Adult Immunization Logic Committee Work

Have you ever had one of those anxiety dreams where it’s the end of the semester and finals are tomorrow and you haven’t been studying or even going to class? For me, it’s usually calculus or French. Now, it’s vaccine logic.

I spent last week in Atlanta as part of the CDC’s Adult Immunization Vaccine Logic committee. Apparently, I failed to burn enough bridges during the Child Immunization Logic committee process to avoid being invited back for this round.  The adult vaccine world is much, much, much more complex than the childhood vaccine space but it is encroaching into our world quickly. Soon, we who focus just on pediatrics will be expected to track all of the risk factor considerations, track adjuvants with each vaccine, and review the clinical histories of every patient looking for indications to vaccinate.   The purpose of our committee is, ultimately, to translate the ACIP recommendations into something “computable” for the rest of the world so that you don’t get different answers to the question, “Does this person need a vaccine?” depending on whom you ask.

The committee is filled with some of the nation’s leading immunization experts (and then me) – about half were highly ranked physicians and the other half were IIS developers, CDSi (Clinical Decision Support for immunizations) experts, and federal/CDC employees who work only on this issue.  My role was clearly to be the “private EHR vendor obstacle” which I played as well as possible.  To give this committee and its managers credit, they have us in during the development phase of the process – to often, I find that we get invited to the table too late, after some key (poor) choices have been made.  These folks get it.

The meeting was largely a “working” meeting, so my small group dove into the literature for the MCV, DTap/Td/TdaP, and Varicella series. Our goal was to outline the precautions, contraindications, vaccine conflicts, evidence of immunity, and wide variety of indications to vaccine and then begin to place these in a context that the rest of the world can use for computing vaccine indication (or contraindication as the case may be).  Here’s a fractional list of what we accomplished:

  • Identified 16 Public Health Priorities to focus initial efforts;
  • Translated ACIP recommendations across 18 vaccine groups into a single common format with traceability back to 63 online publications;
  • Identified 44 unique indications to vaccinate and their recommended schedules across the 18 vaccine groups;
  • Reviewed and Improved 14 of the 18 vaccine groups;
  • Identified 3 corrections to CDSi childhood resources;
  • Brainstormed 28 impacts to health information systems when dealing with vaccines mixed with an adjuvant at the point of administration;

In the childhood world, the focus is largely on age and place in the series of expected vaccines. In the adult world, there is a massive focus on clinical conditions that trigger a recommendation. Although all of these conditions also apply to children, they aren’t often used in my experience. I am going to have to go back to some of my friends and see what their logic tools do…

An interesting dichotomy that popped up during the meeting was a desire by some clinicians for stronger results from the technology while the technicians among us (such as myself or Judy Merritt from STC) argued against it. By “stronger results” I mean that the clinicians wanted the logic tools to be more black and white – “This patient needs X, this patient needs Y” vs. “Review the patient history to consider X, check this patient for a possible Y.” Usually, the technicians are on the side of expanding the clinical role of technology and the clinicians are fighting it, but here it was the reverse. Why, in this instance? Because I think the technicians, like myself, are finally being confronted with making a clinical decision and we don’t like it – for good reason.  Interesting times ahead.

9 thoughts on “Adult Immunization Logic Committee Work

  1. I don’t understand! In pediatrics there is a recommended vaccine schedule promoted by the AAP and ACIP. The onus is on us to defend why we didn’t give a specific vaccine. In adults there are also recommended vaccines like pneumovax, zoster vaccine, flu vaccine and dTaP.
    Why do we need to justify giving recommended vaccines?
    This is just another example of unnecessary work.

    • No, no – you won’t have to justify giving recommended vaccines. You might be given many more reasons to do so, that’s all. Every one of your kids with cochlear implants, every kid with asplenia, etc., etc. And you’ll need to know more about vaccine specific conflicts – many more issues once you get off the standard ACIP schedule.

  2. Chip I’ve known you for a long time it seems in some small way you are starting to tell us as MDs you just may know more about vaccines as a laymen. Please explain yourself in some clearer terms. As I read this also it also reminds me about talking about adult vaccines to my personal doctor. It is nothing short of scary!

    • Dr. Farrell, I am not quite sure how you get the impression that I feel like I know more about vaccines than a physician. I surely don’t. In fact, in the last paragraph I try to describe how uncomfortable we are being pushed towards making a clinical decision – it’s not something I think we are qualified to do! That needs to be left to the clinicians!

      On the other hand, physicians are clearly wildly inconsistent in their application of the ACIP rules and the rules themselves lack considerable clarity. I don’t need to have any understanding of the immune system to work on the logic required to support the process. Ask 10 pediatricians about when they give certain shots and you might get 5 different answers.

  3. The inconsistencies lay more with coordinating office visits and vaccine administration or the preferences of the parents within certain parameters, that lack of knowledge of the schedules.

    • Perhaps within your office, but you should look at immunization results nationwide. I have. The results are shocking. And your peers, especially for adults, routinely miss opportunities to vaccinate because they don’t understand the contraindications or recommendations (or give them credence).

      Let me put it this way: I was in a room of some of the biggest immunization experts in the country and they often had to discuss, at length, the indications for certain vaccines and how to resolve the conflicts. When the ACIP says “heart disease” is an indication for a particular immunization, but “heart disease” isn’t fully defined, you end up with different results from clinician to clinician.

      As I stated in my blog, technicians should not be making these decisions. But the clinicians need to understand that their recommendations also need to be made computable. Hence, this committee.

  4. I think the issue with “adult” doctors is not that they don’t know indications or contraindications of vaccines but that they don’t understand the business or economics of vaccines. They are afraid to purchase them as they are expensive and then afraid they won’t get paid for administering. I have spoke to many in my area and that is the rear. As an example, Most OB/GYNs do not want to purchase HPV vaccine because it is too expensive, so they don’t give it or give the patient a script to go to a Pharmacy and then bring the vaccine to their office. Others just refer patines to CVS, or other RBCs to get adult vaccines. This is especially for seniors who need to get Zostavax.
    Many are also not giving Flu vaccines and they rely on the RBCs to do it-what a loss of revenue.

    If you want to help in this set up part of FP or IM conferences on the business of vaccines-I am sure the Docs would enjoy learning how to do it and make some extra money.

    • I agree completely but certainly don’t think it’s an either/or circumstance. The financial challenges adult medicine faces with vaccination are the primary obstacle to getting the adults in this country vaccinated. However, unless you are giving shots on a daily basis, and staying 100% current with all of the guidelines (which not even all pediatricians do), it’s easy to not be fully cognizant, say, of all the indications. More pointedly, if you know you’re not going to give an HPV anyway, how much time are you going to spend discussing it with your patients? That was part of what I meant by “giving credence.”

      I’ve given many lectures – both public and private – about the business of vaccinating and it’s a funny thing. Many pediatricians, at least, are uncomfortable using vaccines as a “profit” source, or at least discussing at as such. I know practices who make considerable profit, I know practices who lose significantly. But I point out that if RBCs are doing it, there’s obviously money to be made there! I know many folks in the GPO business and they struggle mightily to get much traction in the adult medicine sphere, which is too bad.

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