childhood immunization schedules on Feb. 12.

Both schedules underwent a number of changes and contain updates on several vaccines for each population, including recommendations on vaccination against COVID-19. Schedules are available on AAFP.org and the CDC website.

Highlights and General Updates

• For both the child/adolescent and adult immunization schedules, updates to tetanus, diphtheria and toxoid containing vaccines (Td and Tdap) in the management of wound infections were made with added guidance for use of Tdap for all pregnant women.
• For both schedules, the “Special Situations” section of notes on the influenza vaccination were revised for all patients who have egg allergy with symptoms other than hives, and for situations in which quadrivalent live attenuated influenza vaccine should not be used. These situations include receiving the antiviral medications oseltamivir or zanamivir within the previous 48 hours, receiving peramivir within the previous five days or receiving baloxavir within the previous 17 days.
• Recommendations were added to the general information on childhood immunizations schedules to address the decline in outpatient pediatric visits resulting in declining immunization rates during the COVID-19 pandemic. These recommendations include strategies to separate well visits from sick visits, highlight the importance of in-person newborn visits, continued developmental surveillance and early childhood screenings, and the recommendation to identify children who have missed well-child visits and/or recommended vaccinations to contact them and schedule vaccine appointments.
• Interim guidance to prevent mother-to-child transmission of hepatitis B virus during COVID-19-related disruptions in routine care and preventive services before, during and after labor and delivery was added.
• MenQuadfi (MenACWY-TT) was added to the list of meningococcal vaccines that provide protections against serogroups A, C, W and Y.
• Vaccine catchup guidance job aids were developed for several vaccines, including pneumococcal conjugate vaccine; Haemophilus influenzae type b-containing vaccines; diphtheria, tetanus and pertussis-containing vaccines for children ages 4 months through 6 years; Tdap vaccines for children ages 7 years through 9 years and children ages 10 years through 18 years; and inactivated polio vaccine.
• Changes to the general information on adult immunizations schedules include the addition of links to frequently asked questions for ACIP recommendations on shared clinical decision-making, the removal of any reference to Zostavax, a live zoster vaccine that is no longer available in the United States; the addition of MenACWY-TT to the list of meningococcal ACWY vaccines available for those 2 years and older; and the addition of the American Academy of Physician Assistants as an approving partner of the vaccine schedule.

Additional adult immunization schedule updates that family physicians should be aware of included the following:

• The note for hepatitis B vaccination was revised to include shared clinical decision-making for HepB vaccines in patients with diabetes who are 60 years or older.
• The note for HPV vaccines was revised to clarify that vaccination is recommended for everyone through age 26 years and that no additional doses of are recommended after completing a series at the recommended dosing intervals using any HPV vaccine. Under the “Shared Clinical Decision-Making” section, the text was modified to clarify that a 2- or 3-dose series is recommended for some adults ages 27-45, and under the “Special Situations” section, clarifying language on age ranges recommended highlighting the need for a 3-dose series for those with immunocompromising conditions, including HIV infection, regardless of the age at which initial HPV vaccination was added.
• For influenza vaccination, text was added to the “Special Situations” section regarding egg allergies more severe than hives. “If using an influenza vaccine other than RIV4 (quadrivalent recombinant influenza vaccine/Flublok) or ccIIV4 (cell culture-based quadrivalent recombinant influenza vaccine/Flucelvax),” the schedule says, “administer in medical setting under supervision of health care provider who can recognize and manage severe allergic reactions.” Two additional bullets were added: “Severe allergic reactions to vaccines can occur even in the absence of a history of previous allergic reaction. Therefore, all vaccine providers should be familiar with the office emergency plan and certified in CPR” and “A previous severe allergic reaction to influenza vaccine is a contraindication to future receipt of the vaccine.”
• For meningococcal vaccination, MenQuadfi was added to the “Special Situations for MenACWY” section in all relevant subsections. Booster dose recommendations for groups listed under “Special Situations” and in an outbreak setting (e.g., among men who have sex with men and in community or organizational settings) were added for both MenACWY and MenB booster doses.
• The pneumococcal vaccination note links were updated and reordered for clarity for routine vaccination in patients 65 years or older.

Additional child/adolescent immunization schedule updates that family physicians should be aware of included the following:

• The Haemoplius influenzae type b vaccination note was revised to clarify that for catchup vaccination, no further doses are recommended if a previous dose was administered at age 15 months or older.
• The “Birth Dose” section of the hepatitis B vaccination note added text clarifying the recommendation for infants with birth weight of less than 2,000 grams whose mothers are HBsAg-negative. In these infants, administer one dose at chronological age 1 month or hospital discharge (whichever is earlier and even if weight is still less than 2,000 grams).
• The HPV vaccination note was revised to include recommendations for interrupted schedules. If the vaccination schedule is interrupted, the series does not need to be restarted.
• The note for meningococcal serogroup A, C, W and Y vaccination added information about the use of MenQuadfi in the “Special Situations” section, with additional dosing guidance on use of Menveo in infants who received their first dose at age 3-6 months.

COVID-19 Vaccines: What Family Physicians Should Know

COVID-19 vaccination recommendations for children, adolescents and adults are highlighted under the Table 1 recommendations for each schedule.

The ACIP recommends the use of COVID-19 vaccines within the scope of the Emergency Use Authorization or Biologics License Application for the particular vaccine. Interim ACIP recommendations for the use of COVID-19 vaccines are available on the ACIP Vaccine Recommendations and Guidelines web page.

The AAFP, which reviews all ACIP recommendations for approval through the Commission on Health of the Public and Science, approved the ACIP’s recommendations in December 2020.

Any authorized COVID-19 vaccine in accordance with the recommended age and conditions of use is recommended for those ages 16 and older with a phased allocation of vaccine distribution. The recommendations provide guidance for federal, state and local jurisdictions while vaccine supply is limited, considering scientific evidence regarding COVID-19 epidemiology, ethical principles and vaccination program implementation considerations. ACIP COVID-19 vaccine allocation recommendations are interim and may be updated based on changes in conditions of EUA, FDA authorization for new COVID-19 vaccines, changes in vaccine supply or changes in COVID-19 epidemiology.

Phase 1 of COVID-19 vaccination is divided into three stages. Phase 1a includes all health care personnel and residents of long-term care facilities; phase 1b includes frontline essential workers (non-healthcare workers) and people 75 years and older; and phase 1c includes everyone 65-74 years of age, those 16-64 years of age with medical conditions that increase the risk for severe COVID-19 disease and all essential workers not previously vaccinated.

Phase 2 includes everyone 16 years and older not already recommended for vaccination.

ACIP defines essential workers using guidelines developed by the Department of Homeland Security’s Cybersecurity and Infrastructure Security Agency. Frontline essential workers are a subset of essential workers likely at highest risk for work-related exposure to SARS-CoV-2 infection because their work-related duties must be performed on-site in close proximity to the public or to coworkers. The list of frontline essential workers includes first responders (e.g., firefighters and police officers), corrections officers, U.S. Postal Service workers, grocery store workers, public transit workers and those who work in the education sector.

States and jurisdictions may differ in the phases of distribution, so it is important to refer to the plan being used in a specific area. AAFP members are invited to view a list of state-by-state distributions plans on the Academy’s COVID-19 Vaccine Distribution web page.

COVID-19 and Immunization Rates

Pamela Rockwell, D.O., the AAFP’s liaison to the ACIP and an associate professor in the Department of Family Medicine at the University of Michigan Medical School in Ann Arbor, explained the effect of the pandemic on immunization rates throughout the population to AAFP News.

“As always, improving childhood and adult vaccination rates must be a priority for all family physicians, now more importantly than ever,” said Rockwell. “Childhood vaccination coverage has declined in all milestone age cohorts (except for birth-dose hepatitis B coverage typically administered in the hospital setting) due to fewer outpatient visits to primary care offices during the pandemic. This creates alarming conditions with high probability for a vaccine-preventable disease outbreak, especially due to measles, which requires vaccination coverage of 90% to 95% to maintain herd immunity to prevent outbreaks.”

Rockwell suggested a number of ways family physicians could modify the processes by which vaccines are traditionally administered to children to help them get caught up.

“Successful strategies to improve immunization rates for all ages include regularly assessing patients’ vaccine needs at every visit, whether the visit is for preventive, acute or chronic care, and whether the visit is in person or through telemedicine,” Rockwell said. “Followup immunization recommendations made during telemedicine visits can be completed during established followup visits, or additional ‘immunization only’ visits with medical assistants or nurses can be offered.”

Rockwell also suggested clinicians could reach out to patients by reviewing EHRs and state immunization registries, creating lists of patients who are behind on vaccinations, and offering drive-through immunization clinics.

Rockwell also emphasized the importance of educating patients about vaccines and dispelling myths about immunizations.

“Ongoing vaccine education to combat the growing spread of disinformation and misinformation online is especially important through direct physician/patient contact, use of mailers, office posters and handouts, and through social media platforms like Twitter, Facebook and YouTube,” she said.

AAFP Resources

The AAFP is continually monitoring the COVID-19 vaccine development, authorization and distribution process to update members on how to prepare themselves, their practices and patients. Updated information can be found on the Academy’s COVID-19 Vaccine web page.

The AAFP also recently launched a consumer PR campaign encouraging people to be vaccinated for influenza and to receive other routine immunizations. The campaign aims to reduce vaccine hesitancy and emphasize that vaccination is a selfless act of prevention that helps protect those who are more vulnerable and builds a community of immunity. Members are invited to visit the campaign site, which contains a brief video, patient-friendly materials, and other resources for encouraging people to get their immunizations.

Finally, the AAFP’s Immunizations & Vaccines web page has robust information about immunizations and increasing routine immunization rates during the COVID-19 pandemic.