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Immunizations – Nursing Interventions to Enhance Vaccination Rates

      At the beginning of the 20th century infectious diseases resulted in illness and/or death in individuals of all ages (
      • Center for Disease Control
      Achievement in public health, 1900–1999 impact of vaccines universally recommended for children – United States, 1900–1998.
      ). During the years of 1951 to 1954, 16,316 individuals contracted paralytic polio and all forms of polio were associated with approximately 1879 deaths (
      • Center for Disease Control
      Achievement in public health, 1900–1999 impact of vaccines universally recommended for children – United States, 1900–1998.
      ). In the 1950s it seemed that everyone either knew someone who had recovered from polio or had died from it. When the vaccine became available in 1955, parents lined up at clinics and doctors' offices to have their children vaccinated. In contrast, the 21st century presents a very different outlook as the result of the development of numerous vaccines making morbidity (illness) and mortality (death) from vaccine-preventable diseases rare (
      • Center for Disease Control
      Achievement in public health, 1900–1999 impact of vaccines universally recommended for children – United States, 1900–1998.
      ). Immunizations, one of the ten greatest public health achievements during the 20th century (
      • Center for Disease Control
      Ten great public health achievements – United States, 1900–1999.
      ), are the best way to prevent morbidity and mortality related to infectious illnesses from vaccine-preventable diseases. Many vaccines are initiated during infancy highlighting the pediatric nurses' roles of anticipatory guidance, surveillance and advocacy.
      Immunizations are an important aspect of prevention and pediatric nurses play a key role in monitoring the child's status to ensure that all immunizations are being given and the child is up-to-date. In order to monitor each child adequately, the nurse must know the current recommendations. The Center for Disease Control annually updates the recommended immunizations and specifies the age at which children and adults should receive each one. (Table 1) Before publication, the annual immunization schedule is approved by the CDC's Advisory Committee on Immunization Practices, American Academy of Pediatrics (AAP), American Academy of Family Physicians (AAFP), and the American College of Obstetricians and Gynecologists (ACOG) (
      • Center for Disease Control
      Recommended immunization schedule for children and adolescents aged 18 years or younger, United States, 2018.
      ). In addition to the standard of care recommendations, there is information and suggested plans regarding catch up schedules for a child who was not vaccinated at the recommended ages (
      • Center for Disease Control
      Recommended immunization schedule for children and adolescents aged 18 years or younger, United States, 2018.
      ). The CDC provides information pertaining to combination vaccines, for example, a single injection containing more than one vaccine. These combinations vary according to manufacturer as to type of vaccines and number of vaccines combined. Table 1 does not include any combination vaccines. The wide variability among manufacturers necessitates institution-specific guidelines; however, these are based on CDC's recommendations.
      Table 1Well child check-ups and immunization schedule – the basics.
      Birth1 month2 months4 months6 months9 months12 months15 months18 months4–6 years11–12 years16–18 years
      Hepatitis B (Hep B)Hep B

      #1
      Hep B

      #2
      Hep B

      #3
      RotavirusRV

      #1
      RV

      #2
      Diphtheria, Tetanus, Pertussis (DTaP)DTaP

      #1
      DTaP

      #2
      DTaP

      #3
      (DTaP)

      #4
      DTaP

      #4
      DTaP

      #5
      Tetanus, Diphtheria, Pertussis (Tdap)Tdap
      Haemophilus influenzae type b (Hib)Hib

      #1
      Hib

      #2
      Hib

      #3
      (Hib)

      #4
      Hib

      #4
      Pneumococcal (PCV)PCV

      #1
      PCV

      #2
      PCV

      #3
      (PCV)

      #4
      PCV

      #4
      Inactivated Poliovirus (IPV)IPV

      #1
      IPV

      #2
      (IPV)

      #3
      (IPV)

      #3
      (IPV)

      #3
      IPV

      #3
      (IPV)

      #3
      IPV

      #4
      InfluenzaInfluenza givenYearlyDuring fluSeason throughThe ageOf 18
      Measles, Mumps, Rubella (MMR)MMR

      #1
      (MMR)

      #1
      MMR

      #2
      VaricellaVaricella

      #1
      Varicella

      (#1)
      Varicella

      #2
      Hepatitis A (Hep A)Hep A

      #1
      Hep A

      #2
      Meningococcal (MCV)MCV

      #1
      MCV

      #2
      Human papillomavirus (HPV)HPV

      3 dose series
      Note: Immunizations not in parenthesis recommend the date the vaccine is normally given. If in parenthesis, indicates when the immunization may be given. Adapted from 2018 Immunization Schedule by Center for Disease Control. (2018, January 1). Recommended immunization schedule for children and adolescents aged 18 years or younger, United States, 2018. Retrieved from https://www.cdc.gov/vaccines/schedules/downloads/child/0-18yrs-child-combined-schedule.pdf.

      History of Vaccines

      Immunization provides direct protection to the individual vaccinated resulting in a reduced chance of infection and potentially protecting the individual from complications should one of the diseases occur. In addition, once a large portion of the population has been immunized, they provide an indirect effect or herd immunity that extends the benefit of the vaccine beyond those directly vaccinated. Herd immunity is defined as a form of indirect protection to an infectious disease that results when a large percentage of the population is immune to the infectious disease because they have been vaccinated (
      • Sobo E.J.
      What is herd immunity, and how does it relate to pediatric vaccination uptake? US parent perspectives.
      ). Herd immunity provides a measure of protection to individuals that are not immune because they are too young to be vaccinated, immunocompromised, have co-morbidities that contraindicate vaccines or have chosen not to receive the vaccine. Vaccinated individuals shed excess immune molecules from their body thereby exposing the unvaccinated individuals to the benefits of the vaccine. An increase in the prevalence of vaccine immunity prevents circulation of infectious agents in unvaccinated susceptible individuals. The herd effect played a major role in eradicating smallpox and reducing transmission of pertussis and the childhood illnesses of varicella, rubella and rubeola. Since the early 2000s, it also is being credited with protecting against influenza and pneumococcal disease.
      By monitoring the use of vaccines over time new information was acquired about the trajectory, benefits, acceptance, use and barriers to vaccines. It was discovered that some vaccines necessitated one or more booster doses for full immunity as the early benefits deteriorated over time. For example, the standard varicella and rubeola (measles), mumps, and rubella (MMR) both require a booster between ages four and six to fully protect adolescents from these diseases. The ultimate goal of immunizations is the eradication of vaccine-preventable diseases for the entire world. Smallpox was officially declared eradicated from the world in May of 1980 (
      • Imperato P.J.
      Bob H. Reinhardt: The end of a global pox. America and the eradication of small pox in the cold war era.
      ) and polio is close to being eradicated. Currently, active polio virus is present in only three countries, Afghanistan, Nigeria, and Pakistan (
      • Khan F.
      • Data S.D.
      • Quddus A.
      • Vertefeuille J.F.
      • Burns C.C.
      • Jorba J.
      • Wassilak S.G.F.
      Progress toward polio eradication – Worldwide, January 2016–March 2018.
      ).
      Groups that do not typically receive routine vaccinations because of philosophical or religious reasons receive no direct or herd benefits. Therefore, if one of their members becomes infected with an infectious disease a significant portion of that population has the potential to become infected (
      • Gastanaduy P.A.
      • Budd J.
      • Fisher N.
      • Redd S.B.
      • Fletcher J.
      • Miller J.
      • DiOrio M.
      A measles outbreak in an underimmunized Amish community in Ohio.
      ). In 2014 Ohio experienced the largest and longest outbreak of measles (Rubeola) in the last two decades since the disease was eliminated from the United States. The outbreak lasted 4 months and 383 individuals were diagnosed (
      • Gastanaduy P.A.
      • Budd J.
      • Fisher N.
      • Redd S.B.
      • Fletcher J.
      • Miller J.
      • DiOrio M.
      A measles outbreak in an underimmunized Amish community in Ohio.
      ). In 2015 there was another outbreak of measles (Rubeola). This time it occurred in Disneyland and affected 125 individuals from eight states (
      • Center for Disease Control
      Measles outbreak – California, December 2014–February 2015.
      ). This outbreak was covered extensively in the news in part because it was wide-spread with potential for high exposure rates even though it affected fewer people and lasted for a shorter period of time.
      Across the country parents have become increasingly hesitant to vaccinate their children related to a wide variety of reasons, including but not limited to a fear of the vaccines and their potential to alter the child's immune system.
      • Barrows M.A.
      • Coddington J.A.
      • Richards E.A.
      • Aaltonen P.M.
      Parental vaccine hesitancy: Clinical implications for pediatric providers.
      identified the “common themes of parental vaccine hesitancy which include: a) lack of perceived need for vaccines; b) safety of vaccines; c) lack of trust in health care providers and government; d) perceived lack of involvement in the decision-making process; e) vaccines and autism; f) immune system overload; g) lack of adequate time and resources; and h) religious objections to vaccines” (p. 387). In the United States, in 2015, only 72% of three-year-olds were fully immunized and only 81% of adolescents had received one dose of the meningococcal vaccine and 42% of females and 28% of males had received 3 doses of the human papillomavirus (HPV) (
      • National Center for Health Statistics
      Health, United States, 2016: With chartbook on long-term trends in health.
      ). Choosing not to vaccinate children as recommended is an important public health concern in both the United States and Europe as it sets the stage for a resurgence of vaccine-preventable diseases (
      • Dornbusch J.J.
      • Hadjipanayia A.
      • del Torso S.
      • Mercier J.
      • Wyder C.
      • Schrier L.
      • Ludvigsson J.F.
      We strongly support childhood immunization-statement from the European Academy of Paediatrics (EAP).
      ).

      Intervention to Enhance Immunization Rates

      According to public health guidelines, children's health and safety can be enhanced by using the 3 E's. The 3 E's consist of education, enforcement, and engineering. All three, but especially the first two, are part of the scope of practice for pediatric nurses and should be used to increase immunization rates in infants, children, and adolescents. The primary approach pediatric nurses in acute, ambulatory or home care use is education, often in the form of anticipatory guidance. As pediatric nurses we must spend time listening, interacting and informing parents about the purpose and function of vaccines to keep their children safe from infectious diseases (
      • Barrows M.A.
      • Coddington J.A.
      • Richards E.A.
      • Aaltonen P.M.
      Parental vaccine hesitancy: Clinical implications for pediatric providers.
      ;
      • Edwards K.M.
      • Hackell J.M.
      • The Committee on Infectious Diseases
      • The Committee on Practice and Ambulatory Medicine
      Countering vaccine hesitancy.
      ).
      Education needs to focus on addressing parental concerns about immunizations, sharing data-supported evidence and clarifying any misconceptions parents have about vaccinations (
      • Barrows M.A.
      • Coddington J.A.
      • Richards E.A.
      • Aaltonen P.M.
      Parental vaccine hesitancy: Clinical implications for pediatric providers.
      ;
      • Edwards K.M.
      • Hackell J.M.
      • The Committee on Infectious Diseases
      • The Committee on Practice and Ambulatory Medicine
      Countering vaccine hesitancy.
      ;
      • Wade G.H.
      Nurses as primary advocates for immunization adherence.
      ). The education needs to address the specific concerns brought by the parents in order to dissipate their reasons for not allowing their child to be immunized. Pediatric nurses in their role in the forefront of healthcare have the opportunity and responsibility to discuss with parents the benefit of vaccines including comparing the morbidity and mortality risks related to vaccine complications as compared to contracting vaccine-preventable diseases. Pediatric nurses can specifically discuss with parents the evidence documenting that the risk of a complication is less consequential than the risk associated with contracting the disease itself (
      • Barrows M.A.
      • Coddington J.A.
      • Richards E.A.
      • Aaltonen P.M.
      Parental vaccine hesitancy: Clinical implications for pediatric providers.
      ;
      • Edwards K.M.
      • Hackell J.M.
      • The Committee on Infectious Diseases
      • The Committee on Practice and Ambulatory Medicine
      Countering vaccine hesitancy.
      ;
      • Wade G.H.
      Nurses as primary advocates for immunization adherence.
      ).
      Parents have many concerns about the safety of vaccines and part of this stems from reliance on social media sites, issue related groups and a general mistrust of government policies and reliance on standard of care practices rather than providing individualized patient-specific care. Pediatric nurses can address these parental concerns by first listening, validating the concern and desire to engage in best care as it pertains to their family history and personal knowledge and suggesting options such as available modifications in the administration of certain vaccines. It is important to share with parents data about the safety of vaccines and extensive research prior to Food and Drug Administration (FDA) approval, the continuous vaccine monitoring and tracking of adverse reactions, and response when deviations or new information becomes known (
      • Barrows M.A.
      • Coddington J.A.
      • Richards E.A.
      • Aaltonen P.M.
      Parental vaccine hesitancy: Clinical implications for pediatric providers.
      ;
      • Edwards K.M.
      • Hackell J.M.
      • The Committee on Infectious Diseases
      • The Committee on Practice and Ambulatory Medicine
      Countering vaccine hesitancy.
      ;
      • Wade G.H.
      Nurses as primary advocates for immunization adherence.
      ).
      Another concern frequently mentioned by parents since the early 2000s is the perspective of not being fully involved in the decision-making process regarding whether to and/or when to have their child vaccinated. Since pediatric nurses typically form a trusting relationship with parents as a basis for providing care to their children, the nurses are present and capable to address any concerns that the parents may have regarding vaccines (
      • Barrows M.A.
      • Coddington J.A.
      • Richards E.A.
      • Aaltonen P.M.
      Parental vaccine hesitancy: Clinical implications for pediatric providers.
      ;
      • Edwards K.M.
      • Hackell J.M.
      • The Committee on Infectious Diseases
      • The Committee on Practice and Ambulatory Medicine
      Countering vaccine hesitancy.
      ;
      • Wade G.H.
      Nurses as primary advocates for immunization adherence.
      ). It should be routine for ambulatory care nurses to practice anticipatory guidance and provide parents with written information about the specific immunizations planned for the next appointment. Being given a written plan enables parents time to review the vaccine information and be more involved in the decision making process. Resources include institution specific information and routine practices, the Vaccine Information Sheet (VIS) that includes general information on why to get the vaccine, when to get the vaccine, who should not receive the vaccine, the risks and type of possible reactions, including serious reactions, information on the National Vaccine Injury Compensation Program (VICP), and sites with valid resources for additional information (
      • Center for Disease Control
      Vaccine Information Sheets (VISs).
      ;
      • Edwards K.M.
      • Hackell J.M.
      • The Committee on Infectious Diseases
      • The Committee on Practice and Ambulatory Medicine
      Countering vaccine hesitancy.
      ). The National Vaccine Injury Compensation Program (VICP) is a federal program that was created to compensate individuals who may have been injured by certain vaccines (
      • Center for Disease Control
      Vaccine Information Sheets (VISs).
      ).
      Some parents may request an alternative vaccination schedule as they believe receiving multiple vaccines at a single visit will overload their child's immune system (
      • Barrows M.A.
      • Coddington J.A.
      • Richards E.A.
      • Aaltonen P.M.
      Parental vaccine hesitancy: Clinical implications for pediatric providers.
      ). This is an option that may help to alleviate the parent's fears and gain cooperation with key goals of immunization. The revised schedule should be planned between parent and provider, confirmed and documented in the medical record for all to follow. An alternative schedule usually delays the child's recommended vaccinations increasing their risk for acquiring a vaccine-preventable disease (
      • Barrows M.A.
      • Coddington J.A.
      • Richards E.A.
      • Aaltonen P.M.
      Parental vaccine hesitancy: Clinical implications for pediatric providers.
      ).
      Although pediatric nurses focus on education, it is equally important for them to be involved in increasing immunization rates by participating in enforcement. A key public health goal is to protect the public by prescribing reasonable rules and regulations that facilitate adherence to the recommended schedule for immunizations. Although the debate persists about which is more important, individual rights or protection of the public, active efforts to find an acceptable compromise also continues, Currently children in all 50 states are required to receive certain immunizations prior to entering school, but in some states, parents who are opposed to immunizations may request an exemption because of medical, philosophical or religious reasons (
      • Wade G.H.
      Nurses as primary advocates for immunization adherence.
      ). Mississippi and West Virginia are the only two states that do not offer nonmedical exemptions to vaccinations (
      • Colgrove J.
      • Lowin A.
      A tale of two states: Mississippi, West Virginia, and exemptions to compulsory school vaccination laws.
      ). Since the Disneyland measles outbreak, California legislators voted in June 2015 to change their lenient provisions and eliminated nonmedical exemptions. This action resulted in a higher rate of medical-related immunization exemptions (
      • Colgrove J.
      • Lowin A.
      A tale of two states: Mississippi, West Virginia, and exemptions to compulsory school vaccination laws.
      ). Pediatric nurses can be influential in enforcement by lobbying their state legislators to allow medical exemptions as the only reason a child may enter school without having received their immunizations. As a group, pediatric nurses have a huge political voice and using their combined voices to encourage mandatory vaccinations is a public service to protect children from vaccine-preventable diseases.
      Engineering endeavors are rarely used by pediatric nurses as these endeavors typically focus on improving vaccines and creating new vaccines, which is not routinely performed by pediatric nurses.

      Conclusion

      For multiple reasons more parents in the 21st century are either hesitant or refusing to have their children immunized (
      • Edwards K.M.
      • Hackell J.M.
      • The Committee on Infectious Diseases
      • The Committee on Practice and Ambulatory Medicine
      Countering vaccine hesitancy.
      ). If an increase in unvaccinated children continues to rise, there is risk for a resurgence of vaccine-preventable diseases and potential increase in deaths related to these infectious diseases. As pediatric nurses, it is imperative that we provide anticipatory guidance and education for parents about the safety and importance of vaccines. In addition nurses must take ownership of their social responsibility to protect, promote and optimize health by lobbying their politicians to ensure that they enact laws requiring all children to be immunized prior to entering school. In cases of exception, guidelines should be in place to monitor alternative plans and schedules to demonstrate progress toward the goal of eradication of vaccine-preventable diseases.

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        • Center for Disease Control
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        • Center for Disease Control
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        • Center for Disease Control
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