Sometimes vaccines are given too soon to count toward the required vaccine schedule. This can easily happen if there are changes to the standard vaccine schedule for any reason, but what does that mean for the child? Are they in danger? Do they need extra shots? Is that even safe???

Early vaccines don’t count.

Don’t try to sneak in early before a recommended age.

It’s not appropriate in most cases to give vaccines at shorter intervals or before the recommended age.

The 12-15 month vaccines are occasionally given before the 1st birthday, which does not count in every state. State laws can dictate a grace period in which vaccines can be given earlier than the standard schedule, but not all do.

This is an issue with some children moving from a more lenient state to one with a lesser (or no) grace period.

In some states they can get their MMR a couple days before their first birthday.

Does this protect them against measles, mumps, and rubella?

~ Probably. (Nothing’s 100%.)

Does every school count it?

~No. If they move to a state that doesn’t, they need to repeat it.

International travel changes things.

It is recommended for international travelers over 6 months to get an MMR early due to worldwide measles outbreaks.

This dose does not count toward the 2 doses typically given after the 1st birthday because younger children do not make immunity as reliably, but is felt to potentially benefit those at higher risk due to travel.

Most babies are protected against measles for 6-12 months after birth.

If the MMR vaccine is given when they are already protected, the vaccine doesn’t work.

We don’t know if a 6-12 month old is safe or not, so when the risks increase, as with international travel, it is recommended to give a shot to help if needed.

But that shot might not work, so it should be repeated after the 1st birthday.

Minimal intervals are important.

Most vaccines are given as a series, and each vaccine within a series needs to be separated by a minimal interval.

Before vaccine logic was built into our electronic health record, it could be difficult to know which vaccines were recommended if people got off the standard schedule.

Not all EHRs have smart vaccine logic, so if you’re off schedule, be sure to discuss intervals before giving vaccines.

The hepatitis vaccines are more commonly given off an appropriate schedule than other vaccines. I’ll touch on each of them and why they’re problematic.

Hepatitis A vaccine interval problems.

My office routinely gives the first Hepatitis A vaccine at 12 months and the second at 18 months. The CDC schedule states:

Hepatitis A (HepA) vaccine. (minimum age: 12 months)

Routine vaccination:

• 2 doses, separated by 6–18 months, between the 1st and 2nd birthdays. (A series begun before the 2nd birthday should be completed even if the child turns 2 before the 2nd dose is given.)

Despite warning parents to schedule the 18 month visit 6 months or more from the 1 year visit, sometimes they don’t have the correct spacing. This generally happens when they do the 1 year visit several weeks after the birthday but then try to “get back on track” and do the 18 month exam on time.

The good news is our smart EHR tracks minimal intervals and doesn’t suggest the vaccine if it’s too early.

I typically wait until the 24 month visit to do the 2nd Hepatitis A vaccine if it is too early at the 18 month visit, but I ask the family to come in just before the 2nd birthday. This allows the child gets the vaccine before 24 months of age and fit the main recommendation of getting both doses between the 1st and 2nd birthdays.

Sidenote about HEDIS

A delay to wait until the 2 year well visit follows the CDC recommendation to have the doses separated by 6-12 months.

Despite following the CDC guidelines, it fails to meet HEDIS benchmarks.

If a child gets the Hepatitis A vaccine after the 2nd birthday, the physician loses quality points.

These points help rank physicians for insurance company purposes.

As long as it doesn’t happen often, it’s not an issue.

But if schedules are off too often, a physician’s contracts with insurance companies could be at risk because they are seen as not high quality, regardless of why the vaccine is given after the 2nd birthday.

If you want to keep your favorite physician and use your insurance, please help them meet the standards of care for all metrics. This includes coming in for annual well visits and having regular follow up for chronic issues. It also means taking the recommended medications, such as preventative medicines for asthma and doing certain labs, such as lipid panels, or screenings, such as depression screenings.

Sidenote about vaccine shills

There are many groups sounding alarms about physicians getting paid huge amounts of money to vaccinate from Big Pharma. I wish this was true, but it’s not.

Don’t confuse the HEDIS measures and insurance contracts with this Big Pharma farce. First off, we pay pharmaceutical companies to buy their vaccines. They don’t pay us. Sometimes they buy a lunch for our staff so they can have our attention when they talk about their products, but there is no big money to be made from vaccine companies.

Insurance companies pay us for the vaccine and the costs associated with giving vaccines. These costs are not only for syringes and band aides. We must carry insurance for the vaccine inventory. There must be a dedicated refrigerator and freezer to safely store vaccines. We should use a refrigerator alarm system to alert us if the temperature is too warm or too cold. We pay staff to keep logs about refrigerator temperatures and inventory. All of these costs add up.

Trust me, no one gets rich off of vaccines.

Some insurance companies offer bonuses if we meet HEDIS measures, but more often I think they just pay less if we don’t meet measures.

Why do they pay more if we give vaccines?

Because the insurance company comes out ahead if we vaccinate. Vaccine preventable diseases cost them much more than vaccines. They want to encourage us to vaccinate to save them money.

Hepatitis B Interval problems.

Hepatitis B vaccine is given in 3 doses, with the second 4 weeks after the first, then the 3rd at least 8 weeks from the 2nd and 16 weeks after the 1st.

There are vaccines that just have hepatitis B protection (monovalent vaccines) that can be given starting at birth. They can be used for all three doses.

There are other vaccines that combine the hepatitis B vaccine with other vaccines (combination vaccines). The combination vaccines are given at different intervals, depending on what is in the vaccine. They cannot be given under 6 weeks of age, but it’s still recommended to give the first dose within 24 hours of birth.

Yes, it’s confusing.

From the CDC guidelines:

• A complete series is 3 doses at 0, 1–2, and 6–18 months. (Monovalent HepB vaccine should be used for doses given before age 6 weeks.)
• Infants who did not receive a birth dose should begin the series as soon as feasible.
• Administration of 4 doses is permitted when a combination vaccine containing HepB is used after the birth dose.
• Minimum age for the final (3rd or 4th) dose: 24 weeks.
• Minimum intervals: Dose 1 to Dose 2: 4 weeks / Dose 2 to Dose 3: 8 weeks / Dose 1 to Dose 3: 16 weeks. (When 4 doses are given, substitute “Dose 4” for “Dose 3” in these calculations.)

There are even additional recommendations if the mother is a known Hepatitis B carrier or if her status is unknown.

If any of the doses are given too early, they need to be given again. This is considered safe.

Live viruses need special attention.

Live viruses must be given either at the same time or at least 28 days apart. If they are given at a shorter interval, the second vaccine is presumed to not be effective and must be repeated.

This is another great reason to not alter the standard vaccine schedule your provider uses. If your child gets off track, you run the risk of him or her needing additional vaccines.

Common live virus vaccines include MMR, Varicella, MMRV, and Flumist.

Some vaccines, like the oral typhoid vaccine, cannot be given at the same time as antibiotics.

Quiz yourself!

See if you know what vaccines your child needs.

To avoid vaccines that are given too soon:

• Be sure that whoever is giving vaccines knows any recent vaccines and medicines your child has had recently.
• Try to stay within the recommended vaccine schedule as much as possible to avoid needing extra doses.

Vaccine schedules for children birth – 6 years and 7-18 years: