Texas Immunization Stakeholders Working Group

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

2. Promotion of Adolescent Immunizations I think this from the quotable Mark Twain is appropriate to think about before we begin.I think this from the quotable Mark Twain is appropriate to think about before we begin.

3. Realities 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 Source: 1997 Commonwealth Fund Survey of the Health of Adolescent Girls So, here is an example of what we thought we knew for sure.So, here is an example of what we thought we knew for sure.

4. Identifying The Boundaries Service Demand Service Requirements Systems Capabilities So what are the issues we must confront with adolescent vaccines?So what are the issues we must confront with adolescent vaccines?

5. Today�s Situation- 7/1/06 Potentially very high service demands.Potentially very high service demands.

6. What That Means 2 1/2 minutes to administer vaccine 21,348,000 adolescents between 15-19 years of age Require 1,224,300 man-hours per recommended injection Assuming the most aggressively optimistic estimates of vaccination administration time�Assuming the most aggressively optimistic estimates of vaccination administration time�

7. Well Visits By Age We�ll just do it at their well check exams�not!We�ll just do it at their well check exams�not!

8. Service Requirements Sequence and temporal administration requirements of vaccines How many? How often? How far apart? Optimal age for administration Special conditions Targeted populations Contraindications What are the specific requirements of the services we will provide?What are the specific requirements of the services we will provide?

9. Systems Capabilities Accessibility Hours of operation Location Capacity Funding What are the limits of our systems capabilities?What are the limits of our systems capabilities?

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

11. 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

12. 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

13. 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

14. Adolescent Vaccination Platforms 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 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 Immunization screening tools Immunization registries Reminder/recall systems Providers Patients

17. 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 Will providing adolescent immunizations at non-comprehensive visits remove imperative for routine well care?Will providing adolescent immunizations at non-comprehensive visits remove imperative for routine well care?

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

19. Use of Alternative Vaccination Sites Schools Benefits Sutton�s Law Potential to implement into existing health education curriculum

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

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

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

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

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

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

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

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

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

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

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

31. Education

33. Recent Developments 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 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. Resolution was accepted and referred to appropriate committee

35. Recommendations 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

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

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