ATLANTAThe Advisory Committee on Immunization Practices (ACIP) is considering strengthening its recommendation for the second dose of measles-containing vaccine.
The second dose originally was intended to be phased in one birth cohort at a time, but the progress is slow. In the 7 years since it was first made, the recommendation still has not been fully implemented. The second dose is a key component of the United States' measles elimination policy.
The ACIP is prepared to move aggressively toward the goal of eliminating measles by 2000. As it updates its measles, mumps, and rubella vaccine guidelines, the committee is debating whether to recommend that all states mandate two doses of measles-containing vaccine by a specified age, preferably at school entry.
Nine states currently have no law requiring two doses of measles vaccine, said Stephen Redd, MD, Chief, Measles Elimination Activity, National Immunization Program, Centers for Disease Control and Prevention (CDC). The states that do have second dose laws require vaccination at entry into either primary or middle school (between 4 and 6 years or 11 and 12 years, respectively). The American Academy of Pediatrics (AAP) recommends that the second dose be given between 11 and 12 years.
Recommending that all states adopt laws requiring a second dose by school entry would guarantee uniform policies across the country, said committee member Barbara DeBuono, MD, Commissioner, State of New York Department of Health.
"I was struck by the variability across states in terms of requirements for the second dose," DeBuono said. "I want to stress how important it is to standardize that as much as possible, and I would like us to commit aggressively to that second dose."
The recommendation for the second dose of measles vaccine was instituted after a high rate of vaccine failure was observed in adolescents 12 to 18 years old. The second dose is intended to capture those children who fail to respond adequately to the first dose and those who did not receive measles vaccine.
Before the ACIP or the AAP decide to change recommendations for the timing of the second dose of measles vaccine, convincing data must be presented to the ACIP and the AAP's Committee on Infectious Diseases, which will meet in May, said Neal Halsey, MD. Halsey, a liaison representative from the AAP, chairs the AAP committee. Specifically, information is needed on how changing the recommendation age for the second dose from 11 years to 4 years would affect the disease burden.
To provide that data, the CDC is beginning a study comparing disease incidence between states with school entry and middle school entry laws, Redd said.
The ACIP postponed making a decision on a uniform age for second dose laws until the data are thoroughly analyzed.
The committee indicated that it wants to see the second dose requirement fully implemented by 2001. Setting a timetable would help ensure quicker coverage of high school students and would move the country toward the goal of elimination, Redd said.
That strategy, however, may have unintended consequences, said David Fleming, MD. Fleming, a liaison member from the Hospital Infection Control Practices Advisory Committee, is State Epidemiologist, Oregon Health Division.
"There are a lot of immunization programs states are trying to get done right now, including Vaccines for Children program, Immunization Action Plans, registries, and implementing an adolescent visit," Fleming said. "If the ACIP establishes a timetable for one of these activities and not the others, we risk having people focus, potentially inappropriately, on one priority and not on the others. With respect to school laws in particular, there are a number of changes that the ACIP suggested, including varicella vaccination, hepatitis B vaccine catch-up at an adolescent visit, implementing an adolescent visit, and hepatitis B vaccine requirements for school entry. In some states it may make sense to add all those at the same time; in other states it may be death to try to do too many at once. To focus on one prioritymeaslesthere is a real possibility that we may inadvertently prevent those other things from happening."
The committee made no decision on a timetable for implementation. The ACIP's discussion was strictly intended to give a working group direction in drafting the measles vaccine guidelines and is not a final recommendation.
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