Strategies for Improving Adolescent Immunization Rates

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

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

2011 ACIP Adolescent Immunization Schedule ACIP Schedules. www.cdc.gov/vaccines/recs/schedules/default.htm. Accessed Feb 2011.

Adolescent Catch-up Schedule ACIP Schedules. www.cdc.gov/vaccines/recs/schedules/default.htm. Accessed Feb 2011.

Vaccination Coverage Adolescents 13–17 yrs, United States, National Immunization Survey CDC. MMWR Morb Mortal Wkly Rep. 2009;58(36):997-1001. CDC. MMWR Morb Mortal Wkly Rep. 2010;59(32):1018-1023.

Tdap Boostrix Adacel Approved for use ages 10-64 years catch-up* recommended catch-up Boostrix Approved for use ages 10-64 years Adacel Approved for use ages 11-64 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 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 *off-label ACIP recommendation CDC. MMWR Recomm Rep. 2006;55(RR03):1-34. ACIP. http://www.cdc.gov/vaccines/recs/acip/slides-oct10.htm. Accessed Nov 2010.

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. http://www.cdc.gov/vaccines/recs/acip/default.htm. Accessed Dec 2010.

Average Annual Incidence (#) HPV-associated* Invasive Squamous Cell Carcinomas in Women and Men, 1998–2003 Anatomic Area Average 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):2855-2864. CDC. http://www.cdc.gov/cancer/hpv/statistics/index.htm. Accessed Jan 2011.

This 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?

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

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* Licensed age range 9–26 yrs 10–25 yrs ACIP Recommendations Routine 11–12 yrs, catch-up 13–26 yrs Schedule 0, 1-2, 6 months CIN2+: cervical intraepithelial neoplasia grade 2 or higher and adenocarcinoma in situ *needle-less prefilled syringes contain latex; vial stopper does not contain latex Markowitz L. ACIP Meeting Oct 2009. http://www.cdc.gov/vaccines/recs/acip/downloads/mtg-slides-oct09/02-2-hpv.pdf. Accessed Dec 2010.

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. www.cdc.gov/vaccines/recs/schedules/default.htm. Accessed Dec 2010. FDA. http://www.fda.gov/BiologicsBloodVaccines/Vaccines/ApprovedProducts/ucm172678.htm. Accessed Dec 2010.

Proportion of Clinicians Who Strongly Recommend HPV Vaccine to Female Patients Survey Data Jan–Mar 2008 Daley M, et al. Pediatrics. 2010;126:425-433.

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: 800-986-8999 Bivalent HPV vaccine/pregnancy: 888-452-9622 CDC. MMWR Morb Mortal Wkly Rep. 2010;59(20):626-629.

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 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 CDC. MMWR Morb Mortal Wkly Rep. 2010;59(29):630-631.

HPV Quadrivalent Vaccine in Males Ongoing Considerations 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 ACIP. http://www.cdc.gov/vaccines/recs/acip/downloads/mtg-slides-oct10/08-7-hpv-MaleConsider.pdf. Accessed Dec 2010.

Intent to Vaccinate with HPV among Parents of Females Who Have Not Received Any HPV Vaccine; NIS–Teen 2009 ACIP. http://www.cdc.gov/vaccines/recs/acip/downloads/mtg-slides-oct10/08-3-hpv-Female.pdf. Accessed Nov 2010.

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;37:177-178.

HPV Postlicensure Safety Data 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 No significant increased risk for pre-specified AEs after vaccination GBS, seizures, syncope, appendicitis, stroke, VTE, allergic rxns ACIP. http://www.cdc.gov/vaccines/recs/acip/downloads/mtg-slides-oct10/08-2-hpv -VaccSafety.pdf. Accessed Dec 2010.

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-CRM197 (Menveo®, Novartis) Diphtheria CRM197 conjugate FDA. http://www.fda.gov/BiologicsBloodVaccines/Vaccines/ApprovedProducts/ucm093830.htm. Accessed Feb 2011.

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 *Meningococcal conjugate vaccine, quadrivalent; Menactra® or Menveo ® CDC. MMWR Morb Mortal Wkly Rep. 2011;60(3):72-76.

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 ACIP. http://www.cdc.gov/vaccines/recs/acip/slides-oct10.htm#child. Accessed Dec 2010.

Update on Meningococcal Conjugate Vaccine Safety 2 large post-licensure studies Meningococcal Vaccine Study and Vaccine Safety Datalink Rapid Cycle Analysis Study > 2.3 million MenACYWD (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 MenACYWD 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 MenACYWD ACIP. http://www.cdc.gov/vaccines/recs/acip/downloads/min-jun10.pdf. Accessed Dec 2010.

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 2006-2007 influenza season. These are groups who are at high risk of morbidity or mortality due to influenza. * Without contraindications CDC. MMWR Recomm Rep. 2010;59(RR8):1-62. 25

2010–2011 Influenza Season 2010-2011 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 http://www.cdc.gov/vaccines/vpd-vac/flu/default.htm#ref http://www.fda.gov/BiologicsBloodVaccines/Vaccines/ApprovedProducts/ ucm094045.htm CDC. MMWR Recomm Rep. 2010;59(RR8):1-62. CDC. http://www.cdc.gov/vaccines/vpd-vac/flu/default.htm#ref. Accessed Dec 2010. FDA. http://www.fda.gov/BiologicsBloodVaccines/Vaccines/ApprovedProducts/ucm094045.htm. Accessed Dec 2010.

Route of Administration 2010–2011 Influenza Season Vaccine Trade Name Age Group Route of Administration TIV Fluzone; sanofi ≥ 6 months Intramuscular Fluvirin; Novartis ≥ 4 years Fluarix; GSK ≥ 3 years Afluria*; CSL ≥ 9 years FluLaval; GSK ≥ 18 years LAIV FluMist; MedImmune 2–49 years Intranasal 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 2010. CDC. MMWR Recomm Rep. 2010;59(RR8):1-62. CDC. MMWR Morb Mortal Wkly Rep. 2010;59(31):989-992.

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

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 This 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.

Pneumococcal Vaccine PPSV23 7–10 years 11-12 years 13–18 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: 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 asplenia CDC. MMWR Recomm Rep. 2010;59(RR11):1-19.

Hepatitis A 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® 2 doses at 0 and 6-12 months CDC. MMWR Morb Mortal Wkly Rep. 2006;55(RR7):1-23. CDC Resolution No. 06/07-1. http://cdc.gov/vaccines/programs/vfc/downloads/resolutions/0607-1hepa.pdf. Accessed Dec 2010.

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):1080-1084.

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):1080-1084. CDC. MMWR Morb Mortal Wkly Rep. 2009;58(36):1006-1007.

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):1006-1007.

Hep B Multiple schedules 7–10 years 11-12 years 13–18 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 11-19 years 0, 1, 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 11-15 years of age) No combination Hep B vaccines approved for use in ages 11-17 years Hep B titers are not necessary for teens CDC. MMWR Recomm Rep. 2005;54(RR16):1-23.

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, 21-30 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.

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?

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

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 ≥ 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.

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

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

General Immunization Reminders for Adolescents Use a needle long enough to reach deep into the muscle for intramuscular (IM) Injections 22-25 gauge needle Group Weight Needle Length Children (3–18 yrs) --- 5/8–1” Adults < 130 lbs (< 60 kg) 5/8” 130-152 lbs (60-70 kg) 1” Women 152-200 lbs (70-90 kg) 1-1½” Men 152-260 lbs (70-118 kg) > 200 lbs (> 90 kg) 1½” > 260 lbs (> 118 kg) Immunization Action Coalition. http://www.immunize.org/catg.d/p2020A.pdf. Accessed Dec 2010. Immunization Action Coalition. http://www.immunize.org/catg.d/p2020.pdf. Accessed Dec 2010.

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

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

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

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

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

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. http://vaers.hhs.gov/index. Accessed Dec 2010. CDC. http://www.cdc.gov/vaccinesafety/Activities/VSD.html. Accessed Dec 2010.

Vaccine Safety (cont) Clinical Immunization Safety Assessment Established 2001 Six academic centers with safety experts CISA Network Sites Boston University Medical Center* Columbia University Medical Center Johns Hopkins University* Northern California Kaiser Permanente Stanford University Vanderbilt University Brighton collaboration – International CISA. http://www.cdc.gov/vaccinesafety/Activities/CISA.html. Accessed Dec 2010. The Brighton Collaboration. http://www.brightoncollaboration.org/internet/en/index.html. Accessed Dec 2010.

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.http://www.healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicid=23. Accessed Dec 2010. 50

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;122:711-717.

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;122:711-717.

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;17:248-254. Rosenthal SL. J Adolesc Health. 2005;37:177-178. Guajardo AD, et al. J Sch Health. 2002;72:128-130. Deeks SL, Johnson IL. Can J Public Health. 1998;89:98-101.

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;37:177-178.

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;41:109-118.

Financing for Adolescent Vaccination Public funding for eligible children up to but not including the 19th 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 ‘1st Dollar Coverage’ CDC. http://www.cdc.gov/vaccines/programs/vfc/providers/elig-scrn-rec-doc-req.htm. Accessed Dec 2010. Affordable Care Act. http://www.healthcare.gov/news/factsheets/affordable_care_act_immunization.html. Accessed Dec 2010.

Vaccine Finance Resources for Physicians Pediatrics. 2009;124:S573-S576. http://pediatrics.aappublications.org/cgi/content/full/124/Supplement_5/S573

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.

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;38:321-327. IDSA. Clin Infect Dis. 2007;44:e104-e108.

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.

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

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 Adolesc Health. 2007;41:109-118.

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 1. McInerny TK, et al. Pediatrics. 2005;115:833-838. 2. National Center for Health Statistics. Health, United States, 2005. 3. Klein JD, et al. Arch Pediatr Adolesc Med. 1998;152:676-682. 4. Klein JD, et al. J Adolesc Health. 1999;25:120-130.

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

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 2020. http://www.healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicid=23. Accessed Dec 2010. CoCASA. http://www.cdc.gov/vaccines/programs/cocasa/default.htm. Accessed Dec 2010. AFIX. http://www.cdc.gov/vaccines/programs/afix/default.htm. Accessed Dec 2010.

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;73:1009-1015.

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 www.ImmunizationEd.org Available on iTunes Store Content includes Childhood, Adolescent, and Adult Immunization Schedules for the U.S.

Receive updates from the CDC via email: http://www.cdc.gov/vaccines/pubs/default.htm

Email updates from the Immunization Action Coalition - http://www

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;11:673-677.

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 IIS: immunization information systems The Community Guide. http://www.thecommunityguide.org/vaccines/universally/index.html. Accessed Nov 2010. Szilagyi PG, et al. Arch Pediatr Adolesc Med. 2006;160:157-163.

Standing Orders Are Among the Most Effective Strategies Nonphysicians offer and administer vaccinations Established with physician approved policies and protocols Locations: Clinics and hospitals www.immunize.org/standingorders www.immunizationed.org/standingorders The Community Guide. http://www.thecommunityguide.org/vaccines/universally/index.html. Accessed Dec 2010. CDC. MMWR Recomm Rep. 2000;49 (RR1):15-26.

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):CD003941.

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. http://www.cdc.gov/vaccines/programs/afix/overview.htm. Accessed Dec 2010. The Community Guide. http://www.thecommunityguide.org/vaccines/universally/index.html. Accessed Dec 2010.

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;4:185-192. Glazner JE, et al. Ambul Pediatr. 2004;4:34-40.

Expanding Access Consider new paradigms New venues, walk-in clinics Extended hours for vaccinations Extend vaccination season Nichol KL. Cleve Clin J Med. 2006;73:1009-1015.

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!

Resources for Providers Immunization Schedules www.cdc.gov/vaccines/recs/schedules/ ACIP recommendations & provisional recommendations www.cdc.gov/vaccines/pubs/ACIP-list.htm www.cdc.gov/vaccines/recs/provisional/default.htm Immunization Action Coalition (IAC) www.immunize.org The Guide to Community Preventive Services. Vaccine recommendations www.thecommunityguide.org/vaccines/index.html Assessment, Feedback, Incentives, and Exchange (AFIX) www.cdc.gov/vaccines/programs/afix/default.htm National Foundation for Infectious Diseases www.nfid.org Centers for Medicare & Medicaid Services www.cms.hhs.gov

Resources for Patients and Parents Guide to evaluating information on the web www.cdc.gov/vaccines/vac-gen/evalwebs.htm CDC Vaccine Information Statements (VISs) http://www.cdc.gov/vaccines/pubs/vis/default.htm Vaccine Safety www.cdc.gov/Features/VaccineSafety National Network for Immunization Information (NNII) www.immunizationinfo.org Allied Vaccine Group www.vaccine.org The Immunization Action Coalition: vaccine information for the public and health professionals www.vaccineinformation.org Vaccine Education Center at CHOP www.vaccine.chop.edu TCH Center for Vaccine Awareness and Research www.texaschildrens.org/carecenters/vaccine/default.aspx