AAFP Chapter Lecture Series: Child and

Adolescent Immunizations -

Systems That WorkWilliam R. Sonnenberg, MD,

FAAFP Private Practice, President-Elect,

Pennsylvania Academy of Family PhysiciansTitusville, Pennsylvania

Verbal Disclosure

William R. Sonnenberg, MD, FAAFP returned a disclosure indicating that he has an affiliation with or financial interest with Forest on the topic of COPD – Daliresp.

It is the policy of the AAFP that all individuals in a position to control content disclose any relationships with commercial interests upon nomination/invitation of participation. Disclosure documents are reviewed for potential conflicts of interest. If conflicts are identified, they are resolved prior to confirmation of participation. Only participants who have no conflict of interest or who agree to an identified resolution process prior to their participation were involved in this CME activity.

Learning Objectives1. Create easily accessible files of updated

vaccination schedules for pediatric age groups

2. Integrate practices to ensure maximum vaccination coverage when schedules are updated

3. Counsel parents on the necessity, safety and efficacy of vaccines

Pre-Assessment

Please complete your answers on the sheet provided in the syllabus.

Pre-Assessment Question #1

You want to follow the most current immunization recommendations for the children and adolescents in your practice. Which one of the following statements is true regarding the Recommended Immunization Schedules?

A.The Recommended Immunization Schedules are published every six (6) months.

B.The authority for all immunization recommendations rests with the Center for Disease Control (CDC).

C.The Recommended Immunization Schedules are updated as soon as a new recommendation is published by the CDC in the Mortality and Morbidity Weekly Report (MMWR).

D.The immunizations schedules published by the CDC, American Academy of Family Physicians (AAFP) and American Academy of Pediatrics (AAP) are identical.

Pre-Assessment Question #2

You want to increase the number of your patients receiving a yearly flu vaccine. If you only took one of these actions, which one would be the most effective in raising immunization rates?

A.Send reminder post cards using a statewide registry system.

B.Provide a monthly flu clinic as the method to deliver all of the flu vaccines in your practice.

C.Notify parents at well child checks that the child needs to return during flu vaccine season for a vaccine.

D.Set up an office system so that all decisions about which vaccines are given during a visit are made by the physician.

Pre-Assessment Question #3

A parent expresses concern that vaccines are not safe. You should explain that:

A.Vaccines are extensively studied prior to release and recommendation so that post-licensure safety surveillance is not necessary.

B.Vaccines are safe and are therefore required for all children.

C.Concerns about risks related to vaccines have been disproven.

D.Serious adverse vaccine events are monitored and are rare.

E.Payment into the National Vaccine Injury Compensation Program is voluntary for those who want coverage for potential adverse events.

Consider This:

• How many child/adolescent vaccine recommendation changes occurred in the past year?

• How many vaccine shortages occurred or resolved?

Consider This:

• How many children/adolescents in your practice missed needed vaccines because of shortages or delays in office system changes?

• How many parents declined vaccines for their children because they did not understand the benefits and risks?

Key Question

• How do I maximize childhood and adolescent immunization rates in my practice?

What are barriers to vaccination?

• Lack of knowledge

• Vaccine shortages

• Failure to assess for and give all needed vaccines

• Access to vaccine services

• Vaccine costs

• Concerns about vaccine safety

• Other?

Potential solutions to barriers

• Receive information about vaccine schedules and supply

• Assess vaccine status at every visit• Design office systems to encourage

vaccines• Follow only true contraindications• Reduce costs: participate in Vaccines

for Children• Address parental concerns

Objective #1

• Create and maintain easily accessible files of updated vaccination schedules for pediatric patient groups in accordance with ACIP guidelines and AAFP-endorsed policy

Vaccine Schedule Issues

• Complexity of schedules

• New recommendations

• Shortages

• Delays

How do I stay up-to-date?

How are recommended vaccine schedules developed?

• Schedules published annually (Feb)

• Approved by– Advisory Committee on Immunization

Practices (ACIP)– American Academy of Pediatrics

(AAP)– American Academy of Family

Physicians (AAFP)

Recommended immunization schedule for persons aged 0 through 18 years - 2013

Centers for Disease Control and Prevention. Recommended immunization schedule for persons aged 0 through 18 years – 2013.

Where can I find the yearly vaccine schedules?

• CDC website: www.cdc.gov/vaccines• AAFP: www.aafp.org immunization

resources and American Family Physician

• AAP: www.aap.org• Immunization Action Coalition (IAC)

www.immunize.org

Smart Phone Apps

• CDC links (www.cdc.gov/vaccines)

• AAFP links (www.aafp.org)

When are recommendation changes made and published?

• At ACIP meetings 3x/yr

• Announced on ACIP website

• Published within a few months in MMWR

• Payment plans usually follow

Receive Notices of Changes

• MMWR newsletters www.cdc.gov/mmwr

• AAFP News Now newsletter publishes general notices

How do I stay current?• Sign up for CDC email notices on

vaccine site homepage www.cdc.gov/vaccines

• Immunization Action Coalition weekly email newsletter

IAC Express www.immunize.org

• Some states have newsletters– links on CDC site

The CDC Website www.cdc.gov/vaccines

Immunization Action Coalitionwww.immunize.org• Non-profit organization to increase

immunization rates and decrease disease

• Numerous resources for public and health care professionals

• Email newsletter subscription sign-up on main page (IAC Express)

State-Specific Requirements

• Specific requirements vary by state– School-age children– Day care– Religious and philosophical

exemptions– Registry participation may be

required

• Links on CDC vaccine website

• State health department websites

Objective #1 Summary

• Create easily accessible files of updated vaccination schedules for pediatric age groups

– Obtain the annual recommended vaccine schedule each February

– Subscribe to receive notice of vaccine changes

How will you stay up-to-date?

• Write down your idea now

• Potential options:– Subscribe to CDC alerts, IAC

Express and/or state newsletter– Post laminated cards prominently– Download smart phone apps– Other?

Objective #2

• Integrate practices, such as reminder and recall systems, to ensure maximum vaccination coverage for all pediatric patients when the schedules are updated

Keeping Up With Change

• Have you been able to recall your patients for:– PCV 13 booster?– Flu vaccine?– MCV booster?– High risk for Hib, PCV 13, hep A?

ICSI Standards(guideline)

Health Care Guideline: Immunizations. Institute for Clinical Systems Improvement. March 2011. Available athttp://www.icsi.org/immunizations___guideline_/immunizations__guideline__38400.html

ICSI Algorithm1. Review and update immunization status

2. Are immunizations needed today?

3. Can needed immunizations be given today? (Educate, reassure and screen for contraindications)

4. Document contraindications, deferrals or refusals, or administer vaccines

Health Care Guideline: Immunizations. Institute for Clinical Systems Improvement. March 2011. Available at http://www.icsi.org/immunizations___guideline_/immunizations__guideline__38400.html

ICSI Algorithm5. Document vaccines given and report dose to

registry

6. Arrange follow-up for future immunizations

7. Conduct regular assessments of vaccination coverage rates

8. Develop systems to remind patients and providers when vaccinations are due and to recall patients who are overdue

Health Care Guideline: Immunizations. Institute for Clinical Systems Improvement. March 2011. Available at http://www.icsi.org/immunizations___guideline_/immunizations__guideline__38400.html

Assess For Needed Vaccines

• Assess each patient at every encounter

• Find and recall patients with delays or special circumstances

• Assess practice– Consider AFIX program (CDC, state)

• AFIX=Assessment, Feedback, Incentive, Exchange

How can I assess my patients for needed vaccines?

• Use registries

• State/regional systems

• Electronic health record systems

• Other electronic registry systems– Examples: CDEMS, Cielo

CDEMS=Chronic Disease Electronic Management System from the Washington Diabetes Prevention and Control Program

Statewide Registries: Immunization Information Systems• Available in every state

• Exchange immunization info with health care providers

• Some link with EHR and billing

• Some send reminders/recalls

• State-specific links available at http://www.ecbt.org/registries/ and www.cdc.gov/vaccines

Reminder and Recall Notices

• Reminding people to have vaccinations increased the rates (Cochrane review 1-21-09)

– Whether due or overdue– Phone, letter, postcard, in person– Phone more effective than letter or postcard– Numerous reminders most effective

Jacobson Vann JC, Szilagyi P. Does reminding people to have vaccinations increase the number of people who receive vaccinations? Cochrane Summaries, Jan. 21, 2009. Available at http://summaries.cochrane.org/CD003941/does-reminding-people-to-have-vaccinations-increase-the-number-of-people-who-receive-vaccinations

Reminder and Recall Systems

• What resources could you use?– State/regional systems– Electronic health records– Electronic registry systems– Lists from insurance companies– Tickler file (eg post cards)– Other?

Other Ways to Decrease Barriers

• Give all needed vaccines at well and sick visits

• Use standing orders• Use vaccine-only visits• Follow only valid contraindications

– Anaphylaxis– Severe illness (not mild/moderate)– Pregnancy of patient

• Decrease cost: participate in VFC

Vaccines For Children (VFC)

• Federally funded vaccines

• For children/adolescents who are:– Medicaid-eligible– Uninsured– American Indian or Alaska Native– No vaccine insurance coverage*

• *Underinsured only eligible at FQHC/RHC

VFC Physician Participation

• Keeps care within Medical Home

• Reduces practice up-front costs

• Participation as a Medicaid provider not required

• Enroll through state/territory VFC coordinator (www.cdc.gov/vaccines link)

• Use form to track VFC vaccines given

Objective #2 Summary

• Integrate practices to increase vaccination rates

– Use a vaccine registry

– Use reminder/recall notices

– Give all needed vaccines

– Use standing orders

– Participate in VFC

What office system change would benefit your practice most?

• Sign up for a registry?

• Design a reminder/recall system?

• Use standing orders?

• Participate in VFC?

• Other?

Write down your idea now. What is the next step you need to take?

Objective #3

• Counsel parents on the necessity, safety and efficacy of vaccines

What concerns do parents express to you about vaccines?

• Receiving multiple vaccines

• Autism

• Thimerosal

• Pain

• Other??

Recommend Vaccines: A simple recommendation from a physician is a powerful motivator

Benefits:

• Best preventive intervention

• Maintain herd immunity

• Reduce preventable disease

• Decreased immunization leads to increased disease rates

Communicate about Vaccines

• Recommend vaccines

• Share personal stories

• Involve your staff

• Lead by example

Booklet of stories: Vaccine-Preventable Disease: The Forgotten Story. www.texaschildrenshospital.org

Address Concerns: CASE

• Corroborate (acknowledge, agree)

• About me (knowledge/experience)

• Science (what the science says)

• Explain/Advise (advice based on science)

Reference: Singer, Allison. Vaccines: Communicating with unsure parents. CDC National Immunization Conference 2010.

Vaccine Information Sheets

• Provide basic information in easy-to-understand language

• Required for federally funded vaccines

• Available through CDC or IAC websites

• Some states have own versions (links available)

Resources to Communicate With Families/Patients

• CDC website– Vaccine Safety Information for

Parents– Parents: What You Need to Know

About Vaccines

• Immunization Action Coalition– www.immunize.org

Other Resources

• National Network for Immunization Information www.immunizationinfo.org

• The Children’s Hospital of Philadelphia www.chop.edu/service/vaccine-education-center

• AAP http://www2.aap.org/immunization/illnesses/illnesses.html

How are vaccines monitored?

• US Food and Drug Administration (FDA): safety, efficacy, purity, potency pre- and post-licensure

• Vaccine Adverse Event Reporting System (VAERS)– Sponsored by FDA and CDC– Required reporting– Ongoing data collection and monitoring

Other Vaccine Monitoring: Extensive efforts to monitor safety

• CDC: Immunization Safety Office

• National Center for Immunization and Respiratory Diseases

• National Institute of Allergy and Infectious Diseases

• The Brighton Collaboration (international)

National Vaccine Injury Compensation Program

• No-fault compensation for those injured by vaccines

• Helps ensure adequate supply, stable cost

• Funded by excise tax on vaccines

Hot Topic: Number of Vaccines

• No increased risk for giving many vaccines at one time

• No higher number of antigens than everyday life

• Confirmed by numerous organizations (CDC, IOM, AAP)

Frequently Asked Questions about Multiple Vaccinations and the Immune System. CDC. February 2011. Available at http://www.cdc.gov/vaccinesafety/Vaccines/multiplevaccines.html

Immunization Safety Review: Multiple Immunizations and Immune Dysfunction. Institute Of Medicine Report. February 2002. Available at http://www.iom.edu/Reports/2002/Immunization-Safety-Review-Multiple-Immunizations-and-Immune-Dysfunction.aspx

Give All Needed Vaccines

• Patients are best protected by giving all needed vaccines

• A high number of vaccines can be administered simultaneously

• Use combination vaccines when possible

Hot Topic: Autism and Vaccines

• Multiple studies by Institute of Medicine, CDC, FDA

• No evidence of link between autism and vaccines• Vaccines do not contain bioimmunologic components that

induce autoimmune disease response

Immunization Safety Review: Vaccines and Autism. Institute of Medicine. May 2004. Available at http://www.iom.edu/Reports/2004/Immunization-Safety-Review-Vaccines-and-Autism.aspx Numerous citations and links on CDC website http://www.cdc.gov/vaccinesafety/Concerns/Autism/Index.html

Hot Topic: Thimerosal and Vaccines

• No link to any vaccine risk has been found

• Thimerosal has been removed• except multi-dose vials influenza vaccine

• Based on theoretical grounds only

Frequently Asked Questions About Thimerosal. CDC. October 14, 2011. Available at http://www.cdc.gov/vaccinesafety/Concerns/Thimerosal/thimerosal_faqs.htmlThimerosal in Vaccines. U.S. Food and Drug Administration. March 2010. Available at http://www.fda.gov/BiologicsBloodVaccines/SafetyAvailability/VaccineSafety/ucm096228.htm

Other Common Concerns

• Adjuvants

• Fainting (syncope)

• Febrile seizures

• Guillain-Barre Syndrome

• Sudden infant death syndrome (SIDS)– Information available on links at

http://www.cdc.gov/vaccinesafety/Concerns/Index.html

Objective #3 Summary

• Recommend vaccines to your patients

• Listen and respond to their concerns

• Provide Vaccine Information Sheets to everyone

• Provide more vaccine information as needed to address concerns

Summary

• www.cdc.gov/vaccines

• www.immunize.org

• If you remember no other resources, memorize one of these!

• These are starting points for vaccine information for you, your staff and your patients/families

Take-Away Messages

• Up-to-date schedules are at CDC website (www.cdc.gov/vaccines)

• Registry/reminder/recall systems increase vaccine rates

• Counsel parents about the necessity of vaccines

Recommended Actions

• Subscribe to receive alerts about changes in vaccine schedules

• Use a registry, recall and/or reminder system in your practice

• Use Vaccine Information Sheets and 1-2 websites such as CDC or IAC for parent/patient information

Post-Assessment

Please complete your answers on the sheet provided in the syllabus.

The questions and answers have been scrambled and are not in the same order as the pre-assessment

Post-Assessment Question #1

A parent expresses concern that vaccines are not safe. You should explain that:

A.Serious adverse vaccine events are monitored and are rare.

B.Concerns about risks related to vaccines have been disproven.

C.Vaccines are extensively studied prior to release and recommendation so that post-licensure safety surveillance is not necessary.

D.Vaccines are safe and are therefore required for all children.

E.Payment into the National Vaccine Injury Compensation Program is voluntary for those who want coverage for potential adverse events.

Post-Assessment Question #2

You want to follow the most current immunization recommendations for the children and adolescents in your practice. Which one of the following statements is true regarding the Recommended Immunization Schedules?

A.The Recommended Immunization Schedules are published every six (6) months.

B.The immunizations schedules published by the CDC, American Academy of Family Physicians (AAFP) and American Academy of Pediatrics (AAP) are identical.

C.The Recommended Immunization Schedules are updated as soon as a new recommendation is published by the CDC in the Mortality and Morbidity Weekly Report (MMWR).

D.The authority for all immunization recommendations rests with the Center for Disease Control (CDC).

Post-Assessment Question #3

You want to increase the number of your patients receiving a yearly flu vaccine. If you only took one of these actions, which one would be the most effective in raising immunization rates?

A.Provide a monthly flu clinic as the method to deliver all of the flu vaccines in your practice.

B.Notify parents at well child checks that the child needs to return during flu vaccine season for a vaccine.

C.Set up an office system so that all decisions about which vaccines are given during a visit are made by the physician.

D.Send reminder post cards using a statewide registry system.

Please complete the session/speaker evaluation located on the back of your

pre/post-assessment sheet and return to Chapter staff as you exit.