Child and Adolescent Immunizations

At the beginning of the last century, infectious disease was a common etiology of morbidity and mortality in children. The development and implementation of a widespread vaccination program in the United States has significantly diminished the effects of once common diseases such as small pox, polio, measles, and pertussis. Active immunization against infectious disease is a key element of family medicine practice.

Currently, 24 different infectious diseases are managed with approximately 70 different licensed vaccines in the United States.¹ New vaccines have been introduced in the past 3 years: 13-valent pneumococcal vaccine (Prevnar 13), high-dose trivalent influenza (Fluzone), and H1N1 monovalent influenza vaccine.² New vaccine combinations allow for fewer injections for patients but have increased the complexity for physicians and office staff.

Providing vaccinations in the family medicine office setting requires a conscious effort to stay current on new vaccines and vaccine formulations; changes in vaccine administration schedules; and manufacturer recalls, delays, and shortages. The Centers for Disease Control and Prevention (CDC) and the Food and Drug Administration (FDA) are the primary sources of information about licensed vaccines and vaccination schedules. Both federal agencies produce a variety of educational resources that are available online or as free print materials.

The CDC’s Advisory Committee on Immunization Practices (ACIP) collaborates with professional organizations, including the American Academy of Family Physicians (AAFP) and the American Academy of Pediatrics (AAP), in publishing current vaccine schedules for infants, children, teens, and adults, as well as catch-up schedules.^3,4 The ACIP also publishes recommendations for specific groups such as healthcare workers, minority populations, and individuals with high-risk medical conditions. Additional resources are available from the Immunization Action Coalition (IAC), a non-profit educational organization partially funded by the CDC, which maintains the websites www.immunize.org (for health professionals) and www.vaccineinformation.org (for the public). Both of these sites contain hundreds of public domain educational documents (handouts, posters) and patient forms available for download.

The CDC also publishes Epidemiology and Prevention of Vaccine-Preventable Diseases: The Pink Book: Course Textbook. The 12th edition, published in May of 2012, contains disease-specific information on each of the routine vaccines for children and adults. The appendices of this book contain charts of contraindications for each vaccine, vaccine ingredients, minimum age, and dosing intervals.

The FDA has regulatory and licensing authority for vaccines, and their website provides detailed information on the approval process (http://www.fda.gov). They are also the source for product recalls. Recalls can originate voluntarily from a manufacturer, or be requested or mandated by the FDA. From 2007 to 2011, there were an average of 2.6 vaccine recalls per year, primarily involving specific lots of a vaccine, based on testing or inspection after the product had been released.⁵

Additional vaccine information is provided by state and local health departments. Immunization updates are regularly included in medical journals, including articles in American Family Physician and Pediatrics, and in manuals such as the Red Book, published by the AAP.

When new information is released by the CDC, it is published in the Morbidity and Mortality Weekly Report.⁶ This public health report is available free online and is indexed in PubMed. Subscribers can be alerted to each new issue by email.

The FDA provides email alerts and FDA Patient Safety News, a regular bulletin on safety issues and product recalls.⁷ State and local health departments also publish public health alerts for more localized events.

Hepatitis A Vaccine
Epidemiologic data shows a steady decline in the incidence of hepatitis A when stratified by age, ethnicity, and geography.⁸ This data reinforces the importance of vaccinating children. This vaccine has recently been in limited supply, due to shortages of one (Vaqta) of the two products available (Havrix, Vaqta). Currently, the supply is sufficient to meet the demand. Patients who have missed doses should receive catch-up doses.

Pneumococcal Vaccine
In 2010, a 13-valent conjugate vaccine (PCV13) (Prevnar 13) was licensed as a replacement for the 7-valent conjugate vaccine for children.⁹ The expanded serotype coverage is now recommended for use in high-risk populations throughout the lifetime.³ The 23-valent polysaccharide vaccine (PPSV23) (Pneumovax 23) is recommended for use in the elderly. PCV13 is also FDA-approved for use in healthy individuals age 50 and older, but the ACIP has not published any recommendations for this population. Table 1 (1-page PDF; About PDFs) includes recommendations for pneumococcal vaccination, including booster doses after 5 years for certain populations.¹⁰

Haemophilus Influenzae Type B (Hib) Vaccine
Shortages of Hib-containing vaccines have occurred over the past few years, but these have lessened. The approval of a single antigen Hib vaccine for use as the final booster dose for children aged 15 months to 4 years encourages physicians to get patients caught up at their next scheduled appointment.¹¹ A shortage of DTaP-IPV/Hib (Pentacel)¹² occurred in 2012 and was ongoing at the time of publication, but a single antigen dose for DTaP, IPV, and Hib is available.

In paper-based (and some electronic) health records, reviewing, flagging, and updating a patient’s immunization status can be time consuming. Many practices are efficient at checking and updating immunizations during well-child visits and health maintenance examinations. In spite of this, many opportunities to update vaccinations are missed during acute and other routine office encounters when most vaccines can still be administered.

Maximizing vaccine outreach requires informing patients and parents about the benefits of vaccination, reminding them of vaccines that are due, and streamlining the process for office staff. For instance, in a busy office practice, a 9-year-old soccer player who is coming in for a recheck of a wrist sprain also is due for an influenza vaccination. Ideally, staff could efficiently identify the need for the vaccination, obtain consent from the parent, and administer the vaccine without interrupting the flow of the visit for the wrist follow-up. However, doing so requires having a process that identifies deficient vaccinations, educational materials that are readily available, space for nurses to privately counsel and administer injections, and integration of vaccination functions into the other activities that staff performs so that patient flow is not disrupted¹³ (see Table 2).

The electronic health record (EHR) can improve this process through the entry of all vaccinations into a single immunization record, creation of alerts when vaccinations are due, and the generation of reports on vaccinations due for each day’s patients. An EHR can also generate reminder letters, emails, or text messages to patients and/or parents. Some practices use electronic patient portals in EHRs. These password-controlled portals allow patients to securely view and download their immunization records and upload outside immunization records for physician review.

Practice websites also can support vaccination efforts. Links can take patients to free resources such as vaccine information statements, screening questionnaires, and vaccine administration forms that they can print and complete prior to the visit, making the encounter more efficient. The website also can include immunization consent forms for parents to sign and send with children when the parent will not be at the visit.

With the current vaccination schedule, there are 34 antigens given in a variable number of injections (depending on the availability of combination vaccines) for children between birth and 4 to 6 years of age. The complexity of this schedule, along with the challenges to vaccine safety on the Internet and in the popular media, has contributed to skepticism from some parents.

Two useful tools for patients and parents are available from the IAC. These include charts, such as When do Children and Teens Need Vaccinations¹⁴ and Do I Need Any Vaccines Today?¹⁵, as well as an adult checklist for the waiting room. Another benefit of the IAC site is easy access to many translated Vaccine Information Statements¹⁶ (see Table 3). A useful online tool from the CDC is the Instant Childhood Immunization Schedule¹⁷, which allows parents to create a chart of anticipated vaccination dates up through age 12 by entering their child’s birth date.

Parents have been faced with the increased cost of vaccines. The federal government has also had to deal with these increased costs. The CDC spends more than $3.5 billion a year for childhood vaccines.¹⁸ The addition of the meningococcal and human papillomavirus (HPV) vaccines to the schedule doubled the cost for boys (to age 18 years) and tripled the cost for girls.¹⁹ Some of these increased costs are reduced or eliminated by federal law as part of the Affordable Care Act, but a practice must maximize efficiency and ease of providing vaccines, carefully manage vaccine storage, and follow good business principles in ordering, billing for, and storing vaccines.

Vaccine storage and handling must be managed critically. Many vaccines have similar packaging and names, each has specific temperature requirements for storage, and each vaccine lot has an expiration date. The storage unit must have room for the vaccines without overpacking, must be monitored for temperature changes, and must be safeguarded against accidental power loss and theft. The stock must be rotated to avoid preventable losses. Each new shipment must be inspected to ensure proper packaging and shipment of the vaccine.²⁰

Medical practices offering vaccine services can make use of these noted resources to help save time and allow personnel to stay up to date on vaccine recommendations and availability. The field has changed as much in the past 10 years as in the previous 50 years. In order for vaccinations to be accessible to patients, they must be an efficient part of the practice and managed professionally and safely.

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