Immunization Practices and Knowledge of Obstetricians and Gynecologists Meaghan Leddy1, Britta Anderson1, Stanley Gall2 and Jay Schulkin1 Presenter: Dr. Stanley Gall (1)Research Department, American College of Obstetricians and Gynecologists (2)Obstetrics & Gynecology and Women's Health, University of Louisville

Introduction The American College of Obstetricians and Gynecologists (ACOG) has encouraged the provision of primary care by its Fellows. Immunizations are an important part of primary preventive care, and obstetrician-gynecologists (ob-gyns) can play an important part in immunizing women. For example, this is especially relevant to the excess morbidity due to influenza infections in pregnancy. The new HPV vaccine, Gardasil, is particularly relevant to ob-gyns, as it protects against cervical cancers and anogenital warts.

Method We investigated whether or not ob-gyns are accepting immunization, a primary care practice, as part of their role. A 37-question survey was sent to 771 ACOG Fellows, who are part of the ACOG Collaborative Ambulatory Research Network containing questions regarding demographics, vaccination practices, knowledge and beliefs regarding vaccines (HPV, influenza, etc.), and opinions of their immunization education. The survey was also sent to all ob-gyns from ACOG’s District V (Indiana, Kentucky, Michigan, Ohio and Ontario, Canada). That data is not reported in this presentation. Analyses included only currently practicing respondents, resulting in a 51.0% response rate.

Sample Collaborative Ambulatory Research Network (CARN) CARN members are ACOG Fellows practicing throughout the US and Canada who voluntarily participate in ACOG research studies. This group was created to facilitate the examination of patterns of clinical practice, as well as assess the need for, and aid in the development of, educational materials. CARN is a representative sample of the ob-gyns who are Fellows of ACOG (>90% of all ob-gyns). They are similar in age, gender ratio, and geographic location.

Key Demographics GENDER MALE 50.6% MEAN YEAR GRADUATED MEDICAL SCHOOL 1986 (SD=10.37) PRIMARY PRACTICE GENERAL OB-GYN 77.9% GYNECOLOGY ONLY 11.8% MATERNAL/FETAL MEDICINE 4.9% REPRODUCTIVE ENDOCRINOLOGY/INFERTILITY 2.3% UROGYNECOLOGY 1.3% PEDIATRIC/ADOLESCENT GYNECOLOGY 0.5% OBSTETRICS ONLY 0.3% LOCATION URBAN- INNER CITY 11.5% URBAN- NON-INNER CITY 38.1% RURAL 15% SUBURBAN 34.4%

Practice Patterns AGE GROUP AND CARE PROVIDED ADOLESCENTS GYNECOLOGY 87.4% OBSTETRICS 71.8% PRIMARY CARE 24.4% DO NOT TREAT 2.6% WOMEN OF CHILD BEARING AGE 94.1% 83.3% 40.5% 0% POSTMENOPAUSAL WOMEN 92.3% 21% 30.8%

Vaccination Practices A majority (79.7%) administer vaccines in their offices. Immunization Percent of those who give vaccines that administer this particular vaccine Administered Each Month HPV 91.0 20.59 (28.48) Influenza 74.3 30.07 (31.19) TDAP 29.9 8.78 (11.50) MMR 28.1 4.25 (5.05) Varicella 19.1 5.16 (8.15) Pneumococcal 14.3 1.90 (2.59) HAV 11.0 2.06 (3.24) Herpes Zoster 8.5 3.09 (5.75) Meningococcal 7.3 .71 (.76)

HPV Patterns Most (91.0%) of those who administer vaccines in their offices offer the HPV vaccine. A reported 16.94% (SD=17.85%) of patients inquire about the HPV vaccine and 15.00% (SD=22.5%) of patients refuse the vaccine.

Why Do Patients Refuse the HPV Vaccine? Overall, respondents indicated that financial costs are the strongest barrier to patient acceptance of the HPV vaccine. A majority (83.9%) agreed or strongly agreed that the financial cost of the vaccine was a reason why their patients refused it.

Routine screening for vaccine preventable diseases falls outside of the routine practice of an ob/gyn physician

Should the HPV Vaccine be Mandated? Strongly agree Agree Neutral Disagree Strongly disagree 0% 10% 20% 30% Percent

Why NOT Mandate the HPV Vaccine Again, respondents indicated that financial costs play an important role in acceptance of the HPV vaccine. A majority (65.95%) agreed or strongly agreed that financial costs to the patient was a reason why the HPV vaccine should not be mandated for everyone. Lack of reimbursement was the next most agreed or strongly agreed with reason not to mandate the vaccine, with 35.2% agreeing or strongly agreeing.

Ob-gyns’ Views on Their Immunization Training 67.9% rated their training regarding immunization in medical school to be barely adequate, inadequate or nonexistent. 77.2% rated this type of training in residency to be barely adequate, inadequate or nonexistent.

HPV Vaccine We asked respondents to fill in the following blanks: “Gardasil protects against _ forms of HPV that cause _% of cervical cancer and _% of genital warts.” The correct answers are 4, 70, and 90, respectively. Most (88.4%) knew that the HPV vaccine protects against four forms of HPV. Fewer respondents knew the vaccine protects against 70% of cervical cancers (40.6%) and 90% of genital warts (41.8%) 22.9% filled in all three blanks correctly, and only a small minority (6.4%) got all three questions wrong.

Hepatitis B Vaccine Hepatitis B Vaccine is Recommended For: Percent Who Recognized This Recommendation Patients in High Risk Occupations 99.0% Newborns 86.4% Adolescents 77.2% Pregnant Women With Known Risk Factors 70.3% A small percentage of respondents (16.7%) indicated it is recommended for patients 65 years and older, though this is not currently a recommendation.

Influenza Vaccine 86.9% agreed with the CDC that influenza-associated morbidity and mortality are increased for otherwise healthy women who contract influenza in the 2nd or 3rd trimester in pregnancy. 84.9% agreed with the CDC that all pregnant women should receive the influenza vaccine.

Tetanus/Acellular Pertussis/Diphtheria Measles/Mumps/Rubella Vaccines in Pregnancy A majority agreed with current CDC recommendations that the vaccines below are safe during pregnancy: Influenza 90.5% Hepatitis B 64.6% Tetanus/Acellular Pertussis/Diphtheria 59.2% A small percentage believed the following vaccines are safe to administer in pregnancy, though they are not currently recommended: HPV 15.9% Varicella 7.2% Measles/Mumps/Rubella 2.6%

What Would Help Improve Ob-Gyns’ Ability to Administer Vaccines? Free or low-cost vaccines 75.4% Informational material for patients 65.1% Seminar/Grand Rounds 45.1% In-service program for staff 42.3% Most physicians (86.3%) indicated that their practice would benefit from a CME course on immunization.

Conclusions Certain immunizations (e.g. HPV and influenza) are being incorporated into ob-gyn practice. Though a majority rated their immunization training in medical school and residency to be barely adequate or less, ob-gyns are knowledgeable of current vaccine recommendations. Views on mandating the HPV vaccine are split; cost is a factor in disagreeing with mandating the vaccine. Cost is thought to be a factor in patient refusal of the HPV vaccine.