CEUFast, Inc. is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center's Commission on Accreditation. ANCC Provider number #P0274.
≥ 92% of participants will know how vaccines work, the diseases they prevent, and the most up-to-date vaccine schedule for children and adolescents.
This course aims to ensure healthcare professionals provide consistent and up-to-date information on vaccinations across healthcare settings and are adequately prepared to address challenges in achieving vaccine goals for optimum pediatric health outcomes.
Upon completion of this course, the learner will be able to:
One of the most impactful events in the history of public health is the development of vaccines. In the 21st century, immunizations are credited with minimizing and eradicating more than 20 contagious illnesses and preventing 3.5-5 million deaths worldwide yearly (World Health Organization, n.d.). Children, in particular, have benefited from the development and widespread availability of vaccinations. The current recommended schedule has dramatically reduced the number of childhood deaths and long-term consequences (blindness, deafness, loss of motor function, and sterility) of infectious diseases.
Recommendations for vaccines have and continue to evolve as the healthcare landscape, culture, and circulating diseases change. In particular, vaccine hesitancy fueled by the internet and delays in routine wellness visits due to the COVID-19 pandemic have posed significant challenges to achieving the community levels of vaccination needed for effective herd immunity. A solid understanding of how vaccines work, the diseases they prevent, and the most up-to-date vaccine schedule for children and adolescents are paramount for any professional working in a pediatric setting or encountering vaccine-eligible children regularly. Knowledgeable and compassionate professionals are the first line in making sure as many children as possible are vaccinated appropriately and addressing the gaps in this public health concern.
In January 2021, the Vaccines National Strategic Plan 2021–2025 (Vaccine Plan) was released as an updated and revised version of the 2010 National Vaccine Plan. The National Vaccine Advisory Committee recommended this update in light of new data and challenges regarding vaccine development and distribution since the original plan was published. The short five-year time span of the Plan (compared to the typical ten years for public health plans) allows for flexibility, timely reassessment, and course correction in a rapidly changing world.
Development of the Plan was a collaborative effort from federal and public health entities. The Plan is designed to strengthen the vaccine infrastructure across the country and have ongoing monitoring of vaccine safety with the ultimate goal of eliminating vaccine-preventable diseases through accessible, safe, and widely utilized immunizations (U.S. Department of Health and Human Services, 2021).
Federal agencies across the country are working to establish committees and partner with public and private facilities to coordinate the efforts of the Plan. There are five main goals of the Plan to guide actionable measures and work towards this ultimate goal of being free from vaccine-preventable disease.
One of the greatest successes of vaccines (and also a large contributor to misguided resistance to vaccines) is that for many modern people, the diseases prevented by vaccines are largely unknown other than through textbooks. Gone are the days of pediatric units filled with iron lungs for polio patients and isolation rooms filled with measles. Sterility from mumps and blind or deaf rubella-affected newborns is a distant memory for all but the most veteran doctors and nurses. So while today's healthcare workers may enjoy the benefits of highly effective vaccines, it comes at the cost of lost experience, with few remaining professionals who have seen enough of these diseases to quickly or confidently identify or manage them. Because of this, healthcare professionals need to have frequent refreshers on vaccine-preventable diseases. Updating education can help if they ever need to care for someone with one of these diseases. It also allows them to serve as confident and knowledgeable sources of information for patients with questions or concerns about vaccines.
Below is a brief refresher of the most common vaccine-preventable illnesses and a summary of how vaccines affect their prevalence.
Hepatitis B:
Haemophilus influenzae:
Polio:
Diphtheria:
Tetanus:
Pertussis:
Pneumococcal: Streptococcus pneumoniae is a highly antibiotic-resistant bacteria that cause ear infections, pneumonia, meningitis, and sepsis. Before the vaccine, over 700 cases of meningitis, 17,000 cases of sepsis, five million ear infections, and 200 deaths annually could be attributed to strains of Streptococcus pneumoniae. The bacteria commonly lives in healthy individuals' throats and nasal passages and is an opportunistic pathogen that will cause illness when a person becomes ill with another pathogen.
Rotavirus:
Measles: Measles is a highly contagious airborne virus that causes high fever, cough, runny nose, and a distinct red rash that starts on the face and moves across the entire body. Fatigue, diarrhea, conjunctivitis, and low appetite are common, and for some children, the disease progresses to pneumonia, encephalitis, blood clotting disorders, seizures, and death. About three in every ten measles cases experiences a serious complication. Pregnant women who contract measles are more likely to have preterm delivery or miscarriage (CHOP, 2022). Before the vaccines, around four million people contracted the virus, and 400-500 people died from measles yearly. The vaccine, developed in 1963, was so effective that measles was declared eliminated in the United States in 2000, though around 1,000-1,500 cases still occur annually (CDC, 2020b). The measles, mumps, and rubella (MMR) vaccine is one of the more hotly contested vaccines in the anti-vaccination community. Due to the highly contagious nature of measles, pockets of the disease appear in larger than-average numbers in under-vaccinated communities every few years (CHOP, 2022).
Mumps: Mumps is a virus that affects the parotid gland and causes swelling of the face and neck. It is accompanied by low-grade fever, muscle aches, and headache.
Rubella:
Varicella: Varicella, or chickenpox, is a highly contagious virus that causes widespread red blisters over the body as well as fever, fatigue, and a decrease in appetite. Most of the time, varicella infections are mild, and children recover fully. However, about one in every 1,000 children infected with varicella will experience serious complications like pneumonia, encephalitis, secondary streptococcus ("flesh-eating bacteria") infection of the open sores, or death. Varicella infection during pregnancy results in one in 50 children being born with a congenital disability, commonly atrophied limbs.
Hepatitis A:
Meningococcal: Neisseria meningitidis is a highly contagious bacteria that spreads through schools and childcare facilities and causes fever, meningitis, septic shock, coma, and even death. Complications such as limb amputation, skin grafting, permanent hearing loss, seizures, kidney disease, and intellectual disability occur in about 20% of cases, and 10-15% of cases result in death. There are currently two vaccines available, and they protect against different strains. The first is given around ages 11 and 16 and protects against strains A, C, Y, and W-135. The second is a newer vaccine recommended starting at age 16 and protects against the B strain, which commonly spreads through college dorms and military barracks and is highly fatal. Rates of meningitis from Neisseria meningitidis have declined by 90% since the vaccines emerged in 2005 (CHOP, 2022).
Human Papillomavirus: Human papillomavirus (HPV) affects the skin, particularly the anus, and genitals. There are about 100 types of HPV, and they cause various illnesses, ranging from genital warts to cancer of the cervix, uterus, anus, and oral tissues.
Influenza: Commonly known as the "flu," influenza is a virus that affects the lungs and airways. It causes high fever, cough, chills, headache, and muscle aches. Secondary pneumonia can occur and may be fatal. The influenza virus is always in circulation but "drifts" or changes slightly seasonally. Sometimes it changes enough that a larger percentage of the population is not immune, and it spreads more easily; this is known as a "shift." Because of the potential for the virus to change, the vaccine is not the same from year to year as with other diseases and is developed new for each season based on projected strains in circulation. The effectiveness of preventing the illness can vary widely, ranging from 30-80% effective; however, regardless of whether or not the vaccine is highly effective at preventing the disease, it nearly always reduces the severity of the disease and the rate of hospitalization and death (CHOP, 2022).
Coronavirus: New to the human population since November 2019, SARS-COV-2 is the newest disease to cause serious illness, high rates of hospitalization, and death. Symptoms can range from mild to moderate cold symptoms and loss of taste and smell to more serious symptoms such as shortness of breath, pneumonia, blood clots, and death. It has been shown to irreparably damage the placenta in pregnant women, resulting in increased rates of preterm delivery and stillbirth.
Existing research into mRNA vaccines and massive amounts of funding and power went into the quick development of a vaccine for COVID-19, which has been available since late 2020. The vaccine is currently authorized for emergency use down to age six months, and data is still being collected surrounding its effectiveness. However, it has already been shown to reduce the incidence of serious illness, hospitalization, pregnancy complications, and death (CHOP, 2022).
It should be noted that of the above diseases, only polio is completely eradicated. All others still exist with enough circulation to cause pockets of high infection rates if the community levels of immunity fall enough to allow them to spread. The number of vaccinated individuals varies by disease, but 80-95% or more is usually required to reach effective herd immunity. Believing these illnesses do not exist enough anymore to pose a risk to the general population is a dangerous misconception that could lead to rapid and widespread illness (Macmillan, 2021).
The most up-to-date version of the child and adolescent vaccine schedule can always be found on the CDC's website and is updated annually. The schedule is recommended by the Advisory Committee on Immunization Practices (ACIP), a panel of medical and public health experts who monitor current and emerging data surrounding communicable diseases and current vaccines and make recommendations and updates as the data evolves (CDC, 2022d).
The CDC's website always includes the current schedule as recommended, as well as considerations for missed doses, catch-up schedules, or other unique circumstances for each vaccine. A summary of changes made to the schedule is published by ACIP each year (CDC, 2022d).
If following the routine recommendations, all infants will receive vaccines at their wellness visits at the following ages during the first year of life:
Birth
One month
Two months
Four months
Six months
12 months
Once children reach preschool and school age, the number and frequency of vaccines decrease because their immune systems are more mature and because the risk of serious illness, sequelae, and death decreases as children age. A school physical is commonly required before enrolling in kindergarten and is an excellent time to ensure children are current on vaccines.
Between ages 4-6
The next significant age for routine vaccines is before middle school, around 11, and high school at 16. These are popular ages for school physicals to be required for public school and an excellent opportunity to educate about routine vaccines and catch up on any if needed.
Between ages 11-12
Age 16
Combination vaccines: Many early vaccines are grouped together in multidose injections. Hence, the number of injections given at infant wellness visits is much lower than the number of diseases protected against.
Common combination brands and their components are listed below. The brands and combinations available, as well as how this impacts the exact schedule given (for vaccines with a wide window of recommended administration), varies by clinic and which vaccines they purchase or have available in their region (CDC, 2019).
For children under age four, MMR and varicella are to be administered separately rather than a combination vaccine like Proquad, as this reduces the risk of side effects (CDC, 2022a).
HPV: Once an HPV series is started, it should be completed within 12 months. If the first dose is given before age 15, only two doses are needed, and the second dose may be given 6-12 months after the initial dose. If the first dose is given after age 15, it becomes a three-dose series due to the increased risk of exposure to the virus before maximum immunity is achieved. The interval for the 3-dose series is the initial dose, 1-2 months later for the 2nd dose, and six months later for the 3rd dose.
Influenza:
Meningococcal B: Meningococcal B is recommended for all teens ages 16-18 and can be given up to age 23. It is particularly important for people planning to live close to others, such as college dorms or military barracks, so it is important to discuss with high school students as they approach graduation (CDC, 2022a).
There are endless possibilities for why a child's vaccines may be delayed or interrupted. Sometimes external factors such as moving, illness, natural disasters, or home-life disruptions occur, and children miss appointments or scheduled vaccines are not received on time. The COVID-19 pandemic disrupted many children's routine vaccine schedules and will be discussed later.
Some families purposefully choose to receive vaccines at later ages or larger intervals than the recommended schedule. While this is not recommended by ACIP or the American Academy of Pediatrics, healthcare professionals working in pediatrics need to be prepared to encounter "alternative schedules" and understand how the number and timing of doses may vary depending on the age a child starts a series and the intervals between doses a parent prefers. The intervals between doses and the total number of doses needed are often reduced for children who are delayed starting vaccines.
Frequently encountered differences to note include:
A recent hot topic in the pediatric world is the impact of the COVID-19 pandemic on the routine immunization of children. The effects of the pandemic are many, but an unintended consequence of restricted activities, shelter-in-place orders, increased usage of telehealth services, and healthcare worker shortages is that many children did not receive the same timely and in-person wellness care they were accustomed to before the pandemic.
Current data does indicate that many children have been able to catch up and are back on track in the years since the pandemic first started, but the full extent of these delays is still unfolding. Identifying those still behind and developing a catch-up schedule is imperative for any facility that routinely serves children and provides vaccinations.
While adherence to the routine vaccine schedule is generally associated with positive outcomes for pediatric health, there are some instances where a particular vaccine, or type of vaccine, is contraindicated or precautions should be followed.
Examples of contraindications include:
When discussing vaccines, the mention of one of the most frustrating parts of the topic is unavoidable; vaccine hesitancy. The devastation of many of these illnesses is not something that most people alive today remember. The illnesses and long-term consequences parents once lived in fear of have been mostly forgotten. The level of comfort parents now have in their child's health has led some to question the effectiveness and necessity of vaccines.
Vaccine resistance has been around for many years, with the Anti-Vaccination Society of America being founded in 1879; however, the rise of the internet and social media has provided an easily accessible platform for the anti-vaccine movement, and it has attracted a larger following in the last 20-30 years (Schwartz, 2012). A thorough understanding of common complaints and suspicions with vaccines and where some of these concerns come from is necessary for healthcare professionals to navigate this delicate situation and restore trust in families with young children.
Parents express concern about a few common themes regarding vaccine safety and necessity, the most common of which are explored below.
Perceived lack of need: Most modern parents may not be as educated about the viruses and bacteria targeted with recommended vaccines. They have likely not witnessed anyone with symptoms of the disease or only know of the mild symptoms and do not have a thorough understanding of the potential complications and sequelae. In this way, the overwhelming success of vaccines has led to this skepticism, as many modern parents now believe these diseases are no longer a threat.
Concern over safety and side effects: When children are sick, and medication is prescribed, it is often expected and accepted that these medications come with side effects (such as diarrhea with antibiotics). In this case, most people understand that mild side effects can be tolerated to achieve the greater benefit, reduction of symptoms, or cure disease. However, this acceptance of benefits outweighing risks is more difficult for people to understand when the child is otherwise healthy and then suddenly has soreness at the injection site or fever and fatigue the day after vaccines. There is also no obvious sign of benefit as the sign that vaccines are working is simply the lack of disease. When the side effects are immediate, and the benefits are not readily visualized, parents may grow suspicious of the necessity of vaccines.
Potential side effects should be discussed with parents, typically mild reactions such as local irritation, redness, or soreness at the injection site and a low-grade fever. There are rare instances where more serious reactions occur, but overall, the risk of these reactions is considered much less than the risk of serious complications from the disease itself. Reassurance should be provided regarding the rigorous testing of vaccines and the ongoing monitoring of their safety (Barrows et al., 2015).
Immune system overload: A common concern parents cite is that the routine schedule has too many immunizations given at once and throughout childhood. There is an erroneous belief that the immune system can become overwhelmed by too many vaccine components. These parents are not opposed to vaccination entirely but may desire an alternative schedule where vaccines are spaced out or single-component vaccines are given rather than combination vaccines. The truth is that children are exposed to hundreds if not thousands, of pathogens each day while interacting with the world around them. Each time they share a toy at daycare, touch a doorknob at school, or touch a shopping cart, they are exposed to many viruses and bacteria, most of which are eliminated by the immune system quickly and without any illness at all. The immune system is well-equipped to handle several antigens in vaccines, particularly since vaccines only contain pieces of weakened pathogens (Barrows et al., 2015).
Perceived link to autism: Perhaps the most infamous controversy surrounding vaccines is the falsified Wakefield article published in The Lancet in the 1990s. Andrew Wakefield, who has since had his medical license revoked, headed a publication that claimed the MMR vaccine was directly linked to the development of autism. Despite the legal action against Wakefield and 10 of the 13 authors redacting their opinion, this misconception has persisted in public opinion and has been difficult to eliminate. One of the main concerns brought about by this publication is the preservative thimerosal used to prevent bacteria growth in multidose vials. Thimerosal's connection to autism has been repeatedly disproved, but regardless, it was taken out of vaccines in the 1990s, and most vaccines are now available as single-dose vials or syringes (Barrows et al., 2015).
In addition to concerns about the ingredients in vaccines and their safety, another common cause of hesitancy lies in the belief that accepting a medical product such as vaccines should be an individualized choice and not be regulated by any government entity, primarily public schools.
Lack of control over vaccine schedule: Many parents seek greater control over what vaccines their child receives and when. They may prefer fewer doses or an alternative schedule they have come up with. Education should be provided about the increased risk of serious consequences from diseases in infancy and that booster doses are needed to ensure adequate protection. If vaccines are delayed until a year or two of age, often the biggest window of risk to the child has passed without protection (Barrows et al., 2015).
Mistrust in government and healthcare providers: The highly publicized and polarized development of the COVID-19 vaccines has shed light on a huge hurdle to vaccine compliance: the culture of mistrust in the government. Mistrust has always been a theme in anti-vaccine rhetoric but has been given a much larger platform with social media and the controversy around the Covid-19 vaccine. Since vaccines and monitoring of side effects are monitored federally, some people are suspicious that the government may not be completely honest when disclosing the risks of vaccines or financial involvement with investors in the pharmaceutical industry. There is also a common belief that healthcare professionals do not receive education on vaccines and their side effects or may even try to hide the risks to receive financial gain from vaccines (Barrows et al., 2015).
Though it can be frustrating and tiring to combat the ever-growing misinformation about vaccines, healthcare professionals (particularly those in pediatrics) are in a unique position to build trust with their patients and provide quality information, correct misconceptions, and work collaboratively with parents to make educated decisions to maximize their child's health. Vaccine hesitancy has been so pervasive that there is ongoing research into how to communicate with these families (Anderson, 2015).
Healthcare professionals must have a thorough and up-to-date understanding of vaccines, the diseases they prevent, and common arguments or suspicions that the anti-vaccine community has. A provider who is unable to answer questions or does not appear to be current on vaccine information will only build mistrust in the relationship with their patients, fueling the us-vs-them attitude many vaccine-hesitant families subscribe to (Smith, 2017).
The attitude with which these conversations are approached is also shown to impact the success of increasing vaccine rates. It is important to understand that vaccine-hesitant parents do truly feel they are making a choice that is best for their child and their safety. Approaching this with an attitude of understanding and respect, rather than confrontation, may be both surprising and refreshing to parents who come into the conversation expecting anger or condescension. If a dialogue can be established, parents may feel more able to voice their concerns and listen to evidence-based information (Smith, 2017).
Unfortunately, there may be extreme cases where parents are so deeply entrenched in the anti-vaccine community that they are unable or unwilling to engage in respectful conversation and are unlikely to listen or change their minds. In these situations, it may be a better use of a provider's time to recognize there is no progress to be made and defer to facility policy for dealing with these patients.
The development and accessibility of vaccines is a major landmark in the history of public health and has improved rates of severe illness, injury, and death from communicable diseases for children across the country over the last century. However, there is still much progress to be made in eliminating these diseases and providing a healthy future for children across all demographics; the challenges are always evolving. Knowledgeable, confident, and passionate healthcare workers are on the front lines of this effort, and staying current on vaccine-related evidence is key to fulfilling their role.
Scenario: Harrison is a four-year-old male who presents to the pediatric office for a preschool physical. Upon reviewing his immunization record, the nurse realizes he has not been seen since his nine-month wellness visit, having missed his 12-month visit due to regional shelter-in-place orders during the beginning of the COVID-19 pandemic. Harrison's family is of lower socioeconomic status and lives over an hour from the pediatric clinic. His mother reports he is here today because the preschool he plans to attend requires physical and up-to-date immunizations before enrollment.
His current immunization record is as follows:
Interventions: The nurse reviews the recommended immunization schedule from the CDC and determines Harrison needs the following vaccines today:
He is given a Pentacel injection to combine the first three vaccines and a Proquad to combine the MMR and varicella. Based on the catch-up schedule, the nurse also determines that Harrison will not need additional doses of DTaP, Hib, or Polio based on his current age. He will also not need a 4th dose of PCV13 today. He will need to return in 4 weeks for his second MMR dose and in three months for his 2nd Varicella dose and then will be considered "caught up."
Discussion: The child was current on all his vaccines through nine months and has now missed over three years of vaccinations, so the catch-up schedule is indicated to determine which vaccines he needs today. The recommended number of doses for certain vaccines decreases when a child is over four years old or a certain amount of time has passed since the last dose.
Strengths/Weaknesses: Catching up can feel overwhelming, but with combination vaccines, this child could receive just two injections at his visit. While the nurse was able to determine how to catch Harrison up today quickly, the fact that he went over three years without a wellness visit indicates the clinic needs better protocols to identify at-risk children and schedule visits to catch up on vaccines sooner. Had Harrison not needed a physical for preschool, he would likely not have come in and would have remained under-immunized. He also missed valuable booster doses and his initial MMR and varicella doses at the vulnerable ages of 1-4 years. Harrison also has risk factors (low socioeconomic status and rural location) that make him unlikely to return in four weeks and then again in three months for additional boosters, and strategies to increase his compliance need to be considered.
CEUFast, Inc. is committed to furthering diversity, equity, and inclusion (DEI). While reflecting on this course content, CEUFast, Inc. would like you to consider your individual perspective and question your own biases. Remember, implicit bias is a form of bias that impacts our practice as healthcare professionals. Implicit bias occurs when we have automatic prejudices, judgments, and/or a general attitude towards a person or a group of people based on associated stereotypes we have formed over time. These automatic thoughts occur without our conscious knowledge and without our intentional desire to discriminate. The concern with implicit bias is that this can impact our actions and decisions with our workplace leadership, colleagues, and even our patients. While it is our universal goal to treat everyone equally, our implicit biases can influence our interactions, assessments, communication, prioritization, and decision-making concerning patients, which can ultimately adversely impact health outcomes. It is important to keep this in mind in order to intentionally work to self-identify our own risk areas where our implicit biases might influence our behaviors. Together, we can cease perpetuating stereotypes and remind each other to remain mindful to help avoid reacting according to biases that are contrary to our conscious beliefs and values.
