to more than 500 licensed day-care providers and information stressing the importance of Tdap immunization to school superintendents of 5 local school districts. “One of the strategies we have pursued for the last several years is to use all health department services as an opportunity to promote Tdap vaccination,” Dr. Stevenson noted. “An individual may be coming in for a totally unrelated service, but we will provide education about Tdap and vaccinate when possible: Thus, programs for disadvantaged young mothers, breast and cervical cancer screening programs for women, homeless clinics, and newborn home visitation programs all have provided excellent opportunities to provide information and offer immunization.” Beyond its own venues, the health department has been creative enough to conclude that immunization can take place just about anywhere people will gather. By using nontraditional settings and approaches, such as big-box stores, urgent-care clinics, women’s conferences, faith-based programs, vaccine vans, drive-through clinics, polling places on election days, vital records offices, and community events, public health departments can increase access to Tdap and influenza vaccines. Social media open up excellent avenues for education, especially among adolescents and young adults. Educational booklets and coloring books for children have a way of teaching adults about immunizations as well. Public health departments also can foster a multidisciplinary approach to immunization during training of physicians, pharmacists, nurses, nurse practitioners, and physician assistants.
d create a circle of safety aroun
something Babies can catch pertussis from as simple a cough or sneeze.
coming in contact with your This tool will help identify the people speak to them about getting baby. You can use this diagram to vaccinated. to the words in the circle that Draw a line from the people below in contact with your baby. best describe how often they come
Mom Dad Sibling/siblings Grandma
Antepartum Postpartum
NICU
Uncle Childcare
A few times a month
GET immunized
MercyHealthSystem.or
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#1718646
Figure 3. Upon admission to Mercy Health System, all patients receive handouts on pertussis and immunization of family members, which are included in the Very Important Papers binder. The binder also includes a notice about free Tdap vaccines for eligible relatives. Provided by Mercy Health System.
Bringing It All Together: Models for Collaboration Cocooning of newborns requires immunization of the parents and individuals in close contact with the infant. But cocooning cannot be successful without collaboration among clinicians in multiple specialties. There are many opportunities within the health system, before and after the birth of a newborn, to immunize parents and close contacts of the infant, including the OB/ GYN, family physician or internist, pediatri-
Father
Sibling Newborn
Aunt
A few times a week
Internist
Pediatrician
Grandpa
Every day
Obstetrics
Mother
WHOOPING
cough
YOUR BABY
Well-baby nursery
Figure 4. Schematic of strategies to immunize contacts of newborns, showing multiple opportunities for expectant parents to obtain immunizations throughout the antepartum and postpartum periods. 29
Postpartum standing orders
Reproduced with permission from the American Medical Association via Copyright Clearance Center.
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cian, well-baby nursery, and newborn intensive care unit ( Figure 4).29 To foster cocooning, a recent report from the American Academy of Pediatrics (AAP) suggests that pediatric offices serve as an alternative venue for education and Tdap vaccination of parents and other adults who provide care for children, not to undermine efforts of the adult medical home but to offer an alternative vaccination site.30 The National Vaccine Advisory Committee, in describing a new “pathway to leadership in adult immunization,” underscores the use of alternative immunization venues for adults (eg, pharmacies, public health clinics) and calls for collaboration among health care providers, particularly for adults without a single medical home.31 Many national pharmacy chains now offer Tdap without a prescription and with online appointment scheduling. An online immunization toolkit designed for infection preventionists is available with sample checklists, charts, standing orders, monitoring reports, and other resources that practitioners can share (http://www.infectionpreventiontools.com). The toolkit was developed by roundtable panelist Ruth Carrico, PhD, RN, CIC, Associate Professor of Infectious Diseases at the University of Louisville (Kentucky) School of Medicine. Dr. Carrico and colleagues have also introduced a hospital-based adult vaccine clinic, staffed by nurses and pharmacists, located in the same area as the outpatient pharmacy. Building on these types of experiences, and the multidisciplinary Tdap initiative at Mercy Health System, hospitals can establish immunization committees to educate their practitioners and coordinate vaccination efforts among departments. There are a number of ways to foster collaboration among individual health care providers at the community level. Pediatricians and OB/GYNs, for example, might team up to coordinate care, suggested Atlanta pediatrician Norman (Chip) Harbaugh, Jr., MD. Pediatricians could share their vaccination expertise with, and refer adolescent girls to, close OB/GYN colleagues. The OB/GYN could refer postpartum women and their newborns to the pediatrician if a medical home for the child doesn’t already exist. Training programs for medical students, nursing students, and others preparing for careers in the health professions can be enhanced by offering hands-on experience in immunization delivery. Dr. Carrico suggested, “What if we placed nursing students in physicians’ offices and said, ‘This is your clini-
cal rotation. We’re going to train you about vaccines and vaccine administration.’” Community education on pertussis and the importance of immunization at all ages is a challenge that can be shared by providers in all specialties and settings. Educating the public about waning pertussis immunity in adolescence and adulthood and countering myths regarding vaccine efficacy and safety are important steps to improving immunization rates. Practitioners can coordinate their efforts to seek grant support for innovative immunization approaches from local, state, and federal sources. Health professionals and their state and national associations can also work together to obtain improvements in existing programs—for example, there is no adult equivalent of the Vaccines for Children program. Immunization registries have done a good job of gathering information on pediatric patients but lag when it comes to obtaining information on adults. From a low-tech perspective, something as simple as a walletsized immunization card for adults could help improve the quality of self-reported immunization histories. The CDC’s AFIX immunization assessment program, which in some areas has a primarily pediatric focus, could be expanded to include an evaluation of adult immunizations. The panelists agreed that objective measurement of one’s performance is a necessary reality check. Dr. Harbaugh emphasized the value of showing clinicians their immunization data. “Our Independent Practice Association rates each practice location on how they do with immunization for both Tdap and flu,” he said. “The report card concept is effective. When you share that data with clinicians, it is very powerful.” There is no shortage of good ideas for improving Tdap immunization rates beyond the current, paltry single-digit level for adults and for reaching an even larger proportion of the adolescent population. The key is to see beyond individual silos of endeavor, share
best practices and success stories, and pool resources to make a measurable difference. “Our work is not done,” said Dr. Stevenson. “We still have much to do in order to educate and vaccinate. None of us is as good as all of us.” References 1. Skoff TH, Cohn AC, Clark TA, Messonnier NE, Martin SW. Early impact of the US Tdap vaccination program on pertussis trends. Arch Pediatr Adolesc Med. 2012;166(4):344-349. 2. Centers for Disease Control and Prevention (CDC). Preventing tetanus, diphtheria, and pertussis among adults: use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine. MMWR. 2006;55(RR-17):1-37. 3. CDC. Pertussis outbreaks. http://www.cdc.gov/pertussis/ outbreaks.html. Accessed July 26, 2012. 4. CDC. Pertussis (whooping cough). Surveillance and reporting. http://www.cdc.gov/pertussis/surv-reporting.html. Accessed July 13, 2012. 5. Cherry JD. The epidemiology of pertussis: a comparison of the epidemiology of the disease pertussis with the epidemiology of Bordetella pertussis infection. Pediatrics. 2005;115(5):1422-1427. 6. CDC. Recommended antimicrobial agents for treatment and postexposure prophylaxis of pertussis. MMWR. 2005;54(RR14):1-16. 7. CDC. Updated recommendations for use of tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccine in adults aged 65 years and older—Advisory Committee on Immunization Practices (ACIP), 2012. MMWR. 2012;61(25):468-470. 8. CDC. Recommended immunization schedules for persons aged 0-18 years—United States, 2012. MMWR. 2012;61(5-Quick Guide):1-4. 9. CDC. Recommended adult immunization schedule—United States, 2012. MMWR. 2012;61(4-Quick Guide):1-7. 10. CDC. National and state vaccination coverage among adolescents aged 13 through 17 years—United States, 2010. MMWR. 2011;60(33):1117-1123. 11. CDC. Adult vaccination coverage—United States, 2010. MMWR. 2012;61(4):66-72. 12. CDC. Updated recommendations for use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine (Tdap) in pregnant women and persons who have contact or anticipate having contact with an infant aged <12 months— Advisory Committee on Immunization Practices (ACIP), 2011. MMWR. 2011;60(41):1424-1426. 13. National Committee for Quality Assurance (NCQA). Patient-centered medical home 2011. http://www.ncqa.org/ tabid/631/Default.aspx. Accessed June 6, 2012. 14. National Vaccine Advisory Committee. Standards for child and adolescent immunization practices. Pediatrics. 2003;112(4):958-963. 15. Nichol K. Improving influenza vaccination rates among adults. Cleve Clin J Med. 2006;73(11):1009-1015. 16. CDC. Influenza vaccination coverage among pregnant women—United States, 2010-11 influenza season. MMWR. 2011;60(32):1078-1082. 17. Ding H, Santibanez TA, Jamieson DJ, et al. Influenza vaccination coverage among pregnant women—National 2009 H1N1 Flu Survey (NHFS). Am J Obstet Gynecol. 2011;204(6 suppl):S96-S106. 18. American College of Obstetricians and Gynecologists (ACOG) Committee on Obstetric Practice. Update on immu-
nization and pregnancy: tetanus, diphtheria, and pertussis vaccination. Committee Opinion No. 521. Obstet Gynecol. 2012;119(3):690-691. 19. ACOG. Immunization Coding for Obstetrician-Gynecologists 2011. http://www.acog.org/~/media/Department Publications/immunizationCoding.pdf. Accessed July 2, 2012. 20. CDC. AFIX: Assessment, Feedback, Incentives eXchange. http://www.cdc.gov/vaccines/programs/afix/index.html. Accessed June 1, 2012. 21. CDC. Data on file (2010 Final Pertussis Surveillance Report, Weeks 1-52), November 2011. MKT24380. 22. Healthy People.gov. 2020 Topics and Objectives. http:// www.healthypeople.gov/2020/topicsobjectives2020/pdfs/ HP2020objectives.pdf. Accessed May 21, 2012. 23. Rand CM, Shone LP, Albertin C, Auinger P, Klein JD, Szilagyi PG. National health care visit patterns of adolescents: implications for delivery of new adolescent vaccines. Arch Pediatr Adolesc Med. 2007;161(3):252-259. 24. Oster NV, McPhillips-Tangum CA, Averhoff F, Howell K. Barriers to adolescent immunization: a survey of family physicians and pediatricians. J Am Board Fam Pract. 2005;18(1):13-19. 25. National Adolescent Health Information Center. 2008 fact sheet on health care access & utilization: adolescents & young adults. http://nahic.ucsf.edu//downloads/ HCAU2008.pdf. Accessed May 30, 2012. 26. Immunization Action Coalition. State mandates for Tdap vaccination. http://www.immunize.org/laws/#dtap. Accessed July 2, 2012. 27. Brener ND, Wheeler L, Wolfe LC, Vernon-Smiley M, Caldart-Olson L. Health services: results from the School Health Policies and Programs Study 2006. J Sch Health. 2007;77(8):464-485. 28. ACOG Committee on Adolescent Health. The initial reproductive health visit. Committee Opinion No. 460. Obstet Gynecol. 2010;116(1):240-243. 29. Shah S. Strategies for vaccination of close contacts and expectant parents of infants: the next immunization frontier for pediatricians. Arch Pediatr Adolesc Med. 2009;163(5):410-412. 30. Lessin HR, Edwards KM; Committee on Practice and Ambulatory Medicine; Committee on Infectious Diseases. Immunizing parents and other close family contacts in the pediatric office setting. Pediatrics. 2012;129(1):e247-e253. 31. National Vaccine Advisory Committee. A pathway to leadership for adult immunization: recommendations of the National Vaccine Advisory Committee. Pub Health Rep. 2012;127(suppl 1):1-42. 32. Weber DJ, Consoli SA, Sickbert-Bennett E, Rutala WA. Assessment of a mandatory tetanus, diphtheria, and pertussis vaccination requirement on uptake over time. Infect Control Hosp Epidemiol. 2012;33(1):81-83. 33. Calugar A, Ortega-Sanchez IR, Tiwari T, Oakes L, Jahre JA, Murphy TV. Nosocomial pertussis: costs of an outbreak and benefits of vaccinating health care workers. Clin Infect Dis. 2006;42(7):981-988. 34. Baggett HC, Duchin JS, Shelton W, et al. Two nosocomial pertussis outbreaks and their associated costs—Kings County, Washington, 2004. Infect Control Hosp Epidemiol. 2007;28(5):537-543. 35. Pascual EB, McCall CL, McMurtray A, Payton T, Smith F, Bisgard KM. Outbreak of pertussis among healthcare workers in a hospital surgical unit. Infect Control Hosp Epidemiol. 2006;27(6):546-552. 36. CDC. Immunization of health-care personnel: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR. 2011;60(RR-7):1-46. 37. Rakita RM, Hagar BA. Vaccination mandates vs opt-out programs and rates of influenza immunization. JAMA. 2010;304(16):1786.
Improving Tdap Immunization a
A Collaborative Approach © Alloy Photography/Veer
At a recent roundtable meeting, key leaders from pediatrics, adolescent medicine, family medicine, hospital-health system pharmacy, public health, and obstetrics/gynecology (OB/ GYN) convened to share their successes and challenges in implementing Tdap immunization programs in their respective practices and institutions. Their practical strategies and collaborative models to improve Tdap immunization coverage offer forward-thinking approaches that are applicable across a variety of clinical settings and practices.
Editorial Board
Alix G. Casler, MD, FAAP, Moderator Ruth Carrico, PhD, RN, FSHEA, CIC Bernard Gonik, MD, FACOG Norman (Chip) Harbaugh, Jr., MD, FAAP Don R. Janczak, MS, PharmD, BCPS, CPHQ David W. Kaplan, MD, MPH, FSAHM Everett W. Schlam, MD Audrey M. Stevenson, PhD, MPH, MSN, FNP-BC
Brought to you as an educational service by Sanofi Pasteur Inc. MKT25485-1
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P
ertussis is the least controlled of all bacterial vaccine-preventable infections, despite the availability of safe and effective vaccines, well-defined national guidelines for their use, and immunization rates of nearly 90% in the pediatric population.1,2 Cyclic increases in reported pertussis cases tend to occur every 3 to 5 years, which occasionally reach epidemic proportions.1 In 2012, Washington state became the most recent to declare a pertussis epidemic, with 3180 reported cases as of the week ending July 21—14 times the number of cases reported during the same period in 2011.3 In 2010, California’s epidemic of 9143 reported cases—the most since 1947—claimed the lives of 10 infants.3 The highest incidence of pertussis and related morbidity and mortality occurs in infants <1 year of age ( Figure 1 ), but adolescents and adults account for approximately half of probable or confirmed cases.1, 4 An estimated 800,000 to 3 million adolescents and adults in the United States develop pertussis each year, making them a reservoir of infection and potential transmission to unvaccinated or under-vaccinated infants.1,5 Unfortunately, “pertussis is overlooked in the differential diagnosis of cough illness in this [adolescent and adult] population,” according to the Centers for Disease Control and Prevention (CDC).6 Often overlooked as well is the recently established fact that immunity to pertussis wanes 5 to 10 years after immunization or natural infection, leaving adolescents and adults susceptible to infection.2 The CDC’s Advisory Committee on Immunization Practices (ACIP) recommends that adolescents 11 through 18 years of age and adults 19 years of age and older should receive a Tdap = Tetanus, diphtheria, and acellular pertussis.
a single dose of Tdap in place of a tetanus and diphtheria (Td) booster dose.7-9 Although the ACIP first recommended adolescent and adult Tdap immunization in 2005, vaccine coverage remains less than ideal in adolescents and dramatically subpar in adults. In 2010, 68.7% of US adolescents 13 through 17 years of age had received a dose of Tdap,10 while coverage among adults was only 8.2%.11 The roundtable panelists identified a number of barriers to optimal Tdap immunization and explored strategies for overcoming them. Key barriers include: • Missed opportunities to immunize adolescents and adults in day-to-day patient care • Incomplete or fragmented immunization histories for adults (fuzzy recall on the part of patients, lack of information on adult patients in immunization registries) • Lack of a true “vaccine champion” or a strong pro-vaccine mindset in office practice and other health care settings • Competing clinical priorities in primary care • Lack of emphasis on immunization in some medical school and residency training programs • Liability concerns (for example, concerns related to immunizing adults within a pediatric practice) • Infrequent “well” visits among certain populations (adolescents in particular) • Absence of a collaborative approach to ensuring Tdap immunization for those who need it. The panelists shared the perspectives of their individual specialties but emphasized the importance of coming up with common approaches and collaborative solutions (see box, “Boost Tdap Immunization With a Dose of Collaboration,” page 4).
Figure 1. Incidence of reported cases of pertussis by age group.4 In 2010, the incidence was 8.9 per 100,000 for the US population but 53.4 per 100,000 in infants 6-11 months of age and 157.2 per 100,000 in infants < 6 months of age. 21
Reported pertussis incidence by age group — 1990 – 2010
Incidence rate (per 100,000)
100 80 <1 yr 1-6 yrs
60
7-10 yrs
11-19
40
20+ yrs
20 0 1990
1995
2000
2005
2010
Year 8
SOURCE: CDC, Na�onal No�fiable Diseases Surveillance System and Supplemental Pertussis Surveillance System
Embracing the Cocoon Office visits with women of child-bearing age provide clinicians across many specialties an opportunity to educate their patients about “cocooning”—immunizing the woman, her spouse, and other family members who may come in close contact with a newborn—to help form a ring of protection around the infant. Alix Casler, MD, a pediatrician in Orlando, Florida, counsels expectant parents and gives them a Vaccine Information Statement (VIS) for Tdap well before the child is born, to emphasize the importance of protection. She also conducts educational sessions on Tdap and other immunizations for OB/GYNs, family physicians, and internists within her multispecialty group practice; her nurse has developed a PowerPoint talk on immunization and presents it to staff throughout the organization. ACIP guidelines now identify a number of opportunities for giving Tdap to mothers—preconception, during pregnancy,b or immediately postpartum—and emphasize the importance of cocooning.12 Providers can immunize close contacts—spouses, siblings, grandparents, and other family members and caregivers—before or immediately after the birth of a child. The ACIP notes that, ideally, adolescent and adult close contacts should be vaccinated at least 2 weeks before having contact with the infant.12 “My nurse has a motto,” says Dr. Casler. “She’ll immunize anything that walks. We immunize moms, dads, grandparents, nannies, and babysitters.” Although health insurance and liability concerns may deter some providers from embracing cocooning, many malb Note: Tdap vaccines are classif ied as Pregnancy Category C. Use of Tdap during pregnancy is inconsistent with the currently labeled indications for these vaccines.
practice carriers will cover vaccination of adults in a pediatric setting, allowing entire families to receive Tdap from a single provider. Dr. Casler creates a record for the adult or uses existing records if they see one of the group’s family physicians or internists. Pediatric providers who choose not to vaccinate adults can refer them to their primary care provider or to a pharmacy, health department, or other setting for Tdap immunization. Creation of the patient-centered medical home (PCMH), according to National Committee for Quality Assurance standards, is another strategy to close the immunization gap. The PCMH encourages clinicians to check immunization status at every office visit and take a community-based approach to providing vaccination services.13, 14 For example, OB/GYNs and pediatricians in the community can collaborate and cross-refer patients to ensure that newborns and adoles-
Figure 2. Wristbands given to expectant mothers by the Salt Lake Valley (Utah) Health Department encourage postpartum Tdap immunization before hospital discharge. Courtesy of Salt Lake Valley Health Department.
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cents receive all appropriate vaccines. The PCMH concept “forces you to look at the quality parameters for immunization,” said Everett Schlam, MD, Assistant Director of Family Medicine Residency at Mountainside Hospital in Verona, New Jersey. “It gives you an opportunity to see how you can make things better and essentially pushes you in that direction.” Implementing standing vaccination orders is another strategy to improve Tdap coverage in adolescents and adults, as is administering more than 1 vaccine at a single visit (eg, Tdap along with influenza vaccine). “If you want to get the job done, you’re best off using standing orders. The data support it,” Dr. Schlam noted. “With standing orders, every visit is a vaccine visit, whether the patient is a child or an adult—that’s the real opportunity for us,” said Audrey Stevenson, PhD, MPH, MSN, FNP-BC, Division Director of Family Health Services for the Salt Lake Valley (Utah) Health Department. Becoming Vaccine Champions “Every office needs a vaccine champion, someone who’ll be on top of these issues, making sure that vaccines are a discussion point throughout the practice,” noted Bernard Gonik, MD, an OB/GYN and professor at Wayne State University School of Medicine in Detroit. In many practices, that champion is a nurse, but every health care professional who vaccinates should understand that a strong recommendation from a provider is the most powerful influence on a patient’s or parent’s decision to accept vaccination.15 That conclusion has been expressed in a number of studies over the years, most recently in surveys of influenza vaccination of pregnant women.16,17 A CDC report found that a provider’s recommendation increases influenza vaccination coverage among pregnant women and helps reassure them that the vaccine is safe and effective for them and their babies.16 While pediatricians have been the traditional champions of immunization, the recent proliferation of adult vaccines gives practitioners across many specialties the opportunity to become advocates. “We need to teach the art of vaccination to OB/GYNs,” said Dr. Gonik, noting that the American College of Obstetricians and Gynecologists (ACOG) has recently issued a strong position statement in support of Tdap.18 The ACOG website, he added, is an excellent source of educational materials for both patients and providers (http://www.immunizationforwomen.org).
The site has a wealth of resources including vaccine schedules for women as well as practical assistance such as an immunization coding publication.19 Dr. Gonik and Dr. Stevenson have found that the ultrasound appointment, often attended by several family members, provides a unique opportunity to educate and vaccinate the extended family, as well as to remind the mother to receive Tdap after 20 weeks’ gestation or before hospital discharge if she has not been vaccinated by that time. At the 36-week visit, the Salt Lake Valley Health Department gives the mom a “Protect my baby” wristband to serve as an additional reminder ( Figure 2). Chart audits by hospital nursing staff help ensure that postpartum Tdap immunizations have been given, either prior to discharge or at the first postpartum visit. To become an effective vaccinator, Dr. Gonik said, “The strongest intervention is to make an organizational change within your practice. You say, ‘We will organize ourselves around certain tenets, including good vaccine practices.’ ” A significant step in achieving a pro-vaccine gestalt in practice is to educate every staff member on the importance of immunization. An assistant who escorts the patient into an exam room may inadvertently discourage patients from seeking immunizations with comments about how she “got the flu from a vaccine” years ago and hasn’t had another since. Said Dr. Gonik, “It’s very important to look at some of the issues within your own practices and determine whether your assistants and associates either advocate or don’t advocate for the vaccine.” Obtaining direct feedback on a practice’s vaccination performance also has been demonstrated to improve vaccine practices. The CDC’s AFIX prog ram—Assessment, Feedback, Incentives, eXchange—assesses a provider’s vaccination coverage levels and immunization practices and recommends strategies for improvement along with incentives to recognize and reward improved performance.20 Getting Through to Adolescents Of 27,550 reported US cases of pertussis in 2010, nearly 1 in 5 (18%) occurred in adolescents.21 Although Tdap vaccination rates among adolescents are well ahead of rates for adults, there is still work to be done in reaching pre-teen and teen populations, especially among adolescents without regular access to health care. The roundtable par-
Immunizing Health Care Workers: Key Piece of the Puzzle Health care workers (HCWs) are at high risk for acquiring pertussis in their facilities and also may serve as sources of infection for patients and colleagues.32 Recent nosocomial outbreaks of pertussis among HCWs in hospital surgical units, OB clinics, neonatal intensive care units, and oncology departments indicated the infection was transmitted not only to patients but also to community residents, underscoring the importance of immunization.33-35 Not all HCWs support immunization, however, due to erroneous beliefs about vaccine efficacy and safety. Education is critically important, not only to ensure HCW vaccination but also that HCWs commit to vaccine protocols and recommend appropriate immunizations to their patients. The CDC guidelines, updated in 2011, recommend Tdap immunization of all HCWs.36 Many hospitals and health systems have made immunization against pertussis and other communicable diseases a condition of employment unless medically contraindicated.30, 32, 35 Despite some resistance from labor unions, recent studies have found that mandatory Tdap vaccination leads to nearly 100% coverage rates among HCWs, compared with an opt-in/opt-out policy that achieved only 45% coverage.37
ticipants felt that target coverage rates should be higher than the 80% goal set by Healthy People 2020 for adolescent immunization22 (in fact, the Healthy People 2010 goals were to achieve 90% coverage for any universally recommended vaccine within 5 years of its licensure). A decline in preventive health care visits throughout the adolescent years leads to a decline in immunization opportunities, said David Kaplan, MD, MPH, chief of adolescent medicine at Children’s Hospital Colorado in Aurora, Colorado. Fragmentation of care is another factor, as adolescents may transfer their care from a pediatrician to another specialist, or do last-minute sports physicals at schools or walk-in clinics.23-25 Consent issues pose another challenge. The capability of an adolescent to self-consent for health care, including immunizations, varies from state to state and by health condition. “States really should look at this policy,” suggested Dr. Kaplan, “and support selfconsent procedures that neither hinder adolescent immunization nor exclude parents from giving consent when appropriate.” Younger adolescents often have difficulty understanding the consequences of their actions, and those in middle adolescence seek independence and may balk at the notion of immunization, noted Dr. Kaplan. Gaining their trust and respect, and acknowledging their ability to understand the need for immunization, is often effective. “It has a lot to do with the dynamics between the parents and the kids, the level of trust they have in the clinician, and how comfortable they feel 3
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during the visit,” he said. The most influential driver of adolescent Tdap immunization rates is a state mandate requiring Tdap for middle or high school entry. Currently 36 states have such a mandate, although they vary in their timing and the ease or strictness of their allowance for exemptions.26 Schools and school-based health centers can play an important role in promoting vaccination.27 Immunization is an important service of most school-based clinics, said Dr. Kaplan, but few schools have a fullfledged clinic and thus must find opportunities to partner with health care providers in the community. Indeed, some office practices have teamed up with schools to provide Tdap immunizations. Apart from such collaborations, office practices have a number of opportunities to capture an immunization “moment” with adolescent patients—during sports physicals, camp physicals, and acute illness visits. OB/ GYNs, Dr. Gonik noted, can offer Tdap and other recommended vaccines to adolescent girls as part of the ACOG-endorsed “initial reproductive health visit” for patients 13 through 15 years of age, a visit designed to provide information on the menstrual cycle, reproductive health, and sexually transmitted diseases.28 Developing Collaborative Solutions in the Health System Mercy Health System, an integrated health care delivery system in southern Wisconsin and northern Illinois, has set an example for achieving positive change in Tdap immuniza-
tions. As Director of Pharmacy, Don R. Janczak, MS, PharmD, BCPS, CPHQ, was charged with standardizing the system’s vaccine portfolio in 2010. He assembled a multidisciplinary steering committee for a Tdap initiative to educate providers on current recommendations for adult pertussis immunization, particularly close contacts of infants <12 months of age, and to support outreach efforts to promote immunization of these contacts. Subcommittees focused on postpartum women, health care workers (HCWs), and the emergency department (ED) —and devised action plans for those settings. The project was immediately successful in the ED after implementing CDC guidelines for the use of Tdap for tetanus prophylaxis in wound management. In the first 4 months of the initiative, 84% of eligible patients in the ED and 75% in urgent care clinics received Tdap, compared with only 46% of ED and 66% of urgent care patients receiving Tdap at baseline. Dr. Janczak remarked, “Why the success of this? Out of the gate we had a physician champion.” While the ED should not serve as a source of routine care, it does afford opportunities for Tdap immunization that may be missed in other clinical settings. Strategies that had previously increased influenza immunizations among HCWs— including free vaccine, staff education, and vaccine clinic days—were applied to a voluntary program for Tdap vaccination. A total of 427 HCWs were defined as being at “high risk” for possible pertussis transmission to infants—those working in labor and delivery, postpartum care, neonatal nursery, OB/GYN and pediatric clinics, ED and urgent care clinics, and surgical pediatric units. These workers could decline vaccination but were required to state a reason why. “Our strategy is based on understanding the critical importance of our health care workers in providing an environment for good, safe care,” said Dr. Janczak. The postpartum and clinic initiatives strived to immunize as many family members of infants as possible. Pregnant women admitted to the hospital are given an educational binder containing brochures, pamphlets, and fliers on pertussis and the importance of immunization ( Figure 3). Tdap is part of the standing orders in the OB department, and documentation is linked electronically to the Wisconsin state immunization information system. The Mercy system provides free Tdap
Boost Tdap Immunization With a Dose of Collaboration The multidisciplinary panel discussed the following strategies to increase immunizations in a variety of practices. • Identify an office vaccine champion, ideally a nurse or other staff member who is passionate about immunization delivery. • Create standing orders for Tdap and other vaccines in your practice or institution. • Foster an office culture that is pro-vaccine and be sure that all staff are immunized. • Track immunization data, particularly for adults who are not typically included in immunization registries; record adult immunizations in their children’s patient records. • Implement provider report cards to monitor the immunization progress of clinicians and regularly assess the practice’s vaccine coverage rates. • Educate your adult and adolescent patients about waning immunity and the importance of vaccinating key contacts of infants. • Identify opportunities for immunization in special populations: adolescents during a sports physical exam, expectant parents during an ultrasound visit, new parents during a well baby visit, adults at acute-care adult visits, and wound care patients in the emergency department. • Volunteer to train health care workers in a multidisciplinary setting (eg, family practices training nurses to administer vaccinations). • Network with like-minded health professionals to provide immunizations (eg, pediatricians and obstetricians/gynecologists can cross-refer patients). • Remember that your recommendation is among the most effective means to convince patients to be vaccinated. • Routinely ask about immunization status during every visit and send patients reminder cards, texts, or e-mails about their immunizations. • Make immunizations convenient for your patients. Provide seamless service by coordinating reimbursement for non-patients (eg, parents, grandparents, and caregivers in a pediatric office). • Support the technology that will allow more comprehensive record-keeping—a 2-way interface that allows immunization to be downloaded directly from electronic medical records into an immunization registry, and vice versa. • Use social media to remind patients about immunization.
vaccination of family members at its birthing center and forwards documentation to their primary care providers. Collaboration among providers is viewed as the key to ensuring that mothers and family members are vaccinated. Through interdisciplinary collaboration, leadership support, and ongoing provider and patient educational efforts—including outreach to the public via radio ads—the Mercy Health System project has made a positive impact on Tdap immunization, boosting the average rates from 2 doses per month in May 2011 to nearly 20 doses per month by July 2012. Drawing on the Strengths of Public Health Resources “Effective vaccination efforts for improving Tdap immunization levels take a community approach. I encourage everyone to think of 4
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Improving Tdap Immunization
their local health department as a partner in providing immunizations,” said Dr. Stevenson, who heads up family health services for the Salt Lake Valley Health Department. Partnerships between public and private providers are essential to reduce barriers, and community-wide education is vital, particularly in conveying messages to adolescents and adults about the importance of Tdap vaccination. As part of a consortium of hospital-based health care providers in Salt Lake City, Dr. Stevenson’s department assessed the Tdap status of expectant parents and integrated Tdap immunization into the postpartum standing orders at University Hospital. Most other area hospitals followed suit. The Salt Lake Valley Health Department efforts extend into the community, providing educational materials and Tdap vaccine
Figure 1. Incidence of reported cases of pertussis by age group.4 In 2010, the incidence was 8.9 per 100,000 for the US population but 53.4 per 100,000 in infants 6-11 months of age and 157.2 per 100,000 in infants < 6 months of age. 21
Reported pertussis incidence by age group — 1990 – 2010
Incidence rate (per 100,000)
100 80 <1 yr 1-6 yrs
60
7-10 yrs
11-19
40
20+ yrs
20 0 1990
1995
2000
2005
2010
Year 8
SOURCE: CDC, Na�onal No�fiable Diseases Surveillance System and Supplemental Pertussis Surveillance System
Embracing the Cocoon Office visits with women of child-bearing age provide clinicians across many specialties an opportunity to educate their patients about “cocooning”—immunizing the woman, her spouse, and other family members who may come in close contact with a newborn—to help form a ring of protection around the infant. Alix Casler, MD, a pediatrician in Orlando, Florida, counsels expectant parents and gives them a Vaccine Information Statement (VIS) for Tdap well before the child is born, to emphasize the importance of protection. She also conducts educational sessions on Tdap and other immunizations for OB/GYNs, family physicians, and internists within her multispecialty group practice; her nurse has developed a PowerPoint talk on immunization and presents it to staff throughout the organization. ACIP guidelines now identify a number of opportunities for giving Tdap to mothers—preconception, during pregnancy,b or immediately postpartum—and emphasize the importance of cocooning.12 Providers can immunize close contacts—spouses, siblings, grandparents, and other family members and caregivers—before or immediately after the birth of a child. The ACIP notes that, ideally, adolescent and adult close contacts should be vaccinated at least 2 weeks before having contact with the infant.12 “My nurse has a motto,” says Dr. Casler. “She’ll immunize anything that walks. We immunize moms, dads, grandparents, nannies, and babysitters.” Although health insurance and liability concerns may deter some providers from embracing cocooning, many malb Note: Tdap vaccines are classif ied as Pregnancy Category C. Use of Tdap during pregnancy is inconsistent with the currently labeled indications for these vaccines.
practice carriers will cover vaccination of adults in a pediatric setting, allowing entire families to receive Tdap from a single provider. Dr. Casler creates a record for the adult or uses existing records if they see one of the group’s family physicians or internists. Pediatric providers who choose not to vaccinate adults can refer them to their primary care provider or to a pharmacy, health department, or other setting for Tdap immunization. Creation of the patient-centered medical home (PCMH), according to National Committee for Quality Assurance standards, is another strategy to close the immunization gap. The PCMH encourages clinicians to check immunization status at every office visit and take a community-based approach to providing vaccination services.13, 14 For example, OB/GYNs and pediatricians in the community can collaborate and cross-refer patients to ensure that newborns and adoles-
Figure 2. Wristbands given to expectant mothers by the Salt Lake Valley (Utah) Health Department encourage postpartum Tdap immunization before hospital discharge. Courtesy of Salt Lake Valley Health Department.
2
|
Improving Tdap Immunization
cents receive all appropriate vaccines. The PCMH concept “forces you to look at the quality parameters for immunization,” said Everett Schlam, MD, Assistant Director of Family Medicine Residency at Mountainside Hospital in Verona, New Jersey. “It gives you an opportunity to see how you can make things better and essentially pushes you in that direction.” Implementing standing vaccination orders is another strategy to improve Tdap coverage in adolescents and adults, as is administering more than 1 vaccine at a single visit (eg, Tdap along with influenza vaccine). “If you want to get the job done, you’re best off using standing orders. The data support it,” Dr. Schlam noted. “With standing orders, every visit is a vaccine visit, whether the patient is a child or an adult—that’s the real opportunity for us,” said Audrey Stevenson, PhD, MPH, MSN, FNP-BC, Division Director of Family Health Services for the Salt Lake Valley (Utah) Health Department. Becoming Vaccine Champions “Every office needs a vaccine champion, someone who’ll be on top of these issues, making sure that vaccines are a discussion point throughout the practice,” noted Bernard Gonik, MD, an OB/GYN and professor at Wayne State University School of Medicine in Detroit. In many practices, that champion is a nurse, but every health care professional who vaccinates should understand that a strong recommendation from a provider is the most powerful influence on a patient’s or parent’s decision to accept vaccination.15 That conclusion has been expressed in a number of studies over the years, most recently in surveys of influenza vaccination of pregnant women.16,17 A CDC report found that a provider’s recommendation increases influenza vaccination coverage among pregnant women and helps reassure them that the vaccine is safe and effective for them and their babies.16 While pediatricians have been the traditional champions of immunization, the recent proliferation of adult vaccines gives practitioners across many specialties the opportunity to become advocates. “We need to teach the art of vaccination to OB/GYNs,” said Dr. Gonik, noting that the American College of Obstetricians and Gynecologists (ACOG) has recently issued a strong position statement in support of Tdap.18 The ACOG website, he added, is an excellent source of educational materials for both patients and providers (http://www.immunizationforwomen.org).
The site has a wealth of resources including vaccine schedules for women as well as practical assistance such as an immunization coding publication.19 Dr. Gonik and Dr. Stevenson have found that the ultrasound appointment, often attended by several family members, provides a unique opportunity to educate and vaccinate the extended family, as well as to remind the mother to receive Tdap after 20 weeks’ gestation or before hospital discharge if she has not been vaccinated by that time. At the 36-week visit, the Salt Lake Valley Health Department gives the mom a “Protect my baby” wristband to serve as an additional reminder ( Figure 2). Chart audits by hospital nursing staff help ensure that postpartum Tdap immunizations have been given, either prior to discharge or at the first postpartum visit. To become an effective vaccinator, Dr. Gonik said, “The strongest intervention is to make an organizational change within your practice. You say, ‘We will organize ourselves around certain tenets, including good vaccine practices.’ ” A significant step in achieving a pro-vaccine gestalt in practice is to educate every staff member on the importance of immunization. An assistant who escorts the patient into an exam room may inadvertently discourage patients from seeking immunizations with comments about how she “got the flu from a vaccine” years ago and hasn’t had another since. Said Dr. Gonik, “It’s very important to look at some of the issues within your own practices and determine whether your assistants and associates either advocate or don’t advocate for the vaccine.” Obtaining direct feedback on a practice’s vaccination performance also has been demonstrated to improve vaccine practices. The CDC’s AFIX prog ram—Assessment, Feedback, Incentives, eXchange—assesses a provider’s vaccination coverage levels and immunization practices and recommends strategies for improvement along with incentives to recognize and reward improved performance.20 Getting Through to Adolescents Of 27,550 reported US cases of pertussis in 2010, nearly 1 in 5 (18%) occurred in adolescents.21 Although Tdap vaccination rates among adolescents are well ahead of rates for adults, there is still work to be done in reaching pre-teen and teen populations, especially among adolescents without regular access to health care. The roundtable par-
Immunizing Health Care Workers: Key Piece of the Puzzle Health care workers (HCWs) are at high risk for acquiring pertussis in their facilities and also may serve as sources of infection for patients and colleagues.32 Recent nosocomial outbreaks of pertussis among HCWs in hospital surgical units, OB clinics, neonatal intensive care units, and oncology departments indicated the infection was transmitted not only to patients but also to community residents, underscoring the importance of immunization.33-35 Not all HCWs support immunization, however, due to erroneous beliefs about vaccine efficacy and safety. Education is critically important, not only to ensure HCW vaccination but also that HCWs commit to vaccine protocols and recommend appropriate immunizations to their patients. The CDC guidelines, updated in 2011, recommend Tdap immunization of all HCWs.36 Many hospitals and health systems have made immunization against pertussis and other communicable diseases a condition of employment unless medically contraindicated.30, 32, 35 Despite some resistance from labor unions, recent studies have found that mandatory Tdap vaccination leads to nearly 100% coverage rates among HCWs, compared with an opt-in/opt-out policy that achieved only 45% coverage.37
ticipants felt that target coverage rates should be higher than the 80% goal set by Healthy People 2020 for adolescent immunization22 (in fact, the Healthy People 2010 goals were to achieve 90% coverage for any universally recommended vaccine within 5 years of its licensure). A decline in preventive health care visits throughout the adolescent years leads to a decline in immunization opportunities, said David Kaplan, MD, MPH, chief of adolescent medicine at Children’s Hospital Colorado in Aurora, Colorado. Fragmentation of care is another factor, as adolescents may transfer their care from a pediatrician to another specialist, or do last-minute sports physicals at schools or walk-in clinics.23-25 Consent issues pose another challenge. The capability of an adolescent to self-consent for health care, including immunizations, varies from state to state and by health condition. “States really should look at this policy,” suggested Dr. Kaplan, “and support selfconsent procedures that neither hinder adolescent immunization nor exclude parents from giving consent when appropriate.” Younger adolescents often have difficulty understanding the consequences of their actions, and those in middle adolescence seek independence and may balk at the notion of immunization, noted Dr. Kaplan. Gaining their trust and respect, and acknowledging their ability to understand the need for immunization, is often effective. “It has a lot to do with the dynamics between the parents and the kids, the level of trust they have in the clinician, and how comfortable they feel 3
|
Improving Tdap Immunization
during the visit,” he said. The most influential driver of adolescent Tdap immunization rates is a state mandate requiring Tdap for middle or high school entry. Currently 36 states have such a mandate, although they vary in their timing and the ease or strictness of their allowance for exemptions.26 Schools and school-based health centers can play an important role in promoting vaccination.27 Immunization is an important service of most school-based clinics, said Dr. Kaplan, but few schools have a fullfledged clinic and thus must find opportunities to partner with health care providers in the community. Indeed, some office practices have teamed up with schools to provide Tdap immunizations. Apart from such collaborations, office practices have a number of opportunities to capture an immunization “moment” with adolescent patients—during sports physicals, camp physicals, and acute illness visits. OB/ GYNs, Dr. Gonik noted, can offer Tdap and other recommended vaccines to adolescent girls as part of the ACOG-endorsed “initial reproductive health visit” for patients 13 through 15 years of age, a visit designed to provide information on the menstrual cycle, reproductive health, and sexually transmitted diseases.28 Developing Collaborative Solutions in the Health System Mercy Health System, an integrated health care delivery system in southern Wisconsin and northern Illinois, has set an example for achieving positive change in Tdap immuniza-
tions. As Director of Pharmacy, Don R. Janczak, MS, PharmD, BCPS, CPHQ, was charged with standardizing the system’s vaccine portfolio in 2010. He assembled a multidisciplinary steering committee for a Tdap initiative to educate providers on current recommendations for adult pertussis immunization, particularly close contacts of infants <12 months of age, and to support outreach efforts to promote immunization of these contacts. Subcommittees focused on postpartum women, health care workers (HCWs), and the emergency department (ED) —and devised action plans for those settings. The project was immediately successful in the ED after implementing CDC guidelines for the use of Tdap for tetanus prophylaxis in wound management. In the first 4 months of the initiative, 84% of eligible patients in the ED and 75% in urgent care clinics received Tdap, compared with only 46% of ED and 66% of urgent care patients receiving Tdap at baseline. Dr. Janczak remarked, “Why the success of this? Out of the gate we had a physician champion.” While the ED should not serve as a source of routine care, it does afford opportunities for Tdap immunization that may be missed in other clinical settings. Strategies that had previously increased influenza immunizations among HCWs— including free vaccine, staff education, and vaccine clinic days—were applied to a voluntary program for Tdap vaccination. A total of 427 HCWs were defined as being at “high risk” for possible pertussis transmission to infants—those working in labor and delivery, postpartum care, neonatal nursery, OB/GYN and pediatric clinics, ED and urgent care clinics, and surgical pediatric units. These workers could decline vaccination but were required to state a reason why. “Our strategy is based on understanding the critical importance of our health care workers in providing an environment for good, safe care,” said Dr. Janczak. The postpartum and clinic initiatives strived to immunize as many family members of infants as possible. Pregnant women admitted to the hospital are given an educational binder containing brochures, pamphlets, and fliers on pertussis and the importance of immunization ( Figure 3). Tdap is part of the standing orders in the OB department, and documentation is linked electronically to the Wisconsin state immunization information system. The Mercy system provides free Tdap
Boost Tdap Immunization With a Dose of Collaboration The multidisciplinary panel discussed the following strategies to increase immunizations in a variety of practices. • Identify an office vaccine champion, ideally a nurse or other staff member who is passionate about immunization delivery. • Create standing orders for Tdap and other vaccines in your practice or institution. • Foster an office culture that is pro-vaccine and be sure that all staff are immunized. • Track immunization data, particularly for adults who are not typically included in immunization registries; record adult immunizations in their children’s patient records. • Implement provider report cards to monitor the immunization progress of clinicians and regularly assess the practice’s vaccine coverage rates. • Educate your adult and adolescent patients about waning immunity and the importance of vaccinating key contacts of infants. • Identify opportunities for immunization in special populations: adolescents during a sports physical exam, expectant parents during an ultrasound visit, new parents during a well baby visit, adults at acute-care adult visits, and wound care patients in the emergency department. • Volunteer to train health care workers in a multidisciplinary setting (eg, family practices training nurses to administer vaccinations). • Network with like-minded health professionals to provide immunizations (eg, pediatricians and obstetricians/gynecologists can cross-refer patients). • Remember that your recommendation is among the most effective means to convince patients to be vaccinated. • Routinely ask about immunization status during every visit and send patients reminder cards, texts, or e-mails about their immunizations. • Make immunizations convenient for your patients. Provide seamless service by coordinating reimbursement for non-patients (eg, parents, grandparents, and caregivers in a pediatric office). • Support the technology that will allow more comprehensive record-keeping—a 2-way interface that allows immunization to be downloaded directly from electronic medical records into an immunization registry, and vice versa. • Use social media to remind patients about immunization.
vaccination of family members at its birthing center and forwards documentation to their primary care providers. Collaboration among providers is viewed as the key to ensuring that mothers and family members are vaccinated. Through interdisciplinary collaboration, leadership support, and ongoing provider and patient educational efforts—including outreach to the public via radio ads—the Mercy Health System project has made a positive impact on Tdap immunization, boosting the average rates from 2 doses per month in May 2011 to nearly 20 doses per month by July 2012. Drawing on the Strengths of Public Health Resources “Effective vaccination efforts for improving Tdap immunization levels take a community approach. I encourage everyone to think of 4
|
Improving Tdap Immunization
their local health department as a partner in providing immunizations,” said Dr. Stevenson, who heads up family health services for the Salt Lake Valley Health Department. Partnerships between public and private providers are essential to reduce barriers, and community-wide education is vital, particularly in conveying messages to adolescents and adults about the importance of Tdap vaccination. As part of a consortium of hospital-based health care providers in Salt Lake City, Dr. Stevenson’s department assessed the Tdap status of expectant parents and integrated Tdap immunization into the postpartum standing orders at University Hospital. Most other area hospitals followed suit. The Salt Lake Valley Health Department efforts extend into the community, providing educational materials and Tdap vaccine
Figure 1. Incidence of reported cases of pertussis by age group.4 In 2010, the incidence was 8.9 per 100,000 for the US population but 53.4 per 100,000 in infants 6-11 months of age and 157.2 per 100,000 in infants < 6 months of age. 21
Reported pertussis incidence by age group — 1990 – 2010
Incidence rate (per 100,000)
100 80 <1 yr 1-6 yrs
60
7-10 yrs
11-19
40
20+ yrs
20 0 1990
1995
2000
2005
2010
Year 8
SOURCE: CDC, Na�onal No�fiable Diseases Surveillance System and Supplemental Pertussis Surveillance System
Embracing the Cocoon Office visits with women of child-bearing age provide clinicians across many specialties an opportunity to educate their patients about “cocooning”—immunizing the woman, her spouse, and other family members who may come in close contact with a newborn—to help form a ring of protection around the infant. Alix Casler, MD, a pediatrician in Orlando, Florida, counsels expectant parents and gives them a Vaccine Information Statement (VIS) for Tdap well before the child is born, to emphasize the importance of protection. She also conducts educational sessions on Tdap and other immunizations for OB/GYNs, family physicians, and internists within her multispecialty group practice; her nurse has developed a PowerPoint talk on immunization and presents it to staff throughout the organization. ACIP guidelines now identify a number of opportunities for giving Tdap to mothers—preconception, during pregnancy,b or immediately postpartum—and emphasize the importance of cocooning.12 Providers can immunize close contacts—spouses, siblings, grandparents, and other family members and caregivers—before or immediately after the birth of a child. The ACIP notes that, ideally, adolescent and adult close contacts should be vaccinated at least 2 weeks before having contact with the infant.12 “My nurse has a motto,” says Dr. Casler. “She’ll immunize anything that walks. We immunize moms, dads, grandparents, nannies, and babysitters.” Although health insurance and liability concerns may deter some providers from embracing cocooning, many malb Note: Tdap vaccines are classif ied as Pregnancy Category C. Use of Tdap during pregnancy is inconsistent with the currently labeled indications for these vaccines.
practice carriers will cover vaccination of adults in a pediatric setting, allowing entire families to receive Tdap from a single provider. Dr. Casler creates a record for the adult or uses existing records if they see one of the group’s family physicians or internists. Pediatric providers who choose not to vaccinate adults can refer them to their primary care provider or to a pharmacy, health department, or other setting for Tdap immunization. Creation of the patient-centered medical home (PCMH), according to National Committee for Quality Assurance standards, is another strategy to close the immunization gap. The PCMH encourages clinicians to check immunization status at every office visit and take a community-based approach to providing vaccination services.13, 14 For example, OB/GYNs and pediatricians in the community can collaborate and cross-refer patients to ensure that newborns and adoles-
Figure 2. Wristbands given to expectant mothers by the Salt Lake Valley (Utah) Health Department encourage postpartum Tdap immunization before hospital discharge. Courtesy of Salt Lake Valley Health Department.
2
|
Improving Tdap Immunization
cents receive all appropriate vaccines. The PCMH concept “forces you to look at the quality parameters for immunization,” said Everett Schlam, MD, Assistant Director of Family Medicine Residency at Mountainside Hospital in Verona, New Jersey. “It gives you an opportunity to see how you can make things better and essentially pushes you in that direction.” Implementing standing vaccination orders is another strategy to improve Tdap coverage in adolescents and adults, as is administering more than 1 vaccine at a single visit (eg, Tdap along with influenza vaccine). “If you want to get the job done, you’re best off using standing orders. The data support it,” Dr. Schlam noted. “With standing orders, every visit is a vaccine visit, whether the patient is a child or an adult—that’s the real opportunity for us,” said Audrey Stevenson, PhD, MPH, MSN, FNP-BC, Division Director of Family Health Services for the Salt Lake Valley (Utah) Health Department. Becoming Vaccine Champions “Every office needs a vaccine champion, someone who’ll be on top of these issues, making sure that vaccines are a discussion point throughout the practice,” noted Bernard Gonik, MD, an OB/GYN and professor at Wayne State University School of Medicine in Detroit. In many practices, that champion is a nurse, but every health care professional who vaccinates should understand that a strong recommendation from a provider is the most powerful influence on a patient’s or parent’s decision to accept vaccination.15 That conclusion has been expressed in a number of studies over the years, most recently in surveys of influenza vaccination of pregnant women.16,17 A CDC report found that a provider’s recommendation increases influenza vaccination coverage among pregnant women and helps reassure them that the vaccine is safe and effective for them and their babies.16 While pediatricians have been the traditional champions of immunization, the recent proliferation of adult vaccines gives practitioners across many specialties the opportunity to become advocates. “We need to teach the art of vaccination to OB/GYNs,” said Dr. Gonik, noting that the American College of Obstetricians and Gynecologists (ACOG) has recently issued a strong position statement in support of Tdap.18 The ACOG website, he added, is an excellent source of educational materials for both patients and providers (http://www.immunizationforwomen.org).
The site has a wealth of resources including vaccine schedules for women as well as practical assistance such as an immunization coding publication.19 Dr. Gonik and Dr. Stevenson have found that the ultrasound appointment, often attended by several family members, provides a unique opportunity to educate and vaccinate the extended family, as well as to remind the mother to receive Tdap after 20 weeks’ gestation or before hospital discharge if she has not been vaccinated by that time. At the 36-week visit, the Salt Lake Valley Health Department gives the mom a “Protect my baby” wristband to serve as an additional reminder ( Figure 2). Chart audits by hospital nursing staff help ensure that postpartum Tdap immunizations have been given, either prior to discharge or at the first postpartum visit. To become an effective vaccinator, Dr. Gonik said, “The strongest intervention is to make an organizational change within your practice. You say, ‘We will organize ourselves around certain tenets, including good vaccine practices.’ ” A significant step in achieving a pro-vaccine gestalt in practice is to educate every staff member on the importance of immunization. An assistant who escorts the patient into an exam room may inadvertently discourage patients from seeking immunizations with comments about how she “got the flu from a vaccine” years ago and hasn’t had another since. Said Dr. Gonik, “It’s very important to look at some of the issues within your own practices and determine whether your assistants and associates either advocate or don’t advocate for the vaccine.” Obtaining direct feedback on a practice’s vaccination performance also has been demonstrated to improve vaccine practices. The CDC’s AFIX prog ram—Assessment, Feedback, Incentives, eXchange—assesses a provider’s vaccination coverage levels and immunization practices and recommends strategies for improvement along with incentives to recognize and reward improved performance.20 Getting Through to Adolescents Of 27,550 reported US cases of pertussis in 2010, nearly 1 in 5 (18%) occurred in adolescents.21 Although Tdap vaccination rates among adolescents are well ahead of rates for adults, there is still work to be done in reaching pre-teen and teen populations, especially among adolescents without regular access to health care. The roundtable par-
Immunizing Health Care Workers: Key Piece of the Puzzle Health care workers (HCWs) are at high risk for acquiring pertussis in their facilities and also may serve as sources of infection for patients and colleagues.32 Recent nosocomial outbreaks of pertussis among HCWs in hospital surgical units, OB clinics, neonatal intensive care units, and oncology departments indicated the infection was transmitted not only to patients but also to community residents, underscoring the importance of immunization.33-35 Not all HCWs support immunization, however, due to erroneous beliefs about vaccine efficacy and safety. Education is critically important, not only to ensure HCW vaccination but also that HCWs commit to vaccine protocols and recommend appropriate immunizations to their patients. The CDC guidelines, updated in 2011, recommend Tdap immunization of all HCWs.36 Many hospitals and health systems have made immunization against pertussis and other communicable diseases a condition of employment unless medically contraindicated.30, 32, 35 Despite some resistance from labor unions, recent studies have found that mandatory Tdap vaccination leads to nearly 100% coverage rates among HCWs, compared with an opt-in/opt-out policy that achieved only 45% coverage.37
ticipants felt that target coverage rates should be higher than the 80% goal set by Healthy People 2020 for adolescent immunization22 (in fact, the Healthy People 2010 goals were to achieve 90% coverage for any universally recommended vaccine within 5 years of its licensure). A decline in preventive health care visits throughout the adolescent years leads to a decline in immunization opportunities, said David Kaplan, MD, MPH, chief of adolescent medicine at Children’s Hospital Colorado in Aurora, Colorado. Fragmentation of care is another factor, as adolescents may transfer their care from a pediatrician to another specialist, or do last-minute sports physicals at schools or walk-in clinics.23-25 Consent issues pose another challenge. The capability of an adolescent to self-consent for health care, including immunizations, varies from state to state and by health condition. “States really should look at this policy,” suggested Dr. Kaplan, “and support selfconsent procedures that neither hinder adolescent immunization nor exclude parents from giving consent when appropriate.” Younger adolescents often have difficulty understanding the consequences of their actions, and those in middle adolescence seek independence and may balk at the notion of immunization, noted Dr. Kaplan. Gaining their trust and respect, and acknowledging their ability to understand the need for immunization, is often effective. “It has a lot to do with the dynamics between the parents and the kids, the level of trust they have in the clinician, and how comfortable they feel 3
|
Improving Tdap Immunization
during the visit,” he said. The most influential driver of adolescent Tdap immunization rates is a state mandate requiring Tdap for middle or high school entry. Currently 36 states have such a mandate, although they vary in their timing and the ease or strictness of their allowance for exemptions.26 Schools and school-based health centers can play an important role in promoting vaccination.27 Immunization is an important service of most school-based clinics, said Dr. Kaplan, but few schools have a fullfledged clinic and thus must find opportunities to partner with health care providers in the community. Indeed, some office practices have teamed up with schools to provide Tdap immunizations. Apart from such collaborations, office practices have a number of opportunities to capture an immunization “moment” with adolescent patients—during sports physicals, camp physicals, and acute illness visits. OB/ GYNs, Dr. Gonik noted, can offer Tdap and other recommended vaccines to adolescent girls as part of the ACOG-endorsed “initial reproductive health visit” for patients 13 through 15 years of age, a visit designed to provide information on the menstrual cycle, reproductive health, and sexually transmitted diseases.28 Developing Collaborative Solutions in the Health System Mercy Health System, an integrated health care delivery system in southern Wisconsin and northern Illinois, has set an example for achieving positive change in Tdap immuniza-
tions. As Director of Pharmacy, Don R. Janczak, MS, PharmD, BCPS, CPHQ, was charged with standardizing the system’s vaccine portfolio in 2010. He assembled a multidisciplinary steering committee for a Tdap initiative to educate providers on current recommendations for adult pertussis immunization, particularly close contacts of infants <12 months of age, and to support outreach efforts to promote immunization of these contacts. Subcommittees focused on postpartum women, health care workers (HCWs), and the emergency department (ED) —and devised action plans for those settings. The project was immediately successful in the ED after implementing CDC guidelines for the use of Tdap for tetanus prophylaxis in wound management. In the first 4 months of the initiative, 84% of eligible patients in the ED and 75% in urgent care clinics received Tdap, compared with only 46% of ED and 66% of urgent care patients receiving Tdap at baseline. Dr. Janczak remarked, “Why the success of this? Out of the gate we had a physician champion.” While the ED should not serve as a source of routine care, it does afford opportunities for Tdap immunization that may be missed in other clinical settings. Strategies that had previously increased influenza immunizations among HCWs— including free vaccine, staff education, and vaccine clinic days—were applied to a voluntary program for Tdap vaccination. A total of 427 HCWs were defined as being at “high risk” for possible pertussis transmission to infants—those working in labor and delivery, postpartum care, neonatal nursery, OB/GYN and pediatric clinics, ED and urgent care clinics, and surgical pediatric units. These workers could decline vaccination but were required to state a reason why. “Our strategy is based on understanding the critical importance of our health care workers in providing an environment for good, safe care,” said Dr. Janczak. The postpartum and clinic initiatives strived to immunize as many family members of infants as possible. Pregnant women admitted to the hospital are given an educational binder containing brochures, pamphlets, and fliers on pertussis and the importance of immunization ( Figure 3). Tdap is part of the standing orders in the OB department, and documentation is linked electronically to the Wisconsin state immunization information system. The Mercy system provides free Tdap
Boost Tdap Immunization With a Dose of Collaboration The multidisciplinary panel discussed the following strategies to increase immunizations in a variety of practices. • Identify an office vaccine champion, ideally a nurse or other staff member who is passionate about immunization delivery. • Create standing orders for Tdap and other vaccines in your practice or institution. • Foster an office culture that is pro-vaccine and be sure that all staff are immunized. • Track immunization data, particularly for adults who are not typically included in immunization registries; record adult immunizations in their children’s patient records. • Implement provider report cards to monitor the immunization progress of clinicians and regularly assess the practice’s vaccine coverage rates. • Educate your adult and adolescent patients about waning immunity and the importance of vaccinating key contacts of infants. • Identify opportunities for immunization in special populations: adolescents during a sports physical exam, expectant parents during an ultrasound visit, new parents during a well baby visit, adults at acute-care adult visits, and wound care patients in the emergency department. • Volunteer to train health care workers in a multidisciplinary setting (eg, family practices training nurses to administer vaccinations). • Network with like-minded health professionals to provide immunizations (eg, pediatricians and obstetricians/gynecologists can cross-refer patients). • Remember that your recommendation is among the most effective means to convince patients to be vaccinated. • Routinely ask about immunization status during every visit and send patients reminder cards, texts, or e-mails about their immunizations. • Make immunizations convenient for your patients. Provide seamless service by coordinating reimbursement for non-patients (eg, parents, grandparents, and caregivers in a pediatric office). • Support the technology that will allow more comprehensive record-keeping—a 2-way interface that allows immunization to be downloaded directly from electronic medical records into an immunization registry, and vice versa. • Use social media to remind patients about immunization.
vaccination of family members at its birthing center and forwards documentation to their primary care providers. Collaboration among providers is viewed as the key to ensuring that mothers and family members are vaccinated. Through interdisciplinary collaboration, leadership support, and ongoing provider and patient educational efforts—including outreach to the public via radio ads—the Mercy Health System project has made a positive impact on Tdap immunization, boosting the average rates from 2 doses per month in May 2011 to nearly 20 doses per month by July 2012. Drawing on the Strengths of Public Health Resources “Effective vaccination efforts for improving Tdap immunization levels take a community approach. I encourage everyone to think of 4
|
Improving Tdap Immunization
their local health department as a partner in providing immunizations,” said Dr. Stevenson, who heads up family health services for the Salt Lake Valley Health Department. Partnerships between public and private providers are essential to reduce barriers, and community-wide education is vital, particularly in conveying messages to adolescents and adults about the importance of Tdap vaccination. As part of a consortium of hospital-based health care providers in Salt Lake City, Dr. Stevenson’s department assessed the Tdap status of expectant parents and integrated Tdap immunization into the postpartum standing orders at University Hospital. Most other area hospitals followed suit. The Salt Lake Valley Health Department efforts extend into the community, providing educational materials and Tdap vaccine
to more than 500 licensed day-care providers and information stressing the importance of Tdap immunization to school superintendents of 5 local school districts. “One of the strategies we have pursued for the last several years is to use all health department services as an opportunity to promote Tdap vaccination,” Dr. Stevenson noted. “An individual may be coming in for a totally unrelated service, but we will provide education about Tdap and vaccinate when possible: Thus, programs for disadvantaged young mothers, breast and cervical cancer screening programs for women, homeless clinics, and newborn home visitation programs all have provided excellent opportunities to provide information and offer immunization.” Beyond its own venues, the health department has been creative enough to conclude that immunization can take place just about anywhere people will gather. By using nontraditional settings and approaches, such as big-box stores, urgent-care clinics, women’s conferences, faith-based programs, vaccine vans, drive-through clinics, polling places on election days, vital records offices, and community events, public health departments can increase access to Tdap and influenza vaccines. Social media open up excellent avenues for education, especially among adolescents and young adults. Educational booklets and coloring books for children have a way of teaching adults about immunizations as well. Public health departments also can foster a multidisciplinary approach to immunization during training of physicians, pharmacists, nurses, nurse practitioners, and physician assistants.
d create a circle of safety aroun
something Babies can catch pertussis from as simple a cough or sneeze.
coming in contact with your This tool will help identify the people speak to them about getting baby. You can use this diagram to vaccinated. to the words in the circle that Draw a line from the people below in contact with your baby. best describe how often they come
Mom Dad Sibling/siblings Grandma
Antepartum Postpartum
NICU
Uncle Childcare
A few times a month
GET immunized
MercyHealthSystem.or
g
#1718646
Figure 3. Upon admission to Mercy Health System, all patients receive handouts on pertussis and immunization of family members, which are included in the Very Important Papers binder. The binder also includes a notice about free Tdap vaccines for eligible relatives. Provided by Mercy Health System.
Bringing It All Together: Models for Collaboration Cocooning of newborns requires immunization of the parents and individuals in close contact with the infant. But cocooning cannot be successful without collaboration among clinicians in multiple specialties. There are many opportunities within the health system, before and after the birth of a newborn, to immunize parents and close contacts of the infant, including the OB/ GYN, family physician or internist, pediatri-
Father
Sibling Newborn
Aunt
A few times a week
Internist
Pediatrician
Grandpa
Every day
Obstetrics
Mother
WHOOPING
cough
YOUR BABY
Well-baby nursery
Figure 4. Schematic of strategies to immunize contacts of newborns, showing multiple opportunities for expectant parents to obtain immunizations throughout the antepartum and postpartum periods. 29
Postpartum standing orders
Reproduced with permission from the American Medical Association via Copyright Clearance Center.
5
|
Improving Tdap Immunization
cian, well-baby nursery, and newborn intensive care unit ( Figure 4).29 To foster cocooning, a recent report from the American Academy of Pediatrics (AAP) suggests that pediatric offices serve as an alternative venue for education and Tdap vaccination of parents and other adults who provide care for children, not to undermine efforts of the adult medical home but to offer an alternative vaccination site.30 The National Vaccine Advisory Committee, in describing a new “pathway to leadership in adult immunization,” underscores the use of alternative immunization venues for adults (eg, pharmacies, public health clinics) and calls for collaboration among health care providers, particularly for adults without a single medical home.31 Many national pharmacy chains now offer Tdap without a prescription and with online appointment scheduling. An online immunization toolkit designed for infection preventionists is available with sample checklists, charts, standing orders, monitoring reports, and other resources that practitioners can share (http://www.infectionpreventiontools.com). The toolkit was developed by roundtable panelist Ruth Carrico, PhD, RN, CIC, Associate Professor of Infectious Diseases at the University of Louisville (Kentucky) School of Medicine. Dr. Carrico and colleagues have also introduced a hospital-based adult vaccine clinic, staffed by nurses and pharmacists, located in the same area as the outpatient pharmacy. Building on these types of experiences, and the multidisciplinary Tdap initiative at Mercy Health System, hospitals can establish immunization committees to educate their practitioners and coordinate vaccination efforts among departments. There are a number of ways to foster collaboration among individual health care providers at the community level. Pediatricians and OB/GYNs, for example, might team up to coordinate care, suggested Atlanta pediatrician Norman (Chip) Harbaugh, Jr., MD. Pediatricians could share their vaccination expertise with, and refer adolescent girls to, close OB/GYN colleagues. The OB/GYN could refer postpartum women and their newborns to the pediatrician if a medical home for the child doesn’t already exist. Training programs for medical students, nursing students, and others preparing for careers in the health professions can be enhanced by offering hands-on experience in immunization delivery. Dr. Carrico suggested, “What if we placed nursing students in physicians’ offices and said, ‘This is your clini-
cal rotation. We’re going to train you about vaccines and vaccine administration.’” Community education on pertussis and the importance of immunization at all ages is a challenge that can be shared by providers in all specialties and settings. Educating the public about waning pertussis immunity in adolescence and adulthood and countering myths regarding vaccine efficacy and safety are important steps to improving immunization rates. Practitioners can coordinate their efforts to seek grant support for innovative immunization approaches from local, state, and federal sources. Health professionals and their state and national associations can also work together to obtain improvements in existing programs—for example, there is no adult equivalent of the Vaccines for Children program. Immunization registries have done a good job of gathering information on pediatric patients but lag when it comes to obtaining information on adults. From a low-tech perspective, something as simple as a walletsized immunization card for adults could help improve the quality of self-reported immunization histories. The CDC’s AFIX immunization assessment program, which in some areas has a primarily pediatric focus, could be expanded to include an evaluation of adult immunizations. The panelists agreed that objective measurement of one’s performance is a necessary reality check. Dr. Harbaugh emphasized the value of showing clinicians their immunization data. “Our Independent Practice Association rates each practice location on how they do with immunization for both Tdap and flu,” he said. “The report card concept is effective. When you share that data with clinicians, it is very powerful.” There is no shortage of good ideas for improving Tdap immunization rates beyond the current, paltry single-digit level for adults and for reaching an even larger proportion of the adolescent population. The key is to see beyond individual silos of endeavor, share
best practices and success stories, and pool resources to make a measurable difference. “Our work is not done,” said Dr. Stevenson. “We still have much to do in order to educate and vaccinate. None of us is as good as all of us.” References 1. Skoff TH, Cohn AC, Clark TA, Messonnier NE, Martin SW. Early impact of the US Tdap vaccination program on pertussis trends. Arch Pediatr Adolesc Med. 2012;166(4):344-349. 2. Centers for Disease Control and Prevention (CDC). Preventing tetanus, diphtheria, and pertussis among adults: use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine. MMWR. 2006;55(RR-17):1-37. 3. CDC. Pertussis outbreaks. http://www.cdc.gov/pertussis/ outbreaks.html. Accessed July 26, 2012. 4. CDC. Pertussis (whooping cough). Surveillance and reporting. http://www.cdc.gov/pertussis/surv-reporting.html. Accessed July 13, 2012. 5. Cherry JD. The epidemiology of pertussis: a comparison of the epidemiology of the disease pertussis with the epidemiology of Bordetella pertussis infection. Pediatrics. 2005;115(5):1422-1427. 6. CDC. Recommended antimicrobial agents for treatment and postexposure prophylaxis of pertussis. MMWR. 2005;54(RR14):1-16. 7. CDC. Updated recommendations for use of tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccine in adults aged 65 years and older—Advisory Committee on Immunization Practices (ACIP), 2012. MMWR. 2012;61(25):468-470. 8. CDC. Recommended immunization schedules for persons aged 0-18 years—United States, 2012. MMWR. 2012;61(5-Quick Guide):1-4. 9. CDC. Recommended adult immunization schedule—United States, 2012. MMWR. 2012;61(4-Quick Guide):1-7. 10. CDC. National and state vaccination coverage among adolescents aged 13 through 17 years—United States, 2010. MMWR. 2011;60(33):1117-1123. 11. CDC. Adult vaccination coverage—United States, 2010. MMWR. 2012;61(4):66-72. 12. CDC. Updated recommendations for use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine (Tdap) in pregnant women and persons who have contact or anticipate having contact with an infant aged <12 months— Advisory Committee on Immunization Practices (ACIP), 2011. MMWR. 2011;60(41):1424-1426. 13. National Committee for Quality Assurance (NCQA). Patient-centered medical home 2011. http://www.ncqa.org/ tabid/631/Default.aspx. Accessed June 6, 2012. 14. National Vaccine Advisory Committee. Standards for child and adolescent immunization practices. Pediatrics. 2003;112(4):958-963. 15. Nichol K. Improving influenza vaccination rates among adults. Cleve Clin J Med. 2006;73(11):1009-1015. 16. CDC. Influenza vaccination coverage among pregnant women—United States, 2010-11 influenza season. MMWR. 2011;60(32):1078-1082. 17. Ding H, Santibanez TA, Jamieson DJ, et al. Influenza vaccination coverage among pregnant women—National 2009 H1N1 Flu Survey (NHFS). Am J Obstet Gynecol. 2011;204(6 suppl):S96-S106. 18. American College of Obstetricians and Gynecologists (ACOG) Committee on Obstetric Practice. Update on immu-
nization and pregnancy: tetanus, diphtheria, and pertussis vaccination. Committee Opinion No. 521. Obstet Gynecol. 2012;119(3):690-691. 19. ACOG. Immunization Coding for Obstetrician-Gynecologists 2011. http://www.acog.org/~/media/Department Publications/immunizationCoding.pdf. Accessed July 2, 2012. 20. CDC. AFIX: Assessment, Feedback, Incentives eXchange. http://www.cdc.gov/vaccines/programs/afix/index.html. Accessed June 1, 2012. 21. CDC. Data on file (2010 Final Pertussis Surveillance Report, Weeks 1-52), November 2011. MKT24380. 22. Healthy People.gov. 2020 Topics and Objectives. http:// www.healthypeople.gov/2020/topicsobjectives2020/pdfs/ HP2020objectives.pdf. Accessed May 21, 2012. 23. Rand CM, Shone LP, Albertin C, Auinger P, Klein JD, Szilagyi PG. National health care visit patterns of adolescents: implications for delivery of new adolescent vaccines. Arch Pediatr Adolesc Med. 2007;161(3):252-259. 24. Oster NV, McPhillips-Tangum CA, Averhoff F, Howell K. Barriers to adolescent immunization: a survey of family physicians and pediatricians. J Am Board Fam Pract. 2005;18(1):13-19. 25. National Adolescent Health Information Center. 2008 fact sheet on health care access & utilization: adolescents & young adults. http://nahic.ucsf.edu//downloads/ HCAU2008.pdf. Accessed May 30, 2012. 26. Immunization Action Coalition. State mandates for Tdap vaccination. http://www.immunize.org/laws/#dtap. Accessed July 2, 2012. 27. Brener ND, Wheeler L, Wolfe LC, Vernon-Smiley M, Caldart-Olson L. Health services: results from the School Health Policies and Programs Study 2006. J Sch Health. 2007;77(8):464-485. 28. ACOG Committee on Adolescent Health. The initial reproductive health visit. Committee Opinion No. 460. Obstet Gynecol. 2010;116(1):240-243. 29. Shah S. Strategies for vaccination of close contacts and expectant parents of infants: the next immunization frontier for pediatricians. Arch Pediatr Adolesc Med. 2009;163(5):410-412. 30. Lessin HR, Edwards KM; Committee on Practice and Ambulatory Medicine; Committee on Infectious Diseases. Immunizing parents and other close family contacts in the pediatric office setting. Pediatrics. 2012;129(1):e247-e253. 31. National Vaccine Advisory Committee. A pathway to leadership for adult immunization: recommendations of the National Vaccine Advisory Committee. Pub Health Rep. 2012;127(suppl 1):1-42. 32. Weber DJ, Consoli SA, Sickbert-Bennett E, Rutala WA. Assessment of a mandatory tetanus, diphtheria, and pertussis vaccination requirement on uptake over time. Infect Control Hosp Epidemiol. 2012;33(1):81-83. 33. Calugar A, Ortega-Sanchez IR, Tiwari T, Oakes L, Jahre JA, Murphy TV. Nosocomial pertussis: costs of an outbreak and benefits of vaccinating health care workers. Clin Infect Dis. 2006;42(7):981-988. 34. Baggett HC, Duchin JS, Shelton W, et al. Two nosocomial pertussis outbreaks and their associated costs—Kings County, Washington, 2004. Infect Control Hosp Epidemiol. 2007;28(5):537-543. 35. Pascual EB, McCall CL, McMurtray A, Payton T, Smith F, Bisgard KM. Outbreak of pertussis among healthcare workers in a hospital surgical unit. Infect Control Hosp Epidemiol. 2006;27(6):546-552. 36. CDC. Immunization of health-care personnel: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR. 2011;60(RR-7):1-46. 37. Rakita RM, Hagar BA. Vaccination mandates vs opt-out programs and rates of influenza immunization. JAMA. 2010;304(16):1786.
Improving Tdap Immunization a
A Collaborative Approach © Alloy Photography/Veer
At a recent roundtable meeting, key leaders from pediatrics, adolescent medicine, family medicine, hospital-health system pharmacy, public health, and obstetrics/gynecology (OB/ GYN) convened to share their successes and challenges in implementing Tdap immunization programs in their respective practices and institutions. Their practical strategies and collaborative models to improve Tdap immunization coverage offer forward-thinking approaches that are applicable across a variety of clinical settings and practices.
Editorial Board
Alix G. Casler, MD, FAAP, Moderator Ruth Carrico, PhD, RN, FSHEA, CIC Bernard Gonik, MD, FACOG Norman (Chip) Harbaugh, Jr., MD, FAAP Don R. Janczak, MS, PharmD, BCPS, CPHQ David W. Kaplan, MD, MPH, FSAHM Everett W. Schlam, MD Audrey M. Stevenson, PhD, MPH, MSN, FNP-BC
Brought to you as an educational service by Sanofi Pasteur Inc. MKT25485-1
9/12
P
ertussis is the least controlled of all bacterial vaccine-preventable infections, despite the availability of safe and effective vaccines, well-defined national guidelines for their use, and immunization rates of nearly 90% in the pediatric population.1,2 Cyclic increases in reported pertussis cases tend to occur every 3 to 5 years, which occasionally reach epidemic proportions.1 In 2012, Washington state became the most recent to declare a pertussis epidemic, with 3180 reported cases as of the week ending July 21—14 times the number of cases reported during the same period in 2011.3 In 2010, California’s epidemic of 9143 reported cases—the most since 1947—claimed the lives of 10 infants.3 The highest incidence of pertussis and related morbidity and mortality occurs in infants <1 year of age ( Figure 1 ), but adolescents and adults account for approximately half of probable or confirmed cases.1, 4 An estimated 800,000 to 3 million adolescents and adults in the United States develop pertussis each year, making them a reservoir of infection and potential transmission to unvaccinated or under-vaccinated infants.1,5 Unfortunately, “pertussis is overlooked in the differential diagnosis of cough illness in this [adolescent and adult] population,” according to the Centers for Disease Control and Prevention (CDC).6 Often overlooked as well is the recently established fact that immunity to pertussis wanes 5 to 10 years after immunization or natural infection, leaving adolescents and adults susceptible to infection.2 The CDC’s Advisory Committee on Immunization Practices (ACIP) recommends that adolescents 11 through 18 years of age and adults 19 years of age and older should receive a Tdap = Tetanus, diphtheria, and acellular pertussis.
a single dose of Tdap in place of a tetanus and diphtheria (Td) booster dose.7-9 Although the ACIP first recommended adolescent and adult Tdap immunization in 2005, vaccine coverage remains less than ideal in adolescents and dramatically subpar in adults. In 2010, 68.7% of US adolescents 13 through 17 years of age had received a dose of Tdap,10 while coverage among adults was only 8.2%.11 The roundtable panelists identified a number of barriers to optimal Tdap immunization and explored strategies for overcoming them. Key barriers include: • Missed opportunities to immunize adolescents and adults in day-to-day patient care • Incomplete or fragmented immunization histories for adults (fuzzy recall on the part of patients, lack of information on adult patients in immunization registries) • Lack of a true “vaccine champion” or a strong pro-vaccine mindset in office practice and other health care settings • Competing clinical priorities in primary care • Lack of emphasis on immunization in some medical school and residency training programs • Liability concerns (for example, concerns related to immunizing adults within a pediatric practice) • Infrequent “well” visits among certain populations (adolescents in particular) • Absence of a collaborative approach to ensuring Tdap immunization for those who need it. The panelists shared the perspectives of their individual specialties but emphasized the importance of coming up with common approaches and collaborative solutions (see box, “Boost Tdap Immunization With a Dose of Collaboration,” page 4).
to more than 500 licensed day-care providers and information stressing the importance of Tdap immunization to school superintendents of 5 local school districts. “One of the strategies we have pursued for the last several years is to use all health department services as an opportunity to promote Tdap vaccination,” Dr. Stevenson noted. “An individual may be coming in for a totally unrelated service, but we will provide education about Tdap and vaccinate when possible: Thus, programs for disadvantaged young mothers, breast and cervical cancer screening programs for women, homeless clinics, and newborn home visitation programs all have provided excellent opportunities to provide information and offer immunization.” Beyond its own venues, the health department has been creative enough to conclude that immunization can take place just about anywhere people will gather. By using nontraditional settings and approaches, such as big-box stores, urgent-care clinics, women’s conferences, faith-based programs, vaccine vans, drive-through clinics, polling places on election days, vital records offices, and community events, public health departments can increase access to Tdap and influenza vaccines. Social media open up excellent avenues for education, especially among adolescents and young adults. Educational booklets and coloring books for children have a way of teaching adults about immunizations as well. Public health departments also can foster a multidisciplinary approach to immunization during training of physicians, pharmacists, nurses, nurse practitioners, and physician assistants.
d create a circle of safety aroun
something Babies can catch pertussis from as simple a cough or sneeze.
coming in contact with your This tool will help identify the people speak to them about getting baby. You can use this diagram to vaccinated. to the words in the circle that Draw a line from the people below in contact with your baby. best describe how often they come
Mom Dad Sibling/siblings Grandma
Antepartum Postpartum
NICU
Uncle Childcare
A few times a month
GET immunized
MercyHealthSystem.or
g
#1718646
Figure 3. Upon admission to Mercy Health System, all patients receive handouts on pertussis and immunization of family members, which are included in the Very Important Papers binder. The binder also includes a notice about free Tdap vaccines for eligible relatives. Provided by Mercy Health System.
Bringing It All Together: Models for Collaboration Cocooning of newborns requires immunization of the parents and individuals in close contact with the infant. But cocooning cannot be successful without collaboration among clinicians in multiple specialties. There are many opportunities within the health system, before and after the birth of a newborn, to immunize parents and close contacts of the infant, including the OB/ GYN, family physician or internist, pediatri-
Father
Sibling Newborn
Aunt
A few times a week
Internist
Pediatrician
Grandpa
Every day
Obstetrics
Mother
WHOOPING
cough
YOUR BABY
Well-baby nursery
Figure 4. Schematic of strategies to immunize contacts of newborns, showing multiple opportunities for expectant parents to obtain immunizations throughout the antepartum and postpartum periods. 29
Postpartum standing orders
Reproduced with permission from the American Medical Association via Copyright Clearance Center.
5
|
Improving Tdap Immunization
cian, well-baby nursery, and newborn intensive care unit ( Figure 4).29 To foster cocooning, a recent report from the American Academy of Pediatrics (AAP) suggests that pediatric offices serve as an alternative venue for education and Tdap vaccination of parents and other adults who provide care for children, not to undermine efforts of the adult medical home but to offer an alternative vaccination site.30 The National Vaccine Advisory Committee, in describing a new “pathway to leadership in adult immunization,” underscores the use of alternative immunization venues for adults (eg, pharmacies, public health clinics) and calls for collaboration among health care providers, particularly for adults without a single medical home.31 Many national pharmacy chains now offer Tdap without a prescription and with online appointment scheduling. An online immunization toolkit designed for infection preventionists is available with sample checklists, charts, standing orders, monitoring reports, and other resources that practitioners can share (http://www.infectionpreventiontools.com). The toolkit was developed by roundtable panelist Ruth Carrico, PhD, RN, CIC, Associate Professor of Infectious Diseases at the University of Louisville (Kentucky) School of Medicine. Dr. Carrico and colleagues have also introduced a hospital-based adult vaccine clinic, staffed by nurses and pharmacists, located in the same area as the outpatient pharmacy. Building on these types of experiences, and the multidisciplinary Tdap initiative at Mercy Health System, hospitals can establish immunization committees to educate their practitioners and coordinate vaccination efforts among departments. There are a number of ways to foster collaboration among individual health care providers at the community level. Pediatricians and OB/GYNs, for example, might team up to coordinate care, suggested Atlanta pediatrician Norman (Chip) Harbaugh, Jr., MD. Pediatricians could share their vaccination expertise with, and refer adolescent girls to, close OB/GYN colleagues. The OB/GYN could refer postpartum women and their newborns to the pediatrician if a medical home for the child doesn’t already exist. Training programs for medical students, nursing students, and others preparing for careers in the health professions can be enhanced by offering hands-on experience in immunization delivery. Dr. Carrico suggested, “What if we placed nursing students in physicians’ offices and said, ‘This is your clini-
cal rotation. We’re going to train you about vaccines and vaccine administration.’” Community education on pertussis and the importance of immunization at all ages is a challenge that can be shared by providers in all specialties and settings. Educating the public about waning pertussis immunity in adolescence and adulthood and countering myths regarding vaccine efficacy and safety are important steps to improving immunization rates. Practitioners can coordinate their efforts to seek grant support for innovative immunization approaches from local, state, and federal sources. Health professionals and their state and national associations can also work together to obtain improvements in existing programs—for example, there is no adult equivalent of the Vaccines for Children program. Immunization registries have done a good job of gathering information on pediatric patients but lag when it comes to obtaining information on adults. From a low-tech perspective, something as simple as a walletsized immunization card for adults could help improve the quality of self-reported immunization histories. The CDC’s AFIX immunization assessment program, which in some areas has a primarily pediatric focus, could be expanded to include an evaluation of adult immunizations. The panelists agreed that objective measurement of one’s performance is a necessary reality check. Dr. Harbaugh emphasized the value of showing clinicians their immunization data. “Our Independent Practice Association rates each practice location on how they do with immunization for both Tdap and flu,” he said. “The report card concept is effective. When you share that data with clinicians, it is very powerful.” There is no shortage of good ideas for improving Tdap immunization rates beyond the current, paltry single-digit level for adults and for reaching an even larger proportion of the adolescent population. The key is to see beyond individual silos of endeavor, share
best practices and success stories, and pool resources to make a measurable difference. “Our work is not done,” said Dr. Stevenson. “We still have much to do in order to educate and vaccinate. None of us is as good as all of us.” References 1. Skoff TH, Cohn AC, Clark TA, Messonnier NE, Martin SW. Early impact of the US Tdap vaccination program on pertussis trends. Arch Pediatr Adolesc Med. 2012;166(4):344-349. 2. Centers for Disease Control and Prevention (CDC). Preventing tetanus, diphtheria, and pertussis among adults: use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine. MMWR. 2006;55(RR-17):1-37. 3. CDC. Pertussis outbreaks. http://www.cdc.gov/pertussis/ outbreaks.html. Accessed July 26, 2012. 4. CDC. Pertussis (whooping cough). Surveillance and reporting. http://www.cdc.gov/pertussis/surv-reporting.html. Accessed July 13, 2012. 5. Cherry JD. The epidemiology of pertussis: a comparison of the epidemiology of the disease pertussis with the epidemiology of Bordetella pertussis infection. Pediatrics. 2005;115(5):1422-1427. 6. CDC. Recommended antimicrobial agents for treatment and postexposure prophylaxis of pertussis. MMWR. 2005;54(RR14):1-16. 7. CDC. Updated recommendations for use of tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccine in adults aged 65 years and older—Advisory Committee on Immunization Practices (ACIP), 2012. MMWR. 2012;61(25):468-470. 8. CDC. Recommended immunization schedules for persons aged 0-18 years—United States, 2012. MMWR. 2012;61(5-Quick Guide):1-4. 9. CDC. Recommended adult immunization schedule—United States, 2012. MMWR. 2012;61(4-Quick Guide):1-7. 10. CDC. National and state vaccination coverage among adolescents aged 13 through 17 years—United States, 2010. MMWR. 2011;60(33):1117-1123. 11. CDC. Adult vaccination coverage—United States, 2010. MMWR. 2012;61(4):66-72. 12. CDC. Updated recommendations for use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine (Tdap) in pregnant women and persons who have contact or anticipate having contact with an infant aged <12 months— Advisory Committee on Immunization Practices (ACIP), 2011. MMWR. 2011;60(41):1424-1426. 13. National Committee for Quality Assurance (NCQA). Patient-centered medical home 2011. http://www.ncqa.org/ tabid/631/Default.aspx. Accessed June 6, 2012. 14. National Vaccine Advisory Committee. Standards for child and adolescent immunization practices. Pediatrics. 2003;112(4):958-963. 15. Nichol K. Improving influenza vaccination rates among adults. Cleve Clin J Med. 2006;73(11):1009-1015. 16. CDC. Influenza vaccination coverage among pregnant women—United States, 2010-11 influenza season. MMWR. 2011;60(32):1078-1082. 17. Ding H, Santibanez TA, Jamieson DJ, et al. Influenza vaccination coverage among pregnant women—National 2009 H1N1 Flu Survey (NHFS). Am J Obstet Gynecol. 2011;204(6 suppl):S96-S106. 18. American College of Obstetricians and Gynecologists (ACOG) Committee on Obstetric Practice. Update on immu-
nization and pregnancy: tetanus, diphtheria, and pertussis vaccination. Committee Opinion No. 521. Obstet Gynecol. 2012;119(3):690-691. 19. ACOG. Immunization Coding for Obstetrician-Gynecologists 2011. http://www.acog.org/~/media/Department Publications/immunizationCoding.pdf. Accessed July 2, 2012. 20. CDC. AFIX: Assessment, Feedback, Incentives eXchange. http://www.cdc.gov/vaccines/programs/afix/index.html. Accessed June 1, 2012. 21. CDC. Data on file (2010 Final Pertussis Surveillance Report, Weeks 1-52), November 2011. MKT24380. 22. Healthy People.gov. 2020 Topics and Objectives. http:// www.healthypeople.gov/2020/topicsobjectives2020/pdfs/ HP2020objectives.pdf. Accessed May 21, 2012. 23. Rand CM, Shone LP, Albertin C, Auinger P, Klein JD, Szilagyi PG. National health care visit patterns of adolescents: implications for delivery of new adolescent vaccines. Arch Pediatr Adolesc Med. 2007;161(3):252-259. 24. Oster NV, McPhillips-Tangum CA, Averhoff F, Howell K. Barriers to adolescent immunization: a survey of family physicians and pediatricians. J Am Board Fam Pract. 2005;18(1):13-19. 25. National Adolescent Health Information Center. 2008 fact sheet on health care access & utilization: adolescents & young adults. http://nahic.ucsf.edu//downloads/ HCAU2008.pdf. Accessed May 30, 2012. 26. Immunization Action Coalition. State mandates for Tdap vaccination. http://www.immunize.org/laws/#dtap. Accessed July 2, 2012. 27. Brener ND, Wheeler L, Wolfe LC, Vernon-Smiley M, Caldart-Olson L. Health services: results from the School Health Policies and Programs Study 2006. J Sch Health. 2007;77(8):464-485. 28. ACOG Committee on Adolescent Health. The initial reproductive health visit. Committee Opinion No. 460. Obstet Gynecol. 2010;116(1):240-243. 29. Shah S. Strategies for vaccination of close contacts and expectant parents of infants: the next immunization frontier for pediatricians. Arch Pediatr Adolesc Med. 2009;163(5):410-412. 30. Lessin HR, Edwards KM; Committee on Practice and Ambulatory Medicine; Committee on Infectious Diseases. Immunizing parents and other close family contacts in the pediatric office setting. Pediatrics. 2012;129(1):e247-e253. 31. National Vaccine Advisory Committee. A pathway to leadership for adult immunization: recommendations of the National Vaccine Advisory Committee. Pub Health Rep. 2012;127(suppl 1):1-42. 32. Weber DJ, Consoli SA, Sickbert-Bennett E, Rutala WA. Assessment of a mandatory tetanus, diphtheria, and pertussis vaccination requirement on uptake over time. Infect Control Hosp Epidemiol. 2012;33(1):81-83. 33. Calugar A, Ortega-Sanchez IR, Tiwari T, Oakes L, Jahre JA, Murphy TV. Nosocomial pertussis: costs of an outbreak and benefits of vaccinating health care workers. Clin Infect Dis. 2006;42(7):981-988. 34. Baggett HC, Duchin JS, Shelton W, et al. Two nosocomial pertussis outbreaks and their associated costs—Kings County, Washington, 2004. Infect Control Hosp Epidemiol. 2007;28(5):537-543. 35. Pascual EB, McCall CL, McMurtray A, Payton T, Smith F, Bisgard KM. Outbreak of pertussis among healthcare workers in a hospital surgical unit. Infect Control Hosp Epidemiol. 2006;27(6):546-552. 36. CDC. Immunization of health-care personnel: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR. 2011;60(RR-7):1-46. 37. Rakita RM, Hagar BA. Vaccination mandates vs opt-out programs and rates of influenza immunization. JAMA. 2010;304(16):1786.
Improving Tdap Immunization a
A Collaborative Approach © Alloy Photography/Veer
At a recent roundtable meeting, key leaders from pediatrics, adolescent medicine, family medicine, hospital-health system pharmacy, public health, and obstetrics/gynecology (OB/ GYN) convened to share their successes and challenges in implementing Tdap immunization programs in their respective practices and institutions. Their practical strategies and collaborative models to improve Tdap immunization coverage offer forward-thinking approaches that are applicable across a variety of clinical settings and practices.
Editorial Board
Alix G. Casler, MD, FAAP, Moderator Ruth Carrico, PhD, RN, FSHEA, CIC Bernard Gonik, MD, FACOG Norman (Chip) Harbaugh, Jr., MD, FAAP Don R. Janczak, MS, PharmD, BCPS, CPHQ David W. Kaplan, MD, MPH, FSAHM Everett W. Schlam, MD Audrey M. Stevenson, PhD, MPH, MSN, FNP-BC
Brought to you as an educational service by Sanofi Pasteur Inc. MKT25485-1
9/12
P
ertussis is the least controlled of all bacterial vaccine-preventable infections, despite the availability of safe and effective vaccines, well-defined national guidelines for their use, and immunization rates of nearly 90% in the pediatric population.1,2 Cyclic increases in reported pertussis cases tend to occur every 3 to 5 years, which occasionally reach epidemic proportions.1 In 2012, Washington state became the most recent to declare a pertussis epidemic, with 3180 reported cases as of the week ending July 21—14 times the number of cases reported during the same period in 2011.3 In 2010, California’s epidemic of 9143 reported cases—the most since 1947—claimed the lives of 10 infants.3 The highest incidence of pertussis and related morbidity and mortality occurs in infants <1 year of age ( Figure 1 ), but adolescents and adults account for approximately half of probable or confirmed cases.1, 4 An estimated 800,000 to 3 million adolescents and adults in the United States develop pertussis each year, making them a reservoir of infection and potential transmission to unvaccinated or under-vaccinated infants.1,5 Unfortunately, “pertussis is overlooked in the differential diagnosis of cough illness in this [adolescent and adult] population,” according to the Centers for Disease Control and Prevention (CDC).6 Often overlooked as well is the recently established fact that immunity to pertussis wanes 5 to 10 years after immunization or natural infection, leaving adolescents and adults susceptible to infection.2 The CDC’s Advisory Committee on Immunization Practices (ACIP) recommends that adolescents 11 through 18 years of age and adults 19 years of age and older should receive a Tdap = Tetanus, diphtheria, and acellular pertussis.
a single dose of Tdap in place of a tetanus and diphtheria (Td) booster dose.7-9 Although the ACIP first recommended adolescent and adult Tdap immunization in 2005, vaccine coverage remains less than ideal in adolescents and dramatically subpar in adults. In 2010, 68.7% of US adolescents 13 through 17 years of age had received a dose of Tdap,10 while coverage among adults was only 8.2%.11 The roundtable panelists identified a number of barriers to optimal Tdap immunization and explored strategies for overcoming them. Key barriers include: • Missed opportunities to immunize adolescents and adults in day-to-day patient care • Incomplete or fragmented immunization histories for adults (fuzzy recall on the part of patients, lack of information on adult patients in immunization registries) • Lack of a true “vaccine champion” or a strong pro-vaccine mindset in office practice and other health care settings • Competing clinical priorities in primary care • Lack of emphasis on immunization in some medical school and residency training programs • Liability concerns (for example, concerns related to immunizing adults within a pediatric practice) • Infrequent “well” visits among certain populations (adolescents in particular) • Absence of a collaborative approach to ensuring Tdap immunization for those who need it. The panelists shared the perspectives of their individual specialties but emphasized the importance of coming up with common approaches and collaborative solutions (see box, “Boost Tdap Immunization With a Dose of Collaboration,” page 4).