Compared with children from other ethnic groups, American Indian/Alaska Native (AI/AN) children historically have been at greater risk of acquiring certain vaccine-preventable diseases, such as hepatitis A, hepatitis B, Hib, and S pneumoniae infections, and being hospitalized for respiratory syncytial virus infection and other lower respiratory tract infections. The rate of diarrhea-associated hospitalizations is significantly higher in AI/AN infants than in other US infants. AN women have a rate of cervical cancer 3.4 times that of white women in the United States, indicating a high rate of infection with HPV and lack of preventive care.

Geographic differences exist in disease risk. Increased risk of acquiring vaccine-preventable diseases has been demonstrated among AI/AN infants and children who live on reservations or in traditional rural villages, and the increased risk may be related to crowded living conditions and lack of indoor plumbing. However, high incidences of hepatitis A and hepatitis B infections also have been demonstrated among urban AI/AN children, which may result from high-risk behaviors or frequent visits to extended family members.

During the past decade, universal childhood immunization for hepatitis B and targeted immunization for hepatitis A in the United States have eliminated disease disparities for these pathogens in most AI/AN child populations, and significant decreases in disease have been demonstrated for Hib and S pneumoniae . Continued immunization is critical to maintaining this success and eliminating other disparities. It particularly is important that recommendations for universal immunization for hepatitis A and hepatitis B, S pneumoniae , HPV, rotavirus, influenza, and Hib are implemented optimally in AI/AN children because of high rates of infection and severe disease. Children in AI/AN communities should be specifically targeted to receive immunizations on time and to receive the full schedule of immunizations even in times of vaccine shortages. Specific vulnerabilities are noted here.

• Respiratory Syncytial Virus . The rates of hospitalization for respiratory syncytial virus (RSV) are higher for AI/AN children in the Alaska and southwestern Indian Health Service regions (71 and 48 RSV hospitalizations per 1000 births, respectively) compared with other US children (27 per 1000 births). Use of RSV-specific monoclonal antibody prophylaxis, as recommended by the AAP, should be optimized among high-risk AI/AN infants (see Respiratory Syncytial Virus). AI/AN infants born at 32 and 35 weeks' gestation often have several risk factors for severe RSV disease. Additionally, one third of rural Alaska Native communities lack in-home running water and flush toilets, and this lack of availability of water service is associated with increased risk of hospitalization for lower respiratory tract infections. RSV season length is prolonged in northern latitudes, including Alaska, and RSV prophylaxis should reflect local seasonality.


• Haemophilus influenzae type B . Hib immunization requires consideration regarding preferred vaccine product for AI/AN children. Before availability and public use of conjugated Hib vaccines, the incidence of invasive Hib disease was approximately 10 times higher among young AI/AN children compared with the general US population. Because of the high risk of invasive Hib disease within the first 6 months of life in many AI/AN infant populations, the Indian Health Service and AAP recommend that the first dose of Hib conjugate vaccine contain polyribosylribitol phosphate-meningococcal outer membrane protein (PRP-OMP) as a single-antigen vaccine or in a combination vaccine with other antigens. The administration of a PRP-OMP-containing vaccine leads to more rapid seroconversion to protective concentrations of antibody within the first 6 months of life, and failure to use vaccine containing PRP-OMP has been associated with excess cases of Hib disease in young infants in this population. For subsequent doses, PRP-OMP or any of the other Hib conjugate vaccines can be used with apparently equal efficacy (see Haemophilus influenzae Infections). Because availability of more than one Hib vaccine in a clinic can be confusing, strict attention must be paid to vaccine type. To avoid confusion for health care professionals who serve AI/AN children predominantly, it may be prudent to use only a PRP-OMP-containing Hib vaccine.


• Streptococcus pneumoniae . Recommendations for PCV7 for AI/AN children are the same as for other US children. However, in special situations, public health authorities may recommend use of PPSV23 after PCV7 for AI/AN children 24 through 59 months of age who are living in areas in which risk of invasive pneumococcal disease is increased. The incidence of invasive pneumococcal disease (IPD) in certain AI/AN children was 5 to 24 times higher than the incidence among other US children before use of PCV7. Use of PCV7 in AI/AN infants has resulted in decreased incidence of IPD in AI/AN children. However, AI/AN children continue to have an increased risk of acquiring IPD-more than twice the national average. Therefore, AN and AI children in Alaska and the southwest should receive the standard 4-dose PCV7 series, even in times of vaccine shortages, as recommended by the AAP and the Advisory Committee on Immunization Practices (ACIP) of the CDC.


• Hepatitis viruses . Before the advent of immunization initiatives, rates of hepatitis A and hepatitis B in the AI/AN population exceeded those of the general US population. Universal immunization reduced incidence of hepatitis A and hepatitis B to that of the general US population. Sustained routine immunization of all young AI/AN children will be necessary to maintain high levels of population immunity and low disease rates currently observed in AI/AN communities. In addition, special efforts should be made to ensure catch-up hepatitis B immunization of previously unimmunized adolescents. In 2006, the ACIP approved the recommendation that unimmunized adults at high risk of hepatitis B infection and all adults seeking protection from hepatitis B should be immunized.