Keywords clinical decision support - graphical user interface - immunization information system
- CMC-specific immunizations
Background and Significance
Background and Significance
Immunization is one of the most effective public health interventions to combat disease
but coverage has consistently fallen short of national goals.[1 ] Children with chronic medical conditions (CMCs) often need specific additional immunizations
or immunizations on a different schedule, though many fail to receive them.[2 ] It is important to identify children with immunization delay and provide catch-up
immunizations at every opportunity.[3 ]
Immunization reminders for providers in the electronic health record (EHR) are a type
of clinical decision support (CDS) that can reduce missed immunization opportunities.[4 ]
[5 ] One limitation of these reminders is that they generally rely only on data local
to the EHR which can be incomplete due to record scatter and lead to inaccurate alerts.[6 ] Catch-up doses for children with delayed immunizations present an even greater challenge,
as there are changes to both the dosage intervals and the number of immunizations
needed.[7 ]
[8 ]
An immunization information system (IIS), or immunization registry, is a population-based
system that collects immunization data primarily for children and adolescents from
providers at the regional or state level.[9 ] In part, due to stage-3 meaningful use criteria set by the Centers for Medicare
& Medicaid Services (CMS), many IIS now support bidirectional immunization exchange
through which an EHR can retrieve additional immunizations from the IIS back into
the local EHR,[10 ] allowing providers to receive more complete records of their patient's immunization
records without having to log in to the IIS directly. Some also include forecasting
in which the IIS gives recommendations for immunizations that are due; however, many
do not include recommendations for CMC-related immunizations. Frontline care providers
are most likely to benefit when accurate data and forecasting reminders from the IIS
fit within their current EHR workflow.[8 ]
In this project, we sought to couple IIS bidirectional exchange of immunization information
and forecasting tools with EHR patient-level medical history to deliver accurate,
patient-specific EHR immunization reminders, including risk-based immunization recommendations
for children with CMCs.
Objectives
Our objective was to assess the impact of EHR reminders using regional IIS CDS-provided
rules on receipt of immunizations in a low-income, urban population for both routine
immunizations and those recommended for patients with CMCs. We also developed CMC-related
immunization recommendations in a local EHR.
Methods
Study Setting and Design
The trial was conducted in four community pediatric health clinics affiliated with
the NewYork-Presbyterian Hospital (NYP) Ambulatory Care Network (ACN) and Columbia
University Irving Medical Center who provide care to a primarily publicly insured
and Latino population. The Vaccines for Children (VFC) Program provides the immunizations
for free for nearly all patients at the study sites.
We conducted a randomized cluster–cross-over pragmatic clinical trial in the four
sites from June 2017 to June 2018. Using the configuration tools in the EHR, each
site had four phases each lasting 3 months, two for which the reminder was “on” and
two for which it was “off,” allowing each site to act as its own control while accounting
for some seasonal variation ([Fig. 1 ]). Study sites were academic-affiliated clinics with attendings, residents, academic
pediatric fellows, and nurse practitioners as providers who received the alerts.
Fig. 1 Randomized cluster-crossover design in four academic-affiliated community health
clinics from June 6, 2017 to June 5, 2018. Each phase represented a 3-month quarter.
We designed an EHR-based immunization alert within the Allscripts Sunrise Clinical
Manager (SCM) Ambulatory application. Upon note opening, the alert retrieved immunization
information from EzVac, our hospital's immunization registry, which in turn synchronized
data with New York City's IIS, the Citywide Immunization Registry (CIR) to provide
real-time immunization recommendations for the patient a provider was seeing. The
alert used an open-source rules-based engine provided by New York City's IIS through
their vendor to power the CDS in the reminder for routine immunizations ([Supplementary Fig. 1 ], available in the online version).[11 ] Synchronizing with the city IIS allowed the reminder to act on the most up-to-date
information available for individual patients.[12 ] Accuracy of the alert was verified extensively with test patients designed to test
the various aspects of the alert and its logic, and a usability test was conducted
with a small group of physicians prior to beginning the trial. This is in addition
to the testing that was completed by the vendor to ensure that the rules used by the
CIR are correct. The engine was kept up to date and was updated seven times during
the study.
In addition, we programmed rules for the additional immunizations needed for children
with CMCs. These CMCs were identified based on Advisory Committee on Immunization
Practices (ACIP) recommendations and existing literature and matched with the International
Classification of Diseases, 9th and 10th revisions (ICD-9 and ICD-10, respectively)
codes. When the reminder launched, it additionally queried the patient problem list
in the EHR and provided the additional immunization decision support for children
with CMCs based on the ICD codes ([Supplementary Material S1 ], available in the online version).
Table 1
Demographic characteristics of the study population
Variable
Frequency (n = 15,348)
Percent
Gender
Female
7,598
49.5
Male
7,750
50.5
Ethnicity
Hispanic or Latino
4,306
28.0
Non-Hispanic or Latino
789
5.1
Other
10,253
66.8
Race
White
1,591
10.4
Black
771
5.0
Asian
65
0.4
American Indian
4
0.0
Native Hawaiian/Pacific Islander
90
0.6
Other
12,827
83.6
Insurance
Commercial
543
3.5
Public
14,532
94.7
Uninsured
265
1.7
Other
8
0.1
Language
English
6,300
41.1
Spanish
8,089
52.7
Other language
959
6.3
A user survey was distributed to attendings, residents, nurses, and nurse practitioners
who used the alert during the study period. The Synchronized Immunization NotifiCations
(SINC) survey was distributed via e-mail and completed in Qualtrics, an electronic
survey platform ([Supplementary Material S2 ], available in the online version).
Outcomes
For children ages 0 to 18 years who had visited during the study period, we electronically
abstracted immunization information from the EHR, as well as information regarding
their CMCs at the time of their visits.
Captured opportunities were defined as a medical visit in the study period during
which a child/adolescent was eligible and received an immunization. For the captured
opportunities analysis, patient ages were divided into: overall, 0 to 12 and 12 to
23 months and 2 to 3, 4 to 6, 7 to 10, 11 to 12, and 13 to 17 years. Immunizations
due at time-of-visit varied based on patient age and up-to-date immunization status
and included diphtheria, tetanus, acellular pertussis (DTaP), inactivated poliovirus
(IPV), Haemophilus influenzae type b (Hib), hepatitis B (HepB), rotavirus (RV), measles, mumps, rubella (MMR),
varicella (VAR), pneumococcal conjugate (PCV13), hepatitis A (Hep A), meningococcal
(MenACWY), tetanus, diphtheria, acellular pertussis (Tdap), tetanus, diphtheria (Td),
and the human papillomavirus (HPV) immunization.
We used the Centers for Disease Control and Prevention (CDC) recommended immunization
schedule to determine captured opportunities. For ages up to 2 years, all children
should receive the Healthcare Effectiveness Data and Information Set (HEDIS) Combo
3 series (4:3:1:3:3:1:4) as appropriate for their age which includes 4 DTaP, 3 IPV,
1 MMR, 3 Hib, 3 Hep B, 1 VAR, and 4 PCV doses. They should also have received ≥2 RV
and 2 Hep A. By age 7 years, they should have received the DTaP, IPV, MMR, and VAR
boosters. By age 13 years, all adolescents should receive the HEDIS Combo 2 (1:1:2)
adolescent immunizations which include 1 Tdap, 1 MenACWY, and 2 HPV immunizations.
They also should have received a MenACWY booster by age 17 years.
For children ≥2 years with eligible CMCs, who were due for additional immunizations,
we analyzed any receipt of any dose of pneumococcal polysaccharide (PPSV23; one to
two doses after 2 years of age, condition dependent) and receipt of any dose of MenACWY
immunization (dosing age and condition dependent). For children requiring PPSV23,
we also included receipt of PCV-13 after age 2 years, as captured opportunities in
our analysis when needed prior to PPSV23 doses, and this was also recommended by our
immunization alert.
Under-immunization was defined as the percent of children and adolescents who were
overdue for at least one age-appropriate immunization as recommended by the CDC's
ACIP, by the end of each 3-month study period for those patients seen during that
period. Study ages included children of 7 to 12 and 19 to 48 months, 7 to 11, 13 to
16, and 17 to 18 years. These ages were chosen, as children receive certain immunizations
before each of these age groups and would be considered overdue if they were still
due for immunizations at these ages.
Statistical Analysis
Based on immunization and visit data, as well as previous studies, we expected there
to be 12,380 unique children with visits in any given 6-month period, reflecting the
combined “on” and “off” phases for each site. We expected when the reminder is “off”
that at the end of any given visit, 85% of children would be fully immunized (this
included those who at the beginning of the visit were not due for any immunization,
as well as those who were due for an immunization and received it), and 15% would
be not up-to-date. Based on this sample size and 80% power, we were powered to detect
absolute unadjusted differences in the proportion of children who are not up-to-date
on their immunizations (i.e., underimmunized) of 1.3%.
We compared captured opportunities and under-immunization when the reminder was “on”
versus “off” for all children with visits during the study period. We also assessed
coverage of CMC-specific immunizations including PPSV23 and MenACWY. The list of individual
patients with an eligible CMC for which the alert fired for was reviewed by one of
the pediatrician study investigators to ensure that the patient was actually due for
that CMC-related immunization. Analyses were stratified by age and visit type (well
child care vs. acute care visits). Immunization rates were compared using Chi-square
tests.
Statistical analyses were performed in SAS v 9.4 (SAS Institute Inc., Cary, NC). This
study was approved by the Columbia University Irving Medical Center Institutional
Review Board with a waiver of consent.
Results
Overall, there were 15,348 unique patients seen over the study period including 26,647
visits. Half (49.5%) of the children were female, nearly all (97.4%) were publicly
insured, and a little over half (52.7%) spoke Spanish ([Table 1 ]).
Captured Opportunities
During the study period, there were 10,802 visits in which a child was due for an
immunization in 4:3:1:3:3:1:4 series. There was a small but significant difference
in captured opportunities to complete the entire recommended series when the alert
was “on” versus when it was “off” (54.0 vs. 50.3% p = 0.0001; difference 3.7%; 95% confidence interval [CI]: [1.8–5.6%]). There was a
significant difference in both acute and well child visits ([Fig. 2 ]), as well as across most of the age groups ([Fig. 3 ]). The alert improved captured opportunities for patients seen by attending physicians
for some age groups including patients under 12 months, patients of 12 to 24 months,
and overall (data not shown).
Fig. 2 Captured opportunities when the immunization alert was “On” versus “Off” for the
primary immunization series (4:3:1:3:3:1:4) by visit type well child care versus acute
care visits. Note: The series includes age-appropriate doses of diphtheria, tetanus,
and acellular pertussis (DTaP), poliovirus (IPV), measles, mumps, and rubella (MMR),
Haemophilus influenzae type b (Hib), hepatitis B (Hep B), varicella (VAR), and pneumococcal 13-valent conjugate
(PCV13) immunizations.
Fig. 3 Captured opportunities when the immunization alert was “On” versus “Off” for the
primary immunization series (4:3:1:3:3:1:4) by age. Note: The series includes age-appropriate
doses of diphtheria, tetanus, and acellular pertussis immunization (DTaP), poliovirus
immunization (IPV), measles, mumps, and rubella immunization (MMR), Haemophilus influenzae type b immunization (Hib), hepatitis B immunization (Hep B), varicella immunization
(VAR), and pneumococcal 13-valent conjugate immunization (PCV13).
There were 2,735 visits during the study period in which an adolescent was due for
an immunization in the 1:1:2/3 series; however, there was no significant difference
in captured opportunities when the alert was “on” versus “off” (52.9 vs. 49.7%, p = 0.1; difference = 3.2%; 95% CI: [0.6–6.9%]). There was also no difference when
stratified by visit type well child care versus acute care visits (data not shown).
In addition, captured opportunities were stratified by immunization type. A few of
the immunization types including Hep B, Hib, and Hep A were more likely to lead a
significant increase in captured opportunity during the “on” periods for alert versus
the “off” periods ([Fig. 4 ]).
Fig. 4 Captured opportunities when immunization alert was “On” versus “Off” by immunization
type. Note: Immunizations include age-appropriate doses of diphtheria, tetanus, and
acellular pertussis immunization (DTaP), poliovirus immunization (IPV), measles, mumps,
and rubella immunization (MMR), Haemophilus influenzae type b immunization (Hib), hepatitis B immunization (Hep B), varicella immunization
(VAR), and pneumococcal 13-valent conjugate immunization (PCV13), tetanus, diphtheria,
and acellular pertussis v immunization (Tdap), meningococcal serogroups A, C, W, Y
immunization (MenACWY), and human papillomavirus immunization (HPV).
Underimmunization
There was no measurable difference in overall immunization up-to-date status in patients
of study ages by the end of quarter when the alert was “on” versus “off” (89.1 vs.
88.3% p = 0.16; difference = 0.8%; 95% CI: [−0.3 to 1.8%]).
Immunizations for Children with Chronic Medical Conditions
Two percent of children seen during the study period were eligible for CMC-related
pneumococcal immunization. Overall up-to-date status for PPSV23 remained low for the
299 children seen during the year with a qualifying condition, when the alert was
“on” versus “off” (23.6% [n = 35] on vs. 24.5% [n = 37] off, p = 0.9; difference = 0.8%; 95% CI: [−10.5 to 8.8%]); captured opportunities were also
low (9.7% [n = 12] on vs. 3.6% [n = 4] off, p = 0.06; difference = 6.1%; 95% CI: [−0.5 to 12.9%]). Less than 1% of children seen
during the study period were eligible for CMC-related meningococcal immunization.
Overall up-to-date status for the 35 children who had a qualifying condition for the
MenACWY immunization and were seen during the study period was high both when the
alert was “on” versus “off” (73.7% [n = 14] vs. 87.5% [n = 14], p = 0.31; difference = −13.8%; 95% CI: [−38.0 to 13.8%]). Captured opportunities during
the study period were low (9.1% [n = 1] “on” vs. 15.4% [n = 2] “off,” p = 0.64; difference = −6.3%; 95% CI: [−34.2 to 24.4%]). There was no significant difference
in captured opportunities for patients with CMCs seen by attending physicians (data
not shown).
User Survey
Overall, 63 providers and 14 nurses completed the user survey out of a total of 127
nurses, residents, nurse practitioners, and attendings (response rate 61%). Almost
all respondents (95%) were at least somewhat satisfied with the immunization alert,
and 96% found the alert at least somewhat helpful. However, 45% of respondents reported
encountering at least one problem when using the immunization alert, primarily with
the alert not working properly for some patients. Some respondents (21%) questioned
the accuracy of the immunization reminder or stated that it displayed incorrect immunization
history.
Discussion
The immunization alert which synced with the city immunization registry and gave real-time
recommendations for immunizations due at visits, was associated with improved captured
opportunities across all visit types, in many age groups, and for several immunizations.
The success of the alert in improving captured opportunities is consistent with the
body of literature supporting EHR reminders as a tool to improve immunization rates.[6 ]
[13 ]
[14 ]
[15 ]
[16 ]
[17 ]
[18 ]
[19 ]
[20 ]
[21 ]
[22 ]
[23 ]
[24 ] Interestingly, the impact on captured opportunities was seen not only in acute care
visits where missed opportunities are expected, but it was also observed in well child
checks where health care providers should have an increased attention toward immunizing.
The alert may have increased the likelihood that there was catch-up of immunization
doses, and this is supported by the specific captured opportunities for the Hep B,
Hib, and Hep A immunizations which have more complex intervals and rules relating
to catch-up vaccination.
Despite this, not all opportunities were captured. The rate of captured opportunities
for when the alert was “on” was lower than expected, particularly during well child
visits (57.6%) and overall for the primary 4:3:1:3:3:1:4 immunization series (54%).
There are medical reasons the health care provider could have chosen not to immunize
that day, such as the child having an acute illness or high fever.[25 ] A provider may also not have wanted to give more than a certain number of immunizations
at a time, that is, only four immunizations at the 1-year visit, although the alert
often displayed five to six immunizations due depending on if it was influenza season.
The additional immunizations not given would appear as “missed opportunities” in our
analysis even though providers were following the routine schedule. Other possible
reasons for not immunizing could be logistical, such as the family not having time
to wait to receive the immunization that day, or attitudinal, as parents who are vaccine
hesitant may ask to delay or outright refuse immunizations.[26 ] Alternatively, the provider could have failed to recommend an immunization or provided
a weak recommendation.[27 ]
[28 ] In addition, for patients who received immunizations outside of New York City, the
alert would not include that information, so providers may not immunize until they
have complete records for the patient to avoid over-immunizing. Technical and trust
issues could have also affected the impact of the alert. In a survey of providers
and nurses who used the alert, almost half (45%) of respondents reported at least
one technical issue with the alert. Many of these issues were described as the alert
not displaying properly especially for new patients. In the handful of “errors” reported
to the research team, the alert was indeed correct and the patient was in need of
immunization. Examples of the “errors” reported included interval issues with the
Hep A immunization (<6 months in between doses), live attenuated immunizations (e.g.,
MMR and live attenuated influenza immunization) given too close to one another, among
others. Some providers may have been hesitant to give immunizations long after the
error in immunization administration was made to rectify these issues. When looking
at captured opportunities for attending physicians only, the immunization alert was
significant for patients overall and age 2 years and under only but not for other
ages as it was for other providers. The difference could be from attending physicians
not referring to the alert or not believing it was correct. Other studies have shown
increased use of CDS alerts over time, and a longer study period might have improved
provider trust in the alert.[29 ]
In contrast, there was no statistical difference seen when looking at overall up-to-date
immunization status for the recommended series across the population. Overall, immunization
coverage rates were high across all sites which blunted the potential of the alert
benefit. Although the immunization alert may have been useful to individual providers
treating individual patients, little impact was shown at a population level in a setting
with high baseline immunization rates. In addition, the 1-year study period may have
been too short to see an improvement in overall immunization rates. When analyzing
an up-to-date status for immunization series, we looked at study ages at which time
children would be overdue for immunizations if they had not yet received them. For
the adolescent series, this would be at ages 13 to 15 years, so the overall up-to-date
status wouldn't capture patients, for example, who received immunizations at 11 or
12 years of age but did not turn 13 years during the study period.
The limitations above could have also played a role in the lack of alert's effect
for children with CMCs requiring specific immunizations, but there are also other
likely causes for this finding. During visits with children with CMCs, the alert would
highlight when a patient could possibly require a condition-specific immunization.
The alert directed the provider to the patient's “problem list” and a link to the
CDC's overall medical condition-specific recommendations instead of directly identifying
the triggering condition or spelling out the CDC CMC guidance. More specific guidance
in the alert paired with an order for the specified immunization might have made the
alert more effective. Other investigators have, for example, reported the need for
more specific alerts specifying whether the PCV13 versus PPSV23 immunization is due
to improve the chances that providers would act on CDS for children with kidney transplants.[30 ] Others have also developed immunization alerts for a specific medical condition[31 ] or to recommend the influenza immunization for children with CMCs[32 ]; however, we are not aware of investigators who have developed an alert that encompasses
multiple CMC-related immunizations and numerous CMCs.
It also proved to be a complicated task to convert the CDC immunization guideline
text into disease-specific ICD-9 and -10 codes. Because coding in the problem list
varied substantially, even for the same condition, we had to determine how liberal
we would be in identifying codes that could possibly indicate a condition. We opted
to increase the sensitivity of the alert by including parent codes that could be used
to code for a qualifying condition for which the immunization would be needed, but
which could unfortunately also code for a condition for which the immunization may
not be needed. We educated providers on these features, as well as noting in the alert
that the end user should check the conditions, to confirm whether or not the immunization
was needed. The need to confirm may have acted as a barrier. In addition, provider
alert fatigue could have been introduced if the alert triggered for patients who were
not actually due for the immunization. This could also have enhanced provider distrust.
It is possible that with an EHR system where billing is structured and conditions
are more likely to be coded the same way and with more specificity, an alert could
rely on more specific ICD codes in turn allowing for much more alert specificity.
This would need to be balanced with sensitivity.
Another possible explanation for low rates of CMC-related immunizations could be provider
judgement. Some providers may not be familiar with the need for additional immunizations
for children with CMCs. We expected this to be true for many resident physicians who
are still learning the immunization schedule. However, when we analyzed captured opportunities
and overall up-to-date status by end of quarter for patients seen by attending physicians
who required CMC-related immunizations, we also saw no statistically significant improvement
with the alert. Some CMCs leave little room for ambivalence about opting for CMC-related
immunization such as children with sickle cell disease who have functional asplenia
and are at high risk of infection from Streptococcus pneumoniae and Neisseria meningitis .[33 ] In our analysis, all but one patient who qualified for MenACWY had a form of sickle
cell anemia which likely made it easier for providers to recognize that the patient
was clearly due for the immunization as evidenced by higher baseline MenACWY immunization
rates. However, for other conditions, it may be less clear to a provider that an immunization
is needed since the CDC categories can be broad (e.g., liver disease). In other cases,
the patient may be doing clinically well or have mild disease, and a provider may
believe that the CMC-related immunization is not necessary. A pediatrician on the
research team reviewed each patient's CMC diagnoses and removed patients with conditions
that were deemed ineligible for MenACWY or PPVS23 immunizations prior to data analysis;
therefore, the analyses were limited to those who really were in need of immunization.
However, we used a more conservative approach including patients with all indications
including mild disease in the denominator for CMC-related immunizations which may
be contributory to low immunization rates overall. More specific ACIP guidelines for
CMC-related immunizations could include immunization-related guidance specific to
the severity of the disease in addition to more clearly delineating which conditions
should be included, thus ensuring that all children with CMCs who need CMC-specific
immunizations receive them.
A fair amount of work is needed to keep rules up-to-date highlighting the potential
for open-source centralized rule-based engine such as these; if EHR vendors used such
engines, they could reduce redundancies and more easily ensure they are always using
the most up-to-date rules.[8 ] It would be important that systems are in place to ensure updates are not missed.
Such rule-based engines are helpful for routine immunizations but may be more limited
for immunizations needed for high-risk conditions. While the engine used in this study
highlighted when immunizations may be needed for high-risk conditions, it did not
have a list of ICD-9 or -10 codes that would constitute conditions that could necessitate
that immunization. Having this in the future would potentially be useful, so that
individual sites are not trying to create a list of codes themselves. However, the
caveats of the sensitivity and specificity balance as discussed above would need to
be addressed.
Limitations
There were several limitations to this study. Our population had baseline high immunization
rates which created a ceiling effect with little room for improvement with the intervention.
Few patients required CMC-related immunizations; therefore, power in the analysis
of CMC-related immunizations was low. In addition, for CMCs, the rules engine did
not have a list of ICD-9 or -10 codes that would constitute conditions that could
necessitate that immunization. Therefore, lists of relevant medical conditions were
generated manually but may have included some conditions in grouped ICD-9 or -10 codes
that did not necessitate CMC-specific immunizations. Sites may also have had differing
immunization practices; however, the design of our study was a cluster cross-over
trial which compared sites that had the alert with those that did not which should
account for these differences. Finally, this study also took place in a single medical
system, findings may not be generalizable to other settings.
Conclusion
Ultimately, it was possible to build an immunization alert in an EHR that used a centralized
immunization rules engine, as well as synchronized data, with the local IIS. Immunization
CDS in this population did improve captured opportunities for immunization providing
individual children with their needed immunizations. While we did not see a population-level
effect due to high baseline immunization rates, such an alert may be helpful across
a population at sites that are not routinely checking for needed immunizations at
all visits. The alert did not have an impact on condition-specific immunizations for
children with CMCs. More precise coding may be needed to be able to launch sensitive
and specific alerts that are more actionable for the end users, as well as more clarity
and specificity in the rules themselves.
Clinical Relevance Statement
Clinical Relevance Statement
This manuscript reaffirms current literature which demonstrates that clinical decision
support (CDS) immunization reminders embedded in the electronic health record (EHR)
improve immunization uptake for several immunizations and visit types. We developed
an alert that encompasses multiple chronic medical condition (CMC)-related immunizations
and numerous CMCs which is not previously reported in the literature. Use and trust
in the reminders are important to their effectiveness. This paper further explores
the need for more specific and sensitive reminders for immunizations based on patient
medical conditions, as there was no statistically significant improvement in immunizations
needed for patients with CMCs and suggests that more research should be done to better
improve CDS systems for patients with CMCs.
Multiple Choice Questions
Multiple Choice Questions
What is/are the benefit(s) of having electronic health records (EHR) synchronize with
immunization information systems (IIS)?
To improve captured opportunities for immunization
To satisfy HIPAA requirements
To comply with meaningful use requirements
Choices A and C
Correct Answer: The correct answer is option d. Stage-3 meaningful use criteria set by the Centers
for Medicare & Medicaid Services (CMS), require many EHR to participate in bidirectional
immunization information exchange. This allows local EHR to display immunizations
from the IIS allowing providers to receive more complete records of their patient's
immunization records without having to log in to the IIS directly. Synchronizing with
IIS helps prevent over-immunization by displaying immunizations which may have been
administered at different locations in the EHR and providing a more complete record.
Which of the following immunizations is given in an additional to the primary immunization
series for children with certain chronic medical conditions such as heart disease
or diabetes?
Haemophilus influenzae type b (Hib) immunization
Pneumococcal polysaccharide (PPSV23) immunization
Diphtheria, tetanus, acellular pertussis (DTaP) immunization
Pneumococcal conjugate (PCV13) immunization
Correct Answer: The correct answer is option b. The pneumococcal polysaccharide immunization (PPSV23)
is recommended for children ages 2 to 5 years with several chronic medical conditions
including chronic heart disease; chronic lung disease; diabetes mellitus; cerebrospinal
fluid leak; cochlear implants; sickle cell disease and other hemoglobinopathies; anatomic
or functional asplenia; congenital or acquired immunodeficiency; HIV infection; chronic
renal failure; nephrotic syndrome; malignant neoplasms, leukemias, lymphomas, Hodgkin's
disease, and other diseases associated with treatment with immunosuppressive drugs
or radiation therapy; solid organ transplantation; multiple myeloma: chronic liver
disease, and alcoholism. This PPSV23 immunization is recommended in addition to the
PCV13 series and should be given after the completion of the PCV13 series when possible.
