Practicing family physicians have less input into determining the national vaccine policy established by the ACIP.20 Because they are less involved, they may learn about changes in the vaccine schedule later or be less inclined to incorporate them into their practices.
Family physicians were more likely to recommend and administer OPV than pediatricians, who were more likely to recommend and administer the sequential schedule. A separate analysis of family physicians reporting familiarity with the ACIP recommendations indicated that 30% gave the sequential series, 63% gave all OPV, and 5% gave all IPV. Consequently, awareness of the ACIP recommendations did not correlate with significantly increased use of the sequential series.
Although both pediatricians and family physicians indicate that parent choice and practice preferences are factors that most frequently influence their actual administration of PVV, our study found that choosing the sequential schedule was significantly related to concern for the risk of VAPP and liability. Pediatricians more frequently cited the risk of VAPP and liability concerns as factors in their decision than family physicians. Choice of the all OPV schedule was significantly correlated with concern about the increased number of injections and cost. Family physicians’ concerns about the cost of vaccines have also been cited by Zimmerman and others.10,11,20,21
Although family physicians and pediatricians were both concerned about the number of injections, more family physicians cited this factor than pediatricians. A survey 22 of 32 Minnesota family practice clinics found that most parents, nurses, and physicians believed that 3 injections during 1 visit were too many. However, when parents were given an explanation of polio vaccine options with a recommendation for the sequential schedule, more than 90% chose the IPV vaccine for the first dose.16
Several recent studies support this study’s findings of PVV usage among pediatricians. A Pediatric Research in Office Settings survey of 1424 pediatricians during the fall of 1997 found that 29% were using all OPV, 5% all IPV, and 60% sequential IPV-OPV.23 In another study, risk of VAPP and evidence from vaccine trials were the reasons most frequently mentioned by primary care providers who had switched or planned to switch to the sequential schedule. Cost and legal concerns were not critical factors in their decision making.24
The finding that only 41% of all physicians have the parent read the information provided in handouts from the AAP or CDC is surprising because federal regulations require that “each health-care provider who administers a particular vaccine set forth in the Vaccine Injury Table shall provide a copy of the relevant information materials.”25
Physicians may fail to provide the vaccine information sheet because they perceive that many caregivers either do not read or cannot understand the information. It has been demonstrated that the PVV information sheets increase caregivers’ knowledge but are not as effective as a 15-minute videotape explaining the risks and benefits of IPV and OPV.26 When given only the information sheet to read, more than 90% of the parents and guardians thought that it was an effective means of providing information. Failure to provide current and appropriate information about the different polio vaccines may constitute grounds for legal action in the event of a serious adverse reaction.27
Limitations
This study may have overestimated physicians’ awareness of the 1997 PVV recommendations. Physicians who were not familiar with these recommendations may have been less likely to respond to the survey. Consequently, the reported awareness and implementation of the 1997 poliovirus vaccine recommendations by primary care physicians at the time of this study may be less than indicated. It is also possible that this sample of Ohio pediatricians is not representative of this group of physicians nationally. However, the 67% reported administration of the sequential schedule by Ohio pediatricians is similar to the 60% reported in the 1997 Pediatric Research in Office Settings study.23
Conclusions
This study demonstrates that family physicians more frequently recommend and administer the all OPV schedule. Concerns about cost and number of injections influence this recommendation. Pediatricians more frequently recommend and administer the sequential schedule. Concerns about VAPP and liability influence this recommendation. The majority of physicians report that although they personally discuss PVV options, they do not have the parent read the vaccine information sheet. Although family physicians and pediatricians most frequently cite parent choice as determining the PVV schedule, this study strongly suggests that the provider’s recommendation influences the actual administration of the PVV schedule.
In January 1999, the ACIP, AAFP, and AAP announced a revision in their recommendations for PVV.28 They now recommend that children in the United States receive IPV for the first 2 doses followed by IPV or OPV for the third and fourth doses. OPV is acceptable for the first 2 doses only if the parents will not accept the recommended number of injections, delayed onset of immunization requires an unacceptable number of injections, immediate travel is planned to areas where polio is endemic, or to control an outbreak of wild-type poliovirus infection.