case studies in immunization delivery

Case Studies in Case Studies in Immunization DeliveryImmunization Delivery

Ronald C. Samuels, MD MPHRonald C. Samuels, MD MPHAssociate DirectorAssociate Director

Children’s Hospital Primary Care CenterChildren’s Hospital Primary Care Center

Oct 13th, 2011Oct 13th, 2011

DisclosuresDisclosures

�� May discuss use of vaccines in ways not May discuss use of vaccines in ways not approved by ACIPapproved by ACIP

�� May discuss vaccines not yet licensed by May discuss vaccines not yet licensed by the FDA, and use not approved by FDAthe FDA, and use not approved by FDAMay discuss vaccines not yet licensed by May discuss vaccines not yet licensed by the FDA, and use not approved by FDAthe FDA, and use not approved by FDA

Today’s TalkToday’s Talk

��Some Background Guidance to Some Background Guidance to DecisionsDecisions

��Cases/DiscussionsCases/Discussions��Cases/DiscussionsCases/Discussions

Immunization RecordsImmunization Records

�� A verbal history of previous immunizations A verbal history of previous immunizations is not sufficient evidenceis not sufficient evidence

�� Accept as valid only immunizations that Accept as valid only immunizations that are documented in writing and datedare documented in writing and datedare documented in writing and datedare documented in writing and dated

When in doubt, vaccinate!When in doubt, vaccinate!

Vaccination During Vaccination During Acute IllnessAcute Illness

�� No evidence that acute illness reduces No evidence that acute illness reduces vaccine efficacy or increases vaccine vaccine efficacy or increases vaccine adverse reactionsadverse reactions

�� Mild illness, such as otitis media or an Mild illness, such as otitis media or an upper respiratory infection, is NOT a upper respiratory infection, is NOT a upper respiratory infection, is NOT a upper respiratory infection, is NOT a contraindication to vaccinationcontraindication to vaccination

No need to take temps!No need to take temps!

Challenges To Effective Challenges To Effective Communication With PatientsCommunication With Patients

�� Finding the time to communicate Finding the time to communicate

�� The science of vaccines and immunology The science of vaccines and immunology is complicated is complicated is complicated is complicated

�� Language barriersLanguage barriers

�� Information resourcesInformation resources

One of the most important factors that One of the most important factors that One of the most important factors that One of the most important factors that influence a patient’s decision to be influence a patient’s decision to be vaccinated is a clear and unequivocal vaccinated is a clear and unequivocal recommendation of the vaccine from recommendation of the vaccine from

the provider the provider

Protect yourself, your family and your

patients!

All health care workers should get flu vaccine every year!

Are you up to date on all recommended adult vaccines?

Strategies To Reduce Myths and Strategies To Reduce Myths and Misperceptions about VaccinesMisperceptions about Vaccines

�� Listen to the patientListen to the patient

�� Be a role modelBe a role model

�� Speak from your experienceSpeak from your experience

Approaches To Vaccine Approaches To Vaccine Communication ChallengesCommunication Challenges

�� Keep your message simpleKeep your message simple

�� Advise the patients what to expect after Advise the patients what to expect after �� Advise the patients what to expect after Advise the patients what to expect after the vaccinationthe vaccination

�� Emphasize the return visits Emphasize the return visits

CasesCases

�� Mostly no right answersMostly no right answers�� Often some wrong answers…Often some wrong answers…

�� When no right answers… If in doubt, When no right answers… If in doubt, discuss with the familydiscuss with the family

�� When no right answers… If in doubt, When no right answers… If in doubt, discuss with the familydiscuss with the family

�� Ignore Flu vaccine (until we get to the Ignore Flu vaccine (until we get to the part where it’s obvious I’m asking about part where it’s obvious I’m asking about it…)it…)

Immunization PearlsImmunization Pearls��Think about EACH antigen separately when dealing with Think about EACH antigen separately when dealing with combination vaccinescombination vaccines

��Ie., Pentacel Ie., Pentacel -- think about DTaP, then IPV, then HIBthink about DTaP, then IPV, then HIB

��When looking at lists of shots, think about any vaccines that the When looking at lists of shots, think about any vaccines that the patient hasn’t received AT ALLpatient hasn’t received AT ALLpatient hasn’t received AT ALLpatient hasn’t received AT ALL

��It’s much easier to notice that a patient is short a vaccine (ie., only It’s much easier to notice that a patient is short a vaccine (ie., only had one VZV), then it is to recognize they’ve never received a vaccine had one VZV), then it is to recognize they’ve never received a vaccine (ie., never had Hep A) (ie., never had Hep A)

Case 1Case 1

�� 12 month old patient, presents for routine 12 month old patient, presents for routine well child care visit. New to your practicewell child care visit. New to your practice

�� no immunization recordsno immunization records�� no immunization recordsno immunization records

�� What do you do?What do you do?

Case 2Case 2


�� brings immunization recordsbrings immunization records�� brings immunization recordsbrings immunization records

�� Up To Date (except for 12 month old shots)Up To Date (except for 12 month old shots)

�� No record of birth Hep BNo record of birth Hep B


Case 3Case 3


�� brings immunization recordsbrings immunization records�� brings immunization recordsbrings immunization records

�� Two complete sets of vaccinesTwo complete sets of vaccines

�� No record of birth Hep BNo record of birth Hep B


Case 4Case 4


�� No immunization recordsNo immunization records�� No immunization recordsNo immunization records


Case 5 Case 5 --Today’s Date 1/11/12Today’s Date 1/11/12Brian Samuels

DOB 1/11/10

Age 2.0 years

1 2 3 4 5

Hep B 1/11/10 2/11/10

Pentacel 3/11/10 5/11/10 7/11/10 1/11/11

PCV-13 3/11/10 5/11/10 7/11/10PCV-13 3/11/10 5/11/10 7/11/10

Rotovirus 3/11/10 5/11/10 7/11/10

MMR 1/11/11

Hep A 4/11/11 1/11/12

DTaP 4/11/11

HIB 4/11/11

Case 6Case 6

�� 16 month old patient, presents for ringworm. 16 month old patient, presents for ringworm. Known to your practiceKnown to your practice

�� Not up to date with immunizationsNot up to date with immunizations


�� If you vaccinate today will that decrease the chance If you vaccinate today will that decrease the chance that he/she will return for well child care?that he/she will return for well child care?

�� Are there circumstances where you’d choose not Are there circumstances where you’d choose not to vaccinate?to vaccinate?

Case 7Case 7

�� 18 month old patient, presents for routine well 18 month old patient, presents for routine well child care visit. Known to your practicechild care visit. Known to your practice

�� Reviewing immunization records, there is no record of Reviewing immunization records, there is no record of DTaP given at 4 months of age, but there is a record DTaP given at 4 months of age, but there is a record DTaP given at 4 months of age, but there is a record DTaP given at 4 months of age, but there is a record of IPV, PCV, HIB and rotavirus given at the visit at 4 of IPV, PCV, HIB and rotavirus given at the visit at 4 months of age. All other vaccines are Up To Date months of age. All other vaccines are Up To Date including DTaPs at 2 months, 6 months and 15 including DTaPs at 2 months, 6 months and 15 months of age.months of age.


Case 8Case 8

�� 16 month old patient, presents for well 16 month old patient, presents for well child care visit. New to your practicechild care visit. New to your practice

�� Family refuses vaccinationFamily refuses vaccination�� Family refuses vaccinationFamily refuses vaccination


Case 9Case 9

�� 16 month old patient, presents for well 16 month old patient, presents for well child care visit. New to your practicechild care visit. New to your practice

�� Family reports never before vaccinatedFamily reports never before vaccinated�� Family reports never before vaccinatedFamily reports never before vaccinated

�� What shots do you give?What shots do you give?

Case 10Case 10

�� 12 month old patient, presents for routine well 12 month old patient, presents for routine well child care visit. Upchild care visit. Up--toto--Date with 3 sets of all Date with 3 sets of all shots (including Hep B).shots (including Hep B).

Also has fever to 100.9 and with OMAlso has fever to 100.9 and with OM�� Also has fever to 100.9 and with OMAlso has fever to 100.9 and with OM

�� Parent tells you up front that they don’t want shots Parent tells you up front that they don’t want shots today.today.


�� Is your approach different if the patient is NOT Is your approach different if the patient is NOT upup--toto--date and known to miss appointments?date and known to miss appointments?

Case 11Case 11

�� 3 year old with Cerebral Palsy comes in for 3 year old with Cerebral Palsy comes in for routine visit today. She has had all her routine visit today. She has had all her routine shots through 3 years of age.routine shots through 3 years of age.routine shots through 3 years of age.routine shots through 3 years of age.

�� Given that she has CP what additional Given that she has CP what additional shot(s) should you be advising.shot(s) should you be advising.

Case 12Case 12

�� 7.5 month old patient, presents for routine 7.5 month old patient, presents for routine well child care visit. New to your practicewell child care visit. New to your practice�� brings immunization recordsbrings immunization records

Two complete sets of vaccines, given at 2.5 Two complete sets of vaccines, given at 2.5 �� Two complete sets of vaccines, given at 2.5 Two complete sets of vaccines, given at 2.5 months and 6 months of age (and birth dose months and 6 months of age (and birth dose of Hep B)of Hep B)


Case 13Case 13

�� 5 month old patient, presents for routine 5 month old patient, presents for routine well child care visit. New to your practicewell child care visit. New to your practice�� No previous vaccinations?No previous vaccinations?


Case 13 (cont)Case 13 (cont)

�� 5 month old patient, presents for routine 5 month old patient, presents for routine well child care visit. New to your practicewell child care visit. New to your practice�� No previous vaccinations?No previous vaccinations?

�� Are there circumstances where you’d give Are there circumstances where you’d give rotavirus vaccine rotavirus vaccine

Case 14Case 14

�� 7 year old status post bone marrow 7 year old status post bone marrow transplant last year. Had previously transplant last year. Had previously received all appropriate vaccines.received all appropriate vaccines.received all appropriate vaccines.received all appropriate vaccines.

�� What do you do today?What do you do today?

Questions?Questions?

case studies in immunization delivery

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