Physicians Fail to Adequately Address Postvaccination Syncope

ATLANTA — Physicians who provide immunizations to children need to be cognizant of potential injuries associated with postvaccination syncope—and with the recommendations for preventing them, based on a national survey of physicians and a review of Vaccine Adverse Event Reporting System data.

Although serious injuries are rare, prevention of postvaccination syncope is crucial, according to presenters at the National Immunization Conference sponsored by the Centers for Disease Control and Prevention.

Current guidelines—including those from the CDC's Advisory Committee on Immunization Practices (ACIP)—strongly recommend observing pediatric patients for 15 minutes after the vaccination, but most physicians were unaware of or did not adhere to that guidance, based on data presented in a session on postvaccination adverse events.

In fact, Dr. Angela Calugar of the CDC noted there's been a nearly sixfold increase in the number of syncope events reported to the Vaccine Adverse Event Reporting System (VAERS) in 2008, compared with 2006 (821 vs. 146).

Low Adherence, Low Awareness

Little research has been conducted into how well physicians adhere to postvaccination syncope recommendations, noted Dr. Christina Suh of the University of Colorado at Denver.

She reported on a national survey of physicians who immunize adolescents (conducted from October 2008 through January 2009). Respondents included 321 pediatricians and 299 family physicians.

Most (61%) reported that postvaccination syncope or near syncope had occurred in their practices, but fewer than half were familiar with the ACIP recommendations.

More pediatricians than family physicians were aware of the ACIP recommendations (37% vs. 24%), but fewer pediatricians thought their practices could easily adhere to them (69% vs. 84%).

Fifty-one percent of the pediatricians and 59% of the family physicians indicated that they routinely observe adolescent patients following vaccinations.

Of all the physicians who reported observing patients, only 31% (34% of the pediatricians and 27% of the family physicians) did so for the recommended 15 minutes or longer.

Overall, only 18% of pediatricians and 16% of family physicians adhered to the 15-minute recommendation, Dr. Suh reported.

Physicians cited several barriers, including lack of room space (76% of pediatricians and 65% of family physicians) and lack of staff (69% of pediatricians and 56% of family physicians).

In multivariate modeling, the following factors were associated with adherence: practicing in a hospital, university, or community health center (compared with private practice settings); awareness of ACIP recommendations; a belief that postvaccination syncope can result in serious injuries; adequate room space; and adequate staff to observe patients.

Dr. Suh called for more efforts to educate physicians about the potential for injuries from postvaccination syncope in adolescents, to disseminate guidance, and to identify ways to better implement these recommendations in settings with limited staff and room space.

Surveying VAERS Reporters

Early findings from the survey of VAERS reporters yielded similar findings and highlighted that postvaccination syncope can result in serious injury.

Dr. Calugar presented preliminary data based on 114 cases reported to VAERS between Jan. 1, and Aug. 31, 2009. Most (92) involved females. The mean age for females was 17.3 years and for males, was 16.2.

Thirty-one (27%) of those cases involved falls resulting in injury, three of which were serious.

Of the 88 cases in which the time between vaccination and syncope was reported, 76 (86%) involved fainting within the first 15 minutes. Investigators asked reporters if the provider had a policy for patients to wait after all vaccines. Fifty-six (49%) said no, 44 (39%) said yes, and 14 (12%) did not know. As a result of the incident, nine providers subsequently instituted such a policy.

Not only are the injuries themselves worrisome, but patient fear of such injuries may affect vaccine acceptance, Dr. Calugar warned.

Gardasil (quadrivalent human papillomavirus vaccine), Menactra (meningococcal polysaccharide diphtheria toxoid conjugate vaccine), and tetanus-diphtheria-pertussis vaccine administered alone or in combination were the most frequently reported among the sample of cases; these vaccines are administered to adolescents, Dr. Calugar said. She noted that at the time of the survey, Gardasil was recommended to females in a three-dose series; this also may have contributed to the higher weight of this vaccine among the VAERS reports.

Disclosures: None was reported.

My Take

Time, Lack of Space Are Barriers

I was unaware of the ACIP recommendation to observe children for 15 minutes after a vaccination, and we do not have a formal office policy to do so. The nurses routinely screen kids after shots, and if they seem pale or complain of being dizzy or nauseated, they lie down on the exam table for a few minutes (with a cool towel on the forehead and a cup of cold water to drink) until they feel better.

Keeping all children in the exam room for 15 minutes after the visit would be problematic. An office visit is scheduled for 15 minutes so that would prevent another visit after each exam that includes an immunization, which would have a significant impact on our productivity.

We fortunately have not seen any serious injuries after fainting in the office. Ironically, after discussing this with the nurses this morning, a child fainted later the same morning and then had a brief seizure after receiving DTaP (diphtheria-tetanus-acellular pertussis vaccine) and IPV (inactivated polio vaccine)! She was 4 years old. She was fine after a few minutes but the mom (and the nurses) were a little upset. Again, the main problem we see in teenagers who faint is extreme embarrassment.

H. GARRY GARDNER, M.D., is a pediatrician in private practice in Darien, Ill. He said he had no conflicts of interest relevant to this article.

ATLANTA — Physicians who provide immunizations to children need to be cognizant of potential injuries associated with postvaccination syncope—and with the recommendations for preventing them, based on a national survey of physicians and a review of Vaccine Adverse Event Reporting System data.

Although serious injuries are rare, prevention of postvaccination syncope is crucial, according to presenters at the National Immunization Conference sponsored by the Centers for Disease Control and Prevention.

Current guidelines—including those from the CDC's Advisory Committee on Immunization Practices (ACIP)—strongly recommend observing pediatric patients for 15 minutes after the vaccination, but most physicians were unaware of or did not adhere to that guidance, based on data presented in a session on postvaccination adverse events.

In fact, Dr. Angela Calugar of the CDC noted there's been a nearly sixfold increase in the number of syncope events reported to the Vaccine Adverse Event Reporting System (VAERS) in 2008, compared with 2006 (821 vs. 146).

Low Adherence, Low Awareness

Little research has been conducted into how well physicians adhere to postvaccination syncope recommendations, noted Dr. Christina Suh of the University of Colorado at Denver.

She reported on a national survey of physicians who immunize adolescents (conducted from October 2008 through January 2009). Respondents included 321 pediatricians and 299 family physicians.

Most (61%) reported that postvaccination syncope or near syncope had occurred in their practices, but fewer than half were familiar with the ACIP recommendations.

More pediatricians than family physicians were aware of the ACIP recommendations (37% vs. 24%), but fewer pediatricians thought their practices could easily adhere to them (69% vs. 84%).

Fifty-one percent of the pediatricians and 59% of the family physicians indicated that they routinely observe adolescent patients following vaccinations.

Of all the physicians who reported observing patients, only 31% (34% of the pediatricians and 27% of the family physicians) did so for the recommended 15 minutes or longer.

Overall, only 18% of pediatricians and 16% of family physicians adhered to the 15-minute recommendation, Dr. Suh reported.

Physicians cited several barriers, including lack of room space (76% of pediatricians and 65% of family physicians) and lack of staff (69% of pediatricians and 56% of family physicians).

In multivariate modeling, the following factors were associated with adherence: practicing in a hospital, university, or community health center (compared with private practice settings); awareness of ACIP recommendations; a belief that postvaccination syncope can result in serious injuries; adequate room space; and adequate staff to observe patients.

Dr. Suh called for more efforts to educate physicians about the potential for injuries from postvaccination syncope in adolescents, to disseminate guidance, and to identify ways to better implement these recommendations in settings with limited staff and room space.

Surveying VAERS Reporters

Early findings from the survey of VAERS reporters yielded similar findings and highlighted that postvaccination syncope can result in serious injury.

Dr. Calugar presented preliminary data based on 114 cases reported to VAERS between Jan. 1, and Aug. 31, 2009. Most (92) involved females. The mean age for females was 17.3 years and for males, was 16.2.

Thirty-one (27%) of those cases involved falls resulting in injury, three of which were serious.

Of the 88 cases in which the time between vaccination and syncope was reported, 76 (86%) involved fainting within the first 15 minutes. Investigators asked reporters if the provider had a policy for patients to wait after all vaccines. Fifty-six (49%) said no, 44 (39%) said yes, and 14 (12%) did not know. As a result of the incident, nine providers subsequently instituted such a policy.

Not only are the injuries themselves worrisome, but patient fear of such injuries may affect vaccine acceptance, Dr. Calugar warned.

Gardasil (quadrivalent human papillomavirus vaccine), Menactra (meningococcal polysaccharide diphtheria toxoid conjugate vaccine), and tetanus-diphtheria-pertussis vaccine administered alone or in combination were the most frequently reported among the sample of cases; these vaccines are administered to adolescents, Dr. Calugar said. She noted that at the time of the survey, Gardasil was recommended to females in a three-dose series; this also may have contributed to the higher weight of this vaccine among the VAERS reports.

Disclosures: None was reported.

My Take

Time, Lack of Space Are Barriers

I was unaware of the ACIP recommendation to observe children for 15 minutes after a vaccination, and we do not have a formal office policy to do so. The nurses routinely screen kids after shots, and if they seem pale or complain of being dizzy or nauseated, they lie down on the exam table for a few minutes (with a cool towel on the forehead and a cup of cold water to drink) until they feel better.

Keeping all children in the exam room for 15 minutes after the visit would be problematic. An office visit is scheduled for 15 minutes so that would prevent another visit after each exam that includes an immunization, which would have a significant impact on our productivity.

We fortunately have not seen any serious injuries after fainting in the office. Ironically, after discussing this with the nurses this morning, a child fainted later the same morning and then had a brief seizure after receiving DTaP (diphtheria-tetanus-acellular pertussis vaccine) and IPV (inactivated polio vaccine)! She was 4 years old. She was fine after a few minutes but the mom (and the nurses) were a little upset. Again, the main problem we see in teenagers who faint is extreme embarrassment.

H. GARRY GARDNER, M.D., is a pediatrician in private practice in Darien, Ill. He said he had no conflicts of interest relevant to this article.

ATLANTA — Physicians who provide immunizations to children need to be cognizant of potential injuries associated with postvaccination syncope—and with the recommendations for preventing them, based on a national survey of physicians and a review of Vaccine Adverse Event Reporting System data.

Although serious injuries are rare, prevention of postvaccination syncope is crucial, according to presenters at the National Immunization Conference sponsored by the Centers for Disease Control and Prevention.

Current guidelines—including those from the CDC's Advisory Committee on Immunization Practices (ACIP)—strongly recommend observing pediatric patients for 15 minutes after the vaccination, but most physicians were unaware of or did not adhere to that guidance, based on data presented in a session on postvaccination adverse events.

In fact, Dr. Angela Calugar of the CDC noted there's been a nearly sixfold increase in the number of syncope events reported to the Vaccine Adverse Event Reporting System (VAERS) in 2008, compared with 2006 (821 vs. 146).

Low Adherence, Low Awareness

Little research has been conducted into how well physicians adhere to postvaccination syncope recommendations, noted Dr. Christina Suh of the University of Colorado at Denver.

She reported on a national survey of physicians who immunize adolescents (conducted from October 2008 through January 2009). Respondents included 321 pediatricians and 299 family physicians.

Most (61%) reported that postvaccination syncope or near syncope had occurred in their practices, but fewer than half were familiar with the ACIP recommendations.

More pediatricians than family physicians were aware of the ACIP recommendations (37% vs. 24%), but fewer pediatricians thought their practices could easily adhere to them (69% vs. 84%).

Fifty-one percent of the pediatricians and 59% of the family physicians indicated that they routinely observe adolescent patients following vaccinations.

Of all the physicians who reported observing patients, only 31% (34% of the pediatricians and 27% of the family physicians) did so for the recommended 15 minutes or longer.

Overall, only 18% of pediatricians and 16% of family physicians adhered to the 15-minute recommendation, Dr. Suh reported.

Physicians cited several barriers, including lack of room space (76% of pediatricians and 65% of family physicians) and lack of staff (69% of pediatricians and 56% of family physicians).

In multivariate modeling, the following factors were associated with adherence: practicing in a hospital, university, or community health center (compared with private practice settings); awareness of ACIP recommendations; a belief that postvaccination syncope can result in serious injuries; adequate room space; and adequate staff to observe patients.

Dr. Suh called for more efforts to educate physicians about the potential for injuries from postvaccination syncope in adolescents, to disseminate guidance, and to identify ways to better implement these recommendations in settings with limited staff and room space.

Surveying VAERS Reporters

Early findings from the survey of VAERS reporters yielded similar findings and highlighted that postvaccination syncope can result in serious injury.

Dr. Calugar presented preliminary data based on 114 cases reported to VAERS between Jan. 1, and Aug. 31, 2009. Most (92) involved females. The mean age for females was 17.3 years and for males, was 16.2.

Thirty-one (27%) of those cases involved falls resulting in injury, three of which were serious.

Of the 88 cases in which the time between vaccination and syncope was reported, 76 (86%) involved fainting within the first 15 minutes. Investigators asked reporters if the provider had a policy for patients to wait after all vaccines. Fifty-six (49%) said no, 44 (39%) said yes, and 14 (12%) did not know. As a result of the incident, nine providers subsequently instituted such a policy.

Not only are the injuries themselves worrisome, but patient fear of such injuries may affect vaccine acceptance, Dr. Calugar warned.

Gardasil (quadrivalent human papillomavirus vaccine), Menactra (meningococcal polysaccharide diphtheria toxoid conjugate vaccine), and tetanus-diphtheria-pertussis vaccine administered alone or in combination were the most frequently reported among the sample of cases; these vaccines are administered to adolescents, Dr. Calugar said. She noted that at the time of the survey, Gardasil was recommended to females in a three-dose series; this also may have contributed to the higher weight of this vaccine among the VAERS reports.

Disclosures: None was reported.

My Take

Time, Lack of Space Are Barriers

I was unaware of the ACIP recommendation to observe children for 15 minutes after a vaccination, and we do not have a formal office policy to do so. The nurses routinely screen kids after shots, and if they seem pale or complain of being dizzy or nauseated, they lie down on the exam table for a few minutes (with a cool towel on the forehead and a cup of cold water to drink) until they feel better.

Keeping all children in the exam room for 15 minutes after the visit would be problematic. An office visit is scheduled for 15 minutes so that would prevent another visit after each exam that includes an immunization, which would have a significant impact on our productivity.

We fortunately have not seen any serious injuries after fainting in the office. Ironically, after discussing this with the nurses this morning, a child fainted later the same morning and then had a brief seizure after receiving DTaP (diphtheria-tetanus-acellular pertussis vaccine) and IPV (inactivated polio vaccine)! She was 4 years old. She was fine after a few minutes but the mom (and the nurses) were a little upset. Again, the main problem we see in teenagers who faint is extreme embarrassment.

H. GARRY GARDNER, M.D., is a pediatrician in private practice in Darien, Ill. He said he had no conflicts of interest relevant to this article.