440 - Evaluation and Management of Unvaccinated and Under-Vaccinated Children Age >60 days to 24 Months of Age: a National Survey

Publication Number: 440.4677

Shelby Hall, Jacobs School of Medicine and Biomedical Sciences at the University at Buffalo, West Seneca, NY, United States; Brian Wrotniak, John R. Oishei Children's Hospital, Buffalo, NY, United States; Haiping Qiao, John R. Oishei Children's Hospital, Buffalo, NY, United States; Heather Territo, Jacobs School of Medicine and Biomedical Sciences at the University at Buffalo, Buffalo, NY, United States

Background: The approach to children presenting to Emergency Department (ED) with “fever without a source” (FWS) has changed in the last 30 years due to the widespread use of Haemophiles Influenza type B (Hib) and Pneumococcal Conjugate Vaccine (PCV). The incidence of bacteremia has been largely reduced, with rates as low as 0.25% to 1% in the post-vaccine era. This has led to changes in screening and evaluation of FWS.
The increase in alternate vaccine schedules has raised concern for resurgence of vaccine-preventable bacteremia. Data still shows low risk of bacteremia overall, likely in part to herd immunity. A “one fits all” approach to work up based solely on vaccination status may not be routinely indicated or cost effective. Furthermore, there is no well-accepted definition of “fully vaccinated”.

Objective: There is no consensus for the evaluation and management of these children. To our knowledge, no studies have assessed clinician practice patterns for this subset of patients. We aim to describe practice patterns regarding the definition and management of unvaccinated and under-vaccinated patients age >60d-24 mo old with FWS who visit Pediatric EDs in US. Namely, variations in defining “under-vaccinated”, and what laboratory work up is obtained in various age group based on vaccination status.

Design/Methods: Results were collected via anonymous surveys distributed via the Pediatric Emergency Medicine (PEM) LISTSERV. Data collection was obtained using a secure database. Data collected was primarily categorical and reported as proportions in percentage.

Results: 302 responses were included for analysis, including both pediatric and PEM trained physicians with varying levels of experience, working throughout the US. Only 23.5% of respondents note that their workplace defines “fully vaccinated”. Majority note that their workplace does not have guidelines for work up (73%) or management (70.2%) for un/under vaccinated children >60 days of age. CBC with differential was used more by those who have guidelines in place (94.1%) compared to those who do not (66.3%, p=0.001), as were blood cultures (guideline 91%, no guideline 66.8%, p=0.004). There is noted variability in work up based on increasing patient age.

Conclusion(s): There is heterogeneity in practice patterns for both the definition of, and management for, the un/under immunized child >60d-24mo presenting with FWS. Consensus guidelines for managements of these patients would help reduce variability in practice.