Things We Do For No Reason is an article series in the Journal of Hospital Medicine that reviews common practices in hospital care that may provide little or no value to patients. Obviously this idea is relevant in any clinical setting, including primary care, which brings us to today’s question: is it reasonable to accept a patient’s verbal report that their vaccines are up to date?
Case:
A new adult patient presents to clinic after recently moving to RI from out of state. The patient has not seen a physician in a few years, and has no documentation from their prior PCP. Nevertheless, the patient is certain that they received all their childhood vaccines and believe they are up to date on adult vaccines. The new PCP documents the patient’s report that their vaccines are up to date.
Why you might think it’s reasonable to accept a patient-reported vaccination history:
Vaccination coverage rates (VCRs) for US children are quite good, so patients may be right when they say they have received all of their childhood vaccinations. Check out CDC’s estimates of VCRs for 2008-2019:
- Young children (2yo): 87% for all standard vaccines overall (93% in RI)
- Children entering kindergarten: 95% for all standard vaccines overall (98% in RI!)
- Adolescents (13-17yo): MMR 92%; HepB 91%; Td/Tdap 90%; MenACWY 89%; HPV 71%
Why patient-reported vaccination histories probably aren’t helpful:
VCRs for US adults are much lower than for children. (Accordingly, the prevalence of illness attributable to vaccine-preventable diseases is much greater among adults than among children, including 90% of invasive pneumococcal disease.) Check out CDC’s estimates for vaccination coverage rates in 2015 among adults ≥19yo:
- Pneumococcal vaccine, ever: 23% of 19-64yo adults at increased risk; 63% of adults ≥65yo
- Tetanus vaccine, within past 10yr: 61% of adults ≥19yo
- Herpes zoster (shingles) vaccine, ever: 30% of adults ≥60yo
Furthermore, adults’ awareness of the availability of certain vaccines is quite variable. For instance, 94% and 86% of adults are aware of the influenza vaccine and Td/Tdap vaccines, respectively, whereas rates are much lower for other vaccines: pneumococcus 66%, HepB 64%, shingles 59%, and HPV 59%. As such, many adults who believe their vaccines are up to date may not even be aware of the vaccines they’re eligible for.
What we should do instead:
According to CDC, providers should only accept written, dated records as evidence of vaccination*. An attempt to locate missing records should be made whenever possible by contacting previous providers, reviewing state/local immunization information systems, and searching for a personally held record. However, if records cannot be located, patients without adequate documentation should be considered susceptible and should be started on the age-appropriate vaccination schedule. Serologic testing for immunity is an alternative to vaccination for certain antigens (e.g., measles, mumps, rubella, HepA, HepB, varicella).
- *Exceptions: CDC says providers can accept patients’ verbal reports of receiving influenza and pneumococcal vaccines. Also, if an adult has a record of US military service and does not have vaccine records available, providers can assume that the person has received all vaccines recommended by the military at the time of service entry.
In general, although not ideal, receiving extra doses of vaccine poses no medical problem; however, receiving excessive doses of tetanus toxoid (DTaP/Tdap/Td) can increase the risk of a local adverse reaction.
Recommendations:
- Only accept written, dated records as evidence of vaccination (noting the few exceptions above).
- Recognize that lack of knowledge is the most substantial barrier to vaccination coverage among adults. Make a point to educate your patients about vaccines.
- Make a habit to review patients’ immunization histories, regardless of visit type. Ask yourself 2 questions:
- Are my patient’s routine vaccines up to date? Think about Td/Tdap, influenza, pneumococcus, zoster, and COVID!
- Does my patient have any conditions that place them at high risk for certain vaccine preventable diseases?