Coordinating the delivery of vaccinations and other preventive health care recommendations for adolescents

Practical Approaches to Optimize Adolescent Immunization

With the expansion of the adolescent immunization schedule during the past decade, immunization rates notably vary by vaccine and by state. Addressing barriers to improving adolescent vaccination rates is a priority. Every visit can be viewed as an opportunity to update and complete an adolescent's immunizations. It is essential to continue to focus and refine the appropriate techniques in approaching the adolescent patient and parent in the office setting. Health care providers must continuously strive to educate their patients and develop skills that can help parents and adolescents overcome vaccine hesitancy. Research on strategies to achieve higher vaccination rates is ongoing, and it is important to increase the knowledge and implementation of these strategies. This clinical report focuses on increasing adherence to the universally recommended vaccines in the annual adolescent immunization schedule of the American Academy of Pediatrics, the American Academy of Family Physicians, the Centers for Disease Control and Prevention, and the American Congress of Obstetricians and Gynecologists. This will be accomplished by (1) examining strategies that heighten confidence in immunizations and address patient and parental concerns to promote adolescent immunization and (2) exploring how best to approach the adolescent and family to improve immunization rates.

Parents' and providers' attitudes toward school-located provision and school-entry requirements for HPV vaccines

OBJECTIVE

To determine parents' and providers' attitudes toward school-located provision and school-entry requirements for HPV vaccination.

METHODS

Parents/guardians of 11-17 y old girls and pediatric healthcare providers at one inner-city public clinic and three private practices completed semi-structured interviews in 2012-2013. Participants were asked open-ended questions regarding their attitudes toward school-located provision and school-entry requirements for HPV vaccination. Parents' answers were analyzed with relationship to whether their daughters had not initiated, initiated but not completed, or completed the HPV vaccine series. Qualitative analysis was used to identify themes related to shared views.

RESULTS

129 parents/guardians and 34 providers participated. 61% of parents supported providing HPV vaccinations in schools, citing reasons of convenience, improved access, and positive peer pressure. Those who opposed school-located provision raised concerns related to privacy and the capacity of school nurses to manage vaccine-related reactions. Parents whose daughters had not completed the series were more likely to intend to vaccinate their daughters in schools (70%) and support requirements (64%) than parents who had not initiated vaccination (42% would vaccinate at school, 46% support requirements) or completed the series (42% would vaccinate at school, 32% support requirements; p < 0 .05 for all comparisons). 81% of providers supported offering vaccination in schools, wanting to take advantage of the captive audience, improve vaccine completion rates, and decrease the administrative burden on medical office staff, but were concerned about adequate information transfer between schools and medical offices. Only 32% of providers supported school-entry requirements, largely because they felt that a requirement might provoke a public backlash that could further hinder vaccination efforts.

CONCLUSIONS

School-located provision of HPV vaccination was widely accepted by healthcare providers and parents whose children have not completed the series, indicating that this venue might be a valuable addition to improve completion rates. Support for school-entry requirements was limited among both parents and healthcare providers.

Missed opportunities for adolescent vaccination, 2006-2011

OBJECTIVE

To describe missed opportunities for meningococcal (MCV); tetanus, diphtheria, acellular pertussis (Tdap); and human papillomavirus (HPV) vaccination among adolescents.

METHODS

Retrospective electronic health record data review of adolescents aged 11-18 years at the time of their visit to a university-based pediatric practice in Seattle from 2006 to 2011. The primary outcome was missed vaccination opportunities, defined as the proportion of visits where a patient eligible for MCV, Tdap, and/or HPV remained unvaccinated. HPV vaccine analysis was limited to females. Bivariate and multivariate logistic regression assessed variables associated with missed vaccination opportunities.

RESULTS

During the study period, 1,628 adolescents made 9,180 visits. The percentage of visits that were missed opportunities was 82% for MCV, 85% for Tdap, and 82% for the first HPV dose (HPV1), 63% for the second, and 71% for the third. Adolescents with at least one preventive care visit were significantly less likely to have missed opportunities for MCV, Tdap, or HPV1. Nonpreventive visits were associated with more missed opportunities for MCV (OR = 19.2, 95% CI 15.3-24.0), Tdap (OR = 25.8, 95% CI 19.3-34.6), and HPV1 (OR = 12.1, 95% CI 9.0-16.1) than preventive visits. Adolescent females were more likely to have a missed opportunity for HPV1 than Tdap (p < .001) or MCV (p = .03).

CONCLUSIONS

Missed opportunities for adolescent vaccination against MCV, Tdap and HPV are common. Adolescents who utilize preventive care are less likely to have missed vaccination opportunities. Further research is needed to explore why missed vaccination opportunities occur and to develop evidence-based strategies to reduce missed opportunities and improve adolescent vaccination coverage.

A population-level assessment of factors associated with uptake of adolescent-targeted vaccines in Michigan

PURPOSE

Increases in adolescent vaccine coverage are needed. The aim of this study was to identify population-level clinical and demographic factors associated with adolescent vaccination.

METHODS

A retrospective analysis of data from the Michigan Care Improvement Registry (MCIR), a statewide immunization registry, was performed for 2006-2010. The sample included 1,252,655 adolescents aged 11-18 years. Vaccine coverage levels were calculated for tetanus-diphtheria-acellular pertussis (Tdap), meningococcal conjugate (MCV4), flu (seasonal influenza), and human papillomavirus, females only (HPV) vaccines. For the subset of adolescents enrolled in Medicaid, claims data were used to obtain information about the type of visits in which vaccines were administered.

RESULTS

As of 2010, statewide coverage levels for Tdap and MCV4 vaccines were 46.0% and 46.5%, respectively whereas only 15% of females had completed the HPV vaccine series. Only one in four female adolescents were up to date for all three of these vaccines. Statewide coverage among adolescents for flu vaccine during the 2009-2010 season was 8%. Age was the most significant predictor of HPV vaccination, whereas health care-associated factors (provider type and childhood immunization history) were the strongest predictors for the other three vaccines. Older adolescents were less likely to have received the flu vaccine but more likely to have receive HPV vaccine doses than younger adolescents. Among Medicaid-enrolled adolescents, most Tdap, MCV, and first-dose HPV vaccines, but only 29% of flu doses, were administered during preventive visits.

CONCLUSIONS

Noted variability in adolescent vaccine coverage by age, vaccine type, and health care-associated factors provides a framework for developing future outreach activities to increase adolescent vaccine use.

Adolescents' perspectives on vaccination outside the traditional medical home: a survey of urban middle and high school students

Eleventh- and 6th-grade students from an urban public school district were surveyed concerning vaccination outside the traditional medical home. Survey response rates were 50% for 11th- and 73% for 6th-grade students. Seventy-two percent of 11th-grade students reported that public health clinics were definitely or probably acceptable locations for vaccination; 70% reported this for emergency departments, 65% for school-based health centers, 55% for family planning clinics, and 44% for obstetrics/gynecology clinics. Corresponding percentages for 6th-grade students were 60% for public health clinics, 49% for emergency departments, 39% for school-based health centers, and 36% for family planning clinics. Sixth-grade students were not asked about obstetrics/gynecology clinics. Forty-seven percent of respondents identified a doctor's office as the "best" setting to receive vaccines, more than identified any other setting. We concluded that vaccination in one or more settings outside the traditional medical home was acceptable to most adolescents.

Physician attitudes regarding school-located vaccinations

OBJECTIVE

To assess physician attitudes regarding school-located adolescent vaccination and influenza vaccination.

METHODS

From July through September 2010, a 20-item survey was mailed to 1337 practicing Colorado family physicians and pediatricians. Standard statistical methods were used to examine unadjusted and adjusted odds ratios of factors associated with physician support for school-located vaccination programs.

RESULTS

Overall, 943 physicians were survey-eligible, and 584 (62%) responded. More than half of physicians supported both school-located influenza and adolescent vaccination. However, fewer physicians supported school-located adolescent vaccination compared with influenza vaccination. More physicians supported school-located vaccination for their publicly insured patients compared with their privately insured patients. Some family physicians (32%) and pediatricians (39%) believed that school-located vaccination would make their patients less likely to attend well-child visits, and half of respondents believed that school-located vaccination would have a negative financial impact on their practice. In multivariate analyses, physicians concerned about the financial impact of school-located vaccination were less likely to support such programs.

CONCLUSIONS

Although a majority of Colorado physicians supported influenza and adolescent vaccination at school, they expressed concerns regarding the implications on their practice. Lesser support for vaccination of their privately insured patients and concerns regarding attendance at well-child visits suggests the perceived financial impact from school-located vaccination is a barrier and merits additional examination.