Search Results

Written and Researched by Emma Rapallini Hello and welcome to my global scholar capstone project website! This is a semester long research project associated with the Edina Rotary Scholar Organization. This post will provide an introduction to what I have researched over the past semester and a orienting map of the website itself for the reader's benefit and instruction. Principally, I investigated the importance of pediatric immunization coverage in Minnesota versus in tropical and more rural populations of Guatemala. I began my research analyzing the types and schedules of immunizations for children in Minnesota. In reference to the Minnesotan Health Department and CDC databases, I was able to compile data, graphs, and overall information about past immunization coverage for the state of Minnesota. I also found the types of communicable diseases, the strengths, and the weaknesses within the healthcare department and legislation for promotion of vaccines. In terms of information about Guatemalan vaccines I relied heavily on research and data collected by PAHO and UNICEF to learn the types of immunization their health departments recommended. In continuation I analyzed similar vaccination coverage data, and hindrances within the Guatemalan health system to find lacking points and explained lower rates and/or higher death occurrences because of these issues. Finally, I compared the deficiencies of both Minnesota and Guatemala to put into perspective how pediatric immunization can be targeted and improved. To navigate around the website and learn more about pediatric immunization you must start here: 1 - The Introduction (See Above) 2 - My Research page where in depth analysis of both Minnesotan and Guatemalan vaccinations and more are documented. 3 - Q & A page where I meet with the experts. I interviewed both a pediatrician from a local practice, Southdale Pediatrics, and a pediatrician from Guatemala. Each of their knowledgable perspectives added a personal layer to the importance of immunization. 4 - Action - after having been educated about the immense benefits but lack of action we have made to increase pediatric immunizations, this page will leave donation links and more education in order for you to act. 5 - Works Cited to give credit to each website, graph, and article I read or utilized in the making of this site. 6 - Question and Feedback Inputs are provided in the side bar and footer of the site so please feel free to leave a comment afterwards!

Interview with M.D. Sofia Posadas: Pediatrician in Guatemala So who are you Sofia, what do you do? "Good Afternoon, my name is Sofia Posadas I am a general pediatrician with a masters degree in nutrition. I work in the national hospital in Guatemala, we are located on the South Coast, like 16 miles away from Guatemala city we are a teaching hospital. And I also coordinate the pediatric residency program in my hospital, and I am the chief of the pediatrics department." How do vaccinations work in Guatemala? "They are not administered in the hospital, it has a very good structure in the Ministry of Health. We provide the patients in general clinics outside the general hospitals and they can come for free for the first immunizations: the basic ones. Not included for example is Hepatitis A, or sometimes Pneumococcal, or Rotavirus. When they are out of stock they just have to search for private attention and pay for that, but the more frequent vaccines are available and free for them. So we provide under 5 years old, a scheduled appointment and we cover pretty much the whole vaccination. With the pandemic though, we have found very very low amounts of patients being vaccinated so we are dealing right now with searching for them and just encouraging them. Saying “we have taken the safety measures so you will not get COVID-19”. Because most parents are afraid of getting to a clinic but then getting COVID" What shots are offered free of cost through the Guatemalan healthcare system? "Measles, Rubella, Pneumococcal for the first three doses is free, Haemophilus influenzae, Rotavirus the first two doses are free. Really all the basic ones!" For the vaccinations that are not considered basic, how is that paid for from a parent/family perspective? "Our population doesn’t have good insurance, but we offer the first 5 years free and then when the [non-basic vaccinations] are in stock and there is a good control within the clinic, patients may receive the 5 year old booster or the 10 year old booster for free as well. But that is quite rare, parents just come when the kid is sick, so normal controls of weight gain, and [healthy] patients are not normal in our country." What are the most common child vaccines administered? "We provide every two months the hexavalent vaccine, or for example when they are in a public clinic we provide the two doses of Rotavirus. But when they come to our private office we offer the 3 doses of Rotavirus, Rotatech. A different brand because for Guatemala it is cheaper to offer just two doses rather than three of them. So it is more accessible for [the families]." Why is the vaccination distribution and stock more limited in Guatemala? "I think it's a storage problem, because most of the general hospitals in the city have enough stock but in the rural areas they don't and I think it's because of transportation and refrigeration limits. Sometimes you know, it's 7-12 hours to transport by car to small towns so they have to put the vaccines in a special storage and travel with them with no quality refrigerator change, so the quality of the vaccines sometimes is not really good enough." How is the distribution setup for vaccinations in Guatemala, where is it more accessible to get immunized? "Health workers in rural areas have to go home by home knocking on doors to see the vaccination cards of the kids asking if they want to get vaccinated and it's very hard because they have to walk a lot to search for medical attention we have one doctor for every 100,000 people in Guatemala, and most of the doctors are located in Guatemala City so medical attention is very very difficult to reach in that area. And the income for physicians in general is very very low so we have to do multiple things. Work in a public system and in a private office." Where could a family find information about required immunizations and safe vaccine practice? "In Guatemala they can go to ask for the clinics in the system, to the public clinics, and they offer information for them, just like brochures with information printed and offer the vaccination. No we don’t [have any digital form of vaccination information]. We just have the vaccination cards. There was one time I had one patient with 10 Poliovirus vaccines. So there is no digital record we can find in the computer and we just say “you’ve had enough” and if they wanted more they could get more if they asked because we don’t have an actual record." When is this vaccination card given? At your child’s first immunization? "Yes we give the card the first time they come to the clinic but if they lose their card, we can replace it, but we lose all the information on that card." Would you say vaccinations for commonly preventable diseases are readily available and promoted for the young populations? "Available but not promoted because we don’t teach in schools the importance or teach to the mothers that just gave birth that they have to go to search. It's because you have to be educated about it, but in our schools we don’t have anything. They don’t ask for vaccination cards to go to school, they just open the doors to every child that wants to be educated but they don’t ask for the vaccination cards. In private school it's different though, they ask [pediatricians] to write a medical certificate with the vaccinations and everything. Public schools don’t have this though." What are the most common preventable diseases in children prevalent in Guatemala? "Not anymore, we don’t have spreads of preventable diseases, we just have like 1 every 5 years of Tetanus and Haemophilus influenzae we are not seeing. We have a spread of a virus with COVID at the beginning, but we are pretty much controlling the diseases. But Dengue fever is endemic in Guatemala. Very much yes, we have patients all week, and especially this week that has been very warm and rains 80% of the year, we have it endemic. For example my husband had it 3 times, and I had 1 and it's very common. And we have no vaccine here in Guatemala." - There exists a Dengue vaccine though, why does Guatemala not utilize it? "It’s a vaccine, not every pediatrician recommends it though, because you have 1 bad side effect, and if you contracted Dengue in an endemic region you might have serious hemorrhagic Dengue and it's not well investigated yet so we don’t recommend it yet." When do you administer vaccinations routinely? At well-checks? "Yes. At both well-checks and for other reasons. If vaccines are available we can offer them those. Or we can make another appointment, ask the vaccine to be delivered and administered. As a newborn, vaccinations are administered every month, at 6 months old it’s every 2 months, and then every year or 6 months. Then just check the vaccination card to see if they are updated and if not we offer the opportunity to get the vaccines that they need." Are there any NGOs, organizations, or other initiatives you know of that are promoting child vaccination? "We have UNICEF and PAHO in Guatemala, and they are strong with social media but to be honest with you I don’t see them working in the rural areas to encourage the populations to get vaccines. I don’t see that much, I think that’s a weakness and we have to work on that."

Interview with M.D. Deborah Buchman from Southdale Pediatric Hey Debbie so who are you? “I work outpatient general peds, so literally every single day is based on our wellness checks and are your vaccines up to date? It is what I do for a living, the hard part is that I don’t have the statistics of well what is it like in general but I know the places you can find the specifics” Which clinic or office do you work with? “Yup, Southdale Pediatric. So we’re a private group, so we might work slightly different than Health partners, those kinds of groups, but we are private so we can make different types of decisions which is nice and we prioritize getting all kids vaccinated” What is the difference between a private practice and Health partners? “So those are huge corporations, there’s like health care corporations, for example Health partners and Fairview systems, and Methodist, and Park Nicollet those are these huge healthcare systems. But Southdale Pediatrics we are one of these, not as common anymore, private groups, that we as a group of physicians we own our practice and we buy into the practice and we own it. So we have a little bit more ability to kinda choose how do we want our practice to work? That being said, the private practices, whether its pediatrics or anything else, we all have contracts with insurance providers and they set the goals and the criteria and the pricing. Unless someone is paying out of pocket for care, we don’t even set the pricing for what people pay to come to us. But vaccines are always provided and covered, regardless of insurance status.” How do vaccinations work in the US, are they covered under insurance? “So it depends on where a family lives. All vaccines are –at least in Minnesota– there is a ‘no shot no school’ rule that is optimally upheld and every single child regardless of insurance status is able to get vaccines free of cost. So if there is a family that has private insurance, private insurance covers it. If they are not covered by private insurance, they get public coverage–like Medicaid– or they can go to public health clinics. And we even have at our clinic we are a ‘no questions asked’ vaccine provider that if someone who is not a patient at our clinic comes in just because they need vaccines for schools we absolutely will give it. Like even if they don’t establish care with us or have a visit, yes we will give vaccines. If a parent or child was first looking to get vaccinated, where could they go? “It depends, like for our clinic optimally we like to have the kids patients who are established with our clinic, they come to us. And we have it set up with the well-child check there is a lot. Because with babies and children there is a lot of checks, the vaccines that we offer are in accordance with what the CDC (Center for Disease Control) makes and then the American Academy of Pediatrics which is our kind of governing body every year there are groups of the experts to get together and take these are the vaccine at these times of life, and that is how we set our well-child checks. So babies come in at 2, 4, 6, 9, 12, 15, 18, you know every several months that they come in. We also offer some vaccines to parents, because we want to cocoon the children with healthy people. So anyone that's not in our practice can get vaccines for things like Influenza, Whooping cough, COVID we were providing to people, so there's some we give to adults too.” Do you know of any legislative requirements for child immunization in Minnesota? “So, it’s slippery, it’s really slippery, every state is slightly different and what the requirements are for vaccination status, and unfortunately Minnesota has one of the most relaxed requirements for mandatory vaccinations. Minnesota historically allowed for non-medical and personal exemption, so people can just say “well I don’t believe in this, I don’t want to do it” and they sign a piece of paper and they don’t have to get it. Whereas California, and some other states, they have tighter laws, they say “no you can’t do that, you have to get these things to get your child to go to school”. If you look at the MN AAP website, that lists that immunizations is one of the top 5 priorities at a state legislature level for our group the MN AAP. We go to the capital every spring, we have a day, and we talk with our representatives about vaccines and any legislative options that are on the table. Is school-requirement the only way to emphasize child vaccination? “Well, there is a list of recommendations but in Minnesota it is a fairly relaxed thing, and people in MN have the ability to refuse vaccines and still go to school. Which is tough, we’ve had measles outbreaks here when other states didn’t” What are the most common child vaccines administered? “So at every visit we give a standard, so it depends on the age, the vaccinations we provide are in accordance with what's recommended for that age. These have been tested for both safety and for ethicacy, you know for benefit at that age, so at 2 months we give different combinations of vaccines. Babies get the DTaP which is Diphtheria, Tetanus, and Acellular pertussis. Pneumococcus that covers 13 strains of a bacteria, Rotatech that covers the Rotavirus, uh, Hep B at that visit as well. And then there’s booster doses that are set up at times that testing has shown that babies most benefit from getting boosted at certain intervals. Most of the early childhood vaccines are given within the first 2 years of life, because that's when they’re most at risk of having serious outcomes with the diseases that we can help modify their response to.” Are there newer childhood vaccines as of scientific innovations today, or in the past decade? “COVID, you know COVID is a moving target and it's a question that I get everyday at work: “When are the little kids gonna get it?” “Is it safe?”. Yeah it is a constantly moving target of we don’t know when it’s gonna get authorized for the 6 month - 5 year crowd” “Since I’ve been in practice, Chickenpox was a new one, the varivax vaccine, and that one I have only seen 2 cases of wild-type chickenpox since I have been in practice, which is amazing. I’m sure your mom has had it, I had it, but now kids don’t get it. The cases I’ve seen were actually parents who were international and that they moved here with chickenpox. HPV vaccine, it's not a new vaccine, it’s been out maybe 10-15 years but that vaccine is an anti-cancer vaccine that has just been phenomenally beneficial. I mean your generations will not see the cancers that ours did, because of that vaccine. It is most preventative for cervical cancer, but can men carry it, but when men have this cancer they’re obvious but women you can’t tell.” What are the most common and preventable child diseases you see in Minnesota? “Yeah, you know all of the vaccines modify risk, they don’t eradicate risk. We still see Pneumococcal infections causing ear infections and pneumonias and you know rarely unfortunately, meningitis. But of those, the strains of Pneumococcus that are covered in the vaccine, they’re far less common, this is also a moving target and if you see new strains of Pneumococcus that are getting prevalent, then they’ll make a new vaccine to cover those strains and make sure kids are protected for those. Whooping cough, people don’t realize how common whooping cough is, there are outbreaks all the time. When we get it, when healthy adults and teenagers get it, it's just an annoying cough but when babies get it can be life threatening. I did see a baby die of whooping cough when I was a resident and it was awful, a healthy 6 month old baby, and it was awful. So we see lots of infections but those are usually unvaccinated or too young to be vaccinated, those are the really sad ones” “When I was a med student in Wisconsin There was a child that had Haemophilus meningitis, A serious bacterial meningitis, And I remember that That vaccine, the Hib vaccine was new at that point. And they marched us down –I mean I was 20-something– and they brought us all down to the lab and said “look at this organism, you will never see it again” And I’ve seen 1 child with a Hib Meningitis infection since then, and that's it.” What happens if a child doesn’t have the proper immunizations, can the doctor's office do anything to require or strongly recommend them? “We will have those conversations every visit, I say “these are the recommended vaccines” but in Minnesota I can’t force anything, it all needs to be consented to. I want parents to be on board and consent, and usually I feel like most of my patients, if I talk with them and talk about risks and benefits that eventually kids end up getting vaccinated. But it's really hard when families refuse vaccines: I had a mom tell me once that I was trying to make money and hurt her child. And it's really hard because we go into Pediatrics because we love children haha, I'm not going to hurt your child. So it is tough, we get a lot of pushback on a daily basis. It’s tough, I think families kind of self-select where they go. If there's a family who does their alternate vaccines, or they don't believe in vaccines they are going to quit coming to our Clinic, because we practice evidence-based medicine and we’re going to tell you that this is the evidence. Then they chose to go somewhere else where they are hearing what they want to hear.” Are there any initiatives or programs that promote childhood vaccination that you are a part of or would recommend looking at? “So the MN AAP is the primary group because we are the Minnesota chapter of the American Academy of Pediatrics. Within that, if you go to the AAP website it has an immunization work group that is headed up by Dawn Martin and somebody else I can't remember. They have meetings on a semi-regular basis to go over what is new, what are the things we should recommend, and what is the timing for different vaccines. That is the primary source for different pediatricians in the community, I’m sure that the AMA, the adult medicine, have similar work groups for the adult medicine. We at the AAP, we rely on the data that comes through the CDC, the NIH (National Institute for Health), and then the MDH site (Minnesota Department of Health). They have a ton of information, just when I was peeking at it recently the vaccination rates across the state can be wildly divergent, based on where you live, access, views, cultural views, so there is a lot of data out there but it is hard to compile.” Is access a big causation for people that are under-vaccinated? “There is a lot of challenge with access. Absolutely, it depends on where you live and how your health care is provided. You know I practice in Suburban, West Metro, affluent neighborhoods. They come in their minivans, get their vaccines, and go back to school. But when I worked in Hennepin County there were kids that would come in for a well-check at random, or they would show up every couple of years because they were really sick, and you try and get them done, or parents don’t have the finances. That might be a barrier that they worry about, not knowing that vaccines will be covered for families that don’t have insurance. If you look at statistics up in far Northern Minnesota, rural Minnesota, reservations, all of those rates for access to Healthcare just plummet.” How are vaccinations promoted? Do you see the Minnesotan public being shown this? “All the time, you know it's kind of what we do when we hand out our pamphlets, and if you go to the Minnesota AAP site you can see videos on how we can better promote vaccines to our patients. It's tough, you know most people that are coming in and they want the healthcare, well they are there because they want their kids to be vaccinated. The hard part is that when people are hesitant, the data shows that it is really hard for any physician to change their mind. People will dig in their heels and say “no I don’t believe you” and anything that I say, it’s just going to further discourage sometimes, and that is really tough, that’s a challenge. Well how can I help provide information that is valid. There is so much misinformation out there and fear is a big deterrent, you know people are scared, they are saying “my auntie told me this is dangerous and I’m not gonna do it” and it's scary there’s a lot of scary information out there that may or may not be true.”