How effectively can health care settings beyond the traditional medical home provide vaccines to adolescents?

Effectiveness of hospital-based strategies for improving childhood immunization coverage: A systematic review

BACKGROUND

Hospital settings represent an opportunity to offer and/or promote childhood vaccination. The purpose of the systematic review was to assess the effectiveness of different hospital-based strategies for improving childhood vaccination coverage.

METHODS

A systematic search of multiple bibliographic databases, thesis databases, and relevant websites was conducted to identify peer-reviewed articles published up to September 20, 2021. Articles were included if they evaluated the impact of a hospital (inpatient or emergency department)-based intervention on childhood vaccination coverage, were published in English or French, and were conducted in high-income countries. High quality studies were included in a narrative synthesis.

RESULTS

We included 25 high quality studies out of 7,845 unique citations. Studies focused on routine, outbreak, and influenza vaccines, and interventions included opportunistic vaccination (i.e. vaccination during hospital visit) (n = 7), patient education (n = 2), community connection (n = 2), patient reminders (n = 2), and opportunistic vaccination combined with patient education and/or reminders (n = 12). Opportunistic vaccination interventions were generally successful at improving vaccine coverage, though results ranged from no impact to vaccinating 71 % of eligible children with routine vaccines and 9-61 % of eligible children with influenza vaccines. Interventions that aimed to increase vaccination after hospital discharge (community connection, patient education, reminders) were less successful.

CONCLUSIONS

Some interventions that provide vaccination to children accessing hospitals improved vaccine coverage; however, the baseline coverage level of the population, as well as implementation strategies used impact success. There is limited evidence that interventions promoting vaccination after hospital discharge are more successful if they are tailored to the individual.

"Vaccination needs to be easy for the people, right ?": a qualitative study of the roles of physicians and pharmacists regarding vaccination in Switzerland

OBJECTIVE

Vaccination in pharmacies has been a key component of national vaccination strategies to facilitate vaccination access. Qualitative data on the perspectives of professional stakeholders on vaccination in pharmacies and on the professional relations of pharmacists with physicians regarding increasing immunisation rates is limited. We conducted a qualitative study in Switzerland. The main aim was to gain further insight into professional stakeholders' perspectives on vaccination counselling and administration conducted in pharmacies, and to further understand their views on physicians' and pharmacists' roles in increasing immunisation rates.

DESIGN

We conducted semistructured qualitative interviews. We coded and analysed transcripts using thematic analysis.

SETTING

Face-to-face interviews took place in German-speaking and French-speaking regions of Switzerland.

PARTICIPANTS

We interviewed 14 key vaccination stakeholders including health authorities, heads of pharmacy management and professional association boards. All participants had a background in medicine or pharmacy.

RESULTS

Three main themes emerged from the qualitative data: (1) Participants viewed pharmacists as competent to provide vaccination counselling and administration based on their university training; (2) interprofessional cooperation between physicians and pharmacists on vaccination topics is limited and should be improved; and (3) pharmacists play an important role in increasing immunisation rates by facilitating vaccination access and through provision of vaccination counselling.

CONCLUSION

By providing vaccination counselling and administering vaccines, pharmacists play an important public health role. Healthcare policies and health authorities should encourage more involvement of pharmacists and encourage interprofessional cooperation between physicians and pharmacists in order to improve vaccination counselling and increase immunisation rates.

Childhood and Adolescent Vaccination in Alternative Settings

Although pediatric and adolescent vaccination rates are generally high in the United States, delayed and under-vaccination exist within certain patient populations and communities, leaving them vulnerable to vaccine-preventable diseases. One strategy for addressing this major public health concern is to offer vaccinations in nonprimary care settings such as schools, emergency rooms, hospitals, and pharmacies. This article reviews the unique advantages, challenges, and experiences regarding vaccine delivery in each alternative setting. It describes the key components that each must possess as well as other important factors to consider when assessing the ability of each to deliver vaccines to the children and adolescents they serve. It also highlights the need for sufficient funding and reimbursement for vaccine-related costs in these settings, the importance of orienting staff, providers, and practices to offering preventive care services through education and evidenced-based approaches, and the necessity of effective, efficient coordination of vaccination efforts across sites. By expanding the scope of non-primary care settings to include vaccine delivery and striving to capture all vaccination opportunities in these locations, the proportion of children and adolescents receiving on-time doses will undoubtedly increase. It is important to emphasize that these settings should not replace the medical home as the primary location for vaccination, but rather serve as a critical safety net for high-risk individuals and communities and in situations where access to traditional locations may be limited such as during the COVID-19 pandemic.

A quality improvement collaborative to increase human papillomavirus vaccination rates in local health department clinics

Human papillomavirus (HPV) vaccination rates are well below the Healthy People 2020 goal of 80%. Vaccinating in settings other than primary care, such as local health departments (LHDs), may help achieve higher HPV immunization rates. We tested the effect of a quality improvement (QI) collaborative to reduce missed opportunities (MOs) for HPV vaccine in LHDs. Between 2016 and 2019, we conducted four consecutive cohorts of a virtual QI collaborative at 24 LHDs across multiple states. Participants were trained on topics including how to provide an effective recommendation for HPV vaccine, strategies to reduce MOs, and motivational interviewing. Throughout the 6-month project implementation, LHDs tested strategies to reduce MOs through Plan-Do-Study-Act cycles, performed chart reviews to identify and characterize MOs, and received feedback reports to assess progress on MOs. HPV vaccination rates were assessed pre- and post-intervention. LHDs reduced MOs for HPV vaccine in all four cohorts with aggregated data showing a 25.3 percentage point reduction in MOs. Modified Poisson regression analysis found a 44% reduction in the relative risk of missing the opportunity for an HPV vaccine at a visit (RR = 0.56, 0.46-0.68, p < .001). This project shows that strategies effective in reducing MO for HPV vaccine in primary care settings are also effective in LHD settings. Training LHD staff on these strategies may help the U.S. approach national goals for HPV vaccine coverage.

Level and factors associated with uptake of human papillomavirus infection vaccine among female adolescents in Lira District, Uganda

Introduction

the principal burden of human papillomavirus (HPV) infections is cervical cancer. Cervical cancer ranks as the fourth most common malignancy in women affecting 500,000 women each year with an estimated 266,000 deaths. Uganda has one of the highest cervical cancer incidence rates globally with an age-standardised incidence rate per 100,000 of 47.5. This study assessed the level and the factors associated with uptake of HPV vaccine by female adolescents in Lira district, Uganda.

Methods

a mixed methods approach was employed using a survey among 460 female adolescents. We collected data using an interviewer-administered questionnaire. We interviewed five key informants and conducted ten in-depth interviews. Uptake was defined as completing three doses of the vaccine as per the recommended schedule. Prevalence risk ratios were used as measures of association and were computed using modified poison regression. Content analysis was used for qualitative data.

Results

the mean age of the respondents was 13.97 (SD=1.24). Uptake was at 17.61% (81/460). The factors associated with uptake of HPV vaccine were: attaining ordinary level of education (aPR 1.48, 95%CI 1.11-1.97), positive attitude towards the vaccine (aPR 3.46, 95%CI 1.70-7.02), receiving vaccine doses from different vaccination sites (aPR 1.59, 95% CI 1.10-2.28) and encouragement from a health worker (aPR 1.55, 95%CI 1.15-2.11) or Village Health Team (aPR 3.47, 95%CI 1.50-8.02) to go for the vaccine. Other factors associated with uptake of HPV vaccine included; the existence of community outreaches (aPR 1.47, 95%CI 1.02-2.12), availability of vaccines at vaccination sites (aPR 4.84, 95%CI 2.90-8.08) and receiving full information about the vaccine at the vaccination site (aPR 1.90, 95%CI 1.26-2.85).

Conclusion

HPV vaccine uptake was low in Lira district. Efforts to improve uptake of HPV vaccine should focus on ensuring a consistent supply of vaccines at the vaccination sites, health education aimed at creating a positive attitude towards the vaccine, sensitisation of the adolescents about the vaccine and conducting community outreaches.

Service quality and parents' willingness to get adolescents HPV vaccine from pharmacists

We sought to examine whether pharmacy service quality was associated with parents' willingness to have immunizing pharmacists administer human papillomavirus (HPV) vaccine to their adolescent children. Participants were a national sample of 1504 US parents of adolescents ages 11 to 17 who completed an online survey in 2014. Analyses used structural equation modeling. Parents rated service quality and feelings of satisfaction with their pharmacies as moderate to high. Many (44%) were willing to get HPV vaccine from immunizing pharmacists for their adolescent children. Compared with parents who went to chain pharmacies, parents who went to independent pharmacies gave higher ratings of service quality (professionalism, confidentiality, milieu, all p < .001). Parents who went to clinic pharmacies, compared with parents who went to chain pharmacies gave lower ratings for milieu (p < .01). Parents who went to independent pharmacies had lower willingness to get HPV vaccine from pharmacists compared to parents who went to chain pharmacies (p = .001), but there was no difference in willingness for parents who went to clinic versus chain pharmacies. Service quality and satisfaction partially mediated the effect between independent pharmacies compared to chain pharmacies and willingness (p < .05). Parents who knew their pharmacists or expressed more confidence in HPV vaccine also had higher willingness to get their children HPV vaccine from pharmacist. Many parents were willing to go to immunizing pharmacists for their children's HPV vaccination. Pharmacies that are considering offering HPV vaccine may be able to improve vaccine uptake by increasing perception of service quality.

The Role of Pharmacists in Caring for Young People With Chronic Illness

PURPOSE

To explore the perceived and potential roles of pharmacists in the care of young people aged 10-24 years with chronic illness, through the exemplar of juvenile arthritis, from the perspectives of UK community and hospital pharmacists, health service commissioners, rheumatology health professionals, and lay advocates.

METHODS

A sequential mixed methods study design comprises the following: focus groups with community and hospital pharmacists; telephone interviews with pharmacy and rheumatology stakeholders and commissioners; and multidisciplinary group discussions to prioritize roles generated by the first two qualitative phases.

RESULTS

The high priority roles for pharmacists, identified by pharmacists and rheumatology staff, were developing generic health care skills among young people; transferring information effectively across care interfaces; building trusting relationships with young people; helping young people to find credible online health information; and the need to develop specialist expertise. Participants identified associated challenges for pharmacists in supporting young people with chronic illness. These challenges included parents collecting prescription refills alone, thus reducing opportunities to engage, and pharmacist isolation from the wider health care team.

CONCLUSIONS

This study has led to the identification of specific enhancements to pharmacy services for young people, which have received the endorsement of a wide range of stakeholders. These suggestions could inform the next steps in developing the contribution of community and hospital pharmacy to support young people with chronic illness in the optimal use of their medication.

Timing of Clinical Billing Reimbursement for a Local Health Department

OBJECTIVES

A major responsibility of a local health department (LHD) is to assure public health service availability throughout its jurisdiction. Many LHDs face expanded service needs and declining budgets, making billing for services an increasingly important strategy for sustaining public health service provision. Yet, little practice-based data exist to guide practitioners on what to expect financially, especially regarding timing of reimbursement receipt. This study provides results from one LHD on the lag from service delivery to reimbursement receipt.

METHODS

Reimbursement records for all transactions at Maricopa County Department of Public Health immunization clinics from January 2013 through June 2014 were compiled and analyzed to determine the duration between service and reimbursement. Outcomes included daily and cumulative revenues received. Time to reimbursement for Medicaid and private payers was also compared.

RESULTS

Reimbursement for immunization services was received a median of 68 days after service. Payments were sometimes taken back by payers through credit transactions that occurred a median of 333 days from service. No differences in time to reimbursement between Medicaid and private payers were found.

CONCLUSIONS

Billing represents an important financial opportunity for LHDs to continue to sustainably assure population health. Yet, the lag from service provision to reimbursement may complicate budgeting, especially in initial years of new billing activities. Special consideration may be necessary to establish flexibility in the budget-setting processes for services with clinical billing revenues, because funds for services delivered in one budget period may not be received in the same period. LHDs may also benefit from exploring strategies used by other delivery organizations to streamline billing processes.

Interventions to Improve Adolescent Vaccination: What May Work and What Still Needs to Be Tested

Since the development of the "adolescent platform" of vaccination in 1997, hundreds of studies have been conducted, identifying barriers to and facilitators of adolescent vaccination. More recent research has focused on developing and evaluating interventions to increase uptake of adolescent vaccines. This review describes a selection of recent intervention studies for increasing adolescent vaccination, divided into three categories: those with promising results that may warrant more widespread implementation, those with mixed results requiring more research, and those with proven effectiveness in other domains that have not yet been tested with regard to adolescent vaccination.

Implementing a School-Located Vaccination Program in Denver Public Schools

BACKGROUND

School-located vaccination (SLV) offers an opportunity to deliver vaccines to students, particularly those without a primary care provider.

METHODS

This SLV program offered 2 clinics at each of 20 elementary schools (influenza vaccine) and 3 clinics at each of 7 middle/preschool-eighth-grade schools (adolescent platform plus catch-up vaccines) during the 2009-2010 and 2010-2011 school years. Established programmatic processes for immunization delivery in an outreach setting were used. Billing and vaccine inventory management processes were developed. Vaccines from the federal Vaccines for Children program were used for eligible students. Third-party payers were billed for insured students; parents were not billed for services.

RESULTS

The proportion of enrolled students who received at least 1 dose of vaccine increased from year 1 to year 2 (elementary: 28% to 31%; middle: 12% to 19%). Issues identified and addressed included program planning with partners, development and implementation of billing processes, development of a solution to adhere to the Family Educational Rights and Privacy Act requirements, development and utilization of an easy-to-comprehend consent form, and implementation of standard work procedures.

CONCLUSIONS

This SLV program offered an alternative approach for providing vaccinations to students outside of the primary care setting. To be successful, ongoing partnerships are needed.

Promising alternative settings for HPV vaccination of US adolescents

Vaccination in alternative settings, defined here as being outside of traditional primary care, can help address the pressing public health problem of low human papillomavirus vaccine coverage among adolescents in the United States. Pharmacies are promising because they are highly accessible and have well established immunization practices. However, pharmacies currently face policy and reimbursement challenges. School-located mass vaccination programs are also promising because of their high reach and demonstrated success in providing other vaccines, but control by local policymakers and challenges in establishing community partnerships complicate widespread implementation. Health centers in schools are currently too few to greatly increase access to human papillomavirus vaccine. Specialty clinics have experience with vaccination, but the older age of their patient populations limits their reach. Future steps to making alternative settings a success include expanding their use of statewide vaccine registries and improving their coordination with primary care providers.

Impact of a physician recommendation and parental immunization attitudes on receipt or intention to receive adolescent vaccines

Four vaccines are recommended by the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices for adolescents. Parental attitudes may play a key role in vaccination uptake in this age group. In 2011, we conducted a cross-sectional survey among parents of adolescents in one county in Georgia to identify parental attitudes toward adolescent vaccination, reasons for vaccine acceptance or refusal, and impact of a physician recommendation for vaccination. Physician recommendation was reported as one of the top reasons for receipt or intent to receive any of the vaccines. Physician recommendation of any of the four vaccines was associated with receipt of Tdap (p<0.001), MCV4 (p<0.001), and HPV (p = 0.03) and intent to receive Tdap (p = 0.05), MCV4 (p = 0.005), and HPV (p = 0.05). Compared with parents who did not intend to have their adolescent vaccinated with any of the vaccines, parents who did intend reported higher perceived susceptibility (3.12 vs. 2.63, p = 0.03) and severity of disease (3.89 vs. 3.70, p = 0.02) and higher perceived benefit of vaccination (8.48 vs. 7.74, p = 0.02). These findings suggest that future vaccination efforts geared toward parents may benefit from addressing the advantages of vaccination and enhancing social norms. Physicians can play a key role by providing information on the benefits of adolescent vaccination.

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.

Correlates of comfort with alternative settings for HPV vaccine delivery

Low uptake of human papillomavirus (HPV) vaccine calls for innovative approaches. Offering the vaccine in settings outside the traditional medical home, such as schools and pharmacies, could increase use. We sought to characterize the acceptability of HPV vaccine delivery in these alternative settings using a national (US) sample of parents of adolescent males ages 11-17 y (n = 506) and their sons (n = 391) who completed our online surveys in Fall 2010. We used multivariable regression to identify correlates of parents' and sons' comfort with (i.e., acceptability of) alternative settings. Half of parents (50%) and over one-third of sons (37%) reported that they were comfortable with schools or pharmacies as locations for the sons to receive HPV vaccine. Parents and sons were more comfortable with HPV vaccination in alternative settings if the sons had not recently visited their health care providers or had previously received vaccines at school, or if parents and sons were comfortable talking with each other about new vaccines. Parents who perceived greater barriers to HPV vaccination were more comfortable with alternative settings, as were sons who perceived that their peers were more accepting of HPV vaccine (all p < 0.05). Offering HPV vaccine in alternative settings may increase vaccination, especially among hard-to-reach adolescents. For example, our results suggest that offering the vaccine in alternative settings to boys who had not had recent health care visits could increase uptake by more than 10%. Study findings also highlight factors that should be addressed to maximize the potential success of HPV vaccination programs.

A description of barriers and facilitators to childhood vaccinations in the military health system

PURPOSE

To perform a literature review of barriers to and facilitators of parents' decisions to have their children vaccinated. Both differences and similarities between the civilian sector and the military health system (MHS) were explored.

DATA SOURCES

Articles and documents were identified from the following databases: CINAHL, PubMed, Defense Technical Information Center (DTIC), ISI, and Google Scholar. Reference lists from articles were reviewed.

CONCLUSIONS

Common themes identified in the civilian sector and the MHS included an electronic registry, care access issues, provider characteristics, and child illness. Several themes served as a barrier in one system while being a facilitator in the other, such as provider characteristics. Literature addressing the MHS and factors affecting vaccine coverage is scant; however, a large disparity in vaccination coverage exists between the MHS and the civilian sector.

IMPLICATIONS

The theme of provider characteristics was seen as a barrier in both systems; a better understanding of this theme (i.e., provider effectiveness at interacting with parents) would benefit primary care practice. An electronic vaccine registry and targeted education and media campaign used to facilitate vaccinations in the MHS should be piloted in the civilian sector. Additionally, future studies should be performed on identified themes in the MHS.

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.

Do medical homes reduce disparities in receipt of preventive services between children living in immigrant and non-immigrant families?

The patient-centered medical home model has the potential to reduce healthcare disparities among immigrant children. The purpose of this study is to examine the relationship between medical home (MH) participation and receipt of preventive services among immigrant children age 0-17. The study employed extant data from the National Survey of Children's Health, 2007 (NSCH). Logistic regression analyses were employed to assess the relationship between receipt of preventive services and MH status among immigrant and non-immigrant children. Due to primarily the lack of family-centered care, only 40% of immigrant children met the medical home criteria versus approximately 62% of non-immigrant children. Immigrant children have decreased odds of receiving preventive care despite MH status. Improving the family-centered care aspect of the MH is necessary to increasing medical home access to immigrant children and the receipt of preventive services for immigrant children who meet the MH criteria.

Trends in Michigan early adolescent immunization: 2006-2008

OBJECTIVES

We have described vaccine coverage of Michigan young adolescents immunized with tetanus, diphtheria, and pertussis; meningococcal conjugate; and human papillomavirus vaccines during 2006-2008.

METHODS

We obtained data from the Michigan Care Improvement Registry, a state-based immunization information system that included more than 57 million vaccination records. We examined 3 overlapping cohorts of 11- and 12-year-old children (n > 350 000 in each) to assess temporal trends in vaccination coverage, characteristics of those immunized, funding sources, and vaccination sites.

RESULTS

Vaccine uptake increased during 2006 through 2008, peaking in the summer months. More than half of children receiving more than 1 vaccine received the vaccines simultaneously. Older age, receipt of Medicaid, and prior completion of early childhood immunizations were associated with greater odds of vaccination.

CONCLUSIONS

Vaccine coverage among Michigan young adolescents is increasing but continues to be relatively low. Coverage of 11- and 12-year-old children may improve with efforts to encourage vaccination at all health care visits, an increase in public funding in support of adolescent vaccination, and continued monitoring of adolescent vaccination levels through school-based assessments.

Improving human papillomavirus vaccine delivery: a national study of parents and their adolescent sons

PURPOSE

We examined parents' and adolescents' preferences regarding potential strategies to increase human papillomavirus (HPV) vaccination rates, including offering the vaccine in alternative settings, concomitant administration of vaccines, and optimizing the structure of vaccination medical visits.

METHODS

A national sample of U.S. parents of adolescent boys aged 11-17 years (n = 506) and their sons (n = 391) completed online surveys in August and September 2010. We used analysis of variance for mixed designs to examine preferences for vaccination settings.

RESULTS

Parents and sons were most comfortable with sons receiving HPV vaccine in a doctor's office. Parents of sons who had not visited their regular health care providers in the past year were more comfortable with sons receiving HPV vaccine at a public clinic (p < .001) or school (p < .05) compared with parents whose sons had recent visits. Results from the son survey showed a similar pattern. Parents and sons reported moderate levels of acceptability of concomitant administration. They most preferred to have the three HPV vaccine shots administered during brief nurse visits.

CONCLUSIONS

Offering HPV vaccine in alternative settings and administering it with other recommended adolescent vaccines may increase uptake among adolescent boys. Parents and sons may prefer HPV vaccines be administered during brief nurse visits.

Validation of a Pediatric Primary Care Network in a US Metropolitan Region as a Community-Based Infectious Disease Surveillance System

This cross-sectional study used Geographic Information System methods to compare sociodemographic and clinical characteristics of children enrolled and not enrolled in a primary care network to determine the suitability of the network to estimate population-based disease rates. We validated the network surveillance system by comparing invasive pneumococcal disease rates between network and nonnetwork children using population-based surveillance data. Among the study population of 130300 children, network children were more likely to be female, Black, non-Hispanic, younger, and receive Medicaid. These differences varied across neighborhoods, however, adjusting for neighborhood characteristics did not significantly change observed differences. Rates of invasive pneumococcal disease were not significantly different between network and non-network children. Significant demographic and clinical differences existed between network and non-network children and varied over small areas. Observed population rates of an infectious disease did not significantly differ suggesting that the network can potentially provide valid disease estimates for the community population.

Parent and adolescent perspectives about adolescent vaccine delivery: practical considerations for vaccine communication

We surveyed parents of adolescents (n=430) and their adolescents ages 15-17 years (n=208) in 9 primary-care settings in Monroe County, NY to assess perceptions about adolescent vaccine delivery. Parents and adolescents most wanted to discuss vaccine side effects and the diseases prevented with the adolescents' provider. Those who perceived vaccines as very safe were more accepting of adolescent vaccines. Most participants agreed with vaccinating the teen during a mild illness and with providing multiple vaccines concomitantly. Participants most preferred medical, as opposed to other settings, for receipt of adolescent vaccines. For parents and adolescents who are wary of vaccination, strategies are needed to enhance communication about risks and benefits of vaccinations.

Parents' acceptance of adolescent immunizations outside of the traditional medical home

PURPOSE

Numerous barriers to vaccination exist for adolescents. Using the medical home as the sole source of adolescent vaccination has potential limitations. The objectives of the present study were to examine parents' acceptance of adolescent vaccination outside of the medical home and parents' preferred setting for adolescent vaccination.

METHODS

A standardized, pilot-tested telephone survey was administered to a stratified random sample (n = 1,998) of Colorado households between August 2007 and February 2008. Households with English-speaking parents and adolescent(s) aged 11-17 years were eligible.

RESULTS

Survey response rate was 43%; there were no significant differences between respondents and nonrespondents for three known demographic variables. Although most parents (78%) preferred a doctor's office for adolescent vaccination, a majority were also definitively or probably accepting of vaccination in public health clinics (74%), school health clinics (70%), obstetrics and gynecology clinics (69%; asked for females only), and emergency departments (67%). Parents were less accepting of vaccination in family planning clinics (41%) and retail-based clinics (36%). Perceived convenience and adolescents' comfort in the setting were positively associated with vaccination acceptance in most settings; concern with keeping track of vaccines given outside of the medical home was negatively associated with acceptance. Parents in rural areas were more likely than parents in urban areas to identify a setting outside of the medical home as the preferred "best" setting for vaccination.

CONCLUSIONS

Most parents assessed a doctors' office as the best setting for adolescent vaccination. However, vaccination in certain settings outside of the medical home seems to be acceptable to many parents.

Retail pharmacies and adolescent vaccination--an exploration of current issues

PURPOSE

To describe adolescent immunization practices prevalent in retail pharmacies in the United States, where little is known about their potential for increasing adolescent immunizations.

METHODS

State pharmacy association spokespersons with knowledge of statewide pharmacy practices were interviewed to assess pharmacy practices and vaccine-related attitudes. Descriptive frequencies and score-tested differences in attitudes, using the generalized estimating equation, are presented.

RESULTS

A total of 24 respondents from 24 states completed the interviews. Of these , 14 respondents reported that pharmacists vaccinate adolescents and in these states more than 40% of adolescents presenting for vaccines without a parent would receive vaccines some of the time. Knowledge of minor consent laws was found to be limited. Vaccines were routinely available in <50% of the retail pharmacies. Most of the respondents strongly agreed with Advisory Committee on Immunization Practices' recommendations for tetanus, diphtheria, and pertussis vaccine (83%), human papillomavirus vaccine (58%), and influenza (71%) vaccine. The percentage of the respondents who believed that financial barriers make it difficult for adolescents to obtain human papillomavirus vaccine (96%) and tetanus, diphtheria, and pertussis vaccine (78%) was significantly higher as compared with those who had the same belief regarding influenza (35%) (p < .001). Nineteen respondents (79%) believed that adolescent immunization services in retail pharmacies will likely expand in the next 5 years.

CONCLUSIONS

If pharmacists want to expand their adolescent immunization roles, they should ensure the availability of adolescent vaccine and address clarification related to consent for vaccines in case of minors.

Pharmacy Technicians and Immunizations

Objective:

To provide background on immunizations and community pharmacies and identify opportunities for pharmacy technicians to assist pharmacists in providing community pharmacy-based immunization programs.

Methods:

Articles were identified through searches of MEDLINE/PubMed (1950–July 2010) with the following search terms: vaccination and technician, immunization and technician, vaccination and pharmacist, and immunization and pharmacist. Additionally, immunization resources from the American Pharmacists Association, the American Society of Health-System Pharmacists, and the Centers for Disease Control and Prevention were used.

Results:

Pharmacy technicians can help facilitate immunization programs and help reduce some of the barriers to providing superior services. Specific tasks that can be performed by pharmacy technicians include documentation, billing, assisting in the reporting of adverse events, and facilitating communication. Technicians can also take an active role in pharmacy-based immunization programs by obtaining cardiopulmonary resuscitation training and certification.

Conclusions:

Pharmacy technicians can help facilitate immunization programs and help pharmacists offer more robust and comprehensive immunization services.

Adherence to the HPV vaccine dosing intervals and factors associated with completion of 3 doses

OBJECTIVE

The objectives of this study were to determine (1) adherence to the immunization schedule for the human papillomavirus quadrivalent vaccine and (2) factors associated with completion of the 3-dose series.

METHODS

This was a retrospective review of health information records from an academic medical center. The sample included all 9- to 26-year-old female patients who initiated vaccination within 2 years after quadrivalent vaccine availability. Multivariable logistic regression models were estimated to determine associations with completion of the 3-dose series within 7 and 12 months.

RESULTS

Among the 3297 female patients who initiated vaccination with human papillomavirus quadrivalent vaccine, 67% self-identified as black and 29% self-identified as white. Fewer than 3% of vaccine doses were received earlier than recommended, but >50% of doses were received late. Completion rates were 14% by 7 months and 28% by 12 months. Independent predictors of completion by 7 months included white versus black race (odds ratio [OR]: 2.04 [95% confidence interval (CI): 1.64-2.56]; P < .001), use of contraception that required intramuscular injections every 3 months (OR: 1.53 [95% CI: 1.12-1.95]; P < .001), and private versus public insurance (OR: 1.31 [95% CI: 1.06-1.63]; P < .05). Age and clinic type were not independent predictors of completion.

CONCLUSIONS

Adherence to recommended intervals and completion of the vaccine series were low. Lower rates of completion in black patients compared with white patients raises concern that disparities in vaccine completion could exacerbate existing disparities in cervical cancer.

Does primary language influence the receipt of influenza and pneumococcal immunizations among community-dwelling older adults?

OBJECTIVES

To examine (a) the influence of primary language on the receipt of influenza and pneumococcal immunizations and (b) the feasibility of being immunized in a nontraditional setting.

METHOD

The population was multiethnic, linguistically diverse, community-dwelling, low income, older adults in California. Face-to-face interviews were conducted with 164 participants (response rate 82%). Questions from BRFSS and CHIS were used.The questionnaire was implemented in six languages.

RESULTS

Influenza vaccination within the past 12 months was reported by 75.3%, but only 50.6% reported ever receiving the pneumococcal vaccine. Immunization predictors: Influenza-insurance through MediMedi, rating one's health as excellent/good, living with another person, and English as a primary language; pneumococcal-insurance through MediMedi and English as a primary language. Majority were willing to be immunized in nontraditional setting, especially those with limited English proficiency.

DISCUSSION

Need exists for cultural and linguistically appropriate immunization outreach methods for older adults and practitioners.

Addressing adolescent immunization disparities: a retrospective analysis of school-based health center immunization delivery

OBJECTIVES

We compared completion rates for adolescent immunization series administered at school-based health centers (SBHCs) to completion rates for series administered at community health centers (CHCs) within a single integrated delivery system.

METHODS

We performed a retrospective analysis of data from an immunization registry for patients aged 12-18 years. Patients were assigned to either an SBHC or a CHC during the study interval based on utilization. We used bivariate analysis to compare immunization series completion rates between the 2 groups and multivariate analysis to compare risk factors for underimmunization. We performed subanalyses by ages 12-15 years versus ages 16-18 years for human papillomavirus (HPV) and for the combination of HPV; tetanus, diptheria, and pertussis (Tdap); and tetravalent meningococcus virus.

RESULTS

SBHC users had significantly higher completion rates (P<.001) for hepatitis B, Tdap, inactivated poliovirus, varicella, measles/mumps/rubella, and HPV for ages 16-18 years, and for the combination of HPV, Tdap, and MCV4 for ages 16-18 years. CHC users had higher completion rates for tetanus and diphtheria.

CONCLUSIONS

SBHCs had higher completion rates than did CHCs for immunization series among those aged 12-18 years, despite serving a population with limited insurance coverage.

Vaccination delivery by chain pharmacies in California: Results of a 2007 survey

OBJECTIVE

To better understand the practice standards and scope of pharmacist-administered vaccination services at chain pharmacies in California.

DESIGN

Cross sectional.

SETTING

California in 2006-2007.

PARTICIPANTS

Eight state-level immunization coordinator corporate liaisons to chain pharmacies' immunization programs.

INTERVENTION

Key informant phone survey with follow-up written survey.

MAIN OUTCOME MEASURES

Policies, procedures, and vaccine usage.

RESULTS

All eight chains provided immunization services to adults; four chains also vaccinated adolescents. More than 1,000 California pharmacists employed at chain pharmacies have been trained to vaccinate; more than 500 locations participate with evening, weekend, and walk-in hours. Influenza and pneumococcal vaccines were the most common vaccines administered. Other vaccines were used less frequently. Respondents expressed interest in partnering with public health to improve record sharing, build awareness, receive vaccine news updates, and explore other activities.

CONCLUSION

Chain pharmacies in California have started to vaccinate adults and adolescents--two commonly undervaccinated age groups. To date, patients seeking vaccination at pharmacies are most likely to receive influenza and pneumococcal vaccines. Community locations and extended hours offer patients convenience, although out-of-pocket fees may be a barrier to some patients. Opportunities exist to build and strengthen partnerships among public health, the medical community, and pharmacists in order to vaccinate and protect patients not vaccinated in traditional settings.

How can we communicate about vaccines with adolescents and their parents?

OBJECTIVE

To describe parents' and adolescents' perceptions about vaccination.

METHODS

Qualitative interviews of 22 mothers/grandmothers and 25 10- to 14-year-olds.

RESULTS

Themes emerged in 3 focus areas. (a) Understanding: Both adults and adolescents had difficulty understanding concepts of risks, benefits, prevention, and vaccination. (b) Decision making: Adults saw vaccination as an opportunity to help their adolescent develop skills for transition to adulthood. Adolescents worried about being lied to (reinforced by being told "it won't hurt"), physical pain, and cleanliness. ( c) Preventing sexually transmitted infections: Adults were divided between those who felt their child would not need such a vaccine and those who wanted to "be safe" to protect their child in the future.

CONCLUSIONS

At the same time that even basic concepts about vaccination should be explained to both adults and adolescents, adolescence represents a time for learning about responsible decision making. Discussion regarding the risks and benefits of vaccines can be part of transitioning to adult decision making.

Strategies for implementing school-located influenza vaccination of children: a systematic literature review

BACKGROUND

The Advisory Committee on Immunization Practices (ACIP) recommends influenza vaccinations for all children 6 months to 18 years of age, which includes school-aged children. Influenza immunization programs may benefit schools by reducing absenteeism.

METHODS

A systematic literature review of PubMed, PsychLit, and Dissertation Abstracts available as of January 7, 2008, was conducted for school-located vaccinations, using search words "School Health Services" and "Immunization Programs"; limited to "Child" (6-12 years) and "Adolescent" (13-18 years) for PubMed and "mass or universal" and (immuniz(*) or immunis(*) or vaccin(*)) and (school or Child or Adolescen(*)) for PsychLit and Dissertation Abstracts. Fifty-nine studies met the criteria for review.

RESULTS

Strategies such as incentives, education, the design of the consent form, and follow-up can increase parental consent and number of returned forms. Minimizing out-of-pocket cost, offering both the intramuscular (shot) and intranasal (nasal spray) vaccination, and using reminders can increase vaccination coverage among those whose parents consented. Finally, organization, communication, and planning can minimize the logistical challenges.

CONCLUSIONS

Schools-based vaccination programs are a promising option for achieving the expanded ACIP recommendation; school-located vaccination programs are feasible and effective. Adhering to lessons from the peer-reviewed scientific literature may help public health officials and schools implement the expanded recommendation to provide the greatest benefit for the lowest cost. Given the potential benefits of the expanded recommendation, both directly to the vaccinated children and indirectly to the community, prospective, well-controlled trials to establish the cost-effectiveness of specific vaccination strategies should be high priorities for future research.

Health care utilization by adolescents on medicaid: implications for delivering vaccines

OBJECTIVE

To examine the degree to which current health care utilization patterns of Medicaid-enrolled adolescents living in Michigan would allow opportunities for adolescent immunizations to be provided.

METHODS

Outpatient claims data from 2001-2005 were analyzed for 11- to 18-year-old Medicaid-enrolled adolescents living in Michigan. Visits were classified as either health-maintenance examinations (HMEs) or problem focused by using diagnostic and procedural codes. Data were divided into 4 overlapping 2-year time periods, and the age-specific proportion of adolescents who attended these 2 visit types was calculated for each. chi(2) tests were used to evaluate associations of visit patterns with gender.

RESULTS

Of the 718847 adolescents included in the study, <50% had >or=1 HME visit within any 2-year time period, and substantially fewer (<15%) had annual HMEs. In contrast, at least 75% of the adolescents had >or=1 problem-focused visit in any given 2-year period, and approximately half had participated in at least 2 problem-focused visits. Problem-focused, but not HME, visit utilization was significantly associated with gender, with girls increasing, but boys decreasing, visit utilization as they aged.

CONCLUSIONS

Similar to privately insured adolescents, most Medicaid-enrolled adolescents do not have annual preventive-care visits, which calls into question the feasibility of providing immunizations primarily at annual HMEs. Participation in problem-focused encounters was generally high in our study. However, even problem-focused visit utilization was low among older adolescent boys. This suggests that in addition to strengthening immunization within the medical home, alternative venues for reaching certain subpopulations of adolescents should also be developed.

Public health issues related to HPV vaccination

The human papillomavirus (HPV) is clearly established as the cause of cervical cancer, and vaccines targeting oncogenic forms of the virus are important as a primary method of prevention. However, barriers to cervical screening and vaccination such as a lack of knowledge of HPV, access to healthcare, and poor follow-up prevent the acceptance and utilization of HPV vaccines. Strategies for prevention of disease and implementation of vaccination are in development, but the importance of primary prevention of HPV infection needs to be stressed. This review assesses the potential impact of vaccination for cervical cancer, barriers to vaccination, and the methods used to increase coverage. With the advent of prophylactic vaccines, HPV, a common infection in the United States, can be prevented in most women.

Update: Vaccines for women, adolescence through adulthood

Abstract Recommendations for routine vaccination of adolescents and adults are continually evolving; new vaccines are licensed, and ongoing studies lead to updated recommendations for existing vaccines. Although vaccination is important for both sexes, some recent developments are particularly relevant for women and girls. Human papillomavirus (HPV) vaccine, licensed in 2006, is the first vaccine administered exclusively to women. Another recently licensed vaccine, adult and adolescent tetanus-diphtheria-acellular pertussis (Tdap), is especially important for women who plan to become pregnant and for new mothers to help prevent pertussis disease in infants who are too young to be vaccinated themselves. Other vaccines, such as influenza and rubella, are also important for pregnant women. Several vaccine safety issues are of particular relevance to women, namely, the theoretical risk of administering live vaccines during pregnancy and data suggesting that adolescent females might be at higher risk for syncope following vaccination. Obstetrician-gynecologists are the primary, and sometimes only, contact with the healthcare system for many adolescent and adult women and, as such, are uniquely positioned to provide vaccination services to the country's female population. Vaccine costs, storage and handling requirements, lack of access to immunization information systems (also known as vaccine registries), and unfamiliarity with current recommendations are potential obstacles to ensuring that all adolescent females and women are appropriately vaccinated. Obstetrician-gynecologists can help reduce some of these obstacles by availing themselves of existing vaccination resources.

Immunization programs for infants, children, adolescents, and adults: clinical practice guidelines by the Infectious Diseases Society of America

Evidence-based guidelines for immunization of infants, children, adolescents, and adults have been prepared by an Expert Panel of the Infectious Diseases Society of America (IDSA). These updated guidelines replace the previous immunization guidelines published in 2002. These guidelines are prepared for health care professionals who care for either immunocompetent or immunocompromised people of all ages. Since 2002, the capacity to prevent more infectious diseases has increased markedly for several reasons: new vaccines have been licensed (human papillomavirus vaccine; live, attenuated influenza vaccine; meningococcal conjugate vaccine; rotavirus vaccine; tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis [Tdap] vaccine; and zoster vaccine), new combination vaccines have become available (measles, mumps, rubella and varicella vaccine; tetanus, diphtheria, and pertussis and inactivated polio vaccine; and tetanus, diphtheria, and pertussis and inactivated polio/Haemophilus influenzae type b vaccine), hepatitis A vaccines are now recommended universally for young children, influenza vaccines are recommended annually for all children aged 6 months through 18 years and for adults aged > or = 50 years, and a second dose of varicella vaccine has been added to the routine childhood and adolescent immunization schedule. Many of these changes have resulted in expansion of the adolescent and adult immunization schedules. In addition, increased emphasis has been placed on removing barriers to immunization, eliminating racial/ethnic disparities, addressing vaccine safety issues, financing recommended vaccines, and immunizing specific groups, including health care providers, immunocompromised people, pregnant women, international travelers, and internationally adopted children. This document includes 46 standards that, if followed, should lead to optimal disease prevention through vaccination in multiple population groups while maintaining high levels of safety.

Adolescent immunization delivery in school-based health centers: a national survey

PURPOSE

Vaccinating adolescents in a variety of settings may be needed to achieve high vaccination coverage. School-based health centers (SBHCs) provide a wide range of health services, but little is known about immunization delivery in SBHCs. The objective of this investigation was to assess, in a national random sample of SBHCs, adolescent immunization practices and perceived barriers to vaccination.

METHODS

One thousand SBHCs were randomly selected from a national database. Surveys were conducted between November 2007 and March 2008 by Internet and standard mail.

RESULTS

Of 815 survey-eligible SBHCs, 521 (64%) responded. Of the SBHCs, 84% reported vaccinating adolescents, with most offering tetanus-diphtheria-acellular pertussis, meningococcal conjugate, and human papillomavirus vaccines. Among SBHCs that vaccinated adolescents, 96% vaccinated Medicaid-insured and 98% vaccinated uninsured students. Although 93% of vaccinating SBHCs participated in the Vaccines for Children program, only 39% billed private insurance for vaccines given. A total of 69% used an electronic database or registry to track vaccines given, and 83% sent reminders to adolescents and/or their parents if immunizations were needed. For SBHCs that did not offer vaccines, difficulty billing private insurance was the most frequently cited barrier to vaccination.

CONCLUSIONS

Most SBHCs appear to be fully involved in immunization delivery to adolescents, offering newly recommended vaccines and performing interventions such as reminder/recall to improve immunization rates. Although the number of SBHCs is relatively small, with roughly 2000 nationally, SBHCs appear to be an important vaccination resource, particularly for low income and uninsured adolescents who may have more limited access to vaccination elsewhere.

Deficiencies in immunization education and training in pharmacy schools: a call to action

Approximately 38% of US pharmacy schools provide immunization education and training to pharmacy students as part of their core curricula. These deficiencies in immunization education and training may contribute to low immunization rates for some groups of people, particularly hard-to-reach consumers and those with misconceptions about vaccinations. In this paper, we call upon all pharmacy schools to mandate immunization education and training as part of their core curricula, not just as an elective course. In doing so, we encourage pharmacy schools to adopt the Pharmacy-Based Immunization Delivery program developed by the American Pharmacists Association. We recognize that implementation of these recommendations will require sufficient resources and that it will take time to change the curricula in colleges and schools of pharmacy.

Increasing adolescent vaccination: barriers and strategies in the context of policy, legal, and financial issues

PURPOSE

To increase understanding of the policy, legal, and financial issues influencing efforts to achieve high rates of adolescent vaccination.

METHODS

We conducted semistructured telephone interviews with 49 key informants in nine states, five jurisdictions, and at the national level. We elicited: (a) experiences with human papillomavirus (HPV) and meningococcal vaccine programs; (b) perspectives on policy, legal, and financing issues influencing adolescent vaccine program effectiveness; and (c) strategies to increase rates of adolescent vaccination. Common and informative themes were identified by content analyses.

RESULTS

Participants reported that barriers to adolescent vaccination included: public concerns (insufficient knowledge, negative attitudes, safety concerns, controversy); practitioner concerns (insufficient knowledge or ambivalence about recommendations); delivery issues (insufficient access to or use of healthcare, vaccines not at healthcare site or part of routine care); minor consent issues; cost/financing issues; and lack of coordination in timing of vaccine recommendations, supply, and financing. Many barriers and promising strategies for overcoming them vary depending on adolescent age. For example, concerns about providing vaccines to prevent sexually transmitted diseases are less frequent with respect to older adolescents; issues of consent vary widely between 11 and 25 years of age; and financial barriers/potential solutions vary by age. We develop a framework to address policy, legal, and financial issues influencing adolescent vaccination based on adolescent age.

CONCLUSIONS

A comprehensive description of factors influencing adolescent vaccination reveals variation based on age. A framework that incorporates this complexity may enhance strategies to increase rates of vaccine delivery to adolescent populations.

Human papillomavirus vaccine and adolescents

PURPOSE OF REVIEW

The present review describes recent advances in our understanding about the epidemiology of human papillomavirus infection among female adolescents and describes several adolescent-specific issues related to administering human papillomavirus vaccines.

RECENT FINDINGS

National estimates demonstrate that human papillomavirus infection is most prevalent among adolescents and young adults. Parents, patients, and providers have a high interest in vaccination against this virus, but current patterns of adolescent healthcare utilization suggest that changes in adolescent preventive care delivery may be needed to provide these vaccines in a timely manner. Debate over whether adolescents should be legally allowed to self-consent to vaccination is another issue that remains unresolved and could have a substantial impact on vaccination rates. Legislation on school entry requirements related to human papillomavirus vaccination has been introduced in many states as a mechanism to circumvent some of these concerns, but the details of this legislation and its effect on adolescent vaccine utilization remain to be determined.

SUMMARY

Female adolescents are at a high risk for human papillomavirus infection and are likely to derive significant benefits from vaccination against this virus. However, administering human papillomavirus vaccines to this age group will require providers to be familiar with several issues unique to the adolescent population.

Delivering adolescent vaccinations in the medical home: a new era?

BACKGROUND

Medical homes are health care settings that offer continuous, comprehensive, accessible primary care; these settings generally involve pediatric and family physician practices or community health centers but can also involve gynecologists or internists.

OBJECTIVES

In this article, we review available evidence on the role of the medical home in optimizing adolescent immunization delivery, particularly with respect to health care utilization patterns and barriers to vaccinations in medical homes, and solutions.

METHODS

We conducted a systematic review of the existing immunization and adolescent literature and used a Delphi process to solicit opinions from content experts across the United States.

RESULTS

Most adolescents across the United States do have a medical home, and many pay a health care visit to their medical home within any given year. Barriers exist in regards to the receipt of adolescent immunizations, and they are related to the adolescent/family, health care provider, and health care system. Although few studies have evaluated adolescent vaccination delivery, many strategies recommended for childhood or adult vaccinations should be effective for adolescent vaccination delivery as well. These strategies include education of health care providers and adolescents/parents; having appropriate health insurance coverage; tracking and reminder/recall of adolescents who need vaccination; practice-level interventions to ensure that needed vaccinations are provided to eligible adolescents at the time of any health care visit; practice-level audits to measure vaccination coverage; and linkages across health care sites to exchange information about needed vaccinations. Medical homes should perform a quality improvement project to improve their delivery of adolescent vaccinations. Because many adolescents use a variety of health care sites, it is critical to effectively transfer vaccination information across health care settings to identify adolescents who are eligible for vaccinations and to encourage receipt of comprehensive preventive.

CONCLUSIONS

Medical homes are integral to both the delivery of adolescent immunizations and comprehensive adolescent preventive health care. Many strategies recommended for childhood and adult vaccinations should work for adolescent vaccinations and should be evaluated and implemented if they are successful. By incorporating evidence-based strategies and coordinating effectively with other health care sites used by adolescents, medical homes will be the pivotal settings for the delivery of adolescent vaccinations.