Evaluación de la adecuación del calendario de vacunaciones y el cumplimiento de las recomendaciones adicionales, por su patología de base, en niños con problemas complejos de salud

Resumen

Children with special health care needs (CSHCN) are those who show greater risk of having a chronic physical, mental, or emotional condition during development, who consume more health services than the general paediatric population. Within these, there exists a subset of patients with characteristics that don them even greater complexity, the Medically Complex Children (MCC). These children present multiple, chronic and complex pathologies, with technology dependence, and exhibit greater risk of suffering infectious complications that worsen the base prognosis of their illness or present a more torpid course. Studies performed in countries like ours, show that the children with chronic medical conditions present worse vaccinal coverage than healthy children, with rates between 62-85% depending on the vaccine, age, country, or pathology. These rates are even worse for flu vaccination, with coverage rates under 30% in some populations. Until the date, there are studies in our country that analyse vaccine coverages only in children with chronic diseases, but no in MCC. Since 2008, the Pediatrics, Infectious and Tropical Diseases Department of “La Paz” Children’s Hospital has a Specific Assistance Division dedicated to the integral attention of MCC. In the last few years we have detected multiple problems with the fulfilment the official vaccination schedule and the additional immunization recommended in this population. We have also detected delays in the administration of vaccines. After considering its relevance and verifying the absence of publications on this topic we decided to perform this study. Aims. To study the MCC vaccination coverages, comparing them with the immunization coverage registered by the Health Ministry within Spanish infant population. To analyse the adherence to the additional immunization recommended by the Vaccine Assessment Committee of our country (CAV-AEP) due to their medical conditions. To evaluate causes related to the unfulfillment or the delay in the administration of vaccines. Methods A transversal study of incident-cases was performed in the Complex Chronic Pathology Unit of “La Paz” Children´s Hospital, approved by the Local Ethics Committee, including patients between 12 months and 18 years and excluding immunosuppressed children. The study was funded by the Emergent Investigation Groups Help Grant 2015, from the IdiPAZ Investigation Institute. All the MCC followed at the Complex Chronic Pathology Unit that we could actively recruit and agreed to participate were included. Before their inclusion, the informed consent of their parents or guardian was obtained; previously informing and agreeance from patients older than 12 years old who were mature. The parents provided vaccination schedule that was considered valid if it meets the criteria of the Advisory Committee on Immunization Practices (ACIP). MCC were defined as those suffering from more than one chronically complex condition (CCC) or a CCC and technology dependency. CCCs were defined as any physical, mental or developmental condition that can be expected to last at least a year (unless death intervenes), will use health care resources above the level for a healthy child, require treatment of control of the condition, and the condition can be expected to be episodically or continuously debilitating”. Technology dependency was defined as the continuous need of technology for at least 6 months. The analysis of vaccine coverage data was performed using the methodology of the Ministry of Health, with coverage by age bands and type of vaccine. We collected the following data: Sex and age, date of diagnosis of the main CCC, types of CCC (neuromuscular, cardiovascular, respiratory, renal, gastrointestinal, hematology and immunodeficiency, metabolic, other congenital or genetic defect, neonatal and malignancy), and technological support dependence, doses received of the different vaccines, dates of administration of diphtheria, tetanus, and pertussis (DTP), Measles- Mumps-Rubella (MMR), Hepatitis B vaccine (HBV), Hepatitis A vaccine (HAV), pneumococcus (PCN13, PPN23), chickenpox and influenza. The indication of prophylaxis with Palivizumab and its administration was also registered. Previous medical conditions and current dependence on technology/devices was also collected retrospectively. Medical conditions were classified according to the ICD-9 diagnostic categories considered as CCC, in accordance with Medical Complexity Working Group of the Center of Excellence on Quality of Care Measures for Children with Complex Needs (COE4CCN), Seattle, Washington. The number of admissions, total admission in Intensive Care Units, number of surgical interventions and previous administration of blood products were collected. Compliance with the standard vaccination schedule was analysed comparing our data with those provided by the Department of Prevention and Health Promotion of the Ministry of Health, Social Services and Equality (M.S.S.S.I.) in Spanish population. We analysed the coverage of additional immunization recommended by the CAV-AEP due to their medical conditions, both by type, doses, or optimal interval. We specifically analysed PCN13, PPN23, chickenpox, flu and VHA. We also analyzed which patients followed immunoprophylaxis with Palivizumab. The percentage of householdmembers vaccinated against influenza was also collected. Based on previous vaccination studies, parents / guardians completed a survey of the main barriers or difficulties they encountered in completing the correct timing of the child's vaccination, as well as if they thought that the timing of the vaccination was suitable for their child at inclusion. They were asked who usually reviewed vaccination schedule and how often they did it. As in other vaccine studies, the main socioeconomic data of the family has been collected. The information obtained was included in an anonymous database. Statistically analysed by program SAS 9.3 (SAS Institute, Cary, NC, USA). Results We included 100 patients (55% male and 45% female). The median age was 4 years, (IQR: 2-8). 79% of the sample proceeded from Madrid. 81% were diagnosed of their first CCC at birth. The median number of CCCs was 4 CCCs (IQR: 3-5; Range: 1-8). The most prevalent CCCs in the sample were neuromuscular (82%), gastrointestinal (71%), respiratory (68%), congenital or genetic (46%), cardiovascular (46%) and neonatal (27%). 22% have been premature. 87% were technology-dependent. The respiratory and gastrointestinal supports were the most frequently observed (58% and 67%, respectively). The median days of admission during the first six months of life were 94 days (IQR: 47-133) and in the first two years of 120 days (IQR, 67-172). The median of surgical interventions in the first 2 years was 3 (IQR: 1-5; Range: 0-12). 30% of the families had one unemployed parent. 45% of the families asked for the economic benefit for care of children affected by serious illnesses, mostly mothers [39,4% (39/99)] against fathers [4%(4/99)], (p <0,01). 15% of the children had been followed at some point by Palliative Care Units. 23% of the cases presented an inadequate vaccination record. A 24% (IC95% 0,15- 0,32), does not have a suitable schedule in relation to the systematic vaccines. 88% (IC95% 0.81-0.94) in relation to the additional vaccines for their medical conditions according to recommendations of the CAV-AEP. Therefore, only 11% were correctly vaccinated in number and type of systematic and additional vaccines for basic pathology. In all age groups, systematic vaccination rates did not exceed 90% [84% (16/19) 83.5% (35/42) between the ages of 2-5 years, 71% (22/31) between the ages of 6 and 15 and 37.5% (3/8) of those over 16 years of age; p = 0.03]. The vaccine coverage rates of the sample against DTP and MMR were compared, using the statistical method for comparing an observed proportion with a theoretical one, with the average rates provided by the Ministry (1998-2015). Statistically significant difference was observed for primary vaccination with DTP at first year of life [92% (92/100) in the sample vs. 96.5% in the general population, p=0.014] and booster vaccination at 2 years [DTP 2 years: 88.4% (76/85) vs. 93.9%, p=0.033]. No significance was found among the differences found in the rates of DTP doses at 6 and 16 years [6 years: 79.5% (31/39) vs 87.5%, p=0.1; 16 years: 58.3% (7/12) vs. 78.8% p=0.08]. The rates of vaccination for MMR were similar for the first dose at two years [95.7% (90/94) in the sample vs. 96.2% in the general population, p=0.8], and the booster dose at 6 years [94.2(49/52) vs. 92.6%), p=1]. Patients who received the first dose of DTP after their three months of age were hospitalized 131.8 ± 63.4 days during their first 6 months of age compared with children vaccinated before 3 months of age, who hospitalized 85.1 ± 56.8 days (p=0.04). The percentage of administration of additional vaccination recommended due to their chronic medical conditions was: 31.6% in children of 1 year old (6/19), 4.8% between 2-5 years (2/42), 9.7% between 6 and 15 years (3/31) and 1.2% in those older than 16 years (1/8), p = 0.02. Because of its underlying disease, 100% of the sample had indications of vaccination against pneumococcus, varicella and influenza, 37% against HAV, and 33% had indications of prophylaxis with palivizumab. 24% of the children were correctly immunized against pneumococcus. 83% of the children had a sequential pattern indication (VNC13 followed by VNP23). 16.9% of the children with a sequential pattern indication were correctly immunized (14/83) compared to 58.8% (10/17) of the children who did not require a sequential regimen (p<0.01). Younger children were more frequently correctly immunized against pneumococcus than older ones (p<0.001). Being correctly immunized against pneumococcus was not associated with better coverage against systematic vaccines (p=0.4). Only 37% of children with indication had adequate immunization against varicella, as well as 27% of those indicated for HAV. 75% of the sample was well vaccinated against influenza every year since the indication, 80% in the last three years. Fifty percent of all household contacts were vaccinated annually against the flu. All patients who had indications of prophylaxis with palivizumab received the drug. Regarding social factors, those families with some unemployed members purchased unfinanced vaccines less frequently than the rest of the families [43% (13/30) vs 71% (44/69), p=0.01]. However, the fact of buying vaccines was not associated with greater compliance with the additional vaccination recommendations (p=0.7). The children of families who had applied for economic benefit for care, due to minor children affected by serious illnesses, had worse coverage of systematic vaccination at the age of 6 years compared to the rest of the patients [54.5% (6/11) vs. 89.3% (25/28); p= 0.028]. The neuromuscular and congenital CCCs were associated with an increased risk of additional incorrect schedule [OR 4.12 (95% CI 1.1-15), p = 0.03 and OR 5 (95% CI 1.03- 24.12), p=0.045]. Having respiratory CCC or needing oxygen therapy was associated with a greater likelihood of correct influenza vaccination in cohabiting patients [OR 3.1 (95% CI 1.2-7.6), p=0,012, and OR 3.2 (95% CI 1.4-7,2), p=0,006]. Having a history of prematurity increases the likelihood of adequate vaccination against pneumococcus [OR 2.9 (95% CI 1,1-7,7), p=0,012] and even more if they weighed below 2000 g at birth [OR, 3.4 (95% CI 1.2-9.4), p=0.016]. Having a neonatal CCC was associated with a greater probability of being correctly vaccinated against varicella [OR; 3,5 (IC95% 1,4- 7,2), p=0,007]. Patients who used to review their vaccination schedule with their primary care physician were more likely to have an adequate systematic schedule [OR 2,7 (95%CI 1,07-7,2), p=0,03], even more if they checked it with a paediatrician from the Complex Chronic Pathology Unit [OR 5.6 (95%IC 1.9-17), p=0,002]. 47.4% of the families reported delays in the administration of systematic vaccinations, the majority of them due to decompensation of their underlying disease or surgery at the moment of vaccine administration. 13% of families thought that their child's vaccunation schedule was not up-to-date, but 75% believed they had an adequate immunization regimen, although their child did not have all the vaccines indicated by their underlying disease. The 89% of the sample needed to update their calendar. Conclusions One fourth of the sampled MCC do not conform to the systematic vaccine calendar indicated by the year they were born in, and their Autonomic Community of origin. Only 12 of every 100 receive all the additional vaccines recommended by the CAV-AEP due to their base pathology. All of this comes to show that only 11% of our patients are correctly immunized with all their vaccines. Vaccine coverage rates in CSHCN of our study are less than 90% for systemic vaccines in all age groups. Compared with the general population, systematic vaccination rates are similar and adequate compared to MMR but lower versus DTP, significantly in the first two years of life. Compliance with recommendations for additional vaccines is low for pneumococcus, varicella, and HAV. In the case of pneumococcus, children who require a sequential regimen (PCV13 followed by PPV23) are significantly worse vaccinated than the rest. The coverage against influenza was 75%, higher than those described by other groups, but not for the household contacts (50%). Neuromuscular and congenital CCCs were associated with poorer vaccine coverage. Children with neonatal CCC, with a history of prematurity or birth weight <2000 g were better vaccinated. The household contacts of children with respiratory CCC or children needing oxygen therapy better complies with influenza vaccination recommendations compared to the rest of MCC. According to the families´ opinion, the main cause of the delay in vaccines administration was decompensations of their underlying disease or the need for surgery. A high percentage of families believe they have an adequate vaccination schedule when their children actually need vaccines that have not been given. Monitoring the correct vaccination of CSHCN is essential to combat vaccinepreventable diseases in this high-risk population. Periodically reviewing the vaccination records of these children can improve compliance with the recommendations DESCRIPTORS: Multiple Chronic Conditions; Child; Adolescent; Immunization schedule; Vaccines.