Public Health Feature - August 2008
Tex Med. 2008;104(8):35-38.
By Crystal Conde
Physicians are embarking on a new frontier in vaccinating their patients. Traditionally, pediatricians and family physicians have focused their attention on ensuring that infants and young children receive every vaccine on the immunization schedule on time. However, physicians and parents haven't been as concerned about getting 11- to 18-year-olds into the office for vaccines.
That is because many of the vaccines targeting adolescents have new recommendations or are newly licensed. According to Amy Middleman, MD, an adolescent medicine specialist at Texas Children's Hospital in Houston, thinking about immunizations and their delivery to adolescents has only recently become a priority for physicians.
Before 2005, the tetanus and diphtheria toxoids (Td) booster was the only vaccine consistently recommended for adolescents. Physicians also recommended adolescents who weren't up to date on their immunizations receive hepatitis B and measles-mumps-rubella (MMR) vaccinations. Those who hadn't contracted varicella or been vaccinated against the disease received a varicella vaccination, as well.
The U.S. Food and Drug Administration (FDA) licensed the tetanus, reduced diphtheria and acellular pertussis (Tdap) vaccine and the meningococcal conjugate (MCV4) vaccine in 2005. The following year, the FDA approved Gardasil, a vaccine to prevent human papillomavirus (HPV) infection and cervical cancer in women.
With the rush of new vaccines and recommendations, the Texas Medical Association and the Texas Department of State Health Services (DSHS) recognize the need to make parents, adolescents, and physicians more aware of the latest in adolescent immunizations. To accomplish that goal and improve adolescent vaccination rates across the state, TMA and DSHS are working together in a statewide push to encourage adolescents to receive HPV, MMR, MCV4, Tdap, and varicella vaccinations. Efforts also include updating adolescents on their hepatitis B, hepatitis A, and polio vaccinations. (For a complete updated schedule of recommended immunizations for persons aged 7-18 years, click here [ PDF ].)
The endeavor is part of a nationwide campaign by the U.S. Centers for Disease Control and Prevention (CDC) to encourage parents to have their adolescents vaccinated against serious, potentially life-threatening preventable diseases.
The TMA and DSHS effort sends a clear message: "Good health can last a lifetime. Keep up to date. Vaccinate." Members of TMA's Be Wise - Immunize SM Advisory Committee reviewed the promotional and educational materials - posters, teen vaccine manuals for physicians, vaccine liability books, vaccination reminder cards, and patient brochures.
Free Tools Available
They've also developed a toolkit that addresses barriers to vaccinating adolescents and provides solutions physicians can incorporate into their practices to boost immunization rates in this population. (See " Toolkit Offers Solutions to Adolescent Vaccination Barriers .") The toolkit guides physicians toward making the solutions best practices, enabling them to set preventive care expectations for parents.
In this issue of Texas Medicine , to coincide with National Immunization Awareness Month and to kick off the statewide effort, TMA and DSHS included a poster physicians can hang in their offices to spread the message that adolescents should be immunized.
Physicians can request more posters, along with the other resources, free of charge on the TMA Be Wise - Immunize Web site .
They're also available by contacting Tammy Wishard, TMA outreach coordinator, at (800) 880-1300, ext. 1470, or (512) 370-1470, or by e-mailing Tammy Wishard .
The DSHS Web site also has an online order form .
John Gemar, DSHS adult/adolescent immunization coordinator, says the more than 3,400 participants in the Texas Vaccines for Children (TVFC) program will receive the materials automatically.
Mr. Gemar says the immunization toolkit will help physicians talk to parents about adolescent vaccines. Counseling tips cover the benefits of immunizations, information about adolescent morbidity and mortality rates caused by preventable diseases, and the importance of primary prevention through immunizations.
In addition, the toolkit features physicians' anecdotes for best practices in administering shots to adolescents, quotes on the importance of properly immunizing patients from childhood through adolescence, and additional reading suggestions and resources.
Information on conscientious objection, immunization schedules, sample minor consent forms, a list of adolescent vaccines covered by TVFC, an explanation of the new ordering and shipping system for TVFC participants, and DSHS adolescent immunization outreach resources round out the toolkit.
Dr. Middleman, who's on the Be Wise - Immunize Advisory Committee, says the toolkit gives physicians tangible strategies to improve immunization rates and reminders to screen for and deliver needed vaccines to the adolescent population.
"It was designed to include practical, usable tools to get in the swing of immunizing this particular group of patients," she said. "Adolescents have different consent issues, and there is a difference in the way you approach adolescents."
Mr. Gemar says the materials will be available in late summer.
The Need for Vaccine
DSHS has limited immunization statistics on adolescent vaccination rates in Texas, Mr. Gemar says. DSHS does track immunization status of seventh-grade students in independent school districts and private schools, but the data have not caught up with the newer recommendations and vaccines.
Mr. Gemar says there is a lag between new recommendations for vaccines, newly licensed vaccines, and rules adopted for school entry. For the 2006-07 school year, more than 97 percent of the seventh-graders were up to date on their diphtheria, tetanus, and pertussis (DTaP), hepatitis B, MMR, polio, and varicella vaccinations.
According to Ari Brown, MD, an Austin pediatrician and Be Wise - Immunize Advisory Committee member, educating parents and patients is one of the main goals of the statewide effort. She says parents and adolescents might not be aware of how long some vaccines provide immunity.
Immunity to pertussis, or whooping cough, for example, wanes over time. A Tdap booster shot is available for adolescents and adults.
Dr. Brown says teens and adults are most likely to come down with this illness and then infect infants and young children more susceptible to serious infection and even death.
Edward Dominguez, MD, an infectious disease specialist in Tyler and a member of the Be Wise - Immunize Advisory Committee, says, in general, parents lack an awareness of adolescent vaccine recommendations. (See " Adolescent Vaccine Coverage .")
"Once you get to age 11 or 12, patients go to the doctor only when they need to. We're seeing increasingly a population of kids who have missed some vaccines," he said. "Getting these young people and their parents to the doctor's office to talk about the newer vaccines, their risks, and benefits is very important."
During an office visit, physicians can cover adolescent risk behaviors; preventive services such as physical assessments for sports; screenings for adolescent diet and exercise; and immunization counseling.
Another important resource included in the materials produced by TMA and DSHS, Dr. Dominguez says, is the catch-up immunization schedule, a helpful guide for physicians whose patients are behind in some vaccinations.
He also touts the toolkit's promotion of ImmTrac, a free, confidential registry managed by DSHS that stores child and adolescent immunization information electronically. The toolkit highlights ImmTrac sample registry screen images and informs health care professionals on how to participate. Log on to the DSHS Web site to learn more about ImmTrac.
The key message TMA and DSHS need to send to physicians, parents, and adolescents, Dr. Middleman says, is vaccines' role in reducing the morbidity and mortality associated with preventable diseases.
CDC reported 25,000 cases of pertussis in the United States in 2005. National meningococcal infection estimates range from 1,400 to 2,800 cases annually. About 10 percent of teens who contract the disease die from it, while 15 percent suffer from long-term disability.
"Vaccinations are almost a victim of their success in that people forget about how deadly some of these diseases are. It's up to health care professionals to keep the campaigns going and to be the public's memory to educate people on the importance of maintaining high immunization rates," Dr. Middleman said.
Crystal Conde can be reached at (800) 880-1300, ext. 1385, or (512) 370-1385; by fax at (512) 370-1629; or by e-mail at Crystal Conde .
Be Wise ― Immunize is a service mark of the Texas Medical Association.
Toolkit Offers Solutions to Adolescent Vaccination Barriers
The first step in increasing the rate of adolescent vaccinations in Texas involves breaking down barriers to immunizing. A toolkit developed by the Texas Medical Association and the Texas Department of State Health Services (DSHS) identifies current barriers to vaccinating adolescents, including:
- Adolescents often don't visit doctors for routine or regular preventive care;
- Immunization catch-ups for adolescents are easily missed;
- Newly recommended vaccines targeting adolescents aren't mandated by schools;
- Parents aren't aware of immunization recommendations; and
- Immunizations from multiple providers are difficult to track.
The toolkit offers the following solutions:
- Developing three distinct times for adolescent vaccinations (ages 11-12, 14-15, and 17-18);
- Using noncomprehensive visits (minor injury/illness visits, camp/sports physicals, pre-college visits);
- Using existing systems (standing immunization orders, screening tools, state and county registries);
- Administering multiple vaccines simultaneously;
- Using the adolescent's medical home for vaccinations and alternative vaccination sites as needed (schools, public health clinics, sports complexes);
- Encouraging physicians to ask parents about their adolescents' immunization records;
- Educating parents to encourage them to ask about adolescent vaccines; and
- Implementing school mandates for all adolescent vaccines.
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