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1 Vaccines for Preteens and Teens: The Importance of Timely Vaccination Tuesday, August 23, :00 PM ET In Case of Technical Difficulties If you hear an echo: -- Make sure you are only logged in once on your computer -- Select one form of audio only (either computer speakers or telephone connection) If the audio is choppy: -- Press pause in the top left corner of your screen -- Wait 10 seconds and then click play Dial at any time for live assistance 1

2 Welcome and Introductions Webinar Agenda William Schaffner, MD, NFID Medical Director Agenda Adolescent Vaccination Coverage and Gaps Amy B. Middleman, MD, MSEd, MPH, Professor of Pediatrics, Chief, Section of Adolescent Medicine, University of Oklahoma Health Sciences Center General and HPV-Specific Adolescent Vaccination Barriers Lisa S. Ipp, MD, Associate Director, Adolescent Medicine, Weill Cornell Medical College NFID Report: Addressing New & Ongoing Adolescent Vaccination Challenges Joseph A. Bocchini, Jr., MD, NFID President-Elect, Professor and Chair, Department of Pediatrics, Louisiana State University Health Sciences Center Open Discussion/Questions and Comments All Participants This webinar is supported by an unrestricted educational grant from Merck & Co., Inc. NFID policies restrict funders from controlling program content. General Information Please note that today s webinar is being recorded All phone lines will be placed on mute throughout the program To hear audio: -- Computer: Follow directions -- Phone: ; Access Code After the presentations, there will be a Question and Answer period -- Use the Chat box on the lower left side of your screen to type in your question At the end of the webinar, participants will be directed to an online evaluation 2

3 CME Credit & Webinar Evaluation The National Foundation for Infectious Diseases (NFID) is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education (CME) for physicians. NFID designates this enduring material for a maximum of 1.0 AMA PRA Category 1 Credit. To receive CME credit, you must complete the online evaluation and pass the post-test with a score of 80% or higher Online evaluation and post-test will be available following the webinar at: Certificate will be available for print or download following successful completion of online evaluation and post-test CPE Credit & Webinar Evaluation The National Association of Chain Drug Stores (NACDS) is accredited by the Accreditation Council for Pharmacy Education to provide continuing pharmacy education (CPE) for pharmacists. NACDS designates this enduring material for 1.0 CPE credit. To receive CPE credit, you must complete the online evaluation and pass the post-test with a score of 80% or higher Online evaluation and post-test is available at: You will need to use the following code to claim credit: CJ7J6F 3

4 Disclosures Marla Dalton (NFID staff) owns stock, stock options, or bonds from Merck & Co., Inc. Amy B. Middleman (speaker) is a section editor for UpToDate William Schaffner (NFID medical director, presenter) served as an advisor or consultant for Merck & Co., Inc., Novavax, and Pfizer Inc. and served as a speaker or member of a speaker s bureau for Genentech and Merck & Co., Inc. All other activity planners/reviewers and staff for this activity have no relevant financial relationships to disclose Learning Objectives At the conclusion of this webinar, participants will be able to: Understand the rationale for US adolescent vaccination recommendations Identify gaps in current US adolescent coverage rates Describe the risks associated with missing recommended adolescent vaccines Discuss ways to increase adolescent vaccination rates and improve adolescent vaccine uptake 4

5 About NFID Non-profit 501(c)(3) organization dedicated to educating the public and healthcare professionals about causes, treatment, and prevention of infectious diseases across the lifespan Reaches consumers, health professionals, and media through: Coalition-building activities Public and professional educational program Scientific meetings, research, and training Longstanding partnerships to facilitate rapid program initiation and increase programming impact Flexible and nimble organization Immunization Schedules All US immunization schedules are based on the best medical and public health evidence available 15-member Advisory Committee on Immunization Practices (ACIP), Working Groups, liaisons New/emerging science, new vaccines, etc. = schedule updates Vaccine timing is not arbitrary 5

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7 Adolescent Vaccination Coverage and Barriers to Uptake Amy B. Middleman, MD, MSEd, MPH Professor of Pediatrics Chief, Section of Adolescent Medicine University of Oklahoma Health Sciences Center Adolescent Vaccination Coverage and Barriers to Uptake How immunization coverage rates are moving toward goal rates That differences exist in coverage rates based on age, race/ethnicity, poverty, geographic location, and vaccine type That there are many ways to overcome barriers to vaccinating adolescents That there are specific ways recommended to overcome barriers to HPV vaccination among youth 7

8 ACIP Adolescent Immunization Schedule ( Adolescent Platform ) Vaccines years years years HPV Tdap MenACWY Influenza 3-dose series 1 dose 1 st dose Annual immunization Booster Range of recommended ages for all children Range of recommended ages for catch-up immunization HPV: human papillomavirus; Tdap: tetanus, diphtheria, and acellular pertussis; MenACWY: meningococcal A, C, W, Y; ACIP: Advisory Committee on Immunization Practices HealthyPeople 2020 Objectives Objective: Increase routine vaccination coverage levels for adolescents Baseline rate (2008) Goal rate 1 dose of Tdap vaccine by age years 47% 80% 2 doses of varicella vaccine by age years 37% 90% 1 dose of MenACWY vaccine by age years 44% 80% 3 doses of HPV vaccine for females by age years 17% 80% Annual flu vaccine for age years 10% 80% 8

9 MenB A New Recommendation Meningococcal B vaccines Two products MenB-FHbp 3-dose series MenB-4C 2-dose series Category A recommendation - Routine Increased risk of disease Anatomic or functional asplenia Persistent complement component deficiencies Exposed to isolates of Neisseria meningitidis During an outbreak of serogroup B meningococcal disease Category B recommendation Non-routine Those age years (preferred age years) desiring protection No rates of uptake are currently available in the US NIS-Teen Coverage Results Vaccine Tdap after 10 years of age 40.8% 55.6% 68.7% 78.2% 84.6% 86.0% 87.6% 3 doses HepB 87.9% 89.9% 91.6% 92.3% 92.8% 93.2% 91.4% 2 doses MMR 89.3% 89.1% 90.5% 91.1% 91.4% 91.8% 90.7% 2 doses of varicella (no disease history) 34.1% 48.6% 58.1% 68.3% 74.9% 78.5% 81.0% >1 MenACWY 41.8% 53.6% 62.7% 70.5% 74.0% 77.8% 79.3% HPV >1 dose Among Males 37.2% (17.9%) 44.3% (26.7%) 48.7% (32.0%) 1.4% 53.0% (34.8%) 8.3% 53.8% (33.4%) 20.8% 57.3% (37.6%) 34.6% (13.4%) 60.0% (39.7%) 41.7% (21.6%) ` 9

10 MenACWY Booster Dose Among adolescents 17 years of age: 28.5% received two doses 4.5% received the first dose after 16th birthday Flu Vaccination Coverage by Age Group Age Group (years) Season % % % 10

11 Vaccination Rates by Race/Ethnicity and Poverty VACCINE (13-17 years) White, Non- Hispanic Black, Non- Hispanic Hispanic Asian American Indian/Alaska Native Other, multiple race Below Poverty Level At/Above Poverty Level Tdap>1 dose 89% 88% 87% 85% 86% 82% 86% 88% MenACWY >1 dose 72% 80% 82% 83% 74% 74% 79% 80% HPV>1 dose (F/M) 56/36% 66/42% 66/54% 55/46% 72/50% 56/40% 67/52% 58/40% HPV>3 doses (F/M) 38/19% 39/20% 47/28% 36/27% 39/26% 37/24% 45/27% 38/20% Varicella hx/ >2 doses of vaccine 84% 87% 87% 86% 90% 79% 87% 85% Flu (6 mo-17 yrs) 56% 58% 64% 72% 67% 60% NA NA Vaccination Rates by Race/Ethnicity and Poverty VACCINE (13-17 years) White, Non- Hispanic Black, Non- Hispanic Hispanic Asian American Indian/Alaska Native Other, multiple race Below Poverty Level At/Above Poverty Level Tdap>1 dose 89% 88% 87% 85% 86% 82% 86% 88% MenACWY >1 dose 72% 80% 82% 83% 74% 74% 79% 80% HPV>1 dose (F/M) 56/36% 66/42% 66/54% 55/46% 72/50% 56/40% 67/52% 58/40% HPV>3 doses (F/M) 38/19% 39/20% 47/28% 36/27% 39/26% 37/24% 45/27% 38/20% Varicella hx/ >2 doses of vaccine 84% 87% 87% 86% 90% 79% 87% 85% Flu (6 mo-17 yrs) 56% 58% 64% 72% 67% 60% NA NA

12 Vaccination Rates by Race/Ethnicity and Poverty VACCINE (13-17 years) White, Non- Hispanic Black, Non- Hispanic Hispanic Asian American Indian/Alaska Native Other, multiple race Below Poverty Level At/Above Poverty Level Tdap>1 dose 89% 88% 87% 85% 86% 82% 86% 88% MenACWY >1 dose 72% 80% 82% 83% 74% 74% 79% 80% HPV>1 dose (F/M) 56/36% 66/42% 66/54% 55/46% 72/50% 56/40% 67/52% 58/40% HPV>3 doses (F/M) 38/19% 39/20% 47/28% 36/27% 39/26% 37/24% 45/27% 38/20% Varicella hx/ >2 doses of vaccine 84% 87% 87% 86% 90% 79% 87% 85% Flu (6 mo-17 yrs) 56% 58% 64% 72% 67% 60% NA NA Coverage Varies by State/Region Tdap >1 dose MenACWY >1 dose HPV>1 dose (F/M) HPV>3 doses (F/M) HHS Region I (CT,ME,MA,NH,RI,VT) 93% 91% 68/54% 49/29% HHS Region II (NJ,NY) 91% 85% 55/45% 38/26% HHS Region III (DE,DC,MD,PA,VA,WV) 90% 86% 63/44% 43/25% HHS Region IV (AL,FL,GA,KT,MS,NC,SC,TN) 87% 72% 58/37% 37/17% HHS Region V (IL,IN,MI,MN,OH,WI) 87% 80% 62/40% 42/21% HHS Region VI (AR,LA,NM,OK,TX) 88% 85% 53/38% 34/18% HHS Region VII (IA,KS,MO,NE) 82% 65% 50/31% 32/16% HHS Region VIII (CO,MT,ND,SD,UT,WY) 87% 71% 60/35% 36/18% HHS Region IX (AZ,CA,HI,NV) 87% 80% 67/50% 45/28% HHS Region X (AK,ID,OR,WA) 85% 76% 64/45% 42/20% 12

13 School Requirements Vary by State and Significantly Affect Coverage Rates 2010 NIS-Teen Data (13-17 year olds) Vaccine Vaccination requirement Education Requirement No Requirements # of States (%) # of states (%) # of states (%) >1 MenACWY 3 (70.5) 10 (51.0) 38 (53.4) >1 Td/Tdap 32 (79.8) (69.5) >1 HPV * (45.0) 45 (44.2) Red font indicates significantly lower (p<0.05) coverage compared to states with vaccine requirements Status based on requirements for the School Year *Because of small sample size, one state with a vaccine requirement is included with the states with education only requirements Bugenske et al. Pediatrics. 2012;129: Importance of Eliminating Non-Medical Exemptions 2010 pertussis outbreaks in California Census tracts within an area of exemptions to vaccines were 2.5 (95% CI: ) times more likely to be in an outbreak cluster More cases occurred within areas of exemption (OR = 1.20, 95% CI: ) Despite poor performance of acellular pertussis antigen, opting out has an impact on outbreaks Atwell et al. Pediatrics 2013; doi: /peds

14 Importance of High Coverage Rates Vaccination protects individuals from disease When vaccination rates are low, disease outbreaks occur High vaccination rates protect those who cannot receive/do not respond to vaccination How do we achieve higher vaccination rates? 14

15 General and HPV-Specific Adolescent Vaccination Barriers Lisa S. Ipp, MD Associate Director, Adolescent Medicine Weill Cornell Medical Center Adolescent Vaccination Barriers: Well Defined and Much Progress Made, But More to Do Three types of barriers impacting vaccine uptake: Patient/parent Healthcare provider System Dempsey and Zimet. Am J Prev Med. 2015;49(6S4):S445-S454 15

16 HPV- The Burden Almost every person who is sexually active will acquire HPV at some time in their life Low-risk HPV types can cause genital warts and, rarely, laryngeal papillomas. These types can also cause benign or low-grade cervical cell abnormalities High-risk HPV types cause cancer Annually in the US: An estimated 17,600 women and 9,300 men are diagnosed with a cancer caused by HPV In Women: Cervical cancer is the most common with about 11,000 US women/year and about 4,400 women deaths/year In Men: Oropharyngeal cancer is the most common. ~7,200 US men/year Prevention is key in these cancers because there are no current screening methods HPV- The Vaccine 16

17 Patient/Parent Barriers Too few adolescent well/preventive care visits Lack of knowledge about consequences of vaccinepreventable diseases Streams of misinformation Internet, media, family, friends Safety concerns (unfounded) Hesitancy one or more vaccines Provider Barriers Knowledge: Recommendations, rationale for recommendations, epidemiology of vaccine-preventable diseases, vaccine safety and efficacy Messaging: Strength of HCP recommendation, failure to educate parent/patient; result: difference in uptake of Tdap/MCV4 and HPV Concern: Will I get a negative parent response? (HPV) Perception: Parents don t think this vaccine is important (HPV) Missed Opportunities: We need to keep reminding HCPs that every visit is potential vaccine visit 17

18 Median Values 8/23/2016 HPV: The Unique Barriers to Vaccination Parent Provider's estimate Meningitis Hepatitis Pertussis Influenza HPV Adolescent vaccines 7.8 Adapted from Healy et al. Vaccine. 2014;32: HPV: Unique Barriers to Vaccination CDC reviewed studies published between 2009 and 2012 to systematically examine why preteens and teens aren t vaccinated against HPV at all, or don t finish the series of 3 shots They found: 1. Healthcare professionals (HCPs) often said parents concerns and the cost of vaccination made it difficult to provide the HPV vaccine 2. Many parents and HCPs didn t see a need to vaccinate boys 3. Parents whose children start the HPV vaccine series may forget or might not be aware that their children need to receive 3 doses of the vaccine 4. Parents often said they need more information before vaccinating their children. Many parents who got their children vaccinated said they did so because a doctor recommended it. So, a strong HCP recommendation is powerful! 18

19 Missed Opportunities for HPV Vaccination Most adolescents who have not received HPV vaccine have received Tdap and/or MCV4 HCPs know HPV vaccine is important, they understand its cancerreducing benefits, they have no safety concerns, BUT The age at which HPV vaccination is recommended varies by provider and site Public clinics prefer to administer all vaccines at once, anticipating lack of follow up Private practices expressed more reservations about vaccinating at age 11 (describing more parental resistance) and to co-admininistering HPV and other vaccines NHIS: Adolescent Well-Care Visits on the Rise Percentage of Youths Aged Years Who Did Not Receive a Well- Child Checkup in the Past 12 Months, NHIS, US, MMWR Morb Mortal Wkly Report : cdc.gov/mmwr/pdf/wk/mm6452.pdf 19

20 Percent Vaccinated 8/23/2016 Impact of Eliminating Missed Opportunities by Age 13 Years in Girls Born in Actual Achievable 0 HPV-1 (girls) Vaccine Missed opportunity: Healthcare encounter when some, but not all ACIPrecommended vaccines are given. HPV-1: Receipt of at least one dose of HPV. MMWR. 63(29); Summary Continued focus needed on overcoming all types of vaccination barriers (there is no easy answer, no single answer) Adolescent well-visits are increasing, but we re not taking full advantage of the increased access (missed opportunities, strength and quality of recommendation) Education is needed to close: HPV gaps: age years is optimal for HPV vaccination and simultaneous vaccine delivery is safe MCV4 gaps: new focus on age 16 for MCV4 booster and MenB vaccine (ACIP Category B recommendation) Influenza gap: annual visit 20

21 NFID Report: Addressing New & Ongoing Adolescent Vaccination Challenges Joseph A. Bocchini, Jr., MD NFID President-Elect Chair, Department of Pediatrics Louisiana State University Health Sciences Center-Shreveport NFID Call to Action NFID convened virtual roundtable in February 2016 Wide range of stakeholders represented Report based on presentations and discussions with participants 21

22 Overcoming Barriers to Improve Immunization Rates Utilize adolescent vaccination platform: 11-12, 16? Improve office preparedness Harmonize positive messages and personnel commitment to vaccination Use immunization information systems (IIS) Implement standing orders/emr prompts Schedule next doses at current visit Utilize reminder/recall; social media, cell phone messaging Improve accessibility: vaccine-only visits, non-office settings (school, pharmacy, etc.) Know the facts: concomitant administration, true precautions and contraindications, etc. Support the use of school requirements School Vaccine Mandates: Middle School/High School Tdap: 46 states and DC MenACWY (primary dose): 26 states and DC MenACWY (booster dose): 10 states HPV: 2 states and DC Immunization Action Coalition: State Information (MenACWY page updated May 12, 2016; HPV page updated March 9, 2016; Tdap page updated March 8, 2016). 22

23 Challenges and Potential Solutions for Individual Providers/Offices/Clinics Missed opportunities Every visit is a possible vaccine visit Sick, injury, non-preventive care Review immunization status at every visit Discuss benefits of vaccines NHIS: Adolescent Well-Care Visits on the Rise Percentage of Youths Age Years Who Did Not Receive a Well- Child Checkup in the Past 12 Months, NHIS, US, MMWR Morb Mortal Wkly Rep. 23

24 Challenges and Potential Solutions for Individual Providers/Offices/Clinics Establish ongoing communication with parents/caregivers and adolescents about vaccines Positive messages Education about the risks of vaccine-preventable diseases Education about safety and benefits of vaccines Use reliable internet sources to refer parents to Make strong recommendations Use motivational interviewing techniques Do not offer as an option Understand that delays leave the adolescent susceptible Discourage alternate schedules Challenges and Potential Solutions for Individual Providers/Offices/Clinics Put systems in place in your office to make adolescent vaccination routine Standing orders Effective for age-based recommendations Reminders For provider built into EHR, state immunization information system (IIS) For parent/patient mail, phone, social media (text) Recall For patients who miss appointment 24

25 Challenges and Potential Solutions for Individual Providers/Offices/Clinics Put systems in place in your office to make adolescent vaccination routine Establish immunization only visits, off hours opportunities Align vaccine messages communicated by all office staff Standardize vaccine promotion and commitment Involve all office personnel from front desk on.. Simultaneous administration of all vaccines due 25

26 What Helped Improve Adolescent Immunization Rates in the Late 1990s/Early 2000s? Routinely recommended vaccines for adolescents Vaccines for Children (VFC) Program School requirements Education and awareness campaigns Immunization platform for year olds Slide courtesy of AB Middleman Policies to Continue to Improve Adolescent Immunization Rates Adolescent immunization platforms year olds 16 year olds School requirements Eliminate non-medical school requirement exemptions Explore the use of alternative sites Schools Pharmacies Slide courtesy of AB Middleman 26

27 Establishing Adolescent Immunization Platforms Society for Adolescent Health and Medicine (SAHM) position statement (2006) 11 to 12 year old visit: primary immunization platform 14 to 15 year old visit: catch up on missed vaccines or complete multi-dose regimens 17 to 18 year old visit: update vaccinations that were missed or are newly recommended Middleman AB, et al. J Adolesc Health. 2006;38: IDSA. CID. 2007:44:e104-e108. Rationale for an Adolescent Vaccination Platform at 16 Years of Age A scheduled vaccine visit creates the expectation for parents, patients, and providers that vaccines are due MenACWY is recommended at 16 years old Uptake is poor (2014 NIS-Teen, 17 year olds = 30%) MenB may be given (Category B*) at 16 through 23 years, preferably at 16 through 18 years old Timing is designed to provide protection during highrisk period Supports annual influenza vaccine recommendation *Individual clinical decision making 27

28 Rationale for an Adolescent Vaccination Platform at 16 Years of Age Creates another opportunity for review of vaccine status Completion of HPV series Catch-up of vaccines recommended for earlier ages Evaluation for high-risk conditions which would require vaccination Provides opportunities for improved comprehensive care Creates foundation for good preventive healthcare decisions Questions & Answers 28

29 CME Credit & Webinar Evaluation The National Foundation for Infectious Diseases (NFID) is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education (CME) for physicians. NFID designates this enduring material for a maximum of 1.0 AMA PRA Category 1 Credit. To receive CME credit, you must complete the online evaluation and pass the post-test with a score of 80% or higher Online evaluation and post-test will be available following the webinar at: Certificate will be available for print or download following successful completion of online evaluation and post-test CPE Credit & Webinar Evaluation The National Association of Chain Drug Stores (NACDS) is accredited by the Accreditation Council for Pharmacy Education to provide continuing pharmacy education (CPE) for pharmacists. NACDS designates this enduring material for 1.0 CPE credit. To receive CPE credit, you must complete the online evaluation and pass the post-test with a score of 80% or higher Online evaluation and post-test is available at: You will need to use the following code to claim credit: CJ7J6F 29

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