Pediatric Annals

EDITORIAL: A Pediatrician's View 

A Pediatric Report Card for Vaccine Delivery

William A Altemeier, III, MD

Abstract

How well do we do at giving recommended vaccines? Here is my estimate of how those of us who do this perform. Who appointed me as school teacher? Nobody. My opinions are subjective, but see how they compare with your estimates of our grades. While you are at it, how would you grade yourself and your office for the more specific questions?

HOW HAVE WE DONE AT CONTROLUNG THE MAJOR VACCINE-PREVENTABLE DISEASES?

Tremendous - Grade A. Smallpox (and smallpox vaccination) is gone. Polio (and live poliovirus vaccine) is essentially gone. Pertussis, tetanus, diphtheria, and invasive Haemophilus influenzae infections are rare now. Measles, mumps, and rubella are uncommon. It has not been perfect (we had brief increases in the rates of measles and pertussis), but, all in all, we have done well.

HOW WELL DO WE KEEP UP WTTH RECOMMENDED IMMUNIZATIONS TO ACHIEVE HIGH IMMUNIZATION RATES?

When it comes to the vaccines for the above diseases, we do fairly well, but we could do better. I rate us at about a B. For example, the Centers for Disease Control and Prevention reported that 78% of children 19 to 35 months old were up-to-date for 4 doses of diphtheria and tetanus toxoids and acellular pertussis (DTaP) vaccine, 3 doses of polio vaccine, 1 dose of a vaccine containing measles virus, and 3 doses of H. influenzae type b vaccine in 1999.1 However, our "progress" has plateaued - the rate was slightly higher (79%) in 1998. Almost all children are immunized by the time they begin school, but full protection is delayed for some.

HOW ABOUT OUR PERFORMANCE IN GIVING HEPATITIS B, VARICELLA, AND PNEUMOCOCCAL CONIUGATE VACCINES?

Hepatitis B is spotty (about a C). On the positive side, the immunization rate for children 19 to 35 months old (3 doses) has risen every year from 1995, when it was 68% (to 88% by 1999). However, our performance for older children, especially adolescents, when the risk of infection jumps, is much worse. But, the Advisory Committee on Immunization Practices (ACIP) has reduced the requirement to 2 doses for 11 to 15 year olds, with the second dose given 4 to 6 months after the first.2 This may help.

We stumbled on immunizing newborns at delivery during the thimerosal alert. Further, now that this problem has been solved, it seems that we have not fully returned to the prealert recommendation that all infants receive hepatitis B vaccine, preferably at birth.3 The importance of giving the first injection at birth is that hepatitis B vaccine alone then is 88% effective in preventing infection when a mother has hepatitis B (but somehow this was missed).3 Before the thimerosal alert, 81% of Wisconsin hospitals, representing 84% of Wisconsin births, were offering the first dose of the hepatitis B vaccine to neonates before discharge.

The joint statement recommending that the first dose be delayed for infants born to hepatitis B surface antigen-negative women came out in July 1999. This was based on concern about thimerosal and was to end when thimerosal-free vaccine became available. It did in September 1999, but by March 2000, only 50% of hospitals representing 43% of Wisconsin births had resumed routine neonatal irnmunization. Give yourself an A if you have returned to routinely immuriizing at birth.

The varicella immunization rate could also improve (C+). The rate increased from 26% in 1997, but was only 59% for children 19 to 35 months old by 1999.1 It is too early to assess the rate for pneumococcal conjugate vaccine.

HOW WELL DO PEDIATRICIANS FOLLOW THE CLINICAL GUIDEUNES FOR IMMUNIZATIONS?

This question asks whether we read, accept, and try…

How well do we do at giving recommended vaccines? Here is my estimate of how those of us who do this perform. Who appointed me as school teacher? Nobody. My opinions are subjective, but see how they compare with your estimates of our grades. While you are at it, how would you grade yourself and your office for the more specific questions?

HOW HAVE WE DONE AT CONTROLUNG THE MAJOR VACCINE-PREVENTABLE DISEASES?

Tremendous - Grade A. Smallpox (and smallpox vaccination) is gone. Polio (and live poliovirus vaccine) is essentially gone. Pertussis, tetanus, diphtheria, and invasive Haemophilus influenzae infections are rare now. Measles, mumps, and rubella are uncommon. It has not been perfect (we had brief increases in the rates of measles and pertussis), but, all in all, we have done well.

HOW WELL DO WE KEEP UP WTTH RECOMMENDED IMMUNIZATIONS TO ACHIEVE HIGH IMMUNIZATION RATES?

When it comes to the vaccines for the above diseases, we do fairly well, but we could do better. I rate us at about a B. For example, the Centers for Disease Control and Prevention reported that 78% of children 19 to 35 months old were up-to-date for 4 doses of diphtheria and tetanus toxoids and acellular pertussis (DTaP) vaccine, 3 doses of polio vaccine, 1 dose of a vaccine containing measles virus, and 3 doses of H. influenzae type b vaccine in 1999.1 However, our "progress" has plateaued - the rate was slightly higher (79%) in 1998. Almost all children are immunized by the time they begin school, but full protection is delayed for some.

HOW ABOUT OUR PERFORMANCE IN GIVING HEPATITIS B, VARICELLA, AND PNEUMOCOCCAL CONIUGATE VACCINES?

Hepatitis B is spotty (about a C). On the positive side, the immunization rate for children 19 to 35 months old (3 doses) has risen every year from 1995, when it was 68% (to 88% by 1999). However, our performance for older children, especially adolescents, when the risk of infection jumps, is much worse. But, the Advisory Committee on Immunization Practices (ACIP) has reduced the requirement to 2 doses for 11 to 15 year olds, with the second dose given 4 to 6 months after the first.2 This may help.

We stumbled on immunizing newborns at delivery during the thimerosal alert. Further, now that this problem has been solved, it seems that we have not fully returned to the prealert recommendation that all infants receive hepatitis B vaccine, preferably at birth.3 The importance of giving the first injection at birth is that hepatitis B vaccine alone then is 88% effective in preventing infection when a mother has hepatitis B (but somehow this was missed).3 Before the thimerosal alert, 81% of Wisconsin hospitals, representing 84% of Wisconsin births, were offering the first dose of the hepatitis B vaccine to neonates before discharge.

The joint statement recommending that the first dose be delayed for infants born to hepatitis B surface antigen-negative women came out in July 1999. This was based on concern about thimerosal and was to end when thimerosal-free vaccine became available. It did in September 1999, but by March 2000, only 50% of hospitals representing 43% of Wisconsin births had resumed routine neonatal irnmunization. Give yourself an A if you have returned to routinely immuriizing at birth.

The varicella immunization rate could also improve (C+). The rate increased from 26% in 1997, but was only 59% for children 19 to 35 months old by 1999.1 It is too early to assess the rate for pneumococcal conjugate vaccine.

HOW WELL DO PEDIATRICIANS FOLLOW THE CLINICAL GUIDEUNES FOR IMMUNIZATIONS?

This question asks whether we read, accept, and try to follow the clinical guidelines published by the American Academy of Pediatrics (AAP) (in concert with the ACIP and the American Association for Family Physicians). When considered in the context of how well physicians follow clinical guidelines (also called evidence-based guidelines or clinical pathways) in general, we get an A+ in my view. There are now hundreds of these guidelines for health maintenance and diseases (eg, asthma and diabetes), but ours for immunizations is considered one of the first and most widely accepted and used.4 The AAFs Red Book is also widely accepted.

The acceptance of most other guidelines is more controversial among physicians,5,6 including pediatricians.7 There are many reasons for this. Guidelines are often confusing consensus statements rather than evidence based, many are too complex, and we are resistant to "cookbook medicine," but their importance and the pressure to use them is growing. We have shown that, when done well, they can be widely accepted.

DO WE USE SYSTEMS TO ORGANIZE AND KEEP UP WITH OUR PATIENTS IMMUNIZATION SCHEDULES?

Such systems can be office based or community based. An office-based system tracks immunizations for each patient and uses reminders and recalls to improve vaccine delivery. Rodewald reported that AAP Periodic Surveys of Fellows found that fewer than one-fifth of offices had a credible system to identify patients who needed immunizations, and that there was no improvement between 1992 and 1999.8 Furthermore, even when a system is present, data quality is also a problem because 10% to 40% of doses given may be missing from the tracking database.9 The solution to this last problem is to make the entry of immunization data happen at the point of service.9

The external system is the immunization registry. All states either have started one or have one in planning. The AAP supports these (and reimbursement for entry costs plus data confidentiality). However, many pediatricians feel they are unrealistic, and when they are available (20% of children now can be on a registry, projected to be 95% by 2010), as many as 50% of patients have no data entered.10 Point-ofservice entry should help here also.

These systems do not have to be complicated, and although it takes staff time to enter data initially, think of the time that will be saved in trying to track down a child's immunizations from other sites and proving that a child is up-to-date for school or camp. Besides, there is no other way to be sure that children and adolescents who have high-risk conditions that require influenza immunization get this each fall. That is why so few are immunized. I believe that we, as a group, deserve no better than a D in having systems that tell us who needs immunizing, but give yourself a B if you have and use one and an A if you have a way to ensure that all of your data are entered.

What if you do not need a system because you are sure that your patients are irnmunized? That will not work. Several studies demonstrate that we overestimate rates by as much as 25%.8 If you want a vaccine tracking system, charge your office manager with finding options and then with implementing your choice. It will also protect you from the late summer rush to bring children up-to-date before school begins.8

DO PEDIATRICIANS KEEP UP WITH THE DETAILS OF IMMUNIZATION?

These include the subtle rules about timing, using various formulations of a given type of vaccine for the same child, and the planned and unplanned changes and policies to deal with them. You will have to grade yourself on this. No data were found on how we do as a group, but the task is daunting.

You must be in contact with your state health department to keep up. They make the rules about vaccine exemption for religious or personal reasons, whether and what immunizations are mandated, and whether immunizations are needed for day care, elementary school, or middle school. They coordinate the Vaccines for Children program that can provide vaccines to your office for eligible children and the federal Vaccine Information Statements that you are required to distribute.

If you have and use all of this information from your state, you deserve an A. If not, the spring 2001 issue of Needle Tips (available at www.immunize.org) has a list of coordinators for each state.11 Actually, this and AAP News are excellent resources for keeping up, which is also the purpose of this issue.

REFERENCES

1. National, state and urban area vaccination coverage levels among children aged 19-35 months - United States, 1999. MMWR. 2000;49: 585-586.

2. Poland GA. Adolescent hepatitis B immunization: making it simpler. Pediatrics. 2001;107:771-772.

3. Hurie MB, Saari TN, Davis JP. Impact of the Joint Statement by the American Academy of Pediatrics/US Public Health Service on chimerical in vaccines on hospital infant hepatitis B vaccination practices. Pediatrics. 2001;107:755758.

4. Bergman DA. Evidence-based guidelines and critical pathways for quality improvement. Pediatrics. 1999; 103(1 Suppl E):225-232.

5. Gundersen L. The effect of clinical practice guidelines on variations in care. Ann Intern Med. 2000;133:317318.

6. Grimshaw JM, Russell IT. Effect of clinical guidelines on medical practice: a systematic review of rigorous evaluations. Lancet. 1993;342:13171322.

7. Flores G, Lee M, Bauchner H, Kastner B. Pediatricians' attitudes, beliefs, and practices regarding clinical practice guidelines: a national survey. Pediatrics. 2000;103: 496-501.

8. Rodewald L. Every medical home needs an immunization recall system. AAP News. 2001;18:88-89.

9. Adams WG, Conners WP, Mann AM, Palfrey S. Immunization entry at the point of service improves quality, saves time, and is wellaccepted. Pediatrics. 2000;106:489493.

10. Wallace S. Give immunization registries a shot. AAP News. 2001;18:99, 106.

11. Immunization Action Coalition. Needle Tips and the Hepatitis B Coalition News. St. Paul, MN: 2001;11:1-23. Available at: www.immunize.org.

10.3928/0090-4481-20010601-03

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