Pediatric Annals

Resident's Column When You Run the Zoo: The Need for Residents to Learn Strategies for Delivering Childhood Immunizations

R Blaine EasIey, MD

Abstract

A call comes at 3:00 AM to evaluate a 28month-old child in the emergency center (EC). The child has had a low-grade fever of 100°F and has been tugging at her left ear for the past 5 hours. The child's past medical history is remarkable for 2 to 3 prior cases of otitis media and missed immunizations. Her physical examination confirms a bulging, erythematous tympanic membrane that is immovable on pneumatic otoscopy. You decide to treat with a course of antibiotics, and your intervention is accepted gratefully by a distraught parent. For many residents, the inconvenience of this encounter is made more frustrating by the knowledge that this child should be immunized tonight. At this point, some would debate the necessity of immunizing this child in the EC at this inconvenient time. Others would debate the need to see and treat a child with otitis media in the EC (an issue unto itself). Regardless, you should swallow hard because now is as good a time as any to immunize this girl if EC systems permit. If you read this and feel your call night has just gotten a little longer, you're not alone.

As residents, we fret and resist taking opportunities to immunize children because of parental resistance to immunize, perceived inconveniences to families, and our own biases generated by the constantly changing recommendations for vaccine administration. Many residents are frustrated by the poor immunization rates and incomplete shot records of the children they see, and they often feel, "Things will be different when I have my own private patients!" When I hear this comment, whether in regard to immunizations or other pediatric issues (eg, coming to an EC at 3 AM for otitis media), I always think of the Doctor Seuss book entitled, When I run the Zool Just like the young boy in the story, we plot grand schemes about office decor, informative patient handouts, and other attractions we will use to better our practices. But unlike in the fanciful dream of the budding zoo keeper, the many barriers to successfully immunizing children and adolescents require concrete solutions to better the "zoo" of vaccination practices some of us will enter after residency.

So, do residents really need to learn about strategies for improving immunizations? As the future generation of pediatricians, we will be responsible for bringing new solutions to the old nagging question of how to better immunize children and adolescents. Many surveys have demonstrated that the majority of children in the United States are immunized by private pediatricians and primary care physicians. However, this same group of physicians often over-estimate their success in immunizing patients.1 This fact emphasizes the need and responsibility for us, as future practicing physicians, to leam ways of better assessing vaccination practices in our patients.

How do we learn about these strategies for improving patient immunizations? Following the resurgence of measles in the United States, there was a renewed interest in improving vaccine rates for children, adolescents, and adults. In response, at least one study sought to improve student, resident, and practitioner education. The authors' solution was a "problem based" course that gave residents immunization scenarios and required the resident to demonstrate knowledge of need, route, and purpose for immunizing.2

Another group looked at ways to improve tracking patients in various practice settings in a community. "Tracking" means the timely identification of children who need to receive immunizations. This involved development of a community data base that provided the most up to date information on a patient's shot record and was shared by all practitioners in the test communities.3,4 Both programs were felt…

A call comes at 3:00 AM to evaluate a 28month-old child in the emergency center (EC). The child has had a low-grade fever of 100°F and has been tugging at her left ear for the past 5 hours. The child's past medical history is remarkable for 2 to 3 prior cases of otitis media and missed immunizations. Her physical examination confirms a bulging, erythematous tympanic membrane that is immovable on pneumatic otoscopy. You decide to treat with a course of antibiotics, and your intervention is accepted gratefully by a distraught parent. For many residents, the inconvenience of this encounter is made more frustrating by the knowledge that this child should be immunized tonight. At this point, some would debate the necessity of immunizing this child in the EC at this inconvenient time. Others would debate the need to see and treat a child with otitis media in the EC (an issue unto itself). Regardless, you should swallow hard because now is as good a time as any to immunize this girl if EC systems permit. If you read this and feel your call night has just gotten a little longer, you're not alone.

As residents, we fret and resist taking opportunities to immunize children because of parental resistance to immunize, perceived inconveniences to families, and our own biases generated by the constantly changing recommendations for vaccine administration. Many residents are frustrated by the poor immunization rates and incomplete shot records of the children they see, and they often feel, "Things will be different when I have my own private patients!" When I hear this comment, whether in regard to immunizations or other pediatric issues (eg, coming to an EC at 3 AM for otitis media), I always think of the Doctor Seuss book entitled, When I run the Zool Just like the young boy in the story, we plot grand schemes about office decor, informative patient handouts, and other attractions we will use to better our practices. But unlike in the fanciful dream of the budding zoo keeper, the many barriers to successfully immunizing children and adolescents require concrete solutions to better the "zoo" of vaccination practices some of us will enter after residency.

So, do residents really need to learn about strategies for improving immunizations? As the future generation of pediatricians, we will be responsible for bringing new solutions to the old nagging question of how to better immunize children and adolescents. Many surveys have demonstrated that the majority of children in the United States are immunized by private pediatricians and primary care physicians. However, this same group of physicians often over-estimate their success in immunizing patients.1 This fact emphasizes the need and responsibility for us, as future practicing physicians, to leam ways of better assessing vaccination practices in our patients.

How do we learn about these strategies for improving patient immunizations? Following the resurgence of measles in the United States, there was a renewed interest in improving vaccine rates for children, adolescents, and adults. In response, at least one study sought to improve student, resident, and practitioner education. The authors' solution was a "problem based" course that gave residents immunization scenarios and required the resident to demonstrate knowledge of need, route, and purpose for immunizing.2

Another group looked at ways to improve tracking patients in various practice settings in a community. "Tracking" means the timely identification of children who need to receive immunizations. This involved development of a community data base that provided the most up to date information on a patient's shot record and was shared by all practitioners in the test communities.3,4 Both programs were felt to significantly improve immunization practices and immunization rates. These strategies teach us new ways to approach and implement improved immunization practices in your community.

Why should we implement these strategies? The best reason is they will immunize more children. The second reason is they will make your job easier. By simplifying patient tracking, notification, and comprehensive shot record availability, you will allow for more time to address other factors that contribute to missed vaccination opportunities, such as: family dysfunction, absent immunization data, and parental misconceptions or misinformation concerning immunizations and their contraindications. Providing easy access to community-based shot records in combination with timely immunization reminders (like a phone call or card) will cut down on the missed opportunities to administer shots. This will also bring a higher degree of order to the "zoo- like" atmosphere of immunizing patients and families (who sometimes have multiple doctors or no doctor at all).

Basically, your effective planning for immunization delivery will eliminate frustration and allow you effective ways of adapting to future changes in the immunization schedules of tomorrow. What impact these new vaccines will have is uncertain, but few can debate the benefits of prior immunizations against polio and flu in the United States. Hepatitis A and varicella vaccines are now available and may soon be part of the required schedule for childhood immunization prior to entering kindergarten. Other vaccines, like those being developed against rotavirus and respiratory syncytial vims, may become part of immunization schedules in the next 10 to 20 years.5,6 The sooner we accept and anticipate these changes, the more sense it makes to have a good tracking or reminder system for patients, to ease the transition to and compliance with immunization recommendations as they become available. Preparation will aid in identifying patients in your practice and community that may need help to comply.

As we hone our skills for managing critically ill neonates and children, many other areas, such as adolescent medicine, community-based pediatrics, and child advocacy have been identified as needing greater emphasis in pediatric residency training. Many programs are proficient at teaching the "science" of vaccinations, such as their production, route of administration, side effects, and efficacy. However, few address how to overcome the barriers to immunizing children and adolescents that we all have experienced and will continue to address throughout our careers. Answer the aforementioned questions in your own way, and update your immunization knowledge and practice by reading the AAP Red Book and other articles, like those featured in this issue. They will continue to provide you with details and information, but may not "show you the way" to better immunization rates. The ultimate rewards for overcoming the obstacles to immunizing children are fewer immunization headaches during your career and a healthier, more educated group of patients when future residents begin to "run the zoo."

REFERENCES

1. Rodewald U Peak R, Ezzati-Rice T, m al. Who are die immunization for US children: finding (rom the 1994 National Health Interview Survey (NHIS) Provider Record Check (PRO. Ambuhiory CJuId HaJA, 1997^:168.

2. Zimmerman RK, Barker WH, Strikas RA. er al. Developing curricula to promote preventive medicine skills: the Teaching Immunization for Medical Education (TiME) project. JAMA. 1997;278:705-711.

3. Gostin LO. Lassarmi Z. Childhood immunization registries. A national review of public health information systems and the protection of privacy. JAMA. 1995;274:1793-1799.

4. National Vaccine Advisory Committee. Subcommittee on Vaccination Registries. Deidopnuj a National Childhood lrrammiiaaon System Registries. Reminders, and fecnB. Washington. DO US Dept- of Health and Human Services. National Vaccine Program Office; 1994.

5. Feng N- Vo PT. Chung D. et aL Heterotypic protection following oral immunization with live heterologous rotaviruses in a mouse model, journal of infectious Diseases. 1997:175:330-341

6. Hsu SC, Chargrlegue D. Steward MW. Reduction of respiratory syncytial virus titer m the lungs <? mice after intranasal immunization with a chimeric peptide consist - uig of a single CTL epitope linked to a fusion peptide . Vtroiogj, 1998;240:376-381.

10.3928/0090-4481-19980601-06

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