Although immunization rates have fallen since the start of the COVID-19 pandemic in 2020, rates have begun to rise but have yet to hit pre-pandemic levels.1,2 Back to school is the perfect time to catch up on those delinquent vaccines. The Centers for Disease Control and Prevention (CDC) publishes updated immunization schedules annually in mid- to late February. Further updates are published as the Advisory Committee on Immunization Practices (ACIP) reviews and accepts new best available evidence. This article reviews immunization update on 2024 vaccine schedules for infants, children, and adolescents, as well as the additional changes that have been accepted by ACIP that are in the process of being implemented.3-6
The CDC has provided general information on childhood immunization schedules based on the data they have gathered during the year. The disruptions to health care services during the pandemic resulted in declines in outpatient pediatric visits. Fewer vaccine doses were administered, putting children at risk for vaccine-preventable diseases. Health care providers are encouraged to work with families to keep, or bring, children up to date with their immunization schedules.
Actionable strategies, resources, and data have been offered by the CDC under the RISE (Routine Immunizations on Schedule for Everyone) paradigm, which provides suggestions for health care professionals and partners to ensure everyone catches up on their routine vaccinations. Interventions include identifying individuals behind on their vaccinations; encouraging vaccination catch-up through reminders, recall, and outreach; making strong vaccine recommendations; and making vaccines easy for everyone to find and afford.4
Health care providers are encouraged to contact children who have missed vaccines to schedule in-person appointments. Access to state-based immunization information systems (registries) and electronic health records is a primary means to locate these children.3
To prevent opportunistic infections, the CDC suggests primary care practices continue to use strategies to separate well-child visits from sick visits. Schedule sick visits and well-child visits during different times of the day. Reduce crowding in waiting rooms or set up triage booths to screen patients safely. Collaborate with other health care providers in the community to identify separate locations for providing well-child visits for children.3
2023 CDC Recommendations for Children and Teens
COVID-19 vaccines, measles, mumps, and rubella vaccine, live (Priorixâ), and 15-valent pneumococcal conjugate vaccine (PCV15) were added to the child and adolescent schedule. The text was revised for vaccine injury compensation to include the Countermeasures Injury Compensation Program for COVID-19 vaccines. New abbreviations for the COVID-19 vaccine products were added. These abbreviations contain information on the vaccine’s valency (ie, monovalent vs bivalent, indicated by “1v” and “2v,” respectively) and vaccine platform (messenger RNA [mRNA] vs acellular protein subunit, or aPS).3 A caveat regarding the COVID-19 vaccines on the schedule: Recommendations for these vaccines have been updated since the immunization schedule was published. Please see https://www.cdc.gov/vaccines/covid-19/clinical-considerations/covid-19-vaccines-us.html for the most up-to-date information on COVID-19 vaccines. You will be happy to see that the schedules and dose types have been greatly simplified. Excellent and easy-to-use job aids also have been included in the updated recommendations.5
Other specific updated recommendations for COVID-19 vaccines were also included in this most recent update. The FDA removed the authorizations for monovalent mRNA COVID-19 vaccines. Bivalent mRNA COVID-19 vaccines are now authorized for both primary and booster doses. No changes have been made to the current Novavax COVID-19 vaccine authorization, which can be administered to children aged 12 years and older as an alternative to the mRNA vaccines. Transition to bivalent COVID-19 vaccines should simplify the presentations, reduce administration errors, and allow continued access to vaccines with the expiration of monovalent products. Johnson & Johnson’s Janssen COVID-19 vaccine has been removed from the market and is no longer available in the United States.
It was also noted that an increased interval between COVID-19 vaccine doses may both increase the incremental benefits of a COVID-19 vaccine and decrease the risk for myocarditis, but vaccine protection likely declines over time. The winter months and the increasing number of variants, such as the most recently identified strain EG.5, have affected COVID-19 epidemiology.5
The CDC is now advising that a simplified, annual recommendation could help reduce vaccine and message fatigue. A plan for a fall COVID-19 booster dose could provide added protection, at a time when many would be approximately 1 year from their last dose. Future epidemiology and SARS-CoV-2 virus evolution could help determine the need for continued annual booster doses.5
If someone has not received a bivalent COVID-19 vaccine dose yet, they are recommended to receive one, regardless of their vaccine history. Specifically, the FDA authorized a single age-appropriate mRNA COVID-19 vaccine dose for most previously vaccinated individuals. Children 6 months to 4 or 5 years of age need 1, 2, or 3 doses of a bivalent mRNA COVID-19 vaccine depending on their vaccine history. Children who are 6 months through 5 years should receive at least 2 COVID-19 vaccine doses, including at least 1 bivalent COVID-19 vaccine. The number of doses depends on age, as well as the number and type of prior COVID-19 vaccine doses received.5
One change has been made to the Catch-Up Schedule.6 This is probably the most important table in the schedule since so many children are behind on their doses. Pneumococcal conjugate vaccine catch-up recommendations now note that the interval between the final dose in the series is 8 weeks. This dose is only necessary for children 12 to 59 months regardless of risk, or age 60 through 71 months with any risk who received 3 doses before age 12 months.3
The American Academy of Pediatrics (AAP) has published a new recommendation regarding the age to begin human papillomavirus (HPV) immunization.7 Although this age recommendation is not standardized on the CDC schedule, the AAP makes a compelling case to start HPV immunization at age 9 years. Beginning this series at age 9 years often takes the “‘sex talk”‘ out of the equation. Adolescents who started the HPV vaccine series at age 9 or 10 were 22 times more likely to complete the 2-dose series by age 15 compared with those who initiated the series at age 11 or 12. Starting the series at age 9 years, for example, offers the opportunity to complete the series before the other vaccines in the adolescent platform are due.7 The immune response to HPV vaccine is better at a younger age, and the case can be made for starting at age 9 for parents who prefer fewer shots at each visit.
Meningococcal serogroup B vaccination (Meningitis B) recommendations have been updated. The Special Situations section was revised to add guidance stating that if the second dose of Trumenbaâ is administered at least 6 months or greater after the first dose, the third dose is not needed. In addition, if the third dose of Trumenba is administered earlier than 4 months after the second dose, a fourth dose should be administered at least 4 months after the third dose. Please remember brands cannot be interchanged. The same brand must be used for all doses, or the series will need to be started again!3
Pneumococcal vaccine recommendations for children were updated at the June 2023 ACIP Meeting.8 Use of either PCV15 or PCV20 is now recommended for all children aged 2 to 23 months, according to currently recommended PCV dosing and schedules. For children with incomplete PCV vaccination status, the use of either PCV15 or PCV20 is recommended for healthy children aged 24 to 59 months, and children with specified health conditions aged 24 through 71 months, according to currently recommended PCV dosing and schedules (Table).8 For children aged 2 to18 years with any risk condition who have received all recommended doses before 6 years of age and who have had at least 1 dose of PCV20, no additional doses of any pneumococcal vaccine are indicated. This recommendation may be updated as additional data become available. If PCV13 or PCV15 is used, a dose of PCV20 or 23-valent pneumococcal polysaccharide vaccine (PPSV23) using previously recommended doses and schedule is recommended. For children aged 6 to18 years with any risk condition who have not received any dose of PCV13, PCV15, or PCV20, a single dose of PCV15 or PCV20 is recommended. When PCV15 is used, it should be followed by a dose of PPSV23 at least 8 weeks later if not previously given.8 The CDC also publishes a schedule by medical indication making it easier to ensure that these high-risk children receive the vaccines they need to protect their health as well as avoid those that are detrimental for them.3
Table. Risk Conditions for Pneumococcal Vaccine for Children8
- Cerebrospinal fluid leak
- Chronic heart disease
- Chronic kidney disease (excluding maintenance dialysis and nephrotic syndrome, which are included in immunocompromising conditions)
- Chronic liver disease
- Chronic lung disease (such as moderate persistent or severe persistent asthma)
- Cochlear implant
- Congenital or acquired asplenia or splenic dysfunction
- Congenital or acquired immunodeficiencies
- Diabetes mellitus
- Diseases and conditions treated with immunosuppressive drugs or radiation therapy (such as malignant neoplasms, leukemias, lymphomas, Hodgkin disease, and solid-organ transplant)
- HIV infection
- Immunocompromising conditions (on maintenance dialysis or with nephrotic syndrome, sickle cell disease, and other hemoglobinopathies)
The long-awaited respiratory syncytial ‘vaccine’ (RSV) for infants has been approved by the FDA.9 It is a long-acting anti-RSV monoclonal antibody, but it is being treated like a vaccine. Nirsevimab-alip (Beyfortus) was approved for newborns and infants born during or entering their first RSV season, and for children up to 24 months of age who remain vulnerable to severe RSV disease through their second RSV season.9 This product is recommended to prevent RSV disease and is administered as 1 dose prior to the RSV season. A maternal RSV vaccine, which will be administered to pregnant people at 24 to 36 weeks’ gestation, has been approved by the FDA. Risks and benefits of both RSV prefusion F (Abrysvo) maternal vaccine and nirsevimab should be considered when deciding on maternal vaccination. If the mother is vaccinated, nirsevimab can be considered if the infant is thought to have insufficient protection from vaccine or at high risk for severe disease.9
The “Special Situations” section was updated for influenza vaccine. Live attenuated influenza vaccines should not be administered to close contacts of immunosuppressed people who require a protected environment. Recommendation for people with egg allergy with symptoms other than hives was moved from the appendix to this ”section. All people aged 6 months and older with egg allergy should receive an influenza vaccine. Any influenza vaccine (egg-based or non–egg-based vaccine) that is otherwise appropriate for the recipient’s age and health status can be used.3
The measles, mumps, and rubella (MMR) vaccination note was updated to include the recommendations for additional MMR doses in the setting of a mumps outbreak.3
Other Updates and Apps
For clarification, the Contraindications column was updated to Contraindicated or Not Recommended.3 The CDC has also provided apps for iPhone and Android phones that can be downloaded. One app is the CDC schedule, which puts all vaccine scheduling at your fingertips. The other is the pneumococcal vaccine scheduler, which will indicate whether a pneumococcal vaccine is indicated once previously known pneumococcal information is entered into the app. These simple-to-use apps make immunizations almost foolproof.
The number one public health achievement has been the development of vaccines and widespread vaccination programs. Although the pandemic and vaccine hesitancy have eroded immunization rates, rates of vaccinations are beginning to increase globally.10 Vaccine hesitancy is alive and well, but several resources are available that provide guidance on working with those who question the need and safety of vaccines.
What are clinicians going to do to help increase the rate of vaccinations? Establish trust with parents. Use paradigms that do not belittle or harass parents, and keep the conversation going even if patients refuse or delay vaccines. Back to school is the perfect time to get all of those children to catch up on much-needed vaccines. If this opportunity is lost, the next pandemic could be caused by a vaccine-preventable disease.
- CDC National Center for Immunization and Respiratory Diseases (NCIRD) www.cdc.gov/vaccines
- Children’s Hospital of Philadelphia Vaccine Education Center https://www.chop.edu/centers-programs/vaccine-education-center
- Families Fighting Flu https://www.familiesfightingflu.org/
- Immunize.org www.immunize.org
- Meningitis B Action Project https://meningitisbactionproject.org/
- Meningococcal Vaccine Q & A for Healthcare Providers https://www.health.ny.gov/prevention/immunization/meningococcal/docs/meningococcal_qa.pdf
- Nurses Who Vaccinate https://nurseswhovaccinate.org/
- Vaccinate Your Family www.vaccinateyourfamily.org
- Voices for Vaccines https://www.voicesforvaccines.org/
Mary Koslap-Petraco, DNP, PPCNP-BC, CPNP FAANP, is a clinical assistant professor at Stony Brook University School of Nursing, in Stony Brook, NY, and a primary care provider in private practice. Dr Koslap-Petraco is also Chair of the Scientific Advisory Board of Vaccinate Your Family and a Nurse Consultant for Immunize.org.
- DeSilva MB, Haapala J, Vazquez-Benitez G, et al. Association of the COVID-19 pandemic with routine childhood vaccination rates and proportion up to date with vaccinations across 8 US health systems in the Vaccine Safety Datalink. JAMA Pediatr. 2022;176(1):68-77.
- Childhood immunization begins recovery after COVID-19 backslide. World Health Organization. Published July 18, 2023. Accessed August 22, 2023. https://www.who.int/news/item/18-07-2023-childhood-immunization-begins-recovery-after-covid-19-backslide
- General information on childhood vaccinations. Centers for Disease Control and Prevention. Last reviewed February 10, 2023. Accessed August 22, 2023. https://www.cdc.gov/vaccines/schedules/hcp/schedule-changes.html?ACSTrackingID=USCDC_11_2-DM99336&ACSTrackingLabel=2023%20Recommended%20Immunization%20Schedules%20Now%20Online&deliveryName=USCDC_11_2-DM99336
- Routine immunizations on schedule for everyone (RISE). Centers for Disease Control and Prevention. Last reviewed August 3, 2023. Accessed August 22, 2023. https://www.cdc.gov/vaccines/partners/routine-immunizations-lets-rise.html
- Use of COVID-19 vaccines in the United States: interim clinical considerations. Centers for Disease Control and Prevention. Updated May 12, (2023. Accessed August 22, 2023. https://www.cdc.gov/vaccines/covid-19/clinical-considerations/covid-19-vaccines-us.html
- Catch-up immunization schedule for children and adolescents who start late or who are more than 1 month behind. Centers for Disease Control and Prevention. Accessed August 21, 2023. https://www.cdc.gov/vaccines/schedules/hcp/imz/catchup.html
- O’Leary ST, Nyquist A-C. Why AAP recommends initiating HPV vaccination as early as age 9. AAP News. Published online October 4, 2023. Accessed August 22, 2023. https://publications.aap.org/aapnews/news/14942?autologincheck=redirected
- Advisory Committee on Immunization Practices (ACIP). ACIP recommendations – pneumococcal vaccines. Last reviewed August 4, 2023. Accessed August 22, 2023. https://www.cdc.gov/vaccines/acip/recommendations.html
- FDA approves new drug to prevent RSV in babies and toddlers. News release. FDA; July 17, 2023. Accessed August 22, 2023. https://www.fda.gov/news-events/press-announcements/fda-approves-new-drug-prevent-rsv-babies-and-toddlers
- Centers for Disease Control and Prevention. “Ten great public health achievements—United States, 1900-1999.” MMWR Morbid Mortal Wkly Rep. 1999;48(12):241-243. Erratum in: MMWR Morb Mortal Wkly Rep 2023;72(2):268.