UBC Objectives: Care of Children + Adolescents, Priority Topic: Immunization, Priority Topic: Pneumonia, & Priority Topic: Well-baby Care

By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...

• ​Demonstrate the ability to discuss importance of immunization with parents

Immunization

Key Feature 1: Do not delay immunizations unnecessarily (ex: vaccinate a child even if he or she has a runny nose).
Skill: Clinical Reasoning
Phase: Treatment

Key Feature 2: With parents who are hesitant to vaccinate their children, explore the reasons, and counsel them about the risks of deciding against routine immunization of their children.
Skill: Patient Centered, Communication
Phase: Treatment, History

Key Feature 3: Identify patients who will specifically benefit from immunization (ex: not just the elderly and children, but also the immunosuppressed, travellers, those with sickle cell anemia, and those at special risk for pneumonia and hepatitis A and B), and ensure it is offered.
Skill: Clinical Reasoning
Phase: Treatment, Hypothesis generation

Key Feature 4: Clearly document immunizations given to your patients.
Skill: Clinical Reasoning, Professionalism
Phase: Treatment

Key Feature 5: In patients presenting with a suspected infectious disease, assess immunization status, as the differential diagnosis and consequent treatment in unvaccinated patients is different.
Skill: Clinical Reasoning
​Phase: History, Hypothesis generation

Key Feature 6:  In patients presenting with a suspected infectious disease, do not assume that a history of vaccination has provided protection against disease (ex: pertussis, rubella, diseases acquired while travelling).
Skill: Clinical Reasoning, Selectivity
​Phase: Hypothesis generation

Pneumonia

Key Feature 9: Identify patients (ex: the elderly, nursing home residents, debilitated patients) who would benefit from immunization or other treatments (ex: flu vaccine, Pneumovax, ribavarine) to reduce the incidence of pneumonia.
Skill: Clinical Reasoning, Selectivity
Phase: Treatment

Well-baby Care

Key Feature 6: With parents reluctant to vaccinate their children, address the following issues so that they can make an informed decision:

• Their understanding of vaccinations
• The consequences of not vaccinating (ex: congenital rubella, death)
• The safety of unvaccinated children (ex: no Third World travel)

Skill: Patient Centered, Clinical Reasoning
Phase: Treatment, History

Key Feature 7: When recent innovations (ex: new vaccines) and recommendations (ex: infant feeding, circumcision) have conflicting, or lack defined, guidelines, discuss this information with parents in an unbiased way to help them arrive at an informed decision.
Skill: Professionalism, Patient Centered
Phase: Treatment

Today was my Resident As Teacher session, which meant I chose a topic that would be relevant to my colleagues and I to learn about, and then prepared and delivered a teaching session. I chose to focus on immunization, and I had my amateur improv friend collaborate with me to create an interactive learning session via improv games. The meat of the content revolved around the Immunization CFPC Priority Topic, and is outlined below.

Key Feature 1
“There are a number of conditions that may be raised as a concern about receiving a vaccine,
that in fact should not delay or preclude immunization. For example, routine administration of
vaccines should not be postponed in persons with minor illnesses, such as an upper respiratory
tract infection, otitis media, mild gastrointestinal illness, or concurrent antibiotic therapy.
Repeated infectious illnesses are common in early childhood and will not interfere with the
efficacy of vaccines. Generally, if a person is well enough to present for immunization in the
outpatient setting, he/she is well enough to be immunized.” Resource: Canadian Immunization Guide 

Key Feature 2
5 steps to counsel the vaccine-hesitant parent (Resource: Canadian Paediatric Society Position Statement: Working with vaccine-hesitant parents):

1. First seek to understand
   1. “Do not assume that every parent has the same concerns. Using a nonjudgemental and nonconfrontational tone, ask parents what they are most worried about and to describe their understanding of disease risks and vaccine benefits and risks. Listen carefully. Validate why parents may hold a specific belief about a vaccine, especially if it is based on misinformation and/or misunderstanding.” Resource: Canadian Paediatric Society Position Statement: Working with vaccine-hesitant parents
2. Present evidence on the benefits and risks of vaccines
   1. “Immunization is one of the most important accomplishments in public health that has, over the past 50 years, led to the elimination, containment and control of  diseases that were once very common in Canada.  Before vaccines became available, many Canadian children were hospitalized or died from diseases such as diphtheria, pertussis, measles and polio. Today, although these disease causing bacteria and viruses still exist, such diseases are rarely seen in Canada. However, if the current vaccination programs were reduced or stopped, diseases controlled through immunization would reappear in Canada. This phenomenon has been observed in other countries where large epidemics occurred following a decline in immunization rates, resulting in many preventable hospitalizations and deaths.” Resource: Canadian Immunization Guide 
   2. Suggested reading: Time Magazine article: 4 Diseases Making a Comeback Thanks to Anti-Vaxxers
3. Inform parents about the rigour of the vaccine safety system
   1. “Few are aware of Canada’s robust vaccine safety system or that vaccines are held to a higher safety standard than drugs. As well, because vaccines are often only approved in Canada after they have been in general use in other countries for some time, Canadians benefit from additional safety and effectiveness data. This information is reassuring for some vaccine-hesitant parents.” Resource: Canadian Paediatric Society Position Statement: Working with vaccine-hesitant parents
   2. “There are a number of reasons for not giving vaccines. Sometimes vaccines cannot be given or need to be delayed due to contraindications or precautions. Other times people have unfounded concerns that lead to hesitation to get vaccination when there is no increased risk for vaccination. It is critical for vaccine providers to distinguish among these different reasons.” Resource: Canadian Immunization Guide
      1. Suggested reading: Table 1 of the Canadian Immunization Guide: Contraindications and selected precautions for vaccine administration for inactivated and live vaccines
      2. Maddy’s paraphrased (aka plagiarised) summary of the contraindications as listed in the above table:
         1. Anaphylaxis
            1. If it occurred with a previous dose of the same vaccine or if there is known anaphylaxis to components of the vaccine. Consider referral to an Allergy & Immunology specialist.
               1. Eggs: Anaphylactic egg allergy is rare. When present it is a contraindication to vaccines containing egg with the exception of influenza, MMR and MMRV vaccines.
               2. Gelatin: Anaphylactic allergy to gelatin is extremely rare. Generally safe. Most gelatin allergies are non-anaphylactic and gelatin-containing vaccines may be given.
               3. Latex: “Generally safe. For non-anaphylactic latex allergies (e.g., history of contact dermatitis to latex gloves), vaccines supplied in vials or syringes that contain dry natural rubber or natural rubber latex may be given. Anaphylactic allergy to latex is very rare.’’
         2. A few medical situations
            1. Severe asthma (live attenuated influenza vaccine)
            2. Congenital malformation of GI tract or history of intussusception (rotavirus)
            3. Guillain-Barre Syndrome
            4. Tuberculosis (a bunch)
            5. Immunosuppression (in which case only live vaccines are a concern)
         3. Pregnancy
            1. Live vaccines are contraindicated
4. Address the issues of pain with immunization
   1. There is an entire clinical practice guideline devoted to this! “Reducing the pain of childhood vaccination: an evidence-based clinical practice guideline” by Taddio et al, published in the Dec 2010 edition of the Canadian Medical Association Journal (CMAJ)
5. Do not dismiss children from your practice because parents refuse to immunize (i.e., don’t be a douche)

Suggested reading: Preparing for Vaccine Questions Parents May Ask

Key Feature 3
Vaccination schedules are province-specific. BC has published a set of routine immunization schedules for 3 populations (Resource: BC immunization schedules)

• Infants and children
• School age children
• Adults, seniors, and individuals at high risk

For vaccination recommendations for special populations, I recommend referring to Part 3 of the Canadian Immunization Guide. Know what patient populations may be at increased risk of acquiring a infectious diseases and consider bookmarking this link for quick access when seeing such patients in clinic.  Consider keeping this information at the TIIIIP of your nose: 

• Travellers
• Immigrants
• Immunocompromised
• Infants born prematurely
• Immunization records lacking
• Persistent (chronic) disease

Key Feature 4 & 5
Be a responsible DAD 

• Don’t assume (someone is up to date with their vaccines)
• Ask (what vaccinations they have received)
• Document (what they have received and when)

Key Feature 6
Know that vaccinations don’t guarantee 100% immunity in all people.