The Critical Importance of the Two Month Well Child Visit: The Key is Rotavirus

PHC expects to achieve accreditation this year from the National Council of Quality Assurance (NCQA).  NCQA requires accredited health plans to report on an expanded set of HEDIS measures, beyond those required by the DHCS in California.  We will start collecting data on these measures this year, and they are likely to become part of the PCP QIP in coming years.

One of these new measures is the childhood immunization “Combo 10” vaccine.  The current vaccine measure includes 7 different vaccines given by the 2nd birthday.  The Combo 10 adds the Influenza, Hepatitis A and Rotavirus vaccines to the 7 vaccines currently measured.

Of these 3 new immunizations, the Rotavirus vaccine will be most likely to affect the vaccination rate.  Why is this the case?

First, there is no partial credit for the Combo-10 vaccine measure.  If even one vaccine in a series is missing, it will not count as a vaccinated child.

Secondly, the vaccine window for Rotavirus is unique; if the child misses early vaccine visits, they can never complete the Combo-10 series.  To understand this better, here is some more detail on Rotavirus and the vaccine:

History of the Rotavirus Vaccine:  In 1973 Dr. Ruth Bishop, an Australian scientist, discovered a new virus and named it rotavirus, due to its wheel-like appearance (rota = wheel in Latin) under electron microscopy.

Rotavirus is found almost everywhere in the environment and can survive for months outside of a human host. It is only found in mammals and is typically transmitted via fecal-oral route. Incubation period is 48 hours or less and symptoms usually last 5-7 days. One of the hallmarks of rotavirus infection is extreme watery diarrhea.

Prior to the introduction of vaccines rotavirus illness was responsible for 400,000 doctor visits, 200,000 ED visits, 55-70,000 hospitalizations and 20-60 deaths every year in the U.S. Worldwide it accounts for almost 500,000 under 5 pediatric deaths every year predominantly in developing countries.

The first rotavirus vaccine, Rotashield, was introduced in 1998 but was pulled from the market 1 year later after it was found to be associated with cases of intussusception. (1 case per 10,000 vaccine recipients) Not until 2006 was a second vaccine, RotaTeq, introduced followed by Rotarix in 2008. Both are oral vaccines and have similar efficacy with the only difference the number of doses. (RotaTeq = 3, Rotarix = 2)

The Challenge: Narrow window for catching up. The most unique thing about the rotavirus vaccine(s) is the administration schedule. Like most of the primary series it is given at a set interval – 2, 4, and 6 months. (or 2,4 for Rotarix) However while most vaccines, if missed or delayed, can be given as part of a “catch-up” schedule, rotavirus vaccines cannot be initiated in children if they are older than 15 weeks. And if the infant has not completed the full schedule by 8 months, no further vaccines are given.

This means if the child misses their two month well-child visits and shows up for a 4 month visit (typically at 16 weeks), they are too late to even start the rotavirus series!

As PHC migrates to a new immunization measure, CIS-10, which includes the rotavirus series this may have an impact on a clinic’s QIP scores. Given this small window of possible vaccine administration it is vital to make timely appointments and not delay any vaccines for the youngest of our members.

Of course, prioritizing infant appointments and keeping them on schedule for Well Child Checks will be vital, not just for rotavirus, but all the preventable illnesses they are vaccinated against.

(Thanks to Dr. Jeff Ribordy, PHC’s Whole Child Model Medical Director, for contributing to this article.)

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