Immunizing Infants at 'Sick' Visits: Good or Bad Idea?

William T. Basco, Jr., MD, MS

October 01, 2013

Sick-Visit Immunizations and Delayed Well-Baby Visits

Robison SG
Pediatrics. 2013;132:44-48

Well- vs Sick-Visit Vaccination

For much of the past 2 decades, the American Academy of Pediatrics and the Centers for Disease Control and Prevention have recommended immunizing children at any provider visit, including sick visits. The primary rationale for sick-visit immunization is that it avoids "missed opportunities" to vaccinate, reducing the time during which a child may be at risk for infectious diseases if they do not attend scheduled well visits (where immunizations are typically delivered). However, there is concern that immunizing at sick visits will prompt parents to skip well visits that might have been due around the time of the sick visit. Of note, the recommendation to vaccinate even at sick visits was intended for patients with mild illnesses, such as upper respiratory tract infections or even otitis media. It's also worth emphasizing that the presence of fever did not necessarily constitute a contraindication to vaccination.

Study Summary

To evaluate the relationship among these potentially opposing issues, Robison evaluated children who experienced a sick visit for acute otitis media (AOM) around the time that well-baby visits would typically be scheduled, at 2, 4, or 6 months of age. Whether the receipt of vaccinations at the sick visit for AOM correlated with a lower frequency of subsequent well-baby visits was evaluated, focusing on whether the child who was seen for AOM also returned for the well-child visit corresponding to the infant's age. For example, if a child had a sick visit for AOM at 6 months of age and received vaccinations, did the child return for a 6-month well-child check?

Infants were matched with control infants on the basis of demographics and medical history before the AOM visit, and immunizations and well-baby checks completed by 2 years of age were compared between these 2 groups. The frequency of make-up well-baby checks after AOM visits where vaccination was not given was also evaluated. All infants were born in 2007 and enrolled in the Oregon Health Plan. Claims data and state registry immunization data were used to answer study questions. For vaccination status, the study focused on receipt of the DTaP (diphtheria-tetanus-acellular pertussis) vaccine because other studies showed that receipt of DTaP is representative of overall vaccination status. Moreover, focusing on 1 vaccine addressed the issue of potential voluntary spreading of the vaccine schedule by parents or providers. A case was any child who received DTaP at his or her visit for AOM. A make-up well-baby examination was any well-child visit that occurred within 4 weeks of the AOM visit, matched to the patient's age (2, 4, or 6 months). In addition to evaluating immunization status at 19 and 24 months, the total number of well visits made between 2 and 24 months of age was determined.

Study Findings

More than 21,000 infants were born in 2007, with more than 6500 infants having a visit for AOM in the first 12 months of life. Slightly more than 1000 infants made an AOM visit around the age of 2, 4, or 6 months. The demographics of this case group were 67% white, 30% Hispanic, and 3% nonwhite, non-Hispanic. Among case infants who made a visit for AOM at 2, 4, or 6 months, only 7.5% received a DTaP vaccine at the sick visit. Furthermore, 56.7% of these infants did not receive a vaccination but made a well-child visit within 5 weeks. Finally, 35.8% of the case infants had neither a sick-visit shot nor a make-up well-child visit within the 4-week period.

Case infants who received a vaccination at the AOM visit made an average of 4.7 well-child visits vs 4.5 well-child visits among those who were not vaccinated at the AOM visit, a difference that was not significant. Case infants who did not receive vaccination at the AOM visit but attended a make-up well-child visit within 4 weeks made an average of 5 well-baby visits overall, a number that was not significantly different from the control group. However, case infants who did not receive a vaccination or attend a make-up visit (36% of the total case infants) made an average of only 3.8 well-baby visits, significantly fewer than all other groups. The only infants at significantly higher risk of not being up-to-date on their immunizations were those who had no vaccination at the AOM visit and made no make-up visit within 4 weeks. The immunization status of all other infants was similar at 19 and 24 months. Robison concluded that this study did not find a reduction in number of vaccines received or well-baby visits made in children who received a DTaP vaccination at a sick visit for AOM.

Viewpoint

Whether a child attends a make-up well-baby visit within 4 weeks of a sick visit seems to be the most important factor in this study. Practitioners should take 2 messages from these findings. First, the study suggests that vaccination at sick visits, at least at visits for AOM, does not appear to reduce the later receipt of vaccines or the number of well-baby visits. However, the study also suggests that, regardless of whether the practitioner supports immunizing at sick visits, scheduling a needed well-baby visit quickly after the sick visit is important to both immunization status and the number of well-baby visits made by the child.