Vaccination Schedule: HIV-Infected 0-6 Years of Age

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VACCINATION SCHEDULE: HIV-INFECTED 0–6 YEARS OF AGE

This schedule summarizes recommendations for routine
administration of vaccines for HIV-infected children
0–6yrs and indicates the recommended ages for vaccine
administration in this population for childhood vaccines
licensed in the United States. Any dose not administered
at the recommended age should be administered at a
subsequent visit, when indicated and feasible. Licensed
combination vaccines may be used whenever any
component of the combination is indicated and other
components of the vaccine are not contraindicated and if
approved by the Food and Drug Administration for that
dose of the series. Providers should consult the
relevant Advisory Committee on Immunization Practices
statement for detailed recommendations. Clinically
significant adverse events that follow immunization
should be reported to the Vaccine Adverse Event
Reporting System (VAERS). Guidance about how to
obtain and complete a VAERS form is available at
www.vaers.hhs.gov or telephone (800) 822-7967.

*These recommendations should also be used for
perinatally HIV-exposed children who are awaiting
laboratory confirmation that they are HIV-uninfected.

 

  Range of recommended ages
for vaccination
  Certain high-risk groups

 

Vaccine Age
Birth 1
mo
2
mos
4
mos
6
mos
12
mos
13
mos
15
mos
18
mos
19–23
 mos 
2–3
yrs
4–6
yrs
Hepatitis B1 Hep B Hep B see footnote 1 Hep B      
Rotavirus2     RV RV RV2              
Diphtheria,
Tetanus,
Pertussis
3
    DTaP DTaP DTaP see footnote 3   DTaP     DTaP
Haemophilus
influenzae

type b
4
    Hib Hib Hib4 Hib        
Pneumococcal5     PCV PCV PCV PCV     PPSV
Inactivated
Poliovirus
6
    IPV IPV IPV     IPV
Influenza7         TIV (Yearly)
Measles,
Mumps,
Rubella
8
          MMR           MMR
      Do not administer to severely
immunosuppressed children 
Varicella>9           Varicella   Varicella        
      Do not administer to severely
immunosuppressed children 
 
Hepatitis A10           Hep A (2 doses) Hep A Series
Meningococcal11     MCV4

1. Hepatitis B vaccine (Hep B). (Minimum age: birth)

At birth:

• Administer monovalent Hep B to all newborns before hospital discharge.

• If mother is hepatitis B surface antigen (HBsAg)-positive, administer Hep B and 0.5mL of hepatitis B immune globulin (HBIG) within 12hrs after birth.

• If mother's HBsAg status is unknown, administer Hep B within 12hrs after birth. Determine mother's HBsAg status as soon as possible and if HBsAg-positive, administer HBIG (at no later than age 1wk).

After the birth dose:

• The Hep B series should be completed with either monovalent Hep B or a combination vaccine containing Hep B. The second dose should be administered at age 1–2mos. Monovalent Hep B should be used for doses administered before 6wks. The final dose should be administered no earlier than age 24wks. Infants who did not receive a birth dose, should receive 3 doses of a Hep B-containing vaccine on an age-appropriate schedule.

4-month dose:

• It is permissible to administer 4 doses of Hep B when combination vaccines are administered after the birth dose. If monovalent Hep B is used for doses after the birth dose, a dose at age 4mos is not needed.

Post-vaccination:

• Infants born to HBsAg+ mothers should be tested for HBsAg and the antibody to HBsAg (anti-HBs) after completion of at least 3 doses of a licensed Hep B series, at 9–18mos (at next well-child visit).

• Testing is recommended for HIV-infected children and should be performed 1–2mos after administration of the last dose of the vaccine series using a method that allows determination of a protective level of anti-HBs (≥10 mIU/mL).

• Children with anti-HBs <10 mIU/mL after the primary schedule should receive a second series, followed by anti-HBs testing 1–2mos after the third dose, which usually is more practical than serologic testing after one or more doses of vaccine.

Booster dose:

• In HIV-infected children, the need for booster doses has not been determined. Annual anti-HBs testing and booster doses when anti-HBs levels decline to <10 mIU/mL should be considered in persons with ongoing risk for exposure. See MMWR 2005:54(No. RR-16).

2. Rotavirus vaccine (RV). (Minimum age: 6wks)

• Practitioners should consider the potential risks and benefits of administering rotavirus vaccine to infants with known or suspected altered immunocompetence; consultation with an immunologist or infectious diseases specialist is advised. Limited safety or efficacy data are available for the administration of rotavirus vaccines to infants who are potentially immunocompromised, including those who are HIV infected. However, the following considerations support vaccination of HIV-exposed or HIV-infected infants: a) in infants born to HIV-positive mothers, the HIV diagnosis may not be established before the age of the first rotavirus vaccine dose (only 1.5%–3% of HIV-exposed infants in the U.S. will eventually be determined to be HIV infected); and b) vaccine strains of rotavirus are considerably attenuated.

• The max age for the first dose in the series is 14wks and 6 days; for the final dose in the series, it is 8mos and 0 days. Vaccination should not be initiated for infants ≥15wks old.

• If Rotarix is administered at ages 2 and 4mos, a dose at 6mos is not indicated.

3. Diphtheria and tetanus toxoids and acellular pertussis vaccine (DTaP). (Minimum age: 6wks)

• The fourth dose may be administered as early as age 12mos, provided at least 6mos have elapsed since the third dose.

4. Haemophilus influenzae type b conjugate vaccine (Hib). (Minimum age: 6wks)

• If PRP-OMP (PedvaxHIB or Comvax [Hep B-Hib]) is administered at ages 2 and 4mos, a dose at age 6mos is not indicated.

• Hiberix should not be used for doses at ages 2, 4, or 6mos for the primary series but may be used as the final dose in children aged 12mos–4yrs.

• One dose of Hib vaccine should be administered to unvaccinated or partially vaccinated persons ≥5yrs old who have leukemia, malignant neoplasms, anatomic or functional asplenia (including sickle cell disease), HIV infection, or other immunocompromising conditions.

5. Pneumococcal vaccine. (Minimum age: 6wks for pneumococcal vonjugate vaccine [PCV]; 2yrs for pneumococcal polysaccharide vaccine [PPSV])

• A PCV series begun with 7-valent PCV (PCV7) should be completed with 13-valent PCV (PCV13). A single supplemental dose of PCV13 is recommended for children aged 14–71mos who have received an age-appropriate series of PCV7. For incompletely vaccinated children aged 24–71mos, administer 2 doses of PCV13 at least 8wks apart. Children who have previously received 3 PCV doses need only 1 dose.

• Children ≥2yrs old also should receive PPSV after their last PCV dose.

6. Inactivated Polio Vaccine (IPV) (Minimum age: 6wks)

• If 4 or more doses are administered prior to age 4yrs, an additional dose should be administered at ages 4–6yrs.

• The final dose in the series should be administered on or after the fourth birthday and at least 6mos after the previous dose.

7. Trivalent Inactivated Influenza Vaccine (TIV). (Minimum age: 6mos for trivalent inactivated influenza vaccine [TIV])

• Administer annually to HIV-infected children 6mos–6yrs old and to all their eligible close contacts (including household members). Only TIV is recommended for HIV-infected children.

• For healthy nonpregnant close contacts aged 2–49yrs, either live, attenuated influenza vaccine (LAIV) or TIV may be used.

• Children receiving TIV should receive 0.25mL if aged 6–35mos or 0.5mL if ≥3yrs old.

• Administer 2 doses (separated by at least 4wks) to children <9yrs old per current influenza vaccine recommendations.

8. Measles, mumps, and rubella vaccine (MMR). (Minimum age: 12mos)

• Two doses of MMR vaccine for all HIV-infected individuals ≥12mos old who do not have evidence of current severe immunosuppression (eg, individuals aged ≤5yrs must have CD4 T lymphocyte [CD4] percentages ≥15% for ≥6mos; and individuals aged >5yrs must have CD4 percentages ≥15% and CD4 ≥200 lymphocytes/mm³ for ≥6mos) or other current evidence of measles, rubella, and mumps immunity. In cases when only CD4 cell counts or only CD4 percentages are available for those >5yrs, the assessment of severe immunosuppression can be based on the CD4 values (count or percentage) that are available. In cases when CD4 percentages are not available for those ≤5yrs old, the assessment of severe immunosuppression can be based on age-specific CD4 counts at the time CD4 counts were measured; eg, absence of severe immunosuppression is defined as ≥6mos above age-specific CD4 count criteria: CD4 count >750 lymphocytes/mm³ while aged ≤12mos and CD4 count ≥500 lymphocytes/mm³ while aged 1–5yrs.

• The first dose should be administered at ages 12–15mos and the second dose at ages 4–6yrs, or as early as 28 days after the first dose.

• Individuals with perinatal HIV infection who were vaccinated prior to establishment of effective combination antiretroviral therapy (cART) should receive 2 appropriately spaced doses of MMR vaccine once effective cART has been established (for individuals aged ≤5yrs: must have CD4 percentages ≥15% for ≥6mos; and for individuals aged >5yrs: must have CD4 percentages ≥15% and CD4 ≥200 lymphocytes/mm³ for ≥6mos) unless they have other acceptable current evidence of measles, rubella, and mumps immunity.

9. Varicella vaccine. (Minimum age: 12mos)

• Limited data are available on safety and immunogenicity of varicella vaccine in HIV-infected children aged 1–8yrs in CDC immunologic categories 1 and 2 (CD4+ T-lymphocyte percentages 15% or greater) and clinical categories N, A, and B.

• Single-antigen varicella vaccine should be considered for HIV-infected children who have CD4+ percentages ≥15%. Eligible children should receive 2 doses 3mos apart, with the first dose administered as soon as possible after the first birthday.

• Varicella vaccine is not recommended for HIV-infected children who have evidence of severe immunosuppression CD4 percentages ≥15% at any age; for those >5yrs, CD4 count <200 cells/mm³).

• MMRV vaccine has not been studied in HIV-infected children and should not be substituted for single-antigen varicella vaccine.

10. Hepatitis A vaccine (Hep A). (Minimum age: 12mos)

• Administer to all children aged 12–23mos). The 2 doses in the series should be administered at least 6mos apart.

• Children not fully vaccinated by age 2yrs can be vaccinated at subsequent visits.

• Hep A is also recommended for children 24mos and older who live in areas where vaccination programs target older children or who are at increased risk for infection. See 2006;55(No. RR-7).

11. Meningococcal vaccine. (Minimum age: 6wks for combination Haemophilus influenzae type b–meningococcal conjugate vaccine serogroup CY (Hib-MenCY); 9mos for meningococcal conjugate vaccine (MCV4); 2yrs for meningococcal polysaccharide vaccine (MPSV4)

• Administer MCV4 to children aged 2–6yrs who have functional asplenia and certain other high-risk groups. A primary series of 2 doses should be administered with a minimum interval of 8wks. See MMWR 2007;56(48):1265–6.

• Administer MCV4-D (Menactra) to infants/children 9–23mos who have persistent complement component deficiency, are traveling to an area endemic for meningococcal disease, or are involved in a meningococcal outbreak.

• Children who received MPSV4 ≥3yrs previously and remain at increased risk of meningococcal disease should be revaccinated with MCV4.

• HIV-infected children are not considered at increased risk of meningococcal disease because of HIV infection, per se. Although the efficacy of MCV4 among HIV-infected children is unknown, providers can vaccinate HIV-infected children.

• HIV-infected children who remain at increased risk of meningococcal disease should be vaccinated every 5yrs thereafter.

REFERENCES

Guidelines for Prevention and Treatment of Opportunistic Infections among HIV-Exposed and HIV-Infected Children. November 2013.
Available at: http://aidsinfo.nih.gov/contentfiles/lvguidelines/
oi_guidelines_pediatrics.pdf

(Rev. 10/2015)

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