Transcript www.protectcme.org

Strategies for Improving Adolescent
Immunization Rates
Educational Learning Objectives
At the conclusion of this presentation, the participant
should be able to:
• Discuss the indications and recommendations for the
most current immunization schedules for adolescent
populations
• Respond to frequently encountered questions and
situations during patient discussions including safety,
efficacy, and possible misinformation
• Implement strategies for improving immunization rates
within one’s clinical practice, taking into account current
immunization schedules and guidelines
Definition of ‘Adolescent’
• 7th birthday until the 19th birthday
– Per CDC adolescent immunization schedule
• Society of Adolescent Medicine defines
adolescent as 10 to 25 years
2011 ACIP Adolescent
Immunization Schedule
ACIP Schedules. www.cdc.gov/vaccines/recs/schedules/default.htm.
Accessed Feb 2011.
Adolescent Catch-up Schedule
ACIP Schedules. www.cdc.gov/vaccines/recs/schedules/default.htm.
Accessed Feb 2011.
Vaccination Coverage Adolescents 13–17 yrs,
United States, National Immunization Survey
100
Vaccination Coverage (%)
90
80
70
2007
2008
60
2009
50
40
30
20
10
0
MMR ≥ 2 Hepatitis B Varicella Varicella Varicella Td or Tdap Tdap ≥ 1
with
Doses ≥ 3 Doses
without
without ≥ 1 Dose
Dose
History of History of History of
Disease Disease ≥ Disease ≥
1 dose
2 doses
CDC. MMWR Morb Mortal Wkly Rep. 2009;58(36):997-1001.
CDC. MMWR Morb Mortal Wkly Rep. 2010;59(32):1018-1023.
MCV4 ≥ 1
Dose
HPV4 ≥ 1
Dose
HPV4 ≥ 3
Doses
Tdap
7–10 years
11-12 years
13–18 years
catch-up*
recommended
catch-up
Boostrix
Adacel
Approved for use
ages 10-64 years
Approved for use
ages 11-64 years
• Two FDA-approved Tdap vaccines available
• Both contain the same acellular pertussis component as their
respective DTaP products
• FDA recommended one-time use of Tdap only
– For 11 to 12-year-olds, replaces Td booster if no previous Tdap
– Catch-up for 13 to 18-year-olds
• MCV4 contains diphtheria conjugate protein carrier
– If both are indicated, administer MCV4 and Tdap simultaneously
*off-label ACIP recommendation
CDC. MMWR Recomm Rep. 2006;55(RR03):1-34.
ACIP. http://www.cdc.gov/vaccines/recs/acip/slides-oct10.htm. Accessed Nov 2010.
New ACIP Recommendations
Tdap Children 7 to 10 Years of Age
• Under-vaccinated children ages 7-10 years
– Single-dose of Tdap
– If additional doses of Td are needed, then vaccinate according to
catch-up guidance (Tdap 1 dose only)
• Children 7–10 years never vaccinated against tetanus,
diphtheria, or pertussis
– Start with single dose of Tdap, followed by
– Td > 4 wks after Tdap
– Td 6-12 mo later
• Further guidance will be forthcoming on timing of
revaccination those who have received Tdap prior to age 11
ACIP. http://www.cdc.gov/vaccines/recs/acip/default.htm. Accessed Dec 2010.
HPV-associated* Invasive Squamous Cell
Carcinomas in Women and Men, 1998–2003
Average Annual
Incidence (#)
Incidence
(per 100,000)
95% CI
Cervix
10,846
8.9
8.9,9.0
Vagina
601
0.5
0.4,0.5
Vulva
2266
1.7
1.7,1.7
Anus/Rectum
1935
1.5
1.5,1.5
Oropharynx/OC
1702
1.3
1.3,1.4
17,350
14.0
13.8,14.0
Penis
828
0.8
0.8,0.8
Anus/Rectum
1083
1.0
1.0,1.0
Oropharynx/OC
5658
5.2
5.1,5.2
7568
7.0
6.9,7.0
Anatomic Area
Total Females
Total Males
*Defined by histology and anatomic site
Watson M, et al. Cancer. 2008;113(10suppl):2855-2864.
CDC. http://www.cdc.gov/cancer/hpv/statistics/index.htm. Accessed Jan 2011.
• This 14-year-old has come in for a
sports physical for camp. She is
up- to-date on all of her
vaccinations, except her mother
has decided to “wait until there is
more data” on the HPV vaccine.
• What data can you provide to
reassure the mother that
vaccination now is preferable?
• The HPV vaccine is only effective PRIOR
to exposure
• Immune response is more vigorous the
younger the patient
• ~33 million doses of HPV vaccine have
been given in the US; no patterns of
safety concern have been noted
• The vaccine prevents cancer – period
• Sexual debut is not always the patient’s
choice; protect children while we can
Available HPV Vaccines
Quadrivalent
Merck - Gardasil®
Bivalent
GSK - Cervarix®
2006
2009
HPV 6, 11, 16, 18
HPV 16, 18
Protection against HPV 16/18
related CIN2+
≥ 98%
≥ 93%
Protection against HPV 6/11
related genital lesions
~99%
---
Hypersensitivity-related
contraindication
Yeast
Latex*
9–26 yrs
10–25 yrs
Routine 11–12 yrs,
catch-up 13–26 yrs
Routine 11–12 yrs,
catch-up 13–26 yrs
0, 1-2, 6 months
0, 1-2, 6 months
Licensed in the US
Virus-like particle types
Licensed age range
ACIP Recommendations
Schedule
CIN2+: cervical intraepithelial neoplasia grade 2 or higher and adenocarcinoma in situ
*needle-less prefilled syringes contain latex; vial stopper does not contain latex
Markowitz L. ACIP Meeting Oct 2009. http://www.cdc.gov/vaccines/recs/acip/downloads/mtg-slidesoct09/02-2-hpv.pdf. Accessed Dec 2010.
HPV – ACIP Recommendations
Quadrivalent HPV (HPV4) and Bivalent HPV (HPV2)
• Routine vaccination of females aged 11–12
years
– Catch-up 13–26 years
• ACIP: no preference for cervical cancer
prevention
• Use HPV4 for genital wart and external lesion
coverage
• Use HPV4 for external lesion protection among
males
ACIP Schedules. www.cdc.gov/vaccines/recs/schedules/default.htm. Accessed Dec 2010.
FDA. http://www.fda.gov/BiologicsBloodVaccines/Vaccines/ApprovedProducts/ucm172678.htm.
Accessed Dec 2010.
Proportion of Clinicians Who Strongly
Recommend HPV Vaccine to Female Patients
Survey Data Jan–Mar 2008
100
90
90
94 94
91
85
85
80
Percent
70
56
60
9-10 yrs
50
50
11-12 yrs
13-15 yrs
40
16-18 yrs
30
19-26 yrs
20
10
13
6
0
Pediatricians
Daley M, et al. Pediatrics. 2010;126:425-433.
Family Physicians
HPV Vaccination and Pregnancy
• HPV vaccines are not recommended for use in pregnant
women
• Delay initiation of vaccination until after completion of
pregnancy
• If a woman is found to be pregnant after initiating the
vaccination series, delay remaining doses until after the
pregnancy
• Two vaccine during pregnancy registries:
– Quadrivalent HPV vaccine/pregnancy: 800-986-8999
– Bivalent HPV vaccine/pregnancy: 888-452-9622
CDC. MMWR Morb Mortal Wkly Rep. 2010;59(20):626-629.
HPV Quadrivalent Vaccine in Males
• FDA approved quadrivalent HPV vaccine for
boys and men ages 9 through 26 yrs
• ACIP: Permissive HPV vaccine for males
• Included in VFC program; obtained at no cost
from any Federally Qualified Health Center
(FQHC); manufacturer Patient Assistant
Program
CDC. MMWR Morb Mortal Wkly Rep. 2010;59(29):630-631.
HPV Quadrivalent Vaccine
in Males Ongoing Considerations
• Anal and oral cancers in males
• Efficacy
– High efficacy for prevention of vaccine HPV type-related anal
pre-cancers, genital warts, and persistent infection
• Safety
– Clinical trial data in males good safety profile
– No safety signals in Vaccine Safety Datalink
• Provider acceptability and practices
• Cost effectiveness
ACIP. http://www.cdc.gov/vaccines/recs/acip/downloads/mtg-slides-oct10/08-7hpv-MaleConsider.pdf. Accessed Dec 2010.
Intent to Vaccinate with HPV among Parents of
Females Who Have Not Received Any HPV Vaccine;
NIS–Teen 2009
40
36
35
Percent
30
25
23
20
17
15
15
9
10
5
0
Very Likely
Somewhat
Likely
Not Too Likely Not Likely At All
ACIP. http://www.cdc.gov/vaccines/recs/acip/downloads/mtg-slides-oct10/08-3hpv-Female.pdf. Accessed Nov 2010.
Not Sure
HPV Vaccine Parental Concerns
• Parents discomfort with child sexuality
– Great opportunity to start talking about sexuality issues
– Communicate the importance of completing the 6-month immunization
series before the adolescent becomes sexually active
– Improved immunogenicity at younger ages
• Emphasize cancer prevention
• Communicate the universality of the vaccine recommendation
• No evidence that vaccination supports sexual activity
– Not supported by other interventions such as free condom distribution,
availability of emergency contraception
• Provider recommendation is perhaps the most important
factor in parent decision-making!
Rosenthal SL. J Adolesc Health. 2005;37:177-178.
HPV Postlicensure Safety Data
• Vaccine Adverse Event Reporting System (VAERS)
– HPV4
 6/1/06–8/31/10
 33 million doses in females
 16,442 VAERS reports; 8% serious
 Ongoing monitoring
 No new adverse event concerns or clinical patterns identified
– HPV2
 Licensed 10/16/09
 Insufficient usage to date in US to assess AEs
 Total US reports through 8/31/10: 9
• Vaccine Safety Datalink Rapid Cycle Analysis
– HPV4
 No significant increased risk for pre-specified AEs after vaccination
 GBS, seizures, syncope, appendicitis, stroke, VTE, allergic rxns
ACIP. http://www.cdc.gov/vaccines/recs/acip/downloads/mtg-slides-oct10/08-2-hpv
-VaccSafety.pdf. Accessed Dec 2010.
Meningococcal Conjugate Vaccines
• Two licensed meningococcal conjugate vaccines
– MCV4-D (Menactra®, Sanofi)
 Licensed for persons 2-55 years
 Serogroups A, C, Y, W-135
 Diphtheria toxoid conjugate
– MenACWY-CRM197 (Menveo®, Novartis)
 Licensed for persons 2-55 years
 Serogroups A, C, Y, W-135
 Diphtheria CRM197 conjugate
FDA. http://www.fda.gov/BiologicsBloodVaccines/Vaccines/ApprovedProducts/ucm093830.htm.
Accessed Feb 2011.
New ACIP Recommendations for MCV4*
• Administer MCV4 at age 11–12 years
– Booster dose at 16 years
• For those vaccinated at age 13–15 years
– Booster dose at age 16 through 18 years
• No booster needed if primary dose on or after
age 16 years
*Meningococcal conjugate vaccine, quadrivalent; Menactra® or Menveo ®
CDC. MMWR Morb Mortal Wkly Rep. 2011;60(3):72-76.
Meningococcal Conjugate Vaccines
for Those At High Risk
• Children 2–10 years with
– Persistent complement component deficiency
– Anatomic or functional asplenia
 2 doses of MCV4 at least 8 weeks apart
 1 dose every 5 years thereafter
• Persons with HIV infection, 11–18 years
– 2 doses of MCV4 at least 8 weeks apart
ACIP. http://www.cdc.gov/vaccines/recs/acip/slides-oct10.htm#child.
Accessed Dec 2010.
Update on Meningococcal Conjugate
Vaccine Safety
• 2 large post-licensure studies
– Meningococcal Vaccine Study and Vaccine Safety Datalink
Rapid Cycle Analysis Study
• > 2.3 million MenACYWD (Menactra®) vaccinations
• 0 confirmed cases of Guillain-Barré Syndrome (GBS)
with 6 weeks of vaccination
• Upper 95% confidence limit for attributable risk of GBS
associated with MenACYWD is estimated at 1 case per
million doses
• Background rate of GBS from Meningococcal Vaccine
Study: 5.4 cases/million person years
• These 2 studies provide no evidence of increased risk of
GBS associated with MenACYWD
ACIP. http://www.cdc.gov/vaccines/recs/acip/downloads/min-jun10.pdf. Accessed Dec 2010.
Annual Influenza Vaccine
Is Recommended for:
• All people* age 6 months and older!
* Without contraindications
CDC. MMWR Recomm Rep. 2010;59(RR8):1-62.
2010–2011 Influenza Season
• 2010-2011 Trivalent Influenza Vaccines
– A/California/7/2009(H1N1)-like virus
– A/Perth/16/2009(H3N2)-like virus
– B/Brisbane/60/2008-like virus
• Current information from the CDC and FDA
– http://www.cdc.gov/vaccines/vpd-vac/flu/default.htm#ref
– http://www.fda.gov/BiologicsBloodVaccines/Vaccines/ApprovedProducts/
ucm094045.htm
CDC. MMWR Recomm Rep. 2010;59(RR8):1-62.
CDC. http://www.cdc.gov/vaccines/vpd-vac/flu/default.htm#ref. Accessed Dec 2010.
FDA. http://www.fda.gov/BiologicsBloodVaccines/Vaccines/ApprovedProducts/ucm094045.htm.
Accessed Dec 2010.
2010–2011 Influenza Season
Vaccine
Trade Name
Age Group
Route of
Administration
≥ 6 months
Intramuscular
TIV
Fluzone; sanofi
TIV
Fluvirin; Novartis
≥ 4 years
Intramuscular
TIV
Fluarix; GSK
≥ 3 years
Intramuscular
TIV
Afluria*; CSL
≥ 9 years
Intramuscular
TIV
FluLaval; GSK
≥ 18 years
Intramuscular
LAIV
FluMist; MedImmune
2–49 years
Intranasal
TIV: trivalent inactivated influenza vaccine; LAIV: live attenuated influenza vaccine
*FDA-approved for use ≥ 6 months; however ACIP does not recommend use in children
6 months-8 years due to increased risk of fever and febrile seizures reported among
young children < 5 years who received a similar vaccine in Australia 2010.
CDC. MMWR Recomm Rep. 2010;59(RR8):1-62.
CDC. MMWR Morb Mortal Wkly Rep. 2010;59(31):989-992.
Influenza Vaccination for
Children–1 or 2 Doses?
CDC. MMWR Recomm Rep. 2010;59(RR8):1-62.
PCV13 – Children 6 through 18 Years of Age
with High-risk Conditions
• Children 6–18 years of age
• High risk for invasive pneumococcal disease
–
–
–
–
–
•
Sickle cell disease
HIV infection
Immunocompromising conditions
Cochlear implant
Cerebrospinal fluid leaks
Single dose of PCV13
– Regardless of whether they have previously received PCV7 or
PPSV23
This recommendation is an off-label use of PCV13, which is indicated for children 6 weeks through
5 years of age (prior to the 6th birthday)
CDC. MMWR Recomm Rep. 2010;59(RR11):1-19.
Pneumococcal Vaccine
PPSV23
7–10 years
11-12 years
13–18 years
for certain high-risk groups
• Single dose recommended for:
– 2–18 years, high-risk groups, sickle-cell disease, CSF leaks,
asplenia, cochlear implants
– >2 years and immunocompromised
• Doses of PCV13 should be completed before PPSV23
• Minimum interval following last dose of PCV13: 8 weeks
• One-time revaccination:
– 2nd dose of PPSV23 5 years after the first dose of PPSV23 for
persons aged >2 years who are immunocompromised, have sickle
cell disease, or functional or anatomic asplenia
CDC. MMWR Recomm Rep. 2010;59(RR11):1-19.
Hepatitis A
• Routine vaccination recommended for all children ages 12 to 23 months
• Vaccination for anyone wishing to avoid disease
• In areas without existing Hep A vaccination programs, consider catch-up
of unvaccinated children 2-18 years
• Children at increased risk for infection
• Dosing:
VAQTA®
– For all persons age ≥ 12 months
• 2 doses at 0 and 6-18 months
HAVRIX®
– For all persons age ≥ 12 months
• 2 doses at 0 and 6-12 months
CDC. MMWR Morb Mortal Wkly Rep. 2006;55(RR7):1-23.
CDC Resolution No. 06/07-1.
http://cdc.gov/vaccines/programs/vfc/downloads/resolutions/0607-1hepa.pdf.
Accessed Dec 2010.
Hepatitis A Vaccine
International Travel
• For healthy persons 40 years of age or younger
– 2 doses 6 months apart prior to departure
– The first dose of Hepatitis A vaccine should be administered as
soon as travel is considered
– 1 dose of single-antigen vaccine administered at any time
before departure
• Consider both HAV and Ig for
– Persons age > 40 with chronic illness traveling in less than 2
weeks and only receiving one dose of HAV
– Persons at risk of severe disease from hepatitis A virus
planning to travel in 2 weeks or sooner
CDC. MMWR Morb Mortal Wkly Rep. 2007;56(41):1080-1084.
Hepatitis A Postexposure Prophylaxis
• For healthy persons 12 months through 40 years of age
who have not previously received Hep A vaccine
• Immunoglobulin and/or single-antigen hepatitis A vaccine
should be administered as soon as possible after exposure
– Vaccine preferred for those of age 12 months to 40 years
– Ig preferred for age < 12 months, those with vaccine allergies, or
those with immunosuppression or liver disease
– Ig preferred for age > 40 but vaccine may be used if Ig unavailable
– Hep A and Ig may be administered simultaneously
• Efficacy of Ig or Hep A when administered >2 weeks
postexposure is unknown
CDC. MMWR Morb Mortal Wkly Rep. 2007;56(41):1080-1084.
CDC. MMWR Morb Mortal Wkly Rep. 2009;58(36):1006-1007.
Hepatitis A:
Families of International Adoptees
• Hep A vaccination
– All previously unvaccinated persons who anticipate
close personal contact with an international adoptee
from countries of high or intermediate endemicity
during the first 60 days following arrival in the US
• First dose of Hep A vaccine
– As soon as adoption is planned
– Ideally at least two weeks prior to the arrival of the
adoptee
CDC. MMWR Morb Mortal Wkly Rep. 2009;58(36):1006-1007.
Hep B
7–10 years
11-12 years
13–18 years
catch-up
• Multiple schedules
– Children 1-10 years
• 0, 1, and 6 months
• 0, 2, and 4 months
• 0, 1, 2, and 12 months
– Adolescents 11-19 years
•
•
•
•
•
0, 1, and 6 months
0, 1, and 4 months
0, 2, and 4 months
0, 12, and 24 months
0 and 4-6 months (2-dose schedule uses adult 10 ug formulation,
Recombivax-HB, only for 11-15 years of age)
• 0, 1, 2, and 12 months
• No combination Hep B vaccines approved for use in ages
11-17 years
• Hep B titers are not necessary for teens
CDC. MMWR Recomm Rep. 2005;54(RR16):1-23.
Hep A-Hep B Combination Vaccine (Twinrix)
•
Approved for persons 18 years and older
– Combination Hep A vaccine (pediatric dose) + Hep B (adult dose)
•
First licensed schedule: 0, 1, and 6 months
– Alternate schedule 2007: Doses at 0, 7, 21-30 days; booster dose at 12 months
•
The first 3 doses of the new schedule provide equivalent protection to:
– The first dose in the standard single-antigen adult hepatitis A vaccine series
– The first 2 doses in the standard adult hepatitis B vaccine series
•
Seroconversion is nearly 100% after either 3 doses of the combination vaccine on
the new schedule or a single dose of single-antigen adult hepatitis A vaccine
CDC. MMWR Morb Mortal Wkly Rep. 2007;56(40):1057.
• This 15-year-old is in the office
for an ankle injury that
occurred during a soccer game
• You notice that his last
immunizations were at age 6
years
• Does he need any vaccines?
Recommended vaccines
include:
• Tdap
• MCV
• Varicella (2nd dose)
• Influenza
(Consider HPV)
Varicella
7–10 years
11-12 years
13–18 years
catch-up
• Universal recommendation for routine
vaccination is 2 doses
– Given 3 months apart for those under 13 years old
– ≥ 13 yrs, minimum interval is 28 days
• Formulations
– Varivax licensed ages 12 mos and older
– Proquad (Combination MMRV) not licensed ≥ 13
years
CDC. MMWR Recomm Rep. 2007;56(RR04):1-40.
General Immunization Reminders for
Adolescents–Safety First
• Syncope is a concern with all adolescent
vaccines
• Immature cardiovascular system/response
• Long standing recommendation to have
adolescents sit or lay down for 15–20
minutes following injections
General Immunization Reminders
for Adolescents
• A multidose vaccine series should not be restarted if the
recommended dosing interval is exceeded
– Exception–Oral typhoid Ty21a
• If giving multiple injections in 1 arm, separate 1” apart
• Correct placement for deltoid IM injections
General Immunization Reminders
for Adolescents
Use a needle long enough to reach deep into the muscle
for intramuscular (IM) Injections
22-25 gauge needle
Group
Weight
Needle
Length
Children
(3–18 yrs)
---
5/8–1”
Adults
< 130 lbs (< 60 kg)
5/8”
Adults
130-152 lbs (60-70 kg)
1”
Women
152-200 lbs (70-90 kg)
1-1½”
Men
152-260 lbs (70-118 kg)
1-1½”
Women
> 200 lbs (> 90 kg)
1½”
Men
> 260 lbs (> 118 kg)
1½”
Immunization Action Coalition. http://www.immunize.org/catg.d/p2020A.pdf. Accessed Dec 2010.
Immunization Action Coalition. http://www.immunize.org/catg.d/p2020.pdf. Accessed Dec 2010.
Contraindications
• Increases likelihood of a serious adverse
event
• When present, vaccine should not be given
• Permanent contraindications for all vaccines:
severe allergy to vaccine or component
• Live vaccines generally contraindicated in
pregnancy and for persons with immune
incompetence
Marshall GS. The Vaccine Handbook. PCI Books, Inc.: 2010
Erroneous Contraindications
•
•
•
•
•
Mild acute illness with or without fever
Mild respiratory illness (including otitis media)
Mild gastroenteritis
Antibiotic or antiviral therapy
Low-grade fever, redness, pain, swelling after
previous dose
• Prematurity (delay HepB in infants < 2000 gm whose
mothers are HBsAg-negative)
• Household contacts who are unimmunized,
immunosuppressed, or pregnant (except pre-event
smallpox vaccination)
Marshall G. The Vaccine Handbook. PCI Books, Inc.: 2010
Erroneous Contraindications
•
•
•
•
•
•
Breastfeeding (except pre-event smallpox)
Convalescent phase of illness
Exposure to an infectious disease
Positive tuberculin skin test without active disease
Simultaneous tuberculin skin test
Allergy to penicillin, duck meat or feathers, or
environmental allergens
• Fainting after previous dose
• Seizures, SIDS, allergies, vaccine reactions in family
members
Marshall G. The Vaccine Handbook. PCI Books, Inc.: 2010
Erroneous Contraindications
• Malnutrition
• Lack of a previous physical exam in a well-appearing
individual
• Stable neurological condition (eg, CP, seizures,
developmental delay)
• Allergy shots
• Extensive limb swelling after DTP, DTaP, or Td that
is not an Arthus-type reaction
• Brachial neuritis after previous dose of tetanus
toxoid-containing vaccine
• Autoimmune disease
• History of the vaccine-preventable disease
Marshall G. The Vaccine Handbook. PCI Books, Inc.: 2010
Common Immunization Misconceptions
• Do you need to screen for HPV before giving the HPV vaccine? No
• If someone has an abnormal Pap smear, do you give them the HPV
vaccine? Yes
• Do you continue to do Pap smears following the HPV vaccine series?
Yes
• Is pregnancy testing indicated before giving vaccines? No
(other than small pox)
– Pregnancy screening? Yes
• Do you have to check Hep B titers in teens? No
• Does an 18-year-old need a 2nd varicella immunization? Yes
• Can you get the flu from a flu shot? No
Vaccine Safety
• Vaccine Adverse Event Reporting System
– Passive, voluntary reporting
– Helps signal potential problem
– Cannot determine causal association
• Vaccine Safety Datalink Project
–
–
–
–
Established 1991
CDC and 8 large managed care organizations
8.8 million subjects; 3% of U.S. population
Rapid Cycling Analysis
VAERS. http://vaers.hhs.gov/index. Accessed Dec 2010.
CDC. http://www.cdc.gov/vaccinesafety/Activities/VSD.html. Accessed Dec 2010.
Vaccine Safety (cont)
• Clinical Immunization Safety Assessment
– Established 2001
– Six academic centers with safety experts
– CISA Network Sites
•
•
•
•
•
•
Boston University Medical Center*
Columbia University Medical Center
Johns Hopkins University*
Northern California Kaiser Permanente
Stanford University
Vanderbilt University
• Brighton collaboration – International
CISA. http://www.cdc.gov/vaccinesafety/Activities/CISA.html. Accessed Dec 2010.
The Brighton Collaboration. http://www.brightoncollaboration.org/internet/en/index.html. Accessed Dec 2010.
Adolescent Immunization:
Goals and Objectives
• Effective adolescent vaccine delivery and monitoring are
critical
• Adolescents lag far behind preschoolers in immunization
coverage
• Healthy People 2020 – increase routine vaccination
coverage for adolescents
– 1 dose of Tdap by 13–15 yrs (target 80%)
– 2 doses of varicella vaccine by 13–15 yrs (excluding children
who have had varicella) (target 90%)
– 1 dose of MCV by 13–15 yrs (target 80%)
– 3 doses of HPV for females 13–15 yrs (target 80%)
– Seasonal influenza vaccine for children 13– 17 yrs (target 80%)
Healthy People 2020.http://www.healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicid=23.
Accessed Dec 2010.
There Are Missed Opportunities
• Adolescents who do not seek preventive care
– less likely receive Td/Tdap on time
• In one health care system, missed
opportunities for Td/Tdap immunization 84% of health care visits
• There is room to improve immunization
strategies for adolescents
Lee G, et al. Pediatrics. 2008;122:711-717.
Adolescent Immunization Barriers
• Lack of routine preventive care visits
• Lack of awareness
• Inaccurate risk assessment by
adolescents/parents regarding vaccinepreventable diseases
• Financial barriers
• Lack of complete immunization records
• Missed opportunities
Lee G, et al. Pediatrics. 2008;122:711-717.
Parents Are a Key Influence
• Parental perception of vaccination is an
important factor in adolescents’ vaccination
decisions1,2
– Parents influence adolescent acceptance
– Providers influence parental acceptance
• Parental consent for immunization is the most
cited barrier to immunizing students at
school-based vaccination initiatives3,4
1.
2.
3.
4.
Rosenthal SL, et al. J Adolesc Health. 1995;17:248-254.
Rosenthal SL. J Adolesc Health. 2005;37:177-178.
Guajardo AD, et al. J Sch Health. 2002;72:128-130.
Deeks SL, Johnson IL. Can J Public Health. 1998;89:98-101.
Parent Attitudes Affect Vaccination
• Influenza vaccination more likely if:
–
–
–
–
Parent recalled physician recommendation
Parent believed the vaccine works
Easy access to clinic
Receipt of reminder from provider
• HPV vaccination more likely if:
– Parents received education on human
papillomavirus and HPV vaccine
Gnanasekaran SK et al. Public Health Reports. 2006;121:181.
Lin CJ et al. J Urban Health. 2006;83:874.
Rosenthal SL. J Adolesc Health. 2005;37:177-178.
Patient and Provider Factors That Influence
Adolescent Immunization
Education/
Knowledge
Self-Efficacy
Insurance/
Reimbursement
Time
Provider
likelihood to
administer
immunization
Patient
likelihood to
access
immunization
ADOLESCENT
IMMUNIZATION
Middleman AB. J Adolesc Health. 2007;41:109-118.
Financing for
Adolescent Vaccination
• Public funding for eligible children up to but not
including the 19th birthday
– Vaccines for Children Program (VFC)
– State Children’s Health Insurance Program (SCHIP)
• Funding for adolescents > 19 years
– With health care reform
 Private sector health plans ‘1st Dollar Coverage’
CDC. http://www.cdc.gov/vaccines/programs/vfc/providers/elig-scrn-rec-doc-req.htm. Accessed Dec 2010.
Affordable Care Act. http://www.healthcare.gov/news/factsheets/affordable_care_act_immunization.html. Accessed Dec 2010.
Vaccine Finance Resources for Physicians
Pediatrics. 2009;124:S573-S576.
http://pediatrics.aappublications.org/cgi/content/full/124/Supplement_5/S573
Establishing Adolescent
Immunization Platforms
• Need exists for standard immunization visits
during adolescence
• ACIP recommendations geared to 11- to
12-year-old age group
– Younger adolescents have higher rates of
accessing preventive health care than older
adolescents
Rand CM, et al. J Adolesc Health. 2005;37:87-93.
Establishing Adolescent
Immunization Platforms (cont)
• Society for Adolescent Medicine position
statement
– 11- to 12-year visit: primary immunization
platform
– 14- to 15-year visit: catch up on missed
vaccines or complete multidose regimens
– 17- to 18-year visit: update vaccinations that
were missed or are newly recommended
Middleman AB, et al. J Adolesc Health. 2006;38:321-327.
IDSA. Clin Infect Dis. 2007;44:e104-e108.
Advantages of Building an Adolescent
Immunization Platform Structure
• Puts focus on disease prevention among this age
group
• Presents opportunities for improved comprehensive
care that includes other health issues (eg,
screening and prevention of risk behaviors)
• Creates parental and provider expectation of
compliance with established adolescent
immunization visits
IDSA. Clin Infect Dis. 2007;44:e104-e108.
Adolescent Vaccination Coverage:
Who Is Measuring?
• The National Committee for Quality Assurance (NCQA)
Healthcare Effectiveness Data and Information Set (HEDIS)
update
– Td/Tdap and meningococcal vaccine for 13 yr olds
• National Immunization Survey (NIS) 2006: First year of data
collection for adolescents 13 to 17 years of age
• NIS-Teen:
– Includes provider-reported information
– Now conducted annually
Adolescent
Immunization
Rates:
Strategies
to Hit
the Target
Public Policy
Providers
National
Use of recall
systems
Education
re: provision of
preventive care for
adolescents
Use of immunization
Development
of standard
immunization
platforms by
ACIP,
professional
organizations
information systems
Use of
screening tools
Attend vaccination
“quick visits” if
other preventive
services not
required
Reimbursement/
funding
(currently
VFC, 317)
Development of
specific vaccination
“quick visits” if other
services not needed
Bull’s-eye!
Shots in
Adolescent
Arms
Education
re: need for
preventive care
of adolescents
Patients
Insurance
reform
Middleman AB. J Adolesc Health. 2007;41:109-118.
Mandates for
school entry
Use of
standing orders
Use of alternative site
if no medical home or if
need to complete a series
Enrollment in
of vaccinations
Education re:
immunization
immunizations
information
systems
Funding and
support for
immunization
information
systems
State
Education re:
immunizations
State legislation
allowing immunization
at alternative sites
State review
of “consent”
procedures
Reimbursement/
funding
(currently
SCHIP)
Funding and
support for
immunization
information
systems
Are Providers Seeing Adolescents?
• HEDIS data: 34% of adolescents who
participate in health plans have annual
preventive visits1
• NCHS (CDC) data: 86% of 6- to 17-year-olds
and 76% of 18- to 24-year-olds report at least
one doctor’s office, ED, or home visit within
past year2
• 88–92% of adolescents report having an
identified source of primary care3,4
HEDIS = Health Plan Employer Data and Information Set; NCHS = National Center for Health Statistics
1. McInerny TK, et al. Pediatrics. 2005;115:833-838.
2. National Center for Health Statistics. Health, United States, 2005.
3. Klein JD, et al. Arch Pediatr Adolesc Med. 1998;152:676-682.
4. Klein JD, et al. J Adolesc Health. 1999;25:120-130.
Identify and Address Barriers
Patient Issues for Vaccination
• Awareness
– Disease
– Vaccine
– Personal risk
• Provider Recommendation
• Misconceptions / fears
– About vaccine
– About health care system
• Access and ability to pay
The Goal: To Increase the
Adolescent Immunization Rate
• Healthy People 2020
– Increase routine vaccination coverage for adolescents
• Free assistance from public health departments
(CoCASA software)
• Vaccines for Children quality improvement activities
(eg, AFIX)
.
Healthy People 2020.
http://www.healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicid=23. Accessed Dec 2010.
CoCASA. http://www.cdc.gov/vaccines/programs/cocasa/default.htm. Accessed Dec 2010.
AFIX. http://www.cdc.gov/vaccines/programs/afix/default.htm. Accessed Dec 2010.
Improving Vaccination Rates –
Provider Issues
• Know the facts
• Recommend vaccinations to your patients
• Get organized and use systems approaches
– Ensure offering and administration of vaccine
 Automatic processes that empower nurses are effective
 Address convenience, efficiency, durability
• Evaluate and provide feedback
• Consider new paradigms
– New venues
– Extend vaccination season
• Practice what we preach (get vaccinated!)
Nichol KL. Cleve Clin J Med. 2006;73:1009-1015.
Shots Immunization App - Free
• For iPhone/iPod, iPad,
Android, Blackberry, and PC
• Select vaccine name for
information on
–
–
–
–
–
–
–
High risk indications
Adverse reactions
Contraindications
Catch-up
Administration
Risk communication
Epidemiology
 www.ImmunizationEd.org
 Available on iTunes Store
Content includes Childhood, Adolescent, and Adult
Immunization Schedules for the U.S.
Receive updates from the CDC via email:
http://www.cdc.gov/vaccines/pubs/default.htm
Email updates from the Immunization Action
Coalition - http://www.immunize.org/subscribe/
Provider Recommendation Can Overcome
Negative Attitudes Among Patients
Vaccination Rates Among High Risk Patients With Negative Attitudes
Vaccination Rate (%)
100
80
60
40
20
0
Influenza
PPV
No MD Recommendation
MD Recommendation
Nichol KL, et al. J Gen Intern Med. 1996;11:673-677.
Provider-based Strategies to Improve
Adolescent Immunization Rates
• Standing orders
– Recommended by CDC (strong evidence) to increase adult
immunization
– Would likely decrease missed vaccination opportunities in
adolescents
• Screening tools (NVAC recommends annual review)
• Reminder/recall systems (often with IIS)
– Recommended (strong evidence) by CDC to increase adult,
adolescent, and childhood immunizations
– Complex for adolescents (eg, changing phone numbers, waning
effect of calls)
• Vaccination “quick visits”
• Vaccination requirements for school
• Understanding other adolescent issues/care
IIS: immunization information systems
The Community Guide. http://www.thecommunityguide.org/vaccines/universally/index.html.
Accessed Nov 2010.
Szilagyi PG, et al. Arch Pediatr Adolesc Med. 2006;160:157-163.
Standing Orders Are Among the Most
Effective Strategies
• Nonphysicians offer and administer
vaccinations
• Established with physician approved
policies and protocols
• Locations:
– Clinics and hospitals
• www.immunize.org/standingorders
• www.immunizationed.org/standingorders
The Community Guide. http://www.thecommunityguide.org/vaccines/universally/index.html.
Accessed Dec 2010.
CDC. MMWR Recomm Rep. 2000;49 (RR1):15-26.
Patient and Provider Reminders
Vaccinations Due or Past Due
• Patient/parent
– Telephone, letter/postcard
• Provider
–Computerized record reminders
–Chart reminders
Stamp
Call our office today to schedule your
recommended immunizations:
 Tetanus, diphtheria, pertussis
 Human papillomavirus (HPV)
 Meningococcal
 Influenza
 Pneumococcal
Hepatitis A
Hepatitis B
Inactivated Poliovirus
Measles, mumps, rubella
Varicella
To:
[Insert contact information here]
Jacobson V, Szilagyi P. Cochrane Database Syst Rev. 2005;(3):CD003941.
Provider Assessment
and Performance Feedback
• Retrospectively assess the delivery of vaccine(s)
• Incorporates principles of continuous improvement
• AFIX
–
–
–
–
Assessment
Feedback
Incentives
eXchange
•
Comprehensive Clinic Assessment Software Application
(CoCASA)
• Immunization Information System (IIS)
CDC. http://www.cdc.gov/vaccines/programs/afix/overview.htm. Accessed Dec 2010.
The Community Guide. http://www.thecommunityguide.org/vaccines/universally/index.html. Accessed Dec 2010.
Benefits of Using a Computerized
Immunization Information System (IIS)
• Recommended by National Vaccine Advisory Committee
(NVAC) and National Immunization Program (NIP)
• Consolidates fragmented records
• Keeps track of patients needing recommended or catch-up
vaccination
• Provides automated reminder and recall
• Assists in management of vaccine supply
• Generates vaccination records for parents, schools, other
Yawn BP, et al. Am J Manag Care. 1998;4:185-192.
Glazner JE, et al. Ambul Pediatr. 2004;4:34-40.
Expanding Access
• Consider new paradigms
– New venues, walk-in clinics
– Extended hours for vaccinations
– Extend vaccination season
Nichol KL. Cleve Clin J Med. 2006;73:1009-1015.
Summary
• Stay current with the immunization schedule,
recommendations
• Educate adolescents and parents about the risk of
vaccine-preventable diseases and age-appropriate
immunizations
• Address safety concerns
• Identify and address barriers
• Implement organizational and systems strategies
• Reduce missed opportunities
• Enhance access
• Provider recommendations are important!
Resources for Providers
•
Immunization Schedules
www.cdc.gov/vaccines/recs/schedules/
•
ACIP recommendations & provisional recommendations
www.cdc.gov/vaccines/pubs/ACIP-list.htm
www.cdc.gov/vaccines/recs/provisional/default.htm
•
Immunization Action Coalition (IAC) www.immunize.org
•
The Guide to Community Preventive Services. Vaccine recommendations
www.thecommunityguide.org/vaccines/index.html
•
Assessment, Feedback, Incentives, and Exchange (AFIX)
www.cdc.gov/vaccines/programs/afix/default.htm
•
National Foundation for Infectious Diseases
www.nfid.org
•
Centers for Medicare & Medicaid Services
www.cms.hhs.gov
Resources for Patients and Parents
•
Guide to evaluating information on the web
www.cdc.gov/vaccines/vac-gen/evalwebs.htm
•
CDC Vaccine Information Statements (VISs)
http://www.cdc.gov/vaccines/pubs/vis/default.htm
•
Vaccine Safety www.cdc.gov/Features/VaccineSafety
•
National Network for Immunization Information (NNII)
www.immunizationinfo.org
•
Allied Vaccine Group www.vaccine.org
•
The Immunization Action Coalition: vaccine information for the public
and health professionals
www.vaccineinformation.org
•
Vaccine Education Center at CHOP www.vaccine.chop.edu
•
TCH Center for Vaccine Awareness and Research
www.texaschildrens.org/carecenters/vaccine/default.aspx