389 - Updated Vaccination Schedule, Vaccine Confusion, Gut Feelings
Take 3 – Practical Practice Pointers©
From the Advisory Committee on Immunization Practices
1) New 2021 Schedule Updates – What Are the Changes?
All these changes are written into the schedules – mostly in the Notes sections.
- Child vaccination rates are still low due to the pandemic – risking outbreaks of vaccine-preventable diseases.
- Schedule all well-child checks as in-person visits.
- Identify children in your practice with missed vaccinations and get them in.
- Hepatitis B - Mother-to-infant transmission is a concern due to pandemic-related vaccination disruption – educate pregnant mothers about the need for HBIG and HepB vaccine to the infant less than 12 hours after delivery and ensure that the recommended vaccination schedule is followed.
Child Schedule Changes:
- Vaccine Catch-up Guidance – A series of handouts is available to help interpret and use the Catch-up schedule – see the Schedule Changes web page (Link)
- DTaP and Tdap are both more integrated into the wound management algorithm (also see my other pointer in this issue about DTaP and Tdap)
- For kids aged < 7, you can use either DTaP or DT.
- For all aged 7 or older, you can use either Td or Tdap.
- DTaP and Tdap are preferred if immunization status is unclear.
- Hib vaccine – If you are giving catch up vaccines, and the last dose was at 15 months or greater, no further doses are needed.
- Hep B dose for newborns less than 2000g with HepBSAg negative mothers can be delayed until discharge or 1 month chronological age, whichever is earlier.
- HPV series - A reminder not to restart the series if it is interrupted. (but, if the child gets their 2nd dose at age > 14, they need the 3-dose schedule.
- Influenza vaccines:
- With egg allergy manifesting only as hives – any product is OK
- With egg allergy and symptoms other than hives – any product is OK but administer in a medical setting (unless using egg-free).
- Live attenuated influenza vaccine – avoid in the following patients: immunоcompromised (medications, HIV, no spleen, etc.), on aspirin therapy, aged 2-4 years with history of wheezing, aged < 2 years, pregnant, severe allergy to vaccine or component (other than egg), close contacts of an immunocompromised patient, cochlear implants, CSF leak, received antiviral medication recently.
- Any severe allergic reaction to influenza vaccine is a contraindication.
- MenQuadfi (MenACWY-TT) is a new option available for age >= 2 years with h/o splenectomy, immune compromise, sickle cell, etc.
Adult Schedule Changes:
- Shared decision making - Link to CDC’s FAQ is on the schedule.
- Hep A – An accelerated dosing schedule for Twinrix (HepA-HepB) for people travelling to areas with high rates of Hep A - 3 doses at 0, 7, and 21-30 days, followed by a booster dose at 12 months.
- Hep B – Added a shared-decision making option for people with diabetes > 60 (due to risk of shared glucometers, etc.). Previous recommendation was < 60.
- Clarifications to the wording for shared decision-making recommendations from age 27-45.
- For immunocompromised patients, HPV vaccine is always 3-doses.
- Influenza – Same notes as under Child Schedule.
- MenQuadfi (MenACWT-TT) added as a new option.
- Booster doses recommended during outbreaks.
- Pneumococcal – Rewording makes the sequencing over age 65 clearer.
- Tetanus – Recommendation as above for Tdap for wound prophylaxis.
- Zoster – Zostavax (ZVL) removed as an option for shingles (no longer available).
Not too much new stuff here. We have been defaulting to using Tdap for wound management a lot anyway. The pandemic disruptions in child vaccine schedules are important – pay extra attention to well-child check visits – keep them on-time and in person and seek out the kids in your practice that are still delayed. For adults, it’s useful to read over the shared decision-making guidance.
- Immunization Schedule Changes | CDC. Published February 11, 2021. Accessed February 22, 2021. Link
- Birth-18 Years Immunization Schedule | CDC. Published January 25, 2021. Accessed February 22, 2021. Link
- Adult Immunization Schedule by Vaccine and Age Group | CDC. Published February 11, 2021. Accessed February 22, 2021. Link
From the Advisory Committee of Immunization Practices
2) Childhood Tetanus, Diphtheria and Pertussis Vaccine Confusion
This pointer falls into the realm of things that are usually so automated we don’t have to think about them, so when there is a variance, we need to double check ourselves.
First, the players: DTaP vs. Tdap
- Tetanus, diphtheria, and pertussis vaccines
- The capitals vs. small letters are important – they indicate different strengths of the vaccine for each antigen – these different strengths are licensed and indicated for different age groups.
- The “a” is for acellular pertussis vaccine, the only kind available now.
Next, the packages:
- Infanrix or Daptacel (DTaP alone)
- Kinrix or Quadracel (DTaP with IPV)
- Pediarix (DTaP + IPV + HepB)
- Pentacel (DTaP + IPV + Hib
- Boostrix and Adacel (same formulation)
The basic rules:
- DTaP is licensed for 2 months through 6 years.
- Tdap is licensed for 10 years and older (Adacel only through age 64)
- Alert readers will realize there is a gap here…
How to manage the gap:
- Don’t give DTaP over age 6.
- Tdap can be used for catchup immunization during this gap (off-label use recommended by ACIP)
- If given from 7-9 years, give the 11-12 year Tdap also.
- If given at 10 years, there is no need for 11-12 year Tdap.
How to manage errors – DTaP accidentally given over 6 years:
- If given from 7-9 years, it can count as catch-up, but give 11-12 year Tdap also.
- If given from 10-18 years, count it as the 11-12 year Tdap, but review your clinic practices so this doesn’t happen.
- Since the antigen and toxoid levels are much higher, giving DTaP at older age can increase the risk of vaccine reactions in this older age group.
The yearly updated ACIP schedules (link below) have all this information in them. Also, keep a copy of the CDC’s Pink Book (link below) bookmarked on your computer (or buy a paper copy). Both resources can clarify what to do when the regular schedule gets disrupted, but combination vaccines make this complicated, so review the guidance for each vaccine in the combo. Best of all – be proactive about vaccines to make sure your young patients stay on the right schedule in the first place!
- Birth-18 Years Immunization Schedule | CDC. Published January 25, 2021. Accessed February 15, 2021. Link
- CDC. Epidemiology and Prevention of Vaccine-Preventable Diseases. 13th ed. (Hamborsky J, Kroger A, Wolfe S, eds.). Public Health Foundation; 2015. Link
- Havers FP. Use of Tetanus Toxoid, Reduced Diphtheria Toxoid, and Acellular Pertussis Vaccines: Updated Recommendations of the Advisory Committee on Immunization Practices — US, 2019. MMWR Morb Mortal Wkly Rep. 2020;69. Link
From the Literature
3) Gut Feelings?
If evidence-based medicine is about anything, it is about the more explicit use of research findings to inform healthcare decisions. What then, can we make of research on the “gut feelings” of physicians about whether there is a cancer diagnosis? Gut feelings have been described as “intuition,” “instinct,” and “tacit knowledge.” Believe it or not, this topic has been studied enough in medicine to warrant a systematic review.
In the British Journal of General Practice last year, researchers searched multiple databases, both in the health literature and so-called “grey literature” (non-medical databases). They included a broad range of articles, both quantitative and qualitative studies and critically appraised all the studies using standard criteria. The quantitative studies were of low quality, but the qualitative studies were well done.
From a meta-analysis of the 4 quantitative studies, the researchers found that a feeling that “something is wrong here” is associated with a 4-fold higher risk of a cancer diagnosis (OR 4.24, 95% CI = 2.26 to 7.94). There was substantial heterogeneity, but this was resolved when a lower quality cross-sectional study was excluded, leaving an OR of 5.43 (95% CI = 4.15 to 7.09).
From the qualitative studies, I have highlighted the most important findings:
- the “gut feeling” was more often about the patient being “unwell” than having cancer,
- the feelings derived from a summation of history and physical exam findings as well as non-verbal cues about the patient. Detecting these cues seemed to require a longitudinal relationship with the patient to recognize differences in how they looked.
- the gut feelings appeared to improve with age and clinical experience
- gut feelings mostly cause physicians to “re-explore the patient’s narrative,” “move beyond the most likely explanation,” and order more testing and/or referrals. At the very least, physicians used careful return precautions and watchful waiting.
There are more findings from the qualitative research in the article, which make for very interesting reading. Low quality studies are more likely to show an effect than higher quality ones, so we must be very cautious about extrapolating from this study. This is most certainly not the nail in the coffin for an evidence-based approach to diagnosis. Instead, item #4 seems to be the best take-home point. These “alarm” feelings we get should cause us to go back and re-listen to the patient, expand our differentials, and use our longitudinal relationships with our patients to monitor them closely until we figure out what is wrong. Sounds like primary care to me!
- Smith CF, Drew S, Ziebland S, Nicholson BD. Understanding the role of GPs’ gut feelings in diagnosing cancer in primary care: a systematic review and meta-analysis of existing evidence. Br J Gen Pract. 2020;70(698):e612-e621. Link
Mark and John
Carilion Clinic Department of Family and Community Medicine
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