Physicians struggle when immunizations get off-track

Vaccine registries and good software could help doctors with the complex task of catching up on young patients' missed shots.

By Susan J. Landers, AMNews staff. June 30, 2003.

Washington -- Although vaccines are a tremendous boon to the public's health, they can create major headaches for physicians trying to get young patients back on course to complete complex immunization schedules after they have strayed.

The majority of physicians surveyed by researchers from the University of Chicago readily acknowledged that crafting adequate catch-up regimens for children is difficult.

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And their responses to a test of their knowledge on the subject indicated that they weren't doing such a great job when they did tackle it.

Nearly two-thirds of the 550 pediatricians, family physicians and other primary care doctors who completed surveys sent to them in June 2001 failed to answer correctly any of the questions concerning hypothetical catch-up scenarios.

Only 20% of the doctors responded correctly to four or more of the six scenarios.

"The results show very clearly there is a major problem that hasn't been recognized before, or if it has been recognized, it hasn't received enough attention," said Robert Daum, MD, who designed the scenarios for the study, which was published in the May issue of Pediatrics.

Nearly two-thirds of doctors could not answer any questions about vaccine catch-up schedules.

Dr. Daum, director of the University of Chicago's Pediatric Immunization Program, began to suspect there was a problem with catch-up regimens as he worked with the Chicago Housing Authority to identify children in need of vaccinations following an outbreak of measles and pertussis about 10 years ago.

The survey he and colleagues sent to physicians tested that suspicion and, unfortunately, the low scores of so many respondents proved it correct. The errors were primarily those of omission, said Dr. Daum. Physicians didn't identify which children needed which shots when they were in the office.

Some physicians did better than others. Those who scored well tended to be women, younger, working in inner cities or academic settings, and they tended to be pediatricians.

It's a hard job. Just scheduling 23 doses of single or combination vaccines for each child before he or she enters school is formidable. Then there are nuances involved, such as intervals between doses and the age of the child.

Consider the physician faced with a child who is 11 months, 30 days old. Does the child get an MMR shot that day, or will the parents have to bring the child back later? Schools require that the shot be administered after the child's first birthday.

How about the 2-year-old who has had no vaccines to date?

"To catch up, you could give them eight or nine shots in the first visit. But some parents might get a little upset about that," said Doug Campos-Outcalt, MD, who works with the Maricopa (Arizona) County Public Health Dept. "Physicians are for the most part smart people," he noted. "But it gets to be a pretty complex issue that you have to sort out in a short period of time."

Many physicians who participated in the survey were confounded by the contraindication scenarios sketched by the researchers. They were asked, for example, whether they would administer the MMR and/or Haemophilus influenzae type B vaccines to a child who lives with someone being treated for cancer with chemotherapy or who lives with a family member infected by HIV.

Record keeping

The answer to both scenarios is yes. "There aren't very many contraindications," said Dr. Campos-Outcalt. "But there are a lot of misconceptions about it, particularly with a current illness. Unless a child has a very serious illness or a very high fever, vaccine administration is appropriate."

In addition, most vaccines can be given simultaneously, said Samuel Katz, MD, professor of pediatrics at Duke Medical School. "It's more a matter of how many vaccines do you want to give the poor kid."

20% of doctors responded correctly to 4 or more of the 6 catch-up scenarios.

The timing issue, however, is sometimes important. The two live vaccines that are generally administered -- varicella and MMR -- must be given either during the same visit or separated by at least a month to prevent one from getting a head start and interfering with the action of the second.

Dr. Campos-Outcalt would really like to see software devised that could make the necessary calculations. "You could type in a child's age and vaccines received, and it would spit out a recommended protocol."

He might not have to wait long. Dr. Daum and colleagues are working on the software, and he thinks others are also.

But good software will likely not be enough, said Dr. Daum. "How could you deploy it?" he wondered. How would a physician know which shots a child had already received?

A better answer might be global participation in vaccine registries. But the biggest obstacle is how to get the idea across that every child needs to be on a registry, he said.

Some states have already begun registries, at least for their public clinic patients, said Dr. Katz. But without such a system, vaccine programs can be very complicated.

"There are logistic, not intellectual problems at work," he said. Someone in the physician's office has to look up the records and see which shots are missing, and families in which both parents work must decide who will take a morning off to bring a child to the office.

Dr. Daum is now working on follow-up research to ask the physicians who responded to his survey how they go about constructing catch-up regimens. From this, he hopes to be able to construct interventions that work.

ADDITIONAL INFORMATION:

Weblink

American Academy of Pediatrics' 2003 immunization schedule (www.aap.org/policy/0212.html)

Centers for Disease Control and Prevention, immunization program (www.cdc.gov/nip)

AMA vaccination resources site (www.ama-assn.org/ama/pub/category/1804.html)

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