Technically Speaking: Important Job Aids for Catch-up Vaccination

Imagine that you are having one of those days. None of your patients seem to have received vaccines on the standard schedule:

• One patient’s parent insisted on having only one vaccine per week.
• One patient transferred in from a practice that lost their vaccine record.
• One patient is frequently a “no-show.”

Each of these children needs an accelerated schedule, so they will be protected from vaccine-preventable diseases as soon as possible, but how can you figure out when to vaccinate?

Some offices use an electronic health record (EHR) with clinical decision support that can accurately assess the record and tell you what vaccines are needed. It is likely that your state immunization information system (IIS) has the capability of determining which vaccines are due as well, but this only works if all the vaccine doses that have been given have also been uploaded into the IIS. And for most of us, even if a computer system advises us, we still want to verify the advice before we trust it enough to vaccinate our (real life) patient.

The Centers for Disease Control and Prevention (CDC) and Immunize.org offer keys that will unlock a treasure chest of important job aids to help you with these distinct catch-up vaccination situations.

CDC catch-up resources

The CDC has several tools on the catch-up immunization page of their website. Scroll down to the section titled, “Vaccine Catch-Up Guidance.” Here you see tools related to pneumococcal conjugate vaccine (PCV), Haemophilus influenzae type b (Hib)-containing vaccines, inactivated polio vaccine (IPV), and pertussis-containing vaccines. These tools are designed to help with catch-up vaccines at particular ages, often those ages at which the most complex questions arise. For example, a 7- to 9-year-old who needs a pertussis-containing vaccine.

The best way to get familiar with these tools is to use them with an example. Case #1 is all too familiar.

Case #1: Using the CDC resources

Today, you are seeing a 9-year-old boy who had DTaP at 2 months and 4 months of age. The family stopped making it in for well visits after that. A year ago, he had a dirty wound and received Td in the emergency department. With respect to DTaP/Tdap/Td, what should he receive today and when (if ever) should he return for the next dose in the series?

Turning to the table, called “Tetanus-, Diphtheria-, and Pertussis-Containing Vaccines Catch-Up Guidance for Children 7 through 9 Years of Age,” we scroll to the top of page 2 because the patient has had three doses previously. Dose 1 was given before 12 months of age, and it has been at least six calendar months since dose 3. None of his previous doses were Tdap. Thus, today he should receive Tdap (dose 4), and he should return for another dose of Tdap between 11 and 12 years of age. Voila! A tangled history is smoothed out with clear and concise guidance.

Immunize.org catch-up resources

Now, let’s talk about a more complex patient. Obviously, the CDC tool “Catch-Up Guidance for Healthy Children 4 Months through 4 Years of Age — Pneumococcal Conjugate Vaccine: PCV” does not help you with children at high risk for invasive pneumococcal disease because of its focus on “healthy” children, not those who are immunocompromised or who have a relevant underlying condition. For this group, I recommend the sheet from Immunize.org, "Recommendations for Pneumococcal Vaccines Use in Children and Teens." This resource includes a table (Table 3) that lists “Medical Conditions and Other Risk Factors…” and a separate table (Table 2) that shows the recommended schedule for administering pneumococcal polysaccharide vaccine (PPSV23) to high-risk children.

Use this sheet to help with Case #2.

Case #2: Using the Immunize.org resources

Today, you are seeing a 5-year-old girl (60 months of age) who has diabetes mellitus. She had PCV at 2 months and 4 months of age, but mom is not sure if she had any doses after that and the family hasn’t been able to access old immunization records after a recent move. Is this child due for PCV today? Should she have PPSV23 today? When (if ever) should she return for another pneumococcal vaccine?

Using Table 3 (“Medical Conditions and Other Risk Factors That Are Indications for PCV13, PCV15, or PPSV23”) on the bottom right side of the Immunize.org sheet, we see that diabetes mellitus is on the list of high-risk conditions for pneumococcal disease. Using Table 1 on this sheet, we scroll down to the section, “24 through 71 months (children with underlying medical condition as described in Table 3 below).” This patient was given an incomplete series with less than three doses (at least that is all that is documented). Thus, she needs two additional doses of PCV. The first dose should be given today (since it’s been much more than eight weeks since the most recent dose), and a second dose given at least eight weeks later. Also, using Table 2, “Recommended Schedule for Administering Pneumococcal Polysaccharide Vaccine (PPSV23),” we see that this patient also needs one dose of PPSV23 at least eight weeks after her last dose of PCV (i.e., PCV dose 4).

Immunize.org works closely with the CDC to ensure that complex vaccination questions have answers. Check out these additional helpful resources to catch-up patients who may need doses of meningococcal vaccines.

• Meningococcal ACWY Vaccine Recommendations by Age and Risk Factor
• Meningococcal B Vaccine Recommendations by Age and Risk Factor

The ACIP recommendations are complex, but these sheets can help you sort out how to proceed with patient vaccinations.

For a brand-new tool from Immunize.org, check out the one-question, one-minute “Ask the Experts” videos on YouTube. These short videos feature Dr. Kelly Moore, President and CEO of Immunize.org, answering common, yet sometimes complex, vaccination questions, such as “Ask the Experts: MenACWY Given at Age 10. Revaccinate at 11, or Not?” A new video will be released each week on Immunize.org’s social media platforms.

In sum

The vaccination schedule is complex to begin with, so when a child falls behind, things can get hairy really quickly! We hope that these tools from CDC and Immunize.org can help make some catch-up situations easier.