2. Content Development
Indiana Faculty Faculty Chair
Sarah Strawbridge, MSM, CHES Andrew W. Urban, MD
Executive Director Associate Professor of Medicine
Section of Infectious Disease
Indiana Immunization Coalition (IIC)
University of Wisconsin School of Medicine and Public Health
Madison, WI
Charlene Graves, MD, FAAP
Indiana Immunization Coalition (IIC) Faculty
Marie Brown, MD, FACP
Kristen S. LaEace, MBA Assistant Professor of Medicine
Department of Internal Medicine
Chief Executive Officer
Rush University Medical Center
Indiana Association of Area Agencies on Aging Chicago, IL
Leslie Ray, PharmD Jane Siegel, MD
Clinical Care Coordinator Professor of Pediatrics
Kroger Pharmacy – Central Division Medical Director of Infection Prevention and Control
At Children’s Medical Center
University Texas, Southwestern Medical Center
Tabitha Arnett, MSEd, CAE Dallas, Texas
Professional Development Director
Indiana Pharmacists Alliance Richard Winn, MD
Chief of Infectious Disease
Professor of Medicine and Microbiology
Texas Technical University Health Science Center
Lubbock, TX
2
3. Indiana Faculty Disclosures
• Charlene Graves, MD, FAAP
– Former Medical Director, ISDH Immunization Program (2000 – 2007)
– Chairman, INAAP Immunization Committee
– IIC Policy Committee Co-Chair
– Became a scientific speaker for vaccines manufactured by GlaxoSmithKline in May of 2008
• Sarah Strawbridge, MSM, CHES
– Executive Director, Indiana Immunization Coalition, Inc.
– No conflicts of interest to disclose
• Kristen S. LaEace, MBA
– Chief Executive Officer, Indiana Association of Area Agencies on Aging
− No conflicts of interest to disclose
• Leslie Ray, PharmD
– Clinical Care Coordinator, Kroger Pharmacy – Central Division
– No conflicts of interest to disclose
• Tabitha Arnett, MSEd, CAE
− Professional Development Director, Indiana Pharmacists Alliance
− No conflicts of interest to disclose
3
4. Faculty and Planner Disclosures
As a provider dedicated to independent education and accredited by the ACCME, IPMA must ensure
balance, independence, objectivity, and scientific rigor in all of its educational activities. It is the policy
of IPMA to require disclosure of the existence of any significant financial interest or other relationship a
faculty member, planner, or a sponsor has with either the commercial supporter of this activity or the
manufacturer(s) of any commercial product(s) discussed in an educational presentation. Accordingly:
Faculty
Andrew W. Urban, MD has nothing to disclose.
Marie Brown, MD, FACP has nothing to disclose
Jane Siegel, MD, has nothing to disclose
Richard Winn, MD has reported that he is a speaker for Pfizer Inc., Cubist Pharmaceuticals, Inc., and Merck & Co., Inc.
Planners
IPMA
Dixie Blankenship, Director of Program Development and Compliance, IPMA, has nothing to disclose.
Heidi Ness, Associate Director, IPMA, has nothing to disclose.
UNT
Pamela McFadden, Associate Vice President, UNTHSC has nothing to disclose.
Lauren Ray, CME Coordinator, UNTHSC, has nothing to disclose.
MEDEDR
Jennifer Spear Smith, Chief Learning Officer, MEDEDR, has nothing to disclose.
Amanda Hartley, PhD, medical writer, has nothing to disclose.
Karin McAdams, Vice President, Curriculum Development, MEDEDR, has nothing to disclose.
Melissa Wiles, Vice President, Educational Design and Strategic Alliances, MEDEDR, has nothing to disclose.
4
5. Acknowledgement of Commercial
Support
This CE activity is funded by the Interstate Postgraduate
Medical Association from an educational grant from Pfizer
Inc.
CE credits being awarded: CME, CNE, ACPE
(Pharmacists), NP (Nurse Practitioners), PA (Physician
Assistants), Social Workers
5
6. Learning Objectives
After participating in this activity, learners will be able to:
• Communicate vaccine benefits -- Effectively communicate the
benefits of adult immunization to your patients
• Recognize patient barriers -- Identify changes that can impact
adult vaccinations
• Address provider barriers and make changes--Apply system
changes and address practice barriers to adult immunizations
• Identify patients and vaccinate--Integrate the screening and
administering of adult vaccinations within your practice setting
6
7. Let Us Start With a Case –
Pneumococcal Polysaccharide Vaccine
A 38-year-old woman with well-controlled asthma
presents to your clinic for establishment of primary care.
• She recently moved to your region and, in addition to refills on her
asthma medications, requests a ―complete physical‖, since it has
been several years from the date of the last one
• She is a nonsmoker
• You review her vaccine records. Except for a tetanus booster (Td)
7 years ago and annual influenza vaccinations, she cannot recall
any other vaccines.
7
8. Pneumococcal Polysaccharide
Vaccine Case Study
Is this patient a candidate for the pneumococcal
polysaccharide vaccine (PPSV)?
A. No, because she is not ≥ 65 years of age
B. No, because she is a nonsmoker
C. Yes, because she is asthmatic
D. Yes, but only if she requires oral corticosteroids for
her asthma
E. No, because she is immunocompetent
8
9. What Happens in Your Practice?
Which vaccine(s) are you ―good at‖?
Which vaccine(s) do you struggle with?
Why?
9
11. Burden of Select Vaccine-
Preventable Diseases
Vaccine-Preventable
Disease (VPD) Burden
Influenza1 200,000 excess hospitalizations annually (> 40% in the elderly)
~ 24,000 excess deaths annually (~ 90% elderly)
Invasive Pneumococcal ~ 50,000 cases of bacteremia each year
Disease1 • Higher rates in elderly and persons with comorbidities
• Case fatality rates ~ 20% (up to 60% in the elderly)
78,000 new infections annually (highest in adults)
Hepatitis B1 • 1 million with chronic hepatitis B virus infections
• Complications include cirrhosis and hepatocellular
carcinoma (80% of cases)
Human Papillomavirus 6.2 million new infections each year
(HPV)1 2 HPV strains cause 70% of cervical cancer
27,550 cases reported in 2010
Pertussis1,2 Most severe in infants
• Source often older child or adult
Shingles1 500,000-1 million cases annually; lifetime risk ~ 32%
Shingles and postherpetic neuralgia increase with age
11 1Centers for Disease Control and Prevention Web site. http://www.cdc.gov/vaccines/pubs/pinkbook/default.htm. Accessed March 29, 2012.
2Centers for Disease Control and Prevention Web site. http://www.cdc.gov/pertussis/outbreaks.html. Accessed March 29, 2012.
12. Vaccine Preventable Diseases
Pneumococcal
pneumonia: bacteremic
with cavitation and
a new pleural effusion1
Cervical
cancer2
Herpes zoster
severe shingles3 Measles4
1Source located at: http://www.hiv.va.gov/provider/image-library/pulmonary.asp?post=1&slide=43.
2Source located at: http://archive.nlm.nih.gov/repos/nci.php.
12 3Source located at: www.skinsite.com/info_herpes_zoster.htm.
4Source located at: http://children.webmd.com/picture-of-measles-2.
13. Vaccine-Induced Reduction of
Disease Burden
Reported Cases Reported Cases % Decrease in
Disease (Year) (2011) Reported Cases
Diphtheria 5796 (1950) 0 100%
Tetanus 486 (1950) 9 98%
Pertussis 120,718 (1950) 15,216 87%
Measles 319,124 (1950) 212 99%
Mumps 152,209 (1968) 370 99%
Rubella 46,975 (1966) 4 99%
Hepatitis A 32,859 (1966) 1670 95%
Hepatitis B 26,611 (1985) 2495 91%
13
Centers for Disease Control and Prevention Web site. http://www.cdc.gov/vaccines/pubs/pinkbook/default.htm. Accessed August 9, 2012.
15. Recommended Adult Immunization
Schedule by Vaccine and Age Group —
United States, 2012
15 Centers for Disease Control and Prevention. MMWR Morb Mortal Wkly Rep. 2012;61:66-72.
Centers for Disease Control and Prevention Web site. http://www.cdc.gov/vaccines/recs/schedules/adult-schedule.htm. Accessed March 29, 2012.
16. Vaccines That Might Be Indicated for
Adults Based on Medical and Other
Indications — United States, 2012
16 Centers for Disease Control and Prevention. MMWR Morb Mortal Wkly Rep. 2012;61:66-72.
Centers for Disease Control and Prevention Web site. http://www.cdc.gov/vaccines/recs/schedules/adult-schedule.htm. Accessed March 29, 2012.
17. Information Overload!
Use Technology
Go to:
http://www.cdc.gov/vaccines/recs/schedules/adult-schedule.htm.
Download tool “Adult Immunization Scheduler” to determine vaccines
your patients need according to the 2012 Adult Immunization
Schedule.
Download tool "Shots by STFM" for your mobile device
and smartphone.
• FREE app available for your iPhone®, Android™, and Palm® Pre™
(WebOS) phones
• A small-size schedule is also available for your mobile device
• To be used at your own risk and are provided courtesy of the
Society of Teachers of Family Medicine (STFM). For information,
go to www.ImmunizationEd.org.
17
Centers for Disease Control and Prevention Web site. http://www.cdc.gov/vaccines/recs/schedules/adult-schedule.htm.
Accessed March 29, 2012.
18. Advisory Committee on Immunization
Practices Adult Immunization
Schedule: Key 2012 Updates
• Routine HPV4 vaccine recommended for males aged 11-21 years
HPV Vaccination: • A subgroup of men who have sex with other men, along with
Not Just for Girls1 immunocompromised and human immunodeficiency virus (HIV)-
positive males, should be inoculated through 26 years of age
Hepatitis B
• HBV is recommended for diabetic adults through age 59 years
Vaccination (HBV) for
• At physician discretion, HBV ―may‖ be given to older diabetics
Diabetics1
Tetanus, diptheria,
and acellular • Tdap should be administered during pregnancy; if at all possible,
pertussis (Tdap) after week 20 of gestation
During Pregnancy1
• Egg allergy must be distinguished from influenza vaccine allergy 2
• Prior severe allergic reaction to influenza vaccine, regardless of the
Influenza suspected reason, is a contraindication to influenza vaccine 2
Vaccination: Egg • Because it is what has been studied, egg-allergic patients must get
Allergy Clearance the inactivated flu shot1
and Innovation • A novel intradermal flu vaccine (Fluzone® Intradermal, Sanofi
Pasteur, Swiftwater, PA) is now available for adults aged
18-64 years1
18 1Fryhofer SA.
Ann Intern Med. 2012;156:243-245.
2Centers for Disease Control and Prevention. MMWR Morb Mortal Wkly Rep. 2011;60:1128-1132.
19. Algorithm for Evaluation of an Egg
Allergy Preceding Influenza Vaccination
Yes Administer vaccine per
Can person eat lightly cooked egg (e.g.
scrambled egg) without reaction?* usual protocol
No
Administer TIV
After eating eggs or egg-containing Yes
Observe for reaction for
foods, does the person experience
at least 30 minutes after
ONLY hives?
vaccination
No
Does the person experience other
symptoms such as Refer to a physician with
* Cardiovascular changes (e.g. hypotension) Yes expertise in
* Respiratory distress (e.g. wheezing) management of allergic
* Gastrointestinal (e.g. nausea/vomiting) conditions for further
* Reaction requiring epinephrine
evaluation
* Reaction requiring emergency medical attention
* Persons with egg allergy might tolerate egg in baked products (e.g., bread or cake). Tolerance to egg-containing foods
does not exclude the possibility of egg allergy.
19
Recommendations of the Advisory Committee on Immunization Practices (ACIP), 2012 (MMWR August 17, 2012; 61[32) Figure 2.
20. Know the Facts: What About Egg
Allergy?
A 58-year-old man with stable coronary artery disease
(CAD) and egg allergy
• Comes to clinic for routine follow-up. He is doing very well. You refill his
medications and ask him if he would like to receive the seasonal influenza
vaccine (first batch just arrived).
• He reminds you that he never gets that vaccine because of anaphylaxis to
eggs, but he is happy to get any other shots that you think he needs
• You determine that he should get a Tdap and his first dose of PPSV
What impact does his egg allergy have on these vaccines?
A. Tdap okay; no PPSV
B. PPSV okay; no Tdap
C. Should not give either one
D. Okay to give either one
E. Depends on the severity of the egg allergy
20
21. Know the Facts:
Egg Allergy Contraindication—
Flow Diagram
Can the person eat
lightly cooked egg (eg, Yes Administer vaccine per
scrambled egg) without usual protocol
reaction?
No
After eating eggs or Administer trivalent
egg-containing foods, influenza vaccine.
does the person Yes
Observe for reaction for at
experience ONLY hives? least 30 minutes
after vaccination.
No
Does the person experience other
symptoms, such as:
- Cardiovascular changes (eg,
hypotension) Refer to a physician with
- Respiratory distress (eg, wheezing) Yes
expertise in management
- Gastrointestinal (eg, nausea/vomiting) of allergic conditions for
- Reaction requiring epinephrine further evaluation
- Reaction requiring emergency
medical attention
21
Center for Disease Control and Prevention. MMWR Morb Mortal Wkly Rep. 2011;60:1128-1132.
22. Know the Facts:
Vaccine Contraindications and Precautions
Vaccine(s) Vaccinate?
Vaccine(s) Vaccinate?
YF: yellow fever
Note 1: Protocols have been published for safely administering influenza vaccines to persons with egg allergies.
22 Centers for Disease Control and Prevention Web site. http://www.cdc.gov/vaccines/recs/vac-admin/downloads/contraindications-guide-508.pdf.
Accessed March 29, 2012.
24. US Adult Vaccination Rates
Are Low
2010 Vaccination Healthy People 2020
Vaccine Rates Goal
Influenza 33.4% 90%
Ages 19-49 Years, High Risk 40.1% -
Ages 50-64 Years, Total 65.6% 90%
Ages 65 Years 52.9% 90%
Health Care Workers (19-64 Years Old)
Pneumococcal
Ages 19-64 Years, High Risk 18.5% 60%
Ages 65 Years 59.7% 90%
Pertussis (Tdap) 8.2%
Tetanus, past 10 years 64.0%
Ages 19-49 Years, High Risk 63.4%
Ages 50-64 Years 53.4%
Ages 65 Years
Shingles (≥ 60 Years Old) 14.4% 30%
Hepatitis B (High Risk, 19-49 Years Old) 42.0% 90%
24 HPV Vaccine (Women, 19-26 Years Old)Disease Control and Prevention Web site. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6104a2.htm
Centers for
20.7%
Accessed August 19, 2012
25. Gaps: Differences Among
US States
CLICK HERE FOR WEB SITE
25
Centers for Disease Control and Prevention Web site. http://www.cdc.gov/flu/professionals/vaccination/reporti1011/reporti/index.htm.
Accessed March 29, 2012.
26. Influenza Vaccination Rates
Flu Vaccination Rates for
2011-12 (as of May 2012)
United States Indiana
Adults 18 years and older 38.8% 37.7%
Seniors 65 yrs+ 64.9% 62.1%
Children 6 mos-17 yrs 51.5% 47.4%
Health care Personnel 66.9%
Pregnant women 47.0%
26
27. Gaps: Race/Ethnicity Disparities
Vaccination Vaccination
Rate, Rate, Vaccination
Nonhispanic Nonhispanic Rate,
Vaccine and Target Group Whites Blacks Hispanics
Influenza, ≥ 65 Years Old 68.6% 50.8% 50.6%
Pneumococcal, ≥ 65 Years Old 64.9% 44.8% 40.1%
27
Centers for Disease Control and Prevention Web site. http://www.cdc.gov/vaccines/stats-surv/nhis/2009-nhis.htm.
Accessed March 29, 2012.
28. Gaps: Vaccination Rates Remain
Suboptimal in HCP
HCP Vaccinated (%) 100
80
60
40
20
0
Before After
Institutional Vaccination Requirement
Single-season increases in influenza vaccination uptake remained greater among
hospitals:
1. That imposed consequences for vaccine refusal
2. With lower prerequirement vaccination coverage
28 Miller BL, et al. Vaccine. 2011;29:9398-9403.
29. Back to Our Case…
A 38-Year-Old Woman With
Well-Controlled Asthma
How many subsequent doses of the PPSV should
she receive?
A. A single dose now, at age 38 years, with no other doses
B. A booster every fall along with her seasonal influenza vaccination
C. A booster, only if she was to become immunocompromised
(eg, be diagnosed with a malignancy or undergo a splenectomy)
D. A second dose when she turns age 65 years
E. Booster doses every 5 years, since she is receiving her first dose at
< 65 years of age
F. A one-time booster dose at age 43 years (ie, 5 years from now)
29
31. ―I can’t
Inability
Misconception afford
―I always get to pay
them.‖
theand fear I
flu when
•About vaccine
get the flu
•About health Lack of
shot.‖
care system ―I’m fine.
awareness
•Disease
I’m
•Vaccine
cancer-
Address •Personal
free now.‖
risk
Patient
Barriers
―My other doc
Lack of provider
never told me
recommendation ―No habla
Language
about it.‖ inglés.‖
barrier
―I work
Lack of
every day.
I can’t get
access
here.‖
31
32. Patient Misconceptions
About Vaccines
% of Respondents
Category and Response in Agreement
Vaccines and VPDs
Had Vaccines as a Child—Do Not Need Them Again 40%
Vaccines Not Necessary for Adults 18%
Not Concerned About Catching VPDs 34%
Not Concerned About Spreading Illness to Others 32%
VPDs Are Not Serious or Life Threatening 25%
Vaccine Safety/Efficacy
Have Heard Vaccines Are Not Safe 35%
Vaccines Do Not Work 14%
A Vaccine Made Them Sick 25%
32 National Foundation for Infectious Diseases Web site. http://www.nfid.org/pdf/publications/adultimmcta.pdf.
Accessed March 29, 2012.
33. Address Patient Barriers
Patient Issue Solution
Educate patients
•Use written materials (ie, vaccine information statements)
Misconception •Discuss
and Fear Pain of vaccination
Safety of vaccines—thimerosal/autism
Danger of illnesses caused by vaccines
Lack of Recommend vaccination to all patients
Recommendation
Make it easier for patients
Express vaccinations, extended hours
Lack of Access Extended vaccination season
Vaccination in nontraditional settings
Target hospitalized patients
Communicate with patients
Telephone, letters/postcards, e-mail alerts
Lack of Awareness
―No one ever told me that.‖ – stress the importance of vaccination in the context of
underlying disease
Inability to Pay Discuss options with patient
Language Barrier Use translated educational materials
33
Nichol KL. Cleve Clin J Med. 2006;73:1009-1015.
34. Educate Patients:
Address Misconceptions/Fears
34 Centers for Disease Control and Prevention Web site. http://www.cdc.gov/vaccines/spec-grps/hcp/provider-resources-
safetysheets.html. Accessed March 29, 2012.
35. Educate Patients:
Lack of Access
• Pharmacists: Community Partners in Immunizations
• Access & Proximity
• More than 56,000 community pharmacies in the US
• Nearly all Americans live within 5 miles of a community pharmacy
• Extended Hours
• Many pharmacies are open 24 hours
• Giving patients the opportunity to go at any time
35
36. Educate Patients:
Lack of Awareness
• Pharmacists provide patient profile interventions
– Pharmacies have access to patient’s medication profile and medical
history
• Thus, pharmacists can make a proper recommendation on vaccination
requirements for specific patients
– Ability to provide targeted messages to elderly and high risk
patients
• Marketing Methods
– Advertisements and public announcements help continue to remind
patients the importance of immunizations
• Reduce Missed Opportunities
– These different interventions can help reduce missed opportunities
and continue to strive for the Healthy People 2020 goal for
vaccinations
36
37. Educate Patients:
Address Language and Ethnic Barriers
Barriers
Health literacy
Mistrust of system
Language
Facilitators
Use culturally appropriate
education
Leverage
communities/trusted
leaders/faith-based
organizations
Use translated materials
(cdc.gov; immunize.org)
Daniels NA, et al. J Natl Med Assoc. 2004;96:1455-1461.
37 Chen JY, et al. J Community Health. 2007;32:5-20.
Traeger M, et al. Am J Public Health. 2006;96:921-925.
Logan JL. J Natl Med Assoc. 2009;101:161-166.
38. ―I’m
Lack of
already
behind
time
―It’s not
Inconsistent today.‖
noted on the
documentation
chart.‖ ―It’s hard
to keep up
Knowledge
with
gaps
Address guideline
updates.‖
Provider
Barriers
―I can’t get
No
standing
it all done
myself.‖
orders ―The patient
came in for a
Missed
―Vaccination opportunities
UTI, not
isn’tLow of a
part
regular
prioritization
vaccination.‖
appointment.‖
38
39. Address Provider Barriers
Provider Issue Solution
Know the facts.
Knowledge Gaps Know which high-risk conditions require special
vaccine recommendations.
Missed Opportunities Recommend vaccinations to all your patients.
Lack of Time Get organized and use systems approaches.
Inconsistent Documentation Investigate your state and local immunization registries.
No Standing Orders Evaluate and improve processes.
Consider new paradigms:
Low Prioritization Quality improvement projects
New venues
Extend vaccination season
Practice what we preach (get vaccinated!).
39 Nichol KL. Cleve Clin J Med. 2006;73(11):1009-1015.
41. Know the Facts:
Interim Updates/Tetanus Case
A 67-year-old man is in your office for a routine 6-month visit for hypertension. He also has
hyperlipidemia and mild chronic obstructive pulmonary disease, which are well controlled. Upon
checking in and getting his vital signs measured, he mentions to your medical assistant that he
has heard a lot about pertussis in the news. He is up to date on his pneumococcal vaccine,
influenza vaccine, and last received a Td 3 years ago at age 64, when he had a laceration sutured
in the emergency department. He has never had a Tdap.
What is the correct interpretation and action regarding his Td and/or
Tdap vaccination status?
A. He is OK until he turns 74, then he needs another Td (i.e. 10 years
from the Td he received in the ER)
B. He should get a Tdap today because all adults who have not yet
received a dose of Tdap should get one
C. He is OK until he turns 74, then he needs a Tdap (i.e. 10 years
from the Td he received in the ER)
D. He should get a Tdap today only if he had young grandkids
E. Not Sure
41
42. Know the Facts:
Get Interim Updates
Sign up to get interim updates via e-mail at www.cdc.gov.
For example,
• Tdap use in adults. ACIP recommends that all
adults aged 19 years and older who have not yet…..
• Tdap products in adults aged 65
years and older. Providers should not miss an
opportunity to vaccinate persons aged 65 years and older
with Tdap…
42
43. Know the Facts:
The 3 Shot Challenge…
A 35-year-old man with well-controlled HIV (CD4 850) moves to your area
and joins your primary care practice. Vaccine records indicate that he
received 2 doses of the hepatitis B vaccine series in 2006, but never got
the third.
What is the best approach for handling his HBV vaccine series?
A. Start over with dose #1
B. Check a hepatitis B surface antibody (HBsAb)
C. Start where he left off – give the 3rd dose
D. Nothing – this vaccine is contraindicated in
immune-compromised hosts
43
44. Know the Facts:
The 3 Shot Challenge…Multiple Shots
Are Hard
Retrospective, Cross-Sectional Analysis HIV Outpatient Study
35
32.4%
30
HBV Vaccinated (%)
25
20
16.9%
15
10
5
0
At least 1 dose All 3 doses
44
Tedaldi EM, et al. Clin Infect Dis. 2004;38:1478-1484.
45. Know the Facts: Use the Internet
Immunization Action Coalition: www.immunize.org
For example,
45 Immunization Action Coalition Web site. http://www.immunize.org/askexperts/experts_hepb.asp.
Accessed March 29, 2012.
46. Immunization Action
Coalition
Pharmacists and
Immunization
46 http://www.immunize.org/pharmacists/
47. Know the Facts:
Use the Internet
http://immunization.acponline.org
47
47
48. www.vaccinateindiana.org
• Vaccine Schedules for the Lifespan
• Vaccine-Preventable Disease (VPD) Case Count
in Indiana
• Explanation of Each VPD
– Printable Fact Sheets
• Vaccine Safety
• School Immunization Requirements
• ―Like‖ Vaccinate Indiana on Facebook
• Follow @VaccinateIN on Twitter
48
50. Know the Facts:
Pharmacist Training
• In order to qualify to administer immunizations, a pharmacist must
successfully complete a course of training in immunization that is provided
by an Accreditation Council for Pharmacy Education accredited provider
and meets the standards set forth by:
– (1) the Centers for Disease Control and Prevention;
– (2) a similar health authority; or
– (3) a professional body approved by the Indiana board of pharmacy.
• Training must include:
– Study materials
– Hands-on training
– Techniques for administering vaccines
• Contact the Indiana Pharmacists Alliance for additional information
www.indianapharmacists.org 317-634-4968
50
52. Recommend Them:
Not Enough Primary Care Providers
Recommend Vaccines to Adults
% of Surveyed Primary Care Providers Who Recommended Influenza
and Pneumococcal Vaccines (n = 200)
Patient Group Influenza Pneumococcal
Elderly 37% 65%
Lung Disease 45% 68%
Diabetes 31% 44%
Heart Disease 20% 29%
52
Johnson DR, et al. Am J Med. 2008;121(Suppl 2):S28-S35.
53. Recommend Them:
Let Us Do Another PPSV Case
A 54-year-old woman finished chemotherapy and radiotherapy
for breast cancer 2 months ago. She is otherwise healthy and a
nonsmoker.
Which of the following is the recommended approach to her
pneumococcal vaccine status?
A. She should get her first dose at age 65 years
B. Dose now, with a second dose in 5 years at age 59 years
C. Dose now, with a second dose at age 65 years
D. Dose now, and every 5 years for the rest of her life
E. Dose now, but no second dose, because she is a nonsmoker
53
54. Recommend Them:
Provider Recommendation = Higher
Vaccination Rates
100
No recommendation
82% 85.1%
Recommendation
80
Vaccination Rate (%)
60
40
27%
20 15.8%
0
Influenza PPSV
Even for patients with negative attitudes
High-risk patients were those ≥ age 65 years or those having heart disease, lung disease, diabetes, or other serious illness.
54
Nichol KL, et al. J Gen Intern Med. 1996;11:673-677.
55. Recommend Them:
Avoiding Missed Opportunities
63-year-old woman with a urinary tract infection
• Otherwise doing well
• Antibiotic prescribed; other meds refilled
• Efficient, focused visit
Would you use this encounter as an opportunity to review her immunizations?
55
57. Are You Doing Your Part?
• Are you up-to-date on your vaccinations?
• Check your records and/or check with your health
care provider
• Get a flu vaccination every year
• Set a good example for your patients by being
current on your vaccinations
57
58. Get Organized:
Opportunities for Improvement Abound
Use of Effective Vaccination Strategies by US Physicians
100
Generalists
80 Subspecialists
Physicians %
60
40
20
0
Influenza Pneumonia Influenza Pneumonia Influenza Pneumonia
Very Strongly Recommend Standing Orders Patient Reminders
(Elderly Patients)
58
Nichol KL and Zimmerman R. Arch Intern Med. 2001;161:2702-2708.
59. Get Organized:
Standing Orders Are Often
Key Components of Success
59 Image located at http://www2a.cdc.gov/vaccines/ed/whatworks/pdfs/standing_order.pdf. Accessed March 29, 2012.
McKibben LJ, et al. MMWR Recomm Rep. 2000;49:15-16.
60. Get Organized:
A Multifaceted Program Works Best
Goal Tactics
Increase Demand •Annual reminder to patients
Enhance Access •Walk-in clinics
•Institutional policy
•Standing orders
Get Organized •Standardized forms
•Efficient clinic flow
•Ongoing measurement and evaluation
60
Nichol KL. Am J Med. 1998;105:385-392.
61. Get Organized:
Impact of Multifaceted Program on
Influenza Vaccination Rates
100
Influenza Vaccination Rate (%)
80
60
40
20
0
Baseline After Provider Multifaceted Multifaceted,
Education (Standing Orders) Year 10
61
Nichol KL. Am J Med. 1998;105:385-392.
62. Get Organized:
Impact of Multifaceted Program on
Influenza Vaccination Rates
―Interventions included family reminders, education, expanding immunization
access, reminders and feedback for providers, and coordination of activities with
community stakeholders.‖
25%
20%
15%
10%
5%
0%
Improvement in Overall Improvement in Timely
Immunization Rates Immunization
62
Fu LY, et al. Pediatrics. 2012;129:e496-e503.
63. Summary:
Tips on How to Move Forward
Use acute
You’re doing and
Identify where:
Pay attention
that today! • Current Involve the
scheduled EVALUATE to work
strategies clinic team. CONSIDER
Use the
KNOW THE visits to GET
could be AND flow, efficienc
RECOMMEND ORGANIZED USE NEW
y, etc.
internet.
FACTS recommend improved IMPROVE PARADIGMS
vaccinations • New strategies STANDING
PROCESSES
Use the MAKE
to ALL could be ORDERS!
toolkit. added CHANGES!
patients.
63
Nichol KL. Cleve Clin J Med. 2006;73:1009-1015.
64. Indiana’s Immunization Registry
Children and Hoosiers Immunization Registry Program
CHIRP
• Started in January 2002
• Comprehensive immunization record for a lifespan
• Secured Data
– Provider assigned access code and signed user agreement
– Only accessed by enrolled health care providers, school
nurses, pharmacists, and licensed day-care providers
• Used in physician
offices, hospitals, pharmacies, CHC/FQHC, local health
departments, and licensed childcare centers
• EMR/EHS Connectivity
64
65. Resources
Website Source
www.vaccinateindiana.org Indiana Immunization Coalition
www.cdc.gov/vaccines Centers for Disease Control and
Prevention
www.immunize.org Immunization Action Coalition
www.indianapharmacists.org Indiana Pharmacists Alliance
www.healthychildren.org American Academy of Pediatrics
www.immunizationed.org smartphone app by STFM
www.immunizationinfo.org National Network for Immunization
Information
www.tdapvac.com Indiana Chapter of AAP
65
67. Thank you!
Program Evaluation:
https://www.surveymonkey.com/s/ImprovingAdultVaccRates
Complete evaluation within ONE WEEK
to obtain CE credit.
Hinweis der Redaktion
Answer C: Her history of asthma makes her a candidate for a dose of PPSV. In 2008, the CDC’s Advisory Committee on Immunization Practices (ACIP) reviewed data that showed an increased risk of invasive pneumococcal disease among adults who smoked cigarettes or who had asthma. Consequently, these two groups were added to the categories of adults for whom vaccination is recommendedFollow-up questions for learners: In your practice…Which vaccine(s) are you “good at”?Which vaccine(s) do you struggle with?Why?
Answer C: Her history of asthma makes her a candidate for a dose of PPSV. In 2008, the CDC’s Advisory Committee on Immunization Practices (ACIP) reviewed data that showed an increased risk of invasive pneumococcal disease among adults who smoked cigarettes or who had asthma. Consequently, these two groups were added to the categories of adults for whom vaccination is recommendedFollow-up questions for learners: In your practice…Which vaccine(s) are you “good at”?Which vaccine(s) do you struggle with?Why?
Despite the major successes seen with immunizations in the last century, vaccine-preventable diseases continue to cause substantial morbidity and mortality among adults.Influenza: complication rates are highest among the very young and the elderly. More than 40% of excess hospitalizations and about 90% of excess respiratory and circulatory deaths during influenza seasons occur among the elderly.Invasive pneumococcal disease: more than 50,000 cases of pneumococcal bacteremia occur every year, with highest rates in the very young and elderly. Pneumococci account for about 1/3 of community-acquired pneumonia and about half of hospital-acquired pneumonia in adults. Bacteremia occurs in about 25% to 30% of patients with pneumococcal pneumonia. Case fatality rates can be as high as 60% in the elderly.Hepatitis B: each year there are about 78,000 hepatitis B virus infections in the US. The incidence is highest among young adults, and the most common route of transmission is by sexual contact. While most adults with hepatitis B fully recover, complications can include fulminant acute hepatitis (occurs in 1% to 2% with acute hepatitis with case fatality rates of 63% to 93%). About 5% who become infected will progress to chronic hepatitis B that can cause cirrhosis and hepatocellular carcinoma. About 25% of persons with chronic hepatitis B will die prematurely from cirrhosis or liver cancer.HPV (human papillomavirus) is the most common sexually transmitted infection in the US. There are an estimated 20 million people infected, with about 6.2 million new cases occurring each year. Two high-risk HPV strains (16 and 18) account for 70% of cases of cervical cancer, as well as anal/genital cancers, in women and 70% of anal cancers in men. Two low-risk strains (6 and 11) are responsible for 90% of genital warts and 90% of recurrent respiratory papillomatosis in men and women. HPV is especially common among adolescents and young adults and is related to sexual behaviors such as number of sex partners and partners’ sexual history.Pertussis is an endemic (common) disease in the United States, with periodic epidemics every 3 to 5 years and frequent outbreaks. In 2010, 27,550 cases of pertussis were reported — and many more cases go unreported. The primary goal of pertussis outbreak control efforts is to decrease morbidity (amount of disease) and mortality (death) among infants; a secondary goal is to decrease morbidity among persons of all ages. Complications of pertussis can be serious, especially among infants, with the most common one being secondary bacterial pneumonia. While pertussis and its complications are most severe among the very young, adolescents and adults may also develop pertussis. Often the disease is milder than in the very young, but complications such as difficulty sleeping, urinary incontinence, pneumonia, and rib fracture can occur among older persons. Importantly, adolescents and adults can also transmit pertussis to infants and others who may be susceptible.Shingles (herpes zoster): an estimated 500,000 to 1 million cases of herpes zoster (shingles) occur in the US annually. The lifetime risk is at least 32%, with 50% of persons living to age 85 developing zoster. The risk for shingles increases with increasing age and immunosuppression. Postherpetic neuralgia and ocular or other organ involvement with zoster can occur and can be serious.
According to the Centers for Disease Control and Prevention, reported cases of many vaccine-preventable diseases (VPDs) decreased dramatically during the 20th century. This decrease in reported cases highlights one of the most important public health achievements of the last century—immunizations. As can be seen in this slide, the decrease in the number of reported cases of the VPDs shown ranges from 86% for pertussis to 100% for diphtheria. Vaccinations are, indeed, a major public health achievement.
Changes for 2012:The bar for Tdap/Td for persons 65 years and older has been changed to a yellow and purple hashed bar to indicate that persons in this age group should receive 1 dose of Tdap if they are a close contact of an infant younger than 12 months of age. However, other persons 65 and older who are not close contacts of infants may receive either Tdap or Td. The 19–26 years age group was divided into 19–21 years and 22–26 years age groups. The HPV vaccine bar was split into separate bars for females and males. The recommendation for all males 19–21 years to receive HPV is indicated with a yellow bar, and a purple bar is used for 22–26 year old males to indicate that the vaccine is only for certain high-risk groups. Footnote revisions:A new footnote (1), "Additional information," has been added to the beginning of the footnotes. This footnote provides links to the full ACIP vaccine recommendations and information on travel requirements that might have been referred to previously in subsequent footnotes. The "Influenza vaccination" footnote (2) was revised to clarify that all persons aged 6 months and older can receive TIV and that health-care personnel (HCP) who care for persons requiring a protected environment should receive TIV. HCP younger than 50 years who do not have a contraindication may receive either the live attenuated influenza vaccine or TIV. In addition, age indications for two recently licensed formulations of TIV were included. The link to additional information regarding influenza vaccination has been removed because a link now is provided in footnote 1. The "Human papillomavirus (HPV) vaccination" footnote (5) now clarifies that although HPV vaccination is not specifically recommended for HCP, HCP should receive the HPV vaccine if they are in the recommended age group. This footnote also was changed to reflect the recommendation of the quadrivalent human papillomavirus (HPV4) vaccine for males at age 11 or 12 years and catch-up vaccination for males 13 through 21 years of age. Males 22 through 26 years of age may be vaccinated with HPV4 vaccine. The "Zoster vaccination" footnote (6) now indicates that while zoster vaccination is not specifically recommended for HCP, HCP should receive the vaccine if they are in the recommended age group. This footnote also acknowledges that the vaccine is FDA-approved for use in persons 50 years and older; however, ACIP continues to recommend that vaccination begin at age 60 years. The link in the "Measles, mumps, rubella (MMR) vaccination" footnote (7) that directs the reader to more information about evidence of immunity has been removed. In addition, the information about the use of MMR vaccine in outbreak settings has been removed. Readers are referred to the ACIP MMR recommendations and to the ACIP recommendations for the immunization of health-care personnel regarding the use of MMR vaccine in outbreak settings. The "Pneumococcal polysaccharide (PPSV) vaccination" footnote (8) has been revised to include additional examples of functional and anatomic asplenia. Language is included for persons with asymptomatic or symptomatic HIV infection and persons undergoing cancer chemotherapy or who are on other immunosuppressive therapy. The "Revaccination with PPSV" footnote (9) has been revised to clarify guidance for those aged 65 years and older who had been vaccinated with PPSV23 before age 65 and for whom at least 5 years has passed since their previous dose. The "Meningococcal vaccination" footnote (10) has been revised to include military recruits in the group recommended to receive a single dose of meningococcal vaccine. The language about college students has been clarified to indicate that first-year college students up through age 21 years who are living in residence halls should be vaccinated if they have not received a dose on or after their 16th birthday. Language regarding travel to sub-Saharan Africa and travel to Mecca has been removed, and readers are referred to the footnote on information about vaccines for travelers (1). The "Hepatitis B vaccination" footnote (12) has been revised to include persons with diabetes younger than 60 years old and persons 60 years and older based on need for assisted blood glucose monitoring.
Changes for 2012:A new column was added for men who have sex with men (MSM) to note in the figure that MSM is an indication for HPV, hepatitis A, and hepatitis B vaccines. In addition, the diabetes indication was moved to the same column as chronic kidney disease to accommodate the new recommendation for hepatitis B vaccination of persons with diabetes. Because pregnant women not previously vaccinated with Tdap are now preferentially recommended for vaccination with Tdap during later pregnancy (>20 weeks gestation), the yellow bar has been extended across all risk groups. The HPV vaccine bar was separated into a bar for females and one for males. The bar for females is unchanged from the previous year except that the bar was extended to include HCP to clarify that HCP who are in the recommended age group for receipt of HPV vaccine are recommended for vaccination. Lastly, the HPV vaccine bar for males was added and indicates that all males through age 26 should be vaccinated if they are immunocompromised, have HIV, or are MSM. However, the age indication is through age 21 for males with or without these risk factors.
The web address on this slide will direct the user to the cdc.gov site with a list of recommendations to easy the burden of vaccination on the clinician, including these 2 tools—a computer-based schedule to track adult vaccinations and a mobile device app developed by the Society of Teachers of Family Medicine (STFM).
Key 2012 updates are described on this slide.For reference, the following is a description of the previous key 2011 updates [Fryhofer. 2011. Located at:http://www.medscape.com/viewarticle/736395]:Tetanus, Diphtheria, and Pertussis Vaccine A dose of Tdap wasrecommendeded for all adults, even those age 65 and older, especially if they interact with babies.The once required interval between Tdap and the last tetanus booster was removed.Human Papilloma Virus VaccineQuadrivalent HPV4 vaccine protects against HPV types 16 and 18 (cause cervical cancer), and also types 6 and 11 (cause genital warts) and is US Food and Drug Administration (FDA) approved for both male and female patients. The bivalent vaccine HPV2 protects only against HPV types 16 and 18, and is FDA approved only for female patients.The 2011 schedule stated that a 3-dose series of either vaccine was recommended for female patients age 9-26; but only a permissive recommendation was granted for boys and young men such that HPV4 vaccines could be given to young male patients, though was not routinely recommended. (After new data were presented to the FDA, on December 22, 2010, HPV 4 vaccine indications were extended to include anal cancer prevention in male and female patients age 9-26.)Meningococcal VaccineA 2-dose regimen was recommended for high-risk adults, including those with asplenia, complement deficiencies, and HIV.Influenza VaccinationFlu vaccination was recommended for everyone over 6 months old. A new high-dose flu formulation, designed to improve immune response, became a choice for seniors.
Correct Answer: D. OK to give either oneVaccines Impacted by Egg AllergyInfluenzaImportant to distinguish allergy to eggs from allergy to vaccine componentsDetailed, updated guidance in 2011 CDC/ACIP influenza vaccine guidelinesYellow feverCDC Yellow Book
The 2011 ACIP influenza vaccine recommendations were updated with regard to the approach to egg allergy and influenza vaccines [MMWR Aug 26, 2011] .Issues regarding egg allergy and preservatives (i.e. which vaccines have thimerosal) are confusing to cliniciansThis 2011 influenza egg allergy flow diagram, available through the cdc.gov website, serves as a practical tool for delineating how to approach patients with egg allergy
It is difficult for clinicians to stay educated on vaccine contraindications and changes in these contraindications.Key points to note on this slide are:The CDC has a Guide to Vaccine Contraindications and Precautions which is a good resourceOnly flu and yellow fever are considerations with egg allergyThere is a long list of other issues that may need to be taken into account (e.g. neomycin allergy) This document addresses preservative issues, in addition to side effects, etc
Adult vaccines are safe and effective, and we have clear recommendations for their use. Nevertheless, these vaccines are underused. Data from the 2009 National Health Interview Survey (a nation-wide survey conducted by the Centers for Disease Control and Prevention) show that vaccination rates for adults in this country are, indeed, too low. The highest vaccination rates are seen among the elderly for influenza (65.6%) and pneumococcal diseases (60.6%). Vaccination rates based on risk status (vs age-based) tend to be substantially lower. For example, where the vaccination rate for all persons 65 and older against pneumococcal disease is 60.6%, for high-risk persons younger than 65 it is only 17.5%. In addition, vaccination rates for newer vaccines such as shingles or HPV are also lower.
A source for such individualized data is Final state-level influenza vaccination coverage estimates for the 2010–11 season–United States, National Immunization Survey and Behavioral Risk Factor Surveillance System, August 2010 through May 2011Located at: http://www.cdc.gov/flu/professionals/vaccination/coverage_1011estimates.htm.For example, for 2010 to 2011, among adults ≥18 years, the estimated national coverage was 40.5%, comparable to 2009–10 seasonal (trivalent) coverage (40.4%). State-specific coverage for adults ≥18 years ranged from 56.2% (South Dakota) to 32.7% (Nevada).
Not only are vaccination rates for adults in general too low and short of national goals, but there are also significant disparities in vaccination rates by race and ethnicity. Data from the 2009 National Health Interview Survey show that vaccination rates for the elderly are lower among African-Americans and Hispanics than among Caucasians for both influenza and pneumococcal vaccines.
Requirements for influenza vaccination for healthcare personnel range from institutional policies that mandate declinations to those terminating unvaccinated healthcare personnel. Such situations are increasingly common in the US (Miller et al, 2011). A study was conducted to determine HCP vaccine uptake following requirements for influenza vaccination at 998 acute care hospitals using a survey approach.This study determined that, of 228 hospitals that met analytic inclusion criteria, mean reported institutional-levelinfluenza vaccination coverage among HCP rose from 62.0% in the pre-requirement season to 76.6% in thepost-requirement season, representing a single-season increase of 14.7% (95% CI: 12.6–16.7). After adjusting for potential confounders, single-season increases in influenza vaccination uptake remained greater among hospitals that imposed consequences for vaccine refusal, and among hospitals with lower pre-requirement vaccination coverage. Institutional characteristics were not associated with vaccination increases of differential magnitude.
Answer D: A second dose is recommended for people 65 years and older who got their first dose when they were younger than 65 and it has been 5 or more years since their first dose.
Question to stimulate learner input: In your experience, what is the most important patient factor for not getting vaccinated?I’ll get sick from themNot aware of needNot recommended by HCPFinancialForgotIneffectiveSomething else
In its Call to Action for Integrating Vaccines for Adults into Routine Care, the National Foundation for Infectious Diseases includes some data from a 2007 national consumer survey. In this telephone survey of 1005 adults (504 men and 501 women), respondents indicated their answers to questions about their knowledge and attitudes regarding vaccines and VPDs. These results show that many adults lack knowledge or have misconceptions about vaccines and VPDs for adults. This is clearly a common theme across studies. Cost was another category studied in this survey. 22% of respondents indicated that they would not get a vaccine if they had to pay for it, and 26% indicated that vaccines are too expensive. Thus, cost also seems to be important, though concerns about safety may be more important.
Healthcare providers are key people in ensuring that adults get vaccinated. In order to be effective in this role, healthcare providers shouldEnsure that they do know the facts—VPDs are bad for adults and vaccines (as recommended by ACIP)are good for adults. This includes being aware of the clinical manifestations and complications of VPDs, risk groups for the diseases, the target groups for vaccination, and the safety track records for the vaccines. Healthcare providers can keep up-to-date using a variety of resources, including materials available on the CDC’s Web site, as well as materials available on many state health department Web sites.In addition to being knowledgeable about adult VPDs and vaccines, healthcare providers should recommendthese vaccines to their patients. Patients time and again report that a healthcare provider’s recommendation is among the most important reasons that they are vaccinated. Such recommendations should be clear and definite. “You are at risk for this disease. There is a safe and effective vaccine to help prevent this disease, and I recommend that you get vaccinated.”In addition to a provider’s recommendation, other office-based strategies that use systems-based approaches to automate processes and enhance efficiency can be highly effective.Evaluation and feedback within a practice are also important for quantifying just how well we are doing and for identifying gaps in our performance vs goals (eg, tracking numbers of vaccine doses used compared to numbers of patients seen, or conducting chart audits to identify how often vaccines are given). This is a key component of process improvement activities.It is also important to keep an open mind about new paradigms—if the logistics of vaccine delivery are too difficult for our practice, can we refer patients to another location? For seasonal vaccines such as influenza vaccination, can we extend the time period during which we offer vaccine?Finally, for providers it is important that we are vaccinated ourselves. This is important for the protection of our patients—for example, with influenza vaccination. It is also important because vaccinated healthcare providers are also more likely to vaccinate their patients.
The CDC has resources to help address the misconceptions and fears associated with vaccine use. These materials are intended to help health care professionals keep up to date on vaccine topics. The sheets may also be distributed to parents wanting in-depth information on these topics after talking to their doctor. Most sheets include references and published scientific studies.Link: http://www.cdc.gov/vaccines/spec-grps/hcp/provider-resources-safetysheets.html. Accessed 2.23.12
Questions to stimulate learner input:In your practice who discusses immunization with the patient?When is it discussed?Every clinic encounter?Only during preventive health visits?How do you coordinate with other vaccine providers in your area?Healthcare providers are key people in ensuring that adults get vaccinated. In order to be effective in this role, healthcare providers shouldEnsure that they do know the facts—VPDs are bad for adults and vaccines (as recommended by ACIP)are good for adults. This includes being aware of the clinical manifestations and complications of VPDs, risk groups for the diseases, the target groups for vaccination, and the safety track records for the vaccines. Healthcare providers can keep up-to-date using a variety of resources, including materials available on the CDC’s Web site, as well as materials available on many state health department Web sites.In addition to being knowledgeable about adult VPDs and vaccines, healthcare providers should recommendthese vaccines to their patients. Patients time and again report that a healthcare provider’s recommendation is among the most important reasons that they are vaccinated. Such recommendations should be clear and definite. “You are at risk for this disease. There is a safe and effective vaccine to help prevent this disease, and I recommend that you get vaccinated.”In addition to a provider’s recommendation, other office-based strategies that use systems-based approaches to automate processes and enhance efficiency can be highly effective.Evaluation and feedback within a practice are also important for quantifying just how well we are doing and for identifying gaps in our performance vs goals (eg, tracking numbers of vaccine doses used compared to numbers of patients seen, or conducting chart audits to identify how often vaccines are given). This is a key component of process improvement activities.It is also important to keep an open mind about new paradigms—if the logistics of vaccine delivery are too difficult for our practice, can we refer patients to another location? For seasonal vaccines such as influenza vaccination, can we extend the time period during which we offer vaccine?Finally, for providers it is important that we are vaccinated ourselves. This is important for the protection of our patients—for example, with influenza vaccination. It is also important because vaccinated healthcare providers are also more likely to vaccinate their patients.
Correct Answer: B He should get a Tdap today, because all adults who have not yet received a dose of Tdap should get one. Questions to stimulate learner input:How do you get updates on interim recommendations?How do you communicate updated recommendations within your practice setting?The purpose of this case is to emphasize how it is important to strive to keep up with the changing recommendations on a given vaccine. What happened with Tdap is the in October 2010 the ACIP issued an interim guidance for “permissive recommendation” on the use of Tdap in adults 65 and older, that was published in Jan 2011 MMWR (http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6001a4.htm?s_cid=mm6001a4_w) and subsequently put into the 2011 charts and guidelines. In June 2012 the ACIP issued updated recommendations for the use of Tdap specifically for those adults aged 65 years and older (http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6125a4.htm?s_cid=mm6125a4_w). The question for the learners would be how do they get updates on interim recommendations and what would they do with the recommendations. For example, just because the ACIP issues an update doesn’t mean that reimbursement will cover the cost, etc. Some learners might get updates from medscape, or local societies, or national societies, or none of the above. The Td and Tdap are important vaccines that family medicine and general internists are familiar with and this allows a discussion of the importance of staying updated as well as allowing a brief discussion of the importance of being protected against pertussis in order to decrease the risk of transmission to an infant who may be only partially protected – a hot topic with ongoing pertussis outbreaks and deaths in California, Wisconsin etc. Of concern (and interest) the CDC’s Td/Tdap VIS is out of date as it was last updated 11/08].
Correct Answer: C Start where he left off – give the 3rd doseQuestions to stimulate learner input: Any successful strategies on how to complete multi-dose vaccine series in adults?HBVHAVHPVVaricellaMeningococcal (medical indications)
In a retrospective, cross-sectional analysis in the HIV Outpatient Study sites, just 198 (32.4%) of 612 patients eligible for hepatitis B vaccine received at least 1 dose [Tedaldi et al, 2004]. And, of those who received at least 1 dose, only 104 (16.9% of all patients) of 612 patients completed 3 or more doses
We have already highlighted the importance of healthcare provider recommendations for adult vaccination. Data in this slide summarize the results of a nationwide survey of 200 healthcare providers (100 primary care physicians, 34 RNs, 33 PAs, and 33 NPs). In this study, 85% or more recommended tetanus vaccinations to all adults. But recommendations for influenza and pneumococcal vaccinations were much less common. These responses suggest a real opportunity for improvement.
How do we stay on top of booster doses?
In this slide, we illustrate how provider recommendation can translate into actual (vs intended) vaccination behavior. 364 high-risk outpatients responded to a mail survey conducted in 1995. (High-risk patients were those ages 65 and older, or those having heart disease, lung disease, diabetes, or other serious illness.) Among those respondents who reported negative attitudes towards influenza or pneumococcal vaccination, vaccination rates were low if they did not receive a provider recommendation to get vaccinated. In contrast, even with their negative attitudes, if their physician or nurse recommended vaccination, then their vaccination rates were in excess of 80%. Provider recommendation makes a big difference!
The clinician should view acute problem visits as opportunities for catching up on vaccines.It is also wise to take advantage of the “PR” that flu vaccine gets every year, to dovetail recommendations for other vaccines. Of course, while pairing vaccines is a good idea, it would also be beneficial to use the rest of the year as an opportunity to review vaccines as part of medical visits which are acute in nature (as opposed to annual checks or wellness visits).Use this slide to stimulate follow-up discussion:How many already do this?If yes, share successful strategiesIf no, why not? Could it work?Many pediatrics clinics have the viewpoint of using every visit as an opportunity to make sure immunizations are up to dateCould your clinic work flow be redesigned to take advantage of this – e.g standing orders, medical assistant review…
A critical component of the 10-year program just described was the implementation of standing orders that allowed nurses at the medical center to assess patients and then offer and administer vaccines to them without the direct involvement of a physician at the time of vaccination. This allowed for the systematic review and assessment of patients at the time of check-in, thereby avoiding the need for the provider to try to remember to address vaccination during the visit. Furthermore, the standing orders were used to allow nurses to staff the walk-in clinics (similar to a public health clinic model) without having to involve a physician with each patient. Standing orders have consistently been shown to be among the most effective interventions in other studies as well—including not only the outpatient setting, but also inpatient settings, emergency departments, and long-term care. They have also been successful for many different types of vaccines.
The success of a long-term influenza vaccination program at one medical center highlights the success that can be achieved through the use of combination interventions that address patient demand, access, and provider barriers. At this medical center, influenza vaccination rates for elderly patients at baseline were less than 10% (measured in the early 1980s when national vaccination rates were very low). After an educational intervention directed at providers, vaccination rates increased to nearly 30%. But it wasn’t until a multifaceted program was implemented utilizing the elements listed above that vaccination rates increased to 61% in the first year of the multifaceted program and to almost 90% after the 10th year of the program.
Here is a graph depicting influenza vaccination rates for elderly outpatients followed at the medical center. In 1983-1984, the baseline vaccination rate was only 9%. After an educational intervention directed at providers in 1985-1986, the vaccination rate increased to 29%. But it was not until a multifaceted program including standing orders was implemented that vaccination rates really increased. In 1987-1988 the vaccination rate increased to 61%, and after 10 years of the program, the vaccination rate was 89%.
Quality Improvement (QI) projects can be implemented to improve vaccination rates in pediatric patients (Fu et al, 2012). An example of the efficacy of this approach was published by Fu and co-workers (2012). This QI project was a comprehensive immunization best practices program for pediatric patients that was based on recommendations from the Centers for Disease Control and Prevention’s Task Force on Community Preventive Services and the framework of the Chronic Care Model. The project was conducted at 6 health centers and was aimed at low-income, minority patients in Washington DC. Interventions included family reminders, education, expanding immunization access, reminders and feedback for providers, and coordination of activities with community stakeholders.The cumulative effect of this project was a 16% increase in immunization rates overall and a 14% increase in timely immunization by age 24 months. This impact was sustainable over time.
