As vaccination rates decline, clinicians increasingly ask, “What, if anything, needs to be considered differently in the clinical care of an unvaccinated child?” More broadly, clinical care areas are considering what may need to change in their clinical flow and overall operations. These questions acknowledge that lower vaccination rates change the likelihood of vaccine-preventable diseases (VPDs) — both in a specific patient and in the community at large.
Start with local epidemiology
First and foremost, it’s important to have a handle on local vaccination rates and disease epidemiology. National trends need to be noted, but clinical workflows should be responsive to current local and regional concerns to prevent overcorrection. As an example, in the past year, large outbreaks of measles occurred in Texas and South Carolina, but Philadelphia was never considered an outbreak region. So, while it was prudent for Philadelphia-area providers to know about those outbreaks, such as for screening travelers to those areas, suspicion for measles in a child who never left Philadelphia, even if unvaccinated, remained low. This awareness of epidemiology becomes important so that we do not overcorrect our systems based on changing vaccination rates alone but, rather, by considering both changing vaccination rates and local epidemiology together.
Clinicians, therefore, need reliable methods for obtaining local and broader epidemiologic information. Locally, this can include monitoring local health department alerts or subscribing to institutional outbreak notifications. More broadly, it means identifying and using trusted surveillance tools that track changing disease prevalence. Our recent feature article, “Disease surveillance when systems fail,” has some great resources that may be useful for this aspect of clinical care.
Consider triage opportunities
The first opportunity to assess for a highly transmissible disease typically occurs before patients are fully assessed by a clinician. Phone triage systems are a great first moment to identify symptoms or exposures associated with vaccine-preventable diseases (as well as other infections) that require airborne precautions or that may need specific personal protective equipment (PPE). Triage systems can now integrate symptoms, such as fever, rash, cough or runny nose, with known exposures or recent travel to outbreak areas.
For highly contagious conditions, like measles, pertussis and varicella, it is important to have a process in place that reduces the likelihood for waiting room exposures. In some cases, evaluation may begin with telehealth, examination in the car, or immediate placement into an isolation space rather than sitting in a waiting room.
In locations where triage occurs at the point of entry, such as the front desk of an urgent care or emergency department, risk can still be mitigated. Screening questions included with the check-in process can allow for patients to quickly be moved into isolation areas instead of having them remain in the waiting area.
Confirm vaccination status
At some point in clinical care, vaccination status needs to be reliably assessed. This may occur before a patient enters a care facility, at triage, as a patient is placed in an exam room, or during the history and physical exam. Care settings need to decide when and how this will happen so that it does not fall through the cracks. Too often, “up to date on vaccines” is noted in a chart without clarity on who verified that information and what that phrase indicates for the patient in front of them.
For treating clinical teams who do not have access to a patient’s vaccination records, such as in urgent care settings or in the emergency department, clinicians need to know specifically which vaccines have or have not been received to inform the differential diagnosis. The best way to do this is to directly ask if the family knows which vaccines the patient has received. In some situations, based on current outbreaks or the symptoms that the patient is presenting with, it is beneficial to explicitly ask about a particular disease or vaccine (e.g., “Has your child been vaccinated for measles?”).
Rely on the history and physical exam
History and physical examination are extremely valuable when considering vaccine-preventable diseases. Many vaccine-preventable diseases have characteristic clinical findings that can guide decision-making. Providers may find themselves revisiting clinical presentations they previously encountered only in textbooks or board review materials. For quick reference, check out our “Fast Facts” series at the bottom of our Vaccine Update homepage for a refresher on the nuances of some less commonly seen vaccine-preventable diseases. For example, many providers may be familiar with measles causing fever and rash, but some may not quickly recall that the rash starts three to five days after the start of other symptoms and begins at the hairline developing downward. These distinct clinical features can help with diagnosis or ruling out certain conditions. For example, if the family reports that the rash developed on the lower extremities and started before the fever, clinicians can confidently rule out measles.
Providers should also take a moment to consider epidemiology here as well. If a child has a fever and rash that may be typical of an infection like measles, determining the likelihood of measles requires considering additional epidemiologic clues. Has the child traveled internationally? Are there known local outbreaks? Was there a potential exposure, such as to an undervaccinated community or a household contact with a similar illness? Obtaining a detailed history on the child’s exposures can help rule out infections or at least signal the need for a larger conversation, such as with your local public health authorities, to consider if this patient may be an index case. Because of mandatory reporting for some conditions and a larger view of what is happening locally, public health officials can often provide helpful guidance for assessing the likelihood of infection and need for testing.
Bacterial infections that cause invasive systemic infections, such as bacteremia, can be more challenging to diagnose. Many of the most prominent infections of childhood are now vaccine preventable, but in situations when a child is missing some or all vaccines, bacterial infections caused by Haemophilus influenzae type b (Hib) and Streptococcus pneumoniae must be considered. Unlike many infections, bacteremia has no obvious clinical presentation (e.g., swollen glands, rash, or distinctive cough); however, one feature is worth noting: These children look miserable, and careful physical examination and measurement of vitals can help determine the need for additional testing or referral. If you are managing an unvaccinated child under the age of 2, it can be particularly helpful to bring them into the office for an exam earlier than phone triage protocols may currently dictate, particularly because the history and physical exam can better inform the need for a laboratory workup. Current research does not support an approach in which all unvaccinated children require blood cultures or labs; however, clinical experience with these infections does reflect that a reassuring exam is a good first test to rule out invasive infections, particularly in unvaccinated toddlers.
Prepare post-exposure plans
Clinical settings should proactively plan for post-exposure prophylaxis workflows. At some point, an as-yet undiagnosed vaccine-preventable disease will likely enter the clinic environment and cause exposures. Additionally, diagnosis of infections in one patient may lead to the need for prophylaxis of family or community members. The American Academy of Pediatrics “Red Book” thoroughly outlines post-exposure prophylaxis considerations for all infections. In advance of an exposure, clinical settings should create a plan that includes who will identify exposed individuals, communicate with families, prescribe prophylactic medications, and coordinate with local health department officials. Thinking through these logistics before an exposure event can substantially improve response times, staff stress and patient safety.
Standardize approaches
As practices adapt to local changes in vaccination rates, office policies for unvaccinated patients should be standardized and clearly communicated. Protocols regarding triage and arrival, telehealth evaluation, laboratory testing, masking and exposure management should be developed in advance rather than improvised during a potentially stressful clinical encounter.
Equally important, families of these patients should understand why certain precautions may be necessary or why their child may need certain laboratory studies to evaluate for infections. These conversations require nuance and empathy but are better discussed in advance — when a family is making the decision to remain unvaccinated rather than when they are calling with a sick child. The goal during these, and subsequent, conversations is not punishment or stigmatization. Families and caregivers of unvaccinated children need good working relationships to care for these more vulnerable patients as well as to protect other patients and staff in the event of a vaccine-preventable disease exposure. For support with these conversations, check out our “Vaccinated or Unvaccinated: What You Should Know” resource as it can help families know what to look for and provide a basis for these discussions.
As vaccination rates decline, clinicians need to be prepared to recognize previously rare infectious diseases while also recognizing the need to address the operational realities of managing potential cases in clinical settings. Adjusting workflows, diagnostic reasoning, and exposure planning are increasingly important.
As vaccination rates decline, clinicians increasingly ask, “What, if anything, needs to be considered differently in the clinical care of an unvaccinated child?” More broadly, clinical care areas are considering what may need to change in their clinical flow and overall operations. These questions acknowledge that lower vaccination rates change the likelihood of vaccine-preventable diseases (VPDs) — both in a specific patient and in the community at large.
Start with local epidemiology
First and foremost, it’s important to have a handle on local vaccination rates and disease epidemiology. National trends need to be noted, but clinical workflows should be responsive to current local and regional concerns to prevent overcorrection. As an example, in the past year, large outbreaks of measles occurred in Texas and South Carolina, but Philadelphia was never considered an outbreak region. So, while it was prudent for Philadelphia-area providers to know about those outbreaks, such as for screening travelers to those areas, suspicion for measles in a child who never left Philadelphia, even if unvaccinated, remained low. This awareness of epidemiology becomes important so that we do not overcorrect our systems based on changing vaccination rates alone but, rather, by considering both changing vaccination rates and local epidemiology together.
Clinicians, therefore, need reliable methods for obtaining local and broader epidemiologic information. Locally, this can include monitoring local health department alerts or subscribing to institutional outbreak notifications. More broadly, it means identifying and using trusted surveillance tools that track changing disease prevalence. Our recent feature article, “Disease surveillance when systems fail,” has some great resources that may be useful for this aspect of clinical care.
Consider triage opportunities
The first opportunity to assess for a highly transmissible disease typically occurs before patients are fully assessed by a clinician. Phone triage systems are a great first moment to identify symptoms or exposures associated with vaccine-preventable diseases (as well as other infections) that require airborne precautions or that may need specific personal protective equipment (PPE). Triage systems can now integrate symptoms, such as fever, rash, cough or runny nose, with known exposures or recent travel to outbreak areas.
For highly contagious conditions, like measles, pertussis and varicella, it is important to have a process in place that reduces the likelihood for waiting room exposures. In some cases, evaluation may begin with telehealth, examination in the car, or immediate placement into an isolation space rather than sitting in a waiting room.
In locations where triage occurs at the point of entry, such as the front desk of an urgent care or emergency department, risk can still be mitigated. Screening questions included with the check-in process can allow for patients to quickly be moved into isolation areas instead of having them remain in the waiting area.
Confirm vaccination status
At some point in clinical care, vaccination status needs to be reliably assessed. This may occur before a patient enters a care facility, at triage, as a patient is placed in an exam room, or during the history and physical exam. Care settings need to decide when and how this will happen so that it does not fall through the cracks. Too often, “up to date on vaccines” is noted in a chart without clarity on who verified that information and what that phrase indicates for the patient in front of them.
For treating clinical teams who do not have access to a patient’s vaccination records, such as in urgent care settings or in the emergency department, clinicians need to know specifically which vaccines have or have not been received to inform the differential diagnosis. The best way to do this is to directly ask if the family knows which vaccines the patient has received. In some situations, based on current outbreaks or the symptoms that the patient is presenting with, it is beneficial to explicitly ask about a particular disease or vaccine (e.g., “Has your child been vaccinated for measles?”).
Rely on the history and physical exam
History and physical examination are extremely valuable when considering vaccine-preventable diseases. Many vaccine-preventable diseases have characteristic clinical findings that can guide decision-making. Providers may find themselves revisiting clinical presentations they previously encountered only in textbooks or board review materials. For quick reference, check out our “Fast Facts” series at the bottom of our Vaccine Update homepage for a refresher on the nuances of some less commonly seen vaccine-preventable diseases. For example, many providers may be familiar with measles causing fever and rash, but some may not quickly recall that the rash starts three to five days after the start of other symptoms and begins at the hairline developing downward. These distinct clinical features can help with diagnosis or ruling out certain conditions. For example, if the family reports that the rash developed on the lower extremities and started before the fever, clinicians can confidently rule out measles.
Providers should also take a moment to consider epidemiology here as well. If a child has a fever and rash that may be typical of an infection like measles, determining the likelihood of measles requires considering additional epidemiologic clues. Has the child traveled internationally? Are there known local outbreaks? Was there a potential exposure, such as to an undervaccinated community or a household contact with a similar illness? Obtaining a detailed history on the child’s exposures can help rule out infections or at least signal the need for a larger conversation, such as with your local public health authorities, to consider if this patient may be an index case. Because of mandatory reporting for some conditions and a larger view of what is happening locally, public health officials can often provide helpful guidance for assessing the likelihood of infection and need for testing.
Bacterial infections that cause invasive systemic infections, such as bacteremia, can be more challenging to diagnose. Many of the most prominent infections of childhood are now vaccine preventable, but in situations when a child is missing some or all vaccines, bacterial infections caused by Haemophilus influenzae type b (Hib) and Streptococcus pneumoniae must be considered. Unlike many infections, bacteremia has no obvious clinical presentation (e.g., swollen glands, rash, or distinctive cough); however, one feature is worth noting: These children look miserable, and careful physical examination and measurement of vitals can help determine the need for additional testing or referral. If you are managing an unvaccinated child under the age of 2, it can be particularly helpful to bring them into the office for an exam earlier than phone triage protocols may currently dictate, particularly because the history and physical exam can better inform the need for a laboratory workup. Current research does not support an approach in which all unvaccinated children require blood cultures or labs; however, clinical experience with these infections does reflect that a reassuring exam is a good first test to rule out invasive infections, particularly in unvaccinated toddlers.
Prepare post-exposure plans
Clinical settings should proactively plan for post-exposure prophylaxis workflows. At some point, an as-yet undiagnosed vaccine-preventable disease will likely enter the clinic environment and cause exposures. Additionally, diagnosis of infections in one patient may lead to the need for prophylaxis of family or community members. The American Academy of Pediatrics “Red Book” thoroughly outlines post-exposure prophylaxis considerations for all infections. In advance of an exposure, clinical settings should create a plan that includes who will identify exposed individuals, communicate with families, prescribe prophylactic medications, and coordinate with local health department officials. Thinking through these logistics before an exposure event can substantially improve response times, staff stress and patient safety.
Standardize approaches
As practices adapt to local changes in vaccination rates, office policies for unvaccinated patients should be standardized and clearly communicated. Protocols regarding triage and arrival, telehealth evaluation, laboratory testing, masking and exposure management should be developed in advance rather than improvised during a potentially stressful clinical encounter.
Equally important, families of these patients should understand why certain precautions may be necessary or why their child may need certain laboratory studies to evaluate for infections. These conversations require nuance and empathy but are better discussed in advance — when a family is making the decision to remain unvaccinated rather than when they are calling with a sick child. The goal during these, and subsequent, conversations is not punishment or stigmatization. Families and caregivers of unvaccinated children need good working relationships to care for these more vulnerable patients as well as to protect other patients and staff in the event of a vaccine-preventable disease exposure. For support with these conversations, check out our “Vaccinated or Unvaccinated: What You Should Know” resource as it can help families know what to look for and provide a basis for these discussions.
As vaccination rates decline, clinicians need to be prepared to recognize previously rare infectious diseases while also recognizing the need to address the operational realities of managing potential cases in clinical settings. Adjusting workflows, diagnostic reasoning, and exposure planning are increasingly important.