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Adolescent Vaccines.

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Presentation on theme: "Adolescent Vaccines."— Presentation transcript:

1 Adolescent Vaccines

2 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 childhood, adolescent, and adult 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

3 Definition of ‘Adolescent’
7th birthday until the 19th birthday Per CDC adolescent immunization schedule Society of Adolescent Medicine defines adolescent as yrs

4 2010 ACIP Adolescent Immunization Schedule
Minimum age 9 years ACIP Schedules. Accessed Jan 2010.

5 Adolescent Catch-up Schedule
ACIP Schedules. Accessed Jan 2010.

6 Adolescent (13–17 yrs) Vaccination Coverage, United States 2007–2008
100 90 2007 N = 2947 2008 N = 17,835 80 70 60 Vaccination Coverage (%) 50 40 30 20 10 MMR Hepatitis B Varicella Varicella Td or Tdap Tdap MCV4 HPV4* HPV4* ≥ 2 Doses ≥ 3 Doses ≥ 1 Dose ≥ 2 Doses ≥ 1 Dose ≥ 1 Dose ≥ 1 Dose ≥ 1 Dose ≥ 3 Doses * Percentages for females only CDC. MMWR Morb Mortal Wkly Rep. 2009;58(36):

7 Tdap Boostrix Adacel Approved for use ages 10-64 years
--- recommended catch-up Boostrix Approved for use ages years Adacel Approved for use ages 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 year olds, replaces Td booster if no previous Tdap Catch-up for yrs (5-year interval from last Td encouraged) MCV4 contains diphtheria conjugate protein carrier If both are indicated, administer MCV4 and Tdap simultaneously CDC. MMWR Recomm Rep. 2006;55(RR03):1-34.

8 Tdap 10 to 18 years of age 19 to 64 years of age
Replaces Td booster for 11­12-year-olds Catch-up for yrs (5-year interval from Td encouraged) If no previous DPT series, give as 1 Tdap + 2 Td Give with MCV4 if both vaccines are indicated Replaces Td booster; wound management* 2-year interval from Td for adults in contact with infants; health care workers Anyone who wants to decrease risk of disease The safety and effectiveness of Tdap have not been established in pregnant women If overall risk/benefit is favorable, discount risk of local rxns and immunize Note: 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 received CDC. 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):

9 Available HPV Vaccines
Quadrivalent Merck - Gardasil® Bivalent GSK - Cervarix® Licensed in the US 2006 2009 Virus-like Particle Types 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 Age ranges Routine 11 or 12 yrs, as young as 9 yrs; catch-up yrs Routine 11 or 12 yrs, as young as 10 years; catch-up yrs Schedule 0, 2, 6 months 0, 1, 6 months CIN2+: cervical intraepithelial neoplasia grade 2 or higher and adenocarcinoma in situ Markowitz L. ACIP Meeting Oct Accessed Oct 2009.

10 HPV – ACIP Recommendations Quadrivalent HPV (HPV4) and Bivalent HPV (HPV2)
Routine vaccination of females aged years with 3 doses of HPV vaccine Catch-up yrs (HPV4); yrs (HPV2) ACIP: no preference for either vaccine HPV4 or HPV2 vaccination for prevention of HPV 16/18-related cervical cancers, precancers and dysplastic lesions Vaccination with HPV4 for additional prevention against genital warts Monitor patients for 15 minutes following vaccination for syncopal episodes ACIP Schedules. Accessed Jan 2010.

11 HPV Vaccination and Pregnancy
HPV vaccines are not recommended for use in pregnant women Initiation of the vaccine series should be delayed 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 If a vaccine dose has been administered during pregnancy, there is no indication for intervention Two 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.

12 HPV 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 26 ACIP: Permissive HPV vaccine for males Cost effectiveness Priority vaccinating females to reduce overall disease/cancer burden Quadrivalent HPV vaccine most effective when given before exposure to HPV through sexual contact FDA News Release. Accessed Oct 2009. Dunne E. ACIP Meeting Oct 2009.

13 Avg Annual Incidence (#)
HPV-associated* Invasive Squamous Cell Carcinomas in Women and Men, 1998–2003 Anatomic Area Avg 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 Total Females 17,350 14.0 13.8,14.0 Penis 828 0.8 0.8,0.8 1083 1.0 1.0,1.0 5658 5.2 5.1,5.2 Total Males 7568 7.0 6.9,7.0 *Defined by histology and anatomic site Watson 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.

14 HPV Vaccine Parental Concerns
Many parents uncomfortable addressing subjects related to child sexuality, especially at such young ages Be sensitive to discussing this issue Communicate the importance of completing the 6-month immunization series before the adolescent becomes sexually active Vaccination does not imply current sexual activity, nor will it encourage it Protection against HPV acquired by involuntary sexual intercourse Improved immunogenicity at younger ages Educate parents and adolescents regarding the ubiquitous nature of HPV and its association with cervical dysplasia and cancer Parents who received education on human papillomavirus and HPV vaccine more likely to accept vaccination of their child than those who received no educational intervention Communicate the universality of the vaccine recommendation to avoid feelings of being stigmatized/singled out Rosenthal SL. J Adolesc Health. 2005;37:

15 HPV 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 12/31/08 Disproportional reporting of syncope and venous thromboembolism Increased risk among teens yrs Serious injuries have resulted Providers should strongly consider observing patients for 15 minutes after they are vaccinated Quadrivalent HPV was the only vaccine administered in: 74% of syncope/vasovagal reports 73% of dizziness reports 78% of nausea reports Slade BA, et al. JAMA. 2009;302(7): Calugar A. Oct 2008 ACIP meeting. Accessed Oct 2009.

16 Meningococcal Conjugate Vaccines
Recommended for adolescents aged years and others at increased risk for meningococcal disease 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 years; Serogroups A, C, Y, W-135; diphtheria CRM197 conjugate Revaccination for Persons at Increased Risk Previous vaccination (meningococcal conjugate vaccine or MPSV4) at 2-6 years, revaccinate 3 years after initial meningococcal vaccine Previous vaccination (meningococcal conjugate vaccine or MPSV4) at ≥ 7 years, revaccinate 5 years after initial meningococcal vaccine This includes: Persons with persistent complement component deficiencies Persons with anatomic or functional asplenia Microbiologists who are routinely exposed to isolates of N. meningitidis Frequent 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):

17 Annual 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

18 Trivalent Inactivated Virus (TIV) versus Live Attenuated Influenza Virus (LAIV) Vaccines
Licensed for use in persons age ≥6 mos Intramuscular injection TIV contains purified viral particles that have been chemically inactivated Purified components from 3 WHO-recommended annual strains Immunity developed against disrupted/denatured viral proteins, not against intact virus LAIV Licensed for use among nonpregnant persons aged 2-49 years Administered by nasal spray LAIV contains intact virus that has been propogated in eggs at 25ºC Cold-adaptation results in restricted replication at body temp More mild flu symptoms Contains same 3 WHO-recommended annual strains as TIV CDC. MMWR Recomm Rep. 2009;58(RR8):1-52. Flumist Prescribing Information. Accessed Oct 2009.

19 2009–2010 Seasonal Influenza Vaccines
2009–2010 seasonal influenza vaccine formulation: A/Brisbane/59/2007(H1N1)-like virus A/Brisbane/10/2007 (H3N2)-like virus B/Brisbane/60/2008-like antigens Vaccines Trivalent Inactivated, Injectable Influenza Vaccine Fluzone® (sanofi): age ≥ 6 months Fluvirin® (Novartis): age ≥ 4 years Fluarix® (GSK): age ≥ 3 years FluLaval™ (ID Biomedical/GSK): age ≥ 18 years Afluria® (CSL): age ≥ 6 months Live Attenuated, Nasal Spray Influenza Vaccine FluMist® (MedImmune): age 2 through 49 years (healthy, non-pregnant) Seasonal 2009 influenza vaccine does not protect against 2009 (pandemic) H1N1 influenza CDC. MMWR Recomm Rep. 2009;58(RR8):1-52. CDC. Accessed March 2010.

20 2009 H1N1 (Pandemic) Influenza Vaccines
As of November 11, 2009: 4 monovalent inactivated vaccines approved CSL Limited Age 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 injection Adults ≥ 18 yrs: Single 0.5 mL IM injection Novartis Vaccines and Diagnostics Limited Age 4-9 yrs: Two 0.5 mL IM doses (4 wk interval) Age yrs: Single 0.5 mL IM injection Age ≥18 yrs: Single 0.5 mL IM injection Sanofi Pasteur, Inc. Age ≥10 yrs: Single 0.5 mL IM injection ID Biomedical/GSK 1 live attenuated (nasal administration) MedImmune LLC Age 2-9 yrs: Two 0.2 mL doses (0.1 mL per nostril), 4 week interval Age yrs: Single 0.2 mL dose (0.1 mL per nostril) Prescribing information available at: Accessed December 2009.

21 2010–2011 Influenza Season Universal Influenza Vaccination
All people 6 months and older are now recommended to receive annual influenza vaccination Trivalent Influenza Vaccines A/California/7/2009(H1N1)-like virus Same strain as in the 2009 H1N1 monovalent vaccine A/Perth/16/2009(H3N2)-like virus New strain for northern hemisphere vaccine Same strain as 2010 southern hemisphere seasonal strain B/Brisbane/60/2008-like virus No change Current information from the CDC and FDA CDC. March 2010. CDC. Accessed June 2010. FDA. Accessed June 2010.

22 2010–2011 Influenza Season Continued Emphasis on High-risk Groups:
Children aged 6 months through 4 years Adults ≥ 50 years Women who will be pregnant during the influenza season Persons who have chronic pulmonary, cardiovascular, renal, hepatic, neurological, neuromuscular, hematological or metabolic disorders Persons who have immunosuppression (including caused by medication or HIV) Residents of nursing homes and other chronic-care facilities Health care personnel Household contacts and caregivers of children aged < 5 year and adults aged ≥ 50 years, with particular emphasis on vaccinating contacts of children < 6 months Household contacts and caregivers of persons with medical conditions that put them at higher risk for severe complications from influenza CDC. Accessed March 2010.

23 PPSV23 Single dose recommended for:
7–10 years 11-12 years 13–18 years for certain high-risk groups Single dose recommended for: All ≥ 65 years 2–64 years: chronic cardiovascular disease, chronic pulmonary disease, diabetes, alcoholism, chronic liver disease, CSF leaks, asplenia, cochlear implants >2 years and immunocompromised Asthmatics and smokers age years Proposed 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.

24 PPSV23 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.

25 HepA Routine vaccination recommended for all children ages 12-23 mos
7–10 years 11-12 years 13–18 years for certain high-risk groups Routine vaccination recommended for all children ages mos In areas without existing Hep A vaccination programs, catch-up of unvaccinated children 2-18 yrs old may be considered Recommendations for age ≥2 yrs depend on risk and vary according to state programs Dosing: VAQTA® For all persons age ≥12 mos 2 doses at 0 and 6-18 mos HAVRIX® 2 doses at 0 and 6-12 mos CDC. MMWR Morb Mortal Wkly Rep. 2006;55(RR7):1-23. CDC Resolution No. 06/07-1. Accessed Oct 2009.

26 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):

27 Hepatitis A Postexposure Prophylaxis
For healthy persons 12 months through 40 years of age who have not previously received HepA vaccine Take into account patient characteristics, including chronic liver disease Immunoglobulin and/or single-antigen hepatitis A vaccine should be administered as soon as possible after exposure Vaccine preferred for those of age 12 mos to 40 yrs Ig preferred for age <12 mos, those with vaccine allergies, or those with immunosuppression or liver disease Ig preferred for age >40 but vaccine may be used if Ig unavailable HepA and Ig may be administered simultaneously Efficacy of Ig or HepA when administered >2 weeks postexposure is unknown CDC. MMWR Morb Mortal Wkly Rep. 2007;56(41): CDC. MMWR Morb Mortal Wkly Rep. 2009;58(36):

28 Hepatitis 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):

29 HepB Multiple schedules
7–10 years 11-12 years 13–18 years catch-up Multiple schedules Children 1-10 yrs 0, 1, and 6 mos 0, 2, and 4 mos 0, 1, 2, and 12 mos Adolescents yrs 0, 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 formulation CDC. MMWR Recomm Rep. 2005;54(RR16):1-23.

30 HepA-HepB Combination Vaccine (Twinrix)
Approved for persons 18 years and older Combination HepA vaccine (pediatric dose) and HepB (adult dose) First licensed schedule: 0, 1, and 6 months Alternate schedule 2007: Doses at 0, 7, days and a 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 Duration of protection 4 yrs against HepA No increased benefit of the new schedule for the hepatitis B component compared to administration of 2 hepatitis B vaccine doses 1 to 2 months apart CDC. MMWR Morb Mortal Wkly Rep. 2007;56(40):1057.

31 Varicella Universal recommendation for routine vaccination is 2 doses
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 4 to 8 weeks apart for those ≥ 13 years old Second dose is still valid if >8 week interval Formulations Varivax licensed ages 12 mos and older Proquad (Combination MMRV) not licensed ≥13 years CDC. MMWR Recomm Rep. 2007;56(RR04):1-40.

32 Adolescent Immunization: Goals and Objectives
Effective adolescent vaccine delivery and monitoring are critical Adolescents lag far behind preschoolers in immunization coverage Healthy People 2010 objective for adolescents aged years is 90% coverage with the following: 3 or more doses of hepatitis B vaccine 2 or more doses of MMR vaccine 1 or more doses of Td* vaccine 1 or more doses of varicella vaccine *Healthy People 2010 objectives were set prior to licensure of Tdap, meningococcal, and HPV vaccines. 32

33 Strategies for Improving Adolescent Immunization Rates

34 Healthy 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 years Increase routine vaccination coverage levels for adolescents For yrs olds, 90% coverage rates for ≥ 3 hepatitis B, ≥ 2 MMR, ≥ 1 varicella, ≥ 1 TD Flu vaccine recommendation is new; no specific goal established Healthy People 14-27.htm. Accessed September 2009.

35 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 Rosenthal 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:

36 Patient and Provider Factors That Influence Adolescent Immunization
Education/ Knowledge Self-Efficacy Patient Provider Insurance/ Reimbursement Time Provider likelihood to administer immunization Patient likelihood to access immunization ADOLESCENT IMMUNIZATION Middleman AB. J Adolesc Health. 2007;41:

37 Available Reimbursement for Adolescent Vaccination
Public funding for eligible children up to but not including the 19th birthday Vaccines for Children Program (VFC) Many insurers follow VFC lead State Children’s Health Insurance Program (SCHIP) Funding for adolescents > 19 years: Federal Vaccination Assistance Act, Section 317 Inadequate for large-scale immunization strategies

38 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.

39 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: IDSA. Clin Infect Dis. 2007;44:e104-e108.

40 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.

41 Adolescent 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 2009 National Immunization Survey (NIS) 2006: First year of data collection for adolescents 13 to 17 years of age NIS-Teen: Includes provider-reported information HPV not reported (recommended in 2007) Now conducted annually

42 NIS-Teen Results Vaccine Coverage 2006+ 2007^ 2008*
≥ 1 dose Tdap after 10 years of age 10.8% 30.4% 40.8% ≥ 1 dose Td/Tdap after 10 years of age 60.1% 72.3% 72.2% ≥ 3 doses HepB vaccine 81.3% 87.6% 87.9% ≥ 2 doses MMR vaccine 86.9% 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 vaccine 11.7% 32.4% 41.8% HPV 4 ≥ 1 dose 25.1% 37.2% +n = adolescents ^n = 2947 adolescents *n = 17,835 adolescents CDC. MMWR Morb Mortal Wkly Rep. 2008;57(40): CDC. MMWR Morb Mortal Wkly Rep. 2009;58(36):

43 Adolescent Immunization Rates: Strategies to Hit the Target
Public Policy Providers National State Education re immunizations Use of recall systems Education re: provision of preventive care for adolescents Use of standing orders Mandates for school entry Development of standard immunization platforms by ACIP, professional organizations Use of immunization information systems Development of specific vaccination “quick visits” if other services not needed Use of screening tools Bull’s-eye! Shots in Adolescent Arms State review of “consent” procedures Attend vaccination “quick visits” if other preventive services not required Education re need for preventive care of adolescents Reimbursement/ funding (currently SCHIP) Use of alternative site if no medical home or if need to complete a series of vaccinations Reimbursement/ funding (currently VFC, 317) Enrollment in immunization information systems Education re: immunizations Funding and support for immunization information systems Patients Funding and support for immunization information systems State legislation allowing immunization at alternative sites Insurance reform Middleman AB. J Adoles Health. 2007;41:

44 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: Glazner JE, et al. Ambul Pediatr. 2004;4:34-40.

45 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 McInerny 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:

46 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” Understanding other adolescent issues/care IIS: immunization information systems The Community Guide. Accessed September 2009. Szilagyi PG, et al. Arch Pediatr Adolesc Med. 2006;160:

47 The Goal: To Increase the Adolescent Immunization Rate
Healthy People 2010 Adolescent immunization coverage goal: 90% Increase number of providers who measure vaccination coverage level every 2 years among children in their practice Free 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.

48 Standing Orders Are Among the Most Effective Strategies
Nonphysicians offer and administer vaccinations No direct MD involvement at the time of the visit Established with physician approved policies and protocols Locations: Clinics and hospitals CDC. Accessed September 2009. McKibbin LJ, et al. MMWR Recomm Rep. 2000;49 (RR1):15-26.

49 Success of Standing Orders as Part of a Multifaceted Program
Influenza Vaccination Rates for Elderly Patients in General Medicine Clinics Standing Orders Education Nichol KL. Am J Med. 1998;105:

50 Resources

51 PROTECTTM Website:

52 Resources for Patients and Parents
Guide to evaluating information on the web CDC Vaccine Information Statements (VISs) Vaccine Safety National Network for Immunization Information (NNII) Allied Vaccine Group Immunization Action Coalition (IAC) Vaccine Education Center at CHOP TCH Center for Vaccine Awareness and Research

53 Resources for Providers
Immunization Schedules ACIP recommendations & provisional recommendations The Guide to Community Preventive Services. Vaccine recommendations Assessment, Feedback, Incentives, and Exchange (AFIX) National Foundation for Infectious Diseases Centers for Medicare & Medicaid Services

54 Resources for Providers, Parents, and Patients
The Immunization Action Coalition: vaccine information for the public and health professionals The Immunization Action Coalition: directory of immunization coalitions

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