Send in the Clowns
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Send in the Clowns

“SEND IN THE CLOWNS!”ADOLESCENT VACCINATIONSN.C. IMMUNIZATION CONFERENCEAUGUST 1, 2013Tamera Coyne-Beasley, MD, MPH, FAAP, FSAHMDirector, NC Child Health Research NetworkAssociate Director, Community Engagement NC TraCS Institute - Child Health CoreProfessor of Pediatrics and Internal MedicineDivision of General Pediatrics and Adolescent Medicine

Outline Rationale for adolescent vaccination Review the current epidemiology of vaccinepreventable diseases in adolescents Review the latest vaccine recommendations foradolescents• Meningococcal vaccine• Influenza vaccine• Human Papillomavirus vaccine• Tetanus/Diphtheria/Pertussis Vaccine Discuss strategies to improve adolescent vaccineuptake

Rationale for Emphasizing AdolescentImmunization 1 To protect adolescents against infectious diseases thatcan have lifelong, even life-threatening, complications To reduce transmission of disease from adolescents toothers at high risk of infection To provide clinicians an opportunity to promoteregularly scheduled health-care visits by adolescents The opportunity to eradicate disease and eliminatehealth disparitiesReference: 1. Middleman AB, et al. J Adolesc Health. 2006;38(3):321-327

Protection During a Period ofIncreased RiskMeningococcal disease Greatest risk group for infection is persons aged 15-21 1 Older adolescents and young adults are up to 5 times more likely todie than persons

Protection During a Period of IncreasedRisk Human papillomavirus (HPV) infection Prevalence was 32.9% among 15 to 19 year-olds Peaked at 53.8% among 20 to 24 year-olds 1Satterwhite, et al. Sexually Transmitted Diseases. 2013;40(3):187-193.

Immunization Can Help Reduce Spreadof Disease from Adolescents to Others Persons

Vaccine-Preventable Disease and Death Remain atUnacceptable Levels in the U.S.DiseasesEstimated AnnualCasesAverageAnnualDeathsInfluenza 1 31,000,000 38,000Hepatitis B 2,3 78,000 5000Hepatitis A 2 93,000 100Varicella 4 67,400 54Pneumococcal disease 2 175,000 5500Meningococcal disease 2 2500-3000 150Pertussis 5 800,000-3,300,000 7HPV 6 6,200,000 4000**Estimated deaths from cervical cancer, for which HPV infection is a risk factor1. Weycker D, et al. Vaccine. 2005;23:1284. 2. CDC. Pink Book. 8 th Edition. 2005. 3. American Liver Foundation. Hepatitisand Liver Disease in the United States. Available at: Accessed April 2005. 4. CDC. MMWR.2005; 54(11);272 . 5. Cherry JD. Pediatrics. 2005;115:1422. 6. CDC. Genital HPV Infection – CDC Fact Sheet. Available Accessed June 2005.

Adolescent immunizations in 1983

First Appearance of Adolescent Vaccines on theACIP Routine Recommendation ChartMeningococcalTetravalent vaccineRoutine, adolescents 11 or 12 yrsLicensed for 11-55 yrsTdapRoutine, adolescents 11 or 12 yrsLicensed for 10-64 yrsHPVQuadrivalent vaccineRoutine, females 11 or 12 yrs*Catch-up, 13-26 yrsInfluenzaTwo dose seriesRoutine, adolescentsLicensed for ≥ 6 monthsHPVQuadrivalent or Bivalent vaccineRoutine, females 11 or 12 yrs*Catch-up, 13-26 yrsInfluenzaOne dose seriesRoutine, adolescentsLicensed for ≥ 6 months2005 2006 2007 2008 2009 2010 2011

Centers for Disease Control and Prevention. Available at

CaseSam is a 16 year old male who presents forevaluation of back pain. While addressing hisback pain he discloses he hasn’t seen a health careprovider since he was 11 years old. At that time hereceived his school mandated Tdap. He thinks herecalls getting more than one shot.•What do you think he received?•What if anything does he need now?


Meningococcal Disease 1MeningitisMeningococcemiaFever and headache (flulikesymptoms)RashVascular damageStiff neckNauseaAltered mental statusSeizuresOccurs in ~30% of cases;3% to 10% fatality rateDisseminated intravascularcoagulationMulti-organ failureShockDeath can occur in 24 hoursOccurs in 10% to 30% of cases;up to 40% fatality rateReference: 1. Munford RS. Meningococcal infections. In: Harrison’s Principles of Internal Medicine. 15th ed. 2001:927-931.

Severe Late-Stage Meningococcal Infectionin a 15-Year-Old BoyReprinted with permission from Schoeller T, Schmutzhard E. N Engl J Med. 2001;34:1372., Waterhouse-FriderichsenSyndrome

Cases per 100,000 populationA Peak of Meningococcal DiseaseIncidence Occurs in 15- to 19-Year-Olds*43210< 5 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 ≥ 60Age Group (years)*Average annual incidence rate by age in Maryland, 1992–1999Harrison LH, et al. JAMA. 2001;286:694.

DeathsAge-Specific Fatalities From Meningococcal Disease in the US(1997-2010)300246255223490219200189 181100130109 107860

Current ACIP MeningococcalVaccination Recommendations Routine vaccination of adolescents at age 11 or 12 years All adolescents receive a booster dose of quadrivalentmeningococcal conjugate vaccine (MenACWY-D) at age 16years 2-dose primary series administered 2 months apart forpersons aged 2-54 years with select immunodeficienciesCenters for Disease Control and Prevention (CDC)- Advisory Committee on Immunization Practices, Summary Report,October 2010

Summary of meningococcal conjugate vaccinerecommendations by risk group, October 2010Risk group Primary series Booster dosePersons aged 11 through 18 years 1 dose, preferably at age 11 or 12 years At age 16 years if primary dose at age 11 or 12yearsAt age 16 through 18 years if primary dose atage 13 through 15 yearsNo booster needed if primary dose on or afterage 16 yearsHIV-infected persons in this age group 2 doses, 2 months apart At age 16 years if primary dose at age 11 or 12yearsAt age 16 through 18 years if primary dose atage 13 through 15 yearsNo booster needed if primary dose on or afterage 16 yearsPersons aged 2 through 55 years with persistentcomplement component deficiency* or functionalor anatomical aspleniaPersons aged 2 through 55 years with prolongedincreased risk for exposure†2 doses, 2 months apart Every 5 yearsAt the earliest opportunity if a 1-dose primaryseries administered, then every 5 years1 dose Persons aged 7 years or older: after 5 years§Abbreviation: HIV = human immunodeficiency virus.* Such as C5--C9, properidin, or factor D.† Microbiologists routinely working with Neisseria meningitidis and travelers to or residents of countries where meningococcal disease is hyperendemic or epidemic.§ If the person remains at increased risk.


Influenza: An Annual Epidemic 1Up to 20% of US population becomes ill with influenza annuallyEach year, complications of influenza are responsible for Billions of dollars in health-care and work-loss costs 226,000 excess hospitalizations• About half in persons

Influenza Vaccination 2010-2011 Seasonal Recommendations Annual vaccination be administered to all personsaged ≥6 months Influenza vaccine combined into one (seasonal andH 1 N 1 )MMWR 7/31/09

2013-2014 ACIP RecommendationsRegarding Persons with Egg Allergy Persons who have experienced only hives following eggexposure should receive influenza vaccine with the followingadditional measures: Because studies published to date involved use of IIV, IIV rather than LAIVshould be used Vaccine should be administered by a provider familiar with the potentialmanifestations of egg allergy Recipients should be observed for at least 30 minutes for signs of a reaction Measures, such as dividing and administering vaccine by a two-step approachand skin testing, are not necessary All vaccination providers should be familiar with office emergency plan

2013-2014 Revised abbreviations foravailable influenza vaccinesTIV (Trivalent Influenza Vaccine), previously used for inactivated influenza vaccines,has been replaced with the abbreviation IIV (Inactivated Influenza Vaccine)IIVs as a class will include:• Egg-based and cell culture-based trivalent inactivated influenza vaccine (IIV 3 ); and• Egg-based quadrivalent inactivated influenza (IIV 4 )RIV refers to recombinant hemagglutinin influenza vaccine• Available as a trivalent formulation (RIV 3 )LAIV refers to live, attenuated influenza vaccine• Available as a quadrivalent formulation (LAIV 4 )LAIV, IIV, and RIV denote vaccine categories; numeric suffix specifies the number ofinfluenza virus antigens contained in the vaccine.Where necessary to refer specifically to cell culture-based vaccine, the prefix “cc” isused (e.g., “ccIIV 3 ”)ACIP Abbreviations for Vaccines (

Newly Approved Influenza VaccinesThese include the two quadrivalent vaccines and two vaccinesthat are produced using technologies that are new for USinfluenza vaccines: Quadrivalent Live-attenuated Influenza Vaccine (LAIV4)—Flumist®Quadrivalent (MedImmune) ® Quadrivalent Inactivated Influenza Vaccine (IIV4)—Fluarix Quadrivalent(GSK) Cell-culture based inactivated influenza vaccine (ccIIV3)—Flucelvax®(Novartis) Recombinant hemagglutinin vaccine (RIV3)—FluBlok® (Protein Sciences)

Influenza Vaccines — United States, 2013–14 influenza seasonVaccine Trade name Age indications RouteInactivated InfluenzaVaccine, Trivalent (IIV3),Standard DoseAfluria® ≥9 yrs IMFluarix® ≥3 yrs IMFlucelvax® ≥18 yrs IMFluLaval® ≥18 yrs IMFluvirin® ≥4 yrs IMFluzone® ≥6 mo*; ≥36 mo*; 6-35mo*Fluzone® Intradermal 18-64 yrsIMIDInactivated InfluenzaVaccine, Trivalent (IIV3),High DoseFluzone® High-Dose ≥65 yrs IMAdvisory Committee on Immunization Practices (ACIP)*Age indications dependent on vaccine presentation

Influenza Vaccines — United States, 2013–14 influenza seasonVaccine Trade name Age indications RouteInactivated InfluenzaVaccine,Quadrivalent (IIV4),Standard DoseRecombinantInfluenza Vaccine,Trivalent (RIV3)Live-attenuatedInfluenza Vaccine,Quadrivalent(LAIV4)Fluarix®QuadrivalentFluzone®Quadrivalent≥3 yrs6 through 35 mo*;≥36 mo*IMIMFluBlok® 18 through 49 yrs IMFluMist®Quadrivalent2 through 49 yrs INAdvisory Committee on Immunization Practices (ACIP)*Age indications dependent on vaccine presentation


The Impact of HPV in the US Approximately 50% of sexually active malesand females will have acquired genital HPVinfection 1 Estimated prevalence: 20 million 1 Estimated incidence: 6.2 million per year 1 Up to 75% of new HPV infections occur amongpersons 15-24 years of age 1References: 1. CDC. Human papillomavirus. In: Atkinson W, et al, eds. Epidemiology and Prevention of Vaccine-Preventable Diseases. 11th ed. Washington,DC: Public Health Foundation; 123-134. 2. CDC. MMWR. 2007;56(RR-2):1-24.

Estimated Percentages of CancersAssociated with HPV in the U.S.CancerCervicalAnalVaginalOropharyngealVulvarPenileAny HPV% (95% CI)96 (95-97)93 (86-97)64 (43-82)63 (50-75)51 (37-65)36 (26-47)*HPV 16/18% (95% CI)76 (NA)87 (82-91)56 (35-76)60 (47-72)44 (30-58)31 (22-42)Gillison, Cancer 2008% HPV is percentage of all cancers due to any HPV*% HPV for penile cancer is percentage due to oncogenic HPV type% HPV 16/18 is percentage of all cancers due to HPV 16/ HPV 18

Estimated HPV and HPV 16/18-AssociatedCancers, Both Sexes, 2004-2007Anatomic AreaCervixVaginaVulvaAnus & Rectum (W)Oropharynx (W)Average annualnumber of cases*11,8457143,0622,9772,306HPVassociated11,3704601,5602,7701,450HPV 16/18associated9,0004001,3502,5901,380Total (Females) 20,903 17,610 14,720PenisAnus & Rectum (M)Oropharynx (M)1,0001,6188,9363601,5005,6303101,4105,360Total (Males) 11,553 7,490 7,080There is a trend of increasing oropharyngeal cancers that is expected to surpass cervicalcancer incidence by 2020, especially in men, and anal cancers, in men and women.*Defined by histology and anatomic site; Watson M et al. Cancer 2008. Data source: National Programof Cancer Registries and SEER, covering 83% coverage of US population. Gibson ML, et al. Cancer 2008

FDA Licensure and ACIP Recommendationsfor HPV Vaccine in the United StatesQuadrivalent vaccineRoutine, females 11 or 12 yrs*and 13-26 yrs not previouslyvaccinatedQuadrivalent or Bivalent vaccineRoutine, females 11 or 12 yrs*and 13-26 yrs not previouslyvaccinatedJuneQuadrivalent vaccineMay be given, males 9-26 yrsOctoberQuadrivalent vaccineRoutine, males 11 or 12 yrs*and, 13-21yrs not previouslyvaccinatedMay be given, males 22-26**October2006 2007 2008 2009 2010 2011* Can be given starting at 9 yrs of age** For MSM and immunocompromised males, HPV4 vaccine though age 26 years

HPV VaccinesHPV2 (Cevarix, GSK)HPV4 (Gardasil, Merck) Contains HPV types16, 18 FDA approved for theprevention of cervicalcancer Contains HPV types6,11,16, and 18 FDA approved for theprevention ofCervical cancerVaginal cancerVulvar cancerAdenocarcinoma in-situAnal cancer (males and females)Pre-cancerous lesionsGenital warts (males and females)

HPV2 and HPV4 ACIPRecommendations (Females)Routine vaccination of females aged 11 or 12 years with 3 doses of eitherHPV2 or HPV4Ideally, vaccine should be administered before potential exposure to HPVthrough sexual contactVaccination is recommended for females aged 13 through 26 years whohave not been vaccinated previously or who have not completed the 3-doseseries If a female reaches age 26 years before the vaccination series is complete,remaining doses can be administered after age 26 yearsThe vaccine is a 3 dose seriesVaccination not a substitute for routine cervical cancer screeningCenters for Disease Control and Prevention (CDC). FDA Licensure of Bivalent Human Papillomavirus Vaccine (HPV2, Cervarix) for Use in Females andUpdated HPV Vaccination Recommendations from the Advisory Committee on Immunization Practices (ACIP). MMWR 59(20) 626-629, 2010.

HPV4 ACIP Recommendation for MalesRoutine use of quadrivalent human papillomavirus (HPV4) vaccine in males aged11 or 12 yearsACIP also recommended vaccination with HPV4 for males aged 13-21 yearswho have not been vaccinated previously or who have not completed the3-dose seriesMales aged 22 through 26 years may be vaccinated (9 & 10 years too). For MSM and immunocompromised males, HPV4 vaccine though age 26yearsThese recommendations replace October 2009 ACIP guidance that HPV4 maybe given to males aged 9 through 26 years for the prevention of genital warts. Current recommendations consider prevention of anal cancer indicationCenters for Disease Control and Prevention (CDC). Recommendations on the Use of Quadrivalent Human Papillomavirus Vaccine in Males — AdvisoryCommittee on Immunization Practices (ACIP), 2011. MMWR 60(50) 1705-1708, 2011.


Reported Pertussis-Related Deaths byAge-Groups, U.S., 1980-2009Age-group 1980-1989 1 1990-1999 1 2000-2009 20-1 month2-3 month4-5 month6-11 month1-4 years5-10 years11-18 years>18 yearsTotal3811571310177*681654260210315223212338194*Includes one case with unknown age1Vitek CR et al. Pediatr Infect Dis J 2003; 22(7): 628-342National Notifiable Diseases Surveillance System, CDC, 2009.

Average Cases Per YearReported Cases of Pertussis AreHighest Among Adolescents and Adults1990-1993 1 1994-1996 1 1997-2000 2 2001-2003 3 2004-2005 3 2006-2009 3a9000800070006000500040003000200010000

Common Clinical Manifestations of Pertussisin Adolescents 12-17 Years of Age 1 Any cough 3 weeks in 97%, >9 weeks in 47% Paroxysms 3 weeks in 73% Whoop in 67% Post-tussive emesis in 65%On average, adolescents missed 5 days of schoolAdults missed average 7 days of workAverage 14 days of disrupted sleepComplications include: pneumonia, inguinal hernia,rib fractures, urinary incontinenceReference: 1. De Serres G, et al. J Infect Dis. 2000;182(1):174-179.

Current ACIP Recommendations forTdap A single Tdap dose Adolescents aged 11 through 18 years, routine 11or 12 years Adults aged 19 and older Decennial Td booster for those who havereceived 1 Tdap 5 years for wound management

Tdap Use in Pregnant Women ACIP recommends that providers of prenatal careimplement a Tdap immunization program for allpregnant women. Health-care personnel should administer a dose ofTdap during each pregnancy irrespective of thepatient’s prior history of receiving Tdap. If not administered during pregnancy, Tdap should beadministered immediately postpartum.”Advisory Committee on Immunization Practices, October 2012 Meeting


Results of US National ImmunizationSurvey-Teen, 2011Immunizations US (%) NC (%)MenACWY 70.5 65.9Tdap 78.2 77.8≥ 1HPV dose≥ 3HPV doseF 53.0 54.4M 8.3 -------F 34.8 32.3M 1.3 -------CDC. MMWR.2012; 61(34): 671-677

Adolescent Vaccines Safe and effective Most common side effects Erythema Swelling Pain Associated with syncope

Selected Challenges to Adolescent Vaccination“Send in The Clowns


Opportunities for Improvement:Health Care Provider IssuesKnowledge of vaccinesAdministrative and organizational strategies• Reminders/recall strategies• Helps recapture patients• Update database• Revenue opportunity• Prevention opportunity• Every visit is an opportunity to vaccinate• Schedule preventive health care visits• Ensure discussion about administration of vaccines, best to vaccinate before exposure• Chart reminders, simultaneous administration, standing orders• Use of social mediaEvaluation and feedbackRecommendations to patientsConsider incentivesMinimize painNichol KL. Cleve Clin J Med. 2006;73:1009-1015.

Minimizing pain,discomfort, and anxietyAdopt a reassuring attitude (needle phobia prevalent)Give choices (eg, allow them to sit or lie down for shot)Use relaxation or distraction techniques (eg, allow teen to listen toheadphones)Apply cold compress to injection site after the shotApply adhesive compress over the injection siteConsider analgesic medicationFor injection pain (eg, vapocoolant spray)For subsequent discomfort (eg, acetaminophen)

PostcardYour child received his/her Tdap vaccination today at school. Thiswill meet the requirement for entrance into 6th grade. However, itshould not deter you from contacting your local physician to schedulean appointment for a complete physical and information about otherrecommended vaccines for this age group.Thanks,Amy Parker, RN, April Owenby, RN, & Kim Rogers, RNTransylvania County School Health Nurses



CDC Pre-teen Vaccine CampaignOn August 1, 2007 CDC launched aPreteen Vaccine Campaign. aCampaign materials include flyers,posters, banner ads, and webcontent about pre-teen vaccines andthe pre-teen medical check-up.

Roles as Public Health Professionals Immunize yourself, family, staff Immunize other adults, parents, and adolescents forall recommended vaccines Immunize infants Educate patients and family members aboutimmunizations

Let’s Give Our Adolescents a BetterSHOTAt Prevention from Vaccine Preventable Diseases!!!

Thank you!If you are interested in participating in interventions andstrategies to improve adolescent vaccination as part of theNorth Carolina Child Health Research NetworkPlease send an email to:

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