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Strategies for Improving Adolescent Immunization Rates.

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1 Strategies for Improving Adolescent Immunization Rates

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 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

3 Definition of ‘Adolescent’ 7 th birthday until the 19 th birthday –Per CDC adolescent immunization schedule Society of Adolescent Medicine defines adolescent as 10 to 25 years

4 2011 ACIP Adolescent Immunization Schedule ACIP Schedules. Accessed Feb 2011.

5 Adolescent Catch-up Schedule ACIP Schedules. Accessed Feb 2011.

6 Vaccination Coverage Adolescents 13–17 yrs, United States, National Immunization Survey CDC. MMWR Morb Mortal Wkly Rep. 2009;58(36): CDC. MMWR Morb Mortal Wkly Rep. 2010;59(32):

7 Tdap 7–10 years11-12 years13–18 years catch-up*recommendedcatch-up 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 Boostrix Approved for use ages years Adacel Approved for use ages years CDC. MMWR Recomm Rep. 2006;55(RR03):1-34. ACIP. Accessed Nov *off-label ACIP recommendation

8 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. Accessed Dec 2010.

9 HPV-associated* Invasive Squamous Cell Carcinomas in Women and Men, 1998–2003 Anatomic Area Average Annual Incidence (#) Incidence (per 100,000) 95% CI Cervix10, ,9.0 Vagina ,0.5 Vulva ,1.7 Anus/Rectum ,1.5 Oropharynx/OC ,1.4 Total Females17, ,14.0 Penis ,0.8 Anus/Rectum ,1.0 Oropharynx/OC ,5.2 Total Males ,7.0 *Defined by histology and anatomic site Watson M, et al. Cancer. 2008;113(10suppl): CDC. Accessed Jan 2011.

10 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?

11 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

12 Available HPV Vaccines Quadrivalent Merck - Gardasil ® Bivalent GSK - Cervarix ® Licensed in the US Virus-like particle typesHPV 6, 11, 16, 18HPV 16, 18 Protection against HPV 16/18 related CIN2+ ≥ 98%≥ 93% Protection against HPV 6/11 related genital lesions ~99%--- Hypersensitivity-related contraindication YeastLatex* Licensed age range9–26 yrs10–25 yrs ACIP Recommendations Routine 11–12 yrs, catch-up 13–26 yrs Routine 11–12 yrs, catch-up 13–26 yrs Schedule 0, 1-2, 6 months Markowitz L. ACIP Meeting Oct oct09/02-2-hpv.pdf. Accessed Dec CIN2+: cervical intraepithelial neoplasia grade 2 or higher and adenocarcinoma in situ *needle-less prefilled syringes contain latex; vial stopper does not contain latex

13 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. Accessed Dec FDA. Accessed Dec 2010.

14 Proportion of Clinicians Who Strongly Recommend HPV Vaccine to Female Patients Survey Data Jan–Mar 2008 Daley M, et al. Pediatrics. 2010;126:

15 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: –Bivalent HPV vaccine/pregnancy: CDC. MMWR Morb Mortal Wkly Rep. 2010;59(20):

16 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):

17 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 HPV Quadrivalent Vaccine in Males Ongoing Considerations ACIP. hpv-MaleConsider.pdf. Accessed Dec 2010.

18 Intent to Vaccinate with HPV among Parents of Females Who Have Not Received Any HPV Vaccine; NIS–Teen 2009 ACIP. hpv-Female.pdf. Accessed Nov 2010.

19 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:

20 HPV Postlicensure Safety Data ACIP. -VaccSafety.pdf. Accessed Dec 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

21 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-CRM 197 (Menveo ®, Novartis)  Licensed for persons 2-55 years  Serogroups A, C, Y, W-135  Diphtheria CRM 197 conjugate FDA. Accessed Feb 2011.

22 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 CDC. MMWR Morb Mortal Wkly Rep. 2011;60(3): *Meningococcal conjugate vaccine, quadrivalent; Menactra ® or Menveo ®

23 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. Accessed Dec 2010.

24 Update on Meningococcal Conjugate Vaccine Safety ACIP. Accessed Dec large post-licensure studies –Meningococcal Vaccine Study and Vaccine Safety Datalink Rapid Cycle Analysis Study > 2.3 million MenACYW D (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 MenACYW D 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 MenACYW D

25 Annual Influenza Vaccine Is Recommended for: All people* age 6 months and older! CDC. MMWR Recomm Rep. 2010;59(RR8):1-62. * Without contraindications

26 2010–2011 Influenza Season 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 – – ucm htm CDC. MMWR Recomm Rep. 2010;59(RR8):1-62. CDC. Accessed Dec FDA. Accessed Dec 2010.

27 2010–2011 Influenza Season VaccineTrade NameAge Group Route of Administration TIVFluzone; sanofi ≥ 6 months Intramuscular TIVFluvirin; Novartis ≥ 4 years Intramuscular TIVFluarix; GSK ≥ 3 years Intramuscular TIVAfluria*; CSL ≥ 9 years Intramuscular TIVFluLaval; GSK ≥ 18 years Intramuscular LAIVFluMist; MedImmune 2–49 yearsIntranasal 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 CDC. MMWR Recomm Rep. 2010;59(RR8):1-62. CDC. MMWR Morb Mortal Wkly Rep. 2010;59(31):

28 Influenza Vaccination for Children–1 or 2 Doses? CDC. MMWR Recomm Rep. 2010;59(RR8):1-62.

29 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 CDC. MMWR Recomm Rep. 2010;59(RR11):1-19. This recommendation is an off-label use of PCV13, which is indicated for children 6 weeks through 5 years of age (prior to the 6 th birthday)

30 Pneumococcal Vaccine PPSV23 7–10 years11-12 years13–18 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: –2 nd 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.

31 Hepatitis A CDC. MMWR Morb Mortal Wkly Rep. 2006;55(RR7):1-23. CDC Resolution No. 06/ Accessed Dec 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

32 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):

33 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): CDC. MMWR Morb Mortal Wkly Rep. 2009;58(36):

34 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):

35 Hep B 7–10 years11-12 years13–18 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 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 years of age) 0, 1, 2, and 12 months No combination Hep B vaccines approved for use in ages years Hep B titers are not necessary for teens CDC. MMWR Recomm Rep. 2005;54(RR16):1-23.

36 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, 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.

37 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?

38 Recommended vaccines include: Tdap MCV Varicella (2 nd dose) Influenza (Consider HPV)

39 Varicella 7–10 years11-12 years13–18 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.

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

41 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

42 Use a needle long enough to reach deep into the muscle for intramuscular (IM) Injections gauge needle Immunization Action Coalition. Accessed Dec Immunization Action Coalition. Accessed Dec GroupWeightNeedle Length Children (3–18 yrs) ---5/8–1” Adults< 130 lbs (< 60 kg)5/8” Adults lbs (60-70 kg)1” Women lbs (70-90 kg)1-1½” Men lbs ( kg)1-1½” Women> 200 lbs (> 90 kg)1½”1½” Men> 260 lbs (> 118 kg)1½”1½” General Immunization Reminders for Adolescents

43 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

44 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

45 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

46 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

47 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 2 nd varicella immunization? Yes Can you get the flu from a flu shot? No

48 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. Accessed Dec CDC. Accessed Dec 2010.

49 Vaccine Safety (cont) Clinical Immunization Safety Assessment –Established 2001 –Six academic centers with safety experts –CISA Network Sites Boston University Medical Center*Boston University Medical Center Columbia University Medical Center Johns Hopkins University*Johns Hopkins University Northern California Kaiser Permanente Stanford University Vanderbilt University Brighton collaboration – International CISA. Accessed Dec The Brighton Collaboration. Accessed Dec 2010.

50 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. Accessed Dec 2010.

51 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:

52 Adolescent Immunization Barriers Lack of routine preventive care visits Lack of awareness Inaccurate risk assessment by adolescents/parents regarding vaccine- preventable diseases Financial barriers Lack of complete immunization records Missed opportunities Lee G, et al. Pediatrics. 2008;122:

53 Parents Are a Key Influence Parental perception of vaccination is an important factor in adolescents’ vaccination decisions 1,2 –Parents influence adolescent acceptance –Providers influence parental acceptance Parental consent for immunization is the most cited barrier to immunizing students at school-based vaccination initiatives 3,4 1.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:

54 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:

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

56 Financing for Adolescent Vaccination Public funding for eligible children up to but not including the 19 th 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 ‘1 st Dollar Coverage’ CDC. Accessed Dec Affordable Care Act. Accessed Dec 2010.

57 Vaccine Finance Resources for Physicians Pediatrics. 2009;124:S573-S576.

58 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.

59 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.

60 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.

61 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

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

63 Are Providers Seeing Adolescents? HEDIS data: 34% of adolescents who participate in health plans have annual preventive visits 1 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 year 2 88–92% of adolescents report having an identified source of primary care 3,4 HEDIS = Health Plan Employer Data and Information Set; NCHS = National Center for Health Statistics 1. McInerny TK, et al. Pediatrics. 2005;115: National Center for Health Statistics. Health, United States, Klein JD, et al. Arch Pediatr Adolesc Med. 1998;152: Klein JD, et al. J Adolesc Health. 1999;25:

64 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

65 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 Accessed Dec CoCASA. Accessed Dec AFIX. Accessed Dec 2010.

66 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:

67 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   Available on iTunes Store Content includes Childhood, Adolescent, and Adult Immunization Schedules for the U.S.

68 Receive updates from the CDC via

69 updates from the Immunization Action Coalition -

70 Provider Recommendation Can Overcome Negative Attitudes Among Patients Vaccination Rates Among High Risk Patients With Negative Attitudes Nichol KL, et al. J Gen Intern Med. 1996;11:

71 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 The Community Guide. Accessed Nov Szilagyi PG, et al. Arch Pediatr Adolesc Med. 2006;160: IIS: immunization information systems

72 Standing Orders Are Among the Most Effective Strategies Nonphysicians offer and administer vaccinations Established with physician approved policies and protocols Locations: –Clinics and hospitals The Community Guide. Accessed Dec CDC. MMWR Recomm Rep. 2000;49 (RR1):15-26.

73 Patient and Provider Reminders Vaccinations Due or Past Due Patient/parent – Telephone, letter/postcard Provider –Computerized record reminders –Chart reminders Jacobson V, Szilagyi P. Cochrane Database Syst Rev. 2005;(3):CD

74 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. Accessed Dec The Community Guide. Accessed Dec 2010.

75 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.

76 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:

77 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!

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

79 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 The Immunization Action Coalition: vaccine information for the public and health professionals Vaccine Education Center at CHOP TCH Center for Vaccine Awareness and Research

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