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Revista chilena de pediatría

Print version ISSN 0370-4106

Rev. chil. pediatr. vol.88 no.6 Santiago Dec. 2017

http://dx.doi.org/10.4067/S0370-41062017000600723 

ORIGINAL ARTICLE

Result of a model of management of special vaccines

Sylvina AlvaradoA  B  C 

Ernesto PayaB  C 

María Teresa ValenzuelaD 

Rodolfo VillenaB  C 

A Faculty of Medicine, Master of Epidemiology, Universidad de Los Andes, Santiago, Chile. Correspondence: Sylvina Alvarado sylvina.alvarado.fick@gmail.com.

B Faculty of Medicine, Universidad de Chile, Santiago, Chile.

C Dr. Exequiel González Cortés children's hospital, Santiago, Chile.

D Faculty of Medicine, Master of Epidemiology, Universidad de Los Andes, Santiago, Chile.

Abstract:

Introduction:

Special vaccines recommendation patients are a growing population. The Ministry of Health has developed a special vaccination program for these cases, through which our hospital manages vaccine forms by an established flowchart.

Objective:

To describe the special vaccines model of management results in the period between March 2015 and September 2016, and the clinical and demographics characterization of the pediatric population benefited with this program in Dr. Exe quiel González Cortés Children's Hospital.

Patients and Methods:

We performed a descriptive ob servational study, which covers the chronically ill patient’s population who received special vaccines during the period between March 2015 to September 2016.

Results:

A total of 367 vaccine schemes were administered to 215 patients, with a total of 405 vaccines administered during the period. The medical specialties that most requested vaccines were infectology (39.1%), immune-rheumatology (24.2%) and bronchopulmonary specialists (20%). The National Immunization Program authorized 97.8% of the requested schemes (n = 359), the response time had a median of 15 days (range 0-174 days), the vaccination opportunity had a median of 41 days (range 0-287 days) and the total of sche mes completed at the time of tabulating the results was 52.8%.

Conclusions:

Vaccines are one of the main public health equity policies and Chile has special vaccines request flowchart a flow chart, which requires a multidisciplinary work to provide coverage to this vulnerable child population.

Keywords: Vaccines; vaccine schedule; chronic diseases

Introduction

The pediatric patients that require specific recom mendations of vaccination are the growing population within the public health system users and may present pathologies with an increased risk of immuno-preventable diseases. For this reason, staying up-to-date with their immunizations is critical to improve the protec tion and decrease the severity in case of acquiring one of them1. Various scientific articles, national and inter national guides recommend scheduled vaccines to use in these groups1,2,3,4,5,6. In general, these recommendations point to the importance of a personalized evaluation, adjusting the scheduled vaccines to the patient history and the potential risks in order to focus the work in the administration of the vaccines in a safe and effective manner1,2,3,4. The National Immunization Program (PNI) of Chile has given progressively protection aga inst communicable diseases since its inception in 1978, covering currently 15 immuno-preventable diseases7,8. As complementary support, the PNI provides a model of management of special vaccines with an established flow (see flow diagram)8 that allows us to provide a be nefit and an opportunity of greater protection to diffe rent population at risk. This management model con sists in the individual evaluation by the clinical team, who solicits the non-considered scheduled vaccines under the PNI through a medical prescription and a specific form. Then, the organization, disposal, regula tion, and insurance of the medical requests to PNI are carried out by the local nurse in charge in the wait of PNI answer via email. With the answer, the patient is localized to the final administration of scheduled vac cine, considering all the time what is established in the technical norm about standard operating procedures to ensure quality in the program execution9.

The aim of this study is to describe the results of the model of management of special vaccines imple mented in our institution, for the period March 2015 to September 2016, and characterize clinically and demographically the child population beneficiated by this program in the Children’s Hospital Dr. Exequiel González Cortés (HEGC).

Patients and Methods

Study design

A descriptive, observational study of the pedia tric population that needed vaccines of the ministry program of special vaccines attended in the HEGC, according to the base pathology and the vaccination status for the period March 2015 to September 2016. The HEGC is a high-complexity pediatric hospital of southern area of Santiago de Chile depending on the public health system. The information is obtained from the databases of the registration of requests of HEGC and the control of special scheduled vaccines of the person in charge of local PNI. This study was authorized by Teaching, Investigation, and Innovation Unit depending on the Directory of HEGC.

Patients

The data of all the patients that were managed in the program of special vaccines of PNI. The patients were evaluated by their treating physicians, who requested scheduled vaccines or referred to infectology for that purpose. Then, the local responsible of PNI verified the vaccination status of those whose information was available in the software of the ministry of the National Immunization Register (RNI), then he derived the re quest to the central level, and, once approved, patients and their families were contacted to coordinate the va ccination and after the administration he registered the information in the RNI.

The patients were classified according to their cli nical situation or chronicity in chronic outpatients, outpatients, and inpatients. The patients defined as chronic outpatients are those who were on regular me dical monitoring in the office next to the Specialities Department (CAE) in one of the medical specialties. The acute patients that consult in the CAE and require special vaccines are known as outpatients. The patients that are hospitalized for long stay are defined as inpa tients.

For the clinical characterization and demography, it was described the variants of age, sex, health insurance, medical speciality that requested the vaccine, chronicity, and vaccines administered. The health insurance was described according to those with no health insu rance, the levels of the National Health Fund (FONASA) and the Programme of Compensation and Com prehensive Health Care (PRAIS) that correspond to an compensation instrument of the Ministry of Health, which respond to commitment assumed by the State with the victims of human rights violations, occurred between September 1973 and March 1990.

Evaluation of management model

For measuring the results of model of management of special vaccines of HEGC, indicators were used:

Authorization of scheduled vaccines by the PNI: a schedule is considered authorized when the PNI res ponds positively to the vaccination of the patient with the requested schedule and it is measured by the total percentage of requested schedules in the period.

Scheduled vaccines completed: a schedule completed is one that meets the total of the vaccines planned in the schedule by the medical indication in the evaluated period, and it was measured in the percentage of the total of requested schedules for each vaccine in the period.

Response time of PNI: it is defined as the time that passes from the moment of the request of special sche dule is sent to the PNI to the moment of the respon se of authorization or rejection is received, and it was measured in the number of calendar days grouped for 2015-2016.

Vaccination opportunity: it is defined as the time that pass since it is requested the special scheduled vaccine is sent to the PNI to the initiation of the va ccination of patient by the schedule. It was excluded from this measurement the patients whose mothers have HIV, since vaccines are requested to them from the first month of life and their schedule start at the two months of life. It was measured according to the number of calendar days grouped for 2015-2016.

Statistical analysis

For the data analysis, it was used central tendency statistics for continuous variables and position statis tics for categorical variables. The data were collected in an Excel spreadsheet and they were analyzed with STATA 14.

Results

In the study period, it was managed 367 scheduled vaccines for 215 patients, 43.7% corresponding to men (n = 94), with a median of age of 89 months (range 0/228 months) with a total of vaccines administered until November 30, 2016. In relation to the classifi cation of the type of patient, 88.8% (n = 191) corres ponding to the chronic outpatients, acute patients were 4,7% (n = 10), and 6.5% (n = 14) were inpatients (Table 1). Since the indication of vaccines is individual and it will depend on the base disease and the immuni zation status of each child, there are not standardized schedule but orienting recommendations that are des cribed by diagnosis in the Table 2.

Table 1 Clinical and demographic description of the children. 

Table 2 Medical diagnoses and special vaccines recommended in HEGC patients during the period 2015-2016. 

98.9% (n = 363) of the schemes were authorized by PNI and 1.1% (n = 4) of the schemes were rejected. These rejections corresponded to varicella vaccines, meningococcal ACWY combined with CRM197, qua drivalent human papillomavirus, and 23-valent pneu mococcal polysaccharide, in only one case it was due to an error in the indication. Regarding the response time of PNI to the request of vaccines, this had a me dian of 15 days, varying between 30 days (range 0-174) in 2015 and 4 days (range 0-119) in 2016. Lastly, the vaccination opportunity had a median of 40 days (ran ge 0-287) in 2015 and 35 days (range 0-253) in 2016 (Table 3). The figure 1 shows the flow diagram of management of special vaccines for patients in HEGC for 2015-2016 period.

Table 3 Indicator result variables. 

Figure 1 Flowchart of management of special vaccines for patients in HEGC during the period 2015-2016. 

Discussion

The vaccines are one of the main equity policies in public health care, being provided for free through PNI to the whole target population for its vital cycle, primarily at a pediatric age. There are patients that re quire specific recommendations of vaccination since they are susceptible to immuno-preventable infections or cannot receive programmatic vaccines. Our PNI has special request procedure of vaccination for the se cases, whose management to access them require of coordinated work of the health team with the Ministry, bringing these benefits to a growing number of patients that come from different specialities. The number of patients with special vaccines processed was increasing in time, the value of effective coverage of the program me could not establish be in this moment since the de sign describes those patients that were requested special vaccination and not an analysis of all the patients that are controlled in CAE, but provides an orientation in relation to this increasing demand that we have in pediatrics. Nevertheless, the relevance of dissemina ting of the procedure to improve our coverage in this population is evident and the challenge of knowing the vaccination status of all our patients in control in order to know the effective coverage is evident, which requires to count on the transversal contribution of the health team, ideally exclusive and trained human resource for these purposes in order to disseminate and train the clinical team. Proof of this are the few referred patients from neurology and the absence of request from cardiology, genetic, and endocrinology, among others. The high rate of approval of the reques ted vaccines reflects the coordinated work between the hospital team and the PNI, through the local in char ge. The wide variation found in the latency of the response to the request could complicate the adherence to the vaccination, and the loss of opportunity would impact on the decrease of the immunogenicity in the cases in which the immunosuppressive therapy started before completing the scheduled vaccines, which must be considered by the team members to optimize the moment of request of special vaccines. The reasons for the wide dissemination of the response time from PNI are unknown to us, however, regularly we keep con tact with them to activate the pending requests. The existence of children that had an effective vaccination over the 250 following days to the authorization was due to the geographical distance of some, those who coordinate the vaccination the day of the medical control. These situations could improve through a minis terial norm of recommendations for groups at risk or specific situations that do not require procedure of the central authorization, but local certification of health condition, which might decrease the necessity of requiring analysis from PNI optimizing its response for most complex cases and improving the opportunity for the patients. While the study was not designed to evaluate the safety of the vaccines, for the analyzed pe riod events supposedly attributable to vaccination and immunization (ESAVI) were not presented.

The promotion of ministerial guidelines for special scheduled vaccines is a need, since what is available in the PNI web does not contain clinical guidelines but the request procedure, to all those health professionals in charge of indicating vaccines to the patients at risk count with approval and supported schedules, that ac celerates the flow diagram and the principal goal that is to protect the individual and also the community.

Our local goals to improve the vaccination service of patients is to count on medical staff and exclusive infrastructure for the execution of special vaccination. At the end of this article, a protocol of safe vaccination for special cases was developed, a technical paramedic was recruited exclusively for our patients vaccination, and infrastructure was compromised to carry out this activity. Furthermore, with the aim of improving the effective coverage, the clinical teams of bronchopul monary and the child and adolescent with special ne cessities in health care (NANEAS) are working on a registry of their patients and their vaccination status to evaluate and program special schedules if they need.

In conclusion, the program of special vaccines of PNI is a benefit for our patients with high risk of immuno-preventable infections. In order to access it, there is a flow diagram that can and has to be imple mented in each health center, public or private. The response time of PNI could decrease if there were pre set recommendations for different morbid conditions. We must improve the dissemination of this program among health teams to optimize its coverage.

Ethical Responsibilities

Human Beings and animals protection: Disclosure the authors state that the procedures were followed ac cording to the Declaration of Helsinki and the World Medical Association regarding human experimenta tion developed for the medical community.

Data confidentiality: The authors state that they have followed the protocols of their Center and Local regu lations on the publication of patient data.

Rights to privacy and informed consent: The authors have obtained the informed consent of the patients and/or subjects referred to in the article. This docu ment is in the possession of the correspondence author.

Financial Disclosure: Authors state that no economic support has been asso ciated with the present study.

Conflicts of Interest: Authors declare no conflict of interest regarding the present study.

Acknowledgements: We are grateful to the CAE Nurses and in-patients nur ses, for their unselfish work and commitment in the care and vaccination of pediatric HEGC patients.

Referencias

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6. Unidad de Inmunizaciones, Ministerio de Salud, Chile. Procedimientos de vacunas e inmunización, Programa Nacional de Inmunizaciones. 2011. [ Links ]

7. Departamento de Inmunizaciones de la Subsecretaria de Salud Pública División de Planificación Sanitaria, Ministerio de Salud de Chile. Guía de Vacunación Segura, Sistema de Notificación, Evaluación ESAVI-EPRO. 2013. [ Links ]

8. http://vacunas.minsal.cl/informacion-al-profesional/vacunacion-especial/ accedido el 12 Enero 2017. Procedimiento de solicitud de vacunas especiales del Programa Nacional de Inmunizaciones. [ Links ]

9. Subsecretaría de Salud Pública, Ministerio de Salud de Chile. Norma general técnica sobre procedimientos operativos estandarizados para asegurar la calidad en la ejecución del Programa Nacional de Inmunizaciones. Resolución Exenta No 973. 2010 [ Links ]

Received: January 25, 2017; Accepted: July 17, 2017

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