Since 1985, the use of 23-valent pneumococcal polysaccharide vaccines (23 PS) (Pnu-Immune 23 by Lederle Laboratories and Pneumovax by Merck & Co.) have been recommended for children older than 2 years who are at high risk of invasive pneumococcal disease. However, these vaccines were not recommended for younger children and infants because of poor antibody response prior to 2 years of age. In February 2000 another vaccine, heptavalent pneumococcal conjugate vaccine (PCV7) (Prevnar by Lederle Laboratories/Wyeth-Ayerst Pharmaceuticals), was approved by the Food and Drug Administration (FDA).
Studies have shown that PCV7 induces protective antibody responses
in more than 90% of infants after 3 doses given at 2, 4 and 6 months of age.
The American Academy of Pediatrics recommends the routine intramuscular
administration of PCV7 to all children 23 months and younger, at 2, 4, 6, and
12 to 15 months. The initial 2-month dose should be given no earlier than 6
weeks of age. Infants of very low birth weight (
1500 g) should be immunized at the time they attain a
chronological age of 6 to 8 weeks, regardless of their calculated gestational
age.
All children 23 months and younger who have not received doses of PCV7 before 6 months of age should be given catch-up doses as follows: children 7 to 11 months old should receive 2 doses at least 6 to 8 weeks apart, followed by a third dose at 12 to 15 months of age or at least 6 to 8 weeks after the second dose; and children 12 to 23 months old should receive 2 doses at least 6 to 8 weeks apart.
Two doses of PCV7 are recommended for children 24 to 59 months old at high risk of invasive pneumococcal infection - including children with functional, anatomical, or congenital asplenia; infection with human immunodeficiency virus; and other predisposing conditions - who have not been immunized previously with PCV7. High-risk children should be given PVCT7 or 23PS vaccine at the earliest possible opportunity.
Safety and efficacy of PCV7 and 23PS in children 24 months or older at moderate or lower risk of invasive pneumococcal infection remains under investigation. Current FDA indications are for administration of PCV7 only to children younger than 24 months. However, all children 24 to 59 months old, whether or not they are a low or moderate risk, may benefit from the administration of pneumococcal immunizations. Therefore, a single dose of PCV7 or 23PS vaccine may be given to children 24 months or older. The 23PS is an acceptable alternative to PCV7, although an enhanced immune response and probable reduction of nasopharyngeal carriage favor the use of PCV7.
All doses of PCV7 may be administered concurrently with other childhood immunizations, including all diphtheria and tetanus toxoids and acellular pertussis (DTaP) vaccines, all Haemophilus influenzae type b conjugate vaccines, both hepatitis B vaccines, inactivated poliovirus vaccine, measles-mump-rubella vaccine, and varicella vaccine, using a separate syringe for the injection of each vaccine and administering each vaccine at a different site. Adverse events after the administration for Prevnar include local swelling or erythema at the injection site and some increase in the incidence of postimmunization fever when it is given with other childhood vaccines.
Following the widespread use of Haemophilus influenzae type b vaccines, Streptococcus pneumoniae has become the most common cause of bacteremia, sepsis, meningitis, pneumonia, sinusitis, and acute otitis media (AOM) in children. Children at increased risk of pneumococcal infections include those with anatomical or functional asplenia (including sickle-cell disease [SCD]); recipients of immunosuppressive chemotherapy (particularly children with hematopoietic and lymphoreticular malignancies); those with congenital and acquired immune deficiency (including human immunodeficiency virus [HIV] infections; those with chronic renal disease (including nephrotic syndrome); healthy Native American (American Indian and Alaska Native) and African American children; and children younger than 60 months in out-of-home care. It is hoped that the routine use of the new pneumococcal vaccine will reduce the incidence of these serious childhood illnesses.
Nurses need to be aware of the importance of the pneumococcal vaccines and their indication for immunization of all infants and children at high risk. With the addition of four more intramuscular injections to the list of routine immunizations, nurses must consider appropriate injection sites and pain control measures. Infants can receive as many as 5 injections in one visit, with each one in a different site. The acceptable injection sites for infants include both the vastus lateralis (outer thigh) and the ventrogluteal muscle. Unfortunately, many health professionals are unfamiliar with the ventrogluteal or hip site and confuse it with the dorsogluteal or buttock site. The ventrogluteal site is safe, easy to locate, and may be less painful than the thigh. To reduce the pain of the intramuscular injection, EMLA may be applied two and one-half hours before administration or a vapocoolant spray may be used immediately before the injection.
March 15, 2002