10/11/2013. Emily D. Babcock, DHSc, PA-C, DFAAPA ASAPA Fall Conference Chandler, California October 12, 2013

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1 Emily D. Babcock, DHSc, PA-C, DFAAPA ASAPA Fall Conference Chandler, California October 12, 2013 Learning Objectives After completion of this presentation, the participant will be able to: 1. Describe the four categories of preventive services for adolescents. 2. Describe the screening approaches and anticipatory guidance recommended for adolescents. 3. Identify the basic immunizations recommended for adolescents. 4. Discuss the differing opinions on how often an adolescent should have a routine health evaluation. Adolescence Marked by rapid physical, emotional, cognitive, and social growth and development Characterized by the developmental passage from childhood to adulthood Generally considered to begin at age 11-12, and end between Most teens in the US complete puberty by age In the US, however, the adolescent period is considered to be longer (up to age 21) to allow for further psychosocial development 1

2 Adolescence Has 4 general steps: Completing puberty and bodily growth Moving from concrete to abstract thinking Establishing an independent identity Preparing for the future Preventive Services for Adolescents Typically fall into 4 categories: Screening Counseling to reduce risk/anticipatory guidance Providing immunizations General health guidance Screening for Adolescents USPSTF develops their guidelines based on the ability of screening to improve clinical outcomes Data on adolescent subjects is rare Bright Futures (AAP) and AMA also utilizes expert opinion 2

3 Screening for Adolescents HTN Obesity Eating disorders Hyperlipidemia Healthy lifestyle At-risk for CVD Tuberculosis Physical/sexual/emotional abuse Learning/school problems Alcohol use Tobacco use Depression/suicide risk Unintended pregnancy Sexually transmitted infections HIV infection Cervical cancer Anticipatory Guidance Helps adolescents better understand: Physical growth Psychosocial development Psychosexual development The importance of becoming actively involved in their own health care decisions Anticipatory Guidance Counseling adolescents on healthy habits and risk reduction in these areas: Dietary habits Safe weight management Reduce injuries by using helmets and seatbelts Regular exercise Responsible sexual behavior including abstinence Avoidance of alcohol, tobacco, other substances of abuse, anabolic steroids Avoiding risky online behaviors Strategies to deal with bullying 3

4 Anticipatory Guidance For parents: Providing advice to help parents make appropriate decisions and adapting parenting practices to better meet the changing needs of adolescents Parental involvement and attitudes affect adolescent behavior and health outcomes Monitor use of online social media Discuss risk of sharing personal information with strangers Example: Sports Physical Exam Typical components MS exam CV exam Sudden cardiac death Exertional syncope Labs Orthostatic proteinuria Objective of Sports Physical Exam Primary Objective Screen for conditions that may be life threatening or disabling Sudden cardiac death Screen for conditions that may predispose to injury or illness Secondary Objective Determine general health Serve as an entry point to general health care Provide opportunity to initiate discussion on health related topics 4

5 Medication ROS Stimulants: ADHD Medications Methamphenidates Risk for cardiac arrhythmias Asthma: Intermittent: albuterol Persistent: needing a controller medication Meds: Diuretics, Over use of NSAIDs, weight loss meds Illegal substances: Marijuana, cocaine, others Ergogenic Aids: any substance, treatment or strategy employed to improve physical performance or appearance beyond the effects of training Performance enhancing drugs Immunizations Primary care clinicians should provide basic immunizations as per ACIP and CDC 2012 update added recommendations for vaccines for pertussis, HPV, influenza, meningococcal 5

6 Immunizations By age 11-12, adolescents should have received: Three doses of hepatitis B vaccine Two doses of MMR Varicella vaccine if they haven t had varicella infection Booster dose of tetanus if > 5 years have passed since last one This booster should contain the acellular pertussis vaccine Meningococcal vaccine HPV vaccine Annual influenza vaccine Pneumococcal vaccine if at high risk Background: Extent of HPV Over 12,000 new cases of cervical cancer will be diagnosed this year Incidence of cervical cancer in the US has declined However, medically underserved populations are disproportionately affected More than 60% of new cases occur in underserved areas or underscreened populations There has been an increased understanding of the central role of HPV in cervical cancer development The progression from cervical pre-cancer (CIN) to cervical cancer is usually slow Natural history of genital HPV infection and cervical cancer From Goldman's Cecil Medicine, 24th ed.,

7 Background: HPV Types More than 100 types of HPV have been characterized Approximately 40 types cause genital tract disease Of the genital types, 15 are considered high risk due their association with high-grade precancerous lesions and cervical and other genital tract cancers HPV types 16 and 18 are the most oncogenic The other 25 types are considered low risk because they are mostly associated with genital warts and low-grade precancerous lesions HPV types 6 and 8 cause most condylomas Background: HPV Types Most HPV infections are asymptomatic and clear without treatment 10% persist beyond 2 years Only the persistently detectable HPV infections are associated with development of high-grade pre-cancer and cancer 70% of cancers are associated with the two most common high risk types 16 and 18 Persistent infection with high risk types is necessary for development of cervical cancer (oncogenesis) However, it is not sufficient because cancer does not develop in the majority of infected women Background: Vaccination Clinical manifestations The majority of genital HPV infections remain subclinical Detected only by HPV DNA testing Goal of vaccination is to reduce transmission of infection to prevent subclinical infection, warts, pre-cancers and cancers 7

8 History of Vaccine Development FUTURE I (Females United To Unilaterally Reduce Endo/ectocervical Disease) 5455 women ages Tested quadrivalent vaccine Primary aim assessment of vaccine ability to prevent HPV-related anogenital disease Results Vaccine was 100% effective in preventing anogenital disease in women who were HPV naïve Vaccine was well tolerated, with exception of some injection site reactions, fevers History of Vaccine Development FUTURE II 12,000 women aged Tested bivalent vaccine (types 16, 18) Vaccine efficacy was 98% in those who were HPV naïve Primary endpoint was development of CIN 2 or 3 or adenocarcinoma in situ, or cervical cancer related to types 16 or 18 Vaccine efficacy was lower in the population of women with baseline HPV infection Results suggest limited cross-reactivity of protection and the importance of early vaccination before infection History of Vaccine Development Data from Future I and II trials showed partial protection against acquisition of non-vaccine types that cause a smaller proportion of cervical cancers Types 31, 33, 45, 52, 58 Therapeutic effects In both trials, there was no evidence that vaccination changed the course of infection or disease in women who had evidence of HPV the time of receipt of first vaccine dose Reinforced use of HPV vaccine to prevent infection rather than as a therapeutic intervention 8

9 Background: Vaccination Infection with HPV (and diseases caused by it) is also common in men and boys 4065 boys and men ages Tested quadrivalent vaccine Primary endpoint was effectiveness in preventing infection and anogenital lesions Results showed that quadrivalenthpv vaccine prevents infection with HPV 6, 11, 16, and 18 as well as related external genital lesions HPV Vaccine Approvals HPV vaccines have been approved in approximately 100 countries Age recommendations vary among countries 2 branded vaccines are available in the US Gardasil FDA approved for girls and women 9-26 in 2006 FDA approved for boys and men 9-26 in 2010 Cervarix FDA approved for girls and women 9-26 in 2009 HPV Vaccine Brands Gardasil Quadrivalent vaccine Targets HPV types 6, 11, 16, 18 Types 6 and 11: associated with more than 90% of genital warts, and is causative agent in recurrent respiratory papillomatosis (RRP) Types 16 and 18: associated with the majority of cervical cancers and precancers(cin grade 2 or 3) Cervarix Bivalent vaccine Targets HPV types 16, 18 9

10 HPV Vaccine Recommendations U.S. Advisory Committee On Immunization Practices Recommendations for HPV Vaccines Females Routine vaccination with either vaccine for females aged 11-12, starting as young as 9 Catch-up vaccination recommended in females who have not previously received full series Males All males aged as routine All males who have not had vaccine or who have not finished all 3 doses Men aged who have sex with men or who are HIV positive and have not already been vaccinated, and consider for all males in this age group HPV Vaccine Recommendations No therapeutic benefit against existing infection or lesions Most effective if given before initiation of sexual activity Dose: 0.5 ml IM at 0, 2, 6 months If doses are missed, series does not need to be restarted but second and third doses need to be given as soon as possible HPV Vaccine: Adverse Effects CDC did a review of adverse effects after immunization for Gardasil between June 2006 and December of 2008 There were 53 adverse event reports per 100,000 doses given Similar to that observed for other vaccines Increased reporting of syncope and venous thromboembolic events The age group has increased risk of vaccine-associated syncope Risk is still being quantified for vaccine-associated thromboembolism 10

11 HPV Vaccine: Adverse Effects The death of a young woman in 2009 who received HPV injection the same day received much attention Autopsy demonstrated she died of an undiagnosed tumor HPV vaccine has remained controversial for some patients and providers Attitudes of parents, partners, and clinicians influence whether someone completes the series HPV vaccine has highest efficacy when all three doses of the vaccine series are completed Injury Prevention Screening and counseling to prevent injuries from Violence Accidents Reduce risk for CV Disease Smoking cessation Obesity management Early tx of hypertension Early tx of hyperlipidemia 11

12 Reduce high risk behaviors Health risk behaviors Alcohol use Drug use Unsafe sexual practices Dental Health Promote dental health PAs playing increasing role in dental assessment and services Less Consensus Teaching BSE Teaching TSE Providing routine health guidance to parents Performing routine hearing tests Performing routine vision tests Conducting routine testing for HCT and UA 12

13 Disagreement Recommendation for frequency of routine health evaluations AMA/Bright Futures/AAP: yearly AAFP/USPSTF: every 1-3 years as needed National Commission on Quality Assurance Performance measures for managed care organizations Adolescents between ages should have yearly health visits Preventive Services for Adolescents: A Strategy Medical education may not prepare us to identify and manage preventable disorders related to personal behaviors Practitioners tend to focus more on conditions they are familiar with instead of risk behaviors Practitioners need more than guidelines they need a strategy to help them integrate preventive services into routine medical care Ideal approach is to screen large numbers, identify individuals who need further assessment, and focus on those of immediate concern 13

14 Preventive Services for Adolescents: A Strategy Step 1: Gather information and identify risks This data is easy to collect, and had high sensitivity for issues of great concern Height, weight, blood pressure Utilize questionnaires to assess health risks and habits AMA developed a series of questionnaires for this purpose at? Preventive Services for Adolescents: A Strategy Step 2: Determine for each problem identified in step 1 whether the individual is at high, moderate, or low risk for adverse consequences Referral for specialty evaluation and management for any serious risks identified (high risk category) Step 3: Identify and prioritize problems together to facilitate a therapeutic relationship Can become a negotiation Step 4: Development of solutions References Adams, H.P., & Carnright, E.L. (2013). HPV infection and cervical cancer prevention. Clinician Reviews, 23(9), Boom, J.A., & Healy, C.M. (2012). Standard childhood vaccines: Parental hesitancy or refusal. Retrieved from UptoDate. Campos-Outcalt, D. (2012). HPV vaccine is now routinely recommended for males. The Journal of Family Practice, 61(1), Dixon, D. (2011). Pre-participation sports physical exam. Power Point Slides. Elster, A. (2013). Guidelines for adolescent preventive services. Retrieved from UptoDate. Giuliano, A.R., et al. (2011). Efficacy of quadrivalenthpv vaccine against HPV infection and disease in males. New England Journal of Medicine, 364(5), Hay, W.W., Levin, M.J., Sondheimer, J.M., & Deterding, R.R. (2007). Current Diagnosis & Treatment in Pediatrics. 18 th Ed. McGraw Hill, New York, NY. Orenstein, W.A. & Atkinson, W.L. (2011). Goldman s Cecil Medicine, 24 th ed. Chapter 17: Immunization. 14

15 Thank You! Questions or Comments? 15