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’
7th birthday until the 19th 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 Boostrix Adacel Approved for use ages 10-64 years
catch-up*
recommended
catch-up
Boostrix
Approved for use
ages years
Adacel
Approved for use
ages years
Two FDA-approved Tdap vaccines available
Both contain the same acellular pertussis component as their respective DTaP products
FDA recommended one-time use of Tdap only
For 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. Accessed Nov 2010.

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. 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):
CDC. Accessed Jan 2011.

10. 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?

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
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 Accessed Dec 2010.

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 2010.
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
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):

17. 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. Accessed Dec 2010.

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

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-CRM197 (Menveo®, Novartis)
Diphtheria CRM197 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
*Meningococcal conjugate vaccine, quadrivalent; Menactra® or Menveo ®
CDC. MMWR Morb Mortal Wkly Rep. 2011;60(3):72-76.

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
ACIP.
Accessed Dec 2010.

24. 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. Accessed Dec 2010.

25. Annual Influenza Vaccine Is Recommended for:
All people* age 6 months and older!
According to the Advisory Committee on Immunization Practices (ACIP) of the US Centers for Disease Control and Prevention (CDC), several groups of people should be primary targets for vaccination during the influenza season. These are groups who are at high risk of morbidity or mortality due to influenza.
* Without contraindications
CDC. MMWR Recomm Rep. 2010;59(RR8):1-62. 25

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

27. 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):

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
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.

30. 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.

31. 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.
Accessed Dec 2010.

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 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 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 years of age)
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 (2nd dose)
Influenza
(Consider HPV)

39. 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.

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. 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”
lbs (60-70 kg) 1”
Women
lbs (70-90 kg)
1-1½”
Men
lbs ( kg)
> 200 lbs (> 90 kg)
1½”
> 260 lbs (> 118 kg)
Immunization Action Coalition. Accessed Dec 2010.
Immunization Action Coalition. Accessed Dec 2010.

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 2nd 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 2010.
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*
Columbia University Medical Center
Johns Hopkins University*
Northern California Kaiser Permanente
Stanford University
Vanderbilt University
Brighton collaboration – International
CISA. Accessed Dec 2010.
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 Accessed Dec 2010. 50

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 decisions1,2
Parents influence adolescent acceptance
Providers influence parental acceptance
Parental consent for immunization is the most cited barrier to immunizing students at school-based vaccination initiatives3,4
Rosenthal SL, et al. J Adolesc Health. 1995;17:
Rosenthal SL. J Adolesc Health. 2005;37:
Guajardo AD, et al. J Sch Health. 2002;72:
Deeks SL, Johnson IL. Can J Public Health. 1998;89:

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
Patient
Provider
Insurance/
Reimbursement
Time
Provider likelihood to administer
immunization
Patient likelihood to access immunization
ADOLESCENT IMMUNIZATION
Middleman AB. J Adolesc Health. 2007;41:

56. 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. Accessed Dec 2010.
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. 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:

63. 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:
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:

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 2010.
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 email:

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

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
IIS: immunization information systems
The Community Guide.
Accessed Nov 2010.
Szilagyi PG, et al. Arch Pediatr Adolesc Med. 2006;160:

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 2010.
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 2010.
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