Keeping kids on vaccination schedule can be a struggle

With more shots recommended than ever before, doctors look for tools and strategies to keep children's immunizations up to date.

By Victoria Stagg Elliott — Posted April 25, 2005

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Every summer, when the appointment schedule tends to be lighter, Marsha Raulerson, MD, a pediatrician from Brewton, Ala., reviews her medical charts, looking for patients who might be missing a shot. She writes letters, and, if necessary, she phones their homes to encourage them to come in for missing vaccinations.

"Lots of families don't bring their children in for a well-child visit, and they miss their schedule," she said. "I do a lot of calling."

The challenge of getting kids their shots is in part due to the fact that physicians such as Dr. Raulerson have to convince parents to stick to a schedule that is increasingly crowded and frequently changing.

For example, in 1983, the schedule from the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices recommended eight vaccines before age 2. It was reissued again in 1989 with only a minor change.

The schedule is now issued annually, and the one issued this January calls for more than 20 shots for most toddlers. It's the first one in several years that hasn't changed from the previous one.

"It does make it difficult for people to keep up to date," said Paul Darden, MD, professor of pediatrics at the Medical University of South Carolina. "The change in the vaccine schedule has been dramatic over the last 20 years. You have to pay attention."

It is not an issue of reducing the number of vaccines on the schedule, most agree. And, in some ways, the current situation is an improvement over 20 years ago.

At that time, the schedule was simpler, but it also varied widely because it was issued independently by the ACIP as well as other professional associations, such as the American Academy of Pediatrics and the American Academy of Family Physicians. Since 1995, it has been a collaboration between the ACIP and these groups.

"We are committed to keeping a harmonized schedule," said Richard Clover, MD, the AAFP liaison to the ACIP.

As crowded as the schedule is, most children do get the vaccines they're supposed to. Several studies have suggested, however, that children don't always get them on time, and this delay has many experts concerned.

Most recently, a study in the March 9 Journal of the American Medical Association by CDC researchers found that 37% of children were at least six months behind on at least one vaccine, with 21% being behind on more than four.

"These results confirm that opportunity exists for improvement in vaccine administration in the United States to ensure that all children remain fully vaccinated and optimally protected from vaccine-preventable diseases throughout early childhood," the researchers wrote.

Searching for ways to do better

Studies like these, in addition to the expectation that more vaccines will be added in the next few years, have many physicians wishing for tools and strategies that would make it easier. For example, this study suggested that not having a continuous relationship with one physician was a factor in children falling behind.

"I believe very strongly in the medical home from birth to age 21 so that physicians know their patients," said Larry Pickering, MD, senior adviser to the director of the CDC's National Immunization Program. "But often we don't have that luxury."

This reality, combined with the schedule's complexity, has many feeling that the need for immunization registries is even more pressing. The American Medical Association has had policy since 1999 encouraging doctors to participate in developing registries and to use them in practices, and many states have registries in various stages of development.

But many regions are a long way from the Healthy People 2010 goal of having 95% of children registered. According to a paper in the May 28, 2004, Morbidity and Mortality Weekly Report, only 43% actually were registered by the end of 2002.

"We really need registries," Dr. Darden said. "I can keep them on schedule if they come in, but I can't if they're not in my office. I hope they've gone on to someone else, but I don't know."

Payment is also an issue that can delay the uptake of new vaccines. The AMA has several policies endorsing laws that require insurance companies to pay for recommended vaccines, but physicians complain that it sometimes can take years for public and private payers to pony up for new recommendations.

"As a small businessman, I have to be confident I will be reimbursed," said Ernest Buck, MD, a pediatrician in Corpus Christi, Texas. "It can take three years to get coverage for everyone who could benefit."

Combination shots might have the potential to make life easier for physicians. The first to provide protection against five diseases was approved by the Food and Drug Administration in 2003, and one combining measles, mumps, rubella and varicella is expected soon, although combination vaccines are expected to be outweighed by newly added vaccines.

"The schedule will become even more complex," said Gary Freed, MD, MPH, director of general pediatrics at the University of Michigan, Ann Arbor. "Groups will need to work even harder to make sure everyone is aware of the changes."

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Rising number of vaccines

A review of the vaccination schedule shows how updates and adjustments have accelerated in recent years.

1983: Advisory Committee on Immunization Practices recommends eight vaccines before age 2.

1989: Haemophilus influenzae type b, Hib, vaccine added to ACIP's schedule, bringing number of immunizations up to nine.

July 1995: ACIP, along with the American Academy of Pediatrics and the American Academy of Family Physicians, issues first joint Childhood Immunization Schedule. Fifteen immunizations are recommended before age 2.

July 1996: Varicella vaccine recommended for infants ages 12 to 18 months.

January 1997: Greater reliance on inactivated polio vaccine is advocated to reduce the risk of vaccine-associated paralytic polio. Combination of Hib, diphtheria, tetanus and pertussis becomes available. Combination of Hib and hepatitis B also becomes available.

January 1998: Second dose of MMR recommended for children ages 4 to 6 years. Routine health visit recommended for adolescents ages 11 to 12.

January 1999: Combination Hib and DTP not recommended for infants. Rotavirus shots recommended at ages 2, 4 and 6 months.

January 2000: Rotavirus vaccine removed from the schedule. Inactivated polio vaccine recommended for nearly all situations.

January 2001: Pneumococcal conjugate vaccine added to the schedule.

January 2002: First dose of hepatitis B vaccine encouraged for all newborns. Because of supply problems, some doses of tetanus, diphtheria, pertussis, as well as pneumococcal conjugate vaccine are deferred.

January 2003: Influenza vaccine is encouraged.

January 2004: Tetanus and diphtheria recommended for adolescents ages 11 to 12.

April 2004: Annual influenza shot recommended instead of just encouraged.

January 2005: Annual schedule is issued without changes. Includes 20 vaccines before age 2 plus an annual influenza shot.

Source: Advisory Committee on Immunization Practices

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External links

Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices (link)

"Timeliness of Childhood Vaccinations in the United States," abstract, Journal of the American Medical Association, March 9 (link)

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