Guest Editorial

Family Physicians Are on Frontline of Protecting Kids as School Starts

August 15, 2013 02:29 pm Jamie Loehr, M.D.

Did you think that vaccine-preventable diseases had disappeared? Think again.

Outbreaks continue to happen. In 2006, for example, more than 6,000 cases of mumps occurred in the Midwest. In 2010, California saw more than 9,000 cases of pertussis, and 10 infants died of the disease. And just this year, New York public health officials had to manage more than 50 cases of measles in Brooklyn.

Jamie Loehr, M.D.

Although immunizations have significantly reduced the burden of vaccine-preventable diseases compared to what it was in decades past(www.cdc.gov), we could -- and should -- be doing even better.

The good news is that family physicians can make a difference. Right now, children in our communities are going back to school. Summer well-child visits and sports physicals provide excellent opportunities to review young patients' immunization records and administer recommended vaccines. You can find the recommended childhood and adolescent vaccine schedule, as well as the catch-up vaccine schedule, on the AAFP website.

Children who are entering kindergarten this fall should receive a booster of the measles, mumps and rubella (MMR) vaccine, as well as the varicella, or chickenpox, vaccine. They also should receive a booster of the polio vaccine, as well as a booster of the diphtheria and tetanus toxoids and acellular pertussis adsorbed (DTaP) vaccine.

Fortunately, these four vaccines can be combined into two shots. MMR and varicella are combined in the MMRV vaccine. Although MMRV has a higher risk of inducing fever (25 percent versus 5 percent) than MMR and varicella vaccine administered separately, it's worth noting that the elevated risk is more of a concern at age 12 to 15 months, when the risk of a febrile seizure also is higher. Combination polio and DTaP vaccines have no additional side effects compared with giving the vaccines separately.

One vaccine that often gets missed during well-child checkups of younger children is the hepatitis A vaccine. Although this vaccine is recommended at age 12 months, with a booster six months later, it can be given at any time. Thus, the catch-up schedule recommends offering the hepatitis A vaccine to any child who did not receive it during the second year of life.

Another critical time to review vaccines is at the 11- or 12-year-old well-child checkup. There are three vaccines that should be given during this visit.

  • The meningococcal conjugate vaccine should be routinely given to all children in this age group, with a booster at age 16.
  • The second recommendation is for tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine (Tdap), the adolescent and adult version of DTaP. Only one Tdap vaccine dose currently is recommended for a patient's entire life, with the exception that women should receive one during every pregnancy.
  • The third vaccine to administer during this visit is the human papillomavirus (HPV) vaccine. Originally recommended only for girls and women, the HPV vaccine now is recommended for all children and young adults and can be given to children as young as 9 years old. Parents often are hesitant to give HPV vaccine to their children because HPV is a sexually transmitted disease. For that reason, it often is better to reframe the vaccine as a cancer prevention vaccine. It also is better to recommend the three-dose series early in the teen years, before parents have any concern about sexual activity, and present it as a normal part of the vaccine schedule. Studies clearly show that discussing and giving the HPV vaccine does not make a teenager more likely to initiate sexual activity.

The 11- or 12-year-old well-child checkup also is a good time to make sure that adolescents have received all the recommended childhood vaccines. For example, the Academy and the CDC now recommend that children receive a varicella booster between ages 4 and 6. Children ages 11and 12 who have received only one dose should get the booster.

If you have concerns about discussing immunizations with vaccine-hesitant parents, free resources are available that can help. The CDC, in collaboration with the AAFP and the AAP, developed resources specifically to help physicians discuss the importance of immunizations(www.cdc.gov) with parents. A document posted on the Immunization Action Coalition website also lists numerous related resources(www.immunize.org).

Even if you don't provide vaccines in your office, it is important to know where to refer families for immunizations. For many communities, this might be the local health department.

Finally, keep in mind that children 6 months and older should be immunized against the flu when the seasonal influenza vaccine becomes available.

School is starting now. Are you prepared to protect the kids in your community?

Jamie Loehr, M.D., is the AAFP liaison to the CDC's Advisory Committee on Immunization Practices.


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