Back-to-school office visits should prompt vaccination checks

Pediatricians faced with a multitude of challenges, including new recommendations on influenza vaccine, an influx of new patients and fearful parents.

Back to school means back to the pediatrician’s office for many children, as more schools now require physicals before participation in sport and athletic clubs. This trip provides the pediatrician a good opportunity to make sure that children are up to date with their vaccines, including their yearly influenza vaccine — a recent addition for 2010.

Vaccines by age group

For children starting kindergarten, typically 4- to 6-year-olds, pediatricians should first verify whether early childhood vaccines have been administered, including hepatitis B, diphtheria and tetanus toxoids and acellular pertussis, Haemophilus influenzae type b, pneumococcal conjugate, measles-mumps-rubella (MMR), varicella and hepatitis A.

Children aged 7 to 10 years may need catch-up doses for hepatitis B, inactive polio vaccine, MMR and varicella. Seven- to 10-year-olds belonging to certain risk groups or in certain states may need pneumococcal polysaccharide and hepatitis A vaccines. Eleven- to 12-year-old girls should receive the human papillomavirus (HPV) vaccine to prevent cervical cancer. Children aged 11 to 12 years should also receive the meningococcal conjugate vaccine, as well as the tetanus-diphtheria-acellular pertussis (Tdap) vaccine. Through age 18, children should always be checked for all preceding vaccinations and caught up where appropriate.

Influenza vaccine

Yearly influenza vaccines should be administered to all children, in keeping with the CDC’s Advisory Committee on Immunization Practices recent recommendations.

In an interview, Stan Block, MD, who is on the editorial board of Infectious Diseases in Children, said the burden — and opportunity — of influenza vaccination often falls on pediatricians, and he said the back-to-school visit may be the pediatrician’s only chance.

“It seems that both doctors and families, after about December, get ‘flu vaccine burnout,’” Block said. “Yes, we still give vaccines throughout March, but we don’t give as much because we’re so overwhelmed with acute illnesses that it’s hard to think about flu vaccines.”

In his office of about 16,000 children, vaccination status including flu becomes a “fourth vital sign for our nursing staff,” he said. “They take temperature, pulse, blood pressure and then offer any needed vaccines.”

For school-age children who have not had wheezing in the previous month, Block recommends FluMist (MedImmune), the live-attenuated influenza version of the vaccine. It is recommended by the CDC for children 2 years and older and does not contain thimerosal, which is a point of concern for some vaccine-hesitant parents. Compared with the trivalent shot vaccine, which offers 50% to 80% efficacy for matched flu, FluMist offers 90% efficacy. For unmatched flu strains, the difference is more profound: 20% to 60% for the shot and 70% to 80% for the spray.

Pediatricians will likely face parental suspicion over the influenza vaccine this year, Block said, because the pandemic A/California/7/09 strain replaced a seasonal H1N1 virus in the vaccine. Despite WHO recently declaring the H1N1 pandemic over, Block said vaccination against this strain remains important because of potential resurgence, and pediatricians should discuss concerns with parents.

“You have to approach it gingerly,” he said. “If the parent read something on the Internet or has a specific concern, then you can adequately demonstrate that flu vaccines have extremely safe track records. So it depends on what their source is and how contentious they are about that particular issue.”

Addressing parents’ fears

A University of Michigan study of 1,552 parents found that although 90% said they believed that vaccines helped protect children, 54% were concerned about serious adverse events and 25% said they believed that some vaccines cause autism.

The same survey found that 12% of parents have refused at least one vaccine recommended by their child’s pediatrician. Among refusers, most parents (56%) refused the HPV vaccine. Meningitis (32%), varicella (32%) and MMR (18%) were also commonly refused. The survey also found that mothers were more likely than fathers to be worried about adverse events or to refuse a vaccine.

On a case-by-case basis, the issue of vaccine refusal may appear to be a small frustration, but the dangers of widespread refusal are well documented. A measles outbreak in San Diego in 2008 affected 12 children, all of them unvaccinated.

Physicians at a hospital in Ireland were recently faced with a surge in cases of mumps orchitis, a testicular complication of mumps that causes one or both testicles to swell and may cause infertility.

“Boys who did not receive the MMR vaccine during the mid-1990s are now collecting in large numbers in secondary schools and colleges, and this provides a perfect breeding ground for the virus,” Niall Davis, a urology research registrar who conducted the research, said in a press release.

To avoid similar resurgences of vaccine-preventable diseases in the United States, the burden of vaccine education now falls on pediatricians and nurses. The good news is that many suspicious parents can be reassured of vaccine safety with proper communication strategies, openness and empathy, said Ari Brown, MD, an Austin, Texas-based pediatrician and co-author of Baby 411: Clear Answers and Smart Advice for Your Baby’s First Year.

“There are four types of parents when it comes to vaccines: Believers — those who believe vaccination is safe and necessary; relaxed — those who are cautious but still trust their physicians; cautious — those who don’t really have a problem with vaccines until seeing media coverage or speaking with friends; and the unconvinced — those who staunchly believe that not getting vaccinated is in the best interest of their child,” Brown said in a presentation at the National Immunization Conference in April.

Pediatricians should target the cautious parents, who are typically scared but respond to education efforts. Many parents have been put off by physicians whom they felt were condescending, Brown said, adding that physicians must maintain proper and sensitive communication habits despite time constraints with each patient.

“Break down their fears and see where they’re coming from,” Brown said in an interview with Infectious Diseases in Children. “Fewer and fewer parents are asking about specific vaccines and instead have this global, vague mistrust. If you ask them to specify their fears, you can respond appropriately.

“The most effective pitch for a vaccine is one that is emotional and personal,” she said. “You can throw out all the science and data and research, but at the end of the day, what really makes families comfortable is that you yourself are vaccinated and that you vaccinate your own kids. You must reassure your patients that you wouldn’t do anything different.” – by Andy Moskowitz

For more information:

• Davis NF. BJU Int. 2010;105:1060-1065.
• Freed GL. Pediatrics. 2010;125:654-659.
• Powell D. Pediatr Ann. 2010;39;464-466.
• Shulman ST. Pediatr Ann. 2010;39(8):460-463.
• Sugerman DE. Pediatrics. 2010;125:747-755.