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Strategies for Improving Adolescent Immunization Rates

Strategies for Improving Adolescent Immunization Rates. Educational Learning Objectives. At the conclusion of this presentation, the participant should be able to: Discuss the indications and recommendations for the most current immunization schedules for adolescent populations

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Strategies for Improving Adolescent Immunization Rates

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  1. Strategies for Improving Adolescent Immunization Rates

  2. Educational Learning Objectives At the conclusion of this presentation, the participant should be able to: Discuss the indications and recommendations for the most current immunization schedules for adolescent populations Respond to frequently encountered questions and situations during patient discussions including safety, efficacy, and possible misinformation Implement strategies for improving immunization rates within one’s clinical practice, taking into account current immunization schedules and guidelines

  3. Definition of ‘Adolescent’ • 7th birthday until the 19th birthday • Per CDC adolescent immunization schedule • Society of Adolescent Medicine defines adolescent as 10 to 25 years

  4. 2011 ACIP Adolescent Immunization Schedule ACIP Schedules. www.cdc.gov/vaccines/recs/schedules/default.htm. Accessed Feb 2011.

  5. Adolescent Catch-up Schedule ACIP Schedules. www.cdc.gov/vaccines/recs/schedules/default.htm. Accessed Feb 2011.

  6. Vaccination Coverage Adolescents 13–17 yrs, United States, National Immunization Survey CDC. MMWR Morb Mortal Wkly Rep. 2009;58(36):997-1001. CDC. MMWR Morb Mortal Wkly Rep. 2010;59(32):1018-1023.

  7. Tdap Boostrix Approved for use ages 10-64 years Adacel Approved for use ages 11-64 years • Two FDA-approved Tdap vaccines available • Both contain the same acellular pertussis component as their respective DTaP products • FDA recommended one-time use of Tdap only • For 11 to 12-year-olds, replaces Td booster if no previous Tdap • Catch-up for 13 to 18-year-olds • MCV4 contains diphtheria conjugate protein carrier • If both are indicated, administer MCV4 and Tdap simultaneously *off-label ACIP recommendation CDC. MMWR Recomm Rep. 2006;55(RR03):1-34. ACIP. http://www.cdc.gov/vaccines/recs/acip/slides-oct10.htm. Accessed Nov 2010.

  8. New ACIP Recommendations Tdap Children 7 to 10 Years of Age • Under-vaccinated children ages 7-10 years • Single-dose of Tdap • If additional doses of Td are needed, then vaccinate according to catch-up guidance (Tdap 1 dose only) • Children 7–10 years never vaccinated against tetanus, diphtheria, or pertussis • Start with single dose of Tdap, followed by • Td > 4 wks after Tdap • Td 6-12 mo later • Further guidance will be forthcoming on timing of revaccination those who have received Tdap prior to age 11 ACIP. http://www.cdc.gov/vaccines/recs/acip/default.htm. Accessed Dec 2010.

  9. HPV-associated* Invasive Squamous Cell Carcinomas in Women and Men, 1998–2003 *Defined by histology and anatomic site Watson M, et al. Cancer. 2008;113(10suppl):2855-2864. CDC. http://www.cdc.gov/cancer/hpv/statistics/index.htm. Accessed Jan 2011.

  10. This 14-year-old has come in for a sports physical for camp. She is up- to-date on all of her vaccinations, except her mother has decided to “wait until there is more data” on the HPV vaccine. • What data can you provide to reassure the mother that vaccination now is preferable?

  11. The HPV vaccine is only effective PRIOR to exposure • Immune response is more vigorous the younger the patient • ~33 million doses of HPV vaccine have been given in the US; no patterns of safety concern have been noted • The vaccine prevents cancer – period • Sexual debut is not always the patient’s choice; protect children while we can

  12. Available HPV Vaccines CIN2+: cervical intraepithelial neoplasia grade 2 or higher and adenocarcinoma in situ *needle-less prefilled syringes contain latex; vial stopper does not contain latex Markowitz L. ACIP Meeting Oct 2009. http://www.cdc.gov/vaccines/recs/acip/downloads/mtg-slides-oct09/02-2-hpv.pdf. Accessed Dec 2010.

  13. HPV – ACIP RecommendationsQuadrivalent HPV (HPV4) and Bivalent HPV (HPV2) • Routine vaccination of females aged 11–12 years • Catch-up 13–26 years • ACIP: no preference for cervical cancer prevention • Use HPV4 for genital wart and external lesion coverage • Use HPV4 for external lesion protection among males ACIP Schedules. www.cdc.gov/vaccines/recs/schedules/default.htm. Accessed Dec 2010. FDA. http://www.fda.gov/BiologicsBloodVaccines/Vaccines/ApprovedProducts/ucm172678.htm. Accessed Dec 2010.

  14. Proportion of Clinicians Who Strongly Recommend HPV Vaccine to Female PatientsSurvey Data Jan–Mar 2008 Daley M, et al. Pediatrics. 2010;126:425-433.

  15. HPV Vaccination and Pregnancy • HPV vaccines are not recommended for use in pregnant women • Delay initiation of vaccination until after completion of pregnancy • If a woman is found to be pregnant after initiating the vaccination series, delay remaining doses until after the pregnancy • Two vaccine during pregnancy registries: • Quadrivalent HPV vaccine/pregnancy: 800-986-8999 • Bivalent HPV vaccine/pregnancy: 888-452-9622 CDC. MMWR Morb Mortal Wkly Rep. 2010;59(20):626-629.

  16. HPV Quadrivalent Vaccine in Males • FDA approved quadrivalent HPV vaccine for boys and men ages 9 through 26 yrs • ACIP: Permissive HPV vaccine for males • Included in VFC program; obtained at no cost from any Federally Qualified Health Center (FQHC); manufacturer Patient Assistant Program CDC. MMWR Morb Mortal Wkly Rep. 2010;59(29):630-631.

  17. HPV Quadrivalent Vaccine in Males Ongoing Considerations • Anal and oral cancers in males • Efficacy • High efficacy for prevention of vaccine HPV type-related anal pre-cancers, genital warts, and persistent infection • Safety • Clinical trial data in males good safety profile • No safety signals in Vaccine Safety Datalink • Provider acceptability and practices • Cost effectiveness ACIP. http://www.cdc.gov/vaccines/recs/acip/downloads/mtg-slides-oct10/08-7-hpv-MaleConsider.pdf. Accessed Dec 2010.

  18. Intent to Vaccinate with HPV among Parents of Females Who Have Not Received Any HPV Vaccine; NIS–Teen 2009 ACIP. http://www.cdc.gov/vaccines/recs/acip/downloads/mtg-slides-oct10/08-3-hpv-Female.pdf. Accessed Nov 2010.

  19. HPV Vaccine Parental Concerns • Parents discomfort with child sexuality • Great opportunity to start talking about sexuality issues • Communicate the importance of completing the 6-month immunization series before the adolescent becomes sexually active • Improved immunogenicity at younger ages • Emphasize cancer prevention • Communicate the universality of the vaccine recommendation • No evidence that vaccination supports sexual activity • Not supported by other interventions such as free condom distribution, availability of emergency contraception • Provider recommendation is perhaps the most important factor in parent decision-making! Rosenthal SL. J Adolesc Health. 2005;37:177-178.

  20. HPV Postlicensure Safety Data • Vaccine Adverse Event Reporting System (VAERS) • HPV4 • 6/1/06–8/31/10 • 33 million doses in females • 16,442 VAERS reports; 8% serious • Ongoing monitoring • No new adverse event concerns or clinical patterns identified • HPV2 • Licensed 10/16/09 • Insufficient usage to date in US to assess AEs • Total US reports through 8/31/10: 9 • Vaccine Safety Datalink Rapid Cycle Analysis • HPV4 • No significant increased risk for pre-specified AEs after vaccination • GBS, seizures, syncope, appendicitis, stroke, VTE, allergic rxns ACIP. http://www.cdc.gov/vaccines/recs/acip/downloads/mtg-slides-oct10/08-2-hpv -VaccSafety.pdf. Accessed Dec 2010.

  21. Meningococcal Conjugate Vaccines • Two licensed meningococcal conjugate vaccines • MCV4-D (Menactra®, Sanofi) • Licensed for persons 2-55 years • Serogroups A, C, Y, W-135 • Diphtheria toxoid conjugate • MenACWY-CRM197 (Menveo®, Novartis) • Licensed for persons 2-55 years • Serogroups A, C, Y, W-135 • Diphtheria CRM197 conjugate FDA. http://www.fda.gov/BiologicsBloodVaccines/Vaccines/ApprovedProducts/ucm093830.htm. Accessed Feb 2011.

  22. New ACIP Recommendations for MCV4* • Administer MCV4 at age 11–12 years • Booster dose at 16 years • For those vaccinated at age 13–15 years • Booster dose at age 16 through 18 years • No booster needed if primary dose on or after age 16 years *Meningococcal conjugate vaccine, quadrivalent; Menactra® or Menveo ® CDC. MMWR Morb Mortal Wkly Rep. 2011;60(3):72-76.

  23. Meningococcal Conjugate Vaccines for Those At High Risk • Children 2–10 years with • Persistent complement component deficiency • Anatomic or functional asplenia • 2 doses of MCV4 at least 8 weeks apart • 1 dose every 5 years thereafter • Persons with HIV infection, 11–18 years • 2 doses of MCV4 at least 8 weeks apart ACIP. http://www.cdc.gov/vaccines/recs/acip/slides-oct10.htm#child. Accessed Dec 2010.

  24. Update on Meningococcal Conjugate Vaccine Safety • 2 large post-licensure studies • Meningococcal Vaccine Study and Vaccine Safety Datalink Rapid Cycle Analysis Study • > 2.3 million MenACYWD (Menactra®) vaccinations • 0 confirmed cases of Guillain-Barré Syndrome (GBS) with 6 weeks of vaccination • Upper 95% confidence limit for attributable risk of GBS associated with MenACYWD is estimated at 1 case per million doses • Background rate of GBS from Meningococcal Vaccine Study: 5.4 cases/million person years • These 2 studies provide no evidence of increased risk of GBS associated with MenACYWD ACIP. http://www.cdc.gov/vaccines/recs/acip/downloads/min-jun10.pdf. Accessed Dec 2010.

  25. Annual Influenza Vaccine Is Recommended for: All people* age 6 months and older! * Without contraindications • CDC. MMWR Recomm Rep. 2010;59(RR8):1-62.

  26. 2010–2011 Influenza Season • 2010-2011 Trivalent Influenza Vaccines • A/California/7/2009(H1N1)-like virus • A/Perth/16/2009(H3N2)-like virus • B/Brisbane/60/2008-like virus • Current information from the CDC and FDA • http://www.cdc.gov/vaccines/vpd-vac/flu/default.htm#ref • http://www.fda.gov/BiologicsBloodVaccines/Vaccines/ApprovedProducts/ucm094045.htm • CDC. MMWR Recomm Rep. 2010;59(RR8):1-62. • CDC. http://www.cdc.gov/vaccines/vpd-vac/flu/default.htm#ref. Accessed Dec 2010. • FDA. http://www.fda.gov/BiologicsBloodVaccines/Vaccines/ApprovedProducts/ucm094045.htm. • Accessed Dec 2010.

  27. 2010–2011 Influenza Season TIV: trivalent inactivated influenza vaccine; LAIV: live attenuated influenza vaccine *FDA-approved for use ≥ 6 months; however ACIP does not recommend use in children 6 months-8 years due to increased risk of fever and febrile seizures reported among young children < 5 years who received a similar vaccine in Australia 2010. CDC. MMWR Recomm Rep. 2010;59(RR8):1-62. CDC. MMWR Morb Mortal Wkly Rep. 2010;59(31):989-992.

  28. Influenza Vaccination forChildren–1 or 2 Doses? CDC. MMWR Recomm Rep. 2010;59(RR8):1-62.

  29. PCV13 – Children 6 through 18 Years of Age with High-risk Conditions • Children 6–18 years of age • High risk for invasive pneumococcal disease • Sickle cell disease • HIV infection • Immunocompromising conditions • Cochlear implant • Cerebrospinal fluid leaks • Single dose of PCV13 • Regardless of whether they have previously received PCV7 or PPSV23 This recommendation is an off-label use of PCV13, which is indicated for children 6 weeks through 5 years of age (prior to the 6th birthday) CDC. MMWR Recomm Rep. 2010;59(RR11):1-19.

  30. Pneumococcal VaccinePPSV23 • Single dose recommended for: • 2–18 years, high-risk groups, sickle-cell disease, CSF leaks, asplenia, cochlear implants • >2 years and immunocompromised • Doses of PCV13 should be completed before PPSV23 • Minimum interval following last dose of PCV13: 8 weeks • One-time revaccination: • 2nd dose of PPSV23 5 years after the first dose of PPSV23 for persons aged >2 years who are immunocompromised, have sickle cell disease, or functional or anatomic asplenia CDC. MMWR Recomm Rep. 2010;59(RR11):1-19.

  31. Hepatitis A • Routine vaccination recommended for all children ages 12 to 23 months • Vaccination for anyone wishing to avoid disease • In areas without existing Hep A vaccination programs, consider catch-up of unvaccinated children 2-18 years • Children at increased risk for infection • Dosing: • VAQTA® • For all persons age ≥ 12 months • 2 doses at 0 and 6-18 months • HAVRIX® • For all persons age ≥ 12 months • 2 doses at 0 and 6-12 months CDC. MMWR Morb Mortal Wkly Rep. 2006;55(RR7):1-23. CDC Resolution No. 06/07-1. http://cdc.gov/vaccines/programs/vfc/downloads/resolutions/0607-1hepa.pdf. Accessed Dec 2010.

  32. Hepatitis A Vaccine International Travel • For healthy persons 40 years of age or younger • 2 doses 6 months apart prior to departure • The first dose of Hepatitis A vaccine should be administered as soon as travel is considered • 1 dose of single-antigen vaccine administered at any time before departure • Consider both HAV and Ig for • Persons age > 40 with chronic illness traveling in less than 2 weeks and only receiving one dose of HAV • Persons at risk of severe disease from hepatitis A virus planning to travel in 2 weeks or sooner CDC. MMWR Morb Mortal Wkly Rep.2007;56(41):1080-1084.

  33. Hepatitis A Postexposure Prophylaxis • For healthy persons 12 months through 40 years of age who have not previously received Hep A vaccine • Immunoglobulin and/or single-antigen hepatitis A vaccine should be administered as soon as possible after exposure • Vaccine preferred for those of age 12 months to 40 years • Ig preferred for age < 12 months, those with vaccine allergies, or those with immunosuppression or liver disease • Ig preferred for age > 40 but vaccine may be used if Ig unavailable • Hep A and Ig may be administered simultaneously • Efficacy of Ig or Hep A when administered >2 weeks postexposure is unknown CDC. MMWR Morb Mortal Wkly Rep. 2007;56(41):1080-1084. CDC. MMWR Morb Mortal Wkly Rep. 2009;58(36):1006-1007.

  34. Hepatitis A: Families of International Adoptees • Hep A vaccination • All previously unvaccinated persons who anticipate close personal contact with an international adoptee from countries of high or intermediate endemicity during the first 60 days following arrival in the US • First dose of Hep A vaccine • As soon as adoption is planned • Ideally at least two weeks prior to the arrival of the adoptee CDC. MMWR Morb Mortal Wkly Rep. 2009;58(36):1006-1007.

  35. Hep B • Multiple schedules • Children 1-10 years • 0, 1, and 6 months • 0, 2, and 4 months • 0, 1, 2, and 12 months • Adolescents 11-19 years • 0, 1, and 6 months • 0, 1, and 4 months • 0, 2, and 4 months • 0, 12, and 24 months • 0 and 4-6 months (2-dose schedule uses adult 10 ug formulation, Recombivax-HB, only for 11-15 years of age) • 0, 1, 2, and 12 months • No combination Hep B vaccines approved for use in ages 11-17 years • Hep B titers are not necessary for teens CDC. MMWR Recomm Rep. 2005;54(RR16):1-23.

  36. Hep A-Hep B Combination Vaccine (Twinrix) • Approved for persons 18 years and older • Combination Hep A vaccine (pediatric dose) + Hep B (adult dose) • First licensed schedule: 0, 1, and 6 months • Alternate schedule 2007: Doses at 0, 7, 21-30 days; booster dose at 12 months • The first 3 doses of the new schedule provide equivalent protection to: • The first dose in the standard single-antigen adult hepatitis A vaccine series • The first 2 doses in the standard adult hepatitis B vaccine series • Seroconversion is nearly 100% after either 3 doses of the combination vaccine on the new schedule or a single dose of single-antigen adult hepatitis A vaccine CDC. MMWRMorb Mortal Wkly Rep. 2007;56(40):1057.

  37. This 15-year-old is in the office for an ankle injury that occurred during a soccer game • You notice that his last immunizations were at age 6 years • Does he need any vaccines?

  38. Recommended vaccines include: • Tdap • MCV • Varicella (2nd dose) • Influenza • (Consider HPV)

  39. Varicella • Universal recommendation for routine vaccination is 2 doses • Given 3 months apart for those under 13 years old • ≥ 13 yrs, minimum interval is 28 days • Formulations • Varivax licensed ages 12 mos and older • Proquad (Combination MMRV) not licensed ≥ 13 years CDC. MMWR Recomm Rep. 2007;56(RR04):1-40.

  40. General Immunization Reminders for Adolescents–Safety First • Syncope is a concern with all adolescent vaccines • Immature cardiovascular system/response • Long standing recommendation to have adolescents sit or lay down for 15–20 minutes following injections

  41. General Immunization Reminders for Adolescents • A multidose vaccine series should not be restarted if the recommended dosing interval is exceeded • Exception–Oral typhoid Ty21a • If giving multiple injections in 1 arm, separate 1” apart • Correct placement for deltoid IM injections

  42. General Immunization Reminders for Adolescents Use a needle long enough to reach deep into the muscle for intramuscular (IM) Injections 22-25 gauge needle Immunization Action Coalition. http://www.immunize.org/catg.d/p2020A.pdf. Accessed Dec 2010. Immunization Action Coalition. http://www.immunize.org/catg.d/p2020.pdf. Accessed Dec 2010.

  43. Marshall GS. The Vaccine Handbook. PCI Books, Inc.: 2010 Contraindications • Increases likelihood of a serious adverse event • When present, vaccine should not be given • Permanent contraindications for all vaccines: severe allergy to vaccine or component • Live vaccines generally contraindicated in pregnancy and for persons with immune incompetence

  44. Marshall G. The Vaccine Handbook. PCI Books, Inc.: 2010 Erroneous Contraindications • Mild acute illness with or without fever • Mild respiratory illness (including otitis media) • Mild gastroenteritis • Antibiotic or antiviral therapy • Low-grade fever, redness, pain, swelling after previous dose • Prematurity (delay HepB in infants < 2000 gm whose mothers are HBsAg-negative) • Household contacts who are unimmunized, immunosuppressed, or pregnant (except pre-event smallpox vaccination)

  45. Marshall G. The Vaccine Handbook. PCI Books, Inc.: 2010 Erroneous Contraindications • Breastfeeding (except pre-event smallpox) • Convalescent phase of illness • Exposure to an infectious disease • Positive tuberculin skin test without active disease • Simultaneous tuberculin skin test • Allergy to penicillin, duck meat or feathers, or environmental allergens • Fainting after previous dose • Seizures, SIDS, allergies, vaccine reactions in family members

  46. Marshall G. The Vaccine Handbook. PCI Books, Inc.: 2010 Erroneous Contraindications • Malnutrition • Lack of a previous physical exam in a well-appearing individual • Stable neurological condition (eg, CP, seizures, developmental delay) • Allergy shots • Extensive limb swelling after DTP, DTaP, or Td that is not an Arthus-type reaction • Brachial neuritis after previous dose of tetanus toxoid-containing vaccine • Autoimmune disease • History of the vaccine-preventable disease

  47. Common Immunization Misconceptions • Do you need to screen for HPV before giving the HPV vaccine? No • If someone has an abnormal Pap smear, do you give them the HPV vaccine? Yes • Do you continue to do Pap smears following the HPV vaccine series? Yes • Is pregnancy testing indicated before giving vaccines? No (other than small pox) • Pregnancy screening? Yes • Do you have to check Hep B titers in teens? No • Does an 18-year-old need a 2nd varicella immunization? Yes • Can you get the flu from a flu shot? No

  48. Vaccine Safety • Vaccine Adverse Event Reporting System • Passive, voluntary reporting • Helps signal potential problem • Cannot determine causal association • Vaccine Safety Datalink Project • Established 1991 • CDC and 8 large managed care organizations • 8.8 million subjects; 3% of U.S. population • Rapid Cycling Analysis VAERS. http://vaers.hhs.gov/index. Accessed Dec 2010. CDC. http://www.cdc.gov/vaccinesafety/Activities/VSD.html. Accessed Dec 2010.

  49. Vaccine Safety (cont) • Clinical Immunization Safety Assessment • Established 2001 • Six academic centers with safety experts • CISA Network Sites • Boston University Medical Center* • Columbia University Medical Center • Johns Hopkins University* • Northern California Kaiser Permanente • Stanford University • Vanderbilt University • Brighton collaboration – International CISA. http://www.cdc.gov/vaccinesafety/Activities/CISA.html. Accessed Dec 2010. The Brighton Collaboration. http://www.brightoncollaboration.org/internet/en/index.html. Accessed Dec 2010.

  50. Adolescent Immunization: Goals and Objectives Effective adolescent vaccine delivery and monitoring are critical Adolescents lag far behind preschoolers in immunization coverage Healthy People 2020 – increase routine vaccination coverage for adolescents 1 dose of Tdap by 13–15 yrs (target 80%) 2 doses of varicella vaccine by 13–15 yrs (excluding children who have had varicella) (target 90%) 1 dose of MCV by 13–15 yrs (target 80%) 3 doses of HPV for females 13–15 yrs (target 80%) Seasonal influenza vaccine for children 13– 17 yrs (target 80%) Healthy People 2020.http://www.healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicid=23. Accessed Dec 2010.

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