1. Texas Immunization Stakeholders Working Group Promotion of Adolescent Immunizations Jason V. Terk, MD, Texas Pediatric Society

2. Promotion of Adolescent Immunizations It ain't what you don't know that gets you into trouble. It's what you know for sure that just ain't so. Mark Twain

3. Realities 92% of adolescents report having a source of primary care 92% of adolescents report having a source of primary care 85% of 6-17 year olds report having visited a doctor or clinic in the past year 85% of 6-17 year olds report having visited a doctor or clinic in the past year Source: 1997 Commonwealth Fund Survey of the Health of Adolescent Girls

4. Identifying The Boundaries Service Demand Service Demand Service Requirements Service Requirements Systems Capabilities Systems Capabilities

5. Todays Situation- 7/1/06 Total Total Male MaleFemale 10-14 years 20,383,0009,947,00010,435,000 15-19 years 21,348,00010,378,00010,970,000 20-24 years 20,310,0009,963,00010,347,000 Source: U.S. Census Projections

6. What That Means 2 1/2 minutes to administer vaccine 2 1/2 minutes to administer vaccine 21,348,000 adolescents between 15- 19 years of age 21,348,000 adolescents between 15- 19 years of age Require 1,224,300 man-hours per recommended injection Require 1,224,300 man-hours per recommended injection

7. Well Visits By Age

8. Service Requirements Sequence and temporal administration requirements of vaccines Sequence and temporal administration requirements of vaccines –How many? –How often? –How far apart? Optimal age for administration Optimal age for administration Special conditions Special conditions –Targeted populations –Contraindications

9. Systems Capabilities Accessibility Accessibility –Hours of operation –Location Capacity Capacity Funding Funding

10. Systems Capabilities Costs Costs –To the patient/family –To the provider Characteristics of adolescents being served Characteristics of adolescents being served –Socio-demographic –Frequency of contacts

11. Identifying Solutions Recommendations of Society for Adolescent Medicine Recommendations of Society for Adolescent Medicine –Development of 3 distinct adolescent vaccination visits/platforms –Use of existing systems –Simultaneous administration of multiple vaccines Source: Journal of Adolescent Health 2006

12. Identifying Solutions Recommendations of Society for Adolescent Medicine Recommendations of Society for Adolescent Medicine –Use of non-comprehensive visits –Use of alternative vaccination sites –Education of providers and parents/adolescents Source: Journal of Adolescent Health 2006

13. Adolescent Vaccination Platforms 11-12 year platform 11-12 year platform –Primary platform endorsed by ACIP –Coincides with need for sports physicals –Coincides with discussions on puberty and sexuality

14. Adolescent Vaccination Platforms 14-15 year platform 14-15 year platform –Catch up on missed vaccinations –Complete multiple dose vaccination regimens –Coincides with need for sports physicals

15. Adolescent Vaccination Platforms 17-18 year platform 17-18 year platform –Catch up on missed vaccinations –Complete multiple dose vaccination regimens –Complete regimens while still covered by VFC or third party payors

16. Use of Existing Systems Standing immunization orders Standing immunization orders Immunization screening tools Immunization screening tools Immunization registries Immunization registries Reminder/recall systems Reminder/recall systems –Providers –Patients

17. Use of Non-comprehensive Visits Minor illness/injury visits Minor illness/injury visits –Potentially controversial –Parent education on true and false contraindications to immunizations Camp/Sports physicals Camp/Sports physicals Pre-college visits Pre-college visits

18. Use of Alternative Vaccination Sites Schools Schools Pharmacies Pharmacies Public health clinics/fairs Public health clinics/fairs

19. Use of Alternative Vaccination Sites Schools Schools –Benefits Suttons Law Suttons Law Potential to implement into existing health education curriculum Potential to implement into existing health education curriculum

20. Use of Alternative Vaccination Sites Schools Schools –Barriers Tradition of local control with limited state and federal roles Tradition of local control with limited state and federal roles No existing broad systems for school-based vaccination efforts No existing broad systems for school-based vaccination efforts Quality of informed consent Quality of informed consent Cost Cost Time Time

21. Use of Alternative Vaccination Sites Schools Schools –Controversies Diversion from medical home Diversion from medical home Vaccine integrity Vaccine integrity Maintenance of vaccine record Maintenance of vaccine record Implementation challenges without substantial authority Implementation challenges without substantial authority Politics (imagine hundreds of school board meetings) Politics (imagine hundreds of school board meetings)

22. Use of Alternative Vaccination Sites Pharmacies Pharmacies –Benefits Convenience Convenience Availability Availability Accessibility Accessibility

23. Use of Alternative Vaccination Sites Pharmacies Pharmacies –Controversies Diversion from medical home Diversion from medical home Scope of practice Scope of practice Maintenance of vaccine record Maintenance of vaccine record Quality of informed consent Quality of informed consent Coverage by insurance Coverage by insurance

24. Education Providers Providers –Must engage ALL adolescent providers Pediatricians Pediatricians Family Practitioners Family Practitioners Gynecologists Gynecologists Emergency Medicine Emergency Medicine Hospitals, Urgent Care, Retail Clinics Hospitals, Urgent Care, Retail Clinics –Inter specialty education –Industry –Lead role for federal and state health officials

25. Education Patient/Parents Patient/Parents –Consider commonalities of Tdap, MCV, HPV FDA approval and ACIP recommendations FDA approval and ACIP recommendations Targeted for adolescents to protect adolescents Targeted for adolescents to protect adolescents

26. Education Patient/Parents Patient/Parents –Consider differences of Tdap, MCV, and HPV

27. Education Patient/Parents Patient/Parents –Tdap Pertussis is common and frequently unrecognized Pertussis is common and frequently unrecognized Frequent outbreaks in schools Frequent outbreaks in schools Missed school and work days despite treatment Missed school and work days despite treatment Booster needed due to waning immunity Booster needed due to waning immunity

28. Education Patient/Parents Patient/Parents –Meningococcal Conjugate Vaccine Rare but devastating infection Rare but devastating infection Supersedes polysaccharide vaccine Supersedes polysaccharide vaccine Targeted for age groups at higher risk Targeted for age groups at higher risk

29. Education Patient/Parents Patient/Parents –Human Papillomavirus Vaccine Very common sexually transmitted infection Very common sexually transmitted infection Poorly recognized risk by public and many providers Poorly recognized risk by public and many providers Most infections benign Most infections benign Persistent infections with specific serotypes causally associated with cervical cancer Persistent infections with specific serotypes causally associated with cervical cancer

30. Education Patient/Parents Patient/Parents –Human Papillomavirus Vaccine Ideally given before sexual debut Ideally given before sexual debut Licensed only for females at this time Licensed only for females at this time First immunization developed to prevent cancer First immunization developed to prevent cancer

31. Education

33. Recent Developments 3/2/06 3/2/06 –ACIP votes to provisionally recommend that immediately post-partum women receive the Tdap vaccination to reduce transmission of pertussis to their infants

34. Recent Developments 3/20/06 3/20/06 –Resolution submitted to AAP Board of Directors RESOLVED,that the Academy engage the American College of Obstetrics and Gynecology (ACOG), the American Hospital Association (AHA), and manufacturers of Tdap to develop an effective strategy to implement routine immunization with Tdap of women who are immediately post-partum prior to their hospital discharge. RESOLVED,that the Academy engage the American College of Obstetrics and Gynecology (ACOG), the American Hospital Association (AHA), and manufacturers of Tdap to develop an effective strategy to implement routine immunization with Tdap of women who are immediately post-partum prior to their hospital discharge. Resolution was accepted and referred to appropriate committee Resolution was accepted and referred to appropriate committee

35. Recommendations Establish and promote the 3 adolescent vaccination platforms Establish and promote the 3 adolescent vaccination platforms Strike balance between desire to immunize at every opportunity and maintenance of anticipatory guidance in the medical home Strike balance between desire to immunize at every opportunity and maintenance of anticipatory guidance in the medical home

36. Recommendations Engage specialty societies in effort to promote provider education Engage specialty societies in effort to promote provider education Develop adolescent immunization toolkit to aid providers in educating their patients/parents Develop adolescent immunization toolkit to aid providers in educating their patients/parents

37. Recommendations Develop message for various media to generate public demand Develop message for various media to generate public demand Assess outcomes by tracking rates of adolescent vaccine coverage Assess outcomes by tracking rates of adolescent vaccine coverage Advocate alignment of funding with costs Advocate alignment of funding with costs