Top Vaccine Questions That Residents Have

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Patient Presentation
In August, at the end of continuity clinic a pediatrician remarked, “It really has been a vaccine day. Patients without records, vaccines given too early and trying to catch-up the other patients, has made it complicated today but a great chance to learn.” “It is so complicated and I’m still trying to just learn the schedule,” said the intern. “Don’t worry, that will come along and you’ll just learn more with seeing patients. I still have tons of questions,” the third year resident stated. “Between me, the nursing staff and the other residents, you’ll always have lots of support, plus we already showed you a couple of websites to help you figure it out too,” the attending reiterated.

Discussion
Vaccines are an important part of everyone’s health care. For pediatric patients vaccines are a foundational component of the health care provided at every visit. Therefore healthcare providers need advanced knowledge about vaccine issues, where to find authoritative resources, plus be able to handle the common and not so common questions that arise in their specific practice.

For primary care residents, their continuity clinics usually provide recurrent opportunities to gain experience with evaluating vaccine records, recommending appropriate vaccines and considering absolute contraindications and precautions along with appropriate patient and family counseling for their specific circumstances. Residents are usually first concerned about learning the appropriate vaccine schedule, but quickly run into real world questions because many children don’t follow the specific recommended schedule for some reason.

There are several authoritative vaccine information resources available:

Advisory Committee on Immunization Practices
American Academy of Pediatrics – RedBook
Immunize.org
US Centers for Disease Control – Traveler’s Health
World Health Organization
A comprehensive list of additional authoritative inform can be found here

Learning Point

There are numerous other questions and variations of vaccine questions than those below. Note that these recommendations below are for routine vaccination of healthy children in the United States. Specific information for a specific child, circumstance or location should be reviewed with the appropriate country resources and/or public health authority.

Some of the top commonly encountered vaccine questions include:

  • What is a valid dose?
      The patient is of the minimum age to receive the vaccine licensed for that age and at least the minimal interval between the doses has occurred if appropriate.

  • What is the earliest age to give a vaccine?
      Hepatitis B is given at birth. The first regular vaccines are given at 6 weeks of age in the US.

  • Do you start a routine vaccine series over if a child didn’t show up at the correct times for vaccines, or received duplicate vaccines?
      In general, if it is a valid dose it is counted and you just keep moving forward with giving appropriate vaccines at the appropriate ages. If a child is behind on vaccines, the recommendation is to use the accelerated schedule with minimal intervals until the child is back on schedule.

  • The patient is here 1 day before their minimum age or minimal interval between vaccines. Can I give the vaccine today?
      No. Do not give the vaccine intentionally early. Give only after the minimum age and minimal intervals for the vaccine.

      If it is noticed retrospectively, that a vaccine was given early by mistake, but was given within the grace period then you can count the vaccine as a valid dose but you don’t intentionally give a vaccine early.

      The ACIP allows a grace period of 4 days (i.e., vaccine doses administered up to 4 days before the recommended minimum interval or age can be counted as valid). The grace period is used primarily for reviewing vaccines such as prior to going to school. The grace period is also not used for the minimum 28 day intervals between live-virus vaccines.

      If a vaccine is given too early (by child’s age or the minimum interval) then the vaccines generally need to be repeated.

      Note that sometimes the legal requirements for a state are different than the valid medical dosing. For example, a state law may say that the MMR must be given after the first birthday, and the dose is given on the child’s birthday. The dose is valid medically, but not valid by the state law. For these children, often a statement from the physician declaring this a valid dose is what is needed for the child’s records.
      Some institutions, such as colleges, also may have specific requirements and require a physician’s statement about the validity of the vaccine timing.

  • What is one month? What is same day?
      For vaccine intervals 4 months, a calendar month is used (i.e. same day one month to same day the following month). Same day is generally defined as same visit.
  • What types of vaccines can I give together?
      For routine injectable vaccines:
      Non-live virus vaccines can be given together.
      Non-live virus vaccines and 1 live-virus vaccine can be given together.
      2 live-virus vaccines can be given on the same day OR given after a minimal interval of 28 days between the two vaccines. The 4 day grace period should not be used for the minimal intervals between two live-virus vaccines

      Oral live-virus vaccines and injectable live-virus vaccines do have some differences with the intervals and the combinations. Those recommendations should be reviewed.

  • How many vaccines can you give at once?
      As many as the child needs to be current (or as caught up as possible) and the parent and patient will allow.

      Alternative vaccination schedules to space out multiple vaccines is not recommended as there is no scientific evidence that this is beneficial for children. Spacing out vaccines can leave the child unprotected during that interval, plus increases the likelihood that the child may not receive the vaccines. There is also the additional cost and time for multiple visits.

  • What if the child is given the wrong combined vaccine by mistake? For example, MMR-V which is not currently licensed in the US to a 1 year old.
      Even under the best circumstances a mistake can occur. The components, the child’s age and the minimal intervals need to be considered.

      The components of MMR and V would be considered valid doses because the child is of the proper age and proper interval, even though the combination vaccine is not licensed for this age group. It does not need to be repeated and the next dose would be at 4-6 years.

  • What about giving measles vaccine before 1 year of age?
      Measles can be given as early as 6 months for international travel. Currently it is recommended to revaccinate with a 2 dose series at 12-15 months of age.

  • What about no or missing records? What about suspect or irregularities in the records?
      Vaccine records should be attempted to be obtained the same day for the visit if possible, so as to accurately administer the proper vaccines needed on time. Always try to administer any vaccines that would be due to the child at the appropriate time.

      Depending on the circumstances some practices will not administer a vaccine if they believe it is likely that the child already is current and the family is likely to return if they are found deficient upon later review. Alternatively, some practices will also administer any vaccines that the patient is likely to be due for even without the records.

      Vaccines records sometimes may be difficult to evaluate because of schedules that are different in different countries, translation, or disparate intervals. Clinical judgement is often necessary in these cases, with best judgement being that the child is properly immunized should be the main factor. For example, a record where every vaccine is given exactly every month on the same day may be a false record. Alternatively, if the child was in a refugee camp, the record is likely accurate as that is when the health officials timed their consistent vaccine administration.

  • What if I give an extra dose of a vaccine because I don’t have records. Is an extra dose going to hurt the patient?
      In general no, but there is always the risk of side effects from a vaccine.
  • Can I give a live-virus vaccine to a child whose mother is pregnant?
      Yes. The mother also needs her own vaccines, many of which are recommended to be given during pregnancy such as Tdap, Respiratory Syncytial Virus, COVID, Influenza, etc. to protect her and her children. Tdap is currently recommended during each pregnancy for the mother and other adults in the household to protect the newborn against pertussis.

  • The patient is traveling to or going to live in XXX country? Where can I find information about travel, the specific countries vaccination schedule? What do I do if they need a vaccine that isn’t routinely given in the US ?
      The US Centers for Disease Control has an excellent website with the current information. (see authoritative vaccine information resources above)

      It is best to provide the appropriate vaccines for a child living in any country. The World Health Organization has an international schedule and the US does follow these recommendations. Seasonal vaccines such as influenza should also be given as appropriate. There may be vaccines that are not routine in the US such as Japanese Encephalitis vaccine or BCG vaccines that are routine in other countries. Families should be counseled to establish routine medical care early after the move so they have a health care provider and can start the routine vaccination series for their new country.

  • Where can I find a list of contraindications to vaccines or a list of vaccine components? List of comprehensive contraindications to vaccines?

      The ACIP’s listing of contraindications can be found here
      Information about vaccine ingredients can be found here.

  • How do I counsel families that are vaccine hesitant or against vaccines?
      There is no one way to handle these conversations. Open engagement and communication with families provides for shared decision making at the specific visit and over the long-term.
      Understanding the families’ perspective, experiences, expectations, concerns and beliefs is important. Just as important is the physician sharing their own perspective, experience and judgement of the scientific evidence regarding vaccines and reasons they are recommending a particular vaccine plan.
      Physicians giving a strong recommendation, individualized for a specific child has been shown to be helpful for families who are vaccine hesitant.

Questions for Further Discussion
1. What other advanced questions do you commonly encounter in your location?
2. How do you handle making decisions with incomplete vaccine records in your practice?
3. What are the vaccine requirements for your local state or country?
4. What are some of the most challenging vaccine issues you encounter and how do you handle them?

Related Cases

    Age: All

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for these topics: Vaccines and Vaccine Safety.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Ask The Experts: Scheduling Vaccines. Immunize.org. Published June 6, 2023. Accessed June 25, 2024. https://www.immunize.org/ask-experts/topic/scheduling-vaccines/

ACIP Timing and Spacing Guidelines for Immunization. Centers for Disease Control. Published September 19, 2023. Accessed June 25, 2024. https://www.cdc.gov/vaccines/hcp/acip-recs/general-recs/timing.html

Global Vaccination Schedules. Accessed June 25, 2024. https://vaccineknowledge.ox.ac.uk/vaccination-schedules-other-countries

WHO Immunization Data portal – All Data. Immunization Data. Accessed June 25, 2024. https://immunizationdata.who.int/global

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa

Published