"Ketchup" Vaccinations

August 27, 2017
Terry Brenneman, MD
Terry Brenneman, MD

Figuring out how to bring a child up-to-date with missed vaccinations can be confusing enough, even without a language barrier.

[[{"type":"media","view_mode":"media_crop","fid":"62814","attributes":{"alt":"(Not actual child)","class":"media-image media-image-right","id":"media_crop_9074818350410","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"8001","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"height: 283px; width: 437px; float: right;","title":" ","typeof":"foaf:Image"}}]]Editor's note: this is an updated version of the original article which appeared in December 2015.

A few years ago I walked into the exam room to see a 14-month-old child who was new to our practice, for a regular check-up. The family had immigrated to the US about 9 months earlier and at 5 months of age the child had only received two doses of DTaP, Prevnar, HIB (type unknown), and IPV. Mom’s English was fair-to-good and she mentioned that she knew her son was behind on shots but wanted him to get everything he needed as soon as possible.

The easy part in dealing with children behind schedule on their vaccines is figuring out what they need that day. The tough part is knowing which vaccines will be needed and when their next visit should be scheduled.

I added up in my head the vaccines needed at this visit: MMR, Varivax, HIB, Prevnar, influenza, DTaP, hepatitis B, and IPV. I told mom that we had a lot of catch-up vaccines to do; I looked up from my notes and actually saw a big smile spread across her face. “Oh, doctor,” she began, “I am so glad you have ketchup vaccines because my son loves ketchup and I was so worried he was going to get a lot of needles today.” (Honest truth.)

After straightening out the confusion over the homonyms I had to tell mom when she should return for more vaccines and figure out what he would need then.

1. What should I have told her regarding the HIB vaccine?

A. Your son only needs one more HIB vaccine after the one today and the earliest we should do it is in 4 weeks

B. Your son only needs one more HIB vaccine after the one today and the earliest we should do it is in 8 weeks

C.  Your son will be up to date after his HIB vaccine today.

D. Your son needs 2 more HIB vaccines after today’s dose since we have to assume he got the PRP-T (4 shot series)-type HIB. We can give the last in 8 weeks.

For answer, discussion, and next question, please click here. 

Note: image is representation only, not the actual child in this case. :
©Phase4Studios/Shutterstock.com

The correct answer is C.Your son will be up-to-date after his HIB vaccine today.

After the age of 15 months only a single dose of HIB would be needed even if the child had received none previously. If only a single dose of HIB had been received after the age of 12 months, then an 8-week interval is recommend for the final HIB dose.

2. Regarding the DTaP vaccine, mom should be told that her son needs more doses of DTaP, and:

A. he should return in 4 weeks for his 4th lifetime dose if you want to get him caught up as soon as possible.

B. he should return in 8 weeks for this 4th dose to get him caught up as soon as possible.

C. the one he gets today gets him caught up and he can get his 4th dose at his 18 month routine well child visit.

D. however, he has to wait 6 months between doses 3 and 4, so he will be behind schedule for a few months since children are supposed to have received 4 doses by 18 months of age.

For answer, discussion, and next question, please click here

 

The correct answer is D. He has to wait 6 months, the minimum recommended time interval between doses 3 and 4.

Providers who like to give the 4th dose of Pentacel (DTaP-IPV-HIB) at the 12-month visit need to be careful with this time interval. This has become less of a problem since both 15- and 18-month well visits are now recommended and paid for by insurance. Not that long ago, pediatricians were limited by managed care companies to 2 well visits in the second year of life:  the 12-month visit and then either a 15- or 18-month visit. If you used Pentacel and did not do a 15-month visit, then a child would not get that final HIB dose until 18-months of age if, for example, the child got his 6-month shots at 7 months of age and showed up on time for the 12-month visit meaning only a 5-month interval since dose 3. (Feel free to read that again.)

3. And, regarding the Prevnar 13, mom should be told:

A. Your child will not need any more Prevnar vaccine after today’s dose since a single dose after 12 months of age can be the final dose if the child has received 2 doses before age 12 months and the second dose was given at least 8 weeks or longer before the final dose.

B. Your child needs two more doses of Prevnar, one today and one in 4 weeks since by that time he will be over 15-months of age and only a single dose is needed after age 15 months even in a child previously unvaccinated.

C. Your child needs two more doses of Prevnar, one today and one in 4 weeks.

D. Your child needs two more doses of Prevnar, one today and one in 8 weeks.

For answer and discussion, please click here.The correct answer is A.  A single Prevnar dose will suffice in an unimmunized child only if the dose is given after age 2.


The CDC catch-up vaccine schedule is complicated and despite my interest in vaccines, I usually have to look things up. The CDC has produced a free app for both iOS (Apple) and Android devices named CDC Vaccine Schedules.
 

One final question: do you use “ketchup” or “catsup” on your fries?