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Staying on Track: The Importance of Timely Adolescent Immunizations. Colleen Kraft, M.D., FAAP. Caring for Adolescents. Physical/Developmental Prevention and Anticipatory Guidance Immunizations and Adolescents Barriers to Adolescent Immunizations

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staying on track the importance of timely adolescent immunizations

Staying on Track: The Importance of Timely Adolescent Immunizations

Colleen Kraft, M.D., FAAP

caring for adolescents
Caring for Adolescents
  • Physical/Developmental
  • Prevention and Anticipatory Guidance
  • Immunizations and Adolescents
  • Barriers to Adolescent Immunizations
  • Meningococcal, Tdap, HPV, Varicella, Hepatitis A and B
  • Strategies to Improve Immunizations Rates in Adolescents
physical changes
Physical Changes
  • Extremities grow faster than trunk and head
  • Facial proportions change, nose and chin enlarge first
  • Figure changes:
    • Pelvis enlarges in females
    • Shoulders enlarge in males
  • Subcutaneous fat increases
  • Increased function of sweat glands
  • Increased function of sebaceous glands
secondary sexual characteristics
Secondary Sexual Characteristics:

Girls

  • Breast enlargement begins 8-13years
  • Axillary hair develops 11 to 14 years
  • Pubic hair develops 9-12 years
  • Menarche begins 10-16 years

Boys

  • Genital enlargement begins 9-13 years
  • Axillary hair begins 12-14 years
  • Facial hair develops 11-14 years
  • Pubic hair develops 12-15 years
functional development
Functional Development
  • An increase in self-awareness, self-consciousness, and self-appraisal
  • Becoming pre-occupied with how they measure up to their peers
  • Continue to need family to provide acceptance and feeling of self-worth
intellectual development
Intellectual Development
  • The excitement of thinking through possibilities leads to argumentativeness
  • The joy of putting across ideas and listening to ideas of peers leads to constant gabfests and hours on the phone
  • Concrete to abstract capabilities can be late and affect school performance
adolescent autonomy
Adolescent Autonomy
  • Limit testing (challenging rules)
  • Experimental Behavior (smoking, alcohol)
  • Risk taking (driving, drugs, sexuality)
  • Need for control (resisting authority)
  • Being listened to is more important than getting one’s way
adolescent health problems
Adolescent Health Problems
  • Mortality
    • Accidents
    • Homicide
    • Suicide
  • Sexually Transmitted Infections
  • Substance use/abuse
  • Life long health habits
    • Eating/Exercise
    • Smoking
adolescent problem behaviors multifactorial
Adolescent Problem BehaviorsMultifactorial
  • Community - Media, economic, availability of drugs and firearms.
  • Family-conflict, domestic violence, and substance abuse
  • School and Peers- academic status, friends’ behaviors, and early antisocial behavior.
protective factors
Protective factors
  • Effective parenting
  • Positive adult connection
  • Positive self esteem
  • Spirituality
  • Optimistic outlook
  • Safe community
  • Socioeconomic advantages
prevention strategies
Prevention Strategies
  • Promote competence and self-regulation
  • Education especially for adolescents in high-risk environments
  • Mentoring and opportunities to serve
  • Anticipatory guidance
  • Immunizations
new 2008 adolescent immunization schedule
New- 2008 Adolescent Immunization Schedule
  • HPV:0, 2, 6 mos. routine at 11-12 yrs. of age Eligible: 9-26 yrs.
  • Influenza:universal
  • Tdap:Single dose to replace Td booster, wound care
  • Meningococcal:1 dose MCV4 for 11-12 year olds, high school entry, college freshmen
  • Hep A:high risk, all who wish
  • Hep B:complete series for all
  • Varicella:catch-up 2nd dose
the rationale for emphasizing adolescent immunization
The Rationale for Emphasizing Adolescent Immunization
  • Adolescent immunization protects during a period of increased risk
  • Adolescent immunization can prevent lifelong complications
  • Adolescent immunization can increase herd immunity
adolescent immunization rates fall short of pediatric rates
Adolescent immunization rates fall short of pediatric rates

“We need to utilize all possible resources to immunize and protect adolescents against vaccine-preventable diseases.” 3

  • *MMR, hepatitis B, varicella immunization
  • NCQA. The State of Health Care Quality, 2005.
  • 2. CDC. MMWR. 2005;54:717-721.
  • 3. Society for Adolescent Medicine. J Adolesc Health. 2006;38:321-327.
barriers to immunizing adolescents
Barriers to immunizing adolescents
  • Fewer well visits during the teenage years1
    • Scheduling difficulties posed by school, sports, and extracurricular activities
  • Lack of transportation
  • Insurance issues
  • Missed opportunities to immunize1
    • Providers simply forget to vaccinate during well visits, including preparticipation sports physicals
    • Providers misunderstand vaccine contraindications1,2
  • Lack of population-based immunization registries that include adolescents
  • Oster NV et al. J Am Board Fam Pract. 2005;18:13-19.
  • VHC. Immunization Tool Kit. April 2005.
barriers to immunizing adolescents cont d
Barriers to immunizing adolescents (cont’d)
  • Lack of motivation by families
    • Adolescents and parents underestimate the risks posed by vaccine-preventable diseases1
    • Many states do not require adolescent immunizations for school
  • Misperceptions about vaccine safety
  • Patient resistance to vaccines (eg, needle phobia)
  • Oster NV et al. J Am Board Fam Pract. 2005;18:13-19.
identifying solutions
Identifying Solutions
  • 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

identifying solutions1
Identifying Solutions
  • 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

adolescent vaccination platforms
Adolescent Vaccination Platforms
  • 11-12 year platform
    • Primary platform endorsed by ACIP
    • Coincides with need for sports physicals
    • Coincides with discussions on puberty and sexuality
adolescent vaccination platforms1
Adolescent Vaccination Platforms
  • 14-15 year platform
    • Catch up on missed vaccinations
    • Complete multiple dose vaccination regimens
    • Coincides with need for sports physicals
adolescent vaccination platforms2
Adolescent Vaccination Platforms
  • 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
use of non comprehensive visits
Use of Non-comprehensive Visits
  • Minor illness/injury visits
    • Potentially controversial
    • Parent education on true and false contraindications to immunizations
  • Camp/Sports physicals
  • Pre-college visits
meningococcal disease
Meningococcal Disease

N Engl J Med. 2001;344:1372

meningococcal disease still a major health concern
Meningococcal Disease: Still a Major Health Concern
  • Meningococcal disease continues to cause significant morbidity and mortality in the US
  • Rates of meningococcal disease beyond infancy begin to rise in early adolescence, peaking at 17 years of age
  • Older adolescents have a 5-fold greater fatality rate than those <15 years old
  • Conjugate vaccines induce immunologic memory and herd immunity
  • The attributes of conjugate vaccines give them more widespread utility than polysaccharide vaccines

1. Harrison LH, et al. JAMA. 2001;286:694. 2. Granoff DM, et al. In: Vaccines. 4th ed. 2004: 959.

acip recommendations for use of meningococcal vaccine
ACIP Recommendations for Use of Meningococcal Vaccine
  • Routine vaccination of adolescents with MCV-4
    • Young adolescents 11 to 12 years (during the pre-adolescent visit), OR
    • Teens entering high school (15 years), OR
    • Incoming college freshmen (18 years) living in dormitories

CDC. MMWR. 2005;54(RR-7):13.

acip recommendations
ACIP Recommendations
  • Routine vaccination of other populations at increased risk
    • Microbiologists who are routinely exposed to isolates of Neisseria meningitidis
    • Military recruits
    • Persons who travel to, or reside in, countries in which N meningitidis is hyperendemic or epidemic
    • Complement-deficient and asplenic patients
practice recommendation
Practice Recommendation
  • Tdap and tetravalent meningococcal conjugate vaccine (which both contain diphtheria toxoid) should be administered to adolescents aged 11-18 years during the same visit if both vaccines are indicated and available
  • Approved Source: National Guideline Clearinghouse
  • Website: http://www.guideline.gov/summary/summary.aspx?doc_id= 8818&nbr=004864&string=acip+and+pertussis
  • Strength of Evidence: 1-A:1 Efficacy against and tetanus, diphtheria, and pertussis is supported by immunogenicity results of randomized, controlled clinical trials among adolescents; safety is supported by results of randomized, controlled clinical trials among adolescents.
meningococcal revaccination
Meningococcal Revaccination
  • Revaccination may be indicated for persons at high risk for infection* who received Menomune at least 5 years ago
  • Once a person has received MCV no further meningococcal vaccination is recommended (at this time)
responses to initial reports of gbs following receipt of menactra vaccine
Responses to Initial Reports of GBS Following Receipt of Menactra Vaccine
  • Initial report September 30, 2005 - 5 confirmed cases of GBS reported to the Vaccine Adverse Event Reporting System (VAERS)
  • New Vaccine Information Sheet (VIS) published on October 7th
  • Package Insert Revised – November 2005
    • Previous GBS listed as contraindication
    • Temporal relationship between GBS and MCV4 in Warning section
  • Further monitoring and studies ongoing
updated information on reports of gbs following receipt of menactra vaccine
Updated Information on Reports of GBS Following Receipt of Menactra Vaccine
  • In April 7, 2006 MMWR*, Centers for Disease Control and Prevention (CDC) states that:
    • Only 3 cases reported since October 2005, suggesting that MCV4 [Menactra vaccine] might not be causally related to GBS;
    • Available evidence neither proves nor disproves causal relation between GBS and Menactra vaccine;
    • Reported incidence remains similar to the expected incidence
  • Rate of GBS following Menactra vaccine is similar to what would be expected by chance alone
    • Background incidence rate of GBS is 1–2 cases/100,000 population
    • Ratio of reporting rate of GBS following Menactra vaccination to the expected incidence rate is 1.4 (95% CI, 0.7–2.8)*

* MMWR Vol.55/No.13, pp 364-366

reports of pertussis united states 1980 2004
Reports of PertussisUnited States, 1980–2004

25,827

24

20

16

12

Cases (Thousands)

11,647

9771

7796

6586

8

4570

4

0

1980

1982

1984

1986

1988

1990

1992

1994

1996

1998

2000

2002

2004

Year

CDC. MMWR. 1997;46(54):71-80. MMWR. 2000;50(51 & 52):1175. MMWR. 2001;50(33):725. MMWR. 2002;51(32):723. MMWR. 2003;52(31):747. MMWR. 2003;52(54):28, 72. Bacterial Vaccine Preventable Disease Branch, National Immunization Program, 2004; MMWR. 2005;54(31):770.

complications of adolescent adult pertussis
Complications of Adolescent-Adult Pertussis
  • Complications common in adolescents (16%) and adults (28%)
  • Pneumonia occurs in 2% of patients <30 years old and 5% to 9% of older patients
  • Hospitalization of adolescents and adults at 1.4% and 3.5%, respectively
    • <50 y/o, 2% hospitalized, mean stay of 3 days
    • ≥50 y/o, 6% hospitalized, mean stay of 17 days

De Serres G et al. J Infect Dis. 2000;182:174-179.

age of pertussis source for infants
Age of Pertussis Source* for Infants

60

50

40

% of Infant Cases

30

20

10

0

0-4

5-9

10-19

20+

Age of Source (Years)

*219 known or suspected source-persons with known age

Bisgard KM et al. Pediatr Infect Dis J. 2004;23:985-989

pertussis adolescents and adults
Pertussis – adolescents and adults
  • More than half of cases are adolescents or adults
  • Family member is usual source (75%) for infant pertussis

Source persons by age for infant pertussis: Adolescents and adults were source for 76% of cases

Bisgard KM et al. Infant pertussis: who was the source? Ped Inf Dis J 2004;23(11):985-9.

tdap vaccines
Tdap Vaccines
  • Boostrix
    • Approved for persons 10-18 years of age
  • Adacel
    • Approved for persons 11-64 years of age
tdap vaccines1
Tdap Vaccines
  • No brand preference (except as dictated by age group being vaccinated; off-label use NOT recommended)
  • Licensed only for a single dose
  • Tdap not approved or recommended for children 7-9 years of age or adults 65 years or older (use Td)
tdap precautions
Tdap - Precautions
  • History of Arthus-type reaction following tetanus- or diphtheria- containing vaccine
  • Unstable neurological conditions
  • Severe latex allergy
  • History of Guillain Barre Syndrome after tetanus-containing vaccine
  • Moderate or severe acute illness

MMWR December 15, 2006 / 55(RR17)

contraindications
Contraindications
  • Anaphylaxis after prior dose
  • Unexplained encephalopathy within 7 days of pertussis-containing vaccine. Give Td.
  • MMWR Feb 3,2006;55(Early release):1-34
not precautions to tdap
NOT Precautions to Tdap
  • Stable neurological disorder
  • Pregnancy or breastfeeding
  • Immunosuppression
  • Infection, minor illness, antibiotics
  • History following DTaP, DTP, or DT of:
    • Temp 105° F or higher
    • Collapse or shock-like state
    • Crying lasting 3+ hours
    • Convulsions with/without fever
    • History of extensive limb swelling

MMWR Feb 3,2006;55(Early release):1-34

slide48

Practice Recommendation

  • ACIP Recommendations – Adolescent Pertussis Immunization
    • All adolescents at the 11-12 year old visit
    • All adolescents 11-18 not recently immunized with Td
    • Adolescents 11-18 who received Td and it has been a least 5 yrs
    • Can give Tdap and MCV4 simultaneously
  • Approved Source: National Guideline Clearinghouse
  • Website: http://www.guideline.gov/summary/summary.aspx?doc_id= 8818&nbr=004864&string=acip+and+pertussis
  • Strength of Evidence: see next slide
human papillomavirus hpv
Human Papillomavirus (HPV)
  • Genital HPV is the most prevalent sexually transmitted infection in the US
    • Estimated 80% of sexually active persons will have been infected by age 50
    • ~20 million infected
    • 6 million new infections/year
  • Vast majority of infections are transient and asymptomatic
  • Persistent infection may lead to anogenital cancers

Cates, STD 26:Supp 1-7 (1999); Meyers et al. Am J Epidemiol 151: 1158-1171 (2000)

cervical cancer disease burden in the united states
Cervical Cancer Disease Burden in the United States
  • The National Cancer Institute estimates that in 2007
    • 11,150 new cervical cancer cases
    • 3,670 cervical cancer deaths
  • Almost 100% of these cervical cancer cases will be caused by one of the 40 HPV types that infect the mucosa
human papillomavirus vaccine
Human Papillomavirus Vaccine
  • HPV L1 major capsid protein of the virus is antigen used for immunization
  • Expression of L1 protein uses recombinant technology similar to hepatitis B vaccine
  • L1 proteins self-assemble into virus-like particles (VLP)
  • Noninfectious, nononcogenic, very effective

HPV VLP

quadrivalent hpv vaccine
Quadrivalent HPV Vaccine
  • High efficacy among females without evidence of infection with vaccine HPV types
  • No evidence that the vaccine had efficacy against existing disease or infection (i.e., the vaccine is not therapeutic)
  • Prior infection with one HPV type did not diminish efficacy of the vaccine against other vaccine HPV types
hpv vaccine acip recommendations 3 12 2007
HPV VaccineACIP recommendations: 3/12/2007
  • 3 doses, IM, females ages 9-26 yrs.

- Routine: 11-12 yrs. (0, 2, 6 mos.)

      • Minimum intervals
        • 4 weeks between doses 1 and 2
        • 12 weeks between doses 2 and 3
  • Best to give prior to first sexual activity
  • No evidence of effectiveness against pre-existing infection or disease
  • Even if prior HPV infection, immunize - May not be infected with all vaccine strains
  • Not for males (yet) – limited data

GA AAP

practice recommendation1
PracticeRecommendation
  • ACIP recommends:
    • HPV vaccine (GARDASIL) should be routinely given to girls when they are 11 or 12 years old
    • The recommendation also allows for vaccination of girls beginning at nine years of age as well as vaccination of girls and women 13-26 years of age.

Approved Source: National Guideline Clearinghouse

Website: http://www.guideline.gov/summary/summary.aspx ?doc_id=10634&nbr=005571&string=hpv+AND+vaccine

Strength of Evidence: The type of evidence supporting the recommendations is not specifically stated. Markowitz LE, Dunne EF, Saraiya M, Lawson HW, Chesson H, Unger ER, Centers for Disease Control and Prevention (CDC). Quadrivalent human papillomavirus vaccine: recommendations of the Advisory Committee on

Immunization Practices (ACIP). MMWR Recomm Rep 2007 Mar 23;56(RR-2):1-24. [125 references]

cervical cancer screening
Cervical Cancer Screening
  • 30% of cervical cancers caused by HPV types not prevented by current vaccine
  • Vaccinated females could be infected with non-vaccine HPV types
  • Possible infection prior to vaccination

No change in cervical cancer screening

one dose varicella program
One-dose varicella program
  • Coverage in 2006 – two year olds:
    • United States: 89.3%
    • Virginia: 86%
  • Effects of one-dose program:
    • >80% decrease in cases, hospitalizations, deaths
    • Breakthrough cases & outbreaks persist
    • Second dose will boost immunity, reduce breakthrough

PAAAP

varivax vaccine adolescents and adults
Varivax™ vaccine – adolescents and adults
  • Vaccinate all people without evidence of immunity with 2 doses. Minimum interval: 4-8 wks.
  • Prenatal assessment and postpartum vaccination:
    • Assess women prenatally
      • If no immunity, dose #1 prior to discharge
      • Dose #2 postpartum 4-8 wks. later
varicella immunity revised
Varicella immunity - revised
  • Documentation of age-appropriate vaccination
  • Lab evidence of immunity or disease
  • Born in the U.S. prior to 1980 – except for HCW and pregnant women
  • HCP diagnosis or verified disease
  • HCP verified history of herpes zoster

Don’t assume - Confirm varicella immunity!

ACIP Recommendation, MMWR 2007; 56 (RR-04), 1-40

hepatitis b vaccine adult
Hepatitis B vaccine - adult
  • Routine: 0, 1 month, 4-6 months
  • New HBV recommendations:
    • Vaccinate as part of routine services
    • No need for patient to state specific risk factor
    • Vaccinate all adults in high-risk settings
  • Don’t forget households with international adoptees
  • Continue series if interrupted – don’t restart
  • Booster doses NOT routine
  • Adolescent 2-dose schedule: Recombivax™
  • Combined Hep A-Hep B vaccine: Twinrix™

(MMWR 2006:55(RR-16).Photo: woman with liver cancer caused by hepatitis B/Dr. Patricia Walker

improving adolescent immunization rates

Improving Adolescent Immunization Rates

Strategies for Your Practice

strategies to consider
Strategies to Consider
  • Immunization Charts posted for all staff to see
  • Immunization Champion
  • Team meetings about Immunizations
  • Current VIS information readily available
  • Reminder/Recall system for patients
team discussions
Team Discussions
  • Vaccine supply
  • Storage and handling
  • Vaccine administration
  • Adverse events
  • Talking with Teens
  • Vaccine refusers
  • Reimbursement
  • New vaccines
  • Foreign immunization records
  • Immunization registries
vaccine supply
Vaccine supply
  • New products – ramp up production
  • Change in production of existing product
  • Stopping production (Td)
  • Production problems
  • Slow-growing flu vaccine
  • Document, recall patients when possible

Communication is essential!

influenza practice issues
Influenza – practice issues
  • Ordering
  • Supply
  • Communication
  • Vaccine misconceptions
  • Seasonal vs. avian flu
  • Pandemic is due
  • Immunizing practice staff
vaccine storage handling
Vaccine Storage & Handling
  • Work with VFC
  • Consider more (new) refrigerator space
  • Check & record temps twice daily
  • Keep logs for 3 years
  • Act on out-of-range temperatures
  • Power failure plan
  • Inventory & rotate vaccines
vaccines for children
Vaccines for Children
  • Medicaid
  • Uninsured
  • Underinsured
  • Native American
  • Up to age 19

Virginia VFC Program:

(800) 568-1929

vaccine administration
Vaccine Administration
  • Assess site for each person
  • Use long enough needle for IM injections
  • Aspiration – not required
  • Children > 1 yr. – use deltoid if adequate
  • Anatomic sites below:
adverse events
Adverse Events
  • Screen for contraindications and precautions
  • Administer vaccines correctly
  • Syncope and teens (HPV) – sit during and wait after immunization
  • Acute reactions: have emergency plan, practice
  • Report adverse events to VAERS
talking to teens
Talking to teens
  • Be open and honest
  • Treat the teen with respect
  • Talk directly to teen
  • Begin conversation with less threatening topics
  • Provide confidentiality
  • Listen empathically
vaccine refusers
Vaccine Refusers
  • Use Vaccine Education Center materials:www.vaccine.chop.edu
  • Recommend good web sites:www.cdc.gov/nipwww.immunize.orgwww.cispimmunize.org
  • Document refusal
vaccine coding and payment
Vaccine Coding and Payment
  • Use correct CPT code
  • Use one first admin code then additional admin codes for each vaccine
  • Link CPT code to correct ICD-9-CM V code
  • Use secondary codes for high-risk patients
  • Use codes if vaccination was not completed
  • Review EOBs
  • Use face-to-face counseling codes
  • Check billing
implementing new vaccines
Implementing New Vaccines
  • Stay up-to-date on licensing and recommendations
  • Obtain VIS: www.immunize.org
  • Get new billing codes
  • Buying group for best price
  • Revise office systems
  • Educate staff
  • Target patients – age, high-risk
  • Develop spreadsheet with payers and reimbursement – Is coverage adequate and comparable?
  • Pick date to start using new vaccine

It’s a team effort!

foreign immunization records
Foreign Immunization Records
  • Accept only written records
  • Be skeptical
  • Match up with U.S. requirements
  • Revaccinate (may be simpler) or do serology (when possible)
  • See AAP’s Red Book
motivate your staff to become vaccine advocates
Motivate your staff to become vaccine advocates
  • Increase awareness of adolescent immunization with staff newsletters or staff meetings
  • Share practice goals and Health Plan Employer Data and Information Set (HEDIS) compliance data
  • Use training programs sponsored by the CDC, local health departments, specialty societies, and immunization groups
  • Review charts to identify providers who may need additional education
  • Recognize staff members who achieve immunization goals (eg, gift certificates, awards)

Hernandez SA. AAACN Viewpoint. Jan/Feb 2002

your recommendation makes a big difference
Your recommendation makes aBIG difference!

Influenza immunization rate…

27%when patient attitude toward vaccination was negative and provider made no vaccine recommendation

82%when patient attitude was negative and provider recommendedinfluenza vaccine

Nichol KL et al. J Gen Intern Med. 1996:11:673-677.