Routine pediatric immunization rates decreased in 2020-2021 due to the COVID-19 pandemic, making it even more important for nurse practitioners (NP) and PAs to use the best available evidence to catch up on vaccines for children and keep them on track to receive all medically- and age-appropriate vaccines.

The Centers for Disease Control and Prevention (CDC) published vaccine recommendations for immunizations during the COVID-19 pandemic.1 Routine vaccination is an essential preventive care service for children, adolescents, and adults (including pregnant people) that should not be delayed because of the COVID-19 pandemic, noted the agency.  

All providers need to be up to date with the Advisory Committee on Immunization Practices (ACIP) recommendations to ensure that children receive all of the age-appropriate vaccines they are medically capable of receiving.2 It is important to assess the vaccination status of all children and adolescents at each patient visit to avoid missed opportunities for vaccination and ensure timely vaccine catch-up.

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All vaccines due or overdue should be administered according to the recommended ACIP schedules during that visit unless a specific contraindication exists.  Identify children who have missed well-child visits and/or recommended vaccinations and contact parents to schedule in-person appointments, starting with newborns, infants, and children up to 24 months, young children, and extending through adolescence.

If vaccines for pregnant people (tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis [Tdap] and influenza) have been delayed because of reduced or deferred in-person prenatal care visits, schedule patients for follow-up and administer vaccinations during the next in-person appointment. Provide protection as soon as possible. Giving vaccines during regularly scheduled follow-up visits will reduce the number of health care visits needed to complete vaccination.1

The 2021 ACIP cover sheet of the pediatric/adolescent schedule now includes links to shared decision-making recommendations and updated abbreviations for some of the vaccines. The Recommended Child and Adolescent Immunization Schedule by Medical Indication section has been clarified with additional color coding. While a medical condition may be a contraindication to a vaccine, once that condition has resolved that vaccine may be safely given.2

The following case examples will illustrate some of the ACIP updates.

Case Study 1

  • A 6-year-old fell in the playground and needs sutures for a 2-cm wound of the left knee. The wound is easily approximated and closed with 4 sutures. When the immunization record is checked, it is noted that the child completed the 4-dose primary series of DTaP at age 15 months. What is your course of action regarding DTaP for this child?

In 2021, the DTaP note was revised to include a “special situations” section containing information about the recommendation for use of DTaP in wound management. Wound management in children younger than 7 years with a history of 3 or more doses of tetanus-toxoid-containing vaccine has been updated.

The new guidelines state that for all wounds except clean and minor wounds, administer DTaP if it is more than 5 years since the last dose of tetanus-toxoid-containing vaccine. In the case study, the child would need an additional dose of DTaP at this time.3

Case Study 2

  • A 4-year-old child comes in for a routine examination. On reviewing his medical records, the child only had 1 dose of Hib vaccine administered at age 15 months. What is your course of action for this child?

The current Hib vaccine immunization schedule is illustrated in Table 1. The Hib note was revised to indicate that for catch-up vaccination, no further doses are recommended if a previous dose was administered at 15 months or older.4

Table 1. Haemophilus Influenza Vaccine Schedule4

Dose 1 at age 7–11 monthsAdminister dose 2 at least 4 weeks later and dose 3 (final dose) at age 12–15 months or 8 weeks after dose 2 (whichever is later)
Dose 1 at age 12–14 monthsAdminister dose 2 (final dose) at least 8 weeks after dose 1
Dose 1 before age 12 months and dose 2 before age 15 monthsAdminister dose 3 (final dose) 8 weeks after dose 2
Two doses of PedvaxHIB before age 12 monthsAdminister dose 3 (final dose) at age 12–59 months and at least 8 weeks after dose 2
One dose administered at 15 months or olderNo further doses needed
Unvaccinated at age 15–59 monthsAdminister 1 dose
Previously unvaccinated children age ≥60 months who are not considered high riskDo not require catch-up vaccination (CDC Hib, 2021, February)

Case Study 3

  • A 2-month-old infant, a preemie born of a hepatitis B-positive mother and weighing 1600 gm at birth, received a birth dose of hepatitis B vaccine. How will you complete the hepatitis B vaccine series for this infant?

Based on the hepatitis B vaccine schedule in Table 2, the infant would receive a dose at the time of the visit, another dose at age 4 months, and a dose at age 6 months.5

Table 2.  Hepatitis B Vaccine Schedule for Infants5

Mother is HBsAg-positive  • Administer hepatitis B vaccine and hepatitis B immune globulin (HBIG) (in separate limbs) within 12 hours of birth, regardless of birth weight. For infants <2000 g, administer 3 additional doses of vaccine (total of 4 doses) beginning at age 1 month Test for HBsAg and anti-HBs at age 9–12 months. If hepatitis B series is delayed, test 1–2 months after final dose
Mother’s HBsAg status is unknown  Administer hepatitis B vaccine within 12 hours of birth, regardless of birth weight For infants <2000 g, administer HBIG in addition to hepatitis B vaccine (in separate limbs) within 12 hours of birth. Administer 3 additional doses of vaccine (total of 4 doses) beginning at age 1 month Determine mother’s HBsAg status as soon as possible. If mother is HBsAg-positive, administer HBIG to infants ≥ 2,000 gm as soon as possible, but no later than 7 days of age

There are 2 options for hepatitis B immunization now available for adolescents aged 18 years. Heplisav-B can be given to these adolescents with a 2 dose 0- and 1-month schedule.5 Twinrix is administered in either a 3 dose series (0, 1, 6 months) or a 4 dose series (0, 7, 21-30 days, 1 year).5 This schedule would be useful for an unvaccinated adolescent 18 years or older who is traveling to an area endemic for hepatitis A and hepatitis B and had a short amount of time before travel.

Human Papilloma Vaccine (HPV)

The HPV note has been revised to include recommendations for interrupted schedules. If the vaccination schedule is interrupted, the series does not need to be restarted. No additional doses are recommended after completing the series with recommended dosing intervals using any HPV vaccine. For those aged 9 to 14 years at initial vaccination a 2-dose series at 0 and 6 to 12 months (minimum interval: 5 months; repeat the dose if administered too soon). For those 15 years or older at initial vaccination a 3-dose series at 0, 1 to 2 months, and 6 months is recommended. The minimum intervals between dose 1 to dose 2 is 4 weeks; from dose 2 to dose 3, 12 weeks; from dose 1 to dose 3,  5 months; repeat dose if administered too soon).6


The special situations section of the influenza note has been revised for persons who have egg allergy with symptoms other than hives, and for situations where Live attenuated influenza vaccine (LAIV4) should not be used, including7:

  • Egg allergy, hives only: any influenza vaccine can be given that is appropriate for age and health status annually
  • Egg allergy with symptoms other than hives (eg, angioedema, respiratory distress, the need for emergency medical services, or epinephrine). Any influenza vaccine appropriate for age and health status annually. If using an influenza vaccine other than Flublok or Flucelvax, administer in a medical setting under the supervision of a health care provider who can recognize and manage severe allergic reactions.

Severe allergic reactions to vaccines can occur even in the absence of a history of a previous allergic reaction. All vaccination providers should be familiar with the office emergency plan and certified in cardiopulmonary resuscitation. A previous severe allergic reaction to influenza vaccine is a contraindication to future receipt of any influenza vaccine.2

LAIV4 should not be used in persons with the following conditions or situations:

  • History of severe allergic reaction to a previous dose of any influenza vaccine or to any vaccine component (excluding egg)
  • Receiving aspirin or salicylate-containing medications
  • Aged 2–4 years with history of asthma or wheezing
  • Immunocompromised due to any cause (including medications and HIV infection)
  • Anatomic or functional asplenia
  • Close contacts or caregivers of severely immunosuppressed persons who require a protected environment
  • Pregnancy
  • Cochlear implant
  • Cerebrospinal fluid-oropharyngeal communication
  • Children younger than 2 years
  • Received the influenza antiviral medications oseltamivir or zanamivir within the previous 48 hours, peramivir within the previous 5 days, or baloxavir within the previous 17 days

Meningococcal Vaccine

Guidance regarding vaccination for children who received the meningococcal conjugate (MenACWY) vaccine prior to age 10 years has been added.8 The MenACWY note contains information about use of MenQuadfi, and the special situations section contains information about use of Menveo in infants who received dose 1 at age 3 to 6 months (Table 3). For infants who received the MenQuadfidose 1 at 24 months or older, the guidance recommends a 2-dose series at least 8 weeks apart.2

Table 3. Meningococcal ACWY Vaccine Schedule Changes2

For children with anatomic or functional asplenia (including sickle cell disease), HIV infection, persistent complement component deficiency, complement inhibitor (eg, eculizumab, ravulizumab) use Menveo:
Dose 1 at age 8 weeks: 4-dose series at 2, 4, 6, 12 months
• Dose 1 at age 3–6 months: 3- or 4- dose series (dose 2 [and dose 3 if applicable] at least 8 weeks after previous dose until a dose is received at age 7 months or older, followed by an additional dose at least 12 weeks later and after age 12 months)
Dose 1 at age 7–23 months: 2-dose series (dose 2 at least 12 weeks after dose 1 and after age 12 months)
Dose 1 at age 24 months or older: 2-dose series at least 8 weeks apart

Special situation guidance was published for pneumococcal vaccine. When both pneumococcal 13-valent conjugate vaccine (PCV13) and pneumococcal polysaccharide vaccine (PPSV23) are indicated administer PCV13 first; PCV13 and PPSV23 should never be administered at the same visit. For both younger children aged 2 to 5 years and older children aged 6 to 18 years for whom PPSV23 is indicated (but there is no history that it has been given), administer PPSV23 at least 8 weeks after completing all recommended doses of PCV13.2

COVID-19 Vaccines

We will not end the COVID-19 pandemic until we have a safe and effective vaccine for children. Pfizer vaccine is approved for children from 12 years of age and older; a study evaluated the safety and efficacy in children 6 months to 11 years is ongoing.9 Moderna is enrolling 30,000 children aged 12 to 15 years in a study of their vaccine, and results are expected this fall.10 A trial of the AstraZeneca vaccine in children as young as 6 years, has been paused pending a safety review by regulators in the United Kingdom.11

Mary Koslap-Petraco, DNP, PPCNP-BC, CPNP, FAANP, is a nurse consultant for the Immunization Action Coalition and Owner and CEO of Pediatric Nurse Practitioner House Calls.


1. Centers for Medicare & Medicaid Service. CMS issues urgent call to action following drastic decline in care for children in Medicaid and children’s health insurance program due to COVID-19 pandemic. CMS Newsroom. September 23, 2021. Accessed August 5, 2021.

2. Wodi AP, Ault K, Hunter P, McNally V, Szilagyi PG, Bernstein H. Advisory Committee on Immunization Practices recommended immunization schedule for children and adolescents aged 18 years or younger — United States, 2021. MMWR Morb Mortal Wkly Rep. 2021;70:189-192. doi:

3. Havers FP, Moro PL, Hunter P, Hariri S, Bernstein H. Use of tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccines: updated recommendations of the Advisory Committee on Immunization Practices — United States, 2019. MMWR Morb Mortal Wkly Rep. 2020;69(3):77-83. doi:10.15585/mmwr.mm6903a5

4. Centers for Disease Control and Prevention. Haemophilus influenza note. CDC Immunization Schedules. February 2021. Accessed August 5, 2021.

5. Centers for Disease Control and Prevention. Hepatitis B note. CDC Immunization Schedules. February 2021. Accessed August 5, 2021.

6. Centers for Disease Control and Prevention. Human papillomavirus note. CDC Immunization Schedules. February 2021. Accessed August 5, 2021.

7. Centers for Disease Control and Prevention. Interim guidance for routine and influenza immunization services during the COVID-19 pandemic. April 6, 2021. Accessed August 5, 2021.

8. Centers for Disease Control and Prevention. Meningococcal note CDC Immunization Schedules. February 2021. Accessed August 5, 2021.

9. Pfizer. Pfizer-BioNTech announce positive topline results of pivotal COVID-19 vaccine study in adolescents. Pfizer news, March 31, 2021.  Accessed August 5, 2021.

10. Moderna. Moderna announces first participants dosed in phase 2/3 study of COVID-19 vaccine candidate in pediatric population. Moderna press release, March 16, 2021. Accessed August 5, 2021.

11. Cunningham E, Lati M. Oxford pauses AstraZeneca vaccine trial in children. The Washington Post, April 6, 2021. Accessed August 5, 2021.