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Patient information: Vaccines for children age 7 to 18 years (Beyond the Basics)

INTRODUCTION

In the United States, there are several vaccines that are routinely recommended for children and adolescents between the ages of 7 and 18 years. These include vaccines for Neisseria meningitidis (meningococcus), tetanus-diphtheria-acellular pertussis, and human papillomavirus. Influenza vaccine is recommended annually. Because the recommendation to add a second dose of varicella vaccine was made in 2006, some children will also need a second dose of varicella vaccine if both doses were not given previously.

The recommended schedule is available through the Centers for Disease Control and Prevention.

A separate topic review is available that discusses how vaccines work, the risks and benefits of vaccines, and common concerns regarding vaccine safety (see "Patient information: Why does my child need vaccines? (Beyond the Basics)"). A topic review is also available that discusses vaccines for infants and children age 0 to 6 years. (See "Patient information: Vaccines for infants and children age 0 to 6 years (Beyond the Basics)".)

Topic reviews that discuss immunizations for adults and immunizations for travel are reviewed separately. (See "Patient information: Adult vaccines (Beyond the Basics)" and "Patient information: Vaccines for travel (The Basics)".)

INFLUENZA

Commonly known as flu, influenza is a highly contagious viral infection that occurs in outbreaks worldwide, usually during the winter in the United States. Young children, older adults, and those with certain underlying medical conditions are at increased risk for severe or complicated influenza infection. Immunizing all children (and adults) can help decrease this risk. (See "Patient information: Influenza symptoms and treatment (Beyond the Basics)".)

Timing and dose — There are three ways to receive the flu vaccine: injection into muscle (intramuscularly), injection under the skin (intradermally), or as a nasal spray. The intramuscular injection can be given to adults and children 6 months and older, the intradermal injection can be given to adults 18 to 64 years of age, and the intranasal spray can only be given to people between 2 and 49 years of age. People who have a weakened immune system, are pregnant, or who have chronic heart, lung, kidney, or metabolic disease should not use the intranasal spray since it contains live virus that has been weakened. In very rare situations, household contacts of those who have severely weakened immune systems should also not receive the intranasal spray.

The influenza viruses change every year, which means that a reformulated vaccine must be given every year (most commonly in the fall). In the first year that a child (younger than age 9 years) receives the vaccine, two doses are recommended; the second dose is given at least one month after the first. The influenza vaccine does not prevent illnesses such as the common cold or strep throat.

The vaccine is recommended for all children 6 months and older, particularly those who:

Have chronic medical conditions (eg, lung or heart disease, diabetes, kidney disease, weakened immune conditions, nervous system disorders)

Live with a person who is at high risk for complications of influenza (eg, someone with chronic lung disease)

Influenza vaccine precautions — Most forms of the influenza vaccine are prepared with chicken eggs. Allergic reactions to influenza vaccine are rare. A severe (life-threatening) allergy to egg proteins may be a reason not to receive the vaccine; the vaccine may be given under supervision of an allergist. There is one injection vaccine approved for use in the United States that is made without involving eggs; this “recombinant” vaccine is available to those 18 years of age and older. (See "Allergic reactions to vaccines".)

Injectable influenza vaccine precautions — Vaccination may be delayed in children with moderate to severe illness until their symptoms have resolved. However, the vaccine does not need to be delayed in children with mild illnesses. A history of Guillain-Barré syndrome within six weeks of a flu vaccine is a precaution for all flu vaccines. Flu vaccine should only be given if the benefit of vaccination outweighs the risk.

Injectable influenza vaccine side effects — The most common side effect of the injectable vaccine is redness and soreness at the injection site. A low-grade fever may develop after vaccination. (See "Patient information: Fever in children (Beyond the Basics)".)

Nasal spray influenza vaccine precautions — The nasal spray form of influenza vaccine is not recommended for children who take aspirin daily or those with a weakened immune system, asthma, and other conditions (eg, chronic lung or heart problems, pregnancy, chronic metabolic disease, kidney dysfunction, and blood disorders). It may be necessary to delay the nasal vaccine or to use the injectable vaccine in children or adolescents with nasal congestion.

Influenza vaccine side effects — The most common side effects with the injectable influenza vaccines is pain at the injection site. Serious side effects are rare.

Side effects after the nasal spray vaccine may include nasal congestion or low-grade fever.

MENINGOCOCCAL

Neisseria meningitidis (meningococcus) is a bacterium that can cause meningitis and meningococcemia. Meningitis is an inflammation of the tissues surrounding the brain and spinal cord that causes symptoms of a stiff and painful neck. Meningococcus is the most common cause of bacterial meningitis in the United States. Meningococcemia is a serious infection of the bloodstream that can begin with dramatic rash and fever and lead to shock and death (picture 1). Meningitis and meningococcemia may occur separately or together.

In the United States, approximately 800 to 1500 cases of meningococcal disease occur each year. Large-scale epidemics occur in Africa, parts of Asia, South America, and the countries of the former Soviet Union.

Meningococcus first infects the lining of the nose and pharynx (wind pipe) and is transmitted from person to person by respiratory secretions (eg, from coughing, sneezing). Meningococcal infection is contagious and can spread quickly to close contacts of a person who is infected. This includes household members and anyone who kisses or shares toothbrushes or eating utensils.

Meningococcal disease can be treated in most people. However, the illness is frequently mistaken for a common viral illness (eg, cold) during the early stages, delaying diagnosis. Meningococcal disease often progresses quickly to serious illness or death. Serious long-term complications can occur, even in people who are treated promptly. Up to 15 percent of people who become infected die as a result of their infection. In survivors, 10 to 20 percent of patients have long-term complications, including hearing loss, nerve or brain damage, finger/toe amputation, or skin scarring.

Meningococcal vaccines are available to protect against the five common subtypes of meningococcus affecting humans. It is possible to become infected with meningococcus despite having received one of these vaccines, although the risk is significantly lower than in someone who is unvaccinated. (See "Patient information: Meningitis in children (Beyond the Basics)".)

Timing and dose — Expert groups recommend the meningococcal vaccine that addresses four of the five types affecting humans for all children age 11 or 12 years and a booster dose at age 16 years. Adolescents who receive the first dose of meningococcal vaccine between 13 and 15 years should receive a booster dose between 16 and 18 years of age. Those who receive the first dose after age 16 years do not need a booster dose.

This meningococcal vaccine is also recommended for children aged 2 months to 10 years who are at increased risk for meningococcal disease. The vaccination schedule for children at increased risk for meningococcal disease depends upon the underlying medical condition and whether they remain at increased risk for disease.

Meningococcal vaccine side effects — Approximately 70 percent of people have a local reaction (eg, tenderness, redness) at the injection site.

There is no thimerosal or mercury in the meningococcal vaccine, and there is no risk of becoming infected with meningococcus as a result of the vaccine.

TETANUS AND DIPHTHERIA, WITH OR WITHOUT ACELLULAR PERTUSSIS

Diphtheria is a highly contagious disease. It is usually transmitted via droplet particles that are coughed or sneezed into the air. It can cause a thick covering in the back of the throat that can lead to breathing problems or heart failure.

Tetanus is another very serious infection that is caused by the bacterial toxin of Clostridium tetani bacterium. The bacteria reside in soil and the intestinal tracts of certain mammals. The bacteria can enter the body through an open wound, multiply, and produce a toxin that can affect nerves controlling muscle activity. A common symptom of tetanus infection is stiffness of the jaw muscles ("lockjaw").

Tetanus and diphtheria disease are rare in the United States because of the high numbers of people who have been immunized. However, the consequences of untreated tetanus or diphtheria can be very serious.

Pertussis, or whooping cough, is an upper respiratory illness caused by the toxin of Bordetella pertussis bacteria. The organism is highly contagious, spreads easily and can cause serious illness, especially in infants.

The number of people infected with pertussis is rising to epidemic levels, especially in adolescents, despite widespread vaccination. The Centers for Disease Control and Prevention (CDC) reported over 48,000 cases of whooping cough in the United States in 2012 [1]. Since pertussis is significantly underreported, the number of people actually infected with pertussis each year in the United States is likely closer to 1 to 3 million.

Pertussis was added to the traditional Td booster for teenagers and adults because the vaccine's protection decreases after 5 to 8 years. Protection also decreases after being infected with pertussis. Thus, the vaccine is recommended even for people who have had the disease.

There are several forms of combined diphtheria, tetanus, and pertussis vaccines:

The DTaP, or diphtheria tetanus acellular pertussis vaccine, is used for routine immunization of children younger than 7 years of age.

The Tdap, or tetanus, reduced diphtheria, acellular pertussis vaccine, is recommended as a routine one-time dose for children at 11 to 12 years, for adolescents 13 to 18 years who were not previously immunized, and for pregnant women during each pregnancy. The vaccine is also recommended as a one-time dose for adults requiring the Td booster who have not previously received a Tdap, and as one of the series of catch-up doses of tetanus and diphtheria toxoid (Td) vaccines for children between 7 and 10 years of age who are incompletely vaccinated against tetanus, diphtheria, or pertussis. (See "Patient information: Adult vaccines (Beyond the Basics)".)

The Td, or tetanus and reduced diphtheria vaccine (without pertussis), is recommended for adolescents and adults who require tetanus vaccine and have already received one dose of Tdap.

Timing and dose — A single tetanus-containing booster vaccine is recommended for children and adolescents at age 11 to 12 years; Tdap is recommended unless there is an allergy to one of the vaccine components.

If an adolescent has an injury that requires a tetanus shot, Tdap may be given instead of Td, provided that the adolescent has not received Tdap previously. Only one dose of Tdap is recommended in a lifetime unless a young woman is pregnant; Tdap is recommended with each pregnancy to protect the infant. Subsequent booster doses of Td are recommended every 10 years throughout life. (See "Patient information: Adult vaccines (Beyond the Basics)".)

Tdap vaccine side effects — The most common side effect of the Tdap vaccine is pain at the injection site.

HUMAN PAPILLOMAVIRUS

Human papillomavirus (HPV) is a virus that can be spread by direct skin-to-skin contact, including sexual intercourse or experimentation, oral sex, anal sex, or other contact involving the genital area (eg, hand to genital contact). The risk of HPV exposure increases with the number of sexual partners. It is estimated that more than 50 percent of sexually active persons become infected with HPV at least once in their lifetime [2].

Over 100 different types of HPV have been identified, approximately 40 of which are known to infect the anogenital region and 15 of which are known to cause cancer. Researchers have labeled the HPV types as being high or low risk for cervical cancer. HPV types 6 and 11 can cause warts and are low-risk types because they rarely cause cervical or other cancers. Types 16 and 18 are high-risk types and cause most cases of cervical and other types of cancer (vaginal, vulvar, penile, anal, oropharyngeal); other high-risk types include 31, 33, 45, 52, 58.

A vaccine against HPV is available for males and females. The vaccine is discussed in greater detail separately. (See "Patient information: Human papillomavirus (HPV) vaccine (Beyond the Basics)".)

Timing and dose — The HPV vaccination series is recommended for all youth (males and females) at 11 to 12 years of age. The vaccine can be given as young as 9 years of age. The vaccine is also recommended for the following groups if they have not previously received the vaccination series:

Females 13 to 26 years of age

Males 13 to 21 years of age

Males (age 21 to 26 years) who have sex with males, have an impaired immune system, or would like to be protected

The vaccination series consists of three shots. The second shot is ideally given 1 to 2 months after the first, and the third shot is given 6 months after the first. If the second and third shots are delayed for any reason, it is not necessary to restart the vaccination series.

HPV vaccine side effects — There are no serious adverse events associated with the HPV vaccination series. The most common side effect is pain at the injection site.

VARICELLA (CHICKENPOX) VACCINE

Varicella is a highly contagious viral illness caused by infection with the varicella zoster virus (VZV). The disease causes fever, sore throat, and a distinctive, itchy rash with fluid-filled blisters that later form scabs. Complications of chickenpox can include bacterial infections of the skin, pneumonia, or, less commonly, inflammation of the brain. (See "Patient information: Chickenpox prevention and treatment (Beyond the Basics)".)

A vaccine to prevent chickenpox is recommended for all children. Two doses of varicella vaccine are recommended for children 0 to 6 years of age; the first is usually given at 1 year of age and the second at 4 to 6 years. A second dose is recommended if a child or adult is older than 7 years and was not previously given two doses of vaccine.

OTHER VACCINES

Children who are 7 to 18 years may need vaccines other than those mentioned above if they have missed any of the recommended vaccines for children age 0 to 6 years. This may include hepatitis A, hepatitis B, varicella, polio, or measles, mumps, and rubella vaccines. The recommended schedule is available through the Centers for Disease Control and Prevention. Detailed information about these vaccines is available separately. (See "Patient information: Vaccines for infants and children age 0 to 6 years (Beyond the Basics)".)

Children who are age 7 to 18 years may need additional vaccines if they are at high risk for certain infections, such as pneumococcal infection.

WHERE TO GET MORE INFORMATION

Your child's healthcare provider is the best source of information for questions and concerns related to your child's medical problem.

This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.

Patient level information — UpToDate offers two types of patient education materials.

The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.

Patient information: Vaccines for children age 7 to 18 years (The Basics)
Patient information: Vaccines (The Basics)
Patient information: Meningitis in children (The Basics)
Patient information: Vaccines for babies and children age 0 to 6 years (The Basics)
Patient information: Vaccines for travel (The Basics)
Patient information: Vaccines for adults (The Basics)
Patient information: Whooping cough (The Basics)
Patient information: Sickle cell anemia (The Basics)
Patient information: Tdap vaccine (The Basics)
Patient information: When your child has sickle cell disease (The Basics)

Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.

Patient information: Human papillomavirus (HPV) vaccine (Beyond the Basics)
Patient information: Why does my child need vaccines? (Beyond the Basics)
Patient information: Vaccines for infants and children age 0 to 6 years (Beyond the Basics)
Patient information: Adult vaccines (Beyond the Basics)
Patient information: Influenza symptoms and treatment (Beyond the Basics)
Patient information: Fever in children (Beyond the Basics)
Patient information: Meningitis in children (Beyond the Basics)
Patient information: Chickenpox prevention and treatment (Beyond the Basics)
Patient information: Influenza prevention (Beyond the Basics)
Patient information: Vaccines for travel (The Basics)

Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.

Allergic reactions to vaccines
Clinical trials of human papillomavirus vaccines
Meningococcal vaccines
Recommendations for the use of human papillomavirus vaccines
Standard immunizations for children and adolescents

The following organizations also provide reliable health information.

Centers for Disease Control and Prevention (CDC)

     Toll-free: (800) 311-3435
     (www.cdc.gov/)

National Library of Medicine

     (www.nlm.nih.gov/medlineplus/healthtopics.html)

National Institute of Allergy and Infectious Diseases

     (www.niaid.nih.gov/)

National Network for Immunization Information

     (www.immunizationinfo.org/)

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Literature review current through: Nov 2014. | This topic last updated: Dec 4, 2014.
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