What additional vaccines should a 2‑year‑old child receive at this well‑child visit given her current immunization record of three DTaP (diphtheria, tetanus, acellular pertussis) doses, one hepatitis A dose, three hepatitis B doses, four Hib (Haemophilus influenzae type b) doses, one MMR (measles, mumps, rubella) dose, four PCV (pneumococcal conjugate) doses, three polio (inactivated polio vaccine) doses, three rotavirus doses, and one varicella dose?

Recommended Vaccinations at 2-Year Well-Child Visit

This child needs a fourth dose of DTaP (at least 6 months after the third dose), a second dose of hepatitis A, and a second dose of varicella vaccine at this visit. 1

Analysis of Current Immunization Status

Based on the child's vaccination record, here's what has been completed and what remains:

Completed Series:

• Hepatitis B: 3 doses complete (standard series) 2
• Rotavirus: 3 doses complete (series finished, no further doses needed) 2
• Hib: 4 doses complete (3 primary + 1 booster at 12-15 months) 2, 1
• PCV (Pneumococcal): 4 doses complete (3 primary + 1 booster at 12-15 months) 1
• Polio (IPV): 3 doses complete, but needs 4th dose between 4-6 years 2, 3

Incomplete Series Requiring Immediate Action:

DTaP (Diphtheria, Tetanus, Pertussis):

• Currently has 3 doses (primary series at 2,4,6 months)
• Needs 4th dose now at 15-24 months, given at least 6 months after the 3rd dose 2, 1
• This booster is critical as vaccine effectiveness wanes significantly between 2-4 years without it 4

Hepatitis A:

• Currently has 1 dose
• Needs 2nd dose now (typically given 6-18 months after the first dose) 2

MMR (Measles, Mumps, Rubella):

• Currently has 1 dose
• Needs 2nd dose at 4-6 years (not due at this visit) 2

Varicella:

• Currently has 1 dose
• Needs 2nd dose now (can be given at 12-15 months or later, with minimum 3-month interval after first dose) 2

Vaccines Due at This 2-Year Visit:

1. DTaP (4th dose) - Critical booster dose 1
2. Hepatitis A (2nd dose) - Completes the series 2
3. Varicella (2nd dose) - Completes the series 2

Important Clinical Considerations:

Reactogenicity Warning:

• Local reactions (redness, swelling, pain) and fever occur more frequently after the 4th DTaP dose compared to earlier doses in the primary series 5, 6
• Parents should be counseled to expect increased injection site reactions, though these are generally mild and self-limited 5

Common Pitfall to Avoid:

• Do not delay the 4th DTaP dose beyond 18 months, as vaccine effectiveness declines significantly between 2-4 years of age without this booster (from 83.5% at 6-11 months to 59.2% at 3-4 years) 4

Future Vaccinations:

• At 4-6 years: 5th DTaP dose, 4th IPV dose, and 2nd MMR dose 2