Presentation on theme: "Strategies for Improving Adolescent Immunization Rates"— Presentation transcript:
1Strategies for Improving Adolescent Immunization Rates
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 adolescent 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 10 to 25 years
42011 ACIP Adolescent Immunization Schedule ACIP Schedules.Accessed Feb 2011.
5Adolescent Catch-up Schedule ACIP Schedules.Accessed Feb 2011.
7Tdap Boostrix Adacel Approved for use ages 10-64 years catch-up*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 11 to 12-year-olds, replaces Td booster if no previous TdapCatch-up for 13 to 18-year-oldsMCV4 contains diphtheria conjugate protein carrierIf both are indicated, administer MCV4 and Tdap simultaneously*off-label ACIP recommendationCDC. MMWR Recomm Rep. 2006;55(RR03):1-34.ACIP. Accessed Nov 2010.
8New ACIP Recommendations Tdap Children 7 to 10 Years of Age Under-vaccinated children ages 7-10 yearsSingle-dose of TdapIf 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 pertussisStart with single dose of Tdap, followed byTd > 4 wks after TdapTd 6-12 mo laterFurther guidance will be forthcoming on timing of revaccination those who have received Tdap prior to age 11ACIP. Accessed Dec 2010.
9Average Annual Incidence (#) HPV-associated* Invasive Squamous Cell Carcinomas in Women and Men, 1998–2003Anatomic AreaAverage 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):CDC. Accessed Jan 2011.
10This 14-year-old has come in for a sports physical for camp 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?
11The 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 notedThe vaccine prevents cancer – periodSexual debut is not always the patient’s choice; protect children while we can
12Available 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 contraindicationYeastLatex*Licensed age range9–26 yrs10–25 yrsACIP RecommendationsRoutine 11–12 yrs,catch-up 13–26 yrsSchedule0, 1-2, 6 monthsCIN2+: cervical intraepithelial neoplasia grade 2 or higher and adenocarcinoma in situ*needle-less prefilled syringes contain latex; vial stopper does not contain latexMarkowitz L. ACIP Meeting Oct Accessed Dec 2010.
13HPV – ACIP Recommendations Quadrivalent HPV (HPV4) and Bivalent HPV (HPV2) Routine vaccination of females aged 11–12 yearsCatch-up 13–26 yearsACIP: no preference for cervical cancer preventionUse HPV4 for genital wart and external lesion coverageUse HPV4 for external lesion protection among malesACIP Schedules. Accessed Dec 2010.FDA.Accessed Dec 2010.
14Proportion of Clinicians Who Strongly Recommend HPV Vaccine to Female Patients Survey Data Jan–Mar 2008Daley M, et al. Pediatrics. 2010;126:
15HPV Vaccination and Pregnancy HPV vaccines are not recommended for use in pregnant womenDelay initiation of vaccination until after completion of pregnancyIf a woman is found to be pregnant after initiating the vaccination series, delay remaining doses until after the pregnancyTwo vaccine during pregnancy registries:Quadrivalent HPV vaccine/pregnancy:Bivalent HPV vaccine/pregnancy:CDC. MMWR Morb Mortal Wkly Rep. 2010;59(20):
16HPV Quadrivalent Vaccine in Males FDA approved quadrivalent HPV vaccine for boys and men ages 9 through 26 yrsACIP: Permissive HPV vaccine for malesIncluded in VFC program; obtained at no cost from any Federally Qualified Health Center (FQHC); manufacturer Patient Assistant ProgramFDA 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 contactCDC. MMWR Morb Mortal Wkly Rep. 2010;59(29):
17HPV Quadrivalent Vaccine in Males Ongoing Considerations Anal and oral cancers in malesEfficacyHigh efficacy for prevention of vaccine HPV type-related anal pre-cancers, genital warts, and persistent infectionSafetyClinical trial data in males good safety profileNo safety signals in Vaccine Safety DatalinkProvider acceptability and practicesCost effectivenessACIP. Accessed Dec 2010.
18Intent to Vaccinate with HPV among Parents of Females Who Have Not Received Any HPV Vaccine; NIS–Teen 2009ACIP. Accessed Nov 2010.
19HPV Vaccine Parental Concerns Parents discomfort with child sexualityGreat opportunity to start talking about sexuality issuesCommunicate the importance of completing the 6-month immunization series before the adolescent becomes sexually activeImproved immunogenicity at younger agesEmphasize cancer preventionCommunicate the universality of the vaccine recommendationNo evidence that vaccination supports sexual activityNot supported by other interventions such as free condom distribution, availability of emergency contraceptionProvider recommendation is perhaps the most important factor in parent decision-making!Rosenthal SL. J Adolesc Health. 2005;37:
20HPV Postlicensure Safety Data Vaccine Adverse Event Reporting System (VAERS)HPV46/1/06–8/31/1033 million doses in females16,442 VAERS reports; 8% seriousOngoing monitoringNo new adverse event concerns or clinical patterns identifiedHPV2Licensed 10/16/09Insufficient usage to date in US to assess AEsTotal US reports through 8/31/10: 9Vaccine Safety Datalink Rapid Cycle AnalysisNo significant increased risk for pre-specified AEs after vaccinationGBS, seizures, syncope, appendicitis, stroke, VTE, allergic rxnsACIP.-VaccSafety.pdf. Accessed Dec 2010.
21Meningococcal Conjugate Vaccines Two licensed meningococcal conjugate vaccinesMCV4-D (Menactra®, Sanofi)Licensed for persons 2-55 yearsSerogroups A, C, Y, W-135Diphtheria toxoid conjugateMenACWY-CRM197 (Menveo®, Novartis)Diphtheria CRM197 conjugateFDA.Accessed Feb 2011.
22New ACIP Recommendations for MCV4* Administer MCV4 at age 11–12 yearsBooster dose at 16 yearsFor those vaccinated at age 13–15 yearsBooster dose at age 16 through 18 yearsNo 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.
23Meningococcal Conjugate Vaccines for Those At High RiskChildren 2–10 years withPersistent complement component deficiencyAnatomic or functional asplenia2 doses of MCV4 at least 8 weeks apart1 dose every 5 years thereafterPersons with HIV infection, 11–18 yearsACIP.Accessed Dec 2010.
24Update on Meningococcal Conjugate Vaccine Safety 2 large post-licensure studiesMeningococcal Vaccine Study and Vaccine Safety Datalink Rapid Cycle Analysis Study> 2.3 million MenACYWD (Menactra®) vaccinations0 confirmed cases of Guillain-Barré Syndrome (GBS) with 6 weeks of vaccinationUpper 95% confidence limit for attributable risk of GBS associated with MenACYWD is estimated at 1 case per million dosesBackground rate of GBS from Meningococcal Vaccine Study: 5.4 cases/million person yearsThese 2 studies provide no evidence of increased risk of GBS associated with MenACYWDACIP. Accessed Dec 2010.
25Annual 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.* Without contraindicationsCDC. MMWR Recomm Rep. 2010;59(RR8):1-62.25
262010–2011 Influenza Season 2010-2011 Trivalent Influenza Vaccines A/California/7/2009(H1N1)-like virusA/Perth/16/2009(H3N2)-like virusB/Brisbane/60/2008-like virusCurrent information from the CDC and FDAucm htmCDC. MMWR Recomm Rep. 2010;59(RR8):1-62.CDC. Accessed Dec 2010.FDA.Accessed Dec 2010.
27Route of Administration 2010–2011 Influenza SeasonVaccineTrade NameAge GroupRoute of AdministrationTIVFluzone; sanofi≥ 6 monthsIntramuscularFluvirin; Novartis≥ 4 yearsFluarix; GSK≥ 3 yearsAfluria*; CSL≥ 9 yearsFluLaval; GSK≥ 18 yearsLAIVFluMist; MedImmune2–49 yearsIntranasalTIV: 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):
28Influenza Vaccination for Children–1 or 2 Doses? CDC. MMWR Recomm Rep. 2010;59(RR8):1-62.
29PCV13 – Children 6 through 18 Years of Age with High-risk Conditions Children 6–18 years of ageHigh risk for invasive pneumococcal diseaseSickle cell diseaseHIV infectionImmunocompromising conditionsCochlear implantCerebrospinal fluid leaksSingle dose of PCV13Regardless of whether they have previously received PCV7 or PPSV23This 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.
30Pneumococcal Vaccine PPSV23 7–10 years11-12 years13–18 yearsfor certain high-risk groupsSingle dose recommended for:2–18 years, high-risk groups, sickle-cell disease, CSF leaks, asplenia, cochlear implants>2 years and immunocompromisedDoses of PCV13 should be completed before PPSV23Minimum interval following last dose of PCV13: 8 weeksOne-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 aspleniaCDC. MMWR Recomm Rep. 2010;59(RR11):1-19.
31Hepatitis ARoutine vaccination recommended for all children ages 12 to 23 monthsVaccination for anyone wishing to avoid diseaseIn areas without existing Hep A vaccination programs, consider catch-up of unvaccinated children 2-18 yearsChildren at increased risk for infectionDosing:VAQTA®For all persons age ≥ 12 months2 doses at 0 and 6-18 monthsHAVRIX®2 doses at 0 and 6-12 monthsCDC. MMWR Morb Mortal Wkly Rep. 2006;55(RR7):1-23.CDC Resolution No. 06/07-1.Accessed Dec 2010.
32Hepatitis 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):
33Hepatitis A Postexposure Prophylaxis For healthy persons 12 months through 40 years of age who have not previously received Hep A vaccineImmunoglobulin and/or single-antigen hepatitis A vaccine should be administered as soon as possible after exposureVaccine preferred for those of age 12 months to 40 yearsIg preferred for age < 12 months, those with vaccine allergies, or those with immunosuppression or liver diseaseIg preferred for age > 40 but vaccine may be used if Ig unavailableHep A and Ig may be administered simultaneouslyEfficacy of Ig or Hep A when administered >2 weeks postexposure is unknownCDC. MMWR Morb Mortal Wkly Rep. 2007;56(41):CDC. MMWR Morb Mortal Wkly Rep. 2009;58(36):
34Hepatitis A: Families of International Adoptees Hep A vaccinationAll 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 USFirst dose of Hep A vaccineAs soon as adoption is plannedIdeally at least two weeks prior to the arrival of the adopteeCDC. MMWR Morb Mortal Wkly Rep. 2009;58(36):
35Hep B Multiple schedules 7–10 years11-12 years13–18 yearscatch-upMultiple schedulesChildren 1-10 years0, 1, and 6 months0, 2, and 4 months0, 1, 2, and 12 monthsAdolescents years0, 1, and 4 months0, 12, and 24 months0 and 4-6 months (2-dose schedule uses adult 10 ug formulation, Recombivax-HB, only for years of age)No combination Hep B vaccines approved for use in ages yearsHep B titers are not necessary for teensCDC. MMWR Recomm Rep. 2005;54(RR16):1-23.
36Hep A-Hep B Combination Vaccine (Twinrix) Approved for persons 18 years and olderCombination Hep A vaccine (pediatric dose) + Hep B (adult dose)First licensed schedule: 0, 1, and 6 monthsAlternate schedule 2007: Doses at 0, 7, days; 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 vaccineCDC. MMWR Morb Mortal Wkly Rep. 2007;56(40):1057.
37This 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 yearsDoes he need any vaccines?
39Varicella 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 old≥ 13 yrs, minimum interval is 28 daysFormulationsVarivax licensed ages 12 mos and olderProquad (Combination MMRV) not licensed ≥ 13 yearsCDC. MMWR Recomm Rep. 2007;56(RR04):1-40.
40General Immunization Reminders for Adolescents–Safety First Syncope is a concern with all adolescent vaccinesImmature cardiovascular system/responseLong standing recommendation to have adolescents sit or lay down for 15–20 minutes following injections
41General Immunization Reminders for Adolescents A multidose vaccine series should not be restarted if the recommended dosing interval is exceededException–Oral typhoid Ty21aIf giving multiple injections in 1 arm, separate 1” apartCorrect placement for deltoid IM injections
42General Immunization Reminders for AdolescentsUse a needle long enough to reach deep into the musclefor intramuscular (IM) Injections22-25 gauge needleGroupWeightNeedle LengthChildren (3–18 yrs)---5/8–1”Adults< 130 lbs (< 60 kg)5/8”lbs (60-70 kg)1”Womenlbs (70-90 kg)1-1½”Menlbs ( kg)> 200 lbs (> 90 kg)1½”> 260 lbs (> 118 kg)Immunization Action Coalition. Accessed Dec 2010.Immunization Action Coalition. Accessed Dec 2010.
43Contraindications Increases likelihood of a serious adverse event When present, vaccine should not be givenPermanent contraindications for all vaccines: severe allergy to vaccine or componentLive vaccines generally contraindicated in pregnancy and for persons with immune incompetenceMarshall GS. The Vaccine Handbook. PCI Books, Inc.: 2010
44Erroneous Contraindications Mild acute illness with or without feverMild respiratory illness (including otitis media)Mild gastroenteritisAntibiotic or antiviral therapyLow-grade fever, redness, pain, swelling after previous dosePrematurity (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
45Erroneous Contraindications Breastfeeding (except pre-event smallpox)Convalescent phase of illnessExposure to an infectious diseasePositive tuberculin skin test without active diseaseSimultaneous tuberculin skin testAllergy to penicillin, duck meat or feathers, or environmental allergensFainting after previous doseSeizures, SIDS, allergies, vaccine reactions in family membersMarshall G. The Vaccine Handbook. PCI Books, Inc.: 2010
46Erroneous Contraindications MalnutritionLack of a previous physical exam in a well-appearing individualStable neurological condition (eg, CP, seizures, developmental delay)Allergy shotsExtensive limb swelling after DTP, DTaP, or Td that is not an Arthus-type reactionBrachial neuritis after previous dose of tetanus toxoid-containing vaccineAutoimmune diseaseHistory of the vaccine-preventable diseaseMarshall G. The Vaccine Handbook. PCI Books, Inc.: 2010
47Common Immunization Misconceptions Do you need to screen for HPV before giving the HPV vaccine? NoIf someone has an abnormal Pap smear, do you give them the HPV vaccine? YesDo you continue to do Pap smears following the HPV vaccine series? YesIs pregnancy testing indicated before giving vaccines? No(other than small pox)Pregnancy screening? YesDo you have to check Hep B titers in teens? NoDoes an 18-year-old need a 2nd varicella immunization? YesCan you get the flu from a flu shot? No
48Vaccine Safety Vaccine Adverse Event Reporting System Passive, voluntary reportingHelps signal potential problemCannot determine causal associationVaccine Safety Datalink ProjectEstablished 1991CDC and 8 large managed care organizations8.8 million subjects; 3% of U.S. populationRapid Cycling AnalysisVAERS. Accessed Dec 2010.CDC. Accessed Dec 2010.
49Vaccine Safety (cont) Clinical Immunization Safety Assessment Established 2001Six academic centers with safety expertsCISA Network SitesBoston University Medical Center*Columbia University Medical CenterJohns Hopkins University*Northern California Kaiser PermanenteStanford UniversityVanderbilt UniversityBrighton collaboration – InternationalCISA. Accessed Dec 2010.The Brighton Collaboration. Accessed Dec 2010.
50Adolescent Immunization: Goals and Objectives Effective adolescent vaccine delivery and monitoring are criticalAdolescents lag far behind preschoolers in immunization coverageHealthy People 2020 – increase routine vaccination coverage for adolescents1 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 2010.50
51There Are Missed Opportunities Adolescents who do not seek preventive care – less likely receive Td/Tdap on timeIn one health care system, missed opportunities for Td/Tdap immunization - 84% of health care visitsThere is room to improve immunization strategies for adolescentsLee G, et al. Pediatrics. 2008;122:
52Adolescent Immunization Barriers Lack of routine preventive care visitsLack of awarenessInaccurate risk assessment by adolescents/parents regarding vaccine- preventable diseasesFinancial barriersLack of complete immunization recordsMissed opportunitiesLee G, et al. Pediatrics. 2008;122:
53Parents 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:
54Parent Attitudes Affect Vaccination Influenza vaccination more likely if:Parent recalled physician recommendationParent believed the vaccine worksEasy access to clinicReceipt of reminder from providerHPV vaccination more likely if:Parents received education on human papillomavirus and HPV vaccineGnanasekaran 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:
55Patient 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:
56Financing for Adolescent Vaccination Public funding for eligible children up to but not including the 19th birthdayVaccines for Children Program (VFC)State Children’s Health Insurance Program (SCHIP)Funding for adolescents > 19 yearsWith health care reformPrivate sector health plans ‘1st Dollar Coverage’CDC. Accessed Dec 2010.Affordable Care Act. Accessed Dec 2010.
57Vaccine Finance Resources for Physicians Pediatrics. 2009;124:S573-S576.
58Establishing 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.
59Establishing 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.
60Advantages 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.
61Adolescent Vaccination Coverage: Who Is Measuring? The National Committee for Quality Assurance (NCQA) Healthcare Effectiveness Data and Information Set (HEDIS) updateTd/Tdap and meningococcal vaccine for 13 yr oldsNational Immunization Survey (NIS) 2006: First year of data collection for adolescents 13 to 17 years of ageNIS-Teen:Includes provider-reported informationNow conducted annually
62Adolescent 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 Adolesc Health. 2007;41:
63Are 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 Statistics1. McInerny TK, et al. Pediatrics. 2005;115:2. National Center for Health Statistics. Health, United States, 2005.3. Klein JD, et al. Arch Pediatr Adolesc Med. 1998;152:4. Klein JD, et al. J Adolesc Health. 1999;25:
64Identify and Address Barriers Patient Issues for Vaccination AwarenessDiseaseVaccinePersonal riskProvider RecommendationMisconceptions / fearsAbout vaccineAbout health care systemAccess and ability to pay
65The Goal: To Increase the Adolescent Immunization Rate Healthy People 2020Increase routine vaccination coverage for adolescentsFree assistance from public health departments (CoCASA software)Vaccines for Children quality improvement activities (eg, AFIX).Healthy People Accessed Dec CoCASA. Accessed Dec 2010.AFIX. Accessed Dec 2010.
66Improving Vaccination Rates – Provider Issues Know the factsRecommend vaccinations to your patientsGet organized and use systems approachesEnsure offering and administration of vaccineAutomatic processes that empower nurses are effectiveAddress convenience, efficiency, durabilityEvaluate and provide feedbackConsider new paradigmsNew venuesExtend vaccination seasonPractice what we preach (get vaccinated!)Nichol KL. Cleve Clin J Med. 2006;73:
67Shots Immunization App - Free For iPhone/iPod, iPad, Android, Blackberry, and PCSelect vaccine name for information onHigh risk indicationsAdverse reactionsContraindicationsCatch-upAdministrationRisk communicationEpidemiologyAvailable on iTunes StoreContent includes Childhood, Adolescent, and Adult Immunization Schedules for the U.S.
69Email updates from the Immunization Action Coalition - http://www
70Provider Recommendation Can Overcome Negative Attitudes Among Patients Vaccination Rates Among High Risk Patients With Negative AttitudesNichol KL, et al. J Gen Intern Med. 1996;11:
71Provider-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”Vaccination requirements for schoolUnderstanding other adolescent issues/careIIS: immunization information systemsThe Community Guide.Accessed Nov 2010.Szilagyi PG, et al. Arch Pediatr Adolesc Med. 2006;160:
72Standing Orders Are Among the Most Effective Strategies Nonphysicians offer and administer vaccinationsEstablished with physician approved policies and protocolsLocations:Clinics and hospitalsThe Community Guide.Accessed Dec 2010.CDC. MMWR Recomm Rep. 2000;49 (RR1):15-26.
73Patient and Provider Reminders Vaccinations Due or Past Due Patient/parentTelephone, letter/postcardProviderComputerized record remindersChart remindersJacobson V, Szilagyi P. Cochrane Database Syst Rev. 2005;(3):CD
74Provider Assessment and Performance Feedback Retrospectively assess the delivery of vaccine(s)Incorporates principles of continuous improvementAFIXAssessmentFeedbackIncentiveseXchangeComprehensive Clinic Assessment Software Application (CoCASA)Immunization Information System (IIS)CDC. Accessed Dec 2010.The Community Guide. Accessed Dec 2010.
75Benefits 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.
76Expanding Access Consider new paradigms New venues, walk-in clinics Extended hours for vaccinationsExtend vaccination seasonNichol KL. Cleve Clin J Med. 2006;73:
77Summary Stay current with the immunization schedule, recommendations Educate adolescents and parents about the risk of vaccine-preventable diseases and age-appropriate immunizationsAddress safety concernsIdentify and address barriersImplement organizational and systems strategiesReduce missed opportunitiesEnhance accessProvider recommendations are important!
78Resources for Providers Immunization SchedulesACIP recommendations & provisional recommendationsImmunization Action Coalition (IAC)The Guide to Community Preventive Services. Vaccine recommendationsAssessment, Feedback, Incentives, and Exchange (AFIX)National Foundation for Infectious DiseasesCenters for Medicare & Medicaid Services
79Resources for Patients and Parents Guide to evaluating information on the webCDC Vaccine Information Statements (VISs)Vaccine SafetyNational Network for Immunization Information (NNII)Allied Vaccine GroupThe Immunization Action Coalition: vaccine information for the public and health professionalsVaccine Education Center at CHOPTCH Center for Vaccine Awareness and Research