HONOLULU -- A complex regimen of 21 vaccines added to the routine child immunization schedule since 2000 has left many health care providers shaking their heads.
Dr. Andrew D. Racine took his frustration one step further, and took out his calculator.
By his calculations, administration of the new vaccines recommended for pediatric patients from infancy through adolescence by the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices, the American Academy of Pediatrics, and the American Academy of Family Physicians has added up to 17.8 weeks of salary for a full-time nurse in a busy practice, as well an upfront inventory cost of $100,000-$200,000.
'The instigation for this [study] was just looking at our nursing staff,' said Dr. Racine following the oral presentation of his results at the annual meeting of the Pediatric Academic Societies.
'They were going crazy.'
Dr. Racine, chief of clinical pediatrics at Albert Einstein College of Medicine, New York, noted that 10 childhood vaccines were recommended in 1983. That number now stands at a mean 27 vaccines per healthy child, depending on their gender and risk profiles.
Added to the schedule since 2000 are pneumococcal 7-valent conjugate vaccine (PCV7) at 2, 4, 6, and 12 months; influenza vaccine at 6 and 7 months, then annually to all patients up to 5 years and to 50% of 6- to 21-year-olds; meningococcal polysaccharide conjugate (MCV4) vaccine and tetanus/diphtheria toxoid/acellular pertussis (Tdap) vaccine at 11 years; hepatitis A vaccine at 18 and 24 months; rotavirus vaccine at 2, 4, and 6 months; 3 human papillomavirus (HPV) vaccines to girls at 11 years; and a second varicella vaccine at 5 years.
To find out how much staff time was needed to administer these added inoculations, Dr. Racine conducted an observational time-flow analysis of nurses in a busy urban academic practice as they simulated the tasks required to deliver one childhood inoculation.
He then multiplied the mean time to deliver a shot by the number of vaccines required per one pediatric patient over the course of childhood and calculated the total time cost to practices of various sizes.
The study was designed to be widely applicable to many types of practices: large or small, private or academic, staffed by experienced or relatively inexperienced nurses.
Tasks in the simulation included checking the chart for a vaccine order, obtaining the vaccine from storage and drawing up the medication, accessing the examination room, counseling parents, administering the shot and, finally, recording the immunization on the child's personal immunization card and on the chart.
The analysis used conservative assumptions, Dr. Racine noted.
Even so, the time added up to a substantial burden, even for a small panel of 1,000 patients, he reported.
'We've got anywhere from about 4.5 weeks of nursing time for a small panel that gave shots quickly to almost 18 weeks for a full-time equivalent nurse just to give these vaccines to a large panel of patients,' said Dr. Racine. (See box.)
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The potential implications of the study are profound, he added.
'We think this incremental cost [in terms of nursing time and up-front outlays for vaccine stock] presents significant challenges for the pediatric community and to the public policy goal articulated in Healthy People 2010 of increasing the proportion of all children and adolescents who receive all of their recommended vaccines,' he said.
BY BETSY BATES
Los Angeles Bureau
Full-Time Nurse Equivalent Time per Year to Administer New Vaccines Added to Schedule Since 2000 Patients Additional 5 minutes/ 10 minutes/ vaccines vaccine vaccine 1,000 1,999 doses 4.5 weeks 9 weeks 1,200 2,399 doses 5.3 weeks 10.6 weeks 1,500 2,999 doses 6.7 weeks 13.4 weeks 2,000 3,998 doses 8.9 weeks 17.8 weeks Source: Dr. Racine
