Episode Transcript
Hi and Welcome to Clerkship Ready - Pediatrics - A podcast aimed at helping you excel during your clinical clerkship in Pediatrics.
I am Dr. Rachel Moon and I am a general pediatrician and Professor of Pediatrics at the University of Virginia.
Today, we will be reviewing what you need to know before you first order vaccines.
Providing vaccines is one of the most important things that any of us do, and in general, pediatricians are passionate about vaccines.
However, it involves much more than just putting in the orders for the various vaccines. In this podcast episode, we will briefly review how vaccines work, the types of vaccines, what you need to do before the visit, what you should review with families before ordering the vaccines (including precautions and contraindications), and anticipatory guidance about vaccines. We will also talk a little bit about how to handle vaccine hesitancy.
Here is a list of vaccines that are typically given in the United States to pediatric patients. Depending on where you are, some of these are given in combination vaccines:
Hepatitis B
Rotavirus
Diphtheria, tetanus, and acellular pertussis (Dtap) - this formulation is slightly different from Tdap (Tetanus diphtheria and acellular pertussis) as the latter has more of the tetanus component and is given to children and adults who are 7 years and older
Hemophilus influenzae type b (HIB)
Pneumococcal conjugate (PCV).
Inactivated poliovirus (IPV)
COVID-19
Influenza
Measles mumps rubella (MMR)
Varicella
Hepatitis A
Human papillomavirus (HPV)
Meningococcal and meningococcal B
Respiratory syncytial virus (RSV) monoclonal antibody – as this one is a little different, we’ll talk a little more about this in a few minutes
Because the vaccine schedule can change from year to year, we’re not going to go through the schedule. Instead, I’m going to refer you to the CDC website, which is a great resource. Additionally, the American Academy of Pediatrics annually publishes its recommendations for vaccines. The two are usually aligned, so either resource is good. I’ve put both of these websites in the show notes.
It is also important to know that there may be some minor variations in vaccine timing between practices. For instance, since you can give some vaccines at 12-18 months, some practices may give the diphtheria, tetanus, and pertussis (DTaP) vaccine at 12 months, while others may wait until 15 or 18 months. So just check with your residents or attending to make sure that you’re ordering vaccines using the protocol for your practice.
How vaccines work:
Let’s first talk about how vaccines work.
If you remember from your immunology or microbiology courses, vaccines contain a harmless piece of the particular pathogen or toxin, enough to create an immune response.
If parents are hesitant about vaccines, it’s important to use language that explains how vaccines work without turning parents off. Studies have shown that talking about how vaccines “teach” the immune system are most helpful.
Many experts in communication suggest that we talk about vaccines as protecting the community. This de-emphasizes vaccination as a personal choice that is only important for the person getting vaccinated. For instance, when I am seeing a newborn, I talk about how important it is for the family members and everyone who’s going to be in contact with the baby to be vaccinated against influenza and COVID since the baby is not old enough to be vaccinated yet.
There are other ways to describe vaccines. Many parents will understand the analogy of a “software update”. The update will keep the computer (or body) safe from network viruses that can make the computer (or body) vulnerable or “crash”. If you use the software update analogy, you want to emphasize the “network” part of this metaphor, so that again, you’re talking about the wider impact of vaccines beyond oneself. Some people don’t like the software analogy, because it conjures up the image of computer chips being placed in the body. There are other analogies that have been recommended by communication experts. You can try them and see which ones resonate most with your patients. One analogy describes the spread of infection as a fire, with humans as the kindling that the fire needs to keep going. The vaccine is like a flame retardant that can stop fire from spreading. Another example is that a vaccine is like an insecticide – it stops the bug infestation where it is used, and keeps the bugs from spreading. Note that both of these analogies also imply the wider impact of vaccines beyond oneself.
If you want to learn more about how to frame your discussion about vaccines, I would refer you to research by the Frameworks Institute. The reference is in the show notes.
Types of vaccines:
Now that we’ve talked about how vaccines work, let’s talk a little bit about the types of vaccines.
While there are many different vaccine platforms, for practical purposes, you basically need to know that some vaccines are live, attenuated vaccines, while others are not live vaccines. The live attenuated vaccines are made by taking a pathogen and weakening it so that it does not cause infection in most people. Routinely given live attenuated vaccines include Measles Mumps Rubella (MMR), Varicella, and Rotavirus. There is also a live attenuated influenza vaccine, which is given intranasally. The oral polio vaccine (OPV), which is given in other countries but not in the US, is a live attenuated vaccine. In the US, we use the inactivated polio vaccine (IPV). There is also a live attenuated yellow fever vaccine, but we do not give this to children routinely unless they are traveling to an endemic area.
There are a couple of important things to remember about live attenuated vaccines: 1) They often cannot be given to patients with immunocompromise. And sometimes they cannot be given to patients if there is a household member with immunocompromise. We’ll talk about that in a few minutes. 2) Live attenuated vaccines cannot be given within a month of each other, because some studies have shown that the immune response may be diminished if a live vaccine is given too soon after another live vaccine. However, you CAN give more than one live attenuated vaccine at the same time. For instance, we often give MMR and Varicella vaccines at the same time.
The other vaccines do not contain live pathogens. Rather, they contain killed pathogens, antigens or genetic material from the pathogens, enough to create an immune response. Sometimes the antigens are conjugated to other particles, like inactivated tetanus toxin, to improve the immune response. If you hear someone talk about a “conjugated” vaccine, that’s what they mean. Some vaccines also contain adjuvants, such as aluminum compounds or lipids, which also improve the immune response. One downside of non-live vaccines is that they sometimes do not provoke as strong an immune response as live attenuated vaccines. However, an important upside is that you can give them to patients who are immunocompromised.
An mRNA vaccine, such as the COVID-19 vaccine, also falls into this category of vaccines without live pathogens. mRNA vaccines use a piece of messenger RNA – or mRNA – that corresponds to a protein that is in the pathogen. The body uses the mRNA to make that protein, which then stimulates an immune response and antibody production. It is important to note that once the protein is made, the body breaks down the mRNA, so it does not remain in the body.
Let’s spend a couple of minutes talking about vaccines against respiratory syncytial virus (or RSV). There are 2 types. There is an RSV vaccine that is approved for adults at increased risk of severe RSV disease – usually older adults – and for pregnant persons. When given during weeks 32-36 of pregnancy during the RSV season (during the fall and winter), it protects the infant from severe RSV disease. The RSV vaccine for infants is technically not a vaccine. It is a monoclonal antibody. The rules for giving this are a little complicated: it is recommended for infants younger than 8 months old during their first RSV season – so again fall and winter – IF their parent did not get the RSV vaccine or if the infant is born within 14 days of parental vaccination. It should also be given to children 8-19 months old who are at risk of severe RSV – this includes those with severe immunocompromise, cystic fibrosis, chronic lung disease of prematurity, and those who are American Indian/Alaska Native.
Before the visit
Now that you know the basics about the types of vaccines, let’s review what you’ll do before the visit. Before you go into the room to see the patient, you should review the vaccine record to see what vaccines are needed. You should routinely do this before every well child check, since it is anticipated that vaccines will be given at that visit. I think that it’s also important to check the vaccine record before sick visits as well. If it’s during the fall and winter months, remember to see if the patient has received the influenza and COVID vaccines this year. There are a couple of reasons to check the vaccine record before sick visits. First, you may be able to catch the child up on vaccines. Second, if the child is missing vaccines, that may impact your differential diagnosis. For instance, if you have an unimmunized child with a severe cough, pertussis may be in your differential. Or you might need to worry about measles or varicella if your patient with fever and rash is not immunized.
You also want to review the rest of the medical record to make sure that there are no contraindications to giving the vaccines. We’ll talk about what you’re looking for in a minute.
Double check the vaccines that are needed with your resident or attending. It can get complicated if the child is behind on vaccines, since you’ll have to use a catch-up schedule. Also check to see what your practice says about the maximum number of vaccines that are given at one time. While there is technically no limit to the number of vaccines that can be given at a single visit, some practices are reluctant to give more than 5 or 6 vaccines at a time.
Reviewing vaccines with the family
Now you’re in the room with the patient and are ready to talk about vaccines. You need to be sure that there are no contraindications to giving vaccines, or precautions that you need to consider.
When you look at screening tools for vaccine contraindications, the list of questions seems very long and daunting. However, many of the questions on these screening tools are ones that you will be asking as a routine part of the visit, or you will already know the information from your review of the medical record.
1. Is the child sick today? Even at well child visits, if the parent is concerned about the child being ill, they will generally bring it up. There is no evidence that acute illness reduces vaccine efficacy or increases vaccine adverse events. And mild illness, such as an ear infection, URI, diarrhea, or fever, is not a contraindication. However, some parents and clinicians may want to hold off on vaccines if there is concern that vaccine side effects may make it difficult to sort out how a disease process is progressing. If the child is currently taking antibiotics, that is not a contraindication. Children can also be immunized during hospitalization or before or after a surgery or procedure. However, because other hospitalized patients may be immunocompromised, usually live attenuated vaccines are not given to hospitalized patients. Many hospitals will vaccinate children on the day of discharge to minimize risk of exposure to immunocompromised patients while maximizing the opportunity to vaccinate the patient.
2. Does the child have any allergies? Most allergies to medications and foods are not an issue. However, if the child has had an anaphylactic reaction to gelatin, they cannot get vaccines containing gelatin. Many of the live attenuated vaccines have gelatin. If the child gets a stomach ache or any other reaction less severe than anaphylaxis, gelatin-containing vaccines are fine to give.
Similarly, if a child has had an anaphylactic reaction to latex, that is a contraindication to vaccines that contain latex as a part of the packaging (such as vial stoppers, prefilled syringe plungers, prefilled syringe caps). Children who are at highest risk for latex allergy are those with spina bifida, because they have a lot of exposure to latex products early in life. Spina bifida in and of itself is NOT a contraindication to vaccines. Additionally, a local reaction, such as local swelling, to a prior vaccine or to latex, is NOT a contraindication.
Egg allergy used to be a contraindication for influenza vaccine, but that is no longer the case. You do not need to take any additional safety measures when you give the flu vaccine to someone with an egg allergy. However, given that the risk of a reaction is always possible, regardless of whether they have a history of allergy or not, all vaccines should be given in a setting where there are professionals and equipment to handle any hypersensitivity reaction. However, if the child has had a severe allergic reaction to egg, such as angioedema or respiratory distress, or has required epinephrine or another emergency medical intervention, the vaccine should be administered in a medical setting where severe allergic reactions can be managed. In those rare conditions, we refer those patients to our allergy clinic.
3. Has the child had any problems with vaccines in the past? Many children will have had minor reactions, such as fever or a knot at the vaccine site. These are NOT contraindications. In addition to anaphylaxis to a vaccine or a vaccine component, a prior reaction that WOULD be a contraindication would be a history of encephalopathy within 7 days after receiving a DTaP vaccine. This is an extremely rare reaction, particularly with the newer acellular pertussis DTaP vaccine. However, a child who has had this reaction should NOT get additional doses of pertussis-containing vaccine. An alternative would be to give a diphtheria-tetanus (DT) vaccine without the pertussis component.
4. Does the child have any chronic disease?
—If the child has any immunocompromising disease, such as immunodeficiency, asplenia, or HIV infection, they should not get any live attenuated vaccines. The exception is a child with HIV infection who is asymptomatic and has a CD4 cell percentage of 15% or higher - they should receive MMR and varicella vaccines, because the risk of these diseases is much higher than the risk of giving the vaccine.
—If the immunodeficiency is familial or congenital, also ask if there are any household members who also have the immunodeficiency. If so, then check with the child’s immunologist about their immune status. If the person getting the vaccine is immunodeficient at the time of getting the vaccine, they could transmit the infection to immunocompromised family members.
—In the past 3 months, has the child taken medications that affect the immune system such as oral high-dose steroids, chemotherapy for cancer, immune mediator or immune modulator drugs for rheumatic disease, inflammatory bowel disease, or had radiation treatments? Live attenuated vaccines should be postponed until after the treatment has ended. For specific diseases, double check the specialist’s last note - they will often have made some comment about when the child can get vaccinated.. Children with asthma who are taking inhaled steroids can receive live attenuated vaccines.
—Is the child on long-term aspirin treatment? If so, they should not receive live attenuated influenza vaccine, because of the association of Reye syndrome after children with influenza infection were treated with aspirin. Give this child the inactivated flu vaccine.
—Does the child have asthma? In general, children with asthma or a history of wheezing in the past 12 months should be given inactivated influenza vaccine, because there are concerns that live attenuated influenza vaccine could induce wheezing.
—Other fairly rare problems, such as cochlear implant or a CSF leak, are contraindications for live attenuated flu vaccine. Give them the inactivated influenza vaccine.
–Does the child have asplenia? Remember that without a spleen, one is susceptible to infections with encapsulated organisms. So if the child has asplenia or functional asplenia from sickle cell disease or some other process, they will need to get extra vaccines to protect against encapsulated organisms - which include the pneumococcal-23 valent vaccine and meningococcal vaccines.
5. If your child is 6 months or younger, have they ever had intussusception? If they have, they should not be given rotavirus vaccine, as intussuception can be a rare complication of this vaccine.
6. Does the child have a history of seizures or other CNS problem?
—If the child has a history of seizures, or there is a first-degree relative (parent or sibling) with a history of seizures, they should get MMR and varicella as separate vaccines, since the combination vaccine MMRV, or measles mumps rubella varicella, is associated with a higher risk of seizure for children younger than 4 years of age. Because of this increased risk, most practices routinely give the 12 month MMR and varicella vaccines as separate vaccines.
—If the child has an UNSTABLE progressive neurological problem, some would defer any pertussis-containing vaccine.
—If the child has a history of Guillain-Barre syndrome within 7 days of receiving a tetanus-containing vaccine, that is considered a precaution, not a contraindication. Some would not give any additional tetanus-containing vaccines.. If the child has a history of Guillain-Barre within 6 weeks of a prior influenza vaccine, this is similarly a precaution. Most would vaccinate with inactivated influenza vaccine if the child is at high risk for severe influenza complications.
7. In the past year, has the child received a transfusion of blood/blood products, or been given IgG or an antiviral drug? MMR, Varicella, and live influenza vaccine may have to be deferred. Check the CDC website, as the period of time you need to defer the vaccine depends on the medication and the dose.
8. Is the patient pregnant or is there a chance they could become pregnant during the next month? Live virus vaccines are contraindicated one month before and during pregnancy because of the theoretical risk of viral transmission to the fetus. HPV vaccine is not recommended during pregnancy. On the other hand, we do recommend that all pregnant persons receive inactivated influenza vaccine, COVID, and Tdap, as this decreases the risk of disease in the young infant. In case you are asked, COVID vaccine is not associated with fertility problems in men or women. Also, those who contract COVID infection during pregnancy are more likely to have severe disease. And we already mentioned the recommendation for RSV vaccine during pregnancy.
9. Has the child received vaccinations in the past 4 weeks? If the child has received any live vaccine, they have to wait 28 days before they get another live vaccine. Inactivated vaccines may be given at the same time or at any spacing interval.
That’s the list of screening questions. Again, it seems like a lot, but you can get all of the information by doing a review of the medical record and then asking a few questions:
How is your child doing today?
How has your child done with vaccines in the past?
Does your child have any allergies?
Are there any medical problems?
Has your child ever been hospitalized or had any surgeries?
Usually, if you ask these questions, you’ll know if you need to ask more questions - for instance, if they are on penicillin or amoxicillin everyday, you may want to ask about sickle cell disease or asplenia.
OK, now that you’ve made sure that the child can get vaccines, double-check the vaccines that you’ve ordered with your resident and attending, and then order them.
You will also have to do some anticipatory guidance regarding the vaccines. As we mentioned, there may be parents who are hesitant to have their children vaccinated. Your job is to reassure them and to normalize all of the vaccines. Don’t make it a big deal, and don’t single out specific vaccines, because if you talk about them as being a normal part of the visit, parents are more likely to accept them.
Let the parent know which vaccines that the child will get. There is good evidence to show that parents are much more likely to accept vaccines if you tell them what the child is getting rather than asking the parent if they want to give the vaccines. So I generally say something like “Today, she’ll get her 6 month vaccines. Most of them are combination vaccines, so she’ll get 5 actual shots. She’ll get vaccines to protect against diphtheria, tetanus, whooping cough, polio, certain types of meningitis, pneumonia, and ear infection, flu, and COVID.”
Talk about common side effects. Many children will get a fever or redness/soreness at the injection site. I usually talk about this not as a side effect, but as a sign that the vaccines are doing their job, and that the child’s body is showing that they are developing antibodies and protection against the disease. We do not recommend pre-treating children with acetaminophen or ibuprofen, because studies have shown that pre-treatment can decrease the effectiveness of the vaccine. However, if the child does get a fever, treating with acetaminophen or ibuprofen at the time of the fever has not been shown to diminish the immune response. Calculate the dose of acetaminophen or ibuprofen, and write that down for the parent.
The common side effects for MMR and varicella vaccines, which include mild fever and rash, do not usually occur until approximately 1 week after the vaccine is given. It is helpful to let parents know that, because many people don’t realize that the side effects can come up later.
For parents who are vaccine-hesitant, ask if there are any questions that you can help to answer. Be polite, kind, and understanding. They don’t want anything bad to happen to their child, and neither do you. Let them know that you definitely recommend the vaccine. If you don’t explicitly say that you recommend the vaccine, parents will assume that you don’t care if they get the vaccine or not - or that you don’t want them to get it. I don’t get into an argument about it. I just say that “I recommend it.” If you have children or other relatives in the pediatric population, a statement that “I made sure that my nieces and nephews are vaccinated” or “I vaccinated my children” can be very powerful.
If parents try to argue with you, you can just say, “I don’t want to argue with you. I do recommend it, and I’m happy to answer any questions.” Or you can say something like “I wouldn’t be doing my job if I didn’t tell you what I recommend.”
You can start by asking “Can you tell me what you are worried about?” This may give you insight into if a parent has misinformation about a particular vaccine, about vaccines in general or about some other part of the process and you can target your educational approach. It also lets you know where parents get their information (the news, Facebook, Instagram) so you can diplomatically discourage this and steer them to reputable sources instead.
If they are still hesitant, I also like to offer information from the American Academy of Pediatrics Healthy Children.org website or the CDC website so they can read more. This lets parents know which websites we consider “the standard” for scientific information about children.
One additional note about hesitancy: some parents may think that vaccines - particularly the MMR vaccine - cause autism. This theory has been thoroughly debunked. None of the vaccines are associated with autism, and having autism is not a contraindication to any of the vaccines.
Many of the older children will be scared to get the vaccine. They will often be able to convince their parent to not give them the vaccine. There are a few strategies that may help:
Talk about the importance of the vaccine. This can particularly help if you know of a local outbreak of a vaccine-preventable disease. Or “flu is really bad this year, so most parents want to get their child vaccinated.”
Reassure the child that it will hurt for a quick second, but that they are strong and brave, and that this will help them not to get sick later.
Talk about distraction techniques that can help. This is one time when I really like digital media. I tell my patient to choose what they would really like to watch on their (or their parent’s) phone and give them permission to watch that while they’re getting their vaccine.
Some practices have “numbing spray” (which is either lidocaine or benzocaine) that can be helpful for children.
Some practices recommend that parents place a lidocaine patch (which parents can buy over-the-counter) on their child’s arm before they come to the visit. Obviously, it would be too late to recommend for someone who is already in the office, but you can check with your practice to see if either lidocaine spray or patches are something that they recommend for the next visit.
You’ve now successfully counseled a family about vaccines and vaccinated the child. Good work!
IF you get a chance during your clerkship – I recommend you watch a vaccine and even ask if you can do one!
OUTRO:
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