Family Medicine · Year 3 · from Family Medicine
Case 3: Immunization Catch-Up and Vaccine Hesitancy
Patient Demographics
- Age: 28 years old
- Sex: Female
- Occupation: Preschool teacher
Chief Complaint
"I need some forms filled out for work, and they're asking about my vaccines."
History of Present Illness
Ms. Emily Rodriguez is a 28-year-old woman who recently started working at a preschool. Her employer requires documentation of immunity to measles, mumps, rubella, and varicella. She is also being asked to get a Tdap booster and annual flu shot. She does not have records of her childhood immunizations and expresses hesitancy about vaccines, stating "I've read some concerning things online."
Past Medical History
- No chronic medical conditions
- No known allergies
- No previous adverse vaccine reactions
Immunization History
- Uncertain about childhood vaccines (no records)
- Never received HPV vaccine
- Last flu shot: "years ago"
- Denies history of chickenpox
Social History
- Engaged, planning to get married and have children in 2-3 years
- Non-smoker
- Social alcohol use
Physical Examination
- Vital Signs: BP 112/72, HR 68, BMI 23
- General: Healthy-appearing young woman
- Skin: No vesicular lesions
- Lymph nodes: No lymphadenopathy
Assessment of Vaccine Needs
Immunity Assessment:
- Order MMR titers (measles, mumps, rubella IgG)
- Order varicella IgG titer
- Order Hepatitis B surface antibody (given healthcare-adjacent work)
If Non-Immune (Serology Negative):
| Vaccine | Doses Needed | Schedule |
|---|---|---|
| MMR | 2 doses | Now, then 4 weeks later |
| Varicella | 2 doses | Now, then 4 weeks later |
| Hepatitis B | 3 doses | Now, 1 month, 6 months |
Additional Recommendations:
| Vaccine | Indication | Priority |
|---|---|---|
| Tdap | Booster required | High - workplace requirement |
| Influenza | Annual, required for work | High |
| HPV | Catch-up through age 26, shared decision 27-45 | Moderate |
Addressing Vaccine Hesitancy
Patient's Concerns:
- "I read vaccines can cause autism"
- "There are so many chemicals in vaccines"
- "My immune system is strong, I don't need vaccines"
- "I'm worried about getting too many at once"
Clinician Response (Motivational Interviewing Approach):
"I appreciate you sharing your concerns with me. I can see you've thought a lot about this, which shows you care about your health. May I share some information that might be helpful?"
- Autism concern: "The original study suggesting a link between vaccines and autism has been thoroughly disproven and retracted. Dozens of large studies involving millions of children have found no connection. I understand this concern persists online, but the scientific evidence is clear."
- Ingredients concern: "Vaccine ingredients are carefully tested for safety. The amounts of any additives are far smaller than what we encounter in everyday foods and environment. I'd be happy to review the specific ingredients in any vaccine you're considering."
- Natural immunity: "Your immune system is remarkable, but these diseases can be serious even in healthy adults. Measles can cause encephalitis; rubella during pregnancy causes severe birth defects. Vaccines train your immune system safely."
- Multiple vaccines: "Your immune system handles thousands of antigens daily. The few antigens in vaccines are a tiny fraction of what your body already manages. However, if you prefer, we can spread vaccines across visits."
Patient Response: After discussion, patient agrees to titers and Tdap today. Will return to discuss other vaccines based on results.
Management Plan
- Draw immunity titers (MMR, varicella, Hep B)
- Administer Tdap today (workplace requirement, no concerns expressed)
- Administer influenza vaccine today
- Discuss HPV vaccine at follow-up (within catch-up window at age 28, shared decision-making)
- Schedule follow-up in 2 weeks to review titers and continue vaccination series
Follow-Up Results (2 weeks later)
- Rubella IgG: Positive (immune)
- Measles IgG: Negative (non-immune)
- Mumps IgG: Positive (immune)
- Varicella IgG: Negative (non-immune)
- Hepatitis B sAb: Negative (non-immune)
Plan: Administer MMR #1, Varicella #1, and Hepatitis B #1 today. Schedule second doses appropriately.
Teaching Points
- Catch-up vaccination: Adults often have incomplete vaccination records. Serology can guide catch-up vaccination efficiently.
- Vaccine hesitancy communication: Listen first, acknowledge concerns, then provide clear, empathetic information. A strong physician recommendation is the most influential factor in vaccine acceptance.
- Occupational health: Certain occupations require specific immunizations. Family physicians play a key role in supporting occupational health needs.
- HPV vaccine: Catch-up vaccination is recommended through age 26; shared decision-making is appropriate for ages 27-45 for those not previously vaccinated.