Playing Hard to Get…

1. Playing Hard to Get… Addressing & Overcoming Barriers to Vaccinating Adolescents

2. Outline Status of Adolescent Vaccination Rates in NC Parental Concerns – Adolescent Vaccines General Communication Strategies How to Get Practice-Specific Adolescent Immunization Rates

3. Objectives Describe concerns parents have regarding adolescent vaccinations Identify strategies for communicating effectively and increasing awareness about adolescent vaccines Describe the benefits of understanding practice-specific adolescent immunization rates

4. NC Adolescent Vaccination Rates • CDC’s National Immunization Survey - 2009 • NC’s CHAMP Survey - 2010

5. NIS Teen Rates - 2009

6. NIS Teen Rates Source: 2009 National Immunization Survey – Teen

7. NC CHAMP Data – Heard of HPV Vaccine?

8. NC CHAMP Data – Heard of HPV Vaccine?

9. NC CHAMP Data – Had Any Shots of HPV Vaccine?

10. NC CHAMP Data – Had Any Shots of HPV Vaccine?

11. NC CHAMP Data – Had Meningitis Vaccine?

12. NC CHAMP Data – Had a Tetanus Shot?

13. NC CHAMP Data – Ever Postponed or Refused a Shot?

14. Understanding and Addressing Parental Concerns about Adolescent Vaccines

15. Background • Recommended Adolescent Vaccines: • Tetanus, diphtheria, acellular pertussis (Tdap) • Meningococcal conjugate (MCV4) • Human papillomavirus (HPV)

16. Changes to Tdap Vaccine Recommendations Children 7-10 years: Who were not fully vaccinated against pertussis and for whom no contraindication to pertussis vaccine exists, should get a dose of Tdap. Who were never vaccinated against tetanus, diphtheria, or pertussis or who have unknown vaccination status, should receive a series of three vaccinations containing tetanus and diphtheria toxoids. Recommendations for children 11-18 years are same Adults aged 65 years and older: Who have or anticipate having close contact with an infant aged less than 12 months should receive a single dose of Tdap; Other adults ages 65 years and older may be given a single dose of Tdap

17. Changes to Meningococcal Vaccine Recommendations Routine vaccination of adolescents, preferably at age 11 or 12 years, with a booster dose at age 16 years, and A 2-dose primary series administered 2 months apart for persons aged 2 through 54 years with persistent complement component deficiency and functional or anatomic asplenia, and for adolescents with HIV infection.

18. National Immunization Survey: Selected Survey Questions • What is the main reason [your teen] did not receive tetanus booster shots? • What is the main reason [your teen] did not receive meningitis shots? • What is the main reason [your teen] will not receive HPV shots in the next 12 months?

19. National Immunization Survey: Main Parent-Reported Reasons

20. Summary • Top reasons common to all 3 vaccines: • Lack of recommendation • Parental lack of knowledge • Parental perception that vaccine is not needed • Top reason for not receiving HPV • Daughter is not sexually active

21. Physician Recommendations 78.5% of parents said that their decision to vaccinate their children was influenced by a health care provider Of the parents who believe vaccines are unsafe, 65% said a provider influenced their ultimate decision. Studies have shown nearly 9 of 10 adults believe that a strong recommendation from their doctor would influence their vaccination decisions

22. Lack of Recommendation • In NC – Tdap = required • Meningococcal & HPV = recommended • Why some vaccines required – others recommended? • Cost – when we were still a universal-select state – would require vaccines that state could also pay for everyone to receive, regardless of insurance status • Now VFC-only state – this may change in future

23. Provider Lack of Recommendation

24. Lack of Recommendation What Can You Say? Make a STRONG recommendation that the child receive the vaccine! Even though not a requirement, still important and your child can benefit from receiving the vaccine. Adolescents are more at risk for these diseases

25. Parent Attitudes Higher acceptance rates with: • Greater perceived risk of exposure • Perception that vaccine is effective • Perception that vaccine is safe • Strong physician recommendation • Educational intervention

26. Parental Lack of Knowledge / Believe Vaccine Not Needed Why do Adolescents Need These Vaccines? Adolescents continue to contract vaccine-preventable diseases that have been nearly eliminated for infants and children. Infants and children not yet immunized and seniors whose immunity may be weakened are at high risk for diseases from exposure to adolescents who may be infected. What Can You Say? Share personal experiences/stories Pictures Educate about how vulnerable adolescents are to these diseases

27. Parental Perception Vaccine Not Needed

28. Pertussis in Adolescents Teens who contract pertussis may have a hard time breathing, eating, or sleeping. The disease can also lead to cracked ribs, pneumonia, or trips to the hospital. Full recovery can take several months. More importantly, teens and adults can transmit pertussis down to their susceptible younger siblings.

29. Pertussis in Adolescents Why Vaccinate with Tdap? Immunizations that adolescents received as children begin to wear off after 5 years Adolescents are vulnerable to becoming infected with pertussis and spreading it to infants around them.

30. Meningococcal Disease in Adolescents • Why Vaccinate against Meningococcal Disease? • This is a devastating disease and teenagers are at higher risk. • Behaviors that can put teens at greater risk, include: • Sharing drinking glasses, water bottles, or utensils • Kissing • Smoking • Living in close quarters, such as overnight camp or dormitories

31. Meningococcal Disease in Adolescents Symptoms of meningococcal disease may resemble the flu but progress rapidly and are more severe About 10-15% of people who get meningitis die. For survivors, long term effects can include brain damage, seizures, hearing loss or limb amputations. Adolescents and young adults account for about 30% of all meningitis cases in the US. .

32. HPV in Adolescents At least 50% of people will have HPV at some point in their lives. HPV is most common in women and men who are in their late teens and early twenties. There are over 40 types: Some types cause genital warts or throat warts Other types cause cancer, particularly cervical cancer, but also cancers of the vulva, vagina, penis, anus, tongue, tonsils, and throat

33. Additional Reasons

34. HPV – Encourages Daughter to Have Sex There is no evidence that the vaccine triggers or encourages sexual behavior in adolescents. It’s best to keep in mind that the vaccines protect against cervical cancer and two types of genital warts. Giving child permission not to have cervical cancer – not permission to have sex

35. HPV – Daughter Not Sexually Active The earlier it is given, the more likely it is to provide the best protection. She may not be sexually active now, but at some point she likely will be Even if she waits until marriage to become sexually active, her husband could be a carrier and not even know it, potentially exposing her to HPV.

36. Giving HPV Vaccine to Boys • Reasons to vaccinate boys: • Men can still get genital warts from HPV. • HPV is responsible for up to 63% of oral cancers, 93% of anal cancers, and 36% of penile cancers in the U.S. • Men can also spread HPV to their partners

37. HPV Vaccine for Boys • Higher acceptance if framed as helpful to males • Only for cervical cancer: • 34% of college males • 12-18% of mothers of male children • For genital warts and cancers affecting both genders: • 74-78% of college males • 77-100% of mothers of male children • Providers: 82-92% would recommend Liddon, N. et al. J Adolesc Health. 46(2): 113-23, 2010 Feb.

38. Summary: Vaccinating Adolescents = Perception of Risk for Disease • ‘Not needed’ or ‘not sexually active’ • Unfamiliarity with susceptibility and severity of disease • Parents often unaware of when children become sexually active

39. Communicating with Parents • Take time to listen • Validate their concerns • Use a “heart and head” approach • Balance risks and benefits • Be flexible • Direct them to reliable resources

40. Responding to Parent Refusals Give some vaccines if you can Revisit the immunization discussion at subsequent visits Good documentation of discussion of benefits of vaccine and risks of being unimmunized Sign a refusal waiver

41. Be a Role Model and Ask More of People May want to mention that you are up-to-date on your vaccines… May want to mention that your children, grandchildren, nieces, nephews, etc. are vaccinated Ask people to help you provide a community where children are safer from diseases

42. Healthcare Providers Can Make a Difference • You can have a positive influence on parents’ decision to vaccinate their children • Including parents who believe that vaccinations are unsafe. • Work to increase your efforts to build honest and respectful relationships with parents.

43. http://cdc.gov/vaccines/who/teens/products/

44. www.vaccine.chop.edu/parents

45. www.immunize.org

46. Strategies to Increase Adolescent Immunization Rates • Strong provider recommendation • Avoid missed opportunities • Minor illness is not a contraindication • Give all eligible vaccines simultaneously • Use reminder/recall system (paper, phone, text message, or e-mail) • Audit system to monitor rates of WCC and immunizations – (Adolescent AFIX!!) • Vaccine administration in alternative settings

47. Adolescent AFIX

48. What is Adolescent AFIX? • Adolescent AFIX is an opportunity for vaccine providers to get a current ‘snapshot’ of their vaccination coverage rates.  • The primary goal of the assessment is to increase provider’s knowledge and utilization of adolescent vaccines and to improve adolescent vaccination rates.   • Assessment • Feedback • Incentive • Exchange

49. Assessment • Overall Rate – 2MMR, 1Meng, 1Tdap, 3Hep B • Individual Rates for: • 2MMR • 1Tdap • 1 Meng • 3 Hep B • 1 and 2 Var • 1, 2, and 3 HPV