2Educational 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 childhood, adolescent, and adult populationsRespond to frequently encountered questions and situations during patient discussions including safety, efficacy, and possible misinformationImplement strategies for improving immunization rates within one’s clinical practice, taking into account current immunization schedules and guidelines
3Definition of ‘Adolescent’ 7th birthday until the 19th birthdayPer CDC adolescent immunization scheduleSociety of Adolescent Medicine defines adolescent as yrs
42010 ACIP Adolescent Immunization Schedule Minimum age 9 yearsACIP Schedules. Accessed Jan 2010.
5Adolescent Catch-up Schedule ACIP Schedules. Accessed Jan 2010.
6Adolescent (13–17 yrs) Vaccination Coverage, United States 2007–2008 100902007 N = 29472008 N = 17,835807060Vaccination Coverage (%)5040302010MMRHepatitis BVaricellaVaricellaTd or TdapTdapMCV4HPV4*HPV4*≥ 2 Doses≥ 3 Doses≥ 1 Dose≥ 2 Doses≥ 1 Dose≥ 1 Dose≥ 1 Dose≥ 1 Dose≥ 3 Doses* Percentages for females onlyCDC. MMWR Morb Mortal Wkly Rep. 2009;58(36):
7Tdap Boostrix Adacel Approved for use ages 10-64 years ---recommendedcatch-upBoostrixApproved for useages yearsAdacelApproved for useages yearsTwo FDA-approved Tdap vaccines availableBoth contain the same acellular pertussis component as their respective DTaP productsFDA recommended one-time use of Tdap onlyFor year olds, replaces Td booster if no previous TdapCatch-up for yrs (5-year interval from last Td encouraged)MCV4 contains diphtheria conjugate protein carrierIf both are indicated, administer MCV4 and Tdap simultaneouslyCDC. MMWR Recomm Rep. 2006;55(RR03):1-34.
8Tdap 10 to 18 years of age 19 to 64 years of age Replaces Td booster for 1112-year-oldsCatch-up for yrs (5-year interval from Td encouraged)If no previous DPT series, give as 1 Tdap + 2 TdGive with MCV4 if both vaccines are indicatedReplaces Td booster; wound management*2-year interval from Td for adults in contact with infants; health care workersAnyone who wants to decrease risk of diseaseThe safety and effectiveness of Tdap have not been established in pregnant womenIf overall risk/benefit is favorable, discount risk of local rxns and immunizeNote: Give MCV4 and Tdap simultaneously if both are indicated; carrier protein for MCV4 is diphtheria toxoid, avoid injection site reactions from sequential vaccination.* Only if no previous Tdap receivedCDC. MMWR Recomm Rep. 2006;55(RR3):1-34.CDC. MMWR Recomm Rep. 2006;55(RR17):1-33.CDC. MMWR Morb Mortal Wkly Rep. 2009;58(14):
9Available HPV Vaccines QuadrivalentMerck - Gardasil®BivalentGSK - Cervarix®Licensed in the US20062009Virus-like Particle TypesHPV 6, 11, 16, 18HPV 16, 18Protection against HPV 16/18 related CIN2+≥ 98%≥ 93%Protection against HPV 6/11 related genital lesions~99%---Hypersensitivity-related contraindicationYeastLatexAge rangesRoutine 11 or 12 yrs, as young as 9 yrs;catch-up yrsRoutine 11 or 12 yrs,as young as 10 years;catch-up yrsSchedule0, 2, 6 months0, 1, 6 monthsCIN2+: cervical intraepithelial neoplasia grade 2 or higher and adenocarcinoma in situMarkowitz L. ACIP Meeting Oct Accessed Oct 2009.
10HPV – ACIP Recommendations Quadrivalent HPV (HPV4) and Bivalent HPV (HPV2) Routine vaccination of females aged years with 3 doses of HPV vaccineCatch-up yrs (HPV4); yrs (HPV2)ACIP: no preference for either vaccineHPV4 or HPV2 vaccination for prevention of HPV 16/18-related cervical cancers, precancers and dysplastic lesionsVaccination with HPV4 for additional prevention against genital wartsMonitor patients for 15 minutes following vaccination for syncopal episodesACIP Schedules. Accessed Jan 2010.
11HPV Vaccination and Pregnancy HPV vaccines are not recommended for use in pregnant womenInitiation of the vaccine series should be delayed until after completion of pregnancyIf a woman is found to be pregnant after initiating the vaccination series, delay remaining doses until after the pregnancyIf a vaccine dose has been administered during pregnancy, there is no indication for interventionTwo vaccine in pregnancy registries have been established. Patients and health care providers should report:Quadrivalent HPV vaccine/pregnancy:Bivalent HPV vaccine/pregnancy:CDC.Accessed March 2010.
12HPV Quadrivalent Vaccine in Males FDA approved quadrivalent HPV vaccine for prevention of genital warts due to HPV types 6 and 11 in boys and men ages 9 through 26ACIP: Permissive HPV vaccine for malesCost effectivenessPriority vaccinating females to reduce overall disease/cancer burdenQuadrivalent HPV vaccine most effective when given before exposure to HPV through sexual contactFDA News Release.Accessed Oct 2009.Dunne E. ACIP Meeting Oct 2009.
13Avg Annual Incidence (#) HPV-associated* Invasive Squamous Cell Carcinomas in Women and Men, 1998–2003Anatomic AreaAvg Annual Incidence (#)Incidence (per 100,000)95% CICervix10,8468.98.9,9.0Vagina6010.50.4,0.5Vulva22661.71.7,1.7Anus/Rectum19351.51.5,1.5Oropharynx/OC17021.31.3,1.4Total Females17,35014.013.8,14.0Penis8280.80.8,0.810831.01.0,1.056585.25.1,5.2Total Males75687.06.9,7.0*Defined by histology and anatomic siteWatson M, et al. Cancer. 2008;113(10suppl):Data source: National Program of Cancer Registries and SEER, covering 83% coverage of US population.ACIP Meeting February Accessed Oct 2009.
14HPV Vaccine Parental Concerns Many parents uncomfortable addressing subjects related to child sexuality, especially at such young agesBe sensitive to discussing this issueCommunicate the importance of completing the 6-month immunization series before the adolescent becomes sexually activeVaccination does not imply current sexual activity, nor will it encourage itProtection against HPV acquired by involuntary sexual intercourseImproved immunogenicity at younger agesEducate parents and adolescents regarding the ubiquitous nature of HPV and its association with cervical dysplasia and cancerParents who received education on human papillomavirus and HPV vaccine more likely to accept vaccination of their child than those who received no educational interventionCommunicate the universality of the vaccine recommendation to avoid feelings of being stigmatized/singled outRosenthal SL. J Adolesc Health. 2005;37:
15HPV Postlicensure Safety Data- VAERS Review of 12,424 adverse event reports following immunization (AEFI) with quadrivalent HPV Vaccine from the Vaccine Adverse Event Reporting System (VAERS): 6/31/06 through 12/31/08Disproportional reporting of syncope and venous thromboembolismIncreased risk among teens yrsSerious injuries have resultedProviders should strongly consider observing patients for 15 minutes after they are vaccinatedQuadrivalent HPV was the only vaccine administered in:74% of syncope/vasovagal reports73% of dizziness reports78% of nausea reportsSlade BA, et al. JAMA. 2009;302(7):Calugar A. Oct 2008 ACIP meeting.Accessed Oct 2009.
16Meningococcal Conjugate Vaccines Recommended for adolescents aged years and others at increased risk for meningococcal diseaseMCV4-D (Menactra®, Sanofi): licensed for persons 2-55 years; Serogroups A, C, Y, W-135; diphtheria toxoid conjugateMenACWY-CRM197 (Menveo®, Novartis): licensed for persons years; Serogroups A, C, Y, W-135; diphtheria CRM197 conjugateRevaccination for Persons at Increased RiskPrevious vaccination (meningococcal conjugate vaccine or MPSV4) at 2-6 years, revaccinate 3 years after initial meningococcal vaccinePrevious vaccination (meningococcal conjugate vaccine or MPSV4) at ≥ 7 years, revaccinate 5 years after initial meningococcal vaccineThis includes:Persons with persistent complement component deficienciesPersons with anatomic or functional aspleniaMicrobiologists who are routinely exposed to isolates of N. meningitidisFrequent travelers to or people living in areas with high rates of meningococcal disease (African meningitis belt)Meissner HC. Accessed March 2010.CDC. MMWR Morb Mortal Wkly Rep. 2009;58(37):
17Annual Influenza Vaccine is Recommended for: All people age 6 months and older!According to the Advisory Committee on Immunization Practices (ACIP) of the US Centers for Disease Control and Prevention (CDC), several groups of people should be primary targets for vaccination during the influenza season. These are groups who are at high risk of morbidity or mortality due to influenza.CDC. Accessed March 2010.17
18Trivalent Inactivated Virus (TIV) versus Live Attenuated Influenza Virus (LAIV) Vaccines Licensed for use in persons age ≥6 mosIntramuscular injectionTIV contains purified viral particles that have been chemically inactivatedPurified components from 3 WHO-recommended annual strainsImmunity developed against disrupted/denatured viral proteins, not against intact virusLAIVLicensed for use among nonpregnant persons aged 2-49 yearsAdministered by nasal sprayLAIV contains intact virus that has been propogated in eggs at 25ºCCold-adaptation results in restricted replication at body tempMore mild flu symptomsContains same 3 WHO-recommended annual strains as TIVCDC. MMWR Recomm Rep. 2009;58(RR8):1-52.Flumist Prescribing Information. Accessed Oct 2009.
192009–2010 Seasonal Influenza Vaccines 2009–2010 seasonal influenza vaccine formulation:A/Brisbane/59/2007(H1N1)-like virusA/Brisbane/10/2007 (H3N2)-like virusB/Brisbane/60/2008-like antigensVaccinesTrivalent Inactivated, Injectable Influenza VaccineFluzone® (sanofi): age ≥ 6 monthsFluvirin® (Novartis): age ≥ 4 yearsFluarix® (GSK): age ≥ 3 yearsFluLaval™ (ID Biomedical/GSK): age ≥ 18 yearsAfluria® (CSL): age ≥ 6 monthsLive Attenuated, Nasal Spray Influenza VaccineFluMist® (MedImmune): age 2 through 49 years (healthy, non-pregnant)Seasonal 2009 influenza vaccine does not protect against 2009 (pandemic) H1N1 influenzaCDC. MMWR Recomm Rep. 2009;58(RR8):1-52.CDC.Accessed March 2010.
202009 H1N1 (Pandemic) Influenza Vaccines As of November 11, 2009: 4 monovalent inactivated vaccines approvedCSL LimitedAge 6-35 mos: Two 0.25 mL IM doses (4 wk interval)Age 36 mos to 9 yrs: Two 0.5 mL IM doses (4 wk interval)Age ≥ 10 yrs: Single 0.5 mL IM injectionAdults ≥ 18 yrs: Single 0.5 mL IM injectionNovartis Vaccines and Diagnostics LimitedAge 4-9 yrs: Two 0.5 mL IM doses (4 wk interval)Age yrs: Single 0.5 mL IM injectionAge ≥18 yrs: Single 0.5 mL IM injectionSanofi Pasteur, Inc.Age ≥10 yrs: Single 0.5 mL IM injectionID Biomedical/GSK1 live attenuated (nasal administration)MedImmune LLCAge 2-9 yrs: Two 0.2 mL doses (0.1 mL per nostril), 4 week intervalAge yrs: Single 0.2 mL dose (0.1 mL per nostril)Prescribing information available at: Accessed December 2009.
212010–2011 Influenza Season Universal Influenza Vaccination All people 6 months and older are now recommended to receive annual influenza vaccinationTrivalent Influenza VaccinesA/California/7/2009(H1N1)-like virusSame strain as in the 2009 H1N1 monovalent vaccineA/Perth/16/2009(H3N2)-like virusNew strain for northern hemisphere vaccineSame strain as 2010 southern hemisphere seasonal strainB/Brisbane/60/2008-like virusNo changeCurrent information from the CDC and FDACDC. March 2010.CDC. Accessed June 2010.FDA. Accessed June 2010.
222010–2011 Influenza Season Continued Emphasis on High-risk Groups: Children aged 6 months through 4 yearsAdults ≥ 50 yearsWomen who will be pregnant during the influenza seasonPersons who have chronic pulmonary, cardiovascular, renal, hepatic, neurological, neuromuscular, hematological or metabolic disordersPersons who have immunosuppression (including caused by medication or HIV)Residents of nursing homes and other chronic-care facilitiesHealth care personnelHousehold contacts and caregivers of children aged < 5 year and adults aged ≥ 50 years, with particular emphasis on vaccinating contacts of children < 6 monthsHousehold contacts and caregivers of persons with medical conditions that put them at higher risk for severe complications from influenzaCDC. Accessed March 2010.
23PPSV23 Single dose recommended for: 7–10 years11-12 years13–18 yearsfor certain high-risk groupsSingle dose recommended for:All ≥ 65 years2–64 years: chronic cardiovascular disease, chronic pulmonary disease, diabetes, alcoholism, chronic liver disease, CSF leaks, asplenia, cochlear implants>2 years and immunocompromisedAsthmatics and smokers age yearsProposed language for one-time revaccination:“A second dose of PPSV23 is recommended 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”ACIP Summary Recommendations. Accessed Oct 2009.ACIP Provisional Recommendations. Accessed Oct 2009.
24PPSV23 and Alaskan Natives, American Indians “Routine use of PPSV23 is not recommended for Alaska Native or American Indian persons younger than 65 years old unless they have underlying medical conditions that are PPSV23 indications.However, in special situations, public health authorities may recommend PPSV23 for Alaska Natives and American Indians aged 50 through 64 years who are living in areas in which the risk of invasive pneumococcal disease is increased."ACIP Provisional Recommendations.Accessed Oct 2009.
25HepA Routine vaccination recommended for all children ages 12-23 mos 7–10 years11-12 years13–18 yearsfor certain high-risk groupsRoutine vaccination recommended for all children ages mosIn areas without existing Hep A vaccination programs, catch-up of unvaccinated children 2-18 yrs old may be consideredRecommendations for age ≥2 yrs depend on risk and vary according to state programsDosing:VAQTA®For all persons age ≥12 mos2 doses at 0 and 6-18 mosHAVRIX®2 doses at 0 and 6-12 mosCDC. MMWR Morb Mortal Wkly Rep. 2006;55(RR7):1-23.CDC Resolution No. 06/07-1.Accessed Oct 2009.
26Hepatitis A Vaccine International Travel For healthy persons 40 years of age or younger2 doses 6 months apart prior to departureThe first dose of Hepatitis A vaccine should be administered as soon as travel is considered1 dose of single-antigen vaccine administered at any time before departureConsider both HAV and Ig forPersons age > 40 with chronic illness traveling in less than 2 weeks and only receiving one dose of HAVPersons at risk of severe disease from hepatitis A virus planning to travel in 2 weeks or soonerCDC. MMWR Morb Mortal Wkly Rep. 2007;56(41):
27Hepatitis A Postexposure Prophylaxis For healthy persons 12 months through 40 years of age who have not previously received HepA vaccineTake into account patient characteristics, including chronic liver diseaseImmunoglobulin and/or single-antigen hepatitis A vaccine should be administered as soon as possible after exposureVaccine preferred for those of age 12 mos to 40 yrsIg preferred for age <12 mos, those with vaccine allergies, or those with immunosuppression or liver diseaseIg preferred for age >40 but vaccine may be used if Ig unavailableHepA and Ig may be administered simultaneouslyEfficacy of Ig or HepA when administered >2 weeks postexposure is unknownCDC. MMWR Morb Mortal Wkly Rep. 2007;56(41):CDC. MMWR Morb Mortal Wkly Rep. 2009;58(36):
28Hepatitis A: Families of International Adoptees Hepatitis A vaccination is recommended for 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.The first dose of hepatitis A vaccine should be administered as soon as adoption is planned. Ideally, the first dose of hepatitis A vaccine should be administered at least two weeks prior to the arrival of the adoptee.CDC. MMWR Morb Mortal Wkly Rep. 2009;58(36):
29HepB Multiple schedules 7–10 years11-12 years13–18 yearscatch-upMultiple schedulesChildren 1-10 yrs0, 1, and 6 mos0, 2, and 4 mos0, 1, 2, and 12 mosAdolescents yrs0, 1, and 4 mos*0, 2, and 4 mos*0, 12, and 24 mos*0 and 4-6 mos (2 dose schedule uses adult 10ug formulation, Recombivax-HB)**No combination HepB vaccines approved for use in ages yrs* These schedules provide equivalent seroprotection in adolescents**No long-term data are available for antibody persistence- when second dose is to be administered at age >15 yrs, consider switching to a 3-dose schedule using pediatric formulationCDC. MMWR Recomm Rep. 2005;54(RR16):1-23.
30HepA-HepB Combination Vaccine (Twinrix) Approved for persons 18 years and olderCombination HepA vaccine (pediatric dose) and HepB (adult dose)First licensed schedule: 0, 1, and 6 monthsAlternate schedule 2007: Doses at 0, 7, days and a booster dose at 12 monthsThe first 3 doses of the new schedule provide equivalent protection to:The first dose in the standard single-antigen adult hepatitis A vaccine seriesThe first 2 doses in the standard adult hepatitis B vaccine seriesSeroconversion 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 vaccineDuration of protection 4 yrs against HepANo increased benefit of the new schedule for the hepatitis B component compared to administration of 2 hepatitis B vaccine doses 1 to 2 months apartCDC. MMWR Morb Mortal Wkly Rep. 2007;56(40):1057.
31Varicella Universal recommendation for routine vaccination is 2 doses 7–10 years11-12 years13–18 yearscatch-upUniversal recommendation for routine vaccination is 2 dosesGiven 3 months apart for those under 13 years old4 to 8 weeks apart for those ≥ 13 years oldSecond dose is still valid if >8 week intervalFormulationsVarivax licensed ages 12 mos and olderProquad (Combination MMRV) not licensed ≥13 yearsCDC. MMWR Recomm Rep. 2007;56(RR04):1-40.
32Adolescent Immunization: Goals and Objectives Effective adolescent vaccine delivery and monitoring are criticalAdolescents lag far behind preschoolers in immunization coverageHealthy People 2010 objective for adolescents aged years is 90% coverage with the following:3 or more doses of hepatitis B vaccine2 or more doses of MMR vaccine1 or more doses of Td* vaccine1 or more doses of varicella vaccine*Healthy People 2010 objectives were set prior to licensure of Tdap, meningococcal, and HPV vaccines.32
33Strategies for Improving Adolescent Immunization Rates
34Healthy People 2010 Adolescent Immunization Goals Increase the proportion of young children and adolescents who receive all vaccines that have been recommended for universal administration for at least 5 yearsIncrease routine vaccination coverage levels for adolescentsFor yrs olds, 90% coverage rates for ≥ 3 hepatitis B, ≥ 2 MMR, ≥ 1 varicella, ≥ 1 TDFlu vaccine recommendation is new; no specific goal establishedHealthy People14-27.htm. Accessed September 2009.
35Parents Are a Key Influence Parental perception of vaccination is an important factor in adolescents’ vaccination decisions1,2Parents influence adolescent acceptanceProviders influence parental acceptanceParental consent for immunization is the most cited barrier to immunizing students at school-based vaccination initiatives3,4Rosenthal SL, et al. J Adolesc Health. 1995;17:Rosenthal SL. J Adolesc Health. 2005;37:Guajardo AD, et al. J Sch Health. 2002;72:Deeks SL, Johnson IL. Can J Public Health. 1998;89:
36Patient and Provider Factors That Influence Adolescent Immunization Education/KnowledgeSelf-EfficacyPatientProviderInsurance/ReimbursementTimeProvider likelihood to administerimmunizationPatient likelihood to access immunizationADOLESCENT IMMUNIZATIONMiddleman AB. J Adolesc Health. 2007;41:
37Available Reimbursement for Adolescent Vaccination Public funding for eligible children up to but not including the 19th birthdayVaccines for Children Program (VFC)Many insurers follow VFC leadState Children’s Health Insurance Program (SCHIP)Funding for adolescents > 19 years:Federal Vaccination Assistance Act, Section 317Inadequate for large-scale immunization strategies
38Establishing Adolescent Immunization Platforms Need exists for standard immunization visits during adolescenceACIP recommendations geared to 11- to 12-year-old age groupYounger adolescents have higher rates of accessing preventive health care than older adolescentsRand CM, et al. J Adolesc Health. 2005;37:87-93.
39Establishing Adolescent Immunization Platforms (cont) Society for Adolescent Medicine position statement11- to 12-year visit: primary immunization platform14- to 15-year visit: catch up on missed vaccines or complete multidose regimens17- to 18-year visit: update vaccinations that were missed or are newly recommendedMiddleman AB, et al. J Adolesc Health. 2006;38:IDSA. Clin Infect Dis. 2007;44:e104-e108.
40Advantages of Building an Adolescent Immunization Platform Structure Puts focus on disease prevention among this age groupPresents 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 visitsIDSA. Clin Infect Dis. 2007;44:e104-e108.
41Adolescent Vaccination Coverage: Who Is Measuring? The National Committee for Quality Assurance (NCQA) Healthcare Effectiveness Data and Information Set (HEDIS) update:NCQA eliminated measures in 2008; Web site indicates development of updated measures for 2009National Immunization Survey (NIS) 2006: First year of data collection for adolescents 13 to 17 years of ageNIS-Teen:Includes provider-reported informationHPV not reported (recommended in 2007)Now conducted annually
42NIS-Teen Results Vaccine Coverage 2006+ 2007^ 2008* ≥ 1 dose Tdap after 10 years of age10.8%30.4%40.8%≥ 1 dose Td/Tdap after 10 years of age60.1%72.3%72.2%≥ 3 doses HepB vaccine81.3%87.6%87.9%≥ 2 doses MMR vaccine86.9%88.9%89.3%≥ 1 dose of Varicella vaccine (no disease history)65.5%75.7%81.9%≥ 2 doses of Varicella vaccine (no disease history)–18.8%34.1%MCV4 vaccine11.7%32.4%41.8%HPV 4 ≥ 1 dose25.1%37.2%+n = adolescents^n = 2947 adolescents*n = 17,835 adolescentsCDC. MMWR Morb Mortal Wkly Rep. 2008;57(40):CDC. MMWR Morb Mortal Wkly Rep. 2009;58(36):
43Adolescent Immunization Rates: Strategies to Hit the Target Public PolicyProvidersNationalStateEducation re immunizationsUse of recall systemsEducationre: provision of preventive care for adolescentsUse of standing ordersMandates for school entryDevelopment of standard immunization platforms by ACIP, professional organizationsUse of immunization information systemsDevelopment of specific vaccination“quick visits” if other services not neededUse of screening toolsBull’s-eye!Shots inAdolescentArmsState review of “consent” proceduresAttend vaccination “quick visits” if other preventive services not requiredEducationre need for preventive care of adolescentsReimbursement/funding (currently SCHIP)Use of alternative siteif no medical home or if need to complete a series of vaccinationsReimbursement/funding(currently VFC, 317)Enrollment in immunization information systemsEducation re: immunizationsFunding and support for immunization information systemsPatientsFunding and support for immunization information systemsState legislation allowing immunization at alternative sitesInsurance reformMiddleman AB. J Adoles Health. 2007;41:
44Benefits of Using a Computerized Immunization Information System (IIS) Recommended by National Vaccine Advisory Committee (NVAC) and National Immunization Program (NIP)Consolidates fragmented recordsKeeps track of patients needing recommended or catch-up vaccinationProvides automated reminder and recallAssists in management of vaccine supplyGenerates vaccination records for parents, schools, otherYawn BP, et al. Am J Manag Care. 1998;4:Glazner JE, et al. Ambul Pediatr. 2004;4:34-40.
45Are Providers Seeing Adolescents? HEDIS data: 34% of adolescents who participate in health plans have annual preventive visits1NCHS (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 year288–92% of adolescents report having an identified source of primary care3,4HEDIS = Health Plan Employer Data and Information Set; NCHS = National Center for Health StatisticsMcInerny TK, et al. Pediatrics. 2005;115:National Center for Health Statistics. Health, United States, 2005.Klein JD, et al. Arch Pediatr Adolesc Med. 1998;152:Klein JD, et al. J Adolesc Health. 1999;25:
46Provider-based Strategies to Improve Adolescent Immunization Rates Standing ordersRecommended by CDC (strong evidence) to increase adult immunizationWould likely decrease missed vaccination opportunities in adolescentsScreening tools (NVAC recommends annual review)Reminder/recall systems (often with IIS)Recommended (strong evidence) by CDC to increase adult, adolescent, and childhood immunizationsComplex for adolescents (eg, changing phone numbers, waning effect of calls)Vaccination “quick visits”Understanding other adolescent issues/careIIS: immunization information systemsThe Community Guide. Accessed September 2009.Szilagyi PG, et al. Arch Pediatr Adolesc Med. 2006;160:
47The Goal: To Increase the Adolescent Immunization Rate Healthy People 2010Adolescent immunization coverage goal: 90%Increase number of providers who measure vaccination coverage level every 2 years among children in their practiceFree assistance from public health departments (CoCASA software)Vaccines for Children quality improvement activities (eg, AFIX)Healthy People 2010 Immunization and Infectious Disease. Accessed Oct 2009.CoCASA. Accessed Oct 2009.AFIX. Accessed Oct 2009.
48Standing Orders Are Among the Most Effective Strategies Nonphysicians offer and administer vaccinationsNo direct MD involvement at the time of the visitEstablished with physician approved policies and protocolsLocations:Clinics and hospitalsCDC. Accessed September 2009.McKibbin LJ, et al. MMWR Recomm Rep. 2000;49 (RR1):15-26.
49Success of Standing Orders as Part of a Multifaceted Program Influenza Vaccination Rates for Elderly Patients in General Medicine ClinicsStandingOrdersEducationNichol KL. Am J Med. 1998;105:
52Resources for Patients and Parents Guide to evaluating information on the webCDC Vaccine Information Statements (VISs)Vaccine SafetyNational Network for Immunization Information (NNII)Allied Vaccine GroupImmunization Action Coalition (IAC)Vaccine Education Center at CHOPTCH Center for Vaccine Awareness and Research
53Resources for Providers Immunization SchedulesACIP recommendations & provisional recommendationsThe Guide to Community Preventive Services. Vaccine recommendationsAssessment, Feedback, Incentives, and Exchange (AFIX)National Foundation for Infectious DiseasesCenters for Medicare & Medicaid Services
54Resources for Providers, Parents, and Patients The Immunization Action Coalition: vaccine information for the public and health professionalsThe Immunization Action Coalition: directory of immunization coalitions