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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. 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

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  1. Staying on Track: The Importance of Timely Adolescent Immunizations Colleen Kraft, M.D., FAAP

  2. 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

  3. 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

  4. 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

  5. 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

  6. 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

  7. 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

  8. Adolescent Health Problems • Mortality • Accidents • Homicide • Suicide • Sexually Transmitted Infections • Substance use/abuse • Life long health habits • Eating/Exercise • Smoking

  9. 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.

  10. Protective factors • Effective parenting • Positive adult connection • Positive self esteem • Spirituality • Optimistic outlook • Safe community • Socioeconomic advantages

  11. Prevention Strategies • Promote competence and self-regulation • Education especially for adolescents in high-risk environments • Mentoring and opportunities to serve • Anticipatory guidance • Immunizations

  12. Adolescent Immunization Schedule

  13. 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

  14. 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

  15. 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.

  16. Well Visits By Age

  17. 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.

  18. 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.

  19. 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

  20. 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

  21. 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

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

  23. 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

  24. 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

  25. Meningococcal Disease N Engl J Med. 2001;344:1372

  26. 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.

  27. 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.

  28. 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

  29. 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.

  30. 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)

  31. 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

  32. 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

  33. Pertussis

  34. 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.

  35. 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.

  36. 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

  37. 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.

  38. Tdap Vaccines • Boostrix • Approved for persons 10-18 years of age • Adacel • Approved for persons 11-64 years of age

  39. 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)

  40. DTaP and Tdap Errors

  41. 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)

  42. 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

  43. 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

  44. 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

  45. Human Papilloma Virus (HPV)

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