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PEDIATRICS Vol. 104 No. 3 September 1999, pp. 564-567
Native American children are at greater
risk for certain diseases and conditions such as hepatitis A, hepatitis
B, and diseases caused by Haemophilus influenzae and
Streptococcus pneumoniae. Recommendations for vaccine use in
many Native American communities differ from those for the general
population; vigorous vaccination practices have resulted in a lowering
of the rates of morbidity and mortality from these preventable diseases
in Native American communities. This policy statement provides
immunization recommendations for children residing in Native American
communities, and will discuss how to modify these recommendations for
Native American children in particular situations.
Before universal Hib immunization for infants was realized,
invasive Hib disease occurred with increased frequency and at younger
ages in American Indian/Alaska Native (AI/AN) children compared
with the general US population. Annual case rates of Hib disease were
as much as 10-fold greater in AI/AN children. In ANs, 25% of all Hib
disease and 35% of Hib meningitis cases occurred before 6 months of
age, compared with 15% of all Hib disease and 17% of Hib meningitis
cases in non-ANs.1-3 A younger age among children with
invasive Hib disease also has been observed in other AIs/ANs, including
Apache and Navajo children in Arizona, Utah, and New
Mexico.4,5
Because of the risk of invasive Hib disease at younger ages, the
Indian Health Service (IHS) has recommended a preference for the
PRP-OMP (PEDVAX HIB) Hib conjugate vaccine based on seroconversion rates of 60% after the first dose of PRP-OMP, compared with rates of
only 20% for other Hib conjugate vaccines.6 Therefore, in
regions in which Hib disease in young infants continues to occur,
clinicians should consider using PRP-OMP for the first conjugate Hib
dose (eg, at 2 months) in AI/AN children. However, initiation of Hib
immunization should not be delayed if PRP-OMP is not available. The new
combined PRP-OMP/hepatitis B (COMVAX) vaccine may be used to reduce the
number of individual injections. This vaccine may be used for the first
scheduled conjugate Hib dose and any subsequent dose that is scheduled
for these two vaccines. In the event that PRP-OMP or PRP-OMP/hepatitis
B vaccines are not available, any conjugate Hib can be used for
subsequent doses, because it has been shown that the use of a conjugate
Hib other than PRP-OMP for subsequent doses is associated with
comparable or even higher antibody levels after the second or third
doses, compared with sequential use of PRP-OMP alone.7 If
more than one vaccine has been used for an individual child, four doses will be required.
Large outbreaks of hepatitis A occurring every 5 to 12 years
have been documented in AI/AN communities throughout the United States,
including the IHS Areas of Aberdeen (South Dakota, North Dakota,
Nebraska, and Iowa), Alaska, and Navajo (parts of Arizona, New Mexico,
and Utah).8 The annual incidence of hepatitis A in AI
communities in South Dakota exceeded the South Dakota non-AI incidence
rates by 33-fold during the period of 1990 to 1994 (92.6 vs 2.8 cases
per 100 000 per year, respectively).8 During a 1992 outbreak of hepatitis A in AN communities, the annual incidence was 322 cases per 100 000 in the population, compared with an incidence of 9.0 per 100 000 in the general US population.9 The
seroprevalence of antibodies to hepatitis A in the AN population has
been shown to increase from 7% in children to 85% in older adults.10 Similarly, among certain AI populations, the seroprevalence of antibodies to hepatitis A is 30% to 40% among children younger than 5 years of age, increasing to 90% to 100% among
persons older than 20 years of age.11
Routine hepatitis A vaccination of 2-year-old children in AI/AN
communities has been recommended by the Advisory Committee on
Immunization Practices (ACIP) of the Centers for Disease Control and
Prevention and the American Academy of Pediatrics
(AAP).12,13 In addition, children between 2 and 18 years of age who have not been immunized previously should be immunized
within the next 5 years. This "catch-up immunization" can be
achieved by vaccination of selected cohorts (eg, children 2 to 3 years
of age and/or those entering early childhood programs or school) each
year for 5 years. In communities experiencing new or continuing
outbreaks of hepatitis A, accelerated vaccination of older children
should be instituted. Consideration should be given to immunizing urban
AI/AN children older than 24 months because they are likely to be
exposed to children from AI/AN communities at high risk of hepatitis A
(eg, by being exposed to those living on reservations or in areas with known epidemic or high endemic rates of hepatitis A).
Before routine hepatitis B immunization, ANs experienced high
attack rates of acute hepatitis B (250 cases per 100 000 per year);
the seroprevalence of hepatitis B virus (HBV) infection (hepatitis B
surface antigen [HBsAg]) among ANs was 3.1% with an overall (13.8%)
prevalence of infection.14 In this population, the rate of
perinatal HBV infection is low and the majority of chronic infections
occur by person-to-person (horizontal) transmission during the first 5 years of life, including during infancy.15,16 Since the
institution of universal hepatitis B vaccination for infants and
children in Alaska in 1983, the rate of hepatitis B has decreased by
>98%, to <5.0 cases per 100 000 per year.16 In other
Native American populations the prevalence of chronic HBV infection is
similar to that found in the general US population. However, the
incidence of acute hepatitis B disease is high with most infections
occurring among young adults with known risk factors.17
Continued universal infant immunization is recommended, as is
continuing immunization of all Native American children and adults who
remain susceptible. In addition, universal serologic screening for
HBsAg among pregnant women is recommended. Infants born to mothers who
are HBsAg-positive or to mothers with acute hepatitis B should receive
postexposure prophylaxis with hepatitis B immunoglobulin and
hepatitis B vaccine according to the recommendations of the
Academy.13
The Academy issued an interim report on July 14, 1999 regarding the use
of thimerosal-containing vaccines (www.aap.org). Academy recommendations for prevention of hepatitis B in infants born to
HBsAg-positive mothers and infants born to women not tested for
HBsAg during pregnancy remain unchanged from the 1999 Recommended Childhood Immunization Schedule. If thimerosal-free vaccine is not
available, the AAP has recommended initiation of hepatitis B
vaccination at 6 months of age for infants born to HBsAg-negative mothers. At this time the only thimerosal-free hepatitis B vaccine available (COMVAX, Merck) also contains Hib vaccine (PRP-OMP) and may
be given at the 2-month visit. This product is not approved for use
before 6 weeks of age because of decreased response to the Hib
component. Additional thimerosal-free hepatitis B vaccines are
anticipated within the next few months, perhaps by the time this
statement is published. When supplies become available, it will be
appropriate to resume the previous recommendation that immunization may
begin in the newborn period. The Centers for Disease Control and
Prevention has subsequently recommended infants should receive
hepatitis B vaccine at birth if they are born to HBsAg-negative mothers
belonging to populations or groups that have a high risk of early
childhood HBV infection, including Asian Pacific Islanders, immigrant
populations from countries in which HBV is of high or intermediate
endemicity (see Health Information for International Travel, 1999), and
households with persons with chronic HBV infection (HBsAg-positive
persons) (http://www.cdc.gov/nip/news/thimerosal.htm). Alaska children
are at increased risk of early childhood hepatitis B virus transmission
and chronic infection. Therefore, the state of Alaska has recommended
continuation of the policy for immunization beginning at birth
including infants born to HBsAg-negative mothers (personal
communication, Laurel Wood).
If infants do receive thimerosal-containing vaccine at birth, efforts
should be made to provide them with thimerosal-free vaccines of all
types for subsequent immunizations to minimize exposure to thimerosal
during infancy.
The incidence of invasive pneumococcal disease in certain AN and
Apache Indian populations is 5 to 24 times higher than the rate in the
general US population (Table
1).18 The highest
incidence rates are in children younger than 2 years of age, the period
during which the only Food and Drug Administration-approved polysaccharide pneumococcal vaccine is neither effective nor approved for use. The incidence of invasive pneumococcal disease in AN children
younger than 2 years old is fivefold greater than that in the general
Alaskan population or other US populations. In certain populations,
such as those in southwest Alaska, the incidence of invasive
pneumococcal disease in AN children younger than 2 years of age (1587 cases per 100 000 per year) is 20 times that of the rate in the
general US population.19 Pneumococcal disease incidence is
even higher in Apache children younger than 2 years of age in Arizona
(1820 cases per 100 000 per year).20
TABLE 1
HAEMOPHILUS INFLUENZAE TYPE B (Hib)
HEPATITIS A
HEPATITIS B
STREPTOCOCCUS PNEUMONIAE
Comparison of the Incidence of the Invasive
Pneumococcal Disease in White Mountain Apaches and ANs and the
Incidence in Representative Non-Native American Populations
The incidence of pneumococcal infections decreases dramatically after the second birthday in all populations. In Apache children the incidence is 227 cases per 100 000 per year in children 2 to 4 years old and 54 per 100 000 in children 5 to 9 years old.20 In AN children at similar age ranges, the incidence rates are 98 and 23 per 100 000 population, respectively, approximately three- to fourfold greater than in the general Alaskan population. The incidence of pneumococcal infection in other AI/AN groups needs to be defined.
The ACIP has recommended that the current 23-valent polysaccharide pneumococcal vaccine be given to those children living "in environments or social settings in which the risk for pneumococcal disease or its complications is increased (eg, Alaska Natives and certain American Indian populations)."21 A single dose of pneumococcal 23-valent polysaccharide vaccine should be considered for children between 2 and 4 years of age in those Native American populations in which an increased risk of invasive pneumococcal disease has been demonstrated. A second dose is not recommended for children unless they fall into a risk group for which a second dose of vaccine is considered to be indicated (eg, those with splenectomy). Population-based data on the efficacy of the pneumococcal polysaccharide vaccine in the prevention of invasive disease in AI/AN children are not available. Pneumococcal polysaccharide/protein conjugate vaccines have been investigated in AI populations and have been found to stimulate antibody production in young infants. This vaccine will be available soon, and should be used according to recommendations of the ACIP and the AAP Committee on Infectious Diseases that will be made available after licensure of the vaccine.
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RECOMMENDATIONS |
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References
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Incorporation of the following recommendations will maximize the demonstrated or potential protective efficacy of vaccines currently available for AI/AN children.
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ACKNOWLEDGMENT |
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The Committees would like to thank Rosalyn Singleton, MD, FAAP, for her work in reference identification and consultation and Harold Margolis, MD, for technical support.
COMMITTEE ON NATIVE AMERICAN CHILD HEALTH, 1998-1999
Lance Chilton, MD, Chairperson
Joann Bodurtha, MD, MPH
Mark P. Butterbrodt, MD
Bernadette Freeland-Hyde, MD
Sheila Gahagan, MD
David Grossman, MD, MPH
Jonathan Jantz, MD
LIAISON REPRESENTATIVES
Jandel T. Allen-Davis, MD American College of Obstetricians
and Gynecologists
Donald Bechtold, MD American Academy of Child and Adolescent
Psychiatry
Joseph T. Bell, MD Association of American Indian Physicians
George Brenneman, MD Johns Hopkins Center for American Indian and
Alaskan Native Health
William F. Green, MD Indian Health Service
Brian Postl, MD Canadian Paediatric Society
Barbara Zind, MD Section on Community Pediatrics
FORMER COMMITTEE MEMBERS
John Goodrich, MD
Frederick Mandell, MD
COMMITTEE ON INFECTIOUS DISEASES, 1998-1999
Neal A. Halsey, MD, Chairperson
Jon S. Abramson, MD
P. Joan Chesney, MD
Margaret C. Fisher, MD
Michael A. Gerber, MD
S. Michael Marcy, MD
Dennis L. Murray, MD
Gary D. Overturf, MD
Charles G. Prober, MD
Thomas N. Saari, MD
Leonard B. Weiner, MD
Richard J. Whitley, MD
EX-OFFICIO
Georges Peter, MD
Larry Pickering, MD
Carol J. Baker, MD
LIAISON REPRESENTATIVES
Robert F. Breiman, MD National Vaccine Program Office
M. Carolyn Hardegree, MD Food and Drug Administration
Anthony Hirsch, MD AAP Council on Pediatric Practice
Richard F. Jacobs, MD American Thoracic Society
Noni E. MacDonald, MD Canadian Paediatric Society
Walter A. Orenstein, MD Centers for Disease Control and Prevention
N. Regina Rabinovich, MD National Institutes of Allergy and
Infectious Diseases
Ben Schwartz, MD Centers for Disease Control and Prevention
FORMER COMMITTEE MEMBERS
Donald S. Gromisch, MD
Steve Kohl, MD
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FOOTNOTES |
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The recommendations in this statement do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.
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ABBREVIATIONS |
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Hib, Haemophilus influenzae type b; AI/AN, American Indian/Alaska Native; IHS, Indian Health Service; ACIP, Advisory Committee on Immunization Practices; AAP, American Academy of Pediatrics; HBsAg, hepatitis B surface antigen.
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REFERENCES |
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Recommendation
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Montana.
MMWR Morb Mortal Wkly Rep.
1992;
41:13-14 [Medline]Statement of retirement:
This article has been cited by other articles:
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  K. L. O'Brien, J. Shaw, R. Weatherholtz, R. Reid, J. Watt, J. Croll, R. Dagan, A. J. Parkinson, and M. Santosham Epidemiology of Invasive Streptococcus pneumoniae among Navajo Children in the Era before Use of Conjugate Pneumococcal Vaccines, 1989-1996 Am. J. Epidemiol., August 1, 2004; 160(3): 270 - 278. [Abstract] [Full Text] [PDF]
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 R. C. Holman, A. T. Curns, J. E. Cheek, R. J. Singleton, L. J. Anderson, and R. W. Pinner Infectious Disease Hospitalizations Among American Indian and Alaska Native Infants Pediatrics, February 1, 2003; 111(2): e176 - 182. [Abstract] [Full Text] [PDF]
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